P - 50463Building
Inspections
763-572-3604
763-502-4977 FAX
DA� �I I � Jz6I �-
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
E-MAIL ADDRESS / • !!�+-tT�r..� `�e
❑ OWNER `�ONTRACTOR
� ✓/
NAME: /�� /,—r.iP.�1,'P IS
ADDRESS: 5�,��%�S �7c+ri z�-- �--
PHONE: %(s�.3 °' SS���P �CX� �� %
NAME: �Qao �C R i//�
STATE LICENSE # /� � �,��7 ,���
ADDRESS:�/�'12 z ZL ~'l�•�- �✓�
nunNF /'�,{� -� �> SYl�� Z
2e�1�-- � S��
Permit No.:
Received By:
Date Rec'd:
/�S ✓�,r/`�tSo �'r—a �_'��,,,�.
CITY �,j-!tr%�°�� STATFj�ZIP
CERT
CITY
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTON ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH 0 ROOF O DRAIN TILE
� DECK ❑ SIDING O OTHER
0 SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: KG �'
SIZE OF IMPROVEMENT
ROOFING ��
NUMBER OF SQUARES % s
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ HOUSE ONLY
,'�HOUSE & GARAGE
❑ ATTACHED GARAGE
�DETACHED GARy4GE
SIDING
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA
❑ Aluminum ❑ Trim REMOVED? ❑ YES O NO
❑ Other ❑ Fascia
WINDOWS
IN EXISTING OPENINGS OYes ONo LOCAT[ON OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
A1'E�ZIP S �1 � /�
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,
ADDITIONS_ 8c PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STlCKER ON WINDOW.
� WINDOW TO BE INSTALLED NUMBER OF WINDOWS I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�� t9�
$
$
$
$
ANCY
See Back Page for Fee Schedule
65% of Building Permit Fee
.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 NiWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payabie to: City of Fridley 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 co s of the Ci of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a it d or is not to start without a permit on site; that the work will be in ccordance with the
approved plan in the case of a o wh' h requir s e iew and approval of pl���� ,`�� �/ �/LQ'/ �
SIGNATURE OF APPLICANT P T NAME %�ff� DATE
APPROVAL INSPECTOR SI ATURE .
`J" 'J�.%