P - 46269Building
Inspections
763-572-3604
i63-�02-49'�'i FAX
M!7�11I�r�As
sz� r�DxESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
Al�t) ���.T��AT� OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
; � BUILDING
IDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-i-2011
YOUR E-MAIL
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ADDRESS: _ ��/ �/� ! S v% Sj i ro p i -�f �£C'ITY
PxorrE: '7 � 3�-K 7/ —� la G7
STATE LICENSE
- -78's.
�gcSINGLE FAMQ.YfNEW GONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH �OOF
❑ DECK ❑ SIDING
N �
TYPE OF WORK: O NEW H�ME CONSTRUCTION ❑ ADpITION
�MAINI'ENANCE/REPAIR ❑ REMODELIlVG
DESCRIBE WORK BIING DONE: p �--
SIZE OF IMPROVEMENT LIIVGTH WIDTH
FIl�i �
NRU�MBER OF SQUARES '. � ' ❑ HOUSE & GARAGE
G�RAGFS ❑ ATTACAED CsARAGE
PROPOSID SIZE: ❑ DETACHED GARAGE
PR��USE15 HEiGHT:
� IDIIVG
0 Vinyl
❑ Alwninum
C! Other
os�mt
O Trim
❑ Fascia
wnvnows
INEXISTI23G OPENiNGS �Yes �No LOCATION OF WINDOWS
OR FdR NEW OPF..�tINGS-DESCRIBE SIZE OF
OPII3II3G CHANGES &
TYPE OF WINDOW TO BE INSTAT.T.F.T� rrr rnauFU nF ❑
ALL FEES ARE BASED ON VALUATION, INCLUDING THE
__. (USING THE 1997 U.B.0 FEE SC
Pernut Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
Permit No.:
Received By:
Datb�4��d:"""�
�3Z,,, — v
� ur STATE
CERT NUMBER iV A"T �" � I
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2IES
❑ wirmows
O DRAIIJ TII,E
❑ OTHII2
�ASEMEN'T REMODET TNG SUBMI'�;
1. EasisEing F1oor Ptan
2. Proposed floor plan
3. List of stn�tural members to be used
FOR NEW CONSTRUCTiON INCLUDING DECKS,
A�DTITONS_.@POR . S IRI��T•
1. site P1an�siavey showing the exiating sa,�ccure�
� P�Po� P�Ject.
2. Two sets of oonstnaction plans
3. r,,�y c���r�on�
FOR WlNDOW3 - PROVIDE U-VALUE AND
MANUFACTTJRE STICKEIt ON WINDOW.
OF LABOR AND MATERLALS:
$ iS �Z,S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .QOl times the total job valuation
� .0005 x Permit Valuation Minimum $5.00
_ � � �.a $SAO (State Licensed Residential Contractors)
-' '-` ° m M'$2230 per SAC Unit (Plans to MWCC for de2ee�mmination)
� ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary { )
�a 7__ _ Make checks pavable to: Citv of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALTD iJNfIL PROCESSID
I hereby apply for a building permit and I acknowledge that the information above is cqmplete and accurate; that the work will be in
conformance with the ordinances an es of the City of Fridley and with the Minnesota Conslruction Codes; that I understand this is not a
permit but only an application for a perz t�nd ork is not to start without a p�mit on site; that the work will be in accordance with the
approved plan in the case of 1y�+�rk w-hich� es review and approval of plans. �
3IQNAT[3RE OF APpLICANT �1 J' %�. PRINT NAME �4�1� � d>'�'ll.l DATE ���,�"/I
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