P - 42150Building BUILDING Permit r1o.:ad� 55 _
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Dat���cl:���
763-502-4977 FAX EFFECTrvE i-i-ZOii
DATE -7 �$/I/ YOUR E-MAIL ADDRESS ��F C�. Y►C ^ 1MYl, . C,pv`1
�,. 1+
SITEADDRESS 7eiU �'j% WL
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: l�e.«.I ILass t. r
TENANT ADDRESS: �e�0 G7 A� c Ci�
'�� N �✓:C� It W STATE ZIP
PHONE: 7G 3 ' oZUS ' < <I�%
CONTRACTOR NAME: �� r►.�. ('�nnec,l �.r�
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER RK %77 -(
YOUR STATE LICENSE 1
AND CERTIFICATE OF ADDRESS: a�. r IJ�j✓e. CITY �. uI STATE�ZIP S�f�
INSURANCE PHO % FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCI'ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMTT TYPE � �DITION ❑ GARAGFJSHED w[Nnows
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTI�R
❑ SWIIviMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCEJREPAIIt ,,�REMODELING
DESCRIBE WORK BEING DONE: e � t t ���a, ��ity ?f vV/ wdwt% " ra�'�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
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 ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing situctures
❑ Other O Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes f�No LOCATION OF WINDOWS NE GOr ��r FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & ,�,,,i
TYPE OF WINDOW TO BE INSTALLED t ^ Cf �"`k � NUMBER OF WINDOWS
ALL FEES ARE BASED O VALUATION. INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN�G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � OCCUPANCY
Permit Fee $
Plan Review $
Fire Surcharge $ .
Surcharge $ , 'i
License Surcharge $ 0
SAC Charge $
Curb Cut Escrow $
Erosion Control $
Park Fee $
Sewer Main Chazge $ �-�-�--
Total Due �1 1 •7�
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 Conservation Plan Review
Fee Deternuned by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable 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 aclmowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio r r nd 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 oi uves review and approval of p s.
SIGNATURE OF APPLICA PRINT NAME_ ��o.a �iA.W�..l�. DATE �i/2'QIII
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