P - 45772Building
Inspections
763-572-3604
DATE � ��lJ`ti.A_"
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.: � b
Received By:_
���,��:
e�'ci4 � w
YOUR E-MAIL ADDRESS �SC3�,��� Q eQ(�� DC • C.Cm,
t�lnro �
❑ OWNER OCONTRACTOR
ADDRESS: � CITY
PHONE: T� 3-� S� `i So/ Lp
NAME:
STATE UCENSE #_
ADDRESS:
PHONE
❑ SINGLE FAMILY/NE�
❑ TWO FAMILY/NEW C
❑ ADDITION
❑ BASEMENT FIN[SH
� DECK
❑ NEW
a MAINTENAI�tCElREP,
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
Renewal By Andersen
1920 County Road "C" West
Roseville, NIN 55113
License #20130983
651-264-477'7
ATE_ZIP
STATE_ZIP
❑ GARAGEfSHED � WINDOWS
� ROOF � DRAIN TILE
❑ SIDING ❑ OTHER
ADDITION
❑ HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
O Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &t
TYPE OF WINDOW TO BE INSTALLED NI IMRFR (1F \
i rl � 6
0
WIDTH HEIGHTi
BASEMENT REMODELING SUBMIT: `�
t. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the exisNng structure
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ N �� H� �7 U.B.0 FEE OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
$ i�s, a�
$
$ S,�O �
$ S 00
$
$
$
$
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 checks pavable to: Citv of Fridlev Attac
TH1S IS AN APPLICAT(ON 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 u
conformance with the ordinances d 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 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' requires review an approval of plans.
SIGNATUREOFAPPLICANT �Z�{,4�E�ac�. �. 1I�'SDY\.� DATE �", �/1'`1L�I