P - 40700Building BUILDING Permit No.:� � i�
Inspectioiss RESIDENTIAL APPLICATION Received By: ��
763-�72-3604 CITY OF FRIDLEY Da���'d� ��`� �
763-502-4977 FAX EFFECrivE 1-1-zo� 1
DATE �� YOUR E-MAIL ADDRESS �/Z.�`.�. f//L�`91.�1��''i/7/ICiJC(J.�'/CDd�S'917i�/�«'
SITE ADDRESS _ '�.5�6 �T���GG-Y �Sry� /V� /
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �r y�„
TENANT ADDRESS: 7S'% . �f /�� CITY f-,ri`C!/�i/ STATF�it.� zIP .S.S" S'�
PHONE: ��a7^ �S'�"' G� 13D
CONTRACTOR NAME: � ` t :r
SUBMIT A COPY OF STATE LICENSE #' LEAD CERT NUMBER T �
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �9/ �(x'c S�t� f" CITY � Q'i� � STATE�(IZIP �D %
INSURANCE pHONE % `JO —G/L>Sb FAX
PROPERTY TYPE �,SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ' WINDOWS
❑ BASBMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SID1NG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRI$E WORK BEING DONE: / � �
SIZE OF IMPROVEMENT LENGTH WI H HEIGHT 5 FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List ofstructural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS_ & 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 ❑No LQCATION OF WIND WS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF /�11'i`hS �ny+�� �CPYbc?�t,t� �'�F �iSeF'►�av�f Ca� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & � - �
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUll1NG THE CUS"1' UF LABUIt A1Vll MA'1'L:BlALS:
(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
Total Due
$ ��'"�, ,L� 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$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ (� ,`� Make checks navable to: Citv of Fridlev 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 er t and work is not to start without a permit on site; that the work wili be in accordance with the
approved plan in the case of � r res review and approval of pla,n� .j // �i �y%
SIGNATURE OF APPLICANT e� PRINT NAME !if//A� �L,Cryrf4-l�- DATE /J�.3/��
AND MECHArTICAL WORK