P - 45135Building BUILDING Permit No.: c�'� �}��
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date
763-502-4977 FAX EFFECT►ve �-i-ao�i ��������
DATE lD '-2/ � 2v/ / YOUR E-MA1L ADDRESS f`�L> o'-'h� %�-��( 5'rr/�rn�� C��Y�kc,�.� . ca yv�
SITE ADDRESS _ ��� �T.� �s .vr
THIS APPLICANT IS: ❑ OWNER �ICONTRACTOR
PROPERTY OWNER/
TENANT
NAME: •TJ e W � �x�
ADDRESS: lvo2/ G!k �i idr' CITY ,�`jd/�Y STATE N4tJ Z[P ��t�3z--
PHONE:__ _7�i 3 - �iZ�?- l�'S.�.3
CONTRACTOR NAME: �r j--rk. (ar.�l ��4/in4 � /tiS'�✓a%�o.r1 i�v�- —
SUBMIT A COPY OF STATE LICENSE # S LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: /��b/ �.e��r ,Dr N� CITY L'�L, ✓ STATE � n)ZIP SSa//
INSURANCE PHONE 7� �- 443 - F�3a FAX �63 - �- 9 c� S
PROPERTY TYPE �'SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES /
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMMMG POi
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
_ ❑ MAINTENANCE/REPAIR �REMODELIN
DESCRIBE WORK BEING DONE: Re Ya�
SIZE OF [MPROVEMENT LENGTH WIDT
ROOFING ,,i- O HOUSE ONLY
NUMBER OF SQUARES � � �FiOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
IDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ DRAIN TILE
C1 OTHER
HEIGHT
FT
BASEMENT REMODEL7NG SUBMIT:
I. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUAING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1• Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
I WTNDOWS 3. Energy Calculations '
i IN EXISTING O�'ENINGS ❑Yes �No LOCATtON OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OAENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$ �" �- LS See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the tota] 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 [S AN APPLICATION FOR A PERMIT-NOT VAL1D 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 a work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al rk w i �ir re ' and approval of plans.
SIGNATURE OF APPLICANT PRMT NAME fa �1 (�p�,..vTc� DATE l0 ���" �/
APPROVAL INSPECTOR SIGNATU