P - 50461Building BUILDING PermitNo.:���iD �
Inspections RESIDENTIAL APPLICATION Received By1�� —
763-572-3604 CITY OF FRIDLEY D�°� ov�� n � Z
763-502-4977 FAX EFFECTrvE i-i-ZOia
DATE YOUR E-MAIL ADDRESS V= V ENS ��� he�M at �• Ge.�n
si�nvv�ss 5�110 To..1 �o� � ►�C
THIS APPLICANT IS: ❑ OWNER (,�CONTRACTOR
PROPERTY OWNER/ NAME: Eh bc�t
TENANT ADD�SS: 5 a a Owl �O� Sl • 1� � CITY �ri ��t-y STATE'W��ZIP 5 S'i�l
PHONE:
CONTRACTOR N,�1v1�: J�varct I�oe�•� + s►d�n =.sc.
SUBMIT A COPY OF STATE LICENSE #(3C % D LEAD CERT NUMBER EXP:
YOUR STATE LICENSE ►+1nrLiP 53�3
AND CERTIFICATE OF ADDRESS: 3�p D L 11Iti` I-�1 l� h� CITY I�i'1'Wk�. STATE
INSURANCE PHONE �a2 - 3 Id ���o FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DI1'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FIIVISH I�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTI'ION
4YMAINTENANCE/REPAIR ❑ REMODELING
DESCRIBEWORKBEINGDONE:RCMOV�►aq Si��v►alaS a� 0�� '�' �'GD�a��hA �J•ih nE
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEIvtEN'I' REMODELING SUBMIT:
NUMBER OF SQUARES i D ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: � DETACHED GARAGE 3. List of structurdl members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDIN ADDITIONS & PORCHES SUBMIT:
❑ Vinyl ❑Soffit SIDING/SOFFTl'/FASCIA 1. Site Plan/Survey showing the existing strwctures
❑ A(uminum ❑ Trim REMOVED? O YES O NO and proposed project.
❑ Other ❑ Fascia 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS I�Yes ONo LOCATIO OF WINDOWS�+ FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEIdINGS-DESCRIBE SIZE OF �0 rth Roo T MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8c t
TYPE OF WINDOW TO BE INSTALLED � 7 NUMBER OF WINDOWS
ALL FEES ARE BASED ON VAL ATION. INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUA'
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
(LTSING THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY
$
$ �
$
$ ��7-(�i
$
$
$
$
$
$ -� � ,�
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum or .50
$5.00 (State Licensed Residential Coniractors)
$2365 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Detemuned by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERNIIT-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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a rmit and work is not to start without a permit on site; that the work will be in ordance with the
approved plan in the case of al r 'ch requires review and approval of p s. �
SIGNATURE OF APPLICANT PRINT NAME �_�l%a1 C Iv ��� DATE S� a O 1 a..
APPROVAL INSPECTOR SIGNA
PLEASE NOTE: SEPARATE PERMITS ARE REQUIItED F4R FLUMBINGr> ELECTRICAL AND MECHANICAL WORK