P - 36675Building
Inspections
763-572-3604
DATE �J ?'y\ X
S1TE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
CITY OF FRIDLEY
Permit No.: 'vQ
Received By:
Date
YOUR �MAIL A� ESS ul]SC�,��� Q�/�C�I �i C• C.CJYY1
✓ 1\J `�
t
ADDRESS: r • C[TY
PHONE:�Q� ' � "' �'T
NAME:
STATE LICENSE #_
ADDRESS:
PHONE
❑ SINGLE FAMILY/NE�
O TWO FAMILY/NEW (
PERMIT TYPE O ADDITION
CJ BASEMENT FINISH
O DECK
TYPE OF WORK: I ���►'
O MAINTENANCE/REPAIR
DESCRIBE WORK BEING
IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 55113
License #20130983
651-264-4777 __
'ATE ZIP
r STATE Z1P
.�
0 GARAGE/SHED ❑ WINDOWS
O ROOF ❑ DRAIN TILE
0 SIDING O OTHER
O SWIMMING POOL
O ADDITION
❑ REMODELING
� HOUSE ONLY
O HOUSE & GARAGE
D ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
F�
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl OSoffit ADDITIONS_ & PORCHES SUBMIT:
O Aluminum O Trim 1. Site Plan/Survey showing the existing structure
❑ Other ❑ Fascia and ProPo� P%lect.
�,��p�ys 2. Two sets ofconstruction plans
[N EXISTING OPEMNGS ❑Yes ❑No LOCATION 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 THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ a � y� , OO OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
$ 83 . 0�5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
� .001 times the total job valuation
$ �. .0005 x Permit Valuation Minimum $.50
$ �', p(� $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 ( )
$_ 1_ � Make c6ecks aavable to: Citv of Fridlev Attac
THiS IS AN APPLICATION 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 wi11 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 applicatio or 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 ch requires r i w and approval of plans.
SIGNATURE OF APPLICANT NAME/1 1 aCp • tl� p 1f�7 DATE � f
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