P - 43629Building
Inspections
763-572-3604
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THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMTf A COPY OF
YOUR STATE LICENSE
WITH APPLICATTON
� PR4PERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-
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❑ OWNER CONTRACT R
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Permit No.:
Received By: u
Date��: Q�� � � ���
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STATE LICENSE #�I�.3 � EXP DATE _ S'I
nDDxESS: SS58 ��;►1�,f��- -t�w-�-
PHONE �%SZ • 935 •�(v[e 9 Fa,x 95z • 935 .
O TWO FAMIL
❑ BASEMENT FiNISH ❑ ROOF
❑ DECK ❑ SIDWG
❑ SWIMMING POOL
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
NUMBER OF SQUARES
G G
PROPQSED SIZE:
PROPOSED HEIGHT:
smnvc
❑ Vinyl
❑ Aluminum
� Od�cr
W WDOWS
IN EXIS'fMG OPENINGS es ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES 8c
TYPE OF WINDOW TO BE 1NSTALLED�
ALL FEES ARE BASED
TOTAL JOB V
Permit Fee
Plan Review
Fire Surchaxge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
0
❑ HOUSE & GARAGE
❑ ATTACHED GARA.CsE
❑ DETACHED GARAGE
OSoffit
❑ Trim
0 Fascia
[�J DRAIN TILE
❑ OTHBR
u
WIDTH
• � • ���«
r •��'Jl.:.i i _'t� ♦
�ra,�' i 553`�3
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BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structura! members to be used
FOR NEW CONSTRUCTION INCLUDMG DECKS,
ADDITIONS. & PORCHF.S SUBMIT:
1. Site Ptan/Survey showing the existing struct�res
and proposed project
2. Two sers of conswction plans
3. Energy Caiculations
VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 97 U.B.0 FEE SCHEDULE)
)N $ �'I.Q � OCCUPANCY TYPE
$ ///. Z S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ 't•9� .001 times the total job valuation
$ Z��t8 .0045 x Permit Valuation Minimum $.50
$ S— $5.00 (Sta.te Licensed Residential Contractors)
$ $1550 per SAC Unit (Plans to MWCC for determinarion)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �� 3•?o Make checks aavable to: City of Fridte_y Attach
THIS IS AN APPLICATION FOR A PERMTf-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge 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 p it and work is not to start without a permit; that the work will be in accordance with the approved
plan in the case of all work which re es rev' n a val of ptans. • f�
SIGNATURE OF APPLICANT � PRINT NAME W� I � : DATE f 1-��--�—