AF - 36551City of Fridley, Minn.
BUILDING PER.MIT No 4 8 9 9�
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Owner: _. ----- � ._.__ . <:.:�.�_...:��.�_:�-�.... Biulder �
__._.._._-•---.........__. ._.._
Address ..�...�._..�...t.��_..._.. �' � �
�� �_,,�����...�� Addr�ss
..._..__ _... _.._.. ._._... .. - _..�.._.__._._.___.__
�. , LOCATION F L ING
,�A:.��'.�.� " �° =:
No. . .._ .. Street _ _. .. .. '' ._...._.... ---- . .:.---�- Part of Lot _.__.....
_ q ....___..__.__.._.. ......_
Lot ....------...._..___....__.--- Block -------... :...-----------........._. Addition or Sub-Di �on� ... .�,�.. •- . • ..__! t.��, ���_.....
� �'
Corner Lot ..................-----_...-•-- Inslde Lot ..-�--•----............---�--.. Setback -•-----��.---.....__---•--.. Sideyard ---�._�°.'.`��....._.�.�._.._.......-•---_.
Sewer IIevation
To Used as •
, ,a �
_. �� �:��'
..._........... �---- ..............
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of Construction
Foundation Elevation
DESCRIPTION OF BUILDING
Front _._ ���- DeP� ....._... ��°"....� Height --�. --
�- -
Front ...��. � Depth ...;�.. .�...� _.. Height ......,��. _.
.. .
....._----- ..............__............._..._.... Est. Cost�'�....�/-�-�-�.....---
Sq. Ft. �� �..�� Cu. F� ���',��,�
�
Sq• F� .�.�� Cu. F'k ... ��....�.'��'. �
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 work in accordance with the description above set forth and in compHance with all provisions of
ordinances of the city of Fridley. u
In consideration of the payment of a fee of $�.....:.-_..., permit is herebY granted to....._..._:._..:--••--•_--.--_._..._.._...---_.
_.._._.__._. to construct the building or addition as described above. This pexmit ,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 attd upon said building, or any part thereof, shall conform in all respects to the ordinances of
F'ridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings
within the dty li�nits and tkus permit may be revoked at any time upon violation any of the provisions of said
ordinances. �°"^� .�.� , �
Building Inspector
NOTICE:
Thia permit does nof eover the wnafruetion, inatallaHon for wiring, plumbinp, gaa heating, sewer o� water. 8e sura fo see
the Building Inspector for aeparate permhs for these tiems. �„'3 � r"!�'"
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EsU1LDif�„ FtE��aoc�i:TlI�NS: �` -
APPLICATION FaR BIII�,DIldG PERt�T
CITY OF FRTDLEY, MIlVNESOTA
Ownera Name (���� q��� � r,�� _�,.�'`���—� Bu3lder��:�-� .,�
Address � ��`� � ,�,�„�' ��°�ri � Address
�., �,_ � � � 7
� LOCATIOIV OF BIIILDING
/ .
Nv. �, ,,��, Stree� ��, z� � • ����� Pt�rt of Lot ,� � ,��-:� �-��s �
�: f .._.. ..�- .� _ .
Iot Blocl� . �Sldit3on or Sub.D3v.
Gorner Lot�Inside Lat�___,,,,Set Back ��� , Side-Y�rd�; ���%�-��-_�� �� A
� ��
S�►�i ELEVATION FOUNDAT]AN ELE�TATION ,� �''�„�: ,��� ��� �
Applic�nt attach to th3s form Cer�3,.ficate of Survey of Lot and proposed build3ng
location.
DESCRIPTION OF BUZLDING
To be used as:
� `�,� ��- � Froat �"� a � Depth �-�� ` , _ T3e3ght � ..�
�. Ft. ,,�'� �' ,�`� Cu. Ft.
� � �/ Denth � 1�
Sq. Ft. Cu. Ft.
Type of Conatruction .��4z:��� Fstima.tscl Cost ��� � �� �s � �'
To be complatsd �Gr��� �y �<
Z'he underaigned hereby makes application for a permit for the work herein specifYed,
agree2ng to do al.�. work in stri.ct accordance w3th the C3ty* Ordinances and ru].ing ot'
the Department of Buildings, and hereby declares tha.t all. the faets and representa-
tions atatgd in this application are truc� and correct. � .
