P - 48237Building BUILDING Permit No.: �-� `��` �'��=-
Inspections RESIDENTIAL APPLICATION Received By: � P
763-572-3604 � � � �'�
CITY OF FRIDLEY Da��d'� �= �"
763-502-4977 FAX EFFEC-TTVE i-i-zo�2
DATE /`� (,.,�I 2� YOUR E-MAIL ADDRESS
SITE ADDRESS �.�i � % d T' �
THIS APPLICANT IS: ❑ OWNER ��CONTRACTOR
PROPERTY OWNER/ NAMg: ' �W►.�,y � W<' �
TENANT ADDRESS: t� '^ � CITY � 1 C STATE '��n ZIP_-=��
PHONE: ,.�, j' -1 jS -� -�,� S C
CONTRACTOR NAME: � 1 -�., C�:,f- . LC G.
SUBMIT A COPY OF STATE LICENSE #?,C S�7� � vr LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �c� ci /�� �r i')�LJ�, �. /� � CITY_���-O C("' STAT�%i� ZIP S�L>/
INSLJRANCE PHONE I L_' `Z 2 Q — � O � S FAX �.� j- )_� - j�uC�
PROPERTY TYPE .� SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCT'ION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH J�ROOF ❑ DRAIN TILE
❑ DECK ,� SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � ( ��I � �i, � `� i( i.�'�u�.� �'�,�.;°'
SIZE OF IMPROVEMENT LENGTH � WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � �r 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: °'j
SIDING � FOR NEW CONSTRUCTION INCLUDING DECKS,
'� ADDITIONS. & PORCHES SUBMIT:
,�I Vinyl � ❑Soffit SIDING/SOFFIT/FASCIA 1. Site Plan/Survey showing the existing structures
❑ Aluminum � ❑ Trim REMOVED. ❑ YES ❑ NO and proposed project.
❑ Other \ ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCAT'ION 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 r L� L�,J AKl�, tSAJr:L IJPI
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
a�
VALUA 11V1V, 1NC:LUllIiV(i l HL�' CU51 UN' LAKUK AIVll MA'1'ERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
� U D� OCCUPANCY TYPE
$ �;� '3 . L� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �% , � .001 times the total job valuation
$ .0005 x Permit Valuation Minimurn or .50
�-�;z�
$ ���(.? $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ;a h �, 3� Make checks payable to: City of Fridley 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 o o•' �c�k,r��iew and approval of pla� ' J� D
SIGNATUREOFAPPLICANT /fl � PRINTNAME /rJr, 7C/I i+,e�t DATE �- S��� Z.-
APPROVAL INSPECTOR SIGN RE