P - 43895Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I � ��
SITE ADDRESS
TH1S APPLICANT IS:
BUILDING Permit No.: �(�f ���`U
RESIDENTIAL APPLICATION Received By: �
CITY OF FRIDLEY ���� 1 d����
EFFECTIVE 1-]-201I
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❑ OWNER �❑CONTRACTOR
PROPERTY OWNER/ I NAME: �'J' ( 0
TENANT qDDRESS: Is/�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
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PHONE: � b 3�5 7!• T T Y 5/
Na�E THD At- Home Service, Inc,
STATF 2690 Cumberland Pkwy, Ste 300
n�DR: Atlanta, GA 30339-3913
PHONL Lic # 20268257 Ph. 763/542-8826
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
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.EAD CERT NUMBEA
CITY
FAX
SIZE
STORIES
❑ WINDOWS
❑ BASEMENT FINISH '� ROOF ❑ DRAM TILE
O DECK O SIDING ❑ OTHER
❑ SWIMMING POOL
D NEW HOME CONSTRUCTION ❑ ADDITION
'61MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:�([ Y
SIZE OF IMPROVEMENT
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ZIP s (( �
ATE ZIP
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I� ROOFING O HOUSE ONLY .
� NUMBER OF SQUARES � 3 �B�10USE & GARAGE BASEMENT REMODELING SUB1vtIT:
, I . Existing Floor Plan
I� GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED S1ZE: ❑ DETACHED GARAGE 3. List of structural members to be used
I PROPOSED HEIGHT:
I' SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �Soflit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim l. Site Plan/Survey showing the existing sVuctures
❑ Other ❑ Fascia and proposed project.
2. Two sets of consVuction plans
WINDOWS 3. Energy Calculations
1N EXISTING OPENINGS ❑Yes �No LOCATION OF WfNDOWS FOR WMDOWS — 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 FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ l� G D 3 OCCUPANCY TYPE
Permit Fee $ �/�/�.Z See Back Page for Fee Schedule
Plan Review $ � 65% of Building Permit Fee
Fire Surcharge $ �-%��_ .001'times the total job valuation
Surcharge $ p'�, a,.9j .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �-�'Q $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 () Non Necessary ()
i Total Due $ /�$_�'.� Make checks payable to: Cityo uf Fridle_y Attach Stipulations
THIS [S 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 only an application for a permit and work is n t to start . ithout a permit on site; that the work will be in accordance with the
approved plan in the case of all worl ' ir s revi and ap oval of plan� ��` J j / �� 3/i
S]GNATURE OF APPLICANT y Q P NT NAME /J //) ! DATE � �!/j/