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City of Fridley, Minn. N° 823$
BUILDING PERMIT
��; Ju7,y 20, 1965
owner: �EN W�I� Bu3lder SAN1E
Ad�r�a 6210 E. �iiE:'� 80AD A�
F'ridle�, Minnesota
LOCATION OF BUILDING
No 62� Stceet �T � R0� Part of Lot
Lot 1 _ Block 1 Addition or Sub-Divisian Juli-�
Coraer Lot _ Ins�tde Lot g Setback 35 � S;�y� 10�
Seover IIevation
Foundation IIevation "
DESCRIPTION OF BUILDING
To be Used as:
Ilouble 8glo. �nt 62: Depth ,�.` Height � Sq. Ft -�� Cu. Ft ,�
Front Depth I�eight Sq. Ft Cu. Ft
Type oP Conatniction FPeme E�. Cost _�30�000�� To be Completed
NEW HOUSE
Ea c:onslderatfon of the fesuaace to me of a permft to construct the building des�ibed above I. gree to do
th� proposed work in accordance with the d�script3on above set in comp ce ona oP
ordinaaoea oP the dty of FrirIIsy.
In caa�deration of the paymeat of a fee of � g 38.00 , P�t fa hereby granted to �N i�.�I,RE's
to construct the bu9lding-or addition ae d�crYbed above. Thisp�rmi t is granted upon
tase egPre� condition that the pereon to whom it fs granted and hfs agents, employees an� worlmien, in all work
� e�in, �a�nd upon eaiaab.��ding, oconstr�uc�Ton, alteer�ation�a aia�tena�nce� pair�and �g o�rf b�d�ing�a
wi� dty ]imits�an�this permit may be revoked at a�y time upon violation of any of the provieions of Ba�d
AZLEN G. J�TS�N g� �
^ NOTICEa
11d� pa�eh doa ee1 eovu t6s eonslrueN�, I�tall�ton fer vridee. P�+�e. 6� �*+�8� �►e' or ww�. B� ara to ss�
� ��m6 �i �* apuab � for tha� It�s.
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, . , .. APL'�IGAT'tON FOR � BUILDING , PERMIT .., �� �
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O�,iNER' S NAME � � s 9 _. , _ �.,� �''` ; ., . `�� , BUILDER � ��� � � r
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ADDRE$$�� . . �- . ,ADDRESS � -
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. . . � LOCATION OF BU7.I.DIN� : . � � ;3 , .'
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r�o. ,� �' � �� , ._ .. „- - StreeC . � fl ��`' " "-��,. ;. Part��of Lot
Lo� ��� � . Block , : /" � Addition or. Subdivision_ `-"� �> � -:�� .: , _�,�
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Coraer Lot � Inside Lot �� Setback �� ` � � '� Side-Yard � �`f ' �
SEt+�R �LEVATtON FOUNDATION ELEVATION
Appl�.cant attach..Co this form Two Certificates of,;.Sur.ye�y�af yat and proposed build-
. � ., :
ing l�ocatian drawn on t�ese Certificates. � �
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DE3C�IPTION OF BUILDING � .
To� uae��• . . • . . ri , , ,
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- �< �" ��. �� Front . �' Depth ''f �`� geight � �'
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. Sq,, ��� ' � � �' �. Ft:.` ��. ��,
�Front �Depth Height
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, , • ; Sq� Ft. Cu. FL, �
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Type� of Con,atruc'tion -� �i _�, , � F` � � � . f �' �
.��� , . � �sc�macea cos� �`� � �
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To be leted . . . _ _ . . ,
`� _ , �. - ,
The undersigned�hereby makes�application for a permit for the wo�k her4�n specified,
agreeing to do all work in strict accordaace with the Citq of Fridley Ordinancee and
rulinge.,vf the Departmeat of.Buildin$s; and hereby,declarea that a}.l��he fac�a aad
repreaentatione etaCed in tfiia application are true and correc�; , i.
