P - 39343Building BUILDING Permit rto.: � � ( ` �1-�
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY Date�`��: ����
763-502-4977 FAX EFFECTivE �-i-zoii
DATE q" f Z " Z O I( YOUR E-MAIL ADDRESS S t O'i'j L E F F C. �.2 � 1-Ic�'�wJa�1 t� . C p wL
SITEADDRESS �.Q�n� �CFF�IZSaN S� �r2 � p�-��.t N(� 5�jy j"Z
THIS APPLICANT IS: 1�OWNER ❑CONTRACTOR
PROPERTY OWNER! NAME: �°�j�,O 7�- LcF F LE72
TENANT ppDRESS: �.9 ��� :Tc_Fr-E 2soN S� CITY \ LC \ STATE�ZIP�'�-j 3 Z
PHONE: (� � 2' ZS I— SZO�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE SINGLE FAMIL /NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMTT 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: C��1�� f!/
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ I30USE ONLY
NUMBER OF SQUARES �_ � HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
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:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structwes
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑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 ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATEWALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ S See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �_ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft + 6 ft = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ � Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 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 al work whi h requires review and approval of plans.
SIGNATURE OF APPLICANT �� PRINT NAME �j Co �/ LE.��(,.c Y DATE �I ' l 2"��I