AF - 45048` r�
City of Fridley, Minn.
6431 University Ave. I+�. E., Minneapalis, Minn. 55432
BUILDING PERMIT
na{�; __ October 16,, 1972
Co 3.=3-��
11 �
py��; Robert DeGardner Const. Buiider ___.Same ___�,�� .__._._.__._.._....W.._.
,Address - 7950 East Itiver R.oad N.E._�,� Address __�Same __�__��_.__.____�� __�
LOCATION OF BUILDING
Na 6 215 Street ._._. A1 den Wa� N_. E.__ _-.---- -.-- ---------.--.. Part of Lot .�._
Lot � Block .1_._.�.._�._.._._._.. Addition or Sub-Division .__�A� ose.�j,����,�,o,n.,__._. ,�
Coz7ier Lot ..._ Inside Lot - X _.._..._ Setback _.______.�_..___.___ Sideyard .._..._._._.___ _.._..:_
�v6�IIevatian _...__.$23....45� _ F6uGid�i�ii�i/�a�ti�_____.�26,_�5 Minimum _��
Wye Top of Footing
DESCRIPTION OF BUILDING
To be vsed as:
Dwelling ._... Front 26 ` Depth 38' Height .... �� �.....,. Sc�. F'� __104Q' Cu. Ft _._..
�a..�g& ___ Front .�_� Depth � Height .._. �:�_�___ Sq. F't. .---•----_•-_-•• Cu. Ft ....__
Type of Construction _..bLo4.�..F.���.,_ Es� Cost ..x�.�..la-3�3.,� 56._.__._.._ To be Completed _._.__.6 _months _„_
Stipulatinns: Provide a hard surface driveway. Provide a verifying survey before
capping.
WATER LOCATION: 55.2' North of Manhole 63.6' East of Manhole
SEWER LOCATION: 41� NNW of Manhole (Inv. 823.28)
In consideration of the issuance to me of a permit to constxuct the buil g escribed above, I agree to do
the proposed work � accordan� with the description above se�t for��i^�'�c pliance with all provisions o!
Ordinances of the ci of Fridle . Sc, /'
15.67 State SurcYiarge
In consideration of the paynnent of a fee of $_._..Le9....D1L.__., permit is hereby granted to_...1?�..ga�dne_,r.• �o�,t.
_ to construct the building or addition as described above. This permit is granted
the express condition that the person to whom it is granted and his agents, employees and workxnen, in all wo�rk�
done in, around and upon said building, or any part thereof, shall conform in all respects •to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of building�
�yi'F.hin the city limits and this permit may be revoked at any time upon violation of any of�the provisions of said
ardinancea
_.�_ ffig Inspe�i�
- - ('T ARF1Q F BELTST F ^
NOTICE: I
This permit does not cove� the eonstroation, installation for wiring. plum6ing, gas heating, sewer oe water. Be sun �o sN
N�s Building Inspecfar fo� separata permits for theae items.
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�FP�ICATI�N �Q� RE�IA�NTI��. �LT��AT�AN,
�R �D��TTQN �UILDTNG P�RMT�
��TX 4F PAIA���t MINN��QT�
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' ► - _ ��� e BUILDER r �E5 %�
•WN� S P�AI� .
