P - 84243Building
Inspections
763-572-3604
763-502-4977 FAX
DATE Z /Z—
SIT'E ADDRESS �
TIiIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
❑ OWNER �.9CONTRACTOR
ADDRESS:
STATE LICENSE
a,DDx�ss: I ��O'
PHONE f(B7 (��CD /(�O /
Rl SINGLE FAMILY/NEW CONSTRUCTlON
❑ TWO FAMILY/NEW CONSTRUCT'ION
❑ BASEMENT FINISH ❑ ROOF
❑ DECK � SIDING
Permit No.:
Received By:
/. :�; t�► Ic� � :; ■ �
�l � ,
ATE�ZIP L/ 3 Z-
�I LEAD CERT NUMBER EXP:
CITY '�oo1Gy5 STATE�(1 /ZIP��
FAX
SIZE
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDIT'ION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBEWORKBEINGDONE: r�°-S i�0� Lla-�SC $ qrxSG� r���q�P���
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES O HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Ot6er
❑ ATTACHED GARAGE
❑ DETACHED GARyAGE
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA �pITIONS. & PORCHES SUBMIT:
❑ Trim REMOVED? � YES � NO 1. Site PIan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS j$li'es ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEMNG CHANGES 8c l
TYPE OF WINDOW TO BE INSTALLED �1I�1 / I� H• NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $��w�G THE 1997 U.B.0 FEE SCHEDULE)
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
$ o{ .S /- v See Back Page for Fee Schedule *`
$ 65% of Building Permit Fee
$ �� .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$__ �:'j, � Make checks payable to: City of Fridley Attach
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
�pproved plan in the case of work hich re i'res re 'ew and approval of plans. � r/� DA'FE � � Z7/1 Z
SIGNATURE OF APPLICANT ` PRINT NAME Ki°Nl�l Yh i
APPROVAL INSPECTOR SIGNATURE