P - 84357Building BUILDING Permit No.p�b�� I
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rp� � '' �
763-502-4977 FAX EFFECTTVE i-i-zoiz "L�
DATE I=�'' 3�" i� ^� �OUR E-MAIL ADDRESS
SITE ADDRESS C_sLI I � � � �� � \C
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME:��e �l � ��-�^ �a`-J"
TENANT ADDRESS: C��-/ �G.� G 2�� �� CITY '' �� � STATE /� ZIP S
PHONE:� r�' S��" �ic( a'�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE S�rrGr.E FAIvt11,Y S1zE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDI1'ION
�H'fi�AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: N�-' � ��'�
SIZE OF IMPROVEMENT� �� �� � LENGTH WIDTH HEIGHT SQ FT q��
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �_ ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: �� ❑ DETACHED GARy1GE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDIT'IONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO �• Site Plan/Survey showing the existing structures
❑ Other � Fascia and proposed project.
2. Two setsof construction plans
WINDOWS 3. Energy Calculations
IN EXISITNG OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N1�:N:S ARE BASN:ll UN VALUA'1'IUN, 1NCLUll1NG'1'HL CUSl UN' LAl3UK AIVll MAlr:K1AL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee �
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
ANCY TYPE
$ �� ,S� Q See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 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 payable to: City of Fridley 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 4�f all work w �c� qui�r�es review and approval of pl �ns._„
SIGNATUREOFAPPLICANT'1•�^^'�- G�� "---' PRINTNAME 1�1�'t.l ��G..�S->— DATE �1�'��' �o�
ADDD/IVAi 1AICDR!`Tl1T? Cil1MATfiAF
12