P - 50464Building BUILDING Permit No.: ��%� -� sjS
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate Rec'ct:
763-502-4977 FAX EFFECTTVE i-i-zo�2
DATE `" 'i� o�I � YOUR E-MAIL ADDRESS rv1�-i7-rr.e.� �% �,� �Q US /tii+'N`�n f�� ��^"�
SITE ADDRESS ��J(5 � l.ti[Sc'9f1.5 sCi °�—L' "� ✓ v'�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �yr{-��`C
TENANT ADDRESS: /� �l L.,!'�LS �'�� C� �-� CITY � r`t,%r v STATE ZIP
PHONE: %(03"5% I-.Z��D�
CONTRACTOR NAME: .L�c ,�7 /J �
SUBMIT A COPY OF STATE LICENSE # ;� {p3��CJ�� LEAD CERT NUMBER %�� �v2'�I EXP: ���
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: /`I � Z �Z(o � �/✓%� CITY � ATE�GIP��%('�--
INSURANCE PHONE I� �. �Clr' FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCT'ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
O BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK 'O�IDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: '� -�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �� �OUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GAR;AGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
� Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. SitePlan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE II3STALLED NUMBER OF WINDOWS
ALL FEES ARE BASI�'.11 UN VALUA'1'1VN, 1NCLUll1NG'1'HL�'. CVS"l VN' LAKUK ANll MA1EKlAL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ `'j'�I •�.5 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 Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ %. � Make checks navable 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 complete and accurate; that the work will be in
conformance with the ordinances and co of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a p 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 o•}r� ic q, res review and approval of pl �/j !
SIGNATURE OF APPLICANT �'^' PRINT NAME ��'T � �C�t�+ DATE �" ��
APPROVAL INSPECTOR SI ATURE __ .____
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