P - 44565Building
Inspections
763-572-3604
DATE � 'T- (.:
SITE ADDRESS �O
7'HIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Pernut No.:
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:
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MAIL ADDRESS �SC3�,���'� [ (�0�.� (�C, • C.L�jiY1
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❑ OWNER OCONTRACTOR
ADDRESS: � CITY STATE ZIP
PHONE:�-[o 3 �- SB(Q "" �Z'iyD �
NAME:
STATE LICENSE #
ADDRESS:
PERMIT TYPE O ADDI7'ION
❑ BASEME�iT FINISH
D DECK
TYPE�OF WORK: � ❑ � �
DESCRIBE WORK BEING DONE:
SQUARES
GAAAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
S[DING
❑ Viuyl
CI Aluminum
O Od�er
Renewal By Andersen
1920 County Road "C" West
Roseville, MN 55113
License #20130983
O ROOF
❑ SIDING
n
o xousE ora.Y
❑ HOUSE dt GARAGE
O ATTACHED GARAGE
O DETACHED GARAGE
QSoffit
❑ Trim
❑ Fascia
wnvnows
IN EXISTiNG OPEMNGS OYes ONo LOCATION OF W[NDOWS
OR FOR NEW OPENIiYGS-DESCRIBE SIZE OF
OPENING CHANGES 8c
t STATE ZIP
❑ DRAIN TILE
� OTHER .
HEIGHT
BASEMENT F1uOD .t IN(} IT:
1. Bxisting Floor Plan
2. Proposed tioor pian
3. List of swcturnl members to be u4ad
FOR NEW CONSTRUCT[ON MCLUDING DECKS, '
A�1 DITIONC_ & PORf`WR. C MIT�
1. Site Plan/Survey showing the existing s�e
and ProPosed W'ulect•
2. Two sets of consaucKion pians
3. Energy Cafculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING� E 1997 U.B.0 FEE SCHEDULE)
T(tTAI. _inR VAi.iIATInN S U�`7 �Q -- I'1�Y`itFSN�V Tvot�
Permit Fee
Plan Review
Fire Surcharge
si,rscharge
License Surcharge
SAC Charge
Carb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$
� - —
� .N
$ S.�r'�
$
�
S
$
$
See Back Page for Fe.e Schedule
65% of Building Permit Fee
.001 times the totat job valuation
.0005 x Permit Valuation Minimum 5.50
$5.00 (State Licensed Residential Gontractors)
$I550 per SAC Unit (P[ans to MWCC for determination)
ft+6ft= ftx$21=$
$450 Conservation Plan Review
Fee I�termined by Engineeru�g
Agreement necessary ( ) Non Necessaiy ( )
TH1S IS AN APPLICATION FOR A PERMiT-NOT VALID UNTIL pROCESSED
I hereby apply for a building permit and I aclrnowledge 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�and this is nat :
permit but only an application r a peimit and wark is not to start without a petmit; that the work will be in accordance with the approva
plan in the c�se of atl work w' h requires � and approval of plans.
SIGNATURE OF APPLICANT 1�t�1NT iVAME��,�,,.1I�St11f�7 DATE I�V �/J ��