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Building BUILDING Permit Ivo.: �� /� � � �
Inspections RESIDENTIAL APPLICATION �►i'�ed �:. `J
763-572-3604 CITY OF FRIDLEY ���' "� �"
763-502-4977 FAX a e ec'd:
EFFECTIVE 1-1-201]
DATE�F'� i
��. �� � YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER f�CONTRACTOR
PROPERTY OWNER/ NAME: ',�, ' ! �...`�
TENANT ADDRESS; t,� i� L.. �S� �, CITY �r�^t��Y STATE�ZIPT��
PHONE: d � c� '
CONTRACTOR NAME: �1A ��t�l e.�,��� AIG �
SUBMIT A COPY OF STATE LICENSE # i BER
YOUR STATE LICENSE M��
AND CERTIFICATE OF ADDRESS: i J��.Z� CITY STATE ZIP
INSURANCE pHONE
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY(NEW CONSTRUCTIOrI STORIES
PERMIT TYPE C7 ADDITION ❑ GARAGE/SHED ❑ WINDOWS
Q BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
C�[,MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK B�ING DONE: � G Q. G�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING � HOUSE ONLY
� BASEMENT REMODEL[NG SUBMIT:
NUMBER OF SQUARES � �OUSE & GARAGE
l. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
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-DESCItIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOW5
ALL N'��;5 AK�; BA��li UN VALUA fIUN, INCLUUIIVG '1'Hk: COST UN' LABUR AND MATERIALS:
,., (USING THE 1997 U.B.0 FEE SCHEDULE)
" TOTAL JOB VALUATION
Per►nit Fee
Plan Review
Fire Surcharge
Surcharge .
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
���w
i t�
����
ANCY
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)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERM[T-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 of 1 rk whic requires review and approval of ns.
SIGNATURE OF APPLICANT , � �(T� PRINT NAME ra�Jdb �� racu �1 DATE
APPROVAL INSPECTOR SIGNATURE