P - 42128Building
Inspections
763-572-3604
DATE � �C�� 11
SITE ADDRESS �JJ
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.:
Received By:
,a.
YOUR E-MAIL ADDRESS 1�5c�,,�;c�dd@ � eC�l�. ��c • C.�YYI
❑ OWNER �CONTRACTOR
NAME: � `�ri Y
ADDRESS: � CITY STATE ZIP
PHONE:�Q� o� ' 01 �J� � SS �aZ �
NAME:
STATE LICENSE #_
ADDRESS:
SINGLE FAMIL
�
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 55113
License #20130983
651-264-4777
❑ BASEMENT FIN[SH ❑ ROOF
O DECK ❑ SIDING
TYPE OF WORK: I ❑
DESCRIBE WORK BEING DONE:
SIZE OF
NUMBER OF SQUARES _
ARA .F.S
PROPOSED S[ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
ADDITION
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPEMNGS DYes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
ATE ZIP,
� DRAIN TILE
O OTHER
HEIGHT
BASEMENT REMODELING SUBMIT:
1. 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 structuie
and proposed projxt.
2. Two sets of conswction plans
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�/� �/(p�i.Qn OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
$ 11I . 01 �' See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �-1 .�i (,D .001 times the total job valuation
$ a•a .0005 x Permit Valuation Minimum $.50
$ S�OU $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 ( )
$_� o� .�I Make checks aavable to: Citv of Fridlev Attac
TH1S IS AN APPLICAT(ON FOR A PERM(T-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 u
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 for a permit and 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 h requir r view and approval of plans.
SIGNATURE OF APPLICANT INT NAME/1 IO��Cj,� � Y1GO �') DATE � �