AF - 42036\
SUBJECT R .
City of Fridley ° 1364�
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T '
r
� � RECEIPT NO.
� ; L �����_ COMMUNITY DEVEIOPMENT DIV.
r � PROTECTIVE INSPECTION SEC. �5/
� �
� . ,
, 1 /'��1 � CITY HALL FRIDLEV �55432 NUMBER REV. DATE PAGE OF APPROVED BY �
�----� • ,•' s,2-�so-s4so sio-F�5 7/13/76 / /
JOB ADDRESSXRC1�lI���XgARf4M1C1RXXXXXBAA�X 238 Ely St►^eet N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADD,ITION SEE ATTACHED
oescR. 33 & 34 11 Spri ng Brook Park sHEET
2 PROPERTYOWNER MAILADDRESS 21P PHONE
Rodney Sandman 3511 - 173 Lane N.W. Anoka 55303
3 CONTRACTOR MAIL AODRESS 21P PHONE LICENSE NO.
SAME
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
residential
7 CLASS OF WORK
C� NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
�onstruct hous�e 38 x 30 and 24 x 28 garage
� � .
�i at+li�es
9 CHANGE QF USE FFOM � TO ���� . r�tC7p+t► �
�=1NIP�R'�A1V't'� - G 6 � 111{/ �
STIPULATIONS N�T� ' REQ �
�V�g�pN REGARDING CURB
1. R�� �c�Oi�i'��ibM�tiired 13' side yard setback before beginning house
c��lE�dhC�EhN�ain regulation minimum side yard. (yar�artce granted
2. Delete kitch�door to exterior. 7-27-76)
3. Provide a verification survey before capping
4. Provide a hard surface driveway.
5. Provide sod for the front and side ards
SE�ER�ATE P�RMrTS REQUIRED FpR,;� �,
S�WER (approx. 9.s� �eep) HEATING; PIUM�BiNG ;����
79' East of Manhole (inv. 848.83) ����'�
Wye Elevation 849.23 THE GTY OF �R�D�EY D4 �= ��
Top of footing - 852.23 (Minimum) �ccuR�CY Of uTilrnr LOGATiONS AND EIEYAAGt+�S
WATER THIS DA7A IS FOR INFORNMT{ON PUE:rO3E5 Oi�LI� �.N.�
10 2 East of Sewer Service pERSONS U51NG R SHOUI.p VERiFY iN@ INFOW�AATtoN�
SEPARATE PERMITS ARE REQUIRED FOR ELECTR�CAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING. ��d frame
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION ��964 +672 �9,064 'F6�7Z
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 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND COFiRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPIIED $3Z,195 � 6. � O
WITH WHETHER SPECIFIED HEFEIN OR NOT. THE GRANTING Of A PERMIT
DOES NOT PRESUME TO GIVE AUTHOPITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- � 03.14 350. OO
STRUCTI N OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE TOTAL FEE
-- /3 -�l 25. 78 495. 02
SIGNATURE CONTRACTORORAUTHORIZEDAGENT IDATEI WHEN PROPERIY VALIDATED THIS IS YOUR PERMIT
R
�
SiGNATUREOFOWNERUFOWNERBUILDERI � IDATEI BIDG INSP pATE �.
CITY OF FRIULEY
APPLICATION FOR RESIDENTIAL ALTERATION, `?'L�� �
�� � -
ADDITION, OR REPAIR BUILDING PERMIT �
OWNER' S NAME : i��c� f L�c� BUILDER : S
ADDRESS: ,3�1/-/73 -�-ri. %.ly�G� ADDRESS: �'a-�...
NO • . 2 3� STREET :
LOT : 3 �� 3 Y BLOCK : /J ' ADDITION : S/ /�-yi.� �iJ�� ��
CORNER LOT: INSLDE LOT: /�' SETBACK: SIDEYARD:
Applicant attach to this form �ao Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
HESCRIPTION OF BUILDING
To Be �Jsed As :
/
'���� Fxont: 3� Depth: �G' Height: ��O
�Square Feet : �� / Cubic Feet : / 9, Q lu ,�%
r / � O
'V" �'G Fxont : 02- � Depth : 2 l� Height :
� Square Feet; �v 7Z Cubic Feet: �n !'Z- �
Type of Construction: �� Esti.mated Cost: $�-
To Be Completed: //� �� �2/ l'��
The undersigned hereby makes applicatinn for a permit for the work herein
specified, agxeeing to do all work in strict accordance with the City of
Fridley Ordinances and rulings of the Departrient of Buildings, and hereby
declares that all the facts and representations stated in this application
are true and correct.
