P - 48345Building
Inspections
763-572-3604
763-502-4977 FAX
n� rE� -'1 i/°- l l
SITE AUDRESS ___�.�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFrc�riv� i-�-zon
YOUR G-MAIL ADDRF.SS
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❑ OWNER pC�ONTRACTOR
NAM�:
ADDRESS:
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CITY
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CONTRACTOR NAMF: �(!/.'s�'/Y'U/' C�U^- S�-/'✓� e.z..
SUBM(T A COPY OF STATF. LICENSE #°
YOUR S"I'ATE LICENSE �� LE.a� c�:a�r n�uMBFn
AND CERTII�ICATE OF nDnRCSS: �(7� � `?� S:� v� J� � crrY__
INSURaNCE PHONE G � ��� _ � � - �� 1 � F,��, '' � �
PROPERTY TYPE Ga'�INGLE FAMILY/NEW CONSTRUC7'ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SkIED ❑ WINDOWS
❑ BASEMENT FINfSI� �OOF ❑ DRAIN TILE
❑ DECK ❑ SIUWG ❑ O'l HER
❑ SWIMMING POOL
TYPE OF WORK: ❑ N� HOME CONSTRUCTION ❑ ADD1TlON
��I'VfAINTENANCE/REPAIR ❑ RGMODELING
Permit No.:`'�''�" �-�lJ �''��,�d
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Received Bv:
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_ STAI L: �NI_IP_„��� �L
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DESCRIB� WORK BEING DONE: �(Jt7�-� f'"�'i/%M pl' "— -✓ � i� v�F '�� ��f ie �''�' i!'tt'��i� .1"'�.�� � f"��;
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SIZE OF IMPROVEMENT LENG"fFI WIDTH � GH"I �SQ f"�
ROOFING � ❑ HOUSG ONLY
NUMBER OF SQUARES ❑ IiOUSG & GARAGF. F��.SEMEN"I' REMOD6I,ING Sl_!BMI"�.
— I E�isting Floor Plan
GARAGES ❑ ATTACHED GARAGE 2, Proposed Floor pl�n
PROPOSED SI"LE: ❑ DGTACHEU GARAGE 3 List of structural members to be used
PROPOSED IiHIGHT_
SID[NG FOR NEW CONSTRUC�I�ION INCI.UDING DGIKS_
❑ Vinvl ❑Soffit ADllI'CIONS. & PORCHFS SUBMIT:
❑ Aluminum ❑ Trim I. Site Plan/Survey showing the e�istine structures
❑ Other ❑ Fascia and proposed project
2. Two sets of conslruction pl,�ns
��'INDOWS 3. Gnergy Calculations
IN GXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WWDOWS-PROVID6ll-VALUF: AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKGR ON WINDON'_
OPF.NING CHANGES &
fYPG OF WINDOW TO BE INS"I'ALLED NUMBER OP WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MAT'ERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � �� . OCCUPANCY TYPF.
Permit Fee $ �' 1 See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee .
Fire Surcharge $ .001 times the total job valuation
Surcharge $ `a .0005 x Permit Valuation Minimum $5.00
� License Surchvge $ $5.00 (State Licensed Residential Contractors)
� SAC Charge $ $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 $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O No�� Necessary O
Total Due $ ��— Make checks payable to: City of Fridley Attach Stioulations
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I�HIS IS AN APPLICATION F'OR A PERMI'I'-N07� VALID UN'I�II_, PROCESSF:D
I hereby apply for a building pennit 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 1 understand t�his is not a
pertnit but only an application for a permrt �a'~cvork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all wor h' rf equires review and approval of plans. < /� �
SIGNATURE OF APPLICANT ^J PRINT NAME ��t.. ,S (N� �� `� � DATE (y -" j "� � �
AI'PROVAL fNSPECTOR SIGNATUR
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK