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City of Fridley, Min.n.. �
BUILDING PERMIT o 4 s s s�
��
Date: .....� _�-.- ..�.�.._'��_.C.r_:�_.�_...__.� �
� ,;,.�_ �,�'�'?
,�,'
Owner: -- g ..�.{�..-.�. �.!.2........�+'�-�...`.°�,���.=Z.�.�..... Builder _..._.._.���-� " . ____.�.:t�,�.2��'l._...�._
�:-,��'` .., _
�r��
Address
�, , � L�CATIO(d OF BU DING
No. --,,�----��------• Street _ ���� . _:_ . .._--..,,�?'�� ---• .,�r�•:.� Part of Lot ....._..__....----------�.____._....__..._.._..._..�._.
r
Lot---.._ ........ . ......_........ Bla:k .....----� --�---��---........_......._..: Addil3on or Sub-Divisio ....._.. - � ....._...... �- �---.._..........___...------.........._.._...._---- •------------�-
-� f
Corner Lot ....._........_....-------.... Inside Lot .---��---.......---',�tback ��--" �- - - Sideyard .....---� .._..._...._._........_._. _.
SewerElevation ....._..----...--------�--....._..._.....-----------------....._...._......._---._........ F2�dation IIevation _...__ .........................._............._.........---_.
DESCRIPTION OF BUILDING
To b� us �
, ,
--._.. "f ....-'...._� >�'��-/----- Front �_..._.. Depth ..--'F�-_. �_.. Height .1''.._+�..�......_.. Sq. F� ..�-_�.�.._.. Cu. E'� _.1�...1.`�
-.._......-- ..._. .�.�..._..._.._........._.. Front ----��--�----...._.. Depth ._.._............� eight ........._......._.. Sq. F� ----------......--- Cu. Ft ...__......._........
� ��
Type oP Construction ....�.�-'��'.:.�t.�_........ Est. Cost... _...,�f. � ..............._........ 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 accorda.nce with the description above set forth and in compliance with all provisions of
ordinances of the city of Fridley.
�
In consideration of the payment oP a fee of $._ ....--`.�'.'..'r_---, Permit is hereby granted to--------•--------------------_...---._.._..
_.._.. _..._�_.._.—.—._._ to construct the building or addition as described above. This gernut 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 conform in all res�cts to the ordinances of
Fridley, Minnesota regarding location, constiuction, alteration, maintenance, repair and moving of buildings
within the dty limits and this permit may be revoked at any time upon viola�n of any of the provisions of said
ordinances. �� .�'�:' ;
Building Inspector
NOTICE:
This parmit does not cover the eonstruetion, installallon for wiring, plumbing, gas heating, sewer or wafer. Be sure fo see
4he Bulldfng Inspeeto� fo� sepa�ate pe►mita fo� fhese itema.
i"�' 4 '°^-
.�-d t_. 1,�.- w s .
�
gPPLICATIt�N FOR BU?.�DIi�G P�
CTTY OF FRTDLEY, M�NN�SOTA
I�
Ownera Nanna �� �' '� �" � � �' Bu3lder;, � 8 � � ��. � �. ��- � �
Addresa `�� � �-. � ���!-'�� � 1 � � i�� Address '�l �° � � �.�� r� f�� �.. d �_ %�
� LOCATION OF�BUILDING -
:� :� � S"�reet� � � � � � f�" �: Part of Lot - _ _ �''A�
No.,. -, ----a��____
Lot Hlock. Add3tion or 5ub.Div.
_--
. � ��
Corner Lot� side I,ot= Ba.ck Side-Yard � .
. ._.....,.�
3� ELEil6TI0N
ELEVgTION
Applic�t attach to this form Certificate of Survey of Lot and propose�l building
location.
DE5CRIPTION OF BUILDING
To be u. �-a�s
, � � �`��
e,^ � Fro�t � C?� Depth_ a�...... , He3ght
. � .
Sq. Ft. � Cu. Ft.
Front Depth Height
Sq. I;"t. Cu. Ft.
�
Type of Conatruction I� S' f��a �, �`� Tst3mated Cost.,,, %� s% '� ....,,._.
To be compa.et.ed � �i� � � f ,
The undersigned hereby makes application for a perta�.t for the work herein �peaified,
agreein� to do s7.�. work in striet accordance with the City Ordinences and ruling of
the Depar'tanen� of B�sil.ding�, and hereby decleres that all the facts and representa-
tions stated in this appl3cation are true a--' -����'`
DATT , ✓ � °� � �' % �„_____,_ 3IGNATURE
`��
(A Schedvle of Fee coats can 1� found on the Reverse Slde.)
t'�,
^,
.- • �
—��;
$UI�,DIl�TG PERMIT FEE SCI�ULE
Section 2. 2'he Insgecfi.or of Builclinga ah�l.l, before issuinng any perm3t
for the erect�.on of anX builali.ng or atructure, or for any addition to
any exi.atin� build3n� or structure,.or for any alteration� ar repQ,irs
to any exist3ng building"or structure, upon application therefor, r�uire
the payment by the applicant for such permit of fees to the amount herein
�3ow set forth a.t�d in the manner herein provided to-w3t;
2.7:. For any such permit for .the erection _of any fire-proof bix3.ldiag,. oth�r
then a garag�, warehouse, fac�tory or �rain elevator, or f�r the ereotion oP
any firegroof add3.tion, for simi.].ar occupaney, to eny existin�. bui].ding
shal7.'be at the rate og.�l./.�0 for each one thousand cubic feet, or fraction
thereof, 3n such cubical s�nteata.
2.2. � For an� euch permit for the erection of ariy fireproof gax�a,ge, •were-. �
housQ� factory or grain elev�.tor; or for the erection of' eny fireproof
acldition for eimilar occupancy, to any existing bui].d3.n� shall be +�t the
rate of �1.25 for e�,ch one thousand cubic feet, classified �.s ""Pireproof"
b� 3ection 502 of the Min�eapolis Bu3lding Code. �
HO_„U3E3
2�3. For any suoh perm3.t for th� erection of an
other t�ien a garage, warehouae, factory or grain
fireproof adclition, for sfmi].ar occupancy, to any
Permit �1.00 for each one thousand cubic feet. �
Gl1R�llGFS
y non-fireproof building
elevator, ar any non-
exist3.ng build3ng. •
2.4. For an� such pex•a�it for the erection� of any non-t'ireproof garage,
warehouse, factory or �rain elevator, or far the erection of any non-
f3reprocf 'a�dit3:on, for similar occ�,pancar, to any e�sting building *r
for e�.ch auch buildin� or addition. Ninety Cents for each one thousand
cubie feet or fg°a,etion thereof, iri the cub3cal contents thereof�with e
mirl3mum of $,4...00. � �
� For the purpoae o€ computing iees for.buildin� permita the cubic.�. contents
of any building or addition to a uniform height throughout by mult3pljring
the ground area covered from a point six.(6) inchea be].ow the fl.00r line of
the basement or cellar to tl�e,average height of the upper surface or to the
aeerage heigh�"of the'�oof surface of the main �a,ble of a pitched roof.
2.5. For repairs or alterations tti en exiating atructure, the %e shall be
at the rate of �3.00 for each Five Hundred Do�.3.a,r',� ($500.00), or fraction
thereof in the coet oi' a11 prapased work.
2.6. In no-case ahea.l the fee charged for any permit as set forth �i.n
Secti�n �" be less tla�n $�..00.
�
�---� .r,ti,
�
� ..�--�
SUBJECT
City of Fridley
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
i �
� �
� • COMMUNITY DEVELOPMENT DIV.
� �y-------�
r � � PROTECTIVE INSPECTION SEC.
1 i �
�l ��"1 � CITY HALL FRIDLEV 55432 NUMBER REV. DATE
L--��� � �'� 812-580-3450 910-F15 6/4/74
JOB ADDRESS
5
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION
DESCR.
2 PROPERTYOWNER MAILADDRESS
3 CONTRAC OR MAILADD ESS
Milton L. JOhI130II C�1ttP�I j► � n ral Avc�nnP N=F.
4 ARCHITECTORDESIGNER MAILADDRESS
5 ENGINEER MAILADDRESS
6 USE OF BUILDING
RQaid ntial
PAGE OF
� �
PER
. . 125'7'7
R .
�%/���
APPROVED BY
SEE ATTACHED
SHEET
ZIP PHONE LICENSE NO.
ZIP PHONE LICENSE NO.
ZIP PHONE LICENSE NO.
7 CLASS OF WORK � NEW ❑ ADDITION �] ALTERATION ❑ REPAIR O MOVE � REMOVE
8 DESCRIBE WORK
Install alimm. siding and trim and gutters
9 CHAN(3E OF USE FROM
STIPULATIONS
ro
SEPERA'F`E PERMITS REQI��REp FOR WfRtNG,
NEATlNG, PLUMBtNG AND Sl�NS.
TYPE OF CONST
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING
AUTHORI2ED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. U�
I HEREBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS APPLICATION �'
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHEH SPECIFIED HEREIN OFi NOT. THE GRANTING OF A PERMIT y��.� 5O
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION, � $9.00
�� � PLAN CHECK F
� ` 0 ` � i
SIGNATUHE OF CONTRACT R R AUTHORIZED AGENT IDATEI �
y, �"�
>
��.-.,..��o� �� nuu�co nc e1WIJFR RI111 f1FF1 IDATEI BLDG. ��
)CCUPANCY GROUP OCCUPANCY
SQ. FT. CU. FT.
OFFSTREET PARKING
STALLS GARAGES
SURTAX
.75
$9.75 8
IS YOUR PERMIT �
�PP�T�pTION FOR RLSIllENTI�L, ALTEItaTI�1�,
UR �1llll1�'ION I��JILDING PERMIT
C I'1'Y OF 1-1:1 DLk:Y, �1! tiNESOT�1
��
OW1�1FA � 5 NAME : l / � ! 4d ¢' � r �- �$ � � BU ILDER : � �- i G s.� �, � �' t-1 � �e „� �
�ADDRES S : � 3 °Z �' I S ra� � ld � ADDRES S : r� S / .� �� E+► �� `� �° G �' �
NO : , 5 .3 � STREET : /�"� l � M �r � / d c)
-7—"--
LO�: BLOCK: ADDITION:
CQRNEA LOT: INSIpE I.OT: SETBACK: SIDEYARD;
Ap�lican� attach to this L-orm �ao Certificatea of Survey of Lot and proposed
bt�ild�.xig location drawn on these Cextificates.
To Be Used As;
�ESGRIPTIUN OF BUILDING
Front: Depth: Height:
Square Feet: Cubic Feet:
Front: Depth: Height:
Square �eet; Cubic Feet:
� � � � s-, � , .� q � �,. �,
�`ypet o� Constxuction: T�:rn ��� +c�; Estimated Cost: $/; a d'�
To Be Completed:
T11e undexsigned hereby makes applicativn for a permit fox the work herei.�,
sp�c�fied, agreeing to do all woxk in sttic� accordance with the City of
Fx�.dley Ordinances and rulings of thc� llepartment of Buildings, and herehy
declares that ,ill the facts and xepresentations stated in this application
are true and currc•ct.
DATE: �c�- � SIC;�AT'tJRE:
(Se� verse Side For Additional Tnform�
� L�
�0 7S �����
�� 1
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e
.
,
BUILDIN(: !'�:1L�1J�f I��:f: SCtI1:UUL�
S�GTION 2. The Inspect:�r �f i3��iidings shall, before issuing permits f.or the
e��Ction of sny buiiding or strur��,rc, ur Fo� an�• addition to ,�.ny exi.sC�.ng
building ox sfiructure, or 1or ..iny .+lterati.on or r�pairs to any c?:isting
building or sL-ructure, upon applivation lhereior�, r�q�:irc the payment by the
�.pplieant foz such permit of fec:s tc r.h�� amount herein below set forth and in
the manner hexein provided to-alit:
LT1vI�'ORM BUILDING CODE: Type 1, 2& G-$2.15 for each on�: thousand cubie
�eet, ox fraction ther�of, in such cubical contents. T}'pe 3& 5-$1.85 for
eaoh one thousand cubic feet.
:1DUITIONAI. LNI=URh1ATIUN
Fox the purpo�e of computing fees f�� building permits, the cuhical coi�tents
of any buildin� or .�ddition, is dete�nined by multiplying �he gxound area
ooV�x�d fxom a point six (6) inches below the floox l�.ne of the basement
ox the� �e11ar to tl��� average l�eiKlits of the upper surface or to the avexage �
h�1��tt �f the roof surface of tlie ma.in gahle of a pitched roof.
Fo� r�paixs ox al.�exations to an existing structuze, the fee shal]. be at the
x'a�e o� $�.00 pex eac}� five hundxed dollars ($SOO.Op) ox fraction thereaf in
the 6os� Qf all pxoposed work.
Ta na aase sha11 the fee charged for any permit as set forth in Secti.on 2 be
1e��s than $S.OQ.
VERIFICATION OF FOUNDATION
A1QZ'�= Pc�xmits ior construction will be issued a minimum of 24 hours from the
t� of app�ication, to allow for proper review of the proposed structure and
o$ the ao�struction site.
A Certified Survey of the lot, showing the location of the foundation, once �.t
ha� been eonstructed, will be required before proceedin� with the framing.
�'�RTIFICATE UF �CCUPANCY
Application Eor a Certiiicate oi Uccupancy shall be made ten (10) days prior
to the uae or occupancy of any structure for which a building permit has been
1��tt�d; and s.iid structure sha11 not be used or occupied until a Certificate
�f Occupetncy has been isaued.
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� � . AhIOKA COUNTY .
6431 UNIVERSITY•AVENUE NE September 2, 1975 FRIDLEY, MINN[SOT.� �5�3�
. e
' • � � p1i�.lneapolis Pos� Ofiice Dapartmexz� ' . - - �
. Su]ierintendent of Delivexy ' �
1sL' F� rtaxquette Avenue ' . . , � . . �
A1.a.nneapolis, M�nnesota 55402 . . , �
• ' Re: Change oi Address - Effective Oct. 1, 1975 �
' , City bi rridley � �
Gent].emen : � . , , '
We axe lis�ing L•he follo�t�ing change of addxess in the Cit3� of Fridley;
� . N�; Mr. Gary Westlund . .
.. . FROM:. 532 Highway #100 N.E. � . �
. . . • i
•��. . TQ� 509 Cheri'Lane N.E.• . ' I'
,�, I,�GL�I. DESCI2IPTxON • Lot 16, BTock 1, Murdix Park • .
• . • , • . -
, • �
� We�liave notified Lhe occupani: of this change and we �ould appxeciate
.� i� vexy much i� yau t�ould c}.ianse youx xecoxds accorda.ngly. , .
• ' . � . Si.ncexely, • ;
• . � • • D t�L G . CI.AP.K . .
� . � , Community Development Adm. � � ,
� � DGC /inh � � � . � '
• CC : CiL-y Wa�cr liil7.in� Dept . • . '.
� City Assessing Dr_par�:.nicnt • " . .
. . �iinne�zpolis Cas Company - Bxoolclyn Paxk Offi:ce • .
� , . Noxt]icxn S�t�tes Po�,�cx Company � . ,
' NoxtlnacsL•erii BelJ. Tclephone �
.� CiL-y Vot•crs r.e�ist-xation � .
�. . •j�O1l1GOCd11CT . ' • . ' ,
. , .. . .
�� � ' ' � ' � � . � 560•3450
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. . , �� -E fj.: �-� .
1� ^. ~:�`��`'' ?� ANOKA COUNTY •
�' j E;t��� .:k_t �. :� , , .
tyr �-1'.��t�..J
\� �[:': 6431 U�lIVEkSITY AVENUE NE . September 2, 1975 �• F�IDLEY, MINN[SOTA 55421
' .Ilt� , � � ' �
. ��
(„J -1 � . . ' ' .
� Mr..Gary Westlund � • ' �
� 532 Highway #100 N.E. ' .
� Fridley, Mn. 55421 � � ' .� .�
� � Re: . Change of •House 1.dumbers � �
. . � • - Effective. October 1, 1975 ..
' • •. Dear Mr. Westlund: - .
� �.•• It has been necessary for this of�ice ta change the address
of your hous� ' ' .
•'' �' FR024 532 Highway #100 NE TO 509 Cheri Lane N.E. ••
.� ' Li:GAL DESCRIPTION Lot 16, Block 1, Murdix Park •,
, We have notified the•Post.Office Department, Minneapolis Gas
; . �� Company, Northern States Po�ver Cor.lpany,��Northwestern Bell Telephone
, . Company and various departments in City hall of this change. �
. '• . � . Sincerely, '
� � •DARP.�3L G.. CLTiP..IC . '
. � : • . Cos;umuniL-y Developmeni: Adm. � ��
� ' DGC/mh. ' . '
� . . •
.. . ` .
Building
Inspections
763-572=3604
763-502-4977 FAX
�airc
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
❑ OWNER ;�CONTRACTOR
ADDRESS: S C% �I - C��� �r .1 �� CITY
Permit No.
Received By:
; ;� �.
�i•
.
._�-- - --.-. --
ATE�ZIP S�� i �
CONTRACTOR ADDRESS: CITY �lFIJY�C� 5�Ii e-�STATE�ZIP S-�(I <
SUBMIT A COPY OF PHONE �Co �J —'J' , c� �ol � FAX � C� 3`���S— O G U�
YOUR STATE LICENSE STATE LiCENSE # % D (cy Z � � � r� EXP DATE �'�' � � — � �
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ��DITION u Uw►uurssr►�u
❑ BASEMENf FINISH ❑ ROOF ,
❑ DECK ❑ SIDING
❑ SWINIMING POOL
TYP� OF WORK: ❑ NEW HOME CONSTRUCfION ❑ ADDTfION
❑ MAINTENANCE/REP ❑ REMODELING
DESCR[BE WORK BEING DONE: ^ v
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �� ❑ HOUSE 8c GARAGE '.
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
� Alummum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ WINDOWS
� DRAIN TILE
❑ OTHER
F"i'
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
W CONSTRUCTION INCLUDING DECKS,
�offit � �^�.�, � ���NS. & PORCHES SUBMIT:
❑ Trim � .�L1 �j, I. Site Plan/Survey showing the existing structures
�Fascia "�/ ^ � aed proposed project.
�o�_ 2. Two sets of construction plans
WINDOWS � 3. Energy Calculations
IN EXISTING OPENINGS DYes ONo L�ATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUNIDER OF WINDOWS
ALL FEES ARE BASED ON VALUATIOI�T, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 UBC FEE SCHEDULE)
TOTAL JOB VALUATION $'1— �� OCCUPANCY TYPE
Permit Fee $ �� See Back Page for Fee Schedule
Plan Review $ ` 65% of Building Permit Fee
' Fire Surcharge $ ,7 .001 times the total job valuation ,;� �
Surcharge $ � a,3� .0005 x Permit Valuation Minimum $.50 �i��r
License Surcharge $ �,�zaPp $5.00 (State Licensed Residential Contractors)
SAC Charge $ $1825 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$21 =$
Erosion Control $ $450 Conservation Plan Review
Pazk Fee $ Fee Determined by Engineering •
Sewer Main Cha.rge $ Agreement necessary () Non Necessary ()
Total Due $ �� .� Make checks payable to: City of Fridley Attach Stipulations
THIS IS AAI APPLICATION FOR A PERMIT-NOT VALID UNTIL PRQCESSED
I hereby apply for a building permit and I acknowle 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 nstruction Codes; that I understand this is not a permit but only an application for a permit and work is no[ to start without a
permit on site; that ortc will be in acco ce 'th the approved i in the case of all work which requ�yes,p�revieav and app val of lans.
SIGNATURE OF APP CANT �� ��RINT NAME /!� ��-�� �''1 DATE�' 1�� ��
L. . . • . : .ti-�;_:�_����►�� � • �.
Page 2- Buiiding Residential Application
BUILDING PERMIT FEE SCHEDULE
The Chief Building O�cial shall, before issuing permits for the erection of any building or
structure, or for any addition to any existing building or structure, or for any alteration or repair
to any existing building or structure, upon application therefore, require the payment by the
applicant for such permit of fees to the amount herein below set forth and in the manner herein
provided to-wit:
VERIFICATION OF.FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of applicati�on to
allow for proper review of proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the existing foundation will be
required before proceeding with the framing. New Houses Onlv
City of Fridley
Building Inspections Department
6431 University Avenue NE
Fridley, MN 55432 '
763-572-3604
Fag: 763-502-4977
Engineering WATER AND SEWER Permit No.: :�, l����=�� �
763-572-3552 PERMIT APPLICATION Received By-�`�'�'�a
763-571-1287 fax CITY OF FRIDLEY g�, A���
,•
EFFECTIVE 1/1/2010 D��� �
APPL�CATION DATE: �`�� 1 v' YOUR E-MAIL/FAX:
THIS APPLICANT IS: ❑ OWNER �1' CONTRACTOR
Jos,4nn�ss: _ � c�'�i a�'��~; �v,
NEW CONSTRUC"TION PERMIT# (IF APPLICABLE):
PROPERTY NAME:__ i��,•�lcr �n ✓J�c •'°'
ENN�T ADDRESS: '� (.;a4i C%P1C'r o f-.�'1 � CITY__ i-".^ta;�f[,g STATEI �' ZIP ,� �'d �
PHONE: �tv3 - j %� • '°��LY
CONTRACTOR NAIv1E: �'�`°d'n-- �� ������
SUBMITA COPYOF ,.y, ?'
YOURSTATE ADDRESS: ��-IS.i�) ���� �IV`C'�'�L` CITY ar �,t-vs,a.1� STATE��Gv�LIP .� S i'�`���
' LICENSE WITH PHONE �` r�t'�' � " .5 /�' ,j `i f! % CELL PHONE: %��� - � �L cI's� % �
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/written description: yf�n ' (� � , /
Y�1'!1�'�� ��/�°"� Giln�? /�\CIL1� ��.1rrl"��-i� Cr' v, �/��C�6� Ae,�l�..`
f �r
2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations•
PERMIT TYPE
�. SEWER CONNECTION PERNIIT $50
. ❑ VJATER CONNECTION PERMIT $50
_ � ❑ WATER LINE REPAIR $40
❑ SEWER LINE REPAIR $40
� ADD STATE SURCHARGE $.50 • � �
� SAC CHARGE @ $2100 =
TOTAL $ �� � ��'�
` � F �_
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST - SEE UTILITY BILLING
SPECIAL ASSESSMENTS - SEE FINANCE
WATER TAP - SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMTf NOT VAL(D UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and I aclrnowledge 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. I understand this is not a permit but
only an application for a permit d work i npt to start without a permit. ,� ,
�..n ._.. . ." �- / �
SIGNATURE OF APPLICANT ,� '.�f'��� � !'1✓ �" PRINT NAME: d'���r ` - ,�i,�� iS,� DATE: �� � � �
�_
,
A�PROVED BY: '� � -'� � � DATE: � � 3 � � 0
COPY GIVEN TO: D UTILITY ILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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