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P - 42176Buildin� , BUILDING permit Ivo:� : � ` � �� �, Inspections RESIDENTIAL APPLICATION Received By�Yc� 763-572-3604 CITY OF FRIDLEY D �° : r � 763-502-4977 FAX EFFECTIVE 1-1-2011 �� � DATE_ .� — I S' I I YOUR E-MAIL ADDRESS YYt � QL t Lj"� v' C1 ��r� d e e+'�r�',� 5olu� ' s. SITE ADDRESS S3 9 0 �'��` S'�' /� � �-yY i d � c-� M� THIS APPLICANT IS: ❑ OWNER �ONTRACTOR PROPERTY OWNER/ NAME: L i nc� Q I� ���' TENANT �DRESS: S 3i O �`� �'j}' �j � CITY � ��- �G�( STATE N/ 1� ZIP �S�%� � PHONE: �9(� ' S3 a2" �l� 3 CONTRACTOR xatva: a �-c� � ,rt SUBMIT A COPY OF gTATE LICENSE # oZ0 LEAD CERT NUMBER (� FF� U��I � �'� YOUR STATE LICENSE AND CERTIFICATE OF ADDRESS: o� �{ O0 A! �at �-E c5 �-LiOi{- c�� f�'1�nrtecc� kS STA T� I � ZIP SSy ►( INSURANCE PHONE ��D 3- ��v o�-- I'ZO FAX �I PROPERTY TYPE n�1GL W CONSTRUCTION SIZE ❑ TWO FAMILY/NEW CONSTRUCTION STORIES PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WS ❑ BASEMENT FIIdISH ❑ ROOF ❑ DRAIN TILE ❑ DECK ❑ SIDING ❑ OTHER 0 SWIMMING POOL TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION O MAINTENANCE/REPAIR ❑ REMODELING DESCRIBE WORK BEING DONE:___ trrl S'�d l� �✓� � kl 5�-i r,a o ve.n i na (►) t� m�or,+ ba-�.y ,�-� �p �`h- K W t�..� SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT ROOFING ❑ HOUSE ONLY NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT: 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: IS DING FOR NEW CONSTRUCTION INCLUDING DECKS, ❑ Vinyl pso�t ADDITIONS. & PORCHES SUBMIT: 0 Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures ❑ Other ❑ Fascia and proposed projeck 2. Two sets of construction plans WINDOWS 3. Energy Calculadons IN EXISTING OPEIVINGS es ONo 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 NUIvIBER OF WINDOWS ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: TOTAL JOB VALUA Permit Fee Plan Review Fire Surcharge Surcharge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge Total Due THE 1997 U.B.0 FEE SCHEDULE) $ �as..2r— $ $ S,y-S"'� $ � . 70�--- $ S. � a $ $ $ $ $ See Back Page for Fee Schedule � q �, �' ` 65% of Building Permit Fee /.t r-� r .001 times the total job valuation S• y� " S• y t' .0005 x Permit Valuation Minimum $5.00 �y $5.00 (State Licensed Residential Contractors) ��• �a S'� $2230 per SAC Unit (Plans to MWCC for determination) ft+6ft= ftx$24=$ $450 Conservation Plan Review Fee Determined by Engineering Agreement necessary ( ) Non Necessary ( ) Make checks navable to: Citv of Fridlev Attac6 Stiuulation THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN'CIL 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 pe 't 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 w' ires review and approval of plans. SIGNATURE OF APPLICANT PRINT NAME 1'v1e- t i 53s- f�t.l.��' +--� DATE � f S~ f( APPROVAL INSPECTOR SIGNATU ,- . � v