P - 42288Building BUILDING Permit No.• � � � �
Inspections RESIDENTIAL APPLICATION Received By. �
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE 1-1-2010 ����"����
DATE � c`Za- d � YOUR E-MAIL ADDRESS
SITE ADDRESS � - c �
THIS APPLICANT IS: 0'OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: L'� D'n'1
TENANT ADDx�ss: �'%�✓ ��� ��_ /('•Ci- CITY STATE ZIP
PHONE: �J�% �/^ L S?i�'! C 7�17J�
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # EXP DATE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDIT1oN ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH 4�QtOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRl3CTION ❑ ADDITION
❑ MAINTENANCE/REPAIR D REMODELING
DESCRIBE WORK BEING DONE: I�J— �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING `, � I,7 HOUSE ONLY BASEMEN7° REMODELING SUBMIT:
NUMBER OF SQUARES � �VI� p HOUSE & GARAGE �. Existing Floor Plan
GARAGES �.� O ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ D€TACHED GARAGE 3. List of structural members w be used
PROPOSED HEIGHT:
IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl pgo�� ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing strucdues
C] Alumiwm `� ❑ Trim and proposed proje�G
❑ Other �� ❑ Fascia
ry, � 2. Two sets of construction plans
WINDOWS � 3. Energy Calculations
IN EXISTING OPENINGS �Yes ONo LQGA_ TIOTj1 O�F� I_N�O ,W� lt�� FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS- ESCRIBE SIZE OF }-i��� „� (h! (�-.-r MANUFACTURE STICKER ON WiNDOW.
OPENING CHANGES-&
TYPE OF WINDOW TO BE INSTALLED �V�} h NUMBER OF WINDOWS �(
aLL r�;��.�xr; naa�;l� �lv VALUA11Vlv, 11VC:LUDLIV(;'1'tl� C:US"1' Vb' LAKUK ANll MA7'ERlAL,S:
,�,�USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALL
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
S�AC Charge
Curb Cut Escrow
Erosion Control
Park Fee
5ewer Main Charge
Total Due
$ � L'�j Ji�j 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)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ,, Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby appiy 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 work which requires review and approval of plans.
SIGI3ATURE OF APPLICANT Q.� � c/�,1,�PRINT NAME_ _ L e°�fa ( D�'I CZ V I� DATE 7� ��� 2 �%t