P - 48644Building
Inspections
?63-572-3604
7b3-502-4977 FAX
DATE � /�
S7TEADDRESS 7
THIS APPLICANT TS:
PROPERTY OV'
TENANT
CONTRACT(JR
SUBMIT A COPY OF
YOUR STAT� LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDIN�
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2012
YOUR E-MAIL ADDRESS
C] OWNBR �73'E'RACTQR
PHONE:
NAME: %I�J/
STATE LICENSB #.
ADDRESS:{��QO
PHONE 7�✓ �:
— 3� '�3- ��
�STi�iGLE RAM[LYlNEW CONSTRiJCTION
� TWO CAMiL.YlNEW CONSTRiiCTION
C3 BASEMENT PTN[SH ❑ ROOF
� DECK �SIDING
❑ SWIMM
ING POOL
CITY
Fermit No:
Received By:
Da���� , ��� �
T� iaAr z�
CERT NUMBEI��r ��uG�/ �XP:�
CiTY �S$�__STATE�%I�IP.
FAX
SIZB
STORIL5
❑ WINDOWS
❑ DRAIN TILE
❑ OTHEit
TYPE OF WURK: ❑ NEW t-�otv1E CONSTRUCTION ❑ ADDTTION
L MAINTENANCE/REPAIR �.It�MQDELING
DESCRIBE WORK BEING DONE:__��/�-/�,/�I
SIZE OF IMP[t0 VEMENT L�NGTH W I DTH
Rbbl� I1VG ❑ FIOUSE OIdLY
NUMBER OF SQUARLS ❑ HOUSE & GARAG�
CARAGES
PROPOSED SIZE:
PROPOSED HEIGEI'1': �
SI�anyl
Q Atuminutti
❑ Other
p t1,TTACIiED GARAGE
❑ DBTAC�fED GARAGF
H.E[GHT
�
BASLMFNT REMOY�ELING SUBMiT:
i. Existing Fioor Plan
2. Proposcd flooe pian
3. List of siructural members to bc used
POR NEW CONSTRUCTION INCLi1DlI�fG DECKS,
❑Soffit S�DING/SOFFiT/FASCIA ADDITIONS. &PORCHES SUBMIT_
❑ Trim REMOVED? G7 YES ❑ Pt0 1. Site Plan/Sutvcy showiug the existing struciures
Q Fascia and pmposed project.
2, Two sets of conshuction plans
WiIVDflWS 3. �nergy Calculations
IN EXISTING OPENiNGS ❑Yes ❑No LOCATION OF WINDdW5 POR WINDOWS — PROVIDE U-VA.LUE AND
OR FORNEW OPENINGS-DESCRIBE SIZE OP _ „_ MANLTCACTUl2E STICKER ON WIND��'V.
OPBNING CHANGES &
j TYPE OF WIIVDOW TO BB INSTALLED NiFMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIAL5:
{USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL 30B VALUATION $,� %�./ OCCUPANCY TYPE
Pennit Fee
Plan Review
Fire 5urcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Cantrol
Park Fee
Sewer Main Charge
Total Due
'$ w�, �% � See Back Page for Fee Schedule
$ - ��"65% oiBuilding Permit Fee� '
$ .001 tiines the tolal job valuatian
$ ��^ .0�05 x Pemnit Valuation Minztz�um or .SO
$ `j� � $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for detennination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary { )
$/Q�, Make checks pa able to: City of Fridley Attacli
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL PROC�SSFD
I hereby apply for a building pennit and I acknowtedge 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
pennit but only an application for a permit and work is not to stari without a permit on sife; that the work will be in accordance with the
approved plan in the case o worl which re s review an approval of 1 ,�n n
SIGNAT'URE Or APPLICANT ��.Q� J��.���PRINT 1VAME�.�/L� � M��DATE � `7 ��"�
APPROVAL INSPECTOR SIGIVATURE