P - 45778Building
Inspections
763-572-3604
163-502-4977 FAX
DATE�27 G(
SITSADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
I�����IMWM'��y
�rE oF woRx:
DESCRIBE WORK BEING
ROOFING �
NUMBER OF SQUARES
GARAGES
'ROPOSED SIZE:
_•ROPOSED HEIGH'f:
SIDING
❑ Vinyl
O Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
❑ OWNER 1�EONTRACTOR
NAME: /C�1 �1n �cJ *� �(? CS � D'K�
STATE LICENSE # 2C� (%%� S� EXP DATE
ADDRESS� C�7�%? l / c�✓+^� S� �ii � (`TTY �✓`✓t
�•7.L��wlg-�'rs�l�
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION �GARAG
❑ BASEMENT FIAIISH �"ROOF
❑ DECK ❑ SIDING
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
SIZE
NG POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
0 DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
wn�mows
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENRVGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF �
o w�rmows
❑ DRAIN TILE
❑ OTHER
Permit No.:
�- .:
�� ° „��
. � '�• � ,
�l�
� ��e.. STATEL"!'�aIP��
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ 8c PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE CO5T OF LABOR AND MATERIALS:
;, (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALi
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Dne
$ - -
$
$
$ �
$
$
$
$
$
$ (� � (n
See Back Page for Fee Schedule
65% of Building Pertnit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2000 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$21=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge 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
.,rmit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all k wh' h r review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME �,n,.v._,r (.% c..l,�C DATE