P - 48054Building BUILDING Permit No.: �d I'�'
Inspections RESIDENTIAL APPLICATION Receivecl By: �(Y1 '.
763-572-3604 CITY OF FRIDLEY n��°a� �� 0�����
763-502-4977 FAX EFFECTNE 1-1-ZOii
DATE G"�- �� YOUR E-MAIL ADDRESS Z qb '�1" .� (� �• C
sITE nDD�ss SG 3�0 5� t-4- �/F= Fr ;�(� y
THIS APPLICANT IS: ❑ OWNER C�ONTRACTOR
PROPERTYOWNER/ NAME: I� ri � S �r o(n
TENANT �D�ss: 5� 3 9 •� �, S.�. �1 E ciTY � r� d( o�sTATE � zir SSS<��
PHONE: �I L 3- S% I' S� S�
CONTRACTOR NAME: �IU F h c-�dI S/
SUBMIT A COPY OF STATE LICENSE #? e(„
YOUR STATE LICENSE � y�,, /�� LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS:� � 3 n � (�oi,�,e,�.3 K� g 1 CITY 17T�j STATBAI� ZIP {s3 7 y
INSURANCE pHONE FAX - D
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION �j
❑ MAINTENANCE/REPAIR ❑ REMODELING '� `
DESCRIBE WORK BEING DONE: t � � V�'' �� f I�e
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING /�2 ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES d J f�HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl - ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDpWS 3. Energy Calculations
IN EXISTING OPENINGS OYes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENIIQGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N�1+.��� AKL l3A�L� ll U1V VALUA'1'lU1V� 11V(;LULi1Vli 1tlE C;V�11 Vr LAIfVK A1vL iv1Al1�,K�A� ��1:
(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 Surchazge $ .001 times the total job valuation
Surcharge $ � .0005 x Permit Valuation Minimum $5.00
License Surcharge $ i�'� � $5.00 (State Licensed Residential Contractors)
SAC Chazge $ $2230 per SAC Unit (Plans to MWCC far determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due
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 ordin s and codes of the City of Fridley and with the Minnesota Conshuction Codes; that I understand this is not a
pertnit but only an applic on r 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 f a ork which requires review and approval of plans.
SIGNATCJRE OF APPLICAN PRINT NAME'�p,e•• �n,1�1,1�q e,% DATE �Ej " a' '�'
APPROVAL INSPECTOR SIGN
PLEASE NOTE: S ARA E P ITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK