P - 48033Building
Inspections
763-572-3604
DATE Ue.GI �
SITE ADDRESS � S l9
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 APPLICATIQN
� 1�-e- �
❑ OWNER
CITY OF FRIDLEY
Permit No.: 'L 0
Received By:
D���dE C 0 5
YOUR E-MAIL ADDRESS �1 �C� C� T�,° Q_�� D C• C.C1Y1'1
� • �i �-
OCONTRACTOR
ADDRESS: � CITY
PHONE: T� 3� 5�" I'— V�% J
NAME:
STATE LICENSE #
ADDRESS:
SINGLE FAMILY/NE�.
❑ ADDITION
O BASEMENT FINISH
O DECK
DESCRIBE WORK BEING
NE W
1920 County Road "C" West
Roseville, MN 55113
License #BC130983
651-264-4777
ATE ZIP
STATE ZIP,
❑ GARAGE/SHED ❑ WINDOWS
❑ ROOF O DRAIN TILE
❑ SIDING ❑ OTHER .
O SWIMMING POOL
❑ REMODELING
WIDTH =
ttOOF[NG
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ V inyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
O DETACHED GARAGE
OSoffit
O Trim
❑ Fascia
WINDOWS
IN EXISTING OPEIVINGS OYes ONo LOCATION OF W[NDOWS
OR FOR NEW OPENINGS-DESCRIBE SiZE OF
OPENING CHANGES &
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ & POItCHES SUBMIT:
1. Site Plan/Survey showing the e�cisting struct�re
and pmposed project.
2. Two sets of construction plans
3. Energy Catculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN� � � � � U.�B.0 FEE �H�E�DU�LNCY TYPE
TOTAL JOB VALUATION $
Pertnit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
111 .
$ �� Oa
$
$
$
$
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 Attach
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 will be n
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 application for a permit and work is not to start without a permit; that the work will be in accordance with the approvec
plan in the case of all work ich raquires review and approval of plans.
SIGNATURE OF APPLICANT �� � PRINT NAMEn � a��y,, Y'�l._1I�Sc� 1f�7 DATE °� ��Y.C. �I