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AF - 41812SUBJECT City of Fridley AT THE TOP OF THE TWINS g U I L D I N G P E R M I T r i � � � � • COMMUNITY DEVELOPMENT DIV. r � L � PROTECTIVE INSPECTION SEC. i � � � � � �""1 � CITY HALL FRIDLE� 55432 NUMBER AEv �-"'�' �'' 612-571-3450 9t0-F15 JOB ADDRESS 545 Fairmont �cV�i�i�� NE 1 LEGAL �OT NO. BLOCK TRACT OR ADOITION oESCa. 19,20 I Riverview Heights 2 PHOPERTY OWNER MAIL AODRESS Bruce Emerson 545 Fairmont Street NE DATE 4/8/97 3 CONTRACTOR MAIL ADDRESS Z�P Greg Wills Exteriors 4246 Royce St NE, Mpls., MN 55421 4 ARCHITECT OR DESIGNEFi MAIL ADDRESS Z�P 5 ENGINEER MAIL ADDRESS PAGE OF / / � � .�4��9 RECEIPT NO. �� APPROVEO B� SEE ATTACHED SHEET 786-5328 PHONE UCENSENO. 788-0529 CITY PHONE LICENSE NO. ZIP PHONE LICENSE NO 6 USE OF BUILDING Residential 7 CLASS OF WORK 0 NEW ❑ ADDITION ❑ ALTERATION � REPAIR 8 DESCRIBE WORK Install vinyl siding, alum.inum trim _ 9 CHANGE OF USE FROM TO ❑ MOVE ❑ REMOVE STIPULATIONS � Install building wrap and have inspection of same unless manufacturer specifications state it is not required. TYPE OF GON57. VGGUr'n SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCT►ON ZONING SO. FT. AUTHORIZEO IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS I HEREBY CERTIFV THAT I HAVE READ AND EXAMINEO THIS APPLICATION 1 STALLS AND KNOW THE SAME TO BE TRUE AND CORFECT. ALL PROVISIONS OF LAWS VALUATION AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED �6,230 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pERMIT FEE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- �12(�.75 ST UCTION OFi THE PERFOF;MANCE OF CONSTRUCTION � PLAN CHECK FEE .�s �� [,�� SiGNATUAE CON'AACTOA OR AUTHOFli2ED AGENT IDATEI E(� p9p VA i �DATE� GfiOUP I OCCUPANCV LOAD CU.FT. OFFSTREET PARKING IGARAGES SURTAX $3.11 SAC CHARGE Fire SC $6.23 TO AL FEE $1 4.09 I,S IS YO �RMI j � NEW ADDN ALTER [l [] �� CITY OF FRIDLEY SINGLE FAMII,Y AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: ,�� '��'�D�� d�� Legal Description: Effective 1/1/97 � �� l� Owner Name & Address: ��s i�� ,,� 11�,� �� G{�� i1�,�t'i� Tel. # i ,�� — .S" 3 � $' Contractor: � �� (� �l"� (S ��.��'�'L!� d !2S MN LICENSE #��,��el;��-r.r Address: �a-�� y' �� 5� �� !/d �� l� ,9��f� I Tel. # `� ��'"d .�� / Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. LIVING AREA: GARAGE AREA: DECK AREA: DESCRIPTION OF IlVIPROVEMENT Length Width IIeight Length Width Height Length Width Hgt/Ground Sq. Ft. Sq. Ft. Sq. Ft. OTHER: � Construction Type: � � ,'n,J � � -S/ `� � ;� �, ��e�I �,�Stimated Cost: $ , � , � � O' (Fee Schedule on Back) Driveway C�rb Cut Width Ne,eded: Ft. + 6 Ft = Ft x$ _$ � DATE: `7 APPLICANT: ��-(� Tel. # i�cl ' D�oL 9 Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge � �� 7� $ � -,�� $ �, � $ ,- $ �' $ $ $ $ CITY USE ONLY Fee Schedule on Reverse Side .001 of Perffiit Valuation (1/lOth%) $.50/$1,� Valuation $950 per SAC Unit $5.00 (State Licensed Residential Coniractors) Alt. "A" or Alt. "B" Above $450.00 Conservation Plan Review Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] TOTAL $ G'-�'' �� /��-�`� STIPULATIONS: _ . � � BUILDING PERMIT FEE SCHEDULE The Chief Building Official shall, before issuing pecmits 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 FEES $21 (Minimum Fee is $21 plus surcharge) $21 for first $S00 plus $2.75 for each additional $1(� or fraction thereof, to and including $2,000 $2,U01 to $25,OU0 $62.25 for fust $2,0(}0 plus $12.50 Yor each additional $1,000 or fractio� thereof, to and including $25,000 $25,001 to $50,000 $349.75 for first $25,000 plus $9.� for each additional $1,000 or fiaction thereof, to and including $50,000 $50,001 to $100,000 $574.75 for first $50,000 pius $6.25 for each additional $1,000 or fraction thereof, to and including $1Q0;�0 $100,001 to $500,000 $500,001 to. $1,Q00,000 $1, 000,001 and up $887.25 for first $100,000 plus $5.00 for each additional $1,�0 or fraction thereof,.to and including $5(�,000 $2887.25 for the first $500,�0 plus $4.25 for �eacli addirional $1,�0 or fraction thereof, to and including $1,000,000 $5012.25 for the first $1,0OO,�p plus $2.75 for each additional $1,0� or fraction thereof DRIVEWAY DEPRESSION ESCROW (Cc�ncrete Curb Streets On1Y) Altemate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50_ Alterna.te "B": Removal and replacement of curb and gutter a.nd install a 3 foot wide approach with 6 inch depth - Driveway width plus 6 feet times $15.75. VERIFICATION OF FOUNDATION Permits for construction will be issued a minimum of 24 hours from the time of application to altow for proper review of the proposed structure and of the construction site. A Certific�te of Survey of the lot, showing the location of the foundation once it has it has been eonstructed wi!I he required hefore Proceeding with the framinR. - . ,, ; City of Fridley AT TME TOP OF THE TWINS � � � L D I N G P E R M I T i � � �� ; y _��_ COMMUNITY DEVELOPMENT OIV. r � � PROTECTIVE INSPECTION SEC. � . � � � /"'1 � CITY NALI FRIOLE� '35132 NUMBEA AEV I �--��' �'' 612-5��-3a60 s�aF�s JOB ADDRESS 545 Fairmont Street NE t LEGAL ��T NO. BLOCK TRACT OR AODITION DESCR. ],9,20 I Riverview Heights 2 PFOPERTY OWNER MAIL ADDRES$ Bruce/Sandra Emerson 545 Fairmont Street NE 3 CONTRACTOR MAIL AODRESS Same a ARCHITECTORDESIGNER MAILADDiiESS 5 ENGINEER MAII AODRESS 8 USE Of BUILDING Residential 5/8/00 I / / ZIP 30914 IECEIPT NO. � � �� vaOVEO Br SEE ATTACHEO SFIEET PMONE 786-5328 PHONE LICENSE NO PMONE LICENSE NO. PNONE LICENSE NO 7 CLASS OF WOFiK p NEW O ADDITION ❑ ALTERATION � REPAIR ❑ MOVE O REMOVE 8 DESCRIBE WORK Reroof House (11 Sq) Tear-off 9 CHAN(iE OF USE fROM TO STIPUlAT10NS Underlayment must comply with the State Building Code. SEPARATE PERMITS ARE REGUIREO FOR EIECTRICAL. PLUMBING, MEATIN(3. VENTILATING OR AIR CONOITIONING TMIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTFiUCTION 20NING AUTHORIZED IS NOT COMMENCED VyITNIN 80 DAYS. OR IF CONSTqUCTION OR WORK IS SUSPENDED OR ABANOONED FOp A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. N0. OWI.G. 1 HEREBY CERTIFV THAT I MAVE READ AND EXAMINED THIS APPLICA710N 1 AND KNOW TME SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION ANO OROINANCES GOVERNING TMIS TYPE OF WORK WILL BE COMP�IED WITH WHETMER SPECIFIED MEREIN OR NOT. TNE GRANTING OF A PERMIT $961 DOES N07 PHESUME TO �'iIVE AUTMORITV TO VIOLATE OR CANCEI TM� pEqMIT iEE PROVISIONS OF ANY OTMER STATE OR IOCAL LAW REGULA7ING CON• $38 �]S STRUCTION OR TNE PERFOFiMANC6 OF CONSTRUCTION O�CON"anCTOpOA�Op��IbeGENi i K � � � OCCUPANCY GROUP SQ.FT OiFSTR S7ALLS SURTAx � $.50 OCCUPANCVLOAD CU FT f PARKING GARAGES ;e SC $.96 � FEE �.21 S IS VOUR P MIT c�'_ ..