AF - 45414_
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C�TYOF
FRtDLEY
FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(612) 571-3450 • FAX (612) 571-1287
November 30, 1992
Bailey Tiller
c/o Jerome and Ann Tiller
1555 Gardena Avenue N.E.
Fridley, MN 55432
Subject: 1535 Gardena Avenue N.E.
Dear Mr. Tiller:
I am sorry to hear about the recent loss of your home. Your son,
John, contacted me last week as to whether or not a temporary water
meter could be installed on the storage shed on your property. The
purpose of this letter is to review the procedures necessary to
install the temporary water meter.
I advised your son to have his contractor obtain a repair line
permit in order to remove the existing water meter in the destroyed
basement of the home and to connect it to the storage shed. After
your new home is constructed, the water meter on the storage shed
must be removed and the water lines must be connected to the water
meter on the new house, similar to the arrangement that you had
originally.
It is my understanding that you need the temporary water meter in
the storage shed in order to use the toilet facilities during the
day. The storage shed cannot be used for overnight living
arrangements or as a dwelling unit.
A certificate of occupancy will not be issued for the new home
unless the requirements of this letter have been completed. For
our records, please sign this letter below and return it to my
office to acknowledge the above conditions. I have enclosed an
extra copy for you.
Should you have any questions, please feel free to contact me at
572-3590.
�"in erely,
%
- , �-
rba a Dacy, AIC i
Community Developm Director Baile iller
BD/dn
C-92-344
SUBJECT
c�cy of Fridley 217 5$
AT THE TOP OF THE TWINS g U I L D I N C P E R M I T
r
� ` RECEIPT NO.
_�����_ COMMUNITY DEVELOPMENT DIV. �� �
r � ~ � PROTECTIVE INSPECTION SEC.
� i
� � r"�1 � CITY HALL FRIDLEv 55432 NUMBEii REV. OATE PAGE OF APPFOVED BV
�""'�'� ,'� 612-571-3450 9t0-F15 3/8/93 / /
JOB ADDRESS 1535 Gardena Avenue NE
t LEGAI �OT NO. BIOCK TRACT OH ADDITION SEE A7TACHED
oesca. Pt. 20 Auditor's Subdivision #92 SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Bailey/Marie Tiller
3 CONTRACTOR MAIL ADDRESS ZIP PHONE UCENSE NO.
Rainbow Construction 1715 133rd Lane NE, Ham Lake M13 55403 867-7557 7057
0 AFiCHITECT OR DESIGNER MAIL AODRESS ZIP PMONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
6 USE OF BUILDING
Residential
7 CLASS OF WOfiK
� NEW ❑ ADDITION O ALTEiiATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WOHK
Cons.txuct a 54� x 26� D�elli,ng; a 2�� x 26� Garage; and a 10' x 12' Deck
9 CHANGE OF USE FROM TO
STIPULATIONS �ee nQtations Qn plan. Provide sod in ths front and side yards. Provide
City �ntith.cppy o� verif.ying survey before capping. Provide a hard surface driveway.
SEiniER LQCATIC�i : t:heck with Engineering Dept,
WATER LOCATIpN; Check with Engineering Dept,
Original sewer & water connections for house were relocate������p shed�on
northerly part of lot 20. �
Befare dfgging catl for
DRIVEWAY CURB CUT: TO BE DETERMINED IN FIELD. SIE �lMy IQC�jdR$
�-�
SEPARATE PERMITS REQIlIRED FOR �EQ�lRE� BY �VI/
IRING, HEATING, PLUM
• TYPE Of CONST. OCCUPANCV GROUP OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING.
VENTI�ATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULI AND VOID IF WORK OR CONSTRUCTION ZpNING SQ. FT. CU. FT.
