P - 40731Building BUILDING Permit No.: f t) �� i�
Inspections RESIDENTIAL APPLICATION Received By: ''
763-572-3604 CITY OF FRIDLEY D���� �� �� f11 �
763-502-4977 FAX EFFEC-rrvE i-i-2oit
DATE !/ Z I/�� YOUR E-MAIL ADDRESS � r C- ��� Q' S� ��^ q+ G G+"'�
SITE ADDRESS Z�O C�'� ti U'—� Sf /�" �
THIS APPLICANT IS: ❑ OWNER }�CONTRACTOR
PROPERTY OWNER/ NAME: � r f.� � r� A�f' c. z-- k
TENANT ADDRESS: Z 1 O LA��z�� I/ar� S f` /V� • CITY �i � F STATE ��/�ZIP .rS 5� 3 L
PHONE: ��a .� ° 7�% - 2.1 t7 S
CONTRACTOR NAME: � tC ,' ,.� �'� c . A,
SUBMIT A COPY OF STATE LICE SE # Z-t5 y SC �'� % LEAD CERT NUMBER !`��T �Z % Z�� �
YOUR STATE LICENSE /�
AND CERTIFICATE OF ADDRESS: �3OJ �. C�1-� �� ��� % CITY ONinS u� ��� STATF/l�/1�ZIP 5�33 %
INSURANCE PHONE �SZ � ��� ` 3d �G FAX J5�2- - %Y� `3c� 4' %
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 Q OTHER
� SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAtR �REMODELING
DESCRIBE WORK BE[NG DONE: �F — i� �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES Z� ❑ TtOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structurat members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey shawing the exisring structutes
❑ Other ❑ Fascia
and proposed project.
2. Two sets of construction pians
WINDOWS 3. Energy Calculations
IN EXIS7ING OPENINGS ❑Yes �No LOCA'I'ION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACT[JRB STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES AIZE BASEll OlV VALUA"1'IUN, IN(:LUll1N(G '1�H1: (:U�'1' Ur' LABUH AND MA"1'1�'diIAL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��OiO• oQ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Swcharge
SAC Chazge
Curb Cut Escrow
Erosion Controi
Pazk Fee
Sewer Main Charge
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �� .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ � �� $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plart Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( }
$ h 1 � i.� Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I acknowledge that ttie information above is complete and accurate; that the work will be in
conformance with the ordinances and wdes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicarion 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 w rk whic quires eview and approval of plan� . /
SIGNATURE OF APPLICANT ���� PRINT NAME PG� �Cu D. S��'� `� 6 DATE %�� ����
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANIGAL WORK