P - 43653Building BUILDING Permit No.:aO l4
Inspections ,� RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 . CITY OF FRIDLEY Daj�� '
763-502-4977 FAX E�ECTrvE�-i-ZOlo
DATE I�/� I2.C� �U YOUR E-MAIL ADDRESS
si� .�D�ss :� y�2, �q �1 ✓� N� �r{ ia��
THIS APPLICANT IS: �OWNER �CONTRACTOR
PROPERTY OWNER/ N,�: �o�AJ �ry�v��
TENANT �D��S:,�N 9� E iF_ CITY
,� �-, I�1/ .1% �R/��5� 5TATE1/jt�/ ZIP �y�.2
PHONE: %� �_ '�7 �f � �%S' � �
CONTRACTOR N�:
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE LICENSE
AND CERTfFICATE OF �+DDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ❑ SINGLE FAMII.Y/NEW CONSTRUCTION S�ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ DIT'ION Q GARAGE/SHED ❑ WINDOWS
�BASEMENT FINISH ❑ ROOF ❑ DRAIN TII..E
❑ DECK ❑ SLDING ❑ OTf�R
❑ SWIMMING POQL
TYPE OF WORK: � NEW HQME CONSTRUC'fION O ADDITION
❑ MAII+TTIN.4NCE/REPAIit 0 REMODELING `
DESCRIBE WORK BEING DONE: � � T � r k�tGs /,/,�� ������ w�s
SIZE OF Ilv1PROVEMENT LENG WIDTH t,3 HEIGHT Ff
O HOUSE ONLY gpg�T gEMODELING SUBMIT:
NRU�MB�ERGOF SQUARES ❑ HOUSE & GARAGE 1 ���g �� P�
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor ptan
PROPOSED S1ZE: ❑ DETACI�D GARAGE 3. List of structutal membus to be Wed
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vnryl �Soffrt ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site PIsnlSurvey siwwin� tbe e�tisting struct�s�es
❑ Of}�r ❑ Fascia � PmPo� P%I�•
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXI3TiNG OPENINCrS C]Yes QNo LOCATION OF WINDOWS FOR WII�TDOWS – PROVIDE U-VALLTE AND
OR FOR NE W OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDQWS
ALL FEES ARE BASED ON VALUATTON, INCLUDING TIiE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ °'-35�6 OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchar�e
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Dne
E�
$
$
S
$
$
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)
52100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineeriug
Agreement necessary ( ) Non Necessary ( )
Make checks uavsble to: Cih* of Fridley Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I heretry apply for a building peimit and I acknowledge that the information above is complete an@ accurate; that the work wiil 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 withoitt a permit on site; that the work will be in accordsnce with the
approved plan in the case of work whi requir review and approval of plan�.
SIGNATURE OF APPLICANT � w��✓' PRINT NAME�A� I%% f%R PI�/ �/ DATE /a � 3/ z v i v
APPROVAI, INSPECTOR SIGNA _ �% _-__—
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