P - 48044�
Building BUILDING Permit No.:Z�� ' 3
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate xec'd:
763-502-4977 FAX E��TIVE,-,-zo��
DATE �-_ � j'-= �() I I YOUR E-MAIL ADDRESS v� � c� ✓n; � �� _
SIT'E ADDRESS � '' �
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNERI NpME: '� , ..
TENANT ADDRESS:� -T I .�I %� S� �.��`.!� ./��Sf" AYE CITY ��", [� J E v STATF��U ZIPS��S 5��.�
T��
PHONE:
CONTRACTOR rr�: �• � v ,v c a� � .� , � / r�� : ,;
SUBMTT A COPY OF STATE LICENSE #� `� �� j j
YOUR STATE LICENSE Y- � 7 LEAD CERT NUMBER
AND CERTIFICATE OF ADDxESS: $��?� 3 f�q r� �%� �; � ��_"'�. CITY F�' ,� I� �,/ STA�N zIP'"S 2
INSURANCE PHONE / c� c� J�� FAX %Fi �— 7 ica� °`f,�J`/
PROPERTY TYPE GLE FAMILYINEW CONSTRUCTION SIZE
❑ TWO FAMII,Y/NEW CONSTRUGTTON STORIES
pEgMIT TypE ❑ ADDITION ❑ GARAGFJSHED ❑ WINDOWS
❑ BASEMENT FIIVISH �.ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF W ORK: � NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BE1NG DONE: R�� R t� G� ((,_ iC�a. A��?
SIZE OF IMPROVEMENT LENGTH WIDTH HIIGHT FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � �HOUSE & GARAGE BASIIvI�Ni' REMODELING SUBMIT:
1. Eacisting F1oor Plan
GARAGES O ATTACHED GARAGE 2. Propased floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW COI3STRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDTl'IONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Pian/Siuvep showing the exisking structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of consftuction plans
WINDOWS 3. Energy Calculations
IN E,XISITNG OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEIVINGS-DESCRIBE SIZE OF MANUFAGTURE STICKER ON WINDOW.
OPF.NING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NiJMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDiJLE)
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ �
$ �.
$ �� r
$
$
$
$
$ �
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 oavable to: Citv of Fridlev
i' � . .
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID ITNTII, PROCESSED
I hereby appiy for a building permit and I acknowledge that the information above is complete and accwate; 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 wor whi ires r�'iew and approval of p /
SIGNATIIRE OF APPLICANT �✓ � iL...�_ / PRINT' NAME �G�v� !� �G�N �"G � DATE V�� !�
APPROVAL 1NSPBCTOR SIGN7ATLJRE