P - 41791Building
Inspections
763-572-3604
DATE 1 �T �}'�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
� ._.���//���c�/�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Received By:
Date Rec' d: ��`/'/ �l / /
YOUR E-MAIL ADDRESS �SQ`��� �°�p��C DC • CC�i(Yl
\
❑ OWNER
ADDRESS: � 2 CITY STATE_ZIP
PHONE: T10 �°� J a'" � J��
NAME:
STATE LICENSE #_
ADDRESS:
PHONE
❑ SINGLE FAMILY/NE�
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 55113
License #20130983
651-264-4777 _
PERMIT TYPE I❑ ADDITION ❑ GARAGE/SHED
O BASEMENT FINISH ❑ ROOF
O DECK O SID[NG
TYPE OF WORK: �� NEW
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
NUMBER OF SQUARES �
GAItAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
ADDITiON
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
OSoffit
O Trim
❑ Fascia
WINDOWS
iN EX[STING OPEMNGS �Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
ATE Z(P
❑ DRA1N 1'[LE
❑ OTHER
Ft.
RASFMFNT REMODEL.ING SI�MIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
�DITIONS_ & PORCHES SUBMIT:
1. Site Plan/Survey showing the exisdng structure
and proposal project.
2. Two sets of const:uMion pians
3. Energy Calculations
' WINDOW TO BE INSTALLED NUMBER OF W[NDOWS I
ALL FEES ARE BASED ON VALUATION, INCLUDIIHG THE COST OF LABOR AND MATERIALS:
(USING THE 19�7 U_B.0 FEE SCHEDULE)
AL JOB V
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ 195� �S
$
$ r •
$ � , `-�✓ J�—'
$ S. O C�
$
$
$
$
e
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$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 Engince:ring
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
TH1S IS AN APPLlCAT10N 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 a permit and k is not to start without a permit; that the work will be in accordance with the approve
plari in the case of all work whi r ires revie d approval of plans. `� ���
SIGNATURE OF APPLICANT ME DATE �