P - 84385Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �C� � � � � l Z
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:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
v` Y,���• �i � • �YiGi �CiG(
❑ OWNER ❑CONTRACTOR
---
NAME:
ADDRESS:
PHONE: �lZ' c3 �
NAME: y Ilv
STATE LICENSE # �
ADDRESS: .�, � 7 S� �� � I � {�
PHONE (p �/ " �/� - (Q G�J �lS
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
m BASEMENT FINISH ❑ ROOF
❑ DECK � SIDING
❑ SWIMMING POOL
0 jVEW HOME CONSTRUCTION O ADDITTON
�vIAINTENANCE/REPAIR ❑ REMODEL
�i
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
Permit N
Received By:
Date Rec'd:
LEAD RT NUMBER EXP:
� CITY �'�L�E�'! _ TATE�IP � s�/cG
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT'ION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALLTE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STTCKER ON WINDOW.
OPENING CHANGES 8c
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 $ i` O C> 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 $ �"j �� j'� $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
Park Fee
Sewer Main Charge
Total Due
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ a.(5/ Make checks pavable to: Citv of Fridlev 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 ap for a permit and work i not to st without a permit on site; t at the work will be in accordance with the
approved plan in the case of 1 wo which�qu e r iew and proval of p� _ �
SIGNATURE OF APPLICANT c�d�r I �./-� � RINT NAME .... ..,. ��„� ,. „� Da� I� -/�— I?
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