P - 48015Building BUILDING permit Ivo.:�.0 I-C� � S
Inspections RESIDENTIAL APPLICATION Received By: `Y �'r✓
763-572-3604 CITY OF FRIDLEY vate ��: ��� V`� ��� 1
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763-502-4977 FAX EFFECTTVE i i-ZOi i
DATE �JC7 I� YOURE-MAILADDRESS �VYiN�Ia�=-C�rS9yn�'/��^'P� I�.S�-��'^
srrEAnDx�ss �o��f 1�loa�y /�a�•t F�.�t,�j �,K,, SSy3z y
THIS APPLICANT IS: ❑ OWNER '�CONTRACTOR
PROPERTY OWNER/ NAME: PA� � c�r,�,
TENANT ADDRESS: ���`I Y�lvoGly L,�t CI'1'Y ��: cl l e., S'rA'rFI� ZIP S S" Y3 Z
PHONE: �I5 Z' 2 Z I— q� I"]
CONTRACTOR NAIvtB: � L�41cc. C.�NS�-•��v1.'o;� r+3t y
SUBMIT A COPY OF STATE LICENSE #�3L � 32 S3y LEAD CERT NUMBER Z EXp: o
YOUR STATE LICENSE �- -
AND CERTIFICAT'E OF ADD�ss: 3� 71 �1���� IQ-� �- N� w' CITY ��F�Cu - STATEri+ti ZIP SS 3�3
rivsu�rtCE rxorrE �c.�- 2`- 33SZ Fax 7�-3-- �82-�� SZ
PROPERTY TYPE ❑ srrrcLE FaivnLYmrEw corrs�ucTtorr sizE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGElSHED �WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �Gww�� � IQe-/,I.4u �f v; �" �4'S
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES O 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,
❑ Viny( ❑Soffit SIDING/SOFFTT/FASCIA ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO �� 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 T�Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF N l J� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & The�•� Tec,h �t
TYPE OF WINDOW TO BE INSTALLED � v.NJu..+S NUMBER OF WINDOWS O
AI,i, r��� fucr, nt���L vi� v.a►1,ua1�1VPI, livt;LUli11Vl� �1Hr: (:Ua�l� Vr' LAl3UK AIVll MA'1'LRlALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
AL JOB VALUATION $ � 6_('�C%��`� 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
$ !2S-L�
$
$ �,
$
$ �
$
$
$
$
$
$ I l� .� .�
See Back Page for Fee Schedule
65% of Building 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
A�eement necessary ( ) Non Necessary ( )
Make checks payable 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 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 wc�c which requires review and approval of plans. %
SIGNATURE OF APPLICANT � - PRINT NAME j'H ���c S�'�'"`'3 DATE J I/ 3v � ��
APPROVAL INSPECTOR SIGNA�
PLEASE NOTE: SEPARATE PERMITS ARE REQUIlZED FOR PLUMBING, ELECTRIGAL AND MEGHANICAL WORK