P - 45707Build111g $jJjL�jj�(i PermitNo.%�'���� �� �
Inspections RESIDENTIAL APPLICATION Re�e��ea By:: �'
763-572-3604 CITY OF FRIDLEY D °
763-502-4977 FAX �FFECr�vF t-t-zo>> �� �������
DA'I'E_ YOUR E-MAIL ADDI2ESS _�__ �� Y�� l.J �'i � N S .� D M
SITtiADDRESS�(��__ t.�c � V21�tiQ. � L__ � _ _ � _ _
THIS APPLICANT [S: Q OWNER �CONTRAC'I'OR
PROPERTY OWNER/ NAME: S Cn� R_����_______
TENANT ADDRESS:SOQ�' �n4CS �liC_. �L� CITY �; t�.�j �_STAT$�IVZIP SS��'
PHONE:
CONTRACTOR NqME�2 ��C.S � e�`�nrv.e Sa� �;— � n n S
SUBMIT A COPY OF STATE LICENSE # r,�ti�j �%� � 3 LEAD CERT NUMBER NI�F"fi' —! iOS �
YOUR STATE LICENSE �
AND CERTIFICATE OF ADDRESS: � 6I � C-I-� •� l S �[D�"� CITY����,�}L� STATEM/U ZIP SS�
INSURANCE pHONE �fo3' ["i3c� "Gt� S FAX �to� `,-i oZ " q$ 5�{
TKV�EI�T�' TS'Y�E 1�lN(iLE FAM1LYii�ii;W�CONSTCZU�.iION � SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH 1�ROOF ❑ DRAIN TILE
O DECK O SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�141AINTENANCE/REPAIR ❑ REMODELING
DESCRIBEWORKBEINGDONE: i q.�St' ti.+�G}I �e'1`i.Ch (� a'rQ �'-
SIZE OF IMPROVEMENT LENGTH W[DTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF' SQUARES aa ❑ HOUSE & GARAGE BASEMENI' REMOUELING SUBMI'P:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAUE 2. Proposed floor plan
PROPOSED SI"LE: _ ❑ DFTACHfiD GARAGE 3. List ofstructural members to be used
PROPOSED HEIGHT:
SIDING ` FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl 05offit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calcutations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES &
�Y'PE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
HLL PL' L' iJ H1CL' BAJL' L Vl�l VALUAl1V1V� 11�l:LUL11Vl� 1riE I;VJ�l- VN' LAISVK A1Vll 1VlA'l�L+'K1AL5:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �O � � /"� �r('TrPA�v�'� TvPF
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ 11 I• v�5 {'17 L5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .OQ 1 times the total j�b valuation
$ .0005 x Permit Valuation Minimum $5.00
$ �1, $5.00 (State Licensed Residential Contractors)
$ $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 ( )
$ % b , Make checks payable to: City of Fridiey Attach
TFiIS IS AN APPL[CATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wiil 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 far 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 a ic ui review and approval of p� t ���— v
SIGNATURE OF APPLICANT :'RINT NAME K�� DATE
APPROVAL INSPECTOR SI ATURE