P - 39621_�
Building BUILDING Pernut No.: ZI
Inspections RESIDENTIAL APPLICATION � e �
763-572-3604 CITY OF FRIDLEY ����ec� �
763-502-4977 FAX Er�c� i-i-zoii
vn�e I� YOUR E-MAIL ADDRESS C� �c.� r�.,�., _�� ar m� t.�c.,r�l. �, c� p;: l. • C.orr�
SITE ADDRESS 5 3� 3 Vh�A \ T� \4� �� C,� �2. •(� e.
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NpME: �' p, m� R� i�,� �► S
TENANT �Dx�ss: S3 a 3 M�rr€.2 ��e �►� C-� R�' ci� �2� t� L� STATE1MnrJ ZIP ���-�
PHONE: ��oj` �7 � � o`�3�Q
CONTRACTOR NAME;�6rZ.��l�wccz�„ Q�4���;r-�-iar�.l.L.�—
SUBMIT A COPY OF STATE LICENSE #�.(� ��' -� b h�,' LEAD CERT NUMBER I�i i� T� g� Y� oL ` �
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: I35 S�oF.uSS�.i1 A 1�vE.. IJ. ��c.` �� �DI CITY C7g KDO'3L`f,. STATE MA� ZIP 5512�
INSURANCE pHONE Co$ I' �'S- I lo �7 �S FAX L- 7 3�'- I 23 �
PROPERTY TYPE �SINGLE FAMILY/NEW CONSIRUCTTON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERNIIT TYPE � �DTI'ION ❑ GARAGEISHED ❑ WIlVDOWS
❑ BASEMENT FINISH ,"�OOF ❑ DRAIN TII.E
❑ DECK ❑ SIDING ❑ OTf�R
❑ SWIIv11vIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTTON ❑ ADDTTION
❑ MAINTENANCElREPAIR ❑ REMODELING
DESCRIBE WORKBEING DONE: �T�1i� O%�- �►7 P�`�-� Lli� �. �G7CG�
SIZE OF IIvIPROVEMENT LENGTH WIDTH HEIGHT S FT �
ROOFING p - ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �;1� - ❑ HOUSE 8c GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of strucrival members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl p��t ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim l. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of conshuction plans
WIIVDOWS 3. Energy Calculations
IN EXIST'ING 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 WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL r'1�',l�'.� AHI�'. BA,L�'ll U1V VALUA"1'lUlY� llYC:LUUIIV(i "1'Hi�; C:U,'1' Ur' LAlfUli A1VL MA'1'EKIAL�:
(USING THE 199� U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ I � , lo OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ G; (�' ) .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
G�ub C�t Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservarion Plan Review
Pazk Fee $ Fee Determined by Engineering
Sewer Main Chazge $ Agreement necessary () Non Necessary ()
Total Due $ 1, Make checks aavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII, PROCESSED
I hereby apply for a building permit and I aclaZOwledge 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 ttris 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 o work whic e uires review and approval of plans.
SIGNATURE OF APPLICANT �-- PRINT NAME �t�li2g.i. L�T'C'I,ccw� DATE�I I �
APPROVAL INSPECTOR SIGNATURE