P - 43812��' �
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ `1( / / 11
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SU$MIT A COPY OF
YOUR STATE LiCENSE
AND CERT[FICATE OF
nlsuRaNCE
PROPERTY TYPE
PERMIT TYPE
�rvPE oF wo�:
n�.sc�E woRre sm�rG
BOOF�ING
NUMBER OF SQUARES _
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
V��yl
Alumir►um
Q Othet
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
�cTTVE i-2-aoio
, /
YQUR E-MAIL ADDRESS ���� � �11�� -\
�oc .� r� � ,n �f32— � � , .
0 OWN6R CONTRAC70R �� llL . �LJ� i��.
STA1E LICENSE
❑ SiNGLE FAM[LY/NEW GONSTRUCI70N
O 7W0 FAMILY/NEW C+DNSIRUCRON
O BASEMENT FIIVISH
❑ DECK
HOME CONSTRUCTION
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EXP DATE
�«fo C .Z1K
Fnlc °ZG�3 9�
STLE
S1iORiES
JSHID D WINDOWS
O DRAIN-TILE
O U7i�IER
�iCi PQOL
❑ ADDiTION
❑ REMODELING
D HOUSE OAiLY
O HOUSE 8t GARAGB
❑ ATTACHED GARAGE
0 DETACHED GARAGE
OSoPFit
Trim
Fa�eia
�OWS
!N EXISTING OPENTNGS �Yes �No LOCATION OF WMDOWS
OR FOR IVEW OPEN[NGS-DESCRIBE SIZE OF
OPENiNG CHANGES 8c
Permit No.: d
Received By:
Date �+�_
� �
��
� � � !�l�(N`�
STATE �f
1. F.xisting Flo� Plan �. �„
2. Pcoposod � plan
3. List of �ruct�ael meanbms to be �cd
FOR NEW CONSTRUGTION INCLUBING DECKS,
�DDI7'[ONS_ � PUR HES S Ii�11T_
1. Site Plan/Survey shovving ti►e existi� �
�d ProPoe� ProJeM.
2. 'ISaro sds of cor�n�ctior► p1�s
3. Ericrgy C�lations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKEtt ON WINDOW.
ALL FEES AR.E BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERiALS:
rg .. A�IJSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALL
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tot�� Due
$ `L 3`� �LS See Back Page for Fee Schedule
$ 654�6 of Building Permit Fee
$ l 3 .001 times the to�l job valuation
$ �°I .0005 x Permit Valuation Minimum 5:50
$ 5(J('� SS.t10 {State Licensed Residential Contr�tors}
$ $2100 p� SAC Unit (Plans to MWCC for dete�mination)
S ft+6ft= ftx$24=5
� S45Q CQnservarion Plan Review
$ Fee Dexecmined by Engin�ring
S Agree�nem necc.ssarY () Non NecessarY i)
__ $_ �,. Mske ebecks payaWe to: Citv oiFridlev Attac6
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID UN1iL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and �curate; that the work will be in
canformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I und�tand this is not a
�rmit but only an application for a pennit and work is not to start without a permit on site; that the work will be in �rdance with die
apAroved plan in the case�wo��uires revi�v aad approval of p��
S[GNATURE OF APPLICA l.c r-�-�"' PRiNTNAME 11I� ��IYI ne� 'Y�I/�
SEPARATE PERMiTS ARE REQUIRID FQR PLTJMBING. II.ECTRICAL AI�ID
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