P - 48210Building
Inspections
763-572-3604
763-502-4977 FAX
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BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
DATE (- d'� �� YOUR E-MAIL ADDRESS
SITE ADDRESS �� l v� �'T � S 1t %/-l. �'�-c �(,2
THIS APPLICANT IS: ❑ OWNER ;�C`ONTRACTOR
PROPERTY OWNER/ I NAME:_
TENANT ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vim+l
❑ Aluminum
O Other
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0
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STATE LICENSE #�(9 �Si $Y LEAD CERT
ADDRESS� � 1 I 9 Fc... r(�,,L-� c �,P
rttvNr, - �y �
SINGLE FAMILY/NEW CONSTRUCTT(
❑ O FANIILY/NEW CONSTRUCTION
O BASEMENT FII�iISH ❑ ROOF
❑ DECK ❑ SIDING
I�i��I�J
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
�
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
0 DETACHED GARAGE
O DRAIN TILE
❑ OTHER
Permit No.:
Received By: I 1 J
D����1�� 2 �3 ����
TE�IP l0
BASEMENT FMODEI ING Si 1RMiT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS_ & PORCHES SL►�3MIT:
O Trim REMOVED? 0 YES O NO 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
�'�'���'�'S 3. Energy Calculations
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS. FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & i '
TYPE OF WINDOW TO BE INSTALLED rv � h � NUMBER OF WINDOWS
„ ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING �'HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �� Oa �' __ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ �!'�� L`7 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= $x$25=$
$ $450 Conservation Pian Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �, Make checks�ayable 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 ordin�es, and codes e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applica�ion fo�r a perm t an o is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case f all wark whic u es r�vie�u and approval of pl�.i1s. f r� —
SIGNATURE OF APPLICANT PRINT NAMEs i 1�h(LC-1� ��'(� nrB�- DATE l�- �3'— I d�
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