P - 39838Building
Inspections ,
763-572-3604
DATE i!_i"�''—'
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
BUILDING
Permit No.:
�
�
RESIDENTIAL APPLICATION Received By: 1Y ����'
CITY OF FRIDLEY Da��'�Oiv 1 O` 20°IO
YOUR E-MAIL �DRESS �CtX i� rt'� � n►1�Sv-I-a, r U, s � v� c v m
. . _ ._ � __ , _
❑ OWNER
ADDRESS: � " '�� CITY
SUBMIT A COPY OF STATE LICENSE # o� I%3 ! EXP DATE �I�l O l
YOUR STATE LICENSE ADDRESS: S S�B ��.��� -L�`-L- CiTY �
WITH APPLICATION Pxo� 95z • 935 ��(�teq �,e,X �52 • 9,�5' �j5'1f�/
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION � GARAGE/SE
Cl BASEMENT FINISH O ROGF
❑ DECK CI SIDING
O SWIMMING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
NUMBER OF SQUARES ,_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
❑ Aluminum
0 Other
WINDOWS
IN EXISTING OPENINGS Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & (
TYP�' (1F WfhTTXIW Tn RF iNCTAT.l.F17 S 1
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
SIZE
STORIES
D TNDOWS
❑ i?RAII�7 T?LE
❑ OTHER
�OL
1
li()I 11��%US �n .11.(!,1 s�11�
�
WIDTH HEIGHT
LOCATIQ,` F WINDOWS
f �"
��S NUMBBR OF WINDOWS !U
I:1
A� �p�s3�3
BASEMENT REMODELING SUBMIT:
1. Existing F1oor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
FOR I�IEW CONSTRUCTIQN INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project
2. Two sets of construction plans
3. Energy Calculations
- -.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $/5rL00 • aD OCCUPANCY TYPE
Penr.:t Fee $ �(p5 •o�.S See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ /$ o{ J� .001 times the total job valuation
Surcharge $ "] •(vp .0005 x Permit Valuation Minimum $.50
License Surcharge $ �•v0 $5.00 (State Licensed Residential Contractors)
SAC Chazge $ $1550 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$21 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ ,�q 3•O Make checks payable to: City of FridleY Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
lations
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 p rmit and work is not to start without a permit; that the work will be in accordance with the approved
plan in the case of all work which r ires rfvi nd r val of plans. •
SIGNATURE OF APPLICANT I PRINT NAME W� � (/ DATE �� � �