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P - 47256Building Inspections 763-572-3604 763-502-4977 DATE�� SITE ADDRESS _ 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: BUILDING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFECTIVE 1-I-2011 YOUR E-MAIL ADDRESS ❑ OWNER '�CONTRACTOR NAME: Qy 'Z�i-�, ADDRESS: �' 7 l �Z PHONE: CITY Permit No.: `�iV I� c�� ��j Received By: rn �w l' ��'�e�J�V Q 1 2��1°� STATE /�'�NZIP S,S 3 NAME: i��f'n i�,� �G'i Z-�T �-F.1� ���1�w�.f1� - STATE LICENSE #_��� � LEAD CERT NUMBER ADDRESS: �(�J� �d"�.i'� 5 �' CITY ,/�!� STATE ZIP�_S� PHONE �j I�Z �I G � "12,�i FAX �%� �� Z c�Eit.. �,�SINGLE FAMILY/NEW CONSTRUCTION ❑ TWO FAMILY/NEW CONSTRUCTION ❑ ADDITION ❑ GARAG ❑ BASEMENT FINISH �1ROOF ❑ DECK ❑ SIDING ❑ SWIMM ❑ NEW HOME CONSTRUCTION ❑ MAINTENANCE/REPAIR DESCRIBE WORK BEiNG DONE: SIZE OF IMPROVEMENT �� ROOFING ' NUMBER OF SQUARES �� GARAGES PROPOSED SIZE: PROPOSED HEIGHT: SIDING ❑ Vinyl ❑ Aluminum ❑ Other WINDOWS [N EXISTING OPENINGS ❑Yes �No OR FOR NEW OPENINGS-DESCRIBE SIZE OF OPENING CHANGES & TYPE OF WINDOW TO BE INSTALLED �-- �ck;� SIZE STORIES ❑ WINDOWS ❑ DRAIN TILE ❑ OTHER ING POOL ❑ ADDITION ►�1 REMODELING ❑ HOUSE ONLY ❑ HOUSE & GARAGE ❑ ATTACHED GARAGE ❑ DETACHED GARAGE ❑Soffit ❑ Trim ❑ Fascia LOCATION OF WINDOWS NUMBER OF WINDOWS WIDTH /� HEIGHT FT BASEMENT REMODELING SUBMIT I. Existing Floor Plan 2. Proposed floor plan 3. List of struc±ural members to be used FOR NEW CONSTRUCTION INCLUDING DECKS, ADDITIONS. & PORCHES SUBMIT• l. Site Plan/Survey showing the existing structures and proposed proiect. 2. Two sets of construction plans 3. Energy Calculations FOR WINDOWS — PROVIDE U-VALUE AND MANUFACTURE STICKER ON WINDOW. 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 Surcharge Surcharge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge Total Due � l t�.L.7 $ $ � , i`�I $ a.c�— $ �, $ $ $ $ $ $ . �•. 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 APPLICAT[ON 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 e' and wor s ot to start without a per 't on site; that e work will be in ac or nce with the approved plan in the case of all work �ch r i e w and approval of plan �� SIGNATURE OF APPLICANT PRINT NAME ��t'/ � ��� DATE � I APPROVAL INSPECTOR SIGNATURF