P - 35234�Building BUILDING PermitNo.: LC��'�) ' ?�(��
Inspections RESIDENTIAL APPLICATION Received By: �1,' �'��
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX ���eC°��I�� � �1n1'�
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DATG /--� �% � � 6/ YOUIZ GMAIL ADDRI?SS /.�hL�r'�rh `L' l`"3``/� L°� Ur�
sn e A��nKESS �U y� 1 %�h:KvRw �C. /v �" �P.iOZEy /Yl� �s"t/3x �
I�HIS APPLICANT IS- ❑ OWN[�R �ONTRACTOR
PROPE,RTY' OWNER/ NAMG S%�Z /'Tl'� L/"�N� ��
TENANT ADDRF,SS: ��J l IC��'!� PL- �� CI"CY ��/,OCr�/ STA� E��IIP �SZ � 2—
PHONE: � —S�'%I `j i� &°�
CONTRACTOR NAMG:�J I�TiCYd L�i%Jt` CG�✓IT2uc rr�' /
SURMfI� A COPY O�' STATG LICGNSE#;�0�1� � LEAD CER7� NIIMftER �3��5 �/ � d� Q�
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,4ND CIiRI IFICAI E OF ADURF.SS: �%(� PE�� A� SU`�+L% ��l,TC I75�� CI'I'Y ,[_XGCy'?�inJjr%Lr%✓STATh/� "l.IP��''3%
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PROPERTY TYPE �irvc;i.r rAnnil.Y/rvrw coNSTauc� ioN s�zE
O "iW0 FAMII.Y/NEW CONSTRUCIION STORIES
PERMIT TYPE � ����T��N ❑ cnrznGi:isur:[� ❑ wiN�ows
❑ BASEMENT FINISII �ROOF ❑ DRAIN'I'ILI:
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW I IOMI�; CONSTRUCTION ❑ nDDIlION
❑ MnIN'I�L�:NANC1�:/R1=,PAIR � R[�:MOD[:LING
D6SG21I3G WORiti E3L:ING DONE: ��� �iy'-= (j� S//•�GL�,—'3 �- f�C��`�QGE'
SI"LEOI� IMPROVI:MCNT LENGTH WID�I�H IiL�:IGI�'T SQFT
ROOFING ❑ FIOUSE ONI.Y HqSI,MCiN'I REMODELWG SU[3M1'I`
NUMBER OP SQUARE� ❑ I IOUSF c� GARAGI-: I. Fsistine Floor Plan
G:V2;�GF:S ❑ A'I"fACI IED GARAGIi 2. Nroposed Iloor plan
PROPOSI?D SIZE: ❑ DETACFfED GARAGEi 3. Lis[ of structural members to be uscd
PRONOStiD HF:IGtIT
SIUWC FOIZ NI{W CONSTRUCTION WCLUDING DF.CKS,
❑ Vinyl ❑Soffit ADDI"fIONS. & PORCHFS SUBMI'f:_
❑ Aluminwr� ❑ Trim L Site I lan/Survey showing the esisting structures
❑ Other ❑ Fascia and proposed project.
2. I'wo sets of construction plans
W'INDOWS 3. f?ner�y Calculations
IN GXIS'T'ING OPENINGS ❑Yes �No LOCA'TION O� WINDOWS FOR WINDOWS — PROVIDE U-VALUF. AND
OR POR NLW OPF.NINGS-DESCRIBG SIZG OP MANUFACTURG STICKER ON WINDOW.
OPF.NING CI IANG�S K
TYPE OF WINUOW'I�O BE INS"TALLED NUME3ER01� WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDINC THE COST OF LABOR AND MATERIALS:
(�ISING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $`�,SL� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�$ �:i „% '� See Back Page for Fee Schedule
$ 65%of Building Permit Fee
$ `�1 �� .001 times the total job valuation
$ ��� .0005 x Permit Valuation Minimum $5.00
$ �,�;� $5.00 (State Licensed Residential Coi�tractors)
$ $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 ( )
$ ����-� '� :i Make checks navable to: Citv of Fridlev Attach Stiaulations
"f111S IS AN APPLICA'CION POR A PL?RMI'T-NOT VAI.ID UNTIL PROCL�.SSIi.D
I hereby apply for a building pennit and I acknowledge that the information above is co�nplete 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 1 understand this is not a
permit but only an appli io for a peri�iit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the c e of Il w• hich requires review and approval of pla�.,, �j_, „ �,, � ? �.�%
SIGNATURIiOP,�PPLI NT PRIN'I NAMI ����`(' .�y t` DAiE �.T�.�t��!
APPROVAI. INSPECi�OJ� SIGN E �� �
PLEASE NO ,; PARATE PERM(TS AR.E REQUIRED FOR PLUMB(;VG, ELECTRICAL AND MECHANICAL WORK