P - 48324Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � Z• � �
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
___ EFFECTIVE 1-1-2012
YOUR E-MAIL ADDRESS
s f /�,�E Fr , � �
❑ OWNER �(
NAME: �
ADDRESS: � IG,
PHONE: % � � c�
NAMF. �� IL [ JU
� �Z ��% /Y%�r CITY
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Permit No.:�'�,�'-�
Received By:
Da��2�4' Cl: ;M �� � �' L � �f �
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STATE LICENSE #�U% �` ��� 3 LEAD CERT NUMBER EXP:
ADDRESS: ( G�lG ��� 7�'-- ��' CITy�f G'�� STATt-/""�-LIP,
PHONE �� ! �� yTi �� � FAX
�I-SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTON ❑ GARaGEiSxED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: %�J I n� �C`-t� l
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS_ & PORCHES SUBMIT
❑ Trim REMOVED? ❑ YES ❑ NO � Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-�ESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED ' NUMBER OF WINDOWS
ALL FEES ARE BASED ON VA UATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �(9� 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
� i(], L�5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ -��-� .001 times the total job valuation
$ �5�1,� .0005 x Permit Valuation Minimum or .50
$ `.�' $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ I Z � Make checks pa able to: City of Fridley Attach
THIS I3 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 per it 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 w i h quire and approval of plaps� �/J I �
SIGNATURE OF APPLICANT PRINT NAME J �r� /y�"d���-� DATE 2- �
APPROVAL INSPECTOR SIGNA RE