� f�6Ti NEV1/ [ ] ADDN [] ALTER [ ] Construction Address: �� Legal Description: Owner Name 8� Address: _ _ �Lfc CITY OF FRIDLEY SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION �f ti� Effective 1 /1 /2000 (763) 572-3604 Bldg Insp � �, �b� 1G � �. Tel. # �y�J� �C� °� -3 Contractor. MN LICENSE # Address: Tel. # LMNG AREA: GARAGE AREA: DECK AREA: OTHER: 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 Width Hgt/Gr/o�und Sq. Ft ,,� �. D � s., �, .� � i,�ii U/�l _ %, Construction Type: Estimated Cost: $, '2�� -�'`Z�� l Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x� _$ p� �6� ��-�.�� DATE: � o l oG APPLICANT: � Tel. �� 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�604 for Permit Fees if mailing in application ��, � $ p•`�� Fee Schedule on Reverse Side $ ��_ .001 of Permit Valuation (1/10th%) $ , �� $.50/$1,000 Valuation $ $1100 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 f�fecessary [ ] $ �•� BUII.DING PERMI� 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 amou� 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 $1�,OOl to $5(10,000 $5�,001 to $1,000,000 $1,000,�1 and up FEES $23.50 $23.50 for first $500 plus $3.05 for each additional $1Q0 or fraction thereof, to and including $2,OU0 $b9.25 for first $2,000 plus $14.00 for each additional $1,000 or fraction thereof, to and including $25,0(� $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 $SO,Q� plus $7.00 for each additional $1,OW 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 DEPIBESSION ESCROW (Concrete Cbrlb Streets Only) Alterna.te "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 Sbrvey of the lot, showing the location of the foundation once it has it has been construct� will be required before proceeding with the framing. New Houses Onlv ,`.�, �;`;: ,��. � 0 D r -n m m � m � � � � d cc rn D � J � � � � � � N n °,m� a�i c�n ' c � m o,O� �o�o 0 0 o �� -� � -o � ci AZ ' v � � m � z � � � C�i � � � � � Z � � �� o s � .W � O �o � C .d�► fD � d m N r� r Z o, IV N � O W � o�i �� p3 �� u��, � W� � mZ '� � �' �' m c'"'D F'D � � � f -+ 0 � a � � � � � -, � O .o -ri � � � � _�p � � � �f p�j �i t� � � � �� _" � � 2 -, �• p� y � S • r y � �i c � � co �� 5 c� Z m cc � N � � � � � � �g�.� „ � �. � � m � z I � I I�) I I I I I I I I � �� GA GJ G,: � -+ � -� -► � � tr O O�� O O O O O O O C C C C O O C O C. O, O CI� O 0 0 0 o a o 0 0 0 0 0� o � � r C � � z � � 0 � � � � � � v � 0 � "'C Q. � �V � m � z O ; �� T � � � � �� c � C c � c � m v � v-n�nm w�o'm -n � � � O w 3 O Z N Z C W � � � C � � m m � z � � � 2m D � � W O O � r C � � Z c� � � � m � � z 0 �. O � � O W �' � � 4 v d �C e� V � $�' C� w d w � t°� � C N � �• 0 w z e� �wu�� ' `� „N�v � �D m � m� w N � m , n v � O v . < � m 3 � _� � m � � � � � � � , �FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS COMMON VENT. VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When re►placin� an existina furnace, the undersigned h�reby verifies that the venting has been examined and is free from rust, deterioration, obstructions, and is securely supported and firestopped where required. Yes () No () The venting system is plastic/PVC and meets all current c�des and manufacturer specifications including sizing, length, number of elbows and termination. Yes () No () The undersigned also verifies that the replacement unit is a listed assembly and meets the current codes and manufacturer's specifications. This does include AGA-GAMA Category I Central Fumace Venting Tabies for fan assisted and natural draft appliances. The existina combustio� air is si�ed and in�talled to rr�eet the current codes and manufacturer's specifications. � When required to install a new combustion air, it will be sized and installed to meet the current codes and manufacturer's specifications. Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) When installina a new ventin� svstem, the undersign�d hereby verifies that it is a listed assembly and meets the current c:odes and manufacturer's spec�cations. This does include AGA-GAMA Category B Central Fumace Venting Tables for fan assisted and natural draft appliances. Yes () Is the common vent and vent connectors sized and installed correctly after an appliance has been removed from the common vent �nd vented separately as per current codes. No ( ) Yes( ) No( ) Aaaliance Tvpe and Size/Common V�nt and Vent Connector Information Appliance #1 Type BTU Input Fan Assisted or Nat Applianc� #2 Type BTU Input Fan Assisted or Nat Appliance #3 Type BTU Input Fan Assisted or Nat Total Appliances Tdal Btu Input Common Vent Type Vent Height Diameter inches Applianc8 #1 Vent Connector Height ft Length ft Diameter in Type Appliance #2 Vent Connector Height ft Length ft Diameter in Type Appliance #3 Vent Connector Height ft Length ft Diameter in Type ALTERATIONS: (Describe) HEATING CO: � Signed By: Date : ADDRESS . PIN . LEGAL DESC . PERMIT TYPE . PROPERTY TYPE . CONSTRUCTION TYPE . CITY OF FRIDLEY 6431 UNIVERSITY AVENUE NE FRIDLEY, MN 55432 s�z-36u4 r��: 545 FAIItMONT ST NE 033024230091 RIVERVIEW HEIGHTS LOT 19 BLOCK I PLUMBING DUPLEXES ADDITION/ALTERATION 5%1-1Lif"/ PERMIT N 2004-01696 - .. _ �: DATE ISSUED: 09/29/2004 ° , VALUATION : $ 0.00 NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. INSTALL A GAS WATER HEATER. # ELEC WATER HEATERS 0 VALUE OF FIXTURE/APPLIANCE � # NEW FIXTURES (EXIST OPENINGS) # GAS DRYERS # OF NEW FIXTURES # WATER TRMT APPLIANCES APPLICANT NORBLOM PLUMBING CO 2905 GARFIELD AVE S MIl�INEAPOLIS, MN 55408-2173 (612) 827-4033 OWNER EMERSON BRUCE R& SANDRA L 545 FAIRMONT ST NE FRIDLEY, MN 55432 0 # GAS WATER HEATERS 0 # GAS RANGES 0 VALUE (FOR MINIMUM CALC) 0 AGREEMENT AND 5WORN STATEMENT This permit becomes null and void if work or construction authorized is not commenced witin 60 days or if construction or work is suspended or abandoned for a period of 120 days at any time after work is commenced. I hereby certify that I have read and examined this applicarion and laiow the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or loca law regul tmg ction or the performance of co ct�b . Applicant Date I Bldg Insp Dat PLBG PERNIIT NIINIMUM FEE PLBG FIXTURES (NEW OPENII�TGS) PLBG FIXTURES (EXIST OPENINGS) WATER TREATMENT APPLIANCE WATER HEATER - ELEC WATER HEATER - GAS GAS RANGE FEE GAS DRYER FEE PLBG REPAIR/ALTERATIONS STATE SURCHARGE, PLBG FLAT TOTAL PAID WITH CHECK # 29179 SEPARATE PERMITS REQL�'IRED FOR WORK OTI�R THAN DESCRIBED ABOVE. 1 0 400 0.00 0.00 0.00 0.00 0.00 35.00 0.00 0.00 0.00 0.50 35.50 MINNESOTA DEPARTMENT OF HEALTH Minnesota WeII and Boring �� 67 �� WELL OR BORING LOCATION Sealing No. H County Name WELL AND BORING SEALING RECORD Minnesote Unique Well No. �O� Minnesota Statutes, Chapter 1031 °� ",�;��,�,°„� iownship Neme Township No. Range No. Section No. Fractlon (sm. -+ Ig.) Date Sealed Date Well or Boring Constructed FR(QLEY � 24 03 '�fiW �fIF� T�al: � 29. 