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AF - 43030' Village of Fridley, Minn, BiTII,IDING PEI.i.MIT N•° 85$ Of�'ice of INSPECTOR OF B�JILDINGS n.x.,,a,. d��4]�ye+.*a�s3�..eY 3� � � _..�, �` � � � Architect Fridley, Minn., �...�r'�'� �� N 19 " , �'��. a Buiider £s i ��' � '� ' LOCATION OF BUILDING � � � Na ' i�' ��` � Street �.. ' '�'�,�„'a,,,�,� �,� � +'� ' Part of Lot � Lot .� � Bloci� �, Addition or Sub-Division �� ' � t f �_ -� � . # ,; � D� ;�1R,IP7'IOP+T OF BUILDIlVG Front ��' Depth •�`�'"- �°"� Height Stories_ I�Ianner of Construction �,�e.�.�z�-�.•.•�..,4=- , °° �%, ,r� - � � Tb be used as �:�='�� -Y��- -� -��'" To be com leted '� ��'' � '`r `�"'' �" ''" , P �stimated Cost � �# ,�"j-1:�: ,a.�.,y... -,,,C� �' "k ,;:. Permit is hereby granted to�'`�-� ��+-��.,�� "',�,,��-,� to ��-�-.•!"'�-�-•->?� the buiiding �� described in the above statement. This permft is granted upon the express condition that the person to whom it is granted, a.nd his agents, employees and workxnen, in all the work done in, around and upon said building, or any part thereof, shall conPorm in all respects to the ordi- nances of Fridley, Minn,, regarding the construction, alteration, maintenance, repair a,nd moving of buildings within'the city limita, and this permit may be revoked at aiiy time upon violation of any of the proviaions of said 'ordinances. ��s��+�l�f�c.+�'•r � � Inspector of Buildings. �.�r � _ AGREL+�1l�IENT AND SVVpRN STATEMENT In consideration of the issue and delivery to me by the Inspector of Puildi�gs of Fric3ley of the above permit, i hereby agree to do the proposed work in accordance v�ith the description above set forth and according to the provisions of the ordinance�, o.f Fridley, and, being first duly �worn, I hereby state and say that the facts stated by me and contained 4n the above permit are true as therein stated. ` Subscribed and sworn to before me at Fridley, Minnesota, this r�� - lay of ' ' .D. 19�� SUBJECT PERMI City of Fridley o 258 � AT THE TOP OF THE TWINS g U I L D I N G P E R M I T � � RECEIPT NO. � ; y ______ COMMUNITY DEVELOPMENT DIV. r � � PROTECTIVE INSPECTION SEC. � � i � � /'�'1 � CITY HALL FRIDLEY 55432 NUMBER REV. DATE � PAGE OF APPROVED BY ` ""� � ,�� 612-560-3450 910-F15 7 26 %3 � � JOB ADDRESS 6367 Dellwood Drive 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 21 �� Moore Lake 13ighlands lst SHEET 2 PROPERTY OWNER MAII ADDRESS 21P PHONE Isaac Saari 6367 Dellwood Drive N.E. 3 CONTRACTOR MAtL ADDRESS ZIP PHONE LICENSE NO. Same 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE UCENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHQNE L�CENSE NO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW j�] ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK �onstruct 8' x 14' Addition to Garage 8� Y .2.2' °- .. �� 9 CHANGE QF USE FROM TO STIPULATIONS TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. WOO(1 FiaSC1e THIS PERMIT BECOMES NULL AND V01D IF WOAK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION R-1 OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY 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 ��'� S22 .77 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMITFEE SACCHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- $8,50 STRUCTION OR THE PERFORMANCE 0 CONSTRUCTION. \//� PLAN CHECK FEE TOTAL FEE 1` !