AF - 42022SUBJECT ,
City of Fridley ' ° 14'758
i, ` AT THE TOP OF THE TWINS g U I L D I N G P E R M I E�E�PT
�
� ; L _�_�� COMMUNITY OEVELOPMENT DIV. � !
r � � PROTECTIVE INSPECTION SEC. � � �
1 � �
�` �'��1 � CITY HALL FRIDLEV 55432 NUMBER REV. DATE PAGE OF APPROVED BY
""'� � ,�� 612-560-3450
910-F15 6/16/78 � �
JOB ADDRESS 1579 Ferndale Avenue N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 5 1 Shady Oak Manor SHEET
2 PROPERTYOWNER MAILADDRESS ' ZIP PHONE
Ione M. Anderson 4208 Stinson Boulevard 78 -
3 CONTAACTOR MAILADDRESS ZIP PHONE LIC NSENO.
N.E. Sheet Metal 4347 Central Avenue N.E. 781-2776
4 ARCHITECT OR DESIGNER MAIL ADdRESS ZI - � LICENSE NO.
5 ENGINEER MAILRDDRESS �� " ZIP PHONE LICENSENO.
l�RAi'� 3�ERM1�'
8 USEOF BUILDING �"�+► f'LU14+tBIN� ANp � �
Residential �(�(1�
7 CLASS OF WORK
� NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK '
Construct a 48' x 26' Dyaelling and a 22' x 22' Garage
9 CHANOEOFUSEFROM TO
STIPULATIONS p�vide a hard surface driveway. Provide sod i.n the front ar� side
yards. Provide 12 course basement to meet mini.m� 7'6" headroom requirement.
Provide combustion air to furnace. Provi.de verifying survey and truss design
by July 15, 1978.
SEWER LOCATION: 52' W. of Manhole (W. Inv. 952.95)
WYE ELEV: 953.16 TOP OF FOOTIl�iG: 957.16 Mi.nim�tmm
WATER LOCATION: West of sewer service. NO AS-BUILT TIES AVAILABLE - Conta.ct
City Water Depari�nent for assistance if needed.
DRCVEWAY DEPRES5ION CO5T: 16' + 6' = 22' x�14.50 =$319.00 ������
'� Qn of �aa�r �� r+ot cu�e,w�t �,e . 8efore di8�in� ca111or�1 �ti�itie _
��c�a�ac�r o� urnnir tOGflC�NS AND E�YAT10�5. �ELEFHONE • EI.ECTt�fC - GAS Et .
n�us o��,► ts r� wFOa,�ut�oN �,►�oses orv�r �na REQUtREtJ BY LA .
� us�et� a ssnouu� veR+�r n�e r►���
CM iN� �
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING. WOOCZ FL'�IIle
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT �.2'48 'f' 45�: 29� SOO TOt31
ANY TIME AFTER WOflK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIPY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALIS 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 542�690 yfi2�..35
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-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. � $Z�.9. ZO yi`400. OO
PLAN CHECK FEE TOTAL FEE
�'�+. 0 r M 1 �� e d �� �— "� $29.8 $570.35
iG nTUAE F oNTR TORORAUTHORIZEDA�- IDATEI WHE PROP LY VALIDATED THIS IS YOUR ERMIT
T_ - , � � l� �8
SIGNATUREOFOWNEFIIFOWNERBUILDEHI IDATEI �— BLDG INSP DATE
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SITE ADDRESS
CU��TRACTOR Q��TE � PHONE
Determi re v�or•ki ng square footage of eact�.
1. Total exposed wail area ..... .,,-�t- sq. ft. x .17 = ,,,,�_,��,-� �
2. 7ota1 roof/cei1ing area ..... _,-�•ta sq, ft, x
Total exposecl ti�rall area above �loor = ,��..,,
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a. To�aZ �val � :•ri n�io�r� area . . . . . . . . . . . . . . . . . - • - - - • • - ,�,�,
k1. �O�:il� CIGUY` �1r'E'�! .................... ;�t�
c. Total slici�n� g7ass�door�ar�a ................... _ �,�
d. To'cu7 fire�lace arall area.......... ........... -
e. Tota'I wal7 frM,ning area {average �10%)...:........ ,�.� ^
f. 7ota1 n�i: ��rai 1 area above fl oor . . . . . . . . . . . . . . . . . ,,, .,
g. 7otai rim jois� area .....:...................... ,�:,.
Total e}:posed f��undation area = w�,�
h. To�tal foundation windo��r area ....... ............. _,n
i. 'Taa7 nei foun "`�i�n area above grade ............ �,.�
� De„ nnine "U" value �f each wall segment.
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If item n� is the same as, or ]ess than item �i, you have met the intent '
af SBC 6006(r}2. �� ='
s { . � - � �. � , ,'.,� t'"' �Ni fi"8 !' ��'' �4 �' ; Fr�: cYi �'�:''� ��' �•,- _ �'� ,� � .�,y.a,�r'' �a Y` ��t, L�+`,°�"�sr• ar,�' �"��' '1'.� �� �+iD "e ,�`�rs, $ '�l ♦ �y, ,,,�
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Tota7 exposed roof/ceiling area = ,�;y�
. j. Total slcyligf�t area ............. .......... ..
k. Tota7 raof/cei 1 i r.g frami ng �rea (average 10%) ..._ ,�,,,
7. Totai net i r�siil a�:ed rooflcei 1 i ng area. .......... ,;a,
Determine "U" value for each roof/ceil�ng segr:�ent. ,
�. X ���„ r _ � .
k. X ����� --
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�Jf total of r4 is the same as, or less thGn ,',•7_, you have m�t tfie irtent of
SBC 6G06 ( c } 1. ' ... ... .... _. .
Alternate Building Er�velope D=�s�gn .
To utilize ihe total envelop� sys�ern metnod, the values �;tablis}�ed hy the
sum of i tems #3 and �4 shal ] not be greater �'r;an �h.^_ su� of i te;��s ;� 1 and ; 2.
l. + 2, _
3. + 4. _
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No. Strcet: �' i��� .
