P - 60317Building BUILDING Permit No.: �
Inspections RESIDENTIAL APFLICATION Re� �� ��sy .. �
763-572-3604 CITY OF FRIDLEY Date���� 1: ��� ��� � rz�
763-502-4977 FAX EFFEC�vE �-i-ZOiz
DATE �"o� —I — I c�- YOUR E-MAIL ADDRESS C�Y'�,(,�,.�Q CQi • CJl1�"V"1
SITE ADDRESS � 3�Q �( j/ 1(� �
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPERTY OWNER/ NAME: Q,1(' -�-
TENANT ADDRESS: � � �CJ � � ( �C.L/�n�.,� CITY STATF%wn ZIP SS� ��
PHONE:��g��OZ�,�"� c�Fi
CONTRACTOR NAME: G� ('.fj .
SUBMIT A COPY OF STATE LICENSE # �C CP �. p���, 75 LEAD CERT NUMBER �' 3? EXP: � oZ
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: I�Z c� 7[O � A��bt_.} �"�'/�I I,t� CITY $�J� l STANTE- � ZIP
INSURANCE PHONE _I (O �J "44i -�� �� FAX E� K►c.� ' �'"� S S �J�
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: � '/�-�(f�-�-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT
NUMBER OF SQUARES �� �,HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED S[ZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyi ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Caiculations
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 W[NDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
I`jr
�/
a�
1
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum or .50
$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 ( )
Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply far a building permit and I acknowledge that the information above is complete and accurate; that the work wili be in
conformance with the ordinance nd 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 it 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 o,�Pl work i reyuire review and approval of pl�1 s.
SIGNATU RE OF APPLICANTO �� PRINT NAME (JI�C�.�' bQ� KO L ��"�Ct DATE �J "r� %— ��
APPROVAL INSPECTOR SIGNATIJRE �. A^