AF - 42073C�
•
u
�ity of Fridley, Minn.
BUILDING PERMIT
N° 6919
Da�: _.._....� �--_.�:�-_ � -�____._.. _..._.._.._ � `3 �`�1'
_.
owner: _._ ..... . —�'z.�.�-�,L.�__.__. � ._. ,. _
. ...�.. Builder _..,..._....._._. �..��d.�..._....._ ............._......_..___.__.._____
Address............._.......__._.._....__..__._.__�...._..._._.._......._.._...._...._..._......_.._ Address _..___.._..._.._.._.....__......___._.._..._......_......__._.._.._...._.._._.._.___._.
, LO _ATI OF BUILDING
No. _�..f�...__7.. ... .
. �J
. Street .__�� ..._..��s�..._. ° .....��'---.._ ......................_.._. Part o t ••---_.._. .. __._.._..__ ......_...._._...__._..
Lot .��..._r..�.._...._ Block ._..,...._..._._..l.C.�%._.._..........._. Addition or Sub-Division . ..._.. . �...r'_...�� ...����S.l._`,�� —_
�� > n / `��
Corner Lot ____......._..._.._. _ Inside Lot ._-._.._.._..-•-----.._._------... Setback ...�..si.�----...--._..... ideyard _. �.C�' .._.__..L�C_.r__...._._._..._.....
Sewer Elevation ..._._....Q._.r.,�.�....�,t...-�i.•-.Q_._.__..---•-•........_..._..._.._ Founda.tion Elevation ...,��... .,�_....r�...._!._ 3 Q_..____..._...
DESCRIPTION OF BUILDING
�„_ be U I
j� .
.
...___......._ _ Front ...�:-�.�. DePth _..�..�...�_. Height .__,�-.. ��. Sq. F� %.l.�_�� Cu. Ft�,(L!_l._C? �
.. __._ Front ,��....__ DePth _..� �..,i-�..,qrHeight ....�...��„ Sq. Ft. � �.�1 Cu. F� ��...(�..�
�.. _. � �
Type of onstruction��yL�� Est. Cost �l�,�./ �... �� �---. T be Completed •._._.......__._....._.._._.........._....
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 provisions of
ordinances of the city of Fridley.
_.�.�._.
C� �'
In consfderation of the payment of a fee of $��:`.., permit is hereby granted to._..�...__ _._..._.._....
....._._.,......._......__._...._....:_�___.__. to construct the building or addition as described above. This permit is granted upon
the express condition that the person to whom it is granted and his agents, employees and workmen, in all work
dane in, around and upon said building, or any part thereof, shall conform in all respects to the ordinance� o�
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings
within the dty littuts and this permit may be revoked a t any time upon violatapn of any of the provisions of said
ordinancea �-, _ o� / 1 �
Buildins' �,sl�ector
NOTICE:
ihis p�emi� doa nof eowr th� eonslruetioe. inshilatian fe� wirina. P�vmbinY. Yu h�aNay. srw�e oe wahr. 8� wn to tM
th� BuiWing Insp�cto� for s�p�rat� p�rmits fo� fh� h�ms.
.. . �.
APP'LICATION FOR BUILDING FE?1�IIT
CITY OF FRII3LEY, MINNESOTA
�
OWNER' S NAMG f��-�""'-`�� �►'G1/`�'� BUILDBR
, t
ADDRESS � / c:� �J U�� `�'�-� ADDRESS . � � U _ �� �-
LOCATTON OF BUZLDING
No. Street Part of Lot
��, ��.�, ���,� \
Lot ��- � Block� Addition or Subdivision g��. --_� �
Corner Lot��Inside Lot�Setback � 5� Side•Yard s+�� U
SEWER ELEVATION ���� -� �' FOUNDATION ELEVATION �' S-° • 3 n
Applicant attach Co this form Two Certificatea o£ Survey of Lot and proposed build-
ing locatioa drawn on these Ce=tificates.
