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P - 42116`.r� � ` „'�.� `� Bu� ing BUILDING Permit No.: Inspections RESIDENTIAL APPLICATION Received By: ' 763-572-3604 CITY OF FRIDLEY Date Rec'd: 1� 763-502-4977 FAX EFFECTIVE 1-I-2011 r' Q-hoo � G�M DATE Q G �O t YOUR E-MAIL ADDk2ESS M�� �J 2.S 't q°� � K 9 � j� SITE ADDRESS l� 9�o S !-r � tlG %G � R C i�� /l% � THIS APPLICANT IS: ❑ OWNER [�ONTRACTOR PROPERTY OWNER/ NAME: TENANT pDDRESS PHONE: CONTRACTOR SUBMIT A COPY OF YOUR STATE LICEN5E AND CERTIFICATE OF INSURANCE PROPERTY TYPE f �7 � d f,5 e.. og6s !-f�� �3- �7/ � d �� ceJt-S � (Z(�� o� ,v�'. G U� [TY �2�dG 87 G✓ i n> �J ca.. G a ATE ZIP STATE LICENSE #�I �S �% LEAD CERT NUMBER �J ArT� J%.S ADDRESS: 3 73 9 /�i : A1 Il� � Q- �1 a- %b uG CITY M PL'S STA PHONE lo � i � % a �" .5�.� .3 � FAX G � i — % � l � � � O • �3'SINGLE FAMILY/NEW CONSTRUCTION SIZE ❑ TWO FAMILY/NEW CONSTRUCTION STORIES PERMIT TYPE � �DITION ❑ GARAG ❑ BASEMENT FINISH ❑ ROOF � DECK ❑ SIDING ❑ SWIMM TYPE OF WORK: (❑ NEW HOME CONSTRUCTION � ADDITION � MAINTENANCE/REPAIR ❑ REMODELING ❑ DRAIN TILE O OTHER DESCRIBE WORK BEING DONE: I 7 �' N S�- �� W[�/J O w' S ,- d O�S � S Ti SIZE OF IMPROVEMENT ROOFING NUMBER OF SQUARES GARAGES PROPOSED SIZE: PROPOSED HEIGHT: SIDING O Vinyl O Aluminum ❑ Other ❑ HOUSE ONLY ❑ HOUSE & GARAGE ❑ ATTACHED GARAGE ❑ DETACHED GARAGE HEIGHT FT BASEMENT REMODELING SUBMIT: I . Existing Floor Plan 2. Proposed floor plan 3. List of structural members to be used FOR NEW CONSTRUCTION [NCLUDING DECKS, ❑Soffit ADDITIONS. & PORCHES �UBMIT: ❑ Trim 1. Site Plan/Survey showing the existing structures ❑ Fascia and proposed project. 2. Two sets of construction plans WINDOWS ���� 3. Energy Calculations M EXISTING OPENINGS.iCIYes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW. OPENIIVG CHANGES & a L se. P ae.t fl o o uN ,/ TYPE OF WINDOW TO BE MSTALLED Y� � NUMBER OF WINDOWS � T ALL FEES ARE BASED�N VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: � 773 � (USING �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 $ ��( • � $ $ $ . $ s, . $ $ $ $ $ $ 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) ft+6ft= 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 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 and w k 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 ��vork whic req ' eview and approval of pl s ,I SIGNATURE OF APPL[CANT PRINT NAME �R� � � f�'QT/�� DATE �� 6��A /' APPROVAL INSPECTOR SIGNATURE