P - 48362Building BUILDING . Permit Ivo.: c� ��cl
Inspections RESIDENTIAL APPLICATIDN xeceived By:
763-572-3604 CITY OF FRIDLEY Date Rec'd: r /
763-SOZ-49%% FA.X EFFECTIVE 1-1-2011
DATE � � '�f" / � � ' / YOUR E-MAIL ADDRESS �M'q"� ��'eP��7�'¢'7 �' C��MC,�,7 . n/'E7
S ITE ADDRESS %�lC'� l C R��"� PA��eK L�/ F� /D L�"tiJ , M n! s� 1'3 1-
THIS APPLICANT IS: ❑ OWNER $CCONTRACTOR
PROPERTY OWNER/ NAME: �D�I D�shv� �H ��-�-iF'S
TENANT �D�S: /36/ �Q,EE,� p�e,� �,V LC"'`% STATE MnIZIP�S��
CITY �R �D
PHONE: %6 3 '— .S7/ " $ % 7 �
CONTRACTOR N,4tvtE: /�'1A'G� CA�'PE�t�i2`? ` f1vME /�o�evvEM��T' ��l(� .
$UBMIT A COPY OF STATE LICENSE #��SO�J P O�j LEAD CERT Nt1MBER R^�" �00 39 —'/ 1— 0006 $'
, YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: ��6� �E� pA"Q'K �� CITY ����C� STATEMn/ZIP55�31
INSURANCE PHONE 763 "Z26 — 7870 p,q}{ 763 � S77 — 87 7'y
PROPERTY TYPE �SINGLE FAMILYINEW CONSTRUCTION SIZE 40b �j6+ r' T �
❑ TWO FAMILYMEW CONSTRUCTION STORIES �
PERMIT TYPE 0�DI"fION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT fMISH O ROOF Q DRA1N TILE
O DECK O SIDING '�'OTHER
❑ SWIMMiNG POOL
TYPE U� WORK: ❑ NEW'HOME CONSTRUCTlON O ADDITION
Cl MAINTENANCE/REPAIR .�REMODELMG
DESCRIBE WORK BEING DONE: F�17f�1.e00M iC'�i�-f fj OE�
SIZEDF IMPROVEMENT LENGTH �� ��� WIDTH 9` 3�� NEtGHT g� S FT �� 6
ROOFING O HOUSE ONLY $ASEMENT REMODELING SUBM(T:
NUMBER OF SQUARES ❑ HOUSE & GARAGE • i. Existing Floor Pl�n
_G�.�AGES [] ATTAGHED GARAGE 2. Proposed floor plan
PROPQSED SIZE: O DE'i`ACHED GAItAGE 3. List of sWcWral members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTIQN INCLUDMG DECKS,
O Vinyl OSoffit ADDITIONS_ & PORCHES SUBMIT:
O Alumin�m ❑ Trim 1. Site PlanlSurvey showing thc exis6ng structutes
0 Other . ❑ Fascia and proposed p%�cct'
2. Two sets of construction pians
WINDOWS 3. Energy Calculations
IN EXISTItdGOPENiNGS DYes DNo LOCA77�N OF WTNDOWS FOR WINDOWS =- PROV[DE U-VALUE AND
OR FOR TIEW OPENINGS-DESGRIBE StZE OF MANUFACTURE STICKER ON WINDQW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLEb NUMBER OF WMDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALI
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut E$crow
Erosion Control
Park Fee
Sewer Main Charge
(USING THE 199'7 U.B.0 FEE SCHEDULE)
$ � � 000 , b0 OCCUPANCY TYP�
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ S Ql' j $5.00 (State Licensed Residentiat Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6R= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ , � �� Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALtD UNTIL PROCESSED
I hereby apply far a building permit and I acknawledge that the information above is compiete and accurate; that the work will be in
conformance with the ordinances �d 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 and rk is not to start without a permit on site; that the work will be in accordance witb the
approved plan in the case of all w ich ' s v�w and approval of plan�.O� P� DA� $/�/
SIGNATtIRE OF APPLICANT PRINT NAME J �LW�°S / ��
APPR[1V A1 _ RJCPF( T[1R Cf(:NA'1'I ►RF.
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