LOT: . ,� }3IACY.: � TLDDITIOPI : .as� � • a �
CO}?JiL•"R LOZ': � I1�SIDE UJT: SLT}311CY.: SIUL•'Y11RD5:
ApplicarL- attac;�'ta ::his form �ao Certificat-er of Survey ot LoL- and proposcd
bu�.ldinc� location draf�n on these Cextificates. •
�
�o T3e Used As :
�
DESCRI PTIO(�d OF BUI LDI I�G
��t..ja�� Front: � � Depth : • � � � Heic�ht : � � _
Square Feet: �,� Cubic Feet: .2�% �� � _
�� � �
'LC'¢aG l?ront: �°�Depth: Neight: % �
' Square I'ee�: ��46 Cubic Feei�:
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Ty,pe at Construction: � �� EstianaL-ed Cost: ��
. �Z �� ��
To Be Cor.l�lei:ed: r� �� Alt. I� Al.t. �
Proposed llriti�eway SSid'�h If Ne�,r Opcning Is Desired �� $ � '
(S� 1'.IsV'F'.I'w� SIDE C1F S2iL:ET)
�he undcr�igi�ed 2�ere�y mafies ap�2ica�ion for a permit for the a�crk l�erein
specifa.ed, agr�eing �o do all �:ork in str.icti accordance �vith the Cit}� oi
k'xa_dlea� Ordin.�nces a:id. ri:lings of the Departmcnt oi L=uildings, and h�reby �
c�ccl.ares that all tl�e facts and represei�tatian, stated i�l i:his applicai:ian .
� are Lrue and correct. See xevcrse side Lar ac dit-ioi�al 1I1�02'7ililtl.Oil.
�nT�: � °�% �7 � SxGI�A�rvr.�.:
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BUILDI(JG PER�'iIT F�� SCiiEDULE
S�CTION 2. The Inspec:�:or oL' E3uildings shall, hefare issuing pezznits for �he erection
aL- any buil.diny or structure, or for any addition to any existing building or structure,
oz for any a1L-eration or repairs to any existing b�iil.ding or :-tir.ucture, upon 'applicatio :
therefore, require the payment by tlie a�?plicant fo•r SliCIl. j)Ci[Til'� of, fees to the amount
herein below se1: forth and in ttie manner herein provided to-wit:
NE6� COIdSTRUCTION: Single Family Homes and Garages: $4.00/I,000 cubic fee�.
PLAN CIi�CI:: 25 percent of building permit fee. '
DRIVEWAY DEPRESSION: (Concrete Curb Strcets Only)
Alternate A: Removal and replacement of concrete curb and
gutter only; nriveway width plus 6 feet x$14.50
Alternate II: Removal and replace:aent of concrete curb and
gutter and install a 3 foo t wide approach with
' 6 inc2i depth; Driveway width plus 6 feet x$17.20
•J�►DDITI�JNAL INFORvATION
For the purpose of computing fees for building permits, the cubical contents of any
building or addition, is determined by multipTying the ground area covered from a
point six (6) inches belo�a the floor line of the basement or th� cellar to the
avcrage heights of the upper surf ace or to the average height of the roof surface
of the nai.n gable of a pitched r�of .
Far repairs or alterations to an existirig structure, the fee shall be at the rate
of $3.00 ��er each__five hundred dollars ($500.00) or fraction thereof in the cost
�f all proposed ctiork.
in r,o case shall the fee charged for any permit as set %•rth in Section 2 be lESs
than $7.50 plus $.50 state surcharge.
_ VERIFICATIO� OF FOtJNDATIOfV
NOTE: Permits �or construction will be issued a minimtnn of 24 hours from the time
of a�plication to alla�,� for proper review of the propose� structure and of the
cons truction site.
A Certificate of Survey Qf the lot, showing the location of the foundatian once it
has been constracted will be required before proceedir.g with the framing.
CCRTTFICATE OF OCCUP�NCY
Application for a Certificate of Occupancy shall be made ten (10) days pri�r to the
use or occupanGy of any structure for which a buildi�ig pern;it has been issued; and
• said structure shall not be used or occupied until a Certificate of Occupancy has
iseen issued. �
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PROJECTs
REPORTED TO:
REPORT OF:
79 FERNDALE A
n tw�n c�tti+ test�nq
'�!. ;` . _.. er�o env�neennq �taoreeory,mc
662 CROMWELI AVENUE
'" ST. PAUL. MN 55114
PNONE 612/645-3601
DENSITY _TESTS OF COMPACTED,F=
�..�.�� � � � ���.�.�w. �,
Crown Realty
4347 Central Ave NE
Minneapolis, MN 55421
LABORATORY No. 11-3319
1'EST NUMBER:
DATE TAKEN:
UNIFIED SOIL CLASSIFICATION:
�1�9oisture-Density Sample
Number)
LOCATION:
DEPTH BELOW PORCH SLAB AT
RESIDENCE TO WEST:
DEPTH BELOI�' EXISTING GRADE:
DATE: JU�Y l�e 1978
�
DG ✓
��
�tc.�-
COPIES TO: 1-Ci ty of Fri dl ey
Bldg Insp Dept
1
July 7, 1978
Sand, mostly
fine grained,
trace of ravel,
brown (SP�-1
30' E & 5' N
of NE corner
of residence
to W
10.5'
6"
P�
July 7, 1978
Sand, mostly
fine grained,
trace of ravel,
brown (SP�-1
45'E & 5'S
of NE corner
of residence
to W
10.5'
6"
FIELD DENSITY DETERMINATION:
Method Density in Place B - One Method, ASTM:D1556— - - 4 Basis)
Dry Density �pcf)
Moisture Content (%) 7•5 11.4
Plus #4 Material (%) 4 2
LABORATORY MOISTURE-DENSITY RELATION OF SOIL:
Method ASTM:D698-70, Method "A" (-#4 Basis)
Maximum Dry Density �pcf) 10�.2 10�.2
Optimum Moisture (%) 13.0 13.0
COMPACTION TEST RESULTS: '
Compaction (%) 105� 104 f—
REMARKS: The above test locations were selected by Twin City Testing and Engineering
Laboratory Inc. This report in no way implies that the soil be1ow the
depths:tested is satisfactory.
AS A MUTUAL PROTECTION TO CLIENTB, THE PUBLIC AND OYRBElVEB. ALL NEPORTB ARE BUBMITTED AB TME CONF�DENTIAL PROPERTY OF CLIENTB. AND AUTMOR-
IZATION FOR PUBLICATION OF BTATEMENTB.CONCLUmION8 OR EXTRACTB FROM ON REGARDING OUR REPORTB 18 RESERVEO PENDING OUR WRITTEN APPROVAL
Twin Cify Te g and Engineering Laborater Inc.
Br
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HEA,'��$$ CALCULp'fIQN.S DEPARTMENT (
C�Veatheratrips ��' Con�truetion Ni
Guide
Wicdowe Dcan Refuence Out. Wall In� Qlall Ceiling
Yea—No I Ye�—No 19_
Fl.� G; �,-�� Room I.en8t6 �,�;,, Width ;'% Heighe .�1'
Wiadows and Daora—Crackage aad Ana
�Vidth Helsnt Na. 01 Llneal ! Ana A
Na ot paee ot pa�e tlg6t� ot eraek �q. [G �
.�. "? c`', P� (�, �' � "' �'± ��'; �, Cf-
°`� s.�__..
�` `�
Coef. Btu
In6ltratioa ! ` � ,��' `�%��� �-> �- /�' —
Claas ri f , � T �� �^� `�<� �",
Esp. wall �� � � a _
r � , , � � ��„�; ;, ,'
Net e :p. waU � c� � / ' ��? ,„ (�
InG wall
��
Ceiling G'�'i,f"�� =, ",'r� �;°`
Floor ,�j%�1 /,%iJ G��f`�r��s ,
Total Btu. � � ` �� _.�. �I
Required sq. ft. E.D.R. or eq. ina. WA. I.eader area i
/ Fl.� ��' �' �' Room l.ength / `'^ Width ' �? He.ight ��
Windows and Qoora—Crackage and Area
Wldth Helant No. ot Ltnfeal 1t. Area
No o! Dane ot pane I1�bt� ot enck q. t4 .�'�
s ; ^� , ,-i� � r �i� j 4?
,v , R�' � ��' �I �) I ��:
r'a
f �,
�Gf. BiY
In6laation ^ � "
ll `�.; .-�'�- ;"�� � ��� i
Clase ' �„ �- �, - �� �.�, ,
Fap. wall -� �'
, -,F.-�
Net e:p. wall � ��,- l�<�i �
Int waU
Ceiling %� �%
Floor f � � ..,
Total Btu.
Required sq. k. ED.R. or aq. in�. RI.A. Leader area
/ Fl. r_'r';:A Room �L.engt6 /�� WidtF:
Windowa aad Doors—Crackage and Area
Wldth Ha1�6t No. o! Lfo�al tt. Area
No. ot D=ns ot pans IIS�U ot araCk ip. It
�; .� / .. ��4'/ /%� F� ��F .. /.� ��� {.�'
�II�1�tiah011 � �, � ,i,� �;
Glasa %° ' �
E�. wall �-�
Net e�p. wall � < i'��"�''/','
lat. wall
Ceiling !' �--, � `
E loor �-�
Total Btu.
Reauired sa. f� E.D.R. or sQ. ina. WA. ieader area
C
/' ��
y��-" L-.
��
���,e.. ,�
A��F� �,
�� �_^ ���
-,._
r`r' �; �'
1F INSPECTION
�.
Roof Floor Kind
/� Fl•I � /-� �°, Room � [
ar,�ao,� 8Aa u�m--cr,
Wldt� �ie1�6t No,
No. ' ot pane o[ pane 1161
Li6ltratioa
Glaoa
E:p. wall
Nec e�p. wall
In� wall
Ceiling
F7oor
Total Btn.
,� y� � .�--
,� �tl �' � � -E ' �
;;
N�IIVEAPOLiS. II+ID�QV. '
Insnlation
' I•low
i % � Qlidth r
e and Area
:Inaallt Aroa
ot crack ea. (�.
� A I
/
Btn
�� '�,�
, � �, �, ,��
� � c�% • �
/` �..r� r
RequQed aq. fG E.D.R. or sq. ins. WA Leader area
�/ Fl.I �'' ��%� Room I Length �+ �'°' Widt6 i' ;;� EIeigLt
Windows aad Dooro—Craekagt and Area ��;
Wldth Halsht� �No. ot Llneal tt. Aro�
No. ot yaae ot pans ll`hb ot crack � �. LL _ - "�
� `, l,-, i�. ..�,; .� � i� G-- . �' �
, �, ' �- �
��3�10l1
Ir_�...
Net esp. walt
� Int. _wall
Csilin
F1�r
7'otal Bcw
,� ,
=.
�
: ��
:�- ,�; .� , �a
� � � ,
< ,,
��.
Required W. k. E.D.R. or aq. ins. W.A. L,eader area I
�I " Fl.� �,'� Room I L.ength !% r'� Width : r, � Height ,�l
Windowe and Doon—Cracicage and Area
Wtdts Helsbt Na o! LInW tt Ares �
Na oL yans o! O�n� Il�hta ot eraetc q. tt `
� ��
� � �1 �l %�/� �l /��' /;•� r(
. �
C�f. Btu
1D�i:8�lOII /��F, .�c ��'� (,T /r, s a ^'�_,n.
�ll� .�J; �.' �, c ° ��s � 9_/,'
/ � h - t-
Eap. wsll -'����
Net acp. wall �`�� .�, �' �a r�-� :�
In� well
Ceiling � �r> � `� l <� r�a�
�,
Floor ;'� �� �',� �' � r r` �'
Total Btn. ��6� � a .u�-
Reauind w. ft. ED.R. or �. ins. WA L�eader area
�:
a� _.
HF.�4'F�'LOSS CALCULATIONS DEPARTMENT OF [NSPECTION �pppWg� �.°
� jWestheratrips Guide Con�truetion No. IneWW�tion
Windowa Doors Refaeace Out. Wall Int. Wall CeJing Roof Floor Kind How Applied
Yea— l�o I Yes—No 19
,P Fl.� _;. , s Room Length , M'� Widt6 ;�'�Hei�h� r%`'' Fl.� /�„��,� N Il Room Lene� li r�� Width -=� Heig6t
Wiadows and Doors—Crackage and Area Windowa and Doore—Crackage and Area
�Yldth He1gRt No. ot Wnul t Aroa � �� WIdtA 8el��t No.�o1 Llnqt iL Aeu �
Na ot pane ot D�ne Iliht� ot craek �p. t� ^�,r,. �No. ot pana of pans U�Ab ot cracic q. tb
� � " c, �/� e • � „_,..�+ � � �� ' ' 1�^ . i, ^a . ;� F - =5,
�
�/�, �,, . ��� ��, �� T `� f`'' �' Ir � � /� i, 6 �" � � < �^ „�� s�1
Ar e,r
Coe£ Btu Coef. Btu
Infiltration �.; �; �f ` � " ` ,� ` �;� Wiltratioa ;' a �� <� �' "%�''
..�� , , F.-
; , , �-
Glaas �.; c� �, �, � ,� / �- -�f � ws �,
Glaa ��- � �� ��=
Fap. wall ,�,/� :F-'. Esp. wall � � �,� - �
Net e�p. waU "�� '�� �,^`" � , �� Net ezp. waU � , ,F' ' �' '"r,�
Iat. wall ]nt wall
Ceiling � �, �' �.� i "n�'° ('� � CeilinB ',`;'�%' `;; - � �� ° �J
�
Floor ,ec, ',' �^ ��,, � 4'_ �'�,._�'� F7oor "",« � �* � ;�, �
,� - �'�. � �. ,
Total Btu. r,� ,,� E� �; Total Btu. � ��.� ��
Required aq. h. ED.R. or �q. ine. WA. l.eader area Required �q. ft. E.D.R. or sq. ina. W.A. Leader area
FI.� Room Length Width Height . Fl.I . ]�m I L.ength Width Heigld
Windowa aad Qoors—�raekage and Area R/indews and Doon—Crackage and Area
Wldlh HelQOt No. of Ltn�al fG Araa Wldtp Ha/�ht• No. ot Llneel !t. Area
Na ot pane ot pane ll�nt� ot enek p. tt No. ot Daee of pane t1�6ts ot crack �p. ta
In6ltration � 4
Glaas
Exp. wall
Net e:p. wal!
In� wall
Ceiling
Floor
Total Btu.
Required sq. fG ED.R. or sq. ins. W.A. l.eader area
Fl. Room ( Leegth Widtl:
Windowa and Doon--Craekage and Area
Wldeh Hel�ht No. ot Lln�al tt. Area
No. ot vane ot paos 11[eb ot arack �p. !L
�
�I1ll�[i8hOD
�asf
Exp. waU
Net ezp. wall
Int. wall
Ceiling
Eloor
Total Btu.
fG E.D.R. or �. ina. WA. Luder are�
BiY
Btll
Clau
FsP• vrall
Net ap. wall
� Int. -wall
Ceiliag
%loor
Total Btu.
Required �q. f� ED.R. or sq. ina. W.A. Leader area
FI. Room I Leagtl► Qlidth
Window� and Doo»—Crael�age and Area
WlAt6 Sd�at Na ot Llnwl f4 Ara�
Na o! wn� ot otn� tt�ht� ot crack �a. tt
�hihOD
�W
EA�. WiU
Net ap. wall
Int. w�ll
Ceiliag
Floor�—
�_
Tocal Btu.
or �a. ins. WA L.eader a�ea
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6431 UNIV��t51TY �VEPdU� R�.E., FRIDLEY, PAIFd6dES�TA 55432
i. �'` Ms. Tone Anderson
��•�;� Northeast Sheet r�etal
'� 4347 Central Avenue N.E.
. ;;
� Golumbia Heights, 2�1 55421
Re: Final Inspection a�t 1579 Ferndale Avenue N.E.
Dear Ms. Anderson:
YELEPFBOPdE ( 612�5T1-3450
A final inspection was made on May 17, 1979 of the above address and
the following items �vere noted which must be completed before the
structure can be f inaled out;
1. Post house numbers on structure by June 15, 1979.
2. Provide combixstion air to furnace area by June 15, 1979.
We will expect the above items to be completed by the scheduled date
when a reinspection will be made to determine compliance. If you
have any questions on these items, please contact me at 571-3450.
Sincerely,
DA L G. CLARK
Chief Building Official
DGC/mh
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NOTE: ��1 through �8 required when using a side vent furnace.
�s 1_!_� 1.�1_' � _� ► .� _ �_ � _. /_'_ _L �. �����
T�1� 1iQde1S1gII� iiCT�j/ V�'tf1CS t� ��X1ShIIg Ch11flII�t 01' SG3C�c:
1.
2.
3.
4.
5.
6
%.
8.
Has been cazefully examin�
Is fre� from n�st or deterior�tion
Has no fareiga objects lodged wit�i�o
Is securely supported
Meets all current Cade requirements for size
and totai BTU's conaected
Yes (x) No ( )
Yes (x) �o ( )
Y� (x) No ( )
Y� (x) No { )
Yes (x} 1Vo ( }
Has total heatittg $TU's af 30, 000 (Appliance input)
All other BTU's
Tt}TAL BTU's 3 0, 0 0 0
-. -
i • � ::�i ►; � � �� �• � r�.� :?� r,-��.
Has combustion air besn pr�vided for �s��
fireplace
Yes (x} Na ( )
Yes (x) No ( )
:�. .
