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P - 35057Building $[JII,DjN(i Permit No.: Inspections RESIDENTIAL APPLICATION Received By: 763-572-3604 CITY OF FRIDLEY Dat��'�:F�B 17 2� � 763-502-4977 FAX EFFECT�vE i-i-2oi� DATE OUR E-MAIL DDRESS SITE ADDRESS � � '� THIS APPLTCANT I. ❑ OWNER NTRACTOR PROPERTY OWNER/ NAME:�: r y� (` p-�, �-�-�,'k. TENANT ADDRESS: Ct? %J`'�� J9 �%"f j 00� ��� CITY F�� c�`� (�I STATE��ZIP S��I 30� PHONE: % (P 3— .5 �7 J � ,S S—S'S CONTRACTOR NaME:�_5�-c.Lt Z'nst�► ( �-4-- i'nr� SUBMIT A COPY OF STATE LICENSE # O�aSSOS�'/ '� P LEAD CERT NUMBER YOUR STATE LICENSE M AND CERTIFICATE OF ADDRESS: o�SC7 D i-{ u1.�L �,� Z� S� CITY n'1 PLS STATE ��ZIP SS I INSURANCE pHON� FAx PROPERTY TYPE T�G'SINGLE FAMILY,�NEW CONSTRLICTION SIZE ❑ TWO FAMILY/NEW CONSTRUCTION STORIES PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS ❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE ❑ DECK ❑ SIDING ❑ OTHER ❑ SWIMMING POOL TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION ❑ MAINTENANCE/REPAIR ❑ REMODELING DESCRIBE WORK BEING DONE: e�((,� Ce.. C� F15 2146V�C—� SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT ROOF[NG ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT: NUMBER OF SQUARES ❑ 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. & PORCHES SUBMIT: ❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures ❑ Other ❑ Fascia and proposed project. 2. Two sets of construction plans WINDOWS 3. Energy Calwlations IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND OR FOR NEW OPENINGS-DESCRIBE S[ZE OF MANUFACTURE STICKER ON WINDOW. OPENING CHANGES & TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS ALL NL�J AK� KA�r:ll U1V VALUA'11U1V, 11VCLUll1NC: '1'H� CUS'1' UN' LABUK ANll MA'1'EKIALS: (USING THE 1997 U.B.0 FEE SCHEDULE) TOTAL JOB VALUATION $ OCCUPANCY TYPE Permit Fee $ See Back Page ior Fee Schedixle Plan Review $ 65% of Building Permit Fee Fire Surcharge $ .001 times the total job valuation Surcharge $ .0005 x Permit Valuation Minimum $5.00 License Surcharge $ $5.00 (State Licensed Residential Contractors) SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination) Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$ Erosion Control Park Fee Sewer Main Charge Total Due $ $450 Conservation Plan Review $ Fee Determined by Engineering $ Agreement necessary ( ) Non Necessary ( ) $ �lO •O O Make checks payable to: City of Fridley 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 Construction des; that I understand this is not a permit but only an application for a permit and work i to start without a permit on site; that th ork will be in accor ance with the approved plan in the case 1 ch requi w and approval of plans �,,./� ' SIGNATURE OF APPLICANT6�Li�� - PRINT NAME �� �1�/ : UATE ��