P - 45780Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By: r�
763-572-3604 CITY OF FRIDLEY �` ,f
763-502-4977 FAX EFFECTIVE 1-1-201I D�L�' ""
DATE (� ��3� I� YOUR E-MA]L ADDRESS ��4.� .D.�.jf�.s..�e..1� + 4.� ..,�
SITE ADDRESS �f S 3r �� kl �t�/ �' NL�. Fr'%� �-s �'
THIS APPLICANT IS: ❑ OWNER J$CONTRAC70R
PROPERTY OWNER/ NAME: M- �T�-l-c. f,' �Z •�- w..� s'
TENANT ADDRESS �S 3S OpMG'�y 7Q +UE CITY �"ia�.�.y STATE i�/(LZIP,jSy3Z
PHONF %G�3 � S%I� %G �Z9
CONTRACTOR NAME:�„�vaSS� "o�w� �•�S.:sl��.?o v�
SUBMIT A COPY OF STATE LICENSE # f Q� '7 LEAD CERT NLIMBER /�jp.! — e�/7'�e1,� •
YOUR STATE LICENSE �
AND CERTIFICATE OF ADDRESS:�l�2! Ia'�'M �4�J� A7 CITYti�. J�/ruvv-I�v. STATELy�LIPS�y�v/
1NSURANCE PHONE %L� Sr CII FAX G3^ S�' �
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINISH �'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
O SWIMMING POOL
TYPE OF WORK: ❑ NGW HOME CONSTRUCTION O ADDITION
j�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BE1NG DONE: �� �r.�_ y��..�nJa.gv F S-+ � SC e?E a�- c.w10 /' %g
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING IQHOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES _[ �_ e•�� ❑ HOUSE & GARAGE �. Eaisting Floor Plan
GARAGES �\ve ❑ ATTACHED GARAGE 2. Proposed tloor plan
PROPOSED SIZE: v ❑ DETACHED GARAGE 3. List of structural members [o be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION 1NCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl � ���� I. Site Plan/Survey showing the existing structures
❑ Aluminum � T��m and proposed project.
O O�her Fascia
� 2. Two sets of construction plans
WIIVDOWS 3. EnergyCalculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NCW 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:
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(U�S�N�,'THE 1997 U.B.0 FEE SCH OCCUPANCY TYPE
..,
$ )��`�� See Back Page for Fee Schedule
$ T � 65% of Building Permit Fee
$ .00] times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans ro MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ . Make checks payable to: City of Fridley Attach Stipulations
THIS 1S AN APPLICATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
1 hereby apply for a building permit and 1 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 ll work w _equ}i �e�s review and approval of pJ�vt�is.
SIGNATURE OF APPLICANTL�/I.A+�+l ��.�M. PRINT NAME C.A2�4�Q,iw� DATE G—�13� /j
APPROVAL INSPECTOR SIGNATUR— E �—
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK