P - 36778Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� I � '6 �,��'� ��
-r-
SITE ADDRESS ��F
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
IIJSURANCE
PROPERTY TYPE
PERMIT TYPE
�rYrE oF woRx:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
�� oF SQv,�s I 6
��
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-09
YOUR E-MAIL ADDRESt�� --� � �
>Y'�'L� !✓ �V' �`% � ��'� G'�"�a.,1
0 OWNER �ONTRACTOR
J � 1'� �e.� r� g
�ss:_,� 1_3J �1{° r. 2o n� �� IJ � ct�
NAME: L
STATE LICENSE
��-
Permit No.:1.�1 r" � J14 U
Received By: �
Date��' � — �.'� i
J �0 0 . Cac� �n
STATE ZIP � YZj _
�!- p�s � ��
�I- � EXP DAT,�/E
rr� �!-lQ ATE IP�36
6 eR n �o �7`� �G� 3lS'66 �
❑ SINGLE FAMTLY/NEW CONSTRUCTION SIZE
❑ TWO FAMII.Y/NEW CONSTRUCTION STORIES
❑ BASEMENT FIMSH
❑ DECK
❑ NEW HOME CONSTRUCTION
O MAINTh"NANCEIREPAIR
SIDIN�
O Vinyi
,�o � �� ,s'101 �1$
•
wnvnows
IN E3QSTING OPENINGS DYes ONo
dR FOR NEW OPENINGS-DESCRIBE S1ZE OF
OPENING CHANGES &
❑ GARAGFJSHED
ROOF
IDING
❑ SWA�IIvIING POOL
❑ ADDIT'ION
O REMODELING
�HOUSE ONLY
O HOUSE & GARAGE
� ATTACHED GARAGE
O DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELIIVG SUBMTf:
1. F�cisting Floor Plan
2. Praposed 800r plm�
3. List of struchaal members w be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
OSoffit ADDITIONS. Rc PORCHES SUBMTT:
O Trim 1. Site Plan/Sim+ey sFwwing tl�e existing suuctures
❑ Fascia � Pr�P� Proiect
2. Two �s of c�struction plans
3. �y cat���
LACATION OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF I.ABOR AND MATERiALS:
JOB VALUATION S �SIN %'��� U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Sw�charge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$
S
$ —�
$
$
S
$
$
$
See Back Page for Fee Schedule '
65% of Bttilding Perntit Fee
.001 times the total job vaivation
.0005 x Permit Valuation Minimum �.50
�S.QOy(State Licensed Residential Conh�actors)
$20W per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftxS21=S
5450 Conservation Plan Review
F� Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I aclmowledge tttat 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 Consttuction Codes; that I undeistand this is not a
pemut 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�rk ' h requires review and a�roval of plans.
SIGNATURE OF APPLICANT PRINT NAME S� `� ��� DATE �/� �(
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK