P - 48427Building ''� �
Inspections
763-572-3604
763-502-4977 FAX
�
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR E-MAIL ADDRESS
i'~�,. .-s —
❑ OWNElY � L�GONTRACTOR
PROPERTY OWNER/ NAME:�
TENANT ADDRESS:
PHONE: �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERNIIT TYPE
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CITI'
Permit No.:
Received B �
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D�F�����81"� �u��
STATE�ZIP
STATE LICENSE # LEAD CERT NUMBER EXP:
ADDRESS: _� (!✓ ��j (_�lJ � � � �y- �� f (�,D CITY�, / STATE�IP_��
PHONEI�SI-L�[r�W-����/ FAX ��l-�i[���.3y
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
�itOOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
" IDESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE �
❑ ATTACHED GARAGE �
❑ DETACHED GARAGE �
❑Soffit SIDING/SOFFIT/F
❑ Trim REMOVED? � ❑ NO
❑ Fascia
HEIGHT
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, & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing shuctures
and pmposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Cakulations
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 $ ,�(1( � OCCUPANCY TYPE
Perniit Fee
m
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
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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 MWCC for determination)
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 nereby apply for a buiiding permit and I aclrnowiedge that the infbrmation above is complete and accurate; that the work will be in
conformance with the ardinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
peimit but only an application for a pernut 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 1 worl�rywhic�yi reqn' es eview and approval of pl s. / � ^
SIGNATURE OF APPLICANT yx�c,� t� PRINT NAME�i �jC§L/ � ��p J1 � DATE rry -� S��U l�
APPROVAL INSPECTOR SIGNATURE �—
' ':PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING. ELECTRIGAL AND MECHANICAL WORK ;