P - 44608Building BUILDING pe�it No.: bl `
Inspections RESIDENTIAL APFLICATION Received By: '_
763-572-3604 CITY OF FRIDLEY Date Rec'ct:
763-502-4977 FAX EFFECTIVE 7-I-2010 � n��
DATE II' �`% O YOUR E-MAIL ADDRESS � UQ� ��(;/'►j — S��/1Le.. L�Qi'{�1
SITE ADDRESS SS6 7 f��.�l�o�, Dr�v�
THIS APPLICANT IS: ❑ OWNER QCONTRACTOR
PROPERTY OWNER! NAME: �LLi 1 �Q%GGI T
TENANT ADD�ss: SS67 ���0/'!'� !�l' CITY Fi/K �t.�1 STATE�ZIP S a-
rxorrs: 7 b 3- s.'�- ao.��
co�rx�,cTOR NaME: Crc�'�+sw►r,h Nnrn� Irwnrvveyv►P.�u/s� Tnc _
SUBMIT A COPY OF sTA� Lic�vsE a � a� D 8��f EXP DATE 3— 3l —aDl l
YOUR STATE LICENSE �
AND CERTIFICATE OF ADDRESS: i SFSS Fj�ith�L /�w S -�I 9� CITY E,L�/�V� STATE/�/ULIP�
INSURANCE pHONE �o,s�— �3 ��) iS FAX �— v� � c.�J �
PROPERTY TYPE �INGLE FAMILY SrzE
❑ TWO FAMILY/NEW CONSTRUCTlON 3TORIES
PERMIT TYPE ❑�DI7ION ❑ GARAGE/SHED 17 WINDOWS
❑ BASEMENT FI1dISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTI'ION
f%�MAII�iTENA13CE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING TJONE: �2A/' - D� �- Re s�de
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
OFING ❑ HOUSE ONLY BASBMENT REMODELING SUBMIT:
NUMBER OF SQUARES O HOUSE & GARAGE i. Bxisting Floor Plan
,�ARAG�S �ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of sducWral members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLiJDING DECKS,
0 Vinyl �'S�ffit
ADDITIONS_ & PORCHE5 SUBMIT:
p A���� �j�.m 1. Site Plan/Survey showing the existing structures
Lp�Other LW�1 J � f� S� U'�ascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCA1'ION OF WINDOW3 FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION. INCLUDING THE COST OF LABOR AND MATERiAL.Ss
TION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
Licanse Surcharge
5AC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
USING THE 1997 U.B.0 FEE SCHEDULE)
v — �rrt�,
$ '� [ E oC S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ j 001 times the total job valuation
$ �j s�� .0005 x Permit Valuation Minimum $5.00
$ 5 $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determinarion)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � 0�� Make checks aavable t Citv of Frldlev, Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 al work which rey uires review and approval of plan�. n !/
SIGNATURE OF APPLICANT 'T���j � PRINT NAME. .IOd.f� U�Q��.Y' DATE //— o� l D
APPROVAL INSPECTOR SIGNA RE
P'LEASE NO'T�: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELE�'TRICAL AND MECHANIGAL �V'(yRK