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Building BUILDING Permit No.: .���� �'� �- `�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate iZec'ct;� �`I�
763-502-4977 FAX EFFECTIVE 1-1-2010
DATE t` I I� YOUR E-MAIL ADDRESS
SITE ADDRESS i �S 0 ��[,
THIS APPLICANT IS: ❑ OWNER �ALi,_,TRACTOR
PROPERTY OWNER/ NAME: � t �'
TENANT ADDRESS: S f� CITY �--"�� STATE�uu�ZIP �Sy��
PHONE: G �_� S(�� LISO�_
CONTRACTOR NAME: ./L 4 u>c .1- L�o d F ti n .
SUBMIT A COPY OF STATE LICENSE # 2 a o( 0 Z i EXP DATE ��/ 2 Q t L
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: � C,� CITY M a���L C`r✓L STATfi�it/ZIP�
INSURANCE pHONE W z'S 9<�t FAX
PROPERTY TYPE �&FNGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTON ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH d�pOF ❑ DRA[N TILE
❑ DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: 'i�L �' � a�' '
SIZE OF IMPROVEMENT LENGTH WIDTH HBIGHT S FT
ROOFING \ '�, � USE ONLY /1�`�r/ BASEMENT RFMODELING SUBMIT:
NUMBER OF SQUARESi�;���� ,� OUSE & GARAGE %� 1. Existing Floor Plan
'�►ATTACHE f�'`,�,'� �
C�ARAGES D GARAGE ,,i ) c� /� 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:
❑ Aluminum ❑ Trim 1• Site Plan/Survey showing the existing structures
O Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEIdINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
Al.i, rr,r.� A1cr; 1sn��L v1r vALUA 11V1v, 11vC;LUL11Vt� l HL l:U�l VN' LAl3UK A1Vll MA'1'�KlALS:
AL JOB VALUATION $� (�G �jE 19 7 U�oC FEE SCHOCCU ANCY TYPE
y
Permit Fee
Plan Review
�'ire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�,3�3� �� See Back Page for Fee Schedule
$ �-- 65% of Building Permit Fee
$ . ,�"" .001 times the total job valuation
$ , S L� .0005 x Permit Valuation Minimum $.50
$ � ,aC, $5.00 (State Licensed Residentia! 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 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 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 a1 �ovo'�Cy wh�' /Jrequires rev�ew and approval of plans. /) �
/� '��i6 /// r..���.-... j� / ! �%.$fr'�\ 9 / /O 1
SIGNATURE OF APPLICANT ��"�� PRINT NAME �iC�G. / C DATE O �i