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P - 45135Building BUILDING Permit No.: c�'� �}�� Inspections RESIDENTIAL APPLICATION Received By: 763-572-3604 CITY OF FRIDLEY Date 763-502-4977 FAX EFFECT►ve �-i-ao�i �������� DATE lD '-2/ � 2v/ / YOUR E-MA1L ADDRESS f`�L> o'-'h� %�-��( 5'rr/�rn�� C��Y�kc,�.� . ca yv� SITE ADDRESS _ ��� �T.� �s .vr THIS APPLICANT IS: ❑ OWNER �ICONTRACTOR PROPERTY OWNER/ TENANT NAME: •TJ e W � �x� ADDRESS: lvo2/ G!k �i idr' CITY ,�`jd/�Y STATE N4tJ Z[P ��t�3z-- PHONE:__ _7�i 3 - �iZ�?- l�'S.�.3 CONTRACTOR NAME: �r j--rk. (ar.�l ��4/in4 � /tiS'�✓a%�o.r1 i�v�- — SUBMIT A COPY OF STATE LICENSE # S LEAD CERT NUMBER YOUR STATE LICENSE AND CERTIFICATE OF ADDRESS: /��b/ �.e��r ,Dr N� CITY L'�L, ✓ STATE � n)ZIP SSa// INSURANCE PHONE 7� �- 443 - F�3a FAX �63 - �- 9 c� S PROPERTY TYPE �'SINGLE FAMILY/NEW CONSTRUCTION SIZE ❑ TWO FAMILY/NEW CONSTRUCTION STORIES / PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ BASEMENT FINISH �ROOF ❑ DECK ❑ SIDING ❑ SWIMMMG POi TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION _ ❑ MAINTENANCE/REPAIR �REMODELIN DESCRIBE WORK BEING DONE: Re Ya� SIZE OF [MPROVEMENT LENGTH WIDT ROOFING ,,i- O HOUSE ONLY NUMBER OF SQUARES � � �FiOUSE & GARAGE GARAGES ❑ ATTACHED GARAGE PROPOSED SIZE: ❑ DETACHED GARAGE PROPOSED HEIGHT: IDING ❑ Vinyl ❑ Aluminum ❑ Other ❑ DRAIN TILE C1 OTHER HEIGHT FT BASEMENT REMODEL7NG SUBMIT: I. Existing Floor Plan 2. Proposed floor pian 3. List of structural members to be used FOR NEW CONSTRUCTION INCLUAING DECKS, ❑Soffit ADDITIONS. & PORCHES SUBMIT: ❑ Trim 1• Site Plan/Survey showing the existing structures ❑ Fascia and proposed project. 2. Two sets of construction plans I WTNDOWS 3. Energy Calculations ' i IN EXISTING O�'ENINGS ❑Yes �No LOCATtON OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND � OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW. OAENING 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) TOTAL JOB VALUATION $ 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 $ �" �- LS See Back Page for Fee Schedule $ 65% of Building Permit Fee $ .001 times the tota] 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 Fridlev Attach THIS [S AN APPLICATION FOR A PERMIT-NOT VAL1D 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 a 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 al rk w i �ir re ' and approval of plans. SIGNATURE OF APPLICANT PRMT NAME fa �1 (�p�,..vTc� DATE l0 ���" �/ APPROVAL INSPECTOR SIGNATU