P - 44440Building BUILDING Permit rTo.: �� �
Inspection�, - ' �`''
RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ���'�L ����
763-502-4977 FAX EFFECTivE i-i-zoio
DATE lr� l� "'IU YOUR E-MAIL ADDRESS
S�E�D�SS ra�y �'o��,�,��c ,�� �-,����Y, �.�/ S'Scl3:2
,
THIS APPLICANT IS: ❑ OWNER �]CONTRACTOR
PROPERTY OWNER/ N�: �`NDv /'2'i�i3�G
TENANT �D�SS- !y /✓��T1�-ci /¢vC` NE CI'r5� F��.DGEY STATE/1�ZIP SS�.3o2
PHO►`��,: �G 3� S77 '9��T 7
CONTRACTOR 1vAME: GiJELL!/lh�T � Gt%rNG2��S
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # EXP DATE
AND CERTIFICATE OF ADDRES :�J 93� I�JF�IiO4��' �' �P� CTfY��WK' iACf STATF� ZIP .5��
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INSURANCE PHONE Sz> �33 ^�0 300 FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE •
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FII�iISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTEIER
❑ SWIlvRbIINGPOOL
TYPE OF WORK: ❑ NEW HOME CON3TRUCTION ❑ ADDIT'ION �
�i1 MAINTENANCE/REPAIR ❑ REMODELING `
DESCRIBE WORK BEING DONE: r a/ ppul /� L/¢CEo`lEL'i �
SIZE OF IMPROVEMENT LENGTH �VIDTH HEIGHT S FT
R OFING O HOUSE ONLY SASEMENT REMODELING SUBMIT•
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1, Existing Floor Plan
GARAGES ❑ ATTACHED CrARAGE 2. Ptoposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structurat members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDTiTONS_ & PORCHES SUBM�T:
�����► ❑ Trim l. Site Plan/Survey showing the existing shuctures
❑ Other ❑ Fascia and proposed projeck
2. Two sets of conshucrion plans
WINDOWS 3. Energy Calculatio�s
IN EXISTING OPENINGS�Yes ONo L ATIOl�i OF WINDOWS ��� FOR WINDOWS — PROVIDE U-VALLJE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF " GGY� ��'+ MAIIIJFACTURE 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•
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Sutcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(i�JSIl�G THE 1997 U.B.0 FEE SCHEDULE) �
� ��+' � OCCUPANCY TYPE
� See Back Page for Fee Schedule
$ 65% of Building Pernut Fee
� �� .OUi times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$22-$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
-� -��. Agreement necessary ( ) Non Necessary ( )
� I X y..��' � Make checks payable to: City of Fridley Attach
THIS I3 AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernut and I aclmowledge 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 pernvt and work is not to start without a permit on site; that the work will be in accordance with the
approved pian in the case of which requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME ,�4Yj/����� DATE (9 lG IC