AUTHORI2E0 IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTpUCT10N
OR WORK IS SUSPENOED OA ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFV THAT i HAVE READ AND EXAMINED THIS APPL�CATION 1- STALLS GARAGES
ANO KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROYISIONS OF LAWS VALUATION SURTAX Fire SC
AND ORDINANGES GOVERNING THIS TYPE OF WORK WIIL BE COMPUED $113 78� $56.90
WITH WHETHER SPECIfIED HEREIN OR NOT. THE GRANTING OF A PERMIT { 113. %H
DOES NOT PRESUME TO GIVE AUTNORITY TO VIOLATE OR CANCEL THE pEqMtT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGUTATING CON- $(HS.SO $%SO.00
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
_ f � PLAN CNECK FEE 70TA1 FEE
l� License SC $5.00 $1,614.18
Si uaEOFCONTRAC?OAOR THORIZEDAGENT �DA7Ei H P PER V IDATED THtS IS YOUR PERMIT
� � 3 -8°9�
SiGNATUREOFOWNERUfOWNERBU�IDERi iDATEi BLDG �NSO ��FTE
�W C l
ADDN [ ]
ALTER [ ]
Constiiiction Address
Leg�l Descripdon:
Effective 1/1/93
CTfY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
�����
�7�
Owner Name & Address: 2�- , � Tel. # 7 S� S- 17� �
Contractor: ;� MN LICENSE # 7 G S 7
Address: I � i S � �� �I . 1 � � •� - Tel. # � 7 - 7��
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale. '
LIVING AREA:
GARAGE .A.REA:
DECK AREA:
OTHER:
DESCRIPTION OF IMPROVEMENT
Length � Width z (o Height � � ,
Length �_ Width ,� � Height�� �
Length ) p Width _�_ Hgt/Ground/�
�
Sq. Ft. �1��_
Sq. Ft.
Sq. Ft. ZG
Corner I.,ot C y' �nside �.ot � j Ft. Yd Setback � Side Yard Setbacks 1 7, s f"
Type of Construction: � C� � t� � F1 rN1. � Estimated Cost: $_ (o �I p a o
r-
Approx. Completion Date: �1� U F � q3
�— (Cost on Back)
Driveway Ctu'b Cut Width Needed: �Ft. + 6 Ft = 3�Ft x$ _$ �
DATE: 3- - APPLICANT: (� Tel. #��"] - 7 SS%
� %S''% - QG�1�
CITY USE ONLY
Permit Fee $�� , D Fee Schedule on Reverse Side
Fire Surcharge $/�3, �g .001 of Pernut Valuation (1/20th9b)
State Surcharge $ Jr( • 9v $.50/$1,000 Valuadon
SAC Charge $%�D . O� $750 per SAC Unit
License Surcharge $ �i �$5.00 (State Licensed Residential Contractors)
' - � �' Alt. "A" or Alt. "B" Above
Dnveway Escrow _ - -r - !" •
Park Fee $ Fee Determuned by Engineering
Sewer Main Charge $� Agreement Necessary [] Not Necessary []
TOTAL ��'��
�%�/�, /c�
STIPULATIONS:
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St1RVEY FOR:
DESCR19�0 AS:
LE ROY N. �1IIyNER � ASSOCIATES, lNC.
.�G�sd �'rv�.uei�
[�9iti1�•�d V�d�r la.� of Srol� o! Mieu��►ob
8398 Cent�r Orive • M+nneoPolis, Minn. SS�32
Phone 784-0210 •
�ERTI�ICATE OF SURVEY
City of Fridle;� •
See attached legal description.
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CXTERIOR ENVELOP� AVERAGE "U" COMPUTATION
OWNER � ���--��'� AN `O V�`1\��� ` � ���� �
SIT� ADDRESS
C ONTRACTOR 'Q—'Q\`N `�:O VJ Cp r•I ST DE�TE �-��� ��3 PHONE `�1 �`1 - � Co� `�
Determine working square footage of each.
