P - 42162Building
Inspections
763-572-3604
763-502-4977 FAX
na� .3�t�L�
srt� annxESS �'��c
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
Corrrita,cTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PERMIT TYP'E
�rE oF wo�:
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P'ROPOSED SI2�:
PROPOSED I�IGFTf:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MA1L ADDRESS
5�: ��
O OWNER ,�ON'fRACTOR
��
Pernut No.:
Received
�.��: .`��
nrE�z� .� 3�
NAME: ff v`J /�/-� GG>/1.67 �� /(�N t/LC,
3TATE LICENSE #��3 G��� f8 LEAD CERT NUMBER
ADDRES$:_ �5�� _�� �N� CITYL/TT�cE C/lN� STATE�.�L(�
rttvN� lc�s� �/ —ra c- -- ivv � c
O SINGLE FAMILY/NEW CON3TRUCTION
O TWO FAMILY/NEW CONSTRUCITON
O BA5EMENT Ft14ISH
O DECK
0 NE W H+DME CONSTRUCfION
0 MAIIVTENANC�/REPAIR
O SIDING
O ADDITION
O REMODF.I,ING
� HOU3E ONLY
�'FIOUSE 6t GARAGE
,�(ATTACFIED GARAGE
0 DETAC�lED GARAGE
. r•,i i
■ • i:��
G.
BASEMENT REM4DELING SUBMIT:
1. Existing Floor Plm
2. Proposod �oor plan
3. T.ist of strucbrsl membas to bo naat
� FOR NEW CONSTRUCTION IIdCLUD1NO DECK3,
CI Vinyi �3offit ADDTfIONS. & POR�3 SL3BNIlT:
O Alumimim O Trim i. 3ite Plsn/Smvey showing the wrieting eh9uiiurs
O Ofha O Faacia sad P'°p°e°d p�°�°et'
2. 'Pwo aeta of cwmhvdion plam
WINDOWS 3. Enagy Glculstions
IIV EXISTIIdG OPENIIIG3 CIYes ONo LOCAITON OF WIIVDOWS FOR WINDOWS — PROVIDE U VALUE AND
OR FOR NEW OPENIlVGS-DESCRIBE SI7.E OF MANUFACTURE STICKER ON WIIJDd'W.
OPENIlJG CHANGES �&
TYPE OF WII�DOW TO BE INSTALI.ED NUMBER OF WIIJDOWS
roTAr. os vaLU��A��oN� aD � v ac �� sc��n � Lnsoa nxn �► �xxiai,s: _.
Permit Fee
Plaa Review
Fire Surcharge
Swcharge
License Surcharge
SAC Charge
Cutb Cut Escrow
Erosi� Co�7o1
Park Fee
3ewer Main Charge
See Back Page for Fee Schedule
65% of Building F'etmit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (Stat�e Licensed Residential Contractors)
$2230 per SAG Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=5
$450 Conseivatian Plan Review
Fee Deteimined by Engineering
Agreement necessarY ( ) Non Nece4sazy ( )
THIS I3 AN AT�P'LiCATION FOR A P�RMIT NOT VAI ID UNTIL PROCESSED
I h�ereby apply for a building pennit anci I aclrnowledge that the information abo�+e is complete and eccurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley a�d with the Minnesota Construction Codes; that I understaad this is not a
permit but only an application for a peimit and work is nat to start without a permit on site; that t�e work will be in accordance with the
appraved plan in the case of all wor '�requires a�d proval of plans.
SIGNATURE OF AP'PLICANT ����� GL� ����R1NT NAME �� i'!/ ��_�i�DATE �% 3 �� �
APP'ROVAL INSPECTOR SIGNAT[JRE