P - 59369Building $jJIj�DIN(T Permit No.: ����1�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vat�'�: � pR ���Q �
763-502-4977 FAX EFFECTrvE �-�-zo�z
DATE April 23,20� 2 YOUR E-MAIL ADDRESS jarleigh@hotmail.com
siTE nDDx�ss 6740 4th St NE
THIS APPLICANT IS: L:�OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: James A Larson
TENANT ADD�ss: 6740 4th St NE cITY Fridley sTATE ZIp 55432
PHONE:
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: Replace existing fiberglass shower stall with new one new sink and sheet rock
SIZE OF IMPROVEMENT LENGTH 100" WIDTH 50" HEIGHT $$'� S FT 34
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
� Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED? O YES ❑ NO and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'�r;5 AK� BAJ�L ViV VALUAl1VP1, 11Vl,LULlI�I� i n� �,vai vr LHDVII Hl��/ 1�1[i i iJ1�it�L�.
(U �N HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ a � See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ (p .001 times the total job valuation
Surcharge $ � .0005 x Permit Valuation Minimum or .50
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ y 0�1ci_ Make checks pa_yable to: City_ of Fridle_y Attach
TH[S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I 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 codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a perm�t.a work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the cas f all w r,k� �„requires review and approval of plans. Oa/26/2012
SIGNATURE OF APPLICAN�'. r�-- PRINT NAME James A Larson DATE
APPROVAL INSPECTOR SIGNATURE _