DBSCRIPTION OF BUIL�ING
Ta be used as:
--.=� "_ " _" � � Front � � ��s.eh � �� Height .� �
Sq. Ft. Cu. Ft.
Front Depth Height
Sq, Ft. Cu. Ft.
�crc� °'=
Type of Constructfon J�e.�,,..�_. Estimated Cost � S� .�,
To be Completed -����'J � �� J� y
, �
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City of Fridley Ordinances.and
rulings of Che Department of Buildinga, and hereby declares that aZl the facCS and
representations atated in this application are true and correct.
DATE- u�� � � / 4"� �` SIGNATURE
.
��Schedule of Fee Coste can be found on the Reverse Side).
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HEAT LOSS CALCULATIO -�' DEPARTMENT OF E3UILDINGS MINNEAPOLIS. MINN.
--- ---- ---
-----___ -- -: -- �_ _: - _ _ —__ _-_ _ _ -�_ �_ _-_ -_ -
Weatheratrips A.S.H.V.E. Construction No. Insulation
_ Guide _
— ____ --- -_.— _— — —
Windowa Doors Reference Out. Wall Int. Wall _('eiling Roof F loor Kind How Applied
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Yea—No Yes—No 19_ ( ' --v�
/ Fl.�,��--' oom � Length Width /�_Height �` � FI.� ,,i'�,, �-�, y Room Length - i' Width ;_� Height�`
Windows and Doors—Crackage and' Area ~ Windows and Doors--Crackaga and Area
�Vidth Helght No. o[ Llneat tt. Area � - - ���y�iith Height No. o( Linenl tt. Area
No. o[ pene o( pane lighta ot cr ck eq. tt. No, ol pane o[ pane tlghta ot crack sq. [[.
¢ .� n 5,���� ' �
�° 3 _ �
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_ Coef. Bcu Coef. Btu
lnfiltration
G}aas
Exp. wall �
Net exp. wall �
Int. wall
Ceiling v
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. l..eader area
l� 2S.
l 1�'. 3- Q
hl.�� i v Koom � Length - Width Height
Windows and Doors--Crackage and Area
Width Hefaht No. of Llneal ft. Area
No. ot pane ot pane Ii�ht■ ot crack �p. ft.
il � �
,� /� .S� tr / Z �.' / '7 .
Coef.� Btu
InFiitrateoa
Glas�a _ �}
e�p. Wau 3 .�. �
Net eap. wall =-� � � p
Int. wmll
Cciling 6 / 9. Y d
Floor
Total Btu. p
Reauired a4. ft. E.D.R. or aa. ins. W.A. L.�ad« area / I
�' �7•��,�� Room � Y.ength lp Width
Winsio s and �oora--Crackage and Area
Wldth Hel�ht No. of Llnesl [t, Area
No. . ot yane ot Dan• If�hb o[ crack sq. It.
Inhltration
Glau
Exp. wall � i
Net ezp. wall
Int. �.�all
Ceiling f -tu,.t.( •
Floo�
Total Btu.
Coef. Btu
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Requered aq. ft. E.D.R. or sq. in�. W.A. Leader area
Infiltration
Glass
Exp. wall J �
Net exp. wa11
Int. wall
C.eiling
=�c y6
n
Floar
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area r
jFl.� j� ��,.;y.� Room ( Length G`,` W:dth
Windows and Doors—Crackage and Area
Wfdth Helght No. ot Lineal tt. Area
No. of pana of Dane Itghts ot crack eq. [t.
.� I s`� I�� ♦ iS 7
Inbltration
Glass
Exp. wa[I �"i
Net exp. wall
Int. wall `
Ceilir�g
Floor
Total Btu.
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Required aq. ft. E.D.R. or sq. ins. W.A. L.eader area �'j
F!. Room I Length / Width // Height �'
Windows and Doors—Crackage and Area
Width Helght No. o[ Llneal fL Area
No. ot pane of pane tlBhta of crack ea. tt.
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/ p //
Coef. Btu
Infiltration - ��� `
Glass � p jd ��,,,v
Exp. wall ,2 ¢ ' �
Net exp. wall �
Int. wall
Ceiling f� tt
Floor -°
Total Btu. ,,� � �
Required aq. ft. E.D.R. or sq. ins. W.A. l,eackr arca
.. �, ' • } _ .+�.
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HEAT LOSS CALCt1I.AT10NS DEPARTMENT OF BUILDINGS MINNEAPOLIS, MINN.
_ _.-- __ =—_---_— _-_:_ __-_-_--_.— _ __ _ ----__- --- __ -- --
Weatherstrips A.S.H.V.E. Construction No. Insulation
Guide --- -�---_.�—
Windows Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kind � 1-�ow Anpliea
— ---- -- .. ._ _ _._ _ ----- — -- -- -
---
-
Yes—No I Yes—No 19— _iI
_ __ —. ' -- = -_�.�--- ----
� Fl.� • Room � Length /'.. Width �"'j Height � � FI.� � Room Length Width Height
Windows and Doors—Crackage and Area Windows and Doors---Crackage and Area
�Vidth Hefght No, ot I.Inea! tL Area Width FieiKh[ No. ot Lineal tt. A�ea
No. ot Dane ot pane IiBhta o[ crack eq. ft. No. of pane o( Pa��e IlBhte ot crack eq. [t.
i 3 / .2 /
.z � 4 �... � i / 7 9 —
Yn6ltration
�',laaa
Exp. wall ,;
Net exp. wal!
Int. wall
Ceiling � .�
Floor
Toeal Btu.
Btu
�.ir:..t�' �
Required sq. ft. E.D.R. or aq. ins. W.A. Leader area �
FI. Room � Length ./;t� Width j7,
Windows and Doorr—Crackage and Area
Wldth Hef¢ht No. ol L1nea1 ft. Area
No. ot Dane � of pane llahte of crack �4. tt.
1 I
Inbleration
Cla�a
�c�, wa!! �r �
; Jet exp. wull
�nt. tval!
Ceiling .� ��
Floor
'zotal l3tu.
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Coef.l Btu
l;Zequired sq. ft. E.D.R. or sq. ins. W.A. Y.eader area
�,� FI�.�,,,,�.Q.Q Room � Len�;th ,�� Width
�+i�indows and �oors—Crackage and Area
Wldth HeE�hi No. of Llneal it. Area
No. ot pcn• ot Dan• Ilshb ot crack eq. tt.
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.3 �-� � v t �3 /o-
! I
lnfiltrat�arn
c�.as
E.tp. wsll /4°v ' �
15�et exp. wadl �}..P_
Int. wall �
Ceiling
E ��or ��� '
Total Btu.
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Coef. Btu '�
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�S
s� s
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____ -- -
Required sq. ft. E.D.R. or aq. ins. W.A. l.eader area
:� r.
Coef.l Btu
Infiltration
Glass
Exp. wall
Net exp. wall
Int. wall
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
Fl.l Room I Length Width
Windows and Doors—Crackage and Area
Width Helght No. ot Lineal [t. Area
No. o[ pana of pane llghte ot crack eq. ft.
In5ltration
Glass
Exp. wall
Net exp. wall
Int. wall
Cei�ing
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. L.eader area
FI.� Room I Length Width
Windowa and Doors--Crackage and Area
Wtdth Hefght No. o[ Llneal ft. Area
No. ot pane ot pane Ilghte ot crack �G. ft.
Height
Coef.� Btu
In6ltration
ciess
Exp. wali
Net exp. wall
Int. wall
Ce�iling
� Floor
�Total Btu.
Required sq. ft. E.D.R. or sq. ins. WA. Leader arca
City of Fridley
App�ication for P'lambing and Gas Fittinc� Perm�t
Dept. of Bldgs. Phone SU 4-7470
DESCRIPTION OF WORK �° �y Gj �(
Number, Kind and Lxation of Fixtures Location ��" /
y � � d, UN' WATER HTR.