; F�
�'
DAT� ;� � SIGNATUftE , _ � � � ��-�-��>
- �� �-��
(1 Schedule of Fee costs c�n � found on the Reverse Side ) -
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I: 1 1 1 ' �1' 1 ' �� `� "1911 (
S�etion 2. The Inap�ctor of Bu31d3.nga ahall, before issu3.ng anj► perad:t
for the erection of any building or structure, or i'or an�t addit�.on to
e,ny exiet3.ng buildin� or atructux�e, or for an� alterations or repairs
to any e�c3.sting building or structure, upon application there�or' require
the pa�ment by the applicant far such permit of fees to the amount herein
beiow aet forth and in the manner herein provided to-wit:
2.1.. For any such permit for the erection of any fire-proof building�.other
than a gerage, warehouse, factory or grain elevatar, or for the erection of
an3r f'ireproof addition, for similar occupanay, ta any exi�ting building
shall be at the r�.te of .�1.L�0 for each one thousand cubic £eet, or fractian
thereof, in such cu.bical contente. � �-
2.2. For a.t��r such permit for the erec�ion oi any fireproof -garage� were-
hous�, factory or grain elevator; or for the erection of an�* fireproof
addition, for similar occupancy, to any exiating building shall be at�the
rate of �1.25 for each one thousa.nd cubic feet, classified as "fireproof"
by Section 502 of the Minneapolis Build3.ng Code.
OUS
2.3. For.any� such permit for the erection of an
other than a garage� warehouae, factory or grain
f�reproof addition, for afmilar occup�ncy, to an
Permit �1.00 for each one tlwusand cubic feet.
G�IRAGES
�r non-fireproof building
elevator, or any non-
y exist3ng buildira.g.
2.4. For an� such per�it for the erect3on of an�r non-fireproof garage,
warehousg� fac'to�r ar �°ain elevator, or for the erection of any non-
Fireproof addit3an, for similax° occupanc�, to arr�r existing bu3ldin��
fcar e�..ch such.. hu9.lding or addition. Ninety Gents for each one tho d
eubic feet or fract�.on thereof, in the ceubical contents thez'eof w�.th s
minimum of �4•40. - �
For the ptu'pose of computing fees for buildin� permits the cubic.al con'tants
of any building or addition to a uniform height thraughout b� mult3plyin�
the ground axea covered from a point six.(6) 3.nches below the f�.00r line of
the basement.or cellax to ihe average height of the upper surface or to the
average hei�ht of the roof surface of the s�in gable of a pi�ched x�oof.
- ,
2.5. For repairs or alterations to an exiating etructure, the fee ahe�.�. be
at the rate of �3.00 for eaeh Five Hundred Do11ar,�s (�5�•00), or fraction
thereof in the cost of all propoaed work.
2.6. In no. - ce.se shall tk�e fee
Secti�.a.-2� be less t � .00.
�. . .
charged for any permit as set forth i.n
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Caty of Fridley, Mi.n.n.
BUILDING PE�IT
N° 5930
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' LOC 1� P 1 DING
,
No. , , _ Street +�� " ,,�._ Part Lot
Lot .__ Block �_.. Addition or Sub-Division� �
,� ������
Corner Lot _ Tnside Lot ._._ Setback ���;��� Sideyard �a,�
Sewer IIevation � Fouadation IIevation
DES�RIPTION OF BUILDING
Ta as:
.;� Front ��'DeP'th .����Ieight �� Sq. F`t.' 9��Cu. Ft ����?.7�,�/
Depth eight � Sq. F� ` Cu. Fi. _______
Type of Consiruction � ,� Est Cast � � _�'o be Completed
In consideration of the issuance tn me of a permit to construci the building described above, I agree to do
the propesed work in accordance with the description above set forth and in compliance with all provisions of
ordinanoes of the dty of Fridley.
