AF - 45644Vzllage of Fridley, Niimz.
BUILDING PERMIT
Da�e: . �r% .a�r.-,�f�..tf�...'.. �7�..........
� /'
Cwner�%� .�': i�il";1-1F'. . . f.� t9{ . x.��:YE.JI. . . . .
Address ...............:.
Suilde: �:�.�';'�
Address
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1421
....................
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` C.�. � � �oc�,a�r�io�v o a�,u.,,JiLj DII�IG '
No. ..I. ). °?.... Street . . � �YU..�J.UC.(�....�L .`�. �'. Part of Lot .......
n �}.,� 1 S /�
Lot ...:..��.i.... Block 11N�i-'�...'.��.+:�X , ( ......................
i7 /�
ddition or Sub-Division .... n.:.. ,:... .. 1..
y�t , � .................
Corner Lot ........... Inside Lot ........... Setback�F. V. �%�./. Sideyard/�:..�:���/;!�°�*
..............
C?�SCF2fPTlOI�! OF 6U{LDING
To be lised as:
i i C-`..... ; `��� p � ". ' -g ��.tF , 9 ,. '.
.,t,.•F �`.- Front'� De tn..::Y:.... T3ei ht s�. S Ft.;�:�. �s,. Cu. Ft. ........
li..C�.,....`....... Front .":�-.... De N� ���� Ize'eht << :f��� a Ft. ' �i..�..
, , P d�..:L:.. .m "q. :� ... Cu. Ft. ........
Type of Construction , ,.:,-:;:s.,.•.... �sf. Cost . � � � �� �-���°
'�- �� �` ` ... , To be Completed •:��„d, � ('"
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«.t .�.e..,ry�i� /'�y �'e+- 1,wP t::..ye.t¢ LE.r� � "-, k� �� ',h;,t.�r.�rw' . ' :.1_ p�.
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In consideration of the issuance tn me of a pernut to construct the building described above, I agree to do
the proposed work in accordance with the description above set ",th and in compli e with all provisIons of
ordinances of the village of Fridley. � ��
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Tm m�sideration of the payment of a fee of $!.-,\}..—T;--�, „ permit;i's hereby granted to 7.�� .i7-- .��
.. . .. ...........
� � �' : 9..r....., to construct the building or addition as�described above. This permit is granted upon
the eacpress condition that the.person to whom it is granted and his agents, employees and worlm�en, in all work
done in, around and upon said building, or any part thereof, shail conform in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, �repair and moving of buildings with_
in the village limits and this permit may be revoked at any timz upon violation of any of the provisions of said
ordinances. �
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�• . . . . .�.�: � � � 3!'-. ��:f7�I,.-Building Inspector
IVOTICE:
i� 7his permit does noY cover the construction, installafion or alteration for wiring, glumbing, gas heating,
sewer or water. Be sure to see th^ Building Inspector Sor separate yermifs for t`^se items.
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(�Y OF FRIDLEY � �
Applics�os for Instsllation oi �Vater and Bewer Bervice
This form to be completed before a tsp is made to any eacisting water
or sewer line. /� � �/
Lot ..��...... Block ......:........_._...... Addition C..C.GC�!..J�1X`.__ .%.2 .
-' Address .�.L..3.......:.._ ./...1l�---G_<.---.._--�'J._�.•v.�..f.re:e.�fS_../_ )
Owner ..__ _.. _�..t-.t_��.:G�/�...t_?.1....----_...�..r-_z.�
Piumber � ..�.._..YG�t.l�. �r_..__�.C...Q:. z.: /L. e �S
-. (thia pm�tion of form to be completed by person reguesting tap) �
CHARC:F,S TO BE PAID BEFOR.E TAP LS MADE — WHERE
ASSF.�SMENT HAS NOT BEEN LEVIED AGAII�TTST FROPERTY
Sewer ��Connect{on fee
. . . wStreet patch _.
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Water . Connect3on fee
� Meter depo�it
Msterials uaed
•Btreet patch _...
' Where applicable
The abwe applies fa� all regular residential Ri�p
mateltiate for �wster service
rwer, not to essceed $3.W a f�
AS3E6SP�RV'TS TO BE LEVIEP
D R
�ae�'S. �O'!J� —
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613'
]ae p1tt�Rbet'
a maxfmtm�
BSd..30
� Credit for material ..__............_..........._.._....
