P - 60319Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �' ,_ �_
SIT'E 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
Permit No.��r,�r. �
Received By:.
CITY OF FRIDLEY vate ',� Q�
EFFECTIVE 1-1-2012
_ YOUR E-MAIL ADDRESS �� t'R 7'�''��'S ��S C'� ����%. Pfi
.�
❑ OWNER ��ONTRACTOR
NAME: �� � � 'r
ADDRESS: SG� 9� � S �
PHONE:
STATE LICENSE # F'JC. S� S 3 G'
ADDx�ss: �O � � v ��
xE
v�
�Sii*IGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH �I�OOF
❑ DECK ❑ SIDING
❑ SWIMM
e
.� L
CERT NUMB �
CITY G C K �
SIZE
STORIES
TYPE OF WORK: O NEW HOME CONSTRUCT'ION � ADDIT'ION
�..Iv1AINTENANCE/REPAIR Li REMODELING
DESCRIBE WORK BEING DONE: � O C�' �C-Q C GL C�
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING � 2 ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN T'ILE
❑ OTHER
HEIGHT
STATE �1'J�IP sS � 3 Z
EXP: � �
✓�tiTATE � IP SS3��
FT
$ASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
OSoffit SIDINGlSOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT•
❑ Trim REMOVED? O YES O NO �• 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 ❑No LOCA1'ION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE 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)
'OTAL JOB VALUATION $ _ __ . OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Suroharge
License Surcharge
SAC Charge
Curb Cut Escmw
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ '1`l .�� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ t�lp .001 times the total job valuation
$ i .0005 x Permit Valuation Minimum or .50
$ lJ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans �o MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ I�►` � 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 work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o 11 v�ork}�ii requir,s�f iew and approval of plan�S . ) .��,� v��
SIGNATURE OF APPLICANT �, `1 -_ ���----- p�T NAME (:.'�� q L' �'1C� G^� � DATE d-CJ
APPROVAL INSPECTOR SIG