P - 45762Building BUILDING Permit No.:�lD�'C �d l�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CI�'Y OF FRIDLEY Date Rec'd: ' t� I
763-502-4977 FAX EFFECTIVE i-i-zoi i
DATE � �, ` � � YOUR E-MAIL ADDRESS G-� � �10 • �-#✓r �..
SITE ADDRESS � d U��� �� b
THIS APPLICANT IS: �OWNER OCONTRACTOR
PROPERTY WNER/ NAME: Ct� � (`j
TENAN ADDRESS: fGj a G � O � i� %V� CITY � t, STATE�P
PHONE: � I � - ��'% � d � �-'I �
CONTRACTOR NAtvtE: /
SUBMIT A COPY OF STATE LICENSE # ....-- --- -•- LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRES3: _ CITY STATE ZIP
INSURANCE PHON , FAX
PROPERTY TYPE SINGLE EW CONSTRUCTION SIZE
❑ O FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDI1'ION ❑ GARAGE/SHED ❑ WINDOWS �,
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK S1DING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCEIREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTA WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �� � HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACAED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FORNEW CONSTRUCTION INCWDINGDECKS,
� Vi�l [JSoffrt ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminnm ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project. .
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTTNG OPENINGS �Yes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTIIRE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED N[JMBER OF WINDOWS
ALL FEES ARE BASEll UN YALUATIUN,INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JO� VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surchazge
SAC Chazge
Curb Cut Escrow
Erosion Controi
Pazk Fee
Sewer Main Chazge
$ �,��
$
$ � -•—
$
$
$
$
$
$
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 �ngineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMI'P-NOT VALID UNTIL PROCESSED ..
I hereby apply for a building permit and I aclmowledge 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 Construcrion Codes; that I understand this is not a
permit but only an application for a rmit and work is not to stazt without a permit on sit ; that the work will be in accordance with the
roved lan in the case of a11 wo��i�h re��;' es review a roval of s. ��p
Si�'iriil�li p vc J�9�lJ�PpRINTNAMEp�/'r/.1 Kill.rS� DA1� �`� //
PLEASE NOTE: SEPARATE PEI;d(�ITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHAMCA�L WORK