P - 48319Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_�
SITE ADDRESS
TH1S APPLICANT 1S:
/3 0 //
7YY�
PROPERTY OWNER/
TENANT
CONTRACTOR
j SUBMIT A COPY OF
' YOUR STATE LICENSE
� AND CERTIFICATE OF
' INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
GFFECTIVE I-1-201I
YOUR E-MAIL ADDRESS d �(+S �
e� � � � v �
❑ OWNER
NAME: O (i
ADDRESS: �( �( L 0 , CfTI'
PHONE: 7 L 3` � Q�O ` � d�
N,a�E THD At- Home Service, Inc,
Permit No.: /�V
Received I3y:�
Dat'����'d� � �
Q I /. l' o !�
J
f{-t,
STATH '`� ZI P�s y 3.�
sTATE 2690 Cumberland Pkwy, Si0 3OO _GAD CERT NUMBGR /v/� %' 9�7 L-%
ADDR Atlanta, G`� 3�339-3913 CITY STATE ZIP
PHONL Lic # 20268257 Ph. 763/542-8826 ppx
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGGSHED �WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIUING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BETNG DONE: � W 1�aO W�I dl Q
SIZE OF IMPROVEMENT LENG
ROOFINC
NUMI3ER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
W[NDOWS
❑ HOUSE ONLY
❑ HOUSE & GARAGF.
❑ ATTACHED GARAG[i
❑ DETACHED GARA(iE
WIDTH
GHT
FT
13ASEMENT RGMODELING SU[3MIT:
I . Existing Floor Plan
2. Pro�osed floor plan
3. List of struc!ural members to be used
POR NEW CONSTRUCTION INCLUDING DEChS,
❑Soflit ADDITIONS. & PORCHES SUI3M1'I':
❑ Trim I. Site Plan/Survey showing the existing strucwres
❑ Fascia and proposed project.
2, Two sets of construction plans
3. Energy Calculations
IN EXISTING OPENRJGS`QYes �No LOC TION OF l��I O�� p- FOR WINDO�VS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �I /i � fi �, �A �" p� CI MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED C4S� M� A� 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 $ � � 0 � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � L� � ���j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �-�/ (`)� .00]'times the toCal job valuation
� Q�'-- .0005 x Pennit Valuation Minimum $5.00
$ JO�- $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 ( )
$ � b� � Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPUCATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 hereby apply for a building permit and I acknowledge that the infonnation 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
pennit but only an application for a perm�t nd ork 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 wh' r s e ew an approval of plans
SIGNATLIRE OF.APPLICANT i��. P INT NAME TM Sc he �,� DATF_ �l3 b f J A
APPROVAL INSPECTOR SIG TURE ' / � � .�
PT';FAS�: NnTF.� SF.PARATE PE �RE EOUI FOR PLUMBING, ELECTRTCAL AND MECHANICAL WORK