P - 84324Building BUILDING Permit Ivo.: ' �
Inspections RESIDENTIAL APPLICATION Received By
763-572-3604 CITY OF FRIDLEY � �;���
763-502-4977 FAX EFFECTTVE i-i-aoii ��
DATE YOURE-MAILADDRESS S�j!►A��!',����Wj'n�a1,J (��v.
si� ADn�ss � A �-i-Q!'-IC�.r A�r� 11 � ��� S 5L%��-
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NpME: r-� ;,� �ti ('�C.�.�d��-
TENANT ADDRESS: S�{�-�i /�G�G�m� ��� CITY_�,'�%2.., STATE�i1ZIP SSS�3�
PHONE: rI(p3 - �r71- 8'8��
C�NT�CTOR NAME:� �Lt/� (�/I e' S W'(� �a ! f�il" S� / D
SUBMIT A COPY OF STATE LICENSE #%�(' �D �//t� LEAD CERT NUMBER /LJA�% —�`7O 3l0'.�-
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: o?�lIS f��l.L�1��drQ �r�`U� SfE //o CITY � v STATF��ZIP�
INSURANCE pHONE S� �I � S FAX — rI D 3
PROPERTY TYPE �NGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN T1LE
❑ DECK ❑ SIDING �THER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ��z 1-.�i n�r�W � �_ —
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: � DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �SYes ❑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
ALL FEES A� �A��.11 UN VALUA�l�lU1V� 11VC,LUll11Vli 1-liL� l.V.�l Vl� LAIfVK A1�IL 1VlAl1�.l(lALA:
«TSiNG THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �!� ► oi5
$
$ a�
$
$
$
$
$
$
ANCY
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
$+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
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 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 rmit and ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of 1 work wh r ' es review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME �U.2Q,n n t_. �^� DATE % v�22,' )�
APPROVAL INSPECTOR SIGNATURE _