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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � ��j �� �
SITEADDRESS �� uV
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
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❑ OWNER
PROPERTY OWNER/ ( NAME:�
TENANT ADD�ss:
YOUR E-MAIL ADDRE55 t�•�X�r l'C�lw !�
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-Sit- I<
Permit No.:
Received By:
D����'����"U I�
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I�bIK`21 i?C • CCA1'l
� STATE rNV ZIP S�� �
CONTRACTOR NAME: 1'�Oi�1�e�,1�L � Z-�1C .
SUBMIT A COPY OF STATE LICENSE #�O 5�� LEAD CERT NUMBER N� �^
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �4 �{rlf'ilCX1 U� LY1. � �� CITY� ��}(1�"�"�
INSURANCE p ONE ���'c� � S� FAX (.�'�O�S ' I �g
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION `�❑ ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
� � c�Cc, �.
0
ATE Ir%/ZIP �6� $
DESCRIBE WORK BEING DONE: � I'�C�C� S-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING �\, ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF 5QUARES �/V ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor ptan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUC"iION INCLUDING DECKS,
SID1NG ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy 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 FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � O� OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ _����� .001 times the total job valuation
Surcharge $ � ' .0005 x Permit Valuation Minimum $5.00
License Surcharge $ G�' �, (� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft + 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ �'� ,' Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pennit 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 without a permit on site; that the work will be in accordance with the
approved plan in the case o work which e� e/s r�ev �i'and approval of plaf �s,.
SIGNATURE OF APPLICANT ����C�ijVWL,� !✓ N9 �'L PRINT NAME ( � ltNY1'�Qi� jC..I�'� �� DATE l� I�� �� 1
APPROVAL INSPECTOR SIGNATURE