P - 44939Building
Inspections
763-572-3604
DATE ( � I �
SITE ADDRESS ,
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:
Received B`
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�e���r:
YOUR E-MAIL ADDRESS t�5c��d@ � eo��C DC •
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❑ OWNER OCONTRACTOR
NAME:
O�IJ� 1 l
ADDRESS: � ^� CITY
PHONE: � � � '� � � �1 T S
NAME:
STATE LICENSE #_
ADDRESS:
Y
PERMIT TYPE ❑ ADDITION
O BASEMENT FINISH
O DECK
TYPE OF WORK: � NEW
❑ MAI1
DESCRIBE WORK BEING
SIZE OF 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 __
❑ GARAGE/SHED
❑ ROOF
� SIDING
O SWIMMING POOI.
�
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
TE ZIP
t STATE ZIP
O DRAIN TILE
O OTHER
BASEMENT REMODEL.IN� S(JBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl OSoffit ADDITIONS_ & PORGI-IES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structure
❑ Other O Fascia and proposed project.
�,��WS 2. Two sets of construction plans
IN EXISTING OPEMNGS OYes ONo LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPEN[NG CHANGES &.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN T E 97 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�, �0�� �C� OCCUPANCY TYPE
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$
$
$
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
Attac6
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 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 approve
plan in the case of all work wl�jbh requires re' w and approval of plans.
� � Q�,��. O
SIGNATURE OF APPLICANT �� i C�/1'��'RINT NAME/1 1Q(Cj,,�� V1Sdif�7 DATE [�v /