P - 39618Building
Inspections
763-572-3604
763-502-4977 FAX
DATE q / a � �
SITE ADDRESS l J 3�
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL
7 3 � Y' C.
❑ OWNER 1�(CONTRACTOR
PROPERTY OWNER/ I NAME:,
TENANT ,r�DRESS: �� � �~ 7 3��.'Z r9" �(, ( v F CITY
PHONE: � � � � B Y • G �{ � �
N,a�E THD At- Home Service, Inc,
G
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
Permit No.: °; L�� ��,� ��'�
3
Received By:
D at��'�} d�_���--�-�-� �
04�� S L9Q.(((� !'�o/ll S. !a
AT�� ZIP__S� v 3a
STATE 2690 Cumberland Pkwy, Ste 300 ,EAD CERT NUMBER l� % % Q.7 7 d-
ADDR' At�anta, GA 30339-3913 CITY STATE ZIP
PxoNL Lic # 20268257 Ph. 763/542-8826 F� C
❑ 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
'�MA[NTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �� �� n c 1 O �.i r
' SIZE OF IMPROVEMENT
'� ROOFING
I NUMBER OF SQUARES _
! GARAGES
�' PROPOSED SIZE:
' PROPOSED HEIGHT:
S►DING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ Vinyl ❑Soffit
❑ Aluminum ❑ Trim
❑ Other ❑ Fascia
WINDOWS
IN EXISTING OPENINGS Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENING -DESCRIBE SIZE OF
OPENING CHANGES & �o��p,�,a.� S
TYPE OF WINDOW TO BE INSTALLED sl.d.r_S NUMBER OF W[NDOWS
f;1�1Lsl:i�
.: 7 �T,
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of svuctural members to be used
POR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. 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:
USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ ,� {,�,;;�jSee Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ l2,(�2 .001'times the total job valuation
Surcharge $ (p31 .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �, o � $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 O Non Necessary O
i Total Due $ ��—�--��I1.1`� Make checks payable to: City of Fridlev Attach Stipulations
THIS IS A.N APPLlCAT10N FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 hereby apply for a building permit and I acknowledge that the infonnation above is complete and accurate; that the work will be in
conformance with the ordinances an codes of t e City of Fridley and with the Minnesota Construction Codes; that 1 understand this is not a
pennit but only an application for a p rmit 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 �w i s review and approval of pla l a//
SIGNATURE OF APPLICAN / v PRINT NAME �M S�� d n C DATE !!` 2 !�
.APPROVAL [NSPECTOR SI TURE