P - 48424Building
Inspections
763-572-3604
DATE I � �� I �O
SITE ADDRESS � Rq
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PRQPERTY TYPE
PERMIT TYPE
TvrE oF wox�c:
iti
BUILDING
RESIDENTIAL APPLICATION
CITY QF FRIDLEY
Permit No..
Received By: l'
D��c'�d� �
XOUR E-MAIL ADDRESS .�s�� � C,��-�-V�(,� l��� �
�D C�f r. (` n n 1 f �
❑ OWNER �CONTRACTOR
: C►
ADDRESS: � CiTY STATE ZIP
PHONE: �-�03 " S T o� � o� �� �9 — .
NAME:
STATE LICENSE #
AbDRESS:
Y/NE�
1920 County Road "C" West
Roseville, MN 55113 ^
License #BC130983 T
651-264-4777 .-
Q ADDITION ❑ GARAG
� BASEMENT FiNISH ❑ ROOF
O DECK O StDING
10
DESCRIBE WORK BEING I
�� ��x��
NUMBER OF SQUARES _
GARAGES
PAOPOSED SIZE:
PROPOSED HEIGHT:
NEW
❑ HOUSE ONLY
0 HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
D DRAIN TILE
� OTHER .
'ATE ZIP
BASEMENT RFMODE INCi S iRMiT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural rnembers to be used
SIDING - FOR NEW CONSTRUCTION INCLUDING DECKS, �
❑ Vi�ryl OSoffit ADDITIONS_ & PORCHES SUBMiT:
� Aluminum O Trim 1. Site Plan/S�uvey showing the exisiing structure
O Other ❑ Fascia �d propo� p�j�,
N,���,g 2. Two sets of construction plans
[N EXiSTING OPEHINGS �Yes ONo LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE S(ZE OP
OPENING CHANGES &
TYPE OF WINDOW TO BE tNSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, Il�1CLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S �o � S�' y. O U OCCUPANCY TYPE
Permit Fee
Pian Review
Fire Surchazge
Swchazge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ I�.�R . 2 S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ (o. ``}- .00I times the total job valuation
$ 3. a2 9 .0005 x Permit Valuarion Minimum $.50
$ S• 00 $5.00 (State Licensed Residential Contractors)
$ $1550 per SAC Unit (Plans to MWCC for determination}
$ ft+6ft= ftx$21=$
$ $4S0 Conservation Plan Review
$ Fee Determined hy Engineering
$ Agreement necessary { ) Non Necessary ( )
$ 15z1, I 1 Make checkc pava6le to: Citv of Fridlev Attac
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID UN'I'IL PROCESSED
I hereby apply for a building permit and I acla�owledge that the information above is complete and accurate; that the work will be 'v
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not :
permit but only an applicatio for a permit and work is not to start without a permit; that the work will be in accordance with the approvec
plan in the case of atl work ich requ"ves view and approval of ptans.
SIGNATURE OF APPLICAN PRINT NAME��",�, . v�cn r� pq'I'E� _