P - 60272Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 7—'//'/�
SI1'E ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
❑ OWNER
STATE LICENSE
ADDRESS: �!
YOUR E-MAIL ADDRESS
L�ONTRACTOR
❑ SINGL� FAMILY/NEW CONSTRUCTlON
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH '�d ROOF
❑ DECK ❑ SIDING
❑ SWIMM
CITY
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT'ION
'� MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: G� �� / � _ s�
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � �HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARyAGE
PROPOSED HEIGHT:
Permit No.
Received By: ( 1 �
Da��'d:� 0° i�. � «�
ATE �1�1' ZIP
CERT NUMBER /I7iG.3� -I EXP: �Tv� a�OJ
CITI' � STATE�ZIP-SSya�
❑ DRAIN TILE
❑ OTHER
HEIGHT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDIN ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �, Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED? O YES O NO �d proposed project.
❑ Other .❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ONo LOCA1'ION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE ST[CKER ON WINDOW.
OPENRQG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�D(� � __ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$
$ 'r� " .�-
�
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.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 oavable 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 and 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 all w hich ry�u,�ires review and approval of pl�� ,�j � /
SIGNATURE OF APPLICANT .������ `��%�he*y� PRINT NAIv1E ///f?rYIAS ✓�/�3'1'Q;L—DATE y�/ '��