P - 48187Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY 4F FRIDLEY
763-502-4977 FAX .,.,...,.,�....... . _�
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Permit No.: -
Received By:
Date Rec'd: � �'" < <
DATE ( ?J' �L-
c;���-�� YOUR E-MAIL ADDRES3
SITE ADDRESS �`'i,�� _ / ' - �-• / V ,Ci�
THIS APPLICANT IS: ❑ OWNER '�ONTRACTOR
PROPERTY OWNEIi/, . NA1�tE: INIit: � ,Q (�
TENANT nDDx�ss: S�ZI '�f'� Sf •/LI �. ct't'�t I ' ST.41`EYM%�I1�S
PHONEi��O� �IqZ ����� �
CONTRACTOR N,�: L �??� . _ _
SUBMIT A COPY OF STATE LICENSE �
YOUR STATE LICENSE EXP DATE � I/ Z. —�,,���
AND CERTIFICATE OF ADI]rRESS:�D'..'`l I� ilA1 ��- ��-V`Z» S• CI I STATE� ZIP�3'I�p
INSURANCE PHONE - ��i %• /3' �;q�
PROPERTY TYPE �SINGLB FAM[LY/NEW CONSTRUCI'ION ' SiZE
❑ TWO FAMILY/NEW CONSTRUCfION 5'JY)gIES
PERMTT TY�E o nDnr[zorr ❑ c3n�,G�sx�n , a wnvaows
❑ BASE��IVT FINiISH ❑ ROQF O DRAIN TILE
❑ DECK . _ O SIDING ❑ OTF{gg
� SWIMMING POOiL`
TYPE OF WORK: ❑ xEw xo� coxs�vcz�oN [7 nnarriox
— _ ' l�IAINTENANCE/REPAIR; ❑ REMODELING ' '
DESCRIBE WORK BIING DONE: I �/�/1 *Q� l S K �
SIZE OF IMPROVEMENT LENGTH WIDTFI ` HEIGHT _ Ff
$OOFING ❑ HOUSE aNLY �A$,F,.11� �-►�ODBL-I!d c M1T`
NUMBER OF SQUARES d HOUSE & GARAGE M T
1. Existing F�oor Plan
�:. .;. .- ,, ,. � ATTACHED GARAGE 2. Proposed tla� plan
PROPOSED S1zE: O II�TACI-IED GARAGE . 3. List of stn�ciural members to be used ;
PROPOSED HEIGHT: ` '
�IDING FOR NEW COAfSTRUCTION 1NEI:UDWG DECKS,
❑ VinY� ' (]Sot�t A�DI N3 de PORS'H�S ctTRMiT•
❑ Aluminum ❑ Trim t. :, Site PIanJSurvoy s6orsing the existing structwes
O Other ❑ Fascia .� p���d ProJ�
` . ; .: 2. Two 9ets of con�tuction plans '
WIlYDOWS ���/
IN EXISIING OPEMNGS I�'es ONo LOCATION OF W WS 3• �BY Celculatioas
dR FOR NEW OPENINGS-DESCRIBE SIZE OF ' i�i V i r1p-� ` ` '
OPENING CHANGES &
TYPE OF WINDOW TO BE WSTALLED NUMEER OE' WINDOWS :
ALL FEES ARE BASED ON VALUATION INCLUDING THE COST OF L.A$OR AND MATERIAI.�•
'OTAL d0B VALU�
Permit Fee
Plan Re°view
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
+
��,(U,S��NG THE 1997 U.B.0 FEE SCHEDULE)
�� (J OCCllPANCY TYPE
$ `1. See Back Page for Fee Schedule
$ 65%of Buitdin�g Pernut Fee
$ . . .001 timcs the totsl job valuation
$ � �7 .00QS x Permit Valuation Munimum $.50
$ 55.00 (State Licensed Residential Contractors)
$ �2000 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=5
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ .� Make e6ecks pAyabk to: Citv of Fridlev Atmc
TEIIS IS AN APPLICATION FOR A PERMIT-NOT VAI,ID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; thgt the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I undersfand this is not a
permit but only an application for a pe 't and work is not to start without a permit on site; that the work wili be in accordance with the
spproved plan in the case ork w' requires review and appmval of plans. ,
SIGNATURE OF APPLICANT PRINT NAhf1�,���LYiI,/ 1 cJG{'!/l� _DATE �
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