P - 35327Building BUILDING Permit No.�� ��-�a�
In�pections RESIDENTIAL APPLICATION Received B:�
763-572-3604 CITY OF FRIDLEY D�������` 1
763-502-4977 FAX EFFECTTVE 1-1-2010
DATE j� � oZ- �'(� YOUR E-MAIL ADDRESS
3ITE ADDRESS '] � � 6 �+ ��J (LJ �{}
THIS APPLICANT IS: ❑ OWNE�NTRACTOR
PROPERT OWNERI NAME: ��LQ�ns i ��/�%NSS���I/
TEN ADDRESS: %�ifa��4pi�/ !.t%A �/ CITY !C� � F STATE�ZIP �S y3z
PHONE: %� 3 ^ �%� ` �6OD
CONTRACTOR NAME: (,(��' T Nse�!/
SUBMIT A COPY OF STATE LICENSE # �� ��� �� EXP DATE
YOUR STATE LTCENSE �
AND CERTIFICATE OF ADDRESS: .SO /(Z_}}(��,�pq N CITY STA ,(%ZIP�
INSURANCE pHONE -- S'� —p .3 O FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCT'ION SIZE �/9'R �1- v�d�
O TWO FAMILY/NEW CONSTRUCTION STORIES -f C3A 2�
PERMIT TYPE � ADDITION 0 GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ��OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE UF WORK: �❑ `NEW HOME CONSTRUCTION � ADDITTON
.n�,IAINTENANCE/REPAIR ❑ REI410DELING
DESCRIBE WORK BEING DONE:�qr ^ p-�� �}�lJ,�j �P�� ��
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING p HOUSE ONLY BASEMENT REMODEL[NG SUBMIT:
NUMBER OF SQUARES �,� ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: �ETACHED GARAGE �- ���D 3. List of structural members to be used
PROPOSED HEIGHT:
ING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1• Site Plan/Survey showing the existing structures
❑ Other ❑ g��$ and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCA7'ION OF WINDOWS FOit WINDOWS�– PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE ST[CKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES AKE BASED ON VALUATION, 1NCLUDIN(G 1'HE CUS"T UF LABVK ANll MA"1'L�;H1AL5:
JOB VALUATION $� Lj'IoDUSING THE 1997 U.B.0 FEE SCH OCCU ANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �f ��,� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ ' Q $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 VALID 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.
SIGNATURE OF APPLICANT t PRINT NAME � I J TN :T �P DATE I O' oZ 9` I v