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Building BUILDING Pernut No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'a:
763-502-4977 FAX Er�ECTTVE �-i-ao�z � � �''
DATE "1 "I ' �� YOUR E-MAIL ADDRESS � l,q i e 5 Cd � i� ckx.�c�o r 1 d m�.�,Q rYi
SITE ADDRESS � � � � I � �f' �"� 'J � �.
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ Np,ME: V�'�"�
TENANT �DRESS:�I cJ�C� hd`CJ ����5" QJ( CITY F�"1 � STATE��ZIP 55U 3a
PHONE: -� � 3= � Bc� � 9 a u
CONTRACTOR NAME: IiI�Q(��� (.,�,')(�rI
SUBMIT A COPY OF STATE LICENSE # `�I I LEAD CERT NUMBER %�}'7 - crjc�j 7��EXP: iD IG���I S
YOUR STATE LICENSE �1
AND CERTIFICATE OF ADDRESS: � O� I I CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
'�1�IAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 1(1 S
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Alwninum ❑ Trim REMOVED? O YES O NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of conshuction plans
WINDOWS 3. EnergyCalculations
IN EXISTING OPENINGS �P'es ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED MBER OF WINDOWS
ALL FEES ARE BASED ON VALUATI . INCLUDING THE COST OF LABOR AND MATERIALS:
I_� 1lML1] t�+/l7
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
$
$
$
$ ��.
$
$
$
$
$
$ � 1
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum or .50
$5.00 (State Licensed Residential Contractors)
$2365 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 pavable to: City of Fridlev 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 ermit 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 1 work� 'ch e r review and approval of pl ns. p C / r� 1 `�
SIGNATURE OF APPLICANT �(� PRINT NAME �n Q I` �.JnN�` DATE �'I ` i I'" I d`
APPROVALINSPECTORSIG TU \ % _