P - 50475Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � II �
SITE ADDRESS V �+ �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-201I
Permit No.: � � a��� �
Received By:
Date �e�: M--� . �
YOUR E-MAIL ADDRESS �'O �I ����a �� / O I2.� S l l� I%�%
n . . 1 /1 /'G'
❑ OWNER �CONTR.ACTOR
PROPERTY OWNER/ NAME: � /1 l! Q � G1 i M
TENANT pDDRESS: c7 G�� S��' S� N� CITY %� (�'l �( Y STATH -' � ZIPS SY 3 ii
PHONE: G � i( rJ' � �' lO i7 8
CONTRACTOR N,�E THD At- Home Service, Inc,
SUBMIT A COPY OF STATE 2690 Cumberland Pkwy, Ste 300 �EAD CERT NUMBER %�l'F �` l7 � 7�+ •�
YOUR STATE LICENSE Atlanta, GA 30339-3913 clTV STaTE zIP
AND CERTIFICATE OF ADDR:
INSURANCE PHONL Lic # 20268257 Ph. 763/542-8826 F,�c J o J. � S� 3k 5� • G �Y 7
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEiNG
SIZE OF
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
❑�3itVGLE FAMILY/NEW CONSTRUCTION S[ZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED C�VdINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK � SiDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
Ci'141AlNTENANCE/REPAIR ❑ REMODELING �
WINDOWS
IN EXISTING OPENINGS C�s ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & � • � p �
TYPE OF WINDOW TO BE INSTALLED �I'
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
❑ Fascia
L T10 OF WINDOWS
'��, l�'iv���, Li���, 1gt 1
i NS NUMBER OF WINDOWS � O
,n��
f:l�)[efCrl
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of strucwral members to be used
POR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the 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:
p USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION � P� V V OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � tQ`'j , G5
$
$ _t
$
$ a
$
$
�
$
$
$ t
See Back Page for Fee Schedule
65% of Building Permit Fee
.001'times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks payable to: City of Fridiey
Attach Stipulations
THIS IS AN APPLICATiON FOR A PERMITi�IOT VALID UNTIL PROCESSED
1 hereby apply for a buildin�g p it and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and s o he City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a per it a work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all wor , 'c re i e review and approval of pla�M ��� � l ,� f�/ j�
SIGNATURE OF APPLICANT G"' PR1NT NAME / I•� S DATE < <
APPROVAL [NSPECTOR SIG ATURE r' _