P - 48070Building BUILDING Permit No.:`����� `� �
Inspections RESIDENTIAL APPLICATION Received By: � L'��
763-572-3604 CITY OF FRIDLEY Datep �,��� �
763-502-4977 FAX EFFECT� ii-ZOii I���
DATE � 2� b° 11 YOUR &MAIL ADDRESS � Q�� C,.,r c, Q� L� � iT +.�.0 �?a �n � a- eMO. i�, C� w�
STfE ADDRESS �=� � S 1� p r y-y� "?��.1n1 b r�c7� 9r•
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: Yv� e,rai +- CLo,s�„�e.� �L�e.,r.
TENANT �DRESS: CITY STATE ZIP
PHONE: ''7 b3 '' '� '1 `{ '- 1 b%S
CONTRACTOR N,��: L�„�„�qr� %v�S+ru.ei-1o..� � LL�
5UBMIT A COPY OF STATE LICENSE # (� C(03 t� $°► � LEAD CERT NiJMBER /0,�"39G �/ EXP: 3-/ �f -� ��b
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: S( (o $' D �n r� �li��te 1V� C1TY U' �'S-c.c. o STATE K ZIP SS33fl
n�su�,ricE PHONE a- 3fa ���5'o F.� � b 3- a �f -�� 3 I
PROPERTY TYPE INGLE FAMIL w CorrS'1'RUC'riorr srzE
❑'I'WO EW CONSTRUCTION STORIES
PERNIIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FIIdISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING O OTf�R
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION � ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ��- r��
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES 3 Z �I-IOUSE & GARAGE B.4SEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structutal members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? 0 YES ❑ NO i. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINllOW5 3. Energy Calculations
IN EXISTING OPEI�iINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALLTE 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 U1V VALUA'1'IOlV, ll�1(;LUDl1V(�'1�HN; c:u��l� ur� 1.AKUxAivli MA�11+�.x1a1.�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ /(o, doo OCCUPANCY_ TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Ci�t Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ u �, `� 5 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 deternunation)
$ ft+6ft= ftx$25=$
$ $450 Conservarion Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ► Make checks uavable to: Citv of �-idlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN7TL 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 far a permit and w is no to start without a permit on site; that the work will be in accardance with the
approved plan in the case of al� w 'ch r rev' and approval of plans. �
SIGNATURE OF APPLICANT N'' PRINT NAME ��d`'�t� LG6=nG�' // DATE �a —� °� ���
APPROVAL INSPECTOR SIG A
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