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763-502-4977 FAX
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RE SIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:r��� �'b�-�3 tP
Received By: �
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DATE � � / � � �/ YOUR E-MAIL ABBI�E�S � u � i`
n /o r��'..� ro� 6 v� 4i ld .� +�.. C y� .�J ��F-
SITE ADDRESS ���� /S i� %.} _, ,� ak-. .� /A�c`i C. c ,it�� L�',
THIS APPLICANT IS: ❑ OWNER C3 O TRACTOR
PROPERTY OWNER/
TENArT�'
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
C . J1� Q �
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3 Lr�:�ss: '7 r°� ��.� p� J r�� .�3 ��T :y r.-�..� l �- y s�raT��� z:r ,1"�
PHOIYE: •° �'�� -- (;� "
NAME: L. U � r j t s �[ ,� .� l� o-h c s �.J G^
e
STATE LICENSE # O��- LEAD CERT NUMBER
aDDrzESS: p_ o, •� a h `3 / y cr��u.,�,� ���iC s�rar�'�.�! z�s�3;�7
rxor� � J�� - Y�ir -� l Y� Fnx g�ai -� �S -�'G y h'
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FINISH
EI DECK
�❑ HOME CONSTRUCTION
NTENANCE/REPAIR
❑ GARAGE/SHED � WINDOWS
[a'KbOF ❑ DRAIN TILE
❑ SIDfNG Q OTFIER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE:__ R e, (�c-o � C' x'.�' ��a w �j �,� �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NLJMBER OF SQUARES �� 8 HOUSE & GARAGE BASEMENT REMODELING SUBMIT�
GARAGFg 1. Existing Floor Plan
❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING
17 V1ny1
❑ Aluminum
❑ Other
I FOR NEW CONSTRUCTION INCLUDING DECKS,
�5o#�t � AL�DITICINS c� PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS 2. Two sets of consduction plans
IN EXIST'ING OPENINGS ❑Yes �No LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPEI�IINGS-DESCRIBE SIZE OF FOR WIlYDOWS - PROVIDE U-VALUE AND
()P�NIN�: CHANGF.S � MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALIJATION, INCLUDING THE COST OF LABOR AND
(USING �THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �� ,� �'Q OCCiTPANCY
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb C'ut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
TERIALS:
TYPE
� ��f / L 5 See Back Page for Fee Schedule
� b5% af Building Permit Fee
$ � 1� .001 times the total job valuation
$ .0005 x Permit ValuaUon 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 pa able to• Ci of Fridley Attach
THIS [S AN APPLFCATION FQR A PERMIT-NOT VALID IIN"I'I[, 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 pernut on site; that the work will be in accordance with the
approved plan in the case of a wor����h requires review and approval of pl ns.
SIGNATURE OF APPLICANT ,�� PRINT NAME �j z„� � l% Q� ,, � DATE / l l„? � l/
APPROVAL INSPECTOR SIGNATURE -
PLEASE NOTE: SEPARATE PERM�'TS ARE REQUIRED FOR PLUMBING, ELEC'TRICAL AND MECHANICAL WORK