P - 40823�.� - a a35 . 1 �'
Building BUILDING Permit No.: �i� . "� � �
Inspections RESIDENTIAL APPLICATION Received By: Q
763-572-3604 CITY OF FRIDLEY va 'd �� e��;�
763-502-4977 FAX EFFECTNE 1-1-2011 �� � " '
DATE "� ��� ",, YOUR E-MAIL ADDRESS �,t.LLr t-�` �(w7\'C� �(aji.1 tJ►1 OC� ��M h- C ��M
SITE ADDRESS `�a S L ��QO�.� ��!C _�� i
THIS APPLICANT IS: ❑ OWNER �EONTRACTOR
PROPERTY OWNER/ NAME: f.�n r L,G.'� e�S �..
TENANT ADDRESS: Sc, r,t_. G� 5>>eC. CITY STATE zIP �S�-1 j 2
PHONE��p'� � �� — SL'I�I �
CONTRACTOR NAME: i
SUBMIT A COPY OF 'p�U35Co �� �-- � S ��
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: ��, �t u�1 ��� _ CITY N ATE�IP�((�
INSURANCE PHONE 1 V� << FAX
PROPERTY TYPE �INGLE FAMILY/NEW CONSTRUCTION SIZE _
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �gOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING N'nVw � a-'C
DESCRIBE WORK BEING DONE: «0.i( O+�' 't� � C1C �'G.� t K�p�W P-,OO � ` t�I S Q V G.<e.3 D� RGO�� �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT �
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �_ �IOUSE & GARAGE 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:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl QSoffit ADDITIONS. & PORCHES SUBMIT:
❑ Almuinwn p T� 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construcrion 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 MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATIUN,INCLUDIN(G "1'Hl�; CUS'1' UN' LABUK A1Vll MA'1'LKIAL.�':
(U ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �� � a, 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
$ ��5 � �,�
$
$
$
$
$
$
$
$
$
$ �: �
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)
$+6ft= 8x$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks oavable to: Citv 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 ordinan nd codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application or a ermi d work is not to start without a permit on site; that the work will be in accordance with the
a roved lan in the case 1 work w'ch re es ' and a roval of 1 ns. /, / �^ /
SpGNATURE OF APPLICA PRINT NAME 6�i�(, (�1-(i LD Q�Q/�ATE �� �� I(
APPROVAL INSPECTOR IGN URE _ , /J _.