P - 42360Building BUILDING permit Ivo.: ' � � � � ��
Inspections RESIDENTIAL APPLICATION Received By�r�'�'�
763-572-3604 CITY OF FRIDLEY �t�e,�} �� •
763-502-4977 FAX EFFECTrvE i-i-zoio „�-� v�
DATE iQ �v � YOURE-MAILADDRESS `-I"�'t.Sl(� 1���5�� `2�� 6�CP .�
SITE ADDRESS 0 � I�'i �' � � � ��
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: �--`j- ' �E� j�i f!�
TENANT ADD�ss:�gs� 7r+� �,eE� r �U� ciTY �--�'-t L1 G.�� sTaT�11Y1� )zir�S 3
PHONE: ! �C^ � " s�Jy%�— �f��
CONTRACTOR NAIyE: 0 ��7� � ' T �.. �'� � .1��L
SUBMIT A COPY OF STATE LICENSE # -� � EXP DATE � C� I
YOUR STATE LICENSE �,� r
arr� c�xTr�icaTE oF A���ss: `7 �C- i�l �ua� ,����u �- I�.� v� i�-1 c�TYN� tv �-f� I�£ sTnT ?�Jz�P SS �
INSURANCE PHONE ' � � FAX " c0
PROPERTY TYPE �-SINGLE FAMILYINEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTOrr ❑ GA�G�isxED wiNDOws
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
Q SWIMMING POOL
TYPE OF WORK: d NEW HOME CONSTRUCTION ❑ ADDITION
ISLMAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �Tj..>SCi� l.(� � IJ ���� W l 1� 1`�(7 l�l�e; l/Li � X l5 G 7�l.�C,t— ����
SIZE OF IMPROVEMENT LENGTH WIDTH AEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSB & GARAGE
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:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDI'I'IONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. 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 qNo LOCATTON OF WTNDOWS FOR WINDOWS — PROVIDE U-VALITE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF , MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & V �
TYP& OF WINDOW TO BE INSTALLED �I��SA NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDllVG THE CUS'1' UF LABUR ANll MA'1'EKIALS:
r�( SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION ���J`T �� 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
$ ��j„� �j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ , .001 times the total job valuation
$ � .0005 x Permit Valuation Minimum $.SO
$ �j. � $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Ageement necessary ( ) Non Necessary ( )
$ I,"7 Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a building permit and I acknowiedge 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 bnt 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 all w k which req ire �4iew and pproval of plans.
SIGNATURE OF APPLICANT � /S � Q. T NAME L !�1 /Gd� -f }�-1C-1`7 �" � �DATE ! 1 