P - 46253Building
Inspections
763-572-3604
763-502-497� FAX
BUILDING
RESIDENTIAL APPLICATIUN
CITY 4F FRIDLEY
Permit No.� �, �����
Received By:
Dat�iFi►e�7d��N 2��1
DATE �' oZ o�i ' i� YOUR E-MAIL ADDRESS vYtl� � '• n-��
SITE ADD�SS S'� y9 - 7 S� iv�' Fr� �/.•�y�t ��, s-s�32
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY QWNER/
TENANT
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
ADDRESS;_,S8'y9 — %�S� /�� CITY/��l•Cl.� STATEf�f,�/ZIP .�•i .3
PHONE: 6S/ " i %L — .? %%�
G
STATE LICENSE # d G 6 3c S�'f LEAD CERT NUMBER N/4T- G�J�g�/
ADDRESS: ta�b b'�0 1ll li'trts !3�/1 NE CITY �.Iew�,�e� STA`TE/�iW ZIP s.�0�
� Y7 Y �
�i9 SINGLE FAMILYINEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTIOI3
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH �ROOF
O DECK ❑ SIDING
SIZE
TYPE OF WORK: C7 NEW HOME CONSTRUCTION ❑ ADDITION
�9 MAINTENANCE/REPAIR O REMODELING
DESCRIBE WQRK BEING
SIZE OF IMPROVEMENT
ROOFING �/
NUMBER OF SQUARES � T
�ARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
,�HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ D�TACHED GARAGE
ClSoffit
❑ Trim
O Fascia
WINDOWS
IN EXISTING OP$NING5 DYes ONo LOCATION OF WINDOW3
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE CUST OF
,t�` (LTSING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION S�. d 00 "'_ _ i OCCUP,
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
❑ DRAIAI TILE
❑ OTf�R
HEIGHT
�ASEMEI�iT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor pian
3, bist of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
�DITIOI3S_ 8� PORCHES SUBMIT:
1. Site PIan/Sutvey showing tbe existing strnctntes
and pcnposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
AND MATERIALS:
$ 5ee Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ '�'j .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)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ � „„ „ / Agreement necessary { ) Non Necessary ( }
$ . Make checks aavable to: City of Fridley Attac
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 Cocles; 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 all •�� ich r air '�'ew and approval ofplans. �ml.,��-
SIGNATURE OF APPLICANT / _PRINT NAME T9 (U � DATE L'�.Zx"lf
APPROVAL INSPECTOR SIGNA