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Building BUIl.DINCi Permit No.: %� b �-
Ins ections `
la RESIDENTIAL APPLICATION Received By: l o t�
763-572-3604 CITY OF FRIDLEY Date Rec'a:
763-502-4977 FAX E�FECTivE i-i-zol�
DATE�/a� / ZD�� YOUR E-MAIL ADDRESS `G�'l 1^ G✓
SITE ADDRESS O '�
THIS APPLICANT IS: ❑ OWNER �CONT CTOR
PROPERTY OWNER/ NAME: r�C �r
TENANT ADDRESS: Sd77� ���5 I��t �I� CITY '{�'Y��s( �Ly STAT ZIP S'syzr
PHONE:
CONTRACTOR NAME: S-�V
SUBMIT A COPY OF STATE LICENSE # 2 O(Q '� O 5/ � LEAD CERT NUMBER � ��O�S�f � QOO lp $b
YOUR STATE LICENSE / "�
AND CERTIFICATE OF ADDRESS: /�/� /,J La Kt, �-� CITY%i7j�f�$' STATEI%N�IP Ss�O
INSURANCE PHONE � ��� � �/S FAX �. � �Z 3 � �6
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH (�'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �L�u l� T/tt e.vyta.,,r_ �� v��j Sy��.�e�Qls�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT 5Q FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES Z �• 4 ` \�, �HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES t \/(� �� .�ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ��' � ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: �
SIDING ��y ru � n� C`ftC f1 f'��r� �-�`�"t ��r �i' �Q�"� FORNEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim l. 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 ❑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 WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��I �0 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
$
$ ��
$
$
$
$
$
$
$ �. %
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 far determination)
ft+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 connplete 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 permit 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 all ich requires review and approval of p�. `
SIGNANRE OF APPLICANT �s� PRINT NAMF.� /L � � DATE � ��
APPROVAL INSPECTOR SIG'IVATURE