AF - 38635�,
City of Fridley, Minn..
BUII,DING PERNIIT
Date: . . .! ./� . . . . . � . .' . � .'�. . . . . . . .
Owa� .......................................
Addre�ss ......................................
Builder
Address
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N°
3.441
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LC�CATI�N OF BUILDING
No. . .��'�+. ��tr2et . . .1+:�� . . �s��. ..�. . . .i . . . . . . . . . . Pari of . . . . . . . . . . . . . . . . . . . . . . .
�f . •
Lot . . ��. . . . . . Biack . . . . . . . . . . . . . . . . . . Addition or Sub-Division . . . pef . . . . . . . . .
Corner I.at ............ Inaide Lat ............ Setback ............ 5ideyard ..... . .....................
To be Use,�i �s:
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7�pe of Construction
DESCFtIPTION O� BUILDING
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�`roat .�.7� � Depth � �: � �! Height �.��. . .�� Sq. Ft. /%:�� . C.ii. Fk�� �? ` �"
Fro�,t :�Q.:� ne� :�.�':.� x��t 1�.:.�.'. sQ. �-t.�:'�:�. c�. r�. ��.�1c� ���,
.................. �st. Cost..................... To be Completed ................... ��
,�
In consideration oP Yhe issuance to me of a permit to con�truct the building desribed above, I agree to do
the proposed work in acc�rdance witl� the descrlption above aet forth and in compliance with all prov�isiona of
ordinances of the dty of F'ridley.
�.. !� . L.�� *:���!'�.�i�.�: a�: S : : . G��c��°':° . •� . . . . . . . . .
In consideralaon � �
' oE the payment of a Pee of .$ ��, �. ., permit is hereby granied to . .. .. .. .. .. .. .. . . ..
... .. ............ ........ to construct tlae buildfng or addition as described above. This permit ig granted ugon
the express condition that the person to whom it 9s granted and his agents, employe� and worl�nen, fa all work
dane in, around and ugon said building, or any part theneof, shall conform in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteral3on, maintenance, repa3r and moving of buildings with-
fn the dty limits and this permit zhay be revoked at atiy time upon violation of an,y of the provisions of sa.id
'ordinances. /�
�s�`<. . .l�2 ./. . ! .��: fO.°� ! . . . . . . . . Building Inspector
NOTICE:
This pe�mlt does not cover the conatruatlon, Installatfon o� alteratlon for wi�ine, plumbing, gas heating,
sewe� o� water. Be su�e to see the Bullding Inapecto� fo� saparate permits for these Itama
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Ca.ty of Fridley, Minn.
BUILDING PERMIT
nate: avl� l, 1965
��'�is,
N° 8094
p�r; 80be1^�• iZaetZ guilder j�o�*'d k'l�et?*�d
A� 65�.8 Claver Place N. E. Adar� 3330 � Xei�inm 8: Lane No. (55427 zon.e)
LOCATION OF BUILDING
No. � Stc�et __ �� 94e�' Pl�,ce N. E. Part oE Lot
L�ot �-�- _ Block Addition or Sub-Divisi� Clover I�eaf Addition
Coraer i.ot Inside Lot Setback Sideyard
Sewer IIevati� Fo�mda.tion Elevation
DESCRIPTION OF BUILDING
To be vsed ss:
Front Depth Height Sq. Ft Cu. FL
Front Depth I�eight Sq. Ft Cu. Ft
Type of Construcl3on Fast. Cost �210.f10 To be Completed
Re-dash Stuceo
In co�tderatlon of the issuencae to me of a permit to c
th� ProPosed work 9n accordance with the d�scription above
ordinsno� of the dts► oP Fridley. �
the building described above I agrce to do
h and 9n compHance � th e�l provisions of
�
In conafderation oP the paYment of a fee oP � �0 ��ermtt �s t►eret,�► �aanted *o �eonard �'reund
to conatruct the bufld9�tg or additfon as descrlbed above. This t is giant�i ugan
the exPre� condition that theperson to whom ft is granted and hia ageuts. emP1oY� wor1�►en. fn all work
doae in, aro�md and upon eaid building, or anypart thereof, ahall conform in all reapects to the ordinances oP
F'ridley� M�onesota regardting 11oc�tion, construction, alteration, maintensace, rePa9r and moving of bufldin�s
witiiin the dty ]imits and this permft may be revcked at et�► time upo� violation of aay oi the P��o� oE said
ordinances.
.Al].en Jensea $„q�� �
n NOTICEs
71ds peemN doa aef cmru t6s ee�usHoe, �tap�loe Te► �rirteo. P��+�e. ea 6mio�, awa or wat�r. B� an to sM
Nn eutldtne t�oe �ar apuaN p�rmhs hr ��a I�.
.
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APPLICATION FQR � ING PERI�T .
CI'TY' OF FRID%EY� �NN�SOTA
OWN�R' � NAME ���^�i• ,(lL. �'���'�" BUII�ER,�� ���t�6��
� �. I
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�►nn�ss __��S'`/.S�' ' �� anDR�ss �3 3� � �r ; � �:�.
Loc�z�tor� oF �t�n�Nc
No. Str�et �a�t of Lot.
Lot Block Addit.ia� or Subd�vigion .
Corner Lot Inside iot __,,��e�isa�k Side Yard �
SEWER E�E9AT�QN FOUNDA�.'ION EL�t�lfiION .
Appli�ant atC��h to tt�i�9 form,Two Certificates a£ Survey of Lot aad praposed buiZd-�
ing location rl��twn ort theSe ��f�tificates .
� �T�v be us ed �s :
DESC�IPTIOAT 8F Bi]ILDIATG ,
�'roaC Dept$ �eight � � ;.
9q. Ft. Cu. Ft.
k'z�ont Dmpth Height
� . �t�. Ft . Cu . Ft . .
1'YPe �.��e�� � � �
of Constructioa Estimated Cost �/�, _ ___
_.�--be_ Co�p],eted
The undersignec� hereby �akes applieation for a permit far the �aork herein specified,
agseeing �c� c�o si,l work i�# strict accordance with the City of Fridley Ordi�nances and
rulings �� t�e I}epartment" of Buildings, and bereby declares ttiat all the f�cts and
representatians stated in thia applicatica are true and correct.
. ���d � >Cs�-��� ` ��� >J
r���il.e of Fee Costs caa be �ound on Che Reverse Side).
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BiJILDING PERMIT �'EE S��TL�
, `
� Seetion 2. The Inapector of Buildings•shali, be�or� isauiag an� permit for
. th� erection of aay buildi�g or etr��ture; �or for ar�y add,tti� ts anq euiet-
, iag buildin� or stsucture, or for. any a�,teree��i,s�r�.repai�� Co an�r ex3�Eing .
buildi,�g or structu�re, upon applicat�oni �}er,e�or, ��qe�ire the pa�aa� .by Che
applicaat for auch permit of fees •�b �lie amount •�er�ia�• below set �forth and
• � in the manaes herein p�covided to-w�.t:� ',
. . . .. �: . .
�•. • 2�.1. • F�r aay �uch permit �or the. �aa�ep.�io�i �ca�` any fire+►p�f build�tpg, other
� • � `� t�aa a �ar�ge�, war•ehous�. factory or .��i.:�t' �e���, ,,� .%r. the e�tioa of . .
�.' any fire-pz,�of addi�ion� fo�c sin�i�ar`°a��'�p�acy� �a a�,q �xis•t�i;►g bwildfi�ag =� ..
shelY be at the rate fi �'1,.4Q for• aa�l�.� onc� tboue�ad �et�bi,� fe�t, or � fra�tion
�r� .. thereof, in such cubical cont�n�s.� . �� ' ' . . , , ' � � . . �
� � .
� 2;2„_ Fo� anq such permit..f�r._: e esection o� anq firerproc�f g�raee. .�+�^••--�.,;
gactory �ir graia elevator, or �� the e,�ec_tion ef a�� ��p�oof :•.c
. for simi,lar pccu aaa ta aa exist•i �' .
B �� Y n� 1��ldi�' stial�� •be. at .tjie
. . ..�.�far eaeh. cite .ttiousand cubic .feet,�..olassi�ied �.e�!'firep�ro��" bq .S�
t�18 �liACltj�y�7te $t!�}�i�Iig CiOd�.� �0�':5�,.• .
. ., �` � gOUSgiaS � : � � . � ' .
- � 2_3� Fc�r aay such permifi for ihe er�etion of e,ny noa-Hrep��lrf buildiag oth�
�t� a 8ar�8e, warehouee, factory or, graia eZevator, dr aay doa-firepr.�af �'�; �°.
additicm, For sim��,�� ocCUp��icy, to any eufstidg �b�ildia,� - pexmi.t $I.�QO for
each one thou�a� cc�bii�, fee�.. � �'° . ,'
GARAGES . • • . .• • • �
2. 4_ For anq such pera�3,t for the erectian of any non-fireproof gaaa�e,
warehouse, factory�vr �rai� el�vator, or for the ereckica of say non•f3re�s�oof�
addit�.'�a. €or-simila� occupan:cq, to esX existing building dr for e�c� such �
_:_+:-�ni.ld3ag or addition - ninety .ce�ts ($0.90) for each oae thou�Eand ctsbic feet
or f�actiou thereof, iu the cubical•contents thereof with a mfnimum of $4.00.-
Bor the purpose of computiag fees for building permite, th� cubical ce�t�te�t� �
of anq buflding or additioa to a uniform height throu�`�oLt.t �'�� mu1L-ip�yirsg t1ic� '
ground aree �overed itom a'poiflt aix (6) inch�8 bsl�w Ehe �locr line t�f the
basement or oellar to the average i�eight of the�upper su�face or.to the �
averege height of the rpo£ �urface of the m��.g gable of a:}�itched roo€. •� �
2, 5_•. l�or repaira or a�teratioas to aa exiati�g sCzuct�hrl�y �e �ee aital�l be ��';- .
,• at the rate of $3.00 per each F3ve I�undrefl. Doilar,s
the=ebf in �he cos�t 'o , �i$g�';�y v.r �Ersctfott • �
_ . . �.; �11, prop+ased �aork. . . , , , :� . . . �
. �.• . . ', ,,:�
2_6+ In no csae st�all �he fe�.cha��d;#os auy p�rnni� e�, s�E f�tCh ia �, .. °
- � Sectia�n _2 be les�� ..�han. ,$�.00; . . . ,�:
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� , HOUSE HEATING TEST RECORD
ADDRESS 65�8 �►'].OFeT' ��� P18C� APT. FL�OR`g��' CITY suBURS Fridley
OCCUPANT G1ebII . TOilil@sl� OWNER
HEAT LOSS DATE HTG. INST.
SOLD BY �iA������� INSTALLED BY � �
Electrical Work By Gas Line By � ?
TYPE OF HEAT GA FA HW STEAM SPACE HTR. g UNIT HTR. OTHER
GAS DESIGN CONVERSION
AAAKE �a� �o��ln� MAKE OF BURNER
Model �w �- Model
Serial '-�� Max. BTU Rating
INPUT � MAKE OF FURNACE
Model
CONTROLS
THERMOSTAT'A/� Heat Plug
Valve
Limit
Limit Setting
Fan Setitng
Pilot Type
Pilot Adake
�
Vent Size �, - „
KIND OF LINER_ SIZE NONE
Drak Hood Reguinror
Fi Iters Size Num
Chimney Loeation Insid Outside
Chimney ConstrucPion
Pilot Model Smoke Bomb _
Pilot Timing �� D►aft
L.NI. Cut Off Door Pressure
Wiring
.Test Tag—
Lighting Inst.
Prassure �S� Pereent CO� Date Tested �� �6
Input CFH�������� Percent 02 Company Testing v'
Staek Temp. Percent CO _ �-� Name of Taster �
Form 235
sue�ecr PERM NO.
City of Fridley
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T ��� A� �
r
� �
, � R T NO.
� ` _��� COMMUNITY DEVELOPMENT DIV � ��_ �l�
� �: - - � t �
r � � PROTECTIVE INSPECTION SEC.
� �
, � �'��1 � CITY HALL FRIDLE� 55432 NUMBER AEV �ATE PAGE OF APPROVEO B�
�----� • •'� 612-571-3450 9t0-Ft5 9/2/94 � /
JOB ADDRESS
6548 Clover Place NE
1 LEGAL LOT NO. BLOCK TRACT OF ADDITION SEE ATTACHED
DESCR. 11 Clover Leaf Addit on SHEET
2 PROPERTV OWNER MAIL ADORESS ZIP PHONE
Catherine Smith 6548 C1 ver Pla 571-1726
3 CON7RACTOR MAIL ADDRESS ZIP PHONE LICENSE NO
Central Roofin Co 4550 Main St NE M ls. MN 2 -
4 AFCHITECT OR DESIGNER MAIL ADDRESS 21P PHONE LICENSE NO.
5 ENGINEER MAILADDRESS Z�P PHONE LICENSENO
6 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW O ADDITION ❑ ALTEFIATION ❑� REPAIR ❑ MOVE O REMOVE
8 DESCRIBE WOFiK
Reroof House & Gara e
9 CHANGE OF USE FROM TO
STIPULATIONS
If roof3ng is 2nd layer, it can be 2nd layer but not 3rd. If a tear-off,'
underlayment must comply with the State Building Code.
TYPEOFCONST. OCCUPANCY GROUP OCCUPANCYLOAD
SEPARATE PERMITS ARE REQUIRED FOR EIECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANV TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFV THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 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 �p . SO
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- @
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. �p2S.00 Fire SC �1.00
PLAN CHECKFEE TOTALFEE
License SC $5.00 $31.50
S�GNAiUREOFCON'RACTOAORAUTNOR12EDAGENT 1�ATEi WHEN P RlY V IDATED THIS IS YOUR PERMIT
, ���� ��� � � � �
SiGNATUAE OF OWNEF7�IF OWNER BUILDEAI IDATE� BIOG �NSP �1FTE
NEW
ADDN
ALTER
[l
I]
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CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-Z
Building Permit Application
Effective 1 / i /94
Construction Address: �� 5�� '[ o� c.✓ Y�� � 2
Legal Description:
Owner Name & Address: C��-�-�e �� � e S, �;'F� Tel. #�,� ( 2 - S? I- I�Z�
Contractor: �, w�rr�. (�� �( c�o �. MN LICEI�TSE #
Address: �-�°�Sc.� I�VI � � � S�- �I � I�/lP�s �Vl.�.c �S�-1 Z I Tel. # � %2-ea(o�v
LIVING AREA:
GARAGE AREA:
DECR AREA:
QTHER:
Attach to this application, a Ceriificate of Survey of t6e
1ot, with the proposed conshvction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Lengtb Z�r Width r�v Height j S Sq. Ft. 'L'-I �v
,
Length ZE Width 2� Height Sq. Ft. 5co
Length Width Hgt/Ground Sq. Ft.
Corner Lot [] Tnside Lot � Ft. Yd Setback Side Yard Set6acks
Type of Construction: � � � -�; .�, Estima.ted Cost: $ I �o , �
Approx. Completion Date:
(Cost on Backj
Driveway Curb Cut Width Nceded: Ft. 6 Ft = Ft x$ -$
DATE: � G' APPLICANT: � ��� �2-�V Tel. #
/l,(�c�
�
(�ITY USE ONLY
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
$ �.�
$ I . 60
$ ��
$
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth%)
$.50/$1,000 daluation
$800 per SAC Unit
$ � C��� $5.00 {State Licensed Residential Contractors)
$
S
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Park Fee $ F�e Determineti by Engin�ring
Sewer Main Charge $ Agreemem Nece.ssary [] Not Ne�;,essazy []
���
TOTAL $ � ` � � �
�,. �Z.' ���'i� .
� -�; ��
STIPULATIONS: ��,. C� w� _
,
/�
��
I3UfLD[NG PCRMIT FEE SCHEDULE
'('he Cliief I3uilding Ofticial sfiall, t�efore issuing pecmits for the ercxtion of aay building ar structure,
or for any addition to any existing buildinfi or structure, or for any alteratioa or repair to any cxistins;
buiiding or structure, upon app(�catioa therefore, rc;quire the payment by the a�pticant for such �ermit
c�f fu;s lo thc am�unt herein t�elow set tixth and in thc manaen c�rein �covidccl ta-wil:
"I'OTAL VALUE
$1 to $500
$501 to $2,000
$2,001 to $25,OQ0
r-r_cs
$15 (Minimum Fee is $i5 pius surcharge)
$15 for ficst $SOp plus $2 for each additional $100 or
fracbion thereof, to and inciuding $2,000 �
$45 for fust $2,OOp plus $9 for each additioual $1;000
or fraction thereof, to and including $25,000 �
$25;001 to $50,000 ' $252 for first $Z5,000 pl�s $6.50 far each additional $1;000
� or fraction thexeof, t,o. and inclading $50,000 -.
$50,001 to $100,000
$100,001 to $500,000
$SOO,U01 to $1,Ot?0,000- .
$1,000,0p1 and up
�$414.50 for first $SO,ppp plus �q.Sp for each additional
.$1,000 or fradion thereof, to and including $100,000
�9-� for �rst �$10t1,000 plus- $3_50 for each additional�
$1,000 or fraction thereof, to aad including -$SOO,U00
$203950 for the 5rst $SOp,ppp ptus $3 for each addition.at
$1,000 or fradion thereof, to and including $1,000,0(}0
$3539_SO for i�te first $1,000,0(30 plus $2 for each addifional
$1,OU0 or fractiou thereof -
DRIYEWAY DEPRESSION ESCROW
(Concrete (�rb Streeis On1Y)
Alternate "A": Removal and replacement of curb and gutter only - Driveway widih plus 6 feet times
$13_SO_
Alternate "F3": Recnoval and reptacement of curb and gutter and in,stall a 3 foot wide
approach with 6�inch depth - Driveway width plus G feet times $15_75_
VCRIFICAT[ON OF FOUNDATIOI�t
Permits for constzuction will be issued a minimum of 24 hours from the time of app(ication to allow
for proper review of the pro�scxi structure and of the constr,uction site_
A Certificate of Survey of the lot, showing the location of the founciation c�nce it has it has heen
constructeci wil( be rc;yuireci t�efore proceediag with the frdming_
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r Tki� BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLJCATION WILL BE RETURNED
•i����► ► ► •►► •: �►� ��r: •► � ' � •►
When � i� -t� an PYictjnQ f��rancr�, the undersigned hereby verifles that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes (� No ()
The venting system is plastiGPVC and meets all cuRSnt 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 the current codes and manufacturer's specifications. This does
inGude AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The eY`�+�� ���„h��st;�„ a�r is sized and installed to meet the current codes
and manufacturer's speeifications.
When requireci to ���ta a new r_omh►�stien air�,lt WIII be 51Z@d alld IllStall2d
to meet the current codes and manufacturer's specifications.
Yes�j No ( )
Yes �No ( )
Yes ( ) No.( )
When �n��� a np��ntin�„��, thE undersigned hereby verifies that
it is a listed assembly and meets the cuRent codes and manufacturet's
specifications. This does include AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances. Yes � No O .;
Es the common vent and vent connectors sized and. installed coRec�tly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes () No () •
A�,nlia�nc.�+ T�t� and Si�p/['.ommc►n Vent and Vent .onna__t�r Inferma�ien
Appliance #1 Type ��.�rru.,c;L. BTU Input V U o o Fan Assisted or Nat
Appliance #2 Type �,��- �}� BTU Input',��csT Fan Assisted or Nat
Appliance #3 Type BTU Input � Fan Assisted or Nat
Tota! Appliances ,� Total Btu Input vo
Common Vent Type � Vent Height ��_ Diameter S inches
Applianc.� #1 Vent Connector Height �ft Length � ft Diameter _��in Type ��
AppGancs #2 Vent Connector Height � ft Length _�ft. Diameter �in Type �
Appliancs #3 Vent Connector Height ft Length ft Diameter in 1'ype
��\ii ' � •► �- ..-
HEATING CO: � ''
Signed BY� Date : � �. (� (1�
/ �� �—�� ���C�
Rv I�i o o � ��� �
CITY OF FRIDLEY
3u��ding
�.specrion�s
163-572-3604
���
;rrE t,nv�ss 1�
-�s �r�carrr ts:
.�it�.li��r
Pennit No.:
.RES�Er�AL A►�'FY.YCA�,,'�'I41� R�"�. �y:
C�X !�� FR�U��Y n� ���a:
Yaux E Mnn. n�an�ss
..• �� ,,«. .-
�RTY O'WNExt! r�,ai,�: t. ��� � �=�c�.v-t��a
TT+.NAN'� p�DRESS: Ci'I'Y 51'A7E ZIP
CONTRACTOR
SUBMTT A COPY OF
YptJlt STA'IE LIC�NSE
WI�i APPLICA'�ON
PROP�TY TX��
'�'XPE
O�'
PHONE:
�' :y�L���w.-.. � � � �._
� � �' i . -. j : � i � ♦
.'1 F. �"i !� �
:,rr
0 BASII�N't FtT1�SH O SIDyNCi
�D�CK -----
DBSGRIB� WORK BEING
SIZE OF II�'ROVEMEN�'
� • x ._
c:,��tA�ES
I PROPOSED SIZE:�__
PROx'OSID i�tGH7': _.----
, S@IIVG
'' p v'myl
I ❑ Atuminun�►
D Orh�r,�
� wnvr,ows
W fi7QS'�1G OP'E1dINGS �Yes C3IJo
OR F4R NEW OP&I�1xNGS-�'� S� OF
OPENING C�NGES &- - - — - - . .�
�
permit Fee
Plan Reviow
Surcharge
Fue Sur�harge
License Swrch�rge
SAG Charge
Gl�rb Cut Escrow
Erosion Gon%oi
Park Fee
Sewer Main C1�arge
Tota1 Dne
�xous� � G�►c�
0 ATTACi�D Cr��
D DE'�AC� GARAGE
Q DRA1N TII.E
� OTHEX�
I�'t,
s�T Mrr:
1. fixit�8 F1oo� Pl�m
2 p�po� $oor pfan
3. List a£sss��al members to bc v.�d
FOR t�'W C{)NS"�RUCTIQN IlVQ.UDING GECKS,
Ar�nmarr�. � �� ��Mrr:
�So�t !. SiRC 3'�enJS�'Ci' �°�'�n8 �►c was� S�"�
D Trim and P�Po� P�J�
0 Fasrie 2. Two scis t�£ oo��► P�
3. F�eigY ��aas
LOCATION OF WII�IDOWS
NUIV�ER OF'WA1QR�
'ALII,A�T�oN, YNCLi1p�NG Tffi� COS'� OF
[TSIIVG 'f� 1997 U.B.0 FEE SC�ED�JLE3
V'AY.IlA�OI�i $ � � -� ..•....�� .�- _ _..
g �' � °.�; See Back Page £t►r �ee S�hedule
$ _� ;� 65% of Building Permit �'ee
.Q00� iiu�es the total job vsluation - Mim�� $.50
$ ��' �
$ ��c �I �.�� .00I x permrt Valuahan (1/14%)
$ �' ,)�s— $5.00 (Stata Lfcensed Residential Co�ractors)
� $1450 per SAG Uait (Plans to M'VVCC for detersii�ion)
$ iY+68=�_ftx$"Z0=$
$ $450 Cv�sesvatian Pla�a Revfew
� �� �'ee bete�miaed bY En,��g
Ageeme� �aec�ssa�y' ( ) Naa� Ne�cessarY ( )
c i �a ' �/ �' Make s.hecks Pa bie to: Ci � of k'ri Attaw
- - ROCESS�
���
TtIIS iS A�3 AF8I3CA7jE�1N FOR A PERNITT NO? VALID iJi�"fII. p tifat the wvrk will be ID
- ����ctaaawledge that the informa�ion above is cvmplete and acc�uste>
I�erebY aPP1Y �r a buiIdnng p� y � C�des; t�t i unde�rstand �is is not a
conforme�c� with the ordiwences �d �°des of the City of Fridle and with the Mim�'� C°� oved
p�it but oniy an application foz a germit and wcrk is not to starc without a�ermit; that the work will be in accordar►ce �'i'i� tha �PAr
plan in t1a� cas� of all v�rork^ bich r+z�uirefa�eview and approvai of plans. �%� Q_� 1.�,� , A.�,w t na� �'I � f�' ��
StGNATUitE OF
Building PLUMBING P�t N°.• ��
Inspections � �SIDENTIAL APPLICATION Received By: �
763-572-3604 CITy OF FRIDLE�I D���� T�_ od
DATE �I' D YOUR E-MAIL ADDRESS
SITE ADD
THIS APPLICANT IS: ❑ OWNFR �(;ONTRACTOR
PROPERTY Gregory Leaon
�N�� 6548 Clover Place Northeast
OWNER/ ADDRESS:
.�N� Fridley, MN 55432 ?�
� Pxor�: 7635714728
CONTRACTOR NnME: — - - -
SUBMIT A CAPY OF STATE LICENSE 1! C% E7� DATE
YOUR STATE ADD1tESS' i� CITY '� I/J STATE�LIP rfY
LICENSE WITH . PHONE —�0� FAX Z. �
APPLICATION -
pERNIIT TYPE ]�SINGLE FAMILY ❑ TWO FAMII.Y �0 TOWNHOUSE
� '
TYrE oF woxx: °1'�"'' � ��ri..,4c�rrr
DETAILED DESCRIPTION OF WORK
PER NLS 16B.665 the ��rnut fee is a minimum of $15.00 or SB/a of the total cost up t� $500.00; whichever is greater, for the
im�rovement, installation or replacement of a residential fixtwe, excluding the fixtures. (This.shouldteflect only.the cost of labor )
Labor cost under 5300 =$15.00. Labor cost between $300 to $500 = cost of labor x.OS =
�.FOR�ROJECl's WI�RE LABOIt EXCEEHS'�E10:�FEES ARE BASID ON $10.00 PER FII�'�'(JRE.�EXCEPT'W;t3ERENIZ'I�i� :RI�IRE9:�.(II�DIC.A'I'E TO�TAL
NUMBER OF EACH BELOVi�
BATH S1NK/LAV _FIAOR DRAINS SHOWER _ WA'fER Pg'ING
—gp�g GAS PIPING (nr�ocrrruc,FrvsE) SWINIIV1DdG POOL _ WATER SOFINER ($35)
�� Wpgp� �C�( �� WATER CLOSET _ BACKFLOW PREV. ($1S�
DiSHWASHER ^ LAUNDRY TRAY ,LWATER I�A'fER ($35) FOR IRRIGATION
— — WA; ER MEPER _ OTHER
p� g� � $ Number of fxtures @$10.Q0 x$10.00 =$
S�char e .50 Number of fixt�u�es @$15.00 x$1S�D0 ° S
TOTAL DUE $ Number of fixtures Qa $35.00 � x$35.00 =$ 3S.Oo
State Surcharge = $ .50
. . Total ° $ . O
THIS IS AN APPLICATION FOR A PERMIT-idOT VALID UNTIL PROCESS�
I hereby apply for a building permit and I aclrnowledge that t6e information above is complete and accuiate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minaesota Construction Codes; that I understand this is
not a permit but only aa appli ' n for a germit and work is not to start without a permit; that the work v�rill be in accordance with the
approved plan in the case of w rk which ires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME J� NO/�fION�I DATE
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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tD� Iocatian oi • �o�s�+d r,Ir�lli�.
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