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P - 39355Building Inspections 763-572-3604 763-502-4977 FAX DATE �'f I Z SITE ADDRE�S � THIS APPLICANT IS BUILDING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFECTIVE 1-i-2011 YOUR E-MAIL ADDRESS -- (P�f -�% -%I� �f7 c� (���I , � �OWNER ❑CONTRACTOR T Permit No.:20� % (�(?CoC� Received By: Date Rec'd: / PROPERTY OWNER/ N,a�vtE: �,��--` "'��'�'�( ' ��-I (� TENANT p,DDRESS: b��j?j �`�j ,/J� CITY .�/(� tQ� STATE�ZIP_ PHONE: I(1 f`� ��'�r �!/ ' 3�7 ��_ CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE AND CERTIFICATE OF INSURANCE PROPERTY TYPE NAME: STATE LICENSE # PHONE f�SINGLE FAMILY/NEW CONSTRUCTION f� TWO FAMILY/NEW CONSTRUCTION PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ BASEMENT FINiSH �ROOF ❑ DECK ❑ SIDiNG ❑ SW1MMfNG POOL LEAD CERT NUMBER. CTTY FAX SIZE STORIES ❑ WINDOWS ❑ DRAfN TILE 0 OTHER TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION I�MAINTENANCE/REPAIR ❑ REMODELING DESCRTBE WORK BEING SIZE OF [MPROVEMENT ROOFING NUMBER OF SQUARES � GARAGES PROPOSED SIZE: PROPOSED HE[GHT: SIDING ❑ Vinyl ❑ Aluminum � Other WINDOWS 1N EXISTING OPENINGS ❑Yes ❑No OR FOR NEW OPENINGS-DESCRIBE SIZE OF OPENING CHANGES & TYPE OF WINDOW TO BE INSTALLED LENGTH � WiDTH HEIGHT ❑ HOUSE ONLY I,�`HOUSE & GARAGE /" ❑ ATTACHED GARAGE ❑ DETACHED GARAGE ❑Soffit ❑ Trim ❑ Fascia LOCATION OF WINDOWS NUMBER OF WINDOWS ATE ZIP F"i' BASEMENT REMODELING SUBMIT: I. Exis[ing Floor Plan 2. Proposed Floor plan 3. List of structural members to be used FOR NEW CONSTRUCTION INCLUDING DECKS, ADDITIONS. & PORCHE3 SUBMIT: I. Site Plan/Survey showing the existing structures and proposed project. 2. Two seu of construction plans 3. Energy Calculations FOR WINDOWS — PROVIDE U-VALUE AND MANUFACTURE STICKER ON WINDOW. ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: (USIN THE 1997 U.B.0 FEE SCHEDULE) COTAL JOB VALUATION $ �(�%/ � OCCUPANCY TYPE Permit Fee Plan Review Fire Surcharge Surcharge License Surcharge SAC Chaxge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge Tota! Due $ Gf?. :l S $ $ r $ . $ $ $ 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 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 1 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 wor h' h require r�e and approval of plans. I� /,. f II SIGNATURE OF APPLICANT LL�s�l�� � PRINT NAME ��L�IA ��j 1/�✓� t� �1 DATE ��` ^ I ennnnvei n.rcn�r��rnvctr.�ie�rtrv❑ w �/il�_ T