P - 39340Buiiding
Inspections
763-572-3604
763-502-4977 FAX
DATE R 7 �
SITE ADDRESS � -J
THIS APPLICANT IS:
PROPERTY OWNER/�T
TENANT I
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE _
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
�
BUILDING Permit No.: �iU � I l
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY Date���: �� �,�+� n;�
EFFECTIVE 1-I-2011
YOUR E-MA1L ADDFtESS ,� �� /S � L � d � � � n / S . � O M
F R c u a`i a n Pa s /1/'f
❑ OWNER
NAME: i�I Q/i L I�� � f� Q / Z J
AnnRFSS s s a 9 f. _�'a u o rr a n
CfTY
STATL� -'A ZIP�S'S�I 3 7
PHONE:
N�E THD At- Home Service, Inc,
STATE 2690 Cumberland Pkwy, Ste 300 „EAD CERT NUMBER �`� T= C 4 a 7 y- l
a�DR: Atlanta, GA 30339-3913 ctTV sTa,TE zrn
PHONL Lic # 20268257 Ph. 763/542-8826 F,�t Q��� 3� S- � b 4? �O�i
�STNGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT F►NISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
'� MAINTENANCE/REPAIR ❑ REMODELING
' DESCRIBE WORK BEING DONE:
' SIZE OF [MPROVEMENT
�� ROOFING
I NUMBER OF SQUARES ^
I GARAGES
PROPOSED SIZE:
� PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHEll GARAGE
�C� ��/6i1n�f
HEIGHT SQ FT
BASEMENT RGMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim l. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
3. Energy Caiculations
IN EXISTING OPENINGS "9Yes �No LOC 10 OF WIND WS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �n �l"� / V I/1 �, MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED� Al P/ C NUMBER OF W]NDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION �
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
USING THE 1997 U.B.0 FEE SCHEDULE)
G 3 OCCUPANCY TYPE
$ f` Z� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �. G�/ .001'times the total job valuation
$ / �i � .0005 x Permit Valuation Minimum $5.00
$ 5 0 � $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 ( )
$ 0�, `t � Make checks payable to: City of Fridley Attach S�ulations
TH1S 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 c s of t City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a perm� ork is not to start witnout a permit on site; that the work wi11 be in accordance with the
a roved lan in the case of all w�' ' h r ' es revi and a roval of 1� /� L Q �j
SpGNATURE OF APPLiCANT "'e- PKp T NAME p!/ M S� / f AI� �( DATE ( / ��
APPROVAL INSPECTOR SIG URE