P - 45284Building
Inspections
763-572-3604
DATE l S
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 By:
Date Rec' d: �1""0�l "'
YOUR E-MAIL ADDRESS vuSQ`��� ��p��C_OC • C.QY�_
K, 17. ( 1 V--Q_ �
❑ OWNER �CONTRACTOR
NAME: � qYY� � ►`�.'� S ��D�.
ADDRESS: ' 1- CITY
PHONE: �'�p�j �- �'of — �'J �j3�
NAME:
STATE LICENSE #_
ADDRESS:
PHONE
❑ SINGLE FAMILY/NE�
❑ TWO FAMILY/NEW C
PERMIT TYPE I ❑ ADDITION
❑ BASEMENT FINISH
O DECK
TYPE OF WORK:
� �
DESCRIBE WORK BEING I
SIZE OF IMPROVEMENT
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
NE W
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 55113
License #20130983
651-264-4777 __
� ROOF
❑ SIDING
0 SWIMMING POOL
LJ ADDITION
� REMODELING
ATE ZIP
t STA"i'E ZIP.
❑ DRAIN TILE
0 OTHER
C� � Yl ��i%� r S 7l
LENGTH WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl ❑Soffit ADDITIONS_ & PORCHES SUBMIT:
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structure
O Other ❑ Fascia and proposed project.
WINDOWS 2. Two sets ofconstruction plans
IN 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:
(US[NG THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�" ��J� �— OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
$ ►53• a5'
$
$ .�lU
$ 3 . '} 6
$ S, O
$
$
$
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 Attac6
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 '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 application fo permit and rk is not to start without a permit; that the work will be in accordance with the approve�
plan in the case of all work which ' es revi nd approval of plans.
SIGNATURE OF APPLICANT vP'12IFT NAMEn �a�j�_ . y� � 1f�'� DATE �S�Q�I I I