P - 35462Building
Inspections
763-572-3604
DATE � � 1� �'J
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
sr� ,a�DxESS -i to'll Cawt �`l�ai- �-� il'�I F
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ Nq�: (i i�� Z�j � �5�4:
TENANT .��____
CONTRACTOR
SUBMIT A COPY QF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT
�7Co
or
Permit No � ,�j ����
Received By:
Dat� �' :� � �
STATE Z[P,
STATE LICEN3E #_���}y Q b1 Z„ EXP DATE _ O'3 � 1 Z
ADDRESS: 4'l0� �j L1oq N CITYf►Q�y�op.Q STATF.M'�NLIP �S4ZFS
AH�NE I'f (_�15��1—?�SU c...lnr_�\ Cx_l � �nelif
" O BAS�MENT FW1SH ❑ ROOF �
❑ DECK ❑ SI171NG
❑ SWIMMING P
TYPE OF WORK' ��E�✓ 0 ADDITIQN
O MA[NTENANCE/REPAfR 1� REM(�nR1.TN(
DESCRIBE WORK BEING D T
SIZE OF IMPROV�MENT
ROOFIIVG
NUMBER OF SQUARES „�
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
SIDIIVG
❑ Vinyi
❑ Aluminum '
❑ Other .
O HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
DSoffit
❑ Trim
O Fascia
CTDRAIN TILE
� OTHER
OOL
;
j "��'""�'� --
�L/t.�/`� l.
WID1'H HEIGHT
BASEMENT FMnnFilTJf; STIRMIT•
1. Existing F(oor Plan
2. Proposed floor plan
3. List of strucwral members to be used
Ft.
FOR NEW CONSTRUCTION MCLUDMG DEGKS,
Ai)DITIONS & POR HFS SU$A"'T•
i• Site Plan/Survey showing the existing swctures
and proposed project.
WINDOWS 7. Two sets of construction plans
IN EXISTING OPENINGS �Yes ONo IACATION OF WLNDOWS 3. Energy Galculations
OR FOR NEW OPENINGS- ESCRIBE SIZE OF {�ee�nn�. . L4w,c(r� � S hd d IG � k e., �� �y
OPEN!]dG CHANGES & �— � u{� �s.p �• ; e� I�e.c�fe�—'� ` �d
TYPE OF WINDOW TO BE INSTALLED - Z-1-�i{ u.Se NUMgER OF�WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(IJSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JUB VALUATION $ �� {`7 OCCUPANCY TYPE
Permit Fee
--_ _ _
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totai Due
� "t ` 1��t �j See Back �age for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
� .4005 x P�rmit Valuation Minimum $.50
_ $ � $5.00 (State Licensed Residential Contractors)
$ $1675 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21 =$
$ $450 Conservation Plan Review
� Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( }
$ ��ti�,�J � Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID (1NTIL 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 a perm' and work is not to start without a permit; that the work will be in accordance with the approved
plan in the case of all work wh' requir eview and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME Cv'� � G"� DATE � C � ��