P - 40726Building BUILDING Permlt No.r �I � � _
Inspections RESIDENTIAL APPLICATION Received By
763-572-3604 CITY OF FRIDLEY vate R�r�� � �,
763-502-4977 FAX Er-r�c� i-i-aoii �
DATE / I' � 1 �� YOURE-MAILADDRESS CL.►w[�if`��. S�►^M Q�.d.K.� �CM�t.�L Cd�'\
SITEADDRESS �1SSD ^ S`}'� S�-. iti �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NqME; 3' �'D L�N� t L° ,�
TENANT �Dx�ss: 755 b — 5�` S-�. IJ E. CrrY Ce- 2.�;_Q� STATEI�MIJZIP SS �I 3
PHONE:7Io3- 7 g w�D7 �S i
CONTRACTOR NAME: ofZ. � ��-s�4-c2�4�r� , L� p
SUBMIT A COPY OF STATE LICENSE # � O 3'S� i[ �.b �Y LEAD CERT NUMBER N pl i� O�� S�oi r I
YOUR STATE LICENSE
AND CERT'IFICATE OF ADDRESS:13$5 �a�Ev A�rv £. (v• 54��� J.ol CITY O W �G, �Vq,-1.�. STATENII� ZIPS$�Z�
nvsuxAxcE rxorrB .S 1- "7 3£S- t L g 8' F� L s►-'t 3 - Z 3 3
PROPERTY TYPE �'8°SINGLE FAMII.Y/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES "'Z,
PERNIIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FARSH �ROOF O DRAIN TILE
❑ DECK � SIDING ❑ OT'i�R
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCT'ION ❑ ADDTl'ION
❑ MAINTENANCEJREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ( fC.rk�G C�CQ.. ��J� �R�p L�1rQ. ��bo �' % S IL� � V a_
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING p� ❑ HOUSE ONLY g,�EMENT REMODELING SUBMTf:
NUMBER OF SQUARES �"\�,+\ ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ,�� ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ��DETACHED GARAGE 3. List of shuctucal members W 6e used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTTON INCLUDING DECKS,
,�iVinyl �� M ❑��t ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum � ❑ Trim 1. Site Plan/Survey showing the eacisting structures
❑ Other �� ❑ Fascia and proposed project.
2. 'I�vo sets of construcdon plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes �No LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENRVGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTA,LLED NUMBER OF WINDOWS
ALL FEl�'.S AKE BASl�'.11 UN VALUA"1'lUN, llV(;LUDIiV(T'1'HL (;U�'1 Ur' LAlfUK A1Vll 1V1A"11�:K1ALJ:
_ (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Pernut Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
G�ub Glrt Escrow
Ezosion Control
Park Fee
Sewer Main Charge
$ �JrU�;
$
$
$
$
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 Conservarion Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks uavable 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; that I understand this is not a
permit but only an application for a pemut 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 o 1 work w' requires review and approval of pl c
SIGNATURE OF APPLICANT �� 0�`�� PRINT NAME �i � 2�( FLArj"TU�VV� DATE �1 /�� I I J
APPROVAL INSPECTOR SIGNATURE _ __ _ _ -�
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