P - 48011Building BUILDING Permit No. �� � Z�I ��
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Da�'� �!� � � 0�
763-502-4977 FAX E�c� ii-zoii
DATE I • � ' c f ,� \ /� ��,•
YOUR E-MAIL ADDRESS
SITE ADDRESS —) C7C' � U� ► J �Z
THIS APPLICANT IS: 0 OWNER �CONTRACTOR
PROPERTY OWNER/ N,�: ' � (��-
TENANT Avn�ss: �I (� °1lo UQ.v�.��,ccr�t-� 5�,1� � sTn1'E��rn �' l.�'
PHONE: � � a J� g�(�_
CONTRACTOR N�: �� C n-h�-{�� L`�l ► /
SUBMIT A COPY OF STATE LICENSE #;� � �j�,� LEAD CERT NUMBER EC � ' EXP: �'� �
YOUR STATE LICENSE n
AND CERTIFICATE OF ADDRESS: �I "1 ��` � V{,pr�l�l -�Fp� 1+jCy CTI'1' �1ri STAT�(�,�IP
INSURANCE PHONE � F�
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FIATISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTf�R
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUC'TION ❑ ADDTI'ION
INTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �'� ' S\ Gi�`P.J
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMTT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROP03ED SIZE: ❑ DETACHF..D GARAGE 3. List of stcuctuial members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
�G ADDITIONS. 8c PORCHES SUBMTf:
Vinyl ❑Soffit SIDING/SOFFIT/FASCIA
Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing stcuctures
❑ Ott►er ❑ Fascia and proposed project.
2. Two sets of consiruction plans
q�iNDpRrg 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes QNo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOVJ.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL �'�L�'.+5 AIZH. i3A�l�.l� UN VALUA11V1V� llVC.LUUiIVIi 1t1L� l;V�l V2' LA15VK AlrL 1V1A1L� tt�w�.,�:
r� (USING THE 1997 U.B.0 FEE SCHEDULE) �j, v�,�.
TOTAL JOB VALUATION $ �p ,��� OCCUPANCY�� TYPE t`
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surchazge
SAC Charge
Curb Ctit Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ " I �� ;Z�
$
� ��
$ �Z-
$ �
$
$
$
$
$
$ I '`"i �-i
See Back Page for Fee Schedule � �
65% of Building Permit 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 determinafion)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavabie to: Citv of FridleY Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordin s and codes of the City of ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applica,�o for a p it d work is n t to start without a permit on site; that the work will be in accordance with the
approved plan in the case�,�o w w'ch re i r vie and approval o�$��x�'( ,( \,����I ^^�. ��, �, i�
SIGNATURE OF APPLIC PRINT NAME �� � ��� �` nA� �
APPROVAL INSPECTOR
PLEASE NO�E: PARA'fiE P S ARE REQUIRED FOR PLUMBING, II.ECTRICAL AND MECHANICAL WORK