P - 48372Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDIN(i Permit No.�-
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY vate Rec'd:�
FFFF('TIVF I_1_�(171
DATE �1.�-11 '�- V[i � c%� 1 �
SITE ADDRESS I� I� � l�S ��� Y1
THIS APPLICANT 1S: ❑ OWNER
PROPERTY OWNER/ Np,�tE: _._I l�C
TENANT qDDRESS: i 51
ounr.i�. I/% I.� �
CONTRACTOR
SUk3M1'T A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
NAME:
STATE
YOU�
\
�NTRACTOI
�s
'� �
-J-� , � 9
5�5���1
�.�,r��1�
ADDRESS � �`�_rC' {��yf) ' �[� y
PHONE �'�":.� � /�-" 7. (E%: �! k
❑ SINGLE FAMILY/NEW CONSTRUC"i'ION
❑'I'WO FAMILY/NEW CONS'IRUCTION
PERM[T TYPE U ADDITION LJ GARAG
� BASEMENT FINISH �I ROOF
❑ DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
�C[TY � �� (� � C'
5�
Y1 _ "C _ �I'� �" �•" ` [
EAD CERT NUMBEI� � �� •-
�l� � C[TY ! � CLL�'7'v
FAX ��'_J "'t T /
SIZE
STORIES
❑ W[NDOWS
❑ DRAIN TTLE
❑ OTHER
❑ ADD[T[ON
❑ REMODELING
DESCRIBE WORK BEING DONE: � V' 2' C- .LQ,i1 �-z--� l:= j` l.�Jp " Y 1 `.'Vl. f 4_.M�.�'
SIZE OF IMPROVEMENT NGTH WIDTH HEIGHT S FT
ROOFING ❑� USE ONLY
NUMBER OF SQUARES.� 1�1-I�H3E & GARAGE BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
GARAGES ❑ AT'TACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FORNEW CONSTRUCTION INCLUDWG DECKS,
❑ Vinyl ❑Softit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. EnergyCalculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPF, OF WINDOW TO BE INSTALLED NUMBER OF W[NDOWS
ALL FEES ARE BASED ON VALUATION, [NCLUDING THE COST OF LABOR AND MATERIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �� � OCCUPANCY TYPE
Permit Fee $.;�,_3 . 5�� See Back Page for Fee Schedule
Plan Review $ :d� FI- 65% of Building Permit Fee
Fire Surcharge $ W�fQ .001 times the total job valuation
Surcharge $ -�!}-ref� .0005 x Permit Valuation Minimum $5.00
License Surcharge $ dr . C� C�' $5.00 (State Licensed Residential Contractors)
SAC Charge $ AI� �� $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ �� ft + 6 ft = ft x$25= $
Erosion Control $ ��� $450 Conservation Plan Review
Park Fee $ �� F} Fee Determined by Engineering
Sewer Main Charge $ f,j /}� Agreement necessary O Non Necessary O
Total Due � �$ Make checks a able to: Cit of Fridle Attach Sti ulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAI,ID 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 permi 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,�r�,whicl requires review and approval of pl ns.
SIGNATURE OF APPLICAN�'- � � `���� � L - PRINT NAME � �SCC �� �J--�tV��Y� DATE C� ' � � � �
APPROVAL INSPEC'TOR S1GAtA E �� �� �
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
STATE / �� N ZIP—���
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