P - 39341Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ( R � ( I
SITE ADDRESS ___�1
THIS APPLICANT IS:
PROPERTY OWNER/ I N
TFNANT I
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
' PROPERTY TYPE
PERMIT TYPE
' TYPE OF WORK:
BUILDING-
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
E-MAIL ADDRESS
1�dCONTRACTOR
1 0 A
ADDRESS: � f S / //'S '!.t T/ 1 C/ I' C(
PHONE:%L 3 r 7� 7" l' � L.�
N�� THD At- Home Service, Inc,
sTATL 2690 Cumberland Pkwy, Ste 300
,�DR: Atlanta, GA 30339-3913
Lic # 20268257 Ph 763/542 8826
DESCRIBE WORK BEING DONF
SIZE OF IMPROVEMENT
�� ROOFINC
; NUMBER OF SQUARES
� GARAGES
PROPOSED SIZE:
' PROPOSED HEIGHT:
a d, 5 ca ��4r� r
CITY
.� � � �'� � �
Permit No.: ,�,
Received By:'� `�� �
D���'� � �
�on.� S . � oM
STAT��ZIP `� �y 3 �
�EAD CERT NUMBER ! �' �T T ' � � .� % G ' �
CiTY STATE Z1P
�r S � u J c�
PHONL • - F,43G � 3 4 S • �l '7 • O /
SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED L��V✓�NDOWS
❑ BASEMENT FINISH ❑ ROOF T� DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
/ lr,� � l� [�n l�3 rc �(2 Lt �''? t!1 //1 1 Y l J
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS�QYes ❑No
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF
OPENTNG CHANGES &
(7 HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHEll GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATIO OP WIN OWS
Q�i /
.��i !�
.
HEI
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of sUuctural members to be used
FOR NEW CONSTRUCTION INCLUDING DGCKS,
ADDITIONS. & PORCHES SUBMIT:
L Site P(an/Survey showing the existing strucmres
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF W[NDOW TO BE INSTALLED 3�%1 i NUMBER OF WINDOWS i I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION � I G 3 OCCUPANCY TYPE
Permit Fee $ b v./ O See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
�ire Surcharge $ /. ��! .001'times the total job valuation
Surcharge $ .�? .0005 x Permit Valuation Minimum $5.00
License Surcharge $ 5. O v $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 ."S � Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknow edge that the information above is complete and accurate; that the work will be in
conformance with the ardinances and c es of the ty of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a perm a d rk 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 wor � h s review and approval of plans. G/� /��
SJGNATURE OF APPLICANT �" PRINT NAME �/ %i � � � � � � DATE � ( �
APPROVAL INSPECTOR SIGN URE