P - 45503Building BUILDING Permit No.: Z���"� (�Z�
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY Date Rec'd: r! I I'� �
EFFECTIVE 1-1-201 I
DATE .Tv-/ry �/ ��rj YOUR E-MAIL ADDFtESS Sc•cr�t`c��,�,rr� ,,T ��,,�,r
��' a
SITEADDRESS jy�— ��:.�i�,i�.,iy� f�t� i'— ts ;_,// �yJ�,� ..3�—.f/�t�
THIS APPLICANT IS: p10WNER ❑CONTRACTOR
PROPERTY OWNER! NAME: . �%,p�� /� i'�„r��,,s ,4
TEIVANT �DRESS: -�G— i�i,Fs�w ��/.�`� CITY_ c+/�f/ STAT
� /��ic.' _ F/�_sLfLIP �,�„S"'.l—�
PHONE: �G ,3— 3`"CJe?—/ ���
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME:
STATE LICENSE # LEAD CERT NUMB
ADDRESS: CITY_
PHONE
FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYlNEW CONSTRUCTION STORIES G1�Y:/
❑ ADDITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FINISH I�'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCT[ON � ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
ATE ZIP
': DESCRIBE WORK BEING DONE:1�GaG � JJ�i�f L�G fC'f��„!Ct'i �'�r� ���r �'���,� /}�"�
� SIZE OF [MPROVEMENT LENGTH WIDTH _ _ HEIGHT SQ FT
ROOFING
NUMBER OF SQUARES�?'�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPEi3INGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
�'"HOl1SE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
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
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �3•ZS
$
$
$
$
$
$
$
$
$
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 oavable 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 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 work whic re uires r view and approval of plans. ,�
SIGNATURE OF APPLICAN— �� � 9 PRINT NAMF,�/,Q�`�/���C DATE %�/����
APPROVAL INSPECTOR SIC:NATURE