P - 48635Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS � �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2012
❑ OWNER
PROPERTY OWNER/ NAME:
TENANT ADDREs
PHONE:
YOUR E-MAIL ADDRESS
CITY
CONTRACTOR NAME: ��,F;{�'1 `C'Ki'GVIlSY
SUBMIT A COPY OF STATE LICENSE # � LEAD CERT NUMBER
YOUR STATE LICENSE -
AND CERTIFICATE OF ADDRESS: L CITY
INSURANCE PHONE (-� '�� �L' FAX ip
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK �CSIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: O r1EW HOME CONSTRUCTION � ADDITION
`CX(4AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMEN"I'
ROOFING � �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
►.e� h�1�-e- `�
OUSE ONLY
HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
k
Permit No:
Received By: �1"
Date �e� ��� ��
TATE
A
P
��.7`i,ti-. �t, SV�IG�o "�-'J
HEIGHT SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposcd floor plan
3. List of structm-al mcmbeis to be used
FOR NEW CONSTRUCTION INCLUDINC DECKS,
SIDING D� �} ADDITIONS. & PORCHES SUBMIT:
❑ Vin 1 � �� � ❑Soffit SIDING/SOFFIT/FASCIA
Y 1. Site Plan/Sw'vcy sl�owing t6e existii�g structures
� Aluminu �,an ` j„� ❑ Trim REMOVED? ❑ YES �O and proposed project.
�$,'Other �_I�(./ �`�/"��� ❑ Fascia Z. Two scts of construction plans
WINDOWS �J 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCR BE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEN[NG CHANGES &
-TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING T�IE 19 7.B.0 EE SCHEDULE)
TOTAL JOB VALUATION $ �•�!U � OCCUPANCY TYPE
Permit Fee $ �� See Back Page for Fee Schedule
- Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
I: Surcharge $ .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 $ ,�(�} Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a building pern�it 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
pern�it but only an applicatio for a permit and work is not to start without a ermit on site; that the work will be in accordance with the
a roved lan in the case of hic r�j nf� s��reJ�' iew� hci a roval of s /�, ��/
SIpGNATU E OF APPLICANT I�����''t•C'�-�'"�--'L/ PR NT NAMEp V UIC��i ��.al-�' DATE � Z Z !✓
APPROVAL INSPECTOR SIGNATURE �
.. ... . . ... :�:��_� _— . � '.'�_ �. �"�._.�_... . :���.� �...�.�..::::�w.....-.��>.�...w.... .�.:�.��.r.� �.rrti:':�.�i� r+r..�.�r+�mrir� �/'ti��� � ♦ i.�ii�� n eT.nT.1.A �.TTl� A����T {lllll7V . . .
