AF - 41582a � �� -.
0
Ca.ty �f Fridley, inn
BUILDING 1'ER.MIT N�
.:-
. •�- �r��... � .�.� �� .- �
, � ,, Y ,. . � .
_ �,. _ ,�—„�an,
_ _ . ,. .
� . � ' � .. - ,+r��,� ..rt,r�+'i r
�.
.� < �<
5�43
�
LO OF BUILD9fVG
No. ,���� 5treet —�: ��e--_..,.` Part o Lot �.�.___��
Lot �,9��__ Block � Adc3ition or Sub-Divisio � �.�,��"�",+�-�,�'�"���
Coraer Lot ______.�__._ Insfde Lot � _ Setback -.yr� . Sideyard _.�� '�
Sewer IIeval3on � Founda.tYon IIevation
DESCRIPTION OF BUILDIIVG
To vsea '� ,�'
,�I,��. p, � =�+�,���
� Front ��c' #�' Depth ���� Height � Sq. F� �_�.� Cu. Ft ..����
n Depth Hei t ,�+� Sq. Ft Cu. Ft
Type of Constructiott -�����- Fst Cos� �" ""'�`_`"' To be Completed _..._
In consideration of the issuance to me of a permit to construct the building described above, I agree to do
the proposed work in accordance with the description above set forth and in compliaace with all pravisions of
ordinances oP the dty of Fridley. � ,
In conaideration of the payment of a fee oE $.�. ,�ermit is hereby granted to
to construct the building or additfon as descxfbed above. This permit is granted upon
the express condition that the person to whom it i� grauted and his agents, employees and worl�nen, in a11 work
done in, around and upon said building, or anypart thereof, shall conform in all respects to the ordinances of
Fridley, Mannesota regarding l�ation, construct�on, alteration, maintenance, 'repa.ir and moving of buildings
�4viithin the city ]imits and this permit may be revoked at any i3me upon violation of any of the provisions of said
ordinaac�s. -�,
Building Inspector
NOTICE:
'fhls perroit doea not cove� the eonstruetiaa, installatioe for wiring, Plumbteg. eas heaHag, sewer or water. Be suro to sas
ths Buildleg lespeetor far separate psrmifs for theae hems.
r;- � a+ �, �� ,. 4 I��
v.: t' _ � ,sv.
� � �a��
�:
�
WtLLlAM D. SCHOEL�
AEA/BTLRED CIVIL 6N1§IME@R
[tINM. NO. $105�
so. wuc. �as
wia. eo. a.a»s
�,.oe�arxo. saT�
NO. OpK. 828
:
J
N
Sca/e = /"� 30'
�
�-
SCHOELL and MADSON
ENGINEERS AND SURVEI(ORS
8889 LOIfIStANA AVENUB
MINNEAPOLt$ 88. MINN. -
1NB.B'1' D-04S4
�'
CERTCF'ICATE OF S�URVEY
�.�• �PONA 1 D L�NGESETf/ER
0
•
�LY
S
��� E T
6I �43 /1.79 a
CARLtSLE MADSON
REGISTEIQBII 4AND SURVBYbR
YINM NO. 4i74
. �o. ou►K. �a�
xns. rw. e.s'a
IOWA NO. �705
ao, oaK. t��
' �►
�,, � - -�Q��e
�X��'t ��1
'�" denofes iron monumen�
WE HEREBY CER7IFY THAT 7HIS t5 A'PRUE AND CORRECT REPRESENTA7IQN QF A SURVEY pF i'HE
BflUNDARiES QF: q�� oj t ofs 5 a�rl 6 a�d fhe fas�e�ly Zfl �ecf, f�ont an�'rear,
o{ lof 7, all in Black J, 1�ive�view Neigh�s
RND OF THE LOCATION OF ALL 6UILDINGS. IF ANY. THEREON. ANB ALL YISIBLE ENCROACHMEN7S. {F
APtY. FROM OR ON SAID i..AND. �7� Feb�uar S1 �
AS SURVEYED BY US THIS- DAY OF-- y t8
� ��
LANQ SURV6YOR, MINN. REO. NO.�4974
� � � � � �
, . ���- _�'� � __
. . - _ _ . w . ,� , s,---�.--
�
^I�ARGV 9T7 Y�9Q - . . . . . .
