P - 42261Building BUILDING Pe�it Ivo.:`� ��� 3�
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY ����°d� �� ������
763-502-4977 FAX EFFECTivE�-�-zoio `�
DATE �' 30 ' Z.O � o YOURE-MAILADDRESS K�21 . C,���a.Et� t.�SK.� �'�r��-. �.�L
sITE aDDRESS �(e � t�ta 1"' A-v� iUc� �-'�T9�-�=�
THIS APPLICANT IS: f�'A-WNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: 6
TENANT ,�DRESS: , 3i0 � �2CQ. �' 7T ll t � CITY �`� STATE vK �% ZIP S S 3 Z
PHONE: 7�i 3`'Z l$ � 13 77
CONTRACTOR N,a�v�E:
SUBMTC A COPY OF STATE LICENSE # EXP DATE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOffiES
PERMIT TYPE ❑ .�DITION ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTTION '
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: S�1�T1� (�
SIZE OF IMPROVEMENT 1 Z LENGTH /�,.. WIDTH HEIGHT 3 FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
'gl,�Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
, 2. Two sets of constnxction plans
WINDOWS 3. Energy Calcula6ons
IN EXISTING OPENINGS ❑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 ARE BASED ON VALUATlON,1NCLUDING '1'HE CUS'1' UN' LABUR A1Vli MA'1'L:KIAL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�� 0 _ OCCUPANCY ._ _ TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ QT � J�'�_ 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)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservarion Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ n Make checks uavable to: City of Fridle_y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 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 rk which re re 'ew and approval of pl,��� r'� /
SIGNATURE OF APPLICANT I'�/ � PRINT NAME ��J ►�- � �,�Jµ�tLG"�,7�NA'I'E r 7 I�7 Z�v
APPROVAL INSPECTOR SIG ATURE . � �