P - 35785Building BUILDING pe�t No..� � I����
Inspections RESIDENTIAL APPLICATION xece� �y:� � `
763-572-3604 CITY OF FRIDLEY Date�c'c1:
763-502-4977 FAX E�c� i-i-aoi i
DATE ' dY/ � �� YOUR E-MAIL ADDRESS �'0 0��•' L � / /N 19 (��� I • �O �^
SITEADDRESS SI � Pa JQ I�/'i✓l �� ✓
TFIIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ Nn�: ��jAr//} �6� �+n
TENANT ADDRESS: �� � PsRd4J / A .��/✓C .f�,� CITY Y� � ���1 STATF�n�Z[P�i �> �
PHONE_?G3-S7�- S��oG
CONTRACTOR NpME:
SUBMIT A COPY OF STATE LICENSE # D LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFTCATE OF ADDRESS: Q/ I CtTY STATE�—S�
nlsu�xcE PxorrE F� - 3 0
PROPERTY TYPE ❑ 5INGLE FAMII,Y/NEW CONSTRUC[TON s�
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DTI'ION ❑ GARAGF✓5HED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTf�R
❑ SWIAihIING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCF/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �
SIZE OF IMPROVEMIIVT LENGTH WIDTH HEIGHT FI'
ROOFING ? ,J�HOUSE ONLY
NUMBER OF SQUARES/t! ❑ HOUSE � GARAGE B�EMENr REMODELING SIIBMtf:
1. Existing Fla� Plaa
GARAGES ❑ ATTACHED GARAGE 2. Pmposed floar plan
PROPOSID SIZE: �DETACHED GARAGE 3. List of slivctucal membe�s W be nsed
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDtAiG DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCI�S SUBMTi':
0 Aluminum ❑ Trim I. Site PIanJSmvey showing the �isting struchues
❑ Other ❑ Fa�ia � P�P� �l�
2. Two s� of coost�acti� plans
WINDOWS 3_ Energy Calculations
IN EXISTING OPENINGS ❑Ycs ONo LOCATION OF WINDOWS FOR WIIdDOWS — PRdVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRffiE SIZE OF MANUFACTURE STICKER ON WIIHDOW.
OPENING CHANGES �. .
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WIlVDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING 'THE COST OF LABQR AND MATERiALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION S OCCUi'ANCY TYPE
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
C�irb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �� �, G� 5ee Back Page for Fee Schedule
$ T—� 65% of Building Permit Fee
$ _.001 times the total job vatuation
$ .0005 x Pernut Valaation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 ger SAC Unit (Flans to MWCC for detetmination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �, Make checks navable to: Citv of Fridlev Attach
THI3 IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROC;ESSED
I hereby appiy for a buil ' 't and I aclrnowledge that the infom�ation above is complete and accutate; that the work will be in
conformance with the ordin ces codes of the City of Fridley and with the Minnesota Conshuction Codes; that I understand this is not a
permit but only an applic on f 't 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 f all ork w'ch requires review and approval of plans. ?,��
SIGNATURE OF APPLICANT PRINT N DA'T'E �
APPROVAL INSPECTOR SI
PLEASE NOTE. S ARATE ARE REOUIRBD EOR PLUMStNG, ELFst:TRICAL AND 'W� ''
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