P - 39339�. �a �� �
Building BUILDING Permit No.� ,b Z
Inspections RESIDENTIAL APPLICATION xe�ei�ed By: '
763-572-3604 CITY OF FRIDLEY D��'�°� ��' 1 Q1�
763-502-4977 FAX EFFECTivE i-1-zo>>
DATE / YOUR E-MAIL ADDRESS (�%lJ1�Yl .Q, L��C�X`Q j(?C • CS�1
SITE ADDRESS �t (,p L!C Qr �
THIS APPLICANT IS: ❑ OWNER �1CONTRACTOR
PROPERTY OWNER/ NAME: ��(',� ,d. �JQ,(,(,�('�, �� US
TENANT ADDRESS: ��� CD � K�1� �J�„ CiTY � � I STATE IiiN�ZIP �_�
PHONE: Z��� ��'�y �Z �
n
CONTRACTOR NAME: �pr����"�"�
SUBMIT A COPY OF STATE LICENSE # �'j N��" (1 �`
YOUR STATE LICENSE �,v��` �� LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS�4 �Z,(}'L� �/� ��i l �� CITYUf � KXti STATE�JZIP�-L�
INSURANCE p ONE CO � J� 3J� FAX C9 �v ' 3�3" �� $
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION 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: �Z`Q�I (,I..VC,� c) Wlji I�S�-✓�� . c'�GG�'Yl`Q- � gi L� .
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ RT
ROOFING ❑ 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 FORNEW 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 C�Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-T/�SCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASEll UN VALUA"I'ION, INCLUll1N(U 1'HE CUS1' UF LABUR ANll MA'CEKIALS:
U G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $��U�� . 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
$ b"�•'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 ( )
$ C�� .'1, Make checks uavable 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 acknowl e that the information above is complete and accurate; that the work will be in
conformance with the ordinances and odes of the C'ty f Fridley and with the Minnesota Construction Codes; that I understand this is not a
pernut but only an application for a pe 't and w rk s not to start without a permit on site; that the work will be in accordance with the
approved plan in the case ork which r ir s r vie d approval of ans. y�� p�
SIGNATURE OF APPLICANT RINT NAME �� !'�'rU `I DATE a� O l�
APPROVAL INSPECTOR SIGNATURE