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Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE i-i-zoii
Permit No.:
�
Received By:
D�c��' ��
DATE �r � Z 2- �� YOUR E-MAIL ADDRESS /�'I� �7 �yR.P�0�o1 �K�%va-�tl�.�•rv�`
sITE aDDxESS S 7 3 3 W. M 5ore �..Q,(c� pr ,�,�i d�,�, s,�`r 3 Z
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
3
PHONE: "T�3-Si/- 90$S
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STATE ("��% ZIP S�Y3 Z
STATE LIC$NSE # aDL 3 oS 3 y LEAD CERT NUMB�R �V/�1% :n 7� g9��
ADDRESS: �Ob90 V L����i L�IV.� /v� CITY ��t,,p.��tn STATE/�iI✓ZIP sSc92
rxorrE 7G 3� `�9`J� 86 9S F� 763- �3'�- y`� f�7
I�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DI'FION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �(ROOF ❑ DRAIN TILE
D DECK ❑ SIDING � QTHER
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
❑ NEW HOME CONSTRUCTION
�ffi. MAINTENANCE/REPAIii
ROOFIlVG �
NUMBER OF SQUARES
�ARAGES
PROPOSED SI2E:_
PROPOSED HEIGHT:
SIDING
❑ V inyl
❑ Aluminum
❑ Other
❑ ADDITION
� REMODELING
❑ HOUSE ONLY
�iIHOUSE & GARAGE
�ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
WINDOWS
IN EXISTING OPEIVINGS DYes ONo LOCATION OF WINDOWS
OR FOR NEW OPENIlVGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF
�,�,� (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchar�e
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ 7
$
$
$
$
$
u��
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCH�S SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
'ANCY
AND MATERIALS:
See Back Page far Fee Schedule
65% of Building Permit Fee
.001 times the total job vaivation
.0005 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 Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley 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 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 o 11 � w' req s• iaw and approval of plans.
SIGNATURE OF APPLICANT ,�,(�������PRINTNAME �jd� /�1uf�/e�tll DATE t�,-�.2Z ��j