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Building BUILDING Pe�it No.: �U 1�"�`'
Inspections RESIDENTIAL APPLICATION Received B•
763-572-3604 CITY OF FRIDLEY Date�c�: � � � � � � �
763-502-4977 FAX EFFECTivE>>-ZOii
DATE / YOU E-MpA�IL AD � SS /i � � � . " i �
SITE Arinncec ti n� � r �' l'i� ' 1`r"�.JL.- � �`--�L� /�_Y�� '
THIS APPLICANT IS: � ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: 1
TENANT ADDRESS: � CITY�v>>_ ���_STATE��IP S5y3a
PHONE:� '%(��-s�l- sa8a
CONTRACTOR NAME:_�j�� �.en�Ptli-S i��i1A1C'�[1�IA
SUBMIT A COPY OF STATE LICENSE # o��J�lo3� c/ � LEAD CERT NUMBER�) Ii�I"—oZ3% Id=IEXP: .30 I S
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: o7�I �£t� cS'FY�G�`i'" CITY S-� Rxu� STATE�YI�ZIP551 t i
INSURANCE PHONE ��OS—O iO FAX S"9OS— I �S`
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMIf,YR�fEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ 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: �eoD��o_ �/La Cc�/�?a�7CJ �-H rS�Lccr �OC�J,I�/bl�l
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT RFMODELING �UBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED S1ZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? O YES O NO 1. Site Plan/Survey showing the eacisting structures
❑ Other ❑ Fascia and proposedproject.
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 VALDATION, INCLUDING THE CUST Or' LABUK ANll MA'1'LHIALJ:
_„(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ Q�.1.5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
� .001 times the total job valuation
$ � .0005 x Permit Valuation Minimum $5.00
$ , 0 $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 ( )
$ /�C7 Make checks navable to: Citv of Fridlev Attac
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 ode of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application e i d 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 ires review and approval of plans.,, �/� , // /
SIGNATURE OF APPLICANT PRINT NAME �/� /CKK�� DATE /D�,�o?9�/
APPROVAL INSPECTOR SIG