P - 42847Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �v _�� - //
S1TE ADDRESS �/>>,3 � -
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-I-201I
Permit No
Received By:
YOUR E-MAIL ADDRESS � ru [ e.'f'C%� ���. cf,�p� f� �
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❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME:
TENANT pDDRESS:
PHONE;
' CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
' AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
__--
TYPE OF WORK:
CITY
NAME:( v r�,. >h2// (,f2,h�LC��� n ch ('.l,/e�', /t�r
STATE LICE SN E# ���5� T� LEAD CERT NUMBER�
ADDRESS: I y�'S�� �����'�- (/��— c�Tv
PHONE 95.�.^3S C� ^ 5�/rF' `lr FAX ��o� - �/�Y ' —
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILYMEW CONSTRUCTION S7'ORIES
� BASEMENT F1N1SH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMMG POOL
❑ NEW HOME CONSTRUCTION f�ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
n . ._ I i
DESCRIBE WORK BETNG DONE:
,� �t W
ATE ZIP
o wn�DOws
❑ DRA[N TILE
❑ OTHER
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. . . _ 0 II.X�i
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ROOFING O HOUSE ONLY gASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � � HOUSE & GARAGE 1, Existing Floor Plan
R OSED SIZE: �� �%�. ��jp ,y � ATTACHED GARAGE 2. Proposcd floor plan
,�� "�DETACHED GARAGE 3. List of structural members to be used
PROPQSBD HEIGHT: �_
I � FOR NEW CONSTRUCTION INCLUDING DECKS,
pDDIT10NS. & AP RCHES �UBMIT:
�ny� ����t l. Site Pian/Survey showing the existing swctures
O Aluminum ��� ❑ Trim and proposed project.
❑ Other �'Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTTNG OPENMGS ❑Yes �lo LOCATION OF W[NDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHAPJG6S &
TYPE OF WfNDOW TO BE MSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED QN VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
1'OTAL JOB VALUATION S�40p�'' nCC'TiPANC"'V TVPF ��ri �. a►e
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ l�3�� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ . .001 �mes 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+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ � Agreement necessary ( ) Non Necessary ( )
$ �� Make checks payable to: City of Fridley Attach
s
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 e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applica ' n r a ermi w k is not to art without a permit on site; at the work will be in accordance with the
approved plan in the case f ork w qu' ' w a approval of pl /
SIGNATURE OF APPLICAN P�I�1TN'A�ME V'uc � DATE �LFj ��/
APPROVAL [NSPECTOR SIGNATURE . ,l C'll/
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