P - 43808��<id,�a�
Building
Inspections
763-572-3604
763-502-4977 FAX
S]TE ADDRESS ��
THIS APPLICANT IS:
PROPERTY OWNER!
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LiCENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
RO�FIIVG
NUMBER OF SQUARES _
G�
PROPOSED SiZE:
PROpOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
�cnvE z-i-2oio
YOUR E-MAIL ADDRESS
❑ OWN6R
STATE LICENSE
❑ SINGLE FAM[LY/NEW CONSTRlTCfION
O TWO FAMILY/NEW CONSTRUCf'[ON
❑ ADDiTION ❑ GARAGE/SHED
❑ BASEMENT FINLSH
❑ DECK
HOME CONS7RUCTION ❑ ADDTfION
RENANCFJREPAIR O REMODELING
O HOUSE ONLY
O HOUSE 8c GARAGE
0 ATTACHED GARAGE
0 DEfACHED GARAGE
�
�
❑ DRAIN TILE
0 OTHER
Permit No.: `' I b ?,l � ��
Received By:
Date �ek'�: � � 13 2
�ASEMENiT RFM_[�DII.IN��JBMIT:
1. Exi�it�g F[oor Pi� �.w
2. Propo�d 9oar plan
3. IS� of �urel membeas t� ix used
FOR NEW CONSTRUCTION INCLUBING DECKS,
virry! oSoPFit AnD17'[qxs_ � PC�iCHES SUBMiT_
Aluminum Trim I. Site Plan/Survey showing U�e exi�i� structie�es
O Other �Fascia � � a°�'
2. 7'wo �s of oor�tion plans
WINDOWS : 3. Encrgy�il�io�
IN EXISTlNG OPENTNGS C]Yes QNo LOCA170N OF WINDOWS FOR WINDOWS —PROVIDE U-VALi7E AND
OR FOR NEW OPENINGS-DESCRIBE SI2E OF MANUFACTURE STICKER ON W WDOW.
OPENING CHANGES 8c
'TYPE OF WINDOW TO $E 1NSTALLED NUMBF�t OF WlNDOWS
ALL FEES ARE SASED QN YALUATION, INCLUDING TRE C(}ST OF LABOR AND MATERIALS:
(USING THE 199? U.B.0 FEE SCHEDULEj
['OTAL JOB VALOATION S �'�J.� _�D (lf'_CIiPAN('V TVV�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contra!
Park Fee
Sewer Main Charge
S '�,3 .�� � 5 See Back Fage for Fee Schedule
� _ 65%ofBuiiding Pe�mit Fee
$ .00I tim� the total jab valuation
S .0005 x Pern,it Valuatian Minimum $:50
S S 55.� (State Licensed Residential Comractors)
S 52100 per SAC Unit (Plans to MWCC for determination)
� ft+6ft= ftxS24=S
$ $450 Conseavation Pl� Review
$ Fee Determine.d by Engincering
S Agre�nem neaessary () Non Necessary ()
$ 'd. l Make checks oavaMe M: Citv of Fridi�v Attac
TH1S iS AN APPLICAI'lON FOR A PERMIT-NOT VALID UIJl'iL PROCESSED
I hereby apply for a building permit and I acknowiedge that the information above is cmmplete and �; that the wodc wili be in
conformance with the ordinances and codes of tfie City of Fridley and with the Minnesota Construction Codes; tt�t I undea�tand this is �t a
permit but only an applic�tion for a permit and work is not to start witltout a permit on site; that the work will be in �rdance with d�e
approved plan in the case of �J work � uph quires review and apprnvai of pl
E _'s �j
S[GNA'NRE OF APPLICANT PR1NT NAME . IY� �i�j1Y� BATE 'i I� _
PLEASE NOTE: SEPARATE PERMITS .4RE REQUIRED FOR PLIJMBING. ELECTRICAL Alm MECHATIICAI. WORK