P - 44444Building BUILDING Permit No.: %� ��-�% -� �
Inspections RESIDENTIAL APPLICATION Received B�r
763-572-3604 CITY OF FRIDLEY ����� �
763-502-4977 FAX EFFECTIVE i-1-2010
DATE �-(n '� Z. D�� YOUR E-MAIL ADDRESS T Y� 'D G� v�n (� ��L�Vv�0..� �• L D Yv�
SITE ADDRESS 1 a,y' I� I'.,L.�'i 3�0 Y"�0 h T��/ e N G-
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: A � v�o S �cl Y'erA. Q, +
TENANT pDDRESS: I a�-�'� f('a.�-F�J N�r"�� �� N�CITY_ �Y' i r' -��}� 2
� l e-Y STATE ZIP
PHONE: �I %,�" o� o��" ��j t� i0
CONTRACTOR NAME:
SUBMIT A COPY OF gTATE LICENSE �! EXP DA7E
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE C] SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRA[N TILE
❑ DECK �[SIDING ❑ OTHER
O SWIMMING POOL
TYPE OF WORK: Q NEW HOME CONSTRUCTION 0 ADDITION
�,MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �� �2. S`� � t�i 8 v�,� O ��ti,�,� 2 ��-�a-�2. ,
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT T�
R FIN 1,7 HOUSE ONLY BpSEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
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:
❑ Alumi m y ❑ Trim 1. Site Plan/Survey showing the existing structures
� Other ' Q,f' C21N�e-v� 1 � Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEMNG CHANGES &
TYPE OF WINAOW TO BE INSTALLED NUMBER OF WINDOWS
ALL r���:� Altr; f3A��:D Ulv VALUA�l�1VN,INCLUDING THE C05T OF LABOR AND MATERIALS:
�, �(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ - — `
$
$
$ �
$
$
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 navable to: Citv of Fridlev
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
Attach
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 I work whic req i s revie d approval of plans.
SIGNATURE OF APPLICA PRINT NAME��'I`�,� f..14 ��Q-Yl'�0 ll-�.�pATE 7i ��P '� � i