P - 45787Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Re '
763-502-4977 FAX EFFECTIVE 1-t-201 I ��
DATET T r"/� `��f't �C' S�, YOUR E-MAfL ADDRESS
SITE ADDRESS �%�����C R �°��,C..=�,i•,,L' - I
THIS APPLICANT IS: O OWNER ONTRACTOR i
PROPERTY OWNEW NAME:�iC.� /q�:,f/-l�/ir9 ,� G ��%l�f J•
7'ENaNT ADDRESS: cS -'�� CITY STATE ZIP �
PHON��Z����� i
CONTRACTOR NAME: �j�y�x//�,J ��.t^,�"� CC� ) .
SUBMIT A COPY OF ��—/'i'��-� LEAD CERT NUMBER I
YOUR STATE LICENSE STATE LtCENSE a �
AND CERTIFICATE OF ADDRESS: � A«�i�/ CITY ' STATE ZIP
1NSURANCE pH NE �° FAX • �
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
TWO fiAMILY/NEW CONSTRUCT(ON STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH �OF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ EW HOME CONSTRUCTION ❑ ADDIT[UN
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:� ,f;I^y�!/�'r.� / ,T,,� -� � �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT '
ROOFING O HOUSE ONLY BASEMENT REMODELING SUBMIT•
NUMBER OF SQUARES � ❑ HOUSE & GARAGE I. Existing Floor Plan
GARACES O ATTACHED GARAGE 2. Proposed tloor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: `���
FOR NEW CONSTRUCTION INCLUDING DECKS,
S1DIN ADDITIONS. & PORCHES SUBMIT� i
❑ Vinyl ❑Soffit I. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposcd project, �
O Other ❑ Fascia 2. Two sets of construction plans i
WINDOWS 3. Energy Calculations �
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL N'H:L�'S AKN: 6AJ�U U;V VALUA'1'IUIV, 1lVl:LUU11Vl; 1'HN: CUJ 1' UN' LABUN ANU MATERIALS:
(USINC 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
Park Fee
Sewer Main Charge
Total Due
/:\►[�1'/
$ O�• L5 See Back Page for Fee Schedule
$ 65% of Building Perrr►it 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
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks aavable to: Citv of Fridlev Attac
TH1S IS AN APPLICATION FOR A PERMIT-NOT VAL.tD 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 Ciry of Fridley and with the Minnesota Construction Codes; that 1 understand this is not a
pernut but only an application for a ermit and ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al bo whi eview and approval of pla s.
SIGNATURE OF APPLICANT s �'ii�lA4E � DATE
APPROVAL INSPECTOR SIGNAT
DT � A QC 7��l1'TR. l'+RD A 1? A'TA D� ,tTTC' A A t7 A G(li T(A �T1 A(lA Ai 1 TA,TATATf: RT Rf Ti?T!` A T A l�iil �AA/`L.i Al�il/' A T \ll/1DY