P - 60284Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
DATE T � � � ` �
SITE ADDRESS S 5 O W.
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
' TYPE OF WORK:
I DESCRIBE WORK BEING
i SIZE OF IMPROVEMENT
NAME:
YOUR E-MAIL AD ESS •O Ci
�an � b� J�a a�
1�,CONTRACTOR
0
ADDRESS: �.�i 0� S W+ U 0 n v a` CITY
PHONE: � L 3!�.7 2' �! � s�
N,a�E THD At- Home Service, Inc,
Permit No,����
Received By�� r�
Date Rec'd:
e t . L0/�
STATE�� ZIP 5 S y
STATE 2690 Cumberland Pkwy, Ste 300 �EAD CERT NUMBER �!T T• ��.�% 7 L•�
,�.�DR: Atlanta, GA 30339-3913 C(TY STATE zlp
PHONL Lic # 20268257 Ph. 763/542-8826 F�
�l SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION � GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAfN T1LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
'�.pdA[NTENANCE/REPAIR ❑ REMODELING
I� ROOFING
I NUMBER OF SQUARES _
I GARAGES
j PROPOSED SiZE:
�� pROPOSED HEIGHT:
' SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
TH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
❑ Fascia
IN EXISTING OPENRJGS�iYes ONo LOCATION OF WINDOW
OR FOR NEW OPENINGS-DE CRIBE SIZE OFt �'� ��/�T. �� !l�I� u t� M
OPENING CHANGES & �'t t StA4 �If I"
TYPE OF WiNDOW TO BE INSTALLED /- Q� NUMBER OF WINDOWS �
/��� cp/n/n�//
HEIGHT SQ FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADD1T]ONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed proiect.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VAL ATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
(USING THE 1997 U.B.0 FEE SCHEDULE)
S� � 3 OCCUPANCY TYPE
$ 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 for determination)
$ �+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ .'; R�� Make checks payable to: City of Fridley Attach St�ulations
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
[ 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 code of the Ci of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit n w 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 w`=i k� re e review and PR NT NAME p�; M 5 r h� n� �I � ��
SIGNATURE OF APPLICANT DATE
APPROVAL [NSPECTOR SIG URE