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DA� � �°'' � �� '� � �� SIGNATiTRE �
�(Schedule of Fee Coste cea be fouad on the Reverse Side). ��
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BUII,DING PEP.MIT FEB SCHEDULE
Section 2. The Inspector of Buildings shall, before isauing any permit for
the erecCion of e.ny buflding or structure, or for any addition to any exist-
ing building or sCructure, or for any alteratious or repaire to any esisting
building or structure, upon application therefor, require the paymeat bq Che
applicaat for such permit of fees to the amouat hereia below set forth and
in the mannes herein provided to-wit:
2.1. For anq such permit for the erection o.f any fire-proof building, othe�C
than a garage� warehouse, factory or.grain elevator, or for the erection of
aay fire-proof addition, for similar occupaacy, to any existing building
shall be at the rate of $1.40 for each one ehousand cubic feet, or fractioa
thereof, in such cubical cvatents.
2.2. Eor any such permit.for the.erection of any. fire-proof garage, warehouse,_
factory or grein elevator, or for the erection of any fire-proaf eddition,
for similar accupantcy, Co $ny exieting building shall be at the rate of $1.25
for each one thousand cubic feet, clasaified as °1fireproof" by Section 502 of
the Minneagolis`Suildi�g Code.. �
flOUSES
2.3. For �nq sucb pezmit for the erection of any non-Hreprcot buildiag �other
than a garage, warehause, factory or grain elevator, or any aon-fireproof
additioa, for similar occupancq, to any existiag building - permit $1.00 for
each one thouas.nd cubic feet.
GARAGES
2.4. For anq such permit for the erectioa of any non-fireproaf garage, _
warehouse, factory or grain elevator, or for the erection of aay non-fireproof
additioa, €flr--similar occupancy, to anq existing building or for each such
_u_. -building or additfon - ninety cents ($0.9Q) for each oae thouaand cubic feet
or fza�tian thereof, in the cubical contents thereof with.a minimum of $4.00.-
For Che purpose of computiag feea for building permits, the cubical contents
of auy buildiag or addition to a uniform height throu�hout by multip�ying the
ground area covered from a point six (6) iachea below�the floor line of.tbe
basement or cellar to the �verage hefght of the upger surface or to the
average height of the r�of �urface of the main gable of a p3tched roof.
2.5. For repairs or alterations to an exiating atructwce, the fee aha3.1 be
at the rate of $3.00 per each Five Hundred Dollars ($500.00) or fraction
ehereof�in the cost of all progosed work.
�2.6� `In no case shall the fee_..charged,.for.any permit, alg set forth in
Sectioa 2 be 1ess. than $4.0p.
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�1�ARVEY A. CARTI'JfiYC�NT 'c u3a;3r�Lb S� �'�,r7 t�o-imrr`�mti��¢Ci i� � �� � �S�" �i�
� AVOr:A COUP�TY� SURVEYS ��
�;: NENNEPIN GC�UNIY SUF<VEYS �i:��t��Ii L� (J R� 6i ���ll ti� .
I NINNLAP4L�6 SURVEYS '
�I 6.:10 SHAUY OAr� L'rNC N C. ' qEG�STEftEO UNDER LAWS OF 9TATE OF MINNESOTA
Sl,ti>rr 8-007a �,aGEn1SEU k3Y ORDINANCE OF GTY UF MIIVNCAPOUS
� owtiin
! 345 PLYMOUTH'BWLDING Lirvco�N 8721
iNGUS1RiAL - JUDICIAL �
pUSINE55 - TUPOGRAPHIGAL , S.-•7tII'U(�VDC,� �fYll'fl[iltf
CITY LG75 - PLAI'T{NG
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�6'sB�N:NG TNF_ FE�vHC�S• GP
J. E. NILL, CIYIL ENGINEER
ESTFPlI6�/ED ItlB6
C. F. SANDHOFF
GIV1L ENGINEER
L-.ThFLIS�ItG lnOe
JAh9c5 NELSON
SURVEYOR
kS�ARL��HCU IB22
METROPOLlTAN LANU
SURVE'fURS. .si..eLts�rr �o'+�
Invoice 1??»
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Caty of Fridley, Minn_ N° 911��
BUILDING PERMIT
�
Date: DEC�ER 22, 1966
Owner: Builder BEN WOLKE, INCORPORATED
Address Address � 251 RICE CREER TERRACE N. E.
