P - 36726CITY OF FRIDLEY
6431 University Ave NE
Fridley MN 55432
(763)572-3604 FAX (763)571-1287
MOVING [ ] DEMO �PERMIT APPLICATION
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Job Address: � �2 � Fl+��^'��^�� si • ��
Legal Description: U„�„�;fa6l� 1-�� % ��c-��� i
Owner & Address : C �r F,�cE f-f,e..4- -- �ti nH C�-��s�-, Tel .#�3 �Z 3�3-Bc�¢�3
Contractor: �-f��o�� ��-� 'e. Tel. # l'vS7-Z�r3'`T�2.�
Address: ,3ZoS S`orK�� �- St.Pc,,�„�M•v State License #
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DESCRIPTION OF BUILDING
HOUSE : Length ?� (..P Width � Height � Z Sq . Ft .� 2C� Cu . Ft .�4�
GARAGE : Length `Z-�_ Width �� Height �Z Sq. Ft . s�-(� Cu . Ft .�
OTHER: Length Width Height Sq. Ft. Cu. Ft. ���
Estimated Cost $ //F (o4C� Approx Completion Date / 2/o tp �
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CpT•T•.GOPHER STATE ONE AT 651-454-0002 FOR UTILITY LOCATIONS. CALL ALL
UTILITIES FOR DISCONNECTS BEFORE WRECKING MOVING STRUCTURE.
Moving Route:
APPROVAL(S) REQUIRED PRIOR TO ISSUANCE:
1�CA: NOTIFICATION OF INTENTrTO PERFORM A DEMOLITION �'YES O NO
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�llect[$ ] Signature %
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Conditions
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The undersigned hereby makes application for a pemut to wreck/move the building described above, agreeing to do all work in strict
accordance with the City Ordinances and rulings of the Building Division, and the State Code which requires any water well on the
property to be sealed by a State licensed water well driller, and hereby declares that all facts and representations stated in this application
are true and correct.
ALL DEMOLITON DEBRIS INCLUDING FOUNDATION & SLAB SHALL BE REMOVED FROM SITE.
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PE1tMIT FEE: MINIMUM $20.00 Office Use Only: SAC-D form completed
Effective 1 /O1 /2010