4J OC r- K� 2� W W ? � �Y
•� Fa Z xw iv! Y x <Y Zz `c? [ppp�Z UZ�n Ox ,3 C� Z
0 <�J a ~�^� ` Z � K a O 2 J�<~<��< a � Z< � n F N GAS ELEC.
N ; V 7 � F m N 3- F- p LL IA LL � (J m < 3 i� < i� Q' i� 0
Base � � %
�St a i� i �
2nd
3rd
4th
• Future Connection Openings
* New Fixture, Old Opeaiags
PARTfAL RATE SCHEDULE
Sewer
Cesspool
PLIIMBING FIXTURE RATES: NO. RATE TOTAL
Number F`ixtures . . . . . . . . . . . . . . . . . . . . . � x $1.50 $ � `3: � �
Future F`ixture Opening . .. . . . . . . . . . . . . . . x 1.20 $
New Fixture Old Opening . . . . . . . . . . . . . . x 1.00 $
Catch Basin . . . . x 3.25 $
I Water Heater (Up to 200,000 BTU) . . . . . . x 2.00 $ �� � �
New Ground Run Old Bidg. . . . . . . . . . . . . x 3.25 $
' GAS FITTING FEES: NO. RATE TOTAL
ist 3 Fixtures .................:......... x$1.50 $ �: � d
Additional Fixtures . . . . . . . . .. .. . . . . . . . . x .5Q $
Gas Range to 200,000 BTU .............. x 2.00 �
REPAIAS & ALTERATIONS—Reier io Code
Description ................................................$
TOTAL FEE $�
City of F�idley:
- /� e�:
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The undersigned hereby makes application for a permit for the work herei
specified, agreeing to do all work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the fact
and representations stated in this application are true and correct.
Fridley, Minn r� /� , 19�
Owner �__�� �'�� � '
Kind of Building r/��.�s. R�_
Used as � -�-��'1
To be completed about �-L' � � �
Estimated Cost, $ �� � • � �
c
Old—ATew. Building Permit Na � C/ Permit No. ' � �__
Signe -
By � , /Lu-c�Z
Business Phune Na ��° � "` � �"� ✓�
ROUGH
FINAL
`_�
CITY p� ��I19�EY INSP�CTION DIV. Effective On January 1, 1991
�-4. �1 U�tiv�r�ity /�ve NE
F i�l MIN 5 32
. r. �y, 5 4 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION.
�72-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS z S 7 CS.
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner -
Also Replacement Furnace
Gas Piping (Needed with new furnace)
Gas Range
Gas Dryer
'Air Conditioning - All Sizes
Rate TOTAL
$ 20.00 a U� r u�j
$ 10.00 $
$ 10.00 $
$ 10.00 $
$ 10.00 a
All Others/Repairs 8 Alterations (LIST ON BACK)
1% of Value of Appliance or Work
CommerciaVlndustrial
1% of Value of Appliance or Work
State Surcharge
TOTAL FEE
S�'% /�-��
The undersigned hereby makes appiication for a permit for the work
herein specified agreeing to do all work in strict acco�dance with the
city codes and ruling of the Building Division, and hereby declares
that all the facts and representations stated in this a piication are
true and correct. �G,� / , � gg�
OWNER //l� l�_(�' //C�/2 C�
BUILDING USED AS ���'� � ��' � � �-
ESTIMATED COST
PERMIT NO. /��` r � /
DESCRIPTION OF FURNACE AND OR BURNER
� No. of Heating Units_;� Circle One (Steam) (Hot Water) Warm A'
Trade Name l�e i L Size Na�LI �Cr �� s'-
BTU,%���� HP EDR
a Fuel Nr��/l��a-s Total Connected Load �� ve� �
S .50
� Zc7 . S�cJ
MINIMUM FEE FOR ANY HEATING/COOLINGNENTiLATION
REFRIGERATION/AIR CONDITIONING PERMIT IS �15 00
PLUS THE 5.50 STATE SURCHARGE
REINSPECTION FEE $30.00
' Air Conditioners can not be placed in a side yard without
w�itten permission trom adjoining property owner.
�����
Burner Trade Name Size No.
BTU � HP EDR
HEATING COMPANY ( �CIS%a m //'(e�����-C,,� �= �
Signed By_ � Tei No.� ' .
� 7� , ���
� �� / —��
Approved By Rough-In Date Final Date
FtLL OUT BACK SIDE FOR STACK VERIFICATION ON
REPLACEMENT FURNACE
CHIMNEY AND STACR VERIFiCATION
The undersigned hereby verifies that the existing chimney or stack:
1. Has been carefully examined
2. Is free from rust or deterioration
3.
4.
Has no foreign objects lodged within
Is securely supported
5. Meets all current Code requirements for
size and total BTU's connected
6. . Has total heating BTU's of� �Sc'C>�
Al l other BTU' s �`�� �` �
TOTAL BTU' s � � S Uc� �
Remarks
Yes � No ( )
Yes ( r� No ( )
Yes (� No ( )
Yes (� No ( )
Yes ( � No ( )
List Alterations Being Done:
HEATING COMPANY ',� � YYL � � tG� � G�
Signed BY � `,��/�,���c��.. �ir��
�
Date [�� /� �-ll'� /
C^ CITY OF FRIDLEY INSPECTION DIV
�� 643i University Ave NE
Fridiey, MN 55432
572– 3604
v��ss���
�-� � Effective On March 1, 1996
�'"_ —
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
PLUMBING FIXTURE RATES:
NO. RATE TOTAL
New Fixtures
Old Opening, New Fixture
Beer Dispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Water Heater –Electric
Water Heater – Gas** ___�_
Gas Range**
Gas Dryer**
Back Flow Preventer Required ()Yes () No
Type
$ 7.00
$ 4.00
$ 5.00
$ 7.00
$ 7.00
$ 7.00
$ 7.00
$10,00
$ 7.00
$10.00
$10.00
$10.00
$15.00
Reinspection Fee $42.00/Hr
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture or Appliance
State Surcharge
TOTAL FEE
.50
JOB ADDRESS_
PILGRIM, SCOTf
238 ELY STREET NORTHEAST
FRIDLEY, MN 55432
(612) 785-2382
The undersigned h work herein
specified agreeing to do all work in strict accordance with the city codes
and rulings of the Building Division, and hereby dec{ares that all the facts
and representations stated in this application are true and cofrect.
%2-3/- �' �-
Owner �Wl� /�s �"[�$ .�:.��
Building Used As �5/J��/IiC�
Estimated Cost �� PERMIT NO. !� �/4��
i
PLUMBING COMPANY
SIGNED BY
Approved By
� �".�1`"l!
Rough–in Date
MINIMUM FEE I�OR ANY PLUMBING/
$�O PLUS THE $.50 STATE SURCHARGE
TEL N0. '
Final Date
**COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6–A. MINIMUM SIZE 9 SGl INCHES.
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c�cy of Fridley 0903
AT THE TOP OF TME TWINS g � I L D 1 N G P E R M I T r
r
; � RECEIPT
� • COMMUNITY OEVEIOPMENT DIV.
� ; V �'��� , .
r � � Pi;OTECTIVE INSPECTION SEC.
� . �
� � �"'1 � CITY MALL FRIOIE� SS132 NUMBEp i1EV O�TE P�GE O: APnROVED B
�'""�"� �'' 612-571-3450 9t0-Ft5 5/4/00 / /
108 ADDRESS 2g9 Ely Street NE
t LEGAL LOT N0. BLOCK THACT OF AODITION SEE ATTACMED
oescR. 3,4 14 Spring Brook Park Addition SMEET
2 PROPERTY OWNEFi MAIL AODRES$ ZIP PMONE
Mark Koller 289 Ely Street NE 820-6125
3 CONTFACTOR MAIL ADORESS ZIP PMONE UCENSE NO
ICR Inc 12207 Nicollet Ave S, Burnsville, MN 55337 952-890-4111
� ARCHITECT OR OESIGNER MAIL A�DRESS 21P PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PMONE IICENSE NO
6 USE OF BUII�ING
Residential
7 CLASS OF WOFK
❑ NEW O ADDITION O ALTERATION �7 REPAIR p MOVE O REMOVE
8 DESCRIBE WORK
Reroof House & Garage (23 Sq) Tear-off; Reside House & Garage
9 CHANGEOfUSEFROM TO
STIPULATIONS
Underlayment must comply with the State Building Code
Per Section 1402, 1997 Uniform Building Code, requires that a weather
resistive barrier be placed over exterior sheathing to protect the interior
wall covering. Exceptions for this provision would be if sheathing is an
approved weatherproof panel or when the siding is an approved weather
barrier. Vinyl siding is not a weatherproof covering unless the manufacturer
states this in their application guidelines. Call for inspection of wrap
before covering.
TYPEOFCONST. OCCUPANCVGROUP OCCUPANCVIOAD
SEPARATE PERMITS ARE REOUIRED FOR ELECTFiICAL, PlUM81NG, MEATING.
VENTI�ATING OR AIR CONDITIONING
THIS PERMIT BECOMES NUIL AND VOID IF WORK OR CONSTfiUCT10N ZONING SO. fT CU FT.
AUTHORIZEO IS NOT COMMENCED V�IITHIN 60 DAYS. OFi IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED fOR A PER100 OF 120 OAVS AT
ANV TIME AFTER WOiiK IS COMMENCED. NO OWLG. UNITS OfFSTREET PARKING
1 MEREBY CERTIFV THAT I MAVE REAO AND EXAMtNEO TMIS APPLICATION 1 STA��S GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECi. ALL PROVISIONS OF LAWS VALUATION 7' 800 SURTAI(
AND ORDINANCES GOVERNING THIS TVPE OF WORK WILI BE COMP�IEO �
WITH WMETMER SPECIFIE� MEREIN Ofi NOT. TME GRANTING OF A PERMIT �3.90
DOES NOT PRESUME TO GIVE AUTMORITV TO V�OIATE OR CANCEI THE pEqMIT FEE SAC CNARGE
PROVISIONS OF ANY OTHER STATE OQ LOCAL �AW REGUTATING coN- � 153 .� Sc 153 . 25IF Fire SC �p% . HO
R CTION OR TME PERFOFMANC6' " CONSTRUCTION
/i�//�/f/J, PIAN CNECK fEE TOTAI FEE
`%.
Licens C $5.00 $323.20
ATUAEOFCON'PACTOQ a uT�OAiZEDaGEtiT iDATE� ME PROP L VALIO T D THIS IS V R P R Ii
�.` �� -��t�
S�GNnTUAE O� OwaEQ�iF OwHER Bw�DEQ� �O�iEi Bl G iti5� � qarE
NEW []
ADDN []
ALTER [ ]
Construction Address:
Legal Description: _
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Owner Name & Address: ��1��<
Contractor: __� C%Q ��/I G
Address: % � o� 4 �7 !� �Co /,
LIVING AREA:
GARAGE AREA:
� /��
i
C,�fJ--
Effective 1 /1 /2000
(763) 572-3604 Bldg Insp
Tel. # `���/— �� S
MN LICENSE # O�dl �O ���
Tel. # [� �� ���`lll�
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Attach to this application, a Certificate of Sucvey 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.
DECK AREA: Leng Wid �_, Hgt/Ground Sq. Ft.
� �
OTHER: �
`� (�; ` � "r' �.� ,�'c � � y�/� � 'r�t—
l� �1'�/� C � z� %
�i o °
Construction T e: �C�� �l ot S �� �(.� ��
Yp S Estimated Cost: $ ��� d
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ -- $
a
DATE: �7 Ov APPLICANT: Tel.#__(f�/���v�"� 6.3 �P"
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Call (763��72-3f S_�� ermit Fees if mailing in application
S j �1
$ �� �� �S � Fee Schedule on Reverse Side
$ � �'X`! .001 of Permit Valuation (1/10th%)
$ �� �C� $.50/$1,000 Valuation
$ $1100 per SAC Unit
$ �' C_> U$5.00 (State Licensed Residential Contractors)
$ _ Alt. "A" or Alt. "B" Above
�
$450.00 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement Necessary [] Not Necessary []
TOTAL
STIPULATIONS:
$ •�� � �(`�
�
CI1Y OF FRIDLEY INSPECTION DIV.