%�Q�� Q�( , $9 . 27 SIGNATUREOFCONTRACTORORAUTHORIZEDAGENT IDATEI WHEN PROPERLY V TED THIS IS YOUR PERMIT f ' � e,Q po . �� `. �, - . SiGNATUREOFOWNERUFOWNERBUILDERI IDATEI BIDG INSP D E - � � ( � � � iy Q � �� _ �o' _ _ `7�'-r'� p�a.� above shown .�nd:i.-�atc,s cc�rrectl.�r t:,he sz.�� arzd 1ocaGiori �f , '.��ne bu:�ldings on prerrizse:� he,rro�i�ry :�.r�st�i<7clg �1.sc� �h�; :�c,7��°o`��r�ierats ri�� ';�c�ated c�ri pr°ei�ises _a_n q�i��>t�,car� ar� �.ri�,ixaely. ��v:r�l°i_i_r� �;1�E� :�ot li�i�s�� rxc] r•l�z� '��ra��errierit;�, or, ��dj�7_r��_ri�� p�"�'r,r:I.s�s c1� �1��, �;ri�;�°��z��-i oYY ��:hc� p��cmi: �s (-��°�iri i,rlsl�recl� yo , ;� �� °. ,� _� � . �� ..` . ��: �. A�PLICATION FOR RESIDENTIAL, ALTERATION, OR AllDITION BUILUING PERMIT CITY OF FRIDLEY, MINNESOTA 7�� 15!�`'/ _ OWNER' S NAME ;_, T.� ff �} � f}�} R I �UII,DER t ADDRESS : �� T �El� � u�a � J% �RA��Dx�ss : �/� I !J L F� � !Ir NIV NO :_ '� �. % S TREET :�� LOT: �. j BLOCK: ADDITION: J•a�� J�(e�� .,��r 1�i��L�n�Ds CORNER LOT; INSIDE LOT: �- SETBACK• SIDEYARD: Applicant attach to this form Ztao Certificates of Survey of Lot and proposed building location drawn on these Certificates. �ESCRIPTION OF BUILDING �.C, '.y;- ! To Be Used As; � � � �"" J��E Frontt ��fT Depth: � F' Hei ht: /v T �� 4 � -� �- ��,� y`h�, Square Feet �� Cubic Feet: i r�; ; , a . '� Front: Depth: Height• Square Feet; Cubic Feet• �a Type of Construction; ��'�j',¢�j � Estimated Cost• ,� • ._ *� To Be Completed: J� �;� ,,: �� The undersigned hereby makes applicativn for a permit for the work herein apecified, agreeing to do all work in stfict accordance with the City of Fridley Ordinances and rulings of the Department of Buildings, and hereby declares that all the facts and representai��c�r,s stated in this application axe true and corxect. , AATE : _ '7 / / ._ _ � /-� S IGNAT[JRE : ry� �[ �t cy'-t�C_- �' H 1" - � � �� ^ (Se� Reverse Side For Additional Information.) t,, � . �'� ! ,� � � ' ..� ....�,, � .., �,.�.....��,� �=-~'! �, -` �. fi' � . ';`�-' c' �, � � � r 53-8►,-s-91�.51 �fRiNNEGASCO �it�l O� Fridiey � �F�1�'3�R�9 ��' ��'�!!� �!� �� '�� Aap�t. of Bldq�. Phon� 3�0-3450 -' - DE9CRIPTION OF WOIiR 6367 N. �. �ellwood Drive Plumb�r, Kind and Locaiion of Fix+iura� L��°° p r � • • WATER MII. O�; V� � S� i � i� O�: � � O I V �� (�9 < l`4 Z(�5 p R N GAS � FIEC. ` �� . ■��■■■I � ■��i ' �■■��' ■■■..�' . . . .. PARTIAL RATE SCHEDULE S�w�s � Ccsspool (-] 7LOMBING FIXTUAE RATES: NO. RATE TOTAL Number Fixtures . . . . . . . , . . . . . . . . x a2.00 $ fl�ture F`ixture npening . . . . . . . . . . . x a1.50 s—_- New Fixture Old Opening . . . . . : . . . . , x a�.so a _.__._ Catch Basin . . . . . . . . . : . . . . . . . . x a325 a Water Heater ;Up to 99,000 BTU) .... x 53.00 ; New Ground Run Old Bldg. ... . x�3.25 $ Electric Wat�r Fi�atsr, . . . . . . . . . . . s a2.00 s 3AS FITTING FEEB: NO. RATE TOTAL lst 3 Fixtures • . • • • • • • • • • • • • • . • x 52.00 = Additional P'lxtures . ... . . . ..... . . . . . x = .7b ; Gaa Range to 199.000 STU ..... ....... 1 x a5.04 � 5• 00 City of Flridley: The undersigned hereby makes appiication for a permit tor the work herei specified, agreeing to do all work in strict accordance with the Cit,� Qrdinance and ruling of the Department o! Buildiags. and hereby declares that s1t the facl and representations stated in this appllcatian are true and rnrrect � P�idley, Mina 7-22-7� � l9_ Isaac F_,. Saari - Owner Kind ot Building Fra.me � Used as Res. To be completed about 7�29-7�� Estimated Cost, a 10, 00 Old-10H4QXBuilding Permit No. P.rmit No. � J� Signed ' gy �A�,��;� --•- Business Phune No ROUOFi_ FtNxL l.? - / - 7 d _ REPAIRS 3� 11LTERAT10Na--R.f•r !o Cod• .50 State Surcharge Deacription . . . . . . . . . . .. . , .. . .. . . .... . . . ..... . .. . ... . ... . � . TOTAI. FEE _ ? • 50 � :Class �`A"' .Surcharge: .50¢ a CITY OF FRIQLEY INSPECTION D�V, 6431 University Ave NE F�idley, MN 55432 572-3604 i� � Residential APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTlLA710N, REFRIGERA710N AND AIR CONDITIONIN� SYSTEMS ANp DEVICES Fumace Shell and Duct Work, Burner — Also Replacement Furnace Gas Riping (Needed with new furnacej Gas Range Gas Dryer *Air Condifioning — Atl Sizes All Others/Repairs 8� Afterations (LIST ON BACl� 1% of Value of Appliance or Work Commeraial/! ndustria! t% of Valus ot Apptiance or Work Rate 70TAL $ 20.00 $ $ 10,00 $ $ 10.Q0 $ $ 10.00 $ $ 10,00 $ • � �.�- $ $ State Surcharga TOTA�. FEE � ,� �_1_ Z.._....� MINIMUM FEE F�R ANY HEATING/COOLINGNENTILAi'ION REFRtGERATIONlAIR COND1TtONING PERMIT IS �15.00 PLUS THE 5.50 3TATE SURCHARGE REINSPECTION FEE $30.00 *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. Effective On January 1; 1993 JOB ADDRESS .�i .3 /� / .l%L�ioo/J %/� _ ihe undersigned hereby makes application for a permit for the work herein specified agreeing to do ali work in strict accordance with the City Codes and rulings af the Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. 3 �.� �-3 ,1993 OWNER ��5 - S��i� l BUILDING USED AS ��'�� da ESTtMATED COST �� PERMIT NO. i/�`i;�, • : ., . ... :. No. of Heating Units Circle One {Steam} (Hot Water) (Warm Air) Trade Name ' Size Na. BTU HP EDR Fuel Total Connected Load Burner Trade Name Size Na. BTU HP EDR / � MEA7ING COMPANY ��5 5��E Signed B�� /G�-L�-e�-� Tel No. �3�—.�� /�'S— Approved By�� Raugh—In Date Final Date 3' �-Y� g3 �1LL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE CHIMNBY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack: l. Has been carefully examined Yes O No ( j 2. Is free from rust or deterioration Yes O No O 3. Has no foreign objects lodged within Yes O No O 4. Is securely supported Yes () No () 5. Meets all current Code requirements for size and total BTU's connected Yes () No () 6. Has total heating BTU's of All other BTU�s � TOTAL BTU's Remarks List Alterations BeinQ Done: 0 ��f�G� �r�S �� l/Cr Gv� 7r� C�.1'�' /� HEATING COMPANY Signed By Date � r .�I _ � - .� - � -� - �`� �r � � City of Fridley AT THE TOP OF THE TWINS r � . � � . COMMUNITY DEVELOPMENT DIV. r � L � � PROTEC7IVE INSPECTION SEC. � � � � �"'1 � CITY NALL FRIDIE� 55032 �""� � ,'� 612-571-3450 SuBJECT BU ILDING PERMIT NUMBER REV DATE PAGE OF 910-F15 9/15/98 / / JOB ADDRESS 6367 Dellwood NE 1 LEGAL LOT NO. BLOCK TRACT OR AODITION DESCR. 2], 1 �gic Moore Lake 2 PROPERTY OWNER MAII ADDRESS Power 3 CONTRACTOR MAII ADDRESS Gates Roofing 4 ARCHITECT OR DESIGNER 5 ENGtNEER MAII AODi;ESS MAIL ADDRESS ZIP PHONE 5s�-nRA IIP PMONE ZIP PHONE 2��96 RECEIPT NO. � �V APPFOVED BV SEE ATTACHED SHEET UCENSE NO. 6793 LICENSE NO. LICENSE NO. ..-- —^ .,. �� n�u[: . . . . � - I . . . _. __--- 0 E HEATING TEST RECORD ___. ADDRESS OCCUPANT APT• FLOOR J� � HEAT LOSS OWNER C�TY —�SUBUR'B DATE HTG. INST. SOLD By Eleetrical Wo�k gy INSTALLED BY TYPE OF HEAT GA Gas L;ne gy FA HW STEAM SPACE HTR. GAS DESIGN UNIT H OTHER MA�� ' Model MAKE OF BURNER CONVERSION Serial � � � , Model INPUT Max. BTU Rating � MAKE OF FURNACE ONTROLS Model THERMOSTAT / ,,, �� Valve Heat Plug t b Vent Size L�m�} KIND OF LINER L�m�t Setting Draft Hood �ZE NONE�_ Fan $etting � Regula�or Filters $ize Pilot Type Chimney Location Number �side Outside Pilof lylcke Chimney Consiruction Pilot Model �_ Pilot Timing � 0 �� Smoke Bomb L•w• Cut Off Draft _�_ � �oor Pressure _ Pressure J �nput CFH Pereent C0� Dute Tested � Stack Temp. � Percent p � Percent Cp2 ComPany Testing - Form 235 �� Name of Tester _ A IY V n-nv��.-�__� '. . . _ AND ORDINANGES GOVERNING THIS f`ivt vr ..v.„_ _..__ WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTMORITY TO VIOIATE OR CANCEL THE PROVISI S OF Afj{X THER STATE OR LOCAL LAW FEGU�ATING CON- STRUCT OR THE P RMANCE OF CONSTRUCTION. � �'�S'�� t,..... • Si ATURE OF CONTRACTOR OR aUTHOp�ZED AGENT IDATE� R BUILDEA� iDATE� 0 �Niring iT �< Test Tag� L�9h�irtg f sr. FEE SAG GMAfiGE $56.75 Fire SC $1.71 CHECKFEE TOT FEE cense�'jC $5. $64.32 �� NEW [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 ��p BUILDING PERMIT APPLICATION �� (� 1`' o' l.l7 ConstructionAddress: ��J � � 4J�U�r►/00 � � �� Legal Description: Owner Name & Address: ��yl�' Tel. # Contractor: �uk't,5 1�G�C MN LICENSE #� �Q3 Address: �,(, �li ��h�tlU,GS � Tel. # SSO ' ��3 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. Length Length Length DESCRIPTION OF IMPROVEMENT Width Height Sq. Ft. Width Height Sq. Ft. Widt�i Hgt/Ground Sq. Ft. Construction Type: �,Q -I�Co� T�c� ' ��' Estimated Cost: $ (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$ \�`" �. __ DATE: �°l� APPLICANT: ��u�,(, �a1GQ Tel. # Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: � �� - ��' � 1.'�/ $ �� $ $ S�Dd $ $ $ $ $ �` CITY USE ONLY Fee Schedule on Reverse Side .001 of Permit Valuation (1/lOth%) $.50/$1,000 Valuation $1000 per SAC Unit $5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above $450.00 Conservation Plan Review Fee Determined by Engineering Agreement Necessary [ J Not Necessary [] M SuB�ECT . c�cy of Fridley 3 3 5 8 6 � AT THE TOP OF THE TWINS g U I L D I N G P E R M i T � � R � �• COMMUNITV DEVELOPMENT OIV. ' �'/ � r � y � PfiOTECTIVE INSPEC710N SEC. j j � V � � �"'1 � CITY MAI,� FRIOLE� 55132 NUMBEA AEV O�iE P�GE OF •vPnpvED 8r �"""�" �� 763-571-3450 9t 0-F � 5 6/ 9/03 / / JOB ADDRESS 6367 De��W00C1 DT1V� NE 1 LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED oesca. 21 1 PZoore lake Highlands lst SHEET 2 PFOPERTY OWNEfi MAII ADDRESS ZI� PNONE Richard Severtson 6367 �% Dellwood Drive NE 3 CONTRACTOR MAIL ADDRESS ZIP PMONE IICENSE NO Northwest Exteriors 6500 Wa�ker St, St I�ouis Park, Mn 55426 952-926-8663 a ARCHITECT OR DESIGNEfi MAIL ADDRESS ZIP PHONE LICENSE NO. 20264650 5 ENGINEER MAIL ADDRESS Z�P PMONE UCENSE NO 6 USE OF BUILOING Residentiai 7 CLASS OF WOqK O NEW O ADDITION ❑ ALTERATION ❑ REPAIR O MOVE O REMOVE X 8 DESCRIBE WORK Replacement windows wi•�hir. ex�stizg open�.ngs 9 CHANGE OF USE FFOM TO STIPULATIONS Provide smoke detectors i:� a�i s�eeping rooms and on ai.'� Ievels of the dwei�ing per Section 310.9.1.2 of the 1997 Uniform Building Code. Caulk and flash ai1 exterior openings. TYPEOFCONST. OCCUPANCVGROUP OCCUPANCVLOAD SEPARATE PERMITS AfiE fiEOUIRED FOR ELECTfiICAL, PIUMBING, HEATING. VENTILATING OR AIR CONOITIONING TMIS PEi;M1T BECOMES NULL AND VOIO IF WORK OR CONSTRUCTION 20NING SO. FT CU FT AUTHORIZEO IS NOT COMMENCED WITHIN 60 OAYS, OR IF CONSTRUCTION OR WORK IS SUSPENOED OR ABANDONED FOR A PERIOD OF 120 DAY$ A7 ANV TIME AFTER WORK IS COMMENCED. NO OWLG. UNITS OFFSTREET PARKING I MEREBY CERTIFV THAT I HAVE REAO AND E%AMINED THIS APPIICATION 1 STA�LS GARAGES ANO KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS yq�VAT10N SURTAX AND OR IN CES GOVEANING IS TVPE OF WORK WILL BE COMPUED WITM ETM SPECIFIED ME EI OA NOT THE GRANTING OF A PERMIT �S�OOO ��F.00 OOES OT P ESUME TO GIV A THORITV TO VIO�ATE OR CANCEI �M£ pEqMIT FEE SAC CHARGE PROVI IONS F ANV OT ER S ATE OR LOCAL LAW FiEGU�ATING CON• @ STRUC ION R TME PER NCE OPi`CO TRUCTION � 153 . L.5 1''' �re SC y+8 . 00 / � �� PLAN CHECK FEE TOTA� FEE �s! i,ice e SC $5.00 $170.25 S N47- E OF CON� ACT OFI4UTMOA�ZED OGENT IDATE� EN PROPERLV VALIOATED THIS IS VOU PE IT � S�GNiTUAEO�OWNEQ��fOWNEABU�LOEAi IDATE� � iNS� r�crE FEB-04-2002 10�� FRCJM CITY OF FRIDLEY TO 95292b5�0 P.u1%b2 NEVN [ j. CITY OF FRiDLEY Effective 1/1f2002 ADDN [ j 6431 University Ava NE, �rf�sy, MN 56432 (76:i) s72•3604 Bidg Insp ALTER [� SINGLE EAMILY AND DUPLEXES R 1 AND R 2 BUILDING P�RMIT APPLICATION Construction Address: �' Legal D�scription: 7 �e..Cwa a c� ��- �� o�IQ� �M�I Owner Name & Address: �V�e..R�'Sa I�<<-l�A 2� Tel. # Cantractor. ^�ur '�w �� fi �� 0 2 MN i.iCENSE # � � � Zv Z �� $�� Address: �S� (l�� 2 �� , S.� �C�S 'P � h� � Tel. # S�'� "�(0�3 � c�ee� c� �z: bra-o�3O Attach to this application, a Cerdficate of SuNey of the iot, with the pr�lposed construc.tion drdwn an It to sC�le. OLS��1PTi�N OP 1MPROVEMENi WtNG AREA: Lec►gth Wldth.,�, Helght_.,,^ SQ. Ft �_. GARAGE AI�tEA: DECK AREA: Length WidU� ��„_ H�Ignt ,� �q. �� i.angth Width Hgt/Ground Sq. Ft �_ OTHER: ��w V�� w�� w c�u � o� d Estimafed Cost: $� g o� �nstruction Type aT C- � a 1� ^� ,^� c� 5� �us �r;veway Curb ut ath Needed: Ft + 8 - Ft x� '$ oat�� `� ' 0-3 ap��cahrr: tei. �� Z��'��3 b l:a1i {7S3} 572�604 fa� Pemtit Pees if maiting in applicatlon o� Fax to 763-871-1287 if ustng credit ca�d and we w�ll cg0 you for aard