FRIDLEY, MCNNESOTA 55432
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LOCATION OF BUILDING
No. 6210-20S�t EAST RIVER ROAD N.E. ____ Part of Lot
Lot W 1 �__ Block 1 Addition or Sub-Diviaion _�_ �'Z'� �DITION
Coraer Lot — x Inaide Lot — Setback —_ Sideyard �
Sewer IIevation
Fo�mda.tion IIevation
DESCRIPTION OF BUILDING
To be Used as:
�P�� F'ront Depth Height Sq. Fk (�. FL
Front Depth I�eight �. 5q. F� G�. FL
�pe of Construction F� ��, �_$2 a 5 00 . 00 _ To be Completed
In consideration of the issuance to me of a permit to co bwilding described ve I agree o
the propQSed tgork fn accrordance wlth the deacriptton above and in com ce of
ordinancea of the dty of Fridley, �
_ - — - _ _ -- --` �� _
In consfderation oE the payment oP a fee of $ lI o 00 ��t is hereby granted to B� �� ���'
to canstruct the building or addition as described above. Thispe rmit ia granted upon
the expresa condition that thepe� n to whom it is granted aad his ageats, employees and worl�ien, in all work
done in, around and upon said building, or anypart thereof, shall conform in all respects to the ordinances of
Fridley, Minnesota reg �ng location, constructfon, alteration, maintenance, nepair and moving of bufldin$s
within the dty ]imits and tt�a permit may be revoked at aTMy time upon violation of ar�y of the proviaions of sa�d
ordinanc�.
QIARENCE BELISLE B�� �
NOflCE:
'fhis peneh doa nef cowr tlu censteueNoe, IeshpaHon tee wUine, plumb[ne, eu 6uNne, �r�r o� waM�. B� sms to a�
tho Buildie8 Irnp�to� for aparat� p�rmN� Poe t6as tl�ms.
� . . _•
APISL�QATiO�T �'OA BUILDING PEItMIT
C*�'Y OF FRIDLLY, M�lESaTA
OWAEB'S NAME � �
� G'' - '� �' � �f' l `' /� �_,BU'.r.I,D�R �—e �_ l _.. � �' � �
AUDRESS ADD�ESS
LOCATION OF BUILDING
NO.. _ STREET PART OF LOT
LOT ,�/ BLOCx � ADDITION OR SIIBDIVISION � �� -
CORAiEfl L � INSiDE LOT,_,�_SETBACR • �TDE-YARD
SEWER E%EdATION FOUNDATIOP ELEVATEON
Appiicant attach to thie form Two Gertificates of Surveq of Lot and prop�ed
buildin� location drawa on these Certificates.
DESCRIFTION �OF BUI%DIATG
Used • ���
Ael. „ � .
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��� � � �ront Depth fleight
`� Sq. Ft. Cu. Ft.
Front D�pth � Height
� , �� Sq. Ft. . Cu. Ft .
� ��-� `�
Type of Coastruction � Eatimaeed Cost
To Ba Completed
.�_..,..-..�� .r - ...
The undereigned herebq makes application for a permit for the work herein specified,
agreeing to do all work in atrict accdrdance with the City of Fridley Ordinances
and rulings o� the Department.of.Bu��l.dings, and hereby declares that a11 the facts
and representationa atated in�thi8.applfcation ar��t�ue �nd correct. �� ���
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DATE ���'�� � � �
(Schedule of Fee Costs caa be found an the Reverse Side).
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BUILDTNG . PE1�1IT FEE SCHEDULE
SEGTIOR 2. The Inspector of Buildings aha11� before iasuing perm�its for the
erection of anq building or etructure, or fo� any addi�ion to any exiatiag
buildiag or structure, or for any alterations or regsirs to any existing buiiding
-or structures upaa_agplieation therefose, require the payment by the appl�.cant �
for such permit of fees to the amount herein below set foreh�and in the ma�er
heFein pravided to:wit:_.... , ' ,.. . ,
2� Fos any such permit for the erection of any fire-proof building,
oCher than a garage, warehouse, factorq or grain_elevator, or for the erection
of any fire-proof.addition, for similar occupancy� to any existiag building,
sha11 be at t6e rate of $1.40 for-each t�ne-:thousand cubic feet, or-fractian
thereof, in such cubical contents. ��
2.2. For any, such permit for the erection of any fire-proof garage,
warehouse, factory or �r��n�•�levator, or �or the erectfoa of �anp f.3re-proof
addition, for similar occupancy, to,any existin� building shall b� at the rate_
` of '$1:25 -for each oise thoueand cubic feet, ciaseified as "fireproof" by �Section
502 of the Minaeapolis Building Code.
