P - 44213Building BUILDING Permit No:� ��'"'�,����.�'�-�`'
Inspections RESIDENTIAL APPLICATION Rece��ea By: ����`'
763-572-3604 CITY OF FRIDLEY Da
763-502-4977 FAX �'`���� �' � ����
EFFECTIVE 1-1-2010
DATE C� ° Z� "' �d � YOUR E-MAIL ADDRESS Johs/l
SITE ADDRESS � �/�U SU' G�/%�P /2 •
THIS APPLICANT IS: �PlOWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �i� r�,�A NS�r/� ,
TENANT pDDRESS:_�Ci�p .S'/� c�iR� �- CiTY /�R/t�f t� STATE/��C/ZIP��
PHONE:_1� � 15/ 9���J
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CONTRACTOR NAME: C,�,f}�(/S/C� /�� ,
SUBMIT A COPY OF STATE LICENSE # �6 / � EXP DATE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: ��lts0 SQ tv/'/P�° .P- CITY F�'��LEi- STATE��ZIP��
INSURANCE PHONE 6 96% FAX 6� 5 /33
PROPERTY TYPE j�-SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O ADD�'['toN ❑ GARAGE/SHED WINDO
O BASEMENT FINISN ❑ ROOF ❑ DRAIN LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ RE,MODELING
DESCRIBE WORK BEING DONE: �,f/ �?.�L L ��i� GC//�Da�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R OF ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1, Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2.. Proposed floor pian
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin l ADDITIONS. & PORCHES SUBMIT:
y OSoffit 1. Site Plan/Survey showing the existing structures
❑ Aluminum O Trim and proposed project.
O Other ❑ Fascia 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 FiPdN7 c�F �ocrs-P MANUFACTURE STICKER ON WINDOW.
OPEDTING CHANGES &
TYPE OF WINDOW TO BE INSTALLEDCA 5�/�Jt�vT NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
� ( SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATTON $�� — OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Chazge
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 fondetermination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �-,� Make checks payable to: Citv of Fridlev Attac
THIS IS AN APPLICATTON 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 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 which r�uir s review and approval of plans: �—.
SIGNATURE OF APPLICANT PRINT NAME�'t C/�NS/CY� DA'►'E .rj � Z�^ / D