P - 48212Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � �� r
SITE ADDRESS --s I T�
1'HIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
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❑ OWNER CONTRACTOR
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❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCT'ION STORIES
O ADDTITON ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH � ROOF DRAIN T[LE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTTON O ADDITION
�fMAINTENANCE/REPAIR ❑ REMODELING
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Permit No.:�j�
Received By:
Date Rec'd: i �'��'.
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ROOFING ❑ HOUSE ONLY $ASEMENT RFMODELING SL1�3MIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE I. Existing Floor Plan
GARAGES "❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of sdvctural membe� to be used
PROPOSED HEIGHT:
IN FOR NEW CONSTRUCTTON INCLUDING DECKS,
Vmyl Soffit SIDING/SOFFTT/FASCIA �DITIONS. & PORCHES SUBMIT:
Aluminum Trim REMOVED? 0 YES �NO �• Site Plan/Survey showing the existing structures
and proposed project.
0 Other Fascia !: Two sets of construction plans
WINDOWS 3. Energy Calcuiations
IN EXISTING OPENINGS Yes ONo LOCATION OF WINDOWS�1 FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENING -,�DESCRIBE SIZE OF .�.�vT/�I � MANUFACTURE STICKER ON WINDOW:
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED .�iE �,i NUMBER OF WINDOWS I Z�
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USI HE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �� CJ�� OCCUPANCY TYPE
Permit Fee $ ZO9 , 2 S See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ 1� . 4 .001 times the total job valuation
Surcharge $ (e .D .0005 x Permit Valuation Minimum or .50
License Surcharge $ �, ov $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 $ 3 �'� Make checks aavable to: Citv of Fridlev Attach Stinulations
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 a ork which �q�uJ�es review and approval of 1 � �� �j�
SIGNATUREOFAPPLICANT �__ (.GE•�'t.�C... PRINTNAME�����Es�U�L:+�Fi��L. DATE I��� � 4w
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