1. Total exposed wall area ...�3�2 sq. ft. x 0.11 _ �� ,�� �,� ,
2. Total roof/ceiling area ...\��„�'j sq, ft, x•026 ����� o�
Total exposed wall area above floor = �`�q 2_
A. Total wall window area . . . . . . . . . . \��.yq �
B. Total door area . . . . . . . . . . . . . �q � c��
C. Total sliding glass door area ......�o�,a��
D. Total fireplace wall area. . . . . . . . . p
E. Total wall framing area (average 10%) .. �_'�y , 2 p
F. Total net wall area above floor ..... �'� q-Z,o �
G. Total rim joist area . . . . . . . . . . . � �o. � p
Total exposed foundation area =
H. Total foundation window area ...,... 3'2,d d
I. Total net foundation area above grade ., �,�,o Q
Determine "U" value of each wall segment.
a. �� \.yg, x ��U�� _2.� = 32 .3�r
b. �.r,�.'�G� X��U�� ' 0 6 �T_ = 2. S�
c . '� a . �l f� X ����� ,,�•..L - _� . "7 �
d. p � X ,�U„ �_ _ �
e. �'3 a1 � 2 o x ��U�� . � �?� _ \� � �S
f. \'� a 2. o o x��U�� _ n�\ � _ .S'1, b")
g• � �O . S O x '�U�� wS"� �q . _ -S- ��
h. � 2, oc� x„U�� _ Zp� = aF .2�
i. �'1. op X„U„ . O� 2= r1, �:`�
3. . . . . . . . . . . . . . . . . . . . TOTAL =
If item ��3 is Che same as, or less than, item ��1, you have met the
intent of SBC 6006 (c) 2.
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Total exposed roof/ceiling area = ��-��,�
J• Total skylight area• . . . . . . . . . . p .
. Total roof/ceiling framing area . . . . . �
L. Total net insulated roof/ceiling .... '?
�`� Determine "U" value for each roof/ceiling segment.
.
�. ��j. � X ��U�� _ 0
0 k. X ��U�� _
f 1. X ►rUt� a07 �Z ..
/ 3 � D.
4 . . . . . . . . . . . . . . . . . . . . TOTAL =
3�.0 3
If total of ��4 is the same as or less than 4k2, you have met the
intent of SBC 6006 (c) 1.
Alternate Building Envelope Design
To utilize the total envelope system meChod, the values established
by the sum of items 4k3 and ��4 shall not be greater than the sum of
items ��1 and ��2.
i. �s 3,�� + 2. 3�. o� _`�.2�
3 . � y 3 .'1 � + 4 . ` '� 2 . 2 3 = '1 � . O 2
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A. TYPICAL WALL SECTION "R"
1. In�erior Air Pilm ��
2. Interi.or Wallboard . 4 S
3. Insulation �_
4. Exterior Sheathing �i.� 1_ U
S. Exterior Siding �� R
6. Exterior Air Film y��
Total �� U =,��L�C�
STUD & I-IEADER AREA
Total Area No. 1
Less Insulation "R"
Plus 3�" Softwood
Total
B. RIM JOIST AREA
I
�2x (�
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_Z� • \�
U_' ._�_.�
20. '�a, �
�-�-�31 = U S, ��
y, s� K �9��._
��.�Su = O�� �z.`4�.
�l= .O$�
1. Interior Air Film ,��
2. Insulation ��_
3. 1'�" Softwoad a� °g
4. Exterior Sheathing 1= p
5. Exterior Siding � R
6. Exterior Air Film �_
Total ��.4 � U = .���j
C. FOUNDATION WALL AREA
1. Interior Air Film
2. Insulation
3. Insulation (Block)
4. Exterior Air Film
Total
D. ROOF/CEILING AREA
,6�
� 0..� 0 a,..
_ _2, 03
.__�.c� 6.
_. 1.,_.�'7�.y.,
_ ...,..a.\�.._.
.�.5.'7 6
� = .039.
. �°� .1v�._
�— ��.o 0
�1 = U -- �.-%Z�b ..
