P - 39657Building
Inspections
763-572-3604
763-502-4977 F.AX
DATE % -- / '� (
SITE ADDRESS 7.s'� Z
THIS APPLICANT IS:
BUILDING �
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
VE 1-I-20]
P�����'—p l
Received By: /`-
Date Rec'd:d /� ,
YOUR E-MA1L ADDRESS �`, `l_�. �( �� G; i�i^ `1 ti �� zJ �' L t)°"`1
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❑ OWNER I�,�ONTRACTOR
PROPERTYOWNER/ NpMg: k'i,tSSr`C 1`�Gcn�c`�/�
TENANT qDDRESS: 7J� 2 / %%�%L� � n � �f � ,�� %%� CITY�
PHONE: %�p �� % ��{� LI.S � 3
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTTFtCATE OF
INSURANCE
ATE�ZIP
NAME: ,� QS��'t S J �
STATE LICENSE # �I %��% LEAD CERT NUMBER n
ADDRESS: �2 3� [.6� r y1G n'+ t-� �`C' CiTY�� L1�7 G r S{GrL STATE�J% ZIP�S yzG
PHONE �'`J.`S Z ' � �% � " � �i I "Z FAX
PROPERTY TYPE I� STNGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FfNISH I'� ROOF ❑ DRA[N TILE
❑ DECK ❑ SIDTNG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: C] NEW HOME CONSTRUCTION ❑ ADD1TfON
t� MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: %" "�' i" .�i�3 �i'
SIZE OF IMPROVEMENT
i200FING
NUMBER OF SQUARES 7��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Viny!
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LENGTH WIDTH HEIGHT
❑ HOUSE ONLY
�d HOUSE & GARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WTNDOWS
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of sfruc!ural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCNES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seis of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
- - _ - - - - - - - — —
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(U ING�T HE� U.B.0 FEE SCHEDULE}
COTAL JOB VALUATION $ ���l • OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro]
Park Fee
Sewer Main Charge
Total Due
$ �"�'� .
$
$ /.7
$ �.a�
$
$
$
$
$
$
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 + 6 ft= ft x$25= $
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks oavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICAI'ION FOR A PERMIT-NOT VAL[D 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 wi1] be in accordance with the
approved plan in the case of all rk whichj�1uir review and approval of pl s. /-- G j
SIGNATURE OF APPLICANT C�.�—`-�—�� PRINT NAME �:^�.��4 � DATE /`-l"%/
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