P - 45203Building BUILDING Permit No.: - Q l�
Inspections RESIDENTIAL APPLICATION Re�ei�ea By: `�
763-572-3604 CITY OF FRIDLEY Date xec'd: 1 �
763-502-4977 FAX EFFECrivE 1-i-ao>>
DATE /`V�o�'�� YOURE-MAILADDRESS �it��•�'�'Sl �..-�u�{un�i'•CA�K
siTE aDD�ss � f 6( 6 ri`' �S�t�i' N E.
THIS APPLICANT IS: OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: � t+cLtAt�� Mir�—� {^�(�I^
TENANT AD��ss:��bt 6� 5-�t 1'!E cITY Fr�`di�,l_—_ ,s-raT��_zlr S�(3�.-
PHONE: %��J�-h'6Y'C�J� TT
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE f�SINGLE FAMILY/NEW CONSTRUCTION SIZE
�� TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �C= S � ���' S � c�;�c' +��aL L�'`� •
SIZE OF IMPROVEMENT LENGT W H HEIGHT SQ FT
ROOFING � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � �HOUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: � DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FORNEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS & PORCHES SUBMI_T:
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MAbiUFACTURE STICTCER ON WINDOW.
OPENING CHANGES &
TYPE OF W7NDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALSc
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 3, I`�i"t OCCUPANCY TYPE ___
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
I hereby appIy for a building p�
conformance with the ordinances
permit but only an application fc
approved plan in the ca e of
SIGNATURE OF APPLIC �
APPROVAL INSPECTOR SIG RE
$ "�i•'25"
$
$ 3+t
$ ('
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Pee
.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 NIWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Nec�ssary ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
't and I acknowledge that the information above is complete and accurate; that the work will be in
i od of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
pe i and work is not to start without a permit on site; that the work will be in accordance with the
oval of plans. y�/
S . '^ PRINT NAME Mif ar-� 'f �,Jt_�� DATE ! D`�.Z O��
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