�
In consideration of the paqmeat of a fee of $��"� _, permit is hereby granted to
to construct the building or addition as descrll�d above. Thispe rmit is granied upon
�he express condition that the person to whom it is granted and his agents, employees aad worl�en, in all work
done in, around and ugon said building, or any part thereof, shall conform in all respects to the ordinances of
FricIIey, Minnesota regarding locai3on, constructfon, alteration, maintenaace, repa3r and moving of buildings
t��in the dty ]inaits and this permit ma.y be revoked at any time u�n violation of any of the provisions of safd
NOTICE:.
7'hk permtf doee eot eevee �hs eonslruetion, tnataQadon for wGin� plumbing, gas heating, sewer or wate�, Be sure to see
t6e BuiWiag Iaapeew� for aeparate permNs for theae Items,
,� � � �
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APPLTCATIOAi F'OR BUILDIPIG gE�T...
CZ7."Y OF FATDLEY, MINNESQTA
Owner'a Name�.�� � � 1� a �-�° 1 a � � 1�> Builder_y�� � , � �, � f� 1 � ����{�
.�.__
Address _ _ (� � 1 b - � _ � P� ,��9t� ��Address
LQCATIOH OF BUILDING
No. 0� °1 1 I� � Street_C1� �� �, ��� 4 Part of �,ot
Lot � Elock_�_____ Addition or Subdivision ��� �� l p, _�S, �
Corner Lot�_Inside Lot��Setbaek Side-Yard
SE�1SA EI.EYATZON FOUI�DATION ELEVATION
Applicant atCach to thi8 form Tw� Certificates of Survey of Lot and proposec�
building location drawn on thes� Certificates.
DESCRIPTION OF BUILDING
To be used as:
fl�� I°1 I�c� 'i� ���A�°`�roaC 1�Depth ,�2�Height I� � 1�
��tic�Cs�
sq. �t. � � �/ cu. Ft. � � �`D
Front ' Depth Height
Sq. Ft. Cu. FC.
Type of Conatruction. � p� ��� � Eatimated Goet
�o be Completed ,
- The uadersigaed hereby makes appTication for � permit £os the work hesein
specified, a�reein� to do a1l:wrork ia strict accordance urlth the City of
Fridley Ordinances and ruliags of the Department of BuildiAgs, and hereby
declares that all the facts aad xegreaentations"atated in this application
�re Crue and correct.
t �
nATE�� � � � 1 szcNAZ'tn�� , �1 �„�� � • Ea�,:��
(Schedule of Fee Coats can be Eound on the Reeerse 3ide).
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BUILDiNG PERMtT FEE SCHEDULE
Section 2. TTie.Inspector of Buildings ,sha11, before i�auing any permit for
�che e�ectian of any building or structure, or for auy-additcion to any ex3sC-
ing buildin� or struceure, or for any.alterations or ge�eirs to any_ exist�ng
bgpl3c�ant��or�suchure,,rupAn application therefor,.res�uire Che a
�
.
a Permit of feee�to the amount herein below set�o�thbandhe
in the manner herein provided to-wiC:
. 2_1. For aay such perm�tt for Che erectioa o� any fire-proo£ building, ot�er
than a garage+ warehpuse, facto,ry or gra3u e},evator, or-for the erection of
e.ny fire-p�oaf addition, for eimflar occupaacq, to any existiag building
shall be �t t�e xate of $1.40 for each one tho�usand cubic-feet� or fraction
. .. . th�reo��,' fn sueh �ubical cbntents :�•
Z_•.�. -- For any such permit for �he erect3oa of any fire-proof �arage, ,warehouse,
's �o� s�1�� rain elevator, or fo� the erection of �ny fire-proof add3,tion,
actory or g
oceupancq, to any exiating�building shall be at the r�te of $1.25
. for each oae thousa,nd cubic�feet, classified as °1fireproof" bq $ection 502 of
the Piinneago]:3.'s` Buildiag Code. .
. :. f FOUS.�S - . .
