P - 42203Building
Inspections
763-572-3604
DATE I �Q ( � � I 0
SITE ADDRESS �I S
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:
• - - � � �:�!�
�-�t �- ".- i :
YTOUR E-MAIL ADDRESS vuSQ��C� t�. ��D��[ C• CCiY�"'1
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❑ OWNER �CONTRACTOR
NAME:
ADDRESS: � � � CITY
PHONE: �lU �'��}'� -- VJ��
NAME:
STATE LICENSE t!_
ADDRESS:
SINGLE FAMIL
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 55113
License #20130983
651-264-4777
❑ ADDIT[ON O GARAG
❑ BASEMENT FINiSH ❑ ROOF
O DECK ❑ SIDING
TYPE OF WORK: ❑ NEw
O MAIN7
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE;
PROPOSED HEIGHT:
SIDING
O Vinyl
� Aluminum
❑ Other
ADDITION
LENGTH
❑ HOUSE ONLY
O HOUSE 8c GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
WINDOWS
[N EXISTING OPETIINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES 8c
r
ATE ZIP,
ATE ZIP,
u wtrvuvw�
O DRAIN T1LE
❑ OTHER
HEIGHT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
F�
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ & P�RCHES SUBMIT:
1. Site Plan/Survey showing the existing structuro
and proposed ptoje�ct.
2. Two sets of construction plans
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING TEj� 7 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ o�'? ,_�a� � j�, O D OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �S3 .� S See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �(� .001 times the total job valuation
$ � . �o `S .0005 x Permit Valuation Minimum $.50
$ .S', G717 $5.00 (State Licensed Residential Contractors)
$ $1550 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ , � Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICAT(ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be 'v
conformance with the ordinances and c es of the Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is not ;
permit but only an application for a it and work is to start without a permit; that the work will be in accordance with the approva
plan in the case of all work which requi s rev`ew and aj�val of plans. . _ ,_ .
SIGNATURE OF APPLICANT