AF - 45910y� I.
_114 `
City of Fridley, Mi.nn. � �'�
6431 University Ave. 1�, E., Minneapolis, Minn. 55432
BUILDING PERMIT
��� June 7� 1972
OWnex: _B�.er.t .R�_�aY ri� � ons tru.t' �1..SLXL Builder _..�.�1�.. .__.�__.__._.....__.___...____..v.
,Addx�eSS �F.a a r R; ver $ Q,3 d._.1�.,�._ ..�._. Address __ ��l€__..___...______._.__....._.._.._
__._...._._�_....
78� -/aa o
LOCATION OF BUILDING
Na 6231�. _ Street ___�lden W�,y N LE., ...`�...._.-----__.._...._�--_......---. Part of Lot _..�.__...__ ...—..
Lot �— _ Biock 4._.._.��.__._..�_. Addition or Sub-Division _.._._��.o s e__Add i t i on �
Corner Lot ..._ _ Inside Lot _..._..X.�....._._...._ Setback ....__..__35..'.___.___ Sideyard .__.__�_...5' & 15_'._...�._._____
� ne�a�� �23...sa _._._._____l.�a4����d�l �6(��6� _.._.._s2.6u.9c�.._-.(.�x�...2.-__.._.._..
Snive Top of Footing
DESCRIPTION OF BUILDING
To be vsed as:
�Dw ell in�.�_ Front _ 4.�..._ Depth _...26 �._. Height ....2Q� .._.__ Sq. Ft. .....�Q�2..� Cu. Ft ._.�.�.,..�� �
_.._ Front .....2.4 � Depth _.2.� � .._. Height .._�..Q.� _--• Sq. Ft ,------�.Z �2 � Cu. F� _._..�..�.7.�2 � �
Type of Construction _.�nia.o.tl._F'r�a,m?._._ Es� Cost _._..a��.2�.7�.��_..._.._.._.... To be Compieted _..._._F.?---_months
Stipulations: Provide a hard surface drive and a verifying survey before capping.
WATER LOCATION: 10' W. of Sewer Service SEWER LOCATION: 24' E. of Manhole
In consideration of the issuance to me of a permit to construct fhe building de 'bed above, I agree to do
�he proposed work in accordance with the description above set fo d in m ance with all provisions ot
OTdinances of the city of Fridley.
11.40 State Surcha e
In consideration of the payment of a fee of $ 5� - �� �__., permit is hereby granted to�i�}z��12eg8it11}er Const.
to construct the building or addition as described above. This permit is granted upo11
'the express condition that ihe person to whom it is granted and his agents, employees and workmen, in all work
done m, around and upon said building, or any part thereof, shall conform in all respects •to the ordinances oF
Fridley, Minnesota. regarding loc�tion, construction, alteration, maintenance, repair and moving of buildi�ig�
vyithin the city limits and this permit may be revoked at any time upon violation of any of the provisions of safd
oz'diiiances.
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._._ ._.....__._ .� Buildin8 �nspeeto�
-- �'T �RF T('F RFT TST F
NOTICE:
This permit does eot eover fhe construetion, installation for wiring, plumbing, gas heating, sewer or wafsr. Bs sun to sN
ths Building inspecto� for separate permits for theae items.
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APPLICATION FOR RESIDENTIAL, ALTERATION,
OR AllDITiON BUILDING P,ERMIT
CITY OF FRIDLEY, MINNESOTA
7
OWNER' S NAME : �� (ca � .(���cJ c � BUILDER: � � � �( Qt �t1 � 1�
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ADDRES S : � � ; �C} �.- J�i V � i( /� � � ADDRES S :
NO • STREET • �GQ� �'-N C�-�
LOT: BLOCK: � ADDITION:
L /� C9.S' � /'i-`W-B �.
� �_
CORNER LOT: INSIDE LOT: SETBACK: JS SIDEYARD: '
. ---R—��•
Applicant attach to this form Ttao Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
�ESCRIPTION OF BUILDING
To Be Used As:
L' ° Front : �� a.�� Depth : ,�- �.� Height : -f� ��%
Square Feet: � � Cubic Feet: � + �` ;-' � ,
, .