20� G� Letitude degrees_ minutes_ seconds Depth Before Sealing � ft Orlginal Depth� �� it LOCATI . Lon itu__ degrees_ minutes_ seconds -e 1A1RQUIFER(S) STA71C WATER LEVEL umerical Street Address ar Rre Nu r and City of Well or Boring Location L�) Single Aquifer ❑ MultiaquHer ry�r Fq� g-�� y �2 WEWBORING pC] nneasured ❑ esemated oace nneasured � � Water-Supply Well 0 MoNt Well e�cact Iocatio r ring Sketch map of well or boring Env. Bore Hole ❑ O[her � ft �] below in on gr °X.° location, showing property � ❑ a8ove lend suAace N Iines, roads, and buildings. CASWGTYPE(S) --'--- --�-- -- `-- ---t- �' � TBiCi ,' p� '+ � Steel ❑ Plasbc ❑ Tile ❑ Other � � � � ;r, - - --'--- ---h-- ---T-- "� WELLHEAD COMPLETION �: ; : ;ET --i--- --Y-- ---�-- ---;-- OuTSlde: ❑ Well House ❑ At Grade Inside: ❑ Basemerrt Ot(set � � � � 'k mwe � ❑ Pi�ese AdapterNnit � Buded ❑ Well Pft --;--- --T-- -- ; -- ---;-- l o 8�� S � ❑ wen P�t : ' S�iSf[ti}�rx�tsfia ❑ Other �—i Mue—� ❑ other PROPER7Y OWNER'S NAME/COMPANY NAME CASING(S) - _ - - - -_ - . �, �RI�E 8i $�MIDRA Dlemeter Depth Set In oversize hole7 Mnular space initlally grouted? Properry owner's mailing addreas If rDNererrt than wall locatlon address indcated ebove 2 in. from 5 to � it ❑ Yes p� No .Q Yes ❑ No ❑ Unknown s�iJ F�►�ur.S-�- n� �� in. from to ft ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unlmown in. from ro R ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unlmown WELL OWNER'S NAME/COMPANV NAME SCREEWOPEN HOLE , Well�ownePs meWng address R dHfarent than properry owner's address Inmcated atmve Screen from � t0 iL Open Hole fram to ft. � OBSTRLCTIONS RodslD[op Pipe ❑ Chedc Valve(s) ❑ Debris ❑ FlII ❑ No Obstruction Type of Obstrucdons (Describe) �� X 12J� D(Op P�B 8c .1C1 P�GPd � GEOLOGICAL MATERIAL COLOR HApDNES3 �R FROM TO Obshuctlons removed? �s Yes ❑ No Describe FoAnennoN It not Imown, indlcate estlma[ed formatlon log from nearby well or boring. P��P Ty�e Ooeep We9 .lei Rt�1� & 42 Ga@o11 Tan�c--- � �' � �� Removed ❑ Not Preserrt ❑ Other O iO METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINOS, OR CASMG AND BORE HOLE: �O � No Mnular Space Exisis ❑ Annular Space Grouted with Tremie Pipe ❑ Casing PerforaUoNRemoval in. from to ft. ❑ Pertorated ❑ Removed 531td � �IJ in. from to ft. ❑ Perforated ❑ Removed � � � 8,4 Type of Per(arator - ----- — -- — - - -tlard 84 1Q3- O ou,e. - � �� GROUTING MATERIAL(S) (Orre bag M cemeM = 94 fbs., one bag of beMonite = 50 Ibs.) g, � 140 156 Groueng Materia� �� hom 5 to 5'S ft. �'�15 9f�@� ba9s � 156 159 � from 5� to � n�"� � bags S�(IdS� �� from to ft. �� bags REMARKS, SOURCE OF DATA, DIFFlCULTIES IN SEALINa Ne� Low�ed 3' �brBl S"�de Of t�iwae N� DP�iI � F(OIII i'at'� �RAf�i u�.n� i�was � oo s� � we� s� .D ie� VYe� Seafeg N� Fr�n NLDJ�i Q3 � 24 23 0081 LOC.�L COPY =-01434-10 IC# 140-0423 " �67321 OTHER WELLS AND BORINGS Other unsealed and unused weU or boring on property7 ❑ Yes gj No How marry? LICENSED OR REGISTERED CONTRACTOR CERTIFlCATION This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The Irttormetion contained in this raport is Vue to the best of my knowledge. Myron L Malenke / ke jIV� f�) a�s_3ssa �a2s n Llcen�ee slness N�e IJcense or RegishaBon No. � �A �. � r ��'�,� > > : _ __ �iL L Mal�lce - 347: A ApN 29, 2008 � mrt Reoresentetive lan ture Certfted Rep. No. Date of Person Sealing Weli or Boring �o�a