P - 48209Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS �S�/O
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
0 Vinyl
❑ Aluminum
0 ort��
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR E-MAIL ADDRESS
OWNER Q4�ONTRACTOR
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Permit No.: (d" "`'�'`�
Received By: v -�
� �y�
Date Rec'd�
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STATE�iINZIP Ss'y3L
STATE LICENSE # 63 / LEAD CERT NUMBERg 1 3d� EXP: f! /`�','iC��6
ADDRESS: 7OD G/ASi tA/C j�G't t �I C CITY /I��G S STATE /N/UZIP SS� /
PHONE �� I� 7 SS ���% % FAX
�jSINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION ST�RiES
❑ BASEMENT FINISH ❑ ROOF
❑ DECK O SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR 1�, REMODEL]
L
LENGTH e13 � I
0 HOUSE ONLY
_ ❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ wnvDOws
❑ DRAIN TILE
�$OTHER
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FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDIlVG/SOFFTf/FASCIA �DITTONS. & PORCHES SUBMIT:
❑ Trim REMOVED? � YES O NO 1. Site Pian/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations •
IN EXISTlNG OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALLJE 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 VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � O, � OCCUPANCY 2 TYPE ��"Y �� �"�,S
Permit Fee $ i�' �� See Back Page for Fee Schedute
Plan Review $ _ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ 1 .0005 x Permit Valuation Minimum or .50
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to NIWCC for determination)
Curb Cut Escrow $ $+ 6 ft= ft x-$25= $
Erosion Control $ $450 Conservation Plan Review
Pazk Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due _ $ j ( o, �(� Make checks aavable to: Citv of Fridlev Attach Stioulations
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 o e City of 'dley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work i t to start without a permit on site; that the work will be in accordance with the
approved plan in the case o ork which requi s r i and approval of plans. I
SIGNATURE OF APPLICANT i'// /T NAME �dl V �� r5iGi1 � (�_DATE I_��' �—I 2.—
APPROVAL INSPECTOR SIGNATCJRE
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