P - 48102Building
Inspections
763-572-3604
DATE � �
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.
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YOUR E-MAIL ADDRESS 1�5c�,,`;�dd @ a e[,�� o c• C.�1
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❑ OWNER OCONTRACTOR
ADDRESS: � CITY STATE ZIP
PHONE: �3 �5�� ' �
NAME:
STATE LICENSE #_
ADDRESS:
PHONE
❑ SINGLE FAMILY/NE�
❑ TWO FAMILY/NEW (
❑ ADDITION
❑ BASEMENT FINISH
O DECK
I O MAIN7
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMEr
ROOFING
NUIyIBER OF SQUARES _
GA A .FC
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
0 Aluminum
❑ Other
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 55113
License #20130983
651-264-4777
❑ ROOF
❑ SIDING
ADDITION
LENGTH
O HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
WINDUWS
[N EXISTING OPEMNGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES 8t
TYPE OF WINDOW TO BE INSTALLED NI IMRFR (lF �
t STATE ZIP
O DRAIN TILE
O OTHER
WIDTH
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUD[NG DECKS, '
ADDITIONS_ & PORCHES SUBMIT:
1. Site Plan/Survey showing tfie existing structure
and p*oPo� P%1�•
2. Two sets of construction pians
3. Energy Calcutallons
ALL FEES ARE BASED ON VALUATION,INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN T E 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �J -__ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$
� .03
$ ,0
$ S, O U
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.00I 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 paysble to: Ci�_of Fridtey Attach
THIS IS AN APPLICAT[ON 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 u
conformance with the ordinance and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not ;
permit but only an applicatio �r a permit d work is not to start without a permit; that the work will be in accordance with the approva
plan in the case of all work w' h r uires iew and approval of plans.
SIGNATURE OF APPLICANT T NAMEn za�(�j,� �. 1I�S�If�7 DATE