P - 43810������G�
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � / i / �'
S1TE 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:
DESCRIBE WORK BEING
NRU�M`B�E'R OF SQUARES _
GARA�
PROP05ED StZE:
PROPOSED HEIGHT:
Viny!
Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CIT� OF FRIDLEY
�cnvE ia-aoio
E-MAIL ADDRESS
■ • . f.� :
STATE LICENSE
❑ SINGLE FAMQ.Y/NEW CONSTRUCTION
❑ TWO FAMILYJNEW CONSTRUCfION
0 BASEMfiNT FINLSH
❑ DECK
����3`1,3���
CTTY C�
�C
EXP DATE
�
Fnx 3 9�
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
0 OTHER
NEW HOME CONS7RUCTI�N O ADDTi'ION
MAINTENANCFJREPAIR ❑ REMCJDELtNG
�tvtali� ►�Aa+►t ' � +� (ilt �
I.ENGT7i 1A►IDTFt
❑ HOUSE ONLY
_ 0 HOUSE dc GARAGE
0 ATTACHED GARAGE
� DETACHED GARAGE
OSofiit
Trim
Fascia
WINDOWS
IN EXISITNG OPENINGS �Yes ONo LOCATION OF WiNDOWS
OR FOR NEW OPENtNGS-DESCRIBE SIZE OF
OPENING CHANGES da
Permit No.: �� �Z� S��
Received By:
Date���:
�
� �
�-�C� � ��%Y ► w1 �--
Ra.cHa/[�T IL�rODEC, SUBMlT_
1. Facisting Fto� Plme �. �,
2. Proposed 8oa-plan
3. Li� of �uuai maobers to be uscd
FOR NEW CONSTRUC77QN 1NCLUdiNG DECKS,
ADDI7'[dNS_ � PORGFIES SUBMiI'_
I. Sioe Pfan/Swvey slavving t6c existing s�uchues
� P� Prol�
2. Twu sd.s of cor�truction pix�s
3. F.nergy (;alccdationc
FOR WINDbWS — PROVIDB U-VALUE AND
MATNFACTURE STICKfiR OAI WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDiNG THE CQST OF LABOR AND MATERIAIS:
r�„_ (USING THE 1997 U.B.0 FEE SCAEDULE)
TOTAL JOB VAL[
Permit Fee
Plan Review
Fire Surchar�e
Surcharge
License Succha�e
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totai Due
$ ol �"] W� 01 O See Back Fage for F� Schedule
$ ` _ 65% of Building Permit Fee
$ .�l times the totsl job valuation
$ .00OS x Permit Val�ation M'mimum $:SO
$ 5' U $5.� (State Licensed Residential Comraetors)
$ �2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftxS24=$
S 5450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessaq+ ( ) Non Nec�sary ( )
�D ,__ Make checks payable to: Citv of Fndlev Atmc
THIS IS AN APPLICA110N FOR A P,ERMiT-NOT VALID UNfII, PROCESSED
I hereby �pply for a building peanit and I acknowledge that the information above is c�nple�e and accurate; that the work will be in
conformance with the ordinances and codes of tf�e City of Fridley anci with the Minnesota Consduction Codes; that I under�iand this is not a
permit but only an applicaRion for a�'rt and work is not to start without a permit on site; that the work wi11 be in �ord�we with the
approved plan in d�e case of a1 work i�h quires review and appr�val of pl
StGNATUREOFAPPLICATfI�` ��"" PRiN1'NAME T���V� ���1{`f� DA7E �, I� _y
SEPAR4TE PERMITS ARE REQUIRED FOR PLUMBiNG, ELECTRICAL AI�ID MECHAIJICAL WORK