�
�
�
� �
E� �
p �
:�
: �
. �i
:�
. µ
: N
: �'
� a
. m
�:
� :
� •
�
r
�
�
�
a
�i
�
� �
� � � .�
� p `�
� � '7
� � �
N � .
O •
o •
o � :
O . .
� . .
x
� �a �a 10
p� � �
O 9 O y
�s ���
�H
� �
r
�
z� � z� z x
� � � a � � �
� �
� �' � � � � y
� x � aa
�� ����
� � � � � � �°
h3 •
� ,� � �
� � : � �. :
N . .
� Q � � .
06 p � � . .
Q '
: � : : : :
�
� � � �a � �
6t� L�' W F+ t+ h�+ �
� °o � °o 0 o y
� r� tn
l*J
� ° o
��
0
�
O
a
�
�
0
� :
� � :
�i � 0� :
� � � .
� � :
� � � '
�+ � „ :
� � � :
� C `:
Y
�
r
�
�
m
�
2
17'1
°c
r
m
� • � Iw � � b�
� � � " � Stories
� � �
8 � WATER
� @ aos�
� � URINALS
O � BATH
�
��
a p � ensitvs
� '� �,� SINKS
�• � WASH
� 7RAY5
DRINK.
FOUNT.
sHwes.
,� Fl.00R
DRAINS
� CATCH
BASINS
� AUTO
� wnsHeR
Q GAS
P• APPL
� GAS
RANGE
GAS
OPENINGS
� �
z �
�� � �
8 p
.. .mi � �
�n
o�� ���
�.
CZD �p' � �° � "i
� O � �
� � � � �
�: � � �
�a m
� g
� � h ,�
�
�
�
���
y � O
y � m � tia
�L M
�y r
�, ;:�.
0 0� � �
o�� �
c��o 5' �• ;c
����� `'
ry � O y
R� �
�� p � �
�°�°�
��x e
� �
� ���w
�� �
� �
� y � P7
k1 A� w E�:
0
� � � p
F � R„ o
F�� � � y
P7
t7� ��
R+� ��
~ � e+
�`��y
�� ��
���
� o
���.
� � �.
�
��
�
—
�
c
�
�
�d
�
p+ �
�ro
a ;y
�x°
�
p �
M Q�
'n P9
� A
� �
'�_.
�
3•
�
�
� �
0'
� o
�A -`'
; '�
�� � �
� ��
O � �
� �
� �
�o �
�� �
��
�
�. .
��
0
�
�, �
p,�
��
m
3
a
�
N
'
�
�
�
E��
N
�
�
�
�
w
�
a
�
0
�
x
M �
� z x �
� r � o
� �
xxz�
w � 4� o
RP � � Z
���c�
� �
� �
�n
�
�
o �
�m
�
<p {li
��
,
�
N
�
..
� y � H
m¢ `r �,Hy
�� � �
p � �
m °r r«
a � � N
N��
a
� �
o° m :
o �
� : :
� . .
� � � x
�e � ,� o
N �
O O Q �
{i �fi3 iA �
W
�
�
r
� o w
� �
otl �
I �
� � �
�, �, �
� a
z m
�
�
� �
� d
d �'
�
� �
���
z � �
�
h
�
�
N
m
�
M
x
�
0
�
0
0
0
0
0
�
�
C
C
�
�.7°�
�
�
O
r
t�
�
C i
K o
w
w
��
� �
y ro
�. 'i
o �
y O
� �
� .
� •
�.
�:
��
�:
�.
�
O
O
�
o�i a�i
� �
� �
00
,n �
��
��
x�
� �
�
�
►�f '
. �
� �
n "
� O
m '�
�
R° ,�b
��
W
� �
� �
0
�
�
�
�
,�
� � � �
O O O O
� � �' -�
�
�
b
x°
M
�
O
�
a �
z �.
� �
� �
� �
�
�
z
� �
I m
�
rt
0
0
�
�
O
b
�.
`�.
$�
�.
� �
� n � � �
� � � �� � � � � �
�' �' � 4�, � �' � � �
. �. �
�c����•� ����y
����'� �����
c�D � °w a �i° ,�i � w °H, R, �,
O O � F O O �'�„�
� �Q� � � ��
��`°Q� �b�o
R7 . .
M
a, � ' � ° a � ' �
Q'' . C�i� ' � n'� �' O . .
E/► C : : � c�i � ' :
� � . : Q � S . .
o ! : : � $ : : :
����� Np����
0 o O O O O O�O p �
ifl �fl � {fl
0
�
�
� � ,
�
a' � �
w � .,
M
bd
� !
�� .
\�
I
R� �
m
�
a.a� �
���� °
���� �
���� �
� daa °� �
�.� � `�'
GL�p y
W� �
p�G`4
o�
�,�y �,
w b���
� ��'�
� �.�
Oy�� .
p���
t�e°'Op
p' �a, o
M y
a. � m
`� co ay
a��'�
����
. � �y
�.n„�
��o
�''�vr
�
m
�
�' �$ 5'
D
�
i
�
"i
m
�
2
m
C
m
d
»
M
a
i� �
0 p%
0
,'� � a
�
�
��
�
�a
�
�
�
�
�
�
�w `
= '�
�3�' T.
� 1i
W
�H.
� •
N
a ,
o.�
A �
�. �,
� �
�
�
�s
�
0.
r
�
�� �';
o�
�
' �,y �� �
, � �
Dd6 ....�":`:.a2 � A �F�T� ��-��� �
HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS FRIDLEY, MII�N.
II Weatherstrips A.S.H.V.E, Construction No. Inaulation
Guide
'ndows oors Reference Out. Wall Int. Wall Ceiliag Roof Floor Kind How
Yes No I Yes No 19_ �
Fl.� Room � Length �� Width �� Height FI,� Room Lepgth, / Width
Windows and Doors—Crackage and Area Windows and Doors—Crackage and Area
�Vidth Height No. o[ Llneal it. Ares Wldth Helght No. ot Llneal it Aees
No. ot Dane ot pane llghte oL crack eq. ft. No. ot pane ot pane llghte o1 crack sQ. fG
`° rYer � E �
I � � `�s `�� �. % '� f l
� ---
, ` __ ._�. __—
I - _ _�,� _
- -�__�
, - - - Coef. Btu Coef. Btu
Infiltration � � L�filtration - e
Calass �� ;
Exp. wall a,�, � � Eap. wall �}� �
Net exp. wall � � Net eap. wall �o �
Int. wall � In� wall
Ceiling . � � � Ceiling � .��� g � �'.� �' -
Floor � �� � � Floor
Total Btu. � � � �
Total Btu.
Required sq. ft. E.D.R. or aq. ins. W.A. Leader area Required sq. k. E.D.R. or aq. ins. W.A. Leader area �
F7.� Room � Length Width He' �,� Room � Length f' � Width /� Height
Windows and Doors—Crackage and Area yVindows and Doora--Crackage and Area
Width ilelght No. 01 Lfneal ft. Area � Width - Helght No. o! Llneal tt. Area
No. ot pane o[ pane li6bte ot crack eq. tL
� No. ot Dspe of'yane llghts oL eraek a4, iG ____
_ ! _ � � _ _ � -a,. l � - - ��� -- - - - � � fa °�� ��. 6
In6ltration j `�
Glasa �
Eap. wall
Net eap. wall
Int. wall
Ceiling � ��y
Floor
Total Btu.
Required sq. ft. E.D.R. or aq. ins. W.A. Leader area �
FI. Room � Length Width� � Hei
t
Windows and Doora—Crackage and Area
Wldth Helght No. o! Ltneal tt. Ares
No. ot Dane ot pana Ilghts of crack _: - sa.-tA
' Inhltration � � i
Glaas �
Eap. wall °� p
Nec e:p. wall p
Int. wall
Ceiling � � � � �
Nloor ,�
Tbtal Btu.
