P - 48189Bui,lding
Inspections
763-572-3604
763-502-4977 FAX
DATE i � �S � I Z-
SITE ADDRESS iP z 1
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
❑ OWNER
STATE LICENlSE
ADDRESS: ! Z
E-MAIL ADDRESS
�[CONTRACTOR
rrivr� c�[ li �L'�t — �L ��`�
❑ SINGLE FAMILY/NEW CONSTRUCTTON
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
TYPE OF WORK: I o
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
A1tA , T
PROPOSED SIZE:
PROPOSED HEIGHT:
Permit No.�o��' �6�
Received By:
Date Rec' d: / �
►1
SIZE
STORIES
❑ wnvDOws
❑ DRAIN TILE
'�"OTHER � I 1 1 /� 1 �
HOME CONSTRUCTION � ADDITION
ITENANCE/REPAIR � REMODELING
LENGTH d���'�~ WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
f,1�C�7:�1
�
E�IP�O�
FT
BA .MENT FMOD .I.IN MIT
i. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
�IDING FOR NEW CONSTRUCTION IIdCLUD1NG DECKS,
O Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES � NO i. Site Plan/Survey showing the existing structures
❑ �ei ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALLTE AND
OR FOR NEW OPEIdINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENIDiG 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 $ rj OCCUPANCY TYPE
Permit Fee /• See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surchazge $ �« .001 times the total job valuation
Surcharge $ 2 4 S A005 x Permit Valuation Minimum or .50
License Surcharge $ S�G $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 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 ermit and work ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case or1 u� s iew and approval ofI� s. �y /��� 2 j
SIGNATUREpFAPPLICANT PRINTNAME [�,�1/� 1!�~l,'/�(` DATE l'"'7—'[ Z-
APPROVAL INSPECTOR SIGNA / /1