DATE : / �- 7 � S IGNATfJRE : // 6 �
�'''�-�*�-
.
(See Reverse Side For Additional Information.) ��
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BUILDING PERMIT FEE SCHEllULE
SECTION 2. T'he Inspectox of Buildi.ngs shall, before issuing permits for the
erection of any building or strucCuxe, or for any addition to any existing
building or structure, or for any alteration or repairs to any existing
building or stre.ecture, upon application therefore, require the payment by the
applicant for such permit of fees to the amount hexein below set forth and in
the manner herein provided to-wit:
NEW CONSTRUCTIOK: SingJ.e Family Homes and Garages: $4.00/1000 cubic feet
PLAN CHECK: 25 percent of building permit fee.
AllDITIONAL INFORMATION
For the purpose of computing fees for building permits, the cubical contents
of any building or addition, is determined by multiplying the ground area
covered from a point six (6) inches below the floor line of the basement
or the cellar to the average heights of tne upper surface or to the average`
height of the roof surface of the main gable of a pitched roof.
For repairs or alterations to an existing structure, the fee shall be at the
rate of $3.OQ per each five hundred dollars ($500.00) or fraction thereof in
the cost of all proposed work.
In no case shall the fee charged for any permit as set forth in Section 2 be
less than $7.50.
VERIFICATION OF FOUNDATION
NOTE: Permits for eonstxuction will be issued a minimum of 24 hours from the
time of application, to allow for proper review of the proposed stxucture and
of the construction site. �
A Cextified Survey of the lot, showing the location of the foundation, once it
has been constructed, will be required before proceedin� with the framing.
CERTIFICATE OF OCGUPANCY
Application for a Certificate of Occupancy shall be made ten (10) days prior
to the use or occupancy of any structure for which a building permit has been
r e; and s id s ructure shall not be used occupted until a Certificate
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Minmapolis: Minnesota 55t32
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�oid land. A� surv�yed by m• ►Mis�dor oi t- � A.D. 19�d tt
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CITY OF FRIBLEY
APPLICA7ION FOR POWER PLAfdTS AND HEATING> COOLING, VENTILATION, REFRIGERATION AND
AIR �ONDI7iQNIP1G $YSTEh1S AND DEVICES
PARTIAL �TE SCHEDULE
GPv�VITY WARti1 AIR: R�T'E TOTAL Jeb Address 2�� � �' � �` _
Furnace Sheli & Duct Work $12.00 $
Replacement of Furnace 7-00 $ _
Repairs & Alter.ations-up to $700.00 �•�� S Department oi Buildinqs
Repairs & Alterations each add. $500.00 4.00 $ City of. Fridley
Tel. #571-3450
MECH�NICAL 'AARD1 AIR:
� FUrr.ac� Shell & Ih:�r Work to 100,000 BTU
each a.a.3. 50,000 BTJ
R.eplacement,of Furnace
?tepairs & Alterations-up to 5500.00
Repairs � Alterations each and. $500.00
STF.��'. OR H�T W.1Ti:R SYSTE'�1:
Boiler & Lines up tu 100,000 BTU
each addr.. 50,000 BTJ
Boiler or�1y up to 100,000 BTU
each addn. 50,000 AT!I
OIL BU R�ER- to 3 gal. per hour
•�ach add. 3 gal. per hour
r GAS BUR�'cR- from 100,G00 S2L' '•�0 199,999 BlU
(aver 199,99? ETti see Fee Scnediiie)
t GaS FiTTING rEF,S:
lst 3 Fir,tures
Additional Fixtures
Gas Range to 199,C00 BTU
AIR COtiDITIONING �•
FA� HEA1'I NG SYS i�Z1S '
VENTILATING SYSTE.�1S
ALTERATIONS $ RFPAiRS
ROUGH INSP.
Date
FINAL INSP.
Date
APPROVAL FOR PER*SIT
,r-:� Fee Schedule
The undersigned hereby makes application for a permit for the work herein
$12.00 $�2.�� �pecified agreeing to do all work in strict accordance with the City Cades
4.00 $ and rulings of the Departr.ient of Buildings, and hereby declares that all the
7.00 $ facts and representations stated in this application are true and correct.
7.00 $ % /�
4.00 $� /� r' Fri�/ey, Minn. �_� )�. � . 19j�
//
OWNER
/ %�
$12.00 $ KIND OF BUILDING �✓-r�/
T'�—
4.00 $
7.00 $ USED AS
6.OG $ �..,�/ �
TO BE COMPLETED ABOUT //C2• � ` � ___
$10.00 $
10.00 $
$iQ.GO $ /Q.nc�
$
X S s.00 S 3 c.•
X $ 1.00 $
x $10.00 $
State Surcharce
TOTAL FEE
REIIIS?ECTION FEE
(_$10. 00)
MIWIMUM �'EE FOR ANY HEATING PERN,IT ZS $7.50
S
S�
S
S
$ .50
$�_�
ESTIKATED COST j�O.c�'iD �' C�
OLD - NiW BUILDING PERMIT NO. /��`� y- PERMIT NO. ��� r,�j
DESCRIPTION OF FURNAC�/EURNER
HEATING or POWER PLANTS, Steam, Hot Water, Warm Air- No. �cw�.ti �.�----
Trade Name ��'r" a�rw.� Size No. e Ei -/e� (Z'2. �
Capacity Q`jOc� t's Sq. Ft. EDR BTU �o•�c: v AP ��_
Total Connected Load g'1 b �'' Kind of Fuel r��q�iy
BURNER - Trade Name �(a4 ' Size No. �ES -�� � p 2 C
�
Capacity � G p d Sq. Ft. EDR BTU / G°y p �• c= HP �
Company _ ,
Siqned By
Tel. No. �S3_�3?7 ��
,�,5"//- /�.31d� �-d-�-
�, �.,li�,c�, � s-�a3
r
�'�� 1
�
CITY C7I� FRfDLEY
6431 UNIVERSITY AVENUE N.E., FRIOLEY, MINNESOTA 56432
�
April 1, 1977
Mr. Rodney Sandman
3511 - 173rd Lane N.W.
Anoka, Mn. 55303
Re: 238 Ely Street N.E.
Dear Mr. Sandman:
TELEPHONE ( 812)571-3450
Please be advised that on March 31, 1977 we made a final inspection of your
home. The following is a list of Code violations that were noted and which
must be corrected;
l. Post the address on the outside of the home; numbers to be at least
3 inches high.
2. Complete the sod on the front yard.
3. Provide handrails on all stainaays.
4. Provide proper headroom (6'6") on bas�►ent stairway.
5. E�ctend the hearth on the fireplace so that it extends at least 38 inches
out from the back of the firebox. (A noncombustible floor could be used
in substitution for the raised hearth.)
6. Change the rietal valleys in the roof to 28 gauge galvanized metal with
a diverted rib.
All of the above items except item 2 must be corrected or completed prior
to occupancy. The sodding must be done by June 1, 1977.
If you have any questions on the above items, please feel free to contact me
at 571-3450.
Sincerely,
,
(? �> �j;'.� ��Cl..� , %
c�.- �J
DARREL G. CLARK
Community Development Adm.
DGC/mh
CITY OF FRIDLEY iNSPEC71flN DIV,
6431 University Ave NE
Fridley, MN 55432
572-3604
i� i
APPLICATIDN FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
REFRIGERATION AND AIR CONQITIONING SYSTEMS AtVp DEVICES
Residential
Fumace Shel! and Duct Work, Burner -
A1so Rep{acement Furnace
Gas Riping (Needed with new furnace)
Gas Range
Gas Dryer
*Air Conditioning - Att Sizes ,
All Others/Repafrs & ARerations (LIST ON BAC�
19�0 of Value of Appliance or Work
Ccmmercial/lndustrial
1% of Value af Appfiance or Work
Rate TOTAL
$ 20.00 $
$ 10.00 $
$ 10.00 $
$ 10,00 $
$10,00 $ l� � O l.�
State Surcharge
TOTAL FEE
Effective On January 1, 1993
JOB ADDRESS � �
i'he undersigned hereby makes application for a permit for the wark herein
specified agreeing to da ail work in strict accordance with the City Codes and
rulings of the Building Division, and hereby declares that al! the facts and
representations sta#ed in this application are true and correct,
� - �2 3 �� ss���
'�
BUILpING USED AS
ESTiMATED COST � �� � �— PERMtT NO. � -� ��`"
�!1�1 : r • il.G_ � •; i
$ No, of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Trade Name S(ze No.
BTU HP EDR.
$ Fuel Total Connected Load
� .50
C�� �
Burner Trade Name Size No.
BTU HP EDR
MEATING COMPANY �-�
MINIMUM FEE FOR ANY HEATINGlCOOLIN�ENTILATIQN
REFRIGEAATION/AIR CONDtTtONlNG PERMIT IS �15.00 Signed By�,_? 1._�`'a-� ` Tel Na �� 7� ��g�
PLUS THE 5.50 STATE SURCHARGE
REINSPECTION FEE $30.00 Approved Rough-In Date Final Date � f���
*Air Cendftioners can not be placed in a side yard without ����Z��i' �����%�
written permission from adjoining property owmer. FILL OUT BACK SIDE FOR STACK VERIFICATION ON
8��� ���Das P�.LAC�MENT FURNACE SUI'«t4R CONTqA�TORS 1NC.
aiZ� � Av�nue No. 6121 e2nb Aven�e No.
Ct�, MN b64Zs Cryata�� MN 66422
�
v: � ;�
�'t ;;3
t�,3 • .,,�
Cy, = <
CHIMNEY AND STACK VERIFICATION
� ae. The undersigned hereby verifies that the existing chimney or stack:
� .� �
�
.�� y l. Has been carefully examined Yes () No ()
�::
�;�.1
,� ��� 2. Is free from rust or deterioration Yes () No ()
{.�
°�` 3. Has no foreign objects lodged within Yes ( j No O
. ;
�F 4. Is securely supported Yes O No O
5. Meets all current Code requirements for
size and total BTU's connected Yes { j No ()
� 6. Has tctai he�ating BTU's of �
All other BTU's ,
TOTAL BTU's
Remarks
�r
�"
�� w :
ro - -+ .
�Y � � -
�,� List Alterations Beinq Done•
���
� �i�
��
�
�� ,� .
��
.�
�:
�
HEATING COMPANY
Signed By
Da te
0
CITY OF FRlDLEY INSPECTION DIV.
6431 University Ave NE
Fridtey, MN 55432
572-3604
RATE SCHEDULE
Residentiat
APPLICATlON FOR PUWER PLANTS AND HEATING, COOLING, VENTIiATION,
REFRtGERATION AND AtR CONDITIONlNG SYSTEMS AND DEVICES
F ell and Duct Work, Burner —
Also Replacement Furnace
i e ent — i ut Back)
Gas Piping (Needed with new furnace)
Gas Range
Gas Dryer
*Air Conditioning — All Sizes
AII athersJRepairs & Alterations (LIST ON BACI�
1°� of Value of Appliance or Work
Commercial/lndustrial
1% oi Value of Appliance or Work
Rate TOTAL
$ 20.00 $��
$ 10.00 $
$ 10.00
$ 10.00
$ 10.00
State Surcharge
TOTAL FEE
Effective On January 1, 1993
JOB ADDRESS_ � � � �� �
7he 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�d
ruGngs of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
�/— o'Z �— - Lg94
` � �
BUILDlNG USED AS
� '/ UU
ESTtMATED COST � 7"O� � PERM17 NO. %% �,,�
$
�
$
.50
�irri,�v
MINIMUM FEE FOR ANY HEATING/COOLINGJVENTILAT{ON
REFRIGERATION/AfR CONDITlONING PERMIT IS $15.00
PLUS THE $.50 STATE SURCHARGE
REiNSPECTION FEE $30.00
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
DESCRIPTION OF FURNACE AND OR BURNER
No. of Heating Units�_ Circle One (Steam) (Hoi Water) ( arm Ai
Trade Name ����'� Size No. /IJ(��S �7 �
BTU U CJ HP EDR
Fuel Total Connected Load� c�� `
Burner Trade Name Size No,
BTU HP EDR
HEATING CC)MPANY
Signed By �W¢.� ����_ Tel No. .5�3 7—c%��' /
�
Approved y Aough—!n Date Fina{ Date �
F1L� C�UT BACK SIDE FOR STACK VERIFICATION ON
REPLACEMENT �URNACE
NOTE: 4�1 through ��8 required when using a side vent furnace.
��IMNEY ANA STACK VE.�IFICATION
The undersigned hereby verifies that ihe existing chimney or stack:
l. Has been carefully examined Yes ()() No ()
2. Is free from nast or deterioratian
3. Has no fureign object.s Ic�dged wit�'�in
4. Is securely supported
5_ Meets all current Caie requirements far size
and total BTU's con;�ected
� 6 Has tatal headng BTU's of � S� o� v_____
--r-
Atl other BTU's �% �j G� v�
TOTAL BTU's / / S 6 � �
7. Has a liner been grovided for wdter heater
$. Has combustion air been provided for water heater
Remarks:
�.� ! :• � ��
HEATING CO:
Signed By:
Dai�:
�
//-��- - �
Yes (�) No ( )
Yes (�j No ( )
Yes (�/} No ( )
Yes �) No ( }
Yes()No()
Yes()No()
�� �L / � �
�..�— -- - ,.
sue�ecr P T-N6�.
City of Fridley � � � �6
AT THE TOP OF TME TWINS g U I L D I N G P E R M I T �
r
; � REC O.
� COMMUNITY DEVEIOPMENT OIV. /�
' � ~ � �J
r � � PROTECTIVE INSPECTION SEC. ' �
� �
' � ����1 � CITY HALL FRIDLE� 55a32 NUMBEA AEV DATE PAGE OF APPROVED B�
�"""'�" �'' 612-571-3450 910-F15
5/10/96 � �
JOB ADDRESS 238 Eiy Street NE
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
oescR. 33,34 11 S rin Brook Park SHEET
2 PROPERTY OWNER MAIL ADDRESS 21P PHONE
Don Abboud 238 E1 Street NE 783-9136
3 CONTRACTOR MAIL ADORESS Z�P PHONE LICENSE NO
Horizon Roofin 1333 Larc Industrial Blvd n
4 ARCHITECT OR DESIGNER MAIL AODRESS ZIP PHONE LICENSE NO
5 ENGINEER MAIL ADORESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW ❑ ADDITION ❑ ALTERATION p REPAIR ❑ MOVE O REMOVE
X
8 DESCRIBE WORK
Reroof House 16 S Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
TYPEOFCONST. OCCUPANCVGROUP OCCUPANCVLOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHOFiIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTHUCTION
OR WORK IS SUSPENDED OR ABANDONEO FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFV THAT I HAVE READ AND EXAMINEO THIS APPLICATION 1 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TVPE OF WORK WILL BE COMPLIED @
WITH WHETHER SPECIFIEO HEREIN OR NOT. THE GRANTING Of A PERMIT �1s2HO �p.64
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING coN- �43.00 Fire SC �L.ZH
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE T A FEE
Licens SC $ 00 49.92
SIGNATUAEOFCON-RACTORORAUTHOA�ZEDAGENT IDATEI Pj� Y VAU T HIS IS YOUR PEFMIT
� �-lp,��
$iGNATURE OF OWNER�IF OWNE�7 BUILDERi IDATEI DG �NSP �1A7E
�.
NEW „ [ ]
ADDN [ ]
ALTER []
CITY OF FRIDLEY
5INGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
ConstructionAddress: �3� ��� Sj��T� �=�CidLe� , ��t 5J`J3�
Legai Description: �
Effective 3/ 1 /96 �
��j_`�
�a���
Owner Name & Address: �o� /��60� c� Tel. # 7�3- 9�3�
Contractor: MN LICENSE #� C�v / a�qS
Address: j 3���� a�, ����gtriai Bivd_ Tel. # 6ia -��o - 3�o�c�
BurnS�i{���I �3�plication, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Length
Length
Length
DESCRIPTION OF IMPROVEMENT
Width
Width
Width
Height
Height
Hgt/Ground
Sq. Ft.
5q. Ft.
Sq. Ft.
