P - 35755�,�c3i
Building BUILDING Perrnit r1o.: �� � -�
Inspections RESIDENTIAL APPLICATION Received By: _
763-572-3604 CITY OF FRIDLEY Dat
763-502-4977 FAX EFFECTivE �-i-zo�i ��� �
DATE C�- II YOUR E- AIL ADDRESS �(,L_IG.� )�Q�O� I nG eo��
SITE ADDRESS � 1�1 Yt �
THIS APPLICANT IS: ❑ OWNE f�ONTRACTOR
PROPERTY OWNER/ NA1vtE: �1 /�
TENANT ADDRESS: T CITY STAT �� ZIP
PHONE:
CONTRACTOR NAME:�IQ R.c�o�ttiq C '�R�t.rnoc�.f�.\icxa
SUBMIT A COPY OF STATE LICENSE # �O� LEAD CERT NUMBER N�- a5o3y � �
YOUR STATE LICENSE p��
AND CERTIFICATE OF ADDRESS: 4�� C„sG.ISjO'r T3�Vt� CITY'Sir.�Otats �►wb STATE� ZIPS�V1ii1
INSURANCE pHONE �15a-�/�S-`7?'x FAX C{6i - �f �1:1 -
PROPERTY TYPE .8'Si�GLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAM[LY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH -B'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:��0.Y' o� .i- Y�r oo.c `1euL5 '� d- Q.'�-G�P���� ri�% �il �
SIZE-0F IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �� ,�'FiOUSE & GARAGE 1. Existing Floor Plan
GARAGES .B�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 ADDIT[ONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim I. Site Plan/Survey showing the existing structures
❑ Other O Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculadons
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'��S AK� BASH;U UN VALUA'I IUN, 1NCLUUIIVC: "I HL�' (:U5'1' VN' L.ABUK ANU MA"1'L�'KlALS:
/� (USINC THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ co OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .00OS 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 $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ 0� Make checks pavable 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 ConstrucNon 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 al ork which requir s view nd approval of plans � g� yl � �
SIGNATURE OF APPLICANT /�.�, . �, si PRINT NAME � n.x lI//G� DATE
APPROVAL INSPECTOR SIGNATU
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK