P - 48207Building BUILDING pernl�t No.: ?"� � C
Inspections RESIDENTIAL APPLICATION Received By: J
763-572-3604 CITY OF FRIDLEY Date ��f� J�����
763-502-4977 FAX EFFECrivE >>-zo>>
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT 1S: O OWNER �CONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS:,� F�OvZ �ihh�j �� VC �- j CITY
�� � �'is` STATE ZIP
PHONE:
CONTRACTOR NAME: C, j v�Co(r� ]�q.i1LOC Lo;�s / P�'�] i G��� .1 Nt,
SUBMIT A COPY OF STATE LICENSE # O�i �j Z.. JZ LEAD CERT NUMBER EXP: f/�
YOUR STATE LICENSE �1 � � y
AND CERTIFICATE OF ADDRESS: ��C/O Y%�U� ;S�rt `✓C' W CITY L'Tri'IG��'-. 4I� .� STATE �YII�(ZIP �/
INSURANCE PHONE ? t+ 3- YU y- � 2 7v FAX �
PROPERTY TYPE ❑ SINGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINISH Fd ROOF � DRAIN TILE
❑ DECK (] SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
� MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �i �iC/`�j�' � f�r
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING �HOUSE ONLY
NUMBER OF SQUARES �_ ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT
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,
❑ Vinyl OSoffit SIDING/SOFFIT/FASCIA ADDITIONS, & PORCHES SUBMIT
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO � Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No 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 FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
,�USING TI�,E 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�S �U�� OCCUPANCY TYPF,
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �'���1�
$
$ �25
$ '�
$ ��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: Citv of Fridlev
Attach Stipulations
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 o ark r' uires review and approval of pla
SIGNATURE OF APPLICANT f�--.:�r' � ,�-- PRINT NAME �✓fT.."-t �Pf'�'a' DATE I Z/Zl�% /
APPROVAL INSPECTOR SIGNATURE ' T—+
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