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�ann�ss : ��`j J t� / �' � v ���1 r ��ss :
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LPl1 � '�-' " �yLVtIA � / A1i7i�I.Li�o� �w� .F � � i r R 1 � � e n
CQ�KN�R LOT; �N$� I,0'�:�_,�, 3�TBACRt SIDEY4I,RD:��,�,
.�►�.�,� ��„aci� �o, �h� �+�a+t�,,,,ia Certificatea of SuYVeX o� Lat a�d propQ�est
bai,id�g �.�ati,ot� �� � #�ae Ce��tificates,
���C�tI�'T�QN OF BUILDZNG
�o � U:��d � :
.._.....-...., �._.�. t'°� l �e:tght : oZ. �
1/ , �� �
Squ�xe �'s8�3 Cu�i� �'�eC3
�� ��.' �:.� : .��� Fratt� : % ��'�' �,�, `` f Depth ; �. �,� Hei.ght :�„_�....,�
&�uax� �'eet; Cubic Feet:
�� oi �on��xu��i.�aA� �.. �Y�rr'�.� �at#�ared cost:. $ ��,.,�.� .� �.- �--=� f�
�r� �+S il�l+R��cl;
�et u�t��pi.$xted hereby a�ces s�licativrt €or, a pe��t fax the wp�'k bsreit�
�pa�i��d# a$;eein�, t� do al.l �'ox'k �n st�k�.c� accordance wi�h the ��.ty �f
�'l.d��qr t��d��a�ces �ad �'uli�� �P� ��i��eT� Pf Bu��di.ngs, +�d i�ezeby
d±M,�lasea� �� al1 �h� ��cts �d ���resentati,ans stated � xhis applicatiar�
�� i-.ru� a�d �arre ,
�A'I'Fi; � �-- S�GNATtT$E : . _"�
�t��O R+#��6'0� S�.d� Fo� Add�t�anal InEozt�atian.) �'; ;�. �,� ��`s
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Civit Enyin��rin9 � �� tt/rpllO�Ri fi�t•60�6
Mw�icipa! Enpin�erinq Engineers & Surveyor• '�'�'�� ��3
Certificate of Survey !ar A� IV1� N
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--- �eno�e� pra►nape and �iili� �,aStmtnt � Ocno}tS �rar� m�um4�1�
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Anoka co�n
1 h�rtby ce�tifr tho� �his is o tru• a�d corrsN r�pr�a�nta on o/ a wrv�r ot tl�� bov�deri�s of tl� a►ovs
d�scribsd bnd, and of 1h• location of oll bueldin s� th�►�on� oed oll visiwl• �ncroocl�m�e+�s� if �wr, fr�iw er �n
said land. As surv�r�d by me this dor ol �ib.�a.ry A.D. t4T1 .
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SU:URtAN fNGINEERtNQr, tNC. �
� n �1 i Engin��r Sur y rs
r � �eale: ���h t �� }e« ,'
, � f � � ,,�-�_--���... . __, .
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o ��:-Q s _�, .
Appiication �or Powtr PIaM�s and HtaNng� Cooling, Yentitation. R�ral�ion atd
Air Conditioning S�s �d Devic�s
PARTIAL RATE SCHEDULE
IiAAVTTY WARM AIR: �� T��
lLrnace 3hell dc Ihut Work . . . . . . . . . . . . . . . . .310.00 ;
Replacement oi I�rnace . . . . . . . 6.00 =
Repairs & Alterations—up to ;500.00 g.pp �___ _
Repairs d� Alterations each add. =500.00 , 3.0U ;___ __ ____
MECH. WARId AIA
I+tirnace Shell dc Durt Work to 190,000 BTIJ ... .. . .$10.00
each add. A0.000 BTU ............. .. .. .. 3.W
Replacement of �rnace 6.00
Repairs dc Alterations—up to E500.00 6.00
Repairs & Alterations each add. s500.00 $,pp
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STEAM or HOT WAT'EA SYSTEM
F�rnace Shel] & Lines—to 400 sq. ft. F.DR Steam 110.(!0 $_____ __
Ftirnace Shel] & Line—to 640 sq. ft. EDR Hot Water 10.00 $_.__
Each add. 200 sq. ft. EDR Steam �,p(� �. _. ___ _,_
Each add. 320 sq. ft. EDR Hot Water 3.pp a---
OIL BURNEA—to 3 gal. per hour
over 3 gal. per hour�ee Fee Schedule
GJ1S BURNER (up to 199,000 BTU)
over I99,000 BTfJ See Fe� Seh�dul�
6.00 S— —
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6.00 S °..�•
GAS FITTING £EEB: pp A�� �o•p�
lst 3�xtures xa 200 E. �Of
Additional F3atures x .76 � —
Gas Range to 199,OOp == 6.pp ; ^
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AIR COIfDITIOl�I11G
FAli HEATII�G SYSTEN �''9 T�'! S�e F» seh�da4 �
vsariLAtiuc sYSrax �
AL7`ERATIOltB ! REP11IlM '[OTAI. FE8 �c3�. �U
ROU(3H
�rr�u. � -,� � �- 7 ,Sr
�SURGHARGE $ _.5�)
n.pt. of sw¢. ri►�. seo-�so
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City oi iMdley:
The undersi�ed hereby makes application for a permit !or the work hereir
specified, agreeing to do all work in strict accordance with the City fhdiaance:
and ruling of the Department of Buildings, and hereby declares that aIl t�c facts
and representations stated in this application are true and correct.
�Y ley, 11� ,�/� _ � I��
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Owner �� L.r � `. j
Kind �f Building ____J��i%%>%�
v�� aQ __ _ /��rJ��' _„�i.��G _
To he completed about __.__��'"��-1/y%�G`%L /-�
�, �
Estimated Cost, �___-_-���!G�_---- ---
Old-�! g��uilding Permit No. _ Psrmit No._ '7` �
DP.sCA1PTi01� OF WORR
HEATING or PO R PLANT3-.-Steam� iiot Water,�a�No./
Trade N ame ��L`� ��"� �C�= Size No- 'S y���
Capacity f�FG�vC..�l r%Sq. Ft E.D.R "� �� BTU H.P
Total Connected Load� � �
Rind oi P�ue �
BURNER — 1Y�ad�e Nam ��' �� �°- Siu No��,��.�_
Capacity ��(.� v C%�/�'I gq. !'t. E.DR-��3'.i�.�"�� BTU i�ip!
��:c.1 i /� C? T /`t �f7.t� ---
...v� s T� .�� C � � �%zl, � �. �G',����,� .�9/�
�o�� ���. ;�1' $. W�-�^, .--:' , icti i�l�`dG Ct�.�
T� r�
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��� i�G'.G� h�iL�APOI_IS,, MINN_E�O�'A� �4071�
�s� L�D�i �'� Hs �
�%�D �/'�/�'j — Huafness P6one No �✓ �
(REMARKS-OVERj
HOUSE HEATING TEST RECORD
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' ADDRESS ���� J �� �� � APT. F 00 CIT SUB B; �
OCCUPANT OWNER , � � ,ea.+�.�
' HEAT LOSS DATE HTG. INST. GAS C0. ME7ER BADG #
SOLD BY INSTALLED BY �
Eleetricol Work By Gas Line By
TYPE OF HEAT GA FA HW STEAM SPACE HTR. UNIT HTR. OTHER
� GAS D IG � � CONVERSION
MAKE ���—MAKE OP BURNER
Model �L�//33 � Model
� Seria l ��.��/.L `" ��? Max. BTU Rati ng
INPUT ���..,�� MAKE OF FURNACE
� Model
�y� CONTROLS k
THERMOST '��" t Plug Yent Size
Vaive KIND OF LINER E NONE
Limit Drah Hood Regularor
Limit S�Ning � Filters Size � N%um� r
Fan 5etting �-�-����� Chimhey Loeation Inside +�Outside
Pilot Type �� � Chimney Construetion
Pilot Make *���� t/
Pilot Model Smoke Bomb Wiring �h
Pilot Timing � -Qe=. Draft � Test Tap V_
(...W. Cut Off 62�?�_ �� [�por Pressuro Lightiny lest.
