P - 39342Building BUILDING Permit No.: ��% � �Z'
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 �jTY OF FRIDLEY Da�,��, 'ct� � �" � � � � �
763-SQ2-4977 FA � �� E�FECTTVE 1-i-aoio
DATE �.ZO•e` YOURE-MAILADDRESS CCAMPEAl1QWtLl.l�ibTp�W1�U'�lh.�.CDM
srrE.wD�ss Sq8 iZ�CE CIREEK �t�t�e��E FR�bl,Ei' �nN 55932
THIS APPLICANT IS: Q OWNER P��CONTRACTOR
PROPERTY OWNER/ NA1�t�_�qQOAQA H11�t1ES
TENANT ADDRESS:S'�{g 'Q�� CR.Err. TrRRACC CITY F�����Y STATEM�I ZIP QfiS 32
PHONE:_ 'I(o3 .c�Zl•Co��Z
CON'TRACTOR NAME: �.7 ` c,l N �'�0 � W U 4� .� Ze y r
SUBMIT A COPY OF ' � �
YOUR STATE LICENSE STATE LICENSE # 2��� 3��°i 8 EXP DATE �. 3 �. � Z �� I�:" G�' ��
ANDCERTIFICATEOF ADDRESS: 3g3 � MtAOtKJ�6YtUQK tQ.1D CITY��• IUUtJ PRY1lC STAT�NI�ZIP SS�ZC.
�rrsuRa:IVCE rxorr� 4 s2 . a3 3. �3o d FAx
PROPERTY TYPE �9"SINGLE fiAMILYlNBW CQNSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOItIES
PERMTT TYPE d�DDI"I�oN ❑ GARa,GE�sxED L�}'WINDOWs
CJ BASEMENT FINISH ❑ ROOF ❑ DRt#IN TILE
[] DECK C1 SIDING 0 OTHER
❑ SWIMNIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
Li71v1AINTENANCE/REPAIR ❑ REMODELING
DESCRIBEWORKBEINGDONE: QEP(JtC1c'INV �1N(kiW,� 1N EX►S'�'W� U'PE1���b�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING 0 HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of shuctura! members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDIT'IONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
� ah� ❑ Fascia and proposed project.
2. Two sets of construcfion plans
WINDOWS 3. Energy Calculations
IN EXiSTING OPENINGS [9'�es �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENING3-DESCRIBE SIZE OF MANUFACT[JRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALTTATTnN_ iNC'T.TTiIiNf: TuF. r'�ncT nF T.eunu srrn wr�r�ur�r c.
'OTAL JOB VALUA'
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
SING THE 1997 U.B.0 FEE SCHEDULE)
� � �_— _ OCCUP.
�+ 2 3i .Zi See Back Page for Fee Schedule
$ 65% of Buiiding Permit Fee
� � 3. o't°'� '� .001 times the total job valuation
� 6.�.00QS x Permit Valuation Minimum $.50
� .f� .;� ' $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
� ft+6ft= ftx$22=$
$ $450 Conservation Plan Review
� Fee Deternuned by Engineering
�� � Agreement necessary ( ) Non Necessary ( )
�'�" �$ r'j ,`7 q Make checks uavable to: Citv of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building parmit and I aclmowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of ' ley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application far a pernut and i not o start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work which d approval of plans.
SIGNATURE OF APPLICANT
S CQAIC� GiMhE�v DA1'E $. ZU .(j