P - 42147Building BUILDING Permit No.' � ��G
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 CITY OF FRIDLEY Da��'c ���.�
763-502-4977 FAX EFFECT►vE �-i-ZO>> ��V I
DATE I V'-� - I i YOUR E-MAIL ADDRESS 1(' � C`C �"u bY� Ckti e� io1����` 2�rC . ` O�
SITE ADDRESS % oZ7 �� � l-.7�i /l'� (_} (j�L � (i (Z �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
COI�TTRA.CTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
I AND CERTIFICATE OF
' INSURANCE
PROPERTY
PERMIT 'TYPE
TYPE OF WORK:
❑ OWNER
• .!►l�• �I�A
�
ADDRESS: C� %�/ t, � 1� W� Uv � � v� CITY F� i� L. � Ii STATE�IP
PHONE: ''� Fi3 J 2 l�/ �- S-.� �7 S
NAME:� �L� C K YV l� I1. ��Jl 1 L i� � �Z/l.I C�
STATE LICENSE # 3 7 Y O LEAD CERT NUMBER �/�}'T - IC� �6 S� -�
ADDRES3: _� 7,� C� N W Y G S�V f= #/ O�_CiTY Fl�C f►� (., ��/ STATE /�I�P ,S`S� Z
PHONE _%63- �% �J - 9�% � FAX 7 6 3— S"7 3 � �
O SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF O DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMTNG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITfON
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: r� `�O � sjr'
ROOFi1�iG
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF G
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & POR�HES SUBMIT:
1. Site Piar✓Survey showing the existing sWctures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
Q
$
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)
$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 payable to: Citv of Fridley
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 w9�k w� h requires r�v� and approval of pl ns.
SIGNATURE OF APPLICANT �i,7�'�-" i T"� � PRINT NAME �I CIC ��Z I C IC%V��CDATE__Ii3� 7'-"'��
APPROVAL INSPECTOR S[GNATURE