P - 44941Building
Inspections
763-572-3604
DATE %�//�OI�j d
SITE ADDRESS v� 5 �'/
THIS APPLICANT IS:
PRQPERTY OWNERJ
TENANT
CONTRACTOR
SUBMTf A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMiT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YO`U1R E-MAIL ADDRESS
�6S %��u.r�l lY �
OWNER �TCONTRACTOR
Cia.do n � . �yif,
�S: J'r59 � tS� IS T�(i £ CITY TY l�
763- �5�� � " 81�L
., _ � .
STATE LICENS� #\�
ADDRESS: � U �
PHONE �Sei�- '�I I S �
s'3INGLE FAMILYME
❑ TWO FAMILY/NEW
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
0
DESCRIBE WORK BEING DONE:
SiZE OF
EXP DATE .�/31 /I0,
el� / aT ��V � CITY�
xo��o FAX c?� 01- - �70�� --1
PRUCTION SIZE
JCTION STORIES
❑ GARAGE/SHED ❑ WINDOWS
�'iZ00F ❑ DRAIN TILE
❑ SIDING ❑ OTHER
O SWIMMING POOL
❑ REMODELING
� •f - /1 p h e-�,�.�
Permit No.: ,� �()� �y -� I �.{ 7
Received B '
y� �
Date ��' N O U 01
HEIGHT
AT�'N1zIP ✓aJ�3z-
TEIIWIZIP S 5� j (p
Ft.
xuuruvG ❑ USE ONLY • -
NUMBER OF SQUARES HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
GARAGES � '❑ A ACHED GARAGE 1. Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE 2• �Posed floor plan
PROPOSED HEIGHT: 3. List of structural members to be used
SmING FOR NEW CONSTRUCTION INCLUDING DFr�CKS,
❑ Vinyl �Soffit ' ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ' ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other . ❑ Fascia and proposed project
WINDOWS Z. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3. Energy Calculations h
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & l
TYPE OF WINDOW TO BE INSTALLED NUMBER OF�WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPF.
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ y� a s See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ a��_ .001 times the total job valuation
$ � �(p 3 .0005 x Permit Valuation Minimum $.50
$ $� $5:00 (State Licensed Residential Contractors)
$ $1675 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21 =$
$ � $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ __ , Make checks payable to: City of Fridlev � Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT YALID UNTIL PROCESSED
[ hereby apply for a building permit and I aclaiowledge that the information above is complete and accurate; that the work wiIl be in
�onformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
�ermit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the approved
�lan in the case of all work w ich requires review and app val of plans.
iIGNATURE OF APPLICANT D�/yl/KL� ,/(/ PRINT NAME l/�"�Q' �l� �C DpTE � t/f (� �!o