P - 48643Building BUILDING Permit Ivo.�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vat e'�
763-502-4977 FAX �� `��Z��-�
EFFECTIVE 1-1-2011 w
DATE � �.� d YOURE-MAILADDRESS msample@hwconstruction.com
SITE ADDRESS � • 1 �' � � O '�, � Y � e5 �
THIS APPLICANT IS: ❑ OWNER fffiCONTRACTOR
PROPERTY OWNER/ N�: i
TENANT �DRESS: �y 1 b '�111�� V ��W� I�.�R.N� CITY ��(' �� STATE�ZIP����
PHONE:
CONTRACTOR N�: Hoffman Weber Construction
SUBMIT A COPY OF STATE LICENSE # 4O�J432rJO LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF .�D�ss: 7932 University Ave. NE c�TY Fridley sTa� M�rn 55432
INSURANCE pgp� 763.300.65542 F,�
PROPERTY TYPE $I SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ��DITION ❑ G�GEIS�D ❑ wnv�ows
O BASEMENT FINISH ❑ ROOF O DRAIN TILE
� DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �eS��
S1ZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NiJMBER OF SQUARES ❑ HOUSE & GARAGE l. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPEIVINGS ❑Yes ❑No 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 l+'r:�a AKl�. IfAar:L V1V
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
VALUA'1'lU1V,11VCLUllllVG "1'HE CUST UF LABUR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
�Q6� .Ud OCCUPANCY TYPE
� �b�`L'�jj See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � Make checks payable to: Cityo uf Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTN'I'IL 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
approved plan in the case of all work hich requires review and approval of p s. �7
SIGNATURE OF APPLICANT /�/L-iJ � PRINT NAME � c'V� av � 6 N.S� DATE J
APPROVAL INSPECTOR SIGNATU