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P - 44196Building BUILDING Permit No.: �� Inspections RESIDENTIAL APPLICATION Received By: 763-572-3604 CITY OF FRIDLEY vate xe�'ct: -� �' � 9 763-502-4977 FAX EFFECTIVE 8-19-09 DATE ��ls� 6� YOURE-MAILADDRESS %%�1)Y�,jQC'KSV� C� �F nq�tK�'� Ijocld�r�, Cp � srTSa.DDx�ss l`7/ �CJ�i�� t� (2 THIS APPLICANT IS: ❑ OWNER �ONTRACTOR PROPERTY OWNEW NAME� U Q r�a � TENANT ADDRESS:_ /r7 l � i�' KA Rq �i(_ c['ry � � fJ�L STATFi��'I ZIP,S<S�(� PHONE: CONTRACTOR NAME: � �r �C �� vc � o n s � h� SUBMIT A COPY OF STATE LICENSE # O O O g EXP DATE _ M,A �`C lt � 1� YOUR STATE LICENSE u AND CERTIFICATE OF ADDRESS: lS f.€C-'k �. /) L — �CITy �� C-T STAT6�/lZli��—`i`� Z INSURANCE PHONE�'Z ' S�o� "�� G� FAX % �� S� o� �%6 �o� PROPERTY TYPE .�SINGLE FAMILY/NEW CONSTRUCTiON SIZE ❑ TWO FAMI�LX/NEW CONSTRUCTION STORIES PERMIT TYPE �'ADDITION ❑ GARAGE/SHED ,P1 WINDOWS ❑ BASEMENT FINISH ❑ ROOF ❑ DRA[N TILE O DECK ❑ SIDING ❑ OTHER ❑ SWIMMING POOL 1'YPE OF WORK: ❑ NEW HOME CONSTRUCTION 8'ADDIT[ON ❑ MAINTENANCE/REPAIR ❑ REMODELING DESCRIBE WORK BEING DONE: �t-� � � G I� �� SIZE OF IMPROVEMENT LENGTH ,� �� W[DTH �r HEIGHT �� S FT /�l� �tOOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT• NLJMBER OF SQUARES ❑ HOUSE & GARAGE i, Existing Fioor Ptan GE ❑ ATTACHED GARAGE 2. Proposed floor plan PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used PROPUSED HEIGHT: SIDING FOR NEW CONSTRUCTION INCLUDING DECKS, ❑ Vinyl ❑Soffit ADDI1'IONS & PORCHES StJBMIT ❑ Aluminum ❑ Trim 1• Site Plan/Survey showing the existing structures � Other ❑ Fascia and proposed project: 2. Two sets of construction plans WINDOWS 3. Energy Calculations IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS 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 MATERIAi,S: TOTAL JOB VALUATION Permit Fee Plan Review Fire Surcharge Surcharge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge 1G THE 1997 IJ.B.0 FEE SCHEDULE) _ __ OCCUPANCY TYPE L�(�1i1 � 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) $2000 per SAC Unit (Plans to MWCC for determination) ft+68= ftx$22=$ $450 Conservation Plan Review Fee Determined by Engineering Agreement necessary ( ) Non Necessary ( ) Make checks payable to: City of Fridley Attach THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED I hereby apply for a buitding permit and I acknowledge that the information above is complete and accurate; that the work witl 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 all work which re ui review and approval of plans. SIGNATURE OF APPL NT PRINT NA 'MF/ `� /L�ft,l�/ C ��t�'d"� DATE �o� � lJ��l - . �, .- . , r � �' � � . 2 _` � � � 2 ' `�� J i� _ ' � �°� w - _ � `-fG 2 � a ' �� - � ? � �' � � � �' �' � � � �- � � � � � f .�' _ �{ �� . � � �.�. �, � � � � �-- � � � � r� � � � �, Et, � � ° � , �� `� � �' i c� , � / - � � � - � � � � � _�% � IN �. � .__. � �� Y� � ( ---� � N ��'- � ✓� tN—X � �1'� J � I!� `� • ' � �- � � r� c� � , � • �.5 w _ f 0 �1' � � � � Q� 4� �r �i,. 1 --� — � �, 3 �i' � w f�'� �— � :. . _ _ �. � r (�,f.` � � � � �� I� � v � � �w � ` � � � �� I� �� . f ," � S; �� . ,�,� � �� 4 - �c l� �.�= � � �--� � f I � �_ � � � W �� .a+ � �—� `Td � � �d � � �' � � � 1 w �� . �v