P - 80958Building
Infi�ect�ons
763-572-3604
763-502-4977 FAX
DATE�_
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERNIIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2012
YOUR E-MAIL ADDRESS
■ � �L►L •
Pxoi•rE: —1(0 3— a 3`� -►(0 3 3
Permit No.;��
Received By:�
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STATE LICENSE # �� ' LEAD CER� NUMBER �'A'�' ' ���t y�
ADDRESS: �� 1�! -�� /U L� G �u � I� L� Y STAT�,�ZIP`����
PHONE %�S I � a— �v � `ECL � fC'� FAX � S� "� .�lo "— �L °I �,l
�SiNGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �OTHER - 1= (L � ti� � N G
❑ SWIMMING POOL
'�M❑ EW HOME CONS ON ❑ ADDTTION
AINT'ENAN /REPAIR ❑ REMODELING
DESCRISE woRK sEING DONE: � r a M i n I'-e- a I r aF bra kQn -�f v�i5 -� c� 1 � S -E- � r r�d a� �P a�i e r 1 h �i � � n q Il
SIZE OF IMPROVEMENT �Re �aC2 W� nc� c� W� ��� �'�M � WIDTYI 0. w� HEIGHT �� d S FT 1 J
ROOFING t✓1 S a me Q1 u-CC.-' � HOUSB NLY .��� '�d 2 I 1� c, �Y a I.7{, �i
\,) BASE1vfENT REMODELING SUBMIT• r n� ��
NUMBER OF SQUARES o r o� �� � � 1 s.❑ xousE & G�GE 2�j �-'i rZ--. C�
I �N � , 1. E�sring F1oorPlan ,�3V �L
GARAGES ❑ ATTACHED GARAGE % 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS_ & PORCHES SUBMIT:
❑ Vinyl OSoffit SIDING/SOFFTI'/FASCIA l� p1� showing the e�sting structures
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO ♦'1 A�I��������oject.
❑ Other ❑ Fascia �� � 1' struction plans
WINDOWS 3. Energy Caiculations
IN EXISTING OPENINGS es �No LOCATION OF WINDOW FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENING -DESCRIBE SIZE OF `1 /( 9� A ��� M MANUFACTURE S1'ICKER 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:
(iJSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � 1(� � v 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
Surchazge $ .0005 x Permit Valuation Minimum or .50
License Sarcharge $ $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 � 'iyV I r r,t �' Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERNIIT-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 Cades; 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 work which requires review and approval of plans.
SIGNATCJRE OF APPLICANT �.� a��k--a �> m_�i i��NT NAME K-R-�s�� � M, +},�, S DATE �J � I 7 I J a
PLEASE NOTE: SEPr�RATE I'ERMITS ARE REC?UIRED FOR PLUMBING, ELECTRICAL AND ME(<HANlt>'AL WU1�K
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