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Building BUILDING Permit No.: � �'�, "'"`
Inspections RESIDENTIAL APPLICATION Received B. � t
763-572-3604 CITY OF FRIDLEY �at��t[jd. '`� �, �k��l
763-502-4977 FAX EFFECT�ve �-i-zoi i
DAT'E ��� I�Q ' I� YOUR E-MAIL ADDRESS ��� �Q I C' v� �x-�l f)�L'?C�!C��''r� I C� I�) �, 4 C�C�
siTE aD�RESS iDlo`��l ��' i c11� �1 �� \ f"E'�
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: �' � ' i�1
TE1vAlvT ao�RESS: � � ��l � i �a I _ �. �i' c►TV � r i �� �� �I sTaTe '�Y1�z�P �" �" � ;
PHONE:�I <>' ����-�� � i - �
CONTRACTOR NpME: �,�j ���,jG(��7 �>`( I CI
SUBMIT A COPY OF �G`l,� j��(, � LEAD CERT NUMBER N77� �` )� p� 'I ° I
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS: t� c� � �- I I� f�Z.7� ��" j��-� CITY i�L r f t`� ���`Ztza-I STATE �'�; ZI << { �
INSURANCE PHONE � I ���]C� —�C�I ( FAX �� ' ��� '� Q�-� �'f
PROPERTY TYPE �[NGLE FAMILY EW CONSTRUCTION SIZE
❑ TWO LY/NEW CONSTR'JCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED 'Q�INDOWS
❑ BASEMENT FIN[SH ❑ ROOF C7 DRAIN TILE
❑ DECK ❑ S[DWG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:��CI(' f� ^-t L�I �L�C'�215 f I� �Q �1 ��1 �G i%f�'{�i I� �� ��
SIZE OF IMPROVEMENT [,ENGTH W[DTH HE[GHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETAC: HED GARAGE 3. List of sh-uctural members to be used
PROI'OSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit
ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS es ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS- ESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
--`�
TYPF OF WINDOW TO BE N$Y"AL,LED � �i� - NUMBER OF WINDOWS
ALL FEES ARE BA .4biIAT1 N, INCLUDING THE COST OF LABOR AND MATERIALS:
U ING T 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUAT N$ OCCUPANCY TYPE
Pern�it Fee �.Nl-�. ✓�� See Back Page for Fee Schedule
Plan Review $ � 65% of Building Permit Fee
Fire Surcharge $ �`r`� .001 times the total job valuation
Surcharge $ �""�'� .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �(] M $5.00 (State Licensed Residential Contractors)
SAC Charge $ � $2230 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 $ �' .���� Make checks a able to: Citv of Fridle Attach Sti ulations
TIIIS IS AN APPLICATION FOR A PGRMIT-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 Construction Codes; that I understand this is not a
permit but only an application for a• ermit 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 �a`l,l�w�ork w� h• i-e„s review and approval of plans. �„.
SIGNATURE OF APPLICANT �}�7 1=_ ? � PRINT NAME }�Y1�1; Q' �nC-'C?�� DATE � ' � t.t.� �" � �
APPROVAL INSPECTOR SIGNATUR '�^''"-
PLEASE NOTE: SEPARATE TS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK