P - 84273Building BUILDING Permit No.�I���'�
Inspections RESIDENTIAL APPLICATION Received By: Y
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX ������
EFFECTIVE I-1-2011
DATE
!O �'S� � D� 2 YOUR E-MA ADDf2ESS n u��S �� �� � � n� S. C 11 M
SITE ADDRESS � G L Y Y� % C) Q' �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: ' J t G Y! � 7
ADDRESS: G G �+ K / 1/� � CfTY
PHONE: �S.? � � 0 • �! 3 Y
Na�E THD At- Hoine Service, Inc,
2690 C b 1 d Pk S
A
•�a
STATE Uffi er an Wy, te 300 �EAD CERT NUMBER
�pR. Atlanta, GA 30339-3913 ciTV STATE z►P
PHONL Lic # 20268257 Ph. 763/542-8826 F�
�F] SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF DRAfN TILE
� DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
`� MA►NTENANCE/REPAIR ❑ REMODELING
, DESCRIBE WORK BEING DONE: � W/ O / Q' U /A I
�I SIZE OF IMPROVEMENT LENGTH WIDTH
I� ROOFINC ❑ HOUSE ONLY
I NUMBER OF SQUARES _ ❑ HOUSE & GARAGE
; GARAGES ❑ ATTACHED GARAGE
i PROPOSED SIZE: ❑ DETACHED CARAGE
' PROPOSED HEIGHT:
SIDING
❑ Vinyl ❑Softit
❑ Aluminum ❑ Trim
❑ Other ❑ Fascia
WINDOWS
IN EXISTING OPENINGS �4Yes ❑No LOC TION OF IN S
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �t �i� �i� �� �� V/ i} �%
OPENING CHANGES & /�
TYPE OF W[NDOW TO BE INSTALLED ��f NUMBER OF WINDOWS `
5Y3�
�� � / nQ' (
_ HEIGH SQ FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
POR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, & PORCHES SUBM(T:
I. 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 $ Ci ��s OCCUPANCY TYPE
Permit Fee $ ,%t 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 O Non Necessary O
i Total Due $ �� � Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
1 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 w rk 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 c e�r eview and approval of pla��'^ /�, / //r�
SIGNATURE OF APPLICANT � PR1NT NAME (/M S����l c DATE t d ��l ( J
APPROVAL INSPECTOR SIG A URE
PL�ASE NC)TE: SEPA3�A,'I'E PERMITS AI�E RE��IIRED F(�R PLUMBING. ELECTRICAL AND MECHt1NICt-1L WORK