P - 35791!
Building BUILDING erm t o.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date xe�'d:
763-502-4977 FAX EFFECTiv� 1-�-2oii
DATE �7 'S� f l YOUR E-MAIL ADDRESS
SITE ADDRESS � yS1' I��1 !f Uj"�/1 �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ N�: �.�y,'G% W iJhi �wS�C �
TENANT ADDRESS: �� d '� f�� � CITY STATE ZIP
PHONE: �'G,�"` S i"' —�0 2'9 2'
CONTRACTOR p,e,ME; Rjc,�C'f Y����^'i q�d SiG!�h�i_ /��.
SUBMTI' A COPY OF STATE LICENSE # 3 S 66 LEAD CERT NLIMBER N� T�' �� S�� �
YOUR STATE LICENSE `�
AND CERTIFICATE OF ADDRESS: ��3G �a�'� S'f: N� CITY �t9/Ji L�K� STATF/�1N zIP' .�o
nvsuxarrcE rxorrE ��3-zb9- Soz-''- F� 6- 26 - gG�
PROPERTY TYPE � SINGLE FANIILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES '
PERMIT TYPE ❑ �DITIOx ❑ GARAGE/SHED ❑ wn�lDOws
0 BASEMENT FIDIISH ❑ ROOF � DRAIN TILE
❑ DECK � SIDING ❑ OTf�R
� ❑ SWII�4NIINGPOOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCI'ION 0 ADDTI'ION
MAIlVTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: R aS / G� �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R O G ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES 0 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,
❑ Vinyi ❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
�Other Z,Z� ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EX[STING OPENINGS OYes QNo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENII�iGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINbOW.
OPEIVING CHANGES &
TYPE OF WINDOW TO BE INSTALI,ED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION. INCLUDING THE COST OF LABOR AND MATERIALS:
2�7�3°
'OTAL JOB VALUA
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$
$
THE 199� U.B.0 FE� SCHEDULE)
0
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuaiion
.0005 x Permit Valuarion Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determinarion)
ft+6ft= ftx$25°$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. 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 all w rk wwhic� requires review and a roval of plans. '/ / /
SIGNATURE OF APPLICANT _�°/`"'�!� � /J NAMFr , S� �W FI �t Gflal n IFi DATE � S—��