P - 39804Building � BUILDING Permit rto:: ����� �` �%�
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY Date Rec'a: %/-�' 1�
EFFECTTVE i-]-2010
DATE �' (( I a I� v YOUR E-MAIL ADDRESS �S-{ (� �C "' t'�.K . G'��
SITEADDRESS $oZc9cl ilncol+. Sa. �F
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTYOWNER/ NAME: -7-«�. ���.���-
TENANT ADDx�ss: Sac� l���o(�► �/. IUE CITY rrtdle�, sT,aTE � z�p Ssyar
PHONE: ?63 �`7oi 38$I
CONTRACTOR NAME:�� �..,.•.e��`e•. /
SUBMIT A COPY OP STATE LICENSE # c20 EXP DATE ��� �/ j e�
YOUR STATE LICENSE �^�--T
AND CERTIFICATE OF ADDRESS: Yo't�, � �w�. (� ,U.� CITY (� ,tl(a,(.� rl� STATE �ZIP��
INSURANCE pHOI�iE FAX %
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYINEW CONSTRUCTTON STORIES
PERMIT TYPE � ADDITION O GARAGElSHED �TNDOWS
O BASEMENT FINISH ❑ RO ❑ DRAI13 TILE
0 DECK IDING ❑ OTHER
❑ 3WIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ A N
❑ MAINTENANCE/TtEPAIR REMODELING f' a�� o�'Q c�. yGi� _
DESCRIBE WORK BEING DONE: 2 2 rc 3 � .Sa `C. `�R ,
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING d HOUSE ONLY BASEMENT REMODELING 3UBMIT:
NUMBER OF SQUARES 17 HOUSE & GARAGE
1. Existing Flooi Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor pian
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ minum ❑ Trim l. Site P►an/Survey showing the existing structures
Other +�aSQr•��i� ❑ Fascia
and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXI5TING OPENINGS es ONo LO�� OF WINDQ�IS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �„!. (.�yti 2_ MANUFACTURE STICKER ON WINAOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED QN VALUA'I'lON, INCLUDING "I'HE CUST Uk LABUK ANll MA'1'�;H1ALS:
^ (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUA
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
�Iti_'/��1
$ /j� 2� See Back Page for Fee Schedule
$ �---^ 65% of Building Permit Fee
$ �„ �, .00] 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 pavable to: City of Fridley
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
Attach Stinulations
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 applica ' n for c�'hwork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a w hi h re uires revievD and approval of plans.
SIGNATURE OF APPLICt�" PRINT NAME ��d� I Ath.�.s�wL�. DATE