P - 44560199���
Building BUILDING pe��t No.: �1 L�%��-1 ��'�
Inspections RESIDENTIAL APPLICATION Received By: i��
763-572-3604 CITY OF FRIDLEY D ' `�
763-502-4977 FAX EFFECTrvE �-i-ZOi� �� "
DATE /C��/�//� YOUR E-MAIL ADDRESS �i7�/i�E /�iG/k`rr�.�'1 �(� i y�nr �ene,r��M�J CO°'"`
SITE ADDRESS �lo/% 7 " S°��G�'� /VE
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: QID11 ��l�iyi/t�J�YC_
TENANT ADDRESS: JlG�% y� �S�/L�C�/�E CITY�/G STAT�tnN'ZIP,��3a
PHONE: �I- �%�o Y- /3�D
CONTRACTOR NAME• ' L�o S �
SUBMIT A COPY OF STATE LICENSE # edTD/�yq.3 LEAD CERT NUMBER�#�� %I�-�
YOUR STATE LICENSE
AND CERTIFICATE OF .4DDRESS:�/ F�.lk 4�. CITYCSS�i� STA'T�ZIP.SS',a7
INSURANCE pHONE 'D��� FAX S�— % S
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF DRAIN TILE
0 DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCI'ION O ADDITION
"ji(MAINTENANCE/REPAIR ❑ REMODELING
�
DESCRIBE WORK BEING DONE: O
SIZE OF IMPROVEMENT LENGTH W[D HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE RASEMENT RFMODELING SURMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be u9a1
PROPOSED HEIGHT:
SIDIN� FOR NEW CONSTRUCITON INCLLTDINCi UECKS,
❑ Vinyl ❑Soffit AnDI1'IONS_ & PORCHES SLI�I�LiT:
❑ Aluminum ❑ Trim 1. Site P1anJSurvey showing d�e exisdng struct►ues
❑ Other ❑ Fascia �nd PfOP�d project•
2. Two sets of construction plazis
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �1'es �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE ANb
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON W[NDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS %
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MA1'EKIALS:
U�N� THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�D���� — OCCUPANCY TYPE __
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ��i l, L� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .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 ( )
$ ,'i Make checks aavable to: Citv 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; thst I understand this is not a
permit but only an application fo er ii d 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 � � • view and approval of plang.y�j� , r��/
SIGNANRE OF APPLICANT _ PRINTNAME !%'//��,�/(i�Cf'y/f�i'I DATE I