P - 48412Building BUILDING PermitNo.• 1' — e�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'ct: '� -��
763-502-4977 FAX EFFECTTVE �-i-zo�2
DATE ✓ Z- Z Z- i Z- YOUR E-MAIL ADDRESS °j°`�e-'� `n ��' Z- c�3 c� m c��� << �- � n�
SITE ADDRESS S�"� 3���-�2r��,�.,� D ��' � F 4� � c� �1= -C � 1�t t�
THIS APPLICANT I3: L� OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: L�� -�'�� i�\ �� z s��.\L--cz
TENANT ADDRESS: _5?i i3 Jv(r���-e.r�c��^�� \�C'[Ty G� STATE%`1r. ZIP�_S•�-ZI
PHONE: �`Z -5�l -4 }�1..�
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICAT`E OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE
FAX
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCT'ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTON ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF O DRAIN TILE
❑ DECK �'J SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: � NEW HOME CONSTRUCTTON ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �C ;n �r,�CE � c-• �- �- "��- � C� �E v e 7t � �} � y�r� h,;� ��
SIZE OF IMPROVEMENT LENGTH 1� e= 1 y WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE ]. 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,
❑ Vin I ADDITIONS. & PORCHES SUBMIT�
Y �Soffit SIDING/SOFFIT/FASCIA �. Site Plan/Surve showin the existin structures
� Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO and ro sed o ect. g g
❑ Other =�re��� Cj�"Fascia 2, Two seto f construction ptans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALLTE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW 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 $ g�v ,��O 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
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 for a building permit and I acknowl�dge that the 'nformation above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City iFridle and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo�r� ermit and , is ;not start without a permit on site; that the work will be in accordance with the
a roved lan in the case of a(a�'�f�itk w �'
pp p }�s revie ,,and approval of plans.
SIGNATURE OF APPLICANT ' � %� �r�� � �% � _ ? ` - ' �
T C�c: ✓"-e���l (�� rT ZS C DATE _�� /�-
APPROVAL INSPECTOR SK'iNA . ' �l n//
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