6431 University Ave NE
Fridley, MN 55432
572-3604
APPLICATION FOR PLUMBtNG AND GAS FtTTING PERM{T
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
Effective On Jan 1, 2000
PLUMBING FIXTURE RATES:
NO. Rr'�TE
�- �=�New� Fixtures � �
OId Opening, N�w Fixture :-
Beer Dispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Wafer Heater -Elect�c ,
, Water Heater �- Uas*e a__�__
Gas RangeR*
Gas Dryer"*
Bacic Flow Preventer Required OYes O No`
TYPe
$ 7.Q�
� �.00
� S.C�J
� 7.00
$ 7.00
$ 7.00
$ 7.00
$10_00
$ 7.00
�10.00
$10.^v0
$10,00
$1�a_00
Reinspection Fee $47.00/Hr
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture orAppliance
State Surcharge
TOTAL FEE
TOTAL
JOB ADDRESS `�1'tE �'"� dt�1.1��.
; The undersigned hereby maices �pp�ication for a permit for the work herein
specified agreeing to do ali �ork in strict acc�rdance with the city codes
and rulings of the B.uilding Divisi��, an� hereby declares that a�i the facts
and representations stated in this aoolicatinn arP true and correct.
HALDORSON, CHRIS
289 ELY STREET NORTHEAST
FRIDLEY, MN 55432
�-- (763) 786-2376
Owner _
� D`3/ , 20 03
� Buildin� Used As���t �/li C�,, _�` . .
0
$�D•�Q
; o� , .
��t�mated Cost _��_ _ PEF2MIT NO. � � �
PLUMBING COMPANY �IZC�1�}J� �LUI�[alJl�(,���
SIGNED BY ,�,��L TEL NO.�I�"S�7`'�j�O �,,�
. y � L
Approved By � Rough-In Date Final Date �
�AINIMIlM FEE FOR ANY PLUMBING/Ces pFttM�r i_ �y0 00
PLUS THE 5.50 STATE SUR�HARGE
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE
_
.� �>°:: :
NEW (] CITI' OF FRIDLEY Effective 4/1/2004
ADDN [ J 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp
ALTE ��� [ J SINGLE FAMII.Y AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax
/ BUILDING PERMIT APPLICATION �)��
, �i
� �
Const�.iction Address: � �� ��� ��'�'
Legal I
Owner
LIVING AREA:
a�v� �. C '\ A � �
& Address:� � � �• � Tel. # '�� .� - � �'6 - � 3 7�
��.� � ^ MN ICENSE # BC� �t �G 90 C) !'7
� � .� � �—v-� �a. (� , 3 S � Tel. # �� 3 - °.J ��3 ;�7- 7 '% �t.5--
GARAGE AREA:
DECK AREA:
Attach to this application, a Certificate of Survey of the
bt, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length Width Height
Length Width Hgt/Ground
Sq. Ft.
Sq. Ft.
OTHER• —L�a.�
, � , .,e-c.� Z%i � J
r, � , �%
�' � ��'i �lw�-t/ , � � l%
r � ��.w � v� � � �'
Construction Type: Estimated Cost: � � �
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
;� � � � �
DATE: �i � � �'� � APPLICANT � �''� Tel. # �76 � "' � 37� �_�y�
Call (763) 572-3604 for Permit Fees if mailing in application. Fax to 763-571-1287 if using credit card and we will call
you for card number.
CITY USE ONLY -
Permit Fee
Plan Review
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
$
$
�4� �S Fee Schedule on Reverse Side
65% of Permit Fee
$ �o°-a�lo
$ �� /.3
$
$ � C�
$
$
$
$
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1350 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 [ J
$ �� �� �o� STIPULATIONS:
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