P - 35793Building BUILDING Permit No.: ��( 4Q
Inspections ��I�ENTIAL APPLICATI(JN Received By: -
763-572-3604 CITY OF FRIDLEY Date ��� �� L ��
763-502-4977 FAX EFr�c�v� �-1-201 j
DATE �_ � c�� � YOUR E-;NA1L r1DDRES5 ��-L..�C_Y� f�.t Uc�� �'►'D�1++l�'1A • C:C� �
SITE ADDRESS ���'� ' L f? M' S� • i�C
T'HIS APPLICANT IS: E� OWNER j�ONTRACTOR
PROPERTY OWNER! NAME � Y" Y` �i �' u; �,�
TENANT aDbttESS: ti 3� ?� -- C n''�' .Si- -�l �. crrY �ic� It�STATE�ZIP�
PHONE: `��� ' S 1 �' `L S ( �
corrrRacroR NAME: 1���x P��f-�..,r��-��c.,}; o �
SUBMIT A GOPY OF gTATE LICENSE #� U'�-� Ip Lrt �1 ��I LEAD CERT NL?NBERfZ ' Z- ' I S 3 f�-� O'� �(_"l d
1�OUR STATE LICENSE
AI�iD CERTIEICATE OF nnn�ss:�.� �F. . j l'1 �"� a��, • CITY,�LiiY/LCVi % lG STATELYI/J„ZIP,�,��,�
INSURANCE PHdNE �- i-I- FAX
PROPERTY 1'YPE �SIIdQrLE FAMII.Y/NEW COIVS'IRLiCTI�13 SIZE S
TWD FAMILY/NEW CONSTRUCTIQ?V STORIES
PERMIT TYPE ❑ annrr[ox o G�a��s�a o wn�mows
O BASEMENT EINISH �ROOF ❑ DRAIN TiLE
O DECK ❑ SIDING CI O"!'�iER
E] SW IMMII3G PQOL
TYPE QF Wi1RK: ❑ NEW IiOME COIVST�tUC'RON D ADDI770N
�MAiNTETTANCE/t�£PAIR O REMODEi.ING
DESC`EtIBE WORK BElNG DONE:�L - l� Qo �
SfZE OF tMPROVEMEIe"I LENGTH WIDTH HEIGHT S FT
$QQ� � HOUSE ONLY gq�� �p�EL�G SUBI�IIT:
NtJlNBEIt OF SQUARES �� O HOUSfi & firARAGE
t. Existing Ftoor Ptan
��� ❑ ATTACHED GARAGE 2. Proposcd tloor p18a
PROPOSED SIZE: O DETACHED GARAGE 3. List of stiuctusal members m be usai
PROPOSED HEfG1iT:
sronvc fOR NEW CONSTKUCTION INC.'LLTDING DECKS,
O Vinyi OSoti'rt ADDi"�ION5_ � PORCHES SUBMIT:
❑ Aiwninum i3 Trim
!. Site Pisn/Swvey showing the existing strucUa�es
❑ Oti�er C] Fascia � Proi�d P%I�-
2. Two sds of con�tion pians
}} jNDOW',� 3. Energy Cateutations
Ii3EXI3TINGOPENINCrS OYes CiNo LOCATIONOFWINDOWS FORWTND()WS-PROVIDEU-VALLIEAND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDQW.
UPENiNG CHANGES &
TYPE OF WII+TDOW TO BE iNSTALLED NUMBER qF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST UF LABOR AND MATERIALS:
Pemut Fce
Pian Review
Fire Surct�arge
Surcharge
Licanae Surchsrge
SAC Charge
Cw'b Ci� Escrow
Erosion Control
Park F�
Sewer Maiu Charge
(i1SING THE 1997 U,B.0 FEE SCHEDULEj
S_���q• a S See Back Page for Fee Scheciule
$ __ 65°10 of Suildittg Perntit Fee
S .401 times the total job valuat'son
$ .0005 x Permit Valuation Minimum $5.0(?
� $S.UO (State Licensed Residentiat Contractois}
$ $2230 per SAC Unit (Plans W MWCC for determination)
� ft+6ft= ttx$25=5
$ $450 Cons�ation Plan Review
$ Fee Determined by Engineering
$ Agreement necessaiY () Non NecessarY i)
$ r'�'���T Mxke checks �vabk to: Cftv ot Fridlev Attsc
THIS IS APi APPLICATION FOR A PERMIT-NOT VALID UNTiL PRQCESSED
I hereby appty for a building permii and I acknowledge that tha information above is compiete and accurste; that ihe work will be in
confarmance w�ith tfie ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand ihis is not a
permit but onty an applic�tion for a permit and work is not to start without a p�mit on site; that the work will be in accordance wiih the
approved pian in the case of rk hich wres review d appraval of�.
SIGNATt.3RE OF APPLICANT� ��F1tINT AtAIv¢T'IjO f� ��P�"Sd� DATE '� -�� � �
APPROVAL iNSPECTOR SIts'RQAT[�RE G T-
PLEASE NOTF.: `3RPA�ATF. PF.RMTTS ARE REbUIRED F�R