P - 45100, -----..
Building
Inspections
763-572-3604
763-502-4977 FAX �
DATE } I" Z 3— �. U` G
SITE ADDRESS _
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATIUN
CITY OF FRIDLEY
Utr� R✓,��,
YOUR E-MAIL ADDRESS
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❑ OWNER �(CONTRACI'OR
PROPERTY OWNER/ p�g: (?.c:':12.r- (R �;s., I iJ��+2..
TENANT ADDRESS: 5��++r. �'is" .fi�%
CITY
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
PHONE:
NAME:
and Sidin�a I�c.
Permit No.
TE ZIP
STATE LICENSB # 3�t� � 3�'� JOfltiSQfi 5i. N. E. EXP DATE � 3� �%2
. ______ ` . �ir338�'—��
rr��rv� rax:S„{d3) zss-8o25 Fax
O SINGLE FAMILY/NEW CONSTRUCT'ION SIZE
❑ TWO FAMILY/NEW CON5TRUCTION STORIES
❑ ADDITION
O BASEMENT FINISH
❑ DECK
❑ TiEW HOME CONSTRUCTION
?S' MAINTENANCF�REPAIR
L7 ROOF O DRAIN TILE
❑ SIDING ❑ OT4-IER
❑ 5WIMMING POOL
❑ ADDITION
❑ REMODELING
STATE ZIP
DESCRIBE WORK BEING DONE: ��t� —v(�' � !'Q-�'Gt� .�-rvn,f c�" yt�v,f� �,�t�`
SIZE OF IMPROVEMENT LENGTH WIDTH HETGHT SO FT
ROOFING 4y-
NUMBER OF SQUARES � � Z �
GARAGES
PROPOSED S[ZE:
PROPOSED FIEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�I-IOUSE ONLY
❑ HOUSE 8c GARAGE
O ATTACHED GARAGE
Q DETACHED GARAGB
�Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS C]Yes ONo LOCA1'ION OF WINDQWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF V
BASEMENT REMODELING SUBMIT•
t . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADIIITIONS 8c PORCHES SLfBMIT•
i. Site Plan/Survey showing the existing structures
and proposed projec;.
2. Two sets of construction plans
3. Energy CalculaYions
FOR WINDUWS —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)
TOTALJOB VALUATION S �i $li nrrrrvsivrv �rws
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
� -�-g�,55'(,(jSee Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.SO
$ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determina#ion)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( } Non Necessary ( )
$ �f 2���— ____ Make c5ecks payable to: City of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTiL PROCESSED
I hereby apply for a building permit and i acknowledge that the information abave is complete and accwate; that the work wilt 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 alt work which requires review and approval of plans.
SIGNATUREOFAPPLICANT�, � PRINTNAME 3/ G�+�'1 /'/ ���/�/�'� DATE /�� 2'"� /G
NOTE: SEPARATE PERMITS
F(?R
AND MECHANICAL WORK
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