P - 48673Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � I Z—
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR E-MAIL ADDRESS � � r 'S
yn r�,�� ,.F- r�t� _ ,,�': � � 1�., r M,U SS�
�Q OWNER ❑CONTRACTOR
���1\ � S� �L CITY '}�<�
�
STATE LICENSE #
ADDRESS:
PHONE
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMM
Permit No
�- `-,
��i� i
ATE �I.tiZIP SS1'I Z
EAD CERT NUMBER EXP:
CITY STATE ZIP
FAX
s�zE 2 X �l 4�
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �K.t� ri
SIZE OF IMPROVEMENT LENGTH 7 Z� WIDTH
ROOFING �HOUSE ONLY
NUMBER OF SQUARES '� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
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,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT:
❑ Trim REMOVED? ❑ 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 ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALLJE 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 $ OCCUPANCY TYPE
Permit Fee $ �.�.� See Back Page for Fee Schedule
Plan Review $ � 65% of Building Permit Fee
Fire Surcharge $ " C� .001 times the total job valuation
Surcharge $ C� � .0005 x Permit Valuation Minimum or .50
License Surcharge $ - $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ (1 l: ' Make checks payable to: Cityo uf Fridle_y Attach Stipulations
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 fo 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 . k hic e'• s review and approval of p�r�s. � � � I� I Z
SIGNATURE OF APPLICANT PRINT NAME �.y� i�Sk �� M S �aTE �
APPROVAL INSPECTOR SIG T[JRE