P - 35817- Bui�ding BUILDING Permit No.,,��' I /�/ '9
Inspections RESIDENTIAL APPLICATION Re�e��ed By� =_�
763-572-3604 CITY OF FRIDLEY Date xec'd: �/
763-502-4977 FAX r;��crlvf�. �-i-zoi�
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THIS APPLICAN'T IS: ❑ OWNER �j,CONTRACTOR
PROPERTY OWNER/ N�; p� �, f^ L�,�yn e j-
TENANT �„i„�::�s: . t� y 5fi ►'Y� �� � fiz D+_ ��TY F r i d I�y STATE m�1 ���� 5 h� 3 z
f>�ioNE:: ?�?� ��1 j- y �'� i G
CONTRACTOR NAM};: T`� � CG i'lL� �-� U�%WtfX r�, � I►� c. . M c�r '� h ->
SUBMIT A COPY OF G � �j � �
YOUR STATE LICENSE STAT}�. I,ICENSL: #.,/��' C I(.� I TV C �' ��� • LEAD CERT NUMBER
AND CERTIFICATE OF ��t�iz[;ss: I Z� �i� DDGic� �j IvC� ciTY��c mvt,� �'� sTaTr M�ziPsSU�4'S
INSURANCE YIIONI_? i� Z—�J�I Z� Iv �c i'F � �" FAX �J�� �-° — �' �j � � � � 7%�'�'
PROPERTY TYPE ❑ S[NULE FAMILY/NI?W CONS7'12UCTION SIZ�
❑ 1'WO I�AMILY/NEW CONS"1'RUCTION S"I'ORII:S
PERMTT TYPE � �»t�rrloN ❑ c.a�znGF/sflr:l� ❑ wiNnows
❑ 13ASEME;N'1 FIlVISH ❑ ROOl� ❑ 1�12AIN TILF.
❑ I)1?CK ❑ SIDING ❑ O'PI�IIiR
❑ S�VIMMIN(3 YOOI.
TYPE OF WORK: ❑ Nl�w xo� coNS�i�xuc�rtoN ❑�nnlrlorr
�.MAIN"CLNANCE/REPAIR ❑ F2FiMODELING
DESCRIBF, WORK BF';ING DONI.: C D r' Q� � I� S� cI C �C� l.l-nG) Q'�� �/� W CL I I 3�' I t'� Y1 L� — J i�� ��C� ����� r�. �
SITI; OF IMYROVF?M}�NT ].,t?NGTH WIDTH HEIGHT SQ l�'I�
ROOFING ❑ HOUSf? ONLY BASEMEN'1' RI?MODELING SiJF3MI'I':
Ni.JM13EK OF SQUAf�,S ❑ I IOUS� & UARAGl:
1. Esistingl�loorPlan
GARAGES ❑ A"1°I�ACHF.D GAI2AUE 2. Proposc;d Iloor plan
PROPOSL'll SI'1,E?: ❑ DI:TACIfLD GARAGI: 3. List of siructural membcrs to be used
PROPOS�D I IEIG[I"I':
SLDING I'OR NEW C6NSTRLJCTION INCI,UDINCi DF,CKS,
❑ Vinyl ❑SoYfit ADDITIONS. & YORCIIFS SUt3Ml1':
1. Sitc 1 lan/Survey sho�ving the existing structures
❑ Alwnimuu ❑ 'Tnnt
❑ Chher ❑ I�ascia and proposa3 project.
2. Cwo sets of construction plans
WINDOWS 3. F?n�rgv Calculations
IN �XISTING OPI3NINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS —PKOVIDE U-VALLTF, AND
OR F'OR NEW ONIiNINGS-DESCR1i3I; SIZE OF MANUFACI'URI�. S"I ICKERON WINDOW.
OP�NING C} IANUI�S &
TYPE OF WINllOW TO }3� INS'TALIJ�?ll NUMBF,R OP WINDOWS
ALL FEES ARE BASED ON VALUATION, II�iCLUDING THE COST OF LABOR AND MATERIALS:
(USING TH'E 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $(D � L��� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Char�e
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � �1� L�
$
$ ����1?
$ � c �� s
$
$
$
$
$
$
� �; i "i a
See Back Page for Fee Schedule
65% of Building Permit Fee
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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreernent necessary ( ) Non Necessary ( )
Nlake checks payable to: City of Fridley Attach
THIS IS AN APPI,ICnTION FOR A I'}�:RNll'1�-NOT VAI.Ill UN'1�II. NKOCESS�D
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 co�s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a perm� and wor is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case II wor w�?'tch equir eview and approval of plans. �
SIGNA'fITFLF's Of� AYPf.ICAN� T�/ �� = YItIN'1' NAMI: `�U /i �i% h1 SC.PfRl3�,�% I)ATL' "� '— I� I I
APPROVAL fNSPFiCTOR SIG TURI: '�' � `` y'
PLEASE NOTE: SEPARATE O RED FOR PLUNIBING, ELECTRICAL AND MECF�ANICAL WORK
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