P - 45103Building BUILDING Permit No.: 0�c
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ��sY � 7 2��R
763-502-4977 FAX s�FecTIVE �-1-zo>> �. ,
DATE ��'�/ �— �0�� YOUR E-MAIL ADDRESS
SITE ADDRESS �,j Z��[!� �- (�"irvvd�C�-
TH[S APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAMg: I�q�z �L-��,,�.
TENANT q�DRESS: .S/G' O LV %�C7✓VL��J� c7�G� CITY ��'��t''� STATE ✓��ZIP
PHONE:�%�i 3�SyJ% ` S% y'%
CONTRACTOR r}pME: � //1G��n.95 ,mv�:��
SUBMIT A COPY OF STATE LICENSE #. G$�J��l �'�� LEAD CERT NLIMBER
YOUR STATE LICENSE � y� p`
AND CERTIFICATE OF ADDRESS: �'OG� ����"L' ` Jn^�, !V� CITY C,li-y.;� j STATE i%/YZIP.S_ s�
INSURANCE pHONE ��p , � FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITiON ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SW3MMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
'�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �rC'Pm d�Tf`- D��.:�1�5 y��7�0✓� /�I�y�/
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT OD
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � '6� HOUSE & GARAGE BASEMENT REMODELfNG SUBMIT:
l. Existing Floor Plan
GARAGES 6�J' ATTACHED GARAGE 2. Proposed floor plan
PROPOSED S[ZE: ❑ 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 l. 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-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
` OPENING CHANGES &
I TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL t'r:L' J AKr: l3Alk�ll V1V VALUA l lU1V� 11VC:LUll1NG 1'H�: CU5'1' UN' LA13UK A1VU MA"TERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � z�
$
$ �
$
$ 5a
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Build+ng 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 determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks navable to: Citv of Fridlev
Attach Stipulations
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 all which quires review and approval of pla��n -
SIGNATURE OF APPLICANT a�.�ji�'J�. �v��'�YtNlti� PRINT NAME //jCiylXitS �t�i�� DATE S�� �P%l�
APPROVAL INSPECTOR SIGNA'�URE