P - 48661Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ( � 3 � � �
SITE ADDRESS � 3 3
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
C !! �t �' �
❑ OWNER
PROPERTY OWNER/ I NAME: C� a
TENANT pDDRESS: ,7 3
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
Permit No.:G-�� � V �%�J��
Received By:/U r�
Date ����: � � 201
OUR E-MAIL ADDRESS �J+ O d/�S ����� !.J� d n t.S . C A i�
a n.� IV�F
}�CONTRACTOR
� t� s G n
,� C/� l� I �A r CITY
�9S � 359 a
N.a�E THD At- Home Service, Inc,
sTATF 2690 Cumberland Pkwy, Ste 300
�DR: Atlanta, GA 30339-3913
PHONL Lic # 20268257 Ph. 763/542-8826
�I STNGLE FAMILY/NEW CONSTRUCTION
'd TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
STATt�!-•�%ZIP�S�� �
�EAD CERT NUMBER �/T T • � 7 % �T ` ' �
CITY STATE ZIP
FAX
S[ZE
STORIES
❑ BASEMENT FINISH �ROOF ❑ DRAIN T1LE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
C3-MAINTENANCE/REPAIR ❑ REMODELING
', DESCRIBE WORK BEiNG DONE: 1�Sa • i0 �'� /�
I SIZE OF IMPROVEMENT
'� ROOFING
I NUMBER OP SQUARES � � _
�� GARAGES
I PROPOSED SIZE:
I PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
tN EXISTiNG OPENINGS �Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TvPF f1F WR�iI�(1W Tn RF INSTALLED
�HOUSE ONLY
❑ HOUSE & GARAGF.
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
❑ Fascia
LOCATION OF WfNDOWS
NUMBER OF WIN[
►,
9.
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of strucwral members [o be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Si[e 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 $ i See Back Page for Fee Schedule
Plan Review $ 65% of Building Pennit 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
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ f„I..� , Make checks payable to: City of Fridley Attach Stipulations
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 an work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o all work w ic i s review and approval of pl�s,�-� f�[,� � //�' 3/l a
SIGNATURE OF APPUCAN PR1NT NAME / J n DATE 7 l
APPROVAL [NSPECTOR SI ATURE _ _
��