P - 36799,�,
Bui1"aing BUILDING � ermit No.: �� I��
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY Date x�� �'
763-502-4977 FAX EFFECTrvE la-zo�i
DA� 8-9-2011 YOUR E-MAIL ADDRESS msample@hwconstruction.com
si� nvnxESS 5260 Horizon Dr.
TFIIS APPLICANT IS: ❑ OWNER �ICONTRACTOR
PROPERTY OWNER/ NAME: Tom sandy Haskins
TENANI' AnvxESS: 5260 Horizon Dr ci� F��v sTA� A�Nk� 55432
rxorrE: 763.572.8270
coN�croR NAME: O an e r onstruction
SUBMIT A COPY OF STATE LICENSE �! 4'O�32r'JO LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERT�ICATE OF nnnxESS: 7932 Universittr Ave. NE crrY Fridlev sTn� M�r 55432
INSURANCE PHO� 763.300.65542 F�
PROPERTY TYPE Xl SINGLE FAMILY/NEW CONSTRUCTION SIZE
O 'IWO FAMII.Y/NEW CONSTRL3C1'ION STORIES
PERMTI' TYPE ��DTITON � GARAGF/'SHED � WINDOWS
❑ BASEMEN'I' FINISH I� ROOF ❑ DRAIN TILE
❑ DECK 0 SIDING 0 OTHEI�
� SW'avIIvIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCI'ION ❑ ADDI1'[ON
❑ MAINTENANCFJREPAIR Q9 REMODELING
vESCiuBE woxx Bm�rG noxE: re�oOf storm damage
STZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING 22 ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES O ATTACHED GARAGE 2- Propasad Hoor plan
PROPOSID S1ZE: ❑ DETACHED GARAGE 3. List of structural tcembe�s to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ 8c PORCHES SUBMIT:
0 Vinyl OSoffit 1. Site Pim✓Swvey showin� the existing strt�cha�es
❑ Aluminutn ❑ Trim
0 Ottter CI Fascia � F►�Po� Prol�
2. Two sets of congtructan plans
VYINDOWS 3. Energyr Catculatioiu
IN EX[STING OPENINGS �Yes QNo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE ANA
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLID NUMBER OF R+INDOWS
ALL l+�l:l:.y' AKL�' BA�L�'ll U1V VALUA11U1V� ltVl:LUllliVli ltll: I:VJl Vl� LAlfllKAlVIJ M�ll'.xIAL.�:
(USING 'I'HE 1997 U,B.0 FEE SCAEDULE)
���
Permit Fee
Plan Review
Fire Stttcharge
Seu+chazge
Licx�se Surchar�e
SAC Charge
Cwb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Dne
$
$
S
� Sb
$
$
$
S
$
s �n�—
'ANCY
S� Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valoation Minimum $5.00
ss.00 (state Licensea x,esiaential contraccors)
$2230 p� SAC Unit (Plans to MWCC for detem►ination)
ft+6ft= ftx$25=5
�450 Conservation Plan Review
Fee Deterrnined bY Eagineering
Agreement n�ecessary ( ) Non Necessary ( )
Make checks navable to: CStv of Fridlev Attac
THIS IS AN APPLICATION FOR A PF.RMIT-NOT VALID UNTIL PROGESSED
I hereby apply for a building permit and I actrnowledge tt�t the infonnation 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 Constructi� Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a pemiit on site; that the work will be in acc�rdance with the
approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT PR1N'P NAME Mike Sample nA� 8-9-2011
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.
Mike Sample
e_ � , `-�°z�"
A��ns 1010846 - Haskins, Tom & Sandy
�olb � Jc�b 1 + (�aew �
Company representative: Zach Paciorek Actions
--_.____._ __.__ _..____. __________.____. _ . _____._ ___ _
Location: 5260 Hoizon Dr, Fridley, Mn 55432 0 (763) 572-8270
Progress Summary� Lead Measurements Estimates Balance Sheet Orders
Edit ]ob Progress
7ob Progress
Balance Sheet
Current Balance Sheet
Orders (3)
RoofinQ Order
� ` �` �.
6/20/11
Prospect Customer Built
; �- ,
� F � 'E,
-� "�� �
Invoiced Closed
(
draft submitted appro�
( a�ssii � s/ssii � s�s/
draft submitted
( 8/8/11 � 8/8/11
approved ordered deli�
B/e/11 � 8/8/11 � 8/�
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