P - 35057Building $[JII,DjN(i Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Dat��'�:F�B 17 2� �
763-502-4977 FAX EFFECT�vE i-i-2oi�
DATE OUR E-MAIL DDRESS
SITE ADDRESS � � '�
THIS APPLTCANT I. ❑ OWNER NTRACTOR
PROPERTY OWNER/ NAME:�: r y� (` p-�, �-�-�,'k.
TENANT ADDRESS: Ct? %J`'�� J9 �%"f j 00� ��� CITY F�� c�`� (�I STATE��ZIP S��I 30�
PHONE: % (P 3— .5 �7 J � ,S S—S'S
CONTRACTOR NaME:�_5�-c.Lt Z'nst�► ( �-4-- i'nr�
SUBMIT A COPY OF STATE LICENSE # O�aSSOS�'/ '� P LEAD CERT NUMBER
YOUR STATE LICENSE M
AND CERTIFICATE OF ADDRESS: o�SC7 D i-{ u1.�L �,� Z� S� CITY n'1 PLS STATE ��ZIP SS I
INSURANCE pHON� FAx
PROPERTY TYPE T�G'SINGLE FAMILY,�NEW CONSTRLICTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION 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
DESCRIBE WORK BEING DONE: e�((,� Ce.. C� F15 2146V�C—�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOF[NG ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & 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 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 Calwlations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE S[ZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL NL�J AK� KA�r:ll U1V VALUA'11U1V, 11VCLUll1NC: '1'H� CUS'1' UN' LABUK ANll MA'1'EKIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ See Back Page ior Fee Schedixle
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �lO •O O Make checks payable to: City of Fridley 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 des; that I understand this is not a
permit but only an application for a permit and work i to start without a permit on site; that th ork will be in accor ance with the
approved plan in the case 1 ch requi w and approval of plans �,,./� '
SIGNATURE OF APPLICANT6�Li�� - PRINT NAME �� �1�/ : UATE ��