P - 36719Building BUILDING Permit Ivo.:2d� �UO I Z
Inspections RESIDENTIAL APPLICATION Received By:�( �_
763-572-3604 CITY OF FRIDLEY Date x'� :�,�'' Q���
763-502-4977 FAX EFFECTIVE 1-1-2011 ���
DATE � �I YOUR/E-MAIL ADDRESS /�' �-�-y /c. Gsc�_ �v �aA� �•� I �.., rdG�J, ! o,c.�
SITE ADDR SS �,c.n Cp � �•-� c� L[ y3 Z
THIS APPLICANT IS: ❑ OWNER �R'JCONTRA TOR
PROPERTY OWNER/ N,�v1E: u �
TENANT qpDRESS: �` _U GLt Ga�- !
2 � J• CITY i�!� STATE Mi(�'IP S�Y 3L
PHONE:%�L %[,I �JF �
CONTRACTOR NAME: �G�. ,�/.� /��f .� �
SUBMIT A COPY OF STATE LICENSE #� O�D C� 2� LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: %��y �{��'i 7 �f� CITY �-� CC�STATF�/�IP S 3
INSURANCE PHONE i Z � 7 FAX G SZL O 2
PROPERTY TYPE �I SINGLE FAMILYJNEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ❑�DIT1oN ❑ GARAGE/SHED Q� WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: CrVwvc- c�L rC �-� �✓ .. �ow
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT•
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETAGHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,,
� V�nY� ❑Soffit ADDITIONS. & PORCHES SUBMIT•
❑ Aluminum ❑ Trim l. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS 4a.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 r� I� � NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION. INCLUDING THE COST �F r.ARnR ANn MATF.RTAi.C•
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $/��Q Z� , OCCUFANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ v�i.�—
$
$
$
$
� - -
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+6°ft=" ftx$25=$
$450 Conservation Plan Review ''
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach Stipulations
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 ardinances and codes of the Ci of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for rm' o s not to start without a permit on site; that the work will be in accordance with the
approved plan in the o or wh' requi view and approval of pl�r}q.� /�
SIGNATURE OF APPLIC PRINT NAME /f�l/ c/G o.� DATF S� // /