P - 44833Building
Inspections
763-572-3604
DATE 1 �L/ °'
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
/O
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No ;�
Received By �!�
E-MA[L ADDR SS �SC3�,��� Q�QQI_ C•
YUP� �. � .
❑ OWNER ❑CONTRACTOR
��
ADDRESS: � CITY STATE ZIP,
PHONE:�-�Q� �" � '�' � � v�
NAME:
STATE UCENSE #_
ADDRESS:
FAMILY/NE�
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 551 l3
License #20130983
r STATE Z[P,
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FlIVISH ❑ ROOF O DRAIN TILE
O DECK ❑ SiDING � OTHER
O SWIMMING POOL
TYPE OF WORK: ❑ NEW
❑ MAIP
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDINC
O Vinyl
O Aluminum
❑ Other
❑ HOUSE ONLY
D HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
� Trim
0 Fascia
WINDOWS
IN EXtSTING OPEMNGS �Yes ONo LOCAT[ON OF W[NDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER �F i
HEIGHT
BASEMENT REMODEL.ING SU9MIT: `�
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS_ 8c PORCI-LS SUBMIT:
1. Site P1aNStwey showiag thc existing structur�
and proposed project.
2. Two sets of construction plat►s
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING T 997�.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ S� �' �— OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
$ � a S. a S' See Back Page for Fee Schedule
$ 65% of Building Petmit Fee
$ .001 times the total job valuation
$ �. �% .0005 x Permit Valuation Minimum $.50
$ S. 6(� $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 Attac
THiS IS AN APPLlCAT10N FOR A PERMtT-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 Fridiey and with the Minnesota Construction Codes; that I understand this is not
permit but only 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 require • view and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME/1_ 1Q�(� rl• _1/�S� Y�.7 DATE