P - 42251Building
Inspections
763-572-3604
.
DATE 7 { O
SIT'E ADDRESS //( _
THIS APPLICANT IS:
0
BUILDING
RESiDENTIAL APPLICATION
CITY UF FRIDLEY
Permit No.:L-v t-�
Received By: �,'�� l'� % r
DR�(���u � o- 2 0
m�r���sv+zz-r�.scv• c�►�
PROPERTY OWNER/ Nq�;� �0�
TENANT qnDRESS: .• CITY STATE ZIP
Du�,,T�. r11�.� . �r7/ . � 9�f � —
CONTRACTOR
SUBMIT A COPY OF STATE LICENSE # o� %%3 � EXP DATE �
YOUR STATE LICENSE ADDRESS: SSSS -I�- CITY,
WITH APPLICATION PHQNE �1 SZ • 93.� '�!?� g FAX '�SZ • 9.�5 • 95•
PROPERTY TYPE
0 TWO FAMILY/NEW
PERMIT
0 BASEMENT FINISH ❑ ROOF O DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ S WIMIvIING POOL
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
❑ REMODELING
�
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES 0 ATI'ACI-IED GARAGE
PROPOSID SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:: '
s�.�rz _ .
0 Vinyl ❑soffit :
O Aluminum ❑ Trim -
D'Othcr ' _ ❑Fascia
WINDOWS /
IN EXISTING OPENINGS �Yes ONo L.� O OF S�,/
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �,�i��� �'�� ^�'! O D Y/'� Q'�"
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED � NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LA
TOTAL JOB VALUATION ING � �7�U,B.0 FEE O�UPANCY
Permit Fee
Ptan Review
Fire Surchaxge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
/
HEIGHT
A� �P553`�3
F�
�ASEMENT REMODELING SUBMIT:
1. Existing Floor Plan _ _
2. Proposed floor ptan "
3. Listof struc�wal membzrs to bt used
FOR NEW CONST[tUCTION INCLUDING DECKS, .:.
ADDTfIONS: & PORCHES SUBMIT: :
1. Site Plan/Surv�y showing the wcisting structures
and proposed project
2. Two scts of construction plans
3. Energy Calculation¢
AND MATERIALS:
� 9? 2S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ ,3 ./(o .001 times the total job valuation "
$ /-Sp� .0005 x Permit Valuation Minimum $.50
$ ,5 • oo $5.00 (State Licensed Residential Contractors)
$ $1550 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( ) _.
$ !� le . 9 Make checks aavabie to: Ciri of Fridlev Attactt Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NO'f VALID UNTIL PRO�ESSED � '' �
I liereby apply for a building permit and I aclmowledge that the informadon above is complete and accura�e;" that the �work` viwill be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construcrion �odes; tliat,i understand this is not a
perrnit but only an application for a p it and work is not to start without a permit; that the work will be in accordance wi the approved
plan in the case of all work which r ires Ye e and o a1 of plans. � /'J
/ �
SIGNATURE OF APPLICANT " RIN7' NAME I ATE I