P - 41748Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �(/ - S "'- ��
SITE ADDRESS lL��i' '
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-201 ]
YOUR E-MAIL ADDRESS
��� ��.
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NAME: i �G
TENAI�IT AnnRFCC• //��.,
I CONTRACTOR
SUBMIT A COPY OF
, YOUR STATE LICENSE
I AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
NAME: / � 1 i
CITY ��
Permit No.:L�li �''�;�(;
Received By: � ' I� �
D���'��� � 5 ���i
ATE�.[lLiP
STATE LICE/NS(E,# j�f'"%i�lL)� %% LEAD CERT NUMBERf/�,�-�-,��'✓ S�iS '(
ADDRESS: �J`�- C--/�'�'(/� CITY�%r G:23/� STATE�..!/LIP.��.�E�l
PHONE � � � � 7 �- � FAX I�
� SINGLE FAMILY/NEW CONSTRUCTION S[ZE c� � J
❑ TWO FAMILY/NEW CONSTRUCTION STORTES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION C] ADDITION
j�MAINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES ���
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
OUSE ONLY
HOUSE & GARAGE
�1 ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT ��
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ � $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ ;� '� Make checks pavable to: Citv of Fridlev Attach
THIS [S AN AFPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge 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 permit on site; that the work will be in accordance with the
approved plan in the case �k w�� e s review and approval of � �
SIGNATURE OF APPLICAN7`�� . v• -�=���� PRINT NAME�_����✓✓Y�� DATE �(_�'—'� "—//
APPROVAL INSPECTOR SI ATURE " / �—