P - 36803Building BUILDING Permit No.:Z� �� IS�
Inspections RESIDENTIAL APPLICATION Received By: .�I��
763-572-3604 ,�;, ��� � � ' �
763-502-4977 FAX CITY OF FRIDLEY vat dr°��
EFFECTIVE 1-1-2011
DATE YOURE-MAILADDRESS �a�e-4-C� �Irernocle ���� Ct�✓�'1
s�� ADD�ss �0 /V1uuv�e r
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �G yY1.eS •b- _��/�?Y' �.j �n��p�
TENANT ADDRESS: pO W t�✓e L� ci-rY -�- �c( I e� STATEm�iZIP SS �J32
PHONE: /(���-s��- �a�
CONTRACTOR NAME: ,�I� � F� E? f'�'10 e i ��j
SUBMIT A COPY OF STATE LICENSE # vZ O a 3 3 %O LEAD CERT NUMBER :+� T- a 9 aa 3^�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:13-%�I3 +�GIP��'l �Ji" �'1F� �C 74 CITY�(LVVI SGTATE{M�4 ZIP S$� Uy
INSURANCE PHONE �l(y "? S^' 0 I FAX / � Cl S— %�/
PROPERTY TYPE fA�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH A�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
I�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �� 0'E�' "l' �� ��� � Ci- SU Yl /UO ✓'✓�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
RO FING ^�/- ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES d�o Q� 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. & PORCFiES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing sUvctures
❑ Other ❑ Fascia and proposed project.
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 FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ ���5� oO 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
$ �f l� LS 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 bl� $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 ( )
$ lii�l.� Make checks navable 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 Conshuction 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� ofj�,lnl w'� ��� �evi d approval of pl�n�. , e I� /
SIGNATURE OF APPLICAN�`���i' 1� PRINTNAME�LI tC�.dt P..�% ji( Ct,//��DA� g- %�'�
APPROVAL INSPECTOR SIGNATURE