P - 43638Building BUILDING Permit No.: �� L ���
Inspections ' RESIDENTIAL APPLICATION Received By: `
763-5'72-3664 CITY OF FRIDLEY D��'�°��'� ���`
763'�T5�2-�977 FAX EFFECTIVE 8-14-09
DATE � �� �� YOUR E-MAIL ADDRESS
SITE ADDRESS sd� 7' �T I�lI G
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: —/1Z�N Z���/ •
TENANT ADDRESS: �I: �7�" �7 �e'��✓� CITY F2l l�1 STATE�,�IP
PHONE: � I.Z, c! (p 9�► �� 7 3r
CONTRACTOR NAME: °
SUBMIT A COPY OF STATE LICENSE # EXP DATE 3` 3�" ��
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONS SIZE� °=�
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE 0 ADDITION ARAGE/SHED ❑ WINDOWS
O BASEMENT FINISH ❑ ROOF O DRAIN TILE
O DECK ❑ SIDING ❑ OTHER
� SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �l �� ii $
SIZE OF IMPROVEMENT LENGTH Z LWIDTH HEIGHT 3� S F7 �% �O
ROOFING ❑ HOUSE ONLY �ASEMENT REMODELING SUBMIT:
NL)MBER OF SQUARES � HOUSE & GARAGE , �, Existing Floor Pian
GARAGES Z Aj ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: Z Z X��r �DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
ID FOR NEW CONSTRUCTION TNCLUDING DECKS,
inyl j�Sarffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum p�rim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other p.Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑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 INSTALLED NUMBER OF WIIVDOWS
ALL FEES ARE BASEll UN VALUATlON,1NCLUDING THE COST OF LABOR AND MATERIALS:
,,,.., ,.(USI1�J�"j THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Carb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ``3(��j:,�l� See Back Page for Fee Schedule
$ c%3(l�• (, � 65°/n of Building Permit Fee
$ �2�,�. .00I times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residentiat Contractors)
$ $2000 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$22=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ t! � � 1 Make checks aavable to: Citv of Fridlev Attac
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 on(y an application for a pe it and work is not to start without a permit on site; that the work will be in accordance with the
appmved plan in the case of all h re ires review and approval of pla .
SIGNATURE OF APPLICANT d� `� PRINT NAME �BI1i�I���l�� DATE 7"'I�^��
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7710 Cenuai Avenue NE
Spring lake Park, MN 55432
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7710 Central Avenue N�
Spring Lake Park, MN 55432
(763) 57 -2577
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Truss Design location Zip Code: 55432
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7710 Cen�al Avenue NE
Spring Lake Park, MN 55432
(763) 572-2577
MN Lic, 20515958
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