P - 47964Building BUILDING Permit No.: ,��;
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Da��''c��� � �Q��
763-502-4977 FAX EFFECTIVE 1-I-201 I
DATE �y— g�— I� YOUR E-MAIL ADDRESS /Vt.�iy�If�l,C' ��/w r CUCdS�'Xc"� CiT"—('�J C-CR/ •
SITE ADDRESS ��U �� S% ��iQ-'.��/ �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS: C1TY STATE ZIP
PHONE:
CONTRACTOR NAME: �i�Cy Vv;�3�2 CC1rU
SUBMIT A COPY OF STATE LICENSE #�(��/�/,3c�SZ5 LEAD CERT NUMBER
YOUR STATE LICENSE ���"���0/_ �
AND CERTIFICATE OF ADDRESS: ��c�it C 1�, L �'/'�,f /i�t¢ CITY STATE�LIP ��-y3�1�
INSURANCE pHONE ^� iC�' FAX — Q� G� -,�/ )
PROPERTY TYPE SINGLE FAMILYMEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMtT 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: P� �„QC,� -
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING � HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � Y� ❑ HOUSE & GARAGE I, Exis[ing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. 8c PORCHES SUBMIT:
❑ Vinyl ❑Soffit
❑ Aluminum ❑ Trim �. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
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 MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE 1NSTALLED NUMBER OF WWDOWS
ALL FEES AItE BASN:ll UN VALUA'1'IUiv, 11VCLUU11Vli I H� I,USI VI' LAISIJK A1VU 1VlA 11SKlAL�I:
(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
Totai Due
$ �' ,�.� Cj See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �,,," ;� .001 times the total job valuation
$ � � .0005 x Permit Valuation Minimum $5.00
$ �j�:, i� $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 ( )
� ^ i��� Make checks pavable to: City of Fridley 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 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 aJ�wp rk i r u° es review and approval of plans.
SIGNATURE OF APPLICANT �(a/ r ` _ __ ' PRINT NAME_��„ZZ ,�i%[ � DATE � �!�
APPROVAL [NSPECTOR SIGNA J EIi� _