P - 45753�uilding
7nspections
i 63-572-3604
DATE G! a y l i/
SiTE ADDRESS $ 3 6
THIS APPLICANT IS:
i'RO�ERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
BUILDING
Permit No.:
RESIDENTIAL APPLICATION Received By: V t'�-
CITY OF FRIDLEY Date �'� � `"v ,� � �
YOUR E-MAIL ADDRESS �'a d� 's �v c l�' � r�" o n.� s. � 0�
1� l%' 0 il 0/�. IV E
❑ OWNER '�CONTRACTOR
U l'
. •
t,3 /S�r. s�q�
N,,,ME: CHD At- Hoine Services, Inc.
sTATE Lic 2690 Cumberland Pkwy, Ste 300
aDDt�ss Cuinberland Office Park
PxorrE Atlanta, GA 30339-3913
❑ s�rGLE Lic# 20268257 Ph. 763/542-8826
❑ TWO FA
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I _ � �u'
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NLJMBER OF SQUARES
GARAGES
?ROPOSED SIZE:
PROPOSED HEIGHT:
SEDING
Vinyl
❑ Aluminum
O Other
❑ GARAGE/SHED
❑ ROOF
tp SIDING
❑ SWIMMING POOL
❑ ADDITION
AIR ❑ REMODELING
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GAR.AGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Coffit
❑ Trim
� Fascia
CITY
STATE � �zrP �SSY 3 �
� Q�a 13Y5- Loy7
CITY STATE_ZIP,
�E
.ORIES
�wnlDOws
❑ DRAIN TILE
❑ OTHER
11 � /SGt �F' �►/'i
WIDTH HEIGHT
�'INDOWS
IN EXISTING OPENINGS�es ONo L CAT ON O yj11,�1DOWS /
OR FOR NEW OP£NINGS-DESCRIBE SIZE OF �! �. �7�'�'J (,� . D� R.0 � B4'+��, CdUA! �
OPENING CHANGES & / � i
TYPE OF WINDOW TQ BE INSTALLED NUMBER OF WINDOWS �
a� ho/�'?
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Ft.
FOR NEW COt�iSTRUCTION INCLUDING DECKS,
ADDTTIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of conswction plans
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MA'
(USING THE 1997 U.B.0 FEE SCHEDULE) '
TOTAL JOB VALUATION $ � 0� Y a'S OCCUPANCY ' TYPE
Permit Fee
Plan Review
Surcharge
Fire Surcharge
License Surcharge
5AC Charge
�urb Cut Escrow
3rosion Control
?ark Fee
3ewer Main Charge
I'otal Due _ _
$ 3i. �S'
$
� a. i
$ �- Y 3
$ 5. �0
$
$
$
$
$
$ 37a. � 4
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 (State 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 payable to: City of Fridley 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 Minnesotal Construction Codes; that I understand this is not a
>ermit but only an application for a permit and work 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 requires review pproval of plans.
�IGNATURE OF APPLICANT PRINT NAME �/' L ��� 1� I� DATE � l� 4 C !