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Building
Inspections
763-572-3604
753-502-4977 FAX
SITE ADI�RESS f U
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE
DESCRIBE WORK BEIIVG
R FIN
NUMBER OF SQUARES ,
��
PROP�ED SiZE:
PROPQSED HEIGHT:
Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2020
YOUR E-MAIL ADDRESS
,. � iU1._ ��?v�.-
❑ OWNER
STATE LICENSE
❑ SiNGLE FAMILYINEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCfION
❑ BASEMENT FINISH
❑ DEQC
NEW HOME CON3TRUG PiON
PermitNo.: ���i
Received By:.JV"� �✓
Date �e�'�: � � R 1 � �
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SIZE
S'PORIES
:JStIED D WiNDOWS
O DRAIN TILE
O QTHER
NG POOL
0 ADD1170N
❑ REMODELING
I] HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATfACHED GARAGB
� UETACHED GARAGE
osot�c
�Trim
Fascia
WINDOWS
1N EXISTING OPENINGS OYes ONo LOCATION OF WINDQWS
OR FOR NEW OPENING5-DESCRIBE SIZE OF
OPENING CHANGES 8c
ALL FEES ARE
�OTAL JOB VALI
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chatge
Total Due
1. Fati�ir� Floor Plm� �. �.
2. Propo�ed 8ow- pt�
3. List of stru�haal membe�s to 6e used
FOR NEW CONS'tRUC110N 1NCLUDING DECKS,
ADDiTIONS_ dc PORCHES SUBMIT_
I. Site P1aNSwvcy showing ihe wcisting stru�res
� ProA� Prol�-
2. Two sds of �ion pMna
3. Erwvgy f�l�atior�
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFAC7'[JRE STICKER ON WINDOW.
ON VALUATION, INCLUDING THE COSI' OF LABOR AND MATERIALS:
��(USING TAE 199T U.B.0 FEE SCHEDULE)
5 'L' ('1 r"al � See Back Page for Fee Schedule
$ 65% of Building Peimit Fee
� �� .001 times the total �pb valuation
� .1�Q5 x Pennit Valuation M'mimum SSO
a 6 D $5.00 (State Lice�sed Residentisl Co�rtractors)
� 52100 per SAC Unit (Plans to MWCC for determination}
� ft+bft= ftx$24=$
$ $450 Conservation plan Review
$ Fee Determined by Engineering
$ Agr�nent �ry ( ) Non N�ry ( )
$ (7 �_ Make che�s mxyable to: Citv of Fridlev Att�c
THtS IS AN APPLICATION FOR A PEttMIT-NOT VAL[D UN1TL PROCESSED
I hereby appiy for a building permit and I acknowledge ihat the inf�mation above is comple�te and acc�rate; that the work witl be in
conformance with the ordinances and c�des of the City of Fridley and with the Minnesota Construction Codes; that I under�tand this is not a
permit but only an apptication for a permit and work is not to start without a permit on site; that the work witl be ia accordance with the
aPProved plan in the case o'��wo�' h uires ceview and approval of P�la�..
SIGNATUREOFAPPLICANT lt ��---� r�mrrtae�sr Ni� ( Ri`1L�1� n.,-c �,[��/%i
YLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR
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