P - 36734Building BUILDING Permitivo.: `�
Inspections RESIDENTIAL APPLICATION Received By: �'
763-572-3604 CITY OF FRIDLEY va 'd
763-502-4977 FAX �� �IAY � �'--��
EFFECTNE 1-1-2011
DATE �/ �"7 YOUR E- L ADDRESS ✓� /(�� Cc�✓l S��/ c.E'7,v h, L ,
SITEADDRESS JStJ �f) '�'� - ��. �i(�ECf
THIS APPLICANT IS: ❑ OWNER LRC�ONTRACTOR
PROPERTY OWNER/ N,�E: �jr,ah �n �
TENANT qDDRESS: �SS �� t'7 � N� CITY � STATE ZIP
PHONE: ��2 "�t�Z '336 �
CONTRACTOR NAME: 1GL.� C.�nSt���� Tnc •
SUBMIT A COPY OF STATE LICENSE # ZO�SS �6 �"' LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:_�4�30 °vY�� �� �1�i CITY '�, O STATE�NZtP S$33o
INSURANCE PHO E� IZ- -� FAX 6 3-�{ L�- S S^t �
PROPERTY TYPE SINGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE �7 ADDITION ❑ GARAGE/SHED ❑ WINDOWS •
❑ BASEMENT FINISH ❑� �OOF ❑ DRAIN TILE
❑ DECK ef SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR C9�REMODELlNG
DESCRIBE WORK BEING DONE: �a-Si �—
SIZE OF IMPROVEMENT Ef1�'lf� }�iJ �L LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT R£MODELING SUBM[T:
NUMBER OF SQUARES ❑ HOUSE & 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 HE[GHT:
S�FOR NEW CONSTRUCTION INCI,UDING DECKS,
Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
� Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project:
� Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculafions
M 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 r'�;r:5 AKL SA51�:ll UN VALUATION, 1NCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �b��� 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
$ j b3 � Z c`5� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .6 .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Pians to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ t ,,, Make checks pavable 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 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 r a pe it 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 of work ich requires review and approval of pja,,n's. ,,/ ��� /
SIGNATURE OF APPLICANT PRfNT NAME�Jf[�ON /�Z�-� DATE S �`
APPROVAL INSPECTOR SIGN URE