P - 36739Building BUILDING Permit Ivo.:?/0 ( 0 5�{ �j
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Da ' M
763-502-4977 FAX EFFECTNE 1-1-2011 � ����
Da� �'sZS'%� �t YouxE-MaiLaDD�ss �.D_!s'/��N'�a�o��s�L�'-Desi'r�,�c,RS.C4�.(
SITEADDRESS �SI HK�j� S"�, NE
THIS APPLICANT IS: �❑ OWNER J�CONTRACTOR
PROPERTY OWNER/ NA1�: NA2Nqu� � EG�K SCL+vvt�"0�"
TENANT �D1�SS:_ y.S1 /�UpO gt"'� CITY �12/j�LE`/ STATE/�'I/VZIP SS�3�
PHONE: %�3- �ga= ya9r
CONTRACTOR NAME: �G - Dc..°5 i q n/G 25
SUBMIT A COPY OF STATE LICENSE # �b� � S�o SS� LEAD CERT NUMBER N�4'toZ oi S�iI G- D
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: 38/d G�/esF f�W y/3 CITY 13in,pn►5 ui���� STATE�ZIP�
INSURANCE PHONE a SoZ -�q� - 3(� FAX � S -�5� ��/a`� S
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH O ROOF ❑ DRAIN TILE
❑ DECK J$ SIDING ❑ OTHER
❑ SWIbIMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ,�'REMODELING
DESCRIBE WORK BEING DONE: I�_/ � s F i d�+J
S1ZE 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: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
Vinyl �Soffit ADDITIONS_ & PORCHES SUBMIT:
Alwninum ❑ Trim 1. Site Plan/Survey showing the eacisting structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction 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 N'EL�'� AKr; BAtiL�'ll UN VALUA"1'lUN,1N(:LUll11V(� "1'Hl: (:U5"1' UN' LABUR AIVD MA"1'EIiIALS:
�J ( ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ I L. �/,.� 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
$
$
$
$
$
$
$
$
$
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 MWCCfor determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attac
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 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 all work whi requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME QW/en� k.^n�'�lLl % DATE �/ aS- //
APPROVAL INSPECTOR SIGNA RE �