P - 45773Building
Inspections
763-572-3604
DATE ��� ��
SITE ADDRESS �0� S I
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
�'� C'11RU �
❑ OWAiER
NAME:�
CITY OF FRIDLEY
Permit No.:
Received By:
_ YOUR E-MAIL ADDRESS 1�5c�„c�cl@ � epoi� C• C.CJYY'1
. �N �. .
❑CONTRACTOR
�
ADDRESS: �� � CITY
PHONE: ��J� �I�' 07��
NAME:
STATE LICENSE #_
ADDRESS:
SINGLE F
LJ TWO FAMILYMEW
❑ ADDITION
❑ BASEMENT FINISH
O DECK
TYPE OF WORK: � NEW
O MAIN7
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
Renewal By Andersen
1920 County Road "C" West
Roseville, NIN 55113
License #20130983
651-264-4777 _
❑ ROOF
❑ SIDING
❑ SWIMMING PC
O ADDITION
AIR O REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
Q DETACHED GARAGE
ATE ZIP.
ATE_ZIP
❑ DRAIN TILE
❑ OTHER
WIDTH HEIGHT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl OSoffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structure
❑ Other O Fascia and pmposed project.
WINDOWS 2. Two sets ofconstruction plans
IN EXISTING OPENINGS DYes ❑No LOCAT[ON OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING T 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ Si � �O .00 OCCUPANCY TYPE
--
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Due
$
$ �, a�
$ a. c� �
$ 5,�
$
$
$
$
$
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 Engineering
Agreement necessary ( ) Non Necessary ( )
Make c6ecks payable to: City of Fridley Attac6
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 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 an ork is not to start without a permit; that the work will be in accordance with the approve�
plan in the case of all work whi requires re e and approval of plans.
SIGNATURE OF APPLICANT NAME/[1ac�,,,, �1I�S� Y\.� DAT���NLD ��