P - 84392Building BUILDING Permit No.. la v�'"�(�
Inspections RESIDENTIAL APPLICATION Received By:� �
763-572-3604 CITY OF FRIDLEY Date �e�'�: ���� ���
763-502-4977 FAX EFFECTivE i-i-zoiz
DATE ' ,O YOUR E-MAIL ADDRESS �`�i(�� �y�S -C.e��
SITE ADDRESS � L� - s� S S�' 2
THIS APPLICANT IS: ❑ OWNER �QNT CTOR
PROPERTY OWNER/ N,�: �,,,{,,,, �:�r�
TENANT �DRESS: 1� v+..c,.� CITY STATE ZIP
PHONE: ��� - S%L� -��'L�{2
CONTRACTOR NAME: ��hu �c. �,�,�V,.�S
SUBMIT A COPY OF STATE LICENSE #
YOUR STATE LICENSE �CD� ��7 3_ LEAD CERT NUMBF.R�2%� - i EXP:�
AND CERTIFICATE OF �DRESS: (�UU /.) i�-t/uc. L►-� �l1 CITY '� ,�, • STATE/'liV ZIP S� L i_+7
INSURANCE PHONE � - 32 - S- � FAX �ti3 -�'L3 - ���"i
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK O SIDING � OTHER
❑ SWINIMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �-t_-vU u
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia - 2. Two sets of construction plans
WINDOWS '�� 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑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
ALi, F�ES ARE BASEI� �N VALUATI�N, I;Yi>i,UDTNG THk COSI' OF LABUR AND �!IATERIALS:
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
THE 1997 U.B.0 FEE SCHEDULE)
�__ OCCUPANCY
$ '`�� �Z'� 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 payable to: Citv of Fridlev 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 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 all�'ork whi h requires review and approval of plans. j
SIGNATURE OF APPLICANT �/�� , %���_ � ,� PRINT NAME �Zt� �r � � �n� DATE � /?`'� J {�
APPROVAL INSPECTOR SIGNAT