P - 41906Building
Inspect��r�s
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
Permit No.:
Received By: i 1(,l,
Dat��'d�� "�' `�� 1 � � 011
DATE ���-� T�� �� YOUR E-MAIL ADDRESS �/4/J�'1 . GI C% I U S IC R� Cal'li 4/ �� CCji'Y)
SITE ADDRESS S� l� O �%� T�1� iG ST ✓�I//� �-�%�J L��` �l/I N
THIS APPLICANT IS: �OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
�N/U� }f �} �- US/c.A
ADDRESS: SI� tP � %tll2-TN�-�IrL S J CITY F/�% L�L �� STA
PHONE: �j�/ca� � Fi I 0%� d %�O � S�� S3<jLZi
NAME:
STATE LICENSE #
ADDRESS:
PHONE
INGLE FAMILYMEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FiNISH ❑ ROOF
❑ DECK ❑ SIDiNG
❑ SW1MMfNG POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
�MAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFiNG
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ V inyl
O Aluminum
❑ Other
LEAD CERT
FAX
SIZE
STORIES
� WINDOWS
❑ DRAIN TILE
�OTHER
O ADDITION
❑ REMODELING
o •— G fi-2 A-G �
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
STATE ZIP,
F7'
BASEMENT REMODELING SUBMIT:
i. Existing Fioor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑So�t ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1• Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WtNDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED NUMBER OF WINDOWS .
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�/ (USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $`/I � O(� . DO OCCUPANCY TYPE
Pertnit Fee
Plan Review
Fire Surchazge
Swcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Buitding 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 oavable to: Citv of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERMiT-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 plan in the case of a : whict - ire revie an approval of pl ns. //��
SIGNATURE OF APPLICAN ,� PRiNT NAM�d ��%T7`J9�-G/S.�'— DATE g�� �°����
CONCEPT DESIGN
Concrete & Masonry Inc.
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Decorative Concrete Specialists
763'z45'z4�5
Chris S. Johnson
1055 Bear Circle NE Cambridge, MN 55008
Phone:763-245-2415
Emaii: cdcmincna��mail.com
www.conce tdesi�nconcrete.com
Bid for Services
Customer
John Haluska
Sq. Ft
Location
5660 Arthur St NE
Fridley, MN 55432
John.haluska@gmail.com
612-281-0700
DESCRIPTION
108 Block tearout at garage floor/replace
11 Core Fills (4' on center)
264 Sq.Ft. Garage floor tearout/replace
1850 Sq. Ft. Asphalt Driveway removal
'l,SSO Sq. Ft. Concrete Driveway poured with 6 bag 4,000# falkstone
mix at 4" thick and 1/2" rebar or wire tied throU slab
Block tearout/replace will be first, then tearout garage floor.
*No permits were included in this bid (cheaper if homeowner
is approx.(Final calculation is made at the
*No permits included in this bid
**'/z down at start of job and'h due upon completion**
Pricing Valid for 30 Days (date on the bid)
CODE DATE PROJECT
0703 9�3/11 Homeowner
Accredited Business
RATE
7.00
50
7.00
.95
5.25 '
TOTAL
TOTAL
$756.00
$550.00
$1,848.00
$1,757.50
$9,712.50
$14,624.00
Concept Design Concrete reserves the right to cancel the job
**This is a binding contract that could change depending on job needs or
homeowner desires.
Contractor's Notice to Owner From Minnesota Statute 514.011
"(a) Aay person or company supplying labor or materials for this improvement to your property may file a lien against
your property if that person or company is not paid for the contributions.
(b) Under Minnesota law, you have the right to pay persons who supplied labor or materials for this improvement
directly and deduct t6is amount from our contract price, or withhold the amounts due from us until 120 days after
completion of the improvement unless we give you a lien waiver signed by persons who supplied any labor or material
for the improvement and who gave you timely notice."
Agreement to perform the above services
Concept Design Concrete & Masonry Inc.
--�- _ 9( ��,p.� , I
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C tractor/Homeowner