P - 45690Building
Inspections
763-572-3604
763-502-4977 FAX
DATE r � � /� �l
SITE ADDRESS 7
TH1S APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit Na.: �L i
Received By:
�
.. ��
-��
� YOUR E-MAIL ADDRESS ,� c� dr's � a � de �,� an t s. �O �
� g �-Tfd -� !1 L� Ct �/
❑ OWNER �CONTRACTOR
NAME:_
ADDRESS:
PHONE:
d f? l /
(`/ 1� CtTY
N�nE THD At- Home Service, Inc, ^
sTA.rF 2690 Cumberland Pkwy, Ste 300
a��R Atlanta, GA 30339-3913
PHONL Lic # 20268257 Ph. 763l542-8826
Lg SiNGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILYINEW CONSTRUCTION
❑ ADDIT]ON ❑ GARAGE/SHED
�} o G
.EAD CERT NUMBEI
CITY_
FAX
SIZE
STORIES
❑ BASEMENT FTNISN ❑ ROOF
� DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�QMA�NTENANCE/REPAIR O REMODELING
' DESCRIBE WORK BEING
j SIZE OF fMPROVEMENT_
' ROOFINC
I NUMBER OF SQl1ARES ,
� GAI2AGES
' PROPOSED SIZE:
' PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
fN EXISTING OPENINGS L9.Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGG
❑ DETACHED GARAGE
�Soffit
❑ Trim
❑ Fascia
LOCATION OF W�NDOWS
�/Y/f1� /`dtl�''i
NUMBER OF WINDOWS `
STAT�j�ZIP S�y3 %
� 3yS• G o y�
STATE ZIP
�WINDOWS
❑ DRAfN TILE
D OTHER
e?�/S t�±q b/Il�//2�
NE(GHT � S FT
BASEMENT REMODELING SUBMIT:
I . Exisling Floor Plan `
2. Proposed floor plan
3. List of strucWral members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITION5. & 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �� 7 3 OCCUPANCY TYPE
Permit Fee $ '�,�j� 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 $ ��y ) $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
II Curb Cut Escrow $ ft} b ft= ft x$25= $
i Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
' Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ �j �, (� ! Make checks payable to: City of Fridley Attach Stipuiations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 hereby apply for a building permit and I knowledge that the inforrnation above is complete and accurate; that the work will be in
conformance with the ordinances and codes he City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a p it d 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 r ires revie and approval of pl�us. j. �� /'� /��
SIGNATURE OF APPLICANT PRiNT NAME �/ M S���%% A DATE ( �
APPROVAL INSPECTOR SIG TURE