P - 36674Building BUILDING Permit No.: 2-G ( i`L �`���
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date '- °�I
%G3—SOZ-49%% FAX EFFECTIVE I-1-201( ��
DATE �—� S "' I� YOUR E-MAl[. ADDRESS _�.JOT��q V�� C� C� . C OW`
SITE ADDRESS � S Z I C� O V�' r' P�qC2 I� C
THIS APPLICANT IS: ❑ OWNER '�ICONTRACTOR
PROPERTY OWNER/ I NAME: �AV e-t- iA+�Ie v�,Q �—� n-�-c�r�
TENANT qDDRESS: �o S�- � e\ o v��- P(o. ce NE ciTY
PHONE:
ATE�1I�%ZIP SS�� 32
CONTRACTOR Nq�E: �.� �.,� w�� „� S S'e,,. �;�.e S
SUBMIT A COPY OF STATE LICENSE # 2 e� 6 3q �-11 �S LEAD CERT NUMBER
YOUR STATE LICENSE
ANDCERTIFICATEOF ADDRESS:I� 1y e«'-� �.+� CITYl2oSGw,oc.�h''�'I'aTErhNzIP Oi,$
INSURANCE PHONE b �- Z3 " � 3 S� ��O �F� ��-Z — Z Z
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINTSH Q� ROOF O DRAIN T1LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL •
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
� � MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BETNG DONE: R� �ro o—�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFIN 2 S ❑ HOUSE ONLY BASEMENT REMODELTNG SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
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:
' SIDIN
; ❑ Vinyl
❑ Aluminum
❑ Other
�Soffit
❑ Trim
O Fascia
WINDOWS
M EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIVG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF �
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMTT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$ h � •'�5
$
$
$
$ b
$
$
$
$
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 aavable to: Citv of Fridlev Attach Stinulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 application f a e it d wor is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a 'ch equire ' w and approval of pl ��"j' ('�,,
SIGNATiJRE OF APPLICANT PRINT NAME V^1'-�'A�Iti WO��'24k DATE �— I J� - I �