P - 45500Building BUILDING Permit Ivo.:� �� ��� �'�
Inspections RESIDENTIAL APPLICATION Received By�
763-572-3604 CITY OF FRIDLEY ' � � ��a�
763-502-4977 FAX EFFECTivE �-�-zo�i � R��-�-�—
DATE �� f o�0f l/ YOURE-MAILADDRESS CY14t:(.JCK �� �In-� •�JCJ�_
SITE ADDRESS l 3 eJ7 Y v
THIS APPLICANT IS: ❑ OWNER �CONT CTOR
PROPERTY OWNER/ NAME: b � ,/��
TENANT pDDRESS: � � ���eh � CITY r'�� STATE'1 �I/�ZIP�
PHONE: ��� S�JoZ "' S! �JO
CONTRACTOR NAME: ,lZIQ Rdof+tlq � "R.t.moc�t.\t•ryw
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #�O� LEAD CERT NUMBER N�- a5o3y" �
AND CERTfFICATE OF ADDRESS: 4IOO �(G,�'jj(�t' (31UC� CITY'�„�Ota.Cs �vrt, STATE� ZIPSsV�G
INSURANCE pHONE a5�- a �5 �`7?� FAX C{61 - �( �,� -�/
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH .�B-ROOF �G(� �y�� ❑ DRAIN TILE
❑ DECK ❑ SIDING �M �y ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT[ON
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BE[NG DONE: �'rG.�O iPacC.� G� �%t �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structwal members to be used
VROPOSED HCIGHT:
SIDING FOR NEW CONSTRUCTION INCLUD[NG DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Pian/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
1N EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CI-IANGES &
TYPE OF WiNDOW TO BE INSTALLED NiiMBER OF WINDOWS
ALL h'N;ES AK� BAS�D UN VALUA7'IUN, INCLUUING '1'Hr; CUS"1' UN' LABUIt A1Vll MA7 �KIALJ:
US�NG THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION � IqS� � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� dh�(�U
$
$
$
$ SOb
$
$
$
$
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 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wil] 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 11 work which requ'r �Jreyie v and approva] of plans.'\ )�
SIGNATURE OF APPLICANT � 1% �r A Y.!� PRINT NAME �C.Je+�t�/! r7�.. (it (� C l� DATE �V IZD� /I
APPROVAL INSPECTOR SIGN URE
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING. ELECTRICAL AND MECHANICAL WORK