P - 35455Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATIUN Received By:
763-572-3604 CITY OF FRIDLEY ���
763-502-4977 FAX EFFECTivE 1-i-zoli
DATE t I � YOUR E-MAIL ADDRESS C� d'Y`I L.( !i G^- �/('' �(i(J �!/� ��}N� {i (� . C 4�'VI
SITE ADDRESS tU !i'7 � ,(� /n-!�/� l��C �"V �
THIS APPLICANT IS: ❑ OWNER �'�CONTRACTOR
PROPERTY OWNER/ NAME: f �
TENANT �DRESS:�"!/� O �rY�.(�ii ��_ ��CTTY T"►i � STATE��ZIP��IZ!
rxorrE: '�Q 3�v-1 i - LI �2(�i_
CONTRACTOR N,�: Th Window Store Home Im rov mec��.�
SUBMIT A COPY OF �
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER ' O'' I
AND CERTff�TCATE OF ADDRESS: � I I� CITY S� •�'l�%t..�r�STATE��IP��'
INSURANCE PHONE `Z" ?J S `, �� FAX I ' J
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DIT�oN ❑ GARAGE/SHED ws
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTf�R
❑ SWA�fbIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCI'ION ❑ ADDITION
�iAINTENANCFJREPAIIt ❑ REMODELING
DESCRIBE WORK BEING DONE: Y'P. IO �GY-c: i Yl.�� t�IU 11� �l Pl ul.! � V�-��i'r
SIZE OF Il�Il'ROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMIIVT REMODELING SUBMIT:
NUMBER OF SQU.4RES O HOUSE 8c GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan ,
PROP03ED SIZE: ❑ DETACHED GARAGE 3. List of structutal members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vi�l ❑Soffit ADDiTIONS_ & PORCIiES SUBMIT:
❑ Aluminum ❑ Trim I. Sibe PladSucvey showing the existing siructures
❑ Other ❑ Fascia �d ��� ��' .
2. Two sets of cons�ctian plaos
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �es ONo LOCAITON OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-D CRIBE SIZE OF Oc?r 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:
_ (USING THE 1997 U.B.0 FEE SCHEDULE)
VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb C�t Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
'ANCY
$ �� J,� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Pemut Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � Make checks uavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PIItMIT-NOT VALID UNTII, PROCESSED
I hereby apply for a building permit and I aclrnowledge 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
pernut but only an applicarion for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a11 work whic q es review and approval of p s. "���� C�Q p /
SIGNATURE OF APPLICANT /�.,/�i11.� �E� PRINT NAME7 �/� � J� 1J �-�' � GY1 DATE Z/ // Z � I I
APPROVAL INSPECTOR SIGNAT[)RE . M\