Corner Lot [] Inside Lot [] Ft. Yd Setback Side Yard Setbacks
Tyge of Construction: y�� -(%[ �% 2A�Q- 6�� � Estimated Cost: $�36p •
Approx. Completion Date: /� s�j' k�' /�$D. �
Driveway Curb Cut Width Needed: _
DATE: APPLICANT:
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
� �3-0�
$ l�'
$ .�
$
$ �:60
$
$
$
$
� �� � �
(Cost on Back)
Ft. + 6 Ft = Ft x$
CITY USE ONLY
Fee Schedule on Reverse Side
_ $.x�
Tel. #
.001 of Permit Valuation (1/lOth%)
$.50/$1,000 Valuation
$900 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 [ ] Not Necessary [ ]
���vz �s�� . _
^ r-�a
�o P'�� � /C� ���v = ia Y� , 7?l� a.z� x Y= a�'
Suo
�/� Z �
- 65�
From: unknown Page: Z/2 Date: 3/30l2009 11:35:25 AM
�wvoirau. �ai JY cuuo �i.uuo�
Ff�am: City of Fdrlley Ta 7634245225 Page: 212 �be: 31'50/200911:19:a0 AAA
Building PLUMBIN� p� xo. �O�a
Inspections RESIDE1�tTIAL APPLICATIUN �t�i� $y:
763-s72-��04 �IT�' OF F1�.�,E'Y ���°�AR 200
763-5I�2-4977 FAX ---.._--------- -- --
DATIi 5 ~�D •�'
SITB ADDRb'SS �
7HIS APALICANT t3:
OWNFrR/
TENANT
SU�M1T` A COPY' dF
YouRSrarB
LiC�IVSE, BOND AND
CERTiFICATB OF
[NSURANCE
FFRMIT TYFE
TYPE OG WORK:
YOUIt �-MA1L ADDRFSS
�
�lvvrvrrz C]CQNT►tAC'rq1L
ADUR�SS ���' /a L S' �'J% N�` C:ITY
�r►oN�: �I�� �lqa - �d a'!
� I+�'�" Cr���. f!
�2� �'+
NAM�:
STAT� LICENS� ft ' h:7�CP DA'f�+
STATk HON D# kJCA f7AT�
ADURF�S: C1TY 5TA7'� 'L1P
PHONE
�61NGl.h FAMILY
� NEW
0 TWQ FAMILY
�1t�PLAChMIiNT
NNX
I] 'PO WNHdUSL'
D�STAtLBD DESCR,IPTION �FWQRK_��iP6AC�,r���r 6r �'�,�s�r3"d�� fi'AF�i+�
f�kiL�,S AR}3 i3AS8U dN SEO.OQ Pt'sR FUCTUR�. liXCliPT W1i�Rki N07'ED,
$35.50.
BATH S1NKlLAY wFLpQK DItAlNS
THATH7UH (3AS RtPIN(3 (Nt�d CITY WC1
_�LOTIiCS WA9Hh]i , KiTCH�N 5[�tK
� T3lSliWAShI�R � 4AUSV1)RY TIiAY
Fllfi'URkiS: (INDICATB'[r7TAL NUMki�R OF k�l1CH I�IdI,�W}. MINIMUM N�ie
StiQW�R
SWIMMING POQL
W ATER CI.Og�T
�WATtR HtAi�R (�635}
� WATr,R Mh7�lt
THIS 13 AN APPLICATION F►OR A P�RMtT-hIOT VALIU UNTIL AR(�h'SSBD
` WATkilt PIPING
WATkiR $Ol�l'NhR (S35)
t3RCKPLQW PIt�V. ($15)
}KiR 1RRlGAT10N
'� o'FHER �yryw/ ,SK� �
I hcreby apply for a plumbiQg �cxmit snd I ecknowlcdgc ti�t fhc informstion abavv i� coraploto st�d accurato; that thc war)c will bo ity
co�tfarmancc with 9�c atdinsincc� e�nd codc� of thc City of FYidlcy and with tbc Minnc�ats G�ans�ttruction Coda�; thst 1 wndor�tand thi� i�
nat s pcxrnit but only an appiication for s permit and work is not to siart without a pattbit an $ito; that tho wotk will bo in acconianco
witb thc approvcd plan in nc� caAC ll work which roquim.� rcvicw �d approval of plans.
StCNATUR�OKAPPLIGANT W PRINTNAMli ��r�/ �c ic� pATE �'•�4—�T
City of Fridley
Building In�pection� Depertment
b431 LTniversity Avenue 1V'E, Fridley, MN SS�32
7fi3-572�3b(}4
FAX: 763-502-4977