R —�----1�1---
�.Z�.L3 U ° ..� Z � s ��
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1. Interior Air Film ��_
2. Interior Wallboard •5^ 1
3. Insulation 0�_ 1= U
4. ExCerior Ai F�. m •�� R
(Still)
Total 3g•3� U = �S
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� � ' �1� � 3� %'� ` Minnesota Well and Bonng ,
WELL OR BORING LOCA N �1UINNESOTA DEPARTMENT OF HEA�TH Sealing No. H i Q 3 7 Q
County Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No. L v V
� v � Minnesota Sta�Wes. Chapter 703i or Wse�ies No.
deave b�ank il ooi wnown�
Township Name Townsh�p No. Range No. Seclion No. Fraclion Ism. • Ig.) Date Seaietl Approximate Date Well
� � (. r 3t� �/ �.3 "' �a �L•�i��ic � � �' or BOring Con � eQ�� (`
y J
Numencal lreet A ess or Fire Num r and City of Well Or Boring LocaGOn �,�i
/�3 • � Depth Before Seai�ng fi Original Depth J /� U �I
Show exad location ot we11 or bonng Sketch map oi well or bormo Static Water Level ❑ Accurefe
m secuon gnd wdA "X`. bcation. showing propeny Iines.
roatls. and b ildi gs �Approximale
N
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' �Sing�e Aquder ❑ MuNiaquiter --�� fl. �-- betow above land sudace
i � i
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W -� � � � � u /Y!=
� � � �
-r -y- -r- -r ,�,/
i i � i �� I� Steel ❑ P�astk ❑ Tik ❑ Other
e mik
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S --- � Screen �rom �-tJ-=— to --/�= : bpen Ho�e trom to fl.
�— 1 mik --� ~_ � � �' OBSTRUCTION/DEBRIS/FILL
PFOPERTY O�WN 'S NA��� �Obst�udion ❑ Debris ❑ Fill / �� f
Type o1 debriyobstrudion �,/ �� ��� /� � /��
Ma��1ng Atldress d d ent than propeny atldress indicated above.
ObstruttioNDebris/Fill removetl? �Ves ❑ No
PUMP
_... _ —�� �--- - ----- -- -- -- .. —_— _. ----_.—_ . .
e .�Removed �NOt PreseM ❑ Other `�/J' v�'t � u � ! '
CASING
GEOLOGICAI MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Se1 in oversize hole? Annular space inilially grouted?
tl not known. indicate estimated formation log trom nearby well or boring.
in. Irom l0 11. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in.lrom fo fl. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unk�own
in. irom to H. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BOHE HOLE:
❑ No Annular SpaCe Ezi515
❑ Annular space grouled with tremie pipe . . .
❑ Casmg PedoratioNRemoval
in. lrom to H. ❑ PeAorated ❑ Removed
in. lrom to ri. ❑ Pedarated ❑ Removed
Type of peAo�afor
❑ Ofher
GROUTING MATERIAL _
� /
Groutingmaterial �Uf'�^ ��� from `� to � ft. yards � bags
lrom to fl. yards bags
.REMARKS, SOURCE OF DATA, DIFFICUlT1E5 IN SEALING
irom to fl. yards bags
lrom to fl. yards bags
UNSEALED WELLS AND BORINGS
� Other unsealed well or boring on propeny? ❑ Yes I�Jwo
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance wifh Minnesota Rules, Chapler 4725. The inlormation contained in ihis repon is
true to the best o1 my knowledge.
tl�,;e�� �Y,e�l9 C� .� % D %� .3
Confraclor Business Name License o� Regisfration No.
/ .�T/f[iG(/� v _/� � ��
Aut rized Representative Signarure Daie
I'�:rOFTK�T—FiLE VJITH FROFEP,N u /� Q�] � Q .CJiC/�� �"'�
Ff,'rERS-1'1ELL Ol'uNER CCr'Y n L, �) J p Name ot Person Sealing WeU or Bonng
++E•D'a34•Ot
-
_
CITYOF
FRIDLEY
FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(6l2) 571-3450 • FAX (612) 571-1287
June 11, 1993
Mr. Chris Viger
Rainbow Construction
1715 133rd Lane NE
Ham Lake, MN 55403
Re: Final Inspection at 1535 Gardena Ave NE, Fridley
Dear Mr. Viger:
A final inspection was conducted on June 10, 1993 of the above address and
the following items were noted which must be completed before the structure
can be finaled: .