�._____
2_ •3. �or any such perm�t,t foz, the �rectioa of an noa-fire roof buildi
than a garage, �aare�ouse, facto � y p � othes
addition, for s3milar occupaacy,�torany$existing�buildina�� noa-firepr�f
each one thous�nd cubic feet. �" Perm�t $1.Q0 for
-- - , GARAC.ES . . '
. 2.�4_ For _any �uch permi,t- �cr�-the erection of any non-firepraof garage,
warehouse, factory or.grain,elevator, or £or th� erecftion of any aon-fireprvo.f
. . _
�ddi&aLoa,.foz simiiar occupancy, Eo any�existing building or for each such
build3ng or �,dd3tion - ninety cents ($0,90) for each oae thousand cubic feet
�- Chereof, in C�e cubical contents thereof s,�ith a. mini�� of - 4 00
_ or fracrion�
� � . .
�'or tha_p.urpose of computing fees for buildia
g perm3ts, the cuhic.al contents
of a,ny building or additioa to a uniform height_.throughout bg multiplying the
�.� �rounsi.area-eavered fram a point six (6) inches below the �'loor Aiae of the
basemeat or cellar to z�e avei�age height�o£ ttie u
" anerage heigli� of the rqof�.surface ot the main gablerof�afp�.�chedtroofg
2.____5., For rr�pairs or alterations;to an existing etructure, the fee sha.11 be
� a� the.rate-of $3.00 per each Five Hundred Dollara ($500.D0, or fraction
thereof 3a the cost of a11 propoaed work.
2.6. ..`In no c��e s�iali the fee charged for aaY Permit �s set farth in
Section 2 be lesa th�n $4,pp�
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SUBJECT Q -.,
c�ty of F�ridley - 16 3
AT THE TOP OF 4HE TWINS g U I L D I N G P E R M I T -� �
i �
' � RECEIPT NO.
� �v _ COMMUNITY DEVELOPMENT DIV.
r j ; PROTECTIVE INSPECTION SEC.
� _ �
L-__•� ����� `,� CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY
i 612-571-3450 9/15/81 � /
910-F15
JOB ADDRESS I
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. $rppj{VlE�ni ACZCZ7,"t].OIl SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
Grace Ailen 6716 Channel It�ad N.E. ' 571-4448
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
6 USE OF BUILDING
Res.idential
7 CLASS OF WORK
❑ NEW � ADDITION �] ALTERATION ❑ REPAIR ❑ MOVE 0 REMOVE
8 DESCRIBE WORK
�I�L Enclose Deck into Porch (25' .x 10' )
9 CHANGE QF USE FROM TO
STIPULATIONS
SEPERA�'E PERMITS REQUtR��D �p� �
H�ATING, p���81(�C; A�L� Sl� RIi�G`
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCEO. N0. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION �- STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $1'� OOO $. SO
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pEFMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. y�l.%. SO
PLAN CHECK FEE TOTAL FEE
�'ts 30 .$22 � 3-O
St UREOFCONTRACTORORAUTHORI2EDAOENT IDATEI WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
� � _ /�+�/� � e�, C/
SIGNATURE OF OWNER tIF OWNER BUILOERI IDATEI BLDG INSP �pT
CITY �� FRIDLCY Effective Aug. 1, 1981
APPLICl1TIU'� FOf; RCSIDEi�ITI/i� QUILDIt�G PEf2r�iTTS
(fde►�r, Alter•�tions, Additions, or Repairs)
OtJt�ER: � Na��� �1`t b4 l ��@.l, �UILDER: 5�,�,� �
ADDRESS: _ (�`7 /% - �r��, �1Q� (�.'� � AUDRCSS: ^
TEL N0: S'� /-�/��/� � TEL td0:
Consi:ruction Location
ST7t��T NO: '�/ STREET: �,/� � ��, � �� ,
a
i.oT: �-, � o`f � � sLOac: �unYTZON : ��-ea �C � � � u� . ,
Corner Lot: Insicle Lot: SetbacY.: Sideyards:
Ap�licant attach to this form two Certificates af S�rvey of lot and
proposed building location drawn on certi.ficates to scale.
