P - 48100Building BUILDING Permit No.: �r ��? ?�
Inspections RESIDENTIAL APPLICATION Received By: ,/�
763-572-3604 CITY OF FRIDLEY Date Rec' . ^�
763-502-4977 FAX EFFECTIVE �-�-ZO� i
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS �, � t� s� C; f� 14 /�/ /V ��- 1 S� li ,�, r� �. iJ �€- Y S�S�y 3�- Si6 S.ST
THIS APPLICANT IS: �"bWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: l�fU ��- %y '% L. L<J � L L s
TENANT p,DDRESS�:r�,� y S oZ 7� L� CITY �'1 ��' S STATE ZIP S5�'bG
PHONE: (�'�rZ — L�rZ 3'- �,� `'% t�
GONTRACTOR NAME: ��/: ��
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE pq}�
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O aDD�'r[oN ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE:
` � N��h,
SIZE OF [MPROVEMENT �,eV_ '�'�/ 1 %%�% H L S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �� � ❑ HOUSE & GARAGE �. Existing Floor Plan
GARAGES � �TTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: ���►����,f-�
SIDING FOR NEW CONSTRUCTlON INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITiONS. & PORCHES SUBMIT:
O Aluminum ❑ Trim I. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construcfron 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 4N WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE 1NSTALLED NUMBER OF WMDOWS
Ai.L r��� ,�x� nAa�1� 1�1v v.�11�ua l lulv, 11vCLUll11VG '1'H� CUS"T UF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��� _� _�;a� b 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
$ ��� �Z S 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 ( )
$ __ .(pLp Make checks payable to: City of Fridley 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 Construction Codes; that I understand this is not a
permit but only an applicaf r pe it and wo k is not to start without a perrr�it on site; that the wark will be in accordance with the
approved plan in the case f k i h requ' eview and approval of pla
SIGNATURE OF APPLICAN PR[NT NAME�(��� %,(i� LL,,S DATE
APPROVAL INSPECTOR SI �� �