P - 50466Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
� Aluminum
❑ Other
���� ��� �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR E- AI ADD S ��J U
� �o �..�,�'�� ,
❑ OWNER �CONTRACTOR
NAME: � �' !� te7vl 2_
ADDRESS: jU� �j 3f �✓1. �f� CITY,
PHONE:�,�r'% � 3t} %�" y��'�C�
NAME: � ^ a� �` �tSS r ' �f'��S
STATE LICENSE # r LEAI
ADDRESS: �' +N�-�{O � " � r
PHO -� " � F.
SINGLE FAMILY/NEW CONSTRUCTION SIZI
❑ TWO FAMILY/NEW CONSTRUCTION STC
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
� DECK ❑ SIDING
� SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ DITION
❑ MA CE/REPAIR �MODELING
� �c�S �, >S�S��, �-,��i,
LENGTH WIDTH
❑ HOUSE ONLY
_ ❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GAR�AGE
Permit Nc.�:
Received By:
Date Rec'd:
STATE ��IP �S
CERT NUMBER EXP:
CITY STATE I'�1 �l2IP S.� 3�
❑ DRAIN TILE
� OTHER
HEIGHT
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,
❑So�t SIDING/SOFFIT/FASCIA �DITIONS_ & PORCHES SUBMIT:
❑ Trim REMOVED? 0 YES O NO 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Fascia 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-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 $%�C�- � 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
$ �`f'`y �-j„S� See Back Page for Fee Schedule
$ +� 65% of Building Permit Fee
$ /. � v .001 times the total job valuation
$ , G�j .0005 x Permit Valuation Minimum or .50
$ �C"; C� $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 ( )
$ _ . �Iake checks aavable 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 ' of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a �t wor 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 w whi q approval pf plans.
SIGNANRE OF APPLICAM � PRINT NdIME DATE / /