P - 48646Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � K �%
SITE ADDRESS ,
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE L]CENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
' TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
Permit No. �� � � �
Received By: ✓
CITY OF FRIDLEY Date Rec�:����_�!�
EFFECTIVE 1-I-2011
YOUR MAIL ADDRESS �,O l/ /•,s �i C�� j,'(' ( Q n�t S, � �/Y�
n �n ni
❑ OWNER �7CONTR.ACTOR
NAME: O • a
ADDRESS: �Z �! S,, % Y d/1 L n
PHONE:_7r,'3 � ;�� ` 3 7 Z .[
Na�E THD At- Home Service, Inc,
STATE 2690 Cumberland Pkwy, Ste 300
,�DR: Atlanta, GA 30339-3913
PHONL Lic # 20268257 Ph. 763/542-8826
'9 SINGLE FAMILYMEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FMISH
O DECK
❑ NEW HOME CONSTRUCTION
`Q MA[NTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
!
! i�
CITY / STATE�/ �IP J S y? i
�EAD CERT NUMBER /Y T. 1 Q'� 7 L-�
CITY
e�.x Q 5 7
SIZE
STORIES
O GARAGE/SHED '�W[NDOWS
❑ ROOF ❑ DRAfN TILE
❑ SIDING O OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
❑ Fascia
WIDTH
WINDOWS
IN EXISTING OPENINGS �'es ONo LOF ATION OF WiNn�WS `
OR FOR NEW OPENINGS-DESCRIBE SIZE OF /.1 YIA! /� o o l�1 ��+'�Y /1 f±
OPENING CHANGES & / " 3/ AI —T— n
TYPE OF WINDOW TO BE INSTALLED t �(?41.! 1�"�t� % NUMBER OF WINDOWS /L
STATE ZIP
'G 1!Y
�%i//I �.J
SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members [o be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT
L 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:
USIN 'i'�iE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ,� a ___ 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
$ - �,,�.
$
$
$
$ J. 0 0
$
$
$
$
$
$ �_
See Back Page for Fee Schedule
65% of Building Permit Fee
.001'times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC far determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
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 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 onty an application for a permit a work is not o start ithout a permit on site; that the work will be in accordance with the
approved plan in the case of all work ic re ' s rev' v nd app val of pl� m�L ,(, n j n� O !,�
SIGNATURE OF APPUCANT �/ �:...� P T NAME //.- � /! �t' DATE ���
APPROVAL INSPECTOR SIG TURE /',! Yl ." i