- � . Total assessment $......._ .............__.._.............
. Sewer Lateral $ ....................................._.....
` � � Credit for material 60.00
- � . . � Total assea�nent $._../..g�S.a2..3Q
Clerk's signature �Q/L1l1lrJ._i:..�tl�fp.�)
I hereby authorize the a ve tap �
_._..___..._—.._.....__......_.._..._......_.....:__ __........._...........---__..:.._._........_.....
lst cop�—Public W�ks Director aP Public Works
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GTYOF
FRIDLEY
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FR]DLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(612) 571-3450 • FAX (6I2) 571-1287
January 17, 1990
Mr. Norman Aerzog
115 Glen Creek Road
Fridley, MN 55432
SUBJECT: Plat Map
Dear Mr. Herzog:
PW90-18
Enclosed are two copies of a portion of the half section plat
showing your property. The scale of the map is approximately
1"=200'.
Sincerely,
% / � ,
i '���. . _ � �l � , �
Mark A. Winson
Assistant Public Works Director
MAW/kn
Enclosure
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6����� HEATING HOUSE HEATING TEST RECORD
PJR CONDITONING
AND EIFCTRIC. 1� ��
AODRE33 �I � G�Q'1 �-/ �� APT. FLOOH CITY 3UBURB
OCCUPANT .� ,�DJ' OWNEfl
HEATLOSS L[�'DA�_TE HTGJNBL Q) � � �
SOLDBY ,� w��*^^��� T�- INSTALLEDBY Jlq�
Etactrica� Work By O/n �� �- Q�-� _ _ Gas Llna By �( J I a�
TYPE OF HEqT GA FA / HW STEAM SPACE HTR. UNR HTH. OTHEH
R GAS DESIGN CONVERSION
MAKE� *� MAKEOFBUqNEH
Model Cal- McdN
Serial �/ 3 a / Max. BTU Raling
iNPUT '$ ...OLZ� pAKE OF FUqNACE
�1 CONTHOL9
THERMOSTAT T. ' HeatPlug
Valve _�
Limll
Llmll Setting _
Fan Sotting _
Pilol Typa _
Pila Maw—
Modal
�//
VaM Siu
K1ND OF LINEA (� �I SI� NONE
Dreft Hood � Repula�or
Fllten SISa�X x� Numbar /
Chimnay Location Insldo Outalda
ChlmnayCOnalructlon .i�(yG
Pilol Modal 7` Smok� Bomb Wiriny'
PllotTlminp �Z_ C� U.PLI - Drafl T�stTag
L. W. Cut Off � � Dcor Prossun r Llghting
Pressuro Paro�nICO� J Det�Ta1W � �
InputCFH P�rwMO� ��� CompanYTMinO 9�i '-
StackT�mp. }��_ PoroanlCO d Nam�ot7�Na �
f
Form 23S . �..
�5
�pF FiQ�_
� � ��
PUBUC WORKS
MEMORANDUM
TO: John Flora, Director of Public Works
FROM: Paul Lawrence, Superintendent of Public Works
DATE: July 9, 1998
SUBJECT: 115 Glen Creek Road
Outside Services and I met with Mrs. Herzog at 115 Glen Creek Road regarding clearing the Gten
Creek channel behind the Herzog home. Outside Services will contact Mrs. Herzog a couple of
days before they begin work, to aliow her time to remove the plants she wants to save from her
flower garden. Tentatively the work is scheduled for early August, and will take about one day to
complete. Outside Services' hourty rate for labor and equipment is $225 per hour (log skidder
and four personnel) for total estimated cost of $1,500-$2,000.
The cost of this work may be covered by FEMA funds, as the tree fell into the channel during the
May 15th storm and clearing channels is one of the items covered by the FEMA guidelines. I will
have Brian take pictures to establish the extent of the prob(em for the FEMA claim, in case the
tree is removed before the FEMA inspector has inspected the problem.
sue�ecr � � PER IT
'� City of Fridley o � g��
ATTNETOPOFTHETWINS BUILDING PERMIT �
, � � RECEIPT NO.
COMMUNITY DEVELOPMENT DIV. �
. f � v �� PROTECTIVE INSPECTION SEC. �. ��p�.
�
i �
`�-_-.� ����1,,� C�TY MALL FRIDIE� 55a32 NUM6ER PEV. DRTE PAGE OF 4PPqOVEO 8Y �
L 612-571-3450 910-Fi5 5/31/89 � �
lOB ADDRE55 115 Glen Creek Road N. E.