,,�. v
Prossum c��'2^—Perc�e��.Cjp DaM i�sted `�'
(r�ut CFH ! `�� P�K�{t` 4- "� �` �mpany Testing
2
Stack Tsmp. �'�^%� Percent CO Q� Name of Tester
Form 235
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Num�bef ��xeear�� o � , . . . . . £ . o . � , . � � x iZ.00 :1 D • o�z�
fi�tur� P':�:4urr ,,, rnins . . . , a . � t . s _ .,..�.1..�._ x =1.50 $ 1•�
Ne�r Fixtun� Olc� Opening. .. �.. e.� o.. ,�� x=I.50 =
Calc!� �a��� e , m . . . . . . . . . � � . . . . . . : =3.96 =
V�atEr H�:ter '�,°�p to 99.0(f� BTUI .... j x=3.00 i`3` `�
I�e� Ground Iiun Old BI�Q. ........ x i3.25 f
El�etrle Wabr iirt�r . . . . . . . . . . . . . . ■ �2.00 i
GAf i7TT1NG FEES: NO. RA7'8 TOTAL
l�t � Fixtura . . . • . . . • . • • . • . . • • �— x M.00 : �. �
Additioaal l7:turea . . . . . . . ... . . . . . � i .?6 ;
(fa� Ranse to 19Y.000 BTU . .... . . . . .. x =5.00 i
• 5tate Surcharge $ .50�,
IL�TJ1Ills t 11LTE1tATIOIfb--R�f�r !e Cod� _
De�erlptlon ........................................i d-�J
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_...1: ,.�[�.� MC..0 ,.:if86sWas.:2 ki°�i.� g� "G�,�.:5 e.�; �e%C.Kx�rf^!?; �12'e�c ? .. <t'.P's�� ti`^,�"k°�
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tCind �� �;ni.din� �.a , _n_. __�.._.....
ilsed as �...,...�___�_____ _4 � �—
Tca tx completed af�t� �....�.-. �,.�,.,.,,.�.,�...... _�_
�tiErated t°a+�4, �,_,.�,.�.�,.._ ,
� s;�-4/„�„
OId--New. Build�ng F+^rmit No. �' �
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Br �� • !i �iGS �
HYSines� Phuor NO.:� ,
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FWl1I.o�'��' %�
SUBJECT . P •
City of Fridley 216 71
AT THE TOP OF THE TWINS g � I L D I N G P E R M 1 T
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� • COMMUNITY DEVELOPMENT DIV.
, �L--.--- . 1 � �
r � � PROTECTIVE INSPECTION SEC.
� �
� � /'��1 � CITV HALL FHIDLE� SS432 NUMBER REV. DATE PAGE OF APPROVED BV
�'""'�" ,�� 612-571-3450 910-F15 11/23/92 � �
108 ADDRESS 6215 Alden Way NE
1 IEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 3 1 AZ Rqse AC�C�].'t1.QT1 SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Marion Hubbard 6215 Alden Way NE 572-9204
3 CONTRACTOR MAIL ADDRESS Z�P PHONE LICENSE NO.
Milton L. Johnson Co. 525 Lowry Ave NE M ls. MN 55418 781-9548 2083
4 ARCHITECT OR DESIGNER MAIL ADDi;ESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADORESS ZIP PHONE IICENSE NO.
6 USE OF BUILDING
Residential
7 CLASS OF WOR1E
❑ NEW ❑ AODITION � ALTERATION � REPAIA ❑ MOYE O REMOVE
8 DESCRIBE WORK
Rexoo� Hous.e (24 S; uares) 2nd La er• and Reside with sof£it & fascia
9 CHANGE OF USE FROM TO
STIPULATIONS
Rpo�ing can be 2nd layer but nat 3rd.
