P - 35487Building BUILDING Pe��tNo.:�� ����� �� ��
Inspections RESIDENTIAL APPLICATION Received B• '✓
763-572-3604 CITY OF FRIDLEY ����� L
763-502-4977 FAX EFFECTivE i-�-2oti
DATE 7" %�" �� YOUR E-MAIL ADDRESS a� tk �c b
STTE ADDRESS ��di) ���M jNAN� � ir (�E
THIS APPLICANT IS: �OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: EMK ��d DG6 Ptferto�
TENANT ADDRESS: iIDL F+tir�►s� Ger N� CITY �ryelwy STATE�ZIP S 3Z
PHONE: 7(r 3• i�-' I7 �%
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTffICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTTON STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH i� ROOF ❑ DRAIN TILE
❑ DECK d SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: � NEW HOME CONSTRUCTION ❑ ADDITION
,�MAINTENANCE/REPAIR ❑ REMODELING
DBSCRIBEWORKBEINGDONE: Pi���6d ��(h.►�fd� AH j10wiG Olw� �4�ra�d
SIZE OF IMI'ROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �_ �HOUSE & GARAGE l. Exisung Floor Plan �
GARAGES p 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,
❑ Vin ] ADDITIONS & PORCHES SUBMIT�
y ❑Soffit 1. Site Plan/Surve showin the eatistin structures
O Aluminum ❑ Trim Y g g
❑ Other ❑ Fascia and proposed project.
2. Two seu of construcrion plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF W[NDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LA.BOR AND MATERIALS:
(USING TAE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
I Surcharge
License Surcharge
� SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
OCCUPANCY TYPE
$ ��1� Z,�' See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ Y, $$ .001 times the total }ob valuarion
$�, Z� .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 ( )
_$ �E t. i 2 Make checks payable to: City of Fridley 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 o e' f Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and ork is ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case of o ich i s revie and a proval of pl s. �i
SIGNATURE OF APPLICANT � T NAME �M� K W. �t/7" MI'5��1 DATE %� Ji�► f�
APPROVAL INSPECTOR SIGNATURE