P - 44549Building
�:Inspections
�763-572=3604
�ArE G � ��
SITE ADDRESS �
�'IiIS APPLICANT (S:
BUI�DING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
�� SUn
❑ OWNER
YOUR E-MAIL ADDRESS
�CONTRACTOR
Permit No.:
Received By: ���L�
D�$���� 2 5 201�
:PROPERTYOWNER/ N,�; rvt��r��� Cd�[[Vt�
TENANT ,r,�DRESS: � CtTY STATE ZIP
. PHONE: �9 L Z., Z-?i �— � � Z-�D —
i� SUBMIT A COPY OF
=YOUR STATE LICENSE
.�' WITH APPLICATION
PROPERTY TYPE
���
STATE LICENSE #__ZQt�yQb1Z. EXP DATE _ Q3 �1'2�
ADDRESS: �'IOIi '4ScvV�( 11eA N CITY N��$ STAT�M�L(P„�'�$yZS
wu�r.rv /-.[_Z��?U—?/1tt1 r,.,l�r _�f\ �-fcl.. �n�t�J
❑ $AS�MENT FINISH
� O DfiCK
�
�� TYPE OF WORK: � ��'►'
❑ MAtN'1'ENANCE/REP�
G7ESCRIBE WORK BE1NG DONE:_�Z2�( Gt �
�IZE OF IMPROVEMENT
sQu,�,xFs
SIZE:
HEIGHT:
�IDW.S
� Vinyl
�Aluminum '
, Other .
L1
■
❑ HOUSE & GARAGE
0 ATTACHED GARAGE
O DETACHED GARAGE
DSoffic
❑ Trim
❑ Fascia
urLVw� '/
EiQSTING OPENINt35 [�lYes ONo LACATION OF WMDOWS
FOR NEW OPENINGS-DESCRIBE StZE OF PaPc( . Ba�in � Ltl R� ,%I�h,� ���
sN[NG CHANGFS & (
DRAIIJ TILE
OTHER
Ft.
BASEMENT R��IDELMG SL�3MIT: �
I . Existing Floor Plaa
2. Proposed floor plan
3. List of swcturai membas W be used
FOR NEW CONSTRUCTION MCLUDMG DECKS,
,4t�DIT10NS. dc �►NiRGHES SUB iT:
1. Siu Plan/Survey showing the pcisdng structures
aM! ptoposed project
2'. Two sus of consWcti� plans
3. Energy Galcutations
OF WIlr1DOW TQ $E MSTALLED D� Z�; ..�i.c ���MgER OF'WINDOWS ��_ �
ALL FEES ARE BASED ON VALUATION,_INCLUDINC THE COST O� LABOR AND MA
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S �Z C� OCCUPANCY TYPE
rennit Fee
�lan Review
�ire Surcharge
gevcharge
;icense Surcharge
;AC Chazge
'urb Cut Eserow
;rosion Control
'ark Fee
;ewer Main Charge
�.—�., _. , ..�, �...
$ )�� �� See Back I'age far Fee Schedule
$ ^ 65% of Building Permit Fee
$ �. .001 times the total job valuation
$ -_� .0005 x Fernnit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $1675 per SAC Unit (Plans to MWCC for determination}
$ ft+bft= ftx$21 =$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( }
_$ c����— Make checks payable to: City of Fridley Attach
�` THIS IS AN APPLICA�'lON FOR A PERMIT-NOT VALID UNTIL PROCESSED
`�hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
tinformance with the ordinances and codes of the Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is not a
ermit but only an application a per ' and work is not to start without a permit; that the work will be in accordance with the approved
ian in the case of all work w requir review and approval of plans.
IGNATURE OF APPLICANT - PRMT NAMF��'��F�j(�',v-� DATE �'ZL