P - 48483�uilding BUILDING Permit Ivo.20 � (7161e
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 CITY OF FRIDLEY ���N 2�����
763-502-4977 FAX EFFECTivE i-l-aoi i
DATE 1- Z.$- II Youx E-�,ir. nDD�ss � PA L�t�T�'�GI`bASL •CAM
s�TEaDD�ss '1953 ROMMt ttD 'rk7'pI,EY MN �5421
TffiS APPLICANT IS: � OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: La6AN ADAMS-L��'C�
TENANT ADD�ss: t-{9�� 1Z�AN RU ciTY FRxDL�Y sTaTEMN ziP 55411
PHONE: �'og�•33Qti'3�IQy
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # EXP DATE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITiorr ❑ GA�GE/SxED � wlrrDOws
❑ BASEMEN'I' FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL '
TYPE OF WORK: ❑ NEW HOMF, CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBEWORKBEINGDONE: W=��OWR��IrCC.�M�fT I;AAT}�(RbbN'� RisN16i�L,EL6(.TR?GAL
SIZE OF IMPROVEMENT NO 6 LENGTH N/�l WIDTH N IA HEIGHT N�A SQ FT O
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural 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
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS $IYes �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 Q VAK � DBL ER OF WINDOWS '��
ALL FEES ARE BASED ON VALUATION. INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
I hereby apply for a building pe
conformance with the ordinances,
pennit but only an application fo
approved plan in the case of all w�
SIGNATURE OF APPLICANT
APPROVAL [NSPECTOR SIGNATURE
THE 1997 U.B.0 FEE SCHEDULE)
• �I. U�7U ` OCCUPANCY TYPE
$ �l'l, Z5' See Back Page for Fee Schedule
$ (p ,�_ 65% of Building Permit Fee
$ c-( U .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$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ D 0.� ( n Make checks uavable to: Citv of Fridlev Attach
AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I acknowledge that the information above is complete and accurate; that the work will be in
of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
and work is not to start without a permit on site; that the work will be in accordance with the
h� ires review and approval of plans.
PRINT NAME l.d6AN ADM1S' L��T � DATE I' 2S—I I
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