P - 44935Building BUILDING Permit r1o.:� � d 31�1
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY w e4�1� 4�I �C91�
763-502-4977 FAX EFFECTrvEi-i-aoii �� "'
DATE YOUR E-MAIL ADDRESS
siTEaDDxESS �02� �� c�e t'� �'e_c�ace NE � f-r� r�. e�o. 5 5�-i3 �2
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: 1 rl
TENANT ADDRESS: g O� 14 �Q ���S��C� N� CITY �� �'e-C.1 STATE '� �ZIP SS ��
PHONE: � % 3'°��S 'i�"��-�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
O 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: � C' n UL� � i� 1ih 0.dM�C1l �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT
NUMBER OF SQUARES �_ �IOUSE & GARAGE 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:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing structiues
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia
2. Two seu 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-DESCffiBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N���S AKL SASr;ll UlV VALUAl1V1V� 11V(:LUlli1V(i '1'HL�' C:U�'1� Ur� LAIfUK APIll MA'l�l�',KIAL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge .
Surcharge
License Surcharge
SAC Charge
Carb 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 Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: Ci _ty of Fridle_y Attach
THIS IS AN APPLI�ATION 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 applicatio for pe t ork ' ot start without a permit on site; that the work will be i accor ance with the
a roved lan in the case o wo w r r w d a roval of� Q �/�%�l
SpGNATUREOFAPPLICA PRINTNAMEp�IC'•r'c�'J/1' / `�"n'�ATE �
APPROVAL INSPECTOR SIGN URE