P - 39844Building
Inspections
763-572-3604
763-502-4977 FAX
DATE C� c� �
SI1'E 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:
BUILDING
RESIDENTIAL A.PPLICATION
CIT� OF FRIDLEY
YOUR E-MAIL ADDRESS
Q OWNER �ON"TRACTOR
NAME:�
ADDRESS:
PHONE: �
NAME: 1 ��� �-�
STATE LICENSE # � b
ADDRES5:� �_ �
PHONE ��0�. `��4
�SINGLE FAMILY(NEW CON5TRUCITON
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQ[JARES �
GARAGES
PROPOSED SIZE:
PROPASED HEIGHT:
SIDING
❑ Vinyl
n
Permit No.: [� �I f "` �
Received By: ' f ,
,
D��:� ��-�--���
�`: i�,���i:�. ,( i ��`�
EXP DATE __�_=
CITY �Sil�P1�
FAX Ql vS `. bCc,� ' (�f
SIZE
STORTES
;lSHED O WINDOWS
O DRAIN TILE
[7 OTAER
NG POOL
❑ ADDITION
❑ REMODELING
LENGTH WIDTH
,�OUSE ONLY ` �� n �
�r� HOUSE Sc GARAGE "1��t%.(iS�2�
� � O ATTACHED GARAGE
�-' ❑ DETACHED QARAGE
OSoffit
❑ Trim
❑ Fascia
WINDQWS
IN EXTSTiNG OPENINGS �Yes �No I.CTCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENTNG CHANGES &
ATE�j��`i .ZIP �`Fi`i'��?.�,_
BASEMENT REMODELII�iG SUBMIT:
i. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDTTION5. & PORCHES Si3BMIT:
1. Site PIan/Survey showing the existing s�iructures
and proposed project.
2. Two sets of c�struction plans
3. Energy Calculations
FOR WINDOW5 — PROVIDE U-VALUE AND
MAN[JFACTURE STICKER ON WINDOW.
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINAOWS 1
ALL FEES ARE BASED Ol"d VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTALJOB VALUATION $ �IN ��E 1997�.� ��EE SC OCCUPANCY__ TYPE
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosian Conirol
Park Fee
Sewer Main Cl�arge
Total Due
$ �, �. �, � See Back Page for Fee Schedule
$ 65% of Builrling Permit Fee
$ � G�, .001 times the total job valuation
$ ��- � .0005 x Pernut Valuation Minimum $.50
$ �i�, $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for detemvnation)
$ ft+6ft= ftx$24-5
$ $450 Conservation Plan Review
$ Fee Detennined by Engincering
$ Agreement necessary ( ) Non Necessary ( )
$ ,./� � Make checks payable to: City of Fridley Attac
THIS IS AN APPLICATION FOR A PERMIT-1�TOT VALID iINTIL PROCESSED
I hereby apply for a builtling permit and I acknowledge that the inforn�ation above is complete and accuxate; that the work will be in
confarmance with the ordinances and codes of the City of Fridley and with the Minnesota Consmiction Codes; that I understand this is not a
pernut but only an application for a pe ' d w 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 work view and approval of plans.
SIGNATURE OF APPLICAI�iT PRINT NAM �!'/��S �- f���r�?fT/� DATE �-o�( �� I�
I PT.RACRN(1TR� CRPARA'T'RPFRMfTRARRRR(1TFTiiR}�F(IRPT.TTMRTN('t Fi.F('TRTf`AT.AIVT)MF.("T-TATIT(`AT.WnRK I
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