P - 46605Building BiTILDING P�it rro.- �t
Inspections RESIDENTIAL APPLICATION R���� By.
�63-s�2-3604 CITY OF FRIDLEY ��!�}a� � 1l 2 11
763-502-4977 FAX E�c� i-i-ZOii
DATE l/' �// YOUR E-MAII, ADDRESS
S� �D�SS /y�' � /�.� c���� r�/.
'IT�LS APPLICANI' IS: ❑ OWNER �CSCONTRACTOR
PROPERTY OWNER! N,�: _
TENANT nnnxESS: ( r/ �: crrY �r,c/%y STATE /� HLIP 3.�'�f3 �
�oxE:
CONTRACTOR xntvtE: �. i-rr�r►� ,� �`x. F :
SUBMTf A COPY OF
YOUiL STATE LICENSE STATE LICENSE #��j �[, �3R r%SI"� LEAD CERT NUMBER
AND CER'I'IFICATE OF ADDRESS: oc%(Ofo l 3� �� �N �v�.✓ CTI'Y� �/C�" STATEn?/�21P ST3oy
INSURANCE PHONE G LZl '�"i �I FAX "7 �f ciD "`'r�Y I
PROPERTY TYPE ,i�SINGLE FAMILY/NEW CONSTRUCTION SIZE zJ
❑ TWO FAMII.Y/NEW CONSTRUCTION STORIES �
�i j�111' ��i ❑ ADDTITON ❑ GARAGE/SI�D ❑ WINDOWS
❑ BASENIIIVT FINISH �ROOF ❑ DRAIN TII,E
C] DECK ❑ SIDING ❑ OTIiIIt
❑ SWIl�IbIINCs POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTITON
❑ MAiNI'�'NANCE/REPAIR �`REMODELING
DESCRIBE WORR BEING DONE: �° <b0 �qpQ
SIZE OF II�tPROVEMENT LENGTH WIDTH HEIGHT S FT '�
�e'tluts�lNG O HOUSE ONLY
NUMBER OF SQUARES _�� � HOUSB 8c GARAGE B�ENIINT REMODELING SUBMIT:
i. Eaisting Floor Plan
CsARAGES ❑ ATTACIIID CrARAGE 2. Proposed floor plan
PROPOSID SIZE: � DETACFIED GARAGE 3. List of siructnral members to be uaed
PROPOSED HIIGH1':
SIDING FORNEW CONSTRUCTION INCLUDIIdGDECKS,
❑ Vinyl p�gt ADDTITONS. & PORCHES SUBMIT:
❑ Alumim�m ❑ Trim 1. Site Plan/Survey showing the esisting structuces
❑ Od�er ❑ Fasoia 8°d ProP�� P�.1�-
2. Two s�s of oonstrvati� plans
WIIVDOWS 3. E�rgy Caloulations
IN EXISTING OPENINGS OYes ONo LOCAITON OF WINDOWS FOR WINDOWS — PROVIDE U-VAI.UE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANI7FACTURE STICKER ON WINDOW.
OPIIJING CHANGES dt
1YPE OF WINDOW TO BE INSTALLID NIJMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Ctub C�t Escrow
Faosi� Control
Park Fee
Sewer Main Charge
TMsI Dae
(USING THE 1997 U.B.0 FEE SCHEDULE)
s "a `1 � L S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ 3� j _001 ti�s the total joh valuation
$ � �y'j .0005 x Permit Valuation Minimum $5_00
S S� $5.00 (State Licensed Resid�tial Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ' ft+6ft= ftx$25=$
$ ' 5450 Conservation Plan Review
$ ' Fee Determined bY Engmeering
$ ' Agreement necessary ( ) Non Necessazy ( )
TIIIS IS AN APPLICAITON FOR A PERMIT-NOT VALID UN17L PROCESSED
I hereby s�ly for a building peimit and I acl�owledge that the inforn►ation above is complete and accurate; that the work will be in
confoimance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit lrut only an applic�tion for a pezmit a�i work is not to start without a petmit on site; that the work will be in accordance with the
app�oved plan in the c�se of �� requ�reS review and approval of plans_
SIGNATURE OF APPLICANT %'����R�'7`�. PRINT NAME +�'�'erE Ln r�CI DAIE //� �i '�/