P - 48062Buildin�
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECITVE 1-1-20
Permit No.:
Received By:
Dat��dM
pATE H��%� I� YOUR E-MAIL ADDRES S —
srrE nDD�ss �/C/ 6 7 fb A vE wE �� ivt.r-cy� �yit/ SS�13 a
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICA'I`E OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
ADDRESS: �C � G]��C /¢(/E N E CITY �' fD �'y STATE!% ZIP ssy�O�
PHONE (763� � 34 ' ✓'�' %SS
NAME(�LL/4iGTnD�a, G�%lNQOl.J � Gi7�G CO .
STATE LICENSE # oW�o,� p�~%� EXP DATE
ADDRE3S:�Q,T� �N�D�O�� e,I� CITY��j; �Qv�,f- /��t�iSTAl�/".w' ZIP�.�
'--- - --- - — -
� 3INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SF
O BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCF✓REPAIR ❑ REMODELING
nESCiuBE woiuc BEirrG DorrE:� � I� DO �J E�l.+oG'��'lE�v T r �
SIZE OF IMPROVEMENT LENGTH WIDTH
R�OFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
PROPOSED 3IZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�WINDOWS
DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT'ION INCLUDING DECKS,
❑Soffit ADDITIONS_ & PORCHES SUBMIT�
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2 T ts f
wo se o constructrnn plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS I�S'es ONo LOCATIOl�( OF OWS FOR WINDOWS — PROVIDE U-VALLTE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF L, /�/ !++ y� p ry MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUM.BER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATIOP�T $ ��I '�1 °= OCCUPANCY 'r'vpF
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� ' 1 I , �2.�
$
$ "�
$ �'�
$ �7�
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.SO
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
i�+6ft= ftx$22=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridley Attach
THIS I3 AN APPLICAT'ION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernut and I 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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a rmit and wark is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a r w ich requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME /�C�Y UE� �CV DATE �� 9 �/
NOTE: SEPARATE PERMITS ARE RE UIRED FOR PLUMBING, EI:ECTRICAi, END idlE���.�1��F�I. V���K