P - 84361Building BUILDING Pe�it No.: 81,0 b
Inspections RESIDENTIAL APPLICATION Received By: J
763-572-3604 CITY OF FRIDLEY Date��:�� ��� 2���
763-502-4977 FAX EFFECTivE i-i-2o�z
DATE YOUR E-MAIL ADDRESS �G�()._� S�h h 1°�l �. �I �(� h�Wl Qn. 1 r COWI
SITE ADDRESS (D—I SU �C.`n i'1 G-s�'U ��1 � i ��- ��.i0 l-,E� � IJ �� t-h � Z-
THIS APPLICANT IS: '�WNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: SA�j� N I�-1 d� T��G�TT
TENANT ADDRESS: 10"1 � K.2 n r� 0.5�h 'C� 6-'. N�, C�TI' �F�-1 p t..E� STATE M�Z1P 5 5� 3 z
PHONE: b� � Z�I � ��1 1�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
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: �� P j,p��. �"'j W►�1 O�'1� 5� I�� T�� O(L '(�;G Q-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS_ & PORCHES SUBMIT:
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA
❑ A(uminum ❑ Trim REMOVED? ❑ YES ❑ NO I. 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 �No LOCATION OF WINDOWS C�r�4 rou �r+S ,�%�':�►Y�L FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �..� tiA�.t,✓1 MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BA��ll U1V VALUAI tUlv,1[vc:t,u1�11vt� iti�: �t�� i �r Lan�x ai�li inA i �,�uaL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ a0�� p� � 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
$ �'3 � 25 See Back Page for Fee Schedule
$ `' ',�rT;,. 65% of Building Permit Fee
$ 0 1 Q .001 times the total job valuation
$ C5 _-''-j(� .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Pians to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
� � 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 acknowledge 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 all or w ich requi s eview and approval of p ans.
SIGNATURE OF APPLICANT ��C� PRINT NAME�A��.�.'T£R (,?�[ DATE IU�ZZ l J Z
APPROVAL INSPECTOR SIGNATURE