P - 84238Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTiVE 1-1-2012
DATE �' 2` �+`��' YOUR E- AIL ADDRESS
SIT'E ADDRESS �[�'/ lj �' �' e�'j` �j�^� G�/j�i
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
ADDRESS: ����(" tj C r r.{ �'-
PHONE:
NAME:__ l�'DYY�� ���li(�,13�� ��i�o'
STATE LICENSE # Zi LEAD CERT NUMBERLi 1` J
ADDRESS: �C21-f � U,M 11iLe� �r`l'ti CI1'Y�
PHONE FAX
INGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED WINDOWS
O BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
O DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITTON
❑ MAINTENANCE/REPAIR MODELIr
DESCRIBE WORK BEING DONE: � � �,�/ ��j
SIZE OF IMPROVEMENT LENGTH WID`
ROOFING � HOUSE ONLY
NUMBER OF SQUARES 0 HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARy4GE
HEIGHT
Permit No.:
Received By:
Date Rec;d:�
TE�il�ZIP
p: I = �� - rT
TE�
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 SIDING/SOFFTT/FASCIA ADDITIONS. & PORCHES SUBMIT:
O Trim REMOVED? 0 YES O NO �• Site Plan/Survey showing the existing structures
� F��a and proposed projeck
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENRIGS �JYes ONo LOCATION OF WINDOWS FOR WIND�WS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED �'/11L� NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�JSING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $ L�I�U� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ 'l: .0005 x Permit Valuation Minimum or .50
$ c�_ $5.00 (Sta.te 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 pavable to: Citv of Fridlev Attacl
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 applicatio �r a •mi �rk is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o ii re 6s review and approval of s. �1 %
SIGNATURE OF APPLICANT PRINT NAME !��ir� ` DATE �� a�` ��
APPROVAL INSPECTOR SIGNA '