TVPE Of CONST. OCCUPANCY GROUP OCCUPANCY LOAO
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL. PLUMBING, HEATING,
VENTILATING OR AIR CONpITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENOED OR ABANDONED FOR A PERIOD OF 120 OAYS AT
ANY TIME AFTEFi WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ ANO EXAMINED THIS APPIICATION 1 STAL�S GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF �AWS VALUATION SUFTAX
AND OfiDINANCES GOVERNING THIS TYPE OF WORK WIL� BE COMPUED $7�672 $��H4
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW FEGULATING CON- $�9�QO k'lr2 SC $7.6�
TRUCTION OR THE PERFORMANC OF CONSTRUCTION.
- PLAN CHECK FEE TOTAL FEE
j/ -d 3-5 Y License SC $5. 00 $115.51
NATUAEOFCON'RACTOF70AAUTH0�71ZEDAGENT IDATEI WHEN PRO EiiLY LI TED THIS IS VOUR P/EyRMIT
r 1/��Z� _ J��
SiGNATUREOFOWNEAUFOWNERBUILDEA� iDATE� OG iN5 ���TE
�
NEW [ J
ADDN [ ]
ALTER [ ]
_ CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
Construcdon Address: ��/ S r�L �E'.cJ l�A 1�
Legal Description:
Owner Name & Address: /rj,4,e%
0
w� �' �s
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Eitective 3/1/92
Tel. #.57�- - y'� o �
Contractor: /y� j L To ,cJ � .T-o�,vSo �cJ � • MN LICENSE # �;Zo g3
Address: �"�S" G.oc,�.,� c� i¢�/E .�•F'. ��l��S S3"z,�/ d' Tel. # �l �-� g5'Si�
Attach to this application, a Certificate of Survey of the
lot, with the proposed consbruction drawn on it to scale.
LIVING AREA: Length
GARAGE AREA: Length
DECK AREA: �elrgth
OTHER:
DESCRIPTION OF IMPROVEMENT
Width
Width
Width
Height
Height
Hgt/Ground
4
Sq. Ft.
Sq. Ft.
Sq. Ft.
OL�
�
� : �`�fJ�?
�� �
Comer Lot [] Inside Lot [] Ft. Yd Setback Side Yard S acks
Type of Consiruction: ,e�-,�d�� � S,�s�;v G. Estimated Cost: S�
Approx. Completion Date: �a -�/ -s 1-- �� 7a --�
(Cost on Back)
Driveway Curb Cut Width Needed: Ft. + b Ft = Ft x$ _$
DATE: �/-.i'3 - Y 3.- APPLICANT: c�� � 4����+r�..� Tel. #�%�'%'iS 5��
S'ITY LTSE ONLY
Pernut Fee $ ��, �j � Fee Schedule on Reverse Side
Fire Surcharge $ `�- ��j .001 of Permit Valuation (1/lOth%)
State Surcharge $ �. vy $.50/$1,000 Valuation
SAC Charge $ $700 per SAC Unit
License Surcharge $ .5�. �� C� $5.00 (State Licensed Residential Contra.ctors)
Driveway Escrow $ Alt. "A" or Alt. "B" Above
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement Necessary (] Not Necessary [)
TOTAL
STIPULATIONS:
$ /��-� /
.� _ .
CITY OF FRIDLEY INSPECTION DIV. �-- G��C�, _
6431 University Ave NE ��
Fridley, MN 55432 �--------�'°' APPLICATION �OR PLUMBING AND GAS FITTINC� PERMIT
572-3604
MARK�NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLt�OR
Effective On May 1Q, 1999
PLUMBING FIXTURE RATES:
New Fixtures
Old Opening, New Fixture
BeerDispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Water Heater -Electric
Water Heater - Gas**
Gas Range"*
NO. RA.TE TOTAL
�
Gas Dryer"*
Back Flow Preventer Required ()Yes () No
Type
� 7.00
$ 4.00
$ 5.00
`� 7.00
9; 7.00
� 7.Q0
� 7.00
$10.00
� 7.00
$10.00
�10.00
�10.00
$15.00
Reinspection Fee $47.00/H�
ALL OTHERS AND/OR REPAIRS AND ALTERATION5
1.5% of Value of Fixture or Appliance
State Surcharge
TOTAL FEE
�
. � �i
JOB ADDRESS ��/w �"'
The undersigned hereby makes �h�p�lication for a permit for the work herein
specified agreeing to do alt work in strict accordance with the city codes
and rulings of the Building Divisinn, and hereby declares that all the facts
and representations stated in thi;c application are true and correct.
