P - 35594� �
Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE �-�-2oii
DATE;1 �9 I �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/ I x
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
' 1_._�J� �1'
TYPE OF WORK:
DESCRIBE WORK BEING
C7 / �
� OWNER �CONTRACTOR
C�lI��LI�L��C
STATE LICENSE #
0
PHONE 7� e!^ 7 Y 7-// a( I
� SINGLE FAMILY/NEW CONSTRUC'170N
❑ TWO FANIILY/NEW CONSTRUCIION
CITY
rr�n �, or -
SIZE
STORIES
❑ BASEMENT FINISH � ROOF O DRAIN TII.E
❑ DECK ❑ SIDING ❑ OTI-IER
O SWA�II�IIIVG POOL
0 NEW HOME CONSTRUCTION ❑ ADDTI'ION
0 MAIlV'TENANCFJREPAIR ❑ REMODELING
c. .o .. /7 /9
ROOFING /
NiJMBER OF SQUARES ��%
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
0 Aluminum
❑ Other
wn+mows
IN fiXISTING OPENINGS OYes ONo
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF
OPENING CHANGES 8c
0 HOUSE ONLY
❑ HOUSE 8c GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
Permit No: � ` �' -l� � �
Received By:
Date Rec'd: ,2 ~
1�1 �tJ e C t� n-�
STATE / ll/V ZIP�
�/�A1'F ZIP,
,- �l S 7
BASEMENT REMODII.ING SUBMIT:
1. Existing Floor Plan
2. Proposed 800r plan
3. List of structural membcrs to be usad
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDIITONS_ dt PORCHES SUBMIT:
l. Site Plm�/Survey showing the existing struchues
a� �OPosed Prole�.
2. Two sets of conshuction plans
3. �y cc���ri«�
FOR WIIVDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOVI/.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $ OCCUPANCY TYPE
Permnit Fee $ i� ` See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit F�
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Pennit Valuation Minimum 55.00
License S�rcharge $ $5.00 (State Licensed Resideirtiat Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ � MAke checks uavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and es of the City of �ridley and with the Minnesota Construction Codes; ffiat I understand tlus is not a
permit but only an application for a permi d work ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case all 'c uires 'ew and appmval of pl / /� p
SIGNATURE OF APPLICANT P�INT NAME �(Jdl/ �TAI ��SO N DATE -�-a D- a� ���