AF - 43039v�i���� o� ���a��y, ��.'
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iQ
Of�ice of �T��'��`Ol� OF �fiJYL�D�OTGS
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,f,/') Frid'.ey, 112inn., c�G 'L^�+ru +rC �
L/.e� � i'+a4' w.,+''..=:! "
i����C;�?,II����l'�T �� T��T�LD��?�-
�
Front
� Depth ��� Hei�ht �� Steries � 11![�,nner ef Construction_ "t�`�'��`"'��'�'��-
,�!� .� .�*��,�` _- .. � —
� �c ;
` described in the above statement. This permit is gra,nted
i that the person to whom it is granted, and his agenta, empIoyees and workmen, in alI
l and upon said building, or any part thereof, s�all conform in all respects to the ordi-
regarding the eonstruction, altera,tion, maintenance, re�air a,nd moving of puildings
i thia permit may be revoked at any time upon violation of any of the provisions of said
C���� t �
spector of Buildings.
I�GR.EENdF.1PtiTT 1�N3D SWOR.IV STAT�li�ENT
f the issue and delivery ,to �?e �y t1�e �nspector� o:C �ui��inns o� �+'ridley of
�reby agree to do the pro,�nsed `e�r��r�; z�i a.ecorcd�nce �v�thuthe dewcript�on
:cording:im the pravisions of +�Z� Qrciin�,�,cec ai �'�•r€�l�y, an3, iaeiFig first duly
�,nd. say`that the facts sta�ed. by r:�e and contaaned �1 ttie above �ermit are
-�����' � +
n to liefore me at Fridley, l��iaine�o �, th'� � �•'l�'t � f,� r
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Q.D. I9.�. ,..��.�fi"� , �°�� ,
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City of Fridley, Minn.
BUILDING PERMIT
Date: _._...._._..__Au�us t.._19��1970__.__.._..�.�___._._
s-����
. 1079
Owner: __.__Rs�s�.g.�.x_.�.21�.�'�€�ie ._.._.._._.._..�.__.—.. Builder _. Same. ._._..._....---....._.._.__..._ ............._..._._..___.._...�
Address ...._.. 64Q.1,....12�.�.�.Td.�.Q..� ..��Y..� ..._.........._.--------•---_ Address _... Same _.._.___.._..�_._..__._...._._........_._..._`._.�._._
LOCATION OF BUILDING
No. _--- 64 O 1.._.._.--- Street ._---.. De l lw oo d Dr iv e. N. E._....._. _. _. _...-------_. Part of Lot ._._....__..__....._...._.._ ._.._
24 .. .. Moore Lake Highlands lst
Lot ....._ .............---..........._ Block ._.._.._._....._.._..._...--•-•-•-------- Addit�on or Sub-Division .-----..._._._.._.......___.�..�.__.._..—___.._.._
Corner Lot
Sewer Elevatiam
Znside Lot ---•----X-•-•----•----••---.----- Setback ._._.._.._._.._._..._.
.......... Sideyard
._---..._..._..._.._.._._..._..._....___.._ .............---•--._ Foundation Elevation _.._._Y.
DESCRIPTION OF BUILDING
To be Used as:
__�Addn.. to..Garage,�%ont _._$-.6.� DePth ..._32 �___ Height .._1�.� .--_ Sq. F� ...___.._._� Cu. Ft
__._.._.._..._..._..._...,..._.-••---_-•••--_ Front __---_...._.__ Depth _-----.._..._.. Height _.._....._.._..__ Sq. F't. _.__....._...._.. Cu. F't. _.._.
Type of Construction _..._.....: Frame_.._.._._...._..__.. Est. Cost ...... $2 � 500 . 00.--_......_ To be Completed _._Aug _ l, 1971
Provide Hardsurfaced Driveway
In consideration of the issuance to me of a permit to construct the building described above, I agree to do
th� proposed work in accordance with the description above set forth and in compliance with all provision$ of
ordinances of the city of Fridley. n ,, ^ /J
Ea ca�sfderaiion of the payment of a fee of �._._10.�00 .. _, pernut is hereby granted to_.._.. Mrs . Bourge�ie
._.__,..._....__...__._..._....___.._..__..... to construct the building or addition as described above. Tfiis permit is granted upoa
the express condition that the pexson to whom it is granted and his agents, employees and worlunen, 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 regardfng lceation, construction, alteration, maintenance, repair and moving of bufldings
within the city liaiits and this permit may be revoked a t ax�y time upoz� violation of any of tlie provisions of sai8
ordinances.
r
�
CLARENCE BELI LE
NOTICE:
'Ihi: p�m�h doa not eowr th� aonstruelioe, in�tallNion fo� wieiny, Plun�bino, oas iwatino, aw�� or wN��. M wn 10 s»
th� Buildieg Insp�eM� fe� a�p�rah pwmits for fhq� N�ms.
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APLICATION FOR RESIDENTIAL, ALTERATION,
OR AllllITiON BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
� � �� ,_ � . �_ . � � _ � .�!�✓�
. ��� � �', // �•,.., � � ���
NO :1 � D' l S TREET :�o �.� �
LOT: � BLOCK: � ADDITION: �n�A7.�1����/1'���� g���
CORNER LOT: INSIDE LOT: �� SETBACK: SIDEYARD:
�--
Applicant attach to this form Ztao Certificates of Surve of Lot and proposed
building location drawn on these Certificates.
�ESCRTPTION OF BUILDING
To Be Used As:
� Front : � �� Depth : � �-` Height : �D �
Square Feet: Cubic Feet:
Fronts Depth: Height:
Square Feet; Cubic Feet:
�pe of Construction: Estimated Cost: $�„S �j U
To Be Completed: � ��}-L�
The undersigned hereby makes application for a peYmit for the work herein
specified, agreeing to do all work in stiict accordance with the City of
Fridley Ordinances and rulings of the Department of Buildings, and hereby
declares that all the facts and representations stated in this application
are true and correct.
0
DATE : ' ` . �, S IGNATIJRE :
(See Reverse Side For Additiona.l Information.)
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53-8( � -5-915. 51
� �ity of �rddi+ey .
���������� �� ���� �e� � ��:�� P� ���_ �
Drpt. of Bldys. Phons 560-3�30 .. -
D£�CRIPTION OF WORR 6401 N. E, Dellwood Drive
Numbar, Kind as�d Localion oi Fixiures ���°°
N
N � vf s ri � • • WATEN MII.
3� � S F i � �� G�: � � O I V i3 <� V� l�Y � V Cj � N GAS FLEC.
i:: �������
■■■..■�
' ■�■■■■�
• ���■�■'
■■■■■�'
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PARTIAL RATE SCHEOULE
S�w�s �
Ccsspool (�]
PLIIMBING FI]CTURE RATES: NO. RATE TOTAL
Number Fixtures . . . . . . . . . . . . . . . x $2.Od S
�ture Ftixture npening . . . . . . . . . . . x 31.50 �
New Fixture Old Opening . . . . . : . . . . . x a1.50 ��__ _..
Catch Basin . . . . . . . . . . . . . . . . . . x a3.25 3
Water Heater :LTp to 99,000 BTU1. ... x$3.00 E
New Ground Run Old Bldg. ... . x a3.25 $
El�ctrtc Wat�r H�atas. . . . . . . . . . . . s a2.00 =
:sAB FITTING FEE$: NO. RA?E ?OTAL
lst 3 Fixtures . • . • • • • • • • • • • . • . • x 32.00 :
Additional Fixtures . ... . . . ..... . . . . . x = .7b ;
Gas Range to 199.000 BTU ..... .,.... x 35.0� 6
City o1 �cidley:
The undersigned hereby makes application for a permit for the vrork herei
specified, agreeing to do aZl work in strict accordance with the Cits Ordinance
and ruling of the Department of Buildings, and hereby declares that a3I the tact
and representations stated ia this application are true and correM '
6 -17 -7L�
PY�idley, Minn 19_
Rodger W. �ourgerie �
Owner
Kind of Building
Frame .
Used as R'�s'
To be completed about 6-24'7�
10.00
Estimated Cost, � '
Old-2fl�u0C Building Permit No. P�rmit No. �� (r� �
Signed � ' r'„_`�.,-,.-' �
G'�.* ra�C-:.ts.
By � --�-
.. - ,� ; �t r
Business Phune No
ROUGH
FINlIL � - 2 - 7G
REPAIRS 8c 11L1'ERATIONS--Adu !o Cod• .50 State Surcharge
Description . . . .Inst�ll Gas :Grill , , ... . . . . . . . .... � 5.00 .
Tar.w � = 5 • 5�
�,i,�sfi "'A�° Surcharg� .:50�
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C`11 Ol
FR[DLEY
CIVIC CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MINNESOTA 55432 • PHOIVE (612) 57t-3450
August 18, 1988
Fern Var�der Hart
6401 Dellwood Drive N. E.
Fridle�, N2V 55432
RE: Proposed C�1-De-Sac at 53 zd Avernie N. E. at Rice Creek Road N. E.
De3r Ms. Var�der Hart:
Counci]man Schr�eiaer has forwarded yaur letter to me arrl asked me to respond.
The Council has already requ.i.red that the exit f ran Moore Lake Catm�ons be
designed to prevent txaftic fmn crossing Rice Creek Road N.E. arrl traveling
davn 63 � Avernie N. E. I am er�closir�g a oop� of the f ir�al plan.
Hvwever, if you and your neighbors would like to see 6.ird Avenue N. E.
dead-err�ed with a cu2-de-sac in the viciniiy of Pi erce Street N. E. , mw is
the most opportune time to get this done. Our present contract with the
street construction contractor could be changed to pravide a cul-de-sac
rather than to reconstruct the present intersection at 6�rd Avenue N.E.
Plmse see the er�closed sketch.
If this is the desire of you ar�d your riei��bors, we would urge you to sign
the es�closed petition within the next week or so and I will present this
petition arrl pxvposal to the City Cour�cil for their approval of such a change
order.
Please feel free to contact me or Mr. Flora. Public Works Director, at
571-345U if you have arr� follav-up questions.
Sincerely,
I�sim M. 4ureshi
City I�iager
I� /dn
C`-88-392
CIN OF FRIDLEY INSPECTION DIV.
6431 University Ave NE
Fridley, MN 55432
572-3604
RATE SCHEDULE
APPLlCAT10N FOR POWER PLAN7S AND HEATING, COOLING, VENTILATION,
REFRIGERATION ANQ AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS (� yO� ���i� r'�c�c�� ���• -
Effective On January 1, 1995
_ _._-\.
Residential
r. Furnace Shell and Duct Work, Burner —
Also Replacement Furnace
(Side Vent — Fill Out Back)
Gas Piping (Needed with new furnace)
Gas Range
Gas Dryer
* ; Conditioning — All Sizes
All Others/Repairs & Alterations (LIST.ON BACI�
1% of Value of Appliance or Work
Commercial/I ndustrial
1% of Value of Appliance or Work
Rate TOTAL
� tC/ �J
$ 20.00 $.
$ 10.00 $
$10.00 $
$10.00 $
$ 10.00 $ C� �C� Cl
�_—
$�
State S�urcharge
TOTAL FEE
�•50
�
��, j.�—
�._.__
MINIMUM FEE FOR ANY HEATING/COOLINGNENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $15.00
PI.US THE $ 50 STATE SURC!-IARGE
REINSPECTION FEE $30.00
*Afr Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes ar
rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
7�0?�— g S� 199�
OWNER C��/e� UCl�a��/"1 �i.�---�
BUILDING USED AS �!�' � fG~ /��� l y
ESTIMATED COST 3��� PERMIT N0._�( ��'
� -�.1:.,=.�� • - --- ► r • - _ - � ;
No, of Heating nits� Circle One (Steam) (Hot Water) (Warm Air)
Trade Name � v�'�+ ����<<'� S�ze Na ,!.
BTU ,L �0 HP EDR _
Fuel Total Connected Load
Burner Trade Name Size No.
BTU HP, EDR _ _
Sharp
HEATING COMPANY Heating and Air Conditioning
entra ve.
Columbia Neights. MN��S�` 1
Signed By � _
{;
Approved By '' � Rough—In Date Final Date
v, .
FILL OUT BACK SIDE FOR STACK VERIFICATION ON
REPLACEMENT FURNACE
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
�631572-3604 FAX: (763) 571-1287
ADDRESS : 6401 DELLWOOD DR NE
PIN : 133024310059
LEGAL DESC : MOORE LAKE HIGHLANDS 1ST
: LOT 24 BLOCK 0
PERMIT TYPE
PROPERTY TYPE
CONSTRUCTION TYPE
: HEATING
: RESIDENTIAL
: ADDITION/ALTERATION
PERMIT NO.: 2004-00185 I� ��
i.,
DATE ISSUED: 02/09/2004
� �"
VALUATION .
NOTE: AIR CONDITIONERS CAN NOT BE PLACED IN A SIDE YARD WITHOUT WRITTEN PERMISSION FROM
ADJOINING PROPERTY OWNER. COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A
INSTALL FURNACE (WARM AIR, RHEEM, 50,000 BTU)
VALUE OF APPL OR WORK 0 # FURNACES
# GAS DRYERS 0 # GAS RANGES
ENTER VALUATION 2500
APPLICANT
BONFES PLUMBING HEATING & AIR SERV
505 RANDOLPH AVE
ST PAUL, MN 55102-
(651)288-7140
OWNER
VANDER HART, GARY W& FERN L
6401 DELLWOOD DR NE
FRIDLEY, MN 55432
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time a8er work is commenced.
I hereby certify that I have read and examined this
application and lrnow the same to be true and correct. All
provisions of laws and ordinances governing this type of wor�
will be complied with whether specified herein or not. The
granting of a permit does not presume to giv authority to
violate or cancel the provisions of y oth state or local law
regulating constructio r the pe orma e of construction.�
Applicant Date�L
Bldg
HEATING PERMIT MINIMUM FEE
FURNACE SHELL/DUCT WORK
GAS PIPING FEE
GAS RANGE FEE
GAS DRYER FEE
HEATING REPAIRS/ALTERATIONS
STATE SURCHARGE, MECH FLAT
TOTAL
PAID WITH CHECK # 2963
SEPARATE PERMI'I'S R�OUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
1
0
0.00
30.00
10.00
0.00
0.00
0.00
0.50
40.50
Ltlective Jariudry 1, ZOU3
CITY OF FRIDLEY INSPECTION DIViSION
6431 University Ave NE Q
Fridley, MN 55432 APPLICATI()N FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, � � �
(763) 572•3604 REFRlGERATION AND AIR CONDITIONING SYSTEMS AND DEVIC�S �6 / ���,,����
FAX (763) 571-1287 i i
JOB ADDRESS V'� �-t���6 �k 1�l`� �., �`�'�a.-�.
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner -
Also Repiacement Furnace
(Side Vent - Fill Out Back)
Gas Piping (Needed with new furnace,
but not replacement)
Gas Range
Gas Dryer
*Air Conditioning • All Sizes
All Others/Repairs & Alterations (LIST ON BACK)
1% of Value of Appliance or Work
Commercial/Industrial
1.25°�0 of Value af Appliance or Work
Rate TOTAL
� �.c�_
$ 30.00 $ � "-
�:�
$10.00 $l�•
$ 10.00 $
$ 10.00 $
$ 25.00
State Surcharge
TOTAL FEE
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS ` 25.0
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard �vithout
written permission from adjoining property owner.
$
$
:�
$ .50
�. L:
$L"�•'
� ,_._. rv . F
OWNER � i� L��-� � ��� � �C..�`(:��.;CC� �, �i .
BUILDING USED AS��`z �`1��7"y l� �/
, � .,..-
ESTIMATED COST -�S CT` �� �--'i PERMIT NO.��'-��� j" �i'> `--
DESCRIPTION Os� FURNACE AND OR BURNER
No. of Heating Units �_ Circle One (Steam) (Hot Water) 4 arm Air�.
Trade Name���Z Size No.__
BTU �C , L'(`�(`: HP _ EDR
Fuel_ �' ��t � _ Toial Connected Load
Burner Trade Name Size No.
BTU HI' EDR
The undersigned hereby n�akes application for a permit for the work herein
specified agreeing to do all wo��k in strict accordance with the City Codes an
rulings of the Building Division, and hereby declares that all the facts and
representations statsd in this zpplication are true and correct.
_..
HEATING CO :�CY
;
Signec���
FAX#���"}�I
Approved By
�
R��t�gt�-In Date
DATE � I -3 ����
it� � r�C � �- t-� t 'r. � � v � � \
TEL # L� �- l_ ���-� � t> 1 1
,
Final Date _�� �
THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLlCATION WILL BE RETURNED
•�iu•► I ► I ► •►► •: !►� •��: 1•► ' ! •►
Whe� rp �a i an �i�ctin0 f�rance, the undersigned hereby verifies that the
venting has been examined and is free from nast, deterio�ation, obstructions, �
and is securely supported and firestopped where required. :' Yes (;q No O
The venting system is piasticJPVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination. ':Yes (► No O
The undersigned also verif+es that the replacement unit is a listed assembly
and meets the cuRent codes and manufacturers specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural drai� appliances.
The pYi� in0 r_em� �sf� n air is sized and instalied to me�t the current codes
and manufacturers specifications.
` Yes ( ) No ( )
Yes ( ) No ( )
Wh6n requlfed to jnetall a new cemhuctien air� it will be sized and installed �'-�: -
to meet the current codes and manufacturers specifications. ' Yes ( y No O
Whe� iostallinQ,a new v�r�t�na���, the undersigned hereby verifies that
it is a listed assembty and meets the current codes and manufacture�s
specifications. This does include AGA-GAMA Category I Central Furt�ace
Venting Tables for fan assisted and natural draft appliances. Yes () No ()
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes () No ()
�.. .� .- .�. - .����.. -� ... -. .�.- . � ..��. .�
Appliance #1 Type ,�� <u� � _� c � BTU Input � ` �� Fan Assisted or Nat � ���-
App��ance #2 Type BTU Input Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Tc�tal Appliances _,�� Total Btu Input
Common Vent Type ��` � Vent Height Diameter inches �`� `�'`�"
Appliance #1 Vent Connector Height �`� �ft Length ti' � ft Diameter ��' in Type �"J �
Appfiance #2 Vent Connector Height �ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ��ft Length �ft Diameter _�Lin Type ��
� r : � r•► .- .:�
HEATfNG
Signed By:
�3uiiding
Inspections
763-572-3604
DATE Dl 1 c1�'
SITE ADDRESS _
THIS APPLICANT IS
����
�1�+��
PROf'ERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
Permit No.:
Received By:
CITY OF FR.IDLEY I Date Rec'a: �
YOUR E-MAIL ADDRESS �-���'e�'C� �OV1'CS • CCJY�'1
I�l-C ili. rt . --
NAME: -•[ti < <Jl V 0.q1d�G� hA< �
ADDRESS: �I` Q CITY STATE_ZIP.
PHONE: T �D �J • � �' � • 1 � � 1
N,a�,,iE: PELLA WINDOWS & DOORS
STATE LICE 15300-25TH AVE. N. STE. #100
�DxESS: PL�OUTH, MN 55447
PxorrE 763-745-1400
❑ SINGLE F LICENSE # 20165884
❑TWOFAM..,.,...... __.----------
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW ❑ ADDITION
❑ MAINTENANCE/REPAiR � REMODELING
� r. _ r� � t_ 1
D�SCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
NUMBER OF SQUARES _
GARAGES
PROPQSED SIZE:
PROPQSED HEIGHT:
SIDING
❑ Vinyt
❑ Aluminum
❑ Other
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WiNDOWS
IN EXISTING OPENINGS�IYes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPEI�IING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF `
�•
CITY STATE ZIP.
iRIEs
❑ WINDOWS
❑ DRAIN TILE
❑ OTF�R
W /f
HEIG
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of struc�ral members to be used
FOR NEW CONSTRUCT70N INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project�
2. Two sets of construction plans
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
([TSING TfIE 997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ (D � �Q ��• SS OCCUPANCY TYPE
Permit Fee
Plan Review
Surcharge
Fire Surcharge
I,icense Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ , a$� See Back Page for Fee Schedule
$ ��.�. 65% of Building Permit Fee
$ (.0005) times the total job valuation — Minimum $.50
$ r .OQ1 x Permit Valuation (1/10%)
$ • � $5.00 (State Licensed Residential Contractors)
$ $1450 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$20=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ / _ L Make checks payable to: City of FridIey Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinan es and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati for a permit ork is not to start without a ermit; that the work will be in accordance with the approved
plan in the case of all work 'ch uires and.approval of s.
SIGNATURE OF APPLICAN P AM S DATE �
Buil,din�
�
Inspections
763-572-3604
763-502-4977 FAX
DATE � 1�'I �!
SITE ADDRESS _
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-08
' b{7 0 Ad O!
❑CONTRACTOR
ADDRESS
PROPERTY OWNER/ NAME: ��'% �-�I���LSL'�j �
TENA1vT qpDRESS: f f0'�i OC W D�''
PHONE:�rZ'�71i0 '^�3� D
CONTRACTOR ,�DRESS:
SUBMIT A COPY OF pHONE
YOUR STATE LICENSE
STATE LICENSE #
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
CITY
CITY_
_ FAX
EXP DATE
�SINGLE FAM(LY 51Gt V ♦ v
❑ TWO FAMILY{NEW CONSTRUCTION . STORIE
❑ ADDITION ❑ GARAGE/SHED Q WINDOWS
❑ BASEMENT FINISH �ROOF C] DRAIN TILE
❑ DECK ❑ SIDING Q OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
$( MAINTENANCE/REPAIR ❑ REM�DELING
DESCRIBE WORK BEiNG DONE: R�1I 'rLV1% �-0D �
SIZE OF
ROOFING , /�
NUMBER OF SQUARES /
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
0 Aluminum
❑ Other
W INDOW S
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
WIDTH
❑ HOUSE ONLY
8! HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
Permit No.: (�!�-�i � Q �
Received By:
Dat�d� U L 1 2��$
STATE �� IP�
STATE ZIP,
FT
BASENIENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDiTIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
3. Energy Calculations
LOCATION OF WINDOWS
NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
���r' �USING THE 1997 UBC FEE SCHEDULE)
TOTAL JOB VALUATION � �� �d.�" OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
I hereby apply for a building permit and 1
of the City of Fridley and with the Minrn
permit on site; that the work will be in acc
SIGNATURE OF APPLICANT
$ �- %Q
$
$
$
$
$
$
$
$ � L.ti
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$1825 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$21 =$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
: that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes
c on Codes; that I understand this is not a permit but only an application for a permit and work is not to start without a
e approved plan in the case of all work which requires review and a� p�oval of plans. ���
PRINT NAME DATE
APPROVED BY V � DATE
. .- �
�
_
CI'IYOF
FRtDLEY
FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287
BUILDING PERMIT APPLICANT: PROPERTY OWNER
1
�� � t� understand that the State of Minnesota
requires that ali residenti I buiiding contractors, remodelers and roofers obtain a state
license unless they qualify for a specifi exemEt�on from the licensing requirements. As
the owner of the property at �( yo t �t��11�0� Uj"%V%, , Fridley, I
a m e x e m p t f r o m t h e s t a t e l i c e n s i n g r e q u i r e men t on ly i f I am not building or improving
this property for purposes of resale. By signing this document, I attest to the fact that !
am improving this house for my own use and do not intend to sell it. I hereby claim to
be exempt from the state licensing requirements because I am not in the business of
building or remodeling on speculation or for resale and that the house for which I am
applying for this permit, isl the first residential structure I have built or improved in the
past 24 months. I also acknowledge that because I do not have a state license, I forfeit
any mechanic's lien rights to which I may otherwise have been entitled under Minn.
Stat. 514.01.
Furthermore, I acknowledge that I may be hiring independent contractors to perform
certain aspects of the construction or improvement of this house and I understand that
some of these contractors may be required to be licensed by the State of Minnesota. I
understand that unlicensed residential contracting, remodeling, and/or roofing activity is
a misdemeanor under Minnesota law, and that I would forfeit my rights to
reimbursement from the Contractor's Recovery Fund in the event that any contractors I
hire are unlicensed.
( have also been informed and acknowtedge that by listing myself as the contractor for
this project, I alone will be responsible to the City of Fridley for compliance with all
applicable building codes and city ordinances in connection with the work being
performed on this property. n _
Name
Date / �� a� ,
iG��`i