P - 35412Building BUILDING Perm�t No.: �� ,� '� �
Inspectior� �RESIDENTIAL APPLICATION Re�e��ed By: � ���� �� � �'
763-572-3604 CITY OF FRIDLEY Dat Rec� :
763-502-49 �7 FAX EFFECr�vE �-i-zoi � �
DATF, •� Y I YOUR E-MAIL ADDRESS
SITE ADDRESS __ �Z _� Cf±rP (Tb(.. ST N� �_l 1-�y'` —
THIS APPLICANT (S: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: L,�Sp� (2.E'//V��1 _
TENANT Ap�RESS: �Z�-1�1 � G�MITOL �� /�%� ciTY__��� �� sTATE Ni�✓ziP 5 Sy2 �
PHONE: � � �� S% ( ' J � � �I
CONTRACTOR NAME: `tn/ At IC�2 Roe-�N [n
SUBMIT A COPY OF STATE LICENSE #� 2'2q LEAD CERT NUMBER ���-' ��q �' r� '" �i � � gZ
YOUR STATE LICENSE n,,
AND CERTIFICATE OF ADDRESS: �L2 ? y C!�-PP �'I/ CITY S T� R'�L STATE iVl�IP 55 t W
INSURANCE PHONE ?63-' �{ FAX
PROPERTY TYPE GLE FAMILY/NEW CONSTRUCTION SIZE
L�' TLVO-PAti,IL1:^:: US' C^*:�Tf?I!CTICIN ST(1&iF.S
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS 4
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�J �CMAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: F� PA'1RS N a'� U(� ��Of �Q' ��) Qf��•
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQFT
ROOFING � �-IOUSE ONLY BASEMENT REMODELING SUBMTi: '
NUMBER OF SQUARES �/ ❑ HOUSE & GARAGE
� �T S�� 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 ' ��t' ��� �,� FOR NEW CONSTRUGTION INCLUDING DECKS,
,�Vinyl Z �� S QV�'Q-�/zj `Tj�Soffitii' ���� � n ADDITIONS. & PORCHES SUBMIT:
6�C� o Hc��/5�, 1. Site Plan/Survey showing the existing structures
❑ Aluminum Q,��� T �L��.�n� ❑ Trim and proposed project.
❑ Other �� �O, �Fascia'�., "��,'
s�r �� `T (3"� GlFS�v-rc*►� 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALLJE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL Nr,1�.J AKl�. IfAJl.11 VPI VALUAl1V1�, �1VlJLUUll�ls 1n� l.v�i vr i.t�►nvn r�i�L 1�1H1L' 111HL�.7:
(USINr THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VA-i.UATIUN $ '? . OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% ofBuilding Permit Fee
Fire Surcharge ' $ .001 times the total job valuation �
Surcharge $ .0005 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$25° $
Erosion Control $, $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering _
Sewer Main Charge $ Agreement necessary O Non Necessary.( )
Total Due $ O Make checks a able to: Ci of Fridle Attach Sti ulations
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 witfi the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understiand this is not a
permit but only an application for a permit and or1 ' not to start without a permit on site; that the work �vill be in accordance with the
approved plan in the case of all w ch requires i -and approval of plans. ��/� .7 �
SIGNANRE OF APPLICANT P NAME A+�fl`'{� �Z'�%U7Ci DATE Z �
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMIT A U D OR PLUMBING, ELECTRICAL AND MECHANICAL WORK