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Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date xec'ct: �� %/
763-502-4977 FAX EFFECTivE i-i-zoli
DATE ��v'�/�� YOUR E-MAIL ADDRESS yO�GT�/O�K� /J'l Y/YO �jC�+r�Y//� � G.�>'�,
siTE ADDxESS /d�/ �t� G�i�eC/� T �-r� � �� � .
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: v/ �n ,e�
TENANT ADDRESS: /D�"/ /�i« /� � ��
l�uCTi. CITY ����ty STATE/�i�ZIP
PHONE: (�I� " !%D�� S'S �S�
CONTRACTOR NAME: YO �c,l ' i' �T c.� OS/�
SUBMIT A COPY OF STATE LICENSE # ar G 3?��i LEAD CERT NUMBER/'i _� — SdiloY'"�D �Di1r/Z8�%
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: ✓�IS� �/i 11 �� ✓� /(J/� - CITY�J�%�c� STATFi�LZIPSSD9..2
INSURANCE pHONE G✓? - y.�v'— .s� FAX —�%���
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: /TBD ��- v�� clin9' T� /7DUl� �-/'��+CC �-¢ LastY��—
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING n ❑ HOUSE ONLY
NUMBER OF SQUARES �" / ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: �� Q/��
� tl FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING y ADDTTIONS. & PORCHES SUBMIT:
�Vinyl �v •-� G 1� ❑Soffit 1. Site Plan/Survey showing the existing structures
❑ Aluminum �— � ❑ Trim and proposed project.
❑ Other .� '� ❑ Fascia 2. Two sets of construction plans
WINDOWS � � � 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFAC'I"URE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATlON,1NCLUDIN(G 1'HE CUS'1' UN' LA13UR A1Vll MA'1'�;K1ALS:
TOTAL JOB VALUATION S/ y� �I� THwF.1997 U.�B���E 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
$ �/, ?� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permrt Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ . Make checks payable to: City of Fridley Attac
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 Fr' ley d with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a e• it a wor to without a permit on site; that the work will be in accordance with the
approved pl i i the case of a pl t �� J �,, �, �/
SIGNATURE LICA T NAME < fG-� DATE
APPROVAL INSPECTOR S