P - 41214Building BUILDING Pe�t No.:�.,� � � '� �I �
Inspections RESIDENTIAL APPLICATION Received By:�Yi�`
763-572-3604 CITY OF FRIDLE� Date �� ��� 2 4
763-502-4977 FAX E��.r�,-,-Za„
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srrE .�n�xESS � �' .�' 3 `� S �% ,�v� - ,f1 E .
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ N,�: i L� :TcJ � l�j (r'
TENANT ADD�ss: 1 y S 3 '7 S. i/l�a°. � E �� j-y�l �d t z�y sTA� zrr
rxorr�: 4 r 2- ? 4 q'.��Y Z S' -T
CONTRACTOR N�: � s f' j�i�{-..ti �-��i d f��j
SUBMIT A COPY OF /�
YOUR STATE LICENSE STATE LICENSE # Z � �' 3 � �i � LEAD CERT NUMBER F�� '� � �� �' � � v �� � 1 �'r �
AND CERTIFICATE OF ADDRESS: lA ����i � 2 3 7 CI'ty�N 5� STATE�/�IP 3%U9
rt�rsuRANCE rxorrE ��� . 3v�'�f',� a F�
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION STZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGElSHED ❑ WINDOWS
O BASEMENT FINISH [�ROOF � DRAIN TILE
❑ DECK � SIDING ❑ OTI�R
❑ 5WIMNfING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIl2 L7 REMODELING
DESCRiBE WORK BEING DONE: � �� G1�1G l Z g: da �J
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING '� i � ❑ HOUSE ONLY
NUMBER OF SQUARES Zl+ �� ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
i. Ezisting Floor Plan
GARAGE5 ❑ ATTACiiED GARAGE 2. Proposed floor plan
PROPOSED SIZE: q DETACHBD GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
5IDING �+ Q,, Q FOR NEW CONSTRUCTION INCLUDING DECKS,
C� Vinyl `}� '�j� �Q ❑Soffit ADDITTONS. & PORCHES SUBMIT:
1� Aluminum '� 1�j ❑ T� i. Site Plan/Survey showiag the e�cisting structures
O Other ❑ Fascia
and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes �No LOCATION OF WINDOWS FOR WINDL3WS —PROVSDE [3-VALtJE AND
OR FOR NBW OP�,NINGS-DESCRIBE SIZE OF MANUFAL 1'CTItE STICKER ON WINDOW.
OPENiNG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMF3ER bF WINDOWS
ALL r'L�'L�'� AKL+' �iASL+'ll U1V VALUA'1'IUtV, 1N(:LUll11VCr' '1'HL C:VS'1' Vr' LAt3Uli AlVll MA'1'LK1AL,:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Esctow
Erosion Control
Park Fee
Sewer Main Charge
Total Dne
�
$ C� I, �`.� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ ___��{J� .001 times the total job valuation
$ ��� .0005 x Pernut Valuation Minimum $5.00
$ S �� $5.00 (State Licensed Residential Coniractors)
$ $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 pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID 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 pemvt 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 work w c q �s� r� ew and approval of p p
SIGNATURE OF APPLICAI�iT c� ��'n'~'^ ��%"vh/�� PRINT NAME V�����l'V� DATE 1� Zg 'Z� �(
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED POR PLUMBING. ELECTRICAL AND MECHAIVICAL WORK
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