P - 50467Building BUILDING Perrnit rro.: Zpl� - 6� S�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate xec'a:
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE � YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER OCONTRACTOR
PROPERTY OWNER/ NAME: ' — C.
TENANT ADDt�ss: crrY Pni'i STA ZIP S�Z
PHONE: � O �%
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTTFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING O OTHER
� SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �I REMODELING
DESCRIBE WORK BEING DONE: � � � �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �� ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES $ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GAR e.GE 3. List of strucrival members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTTON INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? 0 YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia
and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑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 VALUATlON,1NCLUDING THE COST UF LABOR ANll MATERIALS:
JOB VALUATION S ���G THE 1997 U.B.0 FEE SCHO CUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ �''i3 • 2 S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �•� .001 times the total job valuation
$ �, 2� .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 ( )
$ -� Make checks pavable 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 accura.te; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Conshuction Codes; that I understand this is not a
permit but only an application for a erm work is not to start without a permit on site; that the work will be in acc •dance with the
approved plan in the case of all '� '� s r i pproval of pl s.� ��.,�SC .
SIGNANRE OF APPLICANT RINT NAME�_j C G') �%'%L � DATE O,
APPROVAL INSPECTOR SIG A