P - 44912Building BUILDING Permit No.: ��
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vat���t:� ;,�� .
763-502-4977 FAX EFFECTIVE 1-1-20ll ���
DATE S�`�c�''�I Y�O/URE-MAILADD[tESS-��7��I'1 �G.-LC P /I, ��0.�"
SITE ADDRESS �%�� �i�-P �i^ o��� ��(/4!
THIS APPLICANT IS: ❑ OWNER '�CONTRACTOR
PROPERTY OWNER/ NpME: � � ,t� G�t •
TENANT n
ADDRESS: y/�i /P�G� �/�21C f'��G!(� CITY `r�� STATE i'�%LIP�
PHQNE: �%,�.�' S 96�
CONTRACTOR NAME: ' � �` � � � �� LG
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #_�O � 3 S 3 Z LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: Z �iT�l^� ��d� /�wc �/�i✓ CITY 1'� ,G�itwGJ,1 STATE�ZIP S 7�
INSURANCE PHONE " Z%� �i 9� FAX
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE /�p .I'a�f'
❑ TWO FAMILYMEW CONSTRUCTION STORIES—�
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �'��+�t i ��C ,_S' �C�+1i_/iP✓ ' q ae�, /18�;✓ �'0��
—y---,-�
SIZE OF IMPROVEMENT � ,S' LENGTH WiDTH HEIGHT S FT
ROOFING p ❑ HOUSE ONLY
NUMBER OF SQUARES �O sq � HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
—7 I . Existing Floor Plan
GARAGES �$ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structurai 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
O Other ❑ Fascia and proposed project.
2. Two sets of construction ptans
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 lNSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�(USING THE 1997 U.B.0 FEE SCHEDULE)
�'�4 U , C5 cJ OCCUPANCY
$ �'�.`l.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 for determination)
$ ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City 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 oniy 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 all wo which r ires review and approval of plans. 7'' �-- �G �
SIGNATURE OF APPLICANT ��.�, j�� PRiNT NAME��r� �,F„� v�'�" DATE J'' a��
APPROVAL INSPECTOR SIGNATURE