P - 43652Buildirig BUILDING Perm�t 1vo.:� b �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Da��j '��
763-502-4977 Ff�X EFFEC�rtvE �-i.zoio ��Cl. U ������'��
DATE ��- a'a � �� r YYOUR E-MAIL ADDRESS ��� l.l�' 1� Q�� � 1 F! �l �•�')
SITEADDRESS �0� ��� �N�+7 'N� i' 1���'�-1 IMN �5y � z
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: v� .� ��e. e
TENANT ADDRESS: � �� �4 '` V�'�%!� CITY i�� STATE�� ZIP �302
PHONE: b�a-��r�-y3�s
CONTRACTOR NAME: �?P
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYlNE�xJ C�?NSTRUCTION STORIES � QS�.,�.
PERMIT TYPE ❑ ADDITTON O GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION DDITTON
❑ MAINTENANCE(REPAIR ❑ REIv10DELING
DESCRIBE WORK BEING DONE:' �Sc+'r1�i 0'!►� CGIq G 1 QM �� re �i °iu
V
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING p HOUSE ONLY BASEMENT REMODELWG SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Pian
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PRQPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDI7'IONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTiNG OPENINGS�,'es ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDQW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION � y t O�pNG�,THE 1997 U.B.0 FEE SCHOCCU ANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cat Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
S
$
$
$ .
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservatian Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridley Attach
THIS IS AN APPLICATION FpR 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 tu►derstand 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 a11 ork which requires review and approval of plans.
SIGNATURE OF APPLICANT �� �' c�-4�-> PRINT NAME E/G�1. Ut rC �•�/ GI�ATE
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