P - 43639Buil'ding BUILDING Permit No.:�, `� �C+�
Inspections RESIDENTIAL APPLICATION Received By: � 1
763-572-3604 �t�: JuN � t� � �
�63-so2-49�� FAx CITY OF FRIDLEY vate
EFFECTIVE i-1-2010
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS ��dO " J'���U NE
- THIS APPLICANT IS: �OWNER OCONTRACTOR
PROPERTY OWNER/ NAME: T LC T�
TENANT ADDRESS: �.3�L7 �,5.3 /7�1%� JUC C►TY �.�LF STAT�_ZIP v�-I
PHONE: %i4�'S%'7�"'�" �3
CONTRACTOR xAME:
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOTJR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STA'['E ZIP
INSURANCE pHONE FAX
PROPERTY TYPE �SINGLE FAMILY/hiEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES /
PERMIT TYPE ❑ ADDITION 0 GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF O DRAIN TILE
❑ DECK ❑ SIDING - ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCElREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMINT LENGTH WIDTH HEIGHT S F?
�tOOFIIYG O HOUSE ONLY BASEMENT REMODELING SiJBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ A7"fACHED GARAGE 2., Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION lNCLUDING DECKS,
❑ Vinyl ❑Soffit ADDI1'IONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim i. Site Plan/Survey showing the existing structures
and proposed ptoject.
❑ Other ❑ Fascia 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST[NG OPENINGS OYes ONo LOCAT'ION 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
�►LL r�;�;� Axr: �sAa�:li VN VALUAI IUIV, 11vc:LUUIN(G "1'H�: C:US'1' Ur' LABUR AtVD MA"TERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! DUe
� 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)
� /U ft+6ft= /6 ftx$24=$.���� '
$ $450 Conservation Plan Review =- - �� f
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ .� Make checks aavable to: Citv of Fridlev Attach Stinulations
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 wi(1 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 wor[c will be in accordance with the
approved plan in the case of all wark which requires review and approval of plans. '
SIGNATURE OF APPLICAN��LZJLLQ�� PRINT NAMF!'�%� ��%/E/�TTE DATE �� I%' o��/O
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F. C. JACfC501�i, MINt1E A ECal37R.iTiC1N. No. 3500
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