P - 84274Building
Inspections
763-572-3604
763-502-4977 FAX
DATE l � � / 3 I
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
PROPERTY OWNER/ NqME:
TENANT ,qpDRESS:
YOUR E-MAIL ADDRESS
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�'CONTRACTOR
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PHONE: �T 6 3 ! � � � ' 0� " � 3 .
CONTRACTOR N,�E THD At- Home Service, Inc, � b
SUBMIT A COPY OF STATE 2690 Cumberland Pkwy, Ste 300 �EAD CERT NLIM
YOUR STATE LICENSE Atlanta GA 30339-3913
AND CERTIFICATE OF ADDR: � CITY
INSURANCE PHONL Lic #�268257 Ph. 763/542-8826 F,�
PROPERTY TYPE �9 SINGLE FAMILY/NEW CONSTRUCTION SfZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE
TYPE OF WORK
❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAfN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�.MA[NTENANCE/REPAIR � REMODELING
I DESCRIBE WORK BEING DONE:
WIDTH
I� ROOFINC ❑ HOUSE ONLY
I NUMBER OF SQUARES ❑ HOUSE & GARAGE
!i GARAGES ❑ ATTACHED GARAGE
�, PROPOSED SIZE: ❑ DETACHED GARAGE
' PROPOSED HEIGHT:
SIDING
❑ Vinyl OSoftit
❑ Aluminum ❑ Trim
❑ Other ❑ Fascia
W'INDOWS
IN EXISTING OPENINGS �QYes ONo LOCATIp N OF WIND WS 1 /�
OR FOR NEW OPENINGS-DESCRIBE SIZE OF L.lV!!l e� �I�/� � 1',�� L�/'00 /Y�
OPENING CHANGES & `�� � P�— �
Permit No.'.
Received By: r � �Y��
Date ��f� � � � � � � a �
STATt/ '� �Z1P � S �i3 .7
3yS• G e�7
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_STATE ZIP
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BA:SEMENT REMODEUNG SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members [o be used
POR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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.
TYPE OF WINDOW TO BE INSTALLED '�"j ���nqS 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 $ �' � Y � OCCUPANCY TYPE
Permit Fee $ ��p r,; 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
� Total Due $ /�'j 3. 3� Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 t ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
pennit but only an application for a pe it work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case f all wo � e' review and approval of plari � /0 �? a 11 �
SIGNATURE OF APPLICANT �' PRINT NAME // M S� � J�i DATE
APPROVAL [NSPECTOR SI ATURE _�%.