P - 60364�� 2�.���
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Building BUILDING Permit rto.: �
Inspections RESIDENTIAL APPLICATI()N r�e�ei�ed By:
763-572-3604 CITY OF FRIDLEY D �°d•
763-502-4977 FAX E��cTTVE �-�-ao�z � N
DATE "i •�(1. �Z YOUR E-MAIL ADDRESS
SITE ADDRESS � P {C� �ji�
THIS APPLICANT IS: ❑ OWNER �ONTRA . OR
PROPERTYOWNERI NA� `�-��� ��� �j�J�`���mC
TENANT ADDRESS: CITY STATE ZIP
PHONE: l(_D�- ZVo ^�I�Z
CONTRACTOR NAME: (lU�\ CXA�S
SUBM[T A COPY OF
YOUR STATE LICENSE STATE LICF,NSE #��,U�7,,L�j LEAD CERT NUMBER EI�:
AND CERTIFICATE OF ADDRESS; Z�Z� CC�C� �d.lYa �S NLI� CITY�C.UJ t7l1G�i�AT�ZIP �1�2„
INSURANCE pHONE �- i�-1�l FAX �� �-
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTiON STORIES
PERMIT TYPE ❑ ADDIT[ON ❑ GARAGE/SHED NDOWS
❑ BASEMEN'f FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WURK: 0 NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTiNANCFJREPAIR Q REMODELING
DESCRIBE WORK BE1NG DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEtGHT S FT
ROQFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUAR�S ❑ HOUSE & GARAGE
(. Existing Floor Pfan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor pIan
PROPOSED SiZE: ❑ DETACHED GARAGF, 3. List of structural members to be used
PROPOSED HEIGHT:
SYDING FOR NEW CONSTRUCTION INCLUI?ING DECKS,
❑ Vinyl OSoffit SIDIIVG/SOFFIT/FASCIA ADDITlONS. & PORCHES SUBMtT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1� Site Plan/Survey showing the existsng structures
❑ Other � Fascia and proposed project.
2. Two sets of consUUCtion pians
WINDOWS 3. Energy Calculations
OR OIRTNEW OPEN NGS-D�ESC BE SIZE OF LOC�T�I�T O� R�,D� ��a- �� A� RE STICOKER ON WINDOW. D
Jy pc
OPENtNG CHANGES & �/ —� ,�r�o���
TYPE OF WTNDOW TO BE INSTALLE� r� a" ��C"NUMg�R�OF WINDOWS
ALL FEES ARE BASED ON VALUATlON,1NCLUD[lYG THE COST OF LABUR A1VD MA'1'EKIALS:
_ (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JO.B VALUATION
Pern�it Fee
Ptan t�eview
Fire Surcharge
Swcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Controt
Park Fee
Sewer Main Charge
Total Due
TYPE
$ �'n �. L`� See Back Fage for Fee Schedule
$ 65% of Buiiding Permit Fee
$ L C� .001 times the total job valuation
$�' .0005 x Permit Valuation Minimum or .50
$ -� $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determinaqon)
$ $+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ���— Make chect�s aavable to: Citv of Fridlev Attacl
THIS I3 AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I herehy appIy for a building permit and I��knowledge at the information above is complete and accurate; that the wark wili be in
con.formance with the ordinances and codes of th City of ridiey and with the Minnesota Consiruction Codes; that I understand this is not a
permit but only an apptication for a permit and w i ot to start without a pennit on site; that the work will be in accordance with the
approved plan in the case of all k hic '- s e and approval of plans. � c�� ���
SIGNATORE OF APPLICANT PR T NAMfi ��t �'c �p �ATE
APPROVAL 1NSPECTOR SIGNATU
PLEASE NQTE: SEPARATE PE TTS OUIRED FOR PLUMBING, ELBCTRICAL AND MECHANIGAL WORK