Required aq. ft. E.D.R. or aq. ins. W.A. Leader area
Btu
��� Infiltration �
�'r'� Glaaa
Ezp. wall � �
� �¢ � Net esp. wall
Int. wall
� � Ceiling � �� �. .�
�dt,� Floor � �, � ,� �
?otal Btu.
,�
��
i � �
�uired sq. k. E.D.R. or aq. ins. W.A. L.eader area
lt ' � %' Fl.� Room I
Windowe and Doors—C
Wtdth �ielght N
' `' NO. = 6f psne ot pana --q
,�� �
� ' � �
��
BtU
� Infiltration
Glaas
Fap. wal�
Net eup, wall
In� wall
Ceiling
Floor
Total Btu.
aq. k. E.D.R. or aq. ins.
� � w;a� Hei�hc
; and Area
�tneal it. Ares
rEreack-°-, ea. tt_
� � - - -
�
area
Btq
. :
p
� �
�
M �
� � �
�
� � �
�
,� r � � �
f3: y � � � '�T
p ��d � � ��J
: y � � w tA
. � � � .
0
; °�x o � :
. � � . .
: �, � : . :
. y . .
. O : . .
� a : : .
y � o
_�--__ � � � -
� : � � �
� : o 0 o y
fn �'» �» rss
k*1
H
, �
4 �
N
�
- -- �-
0
�
�
�
z � z� z x
� � � a � � �
� x��� � °�°
���� �
¢ � � � �
� • � �
�.
� � o � �
¢ D
O °'' : 0 � ' �
a " • � • � • ,��, -�I
� ° : � � : r—
O
• O
� � . . . . �
: � : : : : �
:.:::: m
: : : : : : �
. . . . . . C�
2
m
v
x C
_ .— Q __ r� ---
aa �a �e �a x �a n'
W N � � � � �
C�ji p C�7� O O p �
tsi tn � t�a tn
H
O
C�'
0
c�i
x
�
� - --
�
�
�
�
�
�
�
o � p � �x, �O
I�' � � �.
� � fi V' � y
� � � �
bd n ro �
� Q � �
� � . � � �
�' w
aa
� �
� �
o � �O
�j o '
�0
W ,� r ' I
✓� b
� �
rt
�` z
� O
�
�
V` �
R.�a.� �
� �� °
� ��� �
�oq�� �
/ o��'a� �
� � O � I
�
-� -��� � �
�
� �, � 8 `� `�,
��yO �
� �
m
'� � � ro
� ,�y
w � � �
o � �'P ,
p m p
� " p, � p
���o
� ����
�
a� ��
�
�p � lD M
e+ f►
� w T
�• � �
�
r C� 'G'1
h 7 �
�
►'' � '.S
�� �
d'� m
� � �
�
a
� — -
�.
�
�
� �
� �
� �
; T
d � �
m
� � �
M
� �
� �
� �
� A
�_ �,.
V ��
V
O
(� i .._�,
�
�
�
�.
,
�.
�
�
G �
F9 Q�
w �
o "�
p �
. M
. �
. �
' M
� M
: o
. �
� '
� :
� .
�
G
c�
I��
: y�
�
"�
r �
� �
M
� O W �
� � �
�
� � w �
� �
O '
O � :
O .
O .
O . .
� : :
� . .
�
9C 5C i4
� � �
O Q p �
� t� �
0
G�
�.
z
�
t�
�
�
� � m � � Z �
� � f'"r� $ � ln
H `7 � Q�p'
� x � � � "'� �
� � � �
� �+ p � �
pd : O � �
� � � 0 y
� o ; � � : �
� . � . �
R. o . �. � .
� � . . . .
� . . . .
' hd : : : :
: � : : : :
I I I I I �
>d 51 >C �4 �! DC
W Lv W ►+ f+ � .��wSI.
� Q V�i O O O ,,r,1
w
-�ta t» tsi �» Eas
�
�
�
0
c[i
x
D
'�
i
�
'�
m
�
n
2
�
C
r
m
..
.. ...■,
` . ....,
� : ..�'
� ! ■■■■,
" i. ■�■'
', • ....'
A
� �
� .,
�o��c
�r �. �; �
z � � � a �
� �
$ � °g �
� � b
� �:
� � �
� �
�
� g
�
o �
�' \
�u�
.
�
G
WATER
c�osers
URINALS
ean�
russ
B/151NS
SINKS
WASH
TRAYS
DRINK.
FOUNT.
sHwas.
FLOOR
DRAINS
G4TCH
BASiNS
AUTO
V✓I��i�i
GAS
APPL
GAS
RANGE
GAS
OPENINGS
'n •
z s
H D
m
A
��
��ro �
aa�
�� � �
�a � � �
y � �o� �
� " � � ;�
�
oc�c�"
��o�
�
� ��.o�
� �
��G�
�
� �°�°�
� � �
� � ��
�
b
o��°'
�
p � m o'
m p, � C�
(�, � t�o R� roj
�� � �
�
� ¢� E~�*�.
m`���°+
�
m��
m
�ypo
� �
�' m �' �'
co
y p y
�
� �
� �
�ro
w�
Rx
5r �
p �
M �
� �
� �
�
�
�•
�
� �
��
� °�
��
����
» Q �
° ►°� tli
a �
/ � �.
U� ro �
� � '�
�A
� � �.
,
�
V
O
�
11�
\
�
�
t t I\ I '1 � I L I � 3��• I, ��
� \
- �
sue�ecT PERMIT
City of Fridley 12905
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
� ' R
� � .
� `y _ COMMUNITY DEVELOPMENT DIV.
r i � PROTECTIVE INSPECTION SEC. ���
1 .1 ,
�` 1 /"�l � CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY
"""�'� �'� 612-580-3450
910-F15 1�/16/75 � �
108 ADDRESS
523 Ely Street N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. .rJ, 6� P.t 7 J Rivervie�v Heights SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
Richard G. Dronen 523 E1 Street N.E.
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
B USE OF BUILDING
Residentia.l
7 CLASS OF WORK
❑ NEW C� ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 10' x 10' Kitchen Addition
9 CHANGE QF USE FROM TO
STIPULATIONS
���
Befare digging caN local utilities
TELEPHQNE � CLECTRIC - GAS Etc.
REC�U�RE� �Y l�l�/
SEPERATE PERMIrS REQ�t'RED
���r�n��, ��ts�►�snlc �r��, �; F�R �veRrNG,
�� �;NS.
SEPARATE PEFMITS ARE RE�UIRED FOR ELECTRICAL. PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
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
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT I.00 �.ZOO
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 CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $�-740 �jj�� �` � 8rj
DOES NOT PRESUME TO GIVE AUTHORITY TO V�OLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROV NS OF ANY OTHER STATE OFi LOCAL LAW REGUTATING CON-
ST C ON OR THE PERFORMANCE OF CONSTRUCTION. �g�j� (.2].
PLAN CHECKFEE TOTALFEE
$7.06
SiG TUaEO O nC7o R THORIZEDAGENT (DATEi WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
[� d e L �e°�'i12 � � CZ�Z/ �c /i `%.L
GNATUR OFOWNERIIFOWNERBUILDERI (DATEI BLOG.INSP DA E
e '�
APPLICATION FOR RESIDENTIAL, ALTERATION,
OR AllllITION BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
, (� � n Q�
OWNER' S NAME : I � c. ��1.�1/ �. �2aN g,� BUILDER :_�i �� An.cl� /�1- �/10 �u i aJ
ADDRESS: 5�23- FIy �'�. ���: AnDxESS:_ S' 23- ��� S� ��. �
NO :. S�"� S TREET : 1�Z (. �P
LOT :_�, (,.L.�c���% BLOCK : '� ADDITION t _ Y� � �9 �-i rZ � , � w ➢ � �-
GORNER ZOTt INSIDE LOT: ��SETBACK: SIDEYARD;
Applicant attach to this form �ao Certificates of Survey o� Lot an.d praposed
building location drawn on these Certificates.
