B - 44887�
Building BUILDING Permit No.: ZG W�-'���
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date :��
763-502-4977 FAX �� � ' � � � � �
EFFECTNE 1-1-2011
DATE IQ "��',� YOURE-MAILADDRESS Sq��S t'i A�� �fO�C�r�o✓S �'u�•C6Nl
SITEADDRESS �5~ia �r�ar�•c„�� �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAMg: _ S'+C�e �-o�+�so N
TENANT ADD�ss: 15'19 $r�ar�alc �� cITY �r;Ale
Y STATE M'V ZIP Y3
PHONE: ��f3— S�I�' g35�
CONTRACTOR NAME: A11 Pfa 1Satrxvv5 �NG. C�
SUBMIT A COPY OF STATE LICENSE # Y 03 SSZZ $ LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: 11 Z9't � b� Avc N.�v � k 10� CITY /1�� �� ra �� STATE r N ZIP SS 36 R
INSU�NCE PHONE �SZ -4Sb- 7�34 Fnx �i52-gbo- igy
PROPERTY TYPE O SINGLE FAMILY/NEW CONSTRtiCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ ARAGE/S ED ❑ WINDOWS
❑ BASEMENT FINISH �OOF �' � ��pOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�'1GIAINTENANCE/REPAIR ❑ REMODELING
DESCRIBEWORKBEINGDONE: RB�'`��� d- Rep�acc Q,po'�-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES Z�� � HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
S��G FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim ; 1. Site Plan/Survey showing the existing structures
and proposed project.
O Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTIIVG OPENINGS �Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENING5-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
P►i.i, rr.r;a A1c� n.�a�L V1� VaLUAl1VPI,11vC;LUUl1Vl� lHL l:Val VN' LAI3VK ANll MAIr:K1AL5:
n' ( oS�ING TAE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $$ �• OCCUPANCY TYPE
Perrr►it Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
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 $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 p�yable toc City of Fridlev Attach
THIS IS AN APPLICATION 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 a permit i d ��ya�tfot to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work w' � s-�r ,�rae�'"d approval of plans. ,
S(GNATUREOFAPPLICANT PRINTNAME Ch1'U Y�NJ4Sov DATE ��'�Z�<<