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P - 48621Building Inspections 763-572-3604 763-502-4977 FAX BUILDING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFEC'CIVE 1-i-2012 DATE �/ /o YOURE-MAILADDRESS %.�n:w-Z3 9_ �nv�2 SITE ADD SS G � S �-e THIS APPLICANT IS: �OWNER OCONTRACTOR PROPERTY OWNER/ TENANT NAME: \� ,!� �.nm [' ^ ADDRESS: 5 �/'� ct�/l�S �+-r CITY PHONE: ''jli 3- 5 C"� � r���d CONTRACTOR N�: SUBMIT A COPY OF gTATE LICENSE YOUR STATE LICENSE AND CERTIFICATE OF ADDRESS: INSURANCE PHONE PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION ❑ TWO FAMILY/NEW CONSTRUCTION PERMIT TYPE ❑ �DI7'ION ❑ GARAGE/SHED ❑ BASEMEN'I' FIrIISH �OOF ❑ DECK O IDING ❑ SWIMMING POOL Permit No.: Received B� Dat���d� a��zlr�'SS�z. / LEAD CERT NUMBER ERPc CITY __ STATE ZIP FAX SIZE TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION 0 MAINTENANCF./REPAIR ❑ REMODELING , • / DESCRIBE WORK BEING DdNE: �e✓+Zchr a�n.a� ✓`� :�tS��I � '�-t' w��:': �7i. �.� , SIZE OF IMPROVEIvtENT LENGTH WIDTH ROOFING /' i�tIOUSE ONLY NUMBER OF SQUARES I�.� ❑ HOUSE & GARAGE GARAGES PROPOSED SIZE: PROPOSED HEIGHT: SIDING ❑ Vinyl ❑ Aluminum ❑ Other ❑ ATTACHED GARAGE ❑ DETACHED GARAGE ❑ WINDOWS ❑ DRAIN TILE ❑ OTHER HEIGH'I' FT BASEMENT REMODELING SUBMIT: 1. E�tisting Floor Plan 2. Proposed floar plan 3. List of structural members to be used FOR NEW CONSTRUCTION INCLUDING DECKS, ADDITIONS. 8c PORCHES SUBMIT: �Soffit SIDING/SOFFIT/FASC7A 1. Site Plao/Survey showing the e�tisting structures ❑ Trim REMOVED? ❑ YES 0 NO �d pmposed project. ❑ Fascia 2. Two sets of construcrion pians WINDOWS 3. Energy Calculations IN EXISTING OPENINGS ❑Yes ❑No 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 NUMBER OF WINDOWS ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: (USING THE 1997 U.B.0 FEE SCHEDULE) TOTAL JOB VALUATION $ OCCUPANCY TYPE Permit Fee Plan Review Fire Surchatge Surcharge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge Total Due $ See Back Page for Fee Schedule $ 65% of Buiiding Permit Fee $�$ 001 times the total job valuation �. J �� .0005 x Permit Valuation Minimum or .50 $ $5.00 (State Licensed Residential Contractors) $ $2365 per SAC Unit (Plans to MWCC for determinarion) $ 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 work is not to start without a permit on site; that the work will be in accordance with the approved plan in the case of a11 r�,k,�oGhi c�uires review and approval of pl�l DA'1'� .� x/ / SIGNATURE OF APPLICANT PRiNT NAME -' °!�" �""�rY '� APPROVAL INSPECTOR SIGN RE