P - 84351Building BUILDING Permit No.: �a� �"1
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY D��'�°�C'� 2���12
763-502-4977 FAX EFFEC-nvE i-i-2o�2
DATE I�' a''� ° I�' YOUR E-MAIL ADDRESS
SITE ADDRESS _ 7�jO�o ��1?0 `j�J�i FIC� 6��. }-jZi t��-�-�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME:_ �AV� �KuDt K
TENANT ADDRESS: 75V� ���' ° � .�-" o�-� �J
��(lR C� CITY r/�-� % STATE Y"� z�r � 5�y3a
PHONE: F��o2-7�-0%�+u ^
CONTRACTOR NAME:_ ��/ga2�-A�71�6' �xi ��n S .�.,NG
SUBMIT A COPY OF STATE LICENSE # Z� C� g"�3 j(o LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: 3a y JYf,.�,�.�T,v A� �� CITY V�2^"'�-�-< --� STATE /h^�ZIP 5.�°�^
INSURANCE PHONE fj7 -Z 7`3-12 �(o FAX b�j/ '`j'3 �- L"L S(o
PROPERTY TYPE $SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,$�OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT'ION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �E= �S6 F
3IZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES Z Z ❑ 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 SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other � Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALLTE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE 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 $ �� S See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ '(x� .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum or .50
License Surcharge $ �. p $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessaty () Non Necessary ()
Total Due $ �( j(a. Make checks payable to: City of Fridley 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 w�c requires review and approval of plan� ��
SIGNATURE OF APPLICANT PRINT NAME ,�*� �=-5 ,J^'� ��3`"� DATE ��"�� ' � 2
APPROVAL INSPECTOR SIGNANRE_