P - 44452From: City of Fridley To: 7638476903 Page: 2J3 Date: 6/1412010 2:06:57 PM
Build�ing B[J��,DIN(j Permit No.: �iC���� � �
Inspections RESIDENTIAL APPLICATION Received By:
, 763-572-3604 CITY OF FRIDLEY D��'a
763-502-4977 FAX �rr•r;crive i-i-zoio
vnrt �--/�/—<c� YnUlt t-MAIL ADDK�.SS y�/'t.v�r ��-��'��r —�..�o^�� � e G�--fi
S1T�: AllDRtSS �� CSv�a�^ ��a � � • tiE,
TH1S APPUCANT 1S: ❑ nWNEK �ONTIZACTOR
PROPERTY OWNER/ NAMt: ►' • / �
TENAI�IT ADDIttiSS: �Y�� OOi9tn �4,i�1, S�.L�TY F�• <' STATt�"L1P �y3�
PHONE: ��D� ` S 1 ( " � ��I
CONTRACTOR NAM t: '�j�ii J-.e r �Q.p� al2,e� ��s�e �.,tc
SUBMIT A COPY OF STATE LICENSE it �O3 S% O� g EXP UATE 3-3 / ��
YOUR STATE LLCENSE n �/ �
AND CERTIFlCATE OF AvU��ss: asas /I�e �c��n /`T�, �Y'`o�U� CITY � STATt�'LIP SS'�/a 7
INSURAIVCE pHONt G 3'" o�" �7 •1 ' NAX 3—
PROPERTY TYPE 1NGLE NAMlLY/NEW CONSTRUCTION 3 Sl"LE
OTWOFAM►LYlNEWCONSTKUCTION �� STOKIES
PERMIT 7'YPE ❑ Allll1T10N ❑ GARAC,�SHtiD O wt►�uows
O BAStMENT kIN1SH ❑ Kf�N O UKAIN T1Lti
� lltCK ❑ SIll1NG �TH�.K
� SWIMMING PQOL
7'YPE OF' WORK: ❑ NEW HOMECONSTRUL"TION ❑ AUDtTtON
AINT�NAN(:f1KEPAiR ❑ RtMOUELINCi
U�,SC.IZIBti WOKK Bt1N(i llONti: Q ;+' ��Q c* c�oJ• Co�+ �1 x��S��k� �^�
S1LE ON 1MPItOVEMENT LENGTH W1llTH HEICHT SQ 1�
RbOFIVC ❑ HnUSE ONLY
NUMB�K nN SQUARtiS �� � tiOUSt & GARAG� BAStMtNT R�MOU�LING SUBMIT:
1. �xistiag Hlaor Plan
GARAGtiS ❑ ATTACHtD GARAG� 2. Pro�ed flaorplan
PROPpS�U SI"L�: ❑ U�.TACHEU GAKAG� 3. List of slnichual membeic to lx uRed
PKOPOSED HEiGHL•
lU V' h'OR NEW C'ON5TRUCTInN lNCLUUING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PnRCHES SUBMIT:
1. Site i�tuJSuney chowing the existing strnctures
❑ Aluminum � Trim and rro{msed project.
❑ Other O Naccia
2. Two ce� of concM�ction plarxc
WIVDUWS 3. tnergyCalc►dationc
IN EXISTINCr OAENINGS OYes ❑No L(X:ATION OF WINUOWS WnR WlN1�WS - PROYIUE U-VALUE AND
OR KOIi NEW OPENINGS-lltiSCKIB� S1Lt OK MANUNACTUIt� STtCK�R ON W INqOW.
OPENING CHANGES &
TYPt ON WINDO W TO Bt 1NSTALLtU NUMB�Fi OH WINUOWS
ALL EEES ARE BASED O1V VALUATION, INCLUDING "I'HE (:OS'I' Ur LA13UK AIVU MA"1'�K1A1.�:
� (USING THE ly4'1 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S C�%� oo'a . OCCUPANCY TYPE
Pcrmit Fcc
Plan Rcvicw
Firc Surchargc
Surchargc
Liccnsc Surchargc
SAC Ghargc
Curb Cut E�row
Erosion Control
Park Fcc
Scwcr Main Char�c
Total Due
� /$� • a S Scc Back Pagc for Fcc Sc�cdulc
$ .r.�-; �'7� 65'% of Building Pcrmit Fcc
� �. o° .001 timcs thc total job valuarion
� , 5'0 .0005 x Pcxmit Valuation Minimum $.50
$ �'_ o� �5.00 (Statc Liccnscd RaSidcntial Contractors)
� � ._ �2100 per SAC Unit (Plans to MWCC for dctcrmination)
� -- ft+6ft= ftx�24=$ �.-
S — �450 Conscrvarion Plan Rcvicw
$ Fcc; Dctcrtnincd by Enginccring ,
� Agrocmcnt nca;.s.sary {) Non IY�c ssary ()
$ �, Make checks pa_yable to: City of Fridley Attach Stiput�
THIS IS AN APPLIC:ATION HOK A P�:KMIT-NOT VALIU UNTlL PKOCfSStU
1 hca�cby apply for a building permit and t acknowlcd�c that thc information above is complctc and accuratc; that thc work will bc in
conformancc with thc ordinanc�s and cod�s of thc City of Fridlcy and with thc Minn�cota Construcrion Codafi; tt►at 1 undcrstand this is not a
perrnit but only an ap ' tian f a permit and work is not to start without a permit on sit ; that thc work witl bc in accordancc with thc
approvcd plan in thc 1 rk whic� ui rcvicw and approval of p ns.
SIGNATURE ON APPl.1CAN A'� C PR1NT NAME U ATt
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