P - 40008� � ri.��-
Building BUILDING Permit No.: �A«' Oc154
Inspections RESIDENTIAL APPLICATI N Re�ei�ect By:
763-572-3604 CITY OF FRIDLEY Date Rec'a: ��`-�-�
763-502-4977 FAX EFFECTivEl-�-2oi�
DATE ����' �' YOU E-MAIL ADDRESS
SITE ADDRESS � � � fA��
THIS APPLICANT IS: ❑ OWNER 'BCl�NTRACTOR
PROPERTY OWNER/ NAME: Co/�f'�i �C`� • n/1 /U
TENANT ADDRESS: 7 �'�7��I /�A CITY /�i/ STAT�� ZIP
PHONE: 0�-- 2
CONTRACTOR NAME: ,l
SUBMIT A COPY OF STATE L10E LEAD CERT NUMBER FT "�
YOUR STATE LICENSE �
AND CERTIFICATE OF ADDRESS: /7R�\ �7'i 9.�►Tl � CITY STATE ZIP
INSURANCE PHONE � FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED $GOiNDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ RE ODELING
DESCRIBE WORK BEING DONE: W d /'7AIK.
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1, 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,
❑ Vinyi ❑Soffit 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 Calculations
IN EXISTING OPENINGS BYes ❑No I,OC�30N O�I�O�j(3� FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF _�/L.��— ,S 1 MANUFACTURE STICKER ON WINDOW.
OPENTNG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUA"1'ION,INCLUll1NG'1'HL+' CU�'1' UN' LAl3UK Alvll MA1�KtAL,:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�� 1� �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Ch�
Total Due
j 7 �2 � $ `� /, i2 � See Back Page for Fee Schedule
—�—� $ (� 0 9 �i5% of Building Permit Fee
��'� � $ .�► .001 times the total job valuation
�.,�U $ , .0005 x Permit Valuation Minimum $5.00
�� c90 $ r ei'Q $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
—$ t�-t— Agreement necessary ( ) Non Necessary ( )
/� � I 1 1�� Make checks pavable to: City of Fridle.y 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 o e City Fridley a with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a i d w i n t to st without a ermit on s te; that the wor will be in accordance with the
approved plan in the case of al i 'ew d roval of pl JI /�
SIGNATUREOFAPPLICANT ��N �� ATE �^��� V1
APPROVAL INSPECTOR SIGNATURE