P - 45119Building BUILDING Permit No.:� � ��
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY UF FRIDLEY D��+�'� �
763-502-4977 FAX EFFECTIVE�-1-ao�o �
DATE 1 I �/� YOUR E-MAIL ADDRESS ��F �j (�( I, (1Gi��(��� S� C1�S�C� �! �:)'l.Q.�
5ITE ADDRESS ��O � w t= 5 ( f � �{ tJ � � ( �} (,t,i r�(�} ��� 'j
THIS APPLICANT lS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NpME: L"" — r '�
TENANT a���ss:�b� � (,.� ',i 1° /� U � �.� � ciTY �zrn 5� �
�-�. J D Zt � sTa�
PHONE: 7 �� - �J � 1 '� ( �S Y� N
CONTRACTOR NAME: �G�- ^R� L `� �
SUBMIT A COPY OF ,� -� �
YODR 5TATE LICENSE STATE LICENSE #' n EXP DATE
AND CERTIFICATE OF ADDRESS: �% `�(�t '7 n�c6U� U�: /v!> CITY � � �STA'I'F�_�LIP S o�
INSURANCE PHONE FAX
PROPERTY TYPE (Sj�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
Q SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME COI�3STRUCTION ❑ ADDITION
�MAINTENANCEIREPAIR E [NG
DESCRIBE WORK BEING DONE: EPLP4�'�% l,C/ t I�lD�l.l3S � l� lF-,� S 5 i�l N(a' �) P T IU 1/LY� "' LC.�IU � �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Fioor 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 ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OP6NINGS �+i1Yes �No LOCATION OF WI DOWS FOR WINDOWS — PROVIDE U-VALITE AND
OR FOR NEW OPENINGS-DESCffiBE SIZE OF � MANUFAC"I'URE STICKER ON WINDOW.
OPENING CHANGES & a
TYPE OF WINDOW TO BE IN TA�� DA � `� . � 1 � OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLiJDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
JG THE 1997 iJ.B.0 FEE SCHEDULE)
'�"' OCCUP,
$ I 53, �,�
$ '—
$ � �1
$ �j
$
$
$ --
$
$ --
Q r--._
TYPE
See Back Page for Fee Schedule
65% of Building Permit Fee
.00] times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks navable to: City of Fridley
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 uriderstand 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 ork which k '•es re � and approval of pl ns. ,p�> ,, /
SIGNATURE OF APPLICANT � PRINT NAME �jQ.l�- T ��j�f }%?i DATE j l l pL/ � U
APPROVAL INSPECTOR SIGNA RE
PLEASE NOTE: SEPARATEi ERMITS ARE IRED FOA PLUMBING, ELECTRICAL AND MECHANICAL WORK