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Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate Rec'ct:
763-502-4977 FAX �cr�,E 1-1-�oli
DATE YOUR�MAII.ADDRESS ��Z�n c�c.� 1� L�i �.�pv.�
SITE ADDRESS �'Jr a�f .5� y✓'�$ c),� �( l�c�- 1�1. �
THIS APPLICANT IS: .i�'OWNER �CONTRACTOR
PROPERTY OWNER/ N,�: \ e �r' � ►Z � n ct�,d l
TENANT annitESS: `7� a- � S� � n s o n 3�� cT� "� r+ �� � 1 e.�, STATE m.� ZIP S� ri 3�..
�orrE: 7 6,3 — 3 6 0-�4 73 �
CONTRACTOR N�:
SUBMIT A COPY OF gTATE LICENSE # LEAD CERT NUMBIIt
YOUR STATE LICENSE
AND CERTIFICATE OF �D�SS� CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE ❑ SINGLE FAMILYlNEW CANSTRUCTION SIZE
C] TWO FAMILYlNEW CONSTRUCTION STORIES
PERMIT TYPE O ADDITION O GARAGFJSHED ❑ WINDOWS
❑ BASEMENf FINISH �t'ROOF � DRAIN TII.E
❑ DECK ❑ SIDING O OTIiER
❑ SWIINA�IING POOL
TYPE OF WORK: D NEW HOME CONSTRUCITON ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEIdNG
DESCRIBE WORK BEING DONE:
Si7R OF IMPROVEMENT LENGTH WIDTH HEIGHT S Ff
�OOFING O HOUSE ONLY B.ASF,MENT REMODELING SUBMIT:
NUMBF�.OF SQUARES �� �i HOUSE dt GARAGE
1. Existmg F1oor Plaa
G�GES ❑ ATTA(��D GARAGE 2. Proposed flaor plan
PROPOSED SIZE: ❑ DETA(,'f�D GARAGE 3. List of aWcdrcal mcmbeis to be used
PiiOPOSED HEIGHT:
FOR NE W CONSTRUCITON INCI.UDING DECKS,
O� OSoffit ADDTfIONS. bt PORCf�S SUBMIT:
p Aluminum O Trim 1. Site Plan/Survey ahowing the exiating siructures
❑ Other O Fascia a°d pr°persed pr°�ect'
2. Two sets of co�hudion plans
WINDOW5 3. Energy Galculations
IN EXISTING OPENINGS �Yes pNo LOCATION OF WINDOWS FOR WINDOWS —PROVIDE U-VALiJE AND
OR FOR NEW OPENIIQGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES dt
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION. INCLUDING THE COST OF LABOR AND MATERIALS:
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Cutb Cut Escrow
Erosion Co�l
Park F�
Sewer Main Charge
Total Due
$
$
$
$
THE 1997 U.B.0 FEE SCHEDULE)
See Back Page for Fee Schedule
65% of Building Petmit Fee
.001 times the total job valuation
.OQOS 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 Fa�gineering
Agreement necessary ( ) Non Necessary ( )
Make checks uavable to: Citv of Fridlev Attach
THIS iS AN APPLICATION FOR A PERM[T-AIOT VALID UNTIL PROCESSID
I hereby apply for a building perrnit and I aclrnowledge 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 Consh-�tion Godes; that I understand this is not a
permit but only an app ca o a p work i ot to start without a permit on site; that the work will be in accordance with the
approved plan in the cA�all k a�i approval of plans.
SIGNATURE OF APPLIC PRINT NAME DATE
PLEASE
ARE
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IC�S