P - 42286Buildizlg BUILDING Permit rlo.: ,�, . ��- �7
Inspections RESIDENTIAL APPLICATION Re �� �d By_: ' r�
763-572-3604 CIT� OF FRIDLEY Dat�e�'c1� �' e� �,
763-502-4977 FAX EFFECTTVE 1-I-2010
DATE ` � �d YOUR E-MAIL ADDRESS
SITE ADDRESS _ � [ -,� � ` � ��`'� �%"�7- •
THIS APPLICANT IS: �WNER �CONTRACTOR
PROPERTY OWNERt NAME: t�YLCt "-C'��C��
TENANT ADDRESS: '�`�' � Sl � JW� /t'� �-, crrx F'� ��' STA1'E '1�% ZIP �{'3L
PHONE: -I.i��7"-��-�[- �.�'�
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICBNSE # EXP DATE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
1NSURANCE pI-IONE FAX
PROPERTY TYPE �^SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O ADDITION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINISH ❑ ROOF ❑ DRA(N TILE
❑ DECK ❑ SIDING I�OTHER
❑ SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCR[BE WORK BEING DOI3E:_ 5���" �c�CxQ �-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
F N O HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARFS ❑ IiOUSE & GARAGE 1. Existing Floor Pian
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
��G FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �Soffit ADDITIONS_ & PORCHES SUBMIT:
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing sWctures
� Other ❑ Fascia and proposed project
• 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCA7TON OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEMNG CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
A1,i, r�;�;� A1c� nA��u ulv vALUA i IViV, 11VC:LUUIN(: l�H� (:U5"1' UN' LAKVK ANll MA"1'N:RIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ I, I, OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ f�t.��C_ See Back Page for Fee Schedule
$ � 65% of Building Permit Fee
$ l� .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)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICA7'ION 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(t 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 applicarion 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 work which requires review and approval of plans.
SIGNATURE OF APPLICANT �� _��_PRINT NAME �>�1�mC�`t� DATE