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Building BUILDING Permit Ivo.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd: � lo d/
763-502-4977 FAX EFFECTIVE 1-I-201
DATE ��.- �QIr �J YOfUR E-MAIL ADDRESS ��� / S/ � ID�,�-CC%vl�i
SITE ADDRESS / �l c.] / J °'Yo/ �' � /�G- / iC, l �lL�
THIS APPLICANT IS: ❑ OWNER �CONTRACTO�
PROPERTY OWNERJ NAME: �L C�'��� y
TENANT ADDRESS: /" G � F� ZIPS�z% � Z
% H� � "7J � CITY �� STAT
PHONE: �C� J � 7�� � !t i /
CONTRACTOR NAt�t�: r 5% �yt�Wi �C CJ�
SUBNfIT A COPY OF > /� > /�
YOUR STATE LICENSE STATE L[CENS # �C� Gt �� ZJy LEAD CERT NUMBER %�/ v QCf� I� l� 7�
Cfl
AND CERTIFICATE OF ADDRESS:_ i� /+� �i� 7 Z�� CITY �� STATE�� LIPCA%�!
INSURANCE PHONE��'�' 3vTJ'� !� FAX cj —�--
PROPERTY TYPE rQ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYlNEW CONS'I'RUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED O WINDOWS
❑ BASEMENT FINISH %(� R(X�F ❑ DRAIN TILE
❑ DECK � �6] SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ADDITION
MAINTENANCE/REPAIR REMODELINC
DESCRIBE WORK BEING DONE: � f � i tL/ �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES _� � HOUSE & GARAGE �"�'�{� BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES � ��� ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE � ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
S ING FOR NEW CONSTRUCTION tNCLUDING DECKS,
Vinyl �i��� ��t ADDIT[ONS_ & PORCHES SUBMIT:
,� 1. Site Plan/Survey showmg the existing structures
Aluminum Tnm
❑ Other ���a and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST7NG OPEMNGS ❑Yes QNo LC�ATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR EOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON W[NDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE IN3TALLED NUMBER OF WiNDOWS
ALL N'�r:5 AR�; BA51!;ll UN VALUA"I'ION, INCLtJD1N(; "1'HE COST OF LABOR ANll MATERIALS:
(USING TH�997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ j��Q ._— 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
$' �07� . S5 -- See Back Page for Fee Schedule
$ —�' 65% of Building Permit Fee
$ `3_ o�s .001 times the total job valuation
$ � . .SG .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 ( )
$ . 7S Make checks �avable to: Ciri of Fridlev Attac6
THIS IS AN APPLTCATION FOR A PERMIT-NOT VALID UNTtL 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 ordi�ances a�d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
perrr►it but only an application for a permit and 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 a work whic re ires r iew nd approval of pl s. J� 1—�/
SIGNATURE OF APPLICANT � RINT N E� ,� (� 7 1TJNQ� DATE / K�2� ��
APPROVAL INSPECTOR SIG E
PLEASE NOTE: SEPARAT PLUMBING, ELECTRICAL AND MECHANICAL WORK