P - 42325Build�ng
Inspections
763-572-3604
DATE� U` I v
i
SITE AdDRESS
TH(S APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
W[TH APPLICATION
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.: 2� i.� �
Received By: '�
DateR�R�:.. � !� I... 2 8 �
_ _► YOUR E-MAIL ADDRESS l,�sc�,,rdd@�en� I�r, o c• C.Cm1
'— S � ^ ��.�11Z . � �C.
❑ OWNER OCONTRACTOR
NAME:
ADDRESS: ' 1-
PHONE:��3' ST�- 83�0
NAME:
STAT� LICENSE #_
ADDRESS:
PHONE
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 55113
License #20130983
651-264-4777 __
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED
Q BASEMENT FINISH ❑ ROOF
D DECK O SIDING
❑ SWIMMING POi
TYPE OF WORK: ❑ NEW O ADDITION
❑ MAINTENANCE/REPAIR ❑ KEMODELING
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQUARES i
GARAGES
PROPOSED SIZE:
PROPOSED I-IEIGHT:
SID[NG
O Vinyl
O Aluminum
❑ Other
C7 HOUSE ONLY
❑ }iOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSo�t
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS �Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
STATE_ZIP.
ATE ZIP
❑ DRAIN TILE
0 OTHER
WIDTH HEIGHT
BASEMENT REMODELING SUBMIT•
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structur�
and proposed project.
2. Two sets ofconstruction pJans
3. Energy Calculations
� WINDOW TO BE INSTALLED NUiv}BER OF WINDOWS I
ALL FEES ARE BASED ON VALUATION, IIVCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �P t � I�o � �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
$ t 3q .� S' See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .( � .001 times the total job valuation
� "3 . C� .0005 x Permit Valuation Minimum $.50
$ 5 .00� $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 necessaty ( ) Non Necessary ( )
$ I 53 -�f o1 Make checks payable to: City of Fridley Attach
TH1S IS AN APPLICATION 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
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not
permit but only an application r a permit n work is not to start without a permit; that the work will be in accordance with the approve
plan in the case of all work w ch requires ew and approval of lans. D
SIGNATURE OF APPLICANT T NAME�Q(C,� �1I�S0 Y�7 DATE ��J �U��`