P - 42233Building
Inspections
763-572-3604
763-502-4977 FAX
DATE //
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LTCENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
J 1 V YOUR E-MAIL ADDRESS
t� o � L
❑ OWNER �2QNTRACTOR
NAME: L(�,,.1A�0. �r � 1�-Q-
ADDRESS: � Dd ��Q��"'� f`tC% �
Du„�,�. n r„ >. ��� � G� I i_
STATE LICENSE #��-�y�"7 �
ADDRESS: I �J �St
PHONE ��Q�J 3 "��fl
I�'SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ NEW HOME CONSTRUCTTON ❑ ADDITION
AINTENANCE/REPAIR O REMODELING
� � C1Y� '�li�
LENGTH WIDTH
O HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
Permit No.: �
Received By:
Date ��
\\ _STATEY�) __�ZIP.
EXP DATE 3�-( I Z
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT:
i . Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
O Aluminum ❑ Trim 1• Site Plan/Survey showing the existing structures
and proposed project.
O Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEMNGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
Q�N G TI� 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $�/ J � av OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota�l Due
$ �,�,a-S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �� O Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy 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 Gonstruction Codes; that I understand this is not a
permit but only an application r a permit and work is not to start without a permit on site; that the work wil) be in accordance with the
approved plan in the case of or which r uires review and approval of pl
SIGNATURE OF APPLICANT PRINT NAIvIE������e � LUCGvI DATE �� (