DESCRIPTION OF BUILDING
To Be Used As:
��� �Gcd-cz �J �p Fxon� : J�J Depth : �(� Height : � Z
Squaxe Feet: ��� Cubic Feet: _ ) 7.Q �
Front• Depth;
Height•
Square Feet; Cubic Feet:
Type of Canstruction: �(Z f���vi �. Estimated Cost:_$ 1'% C`O, C) d
To Be Completed:
The undersigned hereby ma.kes applicativn fox a permit for �he work herein
specified, agreeing to do all worlc in stxict 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
axe txue and corxect.
DATE; SIGNAT(TRE ;
(See Reverse Side For Additional Information.)
��
1?�0 �C
�20(� X
' ' �_
�p�U (J U
f��.
��uu
J2� Z
� � �� �
-- /e� , 2 O
2 �02 �
/ f�/i / /� �
( /� �� '• V . /V�..�� �- p g� �
��� �
�� 6 '
�
�e o �
�„�
lBUILllING FERNiIT F�E SCH�llULE �
SECTION 2. The Inspector of Build�ngs shall, before issuing permits for the
erection of any building ox stxucture, ox far any addition to any existing
building or structure, or for any,alteration or repairs to any existing
building or structure, upon applica�ion the�efore, require the payment by ths
applicant fo� such permit of fees to the amount herein below set forth and in
the manner �erein provided to-wi�e
U'NIFORM BUILDING CODE: 2`ype l, 2& 4-$2.15 for each one thousand cubic
�eet, ox fxaction thereof, in such cubical con�ents. 2`ype 3& 5-$1e85 fo�
each one thousand cubic feet.
AllDITIOPdAL INFORI�L4TION
For the purpose of com ees for building permits, the cub ca1 contents
o� any buildi a d-ition, is determined by rnultiplying the g ound area
co e rom a point six (6) inches below the floox line of �he asemen�
ox the cellar to the average heights of the upper surface or to he average.r
height of th� roof surface of the main gable of a pitched roof.
Fo repaixs or altexa ioiis to an isting structure9 the fee shall be at the
ra e of $3.00 per eac five hundxe dollars ($500.00) or fraction hereaf in
the cost of all propos d work. ,
w
In nb case shall the fe� chaxged for
less�than $5.00.
VE�RIF
��
as set forth in Sec
TION
2 be
NOTE: Permits for eonstruction will be issued a minimum of 24 ho om the
ti.me o application, to allow for proper re ' pxoposed structuxe and
of tl�e onsixuction si
A Cextif�.ed Survey of the lot, showing the location of the foundation, once ii.
has been�constructed, will be required befoxe proceeding with the framing.
CERTIFICATE OF OCCUPANCY
Application fox a Certificate of Occupancy shall be ma.de ten (10) days prior
to the use or occupancy of any structure for which a building p.ermit has been
issued; and said structure shall not be used or occupied until a Certificate
of Occupancy has been issued.
s
.
� �'�
,�F� � �' �='.��c��������s
�� ���l���_� .u:., � ��' �y
x�`b' �" �� ZONING - NOTIFICATION OF INTENT
Foster Family Homes
Day Care Homes
T0: �
(Municipali
Political�
� �3i
ressT—
-uivision�
�i, G� - �1��.
�s�3�
FROM: ANOKA COUNTY COMMUNITY HEALTH & SOCIAL SERVICE
ANOKA COUNTY COURTHOUSE
ANOKA, MINNESOTA 55303
APPLICANT: �%/�P�i�ir�-, a� �
Sa3 �� � �, �',
Street Addres
�S �f��
(Number of Natural Children under 18 in Home:
�
(Number of Foster Children included in License:
(Number of Natural Preschool Children in Home:
(
(Number of Day Care Children included in License:
� �� ��� �
,�-> �—��
p
, 7 ��- �/ °l� `
012�45
(Circle Number)
�234567
(Circle Number)
P
)
)
)
012345 )
(Circle Number) �
012345 )
(Circle Number)
DATE OF NOTIFICATION: �-�—/3 —'� %
��� ,' �� �����
���-��sa�
�,
�� �
accx5s 169 (l0/80)
�•
� D
� �
� n
� o
3 q
�. �
°a �'
��
��
a� �
'� �
��
m �
� a
� m
� N
�m
� �
�a
�
�
0
�
� �
��
�o
nc
�
2 n
��
� O
Zm
D �
n�
m
�
�
n
�
<
m
n
�
O
z
z
��
m
z
�
'o
n
�
�
m
�
�
a
�
<
�.
