P - 35212�uilding
�nspections
i 63-572-3604
DATE ,� l� I I l
SITE ADDRESS � 7 � �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL D� SS j. Q�'.�l �
�t 0 D/ �?/'! L� ��
❑ OWNER �ONTRACTOR
PROt ERTY OWNER/ N,�: %/� O/i Q S S7'
TENANT ,�DxESS: /�i( 0 0 %ii S S_ S
PHnNE� � G 3�'S % i � D S� �
CONTRACTOR N,�:_ CHD At- Home Services, Inc.
SUBMIT A COPY OF sT�.TE Ljc 2690 Cumberland Pkwy, Ste 300
YOUR STATE LICENSE .4DDRESS Cumberland Office Park
WITH APPLICATION pHp� Atlanta, GA 30339-3913
PROPERTY TYPE ��G� Lic# 20268257 Ph. 763/542-8826
❑ TWO FA �
PERMIT TYPE U �ll11lUN u �.vxAv
❑ BASEMENT FINISH ❑ ROOF
❑ DECK � SIDING
❑ SWIMM
TYPE OF W ORK:
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
NUMBER OF SQUARES J
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
w / f!
❑ REMODELING
Perrnit No.: �' � ! I �-
Received By: � ,=.
� vu`
Date �e�'�: I ��
Kt
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CITY �%� / Q� l!�(/ STATE_ZIP 5�' y 3�
Jod� � F(dcr on< �!
QS� t 3Y5- (, OV 7
CITY STATE Z1P
❑ DRAIN TILE
❑ OTf�R
TH 'WIDTH HEIGHT
❑ HOUSE & GAR.AGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structurai membets to be used
Ft
SEDING FOR NEW CONSTRUCTTON 1NCLUDING DECKS,
❑ Vinyi �Soffit ADDITIONS. & PORGHES SUBMIT:
� Aluminum ❑ Trim 1. Site Pian/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
V4�INDQWS 3. Energy Calculations
IN EXISTING OPENINGS Yes ONo �CATION F W
OR FOR NEW OPENINGS-D SCRIBE SIZE OF / �� �1. ��� �• '�!'��'� . E�r�iy
OPENING CHANGES & �u �/
TYPE OF WII�IDOW TO BE INSTALLED 'Tr NUMBER OF WINDOWS I 7
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(LTSING T�S �9�U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ , OCCUPANCY TYPE
Pemut Fee
Plan Review
Surcharge
Fire Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ /8/.a
$
$ ,-7�
$ 9. ��
$ S. o 0
$
$
$
$
$
$ 2 d o. S3
See Back Page for Fee Schedule
65% of Building Permit Fee
(.0005) times the total job valuation — Minimum $.50
.001 x Permit Valuation (1/10%)
$5.00 (Sta.te Licensed Residential Contractors)
$1450 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$20—$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
[ hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
�onformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
�ermit but only an application for a permit and ork is not to start without a permit; that the work will be in accordance with the approved
�lan in the case of all work which requi�es revie a approval of plans.
iIGNATURE OF APPLICAN PRINT NAME ` ` f � � � � � � � DATE ` ` � ��`