P - 48095Building BUILDING Permit No.: ��,'� j,-1;�� 'J
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY nate ':��A� ti � 3Aj
763-502-4977 FAX ��,�-�—q-�-�
EFFECTIVE 1-1-2011
DATE I / �� YOUR E-MAIL ADDEtESS � r�'��P. G(J � f/ �� jy�; h Ga . CEJ�+
S[TE ADDRESS �(� /\ i LC Gi'�C l� �--°�/t�'C� /v
THIS APPLICANT IS: �WNER ❑CONTRACTOR
PROPERTY OWNER/ N�E: �y.Q� �J �� rr J
TEAIANT qpDRESS: �gD �� CL Gr-tG /� �iPr'/k' CrCITY !'/ :/��CS, STATF�iC�LIP�Z
PHONE: C�o/L — L3 � ��f 3�
CONTRACTOR Na�tE:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE F,q3{
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE ( 3U(J
❑ TWO FAMILY/NEW CONSTRUCTION STORIES_�
PERMIT TYPE � �DtTION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRATN TILE
O DECK �CSIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDI'TION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ' HG� S`G�;' S '� �Gi
SIZE OF [MPROVEMENT LENG H WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Pian
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCT[ON INCLUDiNG DECKS,
❑ Vin I ADDITIONS. & PORCHES SUBMIT:
y �Soffit (. Site Plan/Survey showing the existing structures
❑ Aluminum � Trim and proposed project.
� Other � S�r�cv I�'3"�i�� C�9'Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE lJ-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS I
ALL r EL� J AK� tSAJl'.11 V1V
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
VALUA"11ViV,1N(:LUll1NG "1'H� CU57' UF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
/)� OCCUPANCY TYPE
$ `��.�1� 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+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ __ � 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 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 a work which requires review and approval of pla�1 s. /
SIGNATURE OF APPLICANT .��i�( �/�-- PRINT NAME CJr^B.�/ G[%%v� DATE_.S^/ ��/
APPROVAL INSPECTOR SIGNATURE