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Building BUILDING Yermit No.:
Inspections RESIDENTIAL APPLICATION xeceived By:
763-572-3604 CITY OF FRIDLEY Date Rec'd: !�I
763-502-4977 FAX EFFECT►vE �-�-2ou
DATE � I� /� � YOIYR E-MAIL DDRESS �(�c (V/� S GL I����-"I /Ki ��--CJ" !
SITEADDRESS 3 �--v�an -��5�
THIS APPLICANT [S: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NnNtE: �,/ �y�
TENANT ADDRESS: � G�'fW1 �5 5 CITY r�K eG1 STAT�/1 ZIP�7'['3!Z
PHONE: f
CONTRACTOR NAME:�t10. R.c�oE+� G "R.+e.w�oc�.�t.\ir�a
SUBMIT A COPY OF STATE LICENSE # �O� LEAD CERT NUMBER NpT- a5o3y � I
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: 4:00 ���"jjpf' (3�� CITYg}.�Ota.is �,vw STATEMt'� ZIP5gV1fi1
INSURANCE pyONE 95z-915•i?a FAX CLa� - aa� -
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORfES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED �I WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDIT[ONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit
❑ Aluminum � Trim 1• Site PlanlSurvey showing the existing structwes
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS � 3. Energy Calculations
• IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS FOR WIND(iWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING ChIANGES & ,¢�gjd`
TYPE OF WINDOW TO BE IN� ALLED NUMBER OF W[NDOWS
ALL FEES ARE BAS�;U Ulv VALUA'l lUlv, 11VCLUUIIV(i ft1E I,VJI Vr LAtfVK A1VU 1V1A11�,KlALJ:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� °O OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ � 4 .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ •• $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ p . Make checks payable to: Cityo uf Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 a ork which re i e� re��w and approval of pl s. '
SIGNATURE OF APPLICANT ������C:liO�"' PRINT NAME �nC �I�CI� DATE �b I G I��
APPROVAL INSPECTOR SIGNA RE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
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