P - 39336Building
Inspections
763-572-3604
763-502-4977 FAX
DATE —� � (�.S °—
SITE ADDRESS _�
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
CITY OF FRIDLEY
EFFECTIVE 1-1-201 I
YOUR E-MA1L ADDRESS
PROPERTY OWNER/ NAME: � 'T - � � � �- �.-r s�
TENANT qDDRESS: ��4 � °- �,3;� N�"C D «�
PHONE: ��r�=��G�i
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
Permit No.:
Received By:
c��l
STA
STATE LICENSE #��J ��(=3�'L LEAD CERT NUMBER
ADDRESS: �{a ���lT�� �i(iG �� C1TY ���3'"tOrC-- STAT�IP�
.� � w v�
FAX ")f.•.�;—
INGLE FAMILYINEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
O ADDITION �❑��T ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FIN15H T$ROOF ❑ DRAIN TILE
❑ DECK �❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE:''���c� Z; �� �"- � C�„�Si.,sir
SIZE OF IMPROVEMENT LENGTH WIDTH HEiGHT SQ FT
ROOFING
NUMBER OF SQUARES I� _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Afuminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SiZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. Lis[ of structurai members to be used
FOR NEW CONSTRUCTION MCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
{. Site P1an/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE lJ-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)
COTAL JOB VALUATION $ L�,.;St7 �%' ��'G' OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Pee
Sewer Main Charge
Total Due
$ `� �-
$
$
$ �� .
$
$
$
$
$
$
� •�
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 (P(ans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks oavable to: Citv of Frid{ev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buiiding permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordin s an des of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applic ion r pe ' an ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case f all w r w h res review and approval of lans. �` , �� (
SIGNATURE OF APPLICAN NT NAME��t p�V �(�� � S�#)ATE �— � 3"I I
APPROVAL INSPECTOR SIG TU