P - 48066Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
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Permit No.:�.� j �
Received By: V u"U'
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DATE �(9J �h Z� 1 \ YOUR E-MAIL ADDRESS � "` � L �' K� �S • �o �h
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SITE ADDRESS � �C(] S� � � � ,� � � � f �7
THIS APPLICANT IS: ❑ OWNER J�fCONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
�
ADDRESS: J{�j � O �SJ/ „! 5 0; s i'� t.�/.� CiTY l�2-i � L� J STA
PHONE:� (v3 - S '7/ - O(v � �
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STATE LICENSE # 1� � ,j,� � 5 �/ (� LEAD CERT NUMBER /��i - ,3/ � //� EXP: �1�- Zc� /S
ADDRESS: 7 5� `/ � t 2A �� �v�c� CITY '13r�.�,;,��y� �°,aek STATE_ k�ZIP SS7�Je
PHONE %�v � - a � °�' - � <% � FAX %(� 3 �- Sb � - � .� / /
� Slt�„E, FAM,I�;Y�IEW CONSTRUCTION SIZE
❑ TWO FAIvIILYMEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �pATHER
— ❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�T9AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: IZ� M.Ot/� f�,1p .�L,S'AL+¢C� So,{�j j, 1''iCT sor-F,T p��T1 �� ���,•i � G hfKT£S
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES O HOUSE & GARAGE BASEMENT REMODELING SUBMIT
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
❑ Vinyl
❑ Aluminum
❑ Other
FOR NEW CONSTRUCTION [NCLUDING DECKS,
""- ADDITIONS. & PORCHES SUBMIT
�offit SIDIN� i7FFI SCI �. Site Plan/Survey showing the existing structures
❑ Trim REMO EV D. E3 ❑ NO
�Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 3,.5 �'c.� OCCUPANCY TYPF,
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb 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)
f�+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION 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 application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of 11 work w h requires review and approval of plans.
SIGNATURE OF APPLICANT ��..�L���'i° --- PRINTNAME �/)i✓ ��/) z%sb� DATE t�`3a�JJ ! f
APPROVAL INSPECTOR SIGNA RE —