Bldg Application 131223 BUILDING :.,.. Permit No.:
Bui63-572-3604 Ct1Q S Fl` TIAL APPLIC
ding P ,.,
'� � � MReceived By:
763-502-49 7 FAX CI OF F' DLFY °
EFFECTIVE a/sn
Date Re d.
DEC 1190 u I
DATE �- Alf_ VOUR MAI DRESS r L(a� 4' S.
SITE ADDRESS L— P -CIN,3
THIS APPLICANT IS: OWNER O� CTOR
PROPERTY OWNER/ NAME
TENANTADDRESS' I r CITY .ir STATEzIP
PHONE: + q-, A�
CONTRACTOR NAME:® '1 IxL rd. t` €� t< `�
SUBMIT A COPY OF STATE LICENSE# �` 41 LEA CERT NUMBER -1 EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:.... _ 5� CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE GLE FAMILY/NEW CONSTRUCTION SIZE
❑TWO FAMILY/NEW CONSTRUCTION STORI
PERMIT TYPE ❑ADDITION ❑GARAGE/SHED ❑WIN15OWS
❑BASEMENT'.-EIFIIsH. ❑_DRAIN TILE
DECK ❑SIDING ❑OTHER
SWIMMING POOL
TYPE OF WORK: HOME CONSTRUCTION ❑ADDITION
MAINTENANCE/REPAIR ❑REMODELING
DESCRIBE WORK BEING DONE: /��LIv e `i`�°S t�`t" `' •l Q
SIZE OF IMPROVEMENT LENGT L-10 WIDTH f HEIGHT SQ FT d
ROOFING ❑HOUSE ONLY BASEMENT REMODELING SUBMIT'
NUMBER OF SQUARES OUSE&GARAGE I Existing Floor Plan
GARAGES / TTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ ETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT,
� FQR NEW CONSTRUCTION INCLUDING DECKS,.
t
G ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS &PORCHES SUBMIT
yl 1. Sitc Plan/Survey showing the existing structures
minum ❑Trim REMOVED? ❑YES O and proposed project.
❑Other ❑Fascia 1 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS Oyes ❑No LOCATION OF WINDOWS FOR WINDOWS—PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES&
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALIDATION,INCLUDING THE COST OF LABOR AND MATERIALS:
(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 $ .00I times the total job valuation
Surcharge $ 0005 x Permit Valuation Minimum or.50
License Surcharge $ $5.00(State Licensed Residential Contractors)
SAC Charge $ $2435 per SAC Unit(Plans to MWCC for determination)
Curb Cut Escrow $ ft+6 tt— R x$26-$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary( ) Non Necessary
Total Due $ Make checks payable to: City of Fridle Attach Stipulations
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 fo 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 al k wh'ch requires review and approval of plans. j
SIGNATURE OF APPLICANT "� PRINT NAME °0� DATE
APPROVAL INSPECTORTURF
fir T °r