P - 42165Building
Inspections
�763-572-3604
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:
Received By:
.� -�•:���:
DATE 3� 3� �� YOUR E-MAIL ADDRESS �Q��(bJ� Q C�n�,yN�W��ov.
'�.G'�Y"`tdt,P�CC�'f'- -CCJVa—►
SITEADDRESS ZSC� Eo1'Y �V� N F'
`fHIS APPLICAN7' (S: ❑ OWNER [i(CONTRACTOR
PROPERTY OWNER/
; � TENANT
CONTRACTOR
Na�: f�n t�.9 �1 t
ADDRESS: CITY
PHONE: j 7to'31 �? ( — S��C7
o r•
A'T'E ZIP
� SUBMIT A COPY OF STATE LICENSE ��O�ky �ib1 Z EXP DATE O'3 I1 Z,
`YOUR STATE L[CENSE ADDRESS: S'101i '4�cw� LloGl N CJTY NQw N"o,�l�2 STATF�,_NNL[P„�'S4ZFS
`� WITH APPLICATION AHONE C7 i�3�'S��I.'�i�iS�l RAXi'1(�3 � S'K-i.� ?Ay�i
PROPERTY TYPE
❑ BASEMENt FII11SH a RQpF
❑ DECK O SIT)INf3
TYPE OF WORK.:
DRAIN 7'ILE
OTHER
�ESCRIBE WORKBEING DONE:� nc � Wt�ciOvUS' C�ws6�''f5 oY►��1, �
SIZE OF IMPROV�MENT LENGTH �VIDTH__ __ __ H�IGHT So. Ft.
aJUMBER OF SQUARES
�.
R� S12E:
�ROPOSED HEIGHT:
r_ ID�VG
� Vinyf
s.`] Aluminum '
� Otl,er . �
�'INDOWS
�1 EXISTING OPENINCiS Q�Yes t;INo
�R FOR NEW OPENINGS-DESCRIBE SIZE OF
�PENWG CHANGES dc
O HOUSE & GARAGE
❑ ATTACHEb GARAGE
C] DETACHED GARAGE
DSoffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
i�'4C�.I� orci t,.l V�uK fOdYv�
T
P*. �
W
�
$ASEMENT REMODELING SUBMIT: �,
i. Existing Floor Plan �
2. Proposed floor plsn
3. List of swctural m�nbers to be used
FOR NEW CONSTitUCTION lNCLUDING DECKS,
At�DITiONS. 8c �iKiRGH_FS SLIBMIT:
1. Site PIaNSurvey showing the exisdng swcwm
and proposed project
2. Two sets of consWcd� plans
3, Energy Galculatis�ns
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIAL.S:
(LJSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 1. t lDCO OCCUPANCY TYPF,
=ermit Fee
�lan Review
� ire Surcharge
xurcharge
,icense Surcharge
=AC Charge
�urb Cut Escrow
irosion Control
'ark Fee
�ewer Main Charge
'otal Due
� y�,
$
S
$
$ D
$
$
$ _�.--------�
See Back a�e for Pee Schedule
_--
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Fermit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$1675 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$21=$
$450 Conservation Plan Review
e Determined by Engineering
greement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
FOR A PERMIT-NOT VAL1D [JNTIL PROCESSED
hereby apply for a building permit'dnd-�owledge that the information above is cornplete and accurate; that the work will be in
onformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
efmit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the approved
[an in the case of all work w� h requ' s r.eview and approval of plans.
IGNATURE OF APPLICANT PRINT NAME S�Gb'l'E— �l P.(�Ci ,/� DATE ���✓ ��