P - 46251Bui�ding
Inspections
763-572-3604
763-502-497'7 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
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Permit No.:
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DATE 6� a/' // YOUR E-MAIL ADDRESS /n 1bQ ��HCe?acwil'Pl�ia/ttiPloh • n2 f
siTE ApDxESS %/6 ,I�lisSiSSi�p.' Sf N� �ri d l���rL� SS /32
THIS APPLICANT IS: ❑ OWNER �1CONTRACTOR
PROPERTYOWNER/ NAME: �C.QI'l'y ��n�/�/S
TENANT �DRESS: %�L /Y/ S$/ SS/�� �, s'� �E CTTY �Y'i el�� y STATE
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PHONE: %ia 3� S T'� "/ S%G
CONTR.ACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
NAME: /�arx��vwn fzPj�o�{tOn /�lN.TKt
STATE LICENSE # Z O(� 3 a S 3 Y LEAD CERT NUMBER I%f�T^ � yiZ S�J ^� I
,twD�ss: aab90 1/i K�nq QIV�( NE f CITY �Ov►t1K�_STATF./��ZIP �92
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0
�iSfNGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE U ADD1T10N u UAxac;
❑ BASEMENT FINISH �dROOF
❑ DECK ❑ SIDING
TYPE OF WORK: I Q NEW HOME CONSTRUCTION
'i� MAINTENANCElREPAIR
DESCRIBE WORK BEING
SiZE OF IMPROVEMENT
ROOk'INC� 3
NUMBER OF SQUARES �_
GARAGES
PROPOSED SI�E:
PROPOSED HEIGHT:
r�i��7's
SIZE
STORIES
3/SHED ❑ WINDOWS
0 DRAIN TILE
� OTHER
NG POOL
❑ ADDITTON
❑ REMODELING
❑ HOUSE ONLY
� HOUSE &,�6�AGE. SIs � d
❑ ATTACHEp GARAGE
O DETACHED GARAGE
FT
BASEMENT RFMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floot plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �a�t ADDITIQNS„y� PORCHES SIjBMI'�;
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other �CFascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calcularions
IN EXISTING OPEIVINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALLJE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANLJFACTURE STICKER OP1 WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NIJMB$R OF WINDOWS
ALL FEES ARE BASED ON VALUAT�ON, INCLUDING THE COST OF LABOR AND MATERIALS:
„� (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � S�� � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ �, ..�
$
$
$
$
$
$
$
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 (St�te Licensed Resideritial Contrractors)
$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 ( )
THIS IS AN APPLICATION FOR A PERMIT-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 11�� ' re u' �es r' w d approval of plans. rL /
SIGNATURE OF APPLICANT PRINT NAME TO a�el /•� k�V��i �� DATE 6'�e2 I—'��
APPROVAL INSPECTOR SIGNA