,
�; ' " Front: �-- `� Depth: ;--� Height: � ''�
Square Feet, """` Cubic Feet: �; �a ��
t�-� -� , " .
�pe of Construction: Estimated Cost: $
-�
To Be Completed: � �� �j �r� '•N�
The undersigned hereby makes applicativn for a permit for the work herein
specified, agreeing to do all work in stiict accordance with the City of
Fridley Ordinances and rulings of the Department of Buildings, and hexeby
declares that all the facts and representations stated in this application
are true and corr ct.
DATE: � Z� SIGNATURE:
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(See Reverse Side For Additiona.l Information. ) !' G/ � � , � � `„ , ` r'`•
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WtLLIAM A. CARLSON, PRES. CERTIFICATE OF SURVEY
2324 WEST 1 }p�h STREET .
888-2084
55431 a �a�.we ,
AR�
SURVEY FOR�
DEGARDNER REALTY� INC� LAND SURVEYORS
Licensed, Insured 8� B,ondsd
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DESCRIPTION� LOT S� �LOCK 1� AL ROSE ADDITION.
�NE HEREBY CERT 1 FY THAT ON THE �I 1 TH DAY OF .JUI, Y� � 9�T2� WE LOCi►TED
THE BUILDiNG ON THE A80VE DESCRIBED PROPERTY AND THA7 TH� A80VE
REPRESEtVTAT I ON I S TRUE AND CORRECT. � �� ,."t
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la�d Planninq
land Surveying
Soils 1�sting
Civil fe+�in�ering
Mu�icipal Et�qi�eerin9
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Certificate of Survey for A� IY,�V��N
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i h��eby csrtify thot thi� is o tru• and co►►ect repr�seMa ion o! o surver of fk� bovadOri�s Of tAf a�ow
d�scribed lond, ond of rhe locntion o4 alt buildings, ther�on, and oll vi�ible •ntroatkia�ntl� if �nr, fr�m er On
said land. As surv�ysd by me rhis day oi ��%ruut� A.D. 197i .
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SU:URSAN ENGINEtRtNQ, iNC.
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Appiica�ion �or'owtr Pla�ts and H�aNng, Cooling, Yenh'totion, R�ig�ralion a�d
Air Conditioning Sxst�n�s a�d Devica�
PARTIAL RATE SCI-�EDULE
Q�RAY*TY WARbt AIR: 1U1T6 TOTAL
ll�rnace Shell d� Dnct Work . . . . . . . . . . . . . . . . . . =10.00 �
Rrplacement of F1�rnace . : . . . . . . . . . . . . . . . : , . . . . . 6.00 �
Repairs dr Alterations—up to �500.00 g.pp = __. _,_,
Repairs dc Alterationa each add. =500.00 . 3.W �__ _
wccH. wuus �n �
Ptirnace Shell dt Durt work to 1�0,000 BTU . . . . . . . . . . a1o.00 �Ld :
eac6 add. A0.000 BTU ............. ... .... .. 3.W i
Replacement oi �rnace . 6.00 ;
Repain dc Alterations�-up to ;500.00 6.00 E
R.epairs & Alterations each add. sS00.00 g,pp ;
STEAM or HOT WA1'ER SYaTEM
�rnace Shell & Lines—to 400 sq. tt. EDR Steam e20.00 $ ___
F�unace Shell & Line—to 640 sq. ft. EDR Hot Water 20.00 a_
Each add. 200 aq. ft. EDR Steam g,(�(► _.___ ___ `_
Each add. 320 sq. ft. EDR Hot Water g,pp =__
OIL B�JRNER—to 3 gal. per hour g,pp a _
over 3 gal, per hour—See Fee Schedule
C �T
GAS B�TRNER tup to 189.Opp BTU) b.pp s J
over 199,000 BT[1 Sse F.� Seh�dul�
GAS FITTING FEEB: Ii0 R11TE OTAL
lst 3 FSxtures . xE 200 5���
Additional Fi�ctures x 96 S
Gas Range to 1�.000 zi 6.0� _ —
AIA COIfDITIO1fIl1
i�----J�__
PAI�i HEATII�G SYa?E�t SM Pw sch�dnt�
YEIfTILAYIifG SY8'1'E!t �-J���
ALTBRATIOIfs � AEPJIIIM TpT�y pEg
ROUC3S
Ftrr�r,
(Sl1RCNARGE $_.�0)
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cic� o� �at�:
The undersigned hereby makes appHcatlon for a permit !or ttie worlc hereir.
specified, agreeing to do all work in strict accordance with the City Ordihance.
and ruling of the Depai•tment oi Buildings. and hereby declares that aIl t6e facts
and representations stated in this application are true and correct.
Owner
Kind of Building ._�__ ���%i�/�
r1se� as . --_ ._ .�����i/V � _
To be completed about ---���, l�rl
,�-
Estimated Cost, a-.—_-� _-_ --_,—
Otd--� Building Permit No. P�rmit No. ,� ' y�
�
DESCAIPTIOIr OF WOA][
HEATING or PO P'LA team� Hot Water Warm Air No /
Trade Name nr�� �C'. Size No`����/�
CapacitY--4 �� Sq. FL E.DR BTU gp
Total Coanected Load /��� Kind oi !Le ���
BURNER — 1Yade l�am � G�C- Siu No�Gi�DG
Capadty- OvOI��/%% gq. �'t. E.D.R.1�. �✓�"� gT[J
i�iP.
2,c�s TAS � C 1) �G9,cJ. �-G'c° T.q %?S'— .�T,�/
��J �/�/�'% — ��/i �d '� ��1 — �G'�i/l)C f}IR �4N�'Ji7l,
(REMARKS-OVER)
si��� RAY N. WEL7ER HEATING C0.
� A AVt.
By MIdL�LEAP_OLI �AI�OTA 5540.�
H� Phooe No �/S `� � �
QESIDEhTIAL
CITY OF FRIDLEY
Effective Date May 1, 1988
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND
AIR CONDITIONING SYSTEMS AND DEVICES
�ATE SCHEDULE
` RATE TOTAL
Furnace Shell and Duct Work,
Burner (Also replacement furnace)
Gas Pipinq
(pipinq needed with new furnace)
Gas Ranqe
Gas Dryer
�
' Air Conditioninq (all sizesl
All Others/Repairs and Alterations
18 of Value of Appliance or Work
COMMERCIAL/INDUSTRIAL
18 of Value of Appliance or Work
S 2U.OU $ 2 v.e�
$ L0.00 $ �/D , vo
$ 10.U0 $ —
$ 10.00 $ --
$ 10.00 $ i� °�'
State Surcharqe
TOTAL FEE
Reinspection Fee ($15.00)
Rough Insp.
Date
Final Insp.
Date
Approval for Permit �i ���
MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00�
PLUS $.50 STATE SURCHARGE
•Air Conditioners can not be placed in side yard without
written permission fran adjoining reighbor.
$
$
$ .50
S
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Job Address ��/ (/ � � %a !� /_� � G� i� �i/�t. �{
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Department of Buildinqs, 6431 University Ave. N.E., Fridley, MN 55432
City of Fridley
Tel. k571-3950
The undersiqned hereby makes application for a pexmit for the work herein
specified aqreeinq to do all work in strict accordance with the City Co�des
and rulings of the Department of Buildings, and hereby declares that all the
facts and representations stated in this application are true and correct.
Fridley, Minn. � 5 , 19� `�
OWNER �� 1l1 t�✓� � � E �- C� . < <_ [!_c � �"�
KIND OF BUILDING � _ -`�-� ` L% �=� 'To !�(
USED AS �( � � �*�--�
TO HE COMPLETED ABOUT J A,� J�- �.-, r Y�- �
ESTIMATED COST
OLD - NEW BUILDING PERMIT NO. +� � �-.� PERMIT NO. �q `7
—'T'
s �ib _ �
� � S DESCRIPTION OF FURNACE/BURNER
%� `'� HEATING or POWER PLANTS, Steam, Hot Water, Warm Air- No.
i
. U Trade Name Size No.
