P - 39916Building � BUILDING Permit No.:�� � ��
Inspections RESIDENTIAL APPLICATION Received By: �� ��'
763-572-3604 CITY OF FRIDLEY Date{�'�:��� ~��
763-502-4977 FAX EFFECT►vE �-i-zon
DATE ��ZS Vl� YOURE-MAILADDRESS �1J�-lrtt�) � C'1.!yJ•.lc�- Loi���l.����� �--� ��
SITEADDRESS SD"L`{ C� aEc„�,v�,Q„LN S��•
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ N.AME: �,U� = F�r-a�- i�.�.r.a ti1
TENANT nDDRESS: S�L`t C.��.�v�l,..� 5;- c►7'v F�z�otc
PHONE: (C�12' �> "Z�L.$
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
NAME:
�
ATE`�N ZIP S�`(Z
STATE LICENSE # Z� l� 3y �SS LEAD CERT NUMBER
ADDRESS: `s�*'so \'��i �C-. eJ CITY �`O STATE�,1_ZIP S�� $
PHONE i4,�� _�3�{ \-`31`-l2 FqX
Q SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ GARAGE/SHED
ft� ROOF
� SID]NG
❑ SWIMMING POO
S[ZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
. t�.>� C� F��r S �� liJ C�,
ROOFING
NUMBER OF SQUARES �—_„ � ( �
GARAGES !f
PROPOSED SIZE:
PROPOSED HEIGHT: \
SIDING . ,!�V
fd�. Vinyl �� S`�j� �`--�� `� l3
❑ Aluminum � �1� li
❑ Other ��
LENGTH
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING DECKS,
❑So�t ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site PlanfSurvey showing the existing structures
and proposed project.
❑ 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 OPENII�IGS-DESCRIBE SIZE OF MANUFACTURE 3TICKER 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�-�� j,�j 7((�% OCCUPANCY TYPE
Permit Pee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge.
Total Due
$� � ��� 11�5
$
$ 1 �$
$ �i i�
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.00I times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$S.OQ (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 aavable 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 Constnaction 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 accardance with the
approved plan in the case of a]] 1� w' requires review and approval of plans.
SIGNATURE OF APPLICANT C' PRINT NAME "C�C.v,t� � e4--� DATE `t��s I��
APPROVAL INSPECTOR SIGNATURE