P - 48414I (��. �5
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTiVE I-I-2012
P�rm�t No.: �� ui
Received By:
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siT� ,aDOR�ss 5l� y �i,�12a�e �'L N� � (� �
THiS APPLICANT iS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME:�
TENANT ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICliNSE
AND CERTIFICATE OF
INSURANCE
PROFERTY TYPE
PERMIT TYPE
CITY
ATE "LIP
NA���: (�Ltct�" %. `�S l.1/ nd.o�7 d� '�/
5TATE LICE S _ pCanONZ % LEAD CERT �UMBER N�.% ZFj 2'rI'% EXP: `� .QG.:�
ADDRESS: /y(o9� l-ke,/p�lCrC /'t� ��w CfTY p(,� A. STATE /NI�Z(P S�IZy
PHONE 95� .ft9/- 3No� FAX /SZ-� � `1�
❑ SINGLE FAMTLY/�dcW CGTQSTi2liCTiGN SiZ�
❑ TWO FAMILY/N�W CONSTRUCTION STORIES
❑ ADD[TIOV ❑ GARAGE/SIIED �WIi�DOWS
❑ BASEMENI FINISII ❑ ROOF ❑ DRAiN TILE
❑ DECK ❑ SIDING ❑ OTH�R
❑ SWIMMING POOL
TYPE OF W ORK: ❑ NEW HOML CONSTRUCTION ❑ ADUITION
MAINTENANCE/RGPAIR ❑ REMODELING
nESCRIBE WORK F3GIVG DONE: �GLCL lI / G(/rS /I'1 I
SIZL OF 1MPROVF,MF_,NT LENGTH � TH HEIGHT
ROOFiNG
NUMBER OF SQUARrS
GAItAGES
PROPOSFD SfZE:
PROYOSED HE[GHT:
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
FT
BASEMENT RLMODLLINU SUBMI7:
1. Existiug Floor Plan
2. Proposed floor plau
3. List of s�ructural members to be used
SIDING FOR NLW CONSTRUCTfON �NCLUDING DECKS,
❑ Vinyl ❑Soffit SIDiNG/SOFFIT/FASCIA ADDTTTONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO I. Site Plan/Su�vey shawing d�e existing shnchu�es
❑ Od�er ❑ Fascia and proposed project.
2. Two sets ofconstniction plans
WINDOWS 3. fincrgy Calculations
T1V GafSTING OPF,NTNGS C�Pcs ❑No LOCATION OF W[NDOWS FOR R�INDOWS - PROVIDF. U-VALUE AND
OR FOR NEW OPF,NTNGS-DESCRIBE STZE OF 1��j�q Lpb,p /�� �,���/�') MANUFACTURE STICKER ON WINDOW.
OPGNING CHANGES & � �'�� 1� - �� �-
TYPE OF WiNDOIi' TO T�F TNSTAI.LED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
r� ( SING�THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ T UD • OCCUPANCY TYPE
Permit Fee
Plan Rcview
Firc Surcharge
Surchargc
License Surchargc
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fec
Sewer Main Charge
Total Due
$ � �J,� LS
$
$ ��� U
$
� ��
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimwn 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 Engincering
Agreement necessary ( ) Non Necessary ( )
Make checks oavable to: Citv of Fridlev Attach
THiS IS AN APPLICATION FOR A PERMIT-'.�IOT V.4LID UNTTL PROCESSED
1 hcreby apply for a building permit and I acknowledge that the information above is cotnplete and accurate; that the work will be in
confonnance with the ordinances and codes of t� Ciry of F�dley and with the Minnesota Construction Codes, that T understand this is not a
peimit but only an application fo � a permit and w�rk is ot to start without a permit on site; that the wark will be in accordance with the
approved plan in the case of all rk w requrr�s • w and approval of pla s.
SIGNATURL- OP APPLIC,4NT i E �� Cu�S ��Id DATE /SRb' ZDIZ
APPROVAL INSPECTOR SIGNATU -�
PLEASE NOTE: SEPA A E PE EO IRED F R PLUMBTNG, ELECTRICAL AND MECHANTCAL WORK