P - 36784Building BUILDING Permit No.: �C`1 '' �
Inspections RESIDENTIAL APPLICATION Recei�ect By:
763-572-3604 CITY OF FRIDLEY D���°��� � � i^�
763-502-4977 FAX EFFECTIVE 1-1-20] I
DATE ����`� � YOUR E-MAIL ADDRESS
SITE ADDRESS ��� 9 �IL,[�.inl '�'�%,�_�
THIS APPLICANT IS: ❑ OWNER UJCONTRACTOR
PROPERTY OWNER/ NAME: �'j�/
TENANT ADDRESS: �S�/ �%JC �� �% �'�I �� N�TY �i/a `�i STATFy�Ih/�IP S`��
PHONE: '7�0 � %S�D' ^ S�� 7 �
CONTRACTOR NAME: TWIN CITY MOME REMODEUNG. INCa
SUBMIT A COPY OF STATE LICENSE # %%�O C�UaI AYeIi�IB' NEEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADD�ss: Spring Lake Parlc, MN 55432 CITY STATE ZIP
INSURANCE pHONE �%63� �J%�'2�J%% FAX
PROPERTY TYPE INGLE FAMILY/NEW CONST SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITIOr1 ❑ G�RAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF � DRAIN TILE
❑ DECK ❑ SIDING ' ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NBW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: '�+« ��=�'�'� �'�'
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
RO FI G � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � ❑ HOUSE & GARAGE I. Existing Floor P(an
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structurai members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
I� DING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl � � ❑Soffit
❑ Aluminum ❑ Trim t. Site PlanlSurvey showing the existing structures
O Other � ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
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 WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES AR�; BASEll UlV VALUA'1'1UN, 11VC:LUll11V(i l'HL+ (:U,'1 Ur' LAIfUK A1VIJ iVlAll�.KIALJ:
'AL JOB VALUATION $%�9 I�--- TIj� �9�7 U.B.0 FEE SCH OCCUPANCY TYPE
r�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ '
$
$ c6
$
$
$
$
$ - -
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 Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridle.y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the infortnation 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 applicatio or a permit and work is not to start without a ermit on s'te; that the work will be in accordance with the
approved plan in the case of � r��hich reauires review and approval of pl . / �/� ����/�
SIGNATURE OF APPLICANT PRINT NAME �C 1'��-� DATE