P - 84229Building BUILDING Permit No.: 0�b
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 � , �,R
763-502-4977 FAX CITY OF FRIDLEY D���� �
EFFECTTVE 1-1-2012
DATE 3� L� JL YOUR E-MAIL ADDRESS � IM''4� �P �f'R'-1 �vl"� � OM
SITE ADDRESS i 5'� � — �t' 0�' � k l`� �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTYOWNER/ NAME: GD/L�`i C7t%v�nc �
TENANT ADDRESS: I S� f ' Cc ��` /�7%F /`�� CITY ��� �� �% STATE ZIP
PHONE: %10.3^ �/lo�- F`��3
CONTRACTOR NAME: IiLl�l'�� i2�S � ar' %NG .
SUBMIT A COPY OF STATE LICENSE #�jC 5 3 a?�a LEAD CERT NUMBER XP:
YOUR STATE LICENSE � �/
AND CERTIFICATE OF ADDRESS: .5'S-�� JI� �gt%YC� �✓ -#� .3'�v? CITY ���/�101%fl-+ STATF/3'���ZIP�
INSURANCE PHONE Z Z- � (o FAX %�P3 " 3 C/O � 3 z-Z )
PROPERTY TYPE �.SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O ADDIT'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �OTHER Fj ILG (Z��-rDRru'nC,�,J
❑ SWIMMING POOL
TYPE OF WORK: ❑ EW HOME CONSTRUCT'ION ❑ ADDIT'ION
�MAINTENANC ❑ REMODELING
DESCRIBE WORK BEING DONE: 1�� l, S E�= '� lf �: ���-�L O� ' S GC �.
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l . Exisfing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: "�— ❑ DETACHED GARQ,GE 3. List of shuctural members to be used
PROPOSED HE[GHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �offit SIDING/SOFFIT/FASCIA ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum �Trim REMOVED? j� YES ❑ NO �• S�te Plan/Survey showing the existing sductures
❑ Other ���a and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST'ING OPENINGS ;�'es ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEIdINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL NEES AKE BASED ON VALUATION, INCLUDING THE CUST OF LABOR ANll MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $ % 0• O � 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 $ $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 $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ �, � G� ,� Make checks aavable 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 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 al , w r hi h re i e' and approval of plans. /
SIGNATURE OF APPLICANT P T NAME�iV/G-� �O�'�-jO-✓ DATE 3�ZQJ/ � 2--
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Page 2- Building Residential Application
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BUILDING PERMIT FEE SCHEDULE
The Chief Building Official shall, before issuing permits for the erection of any building or
structure, or for any addition to any existing building or structure, or for any alteration or repair
to any existing building or structure, upon application therefore, require the payment by the
applicant for such permit of fees to the amount herein below set forth and in the manner herein
provided to-wit:
TOTAL VALUE FEES
$1 to $500 $23.50 (Minimum Fee is $23.50 plus surcharge)
$501 to $2,000 $23.50 for l�` $500 plus $3.05 for each additional $100 or fraction, to and
includin $2,000
$2,001 to $25,000 $69.25 for 1� $2,000 plus $14 for each additional $1,000 or fraction, to and
includin $$25,000
$25,001 to $50,000 $391.25 for 1�` $25,000 plus $10.10 for each additional $1,000 or fraction,
' to and includin $50 000
$50,001 to $100,000 $643.75 for 1� $50,000 plus $7 for each additional $1,000 or fraction to and
includin $100,000
$100,001 to $500,000 $993.75 for l� $100,000 plus $5.60 for each addirional $1,000 or fraction to
and includin $500,000
$500,001 to $1,000,000 $3,233.75 for the 1� $500,000 plus $4.75 for each additional $1,000 or
fraction to and includin $1,000,000
$1,000,001 and up $5,608.75 for the 1�` $1,000,000 plus $3.15 for each additional $1,000 or
fraction
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours frorn the time of application to
allow for proper review of proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the existing foundation will be
required before proceeding with the framing. New Houses Onlv
City of Fridley
Building Inspections Department
6431 University Avenue NE
Fridley, NIN 55432
763-572-3604
Fax: 763-502-4977
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