P - 35313Building BUILDING Permit No.: �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date
763-502-4977 FAX �'��� � � �n�
EFFECTIVE 1-1-2010
DATE t(��2°l ((U YOURE-MAILADDRESS j�'�� fg'�� ����K��� ���-
SITE ADDRESS I.C�WO �.-��-C�'�^1 � �t�.L�l.�°-`1 t�'7 �<1
THIS APPLICANT IS: � OWNER ONTRACTOR
PROPERTY OWNER/ NAME: I:.ARd�- '77�ttfL�i.St��
TENANT ADDRESS: �1�/l� iK fh3u � CITY STATE ZIP
PHONE: `%�/ .3 �✓r%� ` T l �� I
CONTRACTOR NAME: l�t�v� i�'t-L �'�T�-�� 2.7�/� •
SUBMIT A COPY OF STATE LICENSE #! �� S� aS� S EXP DATE 3�(
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: "ZC� S(- 7J° t s /)-�: �KC-' CITY ��1-7�� STATE'r'� � ZIP SSC�I d
INSURANCE pHONE '`JG 3-�f i«l -'�I Z FAX "-`
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRA[N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING !,� p HOUSE ONLY
NUMBER OF SQUARES �`� ❑ HOUSE & GARAGE BASBMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES O ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING " FOR NEW CONSTRUC170N INCLUDING DECKS,
O Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing sWctures
D Other ❑ Fascia and proposed project
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS DYes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR t�[EW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WITIDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut'Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ �"/ d� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .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 payable to: City of Fridley Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I t►ereby 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 Fridley and with theMinnesota Construction Codes; that I understand this is not a
permit but only an applicaf or a 't and wo is ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case atl or hi re uir re 'ew and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME �%K}'1tL /�.*�s�''� DATE �I �°� ��b