P - 46274Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY va�, :'' ���
763-502-4977 FAX EFFECTIVE 1-I-20ll
DATE�z,.-�-n �% l YOUR E-MAIL ADDRESS
SITE ADDRESS �,) G3� � AtlL' IU.,��- .
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: /�F'S cS«T�i.Z
TENANT ADDRESS: S�da �� A�iQ= ,CJ.,C- CITY_ '�j'���LL�-L i STATE iC/LIP�
PHONE:��I,� ��/�' ^L`;� � �_
CONTRACTOR NAME: f-�r�'X1iiU �a�L�3�� .
SUBMIT A COPY OF STATE LICENSE #��� 6'a LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �73a( tJ�C��.Z,SZJr l/� At_ti� CITY ' STATE/'� IP S�%
INSURANCE PHONE � ' �. FAX
PROPERTY TYPE INGLE FAMILYMEW CONSTRUCTION SIZE
TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION O GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OF ❑ DRAIN TILE
❑ DECK SIDING O OTHER
SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
TENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DON :��dQC �1S'7T�iC/ i�t!/FC� <
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S Ff
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �r ❑ HOUSE & GARAGE I, Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE � 3. List of sm►ctural members to be used
PROPOSED HEIGNT: r `
SIDING `� U\ FOR NEW CONSTRUCT[ON INCLUDING DECKS,
O Vinyl ❑Soffit \�� ADDITTONS. & PORCHFS SUBMIT:
❑ Aluminum � Trim ��� 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of consuuction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS QYes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE 51ZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF W[NDOWS
ALL N'L�'N:1 ANI: SA1L�'ll UN VALUA"1'IUN, 11VCLUUIN(i'1'HL�' CUS'1' UN' LAKUK ANU MA'1'L�'121ALS:
(USINC THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ���25
$
$
$
$ �ipb
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 perSAC 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 pernut 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 w r i h r u' es review and approval of pl s
SIGNATURE OF APPLICANT � PRINT NAME�,� �� DATE �!_��,��T_
APPROVAL INSPECTOR SIGN T RE