P - 62725Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS � 1
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
YOUR E-MAIL ADDRESS �� �-GP s �1� ! � �
� w�Y �N N�
OWNER ❑CONTRACTOR
PermitNo.: dbb�b (�
Received By:
Date Rec'd: ��"�
A'
NAME:
STATE LICENSE # LEAD CERT NUMBER EXP:
ADDRESS:
PHONE
pP.SIN�'rLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAC
�%�'
' STATE ZIP,
❑ BAS�MENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR . i REMODELING
DESCRIBE WORK BEING DO
SIZE OF IMPROVEMENT a
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
LENGTH '
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
WIDTH oL3S' HEIGHT
t� �
SO FT�-�-
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural membe�s to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Alutninum ❑ Trim REMOVED? O YES ❑ NO �• Site Pian/Survey showing the existing structures
� Other ❑ ascia and proposed project.
�A� 2. Two sets of construction plans
WINDOWS f���' ��� ` l7 '� � 3. Energy Calculations
IN EXISTING OPENINGS �Yes o LOCA� T�jONJ�F WINDOWS� q � FOR WINDOWS - PROVIDE U-VALLIE AND
OR FOR NEW OPENINGS-DESC BE SIZE OF N 0� 6 h'T'.�.d.�%l,� I.�.+ V� i w,/ ,-�' jy[ANL7FACTURE STICKER ON WINDOW.
OPENRVG CHANGES & ' •
TYPE OF WINDOW TO BE INSTALLEb NUMBER OF WINDOWS
ALL FEES ARE B�1SED ON VALUATION, INCLUI�I�G THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B:°� FEE SCHEDULE)
'OTAL JOB VALUATION $ �. 1. G �(�_ _ � . _ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ e� �i :(� See Back Page for Fee Schedul� ;- .
$ 65% of Buiiding Permit Fee
$ [, a b .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: Citv of Fridlev 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 �vith 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 pian in the case o�11 Work y't�ich req�'e rev w approval of �s;.� ��d r
SIGNATURE OF APPLICANT 1 C/y/�/7JrC-r 1� ��►t1 ,-L�'.� � PRINT NAIv�����/ %/vn .�D�.uS �DATE J-�i ' I�
APPROVAL INSPECTOR SIGNATURE
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