P - 36723Building BUILDING Permit No.: C% �t;
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY vate�� ���`+ �
763-502-4977 FAX EFFECTTVE i-i-zoii
DATE lr� � � ' ,� I / A YOUR E-MAIL ADDRESS ri!�P?�✓'��n � �N �fiI�Q.,vS • [ v �'�'�
SITE ADDRESS J~0'� � � c� ar►NS ./i-�L /� �` �
THIS APPLICANT IS: ❑ OWNER 6i(�ONTRACTOR
PROPERTY OWNER/ NA�: ISo n
TENANT ADDRESS: ,5 D� �j F� I.IG�. S A1.�t� /�I �. CITY �IP__iGllf�,/ STATE rr �nZIP_��,�
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rxorr�:� cp �• 5 ScQ • c� c� Z9
CONTRACTOR NAME: R� lL �-� c�, �� . u�.
SUBMTr A COPY OF STATE LICENSE # a°i 0�(2 ip �j q LEAD CERT ER _R,� ,� —1 O,� (� `�/ �^ ��8
YOUR STATE LICENSE 7
AND CERTIFICATE OF ADDRESS: ��.-t� lP E// 7 r� S�'. CTTY �j f� STA1'�ZIP ��
INSURANCE PHONE a+• 3- �- FAX c� -�-F[:�
PROPERTY TYPE C�SINGLE FAMILY/NEW CONSTRUCTION s�zE
❑ TWO FAMILYlNEW CONSTRUCTION STORIES
PERMIT TYPE � �DTI'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH C�'kOOF 0 DRAIN TILE
❑ DECK �SIDING D OTHER
SVJIIv1MING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDTI'ION
JS}'MAINTENANCE/REPAIIt 6�,'REMODELING
DESCRIBE WORK BEING DONE:'('.�'7-�1.i2 e G�C oc.� d �^� �'or�F
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
�( OFING �OUSE ONLY g,�g�T REMOD�,ING SUBMIT:
NUMBER OF SQUARES o�- S` /��' HOUSE & GARAGE
1, Exi�ting Flppr Pla�►
GARAGES � O TTACI�D GARAGE 2. Proposed floor plan
PROPOSED SIZE: �ETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: y�.�,,
?� O�/� `` \ FOR NEW CONSTRUCTION INCLUDING DECKS,
Vicryl � OSoffit C_ C J �DITIONS. & PORCi�S SUBMIT:
Aluminum � ❑ Trim 1. Site Pisn/Survey showing the existia� structures
O Other � ❑ Fascia � ProP� Pro'.1�
2. Two sets of conskuction ptans
WINDOWB 3. Energy Calculations
IN EXLSTING OPENINGS OYes C]No LOCATION OF WINDOWS FOR WINDOWS - PRUVIbE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKE$ ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDQW TQ BE INSTALLED NUMBER QF WINDQWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOit AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escraw
Erosion Control
Park F'ee
Sewer Main Charge
THE 1997 U.B.0 FEE SCHEDULE)
I �LvI�('l OCCUPANCY
� �,Z, ,5-��' See Back Page for Fee Schedule
S __ 65% of Builditlg Petmit Fee
" � .001 times the total job valuation
�, y .0005 x Permit Valuation Minimum $5.00
S � $S.OU (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+Gft= ftx$25=�
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agrcement necessary ( ) Non Necessary ( )
$ v /D Make checks navable to: Citv of Fridlev AtixC
TFIIS IS AN APPLIGATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buildin� permit and I aclrnowledge that the information above is complete and accurate; �at the work wi11 be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; thet I understand this is not a
permit but onty 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 pian in the case of a11 work which req ' s d approval of plans. I
SIGNATURE OF APPLICANT , . �,,, U1- ,�� f� PRINT NAME 7�F<3 i�b'T'�dZ�S� DATE �� 3""` L
PLEASE NOTE:`'3EPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHAAIIGAL WORK