P - 41216����y
Building BUILDING Pe��t No.: �" G� 1� �
Inspections RESIDENTIAL APPLICATION Received By: ^ 1
763-572-3604 CITY OF FRIDLEY D '
763-502-4977 FAX EFFECTivE i-i-zoii �� �������
DATE � � �% YOUR E-MAIL ADDRESS �/�/ ��Gr� • /Y7 i'/�i�?�'��t[i:ht7EiCYd r'a�hc' •?,L1 �S 'h'lN` Lp;v►
SITE ADDRES9 � % / i�t3 I �
THIS APPLICANT IS: ❑ OWNER TP�CONTRACTOR
PROPERTY OWNER/ �
NAIVtE_ i %a,n �,r /Sc�it
TENANT A��t�ss:o�/i � `�''�=' /�r.a�e /�6�� crTY �ricJ�. sTaT�i9t.! zIr 5S �f � �
PHONE: %�,�°S %�� �S�rP
CONTRACTOR NAME:�� 0' ' CY1c``D!�►���1`l1Lt e'.se'sLA
SUBMIT A COPY OF STATE LICENSE #,y��'%f�`i„� �iL %3 LEAD CERT NUMBER u/�% o`�� `t lF, " J
YOUR STATE LICENSE /�� - - —
AND CERTIFICATE OF ADDRESS: ,�5�/ �eJ�c �/L°�7� CITY ��- /�iGtt,c/ STATL��IP SS t C�i
INSURANCE PHONE /- O•- %D� FAX � r- �-• '"
PROPERTY TYPE �[SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BA5EMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION Q ADDITION
'6�NIAINTENANCEIREPAIR ❑ REMODELING
c
DESCRIBE WORK BEING DONE: / � G' ` ��
SIZE OF IMPROVEMENT LENGTH WIDTH IGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES O HOUSE & GARAGE
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:
IDING ADD TI NS & ORCHESOSUBMIT.DING DECKS,
❑ Vinyl ❑Soffit
❑ Aluminum ❑ Trim 1. Site P1an/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS Yes ❑No LOCATION OF WINDOWS FOA WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS- ESCRIBE SIZE OF �� �f �if hC r'C�+►v1 i BOC��1�. I P�QC�Ird1C'� V►� MANUFACT[JRE STICKER ON WINDOW.
OPENING CHANGES & _—�-- �^
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS s
ALL FEES ARE BASED ON VALUATION, INCLUDING THE CUS'1' V�+ LABUR ANll MA'1'r:1t1AL�:
_ (USING THE 1497 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
ANCY
$ (�LS L`J See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ c .001 times the total job valuation
$ � .0005 x Permit Valuation Minimum $5.00
$ `�U� $5.00 (5tate 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 ( )
$ I 3l� �� `-N Make checks uavable to: Citv of Fridley Attac
THI5 IS AN
I hereby apply for a building permit and I a
conformance with the ordinances de f
permit but only an application e t a
approved plan in the case of
SIGNATURE OF APPLICANT
APPROVAL INSPECTOR SIG
PT.FA�R N(�TF:� '",F.PARATF: PFR T
A TION FOR A PERMIT-NOT VALID UNTIL PROCESSED
cknowle e that the information above is complete and accurate; that the wark will be in
the ity o Frid and with the Minnesota Construction Codes; that I understand this is not a
ork is t o start without a permit on site; that the work will be in accordance with the
� es re i d approval of plj� / ,/ r %� / /
PRINT NAME �%///J� !�'lC/�-m1�'l DATE �i l07% J I/
ay,��,