1. Provide sod in the front and side yards by August 1,
2. Raise egress window well depth before occupancy.
3. Cover inside styrofoam insulation before occupancy.
4. Cover outside styrofoam insulation by July 15, 1993.
5. Provide landing at garage door before occupancy.
6. Change maximum rise of steps to be no more than
occupancy.
7.
8.
9.
10.
11.
11.
iZ.
1993.
8 inches before
Install self-closer on door from house to garage before occupancy.
Complete fireplace.
Provide correct handrails before occupancy.
Provide draft-stop between basement and first floor before occupancy.
Secure sump cover before occupancy.
Send copy of well abandonment to City.
Provide City with copy of verifying survey by July 15, 1993.
We will expect these items to be completed by the scheduled dates and
reinspections called for. Occupancy of the structure is not approved until
the safety items listed above are completed.
If you have any questions on this matter, please feel free to contact me at
571-3450.
Sincerely,
CLYDE E. WILEY
Building Inspector
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, Building
Inspections
763-572-3604
763-502-4977 FAX
DA1'E 1(
STfE ADDRESS _
THIS APPLICANT 1S:
PROPERTY OWNER/
TENANT
CONTRAGTOR
SUBMIT A COPY OF
YOUR STA1E LICENSE
AND CERTIFICATE OF
iNSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
I U YOUR E-MAIL ADDRESS LI�o T�1 WL
� 3 � rr�r4lp,.� r,� %�CU�
❑ OWNER �NTRACTOR
NAME:
aDn�ss: ' ct��(�,Q�
PHONE: � ( p � 3 � ' t �. (I � � Q
.
NAME: l d iV� _,
STATE LICENSE # O I��DO f� EXP AA
ADDRESS:��/�_� s���I-1 � ��j��y'�O3 CITY r�
nvnwrc 'l�n%f.� 1���1� ��TI� C�v ��w�v
f°�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
O ADDITION O GARAGE/SHED
0 BASEMENT FINISH �tOOF
❑ DECK ❑ 5IDING
❑ SWIMMING POOL
SIZE
STORIES
❑ WINDOWS
O DRAfN TtLE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCI'ION 0 ADDI1'ION
1�MAINTENANCFJREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � �
SIZE OF IMPROVEMENT LENGTH WIDTH
❑ HOUSE ONLY
NU� F SQUARES � �IOUSE & GARAGE
GARAC� 0 ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
HEIGHT
Permit No.: 3 �
Received By: �
� ��'
STATEi�,�Z1P JT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structura! members to be used
FOR NEW CONSTRUC710N INCLUDING DECKS,
��IN� ADDITIONS_ & PORCHES SUBMIT:
0 Vitryl OSoffit 1. Site Plan/Survey showing the existing structures
❑ Aluminum O Trim
a 4tfier ❑ Fascia and ProPosed project.
2. Two sets of construction plans
WIlVDOWS 3. Energy Calculations
IN EXIST[NG OPENINGS OYes allo [ACATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENIIVGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDpW TO BE IN5TALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LA.BOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION
Permit Fee `�
Plan Review �
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � ,v v - . , ._
$ �'
S
$
$
$
� !.