�� � DESCRIPTI4iJ OF CQNSTRUCTIOP�
'�"�'�p '�°`�."`.�-- Front: o�_S � �C / De th:
/D P Height:
Squane. Feet: �, Clibic Feet:
�ront: --- __ __
�epth: - Height:
Square�Feet: Cubic Feet:
. `��
Type of Construction: ��� �`�A��� Estimated Cost: $` Dd'�D ,��
Zb Be Q�r�pleted: � /7id�j'7-�Z s - _
Alt. A Alt. B
Proposed Drive�iay Width If New Opening Is D�sired: $� $
. . SE� �VERSE SIDE OF SHEET
The undersigned hereby ma};e� application for a permit for the t�ork�herein specified,
agreeing to co.all work in strict accardanc� ��ith the City of rridley Ordinances �zd
rulings af the Departsnent of IIuildings, and hereby declares that all the facts and
represenfations stated in this applicatian are true and correct.
D�TE: SIGNA7�'URE :
Stipulations:
s ��e��
° � S�!�
8 �
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B�TSLDING PE�RNlIT F�EE SGHEDULE
The Inspector of buildings shall, before issuing permits for the
erection of any building or structure, or for any addition to any
�xisting building or structure, or for any alteration or repai'rs
to any existing building or structure, upon application therefore,
require the payment by the applicant f or such permit of fees to the
amount herein below set forth and in the manner herein provided to-wit:
TO'PAL VALUATION
$1.00 to $500.00
$501 to $2,000
$2, 001 �Go $25, 000
$25,001 to $50,000
FEES
$10.00 Minimum Fee $15.00 plus surcharge
$10.00 for the first $500 plus $1.50 for each
additie�nal $100 or fraction thereof, to and
includ;�ng $2,000
$32.50 for the first $2,000 plus $6.00 for each
additiunal $�,000 or fraction th.ereof, to and
including $25,000
$170.5A for the first $25,000 plus $4.50 for
each a•3ditional $1,000 or fraction thereof, to
and in�,:luding $50,000
$50,001 to $100,000 $283.00 for the fixst $50,000 plus $3.00 for
each a�3ditional $1,000 or fraction thereof, to
and in�l.uding $100, 000
$100,001 and up $443.0� for the first $100,000 plus $2.50 for
each. aciditional $1, 000 or fraction thereof
- - - - - ---- ---- -
PLAN CHECK: 25 percent of building pezmit fee
DRIVII�IAY DEPRESSION ESCROW: Concrete Curb Streets Only
Alternate "A": Removeal and replacement of curb and gutter only
Driveway width plus 6 feet x$13.50
Alternate "B": Rmioval and replacement of curb and gutter and install a 3 foot
wide approach with 6 ir�ch depth
Driveway width plus 6 f eet x$15. 75
VERIFICATION UF F4UNDATI�ON
Permits for construction will be issued a minimum of 24 hours fra� the time of
application to allow for proper review of the proposed structure and 4�f the
construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it
has been constructed will be required before :proceeding with.the framing.
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City of Fridle� 2 8 5 2 �`
AT THE TOP OF THE TWINS g � I L D I N� P E R n l l I T
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� � C O M M U M I T Y D E V E L O P M� N T D I V. RECEIP i
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f � � PqOTECTIVE INSPECTION SEC.
1 . ,
`---_ w ��°',•� CITY HALL FRIOLEv SS132 NUMBER REV OAifi PAGE OF APPROVED BY
t � � 612-571-345p 910-F15
11/4/98 � �
JOB ADORESS
6716 Channel Road NE
t LEGAL LOT NO. 9LOCK TRACT OR ADOITION SEE ATTACNEO
DESCR. �12SO� SHEET
Pt. 24 Brookv ew A
2 PROPERTY OWNER MAIL ADQRE$$ ZIP PNONE
Web Allen _
3 CONTRACTOR MAIL ADDRESS 21P PHONE LICENSE NO
Town & Countr Roofin
4 ARCHITECT OR DESIGNER MAIL ADDRESS 21P PHONE LICENSE NO
5 ENGINEER qtA1LApDRESS ZIP PHONE LICENSENO
8 USE OF BUIIDING
Residential
7 CLASS OF WOiiK
O NEW Q ADDITION � ALTERATION � REPAIR O MOVE : O REMOVE
B OESCRIBE WORK
Reroof house and ara e 31.2 S Tear-off
9 CHANCiE OF USE FROM TO
STIPULATIONS �
Underlayment must comply with the State Building Code.
