P - 45381Building BUILDING -����
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT,vE �-�-ZOi�
DATE �"' (� -- /,� YOUR E-MAIL ADDF2ESS
SITE ADDRESS l %��? C ��'' `_����� `�._
THIS APPLICANT IS: O OWNER
Permit No.c��l� G/!
Received By:
Date Rec'd: � l 7�
PROPERTY OWNER/ N,q�,�E: j'��L'� ��,. r-,,� �� ^
TENANT p,DDRESS: �fOG' � � �j"� ,rt-�`�._-- CiTI' '/� �/�r/' STATE^�"�GIP S�-��i2
PHONE: _ �G� " :S'7� -- � � `! .� /
CONTRACTOR Na.NtE: /`7 • � � �- :�r-�� r'-..a� �-,,,. � /a'� . �: /.� � � � �,
SUBMIT A COPY OF STATE LICENSE #:i�« .5�� ra� I��� LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF �DRESS: �; ��� G1� cc .S ,,r�.r� /t/ � CITY Ci�SP �P « STATE��`i�cILIP-->-S��'1 v
INSURANCE PHONE %E-� � ° `-,�:�_�'""" `�'� � � FAX
PROPERTY TYPE
PERMIT TYPE
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINiSH �'ROOF
❑ DECK ❑ SIDING
_ _ ❑ SWIMMING POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: .i� , -� � �.., � � fi- � <: � �=� r
S[ZE OF IMPROVEMENT LENGTH WiDTH
ROOFING ❑ HOUSE ONI,Y
NUMBER OF SQUARE3 ��' I�HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ V inyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HE[GHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON RJCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT�
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of cons[ruction pians
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�(USI ' HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ , O���.,,,�i„3'. d"' 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
$ � `1' �� See Back Page for Fee Schedule
$ �' 65% of Building Permit Fee
$ .001 times the total job valuation
$ � .0005 x Permit Valuation Minimum $5.00
$ ��' 1� r., $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 ( )
$ lj?, a?S'—' Make checks payable to: City of Fridlev Attach Stiaulations
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 p ' � is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case which re '�° -an approval of pl ,. �/ �/
SIGNATURE OF APPL[CANT PRINT NAME � � ✓i (J'�- �-tn -� - DATE � �' - (
APPROVAL INSPECTOR S �, � i