P - 48659Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `�� �(� ;
SITE ADDRESS ��,
THIS 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
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
� EFFECTIVE 1-1-2012
� � YO R E-MAIL ADDRESS
O OWNER �CONTRACTOR
NAME: � ," Z
ADDRESS: � i' � I
PHONE:
NAME: OI?Q� ,S�M Rcv! �/1 a -
STATE LICENSE # �G ��!/� 6 Y I
PHONE !//e1. 5f�/�1 - 7�U �
BI.SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
0 MAINTENANCE/REPAIR
ROOFING �
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE: >y3 �
PROPOSED HEIGHT: �_
SIDING
❑ Vinyl
❑ Aluminum
� Other
[XROOF
❑ SIDING
❑ SWIMIv1
Permit No � o
Received By:
�.. ,��-��. • _ �
-
STATE %% �IP s /a�
�D CERT NUMBER EXP:
CITY I"I`/�� o^- STATE�ZIP rj
FAX ..�//�'�
STORIES
:J5HED ❑ WINDOWS
❑ DRAIN TILE
O OTHER
NG POOL
❑ ADDITION
P$-REMODELING
� HOUSE ONLY
❑ HOUSE & GARAGE
TTACHED GARAGE
DETACHED GAR�IGE
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/SOF'FIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Trim REMOVED? ❑ YES �O 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 LOCATTON OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE 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 $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum or .50
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to 1vIWCC 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 () Non Necessary ()
Total Due $ , � r Make checks payable to: City of Fridl� 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 ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permi ork is not to start without a permit on site; that e work will be in accordance with the
approved plan in the case of k whic ' es review and approval of pl� /-/
SIGNATURE OF APPLICANT PRINT NAME 9)/yrl ✓l V v ATE � `�
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APPROVAL INSPECTOR SIGNA