P - 39620`� � t� ( `-�t 3�,�
Building BUILDING Permit No.: � --
Inspections RESIDENTIAL APPLICATION Received By:J +�
763-572-3604 CITY OF FRIDLEY n��° ��'
763-502-4977 FAX �"�'����
EFFECTTVE 1-1-2011
DATE, l�I �[ I I YOURE-MAII.ADDRESS C�.u��e.,.� . S � ar � c:rd `� �jrri�: L.c.vnr.
SIT�anDxsSS Co i(p ��g.� S'� m� N �t ��U �-
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAIvtE: R N C� Z ` i I I,�...
TENANT .aDnxESS: (o i L� t'3 C3 � v� J��; , ti%� ci� iz ti hL cs-t STATE YY� N ZIP �s y 3 y
PHONE: i ia 3, 5� a-��� S
CONTRACTOR N,v�: Sl v� �.���„ R��ota'�ltTr� . C�L�
SUBMIT A COPY OF STATE LICENSE #�i�U �� �S C-� C�� LEAD CERT NUMBER. N�T- " FS � y S�" I
YOUR STATE LICENSE
AND CERTIFiCATE oF a.nnxESS: ( 355 C�-u,.�`�e:a 'R � 2-. N° S�� t� �.c � ci� Q�1�b ta-�� STATE�fi1.3 ZIPS � 12�5
INSURANCE PHONE rc S l' � �' ��c"/ � FAX � S 1— 7 3�'s - t 2. 3 3
PROPERTY TYPE ,�SINGLE FA,MII.Y/NEW CONSTRUCTTON s�
❑ TWO FAMILY/NEW CONSTRUCTION STORIES 2
PERMIT TYPE � �DITION ❑ GARAGEJSHED ❑ WINDOWS
❑ BASEMENT FINISH �ItOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTF�R
❑ SWIMbIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTI'ION
❑ MAINTENANCE/REPAIIt ❑ REMODELING
DESCRIBE WORK BEING DONE: f�i�'� C�� l�cl� '�t-�'+�-�- �-'G'�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GAEtAGE 3. List of struchual members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDI1'IONS. & PORCHES SUBMTf:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing struct�ues
❑ Other ❑ Fascia and pmposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calcutations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE t1ND
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 UN VALUATI(3N,1N(:LUDING T1iE CU�T Ul+' LABUK AND MA7'l�'.KIALS:
^, (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL dOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Surchazge
License Surchazge
SAC Charge
G�rb G�t Escrow
Erosion Control
Park Fee
Sewer Main Chazge
C�
$ `��.�L`�
$ �—
$
$ ` .
$
$
$
See Back Page for Fee Schedule
65% of Building PermiY 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 deternunarion)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a building permit and I aclaiowledge that the infonnation 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 applicarion 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 o 1 work which requires review and approval of pF1ans. , {� �,L
SIGNATURE OF APPLICANT �s,e ��.4"�' _ PRINT NAME YSV�C�,2`c�-1 C�.,Pz'C"ilttc� DA'TE �I � I I
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