P - 44920Building BUILDING Permit No.. �
Inspections RESIDENTIAL APPLICATION Received By; !' 1"�
763-572-3604 CITY OF FRIDLEY Da��'� �� ���`�
763-502-4977 FA� E�EC�vEi-i-zoii �
DATE � � �' �( YOUR E-MAIL ADDRESS �L`��r � C� �Z�l.�-/(i`� ` � CJh^
s1�nDD�ss /(J /�i G[, �C:,� i-�/1i£Q-ie N'f, �d�e-c� � .5'3� 3 �-
THIS APPLICANT IS: ❑ OWNER J$CONTRACTOR
PROPERTY OWNER/ N,�tE: u. /� U'-- e�--
TENANT ADDRESS: �� %�� CG L/2-e.F,� %r/�/vGr CITY � LC.r- STATE �%� ZIP ��3�
PHONE: % (p ,3 ~ J� 7 % � -/ �-� �"f
CONTRACTOR xn1�1E: (.tls ✓v�. �n ,
SUBMIT A COPY OF STATE LICENSE # % O% Co LEAD CERT NUMBER /U J�""% � oZ- /�� ZF'�
YOUR STATE LICENSE p
AND CERTIFICATE OF ADDRESS: 0�o�-`J CEn-ki{� D�Nf— CTI'Y Sp. L/L ��C- STATE��LII' 5��3�
INSURANCE PHQNE 7(a .� ' 7�S '� i� 7 FAX ��.3 '%�' S' L S S
PROPERTY TYPE SINGLE FAMILY(NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � .41➢DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �itOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTF�R
❑ SWIlvIl�IING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION � ADDITION
�IMAINTENANCE/REPAIIt ❑ REMODELING
nESCx�� wo� sEnv� nor�: Tep.�� �� & ��'a v�
SIZE QF TMYI�OVEMENT LENGTH 'WIDTH HEIGH'I' S FT
R FIlY ❑ HOUSE ONLY gpSEMENT REMODELING SUBMIT:
NL)MHER OF SQUARES � ��IOUSE & GARAGE'
1. Existing Floor Plan
GAI2AGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O' DETACHED GARAGE' 3. List of structural members to be used
PROPOSED HEIGHT: , , , _
SIDING ' � FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �Soffit �DITIQNS_ & PORCHES SUBMIT:
❑ Alutninum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and P�P� Prol�•
2. Two sets of conslruc6on plans
WINDOWS 3. Enetgy Calculations
IN EXIS'FING OPENINGS OYes ❑No LOCA'I'ION 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:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License $urchatge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Chazge
�USING THE 1997 U.B.0 FEE SCHEDULE)
�I� S 0 OCCUP.
TYPE
$ 5l5 •� S See Back Page for Fee Schedule
$ 65% of Building Perrnit Fee
$ ,�, �-( .001 times the total job valuation
$ /. d3 .0005 x Pernut Valuation Minnnum $5.00
$ ,S . o � $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determinarion)
$ ft+6ft— ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �i /� 93 Make checks uavable to: Ciri of Fridlev Attach
THIS IS AN APPLICA'CION 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 Fridtey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for rmit and w rk is not to start without a permit on site; that the work wili be in accordance with the
apprbvect plan in the case f ork hi requ' s review and approval of pTans. , � a� _
SIGNATCiRE OF APFLICANT � A^ __ PRIN'T NAME �o / C� �— �' v rr, �S DATE �/