P - 39996Building BUILDING Permit No.: C�I '��
Inspections RESIDENTIAL APPLICATION Re�ei�ed By: �
763-572-3604 CITY OF FRIDLEY Date Rec' '� �"
763-502-4977 FAX EFFacT1vE i-�-zo>>
DATE �/����� YOURE-MAILADDRESS ��/(L� S+e �%��.�'/*��? . �d�'+-�
SITE ADDRESS �5�� ^ eC1 �.S � `�
THIS APPLICANT IS: ❑ OWNER �,CONTRACTOR
PROPERTY OWNER/ NpME: _a ,-� l� (Spa..�
TENANT ADDRESS: S.`� � �C� CITY f� STATE �'h ZIP SS 3
PHONE:�i � 3 -' S7 �—• I 3� 7
CONTRACTOR NAME: �tla Rdo�ha c �.�or,�\tc�a
SUSMIT A COPY OF STATE LICENSE # I�� LEAD CERT NUMBER Np't"- a5o3y' I
YOUR STATE LICENSE ,fa,
AND CERTIFICATE OF ADDRESS: u��� �G.ISip'r C�1VC� CITY'�.�Ot�tt ��rbe, STATPM�" ZIP�s5vi6
1NSURANCE PHONE q5�-q�s-'7?7, FAX C{6.'1 - rt.i� -
PROPERTY TYPE INGLE FAMILY/NEW CONSTRllCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GAKAGE/SHED ❑ WINDOWS
❑ BASEMENT FINiSH �"i�00F ❑ DRAIN TILE
❑ DECK ❑ SIDING O OTHER
❑ SW[MMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �� �.��I�
SIZE OF IMPROVEMENT LENGTH WIDTH H HT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �S �'�30USE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structwal members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of consh'uction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OP W[NDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST UF LABOK AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surdiarge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow .
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$ i� � '�t l�
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 for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary { )
Make checks aavable to: Citv of Fridlev Attach Stiaulations
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 pernlit 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 a work which rP�q i s re.v ew and approval of plan , �j �
SIGNATUREOFAPPLICANT �i� ,.,L- . (���,r�� PRINTNAME �c-G-h/1(.`(�1��i� DATE � ��1��
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
����