P - 43704Building ,
Inspections
763-57z-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
VE I-1-201!
Permit No.:
Received By:
Date Rec'
' DATE Y'OIJR E-MAIL ADDFtESS ,J��•Sci-/cJrrlrr�f=-r��r'})S,d'.�v rr� G �
SITE ADDRESS �r %/ p � �`� �-v c ,1.�!''
I TH[S APPLICANT tS: ,�'OWt�iER QC013TRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OE
INSURANCE
PROPERTY TYPE
NAME: � bS�D/� �'%a �C�NUl��i�.� �
ADDRESS: �")/ � � T� �V� �[//� C1TY /`�lll �i�� STATE��ZIP;y��
PHONE: �ip3 " S 7/ " S�p �i7
NAME:
STATE UCENSE # LEAD CERT NUMBER
ADDRESS: CITY_
PHONE FAX
� SINGLE FAMILY/NEW CONSTRUCTION S[ZE�
� TWO FAMILYMEW CONSTRUCTION STORfES
PERMIT TYPE 0 �D�Ttotv ❑ GattaG�
0 BASEMENT F[NISH ❑ ROOF
P'�DECK ❑ StDING
❑ SWIMMI
TYFE OF WORK:
�"NEW HOME CONSTRUCTION ❑ ADD[TION
❑ MAINTENANCEIREPAIR ❑ REMODELMG
❑ DRA[N TILE
� OTHER
STATE ZIP
DESCRIBE WORK BERVG DONE: �u/ ID1 L'�! �erJ��G i�,�C�
� i/ �1
SIZE OF (MFROVEMENT LENGT}i� /� � W1DTH "y�6 HEIGHT •. a(� SQ FT dS
ROOFING
NUMBER OF SQUARES _
GARACES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ V inyl
� Aluminum
❑ Other
WI:�IDOWS
IN EXISTING OPENMGS ❑Yes ONo
OR FOR NEW OFENINGS-DESCRIBE StZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
0 Trim
� Fascia
LQCATION OF WINDOWS
NUMBER OF WINDOWS
BASENiENT REMODELiNG SUBMIT:
L Existing Fioor Plan
2. Proposed floor pian
3. Lis[ of structural members to be used
FOR NEW CONSTRUCTION 1NCl.UDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
t. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction plans
3. Energy Catculations
FOR WINDOWS — PROVIDE U-VAI.UE AND
MANUFACTURE STICKER ON WINdOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIAL,S:
(USING HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��] �� 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
$ _1�,3-2
$ � .
$
$
$
$
$
$
$
$ —'�_� .�—
l 101�)
See Back Page for Fee Schedule
65% of Bui�ding Permit Fee
.001 times the total 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$25=$
$450 Coaservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: Citv of Fridlev Attach
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a buiiding permit and 1 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 firidley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit an work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case af all wh'ch re ' es review and approval of pl�. (
SIGNATURE OF APPLICANT PRINT NAME�JQS,�d!/ /yJ� X'/�a,�'1�7r� DATE
APPROVAL INSPECTOR SIGNAT E
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