1 LEGAL ��TNO. BLOCK TRACtORADDITION SEEATTACHED
DESCR. 38 Renised Aud, Sllb. #i�I . SHFET �
2 PROPERTVOWNER �MAILA�DRESS � 21P PHONE
Norman Herzog 115 G1en Creek 12�ad N.E. 571-6303
3 bONTPAGTOR � MAILADDRESS . Z�P PHONE � IICEN5EN0,
Same
� ARCMtTECTOPDESIGNER MAILA�DRE55 ZIP PHONE� LICENSENO.
5 ENOINEER MAILADORESS Z�P PHONE� � UCENSENO.
e USEOFBWLDING '
Residential
7 CUSS OF WORK �
❑ NEW f�1 ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
S DESCRIBE WORK . � �
Construct a 16' x 13.6' ThXee Season Porch and a 14' x 8' Deck Addition
9 6NANGEOFUSEFROM � TO
STIPULATIONS �
See notations on plan , Yg�YXiid[it3[8�67di�ffi�ii�
Variance approved for rear yard setback - no stipulations.
WI�Rk1MG
Betote digBing �p lacai utAitieS
SEPA�2ATE PERMI7S REQUIRED FOR t€EEPHpNE-E����•�5��. :
WIRING, HEATING, PLUMBING ANU SIGNS. REQ���Ep 8y �qyy:•
SEPARATE PEHMITS ARE REOUIRED FOA ELECTRICAL, PLUMBING. HEATING, TYPE OF CONST. OCCUPANCY GROUP qCCUPANCV LOAD
�VENTII.ATING OR AIR CONDITIONING. � �
TNIS PEPMIT BECOMES NULL AND VO10 IF WORK OR CONSTRUCTION ZONING SO.FT. CU.FT.
AUTMORIZED IS NOT COMMENCED WITNIN 80 DAYS, OR IF CONSTRUCTION .
OR WOHK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 720 DAYS AT -
ANY TIME�AFTER WORK IS COMMENCED. � NO. DWLG. UNITS OFFSTREET PARKING
I MEREBV CEPTIFY TMAT I HAVE fiEAO AND EXAMINED THI$ APPLICATION 1 STA��S GARAGES
ANDNNOWTHESAMETOBETRUEANDCORREC7.ALLPPOVISIONSOFLAWS VALUARON SURTAk .
ANO OPOINANCES GOVERNING THIS TYPE OF WORK WILI BE COMPLIED $5�4QO $z.%O
WITH WMETMER SPECIFIED NEREIN ON NOT. THE GRANTING OF A PERMIT
DOES NOT PqESUME TO GNE AUTMORITY TO VIOLATE OR CANCEL THE pERMITFEE SACCHARGE �
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW RECULATING CON- $l.00
STRUCTIpN OR TME PE NCE OF CONSTRUCTION. �$
PLANCHE KFEE TOTALFEE
3! S $ss.�o
5� mn*uREO�corv'e oana* iZE nGEr+r iD TEi WHEN PROPER Y VAUDAT D THIS IS VOUR PERMIT
S �
SiGNAiUREOFOWNEA�60WNERBUILDEA� 10<}EI BLOG �NSP qLi
� � � Effective 5/1/88
ADCN jxj I�1 AND R-2
ALTFR [ ] Building Pexmit ApQlication
�fLS�Yll�l.�l aa.a......... � �� l� � e. Yi t.., C'QC k V�• .
IBJ31 DE4CI'1pt.1M: •�G't �$ � QeJtSecY i*U�'�'fbY,� o[Ll6AtJiSlori /`O, /7
Owner Name & Address: �prman }�ierzoq ° rCS �(en �re�k �• 'i1�1. # S7/�6��
Contractor: (�orm
.. �
�, � $7f -6jo3
tvtl 63� �f�SA
Attad► to this applicatiar�, a Certificate of Stuvey of the
lat, with the pmposed oonstruction drawn on it to scale.
DF�[St2PTSAN OR+ II�AOVH�il'
zsv���1� �
n�,: �r,grr, /G wiar�, /3.6 ��,t �� sq. Fr.. a/6
C,pRi+I� A[�!►: Iength width Height Sq. Ft.
