P - 84227Building BUILDING Permit rTo.:� �� � 3a'?�
Inspections RESIDENTIAL APPLICATION Recei�ect sy:
763-572-3604 CITY OF FRIDLEY vate xec'd: --
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE J �/� YOUR E-MAIL ADDRESS � !�a UG"f7Ut�1 C_% /L%C. ��/"F ��l E', (//. GD�/1
SITE ADDRESS ( C.s `f 3 C,� �. rd�„tic:, v e� V�.�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: T—c- �
TENANT ADDRESS:1(p��J G�Grd�q F-rJ� 1vE CITY �F � STATE�ZIP�
PHONE.''�L�'� C%►oZ� G���l
CONTRACTOR NAME: S� = d ��•o� �
SUBMIT A COPY OF �-
YOUR STATE LICENSE STATE LICENSE # OrZCS (pJ � S LEAD CERT NU ER EXP:
AND CERTIFICATE OF ADDRESS: ��%I� (.,i, A Lh CITY �c.l �4(T �n STATE IMf�IP
INSURANCE pHONE 'rj.YvZ� S%- FAX
PROPERTY TYPE f3 SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION Q GARAGE7SHED ❑ WINDOWS
D BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �OTHER �,� � ��uGL � � �,� �
❑ SWIMMING POOL �— �
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ,�REMODELING
DESCRIBE WORK BEING DONE: � C� �` {-t� e}C�"'1
{-t�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCI'ION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum � Trim REMOVED? ❑ YES � NO 1. Site Plan/Survey showing the existing structures
� Other � Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS 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 N'EES ARE BASED ON VALUATIUN,INCLUDING THE COST OF LABOR A1Vll MA"I'EKIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�, �e�• � G OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ I d� 5• d See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ _.001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ � $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �, Co 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a permit d w ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of - i r ire e' d a proval ofP�! s. /�� C
SIGI3ATURE OF APPLtCANT P AME 7� �Q„(��lQ ��l. c-� DATE
APPROVAL INSPECTOR SIGN �! �
�.
License lookup
License%Certificate Detail
License Type:
Application No:
Expire Date:
Orig Date:
Enforcement
Action:
RESIDENTIAL BLDG
CONTRACTOR
240113
3/31/2012
11/2/2010
NO
License
No:
Status:
Effect
Date:
Print
Date:
Name: K2 BATH DESIGN & REMODELING LLC
Address: 2710 URBANDALE LN N
PLYMOUTH , MN 55447
Phone: 952-393-5712 Fax: Other:
Business Relationship Requirements
Name: KACHMAN, JON L
Status: ISSUED
Expire Date: 3/31/2012
Orig Date: 11/2/2010
...
: . ..
ISSUED
10/7/2011
Lic/Reg No: QB144116
Application No: 269709
Effect Date:
https://secure. doli. state.mn.us/lookup/licensing. aspx
Page 1 of 1
3/30/2012
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date
project
page
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