numba�, CI'I Y U3E ONLY - Permit Fee Fire Surcharge State Surch�rge SAC Charge L:ic�nse Surcharge Driveway ESCro�w Erosion Control Park �ee Sewer Main Charge TOTAI. � 1 �3 � zS' $ $, o0 $ � ,nO $ $ S.oO � $ $ � $ �� p . ZSr Fes Schedule on R�verse �ide .001 �f Permit Valuation (1/10th%) $.50/$1,OOQ V�luation $1240 per SAC Uni! $S,OQ (State �icensed Residential Contractors) A�. "A" or Ait. "B" AbovB $450.00 Canservation Plan Review Fee Determined by Englneering Agreement Nec:essary [ ] Not Necessary [ ] � �• _ �� i�3 Building PLUMBING Permit No.: Inspections RESIDENTIAL APPLICATION Received By: 763-572-3604 CITY OF FRIDLEY vate Rec'd: y Y� � 763-502-49'77 FAX E�E�,.rv�,-�-0s DATE ��e-� v� YOUR E-MAIL ADDRESS � Se>,i e,f � 5c�� y� n !�l�� MG� i � �e M s�n��ss 6�36`7 el1L�c� pR .vF � THIS APPLICANT IS: �DWNER OCONTRACTOR PROPERTY NAME: �i�G�^��1 �' 4; t I � S e.��tf'-4Sv h owlvEx/ .�nv�ss: 631� � p� �� w b�0 n�,icl E crr�r �Fr � d�l � y sTn�L�IN z� ss y32 TENANT rxorrE: �63-7q� -9/00 CONTRACTOR N,�: ��,pt/ �� SUBMIT A COPY OF " YOUR STATE STATE LICENSE # EXP DATE LICENSE, BOND AND STATE BOND # EXP DATE CERTIFICATE OF pDDRESS: CTI'Y STATE ziP INSURANCE rxoi•rE Fa,x PERMIT TYPE ��GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE TYPE OF WORK: Q �W ��PLACEMENI' DETAILED DESCRIPTION OF WORK% s+�K /��,,,, i�.�s�,� ,�� Wc�ll C��Pr �� PER MS 16B.665 the permit fee is a minimum of $15.00 or 5°/. of the total cost up to $500.00, whichever is greater, for the improvement, instatlation or repiacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor ) Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor �Q(� x.OS = plus .50 surcharge OR FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON E10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMUM FEE $I5.50. �C BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING X BATHTUB GAS PIPING (NEEA CTI'Y LIC) _ SWIMMING POOL i WATER SOFINER (S35) CLOTf�S WASHER � KTI'CHEN SINK WATER CLOSET `BACKFLOW PREV. (�15) _ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) ^ FOR IRRIGATION _ WATER METER _ OTHER PERMIT FEE PROJECTS FOR UNDER $500 PERMTT FEE FOR PROJF,C�'S OV�R �500 Permit Fee $�.� Number of fixtures @$10.00 x$10.00 =$ Surchaz e .50 Number of fixtures @$15.00 x$15.00 =$ TOTAL DUE $�,Z. ��"D OR Number of fixtures @$35.00 x$35.00 =$ State Surcharge = $ .50 INIMUM $15.50 $15.50 Tota1= $ THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII, PROCESSED I hereby apply for a plumbing permit and I acknowledge 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 and with the Minnesota Construction Codes; that I understand this is not a permit bnt only an application for a permit and work is nat to start without a permit on site; that the work will be in accordance with the approved plan in the c f al work ich requires review and approval of plans. SIGNATURE OF APPLIC �' �l ; PRINT NAME F�C-hc.�/` !.l S��%2 �� Sc� ItI)ATE FL�1 APPROVED BY DATE Y PLEASE NOTE: SEP TE PERMITS ARE RE UIRED FOR BUII.DING, ELECTRICAL AND C WORK Cityo uf Fridley Bu�ding Inspechons Department 643 i University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977