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Building BUILDING Permit No.: �
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 CITY OF FRIDLEY ���: �� � I. 2 0 '
763-502-4977 FAX EFFECT�vE�-�-zo�i
DATE � - YOU E�Mg�, ADDRESS
i
SITE ADDRESS ��u
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPERTY OWNER/ N�ME: c� j,�cS' ,
TENANT ADDRESS: Y(S~O _/ CITY /Zt STATE�ZIP �✓� .
PHONE: �(�J — ci %Y � /(�Q�_
CONTRACTOR NAME: ,p
SUBMIT A COPY OF STATE LICENSE # � 7'7� LEAD CERT NUMBER �/ / l ��./� "�
AND CERTIFICATE OF ADDRESS:�7�c�c-lill�/�/ ��. /W/p �'IcS STATE/j"/r{ZIP
CI?Y
INSURANCE PHONE LI�I ' � ' � � FAX
PROPERTY TYPE INGLE FAMILYlNEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION . ❑ GARAGE/SHED 0 WINDOWS '
❑ BASEMENT FINISH �❑ �OOF ❑ DRAIN TILE '
O DECK JS�SIDING ❑ OTHER '
O�`WIMMING POOL '
TYPE OF WORK: 0 NEW HOME CONSTRUCTION ❑ ADDITION '
MAINTENANCE/REPAIR ❑ REMODELING I
�7ESCRIBE WORK BEING DONE: l / O� ,
�iIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING � HOUSE ONLY BASEMENT REMODELING SUBMIT• '
.NUMBER OF SQUARES ❑ HOUSE & GARAGE ' '
] : Existing Floor Plan
C.aARAGES � ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used '
PROPOSED HEIGHT:
�IDDVG FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl OSoffit ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
❑ Aluminum � Trim and proposed project. '
❑ Other ❑ Fascia 2. Two- sets of construction plans
WINDOWS 3. Energy Caiculations ,
IN EXISTt1VG ON£NINGS ❑Yes C3No LOCATIOI�i OF WINDOWS �OR WINDOWS — PROVIDE U-VALUE AND '
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW. '
OPENING CHANGES & '
TYPE OF WTNDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BA5ED 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
THE 1997 U.B.0 FEE SCHEDiTLE)
T� OCCUPANCY
$ r�(o��d5
$ —�r---
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the totai 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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( . ) Non Necessary ( )
Make checks Davable to: Citv of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I heraby apply for a building permit and I acknowledge that the information above is complete and accurate; that the wark will �e in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit nd is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of 11 work w ich requir� view and approval of plan �y / ',
SIGNATURE OF APPLICANT RINT NAME �/'/ S D%%%iY/'I DATE �- l7 '�( �
APPROVAL INSPECTOR SIGNATURE '
PLEASE NOTE: SEPARATE PERMIT RE IRED FOR PLUM$ING, ELECTRICAL AND MECHANICAL WORK