AF - 45506Village of Fridley, Minn.
BUILDING PERMrT
N° -. 7 21 Oi�ce of INSPECTOR OF BUILDINGS
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Architect Frid2ey, Minn., ' "' • 19 �*'
Builder �"'�'
� LOCATION OF BUILDING
No. r�� �r [,m � �Street ,r� � ��.'�,��,c�„�+e�. F`..G.`�°" ' �� ��. Part of Lot �. � � . F
aG iw%�'�yP� �!°''�r �a,-,�
Lot ��. Block Additioa or Sub-Division
� � �
�ESCR.iPTY01� OI' BT.TILDIP�G
< 9;, � ,
F.ront ^� �' Degth Height Stories '� "`� 1VTanner of �onstructian ° � "`
T'o be used as � � °° ' �'a be completecP � '`�sti�atiec� �ost
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aL.w`v �r'�"�1""''a �"�"� e ^�u4:,w.�c,,,.,,<�t_.e�n,...� -� �� u'7' . .�` � �`. �z��t..m., �:,fx . _ `f��-=4. e,.. ��..,,.. ;.,�� ..
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Permit is hereby graated to �...�.�.� ..t',:,; �' s��� �:.���- � r «e �.. �,..,.�,�,- � :,d+ .��..;�.., .,r.�.�..,»�
the building v�-"'=- described in the above statement. Thie permit is granted
upon the espress condition that the person to whom it fs granted, and hie agents, employees and workmen, in all
the work done in, around and upon saici building, or any part thereof, shall conform in a11 respects to the ordi-
nattees oP Fridiey, Mina., rega.rdfng the construction, alteration, ma3ntenance, repair and moving of buildings
within the city limits, and thia pernait may be revoked at any time upon violation of any of the proviaions of said
ordinances.
AGREEMENT AND SWORN STATEMENT
In consideration of the issue and delivery to me by the Inspector of Z3uildings 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 oi Fri�dley, and, being first duly
sworn, I hereby sta,te and say that the facts stated by me and conta�ned in : the above permit are
txue as therein stated. � w�,�' ��� � f� �,,���,;,,�
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Subscrib�d and sworn to before me at Fridley, Minn sota, this �' ''''`''�l ' -
j� ,- .,,� �'� ,
dsy of �»�``�;--.::��.,.,�t -.f;,�.f.��,.,, A.D. 19��. �a��-��_.�-F��.;��,�..�.��,�-�-��.�....
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City of Fridley, Miun..
BUILDING PERMIT N° � s o s��
..�. � � � ,
Date: ._od...,.�:..°"�`-.... /�-�""n..---�--•-�---......._�.------......----...._...........
^ �...'.
Owner: ....'���. � . Builder -- -'�-------..._.._._..........._._......_._...........___......
� ' ..
... ........ .... ...... ,..........-:iC".....�.
�� �� � ��� .........................-----_....----
Address.................._. ...._ ._.........._ � .._. :...--- .��� � Address _.. ---....---.......... ...: ....���,�.,�......_.........----......................
LO TION, OF` UILDING
Na�,,.'r3...��,z...s.�....... Str,eet .... ..._ -.�. � - �- �----...! �..(�.-..i..---....... Part of Lot ....__
Lot .......; ��..r�-:....... .. Block ....._ ........ ............ -- - - - - . Addition or Sub-Division/,��"`""'°"_..,v..:._ ----- � �� -�� � ----f•••.-+P'�.'..*--....._.- -
Corner Lot ..-- ..............._.............. Inside Lot ..- ....._�"'''/........... Setback ....._._��....�.L.:'................. Sideyard ..........�..._......_--.........................._..._...........
Sewer Elevation ......... ......... -..........- .._......... -.........- .................::...... Foundation Elevation ... -�-..... ........._................... --......
. ....................... .� -.........
DESCRIPTION OF BUILDING
To be Us�d as.•:
�'�� ,r '
"�"" �,'� .� r� t°,,+ _ �" i� ,F ,�'., ,,, .r �e',��r � , �� �
f ff.._. _. Front ,,.�. ._:....._ Depth 4;a �'.. Height t.,_�_._ Sq. Ft.r.!`__,!" =_:. Cu. Ft. ....�.. ,"- "-..
. ._ � � '`
__.._......._.__.......� _ _..__....._.. _. _._ r ront ..............:......... Depth _ __._ ._....... Height _ ......____ _... 5q. Ft. ... __ _.._.. ..... Cu. Ft. .......__ ......_....
Type of Construction _..._..... _......... _.._... Est. Cost ._..._.._ _....___...... To be Completed ..__ ...........
_ ... ___ -..
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In consideration of the issuance to me of a permit to construct the building described above, I agree to do
the prnposed wo�k in accordance with the description above set forth and in campliance with all provisions of
ordinances of the city of Fridley. ,,
In consideration of the payment of a fee of $�_�....��""'"......."� ............. permit is hereby granted to....._....._..._..._.
