P - 62722Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� / �7 f /�2�
STI'E ADDRESS ��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTTFICATE OF
INSURANCE
,
� BUILDING
RESIDLNTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR E-MAIL ADDRESS
�ONTRACTOR
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PHONE:�pS / � � �S � � G'C�.�i �
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NAME: �^.oS ♦ � 1 'r._ � e
STATE LICENSE #
PHONE G�5 ! °' � }t S `"`,
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CERT
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Permit No.: B �i�
Received By:
vate��c�t: A P R 1 7 2 1
i2
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION StzE
__
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �$'bTHER j `
❑ SWIMMING POOL �t� /a Ge (/�C�!'1 / t C
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION L
❑ MAINTENANCERLEPAIR �tEMODELING ��°!%?O �����-°%1 �v ���
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GAR�AGE
� crt�r5 u/�'.
�J
SO FT
�ASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of struchual members to be used
FOR NEW CONSTRUCT'ION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Trim REMOVED? O YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS� �� � J/� FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF a G►7`L MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS � "� � ��-°�S
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR ND MATERIALS:
r (USING.THE 1997 U.B.0 FEE SCHEDULE)
?4'TAL JUB YALUATION $ l�f ) C� OCCUPANCY TYPE
Permit Fee V
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �J �;'� el See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ a a .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ 5 $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 Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I ackn edge that the information above is complete and accuraxe; that the work will be in
conformance with the ordinances and codes f e C' of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit d wo is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all r uir review and approval of plans. ,
SIGNATURE OF APPLICANT PR1NT NAME �2� qs1, �y' /L,G� DATE�� y`"Z' /
APPROVAL INSPECTOR SIGNA �
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