P - 48315�� `�°� 3
Building BUILDING Pe "
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY vate xec'ct: v�'
763-502-4977 FAX EFFECI"IVE 1-1-2012
DATE o�' ID � �� YOURE-MAILADDRESS
SITE ADDRESS .�GC?i ^ /�f%l�'V /�%//�%/�% �/� y�
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �
TENANT ADDRESS:��p� t7T-r�/ �i %//� CITY // `�-�'� STATE 'LQ%iZIP_�
PHONE:
CONTRACTOR NAME: C� t �GI'10✓'
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBE,, �� ����D'67 XP: �^�''�p
YOUR STATE LICENSE �'!
AND CERTIFICATE OF ADDRESS: � 4 CITY �/l77��t��919 STAT�lJ/lLIP�
INSURANCE PHONE 6 F� FAX �
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUC7'ION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
� SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT
NLTMBER OF SQUARES ❑ HOUSE & GARAGE l, Existing Floor Plan
GARAGES � ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROP03ED HEIGHT:
SIDING FOR NEW CONSTRUCI'ION INCLUDING DECKS,
❑ Vin 1 ADDITIONS & PORCHES SUBMIT'
Y ❑Soffit SIDING/SOFFIT/FASCIA l. Site Plan/Surve showin the existin structures
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO and proposed p oject. g g
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION F WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �'G G G�`�'Y!^ MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & —°—
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
HLL i'L� L�.� AKL' ISA.7L� L V1V VALUAl1V1V� L1VC:LU1JliVlT �I�HL CUS"l� Ur' LA13UR ANll MATERIALS:
US��T £ 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ��_ S"'� See Back Page for Fee Schedule
$ —�- 65% of Building Permit Fee
$ �-� �+ .001 times the total job valuation
$ ,� .0005 x Permit Valuation Minimum or .50
$ �-� C> $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 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 w rk whyi�ch, /re uires review and approval of plans.
SIGNANRE OF APPLICAN��-�SS�—�'l"� PRINT NAME DATE � �� I�
APPROVAL INSPECTOR SIG ATU
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