P - 35816Building BUILDING Permit No.: �
Inspections RESIDENTIAL APPLICATION Received By� �-,•
763-572-3604 CITY OF FRIDLEY vat��:��G 3 2
763-502-4977 FAX EFFECTrvE 1-1-zoii
DATE `ci� YOUR E-MAIL ADDRESS r J o� n� Sd'J U� S� �'e � NCT
siTE nDn�ss �lc7 G?�'`-`� tFcJ. Nd �,7� c�.� s I � i o� %., lnJ
THIS APPLICANT IS: ❑ OWNER $CONTRACTOR
PROPERTY OWNER/ NAME: PA� /N��4 G
TENANT �Dx�ss: ! c7 G � �✓ crrY �
RE � � �le � sTAT➢��1 zIP
PHONE: l�j 1 2^" 3 GO '�O� 2.
CONTRACTOR NAME: R�^�'C�I �o�n�stXv
SUBMIT A COPY OF STATE LTCENSE # Zt7 S%1. S 7 Z LEAD CERT NUMBER /�//Q� "'9' -�
YOUR STATE LICENSE �
ANU CERT�ICATE OF ADDRESS: 3�T /�/ 1� t c/ „! SCGQt� G%� CITY �I'�t BA�Ii STATE /MN ZIP�
INSURANCE PHONE 6�S � FAX
PROPERTY TYPE �SINGLE FAMILY CONS'i'ItTJeTi()1�I, SIZE I.2 00
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
pEgMIT TypE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF O DRAIN TILE
❑ DECK ❑ SIDING 6t''OTE�R n_� r�`
❑ SWIMMING POOL ���'
TYPE OF WORK: ❑ NEW HOME CONSTRUCI'ION ❑ ADDI1'ION
O MAINTENANCE/REPAIR 6�REMODELING
DESCRIBE WORK BEING DONE: e c.�o ��lre}o�+ w 61�� 1` 1 Cw�.�-c l.��N�.r✓ ��'i ���,Jd■ ►�Od+O � G(�7G,Iq/
SIZE OF IMPROVEMENT LENGTH WIDTH � HEIGHT fS S FT
❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NRU�MBE QF SQUARES ❑ HOUSE & GARAGE
i. Existing Floor Plan �
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural membets to be used
PROPOSED HEIGTiT:
SIDING FOR NEW CONSTRUC'ITON INCLUDING DECICS,
O Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
O Aluminum ❑ Trim 1. Site Plan/Survey showing the eacisting structures
0 Other ❑ Fascia and proposed pmject.
2. Two sets of construction plans
WIIVDOWS 3. Energy Calculations
IN EXISTING OPENII�TGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOit NEW OPENINGS-DESCRIBE SIZE OF MANUFACTfJItE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW T4 $E INSTALLED NUMBER OF WINDOWS
A1,L FEES ARE BASED UN VALUATlUN,1N(:LUDllV(� "i'HL (;(�"I` UF LABUR A1VD MA"1'L�'KIALS:
S THE 1 U�C FEE SCAEDITLE)
JOB VALUATION $� I SO 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
$ See Back Page for F� Schedule
$ 65% of Building Permit Fee
$� .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ �'rj $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 ( )
$ ., S Make checks navable to: Citv of Fridlev Attsch
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROC6SSED
I hereby apply for a building permit and I acknowledge that the information above is complete arid accurate; that the work will be in
conformance with the ordinances and codes of th ,'ty of Frid ey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo permit and wor is not start without a permit on site; that the work will be in accordance with the
approved plan in the case of al which 'ew d approval of plans q /�_ , ��,, /
SIGNATURfi OF APPLICANT PRINT� ��� l d0/�u�v DATE i���a• �/ I�
APPROVAL INSPECTOR SIGNATURE . �7�
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