Ii00SES
,.
2•3• For anq eucb permit for the �erection�of anq non-fireproof building,
other than a garage, warehouse, factory or grain elevator, or any non-fireproof
additioa, for aimilar occupancy, to any euistiag building permit fee�,$1.00.for
each one thoueand cnbic feet. ��
GARAGES _. . � .
_._r._ _
_ _.�. .. . ...
2_ 4. For aay such permit for the esection of aay aon-fireproof garage,
warehouae, f�ctory or grain'elevator, or,for the, erection.of any non-fireproof
addition, for similar oacupancy, to any existing building or �for eacb such
buildiag-or.additio�t - ninety ceats ($0.90) for each one thousand cubic feet
or fractia�n thereof, in the cubical contents thereof �rl.th the minimum of $4.00.
Ror.the purpose of computing fees for buildiag permits, the cubical contente of
anq buildin� or addie�i.,oq to,a uniform heighC through�t bq multipl,y�ng the ground
area covered from a point six (6) inches below tbe floor l�tne of the b$eement or
cellar to the average height of t6e upper surface or to the average height of the
� roof eurf�ce of the mai�t gab�le of a pitchecl roof.� , �
�� 2.5. For repaire or aiterations to an esisting struc�ure, the fee sha11
be at the rate� of $3.00 per�each Five H�ndred Ddllars �$5,OQ.00) Qr frac�iaa
thereof in the cost of all proposed work.
�-2` Tn no,_aase ehall.the fee ¢herged for_any permit as set farth in
Section 2 be lese thaa $4.00. `� " �
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RE: 6210-20 EAST RIVER ROAD N.E.
DAMAGED BY AUTOMOBILE - DECEMBER 11, 1966
INSPECTION DATE - DECEMBER 12, 1966
(1). Security Insurance agreed to have Ben Wolke provide
temporary shoring to prevent further damage at Insurance
Company's expenae.
(2): REPAIRS.REQUIRED AS FOLLOWS:
.(a). Replace loose and damaged concret�e block, brick veneer
(N.E, corner to door) and basement wlndow unit.
(b). Replace or add to three - 2 x 8 floor �oists by
removing hardwood floors, pull loose nails in sub-
floor and renail and replace, sand and finish
hardwood floor, replace ring joist where moved or
damaged.
(c). Remove siding from North wall, repair or replace
sheathing - Re-frame wall, window and replace
insulation.
(d). Sheet�ock cracked in basement stairwell, bath,
living room, both bedrooms and few nails popped in
kitchen. Renail where needed ancl retapeo
(e). Tile at both cornera above tub. Repl�+ce if loose
and regrout.
(f) . Furnace wracicecl - ducts, furnace, stack need check a�.d.
overhauling.
(g). Replace ox� repair raater heater, vents and piping.
� C�ARENCE �ELISLE
, Building Inspector
CITY OF FRIDLEY
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RE: 6210-20 EAST RIVER ROAD N.E.
DAMAGED BY AUTOMOBILE - DECEMBER 11, 1966
INSPECTION DATE - DECEMBER 12 1966
(1). Security Insuranc� agreed to have Ben Wolke provide
temporary shoring to prevent further damage at Inaurance
Company'.s expense.
(2). REPAIRS.REQUIRED AS FOLLOWS:
(a). Replace looae and damaged concret�e block, bricl� veneer
(N.E, corner to door) a�d basement window unit.
(b). iteplace or add td three - 2 x 8 floor joista by
removing hardwood floors, pull l.00se nails in aub-
floor and renail and replace, sand and finish '
� hardwovd floor, repl.ace ring j.oist where moved or
daanaged .
(c). Remove siding from North wall, repair or replace �
sheathing - Re-frame wall, window and replace
insulation.
(cl). Sheetrock craciced fn basement stairwell, bath,
living room, both bedrooms and few nails popped in
lcitchen. Renail where needed and retape.
(e) . Ti1e at both corx�e�a aY�ove tub . ltepl�+ce if loose
and regront.
(f) . �urnace wiracicecl - duc�s, furn�.ce, sta.cic need check and
overhauling.
(g). lteplace o� repair wate� heater, vents and piping.
� CL�ARENCE BIEY,ISLE
� Building Ynspecto�
CITY OF �RIDLEY
IFORM J�S���i � U.S
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City of Fridley � �� � � �
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T V
r
� � RECEIPT NO.
• COMMUNITY DEVELOPMENT OIV.
i LV ������ o
r � � PROTECTIVE INSPECTION SEC. ���
� �
' � �'��1 � CITY HALL FRIDLE� 55432 NUAABER pEV OATE PAGE OF APPROVED BY
�----� • •'� 612-571-3450 910-F15 / /
12/27/95
J08 ADDRESS 6210-6220 East River Road NE
1 LEGAL LOT NO. BLOCK TRACT OR AODITION SEE ATTACHEO
DESCR. 1 1 Juli-Ann SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Revin Woods 6210 East River Road NE 425-6384
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO
Affordable Roofin 9620 25 Ave N P1 outh MN 55441 542- 374 Cit
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
6 USE OF BUILDING
Residential Double
7 CLASS OF WORK
❑ NEW ❑ ADDITION O ALTERATION �] REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof Structure 40 S Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
tinderlayment must comply with the State Building Code.
SEPARATE PERMITS ARE FEOUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCV LOAO
VENTILATING OR Alq CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT CU. FT.
AUTHORI2ED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 OAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFV THAT I HAVE READ AND EXAMINED THIS APPLICATION 2 STAILS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS ypLUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL 8E COMPLIED
WITH WHETHEH SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT �3 � 2OO � 1. CO
DOES NOT PRESUME TO GIVE AUTHOiiITV TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STR CTION OR THE PERF ANC F CONSTRUCTION. �87. ZS �S%. LS IF Fire SC �3. ZO
"�° PLAN CHECK fEE TOTAL FEE
$179.30
,� SIGNATUAEO ON'RACTOAOAA OAIZEDAGENT IDATEI EN P RlY VA TED THIS IS VOUR PERMIT
f, ' �-�� - �S
S�GNaTUREOFOWNEA�iFOWNEPBURDERi iDATEi „ R�p� i p qpTE
NEW
ADDN
ALTER
[]
Il
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CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
Effecdve 8/1/95
.
�, .
ConstructionAddress: ��1� � �- `�-� �° ���� ��� `'` � � �
Legal Description: �? % ��' ����
Owner Name & Address: �.� v.� 1�/�-�ex� "�;�✓� ,F,��` �i����� �I� Tel. # �� � --� 3 �
Contractor: /`��';� /�� %� /`(�i i�i � e�- L1,�1 ��t_"I � MN LICENSE # � � �%� u�//�
Address:�1.0 S�� �✓/U�� �� �Ja`�%S f,,sE�,�°� Tel. # S� �c�� i��
d� ��^ �� Attach to this application, a Certificate of Survey of the
� S' �/ y/ lot, with the proposed construction dra.wn on it to scale.
LIVING AREA: Length
DESCRIPTION OF IMPROVEMENT
Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECB AREA: Length Width Hgt/Ground Sy�.
OTHER: T ;�°U� � 1s✓�e� � — �O� ��j�i'� �S _-,- I � � I� ` � �
,.