Capacity Sq. Ft. EDR BTU HP
Rbtal Connected Load Kind of Fuel
BURNER - Trade Name Size No.
Capacity Sq. Ft. EDR BTU HP
Company _
Signed Hy � ���
Te�. �. .� j/ 2 q ys
Fill out back sid� for stack verification on replacement furnaces
sue�ecr PERMI
City of Fridley 19587
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
f
t �
, � RECEIPT NO.
� 1 y_ COMMUNITY DEVE�OPMENT DIV.
r � � PROTECTIVE INSPECTION SEC. � 9�SID
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l.--- j;/'��;,J CITY HALL FRIDLEY SS432 NUMBEFl f7EV. DATE PAGE OF APPHOVED BY
L J� 6�2-571-3450 910-F15 7/11/88 / /
JOB ADDRESS 6231 Alden Way N. E.
1 IEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 5 1 A�. ROSG' Af.�dlt].OII SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
,3ames E. Walker 6231 Alden Way N.E. 571-2945
3 CONTRAC70R MAII ADDRESS ZIP PHONE UCENSE NO.
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW � ADDITION ❑ ALTERATION p REPAIR O MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 20' x 14' Addition to Dt�relling
9 CHANGE QF USE FFOM TO
STIPULATIONS
See notations on plan. Tnstall smoke detection in existing house. � ,
Setback variance approved by City Council
WAR�����
SEpqRArE p ""
�R BQfore d;��+n : ��� + � �� utilities
WPR�NG� HE JI+IITS RE TELEPNC�F ��; �,� „:;, •�;�,� Et�.
Ari��. P��,Y,B N ED FpR R��QUi��D ��( !►��
G ,qN� S��NS.
SEPARATE PERMITS ARE RE�UIRED FOR ELECTRICAL, P�UMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING Ofi AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT. CU. FT.
AUTHORI2ED IS NOT COMMENCED WITHIN 60 DAYS, Oli IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANV TIME AFTER WORK IS COMMENCED. NO. DWIG. UNITS OFFSTREET PARKING
I HEFEBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION �' STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VA�UATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED $13 �600 $(.HO
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING Of A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOlA7E OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING coN- $153.00
STRUCTION OR THE PERFORMANCE OP CONSTRUCTION.
LAN CHECK FEE TOTAL FEE
$159.80
. SIG1� TUREOFCONTRACTORORAUTHORIZ AGENT IDAT6�. � r WHEN PROPERLY UDATEO THIS IS YOUR P RMI
£ 7"" /%,-�'�i � //
S�GNATURE OF OWNEA iIF OWNER BUILDERI �DA7E� BIOG iNSP
f1F
l�ia [ l
�ON �
ALTER [ ]
�nstruction Address
Co 2 3 1
City of FYidley
R-1 AND R-2
Building Permit Application
L IJ E�.I ��
EEfec�ive 5/L88
Legal Descriptian:_ �o T S l3 Lo � f� � /� c. R.os ��¢�,D ,Ti o•�
Owner Nane & Address : � �t �. � � � - ; .v.�- � lc-�-Y2- -- � .� �-e-- �. # ,5�?/ 2 4'�.�
(bntr ac�or : _ Lu-�-1 S-e � -� �. #
Addi'ess:
Attadl to this appl ication, a Certif icate o� SL�rvey of the
lat, with the proposoed o�nstructian c]ra�m on it to scale.
�.SQtIPPId[�1 � II�tOVII�Tr
LIViI� AREA: i,ength �' � Width /`i Heic�t St�. Ft. ��
(�,RAGE ARFA: i,ength Widtt. � Heic�t Sk�. Ft. '
D�C[t ARFA: Length Width Hgt/Grotnd SL7. I�t.
�:.
