P - 44818Building BUILDING Permit No.•
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3so4 CITY OF FRIDLEY r�at�!�jd��� �'
763-502-4977 FAX � � ���
EFFEC7'IVE 1-1-2010
DATE �' t% YOUR E-MAIL ADDRESS
SITE ADDRESS � O �t�df 5/� N,�
THIS APPLICAN"f IS: ❑ �WNER ONTRACTOR
PROPERTY OWNER/ NAME: R°'�Y rh� 6 t
TENANT pDDRESS: �� 3 y� /"1�C'11 J�Y �✓1 I U� CITY �� ��Y STATE ZIP
PHONE: �� J'� �g(p ` �3d3
CONTRACTOR NAME: n� � S y` �
SUBMIT A COPY OF STATE LICENSE # 20 3 ss 2s ti 3 EXP DATE 3 3 ��� �
YOUR STATE LICENSE t/
AND CERTIFICATE OF ADDRESS: � O L� �-- .�{/Y,-rl'� CITY�� 1 de ifi�'� STATE ��1ZIP S o//
1NSURANCE PHONE �/ �M! -3 FAx 6 ' `"1 � ' Z � ��
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE �] 1i
TWO FAMILY/NEW CONSTRUCTION STORIES�_
PERMIT TYPE ❑ ADDI7'fON � GARAGEJSHED ❑ WINDOWS
O BASEMEN7 FINISH OOF ❑ DRAIN TILE
❑ DECK SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUC7'ION ❑ ADDITION
❑ MAINTENANCE/REPAIR MODELING
DESCRIBE WORK BEING DONE: ��''T � , lC.�cOt�
SIZE OF IMPROVEMENT 2�I S LENGTH WIDTH HEIGHT S FT 2 7
R FIN p HOUSE ONLY
NUMBER OF SQUARES 2� ❑ HOUSE & GARAGE $ASEMENT REMODELING SUBM7T:
1. Existing Floor Plan
GARAGE5 ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: Q DETACHED GARAGE 3. List of structurat members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDIT3G DECKS,
❑ Vinyl �Soffit ADDITIONS_ & PORCHES SUBMIT:
� Aluminum ❑ Trim 1• Site PlaniSurvey showing the existing structures
and proposed project.
Other ���a 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑No LOCA7'ION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE S"f'ICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
���rl� �YL'� �1
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Suroharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
D ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
'� (USING THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYP�
$ (,} See Back Page for Fee Schedule
$ 65% of Building Pecmit 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 aavable to: Citv of Fridlev Attach
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 a work whi re ires review and approval of pl
SIGNATURE OF APPLICANT ���' N. PRINT NAME �n n� � �I \I '� DATE I I�-1 ~ I O