P - 45821Bui1d111g BUILDING Permit No.: �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY °
763-502-4977 FAX ����� : ,
EFFECTIVE 1-1-201]
DATE ZG t � YOUR E-MAIL ADDRESS
sITEaDDRESS �2`Z � V�-P�T.�L. St /��.
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPERTY OWNER/ NAME: D �( /
TENANT ADDRESS: S CITY f--ID1�✓� STATE�'i/tlLIP�
PHONE:__�_"�-�� /G'� — �/ (....'�Z�I
CONTRACTOR NAME: (.J'A�t.-�c.� ��'�rJ'�
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER �' �{W 3— � 6-�` S� �2
YOUR STATE LICENSE /� �^
AND CERTIFICATE OF ADDRESS: �fL•f7 � C .p�i�i CITY j3';' PA'�L STATFYi�LIP SS
INSURANCE PHONE -- !% t FAX
PROP�;R'TY TYPE �SINGLE FAMILY/NEW CONSTRUCT►ON SIZE �
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADD1T10N (s� A C.�
�v1AINTENANCE/REPAIR ❑ REMODELING J`��
DESCRIBE WORK BEING DONE: ��.- [� � � /'7T�f% �j�-c�v�' O� �IUV � � Gy�[r,(�i %WD S�}-/�"�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING Q � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF S UARES � "�HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: �ETACHED 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
and proposed project.
❑ Other ❑ Fascia 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No 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 r L� L� � AKN, tSAJEll V1V YALUA1lU1V� 11�(:LUUINC: "1 Hr; (:USI' UN' LABUK ANll MA'1'EKIALS:
(US N HE 1997 U.B.0 FEE SCHEDULE)
TOTA� JOB VALUATION $ ��.�N �� 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
$ i
$
$
$
$
$
$
$
$
I hereby apply for a building e
conformance with the ordinances an
permit but oniy an application for a
approved plan in the case of a w
SIGNATURE OF APPLICANT
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEP�
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 ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
� and I cknowledge that the information above is complete and accurate; that the wark will be in
d c des o,�the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
pe it�nd work is not to start without a permit on site; that the work will be in accordance with the
hich quires review and approval of plans,�`+ Q�� /�
PRINTNAME [T/"� /"K.�� DATE (s JZ�iI � I
FOR PLUNIBING, ELECTRICAL AND MECHANICAL WORK