P - 42371Building BUILDING Permit No.:2(7�( '��� 5
Inspections RESIDENTIAL APPLICATION Received By: �'('
763-572-3604 CITY OF FRIDLEY vate�'�: � � �.. � � � �
763-502-4977 FAX EFFECTIVE i-1-2010
DATE ��2 �/�ti YOUR &MAIL ADDRESS s,�,� S'�f7 M�� n"1 � o-e I i h�-� �(�'1 S:l . C Q/%7
SITE ADDRESS S c�-� / L( �" S'�. . �( �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: � 2� �� �U K� S��N �C �
TENANT pDnxxESS:_�'3S t �-{'t�- St� �^
J'�( C CITY I� i h�"t.� STATE �'r'� ZIP S�S �3Z
PHONE: '7 b 3* .5 � Z' g'7 L!S
CONTRACTOR NAME: 0 M t1� /J1pc�Q (+`n 2h C�
SUBMIT A COPY OF STATE LICENSE #�Z0,.3 � 72,. (,�� EXP DATE G'�%3 3% � Ol L
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �S� 7�� S'� •�� CITY C'O�G�nb�? �'j�['ATEN`��ZIP��'?�
INSURANCE PHONE 7.3 "..�-7ri-R7�j� FAX `7 f�3°�O -�'LC7S�
PROPERTY TYPE ❑ S�_E FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDIT'ION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINISH G3�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR C�'REMODELING
DESCRIBE WORK BEING DONE: /"� �� p� �y,Js-Q ,�{ ff.a C�e tm q c� �a��'
SIZE OF IMPROVEMENT LENGTH Z WIDTH 3 HEIGHT S FT
ROOFING O HOUSE ONLY BASEMENT REMODELING SUBMtT:
NUMBER OF SQUARES �2- fi�'HOUSE & GARAGE 1. Existing Floor Plan
�ARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. 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 DYes QNo 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 INSTALLED NUMBER OF WINDOWS
aLL r�:�;� Ax�: 13A��:1� t�N VALUAl1Viv, 11vl;LUll11V(G lH� C:U51 VN' LA13UK ANll MA"1'�:1ZlAL5:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�D..3�'S� °b OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totai Due
$ �� a� See Back Page for Fee Schedule
$ ` 65% of Building Permit Fee
$ (� .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ ��_ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ �+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �� Make checks payable to: City of Fridley Attach
THIS TS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTTL 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 Gonstruction 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 att work which r qaires review and approval of plans.
SIGNATURE OF APPLICANT �� Q�� ��,��A,ti�__PRINT NAME �'C E� L�� ! t�i C7 �?LL DATE �/Z-�S /l L7