P - 42342Building BUILDING PermitNo.: ��1,'- /�(�
Inspections RESIDENTIAL APPLICATION Received By '-
763-572-3604 CITY OF FRIDLEY Date xec'ct: ��i �- �(j
763-502-4977 FAX EFFECTivE�-�-ZO�o
DATE � � ��!I D YOUR E-MAIL ADDRESS
SITE ADDRE3S '�' 1V.� �� D� M� �3 2
THtS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: ,E(L�
TENANT ADDRESS: rj L�'O �' ST ►`�E CITY STATE�ZIP ���j,
PHONE: 7 (o ,3 — S �.Z � •a%-D / g
CONTRACTOR NAME.
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE SINGLE FAMILY N SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O ADDITION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINISH �ROOF ❑ DRAIN TILE
� DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ODrEW HOME CONSTRUCTION ❑ ADDITION
QIMAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DQNE: � G AAI""' Slt.t. tS G���. O�/�- 6� SO (A�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING �HOUSE ONLY BASEMENT REMODELING SUBMtT:
NUMBER OF SQUARES �_ ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED ARAGE 3. List of structural members to be used
PROPOSED HEIGHT: �\\\� i
SIDING � � �� � FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit � j' � ADDITIONS. & PORCHES SUBMIT:
� Aluminum ❑ Trim 1 . 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
'1 _ , {� � �.4 C � � � � 2. Two sets of construction plans
W IN D O W S `- � E� w� 3. E n e r g y C a l c u l a t i o n s
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WIND O W S - P R O V I D E U- VA L U E A N D
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUA'1'1(�iv, 1NCLUll11VG lHN; C:VJ1 Ur LAIfUK APIL IV1AlL� 1(lAL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$
$ �x'
$ (�
$
$
$
$
$
$
$ . C3.
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)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridley Attach
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 work w ic re a' •es review and approval of plans. 1 LD �
SIGNATURE OF APPLICANT PRINT NAME DATE T
APPROVAL INSPECTOR SIGNATURE —