P - 84395Building BUILDING Perrnit Ivo.�jo�� �`](�3�� ,
Inspections RESIDENTIAL APPLICATION Received By: i�
763-572-3604 CITY OF FRIDLEY D °
763-502-4977 FAX EFFECTTVE �-�-zo�z �"'��C�'�
DATE �C' '— /�^ %�- YOUR E-MAIL ADDRESS ��� C! v u� �f td %%'1N � aO i. C�c�"�
SITE ADDRESS Po H�I �,�I C-�f � bU�/
THIS APPLICANT IS: ❑ OWNER f41CONTRACTOR
PROPERTY OWNER/ NAME: V
TENANT ADDRESS: CITY STATE ZIP
PHONE: c
CONTRACTOR NAME: t,(ntfr �.1/e�� �v .
SUBMIT A COPY OF STATE LICENSE # t� y 9ss LEAD CERT NUMBER NA� - l'�6! 3j EXP:
YOUR STATE LICENSE p
AND CERTTFICATE OF ADDRESS: 80 � 3 !'� W•(:�G a:%W CITY��ok'l�,J Pcu'i� STATE �'''��ZIP �.5� Y
INSURANCE PHONE � "O"� FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTON ❑ GARAGE/SHED NDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
O DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: R2.p I/4C'� l.L) ; NUaI.�JS
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 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 ❑Soffit SIDING/SOFFIT/FASCIA ADDI1'IONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES O NO I. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGSyZ1Yes ❑No LOC_A,�ION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF 4�� '�� MANUFACTtJRE STICKER ON WINDOW.
OPENING CHANGES & ,�-e�,, p
TYPE OF WINDOW TO BE INSTALLED Q'�'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)
AL JOB VALUATION $ �" �O. C�� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Controt
Park Fee
Sewer Main Charge
Total Due
$ �3 -U3 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ .'l Make checks aavable to: Citv of Fridlev Attach
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 of al work which requires review and approval of plan /�� �
SIGNATURE OF APPLICANT ���i�.- PRINT NAME �OH-rCx.`"i Q�f+K��° DATE %D -I %��� o