P - 48606Building BUILDING Pe��t No.:�U� � �� � �`��i
Inspections RESIDENTIAL APPLICATION Received By: J
763-572-3604 CITY OF FRIDLEY ��:����� r J1
763-502-4977 FAX EFFEC�nvE i-�-2oiz
DATE %� _ v�� _ +�`� I � YOUR E-�DDRESSL� < �1 d'C�d � � �G� �i G'v , f�' C::�ll.
SITE ADDRESS ��C, � �/
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTYOWNER/ NAME: U•/�t'� ':u�l
TENANT ADDRESS: � CITY STATE ZIP
PHONE: � �� S �/�(�
CONTRACTOR NAME: !�I��,L �" ..c?,�L�'�'..5 ��
SUBMIT A COPY OF �' ,2L ��-- LEAD CERT NUMBER EXP:
YOUR STATE LICENSE STATE LICENSE #�U ,2 �� �c,
AND CERTIFICATE OF ADDRESS: � �j' �`D SSr,� �` (�i� CITY �� STATFi�'��i'�`LTP � G�
INSURANCE PHONE f �% � ! �- `L"��t'(,� FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTON � GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �f�t' ,/ D^ f �x- c-i%�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING � USE
NUMBER OF SQUARES �- �-� �HO� SE & GARAG � BASEMENT REMODELING SUBMIT:
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:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Viny] ❑Soffit 5IDING/SOFFIT/FASCIA ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO I. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ 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 OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
.�LL r�,r.� .�xr� tsA��;1� V1v VALUA11Viv, IiVC:LUll1NG'1'H� CU5'1' UF LABUR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ „ h, �. LL See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ � .001 times the total job valuation
Surcharge $ �� .0005 x Permit Valuation Minimum or .50
License Surcharge $ L.� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due _ $ �i j) ,�/ , Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 appiication 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 all wo ic re� es review and approval of plan ..p�' �__��� ,., ��j � �
SIGNATURE OF APPLICANT /��5�/,'�� PRINT NAME ��`" ���e /.'�✓"t.G DATE ,�l�l�`f-� �� �—
APPROVAL INSPECTOR SIGNATURF%