P - 60281Building
Inspections
763-572-3604
763-502-4977 FAX
DATE T l � ��j f� .l
SITE ADDRESS -i 7 O
BUILDING
RESIDENTIAL APPLICATION
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NAME:�
TENANT . ����,.,. �, ,
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
' TYPE OF WORK:
r�
CITY OF FRIDLEY
EFFECTIVE I-1-201I
'`QGONTRACTOR
Permit No.
Received By:
��1�
`" �� �SS �'o c�,'s co ¢ �4�� r�l o!� t.s�. �� A'�
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Na�E THD At- Home Service, Inc,
STATE 2690 Cumberland Pkwy, Ste 300
�pR, Atlanta, GA 30339-3913
Lic # 20268257 Ph 76
CfTY �%� %��[ q/ STAT� � ZIP 7 y�Z �
.,EAD CERT NUMBER �('r T• ! T� 7 G'�
CITY STATE ZIP
PHONL • 3�54'Z-$$26 fa43C 777� '
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
'� MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE:� ♦ •
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
O Other
WINDOWS
IN EXISTTNG OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
''B.j-IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACIiED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
S • G vy
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing [he existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ (U O 8�1 � 997 U.B.0 FEE SCH O CUPANCY TYPE
Permit Fee $ �`, See Back Page for Fee Schedule
Plan Review $ 65% of Building Pennit Fee
Fire Surcharge $ .001'times the total job valuation
Surcharge $ �� .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (P(ans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review •
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ i%. � Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A P6RM1T-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit a acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes o the C' of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit an k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a�rk . e s review and approval of pla� � C C f j / /�
SIGNATURE OF APPLICANT �--, INT NAME J/) � i� 1� DATE �( ���