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P - 84226Building BUILDING Permit No.: � l`Z- Inspections RESIDENTIAL APPLICATION Received By. 763-572-3604 CITY OF FRIDLEY ����li �. � Q� 763-502-4977 FAX EF��Tn,E 1-1-2012 DATE � : 1� . �Z- YOURE-MAILADDRESS (�.A-R-IL-Fv �f��'y{vl;c.�cv-.itSc�i;V'G.�. S1TE ADDRESS �'Z� � � g� V✓ �� � THIS APPLICANT IS: O OWNER �CON"PRACTOR PROPERTY OWNER/ N,�: '� ��,,,��r� �v, S•S-- TENANT �DRESS:_�� '"'� r S � W � CITY "�� � t�- � STAT � ZIP,7 :7 �3Z Pxo1•rE: (o • "7 2 "��� CONTRACTOR N��j�>y�,,,�—�.��� �`,,� SUBMIT A COPY OF STnTE LICENSE # 20� �{ "10� LEaD CE1tT NUMBER EXP: YOUR STATE LICENSE 9 AND CERTIFICATE OF aDDRESS: "I'S% 7r[ [[ S�'�" /�-�,� CITY L� �1-c, {-'�US STATEM�zIP :1234 INSURANCE PHONE b� '%i bZJ �(" �i FP,X �k�" t� i-i3 S OCS� ( PROPERTY TYPE SINGLE FAMII.Y/NEW CONSTRUCTION SIZE O TWO FAMILY/NEW CONSTRUCTION STORIES PERMPr TYPE � �DTI'ION ❑ GARAGE/SHED ❑ WINDOWS ❑ BASF.MENT FINISH ❑ ROOF ❑ DRAIN 1'ILE ECK ❑ SIDING ❑ OTIIF,R ❑ SWINIIvIING POOL TYPE OF WORK: ❑�w xoME coNS�ucTTOrr ❑ ADDTTION ' ❑ MAINTENANCF./REPAIR ❑ REMODELING � DESCRIBE WORK BEING DONE: /✓ � O YL� '� SIZE OF IMPROVF..MENT I LENGTH WIDTH HEIGHT �� S FT �� ROOFING ❑ HOUSE ONLY NUMBER OF SQUARES (�•� S ❑ HOUSE �@ GARAGE BASEMENT REMODELING SUBMIT: 1. Existing Floor Plan GARAGES ❑ ATTACFIED GARAGE 2. Proposed floor plan PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of shuctural members to be used PROPOSED HEIGHT: SIDING FOR NEW CONSTRUCTION INCLUDING DECKS, ❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITTONS_ & PORCHES SUBMIT: ❑ Aluminum ❑ Trim REMOVID? O YES 0 NO 1. Site P1an/Survey showing the ceisting stnutures ❑ Other ❑ Fascia �d proposed project 2. Two sets of construction plans WINDOWS 3. EnergyCalculations IN EXISITNG OPEI�IINGS OYes ONo L�ATTON OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE t1ND OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACT[JRE STICKER ON WINDOW. OPEATING CHANGES & TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS ALL 1�'L�'L�'� AK� IiASL�'D U1V VALUA"1'lUN, llV(:LUllllV(G Tt1L�' COST OF .LABOR A1VD MATEitIALS: ,��.`� (_LTSING�TI�3E 1 97 U.B.0 FEE SCHEDiTLE) TOTAL JOB VALUATION ��-�7 0 �� S 7 OCCUPANCY TYPE Permit Fee Plan Review Fire Surcharge Surcharge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Pazk Fee Sewer Main Charge Total Due $ $ $ $ $ See Back Page for Fee Schedule 65% of Building Permit Fee .001 times the total job valuation .0005 x Permit Valuation Minimum or .50 $5.00 (State Licensed Residential Contractors) $2365 per SAC Unit (Plans to MWCC for detern►ination) ft+6ft= ftx$25=$ $450 Conservation Plan Review Fee Determined by Engineering Agreement necessary ( ) Non Necessary ( ) Make checks pavable to: Citv of Fridlev Attach THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED I hereby apply for a building permit and a owledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of th City Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an application for p w k� not to start without a permit on site; that the work will be in accordance with the approved plan in the case o c e uir w and approval of pl j r� SIGNATURE OF APPLICANT PRINT NAME ��a. � � p� r�•(p-�-DATE �.��. � L° APPROVALINSPECTORSIGNATURE PLEASE NOTE_ SEPARATE PERMIT D FOR PLIJMBING. ELECTRICAL AND MECHANICAL WORK _._. ,..-.�_*_--� ;._ ' _� t._�.. _J i --' — -- _ `� - -� A -- _ . � � � ! _ __ _ _ _ �.1�JOr ♦ '' � \ �.�: q __ � ��_-- _.. �" �;-- _ J' � _ , . 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