Remarlcs:
Appliance to be installed is CFM Model DVHE-30, direct vent
sealed natural gas fireplace insert: Unit is shipped with all
UL & AGA required components, including dual .4• aluminum �lex. vent.
j,�j� Ai.TER,.�►_TIO�TS �'�rg� Note.: 3/8" copper service line about 24'run.
New 3/4" black iron pipe service entrance from gas meter into
basement to supplv 3/8" conper tubing brar3ch �.iney� �ni . to
i n 1�dc� '��4�� p�tranr•a ahiitnff Va1Ve tP„�d a�Y d�1 u J(�pd fnr �; ble
future t�ke�,ff 3,L8" ShLt��„f�alvr� fin h inci-al7r�r� at_ firohnx
for service disconnect. Installation requires partial access
through existing masonry for service line (to be sleaved).
HEATING CO: owner .
Signed By: �
Date:
To:
CC:
From:
Date:
Re:
Mr Jim Mi I'�n,1579 ferndale Avenue,
Tom Roushar� MSA o in_�_F
Paul Boettchv �
january 7,1996
T�-�� �G
� Plwne 571-5571, fAX 511-1919
hidlep/New BrighWn Wiemnin IMvconnation 685-00430
Please Eind attached copies of 2 half size plan sheets along with
35 pages of Daily Reports from the inspector on the project
I only copied the Daily Reports which pertained to work in the
azea of your property as reuested. We have highlighted in blue,
notations which may be of interest to you in regards to the work
activity occuring on the date of the report. Your property
appears along Benjamin Street in the azea of 33+00 to 35+00,
which a 200 foot stretch from Femadale Avenue to your
back(nordi) lot line. Since some of the terntinology may be
unfamiliaz to you, I have noted below what it means more
speufirally.
CB
Overlay
Iron
B/curb
Catchbasin, storni sewer inlet with grate
Second lift of bituminous pavement
Manhole castings and water valve castings
Behind curb or back of curb, boulevard
Base, Base 32 Frst or base lift of Uituminous
C-S Class S, gravel base beFore bituminous pavement
33+00 Stationing, intervals of 100 feet plus units of feet,
Fernciale is at 33+23 or 3323 feet from a
refereiice point of 0+00
String String line that was set on metal stakes and
Urac:kets along dte street edge that the curb and
gutter machine foll;owed for alignment and grade
Subgrade
Bit
DIP
Soil upon which d�e gravel is placed
Bituminous pavement
Ductile Iron Pipe, 20' DIP, watermain installed
If you have any questions aUout interpreting this information,
you �:an call me at MSA Consulting Engineers, G44-4389.
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CHIlI�INEY AND STACS VERIFICATION
The undersigned hereby �erifies that the existing chimney or stack:
1. Has been carefully examined
2. Is free from rust. orsleterioration
3
G�
5.
Has no foreign objects lodged within
Is securely supported
1l�Ieets all current Cod� rPquirements for size
and tc�tal BTLT's connected
6 Has total heating BTU's of ��� �
All other BTU's � (J 0
'TOTr'�I, BTU's 1 �j o��
Yes (i'� No ( )
Yes ( �No ( )
Yes (°�No ( )
Yes (�PTo ( )
Yes ( ) No �
7. Has a liner been provided for water heater Yes � No ()
8. Has combus�ion a�r been provided for water heater Yes (� No ()
Remarks:
o, � � 1) �.IIC 7v ��,s�- � ���?– �%v��� S %��e —
List ALiERATIONS Being Done:
,�%S r (
ROYFiLT��J ?-BEAT�P��� ,� ��-��I�E?s�
� � �"�l - 8� ih F'e°�;"c !��e�. [��;� '
�RO��`:L"��P�l P,�E�,6;, ���9 5 a443
HEATING CO: PH��� °�2�-�'��
Signed By:
Date:
�I-I`3-b0
�����
.�...��.� —
D►06
HFAT LOSS C1ILCULATIONS DEPARTMEIV'1' OF 1NSPECTION
Wc.therseripa �� Coas� Na
R/indnwa Davn Refaeace Qut. Wdl fat Q/ai) Ceer�iss Roof Floo�
00
� 0 19____
Fl.� Roou� LeaBtb �l'uleb Height F�.(
Rliodavvs aad Gaorr—Cracka�e aad Atea �aidewi aAd
Idtb N�Iro� 7�a at Llps►1 [R wn� qy� I
Na o[ pa0• o[ �n� 11�Aa ot e+ac4 p. ft Kq ��w �
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Iafiltrneioa
�ats
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Net exp. waU
InL wali
Ceiling
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Total Bta
Required sq. h. E.D,R. or aq. ina WA llader urea
Fl.� Room l.ansth Width
'Windows apd Doors--Crac.kaBe aod Area
WIdtO 1c���e� Na et Ln�a! h A��w
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rk< «p. .�u
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Total &u.
Required sq. h. E,D.R. or p. ia�. wA Leader ares
Fl.� Room � Length Widih
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lnfiltratioa
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Exp. wall
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THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
C(�MMnN VFNT* NT nNN .TOR 4ND .C)MB ICTIC)N AIR RIFI _ATInN
When � I,�a -ing an eYistinA f�rance, the undersigned h�reby verifies that the
venting has been examined and is free from rust, deterior�tion, obstructions,
and is securely supported and firestopped where required. Yes () No ()
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and teRnination. Yes () No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturers specfica�ons. This does
inGude AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The pxi_ctin�emb ��t�en air is sized and installed to meet the current codes
and manufacturers specifications.
V1/hen required to insta�t a new cnmbustien air_ it will be sized and installed
to meet the current codes and manufacturers specificatior�s.
WhE� inc_±alline a new ventin��ys±em, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and m�nufacturer's
speciflcations. This does include AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances.
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes.
