P - 84325Building BUILDING PermitNo.: l�jIZ�I�i
Inspections RESIDENTIAL APPLICATION Received By: �
�63-s�2-3604 CITY OF FRIDLEY va�c1 �' �
763-502-4977 FAX EFFECnvE i-i-2oi2
DATE ./� ` ' oZGS � Z- YOUR E-MAIL ADDRESS
SITE ADDRESS _ �5�3/ �7?04/� /����_ ,�y�'/!/
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: ��j/yiO!/7�. /`�110 J��'
SUBMIT A COPY OF STATE LICENSE #/j G(i�i S.3Sd' LEAD CERT NUMBER1// �d%S�I EXP: �J� D/,G
YOUR STATE LICENSE / 7
AND CERTIFICATE OF ADDRESS: _/ �S�S �'� .�2, �r,/ CITY U1/� STATE��'IP S�
INSURANCE PHONE - ,3 FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: 0 NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �et'rr,��� � / � �jQ•�� 11c'-f— %/s� �'�i✓� �/ivr�j
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING 7 ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES Jo�--- - �' -IOUSE & GARAGE
- 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARy�GE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FORNEW CONSTRUCTION INCLUDING DECKS,
O Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 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 OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALLJE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE 1NSTALLED NUMBER OF WINDOWS
ALL NEL�'J AKL�' l3A�L+'ll V1V VALUA'l�lUN, 1NCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALIIATION $ 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
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum or .50
$5.00 (State Licensed Residential Contractors)
$2365 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee D�termined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: Citv of Fridlev Attach
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 compiete 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 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 a rk q' e review and approval of pla,��s' � /
SIGNATURE OF APPLICANT PRINT NAME�f�'i,�'���f��/S/G!Q'l� DATE /�� '��~'o�O��
APPROVAL INSPECTOR SIG A RE '