S
$
$ i�.�_na —
TYPE
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Pernvt Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= Rx$24=�
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATTON FOR A PERMIT-NOT VALID UN'i'iL PROCESSED
I hereby apply for a building permit and I aclmowledge that the information above is complete and accurate; that the work will be in
confortnance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of whic wres review and approval of plan1s /� �
SIGNATURE OF APPLICANT *� ��� PRINT NAME 7�(,� LG,n, �l M,/ � � DATE_ �a—� lO
FOR
�
MINNESOTA DEPT. OF LABOR & INDUSTRY
Construction Codes and Licensing Division
P.O. Box 6421T
St. Paul� MN 55164-0217
0
C& D ANGEI.LS TRIM WORK INC
ANGELLS CONSTRUCTION SERVICES
16484 149TH ST
#103
BIG IAKE, MN 55309
: S#�e t� ll�ittnesota Cons#ru�tio�t �od�.s and Licensing Division
` ,��partm�n# of Labor and Industry Telephotte: {651) 2�4-5034
.; P.a. Box84217 E-rr�ail address: d�i.license@state.mn.us
,;; .- �t. Paul, MN 55164-0217 Website address; www.dli.mn.gov
' RE�1i���IT1AL BI��LDING CONTRACTOR LIC��iS�
E.ega! N�tt�e: ,�� M,� A�+t�`xELL:S TRIM WORK INC
���� I�NGELLS �ONSTRUCTION $ERVICES
Address: � 64g4 149TH �T
#103
BIG IAKE, MN 553Q�
Lica'nse Identi�caifion Number: 2@'i960i1
Lice�rs+a F.�pir�#on Qa�e; ��/31 /20y 2
Susinesa Structure:
CORPE3RATiON
' Qualifying Person: STACEY A ANGEiL -
Continving Edu�ation: 7' hours rsq�ired yearly
�
,.
CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD,
C&� 1 08/06
Apollo Insuraace Aqeacy
P O Box 1206
3t Cloud MN 56302-1206
Phone:320-253-1122 Fax:320-259-3890
C& D Anqeii's Trim LPork Inc
Aageii's coastruct'oa services
16+�84 149th 3t SE � 103
Siq Lake DIl�T 55309
COVERAGES
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTtFICATE DOES NOT AMEND, EXTEMD OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSl�2ERA: Cincimuti Ituurane� CaaOa*pp 10677
iNSUReR e: Americaa =ateratate Ins Co 31895
INSURER C:
INSURER D:
lNSUF2ER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REOUIREMENT, TERM OR COI�DITION OF ANY CONiRACT OR OTF�R DOCUAAENT WITH RESPECT TO WHICH THIS CERTIFICAiE MAY BE ISSUED OR
MAY PERTAIN, iFIE INSURANC',E AfFORDED BY TTE POLICIES DESCRIBED FEREIN IS SUBJECT TO ALL Tt� iERMS, EXCLUSIONS AND COrDITIOrS OF SUCH
POUCIES. AGGRECHTE UMITS SFIOWN MAY HAVE BEEN REWCED BY PAID CLAIMS.
LTR 8 TYPE OF WSI�iANCE POLICY NUMBER DATE (MMIDDNY71� DATE (MMIDD/YYY1� LIMrtS
c�►�u unsN.rtv �cri ocCURREracE $ 1, OOO , OOO
A X ca�acuu.c,o�n��weiurr CPP1073392 02/01/10 02/01/il pREMISES�Eaoccurence) s 500,000
CLP.IMS MADE � OCCUR N�D EXP (My one person) $ �.� � � � �
�asoruw a nov �N.iuRV 3 1, 000 , 000
X Slaaket AI-C7�A233 GEI�RAL AGGREGAiE z 2, 000 , 000
GENL AGGREGATE LIMIT APPLIES PER: PR�UCTS - CONF/OP AGG $ Z� OOO � OOO
POLICY �� LOC
AUTOMOBILE LIABILRY
GOMBINED SINGLE LIMIT g 1� OOO � OOO
A X�Y�'0 CAA1073392 02/01/10 02/O1/11 (Eaeccident�
ALL OWNED AIfTOS BODILY INJURY
SC�Dl1LE� Allf�s (Per person) $
X HIREDAUTOS BODILYINJURY
][ NON-OWNEDAUTOS (Perecciderd) $
PROPERTY DAMAGE $
(Per eccideM) .