Yes ( ) No ( }
Yes ( ) No ( )
Yes(}No()
Yes ( ) No ( )
Yes( )No( )
�.. .� .- .�. - .����.� -�i .�. -� .��-.,. � ..u,w.�
Appliance #1 Type BTU Input
Appliance #2 Type BTU Input
Appliance #3 Type ' BTU Input
Total Appliances Total Btu Input,
Fan Assisted or Nat
Fan Assisted or Nat
Fan Assisted or Nat �
Common Vent Type Vent Height Diameter inches
Appliance #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
r r•► .- ..�-
HEATING CO:
Signed By: Date :
SuBJECT
City of Fridley
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
r
� �
� �
� `� __��� COMMUNITV DEVELOPMENT DIV.
r � � PROTECTIVE INSPECTION SEC.
i----� �"' �,� CITY NALL FRIOLE� SS132 NUMBER AEv
L 763-571-3450 si a F � 5
108 ADDRESS 1579 Ferndale Avenue NE
1 IEGAL LOT NO. BLOCK TFiACT Ofi ADOITION
oesca. 5 1 Shady Oak Manor
DATE I PAGE Oi
9/17/02 � �
33095
_�^�
RECEI T NO.
;.J"'� ��J
APVqOVED BY
SEE ATTACNED
SMEET
2 PROPERTY OWNER MAIL ADORES$ ZIP PMONE
Jim Million 1579 Ferndale Ave NE 763- 71-5571
3 CONTRACTOR MAIL ADDRESS 21P PMONE LICENSE NO
Dan Netko Exteriors i305 104 Lane NE, �aine, MN 55434 763-784-0227 20060494
d ARCHITECT OR OESIGNER MAIL AODRESS ZIP PMONE LICENSE NO.
5 ENGINEER
8 USE OF BUILDING
Residential
� CLASS OF WORK
MAIL ADORESS
O NEW O ADDITION � ALTERATION
8 OESCRIBE WOfiK
Reroof house & garage (23
9 CHAN(3E OF USE FROM
STIPULATIONS
) Tear-off
TO
21P PMONE LICENSE NO
� REPAIR ❑ MOVE ❑ REMOVE
Underlayment must comply with the State Building Code.
TVPE OF CONST. OCCUPI
SEPARATE PERMITS ARE FEOUIRED fOR ELECTfiICAL, PLUMBING. MEATING.
VENTILATING OR AIR CONDITIONING
TMIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION 20NING SO. FT
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS. OR IF CONSTRUCTION
OR WORK IS SUSPENOED OR ABANDONEO FOR A PERIOD OF 120 DAYS AT
ANV TIME AFTER WORK IS COMMENCED.
NO DWLG. UNI7S
I HEFiEBV CERTIFY 7MAT I HAVE READ AND E7(AMINED THIS APPLICATION 1 S7ALLS
AND KNOW TME SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VAlUAT10N
AND ORDINANCES GOVERNING TMIS TVPE OF WORK WILL BE COMPLIED �2�465
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
OOES NOT PRESUME TO GIVE AUTHOii1TV TO VIOLATE OR CANCEL THE pEpMIT FEE
PROVISIONS OF ANY OTHEF STATE OR LOCAI LAW FEGULATING CON- @83.25
STqUCTION OR TME PERFORMANCE OF CONSTRUCTION �p
�7 PLAN CNECK EE
9'� /i�✓� Lic s SC $ .00
SiGN U�7E OF CON'FACTOA Op 4UTMOAIz D OGENT ipATE� WH N P RLY VA
'
� ,���i�/��%��
OUP OCCUPANCVLOAO
CU FT
iFFSTFEET PARKING
IGARAGES
iUFTAX
$1.23
Fire SC $2.47
TAL FEE
$91.95
►HIS IS YOUii PEiiMIT
� �ic�•V ir'
���� ������
N� [ l Effective 1/1/2001
ADDN [] CITY OF FRIDLEY (763) 572-3604 Bldg Ihsp
ALTER [✓]' SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: 1 � % °�/ ��ti �,�� � !�E
Legai Description:
Owner Name & Address: J 1 I�►-t j'Ylo� �� j� - S�u es s Tel. # 763 -�7 /- �"'�i /
Contractor: �[.JGtvl ��L�p �y, y 2Vi B-v MN UCENSE # �-D j� �,p y �j �
Address: i�DS- / D��, l�, NE Q�rtir S�� �f Tel. #��3—?g�l `D�-�7
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Sutvey 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 .
Length Width HgU� ,round Sq. Ft.
�.�� -- `rr t . C � � / �i,-�r� .r-� r<a ;
Construction Type: l�1f��D� t� r���- Estimated Cost: $ �'�L-, �
Driveway Curb Cut Wdth Needed: Ft + 6 Ft = Ft x$ •_$
DATE: �'�� 7�� APPLICAN7: J c� Tel. #% b�J'%Fi�—U�c�%
�i"
CITY USE ONLY -
Permit Fee
Fire Surcharg�
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
Call (763) 572-3604 for Permit Fees if mailing in application
$ ���� Fee Schedule on Reverse Side
$ �? �`7 .001 of Permit Valuation (1/10th%)
$ a�� $.50/$1,000 Valuation
$ $1150 per SAC Unit
$ � < C.`'�C� $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 [ ]
$ �° ���
6
BUII..DING PERMIT 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 amount 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 $50,0(30
$50,001 to $100,000
$1�,001 to $500,000
$5(?0,(?O1 to $1,000,000
$1,000,001 and up
FEES
$23.50
$23.50 for first $500 plus $3.05 for each additional $100 or
fraction thereof, to and including $2,000
$69.25 for first $2,000 plus $14.00 for each additional $1,000
or fraction thereof, to and including $25,000
$391.25 for first $25,0� plus $10.10 for each additional $1,000
or fraction thereof, to and including $50,000
$643.75 for first $50,000 plus $7.00 for each additional
$1,000 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 DEPRESSION ESCROW
(Concrete Curb Streets Only)
Alternate "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 tunes $23.25.
VERIFICATION OF FOUNDATION
Pernvts for construction will be issued a minimum of 24 hours from the time of application to allow for proper
review of the,proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the , foundation once it has it has been constructed will
be required before proceeding with the framing. New Houses Onlv
SuB�ECi
c�ty of Fridley
AT THE TOP Of TME TWINS g � I L D I N G P E R M I T
f
� �
� �
� ; y ����� COMMUNITY DEVELOPMENT DIV.
r � � PROTECTIVE INSPECTION SEC.
