P - 44928Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D
763-502-4977 FAX ���'��N � � ����
EFFECTIVE 1-1-2011
DATE �� ��`-�� YOUR E-MAIL ADDRESS �Lh u r4 w'��,� C� YY�S �-'� , ClJ�
SITE ADDRESS �`2 �� f� E�C•.!S �£'Yz/�NC£
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTYOWNER/ NAME: �£�+� G�'o�Gf Z3uKou��r(
TENANT ADDRESS: �2 �`� ,��C.is %�'��2F►tF
/� CITY ��/�L%`� STATE��ZIP SS�3 L
PHONE:(7G � S 7/- r{3-��
CONTRACTOR NAME: ��'�R� ��Ln��� ON%/IA�'%O%1S �L �
SUBMIT A COPY OF STATE LICENSE #_ 2 O�o 3�D � PJ EXP DATE 3 3//2
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: l.SG 7�F 7.�A2c�n1(, �q,-,•� �fTy�2a�fMau�7 STATEy%N ZIp�SOle�j
INSURANCE PHONE G�2 �(��(-�G 2� FAX � G Si 3u�- 7�-/O
PROPERTY TYPE ihSINGLE FAMILY/NEW CONSTRUCTION SIZE S+ 3£n�'^' ST'�T
❑ TWO FAMILYJNEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED INDOWS
O BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDWG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCElREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: REn�'�t�f�4' S�p(�r�f. CAS£Mf� AN]� � Si�cl6C[ ASC�Pw?' ,�ocd
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
FI ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE � 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of siructural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUC7'ION [NCLUDING DECKS,
❑ Vinyl psa�t ADDITIONS & PORCHES SUBMIT�
Cl Aluminum ❑ Trim 1. 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 e6,Yes ONo 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 INSTALLEDm+�RV�H C�ISrmFrr�UMBER OF WINDOWS �v
HLL PGG�7 Hl(G DAJGU Vl�l VALUAl1V1V� 11v1,l�UUI1Vl� 1t1L� I;VJI- VN LAIfVK A1Vll MA�1�L+�KIALJ:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUA
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
� Total Due
TYPE
$ { 4 1�-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
$ 5U�3 $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ fr+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
�$ —y-� -�^--- Agreement necessary ( ) Non Necessary ( )
a � �� > Make checks payable to: City of Fridley 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 for a permit and worl ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of r C � re ire iew and approval of plans.
SIGNATUREOFAPPLICAN ! � � PRINTNAME `�aD (.�CN�+?CNa/�2i� DA� (-(�j^/1
APPROVAL INSPECTOR SIGNANRE