P - 45309�uilding
rnspections
i63-572-3604
DATE f � l � l �
SiTE ADDRESS S Y �
THIS APPLICANT IS:
PR�t ERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WTTH APPLICATION
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:
Received By;
Date Rec'd:
YOUR E-MAIL ADDRE ,f � Cl (�S G� ��c( ! i �(i %i :! S. i O�
,rnn�f- � s�
❑ OWNER �CONTRACTOR
u.�: J b n t 1� J 1 n S-� n
�,D�ss: S y��S !,�• 8`� n nc r Ps
PHONE: Z 4�S � Y 3%� , 0 0 3 3
N,�E:_ I'HD At- Home Services, lnc.
sTa.TE Lic 2690 Cualiberland Pkwy, Ste 300
�DttESS Cumberland Office Park
PxoNE Atlanta, GA 30339-3913
'QSatGiE Lic# 20268257 Ph. 7C3/542-8826
❑ TWO FA
Q ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I � ��'
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFTNG
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ROOF
� SIDING
❑ SWIMMING POOL
❑R
%�f
LENGTH
❑ HOiJSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
O Fascia
F��INDOW S
IN EXISTING OPENINGS �Yes �No LOCATI9� Of W� OWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF K� T'�"'�
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED `� S����� NUMBEIt OF WINDOWS �
CITY ��' ��`� l� STATE_ZIP J s y3 a
Jod� m F(d�r Jon�c 5
qsa (3Y5- (.oU7
CITY STATE ZIP
�E
.ORIES
WINDOWS
❑ DRAIN TILE
❑ OTHER
/i� �r/s /��•' Oo.ln/il.�
WIDTH HEIGHT S . Ft.
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurat members to be used
FOR NEW CONSTRUCTION 1NCLUDING DECKS,
ADDITIONS, & 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 MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ /.�% 3 7 OCCUPANCY TYPE
°ermit Fee
Plan Review
Surcharge
Fire Surcharge
L'acense Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� 'Y 7. g o
$
$ .`a
$ ���3
$ S. o V
$
$
$
$
$
$ Y. 7
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 (Pians 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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID ITNTIL PROCESSED
Attach
[ 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 work is not to start without a permit; that the work will be in accordance with the approved
�lan in the case of al] work which re uires re i andapprovat ofplans. �� �
iIGNATURE OF APPLIC � \/ v PRINT NAME ��' - ` � ! " ' ! n � DATE ( � /