SOWELL, GARY
6215 ALDEN WAY
Owner_ FRIDLEY, MN 55432
(612)572-2399
IZ��Z-7 , �sss
Building
i'�'�� �'
Estimated Cost PERMIT NO. � c J
PLUMBING COMPANY ���� ��'� ��-�����I�G CQ.
, 2
SIGNED BY ��t�5 : 6 Ee� _�� /�,`'�t �. .
b.�'.�i'�;' ?; ���..i�� �'�!t�! ���-�_��
A roved B � ���'�
pp y Rough-In Date Final Date �
"•COMBUSTION AIR SHALL BE PROVIqED PER UMC SECTION 504(A) AND TABLE 6-A. MINIMUM �IZE 9 SQ INCHES.
CITY OF FRIDLEY INSPECTION DIViSION
�� ����
6431 University Ave NE �
Fridley, MN 55432 APPLICATIC►N FOR POWER PLAN7S AND HEATING, COOLING, VENTiLATION,
572-3604 REFRiGERA7fON AND AIR CONDI710NiNG SYSTEMS AND DE�ICES
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner
Also Replacement Furnace
(Side Vent - Fill Out Back)
Gas Piping (Needed with new furnace,
but not replacement)
Gas Range
Gas Dryer
*Air Conditioning - All Sizes
All Others/Repairs & Alterations (LIST ON BACK)
1% of Value of Appliance or Work
Commercial/Industrial
1.25% of Value of Appliance or Work
Rate TOTAL
� 30.00 $ 30 . o0
$ 10.00 $
$ 10.00 $
$ 10.00 $
$ 25.00 $ c�5� d0
$
$
State Surcharge
TOTALFEE
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATfONlA1R CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
$ .50
�.�.� d
Effective On May 10, 1999
JOB ADDRESS (D d 1 S /'t L d2)1.J � A�-f
OWNER_�B_(r� 1�_ �� W 2.�,L.
-. --��
BUILDING USED AS �W � II i N�
ESTIMATED COST �I�D� • �O PERMIT N0. /-� 1L�'/
DESCRIPTIQ�1 OF FURNACE AND OR BURNER
No. of Heating Units�_ Circle One (Steam) (Hot Water) ( arm Air
Trade Name IQu,t�.,� _ Size No. 6
BTU 75'�_ c�oo HP EDR
Fuel /L� A T � RS _ Total Connected Load
Burner Trade Name , Size No._
BTU _ HP __ _ ED
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes an
rulings of the 8uilding Division, and hereby declares that all the facts and
representatio tat�l�n fhis applacation are true and correct.
�i�er i sneet metal, Inc.
9928 Bluebird St. N.W.
Coon Rapids, MN 55433
H EAT I N G�� ����_,__-� 1 gA�—F�-i ,�c�- ,�,�'r:r�i "
Signed q�_ DATE � a
Approved By Rough-In Da���� Final Date ��.'J
�T1i,�l�g
�s�ections
�3-572�3644
From: 6513651332 Page: 1/1 Date: 11/6/200811:37:21 AM
P��Tfilt 1`+T4.:
��'�����* T�tecei�ved By:
1�+ SI�ENrC�I1.A.�.'PL�CA�"ION �a�;N 0 V 6 21
CIT'Y� (�� x'R�LEX
.TE %/y..5~-0 � /�
CE ADf7R£3S � aG�
Q3 A�FLiCANT SS: ❑ O �'��
A , ,�r . e
YbUR �-MAIi. ADDRESS �
awrt�t�
TENANr
SU$NfiT A CaPX OF
YbUR STA'I'�
LiCENSE WTi�l
u�nrtE: e sr��,�._,m�.���.
