P - 41740Ir�iections
763-572-3604
763-502-4977 FAX
DATE �U -- .j �
SITE ADDRESS / � %
BUILDING
RE SIDENTIAL APPLICATION
CITY OF FRIDLEY
VE I-1-20] 1
Pe��t
Received By:(�,r' i� k`
��'�e�� �' � � � C� � 1
YOUR E-MAIL ADDRESS �Q S'�.l ��s�?�O�"�`JhA/ • CO�
V
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: S"e�n, j'►�1� ��..�--
TENANT . r�_�,,.. i � "� L� ._l _ .
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PHONE: �6 c� � S%�"- 10 Z�
NAME: Sttt�GT" ��FietS' �,,,L-
f" y` tGlls,�_ ___STATEAIII>ZIP.
STATE LICENSE # 2O6 �$ S'�'f � LEAD CERT NUMBER
aD��ss:l362.5 Oc,r�en� S-�'r�'� /✓� ciTY�4in... sTaT�i�✓ziP SS
PHONE /63—
FAX /6S �-
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUC7TON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES /
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED _ ❑ WINDdWS
❑ BASEMENT FINISH �TZOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCEJREPAIR � REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPKOVEMENT
ROOFING
NUMBER OF SQUARES Z S
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
5IDING
❑ Vinyl
❑ Aluminum
❑ Other
LENGTH
❑ HOUSE ONLY
':�JiOUSE & GARAGE
Y�ATTACHED GARAGE
Q DETACHED GARAGE
WIDTH HEIGHT
FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor P!an
2. Proposed floor plan
3. List of structucal members to be used
FOR NEW COiYSTRUCTION INCLUDING DECKS,
OSoffit ADDI1"[ONS_ & PORCHES SUBMIT:
❑ Trim 1. Site Pian/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction ptans
I WINDOWS 3. Energy Calculations
IN EXISTING OPENTNGS OYes ONo LOCATION OF WINDOW3 FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENRVG CIIANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 2997 U.B.0 FEE SCHEDULE) �-
TOTAL JOB VALUATION $ %. D?TD.`� OCCUPANCY TYPE �►�v1I�T-��l
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Controi
Paxk Fee
Sewer Main Charge
Total Due
$ t� <� L,�'
$
$ _�,�_.
� ,�� > �
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times tha 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 Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLTCATION 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 perm� 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 quires review and approval of pla s.
SIGNATURE OF APPLICANT PRINT NAME� r,_('� Sy C'.r'�arS' DATE ��' `� �.DI�
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK