P - 44340Building
Inspections
763-572-3604
DATE �O �> I �� rv
S[TE ADDRESS / Y'4r e
TFiIS APPLICANT IS:
. 1
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
1' Z�I f I ; � � ur / �.� 1 � �] �7 :7 � I.Y.9
Permit N
Received By:
Da�' cl� � � � �
PROPERTY OWNER/ NAME: �� �O✓1 Csar�/ F'�'"'
TENANT �DRESS: ��(o� N.�n r.,CI�t�C7d � CITY lc� ��" STAT� �IP�=Y3 2.
PHONE:� �0,3 �-' S7 �--� I d KS
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME:
STATE LICENSE # d 1 M�£�n nr em �
vuL►�svt�
ADDRESS: ST_ T.ni1T� PARii MN K1�� STATE ZIP
PHONE �e 1�—�� �S o�i �o FAX TD �000] 050
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHEI
❑ BASEMENT FINISH O ROOF
❑ DECK ❑ SIDING
❑ SWIMMING PC
❑ NEW ❑ ADDITION
O MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
� NUMBER OF SQUARES
I GARAGES
! PROPOSED SIZE:
i PROPOSED HEIGHT:
SmIlVG
❑ Vinyl
❑ Aluminu�n�-�'
❑ Other ��i�LOS �./elt�.
WINDOWS
IN EXISTING OPENINGS�Ybs �No
OR FOR NEW OPENINGS-DESCRIBE StZE OF
�p��G CHANGES &
LENGTH _
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
IACATION OF WINDOWS
O DRAIN TILE
❑ OTHER
,
HEIGHT
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calculations
� WINDOW TO BE INSTALLED ISt(Jt — u�� �NUMBER OF WINDOWS � I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND 114ATERIAL5:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ f% OCCUPANCY TYPE
Permit Fee $ ' See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
�e Surchar�e $ Cr imes_ th� tO�jDb v�lll � —
Surcharge $ � .0005 x Permit Valuation Minimum $.50
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $1675 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ 8+ 6 ft= ft x$21 =$
Erosion Control $ $450 Conservation Plan Review
Pazk Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary (')
Total Due $ Make checks a able to: Ci of Fridle Attach Sti ulations
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; thaf the work will be in accordance with the approved
plan in the case of all work hich requires review and approval of plans.
SIGNATUREOFAPPLICAN�/�r.c_UJ�:�t'lf,t.i PRINTNAME ,lJ��1n�, l�tll� DATE blc d���a