P - 48600�� ��'
Bui�cting BUIL,DIN(J Permit No.: �
Inspections RESIDENTIAL APPLICATION Received By; �" '
763-572-3604 CITY OF FRIDLEY �at��e'�a� ����� ��
763-502-4977 FAX EFFECTivE �-�-zo�z
DATE_ � 1 YOUR �E-MAIL ADDRESS /Yf/Ke ylL�lJ1�7F��1 �C�:: i 3�C'�tlw� �S i�'1!� Ca.� 1�v��
SITE ADDRESS ���� �/2S � �,lY�il9iLfrlij�' /`�L�L�,Qi
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAMF: �
TENANT ADDRESS: �r�% Gtl�%S� !)�'IG�y//�� � .S"Sy3�
�CITY STATE ZIP
PHONC-: %�,�°.jL'�°- S1///
CONTRACTOR NAME: � � J
SUBMIT A COPY OF STATE LICENSE #,�%�i3t% 9� LEAD CERT NUMBER /�y,�'T- o!�%��'�XP: �,3C���S
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:�%�/ �L1Cc S��' � CITY ,s� �� STAT�Z[P�S/��7
INSURANCE pHONE I- �DS""CJ FAX (rpS�' O'�%�S
PRUPER'I'Y T'YPE I?�s[NGLE Fami�Y/N�w coNS'rKUCT�oN SizE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHF,D � W[NDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN T[LE
❑ DECK ❑ SID[NG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ��NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODF.,LING
r , . .
DESCRIBE WORK BEING DONE: �� '` / 4
SIZE OF [MPROVEMENT L,ENGTH WIDTH HEIG SQ F'I'
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGG BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ AT'�ACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHGD GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SID[NG FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDI\G/SOFFIT/FASCIA ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑;VO � Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑No LOCATION OF WfNDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BF INSTALLED • �(f CtC� NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR ANU MA'1'N:RlALS:
9(, NG THE 1997 U.B.0 FEE SCHEDULE)
TiiiHi,.iv� J.Ai,ufiiiv7: ;u �„�1�� nr��tpn,tv�V TYPF,
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �!�-L:�
$
$ �v
$ �� � r
$ `7 `l.1
$
$
$
$
$ >.
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum or .50
$5.00 (State Licensed Residential Contractors)
$2365 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 Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN7'IL 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 ordinance f the C� of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio a er ' d w k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o r eq eview and approval of plan,�,,,q;� �J����� t �/y�Z
SIGNATURE OF APPLICANT PRINT NAME ��/ DATE
APPROVAL INSPECTOR SIG A URE
PLEASE NOTE: SEPARATE P MI S AR REQUI ED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK