P - 48531Building BUILDING Permit No.: =�` �� �� I�i ".
Inspections RESIDENTIAL APPLICATION Received By: '' �='
763-502-4604 CITY OF FRIDLEY ;�`
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977 FAX E�FC-r�vEl-i-zoi� � � � �
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DATF, �� ' i I ` ��� l i ( YOUR F.-MAIL ADDI2ESS �/ � � p(. �� i �q ��i j � .v ,l,<' 1 ��t� . "�' (' t�� �
SITE ADDRESS � ;``� . . �i: �
� i�l�l� SS /_S S . �aF� d �`�
1'HIS APPLICANT IS: ❑ OWNER C�CONTRACTOR
PROPERTYOWNER/ N,�„� _�'�,,, t..� ,�,,,�,' �/` ���. �
TENANT' 1 - _
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ADDRF.SS:�'.�1 � � S S�� ..$' j� � ;�-'� � 5-/�%�CITY 'd—�. _ � r_ STATE/f'i /I.ZIP_ � : � y.? �
PHONE: � f��� � �/� �%�° ��'�Fi S
CONTRACTOR rr.�: �_ � w �.: �,. � ,�, ,_; , /� � -� :� --�- ���
SUBMIT A COPY OF STATE LICENSE #.� c.' .� _i `'
YOUR STATE LICENSE �- `� � 7 LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: �G �'. � ,Jf':j.L c� v; a(��I .A CITY �.�l /� STATE/y��IP: S j`�
INSURANCE PHONE -. /.� _ ;;���5'l— . �S `i S'� FAX . E� : � c�� ,�./ ' Y
PROPERTY TYPE ❑ SINULE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIF.S
PERNIIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINI�WS
❑ I3ASEMENT FINISH ❑ KOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMIvffNG POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUC'1'ION ❑ ADDITION
❑ MAIN"I'ENANCElREFAIR ❑ RFMODELING
DESCRif3E WORK BF,ING I�NE: I` �.+� G�, ��' c� �� �-/ •��- F � � � v � I� �S j' � ILl c i
J
SIZE OF IMPROVEMENT LENGTH � WIDTH HEIGFIT SQ F"I'
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NIJMBER OP' SQUt1RES �_� , r�,-�'\ �IiOUSE & GAIZAGE ]. Existing Floor Plan
GARAGES ,�'� f�, ' O ATTACHED ('�AI2AGF, 2. Proposed floor plan
PROYOSED SIZE: ,7- ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HF,IGHT: �
SIDING ,� i' FORNEW CONSTRUCTION INCLUllING DECKS,
❑ Vinyl �offit I �DITIONS. & PORCF�'S SUBMIT'
❑ Aluminum ❑ Trim � ����` 1. Site Plan/Survey showing the existing structures
❑ Other �'F'ascia �y \' 2. '� o sets ofcons�tru tionplans
WINDOWS 3. F,nergy Calculations
IN EXISTING OPENRVUS ❑Yes �No L(�ATION OF W1bilJOWS FOR WINDOWS - PROVIDE U-VALi7E AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPl'sNING CIIANGES &
TYPE OF WINDOW TO BE INSTALLED NIJME3FR OF WINI�OWS
ALL FEES ARE BASED ON VALUATION INCLUDING T'IIE COST OF LABOR AND MATERIALS•
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
' Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� .
�; ��,_``'�(�JSING'I`HE 1497 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
$ � t' s�� � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
� �� .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ ° �� ;`:. - $S.OQ (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ �+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � i�'; ��.'- .;°. �-� Make checks payable to: City of Fridlev Attach
I hereby apply for a building perm
conformance with the ordinances anc
permit but only an application for a
approved plan in the case of all o
SIGNATURE OF APPLICAN'I' '"f
APPROVAL INSPECTOR SIGN
PLEASE NOTE: SEPARATI
THIS IS AN Al'PLICATION FOR A PEI2MIT-NOT VALID iJNTIL PR(X;ESSED
' nd I acknowledge that the information above is complete and accurate; that the work will be in
i co s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permi and ork is not to start without a permit on site; that the work will be in accordance with the
wh� � es review and approval of pla�j�' / �
_ __ PRINT NAME c'�$Gt�/ �-I- �/n,a�/ �, /�- T34T� ���J ��F7 /i
FOR PLUMBING, ELECTRICAL
WORK