P - 44837Building
Inspections
763-572-3604
763-502-4977 FAX
DATE l� �8 � �
SITEADDRESS yD3�v ,
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER
ADDRESS:
STATE LICENSE #,
ADDRESS: O � 1
Permit No.:
Received By:
YOUR E-MAIL ADDRESS 66essen � a/l�iY�X� �!"��%
p6;ONTRACTOR
C�7SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
0 ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �OOF
❑ DECK B'�IDING
EXP DATE
CITY�
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ W HOME CONSTRUCTION ❑ ADDITION
�INTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: OO�/%) �¢ /� li �
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING UrnOUSE ONLY
NUMBER OF SQUARES 7 � ❑ HOUSE & GARAGE
GARAGES }i% � ❑ ATTACHED GARAGE
PROPOSED SIZE: `� � ❑ DETACHED GARAGE
PROPOSED HEIGHT: l
HEIGH'T
A
FT
BASEMENT REMODELING SUBMIT:
1. Exisring Floor Plan
2. Proposed floor plan
3. List of stnictural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �� ❑Soffit ADDTfIONS. & PORGHES SUBMIT:
❑ Aluminum �, �❑ �Trim L Site Plan/Survey showing the existing structures
I�ther� / I�'Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
_ (USING THE 1997 U.B.0 FEE SCHEDULE) ,
'AL JOB VALUA
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
I�C • -Il'� i �1
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2000 per SAC Unit (Plans to NIWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$/�9. /9/� Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMTT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge 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 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 all work which re u' •es review and approval of pian
SIGNATURE OF APPLICANT ` .�'�� , �� PRINT NAME /<�rlti/ ��Qi �LI SS P/��DATE�O� �/
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK