AF - 38546City �f Fridley, Minn.
BUILDING PERMIT
Date: "' � °� �
....•-• _••__.....__.� ..._...__.----_._...!�?. �✓',..._...__...�.--
A ��,+%"� ;r
Owaer: �-_�._�..y�.�....�l... "./. +....__ � �,�.�..... Builder
,., �,, �� �.
Address ���----..�----•--- - ddress
e
i
N° ���43
��
�-----.._. ...:...---•-��------.._.._...-•---__..__._---_.:_..—.�'.__..
LOCA�TION ; BUILDING
�.. .� ��' s
No. ��,,�--- j.,/�_.._ Street -- - -���"'�� ..�°'.�..°._.... P�pP Lot .---._...___:..._..._._..._..._... .._..._..._._
� -- ,-�--_
/y, � •° � ,.. _
Lot ......�-�:'`......._........ Block .--._...:.-----.----......._ ................ Addition or Sub-Division ..� .�.
�� ' . . ..---- ___..._ ..._.. -----�— � ��':s,�,,�
• d
Corner Lot .........................._........ Inside Lot ..... --� �-�� - �-� ........ Setback ----._....---�-��----
..........----...... Sideyard ...----�--: _..---�----..._..--�--......_ .............---..... . „ .
Sewer Elevation
Foundation IIevation
DESCRIPTION OF BUILDING
` be Used as:
�j__.� /�� � � ��,+�
'T�------ =�-l--. Front ----�. �. Depth ��......�.�.._. Height ��r.!`.......... Sq. Fk ;y���. Cu. F� "'°'���i�
t��-
4'
...._ ..............__... ......_......._......--_... F'�ont --...------....... Depth ................. .. He' ht ._ ._...._--�°'� �4. F� .....__..........._.. Cu. F'� -�----.........- � --
Type of Construction ..��,��.:.. ,. Est. Co $....���.�. �,,.�.._......�... �T�o be Completed .....--..---------...--.----.._......._........
T�m ��a ����. ��,..��,��
,_ ,� 4
- ir4��iif ` ii�),_. , ------
C _�..
_.�`��r au���u�,s�L i��;�.����;.
�� `' ' ��'�'w� � �,.���� r_ �vE�a.��rv�� ,�raf
..1� , _ 1' �r:
� .. kE:�� i .i.:'��•�.�o
In consideration of the issuance to me of a permit to construct the building described above, I agree to do
the propased wvrk in accordance 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 $�_'�"�..� .--.-., permit is herebY granted to...__ ............._....._......._:........._.._......._..
_� ._.__.._._._._..___..._.._.._ to construct the buildu►g or addition as descrlbed 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 conform in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, rep and mo ' of buildings
within the city ]imits and this permit may be revoked at any time�xp olation any of the �p °visions of said
ordinances. � ��!. .� /
Inspector
NOTICE:
This permH does not eover Ihe eonstruefion, installation fo� wiring, plumbing, gas healing, aewer or water. Be wre to see
fhe Building Inspector for separate permits /or these hems.
� 4 ,�..
- '�--", -
�� - - ,
tPPLICATION FOR BUILDING PERMtT
CITY OF FRIDLEY, MINNESOTA
• - - : �� = , /.��..�� � /. � � . � r i.:.� I � -
X . �, / / : � • .. �
: � • � / .`_� ./� _ � _
� LOCATION OF BUTLDING •
Part of Lot ����-
No� Street _ '
.,
�t =�_ Block � ^ Addition or Sb.b.Div., � � �, �_ .�-�!�^ � �iZ��
Corner Lot� side Lot, j�5et Ba.ck Side-Yard
SEWER ELEVATION FOUNDATION ELEFTATION
Applicant attgch to this form Cert3iicate af Survey of Lot and gropos� building
1oca.tion. �
DESCRIPTION OF BUILDING
To be used es:
�� Front � � � Depth Height �
.�._.___-._.._ �_........_.�
�. Ft. �� o°�._...Cu• Ft.
.
F'ront �„__, ,_„_ DeP� Height
Sq. Ft. _ _�• Ft•
Type of
ted Cost __
To �e completad
3`he underaigned hereby makes application for a perm�-t for the work herein apecified,
agreeing to do all work in strict accordance with the City Ord3nances and rulirsg of
the Department of Buildings, and hereby declares tha.t all the facts and repreaenta-
tions stated 3.n thi.s e.pplication are true and cor t. �
DATE SIGNATBRE
(A Schedule of Fee costa can be found on the Reverse Side.)
�
�
. y � .. . ., _
BIIILDING PERMIT FEE SCHIDULE
Sec�ion 2. The Tnspector of Buildings ahall, before issuing any permi.t
for the erection of e.ny building or structure, or for any addit3on to
any existing building or structure, or for any alteratione or re�.irs
to an� existing building or structure, upon application therefor, require
the payment by the applicant for such permit of fees to the amourit herein
below set forth �nd in the manner herein provided to-wit:
' 2.1. For an�r such permit for the erection of any fire-proof building� other
than a gara.ge, warehouse, factory or grain eleeator, or for the erection of
any fireproof addition, for si.milax occupancy, to an�r existing bui].d3n�
sha11 be at the rate of �1./,.0 for ea,ch one thousand cubic feet, or fraction
thereof, in such cubical contents.
2.2. For any such perm�tt £or the erection of any £ireproof garage, ware-
house, faetory or grain elevator, or for the ereetion of any fireproof
addition, for similar occupancy, to any sxisting build3ng shall be at the
rate of �1.25 for each one thousa.nd cubic feet, classified as "fireproofn
bg Section 502 of the Minneapolis Buil.ding Code.
HOUSES
2.3. For any auch permit for the erection of any non-fireproof build3ng
other than a garage, warehouse, factory or grain elevator, or any non-
fireproof addition, for similar occupancy, to any exist3.ng building.
Permit �1.00 for each one thousand cubic feet.
GARAGFS
2.4. For ang such permit for the erection o£ any non-fireproof garage�
warehouse, factoxy or grain elevator� or for the erection of any non-
Fireproof addition, for similar occupanc�r, to a,riy existing building or
for each such buildi.ng or addition. Ninetg Cents for each one thousand
cubic feet or f�action thereof, in the cubical contents thereof with a.
minimum of �/�.00.
For the purpose of computing fees for build3ng permita the cubical contents
of any bui.lding or addition to a uniform.height throughout by multiplying
the ground area covered from a point six.(b) inches below the floor line of
the basement or cellar to the average height of the upper surface or to the
aeerage height of the roof surface of the main gable of a pitched roof.
2.5. For repairs or alterations to an exiating structure, the fee shall be
at the rate of �3.00 for each Five Hundred Dollars (�500.Q0), or fraction
thereof in the cost of all proposed.work.
2.6. In no case shall the fee chaxged for any permit as set forth in
Section 2 be less than �4.00.
�
�`1
_ _ " -, __�.:. ¢..
��
5
�
�
�
�-
�
�
� �
�'�
�
�
�
� �
�
�
�
�
�
�'
�
� �
� ��
� ��
�
�: �
� 3
�
�
�
�
W
�
�
�
�
��,�:.
w
� d
Q �
��� .
�
����-
��b �
����
w
M O� �
�u
���A
c����
�
�
� % �
�j'� p�q �
�3°�
,, a a
.°�a� ��
'�°��
� ���
. � � � O �
W q
M
� ���d
�
�
U u, � m
� I
�
� I
�
� 8 8 8 8
�o m � �
� . .
: � : �
: : o �
: : �
. p �v
����
����
� ��
�� o �.�
�� aaa
N���
� u � y �
� � � �
�a�
� a��
�
��
.�r
�
�
0
�
�
�
0
� �
0
�
a
1^
��
�
� �
i"i
� �
� �
`J F+
a�s �►
S � g g g
� � m m �
�
pFq : ' : $
$ ; : g �
� . � � '�
�� ��.�
� � �' �
����o
��
�y � � � � �
a � � �
� � � � �
� � � �
� a � �
�� �a�
�
�� o
, z
� •�
� �.
a,
� �
� �
� a1
�
� b
W O
o'
w
O
O
A
�r u�►
g g g �+,
� � � �
�
� � : :
� � � :
a, � :
� .� :
�" w � .�
o � � �
����x
��,���
�����
��� � �'
� � � d o
F °' °' � M
O � t�i�
x � '�
w � � � �
�
0
W�
�
�
d
z �
�� �
� �
0
dC
�
�^
W
�
�
�
�
$
�
�
�
� z
o �
�
�
z
� �
� �
O
� �
� � �
�
�
�
�
� �.
� �
�
� �
�W `' \
ag' , �l
��
�
� �
��
a
4 �y'
O `� �
� !
va
� g �: $
� �'�
e
�
�
�
�
�
�
�
� (��j �
�
� L n r
1„�1 �9 �
\
F �
�
. � o �� �
: : x �
. � ' m . . . w
: � ; ; - • ,
: w : ' �: :
� ' w � : . -
o M � � : .
�
,� o
� � �� � � �
� � ��.. � �
��
�
.� M a � � k ° �'
� a
I o v��M��
� � � �
D �
� �
o � � �,
-�
�
����
����
� � � O
����
� �
��
�
�
1
�
SUBJECT
City of Fridley
AT THE TOP OF TNE TWINS g U I L D I N G P E R M I T
r
� �
COMMUNITY DEVELOPMENT DIV.
v PROTECTIVE INSPECTION SEC.
i L �.��
r ; ';
� . ,
i_-_.� ��"',•� CITY HALL FRIDLE� 55432 NuMBER
L 612-571-3460 910-F15
JOB ADDRESS
5057 Clearview St
t LEGAL LOT NO. BLOCK TRACT OR ADDITION
DESCF. lO 5 Carlson' s
2 PROPERTY OWNER MAIL ADDRESS
4 ARCHITECT OR DESIGNER
5 ENGINEER
8 USE OF BUILDINO
Residential
Z CLASS OF WORK
B OESCRIBE WOiiK
Reroof hous
MAIL ADDRESS
,AP1
MAIL ADDRESS
MAIL ADDRESS
REV
DATE
8/7/98
ZIP
ZIP
PAGE Oi
� �
27040
RECEIPT NO.
���6.J
APGROVED BY
SEE ATTACHED
SHEET
PHONE
572-8724
PMONE LICENSE NO.
-9410 20138780
PNONE LICENSE NO.
PHONE LICENSE NO.
O NEW ❑ ADDITION ❑ ALTERATION � REPAIR ❑ MOVE ❑ REMOVE
and
9 CHAN(iE OF USE FROM
STIPULATIONS
Tear-off
TO
Underlayment must comply with State Building Code.
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL. PLUMBING. HEATING.
VENTILATING OF AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF /20 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DN
I HEREBY CERTIFV TNAT I HAVE READ ANO EXAMINEO THIS APPLICATION
AND KNOW THE SAME TO BE TRUE ANO CORRECT. ALL PROVISIONS OF LAWS VAIUAT
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHEH SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT l,rj�
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL TNE pEqM1T
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
S CTIO OF THE PERFORMANCE OF CONSTRUCTION. SL
� �� � R�- � PLAN CI
� �-t�� �� �,, � �� Lice
�� SIGNATURE O CONT,f��CTOR OR AUTHOiiILED AGENi IDATE�
F' �y� . D
- c�GNATUiiF (1F OwNEP �Ii OWNEP BUI�DEAi �DATEi
UNITS
STALLS
P OCCUPANCYLOAD
CU. FT.
STREET PARKING
IGAFiAGES
ITAX
�.75
'L'
rlaTE
j�TE�,y � � . . Effecdve 1/1/98
C � OF FRIDLEY .: .�• .
ADDN [ ] � t ',�'�,i��.+'kw� ��'n . „�. u, _✓
ALTER [] SINGL�=FAM�,x,,�A►ND DUPLEi�►S: R-1`� AND R-2 �O �
. � 8�. Ci'�� T �►PPI�.IC'A{�TIO,N. ), , , �,��� ,
', , i':� i � i 4vu. M,e���?��tEr� k iwr}ftf'S1 1'A..T"'��'14.�f3�'1�i;6}�cff�l:�' i'�f�'�.9� ���F �.�'+`���ri��:'��+..'
�" ' .. '.t� i� t �,� t�`��?%� � J ,��QFS; e4 r ?' Si�Av � n� �` � �"�� t �' e'����w��p��WR;� � �. .
. � .. ':' .. w � ... ?7k,t � � . � i� J . S
,. @ i�,��� �'!� .. 1��'�� � ..Nu t y e .a!�.P�'y�� j �,p
ConstructionAddress. c�� Y ' ta' � ,�.4 Y3 , iw 9i a�A��' "Ji"':d�T•i�����Ct• i�'%y���'�.�l��
::�;��a� �j,�3�,'�1,�••i',r'a`�.. , . . `�t" .. h . .��CY��,+j.�#'� "w, :': . ;��- ""�.—. >
?�c;gal Description: , , . � �
� . Te,l,. �.. '��-���
O�vner Name & Address• � , . - ���--�
` ,��MN LICENSE �
Contractor: ,�U �1( S�i.s o�'l .�� O d�� a r�l �e.y!'� �r1 ,IrKQ Lc' , `
. j �'t? . S `+ r : i,�s$ .i'-�r. t-? � . _ . � .. � , a-
�ddress• G% 3 d k � Tel. #�'7���' �l �I lD
. � �. .�Attach to tbis�Y� �lic.�t%��ar:Ce.rtificate-.o£�Survey of tlie i;� �a�T� �k�f;,41�� a.
lot, witxi�tli'���'�rapr�sed�con'struction.drawn oa'�it,to scale. . �
. . . _ � DESCRIPTION, OF•IlVIPROVEMENT . . ,
. • .'. . .�qv, ,
. ,,.��.,�.• ... . ��� .in.. . . .
L1YrNG AREA: Length� Width Height _ Sq. Ft.
� �'�tAGE AItEA: � Length � ' . . � . Width . Height � Sq.� Ft. �.
; , ` Width . .. • ' HgdGround _ Sq. Ft. _
DEC� A.�EA: gth ' ;
• p �F 4C{ ��
o r�R: � , :.r y�^�� . n
- . � . , . . . . 1 � .f �. . P `w.:�..i (�i�:,Sl,i�/C.,y��-..i=l•:..
. Y
�s.li._, a ii ii � . . . , � , • .
Canstruction Type: � � Estimated Cost: $ '
.. ..•::... .. . . .: s � �_� ���5 �jL� ��;°YS r, , i;� . . �. (Fee Schedule, on Back) . ..., r .. ;
, � `.�,�,� ' •. C Ft ii = $ ���� � ' +.�.
Driveway Curb G�t Width Needed. � Ft:'` ' 6 Ft $
DATE: �'° �i�"'"6 d ..APPLICAlYT� �,e: �.Tel: � '�9��� ��`�
E r�rp-,�.��f�� � � .. .
. . . r �,�fr
.r . '.x ' ��.
t . . ., � �. " �Y� .. Y 'y�� � p . i
'��:� .'� � �,��'i 9�,���P p �(,�iTY� USE�� ON�.Y ;., ,.' �, a,�` � n s
� . . . ��• XhM�.'E'3�' yt���, )'dW��q�'(¢1����'�+�i► ��l >t'�� � 5�f . ��;.,�'}�� ,�}��'7r��P�z���`��1 ��?•
• ' ��" � N; s: � N+k.C4'��.'�W �+:�'/`T'��:.f.. a �. �.e { .. •�'1,�, 1 S.l' � `��t.�' . ' ' r^d� �'`'�°��t +"'�'Y'r �ii �nt�{'�, 4 a.�1i.'.
��1�. �:�-P�Fae Schedule. on Reverse Side �� f��_
Permit Fee $ .. ,���
;
��+A ��;ti'��.r R �^� ' k 'd-� , � �: .
..�..�� r
Fire Surcharge $ d ���:�1�of Perniit'Valuation (1/lOth%)
5r t,
ps' '` ' � '• � 0 ^ �x. . A • .
Scate Surcharge $ � .� ' $.50/$1;000 Valuation
�
SAC� � : .. � � ' gg$1p��y�0�e� SAC Unit. : > 1 � � f ���� ;
Chaxg�:��=r� , � � �h� 'i;i ����$'}A5r�4{V'* �7�3��.�� 4sa ?. :. :.. ' :rf J� : �; d • +{<�X� 3,db�, y �6 . .
License Surcharge + $ ,, . .�'�:�'�,� ' � N$5' OQ$(Stat� Li�c,�n'sed Res����l. Co '�' � �,�,� .
, . . ... , . M1 Y� •F ` aa � �,.' • �.,a . .', t sw,� _� .:.r •„�q���54��' '�}
Q� y� �y L� 1 �p /� q M
DIIVVWGIY ESC�OW � .l� ' lp7 A�1A a [> 3 t t �4 +" .l •M I tl 1 , ���R 4Y �` � �� �
,r e'4l.�'M" �t �k��,�� :1��A°�r%r��t:' pDn' 11bOV�1 '` � ,�i > ,a��.�'S;` T�..:a r,
.%r1 ...0 fY a.. . .� c �7S!ar, y.� 9 �+�.p �+„�'C°,'rrtj �
� 2:ay ,� '{sJ r . .t: �{i.. �. • � .i;4-.0��'�`� a + �Yf r � r�YC4�F� !�y „ �
r r�,L ,�x � �p� o�v aoa Pl ev ew ��_� �.�� �, r,t y
Erosion Control, $ ; � �r. ����d. >���"?�,,�.:�pa�+�.h„�a ���*�,,,., � � �f � ,� 4 � ��'�� ;���'� ���.
Q c u t' �� c �, . �. l. r. : -. �� ' ', 4r � t �wp, � �n '
�'ark Fee 4 .p � a f'�?� � �,"��� ��� �i�r�ed by Engine�ring... ;i ;�+��i'�t� frr�{`"'+yt ;�"��`���*' ,
� �ewer Main` �Charge' $ �`�� � �,�'4 ���� Agreement Necessary [ ] ,a�Not� Nec�$s�►� p�.� � � P � _ r ��i�`
,.
. . . Sj r5r ti-.. t t::�° °...{ :. -k:� � ,. . . ... �' ;�.. ..�r .. �, �1�':i r ��i��� �."'�...�
/p� � ,/ p �k • � 4�5�e�r�a�'w-µ('�'� ��t '���;1Cw�3°���F n :
Te7 V t�a'� � 9?°�� �se:k. � �: P� 1 y � aM .��'�r � �ri � ��i t � ..
� �`� � vi.gs �'r � i:t� A/ ! y�.�
TO 1f7L , at r �p� 7., $ � +,PAJritd�.�i:'il 1 :a:� • .. j � . a -�� 'N�i,��i� �� W C. �
i �.
� �, w y^ J,�. �� , � �
,. �i- � . , . . .... .r �' 4�.-0%�.��h1��, ��1������ p ��}�'� '..
P �
..� �.r '+�. 4'�.�� °k � brKfa �.. �
STIPULATIONS: . ,t� �,; . . �x��.. � ��� s�����'��r� � f����
++��� , � -` ,�r �., +.� ��� �
'y ., F ��"t� ��� u�'t{ . . . � � _ lA . . Fr:�, . ek h { ..
�•
�� i�: S '. �h n��Y. � nA 4'�! Y� � �i. � f P�` �tj� a � i.
s i r� y?� 4?����d�� A°1i �'�'F � ; �f �,����� �k�� ' � �y�j t ,�� .
Y �4 � S C A- ��� . Y-j
�� • 2� �'�.7C� c„�.�';:rj ' -?�°'� �az�..�{�c!�,� ��.t-�� 'L`�,�'; ��
� pt�'."�,;�i`�,� . . , , t�p'b wr�'�}�4�` r`�::,. �'
1' `
: :� �Jll.�.:�� � I'EItMtIT' k'EE SCHED U1.E
. , . .. . . ; y.=:;�,...:.:..�. . � . .. � . .
�
._ �._:� � �. ::��� ____..._.. �:.::11, l�r`r'oi� 'issuing'permits for the'eiection�of �ny building or structure, or ...
�..:-::.o��l: �,� �::�:. -� ��... �uild'ur� or struccure, or for any alteration or repair to any existing buildin� _
. , �....... „
.��uc�ur�, ul�cr� •au�.�c,��iu:� �t��:refore, require the payment by the applicant for sueh permit of fees to the amo�::_.
-r�i.. ��;;io�ti� ;��� t'�r�i� a:.0 i:: �Y�e �maru�er herein provided to-wit: �
- �---' �--- --
..i1J ; : l,� ; � _� , lJ 1..' �
=VIJ��•JV: �U y`�_iv��"',.',liJ�'
�,li('�,UU1 arui uu
%�,ES
�'_' Y(T��iinimuri7 Fee is $21 plus surcharge)'
�2:t i'ar tirse $SOU plus $2.75 for each additional�$100 or ,,
i'� ��c�iu�l �lier�of, to aiid includin� $2,000.
�62.25 for first $2,000 plus $12.50 for each additional $1,000
__ ......:�ri therecif, �o arid includi::� $25,000
;:�-�:�.,`.• tur Tirst $'?S,UUU �lus �9.UU f'or each additional $1,000
v. ±iuction [h�reor, w aiid includii�� $SO,OQO
� ,"' '' � i�or `ilrs� �SO,OOU plus $b.`r� for each additional
r� �`Y. i
�1,00U or fractioii thereof, to and including $100,�00
, ���; .'.'� i,,r ::��� �iUU,uttU �lus :��.vU for zach additional
;:,vG�.� ;�i trai:tioii �ticrec�i, to atid i�iclutiing $5(}0,000
;�"�o:��l.'�S tor ttie tirst $SUO,OOU plus $4.25 for each additional
�'1,U1}0 or fractioii chereof, to and including $1�000,000 .
$SU12:25 for the first $1,Q00,000 plus $2.75 for each additional
� 1,000 or fraction thereof
���ll � \'��.'Y I)EPFtICSSi01�1 ESCgtUW
(f:oncrete Curb Stree�s Only)
"�:�:'.:c- '-.: �<---.� ,-._ .....: _,:placc���c�i� uP curb and gutter only - Driveway width plus 6 feet times $13.�:
-���'�==��_ "�' :-,-.. �...:� c�lacement of curb anci gutter and install a 3 foo wide ;,
<�- _ . _ :u � t
::L���_ �.:�!: ti-, iu� u inch dep[li - Driveway width plus 6 feet times $15.75. �
'��:��i��'�IOIV i)F FOiJNDATit�P�t .. � .�. . . _ ::,�:.
---- !�� -� '�.--..._. .._ �_. ., ___ ., �.s� ��� �, s,:�;�urnui�a vr �=f �ioui� from th.� �u��e of appli�ati0n to a11Qw for prv� _
. .� `�� �_ r r__ � i-_ - - - - -. _ _ ._:�C ..,...1 Jx ��eC e:UAJliIlCllUI1 51[C. -_ _ . . .... . , ;}r.c..,+..., .. I..
-=�:=•'�-��� v�� y�.- ,: ��. :� -±u., �::uwin� rh� locaciu�� of �he f�undaciu:a once it.has.�t has been constru�::,
�il t�C r�c;uir�:l u�.c���;: ,;:vcr��iiiig wi�l� ttie framir.�. �
� � ,_�
�i�;.. . .
Building MECHANICAL Permit Ivo.• �t i�,
Inspections RESIDENTIAL APPLICATION R�i��a By:
763-s�2-3604 CITY OF FRIDLEY �,�,,�
763-502-4977 FAX �� i-i-2oio �� ���� �� � � �U I
DATE C�' �iL�" �O YOUR E-MAIL ADDRESS
srre AnnxFSS �4t�S (�!a,� v; ��,� bT 1J E
�s nrrucarrr is: o avvx�t ,�orrr�crax
PROPERTY NpME: �
OWNER/ ADDRESS:���lY�iRd1[ W�S� A�6 CTfY � IG STATE �I
�N� PHONE: �II�i3• 4 ys• '�S'��
CONTRACTOR co�n� rr,�: 1
StJBMTT A COPY OF CONTACT PERSON: � i�a w.�
YOUR STATE STATE LICENSE !�� '� —� T— E3� DATE '�
LICENSE WTTH ApDgESS;,�Cj /lTL�9/w. /1� �/ � CITy S�aT Qk STAT�ZIP�e�%%
APPLICATION PHONEl�• �70• �/i�vg FAX b51' ��-�i�
pERMIT .l YPE �iSINGLE FAMII.Y O TWO FAMILY ❑ TOWNHOUSE
TYPE OF wORK: °� ��'�cnamv�r a nr.�nTTOx�onE[,
DETAILED DESCRIPTION OF WORK
�s nx� snsEn ox siaoe r� �x�, Exc�r w� �vor� �xTUxES: c�icn� Tarni. rrv��x o� Er►cH BEZ.ow�
PROVmE HEAT LOSS CALC'S PER MANU�T 1,�6 ASHRAE H.'1NDBOOK
v
Equi�t t�staued MF(3: �Y1 t� MODQ.: ���� SIZFIBT[J �`i�
MFG: MODII.: SIZFBTU
MFG: MODEL: SIZFJBTU
�A/C $25.00 FIREPLACE (GAS) $15.00 CiAS RANGF/OVEAT $]0.00
AIIt TO AIR EXCHANGEER $1S FIItEPLACE (WOOD) $35.00 1VEW GAS GRILL $10.00
BOII.ER $35.00 FURNACE $35.00 t3AS UNiT HTR $lO.OD
CFID11AiEY LINER $10.00 GAS DRYIIt $10.� PlaOL HEATER $35.00
DiICT WORK $IO.QO GAS PIPING $10.W VENTII.ATOR $15.�
Nwnber of i'uchues @ $10.04 x $IO.� _ � _
Number of Sxques � $15.00 x $15.Ot1= $
Number of fixtwres @ $ZS.OU x $25.00 = $
Number of �xtures a7 $35.� x $35.OU = $
State Svt+charge = $ .SO
FEE �i5S0 Tatal = $ 3S �
THIS IS AN APPLICAITON FOR A PERMIT-IdOT VALID UNT1L PROCFSSED
I hereby apply for a building permit and I ac1Q►owledge that ffie information above is complete and accurate; that the work will be in
conformance with the ordinances aad cades of the City of Fridley and with the Minn�ota Construction Codes; that I understand this is
nat a permit but only an applic,ation for a pemiit and work is not to start without a penni� that the work will be in accordance with the
approved plan in the case � ork w' h re,quires review and approval of plans.
SIGNATUREOFAPPLICANT �_PRIIVTNAME �b i .�'�.� DATE II•�i���%
APYROVAL INSPECTORS SICiNATURE DATE
PLEASE lYOTE: SEPARATE PERNIITS ARE Ff?R BUILDING ELECTRICAL AND MECHANICAL �VC3RK
(;ity of r'ridley
Building Inspections Dep�rtment
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604 FAX: 763-502-4977
� .
�
�
.�
4
0
�
>
�
w
�
�
�
�
t�.
0
0
�
�
�
�
W
W
0:
i-
�
�
�
�
������
, `
�
leJ
itJ
�
�
�
�
w
>
�
a
w
�
v
�:
�
�
�'
M1