P - 35790Building
Inspections
763-572-3604
763-502-4977 FAX
S1TE ADDRESS � 7' l J�
THiS APPLiCANT i5:
PROPERTY OWNER/
'�ENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LTCENSE
AND CER'1'tF[CATE OF
iNSURANCE
PROPERTY TYPE
x i_� 1 �'
�rE oF wo�:
DESCRIHE WORK BEQVG
SiZE OF IMPROVEMENT
BUILDING
RE5IDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER
STATE LiCFNSE
YOUR �MAIL ADDRESS
E
i�CONTRACTOR
PHONE l0�" 1
INGLE FAMILYJNEW CONSTRUCTION
TR�O FAMILY/NEW CONSTRUGT(ON
❑ B.qSEMENT FINLSH �ROOF
❑ DECK SIDIN
❑ NEW HOME CONSTAUCTiON
� MAINIBNANCFJREPAIR
ROOFING
NUMBER OF SQiJARES
G4RAGFS
PROPDSED 5IZE:
PROPOSED HEIGHT:
SIDING
❑ v�
�'°�.r.���as�
Other
�j+jNUOWS
TN EXfSTTNG OPENiNGS OYes QNo
OR FOR NEW OPII�IINGS-DESCRIBE SIZE OF
OPE13ft3G CHATiGES &
TYI'E OF WtNDOW TO B� 1NSTALLED_
Permit No.:�� � � �
Received Byt✓V' �
D��'��� U L 1
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❑ NOUSE ONLY
T�HOUSE � GARAGE
�ATTACHED GARAGE
DETACHED GARAGE
�ISoi�t
C'� Trim
� Fascia
LOCATTON OF WiNDOW5
nT��zrP 55 y 3a
RACFMF.NT RF�u�JDF.t 1Ni: SiIRMTI'�
1. Exisl� Fla� P� - — --
2. Prq�osed floor plan
3_ List of swcmral �o�crs to bc nscd
FOR NEW CQNSTRUC110N INQ.UDING DEGKS,
ADDITfONS_ & PORCHFS SUBMIT:
1. sicc Plan/swvag a�Ow;ng nc� cx;ctiog st�mca
� P� �JccL
2 Twa sers of ct�vsmtcuon plans
3. Energy Caiculations
FOR WfNDOWS - PROVIDE U-VALUE AND
MANUFACR]RE STICKEit ER�I WINDOW.
ALL FEES ARE BASED OAT V�LUATION, INCLUDING THE COST OF LABOR AND MA'�'FRIa�C:
(tJ'Sfl�T� THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION S� i Z�(7 �_ _ OCCUP'A1�TCY TYPE
PertrritFee
Plan Review
Fire Sutchar�e
Surchazge
License Sutcharge
SAC Charge
t.'wb Cut Escraw
Erosi� Cantrol
Padc Fee
Sewer Main Charge
Total Dne
$ �,dS See Back Page for Fee Schedule
$ 65% of Building Peamit Fee
$ �QO _001 times the total job valuation
$ .0005 x Permit Valuatian Minimum 55.00
$ $5.00 (State Licensed Residential Contracto�rs)
$ $2230 per SAC Unit (Plans w MWCC for determinati�xi)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Deteimined bY �K��B
a .r Agreement necessary () Non Necegsary ()
S t, Make cheeks �vaWc to: Citv of Fridlev Atta�
THiS TS A PPL]CATfON FOR A PERMIT NOT VALID UNTIL PROCESSED
I hereby apply far a buildiag peimit an ackn wledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and of th City of Fridley and with the Minnesota Construction Codes; rhat I understand flris is not a
permic but only an applicadon for a t ork is not to start without a pecmit on site� tliat the work will be in accordance wah tlie
approved plan in the case hich 'res review and ap�moval of p�l .�,j�TJ �` J���� ,��Z l�
SIGNATURE OF APPLICANT pRINT NAME. �/�"�'Gti ATE