P - 42762-�a ���
Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By: � t
763-572-3604 CITY OF FRIDLEY Date Re�'d��-- / �b
763-502-4977 FAX EFFECTIVE I-1-2010
DATE �—L \ J�iC r�- U�� YOUR E-MAIL ADDRESS
SITE ADDRESS `� e�- eZ �C. �\�" t-�-J� i�- �•
THIS APPLICANT IS: ❑ OWNER '�ICONTRACTOR
PROPERTY OWNER/ NAME: U.SS ,� P�� S
TENANT ADDRESS: S.P•M� CITY STATE ZIP
PHONE:
CONTRACTOR NAME: V�N \`��'c,�'� S`���'`' � G:z �� 2-� <<�Y�S
SUBMIT A COPY OF STATE LICENSE # yC�''�—] EXP DATE
YOUR STATE LICENSE Q�pr� j STATFM_�ZIP `�a�``E�j
AND CERTIFICATE OF ADDRESS: �aC�Y`� � CY-'LT'A �-�� N l..r� CITY C���s
INSURANCE pHONE —�'l - � FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDI1'fON ❑ GARAGE/SHED '�WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:��'�C� S�`� W'� �'J �� S
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING O HOUSE ONLY
NUMBER OF SQUARES O HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE; ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & G� jE[��� /
TYPE OF WINDOW TO BE INSTALLED PR-v� �i NUMBER OF WINDOWS �O
ALL FEES AIZI; BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
'OTAL JOB VALUATION $ (�S�NG THE 1997 U.B.0 FEE SCHO CU ANCY TYPE
�; .�
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ ,� .001 times the total job valuation
Surcharge $ �—' .0005 x Permit Valuation Minimum $.50
License Surcharge $ ' , $5,00 (State Licensed Residential Contractors)
SAC Charge $ $2100 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ ,(� Make checks pavable to: Citv of Fridlev Attach
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 only an applic tio for a ermit 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 Il ich requir eview nd approval of plans.
SIGNATURE OF APPLICANT l/" PRINT NAME�\L�A`CL ��P`t� Lb�CTE 1`� �JF C��