GARAGE L1A8LfTY AUTO ONLY - E^. ACCIDENT $
ANY AUfO OTHER THAN � ACC $
AlffO ONLY�. AGG $
EXCESS / UhBRELLA LIABIUiY EACH OCCURRENCE S�. � OOO � OOO
A X occuR � aaensnnaoe CPP1073392 02/01/10 02/O1/11 �c��� S 1,000,000
S
DEIXICTIBLE S
X RETENf�ON S S
ArD EMPLOYERB' LIABII.flY
X TORY LIMITS ER
g�F� �iEr�R�a�� cunve a AV4QCI�i1789172009 02/01/10 02/01/11 E.L.EACHACCIDENT 3500,000
(M�ndatory In NiJ E.L. DISEASE - EA EMPLOYEE $ 5OO � OOO
If yes, describe untler
SPECIRLPROVISIONSbebw E.L.DISEASE-POLICYLIMIT $rjOO�OOO
OTHER
DESCRIPTION OF OPERATIONS 1 LOCAT10N31 VEHICLES! EXCLUSIONS ADDED BY ENDORSEMENT! SPECULL PROVISIONS
CERTIFlCATE HOLDER
sampie Certificate
CANCELLATION
SHOULD ANY OF TF� ABOVE DE8CR�ED POLICIES BE CANCELLED BEFORE THE EXPIRATON
DATE THEREOF, THE ISSUNG INSURER WILL ENDEAYOR TO MAIL ZO DAYS WRIT1�1
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 8UT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIA&LRY OF ANY KIND UPON THE INSURER, IT'S AGENTS OR
REPRESENTATNES.
AUiHORIZED9ePRESENTA7UlE .
) �T988-2009 AC
The ACORD name and logo are registered marks of ACORD
Buildi,}�g BUILDING Permit No.: oti�
Irr��ss�ections RESIDENTIAL APPLICATION Re�ei��
763-572-3604 CITY OF FRI L vate �t c�'d� 10
763-502-4977 FAX D EY
EFFECTIVE 1-1-2010
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER OCONTRACTOR
PROPERTY OWNER/ Nq�: l/� h ti � T u� C� L c.` t,�r, �!
TENANT ADDRESS: I �3 `� G.�..
�.�,�CITY�Ytoll.� f STA'tE�2ZZIP-�,�'�r �.L/
PHONE:
CONTRACTOR NAME: l�� C�hS�i-� .�-K— r/�.
SUBMIT A COPY OF � ��� 6�j 7 r EXP DATE
YOUR STATE LICENSE STATE LICENSE �!
ANA CERTIFICATE OF ADDRESS: I�o �F$�/ /GtGi' �" 5�, lj s�e �D� CITY /.3� l.c lct STA� ZIP
INSURANCE pHONE �� — '-v ` FAX �r.� "'d�C�J'2�C�2
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ O FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITIOt3 ❑ GARAGEISHED ❑ WINDOWS
�Q3ASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ 07'HER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: %^• -, . 5 � �3 z Sc G^ �^-�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
RO FIN 17 HOUSE ONLY
NtJMBEROF SQUARES d HOUSE & GARAGE BASEMENT REMQDELING SUBMIT:
I. Existing Floor Plan
GARA O ATTACHED GARAGE 2, Proposed floor plan
PROPOSED S[ZE: ❑ DETACHED GARAGE 3. List of structural members tA be used
PROPOSED HEIGHT:
SIDING FORNEW CONSTRUCTION INCLUDINGDECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1• Site Plan/Survey showing the existing structures
O Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES Rc
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
_QJSING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ �a� �% OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro!
Park Fee
Sewer Main Charge
Total Due
$ `� /u ���( -
$ I
$ (�
$ -
$
$
$
$
$ ---�--��a.�
THIS IS AN APPLICATIOP
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$45U Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridtey Attach
FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building 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 and with the Minnesota Construction Codes; that I understand this is not a
permit but onSy an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of ork which r ires review and approval of plans.
SIGNATURE OF APPLICANT f�`""`� G�� PRINT NAME !/�'t /TLrc�G l I DATE 1•�-.-- a- 3- l o
r �� �
� � �����
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