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WTI'H APP�,ICATION
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RE�IDEN�IAL APPLI�ATiC�� ����'�s�': r, "�
CITY UF F1tIDLE'Y '�-
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PRaP(ySEt3 SI2E:
PRQPOSED EtE1Q1?I'1':
Renewal By AndQrsen
192Q County Road "C" West
Roseville, MN 5511�
License #BC13(1483
651-2 64-4777
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D' Other t7 Fascia
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1lN E.X[3TINii OF6MNG3 C7Yes GI+Fo LOCATION OF W[NDC)WS
OR FOR NEW' £?PENItdfiS-DE�CRIBE SiZE UF
UFEN]I�IQ CHA1Vf3ES dt '
TYPE OF WiNi�OW TO �� iNSTALLED NUMi3ER OF WINAC��SiVS
ALL �ES ARE BASED QN VALUATIfiN, iNCLUUING THE CC187' t
(USING THE 1937' U.B C FEE 3CHEDUL
Ptan Revicw
Fire Surcharge
Surcharge
Licenso Suncharga
SAC Chaige
Curb Cut Escro�?��
Er�itm Gcmtrol
Park Fee
Sewer Msin Charge
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CI DR/S1N 77LE
[3 0'THER .
81�.��MEI���dNGi Sl •••''.
1. Bx�eing Floor Pt�►
2. l�sa�po�ed � p�rp
3. List of � nx�mbexs t�a ba aea[
FOlLNEW Ua1�SZRLJC[7C)N INCLLIQ[1'�fi UEQCS, -
AT?vina�s. ae c-xR.c'�Lrn�rrtT.
f. Si� PIauJSwoy aLowa�g the exietL�g s�eucx�e
aad pEapo:ed pr�p�j�ct.
3. 'fv►�r sata ofe�radian plaas
3. �eeigy Galc�d�iuns
�`�17
See Back Page far Fce Schadulc
65%o af Building Pcrmit Fee
.001 times tha tota] job vaiuntion
.U(IDS x Permit VaJu�tian Muii�aum S.SO
$S.tiO (Sta#e Licensed Resitientia� Cv�tractors)
S 1550 p�er SAC Ur�it (Platts to �+fW�C foar deternt�tioaJ
R+Gft= fixg2t =S .
5454 Cans+ervatia� PLL�n ReviGw
Fe.es il�tertnined by Engineering
Agreemem necassarY C 3 N� �*Y i)
Txis is �ua n�►��cn�o�u �aR n r���r-�mr vn;.m uurrrrn. r�.ac�ssEa
i he�aby apply far a buil� peirr�it ar�� i scla�owledge that the inf�matian abwva is etnnp�ete and accura�e; t#mt the worlc will be n
aQnfi�nanoe with the nrdirisnces a� c.+�des of the City of Fridley end with the Minnesot�a Construction Cadas; th� 1 undastand dus is not �
p�emtit but ortly ait app�icatiott for a peaYttit and ro�ra�rk is nat fio start wi�thout a pe�mit. �et the wda�C w€�I be in aecm�fanc� with the a�pmu�c
plan gi the casQ oFall wark 'eh req � neview and ap�proval of plans.
SKINATURB OF APP'LICANT �~i PRINT 1�lAMEIf�C� ,� �.e �i' n fr._.'� CfATE .� ' i��
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Wd £S�9E�8 Z40Zf9L/b :a��o. Z/Z :�6�d. 0649bL9LS9 :�o��