�rner Lot [] Inside Lot [] Ft. Yd Setback Side Yard Setbacks
Type o� �nstruction: W o° p �'�z.i4w� G Fstimated Cost : Sg 1
Approx. Cbmgt e�tion Date : � G�r' 1,, /�',�� i�j ,`c9 0, U ci
a�o,�w�.6� � ��,�.� � ��
` Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: S_
Width + 6'
DATE : � ' � `" �� APPL ICANP : `�� � c� a11�--
Pe�it Plee
state surc�arge
SAC Qisrge
Driveway Escrow
Park Fiee
Sewer !lai.n �arge
�o►r�w
s_ IS'�o0
S 4,YO
S ._"'_
S �
S --
S —"r
s I �9.So
CQY OSE Q�LY
S
See Back Page
Tel. # S? / Z� �l S'
P�ee Schedule on Reverse Side
5.50/51,000 Valuation
5550 per SAC Unit
A1� '�" or Alt. "B" Above
P�e Determired by Ehgir�eering
Agreenerit Neaessary I l Not Neoessary [ l
�m�.s: . �.
��.o�'� a,�� c���.i�� ,�' 9��-�
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13,Goo
'� u o u- �i S UO
� 2� � ` 1 Dg,OD
IS3,otl
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On aii new roofs or tgar-otf� and replacemerrt;%ols,
State Code reQuires tl�at 2 layers of 15 �.,'1�, .;�,
rnopped together, be jnstalted to a�oinf�74 inche�s �
up from exterior wail liee, or the use of�other
approved underla�men� membrane.
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�Air conditioners can not 6e placed tn the side
yard wit�out written permission from ad oinin
, ne+ghbor. � . : � 1 g .
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WILUAMA.CARLSON,PRES. CERTi�ICAtE OF St10�V� 1 p� #88-02 . • .'�
2324 WEST 110th STREET .
see•2oea � . �7ames Walker
65431 � � „� � .
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SuRVeY FOR� ,
OEGARDNER REAL7Y� (NC, LANDSURVEYORS
' Licensed, lnsured � Bonded '
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DESCRIPTION; LOT S� BLOCK �� AL ROSE ADDITION.
�NE HEREBY CERTIFY THAT UN THE ��TH DAY OF JULY� i9%Z� wE LOCATED �
TNE BUILDING ON THE A80VE DESCRIBED PROPERTY AND THAT THE AeOVE '
REPRESENTATION 1S TRUE AND CORRECT.
_�.�� :;:;i r ' r�. �„� �; ,,,
�:1`..�.�G1�.�s. , rt•-S�.LZi.. �r..�-.-..-
P�1 i NN. REa. No. 5648 �
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^ITY OF FRIDLEY BUILDING 1NSPECTION
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4 3431 University Ave ME
9 =ridley. MN 55432
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763-5723604 FAX 763-571-1287
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D
n RATE SCHEDULE
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Residential
Furnace Shell and Duct Work, Surner &
also Re�lacement Furnace
Gas Piping (Ne►v Furnace, Firepfacs, Insert)
� Gas Range
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Gas Dryer
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Effective 4/1/2004
APPLICATlON FOR POWER PLANTS AND HEATING, COOLING, VENTlLAT10N
REFRIGERAT10iV AND AlR CONDITIONI�G SYSTENIS AND DEVICES
JOBADDRESS COa� ` �t�'+�Y\ �c�--t N�
Fee To �, _ , ,
Owner Ln\�
$35.00 $ Building Used As �E? 5�� e r'1 ��
$10.00 $ ESTfMATED COST��I C�d. C�U PERMIT f30
$10.00 $
$10.00 $
*Air nditioning-All Siz�s Tx � �a� $25.00
�A.rri.� � � cS
All Other Repairs or Aiterations (List on Back)
196 of Value of Appliance or Wor1c
Minimum Fee $15.Q0 for Residential or 5% of cost of
improvement whichever is greater on work less than $300.Q0
Commercial/fndustriaUlnstitutionai
1.25% of Value of Appliance or Work (tist on Back)
Minimum Fee $35.00 for Commerciatjindusir'saijinsiiiuti�na�
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� REtNSPECTION FEE $50.00lHOUR
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5tate Surcharge
TOTAL FEE
$ -�5�°
$
$
� .50
$�'
*Air Conditioners can not be placed in side yard wfthout �vritten approval
from adJoining property ovrner - oopy to City
FILL 4UT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
DESCRIPTION aF FURNACE AND BURNER
� of Heating Units Circle One (Steam) (Hot Waterj (Warm Air)
Trade Name Size No.
