P - 48178Building B�UILDING Permit No.:�r' � v�
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 - CITY OF FRIDLEY vate�e�: �°�� 1 ��
763-502-4977 FAX E�F�cTIV� 1-�-zoi2
vn� %- 1 Z-�' U� 2 YOUR E-MAIL ADDRESS T W r N C i�' �j' GcJ i o� � 0 W�!� T'v►�t �� L� c'�1,
srre .aDDxFSS ? 3 3 I /'1 !� G o o"I p 2 ,/�J r � 2 �°�£y -
THIS APPLICANT IS: ❑ OWNER �ONTRAC'1'BR Y,
PROPERTY OWNER/ N�: �"yj / X r 'S T� �t,/,,E
TENANT annxESS: '7 -S' ��/ fi�£ � o�Y O R M�crrY r�, A�� y sTn��► I� z�
PHONE:_ _ lC? I Z + c� U � ^ Q' / � % ' ,
corrr�icTOR N,4,,,�: � c� N y o � C� r
SUBMTP A COPY OF �/ i-
YOUR STATE LICENSE STATE LICINSE # 2 �� 2�-7 '�I LEAD CERT NUMBERR f 3 � 3 S$- Egp; 3-�- 20�
AND CERTTFICATE OF nnnxESS: 2� 9 D� // d��s r�s► v � 2 crrx ev l� co � aJ sTa�M�lz� S'�
INSURANCE PHONE / — Z S/^ � c�i Z R FAX .
PROPERTY TYPE �SINGLE FAM[LY/NEW CONSTRUCITON S1zE
❑ TWO FAM[LY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DTI'ION ❑ GARAGFJSHED wu�noWs
❑ BASEMEN'C FIAIISH O ROOF ❑ DRAIN TII.E
❑ DECK ❑ SIDING ❑ OTHIIt
❑ SWIlvIMING POOL
TYPE OF WORK: O NEW HOME�OAISTRUCTION ❑ ADDTI'ION
ANCE/REPAIK ❑ REMODEL,ING
DESCRIBE WORK BElNG DONE: %�'� p�� C� r X/.S �I /�J C µ! //✓ Ci �J w 3 W 1 j 1; �(� t3 A t � 1��
SIZE OF IlNPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY g,q��� g�MODELING SUBNIlT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSID SIZE: ❑ DETACHED GARAGE 3. List of shuctural �mbers to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl OSoffit SIDING/SOFFIT/FASCIA �DIITONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? O YES O NO 1. Site Plan/Survey showing ihe exislc� structufl�s
❑ Other ❑ Fascia � ProPo� Pro1�
2. Two sets of construction p(aos �'
WINDOWS 3. Energy Calculations
IN EXISTING OPErIINGS�' es QNo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & AW w//Y C Q
TYPE OF WINDOW TO BE INSTALLED S�-+� �� � NUMBER OF WINDOWS r
ALL FEES ARE BASED ON VALUATION, INCLUDING TI� COST OF LABOR AND MATERIALS:
TOTAL JOB VALL
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Chazge
Curb C�t Escrow
Emsion Control
Park Fee
Sewer Main Charge
G THE 1997 U.B.0 FEE SCHEDULE)
O (N`(`iTP,
$ r�l�G�
$
$
$
$ �=,
$
$
$
$
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 uavable to: Citv of Fridlev Attacl
THIS IS AN APPLICATION FOR A PERNIlT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes o�the City of Fridley and with the Minnesota Consiruction Codes; that I understand this is not a
permit but only an appli "r a rt` wor is not to start without a permit on site; that the work will be in accordance with the
a{Zproved plan in the case � rk �►ich ��view and appmval of plans.
SIGNATURE OF APPLICANT i! i PRINT NAME R I C k N Y Q v S �'T DATE ��( Z- l 2