AF - 45464N° 892
Village oi Fritlley, Minn.
BUILDING PERMIT
Oifice of INSPTGTOIZ OF BUILDINGS
Owner �..�.�°�� ��� � �.�,�'°•-�m�,� -R. _.��..,�,,., r
Architect
Builder
�,,.., ; �� . �,,�.. �,,, . �,,,
Frid�ey� Mi2lri. I ,.�- ....�,,,.,a_ .t � .., � � lg ....,t
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LOCATION OF BUILDING
No. � . -•,F t, ,r' :..,� Street � .�' ?� �...�,�r �-�,,� �:.. ,. Part of Lo+ --
Lot Block,_ Addition or Sub-Division
DESCR,IPTI�II�TT OF BUILDING
Front� Depth� Fieight�_ Stories_�L BRanner of Construction � �%'�-�' �..
To be used as �'�� ��'(j.��di1E t�{� To be completed 1 �� �stim�,teci Cost
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Permit is h�ereby granted to � �.,� f �= �. . , . �.. r . E. _. �� .. , � ,��« , : _ „� ,. � :,, �_ ., . ,
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the building '�� "' described in the above statement. This permit is granted
upon the express condition that the person to whom it is granted, a.nd his agente, employees and workmen, in all
the work done in, around and ugon said buildfng, or any part thereoP, shall conform in all respects to the ordi-
nances oP Fridley, Minn., regarding the construction, alteration, maintenance, repair and moving of buildinga
within the city limita, and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances. ,_ , '�ti
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�"'`�^,�° ' ° ,�'r �°� �;w,�� ° -P 8'
r` � �� 3:.. �+'° : Tiis ector'of Buildin s.
�_.—°,...� -
�AGR,EF'MFN'�' AND SWORN STATEMENT
In consideration of the issue a,nd delivery to me by the Inspector of Buildings of Fridley of
the above permit, I hereby agree to do the proposed work in accordance with the description
above set forth and according to the provisions of the ordinances of Fridley, and, being first duly
sworn, I hereby state and say that the facts stated by me and contained in the above permit are
true as therein stated.
Subscribed and sworn to before me at Fridley, Minneso�a; this �=�
.
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Building
Inspections
7. 63-572-3604
DATE ��', �'�'7
S.ITE ADDRESS ��J�
THIS APPLICANT IS:
....
MECI3ANICAL
RESIDENTIAL APPLICATI()N
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
O OWI�IER d�L°•OTITRACTOR
Permit No
Received By �
Date Rec'd: t`�`�
PROPERTY NpME: �� ��
OWNERJ �DxESS: �SIQS C`���:��, F''�� —
CITY �� � � � ' + STATPi�1Al ZI��
TENANT PHONE�t -�Z `9 S7
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WI'TH
APPLICATION
PERNIIT TYPE
TYPE OF WORK:
COMPANY NAME: ' "' " _ .
CONTACT PERSON: � �
STATE LICENSE # EXP DATE
CITY � ��=�-� STA7$��% ZIP�'U3
�+nDRES s� 4�i f� 1.�� r�,e iJ✓
PHONE � t03° �%3 �y'1 S�I ? FAX �i4� � 3-i� � -
0iSI1�3GLE FAMILY ❑ 7W0 FAMILY
�j �W �L�.$EPLACENCENT
❑ TOWNI-10USE
❑ qi,TERATI0N1REt�iODEL
DETAILED DESCRIPTION OF WORK �� t ��` ��'
PER MS 16B.b65 the pernnit fee is a minimum o aen5'� fxture� xcluding the fixtw-es� (Ths Ohouldlreflect only there st of labor )
improvement, insta.11ation or replacement of a resa �
Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost af labor Y_____
x.05=
FOR PROJECTS WFIERE 1.ABOR BXCEEDS $500, FEES ARE BASED ON 510.�0 PER. FIXTURE, EXCfiPT WHERE N�T�DSI �rUU�U �� VATE TOTAL
TIUNBER OF EACH BELOW) �,G. �� MODEL. �)�������±
Equipment Installed . , MODEL: 5��� --�—
MFG: �— SIZE/BTL3 _,�
�G: MODEL:
FTREPLACE (GAS) $15.00 GAS RANGElOVEN $10.00
AJC $25.00 _FIREPLACE (WOOD) $35.00 _NEW GAS GW1-L $1D.00
_AIR TO AIR EXCHANGEER $15 LF�yACE $35.00 GAS UNlT HTR $10.00
BOILER $35.00 _G,qg DRYER $10.00 ^POOL HEATER $35 �0
_CHID4NEY LINER S10.00 �AS pIpING $10.00 VENTILATOR $15.00
—
nUCT WORK 510.00 �.x:���� �4.,.�,�.T,.,�:: �`��'���� <. �����������"�� _
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q . .�'b.� _........ � � � . .+R.:'��t•.v Y.�. k ta:.....'.'.J.�:... . - �. .
Ja�. J�.,, ,� i�. f.,x.'.....,.<. . r. . .. . .. ,. ..�.:.. ..
Permit Fee $�_• Number of fixtures @$10.00 x$10.0o-; —
Surcharge $ .50 Number of fixtures @ $15.00 x $15.00 = �
TOTAL DLJE $ Number of fixtures @$25.00 x$25.00 =$,__
Number of fixhues @ $35.00 (, x $35.00 = �_
State Surcharge = $
Total = $,_ -5v
THIS IS AN APPLICATiON FOR A PERMTT-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 �and1workFslnot o startlw thou a permit; th t theCVaork w 11 be�'in� ccordance withlthe
not a permit but only an application for a permit
approved plan in the case of all k w ich r uires review and appro��al of pl s. f
pRiNT NAME DATE � �
SIGNATURE OF APPLICANT , ...�,.,. :�,-.�:;�.>�.a��:.�-,..�. ,.�;;�T�,7,.��-��
City of Fridley
Building Inspections Department .
6431 University Avenue NE, Fridley, MN 55432
763-572-360A-
� n v• ��'�_5n7-4977