P - 43807��;,�a,�# 1
Building
Inspections
753-572-3fiO4
�s3-so2-�9�� F�
DATE i / / / �'
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNERJ
TEIVANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BIING
$Q�FING
NUMBER OF SQUARES `
yiA�
PROPOSID SIZE:
PROPUSED HElGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY UF FRIDLEY
❑ OWNER
STATE LICENSE
ADDRESS t'l�tl't«�iir��lrC�a+�-�.
���. s� a ���5,
�sa�t, a�, ��
55CC.
crrY � c� l�it
� ��
EXP DATE �
O SINGLE FAM[LY/NEW CONS'TRUC110N
O TWO FAMILY/NEW CONSTRUC7'ION
Q BASEMENT FIAlISH
O DECK
HOME CONSTRUCTION O ADDiTH3N
ITENANCE/REPAIR 0 REMODELIIVG
O HOUSE ONLY
❑ HOUSE dc GARAGE
0 ATTACHED CsARAGE
O DETACHED GARAGE
O DRAIN TILE
0 0��
PermitNo.���� 5�
Received By:
Date �!� R i� �"� �� n o
��
�-. ii o r_ ,� r��rs,,.� ,�vl- o,
(�
B.4SEMEWT RF�aODELING SIIBMIT_
1. Existir�g Floor Pl� �. m.
2, Proposed 800r p�
3. List of �sl membas to be u�
FdR NEW CONSTRUGTtON iN(�.UDING DECKS,
Viiryl OSofftt ADD11iONS_ � PORCHES SiJEMiT_
Aluminum 'Itim i. Site PIen/S�avey showing the wcisti� �
� Other �FasCia � ProP� Pro7�
WIND(�WS 2. Two s�s o£�iai plaais
3. Energy C.ekul�iaas
[N EXiSTWG OPENINGS �Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVlDE U-VALUE ATiD
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON W WDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE iNSTALLED NUMBEIt pF W1NppWS
ALL FEES ARE BASED ON VALUATTON, INCLUDING 1`HE COSf OF LABUR AND MATERIALS:
(USINC TAE 1997 U.B.0 FEE SCHEDULE}
['OTAL JOB VALUATTON S I��� •�i nrr-rmswirv �rvus
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Controt
Park Fee
Sewer Main Charge
$
$ / (���
$
� 5 C�S-�
S
S
$
$
See Back Page for Fee Schedule
65%ofBuilding Pennit Fee
.QOl tia�es the total,pb valuation
_0005 x Permit Valuation Mutimum $SO
SS.00 (State Licensed Residentiat Contradors)
�2100 per SAC Unit (Plans �o MWCC for detennination)
ft+6ft= ftxS24=$
$450 Conse�vation Plan Review
Fee Determined bY Engineering
ageemea,t nec�sar�+ ( ) rion rte�ssar�+ ( )
Make chedcs payAble to: Citv af Fridlev Attac
TH1S IS AN APPLICAT'ION FC3R A PERMIT NOT VALm UNTII, PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is camglete and � that the work wiil be in
conformance with the ordinances and codes of thc City of Fridley and with the Minnesota Construction Codes; that I under�tand this is not a
pennit bnt only an application for a�it and work is not to start without a�it on site; that the work wi}! be in sccordanct with the
approved plan in the case of 1 work r'�h quires review and approval of pla .
3IGNATURE OF APPLICAN'L - PRIIVT NAME PsY � l�t+n„ DA7E I�
ARE REQUIltED FOR PLUMBING, ELECTRICAL AI�ID MECHANiCAL WORK