�
�
1)
0
�
s
i
�
0
�
m
�
v
p.°
�
�
11
�
W
cr� _
�
�°a �
�
�
�
s
O
a
r
m
m
N
�
m
c
�
�
�
�o
0 3
<�
c �m
°�
�
�
0
0
�
�Q
°. �
a�
��
�
��
�
� p°
� m
� �
� O
o :�
�N
�
�
z
D
c�
3
.
D
A
�
�
a�o
�
�
�
�
�
°�
�
�
�
d, en �r,
f J ...�
.P�'. v v
Q G C
a � � � � �
� � -. �
c3
m
�
�
�
�
�
i
N
0
0
�' •
�
� -�i � o
m ca•
_ m °.
�� �
0 m °m
� � �
� �
� $
= Q
o � i� c� °�
m � �
n m �
� m �
� y m
� 'y m �
o m 3 �
apo,� �
�• = m
� c
� z
m �
�
c� _
�D
�
�
a
v
�
�
�
�
�
l�
�
m
�
�
�
z
0
�
�
�
m
c
v
z
C
�
v
�
.
� D��
� � 3
�, m �
m �y
. � � I
� � �I
�+ o
� � �
� � �
� m
� m
1
�/ '
�
�
8
�
� �
� � s
O � m
a d,
� O
� a
� � .
p � -�?e� s�
�a.�'.g�m
� � � �
� ��m m
�
0� � �
��aB,�
�° � c ¢, a
� am m �
�°.�Dc
� � �m�
� m a 3
� � �am
� o
�a��
_ s�
, �m i�
�� ��
� o
�� �, � � � �.
����
�a��
��,�
� � �
�c Q
o � ?
� � m
:�
m � � o
o �
�
��
�
m
�
N���m
o�i :� C O
��i �
Z��
� �.�� �
�
a� �
Z N
m�
A
�
Z
�
<
��
�a
��
�Z
O �
L V
a�
vo
D �
��
c� �
0
vi
�N
OD
ZZ
�v
�n =
N�
��m
N �
>g
2
v
vz
� c
nm
��
�
o �
z �
m
O
�
. �
�� �
� �
,,- --� �
/
� I
�
�
� �
� __ �.%�.
_�
.!/�%�y�ii�li '"� r�w� - ._ .
, -,.. � - , <-
� � . .
� � I� - �' �� _ � � � � ��� . .
, _
- _.a...�.�...� - .�.�,._ s.,. --.-� - _ �
�
� %�`a"`�� ,�� � � a'/� arr� � ; �!! f� d�� .
II eH suo���se�t�t �s�z
sxsEacag
` , 90'� � s � c�.LS z�rsos
� s� 00 Z� s� lLbB �au�o tZY
, or�o S� 3o s, tLLH b���88K ZB�o� �BH ' 9
( ) oH � gsx
( ) oN �) sa�
()oH �1sex
� ) oN (� ssx
( i oN ii�� sex
pe��ettc�toa s,�yyg tE�o� ptt8 a z� s
so3 s�uamai�nbe.t apo� �ctasina tt8 s�aayl • g
pa�soddns �ta�n�as sI •b
u�rc��w pabpot s��a �qo ub�a.zo; ou sEg •£
uo��B.�o��a�ap so �sns n�oi; aa�3 sI 'Z
p�u��aexa �TZtn�aiEO uaaq sex • t
r:X�e�s =o �Cact��Ka bu��s�xa e� �e� �a�3�=an �Cqasaq paub�ssapun a�y
�
�. �1�1"�S���T1T�� �i�'i'����,��T�•1'�*T��J