P - 39569Building BUILDING Perrnit 1vo.: "� - ' �� ? ,
Inspections RESIDENTIAL APPLICATION Received By: ;'�C ,
763-572-3604 CITY OF FRIDLEY Date ��: �(
763-502-4977 FAX
EFFECTIVE 1-1-201I
DATE �`.Z-� "" ZQ/ I YOUR E-MA1L ADDRESS {' - Z-- C,.�,�t3cti�, C a-•-••.,
S ITE ADDRESS '] /$�j �w �� V'. � L'-� �t V Frs C.,,�
THIS APPLICANT IS: ❑ OWNBR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK
DESCRIBE WORK B�iNG
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum �
°�ther ��
NAME:
r�
ADDRESS: %.� 3 C'�ivc�-1/�`c L�•! %�fti•'e, �-c. CITY
NAME: C-Z'
STATE LICENSE #�o� 3 r� i 5' LEAD CERT NIJMBER �l
ADDRESS:_ QZ�I f� vc.0 �"l/'�. CITY F��
. K
PHONE /b S"75 `'�' l b`'f �-- FAX
I�INGLE FAMILY/NEW CONSTRUCTION S[ZE_
�7 TWO FAMILY/NEW CONSTRUCTION STORII
❑ ADDITION ❑ GARAGE/SHED "�WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �+SIDING ❑ OTHER
❑ SWIMMING POOL
� NEW HOME CONSTRUCTION ❑ ADDITION
8'MAINTENANCE/REPAIR ❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
`�otiit
❑ Trim
�'ascia
WINDOWS
IN EXISTING OPENINGS�'es ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
f�J'►„ �'ot�
HEIGHT
STATE�ZIP
T—I t� '
✓`e-�' STATE�ZIP__ 3��
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED. [�}�Q�q,t,ta„"E' NUMBER OF WINDOWS ((7 �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �Z � O�� 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
I hereby apply for a buildi
conformance with the ordin�
permit but only an applicati
approved plan in the case of
SIGNATURE OF APPLICANT _
APPROVAL INSPECTOR SIGNA
$
$
$
$ ��� �
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.00I 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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreernent necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
't and t acknowledge that the information above is complete and accurate; that the work will be in
;s and c es of the ' f Fridley and with the Minnesota Construction Codes; that I understand this is not a
for a per t wo is not to start without a permit on site; that the work will be in accordance with the
work ic ir r' approval of plans r
� RINT NAME__ � ��/l DATE