P - 42144�-3uilding
�nspections
763-572-3604
c�ATE � / � � �I
SITE ADDRESS � � �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
� OWNER
PROt ERTY OWNER/ N�:�
TENANT ,4pDRESS: �
PHONE: � L
CONTRACTUR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROFERTY TYP�
PERMIT TYPE
TYPE OF WORK:
Permit No.:
Received By:
Y UR E-MAIL ADDRESS ,� � ��i 's cA e/d s�` }. o n� S.!� b M
S � YG . ��
Z9GONTRACTOR
�� 5��
3� ��SR !�v
S7 9- ��l�,^I
x,a�E:_ THD At- Home Services, Inc.
sTA� LIC 2690 Cumberland Pkwy, Ste 300
a�Dx�ss Cumberland Office Park
PHONE Atlanta, GA 30339-3913
❑ srt•rGt,E Lic# 20268257 Ph. 763/542-8826
❑ TWO FA •
Q ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �OOF
� DECK ❑ SIDING
❑ SWIIvIMING POOL
❑ NEW ❑ ADDITION
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � 3
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
_, SIDING
' ❑ Vinyl
O Aluminum
❑ Other
Vi�INDOWS
IN EXISTING OPENINGS �Yes ONo
OR FOR NEW OP�IINC:S-DESCRIBE S3ZE OF
OPENING CHANGES &
TYPE OF WII�tDOW TO BE 1NSTALLED
" t- P o 0�. !�! �? D
LENGTH
❑ HOUSE ONLY
�iOUSE & GAR.AGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
IACATION OF WINDOWS
__ NUMBER OF WINDOWS_
o n
:ITY I� / C �! 'S/ STAT
Jdd� m �' �r n
qS� � 3Y5- (. CU'7
CTTY S'
�E
.ORIES
❑ wINDOws
❑ DR.�IN TILE
❑ OTf�R
0 Q �> S /�
WIDTH HEI HT
�Sy37
ATE ZIP,
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
FOR NEW CONSTRUCTTON INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing thc existing structures
and proposed projec�
2. Two sets of conshvctiot� plans
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ G� E�; 9;7� .B.0 FEE OCICUPANCY TYPE
Permit Fee $ . Z. � See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Surcharge $ j'�_ (.0005) times the total j ob valuation — Minimum $.50
Fire Surcharge $ � .001 x Permit Valuarion (1/10%)
License Surchazge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $1450 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 8= ft x$20 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ / D �• 9 S Make checks pa_yable to: Cityo uf Fridley Attach
THIS IS AN APPLICATION FOR A PERMTT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
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 approved
plan in the case of all work which re u�res re ie,�6v andapproval o€plans. T /
SIGNATURE OF APPLICANI�� '/ v PRINT NAME l`_` ���� e�� Daz� � ll g l �I