P - 43650Buildillg $jJjl,�jN(i PermitNo.: �6��i� �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ��e��=��„�
763-502-4977 FAX EFFECT►vE �-i-zo>>
DATE � � '- YOUR E-MAIL ADDRESS 1,� � . CG
SITE ADDRESS �^-
TH[S APPLICANT IS: L�OWNER ❑CONTRACTOR
PROPERTY OWNER/ NpME:
TENANT pDD�ss: L cr� ST.a z[P
PHONE: �
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STA'TE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMTLY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NE W HOME CONSTRUCTION ❑ ADDITION
"�t(MAINTENANCE/REPA[R ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R OFING � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �;��� /�'� I�HOUSE & GARAGE l. Existing FloorPlan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structaral members to be used
PROPOSED HEIGHT:
5IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
0 Aluminum ❑ Trim 1. Site Plan/Survey showmg the e�cisring shuchues
❑ Other O Fascia
and proposed project.
2. Two sets of construction plans
WINDOWS 3. Ene�gy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS -PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL r'L�'L�'� AKr; IiA51�.'ll UiV VALUA'1 IUN, llV(;LUllIiV(U '1'Hl�'. C:US'1' UN' LAIfUK AiVll MA'1'Lr1ZlAL5:
(USING THE 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
$
$ 3(e�
$
$ �o>
$
$
$
$
$
$ � . �
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 + 6 ft = ft x$25= $
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes f the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio for perm' d wark is not to start without a permit on site;�at the work will be in accordance with the
approved plan in the case of a wor whi equires review and approval of p ns. �r,� ^��^ 11
SIGNATURE OF APPLICANT PRINT NAME DATE U
APPROVAL INSPECTOR SIGN T RE �
0