AF - 44074i City of Fridley, Minn �
BUILDING PERMIT N° 4 0�r s
�
Date: - ........ ........ ........_/ �-...-��,.�....-.....-.��. .--............ - ..........._
Owner: - ....... Builder .� ...._ � ........ . ......�..yi�Q[.� ... � .. ...............: _........
Address..........................-- � ..........---� .............._..................................... . Address ....... ....... .......................................................................--�-......_........
LOCATION O I G
No. ��'��/........ Street ..��G��►.._�,.��2������f'�........ Part of Lot .......--..--...--......._ ` .. ...............__.....
�-----. Block -.-------����..__ ...............__--- Addition or Sub-Division ......i����;�s�t�,r,. �-....................
Lot ....... -
- - f �_ f 4
Corner Lot ......_%� ..................... Ins�e Lot .._.__.. _......_...._..___.. Setback ��.:_�..--........... Sideyard .��....'_.�.�.............. - ........-- ._...........
Sewer Elevation ......�i � __._.....�5!'!c�P._ .............. --_......... Foundation Elevation ..........._ - ... ................. -- ...................... ..................
To be Used as:
�. ... �.. .. ....
Type of Construction
DESCRIPTION! OF BUILDING
Front ..�(�� Depth Za.......� Height �.Q..��~ Sq. Ft. /�Q..L Cu. Ft. ���....�..,�0 �
Front ._...._......._...- . Depth __....__._._..._.. Height .._ ..............._
_ ..............._ ..._.__...._........._......_ Est. Cost_��,�� .
Sq. Ft. .__.._ ............... Cu. Ft.
To be Completed
In consideration of the issuance to me of a permit to construct the building described above, I agree to do
the proposed wark in accordance with the description above set forth and in compliance with all pravisions of
ordinances of the city of Fridley. • —
-� ._. p_�.�_-�.�-�-vc ................................._......--
In consideration of the a ment of a fee of $� '
P Y :..��', Permit is hereby granted to ............ ...................... -.......... -
....._ .........................................................._........ to construct the building or addition as described above. This permit is granted upon
the express condition that the person to whom it is granted and his agents, employees and workmen, in all work
done in, around and upon said building, or any part thereof, shall confarm in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings
within the city limits and this perniit may be revoked at any time upon violation of any of e provisions of said
ordinances. _ �
Building Inspector
NOTICE:
This permif does nof cover fhe wnstruction, insfallafion for wiring, plumbing, gas heating, sewer or waler. Be sure �o see
the Building Inspector for separate permits for fhese iiems.
►•
�
APPLZCATION FOR BUILDING,_PERMIT
CITY OF FRIDLEY, MINNESOTA
l �,,/� �v `�� r .
Owners Name ,�����..0 7J, /T,c�-9-*•�.�� Builder �
Addxess '`�� ��� d�2�✓�-�'�� Address�
�'Yt y�-� < �, �i �� `
LOCATION OF BUILDING
No. �� _. r� Street ���..�C�-��► _�a,��/f'`"�. Part of Lot
Lot � Block � Addition or Sub.Div. �`�'/c�.c� �" �-o
Corner Lot "� Inside Lot Set Back 3�� r 5ide-Yaxd 3 S'
SEWBR: ELEVATSQN �', ��E� P FOUNDATION ELEVATION �
Appli^,ant attach to this form Certifica.t�e of Survey of Lot and pro�osed building
loca.tion.
DE5CR.IPTIOIv OF BUILDING
` ���� c `
To be :used as: l ��p,.�,d
��
�=- Front � Depth o�-� Height �
Sq . Ft � / �- �' �' Cu . Ft . � G . �9
Front Depth ,Hezght '
Sq. Ft, Cu. Ft. �� �
� —
Type of Construction �� Estimated Cost �'�
To be eompleted �icrc>-� / R s- `�[
The undersigned.hereby makes application for a permit for the work herein specified,
agreeing to do al3�.work in strict accardance with the City Ordinanc���and ruling of
the Depaxtment of Buildings, and hereby declares tha.t all the facts.and representa-
tions stated in this application are true and correct. -
,
DATE ,% ( ' / � 3� � SIGNATURE T�D � `' s
�
(A Schedule of Fee costs can be found on the Reverse Si,de.) - -
�...,,,�.. - • " � • .
.. �
sue�etT PEpMIT NO.
City of Fridley 2 914 3
�
AT THE TOP OF TNE TWINS g � � L D I N� P E R M I T
; � RECEIPT NO.
� ; y __��_ COMMUNITY DEVELOPMENT �IV.
f � � PROTECTIVE INSPECTION SEC.
� �
( � /"'1 � CITY HALL FRIOLE� SS�32 NUMBEf1 NEV DATE PAGE OF APPROVEO 8V
�""�"� ,'' 612--571-3450 9t0-F15 4/5/99 / /
109 ADDRESS
5191 Buchanan Street NE
t IEGAL �OT NO. BLOCK THACT OA ADOITION SEE ATTACNE�
oesca. g 2 Marian Hills Addition SNEET
2 PROPERTY OWNER MAI� ADDBESS ZIP PHONE
Roof Design Partners 4026 7 Street NE, Columbia Heights, MN 55421 789-6566
3 CONTRACTOR MAIL AODRESS Z�P PHONE LICENSE NO
Joanna Plante 5191 Buchanan Street NE 2004817
d AqCHITECT OR OESIGNER MAIL AODRESS ZtP PNONE IICENSE NO.
5 ENGINEEF MAIL ADDR£SS ZIP PHONE UCENSE NO
6 USE OF BUILDING
Residential
7 CIASS OF WORK
� NEW ❑ ADDITION O ALTERATtON �7 REPAIR O MOVE O REMOVE
8 DESCRIBE WOiiK
Reroof House & Garage (20 Sq) Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
CONSTRUCTION WORK HOURS: 7:00 am to 9:00 pm, Monday thru Friday; 9:00 am to
9s00 pm on Saturday; No work on Sunday.
TYPEOFCONSL OCCUPANCVGROUP OCCUPANCY�pAD
SEPARATE PERMITS AHE REOUIRED FOR ELEC�RICA�, PLUMBING. HEATING,
VENTILATING OR AIR CONDITIONING. � � �
THIS PEFMIT BECOMES NULL AND VOID IF WORK Oq CONSTRUCTION ZpNING SO. FT CU fT.
AUTMOR12ED IS NOT COMMENCED VyITHIN 60 OAVS. OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONEO FOR A PERIOD OF 120 DAVS AJ
ANV TIME AFTER WORK IS COMMENCED. NO DWLG. UNITS OFFSTqEE? PARKING
I MEREBY CERTIFV THAT I HAVE READ ANO EXAMINEO THIS APPLICATION 1 STA��S GARAGE$
ANO KNOW TME SAME TO BE TRUE AND CORRECi. ALL PROVISIONS Of LAWS VALUATION SUpTAX
AND ORDINANCES GOVERNING THIS TVPE Of WORK WILL BE COMPUED � 1 s 714 �. H6
WiTH WHETMER SPECIFIED MEREIN Ofi NOT. THE GRANTING Of A PERMI�
DOES NOT ESUME TO GIVE MORITV TO VIOLATE OF CANCEI TME pERMITfEE SACGMAqGE
PROVISION F ANY OTHER T OR IOCAL LAW REGULATING coN. 56 . 7S F1 SC � 1.% 1
STRUCTIO TNE PER OR A C OF CONSTFUCTION �
�� � PLAN CMECK FEE TOT � FEE
Lice SC $5 0 $64.32
S�cNS U�7EO�CONCFA(;TQFOAA THOA�ZEO�GENT io�rE� HEN RO VAUO ;IS IS � PEQ ii
�
✓
S�GNniuAE O� OwrvEQ��F OWNEQBU�IOEAi �O�TEi � g� iNSP ' � •�E
r �
NEW
ADDN
ALTER
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CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: � � � � +l�ti ��r� � �e
Legal Description:
Owner Name & Address: ��-���,�a t����� Tel. #
� n� . � �
Contractor:
Address:
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Effective 1/1/99
MN LICENSE # Zc� `{f�t 7
�[= ' • �`r _
,:�
Attach to this application, a CeRificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
`- r`"
Length Width Height --Sq t• �_
Length Width Height S Ft.
I,ength Width Hgt/Ground Sq. Ft.
,� ` Estimated Cost: $ �: �' l / � `�
Construction Type: ���- s F �c--
�
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$
_$
DATE: `�- (o-R� APPLICANT: �,�� r�44�� Tel. # ��°( —�o�{o�
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
$ � ��5�
$ %-%/
$ �� ��
$
$ � . UU
$
$
$
$
$ �� - ��
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth%a)
$.SO/$1,000 Valuation
$1050 per SAC Unit
$5.00 (State Licensed Residential Contractors� �
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
� r
sue.,ecT PER
C�ty of Fridley 3 � 7ss
AT THE T�P OF TME 7WINS g�J I L D i i� G P E R M I T
r
RECEIPT NO.
; � 0?3
� ; y____�_ COMMUt�tTY OEVELOp�ENS OW. P
r � � PROTECTIVE INSPECTION SEC. o172r3� ��
1 . , V
l•-__�,�����;'� CITY HALL FRIOLE� 55�32 NUMBEA REV OATE PAGE OF APPROVED BY
L 612-571-3450 9t0-F�5 5/3/O1 � �
J08 ADDRESS 5191 Buchanan Street NE .
t LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHEO
oesca. g 2 Marian Hills Addition SMEET
Y PROPERTY OWNER MAIL AOpRESS ZIP PHONE
Jim Plante 5191 Buchanan Street NE 763-571-7152
3 CONTRACTOR MAIL ADDRESS 21P PHONE IICENSE NO
Norling Exteriors Inc 341 79 Way NE, Fridley, MN 55432 763-518-2399
4 ARCNITECT OR DESIGNER MAIL AODRESS ZIP PHONE UCENSE NO.
20098700
5 ENGINEER MAII ADDFESS ZIp PHONE LICENSE NO
6 USE OF BUILDING
Residential
7 CLASS OF WOFiK
O NEW O ADDiTION O ALTERATION ❑ REPAIR ❑ MOVE O REMOVE
X
8 DESCRIBE WOfiK
Install soffit/fascia/gutters
9 CHANGE OF USE FROM TO
STIPULATIONS
Install soffit ventilation to meet the State Building Code.
TYPE OF CONST. OCCUPANCV GROUP OCCUPANC� IOAD
SEPARATE PERMITS ARE REOUIRED FOR ELECTR�CAL. PLUMBING. HEATING.
YENTI�ATlNG OR AIR CONOITIONtNG
TMIS PERMIT BECOMES NULL ANO VOIO IF WORK OR CONSTRUCTION ZONING SO. FT CU FT
AUTHORIZED IS NOT COMMENCED WITMIN 60 DAYS. OR IF CONSTRUCTION �
OR WORK IS SUSPENOED OR ABANQONEO fOii A PERIOO OF 12Q OAY$ A7
ANV TIME AFTER WORK IS COMMENCED. ° NO OWLG. UNI7S OfFSTREEI PARKING
I HEREB� CERTIfV THAT I HAVE AEAO ANO E%AMIN�O TMIS APPI,ICA710N 1 SiA�LS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT ALl PROVISIONS OF LAWS VA�UATION SURTAI(
ANO ORDINANCES GOVERNING THIS 7VPE Of WORK WILL BE COMPUED �2 lOO �1.OS
WITM WMETMEii SPECIf1E0 MEREIN OA NOT THE GRANTING OF A PERMIT �
OOES NOT PRESUME TO GIVE AUTHORITV TO V10lATE OR CANCEL THE pEqM17 fEE SAC CMARGE
PROVISIONS OF ANV OTHER STATE OR IOCAL LAW REGULATING CON• 583.25 Fire SG �L.IO
STq CTION OR THE PERfORMANCE Of CONSTRUCTION y'
J PLAN CHECK TO A� FEE
_ � � � Lice e C $5 .0 , $91.40
S�GNA U EOFCON7RACTOAOQ�UTHOQ�2ED�GENT iOATE� E PROP VAL ED THIS IS VOUF PERMIi
G. o ,��
$�GN4�U�7EO�OWNEQ���OWNEABWIDEAi �O�TEi . � � � B� G��tiSo . � � - r�ctE
i �
NEW [--�'
ADDN []
ALTER [ ]
Effective 1/1/20Q1
CITY OF FRIDLEY (763) 572-3604 Bldg Insp
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDlNG PERMIT APPLICATION
Construction Address: 5 l � � � u � h �n c�`n � T � � �`� ���1 � '`� ' s5 `��2
Legai Description:
Owner Name & Address: �1l � �� �A'►.�' _ - - -_ Tei. # '��, 5�� I� 115 Z
Contractor: ��C� .�� �P�' L05' , ��G - � � MN LICENSE # � � ZoCf 8'7nU
Address: 3`a►1�, ? �' � c�.���-� ���� � , � -�3 2 - Tel. # F�� ,1 5I� -z3�9 _
„ �,
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length
Length
Width Height
Width Hgt/Ground
Sq. Ft.
