P - 43139Building B�JILDING Permit No.: �'1 �i
Inspections RESIDENTIAL APPLICATION Received By:
^63-572-3604 CITY OF FRIDLEY vat��jd 1
763-502-4977 FAX EFFECTIVE 1-1-2010
DATE �-%' � ��1 � U YOUR E-MAIL ADDRESS f �F,%r1�2� l , �'' .:' � , �. � >� `;r � P ��' p�, ; .! ."', :`.�": `°�� z;�f!>; /L"I
si-rE anDxESS _/�' N f 7.� 1. �. .'`� �, �' -. t' �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME. ���, �, {j _S-E-�.���,� ��°�> ;t ..,}»
TENANT ADDRES$: //�i �/% %.S � �� /° t,�'G �1': CITY ��;+ STATE �"'GZIP ,�� � 3Z
PHONE: ��' 3' i�" H� "` �J LI C?
CONTRACTOR NAME: /4lCP.�SS�Ea�`�' �� �GD"°�' A`C`
SUBMIT A COPY OF STATE LICENSE #� Qg ,� `e.-'' �i*�' EXP DATE O //
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �'f lZ Ti��� �i— CITY��'!�� STATE./�rI%ZIP S�S d
INSURANCB PHONE %t+ - �%1 � � 7 �dI FAX
PROPERTY TYPE k]'SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDIT'ION ❑ GARAGE/SHED ❑ WINDOWS
BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTTON D ADDITION
❑ MAINTENANCE/REPAIR !8'REMODELING
DESCRIBE WORK BEING DONE:_ _r�•., r�oi t� 01 �2 J .�i'►�G►�r C�/" b�+Q/',F'
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R� ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NLJMBER OF SQUARES ❑ HOUSE & GARAGE 1. 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,
ADDITIONS_ & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing structures
� Aluminum O Trim and proposed project.
O Other ❑ Fascia 2. Two seu of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VAWE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEIVING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
wi.i. rr.�� Aic� ts,a►�l;l! Vlv vALUA 11VN, 11VC;LUll11V(�'1'HL (;US'1' Vr' LAKVK ANU MA"!'ERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ S�0 OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Swcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
$ c( ' See Back Page for Fee Schedule
$ 65%ofBuilding Permit Fee
$ .001 times the total job valuation
�v .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 aavable 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 accuraxe; 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 w c v�+ ich r ires review d approval of plans.
SIGNATUREOFAPPLICA ____� PRINTNAME XT�G� ""� ����� DATEV ��y/0
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