P - 84390Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �'Vf ��, CJ� �� 2"
SITE ADDRESS /
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-i-2012
❑ OWNER
NAME:�
ADDRESS:
STATE LICENSE # �
ADDRESS:�9��
PHONE ?7�iP • �
YOUR E-MAIL ADDRESS
�JCONTRACTOR
%�
5J SINGLE FAMILY/NEW CONSTRUCTTON
� TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH �$'ROOF
O DECK ❑ SIDING
❑ SWIMM
Permit No. �� 1 ��
Received By:
n�rA uo..�,�. A
ATE '�,i�. �IP�7j�'32
EAD CERT NUMBER EXP:
i CIT'Y�i"lU��C STATE�IP..�
FAX �
SIZE
O DRAIN TILE
❑ OTHER
TYPE OF WORK: � NEW HOME CONSTRUCTION O ADDITION
�'MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ✓' p - j�l�
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ��' HOUSE ONLY
NUMBER OF SQUARES � �HOUSE & GARAGE
GARAGES �❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARyIGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA
❑ Aluminum ❑ Trim REMOVED? O YES ❑ NO
❑ Other ❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LOCATTON OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
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 ST'ICKER ON WINDOW.
� 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 $ `'�C� 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 $ 8+ 6 ft = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
� Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ (�°j , �°] Make checks payable to: City 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 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 ,. ork which r qu'res review and approval of plan /�' /
SIGNATURE OF APPLICANT „��PRINT NAME ��Rm.� ��/K�tt Pi DATE I D,f X�� ��
APPROVAL INSPECTOR SIG RE