P - 40001Building BUILDING
Inspe,;tions RESIDENTIAL APPLICATION
7f3-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE �-i-2o>>
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THIS APPLICANT IS: :I� OWNER ❑CONTRACTOR
Permit No.:
Received By
�?���n e�� r
� !� l .. L V x �y�7
PROPERTY OWNER/ NAME: L iJ E. S �° ��i��N
' TENANT .q�DRESS: � �i 3�3 5 't�d SOc9 - L(/ - CtTY G�� � � ! ��
� STATE ��ZIP -� - I3 .
PHONE: 76.j -� 7/ ' De7 v�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
STATE LICENSE #
ADDRESS:
LEAD CERT NUMBER
PHONE FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
� DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
STATE ZIP
DESCRIBEWORKBEINGDONE: N�u/ �v�%-�j�c1S ^ GU-4.� I�P4c�� Y?� {J�r�c�,5 ���-c wtT�l ��cW �r2m�s�icC'
J
SIZE OF [MPROVEMENT � 7� Z? � LENGTH 3% WiDTH �� HEIGHT SO FT -
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
I. 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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$
$
$
$
$
$
$
$
$
$ --
$ (�1
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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 'ty of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and wor is t to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all rk wh' h re �res re i and approval of pl�ns. /� p
SIGNATURE OF APPLICANT P�Ir1T NAME UL S �• c..�j/1Du DATE d— l�— �I
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