P - 47311Building BUILDING PermitNo.:� ��%' l��
Inspections RESIDENTIAL APPLICATION Received By: �`��
763-572-3604 CITY OF FRIDLEY vate � : ' ""'f `� � `��
763-502-4977 FAX EFFECrivE � i-ZOi i
DATE �� i:Z ��`ZdI� YOUR E-MAIL ADDRESS
sr� ADD�ss S" l C�C> S�_� 5� l�lF F lt i rl l�' � i ,.v� ,. � Ssy �: ��
THIS APPLICANT 1S: �1 OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: (=P ,' n c�. ri rA� � m P r; c( tt� ��
TENANT ADDRESS: 5 c C c� ��� S t �/� CITY r.2 I o( /e w STATE_�i-�ZIP SS y � �
PHONE: '� (� .'� ' . j % Z � � j �o �
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: C[TY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING m�6THER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR f�EMODELING
DESCRIBE WORK BEING DONfi• ' ��� h ��17 ,�% C�e �/{�Ili�P f{C�rJ
SIZE OF IMPROVEMENT �� vuµ�tS' ' LENGTH /S IDTH /4% �� HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT: �
NLJMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Pian
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Vin 1 ❑Soffit SIDING/SOFFIT/FASCIA
Y 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED? ❑ YES O NO and proposed project.
❑ Other � Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS J�Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES AKE KASL� ll UN VALUA1lU1V� 11V(:LUUllrt� 1 riL� l..vJl vr LHiSV1C H19L lY1H 1 GICIHLJ.
(USING THE 1997 U.B.0 FEE SCHEDULE)
AL JOB VALUATION $��� ___ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ 'Z � = `.� f�
—$ �—
� 'aC'�
$ S (�
$
$
$
$
$
$
$ � ��I � �
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley _ Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe � and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of.a�-nvork w ic uires review and approval of pl�ns. � �
SIGNATURE OF APPLICANT rn , PRINT NAME ; f"(�'���a/�i'r: �iJc-: r'`Z— DATE I�I �I
APPROVAL INSPECTOR SIGNATURE