P - 48449Building BUII,DIN(s Permit No.:
Inspections RESIDENTIAL APPLICATION Re�ei�ect B:
763-572-3604 CITY OF FRIDLEY �� ` �
763-502-4977 FAX EFFECTivE �-i-zo>>
DATE � /g-// YOURE-:v1AILADDRESS /IirNN�19P�uS.pi[AtG2�,��jAAio�TSayd/RGCT. �A�
SITE ADDRESS 9S2 M/S,f/ts'/�r� ,S7' A/6
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NA,�tE: (')�/�RA A�O�
TENANT ADDR�SS:
�`5.2 lJ1iSSissirr� s'T. tiJLr ccTV ��C�/o�Y sTa.Tt�Mn/ zlrSl�/!Z
PHONE: �i/,2-�70-�j/t7
CONTRACTOR NqMr: CN�lM/M�J u/iN�vw1
SUBMIT A COPY OF STATE LIC�NS� #?o �l�l9672 LEAD CERT NUMBER �i�r ,QB qLP'O
YOUR STATE LICENSE /
AND CERTIFICATE OF ADDRESS: S/UO �-I�J✓. llr9 I✓, . ST�. d CITY�Q�l �{/l9� STATH/%IAJIIP,g'�J$
INSURANCE PHONE - ? - •�/ FAX �- -
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCI'ION SI'LE
� TWO FAMILY/NEW CONSTRUCTION S'I'ORIES
PERMIT TYP�' ❑ ADDITION ❑ GARAGE/SIiGD ❑ WINDOWS
❑ BASEMGNT FINISH ❑ ROOF ❑ DRAIN T]LL
�DECK ❑ SIDING �-O"CHL;R �OICCN ��CLO,SLIRL
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DF,SCRIBE WORK BEING DONE:��/flayd LsX/S7i�C A�LK � B�l/L 0 Nl.dl �L147F��/( � E�fKLBS� iJ�/Af/Idr.6 f/ Opo�t
SI .7.E OF IMPROVGMENT LENGTH �'� � WIDTH IG � HEIGHT � SQ FT I�Z
ROOFIIG ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGL 2. Proposcd floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim l. Sitc Plan/Survcy showing thc cxisting structures
❑ Other ❑ Fascia and proposcd projcct.
2. Two sets of construction plans
WIhDOWS 3. Encrgy Calculations
IN LXIS"I'ING OPEMVGS �Ycs ❑No LOCATION OI WINDOWS SN�SiF fAA� FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEMNG CHANGES & `
I YPE OP WINDOW TO BE INSTALLED SL/O�S NUMBER OF WINDOWS ✓
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �O. 90o OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcl�arge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ L � a, "LS
$
$
� 5t
$ ��,
$
$
$
$
$
$ 7��fni7
See Back Page Por Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
S2230 per SAC Unit (Plans to MWCC far determination)
ft+6ft= ftx�25—$
$450 Conservation Plan Rcview
Fee Detennined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJTTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the inforniation abovc is complete and accurate; that the wark will be in
conformance with the ardinances 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 r a permit and w�'k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all ork w� ret�uire,s �leview and approval of plans. /'��
SIGNATURE OF APPLICA\T � j PRII�'T NAME S%1'U� L;(JLL/Lr l�- DATE V- Id-II
APPROVAL WSPECTORSIGhATURE
PLEASE NOTE: SEPARATE PERMITS �� REQUIRED"FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
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