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Inspections
7b3-572-3604
763-502-4977 FAX
DATE � ` / '-
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
Permit No.: '�� � �'� I �
RESIDENTIAL APPLICATION xe�elvea By��C�
CITY OF FRIDLEY nate ��t: � �. � � � (� 1
EFFECTIVE 1-1-201 I
' �� YOUR E-MA1L ADDRESS (� � Zt ��p ��i ci a..., c� t�� -� D h7
❑ OWNER fy�CONTRACTOR
PROPERTY OWNER/ NAME: � b iv���7 �^ 1_ZZ��-�
TENANT p,DDRESS: %�p �Ib %lo ��' �lU� ,�F CITY /'! r�� STATE�ZIP ��t/,j �
PHONE: 3 /Z'- � D.S'— `���'�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
NAME: (� d'�ca � �/� b<'�hF�'n I1°PSE')WV'L•{
STATE LICENSE #? dZ,� / 3 I�% LEAD CERT NUMBER
ADDRESS: 3 Z� G� �7 f)f' l+� .^�-► AV � CiTY S'f`• L d G. ��� l4a�TATFj�ZIP S� 2
PHONE S�`- S%.f °`f 7/ 2 FAX
L� SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORI]
PERMIT TYPE I � �DITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
C�9CMAINTENANCE/REPAIR
DESCRIBE WORK BEING IIONE: /�� i" �� "F
SIZE OF
ROOFING
NUMBER OF SQUARES _ �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ GARAGE/SHED ❑ WINDOWS
i$('ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELTNG
❑ HOUSE ONLY
$ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF G
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Exis[ing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction plans
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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB �ALUATION $ 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
$
$
$ —
$
$ .�j �?
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)
$+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridley Attach
lations
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 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 of all ork which r�gires jeview and approval of plans. % p
SIGNATURE OF APPLICANT �� i� PRiNT NAME C!G ' S �li / DATE 7`���f
APPROVAL INSPECTOR SIGNATURE