P - 39628Building
Inspections
763-572-3604
DATE " 1 d"'.� 1 1 I
SITE ADDRESS �.��,
TFiIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
BUILDING �
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER� �NTRACTOR
��Yi��
rta�: l �Cs_.� �� c�
STATE LICENSE #
.4DDxESS:O�t�� 1—�'��C-
PHONE -�".� � ' ��S ( ` � L
❑ SINGLE FAMILY/NEW CONST
� TWO FAMILY/NEW CONSTRU
PERMIT TYPE ❑ ADDITION u fuzaU
❑ BASEMEN7' FINISH ROOF
❑ DECK ❑ SIDING
❑ SWZMM
TYPE OF WORK:
DESCRIBE VJORK BEING DONE:
SIZB OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED 51ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS OYes �No
OR FOR NEW OPEMNGS-DESCRIBE SIZE OF
OPENING CHANGES 8c
TYPE OF WINDOW TO BE 1N5TALLED
!U KJC CITY ('"7' ! t',( f�' C
�
F ti (�C-� `�- � �.G
EXP DATE
�► � CITY G
F� (�S1- �S�- �
SIZE
STORIES
'SHED ❑ WTNDOWS
❑ DRAIN 7'ILE
❑ OTHER
�-° %e' - l�
LENGTH
❑ HOUSE ONLY
,�,�iOUSE & GARAGE
.�-ATTACHED GARAGE
� DETACHED GARAGE
❑Soffit
❑ Trim
CI Fascia
LOCATION OF WINDOWS
NUMBER OF
Permit No.:2� [
Received By:
Date Rec'd: �'f l (
,L.�
STAT ��
��� ��-�
�1 m U STAT$';ZIP �=k�C-�`+
WIDTH HEIGHT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Pian
2. Proposed floor plan
3. LisY of structural membets to be used
Ft.
FOR NEW CONSTRUCTION Ii3CLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed projecG
2. Two sets of construction pians
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 997 U C FEE SCHEDULE)
TOTAL JOB VALUATION $��-�-� i��• _ OCCUPANCY TYPE
Permit Fee $ 2, �' See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ D .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $.50
License Surcharge $ ��� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $1550 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$21 =$
Erosion Control $ $450 Conservation Plan Review
Patk Fee $ Fee Determined by Engineering
Sewer Main Chazge $ Agreement necessary O Non Necessary O
Total Due $ a Make checks payable to: City of Fridley Attach Stipulations
. THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 understand this is not a
permit but only an application for a permit and work is not to start without a pernnit; that the work will be in accordance with the approved
plan in the case of all work whi requires review nd a proval of plans.
SIGNATURE OF APPLICAN � � � � /� � L!i'�-!�' PRINTNAME� : `�� ' � c DATE___�'� li