BTU HP EDR
Fuel Total Connected Laad
Bumer Trade Name Size No.
BTU _ HP EDR
The under5ig�ed hereby makes application for a permit for the work herein
specified agreeing to do a{I work in strict aocordance with the City Codes
and rulings of the Building Division, and herehy declares that all the facts
a!?d representatior�s stated in this application are true and correct.
CENTERPOINT ENERGY
HEATING CA 13562 CENTRAL AVE NE BLAINE, MN 55304
Signed �'�4-� �° � Tel # �63-757-6202
FAX #1 763-757-6701 Date CD �—/ � 6�
Approved by Rough-in Date Finai Date
Z0 ' d �d101
FILL IN COMPLETELX FOR REPLACEMENT FUEL BURNING APPLIANC� PERMfTS
COMMON VENT, VENT CONNECTOR AND COMBUSTIPJN AIR VERIFICATION
When re�,tacin� an existinq furnace, the undersigned hereby verifies tfiat the
venting has been examined and is free from nast, deterioration, obstructions,
and is securely suppor�ed and firestopped where required. Yes (� No ()
The veniing system is plasticlPVC and meets a!! current codes and manufacturer
specifications including sizing, length, number of elbows and termination. Yes (� No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets fihe current codes and manufacturer's specificatians. This do�;s
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances.
The existinq combustion air is sized and installed to meet the current codes
and manufacturer's specifications.
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacturer's specifications.
Yes ( � No ( )
Yes ( � No ( )
Yes � ) No ( )
When installinq a new ventinq s stem, the undersigned hereby verifiF:s that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does inc{ude AGA-GAMA Category I Central Furna<;e
Venting Tables for fan assisted and natural draft appliances. Yes (�
ls the common vent and vent connectors sized and i�stalled co�rectly after
an appliancs has been removed from the common vent and vented
separately as per current codes.
No ( )
Yes � ) No ( )
Appliance Type and Size/Gommon Vent and Vent Cunnector Information
Appliance #1 Type BTU lnput Fan �lssisted or Nat
Appliance #�2 Type BTU Input Fan �lssisted or Nat
Appliance #3 Type BTU Input Fan flssisted or Nat
Total Appliances Tatal Btu Input
Common Vent Type Vent Height Diameter inches
Appliance #1 Verrt Cannector Height ft Length ft Diameter• in Type
Appliance #2 Vent Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS• (Describe}
CENTERPOINT ENERGY
HEATING CO: 13562 CENTRAL AVE NE BLAINE, MN 55304 _
Signed By: � � '� ° Date
�. -
?Fi/�Fi'rl tR1,91.SL Ql 1.�"1Q1�1� �Cl .111� 4J02i-i Sr�.:LT b00Z-LZ-�Idd-
Building PLUMBING P��t �°.:
j Inspections ���E�T'�TAT, �ppLICATION R��i°�a By:
1763-572-3604 CITY OF FR�DLEY D�e Re�'d: �� ��
DATE YOUR E-MATL ADDRFSS
SiTE ADDRESS
THIS APPLICANT LS: ❑ OWNER CONTR gOTTOMLY, GLENN
PROPERTY N� 6231 ALDEN WAY NORTHEAST
�W�� FRIDLEY, MN 55432
TENANT �D�S: (763) 572-3795 �A� �
PHONE:
co�cTOR ��: �nRRI nl�� P�,� �l1,IlRI�U�-�^,
SUBMTT A COPY OF '�A� � EXP DATE
YOUR STATE ADDRESS: C1TY STATE ZIP
LICENSE WTI'Ii PHONE • -
APPLICATION
PERNII'T TYPE SINGLE FANIILY ❑ TWO FAIvtII.Y ❑ TOWNHOUSE
TYPE OF W ORK: � �' ��P�'�E�r
DETAILED DESCRIPTION OF VJORK Y� P� 2 C� w z��� n� Z��
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PER MS 16B.665 the permii fee is a minimum of $15.Od or 5% of tlte tota.i cost np to 5500.00, whichavez is greater, for the
