P - 35276� ow��s�e� 11- ��S�Qj �' l2Z � Z�
Building BUILDING Permit No.:r�iU �`U I�J
Inspections RESIDENTIAL APPLICATION Received By: ✓��"
763-572-3604 CITY OF FRIDLEY vatR�ct; ;�
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �� I� ,� YOUR E-MAIL ADDRESS \ O-�C-K�►':. �,l(G W�� C� � W v� �� i1l �I - C.�l�Yl
SITE ADDRESS (�O 1 'vt�( � % N E•
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: "i� GG� l v� il1
TENANT pDDRESS: I�(� � � eC M% _ /V C� . CITY ( STATE�IP�
PHONE: %(n3 - 5a� -- �a �
CONTRACTOR NAME: 1
SUBMIT A COPY OF STATE LICENSE # 0�(J3�(o �)�"�`I LEAD CERT NUMBER N P� \� S��JJ� �`
YOUR STATE LICENSE r�.�
AND CERTIFICATE OF ADDRESS: o�d�(I �I'�'� ��-„ CITY I�it�i�:l �_'�t�'ATE/�ZIP SS�
INSURANCE PHONE ��7 I'� �(i- I I FAX �' � J
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FITASH ❑ ROOF DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �I�i �%�J1 � C� ':L'i S
SIZE OF IMPROVEMENT LENGTH WIbTH HEIGHT S FT
R I G 0 HOUSE ONLY BASEMENT 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 membeis to be usad
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �Soffit ADDITIONS. & PORCHES SUBMIT:
O Aluminum ❑ T� 1. Site Plan/Survey showing tbe existing shvctures
❑ Other ❑ Fascia �d Pi'alpged ProJect.
2. Two sets of construction plaas
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS es ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENIIdGS- ESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEIdING CHANGES &
TYPE OF WINDOW TO BE INSTALLED � 1 NUMBER OF WINDOWS
ALL FEES ARE BASED UN VALUA"1'lUN,1NCLUll1NG'1'tll+'. CUS'1' UN' LAI3VK A1Vll MA'1'1+'.KlALS:
( ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� D�� � _ OCCUPANCY _ TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �..�, I . 2-S
$
$
$ d
$ `j,�_
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 a perm' and ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case all work h'c req ' s review and approval of pl s. �7
SIGNATURE OF APPLICA �� `�--y�— PRINT NAME ��a(� . '`� �_DATE [ � Z � — I 1
APPROVAL INSPECTOR SI N TURE [`i•)ll'11 I t\