P - 48621Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFEC'CIVE 1-i-2012
DATE �/ /o YOURE-MAILADDRESS %.�n:w-Z3 9_ �nv�2
SITE ADD SS G � S �-e
THIS APPLICANT IS: �OWNER OCONTRACTOR
PROPERTY OWNER/
TENANT
NAME: \� ,!� �.nm [' ^
ADDRESS: 5 �/'� ct�/l�S �+-r CITY
PHONE: ''jli 3- 5 C"� � r���d
CONTRACTOR N�:
SUBMIT A COPY OF gTATE LICENSE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:
INSURANCE PHONE
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ �DI7'ION ❑ GARAGE/SHED
❑ BASEMEN'I' FIrIISH �OOF
❑ DECK O IDING
❑ SWIMMING POOL
Permit No.:
Received B�
Dat���d�
a��zlr�'SS�z. /
LEAD CERT NUMBER ERPc
CITY __ STATE ZIP
FAX
SIZE
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
0 MAINTENANCF./REPAIR ❑ REMODELING
, • /
DESCRIBE WORK BEING DdNE: �e✓+Zchr a�n.a� ✓`� :�tS��I � '�-t' w��:': �7i. �.� ,
SIZE OF IMPROVEIvtENT LENGTH WIDTH
ROOFING /' i�tIOUSE ONLY
NUMBER OF SQUARES I�.� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGH'I'
FT
BASEMENT REMODELING SUBMIT:
1. E�tisting Floor Plan
2. Proposed floar plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. 8c PORCHES SUBMIT:
�Soffit SIDING/SOFFIT/FASC7A 1. Site Plao/Survey showing the e�tisting structures
❑ Trim REMOVED? ❑ YES 0 NO �d pmposed project.
❑ Fascia 2. Two sets of construcrion pians
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchatge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ See Back Page for Fee Schedule
$ 65% of Buiiding Permit Fee
$�$ 001 times the total job valuation
�. J �� .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determinarion)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
� : Make checks payable 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 codes of the City of Fridley and with 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 plan in the case of a11 r�,k,�oGhi c�uires review and approval of pl�l DA'1'� .� x/ /
SIGNATURE OF APPLICANT PRiNT NAME -' °!�" �""�rY '�
APPROVAL INSPECTOR SIGN RE