Corner Lot [] Inside Lat [] Ft. Yd Setback Side Yard Se,tbacks
�
Type of Construction: Estimated Cost: $ - J
Approx. Completion Date:
(Cost on BackJ
Driveway Curb Cut Width Ne,edal: F� + 6 Ft = Ft x$ _$
DATE: A,PPLICANT: Tel. ,#
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosioa Comrol
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
� � �� � � CITY USE ONLY'
$ `�- � S� Fee Schedule on Reverse Side
$ � �. � � .001 of Penmit Valuation (1/14t6%)
$ � , �0 0 $.SO/$1,000 Valuation
$ $850 per SAC Unit
$ .00 (State Licensed R�idential Contra.ctors)
$ Alt. "A° or Alt. "B" Above
$ 50.00 Conservation Pl�n Review
$ — Fee I�termined by Engineering
$ Agreement N�azy [ ] Not Nece,ssary [ ]
$ l `� .31�
.��
-----_..� . ---.._ _ _ __ _.,-
� �� ��.��
�
BUILDING PERMIT FEE SCHEDULE
The Chief Building pfficial shall, before issuing permits for the ere�tion 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 a,nid in the mann�. he�.ein provided to-wit;
TOTAL VALUE
$1 to $500
$SO1 to $2,000
$2,�1 to $Z5,0�
$25,(�1 to $50,000
$50,�1 to $100,�
$1�,�1 to $500,(�l0
$5(J0,�1 to $1,000,�
$1,OOO,W1 and up
FEES
$21 (Minimum Fee is $21 plus surcharge)
$21 for first $S� plus $2_75 for each additional $100 or
fraction thereof, to and including $2,(Hl0
$62.25 for first $2,p00 plus $12.50 for each additional $1,000
or fraction thereof, to and including $25,000
$349.75 for first $25,� plus $9.� for each additionat $1,000
or fraction thereof, to and including $50,000
$574.75 for first $50,� plus $6.25 for each additional
$1,(?00 or fraction thereof, to and including $100,�
$887.25 for first $100,0� plus $5.00 for each additional
$1,000 or fi�ction thereof, to and including $5�,�
$2887.25 for the first $500,000 plus $4.25 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$5012.25 for the first $1,0�,000 plus $2,75 for ea,ch additional
$1,000 or fraction ther�f
DRIVEWAY DEPRESSION ESCROW
(Concrete C�rb Streets Only)
Alternate "A": Removal and replacement of curb and gatter oniy _ Driveway width plus b feet times $13.�.
Alternate "B"; Removal and replacement of curb and gutter and install a 3 foot wide
a�proach with 6 inch depth - Driveway width plus 6 feet times $15.75.
VERIFICATION OF FOUNDATION
P�� fOi' CO��On �ll be issued a minimum of 24 hours from the time of application to allow for proper
review of the proposed structure and of the constivction site_
A Cemficate of Survey of the lot, showiag the loration of the foundation once it has it has l�en const�vct�i
will bs required before proceeding with the framing.
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ThC UQdeTS1gIIP� �iC�] V?.?If1�S t� ��xtS1�g Ci11mIILj► 01' S�Ck:
1. Has b�n r.�refully examined Yes () No {)
2. Is free from n�st or dete�rioratioa
3.
4.
S.
Has no foreign objec�ts lodged within
Is s�curely support�
Meets all current Code requirements far size
and t;otal BTU's connected
6 Has tatat heating BTU's of
All other BTiT's
TOTAI. BTU's
7. Has a liner b�n p�ovidecl for water heater
S. Has combustion air been provided for water heater
Remarks:
���-�TIO�T$ l�n� D�ne:
Yes ( ) No ( )
Yes()No()
Y�(}No()
Yes()No()
YesONoO
YesONoO
y
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HEATING CO:
Signai By:
Date:
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HOUSE HEATING TEST RECORD
ADDRESS ���o �� �C�� APT. FLOOR CITY SU�URB
OCNPANT 01NNER
HEAT LOSS DATE HTG. INST.
SOLD BY INSTALLE� BY
Elsctrieal Work' By Gas Lin� Br
TYPE OF HEAT GA FA HW STEAIiA SPACE HTR. UNIT HTR. OTHER
MAKE.
Mod�l
SKial _
INPUT
THERMOSTAT
Volve
Limit
Limtt S�tting _
Fan SeHing —
Pilot Typs _
Pilot Moks —
Pilot Modsl —
Pilot Timing _
L.W. Cut Off _
Praasure —
Input CFH_
Stock Temp.
Fwm 235
GAS DESIGN
CONTROLS
— Hsot Plup
CONVERSION
MAKE OF BURNER
Mod�l
I�lax. BTU Ratiny
MAKE OF FURNACE
Model
V�nt Sizs
KIND OF LINER SIZE NONE
Drah Hood Rpularo�
Filt�rs Sizs N���
Chimn�y Loeotion Insid� Outsfd�
C�imnsy Conatrudion
Smoks Bomb Wiriny
D►aft T�st Taq
Door Prssswe Liphtlna Inst.
P�reent CO2 Date Testsd � - � ���
Psrc�nt 0� Company Teating
Psrcent CO Name oi Teater _
y HOUSE HEATING TEST RECORD
ADDRESS �� �O �� ''�•��- APT. FLOOR CITY SUBURB
OCCUPANT OMINER
HEAT LOSS DATE HTG. INST.
SOLD BY INSTALLED BY
El�etrieal Work' Br Gos Lin� 9r
TYPE OF HEAt GA FA HNf STEAM SPAC� HTR. UNIT WTR. OTHER
GAS DESIGN
MAKE MAKE OF BURNER
Mod�l Mod�l
S�rial IiAox. BTU Ratin9
INPUT MAKE OF FURNACE
Modsl
CONTROLS
THERMOSTAT
Va Ivs
Limit
Limit S�Ming -
Fan Setting �
Pilot Typs _
Pilot Maks —
Pilot Modsl _
Pilot Timi�g _
L.W. Cut Off _
CONVERSION
— Hsat Pluq V�nt Sizs
KIND OF LINER SIZE NONE
Droh Hood . RpulaTOr
Filt�►s Siz� NumiNr
Prsssure P�rcent COZ
Input CFH Peresnt O�
Stock Temp. Peresnt CO
Form 235
ChimrNy Location
Chimney Conatrudion
Smoks Bomb
Droft
Insid� Outsid�
Wirinq
T�st Tap
Door Prsssure Liyhtiny InsL
Daro Tsstsd � -� � l lJ
Company Testing
No� of Teatsr
� ' � " SuB�EGT - " �
City of Fridle� 32312'
AT THE TOP Of TME TW1NS g�J � L D I� G P E R M I T
;,
� � COMMUNITY DEVELOP�ENT DIV. O
' � �3/�
� � �: -
r � � PROTEGTIVE INSPECTION SEC.
i---. A �r"�,'; CITY HALL FfiIDIE� SS��Z NU4BEF pEV DATE 11/9/O1 PAGE Oi APPROVED BY
L �� 612-571-345p 910-F15 � �
JOB ADORESS 6210 East River Road NE �
t LEGAL ��T NO. BLOCK TRACT OR ADDITION SEE ATTACNED
DESCR. 1 1 JLll�—Ailri S1iEET
2 PROPERTY OWNER MAIL ADOR�S$ 2�P PMONE
Mark Algren 6210 East River Rd NE 757-8086
3 CONTRACTOR MAIL ADDRESS 21P PMONE UCENSE NO
Northwoods Services Inc 544 3 St, Elk River MN 55330 76 - -
a ARCHITECT OR DESIGNER MAIL AOORESS ZIP PMONE LICENSE NO
20244588
5 ENGtNEER klAll ADORESS 2�P PNONE LICENSE NO
8 USE OF BUILDING
Residential Du lex
7 CIASS OF WORK
❑ NEW � ADOITION � ALTERATION O REPAIR O MOVE � O REMOVE
B DESCRIBE WORK
Interior alterations to add bedroom � in basement
9 CHANGE OF USE FROM TO
STIPULATIONS See notations on plan.
SEPA����°� �������.��� � ��
REi������ ���;
W�K'i��x��:1� ��t<:�19 5iy�t.i
��.U�����'�� ���" ���°����
" ' TYP� O� CONST. OCCUPANCY GROUP OCCUPANCV �OAD
SEPARATE PERMITS ARE REOUIRED fOR ELECTRICAL, PLUMBING, HEATING.
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTiiUCTION 20NIN(3 SO. FT CU FT
AUTHORIZED IS NOT COMMENCED V�IITNIN 80 OAYS. OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANQONEO fOR A PERIOD OF 120 DAYS A7 `
ANV TIME AFTER WORK IS COMMENCED. ' NO DWLG. UNITS OfFSTpEET PARKiNG
I NEREBY CERTIFY THAT I MAVE REAQ ANO EXAMIN�O THIS APPlICA710N L STA��S GAflAGES
AND KNOW THE SAME TO BE TAUE AND CORRECT. ALL PROVISIONS Of LAWS yAWATION SURTAX
ANO ORDINANCES GOVERNING TMIS TYPE Of WOAK WILL BE COMPI,IEO @
WITH WMETHEN SPECIfIED MEpEIN Op NOT. TNE GRANTING OF A PERMIT W3sSOO �1.75
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOIATE OR CAMCEL THE pEqMIT FEE SAC CMARGE
PROVISIONS OF ANV OTMER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFOFMANCE OF CONSTRUCTION �97.LS Fire SC �3.SO
PLAN CMECK FEE TOTA� FEE
Licen C $5 0 $107.50
S�GNATUAEO�CON'AACTOAOpAU1MOA�2E00GENT �O�iE� ME Pii LV VA DATED THIS IS VOUR PERMIT
//•c3'4/
S�GNOtUAEO�OWNEA��fOWNEpBWLOEA� �OarE� � oa �NS� � Q6tE
NEW [ ] Effecave 1M/2001
ADDN (] , CITY OF FRIDLEY ,(763) 572-3604 Bldg Insp
ALTER [] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: �� �� � � ���%�r ��
Legal Description:
Owner Name & Address: ��-�� �i����e� Tel. # �S�- ���b
°`�-• MN UCENSE # ZQ �'k ��
Contractor. �J� `��•��� ds +��'e5 �
S�ti 3 `�
LNING AREA:
GARAGE AREA:
DECK AREA:
� I�J� ��
� Tel. # 7�4 -er et (- 4�i 6`7
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
. DESCRIPTION OF IMPROVEMENT
Length �� Width ��� Height �` Sq. Ft
Length Width Height Sq. Ft
Length Width HgUGround Sq. F�
OTHER:
�^�^� ,p
Construction Type: �-e �^�� e�/ ��� `^ �� Estimated Cost: $`� 3�� a
. j
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x� _$
DATE: ���6-� � APPLICANT: C���3 t�(5� �`'���1 Tel.# �� "�46 °7
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
Call (763) 572-3604 for Permit Fees if mailing in application
$_ �/, �� Fee Schedule on Reverse Side .
$��,5`� .001 of PermitValuation (1/10th%)
$ �. �%Sr $.50/$1,000 Valuation
$ $1150 per SAC Unit
$� DC� $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement Necessary [] Not Necessary [ J
� � , S2�
BUII.DING PERMIT FEE SCHEDULE
The Chief Building Official 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:
TOTAL VALUE
$1 to $500
$501 to $2,000
$2,001 to $25,000
$25,001 to $50,000
$50,001 to $100,000
$100,001 to $500,000
$500,001 to $1,000,000
$1,000,001 and up
FEES
$23.50
$23.50 for first $500 plus $3.05 for each additional $100 or
fraction thereof, to and including $2,000
$69.25 for first $2,000 plus $14.00 for each additional $1,000
or fraction thereof, to and including $25,OQ0
$391.25 for first $25,000 plus $10.10 for each additional $1,000
or fraction thereof, to and including $50,000
$643.75 for first $50,000 plus $7.OU for each additional
$1,000 or fraction thereof, to and including $100,000
$993.75 for first $100,000 plus $5.60 for each additional
$1,000 or fraction thereof, to and including $500,000
$3,233.75 for the first $500,000 plus $4.75 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$5,608.75 for the first $1,000,000 plus $3.15 for each additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
(Concrete Curb Streets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $15.50.
Alternate "B": Removal and replacement of curb and gutter and install a 3 foot wide
approach with 6 inch depth - Driveway width plus 6 feet times $23.25.
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper
review of the proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has h�en constructed will
be required before proceeding with the framing. New Houses Onlv
No�T�rr�ooDS c�sz�o.n�r�oMEs
A Division of NORT�TWOODS SE�2V7CES, INC.
P.O. Boz 395, 544 3`'d St NW Elk River,lVllY 55330
Office (763) 441-4967 Toll Free: (866) 441-4967
DATE: � � I
TO: ��.Y
�ax: (763� 633-4967
MN Builder Li�cense #z0244588
FAX TRANSIV,[I�'TA�
0� o �
�ir���.
,,
FRO1V�: � �i�� � �1 ��
RE:
-�
# OF �',A.GES (YN'CY,UDINGr COVER SH�E�') :
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