P - 44199�uz�di.ng
Zz�spectxons
763-5'�2-3604
763-502-4977 FAX
nn� l z`1� � Oi
SITE ADDRE55 � �O ��
THIS AP�,iCANT [S:
�.I���/dl►`l�
From: 7634344933 Page: 2/3 Date: 1 2/1 6/2009 1:28:22 PM
�u��.u��r�
RESIDENTIAL APPLTCATION
CiT3� ��' �"R�DI��Y
F.FFRCTi VP. 1.1-09
K_� U � 5 T
CI OWNbft
NAME; ���
nRyr��.�ss, 5'to�
PHONE: (D t Z —
` YOUR &MAIL ADDRES9
a��i rR��l�.l
C]CONTRr1CTOR
__ . ___. . .. _. . .
' �/ d� 1 n �s �,�
0
�- �
��,��t NQ.� a
Received By:
nat� ���°a:L
�� V{Z (Z-ia� G� 2v� o N y� P__ i 1 IJ [: •��' �
_. .. _ - --
i��13`L
�+
i4 �.y `t� A 2 }'7-r�
�ti ► � y STATE,� _ZIP,
CONTRAC"�OR NAME:'��' � M 0 N�l 'i-l-�� wtr s 11J c•
_�_ .
SUBMIT A COPY O� gTATE 41CfiN9F, #__ �� f7 O(�tS g� EXP QA'CG 3'�ll -��� V
YOtiR STATE LICENSE -
AND CERTIF[CATE OF AI]bRt,"SS: l I 2- a�% ' ti''r��- � r N� CTTY._..� P( 5 gTATEN
INSLiR11NC� pH 1 � • Z '�j `t� ^ � rJ � 2 F'AX '�% (A �'- � � � Q � /
PROFERTX'FYPE gL6 FnMIT EW CONS7iiUCTION srze
O TWp FA ./NF,W CON3TRUCTTON STORIES
'�'YPE OF WORK:
aESCR1BE W4RK BEING
O HASEMENT F[NISH
o nrcx
n xsw xa� coxsrxucryor,
� MAINTENAFYCElREPAIR
�. � � �K.�tkJ i� i o
HObFirvG
NCFMBEIi OF SQUARES
GARAGE9
A�OFOSED $IZL':
PROPOSGD HETGHT:
�DIe1G
O Viny{
O Aluminum
CI pther
WILIDOWS
IN EXTSTIN� OPEN)NGS �Yca �t+to
OR FOR NfiW OPBNJNCi3•DESCRIBE 51ZE OF
OPFNING CHANGES 8c 11
Permit Fae
Plan Review
Fire Surcharge
Suroharge
License Surcharge
SaC Chargc
Curb Cuc Esctow
Erosion Control
hark Fa
$ewer Main Charge
❑ RppF
0 SIbING
� ADDiTIpN
0 REMODELING
, w�ow � �a
❑ H4USE ONLY
O HOUSE & GARAGE
O ATTACH�A C�RAC3E
❑ llETACHED GARAGb
CISo�t
❑ Trim
f� Foscie
f OCATION 0� W[NDOWS
ARE BA5�A ON VAL
�AT10N S IrI� � [11 S�
❑ DIG11N t1L�
O qTHER
N 4 ftUV fd
.EL�.G.�
I, F,xi�ing Fl�or Plan
2. Prvpo9ed flanr plan
3, List of suuaurnl membera to bc usad
0
FOR NEW CQN$TRUGTION iNCLUDING DECKS,
(�tDITiDNS_ &. POACHES "�l��Tt,'•
1, S+ta �lan/3urvey showing the Cxiating atructures
and propoaed pmject,
2, Twa se4s af canauuction plans
3, F,nargy Calculationa
' NUMBER OF WINAOW9 i� I
I'70i�i,1TiC�.ifDING THE CO$7' QF �,A,�30R AND
TAE 1997 U.B.� T'E� ��HEDULE)
S ot�1'�,bl -,�j See ��ck Page fov Fee 3chedule
� 65"/0 of SuJldi�g Permit Fee
$ 1 .001 tim�s the totai job valuation
� .0005 x Aermit Valu�tion Minimum $.50
$ _,_�Gj� $5,00 (State I.iCenscd Residential Contracto3's)
$ $2000 per SAC Unit (Flans to MWCC for determinativn)
� �}+6ft= ftx$21 �$
$ $45p Conservation Plan �evlow
$ Fee Dctormined by Fngiaccring
� Agreement nece€s�sry ( ) Non Nece.�sary ( )
$ j Make checks pAVAble to: City of Fridley Attach
TNf31S ATI APPLiCATTON POR A PERMfT-NOT VALID UNTIL PRpCFSSECI
T hcrcby apply for a building permit and 1 acknewtcdge that tF�e infatmation above is complete and aocut�te; that tho wark wiil be in
oanformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Cod�; that I underst�nd this is not a
permit but only an appHcation for A permit d work is not to start without a permit on site; that the work will be in necordance with the
t�pproved pl¢n it� the c aER� ec�uires review patd spproval of ians.
SIGNAT[)RS�FAPPL7CANT PRTIVTNAME#-r��/� �V�� DA7'E I Z���' p�
, . . PLEAS� 1VOTE: S�PA�'I'� 1' �it1lK�.T ;4R'�.:� LlIRE�! �C3�t PLLIPV��T .f x' ;�L':E�C�A,�, �,Nl�' 11��I ' . � �T, VV'I�I1�Tt. ; . . :