P - 46724Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:2 b� �7% ?
Received By: % " ' "'
Date�:�� �7 � � �
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THIS APPLICANT IS: ❑ OWNER °�CONTRACTOR
PROPERTY OWNER/ NqME: �eD-}.j-� a(- � u� VL Y� e C h i h
TEN� nnn�ss: I(o `� �IC I� I S`� h C T crrx.
rxor�:� 1 a-`7 � q-�=a 3
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE LICEN3E
AND CERTTFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DI
3IZE OF IINPROVEMII�iT
STATE LICENSE #
PHONE �DSC-6�b�27,��
SINGLE FAMII..Y/NEW CONSTRUCT[ON
❑ TWO FAMII.Y/NEW CONSTRUCI'ION
❑ BASEMINT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ xEw xoME coxs�uc�riox
O MAINTENANCF/REPAIIt
LENGTH
�c c�v► �" �n�T xvN,a�x N !4 i - � I 3c.{ �v �-I
i Su/'�f. �0 CTfY�,�b�� i1 �� STATF�ZIP�7
%1� F� 6's� -3os � �y/S(
s�
STORIES
HED WS
❑ DRA1N TII.E
0 OTfiER
iPOOL
ADD[T[ON
�2EMODELIN(3
:v.S - .P X !,S `�/�v��� �-�,,f
wIDTH HEIGHT SQ FT ___—
R�G CJ HOUSE ONLY g� �T gFMODEi_�INfi SLI��
NUMBER OF SQUARES ❑ HOUSE 8c GARAGE 1 Existing Flo� �n
❑ ATTACH&D GARAGE 2- Pmposed 9oot p�n
PRO�POS�ID SIZE: ❑ DETACf�D GARAGE 3. List af shucbual me�s to be used
PROPOSED HEIGHT:
' FOR NEW CONSTRUCTIQN INCLUDING DECKS,
p�� OSoffit ADb11'IONS_ & PORCHES SUBMlT:
1. Site Plan/Sutvey showin� th6 eluffiiug strucuara
❑ Aluminum ❑ Trim � � ��
❑ Other ❑ Fascia 2. Two s�s of oan�oa plao§
�NDOVYS 3. Eaugy Calailations
IN EX[STII1G OPENINGS �es ONo LOCA ON OF WINDO OJ I�,�,, I�R WINDOWS - PROVIDE U-VALUE ANfl �� ��.13
OR FOR NEW OPENIN(iS-DESCRIBE SIZE OF Yi�Ir qp) OQ CK �Tp� nAairv- �� �� MANUFACIIJRE STICKER ON WINDOW. ��p��
O P E N I N G C H A N G F S d t r�� r i N f( C ��° V/ D I� O � C� G W i c�►�' /� e- -.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �/
ALL FEES ARE BASED ON VALUATION, INCLUDING THE GOST OF LABOR AND MATERiALS:
(USING TH� 1997 U.B.0 FEE SCHEDULE)
f'(Yl'Ai. JnR VAi.ilATinN S'r�� t�'il r7. 00 �CUPANCY _ TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
C�rb Gut Escrow
Erasion Control
Park Fee
$ewer Main Charge
Total Due
$ � a 3 s� 5 See Back Page for Fce Schedule
$ 65% of Building Permit Fee
$ .001 tim�s the total job valuarion
$ .0005 x Pernut Valuation Mitrimum $5.00
$ $5.00 (State Licensed Residernial Coniractors)
$ $2230 per SAC Unit (Pians to MWCC for determination)
$ ft+6ft= ftx$24-$
$ $450 Fonservation Plan Review
$ Fee Det�ned by Engineering
$ Agreetpent necessary ( ) Non Necessaiy ( )
P n� Make �hecks uavsble to: Citv of Fridley Attsc
THIS I3 AN APPLICATION FOR A PERNIIT NOT VALID UNTIL PROCESSED
I hereby apply for a building permi and I acknowledge diat the informarion above is complete and accurate; ffiat the work will be in
conformance with the ordinances ffid es of 'ty of Fridley,and with the Minnesota Construction Codes; that I,understa�nd xhis is not a
p�nnit but only an application for a d w is not to start without a permit on site; that the work will be in accardaace with the
approved plan in the case of all e t � ic „[ ' 'ew and approval of pl �p ��
SIGNATURE OF APPLICANT ' ,�_PRINT NAME �RlS/�/S��C �• (,D�+( DATE ���I"
��3�} � c�2Y 3� 7 qr YYo7 ,�I�
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