P - 48537Building BUILDING Perrnit No.: �` �' �' `
Inspections RESIDENTIAL APPLICATION Rec ' �
763-572-3604 ��y'� Y;� " . ,„ � ,
763-502-4977 FAX CITY OF FRIDLEY Date xec'd: ��'-' �
EFFECTIVE 1-1-2012
DATE • � � ' YOUR E-MAIL ADDRESS
SITE ADDRESS ' ` ` . "r �r ��. � � ' �
THIS APPLICANT IS: ❑ OWNER ,Ct1CONTRACTOR
PROPERTY OWNER/ NqME: / ��� �" '��' x '_' �
TENANT n���ss: ' r ` � � "� "�' . < ' ,-
'" f � ,�' CITY ` STATE.,�:�. :� ZIP �"'` ;' .
PHONE: � � � '�'} ,:� "� �
CONTRACTOR NAME: , , � � •" r � . � � , � . , ' .
SUBMIT A COPY OF • �
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICATE OF ADDRESS: "�= = �' *;,' C'r �� CITY -� STATEr%%° ZIP '";' -�-
INSLIRANCE - , � ,_, , . , ;•', ; , . i,. : ,, ' ° "° . ,
PHONE FAX
PROPERTY TYPE `�,SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED }7 WINDOWS
❑ BASEMENT FINISH II ROOF ❑ DRAIN TILE
❑ DECK QSIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: C_>, ✓t '` U�j � � .
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ 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 GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
.E] Vinyl F�Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT'
❑ Aluminum �,F� Trim REMOVED? ❑ YES 6� NO � Site Plan/Survey showing the existing structures
❑ Other E].Fascia ' and proposed project.
` ��_,C J 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ,E�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 i°• �: NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING TH 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
$ i�� .�_ 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 ( )
$ b"G? �� . ' 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 wark is not to start without a permit on �ite; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans. ' ., •-_
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SIGNATURE OF APPLICANT '" �'" ' � - �'� '
PRINT NAME DATE •
APPROVAL INSPECTOR SiGT.iATI iRF