P - 44530Building BUILDING Permit No.: ZrO
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ��'��e�Y
763-502-4977 FAX EFFECTivE i-t-zoii
DATE . �� % ��� YOUR E-MAIL ADDRESS .(L 1/� � -Y� •
stTEADD�ss /�f[) D/i/!i SS, Ss.�o: �i��_�iGl�u. M�I S's" `� a--
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTYOWNER/ NAME: p,n S ne,
TENANT ADD�SS: J�00 �� S 5. S 5� ���CrrY STATE rn�S 3�?,
PHONE: %:0.3 ' Jr %Z � t�.J o7- g
CONTRACTOR N�: �.�, "
SUBMIT A COPY OF STATE LICENSE # (B % LEAD CERT NUMBER N A'"T - a> y3 �—
YOUR STATE LICENSE ---��
AND CERTIFICATE OF aDD�ss:�N�� �,�r�.-�ry � r � CITY�nL..� i�K- STATE�IP S�S
INSURANCE pHONE � � -�/L% % FAX �,3 - S -
PROPERTY TYPE ❑ SINGLE FAMII.Y/NEW CONSTRUCTTON SIZE
Q TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ItOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
INTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �e�� O C� �- �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
O FIN �� �7 HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �F�OUSE & GARAGE 1. 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,
C7 Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT�
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the exisring structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ONo 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 FEE� AHI: BASI;ll U1V VALUA"1'1UN, 1N(:LUll1N(� '1'Hl; (:U�'1' Ur' LA13UK AND MA"1'LitIAL�:
_ (USIN� THE �997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUA'
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surchazge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
..•
TYPE
��ZU 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+68= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ 0. Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge 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 this 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 Po�r�k�' u�res review and approval of p� ��m �. �,�_��
SIGNATURE OF APPLICANT�l•8-C�L.GIh���C,[o A__ PRINT NAME ��� �/ DATE
APPROVAL INSPECTOR SIGNATURE J -