P - 46289Building BUILDING Pei-mit Ivo.:: �
Inspections RESIDENTIAL APPLICATION Received By.
�63-s�2-3604 CITY OF FRIDLEY Da���'c��� ^ ��
763-502-4977 FAX � EF�cTTVEi-i-zoii
DATE � �� �� YOUR E-NIAIL ADDRESS
s�� �D�ss (ool0 5'—" �t �1E
THIS APPLICANT IS: ❑ OWNER @G'�N'TRACTOR
PROPERTY OWNER/ N�:
TENANT �Dx�ss: CdiIO r'J� c�3;" IS� CITY � v�l STATE�ZIP �{�
PHONE: 7iQ3 � � I�v l �
CONTRACTOR Np,�,�: �, � �, �
SUBMIT A�OPY OF STATE LICENSE # Z���I7 LEAD CERT NUMBER "' 1� � IO �08���
YOUR STATE LICENSE �p
AND CERTIFICATE OF ADARESS: ,J70I CITY�yw STATE Rh ZIP ��3
INSURANCE pHONE %(o�J Zf�) 0�'f�3�✓ FAX ?6'S �3 ��b(o
PROPERTY TYPE NGLE FAMILY/NEW CONSTRUCTION SIZfi
❑ TWO FAMILY/NEW CONSTRUCTION STORIES (
PERMIT TYPE ❑ ADDITION ❑� �G �GE/SHED ❑ WINDOWS
❑ BASEMENT FINISH B'ROOF ❑ DRAIN TII,E
� DECK ❑ SIDING ❑ OTHER
❑ SWIlvIIvIINGPOOL
TYPE OF WORK: �W HOME CONSTRUCTION ❑ ADDITION
NTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: B�O O�i�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROO ING f,Q� ❑ HOUSE ONLY $ASEMENT REMODELING, SUBM[T:
i`TIJMBER OF SQUARES 1✓ �'frOUSE e& GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTAOHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACf�D GARAGE 3. List of atructural members to be uaed
PROPOSED HEIGHT:
I G FOR NEW CONSTRLJCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the exiating sTructurea
❑ Other ❑ Fascia
and proposed project.
2. Two sets of construction plana
VYINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATTON OF WINDOWS FOR WINDOWS —PROVIDE U-VALiJE AND
OR FOR NEW OPEIQINGS-DESCRIBE SIZE OF MANLJFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NLJMBER OF WINDOWS
ALL N'L�'L�'� A1ZL�' BASk:ll U1V VALUA'1'lU1V, llVCLUDllVG'i'HE CU5'1' UF LABOR A1VD MATERIALS:
,�_�,,,�(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
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)
$223� 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 navabie to: Citv of Fridlev Attac
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 or�y an application for a permit d 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 d qrk atlri� wres review and approval of pl /� �%
SIGNATURE OF APPLICANT ��i` PRINT NAME �M CrO� DATE fG�f I�II
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