P - 41782Building BUILDING Permit No.: `L ��.�(j s(ii�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Da��p'a�CT a 5�''�'�
763-502-4977 FAX EFFECTTVE i-i-ZOii
DATE �d DJ � � YOURE-MAILADDRESS J�d�`r` �� ���l1���' ,C�
SI� ADD�SS � 21 �' 'rtA Y 1.0�- `��C" N C� F21 JJ l.� X.►Mv�1 5 5 �i21
THIS APPLICANT IS: O OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �1�i/� I LY ��b,-I�l
TENANT ADDRESS: �1. �-1 "'r� YL 0� S� CITY C�� O L�y STATEM�'�I ZIP 5S Z
PHONE: �S�L� �'{ Sj'I ` ��3 b
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE .�SINGLE FAMILY/NEW CONSTRUCTION SIZE I
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �FOOF 0 DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
� SWIMMING POOL
T'YPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
INTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: f�L 0 bF �hI r7.
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING �!-IOUSE ONLY
NUMBER OF SQUARES � S ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES O ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum O Trim . 1. Site PIanlSucvey showing the existing structwes
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANU�ACTURE 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee �$ See Back Page for Fee Schedule
Plan Review _$ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ �.0005 x Permit Valuation Minimum $5.00
License Surcharge $ • $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks oavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION 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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work 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 �w.�f��fj ,w�lri� requ s review and approval of s. • {�� ///
SIGNATURE OF APPLICA23T lY► �/ Y V►�I /i�� �'1'RINT NAME DATE �/'����
APPROVAL INSPECTOR SIGNATU ,