1 . �
i.-_• i�'�',-� CITY HALL FRIOLE� SSI$P NUMBEp REV DATE
L J` 763-571-3450 9/0-Ft 5 10/ 16 / 02
JOB ADORESS 1579 Ferndale Aver.ue NE
1 LEGAL �OT N0. BLOCK TRACT OR ADDITION
DESCR. S 1 Shady Oak Manor
2 PROPEiiTY OWNEq MAIL ADDRESS ZIP
Jim Million 1579 Ferndale Avenue NE
3 CONTRACTOR MAIL ADDRESS 21P
Dan Netko Exteriors 1305 104 Zane NE, Blaine, MN 55434
4 ARCHITECT OR OESIGNEii MAIL AODRESS Z�P
S ENGINEER MAIL ADDRESS ZIP
/
33179
s�
RECEIPT NO.
Oi APPROVEO B�
/
SEE ATTACHED
SHEET
PNONE
763-571-5571 �
PNONE LICENSE NO
763-784-0227 200fi0494
PMONE LICENSE NO.
PMONE IICENSE NO
B USE OF BUILDING
Residential
7 CIASS OF WORK
O NEW O ADDITION � ALTERATION C� REPAIR O MOVE O REMOVE
B DESCRIBE WORK
Soff�t & Fascia
9 CHANGE OF USE FROM
TO
STIPULATIONS
Install aof£it ventilatio� to meet the State Building Code.
P�rmi� �nspection Cards
INili e Ma11ed
To Homeo�ner T� Post
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, MEATING, TYPE OF CONS
VENTILATING OR AIR CONDITIONING.
TMIS PERMIT BECOMES NULL AND VOIO IF WORK OR CONSTRUCTION 20NING
AUTHORIZEO IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WOiiK IS SUSPENDED OR ABANDONEO fOR A PERIOD OF 120 OAYS AT
ANY TIME AF7ER WORK IS COMMENCED.
NO DWLG. U
I HEFEBY CEfiTIfY THAT I MAVE REAO AND EXAMINED THIS APPLICATION 1
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALl PROVISIONS OF LAWS VALUATION
ANO ORDINANCES GOVEiiNING THIS TVPE OF WORK WILI BE COMPLIED @
WITM WHE7HER SPECIFIED NEREIN OR NOT. TME GRANTING Of A PERMIT W8OO
OOES NOT PRESUME TO GIVE AUTHORI7V TO VIOLA7E OR CANCEL THE pERMIT FEE
PROVISIONS OF ANY OTMER STATE OR LOCAL LAW FiEGULATING CON•
STRUCTION OR TNE PERfORMANCE OF CONSTRUCTION �32.65
PLAN CNECKi
Licens�
S�GNATUpE O� CON'AACTOQ Ofi nUTMOpIZED AGENT IDAiE1
iD�fEi �t
� -
SQ. fT
S7AllS
GROUP �OCCUPANCVLOAD
OFFSTiiEET PARKING
IGARAGES
$.50
AC CNARGE
Fire SC $.80
OTAL FEE
$38.95
TNIS IS VOUR ERMI
FROM : DAN NETKO EXTERIORS
NE1N ( �
ADDN ( � _
ALTER ��
Constrt�cticn Address: v ^ �
Legal Description:
Owner Name 8 Address; .� i�a
FAX N0. : 7637840227 Oct. 16 2002 12:01PM P1
C.�7Y O� FRIDIEY EftecDve 1012002
(i431 Unive�iry Ave NE, Fridley. MN 5b432 (763� 5?►Z�6pq g�d9 ��gP
S�NG�E FaM1LYAND DUPLEXES R-1 aN� R-2
BUILDIN�C; PERMITAPPLICATION
�
LMNG AREA;
GARAGE AREA;
OECK ARFJ1:
OTHER:
`_ Tel. �'�'�i�- v�- r7�—.5`�S"'7�
MN LICENSE # a�t��o���
��Te�. � �� 3-� �; �aa�
Attach to this application, a Certificate of Survey of the
Iot, with the proposed constru�tion drawn on it to scale.
DESCRlPTION OF IMPROVEMENT
Len9� �_ wdth . Height
Sq. Ft
Len9� Width Height �,._ Sq. Ft
length Vlldth Hgt/Ground Sq, FL
Construction Type: �G7� �� � '` �
rEstimated Cosk $ ��� J
Drivewsy Curb Cut Width Needed: ,_Ft + 6 Ft =,_„�_Fc x g =$
CATE: D" -� APPUCANT: ..I Q� ���� �� 6`? S �� 3—
Tei�# ����v�a.7
Call (763) 572�604 for Aermit Fees if mailing in applic�tion o� Fax to T63S71-1287 ip using credit card and we will
cali you for card number;
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Drnreway Escrow
Erosion Coniral
Park Fee
Sewer Main Charge
TOTAL
$ �3��. ��
$ = ���
� ���
$ . `—
-��
� E^` �� �
�
$
S
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Fee Sch�dule on Reverse Side ��
.001 of Permit Valuafion (1/10th%}
$.501$1 �000 Valuafion
$1200 per SAC Unit
$5.00 (State Licensed Residential Contractors) �
Att. "A" Or Alt. "B" Above
$450.00 Conservation Plan Review
Fee Determined by'Enginee�ng
Agreement Necessary [ ] Not Necessary [ ]
�b /� d'✓'
STIPULATIONS:
From:RUM RIVER LU�BER 763 862 7359 10/16/2002 11:23 #518 P.001
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CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, NIN 55432
PERMIT N�.: 2004-01875
�,_ �
DATE ISSUED: 10/14/2004
(763) 572-3604 FAX: (763) 571-1287
ADDRESS : 1579 FERNDALE AVE NE
PIN : 243024110083
LEGAL DESC : SHADY OAK MANOR
: LOT 5 BLOCK 1
PERMIT TYPE : BUII.,DING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : WINDOW/DOOR REPL
VALUATION : $ 2,655.00
NOTE: PROVIDE SMOKE DETECTORS IN ALL SLEEPING ROOMS AND ON ALL LEVELS OF TI� DWELLING PER R317
OF TI� 2000 INTERNATIONAL RESIDENTIAL CODE. CAULK AND FLASH ALL EXTERIOR OPENINGS. REPLACE PATIO
DOOR WITHIN EXISTING OPENING.
