P - 84371\��
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE__ T��P/p"�9/,
SITE AD RESS
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING M
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1
Permit N
Received By: V I v
Dat���'�'d .�s�' �, i e�i
YOURE-MAILADDRESS ������/f�[�S��K�� Cl��%
4/ �
❑ OWNER �CON'I'RACTOR
NAME: - �
nnDxESS: / �'`i
rxorrE: � / - -
NAME:
STATE LICENSE # �D 7�,��
ADDRESS: �
PHONE �� �%�� � �� r
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTTON
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FII�IISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
ci�
CERT NUMBER�I�IT$�'-jr,��"� EXP:
CITY���lrr� STA"Ii
FAX %/� - (�j�
SIZE
STORIES
�.wirrDOws
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCITON ❑ ADDTI'ION
�MAINTENANCE/REPAIR ❑ REMODELING
.�<-� �j j
i: �/J�lu' /GLe _�✓�f�!/l� �i�/l d rS i�
LENGTH WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
ZIP.
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3: List of structwal members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin I ADDITIONS & PORCHES SUBMIT:
Y ❑Soffit SIDING/SO'FIT/FASCIA 1. Site Pian/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED. ❑ YES ❑ NO �d proposed project
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS I,�Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & cy
TYPE OF WINDOW TO BE INSTALLED���� � NUMBER OF WINDOWS �
ALL FEES ARE BASED iv vALUATION, INCLUDING THE COST OF LABOR AND MATERIALS•
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
j� ¢ G THE 1997 U.B.0 FEE SCHEDULE) .
�1 _ L�� OCCUPANCY TYPE
$ �,�'7 �,� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ v�i .001 times the total job valuation
$ t� .0005 x Permit Valuation Minimum or .50
$ � $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ `, Uj,�j U j Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit a I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and cod s of the Ci of Fridley and with the Minnesota Construction Codes; that I understand tliis is not a
permit but only an application for a permt and w is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a work w ich eview and approval of pla s. �, /
SIGNATURE OF APPLICANT tJ'Siv � PRINTNAME� l�_ /�/'��� J DATE �/�i'/,/,o�
APPROVAL INSPECTnR , rNA TRR T-T