P - 48048Building BUILDING Permit No.:�
Ins ections �
p RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd:
763-502-4977 FAX ��� i_i-2oii
DATE i0 '�p - i( Youx E-�L anD�ss roo� e�.�r.r,.,n.��l•� I-�'� �
5ITE ADDRESS �7{��� G� �jf � E
THIS APPLICANT IS: ❑ OWNER C�CONTRACTOR
PROPERTY OWNER/ Na�: '(�,�f \k
TENANT ,�D�ss: K L���, � 4�- n! � ci� �r►`c9��, STATE/FN zrn Sfy �2
PHONE:%b3- S%1• `I`Fg
CONTRACTOR NAME: ���D�� SnG
SUBMIT A COPY OF STATE LICENSE # oi 6 3 D LEAD CERT NUMBER
YOUR STATE LICEN5E
AND CERTIFICATE OF ADDRESS: � I 3�%I (' �„L� (2pc � 1 CTTY STATE .l.t.t�IP��
INSURANCE pHONE � ii � � FAX ��3-�/� ' J��.�9
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCT'ION s�zE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDTTION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTTION
� MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: E i S,e. 4
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. Pcoposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of siructural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyi ❑Soffit
ADDITIONS, 8c PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site P1azilSurvey showing the existing sWctures
❑ Other ❑ Fascia and proposed project.
2. Two sets of consixuction plans
WINDOWS 3. Energy Calculations
IN EXISITNG OPEI�IINGS OYes ONo LOCAITON OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACT[JRE STICKER ON WINDOW.
OPENING CITANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL l+'1:N:� AKI: BA51:ll UiV VALUA"I'lON,1NCLUDIN(G THE CUST UF LABOR AND MATERIALS:
(LTSING THE 1997 U.B.0 FEE SCHEDiJLE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Conttol
Park Fee
Sewer Main Charge
Total Due
$ �(1C>`- � �'
$
$ / ",
$
$ �
$
$
$
$
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 paYable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PF.RMI'C-NOT VALID LJNTTL 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 ordinanc d codes of the City Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio for pernut and s ot to staR without a permit on site; that the work will be in accordance with the
approved plan in the case of 1 w w requires i and approval of plan �—t_�
SIGNATURE OF APPLICANT ;y' P NAME �th-- C�. �..'�..�rrr� DATE �•�
APPROVAL INSPECTOR SIGNA
PLEASE NOTE: SEP TE PE REOUIRED FOR PLUMBING. ELECTRICAL AND MECHANICAL WORK