P - 45695Building
Inspections
763-572-3604
763-502-4977 FAX
D.�T'E --J�
SI1'E e1DDRESS
THIS APPLICANT IS:
PROPERTY OWNER!
TENANT
SUBMIT A COPY OF
YOUR S'FATE LICENSE
AND CERTIFICATE OF
IP3SURANCE
PROPERTY TYPE
PERNIIT TYPE
�rE oF wo�:
. BUILDING
RESIDENTIAL APPL�CATION
CITY UF FRIDLEY
�cTtvE i-i-wii
YOUR E-MAII. ADDRESS
❑ OW1V�R
STATE LICENSE #
aDDxESS: 3�I a i
�'SINGLE FAMILYlNEVJ COI3STRUCTION
� TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
o BnsEMErrr �sx ❑ ROOF
❑ DECK ❑ SIDING
❑ N� HOME CONSTRUCTION
DESCRIBE WORK BEING DONE:
ROOFING
NUMBEI2 OF SQUARES _
GfLi? AGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
Permit No.: � (� I �'���� �
�-- -,: /I v
�
_._ r
' :��i � , ,,, .
C CI'rY �T,�� STATE�zIP ��-J7�
y�
LEAD CERT PiUMB I — ( � "�
QTY � , . STATE�ZIP ���
F� 7�3- �2;� - q ilde�
SIZE
STORIES
i1SHED ❑ WINDOWS
�t��x� Co.'�wn �'� �a� 4. �►�jl 2l �?l�
NG POOL
❑ ADDTITON
❑ REMODELING
❑ IiOUSE ONLY
❑ HOUSE 8c GARAGE
❑ ATTACFIED GARAGE
O DETAQIED GARAGE
BASEMENT REMODELING SUBM[T•
i. Existing Floor Plan
2. Proposed floor plan
3. List of sTructnral membeis to be uaed
FOR NE W CONSTRUCTLON INCLUDII•IG DECKS,
❑Soffit ADDTfIONS. �& PORCI�S St�3MIT-
0 Trim 1 Site Plan/Survey showing the eitisting situdures
�cia `Z��P�� andproposedprojaK.
2 Two sets of construdi Jafla
on p
WINDOWS 3. Eneagy Calculations
I�T EXISTTNG OPENiNGS OYes pNo LOCATION OF WINDOWS FOR WINDOW$ —PROVIDE U-VALUE AND
OR FOR NE W OPENINGS-DESCRIBE SIZE OF MANL3FACTIJRE STlCKER ON WINDOW.
OPEIVING CHANGES 8c
TYPE OF WINDOVA TO BE INSTALLED NiJMBER OF FJINDOVJS
ALL FEES ARE BASED ON VALUATION, INCLUDING TAE COST OE LABOR AND MATERIALS:
(USING THE 199'7 U B.0 FEE SCHEDULE)
'OT.AL JOB VALUATION $�� f� [vr'�rro � i►rrv �...��.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
� h G- l�' `� See Back Page for Fee Schedule
$ 65% of Buiiding Permit Pee
$ .001 times the total job valuation
$ .0005 x Peimit Valuation Minimum $5.00
_ $ � l) $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for detennination)
$ ft+ 6 ft = ft x$25= $
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ i� Make checks navahte tn� Citv nf F.�:dlo., ...�.._
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID L7VTIL PROCESSED
I hereby apply for a building pemiit and I acknowledge that the information above is complete and accurate; that the work will be in
confonnance with the ordinances and codes of the City of Fridley and with the Minnesota Construction �Codes; that I understand this is not.a
perniit but only an application for a pernut and work is not to start without a pennit on site; that the work will be in accordance v,�ith the
approved plan in the case of �i work quires review and approval of p�� ��
SIGNAT[7RE OF APPLICANT PRINf NAME 'ZYl � DATE_ t�� f I I
APPROVAL INSPECTOR SIG A