Sq. Ft.
Construction Type: So�c��- /=hzcta ��vTTP� - Estimated Cost: $ 2�00, �°
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
Wc�r� -
DATE: 3ft�' � APPLICANT'� �� C� �o� Tel. ���3 51����
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
Call (763) 572-3604 for Permit Fees if mailing in application
$ �r�1S� Fee Schedule on Reverse Side
$ �:;1. iU .001 of Permit Valuation (1/10th%)
$ j, rs� $.50/$1,000 Valuation
$ $1150 per SAC Unit
$ �� C C� $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [ ]
$ . �/G'
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
- . -="�
PERMI O.: 2004-01417
DATE ISSUED: 08/26/2004
(763) 572-3604 FAX: (763) 571-1287
ADDRESS : 5191 BUCHANAN ST NE
PIN : 253024210052
LEGAL DESC : MARIAN HILLS
: LOT 8 BLOCK 2
PERMIT TYPE : BUILDING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : RESIDING
VALUATION : $ 10,650.00
NOTE: PER R703, 2000 INTERNATIONAL RESIDENTIAL CODE, REQUIRES THAT A WEATHER RESISTIVE BARRIER BE
PLACED OVER EXTERIOR SHEATHING TO PROTECT THE INTERIOR WALL COVERING. EXCEPTIONS FOR THIS
PROVISION WOULD BE IF SHEATHING I5 AN APPROVED WEATHERPROOF PANEL OR WHEN THE SIDING IS AN
APPROVED WEATHER BARRIER. VINYL SIDING IS NOT A WEATHERPROOF COVERING UNLESS THE
MANUFACTURER STATES THIS IN THEIR APPLICATION GUIDELINES. CALL FOR INSPECTION OF WRAP BEFORE
COVERING OR TAKE PICTURES. RESIDE HOUSE & GARAGE; 3 WINDOWS REPLACEMENTS WITHIN EXISTING
OPENINGS.
STATE LICENSED CONTRACTOR 1
APPLICANT BUILDING PERMIT FEE 195.25
NORLING EXTERIORS INC (20098700) FIRE SURCHARGE 10.65
341 79 WAY NE STATE SURCHARGE, VALUE 5.32
FRIDLEY, MN 55432 LICENSE SURCHARGE 5.00
(763) 784-8936 TOTAL 216.22
PAID WITH CHECK # 6895
OWNER
PLANTE JAMES M& JOANNA M
5191 BUCHANAN ST NE
FRIDLEY, MN 55421
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of wark
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions f any other state or local law
regulating co truc ' e erform of construction.
Applicant . � Data�S`�6-��/
r
BiCig rI1S ii r;J � ,. .
. SEPARATE PERMITS QUI D FOR WORK OTHER THAN DESCRIBED ABOVE.
NEW [ J CITY OF FRIDLEY Effective 4/1/2004
ADDN [) 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp
ALTER [) SINGLE FAMILY AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax
BUILDING PERMIT APPLICATION �� �/* D/ L/I �y
� I �
Construction Address:
.j
.�, ..S f
Legal Description:
Owner Name & Address c� r� � JG � n-� �/� n t� " re�. #1 � 3-�7�--7�5`�
Contractor: /�L� ��� ��. _F,��{�: � c.. r..� � MN LICENSE # a� 5�� o v
Address: 3 S� � %� f<, !�✓�t y ��a�/��� �%/(/ �S� J � Tel. # TG 3 -�� `r- ��.� �
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Survey of the
bt, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length
Length
Width Height
Width Hgt/Ground
Sq. Ft.
Sq. Ft.
