P - 43809!�
Building
Inspections
763-572-3604
763-502-4977 FAX
DA7'E "� % f / ��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AAID CERTIFICATE OF
MSURANCE
PROPERTY TYPE
PERMIT TYPE
�rvrE oF woRx:
DFSCRIBE WORK BEING
ROOF[NG
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PCtOPOSED HEIGHT:
Vinyi
Aluminum
❑ �r
BUILDING
RESIDENTIAL APPLICATION
CIT� OF FRIDLEY
,z. .,�
STATE LICENSE
ADDRESS ,���( «+ �i iY �t
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O SINGLE FAM[LYMEW COAISTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
0 BASElutENT FINISH
❑ DECK
HOME CONSTRUCI'ION ❑ ADDITION
ffENANCE/REPAIR ❑ REMODELING
❑ NOUSE ONLY
D HOUSE Bc GARAGE
❑ AITACHED GARAGE
� UETACHED GARAGE
OSoffit
Trim
FaSCia
iYINDOW�
IN EXISTWG OPENINGS []Yes ONo LOCATION OF WiNDOWS
OR FOR NEW OPENMGS-DESCRIBE SIZE OF
OPENING CNANGES 8c
O DRAlN TIL.E
0 07'tIER
Permit No.: ' 1` G' S� �
Received By:
Date ���: A P I-Z 1 2�
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BASEMENT I�F1ui[�DII,ING SUBA�I7':
1. Fac�ing Flo� Plm� �.„,
2- Pioposed 8oa Pha�
3. I.ist of �tura! m�mbers M b� �ed
FOR NEW CONSTRUCfION INCLlJDING DECKS,
A?�31T[QNS_ � PORGHES 4L1R.*.n_'!'_
I. Site PlanlSurvey showi� f8e axisting stnichaes
� P� P%1�
2. 'iiro � af �tia� �ant
3. Energy (;xlcu�ions
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATIOW, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 199? U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S �.8 _____ OCCUPANCY ' TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License S�u�charge
SAC Charge
Curb Cut Escruw
Erosiom Control
Park Fee
Sewer Main Charge
Total Due
$ SOv
S
See Back Page for Fee Scheduk
65% of Building Pe�mit Fee
.00I times the total job valuation
.0005 x Pennit Valuation Minimum $:SO
55.00 (State Licensed Residential Comractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftxS24=$
5450 Conservatio� Plan Review
Fee Dete�mined by Engineering
Agrtemem necessarY i) Non Nec�ssa*Y t)
Make che�ks payable to: Citv of Fridkr Attach
TH1S IS AN APPLICAI"lON FOR A PERMIT-NOT VALID UNTTL PROCESSED
1 hereby appty for a building pera�it and I acknowledge that the information above is c�nplc.te and accurate; that the wodc witl be in
conformance with the ordinances and codes of the Ciiy of Fridley and with the Minnes� Construction Codes; that I �nder�tand this is not a
pennit but only an applic�tion for a pennit and work is not to start withoat a permit on site; fhat the work will be in a�rdance with the
approved pian in the c�e of al work h quires review and apprnval o€pl��
S[GNATUREOFAPPLICATI1f��'�,������ PRINTNAME i�"'•�Yi �IY1 DATE I�
NOTE: SEPAR4TE PERMITS ARE REQUIItID FOR PLUII�ING. ELECTRICAL AI�ID MECHAIJICAL WORK