P - 39846Building BUILDING Permitivo.i � �
Inspections RESIDENTIAL APPLICATION Received By: �
�63-s�2-3604 CITY OF FRIDLEY nate R�� '���
763-502-4977 FAX �FECZrvE �-i-zoii
DA� 8-25-11 Youx E-MAIL aDDxESS msample@hwconstruction.com
si� nnD�ss 5724 Jackson St
THIS APPLICANT IS: Q OWNER f�CONTRACTOR
PROPERTY OWNEW NAME: Gerald Guse
TENANT ADD�ss: 5724 Jackson St ci-rY Fridley sTA� MNzir 55432
PxorrE: 763.574.Q070
CONTRACTOR NA�: Ho man Weber Construction
SUBMIT A COPY OF STATE LICENSE #'4'054'3250 LEAD CERT NUMBER
YOUR STATE LICENSE
r� cERTTF�cA� oF nnD�ss: 7932 Universit�Ave. NE c��r FridleY sTn� M��r 55432
�rrsu�rrcE PHO� 763.300.65542 Fr�
PROPERTY TYPE $1 SINGLE FAMILYlNEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GA�G�sxED ❑ wlrmows
❑ BASEMENT FINISH lyj ROOF ❑ DRAIN TILE
❑ DECK D 51DING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCT'ION ❑ ADDITION
� MAINTENANCEIitEPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: R@-�OOf StOft11 C�1171ci�@
51ZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �_ ❑ HdUSE & GARAGE
1. Existing Floor Plan
C�ARAGES ❑ 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 ADDITfONS_ & PORCHES Si3BMIT:
Q Vinyl ❑Sof6t 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
� Other O Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIS'ITNG OPENII3GS QYes ONo LOCATION OF WINDOWS FOR W[NDOWS - PROVIDE U-VALLIE ANI�
OR FOR NEW OPENINGS-DESCRIBE STZE OF MANUFAC'I'URE STICKER ON WINDOW.
OPENING CI�ANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL l��El+;� AKH; IfASL+'ll U1V VALUAl1ViV, 1PIl:LUillPili 1nL� l:vJl vr LAnvx a1�L ivu�i�.c.f+. ��:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � 2� h Z� See Back Page for Fee Schedule
$ 65% of Building Pernvt Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ 5 U $5.00 (State Licensed Residential Contractors)
$ $223Q per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
� .n� �'h� Make checks pavable to: City of Fridley Attach
THTS 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 permit and work is not to start without a permit on site; that the work will be in accordance with the
appraved plan in the case of 1 ork which requires review and approval of plans.
SIGNATUREOFAPPLICANT � PRINTNAME Mike Sampie DATE 8-25-11
APPROVAL INSPECTOR SIGN RE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
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