P - 60337Building BUILDING Permit No.�bi� „�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Da�' �
763-502-4977 FAX EFFECTrvE i-i-ZOia
nA� y` 1�� �a Youx �-Mau,,�nnxESS 'C YlOUS�C� Yl � Cb YISt �C V. C�C t� Yl •�„ O 1'�
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: O� \�'� 2.11�W>
TENANT �Dx�ss: rJ $`6 S '� � 5�' ci'rY �'f ���iV STATE M zu� SSy �a,
PHONE:
CONTRACTOR x�: r1 �1��
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # � � LEAD CERT NUMBER EXP:
AND CERTIFICATE OF �DRESS: � � �� Z,Y � Fi CITY � 1���.� STATEI�N ZII' ss�i 3 a
INSURANCE PHONE � •57 �• �I�� ' FAX
PROPERTY TYPE SINGLE FAMII,Y/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES�_
PERMIT TYPE ❑ �Drr�orr ❑ GaxAG�s�v ❑ wixnows
❑ BASEMENT FINISH � OOF ❑ DRAIN TII,E
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 2���%C7� "�
SIZE OF IMPROVEMENT LENG WIDTH HEIGHT S FT
ROOFING � �HOUSE ONLY BASEMENT REMODELING SUBMIT:
NLTMBER OF SQUARES ❑ HOUSE 8c GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACAED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
�SIDIN _ FOR NEW CONSTRUCTION INCLUDING DECKS,
-L']�Vinyl �'—� ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
O Aluminum • � ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing struchues
❑ Other � ,� ❑ Fascia �d osed ro ect.
� A\� • 2. Two s%ts of construction plans
WINDOWS 3. Energy Calcularions
IN EXIST'ING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF VJINDOWS
ALL r'L�'LS AIZL�' BA�l�'.11 UN VALUAI'1UN,INCLUll1NG THE C;OST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�� OCCUPANCY TYPE
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ f�2�?,l(,�
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Pernut Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimuxn or .50
$5.00 (State Licensed Residential Contractors)
$2365 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 IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 applicarion 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 ll o k which requires review and approval of pl s., 1 G
SIGNATURE OF APPLICANT F�'"�� �"'— PRINT NAME ��(,�G.Y Q��, v11�S-� DATE �" I D� I�
APPROVAL INSPECTOR SIGNATURE