P - 37249Buildit�g , BUILDING permit rTo.: � � 1�
Inspections RESIDENTIAL APPLICATION Received By
763-572-3604 �ITY OF FRIDLEY D������:� � � � � � �
763-502-4977 FAX �FFECT�vE 1-i-ZOio
DATE �I�Z�.�� YOURE-MAILADDRESS CCA�IQEAUQWECCI�IIb�Oclli,�bl1`DOI.i�•�UM
SITEADD�SS 56�2_ G) �AvAQ\A�U PASS �R1AL�?' ,1��1 �'�932
THIS APPLICANT IS: ❑ OWNER QCONTRACTOR
PROPERTY OWNERI NAME _�UO IT{i W b(,S N
TENANT anD�ss: S6oZ W. �BAvA�.�A�v �P�SS cirY F��n LE7� sTa� n�l _zrr �5932
PHONE: '% �o �j , S U Z, •? 1p (p q
CONTRACTOR NAME: �,J F(,l � Aj (t T(�J W � 1��Q � W
SUBMIT A COPY OF STATE LICENSE # Z d 6 3 82'78 EXP DATE 3. 3 i� �2
YOUR STATE LICENSE
aivD cExTiFICA� oF AnD�ss: 3 G 3 8 M�'�pow �5ttou� � b l� c�� S� •�0��5 Q��2� srA��z�r„�2�
�rrsu�NCE rxorrE a""2. , 3 .� 3 c� o FAx
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CQNSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DI'I'ION ❑ GARAGE/SHED �'WINDOWS
O BASEMENT FIi3ISH C7 ROOF ❑ DRAIN TILB
❑ DECK ❑ SIDING ❑ OTiiER
❑ SWIMMING POOL
TYPE OF WORI�: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
0'Iv1AINTENANCEBEPAIR ❑ REMODELING
DESCRIBE WORK BEiNG DONE: � Fp�i� [� EjC�s� �,Aj (� (�1j/U� d�,,,) �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEPvIENT REMODELING SUBMIT�
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GAIiAGES ❑ 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,
� v�Y� ❑So�t ADDIIYONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site P1anlSurvey showing the existing structures
❑ Other p g��� and proposed projec�
2. Two sets of constnxction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS H`i'es C]No LOCAITON OF WINDOWS FOR WINDOWS — PROVIDE U-VALLIE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE 3TICKER ON WINDO W.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED U E S NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING TI� COST OF LABOR AND MATERIALS•
'OTAL 30B VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE) �
OCCUPANCY TYPE
� 5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
� .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ � $5.00 (State Licensed Residential Contractors)
$ $21Q0 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$22=$
$ $450 Conservation Plan Review
� Fee Deternuned by Engineering
� Agreement necessary ( ) Non Necessary ( )
� 1?,5�.1 � Make checks payable to: City of Fridlev Attac
THIS I3 AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 pernut and work ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of ail work whi u+e��id approval of plans.
SIGNATURE OF APPLICANT
PLEASE NOTE: '
Na�_C(tAI� CqMQE�k� DAZ� '1•Z�•II
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