,�'' o°
Construction Type: /z °�� �' �� �� S �P� (��^ y � S `�°�'�stimated Cost: $ �� �°�� •
3 c:✓,`,i�,(ld�✓ ���l�c�n�r��-f-S
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: �S `� �' —� �/ APPUCANT: cJa�'"� � s i " �' ��� "' Tel. # 6/d - S�8- � � � 9
Call (763) 572-3604 for Permit Fees if mailing in application. Fax to 763-571-1287 if using credit card and we will call
you for card number.
CITY USE ONLY -
Permit Fee
Plan Review
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
$_ � S-�,"
$ �,,----
$ ,�d . l�S.
$ �� �
$
.$ � �lC�
$
$
$
$
$ o�/���
Fee Schedule on Reverse Side
65% of Permit Fee
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1350 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [
STIPULATIONS:
____�,.
CITY OF FRIDLEY PEx�I No.: 2004-01574
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432 DATE ISSUED: 09/13/2004
(763) 572-3604 FAX: (763) 571-1287
ADDRESS : 5191 BUCHANAN ST NE
PIN : 253024210052
LEGAL DESC : MARIAN HILLS
: LOT 8 BLOCK 2
PERMTT TYPE : BUILDING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION : $ 11,000.00
NOTE: SEE NOTATIONS ON PLAN.
CALL GOPHER STATE ONE AT 651-454-0002 FOR UTILITY LOCATIONS.
PROVIDE SMOKE DETECTORS IN ALL SLEEPING ROOMS AND ON ALL LEVELS OF THE DWELLING PER R317 OF THE
2000 INTERNATIONAL RESIDENTIAL CODE. REMOVE EXISTING BRICK ON THE FRONT OF THE HOUSE AND TWO
CHIMNEYS WITHIN ONE CHASE AND REPLACE WITH NEW BRICK.
STATE LICENSED CONTRACTOR 1
APPLICANT BUILDING PERMIT FEE 195.25
JAMES CHIM & MASONRY REP 20232750 FIRE SURCHARGE 11.00
10848 262 AVE STATE SURCHARGE, VALUE 5.50
ZIMMERMAN, MN 55392- LICENSE SURCHARGE 5.00
TOTAL 216.75
PAID WITH CHECK # 4425
OWNER
PLANTE JAMES M& JOANNA M
5191 BUCHANAN ST NE
FRIDLEY, MN 55421
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of work
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of other state or local law
regulating construction or the perf ance f construction.
Applicant Date
Bldg Ins Dat� �
�
SEPARATE PERMITS QUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
NEW [ J
ADDN ( ]
ALTER [ ]
CITY OF FRIDLEY Effective 4/1/2004
6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 B{dg {nsp
' SING4E FAMILY AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax
BUILDING PERMIT APPLICATION �/ �"/-�, %
�OC��- J !'7
Construction Address: � (�I '����� S�
Legal Description:
Owner Name & Address: �� � .�e�►�► Y�ah�2 Tei. #�°3'S�I��1 s�
Contractor: �%t��,� �4'+�r�e�, c�-- �tise�n�.F Q��'� MN LICENSE #�QL �Z3a',7�
Address: I bR�� c�.,b`a �� c„ ��+'M•�e�Ma,. M� S�`�? Tel. #`7,�3�7/? ��3,6
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Survey of the
bt, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length
Length
Width Height Sq. Ft.
Width HgUGround Sq. Ft.
t �v1i` O�� �'e
d- �f�a��e �v � � r�ew �^� ck �
Construction Type: I�r�'�� ����Ac-� r.�en'� Estimated Cost: $
. --�
� j �, el --
(� Vl� M►'�.eT
rr�
� ��!�
����� �.
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ =$
�- �- �` ��r (�
DATE: �"�°-r'�-tf APPUCANT: ���fl� �P'���'"��S Tel. # �63"�17-�36
Call (763) 572-3604 for Permit Fees if mailing in application. Fax to 763-571-1287 if using credit card and we will call
you for card number.
CITY USE ONLY -
Permit Fee
Plan Review
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
r �
$ �'r� ,� 1�� Fee Schedule on Reverse Side
$ - - 65% of Permit Fee
$ / j. �� ��� .001 of Permit Valuation (1/10th%)
$ '�, , _� ; � $.50/$1,000 Valuation
$ $1350 per SAC Unit
$ �. �; �� $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [ ]
$ �I �- • ` v- � STIPULATIONS:
. �.1 �o� o�C� �`� . G .
��� `�
, �