P - 48056Building BUILDING Permit No.: d�"'� �`
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY -
763-502-4977 FAX ������",` `
EFFECTIVE 1-1-201 I �
DATE__S�'�� �� �_ YOUR E-MAIL ADDRESS �� ���JF�G?--�C� I C� n.�vyv ��e'� �� � Cc,•�,�
SITE ADDRESS �+ �; SS � c� 1f � Q�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NfwtE: '� �
TENANT pDDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME. �� � �a � �j c�� �� S
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS: �Z`�-{Z C 5,�.� �", ��� �g CTTY N�o�.c��c)tC�.J STATE�ZIP S5I I
INSURANCE PHONE � — FAX �63� �z-y3�i
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMiLY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �$OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �OTHER `� � ,-{�
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR REMODELING
DESCRIBE WORK BEING DONE: t� �� A o ��
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ 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:
SLDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �o�t ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other �Fascia 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 1' L' L' J AI(L' 15AJL' U V1V
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
vALUAllulv, 1PIl:LUll11Vt� 1 H1; C:UJ7 Ur LAIiUK ANll MA'1'�;KlALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
�f�D , � OCCUPANCY TYPE
$
$ ,� C�—
$
$
$
$
$
$
$ .i�
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 Fridley
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED
I hereby apply for a building permit and 1 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 all ark '�i �uires rev�e and approval lans. ( I
SIGNATURE OF APPLICANT ��� �T NA1v�f����� L.s� ����+DATE �/�� J��
APPROVAL INSPECTOR SIGNATURE �� .., �— 7--