P - 48086Building BUILDING Permit No.:a� P/�%�''
Inspections RESIDENTIAL APPLICATION Received By•
763-572-3604 CITY OF FRIDLEY Date Rec'c1:ll C! /
763-502-4977 FAX EFFECTIVE 11-20] 1
DATE �
' 3- L�— �� %( YOUR E-MAIL ADDRESS
SITE ADDRESS �� � � - , �� y� �/ � y� � C
THIS APPLICANT 1S: �E�OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �
TENANT —
ADDRESS - 7�- E ' � G ciTY f r�`� -"� sT,arE i�►v z�p �' S y a
PHONE: %j � - `� � /' � (��T �
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTiFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE B SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES '�
PERMIT TYPE � ADDITION ❑ GARAGE/SHED L4 WINDOWS
❑ BASEMENT FINTSH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR REMODELING
DESCRIBE WORK BEING DONE: ��� 'I'" �,v; ,�L� n��
SIZE OF IMPROVEMENT LENGTH W1DTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � HOUSE & GARAGE BASEMENT REMODELING SUBMIT
l. 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,
O Vin I ADDITIONS & PORCHES SUBMIT
Y ❑Soffit SIDING/SOFFIT/FASCIA �, Site Plan/Surve showin the existin structures
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO and proposed p oject. g g
❑ Other ❑ Fascia
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes allo LOCATION OF }yINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF :��^�;�� r9-f�{tp, r5 �' MANUFACTURE STTCKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED �`N '"��IUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�,.t (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� t�(? � c.�U _ 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
$ "� �� ;`)�) 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)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
_$ �-j ,�-}� Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit 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 permit and work is not to start ithout a permit on site; that the work will be in accordance with the
approved plan in the case of all work which requires rev' w and app val of lans.
SIGNATURE OF APPLICANT _ ��L `' ,_ - :,�- : . P T NA� /� � ; � n DATE � � - � �t ' �� �=%J I
APPROVAL INSPECTOR SIGNATURE ����r�l�"�� � _Y, 1 > :' �— _ � ��
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