nr�xESS:_ � f�" .41.d �., r.rJ..� �--�TY f
p�o�: �sl- ai 6- 6 q
NAME: a 1 a �� J g�_p �
STATE LiCE135� # �+ / '1 %0 ��/�i EXP BA'fE �� gTAT6M�ZIP�`�/�3
d i �d e� .� i� d, CiTY_ ��° a�
A�tix�ss: G
PIi�NE l� - o FA7C �S/ 6f%2�e�
.-..........._---
PERMCi` TYl'Ts �'S��a.�Fr�m-Y
Cl TWO FAMX[-Y ❑ TOWt1Fi0U
� a t�w ��pc,acEn�'r
TYp� oF wo�:
� � e r j r".� /e t/�/u a
1)ETAiLED AESCRIPTIOAT d� 'V'►�ORK .
PER MS 168.66� tbe permit fee is a minimuro of �15,00 or S% ���� �°OS�cs �.f�s sb uld refSe t only tbercost o� Labor )
improvement, insta�lat►°n or replacem�nt of a residentiaJ �e� . �
x AS = y�
Uabar cost uader $300 =� t 5.00. Lsbor cost between� �300 to $500 = cost of labor �� ��� ���, �1�� r��
F4R P1tO5E�TS VJE�� iAB�iL E3CCEEDS $506. FEES ARE BASED b'hl S10.04 PE SHOW'ER ,� WATSR PLPING
tVU1vIBER 4F EACF[ BELOY� ��R DRAIrIS 'r' SW[MMI1�3O PdOL � WATER SO�F'fNER (�35}
aA'i'H SIl^TKlLAV GAS FIPIt3G lxF� �t►CEn'S� — vJAT1:R Q.QS'�[' ^�ACKI�'LOW PREV, (S15i
� iCITCfIEtJ SINIG � P�R iRR1GA � �n /�
� CIATHES WAS�-tER � LALiNDRY TRAY �WATSR HEAT�R (S35) � O'fHER bwh F�'•.I �`
� �D15HWASiI�R -- � Wf�TERl�fE7ER
r�w ,
Fce
� .�.ao Number of fixt�u'es �a $10.00 �X $10.00 = ti�__.�__�
.SU
Numher of fixnxres @ �15.(10 __ x �15AU � �
Numbes af f�xtuxas (a� $3 5.04 � x�3 5.00 =$�____..__
$ , �s. SD State SuYCbsrge - $
Tocal = S —
' THiS �S AN APPLICATION FOR A PERMI'i'-NO'i VALID LINTIL PROCF�SED
that T understa.nd this is
I hereb appiy for a building per�zsit and I acknowledge th ridle � and aeh the Minnesora Con�structiomcCc'des;�at �e a Dce with �e
Y
canfprmance with rl�e ordtnattces and c�des of tise City of Y
not a pasmit but only an apptication. for a permu� s�r �° wi�d epprfl a p gi�sa perr"lt; that tbe wvrk wi11 be in a�cor
approved plan in the case o wris re4 p� N�� D�.�.� � p f
Sj�yAT� OF APP1.I
._��+s w
���^��d
� �/�y� tSa�-l��►x"-7S',�s�
�r�rd y�s g��
��fr� I6G�
Z%� = ,�� 1�
City �f �'ridley
Building Y�spection.s �epart�nent
b431 University Avenue NE, k'ridley, MN 55�32.
763-572-3b�4
�'��: ?63-502-4977
Engineering
763-572-3552-
763-571-1287 fax
_.. -_ _ , . ..�.
