P - 35776Building
Inspections
763-572-3604
763-Sp2-4977 FAX
DATE_7_°' o��
STTE ADDRESS _(�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCB
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2f111
YOUR E-MAIL ADDRESS /
❑ OWNER �CONTRACTOR
Permit No.: (�f: � �3���t�
Received By: 1 _
Date ��'�� "� � 1�
aDD�ss: � y�� - S��".�✓� il/� ciTY��Q/%�_ STATEMN ZIP SS �32.
PxorrE: � /� - 3og — 71/38
STATE LICENSE # o�D� � �,,'S 3'� LEAD CERT NUM:
ADDItESS:�� �'�,�irio �/'I,�NE cITY,
76 3
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
'-, ...,�......,�, r, ,. ... . �
❑ BASEMENT F1I�TISH ]j�ROOF
O DECK [j SIDING
' ' � O S WIMMING POOL
r.,,� , o_, — r .
SIZE
STORIES
o w�rm�ows
❑ DRAIN TILE
O OTHER
TYP'E OF WORK: � NEW HOME CONSTRUCTION l] ADDITION
¢iI MAINTENANCElREPAIR ❑ REMODELING
DESCRIBE WORK BEING
ROOk7NG
NUMBER OF SQUARES �
GARAGES
PROPOS�D SIZE:
PROPOSED HEIGHT:
�IDING
❑ Vinyl
O Aluminum
❑ Other
C] HOUSE ONLY
�.HOUSE & GARAGE
❑ ATTACHED GARAGE
JR(D�TACHED GARAGE
OSoffit `
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING QPENRVGS DYes ONo LOCATION OF,WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & .
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�, dQ� °" OCCUP.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$
$ �_.�
$ —
$ 5
$
$ .
$
$
$
BASEMENT REMODELING SUBMIT:
1, Exisring FloorPlan
2. Proposed floor plan
3. bist of strucwral members to be used
r '
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADpITIONS, Yr PORCHES SUBMIT:
i. Site Plan/Survey showing the existing structures
and proposed project:
2. Twa sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
LABOR AND MA'
See Back Page for Fee Schedule ^,
65% of Building Permit Fee .
.001 times the total job valuation
.0005 x Permit Valuation, Maumum $5.(10
$5.00 (State Licensed Residential Coniractors)
$2230 per SAC Unit (Plans to MWCC for determinatian)
ft+6ft= ftx$25=$
$450 Conservation Plan Review '
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
M�ke checks payable to: City of Fridtey Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acla�►owledge 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 a I wo�'�v��l�j�l�e ' es • and approval of plan,.�s // �j�_/ -/
SIGNATURE bF APPLICANT � � PRINT NAME /pdd /�/l�1Y�hi �� DATE 7'Z���