P - 44965�3uilding
rnspections
763-572-3604
/ � ,?3 �> o
SITE ADDRESS _ B n� b
THIS APPLICANT IS:
BUILDING Permit No. ��
RESIDENTIAL APPLICATION Received By: �
CITY OF FRIDLEY Dat�'�e�'� 0 U
YOUR E- L ADDRESS � ti 4' / fS � LI �f L�� 0/� /�.� fl�%
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❑ OWNER �'CONTRACTOR
PR�t ERTY OWNER/ N,�: !!) /��' C�G
TENANT ,r�DRESS: S d/7 � R L+ S-( : CITY P! I,� '�/ STAT� �IP�S �,� �:'
PHONF.� �L 3 I %8G �3 I��
G
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLIGATION
PROPERTY TYPE
PERMIT TYPE
N�: 1�Hll At- Hoine Services, lnc.
sTa� Ltc 2690 Cumberland Pkwy, Ste 300
�DttESS Cumberland: Office Park
PxoNE Atlanta, GA 3 03 3 9-3 913
� GLE Lic# 20268257 Ph. 763/542-8826
❑ TWO FA �
� ..,..,Tr„�. r, ., .,, . �,.,n.,,_r
I ❑ BASEMENT FINISH
i❑ DECK
TYPE OF WORI�: � ��'�'
'0 MAINTEAIANCE/REPAiR
DESCRIBE WORK BEING DONE: o? (�I �!1 11�D !
❑ ROOF
❑ SIDING
❑ SWIMMING PC
❑ ADDITION
❑ REMODELING
�va� cy c�ac� dv�tc 7
qSa�3Y5- 40�1�
CITY STA'FE ZIP
:E
_.ORIES
.�, ...r.,.,,.,,.,
❑ DRAIN TILE
❑ OTf�R
SIZE OF IMPROVEMENT LEIVGTH WIDTH �EIGHT S. Ft.
ROORIIVG " ❑ HOUSE ONLY
IJUMBER OF SQUARES O HOUSE & GARAGE BASEMENT REIvIODELING SUBMIT:
GARAGES ❑ ATTACHED GARAGE
1. Exisfing Floor Pian
PROPOSED SIZE: ❑ DETACHED GARAGE Z. Proposed floor plan
?ROPOSED HEIGHT: 3. List of structural members to be used
3IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
� Vinyl ❑Soffit ADDITIONS. � PORCHES SUBMIT:
� Aluminucn ❑ Trim I. Site Plan/Survey showing the existing structures
� Other ❑ Fascia and proposed project.
r�rINDOWS 2. Two sets of construction plans
N EXISTING OPENINGS�IYes L7No LOCATION F'WINDOWS 3. Energy Caiculations
�R FOR NEW OP£NINGS-DESCRIBE SIZE OF �I dI /' oti M
�PENING CHANGES & �
[YPE OF WINDOW TO BE 7NSTALLED ��� NUMBER OF WINDOWS �
ALL FEES ARE BASED QN VALUATION, INCLUDING THE COST OF LABOR.AND MATERIALSs
(tTSING THE 1997 U.B.0 FE� SCFIEDULE)
TOTAL JOB VALUATION $ / S!,3 OCCUPANCY TYPE
'emut Fee ' .$ S?. c S; See Back Page for Fee Schedule :
'lan Keview $:. 65% of Building Permit Fee
_
>urcharge $ ,>? L, (.OQOS) times the totsl job valuation - Minimum $.50 .
�ire Surcharge $ /. '$ 1 , .001 x Permit Valuation {1/10%) , �
,icense S�.u�charge $ �, o d $S.OD (State Licensed Residential Contractars)
�AC Charge $ $1450 per SAC Unit {Plans to'MWCC for determination)
:urb Cut Escrow $ ft+ 6 ft= ft x$20 =$
irosion Control $ $450 Conservation Plan Review
'ark Fee $ Fee Determined by Engineering
ewer Main Charge $ Agreement necessary O Non Necessary O
'otal Dne $ , 2 Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLTCATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
hereby apply for a building permit and I aclaiowledge that the information above is complete and accurate; that the work will be in
�nformance with the ordinances and codes of the City of Frrd�ley and wi�h°theMinnesota Construction Codes; tiiat Ttmderstand 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 accoxdance with the approved
lan in the case of all work which requires review n proval of plans.
.GNATURE OF APPLICANT�C /�--�� PRTNT NAME ! �� S ` � / �' 1 � DATE �( � � l � �