P - 84372Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATIUN
CIT� OF FRIDLEY
� EFFECTTVE 1-I-2012 �
DATfi v l �Z� • I� YOUR E-MAIL ADDRESS
SITE ADDRESS CDI (,QO �1 �Ct;CY14n �• N� ��jZ
THIS APPLICANT IS: ❑ dWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
eorrT�.cTOR
SUBMIT A COPY OF
YQUR STATE LICENSE
AND CERTIFICATE OP
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BE1NG
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED S[Z@:
PROPOSED HEIGHT:
�
PHONE:
STATE LI('ENSE
PHONE �� Q��-��
'INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYlNEW CONSTRUCTiON
❑ BASEMENT FINISH O ROOF
O DECK ❑ SIDING
SIZE
� SWIMMING PaOL
0 NEW HC)ME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELiNG
❑ HOUSE ONLY
0 HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAG�
� �z.u�
Permit No.:
Received By:
�l�d';p
Da �
ATE ZIP,
CERT NUMBER EI�:
CITY�eU.� �71���5`'�ATE�ZIP '�-�1�2,
❑ DRAIN TILE
❑ OTHER
HEIGHT
BASEMENT REMODELRVG SUBMIT
[. Exisring Floor Ptan
2. Proposed floor pian
3. List of structural members to be used
SIDING FOR NEW CONSTRUGTtON INCLUDING DECKS,
❑ Vinyl QSoffit SIDING/SOFFTT/FASCIA �DITIONS_ & PORCHES SUBMIT:
❑ Aiuminum ❑ Trim REMOVED? ❑ YES ❑ NO I. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of conshuction plans
WiNDOWS 3. Energy Calculations
IN EX[STING OPENINGS�IYes ONo LOCAT'ION OF WINQQWSQ ��q� p��s,� FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF _�� LJ V MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WtNDOW TO BE INSTALLED C F.R OF WINDOWS 3
ALL FEES ARE BASED Olv VALUATION, INCLUDII�iG THE COST OF LEIBOR AND MATERIALS:
'OTAL JOB VALti
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totai Due
(USING THE 1997 U.B.0 FEE SCIIEDULE)
$ OCCUPANCY TYPE
$ 3. ,� See Back Page for Fee Schedule
$ � _ 65% of Building Permit Fee
$ �(7 .001 times the total job valuation
$ t�c�,Q .0005 x Permit Valuation Minimum or .50
$ 4St1� $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 ( )
$ ,!�--i , Make checks navable to: Citv of Fridtev 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 i❑
conformance with the ordinances and codes the City of Fridley and with the Mir►nesota Construction Codes; that I understand this is not a
permit but only an application for mit nd 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 l worl h� qu' �s review and approval of plans �E v t� � -_-_��
SiGNATURE OF APPLICANT PR[NT NAME d^ � f DATE !.1! �-�.
APPROVAL INSPECTOR SfGNATURE
PLEASE N�TE: SEPARAT� S ARE REQUIRED FOR PLUMBING. BLEGTRICAL AND MECHANICAL WORK