improve,rnent, instaliation or replacement of a residential fixrture, exclnding the fixtures. (This should reflect onIy the cast of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $SOA = c.�st of labor - x.OS = `
FCR PR03EGTS WHERE LABOR EXCEEDS �SDO, FEES ARE BASED OTi �10.00 PER-FI3CTCTRE, EXCEPT WI�REN�TID. FtXT'URES: (INDICATH TOTAL
MJMBIIt OF EACH BELOV�
BATH SINK/LAY _Fi.00R DRAINS SHOWER WATER PIPWG
BATHTUB GAS PIPD3G �n� �n't�cEr+s�j SW1MIyIlNG POOL _ WATER SOFTNER (S3�
CI,OTi�g Wp,SHEIt � KTI'CF�N SINK � WATER CLOSET BACKFLOW PREV. (S17
DI5HWASHER ,_ LAUNDRY TRAY �WATER HEATER (S35) ^ FOTt IRRICrATION
— , WATER MEI'ER _ OTf�R
;..::.. .� __ :- _ , . •
Fermit Fee . $ Number of fixtures (a� $10.00 x SY t�.00 = S
Surch e .50 Number of fixtures Qa`$15.00 x$25.00 =$
TOTAL DUE $ Number of fixtures (a� $35.00 � x $35.00 = $ �iS�
State Surcharga = $ .50
Total = $ 3S�S'i�
THIS IS AN APPLICATION FOR A PERMIT NO'f VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
confonnance with the ordinances and codes af the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a pezmit but only an applicabon for a it and work is not to start without a permit; that the work_ will be in accordance with the
approved plan in the case of all 'c requ' review and approval of plans. .� 5 2 3 0 6
S I G N A T U R E O F A P P L 7 C f W T � r i����"` P R I N T N A ME ��'`� v� I�� U(� DA �,
City of Fridtey
Building inspections Department
643I University Avenue NE, Fridley, MN SS432
763-572-3604
Building
Inspections
763-572-3604
763-502-4977 FAX
�/� I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-09
Permit No.:
Received By:
Dat��e�c�d�
�,
� YOUR E-MAIL ApDRESS � C I� l P S�� �^ a,,..�
� Q'� f ✓i Wo`�/
❑ OWNER aOCO RACTnR
rvAnn�: �e�n� 6a-ffo��
ADDRESS: �7Sa ,rq�C.e .D✓'. CITY �� G✓� STATE /�I IP SS� 2-
PHONE: �S � — jtS� — �9Fi �
NAME: �_ 1 c S%Gj i�..' �'%c -
STATE LICEN # ZO f� Sb �%
aDDxESS: /3c> / E'. C (� -F� IZ / / �7
K
PHONE_ /SZ—%S�6 ° 30 f/% F
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION ST(1RiFC
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
�AINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:_ ��—�`� c�`
SIZE OF
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
EXP DATE _,3�.3/ � �—� j U
_CITY��y✓�5`� � ��C' $TATE.N/�ZIP SS33
�S 2'% Y� -- 3 6 i� 7
d`ltvur ❑ DRAIN TILE
O SIDING ❑ OTHER
7 SWIMMING POOL
❑ ADDITION
❑ REMODELING
WIDTH
❑ HOUSE ONLY
��OUSE & GARAGE
❑ ATTACHED GARAGE
CIDETACHED GARAGE
FT
BASEMENT REMODELING SUBMIT•
I. Existing Floor Plan
2. Proposed floor plan
3. List of sductural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑5offit ADDITIONS. & PORCHES SUBMIT•
❑ Trim 1. Site Plan/Survey showing the existing structures
O Fascia and proposed project.
2 Two sets oFconstru t' I
c ion p ans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCffiBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $%� I�D 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
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Pernvt Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2000 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge 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 whic equi es •evi and approval of plans.
SIGNATURE OF APPLICANT � _ PRINT NAME K/CC V 1� �GLt�c..1� DATE "/21/� (