P - 35504Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESII)F,NTIAL APPLICATION
DATE I � J`""I V
S(TE ADDRESS S Y Z� �'
THIS APPLICANT 1S: ❑ OWNER
t�'�TY OF FRIDLEY
EFFECTIVE 7-1-2010
�YOUR E-MAIL ADDRESS Y) %V�GI
ENNE �Z PA-SS
PROPERTYOWNER/ NAME: I L�.��LM �vU/2N S
TENANT ADDRESS: ,'rj �f Z% � �Z EN N E� �
PHQNE: � �o �J— �J�T 2 ^ � �O `J �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
II�ISU RANCE
NAME: S�'iPl'�s �-}OME TMPQOVEMf
STATE LICENSE # 2DO �IOO � %
AnDRF.SS�2�TDO W!N ��- ST' N E S1'E I
0
Permit No.: ���li� a� r-�,'��
Received By:
Da�•R�' d'� 0 �% � 3 2 � � �
a h p0 • C.��
TELZTP SS 73
EXP DATE ^ 3 I"' � �
CITY M PLS STATE � IP SS� � 3
�� � �:a
PROPERTY T'YPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
D TWO FAMILYlNEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE(SHED WINDOW
❑ BASEMENT FINISH ❑ ROOF TILE
❑ DECK ❑ StDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT[ON
JN�MAINTENANCEJREPAIR ❑ REMODELING
DESCRIBE WORK BEfNG
OFIN
fVUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
C7'S
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
L Existing filoor Plan
2. Froposed floor plan
3. List of structutal members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING PECKS,
❑ Vinyf ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Triro 1. Site Plan/Survey showing the ex�sting structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction pla.ns
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS Ye ❑No LOCATIOA[ OF WINDOWS FOR WINDOWS — PROVIDE L3-VALiJE AND
OR FpR NEW OPENINGS- CRBE SIZE OF MANLJFACI'URE STICKER ON WINDOW.
OPENING CHANGES & Z ��yH
TYPE OF WINDOW TO BE INSTALLED l.l� NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
„„(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALL
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �°'�Gr,dl � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ [�!p .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $SAO
$ 0 $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 navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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,�l��ic�Fqre uires revigw and approval of plan� �
SIGNATURE OF APPLICANT {�J� �� .�.. PRINT NAME T�? v�r I'W/��� aTa �(-3^'1'0
APPROVAL INSPECTOR SIGN�tIRE