P - 39353Building BUILDING P��it No.: I� (�
Inspections RESIDENTIAL APPLICATI4N Received By:
763-572-3604 CITY OF FRIDLEY Date x.e�
763-502-49'77 FAX Er-�ECTrvE �-i-zai i �:,
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DATE / YOURE-MAU.ADDRESS i .�itc.t �'c v[+
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STCE AbDRESS ��4� �% � � �� `� S�"�' � %
THIS APPLICANT IS: L7 OWNER CONTRACTOR
PROPERTY OWNER/ N�: ...�j/�� �a�,,,��
TENANT ADDRES5: ,SC��Cni�i ;'�, 5"i" d/� cTr�t t�t^���atid STATE�%'�ZIP
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CONTRACTOR NpME: jZ� � j�' t�k'n: �v`� u�',� [,�,.zr� : s' �
SUBMIT A COPY OF STATE LIC6TISE # c�C?�Gs G' �� LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTfFICATE QF ADDRESS: ���', t� � 1 r Z�f �"� CITY,�C.rZ+���.'i�-i� STATE,�.ZIP��.� ��
1NSURANC$ PHONE cSt�+� 'rS�►'�G% '�Sf�.�'i[.a ✓ FAX ' ' �.� " ��'<`
PR4PERTY TYPE ❑ SINGLE FAMILYlNEW CONSTRUCTION SIZE
❑ TWQ FAMILY/NEW CONSTRUCTION STOItIE5 i
PERMIT TYPE ��DTIION ❑ GARAGE/SHED ❑ WINDOWS
Q BASEMENT FIATISH l'�ROOF ❑DRAIN TILE
C1 DECK I� SIDING � OTHER
❑ S WIMMING POOL
'TYP'E OF WORK: ❑ NEW HOME CONS CTION ❑ ADDITION
4i'�MAINTENANC AIR � ItEMdDEI.ING
DESCRIBE WORK BEING DONE: `1�'�' G3� !�i� :��a �C'��
SL2E OF TMPROVEMENT LENGTH WIDTH IiEIGHT FT
^ C�7� OUSE ONLY g�SEMEN'F REMQD�LING SUBMIT:
RNUMBER bF SQUARES �.+° r R HOUSE a� GARAGE �. Existing F(oor Ptan
GARAGES d��_j� TTACHED GARAGE 2. Proposed floor plan
PROPOS�U SIZE: l3 DETACHED GARt1GE 3. List of structural members to be used
PROPOSED HEIGHT':
Sy,IDING FOR NEW CONSTRIJCTIpN TNCLUDING DECKS,
❑ vu,yt osotrt
Annr�orrs_ � �R�F�su��
� Atuminnm ❑ Trim 1. Site PlanlSurvey showing the e�cisting strucwres
❑ Oiher 4 Fascia and proposed project.
2. Two sets of consUvction plans
WINDQW$ 3. Energy Calculations
IN EXISTING �P�NINGS C7Yes C7No I.00ATiON OF WINDOWS FOR WINI)OWS — PROVIDE U-VAI.[JE AND
OR FOrR NEW OPENINGS-DESCRIBE SIZE OF MANUFACT{7kE STICKER OI3 WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL r'��� AKE ifA�l�:U VPI VALUAl1V1V� IPIC:LUllltYli lHl; t:V�l Vr LASVK A1VU MAi�lilALa:
([JSING THE 1997' U.B.0 FEE SCHEDULE)
AL JOB VALUATION S OCCUPAI�TCY TYPE
Permit �ee
Plan Review
�ire Surcharge
Surcharge
License Surcharge
SAG Charge
Curb Cut Escrow
Erosiott Control
Pazk Fee
Sewer Main Charge
$
$
See Back Page for Fee Schedule
65°/a of Buifding Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$S.UO (State Licensed Residentia! Coniractors)
$2230 per SAC Unit �Plans to MWCC for determination)
ft+6ft= ftx$25=$
$aS0 Conservation Plan Review
�ee Determinsd by Engineering
Agreement necessary ( ) Non Necessary ( )
Ms�ke checks uavable to: Citv of Fridiev Attac
TFIIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PR4CESSED
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 uiaderstand 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 war_k which rec�u'ues revisw and approval of plans. ,..
SIGNATU1tE OF APPLICANT _ a^� ��`�'"�,�w"'`�� PRIN'T NAME % �'yy�� [ ' � ���-� AATE � '"'�' � �
APPROVAL INSPECTOR SIG13A'T B� •
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