P - 48144Building BUILDING Permit No.: (�� I�✓
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Dat p E����� 1
763-502-4977 FAX ���
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DATE ( �\ _ YOUR E-MAII. ADDRESS
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THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTYOWNERI xAME:� R�3c 1�R��t,s
TENANT ADDRESS: 1'�l*z. A.�o�RM�. R� �— CITY ��� � STATE A�ZIP 5`-�'�-I
�ortE� lfo,3- 5 �� = I3 59
CONTRACTOR N�: v �,5 < c _ _ -�S'Z
SUBMIT A COPY OF STATE LICENSE �1 Gc��{'3`"�—i LEAD CERT NUMBER EXP:��1�_
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: Z.`-(�3 �-A�tiC.� AJ �. C1TY M�Sc��tc�STATE �ZIP �c�?T
INSURANCE PHONE — FAX ^ Z�' 33 �
PROPERTY TYPE ❑ SINGLE FAMII Y/NEW CONSTRUCTI013 stzE
❑ 'I'WO FAIuIII.Y/NEW CONSTRUCTION STORIES
PERMiT TYPE ❑ Annrr[ox ❑ anRnG�s�v ❑ wnvnows
O BASEMENT FINISH j'uROOF ❑ DRAIN TII.E
❑ DECK ❑ SIDiNG ❑ OTHEIt
❑ SWIIvII�lING POOL
TYPE OF WORK: � NEW HOME CONSTRUCITON ❑ ADDTI'fON
�;MAINITENANCE/REPAIIt ❑ REMODELING
DESCRIBE WORK BEING DONE: Q. o a � �Q{''
SIZE OF IlvIPROVEMENT LENGTH WIDTH HEIGHT S Ff
ROOFING a ❑ HOUSE ONLY gpc�iT gBly(ODELING SUBMIT•
NUMBER OF SQUARES '�? i$ HOUSE & GARAGE 1 ��g�g �� P�
GARAGES ❑ ATTACHLD QARAGE 2. Proposed floar Plan
PROPOSED SIZE: fi� DETACHED GARAGE 3. List of st�ucUual members to be used
PROPOSED fIEIGHT:
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
� ADDITIONS. & PORCI�S SLTBMI'�:
❑ Vieyl ❑Soffit 5IDING/SOF'FIT/FASCIA i. Site PlanlSurvey showing the existing shuci�ues
❑ Aluminum ❑ Trim REMOVED? ❑ YES � NO and Propoeed Prolect.
❑ Othea O Fascia 2. Two sets of conshuctia► plana
WIlVDOWS 3. Energy Calculations
IN E}IISTING OPENINGS OYes ONo LOCATION OF WINbOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF A+INDOWS
AY.i. Ti F.FC ARF. RA�F.D ON VALUATION. INCLUDING THE CO5T OF LABOR AND MA7'F'RiAi.S:
TOTAL d0B VALiI
Perinit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
G�rb Cut Escrow
Erosion Cantrol
Park Fee
Sewer Main Charge
$
$
$
(USING THE 1997 U.B.0 FEE SCHEDj1LL)
�r-�r� _ vo OCCiJP�INCY
See Back Page for Fee Sch�ule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Penmit Valuation Minunum �5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Pl�s to MWCC for determination)
ft+6ft= ftxS25=$
$450 Conservation Plan Review
F� Determined by Engine�ring
Agreement necessary ( ) Non Necessazy ( )
Make checks uavable to: Citv of Fridlev Attsc
THIS IS AN APPLICATION FOR A PIItM[T-NOT VALID UNTII. PROCE5SED
I hereby a�ly for a building permit and I aclmowledge tl�at the information above is co�lete and accuiate; that the work will be in
conformance with the ordinances and cqdes of the City of Fridley and with the Mumesota Conslruction Codes; that I undeistand this is not a
permit but only an application for a perniit and work is not to stait without a permit on site; that the work will be in accordamce with the
approved plan in the cas f all work which requires review and approval lans.
SIGNATURE OF APPLICAS���..��� PRIIdT N �.� �i.'9�?° DATE, \Tr \�
.......�...• nrnnr.��n c.riwi��ma c
PLEASE NOTE: SEPARATE PERMITB ARE REQUIRED FOR_PLUMBING, ELEGTRICAL AND