WATER AND SEWER Permit No.:
� PERMIT APPLICA?I'ION �eceived B " � �
y v �� �
CITY OF FRIDLEY
EFFECTIVE 1/1/20t0 .��, _
:�
APPLICATION DATE: - _ Jl�f �- � O YOUR E-MAIL/FAX: . ; � 'a
T°HIS APPLICANT IS: / ❑ OWNER C�7C;UNTRACTOR v�s>' 4 F;
JOB ADDRESS: G� Z/ S /� � q�h C�� �
..-..;..=.,....— ..�-.�_... '
NEW CONSTRUCTION PERMIT# (IF APPLICABLE): -
PROPERTY rt,v�: D ..?-A � e l� .� _> � �;
��E� ADDRESS: _ � 7-/ SR� °J'� ✓J CITY eI '� STATE �21��;;,,,,, �, �
TENANT —
PHONE: I� r'Z ° 3 ia �o ~ 3 O y ;,, }'` .�
1 ' (� 3 �{
CONTRACTOR xA1vtE: �'o'!-'�-� JQ..a.R� � `� � f� :,r °
SUBMITA COPYOF �DRESS:_ -7 ?,� `�p �R V� CJ (� CITY A L STA , n �',�� `'� d' ,.
YOUR STATE �, � , 9
'� LICENSE WITH PHONE�Z � 3-�-( 7�- 6'� 1 2 CELL PHONE: �� 2-'Z 5 0-� 3 5.f' ` �
APPLICATION STATE LIG # ^ /vI STATE BOND�J S o a y� bF EXP DATE: ��" #' � t��� :, �`�
� � � � �' - �
� 1. Narrativ tten description: . °� -{ ' -
/ 1'" �� vl S8'P...c-S-�i � ✓'..� / C 2.� A � �� %'�d � r. �/�% � � `�:n�r r .
- #
. � �..0
2. Please attach sketch showing curb line, utility line, building, etc. with distances on b�ck psga �.., "'+
�
3. Stipulations: i�;� � � � ;
- �
� - �, .
k �
ti�
� -
PERMIT TYPE % ''� . x �
� � � � �� �.�� . � �� �
O. SEWER CONNECTION PERMIT $50 -
0 WA1'ER CONNEC.TION PERMIT �50 ` } ��b
' ❑ WATER LINE REPAIR $40 ,���;�:,
G SEWER LINE REPAIR �40 � � � ; - ��: �:
❑ ADD STATE SURCHARGE $.50 ~ � ' '
�� --'
❑ SAC CHARGE @ $2100 = ' � " �.
�;,...-.�..-;;
. 1.� �-V "' � ' x,
TOTAL S / ''
OTIiER CHARGES (IF APPLICABLE) PAY TO UTILTTY BILL�AIG '' z. �
NEW WATER METER COST - SEE UTILITY BILi.ING
SPECIAL ASSE5SMENTS - SEE EINANCE . ;
WATER TAP - SEE ENGINEERiNG '' +� � "�
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKETFDS 8c HOLIDf►YS �1i3 f� ' �
TFIIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED ' � �, ` � '' 4
Yv. , �
I hereby appiy for a water or sewer (new connection or repair) permit and I acknowledge that the informattic�e�v� i��tx�p�Z�jip�d;; �,.
accurate; that the work will be in co forrnance with the ordinances and codes of the City of Fridley. I ur�r�t�d th�s�:�4tt ��'�tt , t
only an application for a 't work i t to tart without a permii. '' � �:
SIGNATt3RE OF APPLI T�' > PRItJT NAME. pAT�; �b� /�_ � y''�
._�
,'-.' , : • .z
��VGVD�.. '� � � ^������� '`-4 3�.
DA't"�:. � , W� �
COPY G�VEN TO: o ITY BILLING (only if new meter) O PUBLIC WORKS �`��i�II�t� ;.
City of Fridley '
� -
ngineering Department
b431 University Avenue NE, Fridley, MN 55432
763-5?2-3552
FAX: 763-571-1287
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