P - 48479Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � % I Z-
SITE ADDRESS y% 3z
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 DO
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES =
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2012
YOUR E-MAIL ADDRESS Qf (5
❑ OWNER '�CONTRACTOR
PHONE: �'JSZ"3S$ —�%J7
,. . . �,.. ✓1 _ _ � _._ _ , 1 _. . - - --- f i. �`�a
STATE
rnuN� 6 /!'— 7/7—Ut�Lb
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
�BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
_ . . � e .
WINDOWS
IN EXISTING OPENINGS OYes �No
OR FOR NEW OPEAtINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
� (USI G r� 997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION l��V OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum or .50
License Surcharge $ $5.00 (State Licensed Residential Contractors}
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ j�;, ,� Make checks pavable to: City of Fridlev Attach
�
Permit No.:
Received By:
Date Rec'd:
���y�vltiz7v�� STATE '11Y1iZIP �5�%U
On2
LEAD CERT NUMBER EXP:
CITY Zin✓G( Gf�✓L STATE 1�_iNLIP s�07('
FAX
SIZE
[NG POOL
❑ ADDITION
�'REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
l8' OTHER.
❑Soffit SIDING/SOF'FIT/FASCIA
❑ Trim REMOVED? 0 YES O NO
❑ Fascia
LOCATION OF WINDOWS
!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,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
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 all or w'd re i' s review and approval of pl A / ) )
SIGNATURE OF APPLICANT � PRINT NAME�yv �Gc�2r�.n DATE Z/%/ I Z
APPROVAL INSPECTOR SIG �i � .�
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