.....__.........__._.........__..........._ ............._........ to construct the building or addition as described above. This permit is granted upon
the express condition that the person to whom it is granted and his agents, employees and workmen, in all work
done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings
within the city limits and this permit may be revaked at any time upon violation of {iny of the provisions of said
o�►�. ��� �
�
Inspector
NOTICE:
This permit does not eover fhe eonslruction, installafion for wiring, plumbing, gas heating, sewer or water. Be suro fo see � ;
the Building Inspecfor for separaie permits for thesa ifems.
4
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
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Na
Lot
LOCATION OF
% � (O� , Stree�„ /.�l'i1-�.�..ci% _..�Lr"% _ Part of Lot
��� ga,o� Addition or Sub,Div. �-���: — •� ��'....=_
r
Corner Lot� naide Lot� 3et Back ,�, Side-Yard .��_, ,____.
. .,._.,.
SEWER ELLrVATION FOtJNDATION ELEVATION
Applicant attach to this form Certificate of Survey of Lot and proposed building
location.
DESCRIPTIOIv OF BUiIDING
To be used s
� Front _.� eP'� ���t ----
Sq. Ft. r�D Cu. Ft. �r D �
���--�--
�'ront Dept,h Height � ___._
Sq. Ft. Cu. Ft� �
�pU
Type of Construction ���� Estimated Cost ______
To be completed
�'he uhdersigned �ereby makes application for a permit for the work herei.n specified,
agree3.ng to do's1I. work in strict aceordance with the City Ordinances and ruling of
the Department of Buildinga, and hereby declares that all the facts and representa-
tions stated in this application axe true and correct.
DATE SiGNATURE
(A 5chedule of k'ee costa can be found on the Reverse S3de.)
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Building
Inspections
763-572-3604
763-502-4977 FAX
r
DATE� �b O �
SITE ADDRESS � G
THIS APPLICANT [S:
PROPERTY NA
OWNER/ A�
TENANT
PLUMBING Pennit Ivo.: Z
RESIDENTIAL APPLICATION Re�eived sy:
, CITY OF FRIDLEY Da�a�
_ YOUR E-MAIL ADDRESS
OCONTRACTOR
�
. i
CITY f"/e��JL E� STATF/�'INZIP�S�SZ
PHONE:�� 5��,%� �C)" Q Sl % %
CONTRACTOR NAME:_S�j �
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE
PHONE FAX
PERMIT TYPE I �INGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�tEPLACEMENT
cC Nous�
❑ TOWNHOUSE
S.�/fit l- O ! � i//4L.✓�
FEES ARE BASED ON SI0.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER�OF EACH BEI,OW). MINIMUM FEE
535.50.
BATH SINIULAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($
_ CLOTHES WASHER I�ITCHEN SINK WATER CLOSET BACKFLOW PREV. $1 )
_ DISHWASHER _ LAUNDRY TRAY WATER NEATER {$35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
I hereby apply for a plumbing 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 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 all work which requires review and approval of plans.
SIGNATURE OF APPLICANT (/�ff�l'- PRINT NAME �d S S L.��SC�% DATE ��6 O
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
Engineering
7b3-572-3551
?63-571-1287 fax
WATER AND SEWER
PERMIT APPLICATION
CITY OF FRIDLEY
EFFECTIVE 6/9/09
APPLICTATION DATE:
THIS APPLICANT IS: ❑ OWNER /C��'CON
JOB ADDRESS: � S�6 L1 A' YE
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME:
OWNER/ ppDRESS: CITY
TENANT
PHONE:
COIVTRACTOR NqM : r
SUBMlT A COPY OF ^
YOUR STATE �DRESS:
LICENSE WITH PHOTiE D CELL PHONE: �
APPLICATIDN STATE LIC # __ STATE BOND:
YOUR E•MAIL ADDRESS:
i���
1. Narrative/written description:
��r•�':.�� � . ,. �
�
Permit No.:
Reeeived By: .t� -� �
Date R�� t,��i� �
ATE ZIP,
AT�Z(P
�----- AIR GAP �
2. Please attach sketch showing curb tine, utility iine, building, etc. with distances.
PERMIT TYPE
❑ SEWER CONNECTION PERMIT
[J WATER CONNECTION PERMIT
❑ WATER LINE REPAIR
C�' SEWER LINE REPAIR
❑ ADD STATE SURCHARGE
r SAC CHARGE @ $Z000 =
$50
$50
$40
$40 �'
$.50 f J�
�� ��
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / WEEtcENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
I hereby app�y for a water or sewer (new connection or repair) permit and 1 acknowledge that the information above is complete and
accurate; that the work will be in confo nce with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit o is n ithout a permit.
.
SIGNATURE OF APPLICANT PRMT NAM • DATE: O
APPROVEDBY: w.,,,.,,���4...,.,...,'a �
"�" DATE: � � '° �
96
COPY GI��N TO: ❑ UTILIT�' BI�LING (only if new meter) D PUBLIC WORKS I�' ENGINEERING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
' 763-572-3551
FAX: 763-571-1287