P - 48344Buildi�g ' BUILDING Permit No.:� 1�1�,6�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ��;�� I� � � � � � �
763-502-4977 FAX EFFECTivE �-i-ao� i �
DATE I�U �� ` p YOUR E-MAIL ADDRESS S���l �i k) nr��� ��ct�l°l.�C�nStYULt� �n � �� �
SITE ADDRESS C'1 "1 l, �� / IY ` �
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: �C E� Y� '�' �i1 C,P/ IPL' S
TENANT ADDRESS: �I � O � iI�(� : �W CITY r y ��L�'`/ STATE�ZIP �C �,�
PHONE: �II.��J�� � J I �2� �
CONTRACTOR NAME: Si1 � `l� '�t' C S�'�'�1�fi
SUBMIT A COPY OF 4�1,� '� LEAD CERT NUMBER
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS: ���� ��'� l�imc�v�c s r nl � S�"G� �� (�_CITY ��lhlv�lZ� STATE �NZtPG��
INSURANCE p NE �l� � Z� �� d FAX �� `!� � 7� ���i Z
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOR[ES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISIT Y�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDWG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �' � (.� G G:,
SIZE OF [MPROVEMENT LENGTH WIDTH � HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �_ �HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l. 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 structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST[NG OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
I�� �`�\1��■a�Y�lZ17�\�L•7�U1.•M.�.C�i\A IlC�1L111\`Cl'� �:19[K�3s� i�] � R,]_ei�] :r �►111►'/ I_r � DI N I_\ rY.�
fy(,U��SI G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ L!� ��V 'J� �� OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ II 1 La
$
$ u�
$ �i
$ ; G
$
$
$
$
$ - -
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 Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 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 d�l�v�k�wh� re u �r review and approval of pla � 1,� ' �i
SIGNATURE OF APPLICANT ��k �1 � � Ai 4`-+ PRINT NAME �'u,%� �(J,1�•,�.f'(J�! DATE �Q �" ( � �'
APPROVAL INSPECTOR S[GNA R
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK