P - 39998.
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E� .ilding BUILDING pe�it Ivo.:'�� �
It�spections j�SIDENTIAL APPLICATION xe�ei�ed By:r�`'i '
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX ����� �
EFFECTIVE 1-1-20] ]
UATE GT ,S °/� YOUR E-MAIL ADDRESS
S1TE ADDRESS � ��.=1 % IZ� 1. %� �� pC
THIS APPLICANT IS: 0 OWNER ONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDIZESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME:_ i ` �Pi7')'7' , f • �
SUBMIT A COPY OF STATE LICENSE # � LEAD CERT NUMBE " �
YOUR STATE LICENSE — � -
AND CERTIFICATE OF ADDKESS: I C CITY/d('i9t�0 ��S' STATE�ZIP SD�'�
INSURANCE PHONE � �' �� �� � FAX
PROPERTY TYPE INGLE FAMILY/NEW CONS'TRUCTIOi�i SIZE
TWO FAMILYlNEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK O SIDING O OTHER
❑ SWIMMING POOL
. T'YPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
AINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: � ' �„jL ')G' � �
�IZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING O HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor pian
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT
❑ Vinyl OSoffit I, Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3 Energy Catculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR �OR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE 1NSTALLED NUMBER OF WINDOWS
ALL r'i;r;S AKL BA,Ell VN VALUA'1'lUN,1NCLUll1NG '1'HE CUS'1' OF LABOR AND MATERIALS:
` / (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB YALUATION $�.l(n �U - G�� OCCUPA�NCY TYPE
Permit Fee
Plan Review
Fire Surcharge
�urcharge
License Surcharge
SAC Charge
�urb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ���, v� �_ 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)
$ �+bft= ftx$24=$
$ � $450 Conservation Plan Revie�w
$ � Fee Determined by Engineering
$ greement necessary ( ) Non Necessary ( )
$ �. , i � ake checks pavable to: Citv of Fridlev Attach
I hereby apply for a building permit and 1 acknow
conformance with the ordinances and co� of the Ci
psrmit but only an application far a perm�t�u�d w
approved plan in the case of all ork whic re u' es
SIGNATURE OF APPLICANT �
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE P ARI
A3Q FOR A PERMIT-NOT VALID UNT1L PROCESSED
e that the infarmation above is complete and accurate; that the work will be in
f Fridley and with the Minnesota Construction Codes; that I understand this is not a
not to start without a permit �n site; that the work will be in accordance with the
w and approval of plans n,
�PRINTNAME�r/S C.�il%�`� DATE d` �l��S� %�
;QUIRED FORPLUMBING, ELECTRICAL AND MECHANICAL WORK