P - 84307Building BUILDING Pe�it Ivo �' I �- � j���
Inspections RESIDENTIAL APPLICATION Received By: �
�63-s�2-3604 CITY OF FRIDLEY Date�e ': � v�•
763-502-4977 FAX EFFECTTVE �-i-aoi2 K��� - �°" ��
DATE I� ^ Z� � L Z-- YOUR E-MAIL ADDRESS �11.`��..'� l-_ EGtih� t�� CX)� 4�.�D C�tCA�►� • CO�
SITE ADDRESS �I (�b l GI-P.T4LJ� ,,�� 1�.�` �T
THIS APPLICANT IS: ❑ OWNER �EONTRACTOR
PROPERTY OWNER/ NAME: �o�� � �La.ST�?Z
TENANT ADDRESS: CITY STATE ZIP
PHONE: ��?J ` �� ' �Z� �7
CONTRACTOR NAME: �1�6` i�E oc� ,�la �`rt� � �
SUBMIT A COPY OF STATE LICENSE # �2� c`E`. LEAD CERT NUMBER /V�'17=J�{T��` EXP: r7 ����
YOUR STATE LICENSE �` �
AND CERTIFICATE OF ADDRESS: 3�C � L r �%�� �"iY.t�G? CITY STATEIIG1t�ZIP
INSLJRANCE PHONE % Z.� ' ZL�J ^ SLa'v�' FAX Z° %�' -'i Z-I �
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTTON STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED "'�WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBEWORKBEINGDONE: �i-tiv- �'E 1 T�r�l IJSZtDIn% C�1'SZAU,,N�i,J t+J'� 1+��6'�'f
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ 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 GAREIGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑So�t SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
� Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO �• 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 �LYes ONo LOCATION OF WINDOWS � (7 FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF L.r� u1C`� LE�I �i, 6-�1h6�c �,� lCxrit�`- MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & L
TYPE OF WINDOW TO BE INSTALLED JL Jur1E.eZIUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING T�E 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION � /i ��v t' OCCUPANCY TYPE
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ 1�j�1 t�j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ (�� .001 times the total job valuation
$ �C'q , .0005 x Permit Valuation Minimum or .50
$ lT $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 ( )
$ �, -G"'i in� Make checks aavable 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 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 work c r eview and approval of plan . ���}
SIGNATUREOFAPPLICANT G�'�i"7� PRINTNAME �i'44>�c1t� /'� T�%�`-I�C� DATE /G���/'u
APPROVAL INSPECTOR SIGNATU __-