P - 48411Building BUILDING Permit No.: C� (�� Z
Inspections RESIDENTIAL APPLICATION Received By: -
763-572-3604 CITY OF FRIDLEY vate xec'd: Z
763-502-4977 FAX EFFEC�vE i-i-2oiz
DATE �� ' � - �-_ •' i C YOUR E-MAIL ADDRESS -yc � -�T� �� i '� �J �
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SITE ADDRESS � % '� `— � ` '""
THIS APPLICANT IS: ❑ OWNER �,. .� ONTR ACTOR
PROPERTY OWNER/ NAME: �`7 .<z ,� .- � ='' '~r,
TENANT ADDRESS: CiTY STATE ZIP
� PHONE: "�,% �, � c� "� �' � ; '� I
CONTRACTOR NAME: � � . �- ( '-t ' �' /r. ( ,'' '
4
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENS� # LEAD�q CERT NUMBER EXP:
AND CERTIFICAT`E OF ADDRESS: .1 � . � ! T. � c� �v � � -i ✓ � �,�, j /� f ,: .-'.t CITY =. , ; �r� � STATE�� l t � Z /
INSURANCE PHONE � . � �. , �_ c'_ ' ` v.. /, _. .. - FAX � � � .� � /_r/ � �� �l t, j !.
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE �
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � .4DDIT'ION ❑ GARAGE/SHED ; 'WINDOWS
❑ BASEMENT FINISH �-itOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTTION
❑ MAINTENANCE/REPAIR '�EMODELING
DESCRIBE WORK BEING DONE: %' � � c � � ��� ,/_ - ,/� '� �" i
t � , � i_i.. �
SIZE OF IMPROVEMENT �� LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NiJMBER OF SQUARES i �% ❑ HOUSE & GARAGE ]. Existing Floor Plan
GARAGES � 1�1 Q ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE:� ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING _ w� �,�, Q�}7S FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit 5IDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT
❑ Aluminum ��� Z. 5�� ❑ Trim REMOVED? ❑ YES ❑ NO � Site Plan/Survey showing the existing structures
❑ Other -- ❑ Fascia and proposed project.
L� 2. Two sets of construction plans
WINDOWS � � � 3. Energy Calculations
IN EXISTING OPENINGS ,�Yes �No LOCATION OF WINDQWS FOR WINDOWS — PROVIDE U-VALLTE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �% rr �;,�. ,;� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS•
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
(USING THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
$ 5.3 • 25' See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �, .001 times the total job valuation
$ ���d .0005 x Permit Valuation Minimum or .50
$ S ���� $5.00 (State Licensed Residential Contractors)
$ $2365 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 pavable to: Citv of Fridlev Attach
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 permit ai►d work i�s }ot to start without a permit on site; that the work will be in a orda e with the
approved plan in the case of ,all_�rork whk�li.requires r iaW and approval of plans.
SIGNATURE OF APPLICANT �= �� �� PRINT NAME DATE
APPROVAL INSPECTOR SIGNATURE " % ; / � �'�/J