P - 48380Building BUILDING Permit Ivo.: ��3 G�
Inspections RESIDENTIAL APPLICATION Recei�ed By: `
763-572-3604 CITY OF FRIDLEY Da��d� �' B�. ���
763-502-4977 FAX �c� ii-�oii
DA� l�.. — z. 7� I I YOUR E-MAIL ADDRESS h� 5�,_�� h a"� � Ser �, °� � s, c o.w
srre nvvxF:ss '738 c� uex-�,-� !��': v e ���--
THIS APPLICANT IS: ❑ OWNER �6NTRACTOR
PROPERTY OWNER/ NAME: eC r�Gti �._S�h.�-, �` cl �-'�
TENANT twnxESS: ,'� we s F Z' ��1 LA.�.2 crr5r rt t n� ��'� STATE 04� ZIp 5�3 �{ �
PHONE: iQ.s I 3� ' S�o%�
CONTRACTOR rr,�: t/or� ���v� c. �S c-C C
SUBMIT A COPY OF gTATE LICENSE # a�0 D LEAD CERT NUMB M, ��'D f�
YOUR STATE LICENSE
AND CER'TIFICATE OF .�nnxESS: �S ��� e S'� crrx Sk �'e%'f'-"+� STATE �'� ZIP 'S S/L
INSURANCE PHONE ��"' S� o o FAX
PROPERTY TYPE 3INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMII.Y/NEW CONSTRUCTION STORIES
PERNIIT TYPE � �DITION ❑ GARAGFJSHED WS
❑ BASII�IENT FINISH ❑ ROOF ❑ RAIN TILE
❑ DECK ❑ SIDING ❑ OTf�R
❑ SWIlvA�II1VG POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDTfION
❑ MAINTINANCF/REPAIR ❑ REMODELING G�1`�-, `� �,l•'w•�`+'�S
DESCRIBE WORK BEING DONE: fC�,(� �-e >`� W �f ►� G) ���
STZE OF IIvIPROVEMENT LENGTH WIDTH HEIGHT S Ff
ROOFING ❑ HOUSE ONLY BASIIvIIIVT REMODELING SUBNIIT:
NiJMBER OF SQUARES ❑ HOUSE Bc GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACI�D GARAGE 2. Proposed floor plan
PROPOSID SIZE: ❑ DETACHED GARAGE 3. List of structutal members to be used
PROPOSED HIIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
O�V�� OSoffit SIDING/SOFFTIYFASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? O YES [�TO �• Site Piao/Swvey showing the existing str�
❑ Ofher ❑ Fascia � ProP� P%1�
2. Two sets of construction plans
WINDOWS 3. Energy Calculationg
IN EXISTING OPENINGS �'es �No LOC,�Q TI F 1VINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF l(`-���`^� . f' �a�'l 1� /L✓ti ivIANUFACTURE STICKER ON WINDOW.
OPINING CHANGES & ��t s 6 �-- �ns �^ �' � �6 'n/y
TYPE OF WINDOW TO BE INSTALLED �' 4 NUMBER O WINDOWS
ALL FEES ARE BASED ON VALUA ON, INCLUDING THE COST OF LABOR AND MATERIALS:
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Dae
(USING THE 199'1 U.B.0 FEE SCHEDULE)
� b.,o�+�=• OCCUPANCY
S ��( `�i'S 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�fc r determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCFSSID
I hereby apply for a building permit and I aclmowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of tr�e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe� 't 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 work which 'ew and approval of plans.
SIGNATURE OF APPLICANT NAME �e�(�f 1�i9-�'�" DATE, � L�� I��
APPROVAL INSPECTOR SIGNA �
PLEASE NOTE: SEPAItATE RE FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK