P - 48616Building BUILDING Permit No.: �� ° �� � =�
Inspections RESIDENTIAL APPLICATION Received By•
763-572-3604 CITY OF FRIDLEY Dat ��?�t1"�'�
763-502-4977 FAX ��'���--�
EFFECTIVE 1-1-2012
DATE .7 / Z YOUR E-MAIL ADDRESS
SITE ADDRESS liC� ��'
THIS APPLICANT IS: ❑ OWNER �NTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: US � �-'
SUBMIT A COPY OF STATE LICENSE # 7� !6 36 a f'� �' LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: Zc�'�/ %�-y S CITY ��k-µ-'��' STATE �►'ZIP S�/S'
INSURANCE PHONE l2 '� 7L� 8"!�O � FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O ADDI1'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ R F ❑ DRAIN TILE
❑ DECK IDING 0 OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE PAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: !S1 �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
I . Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
�,,,,,�,,, FOR NEW CONSTRUCTION INCLUDING DECKS,
Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
� Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction 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 Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ Z.`a 1. z j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ (�"' .001 times the total job valuation
$ ��"Z,� .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�, ,,, ."� Make checks pavable to: Citv 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 des e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an appiication f pe ' and ' not to start without a pe rt on site; that the work will be in ccor ance with the
approved plan in the case of k and approval of pla� �, �G��t�— � Zl ��
SIGNATURE OF APPLICAN"f PRINT NAME DATE
APPROVAL INSPECTOR SIGNATURE