P - 47294Building
Inspections
763-572-3604
SITE ADDRESS I { 7�1 `f
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
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ADDRESS: � " •� CITY,
vuniaF• (�J� • Z �O • � Q"S3Z
STATE LICENSE # o� I%3 � EXP DATE �I�1�0 %
ADDRESS: S S5S �L�"L' CITY �
Pxor� 95z, • 93.� � 4l0�9 Fax 95z • 935• 9s�y
� SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILYMEW CONSTRUCTION ___ STORIES i
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
�
LENGTH
Permit No.:
Received By:�'r�l�
Date �'°�: �� � �` �v� � � �
�U.Sev • c v m
❑ DRAIN TILE
O OTHER
POOL
1G
) Wl�01� � � c�llS �_
WIDTH HEIGHT
�
A� ���53�3
Ft.
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
GqgAGES ❑ ATTACHED GARAGE 2. Prop s dFfloor plan
PROPOSED SIZE: ❑ DETACI-iED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyi QSaift AI?DIT:QNS. & PORCHES SUBNIIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing ffie existing swctures
❑ Other ❑ Fascia and proposed project
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS es �No LOCA i0 OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SiZE OF ) I%1 Y 0 6 Yh
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED O NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
([JSING THE 997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ���� OCCUPANCY TYPE —
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ///, Z$' See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ L�,�jZ .001 times the total job valuation
$ z. cf (9 .0005 x Permit Valuation Minimum $.50
$ � -- $5.00 (State Licensed Residential Contractors)
$ $1550 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ . Q Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclaiowledge 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 permit and work is not to start without a permit; that the work will be in accordan e with the approved
plan in the case of all work whi requir'e r iew n a roval of plans. � �(
SIGNATURE OF APPLICANT PRINT NAME W� ( U DATE - -