P - 35807Building
Inspections
763-572-3604
763-502-4977 FAX
______
DATE � 0�7 .I1I
S1TE ADDRESS S�i /.�
THIS APPLECANT IS-
PROPERTY OWNER/
TENANT
CONTRACfOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERT[FtCATE OF
IAISURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:�� ��
Received By:
�
YOUR E-MAIL ADDRESS
O 4WNER �OIVTRACTOR
ADDRESS:�� � I-��•�%� l�t1t CITY
PHONE:?��-S7 J�S
STATE LtC£NSE �' OI � I o�9 �-i O� _ LEAD CERT NUMBER
non�ss:, j�? s�o 5a �w�.se � � E. , crn l�
e�r�E �1(s"� d�14 � 7� 9 �nx �(� 3
�INGLE FAMILYlNEW CONSTRUCTiON SIZE
❑ TWO FAM[LYiNEW CONSTRiICT[ON STORIES�_
� ADDTftON CI GARAGFJSHED LI WINDQWS
❑ gpSEMENT F[N[SH J�.1tQOF � DR!►IN T[LE
❑ DECK � S[DING 0 4THER
TYPE OF WORK: � NEW HOME CONSIRUC7'10N � A�W7'!ON
&(ju[A[NTENANCEJREPAIR ❑ REMODEL[NG
DESCRiBE WORK BEING DONE: C � I�1,.C�A.�
SIZE OF }MPROVEMENT LE]VG7'FI WlDTH
�HOUSE ONLY
� F SQUARES � HOUSE 8c GARAGE
�
�oPOSEa su�:
PROPOSED HElGHT:
SIDRYG
O Vinyl
❑ Alwninum
� ONkr
p pTTACHED GARAGE
p DETACHED GARAGE
pSoffit
p Trim
❑ Fascia
IN�G OPINtNGS OYes C7No LOCATION OF WINDOWS
OR FOR NEW OPENING3-DESCRIBE StZE OF
OPENING CHAT►GES 8c _.......,... ..,,.
ALL FEES AR� BASED
'OTAL dOB YALUATION
Pecmit Fee
Plan Review
Fire Strcd�arge
Surcharge
License S�acharge
SAC Charge
Curb Cnt Fscrow
Erosion Co�rol
Park Fee
Scwer Main Chatge
Total Due
qT6�ZiP����a
ATE,�IP
`� i
�i►c.EMENT I�FMOI)EL�1NC,�SUBMtT'
t . Eacisting Fbor Plmi
2. Pmpo� floa pian
3. L.ist of sa�ucdual �nbas �o b�n�ed
FOR NEW COAISTRUCTION INCLUDIt�iG DECKS,
ADDf170NS � POR�'NFS s-��!�T'
1 _ Si6e PIeNSun^oY $tawi"S � �S �
a� V�P� P�I�
2_ Twn sds of� P�
3. Errcxgy Cslwl�io�
FOR WINDOWS - PROV(DE U-VA1-t1E AND
MANUFACTURE ST[CKER ON WINDOW.
VALUATIOIY, INCLUDING THE CUST OF LABOR AND MA
(USING THE 1997 U.B.0 FEE SCH�C PANCY �'
$ ,�, Sae Back Page for Fee Sche�iule
s 65% of Building Permit Fee
$ o -OOi times the total job valuation
$ 01 .0005 x Permit Valuation Minimum 55.00
$ �U $5.00 (State Licensed Residential C�tractors)
s 52230 per SAC Unit (Plans to MWCC for determit�ation)
a ft+6ft= ftx$25= $
s $450 Conservation Plan Review
a Fce pctcrmin� try Engineering
$ Agreement naxssary ( ) Non Necessary ( )
� .�- Make checks_paYsble to: CitY of FridleY Attai
- THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN'[1L PROCESSED
I h�eby apply for a building peimit and I admowiedge that the inforneation above is complete and a�a►rabe: t� d� �* �II be in
canformance with the ordinances and codes of the City of Fridley and with the Minnes�a Constructia� Codes; thai I understand ti�is is not a
pemiit but only an applic�tion for a permit and work is not to start without a p�mit on site; tha� the work will be in �ccordactce with the
approved plan in the case of all w u�res review and approval of plans. ,/
SIGNATURE OF APPL[CANl',�,,,,, •.. ,• PRINT NAME_�/`Y�r�dO�''� DATE %�%
TE PERMITS ARE REQ_iJIRED FOR PLUMBING, ELECTRICAL AND MECHAMCAL WORK