P - 48413Building
Inspections
763-572-3604
DATE L � -}�� � Z
SITE ADDRESS c� �- a,
TH[S APPLICANT [S:
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: ��' �
Date ��i�'.'� � � zx3- I k'`_ !J
YOUR E-MA1L ADDRESS �SC3�.`�d °Q � �� rt.' �"'U,�' ,� � ,it, k, ,, !t'�
� �,�. • . �
OWNER ❑CONTRACTOR
ADDRESS: ^ CITY
PHONE: � 3 ^ � � � S S�U
NAME:
STATE LICENSE #
ADDRESS:
O SINGLE FAMILY/NE�
❑ TWO FAMILY/NEW C
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEw
❑ MAIN'I
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
n
n
1920 County Road "C" West
Roseville, MN 55113
License #BC130983
651-264-4777
� GARAGE/SHED ❑ WINDOWS
❑ ROOF ❑ DRAIN TILE
O SIDING ❑ OTHER
C) SWIMMING POOL
O ADDITION
❑ REMODELING
�-`!�� �i�S � � n �Q1� .S'�l (t�-. C
LENGTH WIDTH -
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
ATE_ZIP
ATE_ZIP.
BASEMENT REMODELING S BMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
D N FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS & PORCHES SUBM[T�
� Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structure
❑ Other ❑ Fascia and proposed project.
WINDOWS 2. Two sets ofconstruction plans
IN EXTSTING 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, [NCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �'I , O(o 3— OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Swcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
$ ri�.a�—
$
$ �. �io
$ Z •v3
$ S.C31�
$
$
$
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 payable to: City of Fridley
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
Attach
[ hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be i�
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 oniy 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 w h requires r�ew and approval of plans.
SIGNATURE OF APPLICANT ��>�'_T' A/� � Q����.sW, v PRINT NAME�U.Cl:�1. e tnSC� Y�'i DATE � I� I Z