P - 43811����
Building"
Inspecii�ns
7b3-57�-3b04
763-502-49'77 FAX
DAT'E � / f / ��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TEIVANT
CONTRACTOR
SiJBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
�NU�MB�E�R�OF SQUARES _
GARAGES
PROPOSED SiZE:
PROPOSED I�IGHT:
. �
.
� , � , ,. , '- ' .`- :�-
_ 1. ,�_;�. _ ,
YOUR E-MAIL ADDRESS
■ � J�L •
STATE LICENSE
❑ SMGLE FAM[LY/IVEW CONSTRUC770N
❑ TWO FAMILYJNEW CONS'[RUCPION
❑ BASEMENT FINtSH
❑ DECK
HOME CONSTRUC770N
�+V .Lv�C -
EXP DATE
� ��fp �
FAX ZIa3 �F
SIZE
STORiES
JSHED ❑ WINDOWS
❑ DRAIN TILE
❑ OTEiER
�IG P()OL
O ABDI'i7UN
o �rouELnac
❑ HOUSE ONLY
O HOUSE ,tc GARAGE
0 ATfACHED GARAGE
0 DETACHED GARAGE
Permit No.:
Received By: I
Dat��d� �
l. Facisting Floor Plan +.�,
2- P�vposcd floor plan
3. East of �uctwal membeas w be uaed
FOR NEW CQNSTRUCfION INCLUDING DECKS,
Vinyl OSoffit ADDITIONS_ � PORCHES 4L1L�1�i1_'!'_
Alwninum Trim i. Sibe Plan/S�evey showing tlre existing �
❑ Otha �Fagcia � P� �•
2 iwo sets of cwnstniction pJane
WINDOWS 3. Energyt'�Iculatia�s
IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS FOR WINDOWS —PROVIDE U-VALU& AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER OAi WINDOW.
OPENING CHANGES dc
TYPE QF WINDOW TO BE INSTALLED NUMBER OF W[ND�WS
ALL FEES ARE BASED ON VALUATTON, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCREDULE)
TOTAL JOB VALUATION � I�r FI �•0O ()[Y`iiVAN1"'Y 7'V��
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Cw�b Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
S �� � ot ,S See B�k Page for Fee Scl�edule
$ 65% of Building Pe�mit Fee
$ .OQI 6m� the to�l job valuation
$ .0005 x Pe,r�nit Valuation Minimnm 5:50
$ 5 $5.00 (State License� Re.sidential Contractors)
:6 $21il0 pex SAC Unit (Plans to MWCC for determirtatian)
� ft+6ft= ftxS24=$
$ $450 Conservadon Plan Re�wiew
$ Fee Determined by Engineering
� Agreement nece,ssnrY i) Non NecessarY i)
$ (Da1 �, Make cha�cs �vable to: Citv ot Fridlev Athc
TH1S iS AN APPLICA7IQN FOR A PERMiT-NOT VALID UNl7L PROCESSED
I hereby apply for a building peimit and I�knowledge 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 under�tand this is not a
permit but only an apptication for a pennit and work is �rot to start without a permit on sibe; thai the work will be in �cordance with dte
approved plan in N�e case of �1J,vFOrk r�' h c�quire.s �eview aad appmval of F��• „ � I�
SIGNATURE Of APPLICA�i(�'1.cv.�fi. �d�d.G --�' PRiNTNAMF. TI�V 11�
SEPARATE PERMITS ARE