P - 42127Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I O � S
SITE ADDRESS _
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-i-20I I
�IL ADDRESS
/' 11r 4
❑ OWNER j�CONTRACTOR
PROPERTY OWNER/ I NAME: J d M� S !�{4 M/��C i� /
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
' TYPE OF WORK:
ADDRESS: S�i Q f3 � n n,c��
PHONE:_ ��3� %$�' c�0 �D
N,a�E THD At- Home Service, Inc,
STATE 2690 Cumberland Pkwy, Ste 300
�pR: Atlanta, GA 30339-3913
Lic # 20268257 Ph
�n c�/� ta I
�
�. C
CITY
�
�EAD CERT NLIMBER
CITY_
PHONL .763/542-8826 pq}{
'6� SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
O SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�BMAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OP SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
❑ HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
Permit No.: Z � � ��
Received By:
�R���e��:� �
�loncs r�
STATB�iI Z1P ��
�sa ays� �oy�
_STATE ZIP
' 1 fi/1 � 0�,� /1 / n F s
HEIGHT _ SQ FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim I. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
3. Energy Calculations
IN EXISTING OPENINGS�j'es ❑No LOC T10N OF WIND9 WS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF � a S� M/ /1 f� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �
TYPE OF WMDOW TO BE INSTALLED � 1�7� S NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � G 3i '� OCCUPANCY TYPE
Permit Fee $ 3,? S' See Back Page for Fee Schedule
Plan Review $ 65% of Building Pennit Fee
Fire Surcharge $ �, 6 �� .001'times the total job valuation
Surcharge $ ���� .0005 x Permit Valuation Minimum $5.00
License Surcharge $ 5, p � $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
Sewer Main Charge $ Agreement necessary () Non Necessary ()
� Total Due $ Q,?, � t� Make checks payable to: City of Fridley Attach Stipulations
THIS APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby apply for a building�permit an I a knowledge that the infonnation above is complete and accurate; that the work will be in
conformance with the ordinances atad codes o the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a r 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 work r 'res r'ew and approval of plans.�/y� ( O / S„ j/�
SIGNATURE �F APPLICANT � PR1NT NAME // /- a S C�� ll � DATE � l
A DDDl1\/ A I 1"AIC`nL'l�Tlln [�ll�T ♦ � fT � �