' TVP�` OF CONST OCCUPANCY GROUP OCCUPANCV IOAD
SEPARA7E PERMITS ARE RE�UIREO FOF ELECTFICAL. PLUMBING, MEATING.
VENTILATING OR AIH CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUGTION ZONING SO. FT CU FT
AUTHORIZED IS NOT COMMENCED VjIITHIN 80 OAYS. Ofi IF CONSTHUCTION
OR WORK IS SUSPENDEO OR ABANQONED FOR A PERIOD OF 1�p DAYS AT "
ANY TIME AFTER WORK IS COMMENCED. ' NO. DW�G. UN17S OFFSTFEET PARKING
I HEHEBY CERTIFV THAT I HAVE READ ANO E7(AMIN�O THIS APPL,ICA710N STALLS GARAGES
AND KNOW THE SAME TO BE TqUE AND CORR�CT. ALL PqOVi$IONS OF LAWS yALUATION SURTAX
AND ORDINANCES GOVERNING THIS TVPE OF WQiiK WILL QE CpMPLIEp
WITM WME7HER SPECIFIEO MEREIN Ofi NOT. TME GRANTING OF A PERMIT 2]�{Z ]..3]
DOES NOT PRESUME TO GIVE AU7HORITY TO VIOLATE OR GAMCEL TNE pEqMIT fEE SAC CMARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION 7�F.75 Fir SC $2.7�F
PLAN CNECK FEE TOT FEE
� ° - �'�°^� ���'u -� � Licen 5 0 3. 86
S�GNATU�7E OF CON: AACTO Op AUT OAl2ED AGENT IDATE� N RO� V LIO T'FIIS IS VO R PER I
�- I�
S�GN4TUAE O� OWNEp�iF OWNEA BWIDEiii IOAfQ� . ` Bl �NS� ' � r��rE
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RUG--13-1�
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ADDN [ �
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Consm�ctionAddress:
��42 FROM CITY OF FRIDLEY -- - TO
Legal Description: �
CITY OF F'RIDLEY
SINGLE FAMYiY AND pUpLEXFS R i AND R-2
BUILDYNG PERNIIT APPLICA?ION
�
�i89320 P.01/02
raiex;uv� u i�ya
�P�y�'�
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Owner Name & Address: (il7C % I�-I �.e v� �n� 1 Co C�IOIYi ►� e I � Tel. � s� 1- 4 y y S'
Contractor: Y� � ' MN LIGENSE #�.L� 0 j 12 5� �
J J� r
Address• T"�� j. O �5�1�5 TcI. #,�l5 -`i Z-3.3
Attach co this application, a Certificat�e of Survey of the
lot, with the proposed consavction drawn on it to scale.
LIVING AREA:
GARAGE AREA:
DECK A.REA:
01'SER:
DFASC�TYON 4F IDIPRO��:MENT'
Ixn$Th Width � Heig,ht Sq. Ft.
Length . Width Hei�ht Sq. �t.
Length Width HgtlGround Sq. Ft.
a g�.`� � i � 2�S � � ��_ .�
3+ a
Consuucdon Type• i�t�1�'+2 Fscimated Cost: $ `�'j 'q $ a oc7
(Fee Sci2edule r�n Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: � �
�.�. . � �
��. � � ����- �,1� 3 �
r -
Permit Fee $ y�� Fee Schedutc on Reverse Side
Fire Sumharge $ .�1 of Permit Valuation (111�h°6)
State Surcharge $ ` $.50/$I,OOQ Valuatioa
SAC Charge $ $100p �r SAC Unit
Licev.0 Surcbargc $ s �$S.� (Stat�c Liccnsod Rcsidc�ial Contractors)
Driveway F.scrow $ Alt. "A" Ur Al� "B" Above
Faosion Control $ $450.00 CoaServvadon Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Chazge $ Agr�ment Necessary [) Not Necessary (]
roTai,
STIPULATIONS:
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