P - 48295Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � � � � �
SITE ADDRESS � G 3
TH]S APPLICANT IS:
PROPERTY OWNER/
TEIVANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
. TYPE OF WORK:
B�.T�LDING
RESIDENTIAI. APPLICATION
�
❑ OWNER
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADD}2ESS �
renu4 NF
'�CONTRACTOR
��
Permit No.: �.
Received By�
D�����'�
NAME: G (� SC / ) ! ! C' ' %�i Q � /�
ADDRESS: G S CITY STATEM�1 ZIP S�il 3'�
PHONE: 7L � S %ei • I��I
Na�E THD At- Home Service, Inc,
STATE 2690 Cumberland Pkwy, Ste 300 �EAD CERT NU�iBER NIa% '��� 7�+ •�
,�DR: Atlanta, GA 30339-3913 CITY STATE zJP
PHONL Lic # 20268257 Ph. 763/542-8826 � J odc �$ � 3Y S• G d Y 7
�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
'QMAINTENANCE/REPAIR ❑ REMODELING
j DESCRIBb WORK BEING DONE: A�-
i
I cr�r nc rr„rnnnvra,���rr
� ROOFING
I NUMBER OF SQUARES � �
i GAR?�GES
; PROPOSED SIZE:
' PROPOSED HEIGHT:
� SIBING
❑ Viny!
D Aluminum
❑ Other
WINDOWS
IN EXISTING OPENI?JGS DYes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ .4TTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
0 Fascia
LOCATION OF WINDOWS
NUMBER OF
f�
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNC(,UDiNG DECKS,
ADDITIONS & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing sVuctures
a��d proposed project.
2. Two seu 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � a� ��� OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit 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 (Plans 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
iSewer Main Charge $ Agreement necessary () Non Necessary ()
� Total Due $ 9.�.� Make checks pa_yable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMI"f-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 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 on site; that the work will be in accordance with the
approved p(an in the case of all wo ' re ' es r� eview and approval of pl�-� ���� n� DATE �( �l ��
SIGNATURE OF APPLICAN"1�( G_ �.� PRiNT NAME /� �•