P - 50462Building BUILDING pe�it rto.:�s� ��2 �
Inspections RESIDENTIAL APPLICATION xeceivect By: ��
�63-s�2-3604 CITY OF FRIDLEY vate Rec'ct: � �
763-502-4977 FAX EFFECTIVE 1-I-2012
DATE Z YOUR E-MAIL ADDRESS �� C'Q 5 P
SITEADDRESS e�-� � ��'l��n � ���,C/ /" C�
THIS APPLICANT IS: • ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: I`1
TENANT ADDRESS: ,�-d 1 �'I e l O LtJ CITY� STATE� P
PHONE:
CONTRACTOR NpME: ` � '�l
SUBMIT A COPY OF STATE LICENSE # � �/ LEAD CERT MBER XP:
YOUR STATE LICENSE �� �� D o a ��� ��
AND CERTIFICATE OF ADDRESS: �rL � � Z �-( a�vv� � vLP� � iU/tiCITY �4S�AT�/�' IP�
INSURANCE PHONE % 2- ' ' FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK O SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ TENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � 6
SIZE OF IMPROVEMENT LENG WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARy4GE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? � YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
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 VALUATlON,1NCLUll1NG'1'HL CUS"1' Vr' LAKVK ANll MA1�KIAL�:
__(U,�ING 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
$
$
$
$
$
TYPE
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: Cityo uf 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 f9� permit and work is not to start without a permit on site; that the work will be in accordance with the
pp p ��v f r ' s. ' and a roval of 1. , .,
SIGNAVTUREIOF APPLICANT f 1- 0 IC W�1�C 1, �'...._�'...,__. pRINT NAMEp f+ � DATE
APPROVAL INSPECTOR SIGN`A J �. ' ___