P - 48292Building BUILDING Permit No.: L G
Inspections RESIDENTIAL APPLICATION Received By:�_
763-572-3604 CITY OF FRIDLEY vat 'd:� _{ �
763-502-4977 FAX EFFE C T I V E 1- 1- 2 0 1 2 �� . �
DATE �•� �� 1 Z YOUR E-MAIL ADDRE3S
SITEADDRESS 73/0 ���� �vC N�- f=r� �le�� �ti• SSv3Z
THIS APPLICANT IS: �OWNER �CONTRACTOR
PROPERTY OWNERI NAME: Q �rr a e,r�o, ,r. � M �„ z
TENANT ADDRESS: 7 3/ b l�jl.� /c� ,� q vi c e� � CITY F�' ���� f " STATE M A/ZIP 55'�/ 3 Z
PHONE: 7�3 - %y2 - %'S J�
CONTRACTOR N,�:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICATE OF .4DDRESS: CITY STATE ZIP
1NSURANCE pgp� FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF O DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFIlVG _� J.7 ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES� � I` ❑ HOUSE & GARAGE 1, Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of struetural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl ❑Soffit SIDING/SOFFTT/FASCIA ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? O YES O NO 1. Site Plan/Survey showing the exisdng structures
O Other ❑ g��$ and proposed project.
2. Two sets of conshvction plans
WIIVDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENRJGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
Ai.l, rr,�a anr, is�r,L �iv vALUA11Viv, livC:LUliliVC� "1'HL C:US'1' UN LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee �
Plan Review
Fire Suroharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ �,U �((� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 ConservaUon Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ -�— Make checks pa.yable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge 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 Cades; 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 qf a�l �vorlywhicly �equires review and approval of �(��. � / 1 i� � r„ sL
SIGNANRE OF APPLICANT'\/A (I p•I , n I/ P"^-� � 0 2 PRINT NAME Va P� �^ ��/ ���`�� S DATE 2— 3� � Z-