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Building BUILDING Permit No.. `u ���
Inspections RESIDENTIAL APPLICATION xeceived By: ��`
763-572-3604 CITY OF FRIDLEY vate ��E� ���� ����
763-502-4977 FAX Er-�cTTVS i-i-aoiz
DATE J' /' %a YOUR E-MAIL ADD SS �DO � CK� Qf-� f1(( n�q n'vQ.r I. CD/1'1
SITEADDRESS ��J �`CC �dC�C �Iv /U� /-�i /rl
THIS APPLICANT IS: ❑ OWNER f�ONTRACTOR
PROPERTY OWNER/ N,�; % f I; %C a _/
TENANT �DRESS: � � �� LG ld 2�eK �i/ /�� CITY J�� STATF/�N ZII' J'r�
PxorrE: 7G 3 - .� ?� . A�i'S3
CONTRACTOR N,�: o�" {�,
SUBMIT A COPY OF STATE LICENSE # v LEAD CERT NUMBER�f'Io���B/• � EXP: °�'�I '/�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:o� �.�Ol La.J/!� B' � CITY � S STATE�ZIP SS_�
INSURANCE pHONE 7G - %' b FAX ' �
PROPERTY TYPE ❑ SINGLE FAMII,Y/NEW CONSTRUCTION SIZE
❑ TWO FAMII.Y/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION �GARAGE/SHED ❑ WINDOWS
� BASEMENT FII�IISH ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTf�R
❑ SWIMI��IING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: Rff Df?F }�QJ �
SIZE OF IlVIPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ��' ❑ HOUSE ONLY
NUMBER OF SQUARES [�`IiOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES 1i�t1TTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structutal members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMTI':
❑ Aluminum ❑ Trim REMOVED7 ❑ YES ❑ NO 1. Site Plan/Survey showing the existing struchues
❑ Ofher ❑ Fascia and proposed project.
2. Two sets of construction 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 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 $ ____ OCCUPANCY TYPE
Pernut Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
I hereby apply for a bui
conformance with the ord
permit but only an applic
approved plan in the case
SIGNATURE OF APPLICANT
APPROVAL INSPECTOR SIG:
$ �"( � l�� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 tixnes the total job valuation
$ .0005 x Pernut Valuarion Minimum or .50
$ J $5.00 (State Licensed Residenrial 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 ( )
$ �'� � Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
nit and I aclrnowledge that the information above is complete and accurate; that the work will be in
id codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
a permit and work is not to start without a permit on site; that the work will be in accordance with the
(C wlucj� requires review and approval of plans. A
\ / PRINT NAME�"TOn '��DATE � ' 7 ' � a