P - 48193Building
Inspections
763-572-3604
763-502-4977 FAX
DATE L
SITE ADD SS S—% ��
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
n
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-2012
c
Y UR
c
STATELICENSE# ZU �P>/O � f
ADDRES • � z % 3 �� .¢�/L°' �
PHONE 3 — %�Z Z
❑ LE FAMIL lNEW CONSTRUCTION
❑ TWO`FAMiLi' EW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK 0 SIDING
SIZE
STORIES
❑ NEW HOME CONSTRUCTION O ADDTITON
❑ MAINTENANCE/REPAII� ❑ REMODELING
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
� Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS OYes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
Permit No.:,�(�1 �
Received By•
Date Rec'd: J � — �
�fi A (l C/Jt/�/'.0 r �ri1/I
�
NUMBER EXP:
CITY f STATEf�ZIP�S�<�i
❑ DRAIN TILE
L�Y�1TI-IER
❑Soffit SIDING/SOF'FIT/FASCIA
❑ Trim REMOVED? 0 YES ❑ NO
❑ Fascia
LOCATION OF WINDOWS
3=ZS tS�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural mcmbers to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ 8c 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 STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ I � 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 $ 0 .0005 x Permit Valuation Minimum or .50
License Surchazge � $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 O Non Necessary O
Total Due $ .-�'�r _ Make checks navable 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 City of Frid ey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work ot start without a permit on site; at the work will be in accordance with the
approved plan in the case of all work 'ch re uires review approval of plaps, / � / /
SIGNATURE OF APPLICANT /�l �f � n 'L tS/U� DATE 2� (`�
APPROVAL INSPECTOR SI RE 1�I
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