P - 62715I�
Building BUILDING Permit No.�1�1�'� �4� �� �
Inspections RESIDENTIAL APPLICATION Received B•.
763-572-3604 CITY OF FRIDLEY Date��c�ct��� .:
763-502-4977 FAX EFFECTTVE i-i-2o�2
DATE -� �� Z YOUR E-MAIL ADDRESS
SITE ADDRESS .S�! Z � � u� r Z� n ��- vyE
THIS APPLICANT IS: cfY6WNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: N 1 ,.�� � r� ` � �
TENANT ADDRESS: .SZ 2 S a.- � CITY /-r� STATE �NZIP ,��r`��
PHONE:/ ,� I� L 3/ •- Z S�/ L
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 ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ 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 ❑ ADDITION
❑ MAINTENANCE/REP ❑ REMODELING
DESCRIBE WORK BEING DONE: `� r
SIZE OF IMPROVEMENT LENGTH i WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NLTMBER OF SQUARES ❑ HOUSE & GARAGE �. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARQGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Viny1 ❑Soffit SIDING/SOFFITIFASCIA 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING 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 FEES ARE BASED ON VALUA'1'lUlv, 1NC:LUll11VCT lH� C,V�i Vr LAnvtc aivL iv�A���c�HL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$ � �U "
$
$
$
m ^7 . �f-�� .-
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 deternlination)
=�_ftx$2s=$ �?�J
$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 applic 'qn 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 th se of 11 wo whic �equi�res/�' iew and approval of plans. / J /
SIGNANRE OF AP ICANT/���t,•�i �L„�, ��4i-+r-^-4� PRINT NAME �.7� �Y � I� I-1 i, �:r>,;a.� DATE J!%�/ / 2— -