P - 35320Building BUILDING Permit No.: Z� �
Inspections RESIDENTIAL APPLICATION Received By: �f�
�63-s�2-3604 CITY OF FRIDLEY Date Rec'd:
763-502-4977 FAX EFFECTIVE 1-1-20ll r
DATE � '� � � ' �/ YOUR �MAIL ADDRESS // �� �V�- � ��'���"r� > � y��
s�� aDn�ss (� � �� �-en �'/ore. �r� �r��� /�-t ,�J .SS �3�,
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ N,�: MGtS�- .��- � r'�, � Q� d gju -
TENANT AD�,�ss: � a�S �3�n �tor� �r c�� ii�—��' ce� sTA�M.�P �S 5�3
PHONE: % �0�� 'll � 0 �02 L /
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CONTRACTOR xAME: �i� i,tC�. ►''v� /I°�i"Q ��i't c,
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER N�"T —°Z �� 3 T—b
YOUR STATE LICENSE
AND CERT'�ICATE OF ADDRESS: g�.Z'� Cs�l D� CITY S�'��i LK��TATE p SS �
INSURANCE PHONE � iS �/ S� % oZ FAX Lo -3 ` % �
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYlNEW CONSTRUC7'ION STORIES
PERMIT TYPE � �DTITON ❑ GARAGF/SHED ❑ WINDOWS
❑ BASEMENT FINISH �FROOF ❑ DRAIN TILE
❑ DECK 0 SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑�`IEW HOME CONSTRUCTION ❑ ADDTI'ION
� MAINTENANCFJREPAIIt ❑ REMODELING
DESCRIBE WORK BEING DONE: 1 P_!L%� 13 �� I�Q —i�0�'�
SIZE OF IMPROVEMENT LENGTH Q WIDTH HEIGHT SQ FT 3�
ROOFING ❑ HOUSE ONLY BASEr4II+iT RENSODII.ING 3UBMIT>
NUMBER OF SQUARES �� �iOUSB 8c GARAGE i: Existing Eloor Plan
GARAGES ❑ ATI'ACHED GARAGE 2. Proposed floar plan
PROPOSED SIZE: ❑ DE'FACHED GARAGE 3. List of structutal members to be used
PROPOSID HIIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl p��t ADDITIONS_ & PORCHES SUBMTT:
0 Aluminum [] Trim 1. Site Plan/Survey showing the eacisting structures
❑ Other ❑ Fascia � ProPosed Project.
2. Two �s of construction pl�s
WINDOWS 3. Fnetgy Calculations
IN EXISTING OPErIINGS OYes ONo LOCAIION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF MAN[JFACTURE STICKER ON W[NDOW.
OPENING CHANGES & .
TYPE OF WINDOW TO BE INSTALLID NUMBER OF WINDOWS
ALL FEES ARE BASED UN VALUA'17UN, liV(:LUllllYG "I"tIL�' (:VS"I' UI�' LAIfUK ANU MA"I'L�'KIAL,:
(USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ / �. /�n/i OCCUPANCY TYPE
Permit Fee �
Plan Review
Fire Swcharge
Surcharge
License Surcharge
SAC Charge
Curb Ctit Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
��
�.'�'/�
—� —^� S��j�q`�¢ee Back Page for Fee Schedule
$ �_. 65% of Building Pertnit Fee
$ .001 times the total job valuation
$ � .0005 xPernut Valuation Minimum $5.(ro
$ $5.00 (State Licensed Residecrtial Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ �--�"" $450 Conservation Plan Review
$ ^-"'"'— Fee Determined by Engineering
$ Agrcement necessary ( ) Non Necessary ( )
$ n�--r-�" `�`.—r � Make checks navable to: Ciri of Fridlev Attach
THIS IS AN APPLICATION FOR A PERNIIT-NOT VALID LJNTIL 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
pernut but only an application for a per 't 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 o�a work hich • qu' review and approval of planjs,� ���c� �a� 3/_ ,�J
SIGNATURE OF APPLICANT �4 PRINT NAME /V ` l S DATE �-�1j
APPROVAL INSPECTOR SIGNA'I'[IRE
PLEASE NOTE: SEPARA REQiJIltED FOR PLUMBING, ELECTRICAL AND MECHANICAL WOitK ___ _