P - 48544Building BUILDING �� , 4��3 Pe��t No��'� � � ��� � �5
Inspections RESIDENTIAL APPLICATION Received By: r.
763-572-3604 CITY OF FRIDLEY Dac��'� }� " �: � � � � ; �
763-502-4977 FAX EFFECTIVE 1-I-20] 1
DATF �J �/ •/ ( �y
SITE ADDRESS C.P Jd'
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL A
❑ OWNER
NAME: l�l�X[, �
ADDRESS: lP c�� O u
PHONE:��� ' D � � '
� N�ciTY
C,t�,SiZS►n Y e w�o
STATE LICENSE # �G C.XJ I t��5 LEAD CERT NUMB�
ADDRESS: -T CITY i
PHONE I— � —aCo � FAX �`" �
.0"SINGLE FAMILY ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION 3TORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �0'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
.0'A�SAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:�
SIZ6 OF IMPROVEMENT
ROOFING /�
NUMBER OF SQUARES v�
GARAGES
PROPOSED SIZG:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other _
WINDOWS
IN EXISTING OYEMNGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPF.NING CHANGES &
TYPE OF W[NDOW TO BE INSTALLED
�/'�ENGTH
❑ HOUSE ONLY
,�0'�IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascfa
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
TATE� u ZIP SS �3 a
7 a�oc��-i
STAT�',��/ ZIPSSO�
—9D50
FT
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. & PORCHES 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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� U� • vv OCCUPANCY TYPE
Permit Fee $ j� �t`; See Back Page for Fee Schedule
Plan Review $ � 65% of Building Permit Fee
Fire Surcharge $ ��( �}-� .001 times the total job valuation
Surcharge $ l .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$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ � 1�.. df' ,?7 Make checks payable to: City of Fridley Attach
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 w k is not to start without a permit on site; hat the work will be in accordance with the
approved plan in the case all ork whi requi review and approval of plans I,�� /
SIGNA"fURE OF APPLICANT PRINT NAME V� DATE �• �' l�
APYROVAL INSNECTOR SIGNA E
PLEASE NOTE: SE RATE PERMITS ARE REOUIRED'FOR PLUMBING, ELECTRI'CAL AND MECHANICAL WORK