P - 48255r--6a���
Building BUIY,I�ING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'a: y a
763-502-4977 FAX EFFECTrvE i i-zoi i
DATE �L.O • D�C. ZAiI YOUR E-MAIL ADDRESS �1 ,
SITEADDRESS (/�jA(� Ch�f1 ( �,Z, N�.
THIS APPLICANT IS: ❑ OWNER L�fCONTRACTOR
PROPERTY OWNER/ NAME:_ �g{�h � M�
TENANT pDDRESS: �t�IO CI�y1^1M p.d, I�1� CITY_F ' STATE ►�I ZIP ssw�z
PHONE: 11a 3• 51H •►�oe te
CONTRACTOR NAME: I� � • �
SUBMIT A COPY OF •
YQUR STATE LICENSE STATE LICENSE # �, b�P ��( Z, �' AD CERT NUMBER NAT •tiSZ�I'I EXP: �.(I . ZO IS
AND CERTIFICATE OF ADDRESS: `�� D Ciu�•(,i� PV� �' IOO CITY STATE�ZIP SS� Z4
INSURANCE PHONE SZ• I. OD FAX Z• �I .
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSIRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORlES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
L�BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIIvIl�qIVG POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAII2 i�REMODELING
DESCRIBEWORKBEINGDONE: �n� h b S�+�+q� uS�nl� � �V+:� �?5��� ,p;,,�;a �il�q ='�S�
SIZE OF IMPROVEMENT � �
LENGTH WIDTH HEIGHT v S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of shvctural members to be used
PROPOSED HEIGHT:
IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of conshuction plans
WINDOWS 3. Energy Calcula6ons
IN EXISTING OPEAIINGS ❑Yes ❑No LOCAITON OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEI�IINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ �'j , qQ GJ W� 1997 U.B.0 FEE SC OCCUPANCY TYPF.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ . .0005 x Pernut Valuation Minimum $5.00
_ � � . Q $5.00 (5tate 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 ( )
$ _. Q- Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCES5ED
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 Frid y 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 start w' hout a permit on site; that the work will be in accordance with the
approved plan in the case of II v�o �k hi r s rev' w d appr al of plan�s".�� �'�'"
SIGNATURE OF APPLICANT ' P NAME��LW.wr w�kS W�/1aOMl DATE 1D. ZDI'
APPROVAL INSPECTOR SIGNA /! i i'� ._�..
QlLBSe- C?,1���P��� 01� �1.�+�f� 'L �SZ.• �fll•3'�0�
w' ��C�..
SCALE�
Measurements and scale are only approximations.
��