P - 45788Building BUILDING Permit No.: C) 'U
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY vat : � �
763-502-4977 FAX EFFECTNE 1-i-20I t e��
DATE�o ��� I YOUR E-MAIL ADDRESS
S)TE ADDRESS y�Y j) 1��t j��T�zC J���' ��� � �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: r--
TENANT ADDRES : � CITY STATE ZIP
PHONE:
CONTRACTOR NAME: ����_�j\� �.�).
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #�'1_;'ZG�1�� LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: `j' �����',,tcS� ,• /.1� � CITY STATE ZIP
INSURANCE pHONE � FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ WO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION Q GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FIN►SH CT�EOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
INTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:���.r ��.�- �� �CT�
SIZE OF IMPROVEMENT LENGTH WiDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES _�_ ❑ HOUSE & GARAGE
I . Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed tloor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDiTIOiVS. � PORCHES SUBMIT:
� Vinyl OSoftit 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia
2. Two sets of consuuction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRLBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'L;L�'S AKr: BA�N:U UN VALUA'fIUN, 1NCLUUING '1'H� CUS"1' UN' LAKUIt ANU MA"1'LRIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ , See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit �Plans to MWCC for determination)
Curb Cut Escrow $ ft + 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ , n Make c6ecks aavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NO'f 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 applicatio for 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 k ' ��' review and approval of pl s.
SIGNATURE OF APPLICANT _���i�,�(�-� PRINT NAME_ ��,� �JC�':Z _DATE_