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P - 47798Building Inspections 763-572-3604 763-502-4977 FAX DATE (,� �� SITE ADDRESS FL THIS APPLICANT IS: PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE AND CERTIFICATE OF INSURANCE PROPERTY TYPE PERMIT TYPE TYPE OF WORK: DESCRIBE WORK BEING BUILDING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFECTIVE 1-1-2011 YOUR E-MAIL ADDRESS ❑ OWNER �ONTRACTOR NAME:_ 1 i�`n C1 � fl s-}�r',�r — ADDRESS:��.+,�'���-� �� PHONE: CITY Permit No.: Received By: Date Rec' STATE (�ZIP '�'-� �C�"�j? ' '� " " t'ic�Kls-cNuf� STATE LICENSE # LEAD CERT NUMBER ADDRESS:�� .�a� r"(�l0 CITY �r�oC STATE�ZIP SS Z PHONE Z � �i ` ' ❑ SINGLE FAMILY/NEW CONSTRUCTION F� ❑ TWO FAMILYMEW CONSTRUCTION eTZ,n.r�---- ❑ ADDITION ❑ BASEMENT FINISH ❑ DECK ❑ NEW HOME CONSTRUCTION �1"MAINTENANCE/REPAIR 6�ROOF ,� ..���,�.�rv� ❑ DRAIN TILE ❑ SIDING ❑ OTHER ❑ SWIMMING POOL ❑ ADDITION O REMODELING SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT ROOFING ❑ HOUSE ONLY SQ FT NUMBER OF SQUARES _��_ BASEMENT REMODELING SUBMIT: ❑ HOUSE & GARAGE GARAGES ❑ ATTACHED GARAGE � Existing Floor Plan , PROPOSED SIZE: ❑ DETACHED GARAGE 2 P�oposed floor plan PROPOSED HEIGHT: 3. List of structural members to be used SIDING ❑ Vinyl FOR NEW CONSTRUCTION INCLUDING DECKS, ❑ Aluminum ❑Soffit ADDITIONS & PORCHES SUBMIT: ❑ Other ❑ Trim I. Site Plan/Survey showing the existing structures ❑ Fascia and proposed project. WINDOWS . 2. Two sets of construction plans IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS 3 Energy Calculations I OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS - PROVIDE U-VALUE AND IOPENING CHANGES & MANUFACTURE STICKER ON WINDOW. TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: TOTAL JOB VALUATION $ �USING THE 1997 U.B.0 FEE SCHEDULE) Permit Fee OCCUPANCY TVPF Plan Review Fire Surcharge Surcharge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge Total Due �D �i . $ $ - `� $ j �$ �. $ $ $ $ $ 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) �+6�— ftx$25=$ $450 Conservation Plan Review Fee Determined by Engineering Agreement necessary ( ) Non Necessary ( ) Make checks payable to• City of Fridley Attach THIS IS AN AppLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED N��4������ 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 e' a work is not to start without a permit on site; that the work will be in accordance with the approved pian in e ase of ail work whic re uires review and approval of plans. SIGNATURE OF AF��r��-eANT _ � . -- APPROVAL INSPR('T �r:�.i n-rt m�- 4���_PRINT NAME ., C.�-�5