P - 36667Building BUILDING Pe��t No.: `L� �-0 � S 1��'
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date ��
� �� �� �
763-502-4977 FAX EFFECTIVE �-t-zoi i
DATE YOUR E-MAIL ADDRESS �,1�/)Q4i/? G�XG� ���� � e0�'�
SITE ADDRESS QoI D l0 ��'�. /V �
THIS APPLICANT IS: � OWNER J�CONTRACTOR
PROPERTY OWNER/ NAME: ''f2(��il'J
TENANT ADDRESS: Oq�D �p � �� /�� CITY
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE L[CENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PHONE: /� ��%�' D�/oZ
NAME: CX (�!
STATE LICENSE #
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
CERT
FAX % lQ� ' '/,
SIZE
STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DC
SIZE OF IMPROVEMENT /h
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE '
❑ DETACHED GARAGE
_STATE I��ZIP��� y3�
- Dd -!/- Od �3
�J STAT IP ,+�ri-�G('9
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
��inyl ❑Soffit ADDITIONS. & PORCHES SUBMIT.
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
O Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo 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:
__ (IJSING THE 1997 U.B.0 FEE SCHEDULE) _ ,,. ,
TOTAL JOB VALUATION
Permit Fee �
Plan Review
Fire Surcharge
Surcharge
License Surchazge
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 tha 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)
�+6R= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridlev 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 th i of Fr' ley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permi to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all w ew and approval of p 1L
SIGNATURE OF APPLICANT PRiNT NAME��Q�j/� LLG7QC.�' DATE
APPROVAL INSPECTOR SIGNATURE