STATE LICENSED CONTRACTOR 1
APPLICANT BUII,DING PERMIT FEE 83.25
RMA HOME SERVICES INC FIItE SURCHARGE 2.66
3200 COBB GALLERIA PKWY #200 STATE SURCHARGE, VALUE 1.33
ATLANTA, GA 30339- LICENSE SURCHARGE 5.00
TOTAL 92.24
PAID WITH CHECK # 37408
OWNER
MII.LION J R& JOHNSON V A
1579 FERNDALE AVE NE
FRIDLEY, MN 55421
���mit �n�,p��tion Car�a
AGREEMENT AND SWORN STATEMENT IN�I6 �e Mailed
This permit becomes null and void if work or construcrion
authorized is not commenced witin 60 days or if construction �'� Harrreowner'ib Pos�
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby cerrify that I have read and examined this
application and know the same to be true and conect. 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 o any other state or local law
regulating construction or the pe�o ance of construction.
Applicant Date
B1dg Insp - Da�� 1 r ,.
_ SEPARATE PERMITS QUIItED FOR WORK OTI�R THAN DESCRIBED ABOVE.
04/02/2004 FRI 1a:21 FAA -�33 ELDER JONES
NEW
ADDN
ALTER
. .. � �� �4 �i
�� . �
CITY �F FRIDL�Y
� j � Q431 UniversityAve NE, Fridley, MN 55432 �
�� STNGI�E FAMILYAND DUPLh��S R-4 AND R
BU{LDING PERMITAPPLICATION
Construction Address: �
Legaf Description:
Owner Name � Address:
Contractor. _ �A HO SERVICES, INC.
Address: Home Deopt Installed Sales
3200 Cobb Galleria Pkwy.Ste. #200
Atlanta, GA 30339
� 763-542-8826 BC-20268257
�001/001
:.,.�...: ..
Effective 4/1/2004
(763) 572-36Q4 Bldg Insp
2 (763) 571-128� Eax
����1� �����
MN LICENS� # �
Tel. #
� Certiflcate of Survey af the
truction drawn on it to scale.
DESCRIPT►pN OF IMPROVEMEN7
LININa AREA: Length �dt1� �,�' Height,_ �. Ft
GARAGE AREA: Lengtfi ,�^ �dth Hefght �_ S. Fi
bECK AREA: /, 7 LeneEh . ur.�.�. ... . p .
o-�-t�;
� �yvv��u��u .7 f'L.
C� �"1 /� l�i n� �� A/� ��i �r,.. �rb
�%
Construction Type: Estimated Cos� $� , vs 5. � �J
Drivaway Gurb Cut Wdth Nead�d: F� + 6 Ft = Ft x$ _$
DATE: � .��r% •�� APPLICANT: Tel. # ��'���� •�A�'�,
Caq (763) 672-3604 for Permit Fee.s if ma7;ng in applicabon. Fr�x to 763-571•�f287 if using credit c�rd and we witl call
you for card r�umber.
Permit Fee
Plan Review
�re Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
CPfY USE ONLY-
� �. .��`�
Fee Scheduls on Reverse Side
� "`�— 65°/a of Permit Fee
$ .001 of Penni� Va(uation (1/10fh%)
$ - $.50/$1,000 Valuafian �
$ $1350 per SAC Unit
$- $5.00 (Staie Licensed Residenfial Contra�tors)
$ Alt. "A�� or AI�. ��8�� qbove
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
� Agreement Necessary [ ] Not Necessary [ ]
TOTAL $ . � STIPULqTIpNS:
! ��� v
•. s
. ,, . -
Building WATER OR SEWER PermitNo.: �v���t�
Inspections PERMIT APPLICATION Received By: /2
763-572-3604 CITY OF FRIDLEY vate xec'a: �/i �'
763-502-4977 fax EFFECTNE 1-1-08
APPLICATION DATE: S 11 qla d� YOUR E-MAIL ADDRESS: �r�� K� � J'r�7r7 e� �• � 0 YY1
THIS APPLICANT IS: 1�'CONTRACTOR ❑ OWNER
JOB ADDRESS: � rj7 � 1'G�1 G� � �. �'VC, (�1�
NEW CONSTRUCTION PERMIT # (IF APPLICABLE):
PROPERTY NAME � m i �� b
OWNER/ ADDRESS: 7 0� ►'tf CITY: ` t STAT'E1'ri�, ZIP:
TENANT PHONE: 1•$57
CONTRACTOR NAME:
SUBMIT A COPY OF ADDRESS: ' STATE: ZIP:
YOUR STATE LICENSE PHONE: � ELL PHONE: ii
AND BOND STAT'E LIC: �ms� � A E BOND: � X:
PERMIT TYPE
❑ SEWER CONNECTION PERMIT $50
❑ WATER CONNECTION PERMIT $50
L�WATER/SEWER LINE REPAIR PERMIT $40 �j�s `''
�D STATE SURCHARGE $.50 r�
❑ SAC CHARGE @ $1825
TOTAL y o s�
OTHER CHARGES (1F APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST SEE UTILTl'Y BILLING
SPECIAL ASSESSMENTS SEEFINANCE
WATER TAP SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHLJT-OFF / wFB�i•ms & xor.maYS $125 / HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMTl'-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and I acknowledge that the information above is complete and
accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit work ' t t s ' out a permit.
SIGNATLJRE OF APPLICANT: PR1NT NAME �G\�. �� ns DATE 8 I 9Ib �
APPROVED BY: DATE
COPY GIVEN TO: ❑ UTILITY BILLING
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977