DE7C1C ARE�: I.er�qth /y� Width S� Hgt/Grauri �� Sq. Ft. /�
[:i�•ir�
a� ��a �.vti z y,��u.T. ►� ��v� �. �a :'+�'p sc� z Sy �&z8
Corner Iat [] Insi� Iat [%(] Ft. Yd Setback Side Yaztl Setbacks
Zype of oonstxuctio�: FY'a�xe Fstimated Cost: $ c��98 ��PDO
Approx. �letion Date: H�qa� �S� ! 9 s 9
Pt�bsea nriveway wiatit Zf xew q�enirrq xs Il�siziea: Ft. S S
�,jy1/J��� a'� CP�9 width + 6� see Back Page
��: / "-7 � APPLICANP: ll�a �'map �er Zc� Tel. # •S7/ -6303
--r—�—
Petmit Fee $ ��
State S��x+d�azge S � �'?O
� � $
Driveway Escrow $
Fark Fee $
Sewer Main Chatge $
�. s ���
���:
..� �._�- . �
Fee Sci�edule m Reverse Side
S.5o/Sl,000 vaivati«�
$575 per SAC Unit
Alt. "A" ar A].t. oBn p�OVe .
F'ee DeteYmined by II�qinacrinq
� �tY t ] � �s-�Y L l
� P�,2,� A,� � �, �� �2 � � c� ' ,� d� /��s
S�4 06
2dn6 - 4S
4� � - �
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M�NMCAp ll SURVCTS
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B�:EiHEfS - iO�OGRA►NICAL
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[itlipLl�MCO \���
L A ND S UR I'� Fi }' URS C. F. SANDHOFF
RE61fT[11[O YNDQ L�W� Oi /TAT[ Of MINN[50T� GVIL ENGINEER
OT��L16ME0 IYOY
ucch�[o •r OADINI.NC[ or uir or MINNEl1►OUf �qMES NELSON�
326 PLYMOUTH BUILDING FEO[w�� B�B727 SUR�G�R
HENNEPIN AT SIXTH • MINNEAPOLIS 3. MINNESOTA i"`°����E° ��:a
� METROPOLITAN LAND
$�urbrpor's 6rrtificalc Suev[rons c��.oiic�m ����
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Ad�/. P/�f <.
Znv, (/207E�97-.e3
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I:.e:c';�; ec.r;.ify th�t this is a true �ad correct repre�entation of �
:, st:rvcy cS_L?�e bcw,dsrie� of �thct �art of Lot 3II., RevSsed Auditcr�s !
:.�:L.:iivisicn ":•�::_hcr 7i� Ano}:a County, i�:inr�eccLa.lyin�� Easttrly of thc, f
cx�c :si.n 5ortherly cf t'ie na�t line of Lct 4� :'loek 1� Ciak Creek �
6d�i�ion Flat 2, and Aest of a line draun Horth at a right ar.�;lc frc� a point in
t:,e tiorth li::e of aald Da� Cre.ek Addition Flat 2� distiint 216.0 Teet West �a;,ured
en saiu :dcit;i line frcn ita intcrseeticr. srit:i ttie �{ecterly ;.L7e of East F�iver F.oad�
• s �i � a:_:.e is cst;:blicacd acccruin� to the a£ore,aid record Flat of' Cril; Cre:ek
i+dcitioa :;nt 2; to�•rther uitY. un ea:Er,ent for cirivavay pui•rc�e� ever t`ie Sauth
1;'.0 ieet c£ saiu Lot 3°� exi;endin� Easterly frota the r;a:t line of above de�cribec
t:act to Lt:e We�t line c^ East P.iver ficad� all acaordin�• t,o the re�}ective plats
t:,c:ec° cn iile anc oi reccrd in tP�e office o: the %e€ister df Deeds in u^d for
__ i+a^ka Co,::.ty�_F:i.�neauta; aaa c.° tne looaticn of all t�uildings� if an� thernon� and
a-ll-�isi�ie Pncrescts::er.ts� if any� ;ro:� or on said lard. TF:is survey ie r�:,ce cniy
�:� .^::P.'f:�i,1C.^, �..:L:i i 7.1GtL�8�;P IOttG II[�1✓ Lflli€ F`l.;i�:v'i: OA ti�C :r!`�tf�.I'�j" iL'lil I10 Z1F1DlI1�J
i> ;... �.._.: excej t to t::E hclucr e° esch r_ortga�e cr any ut,h��r ir.tere,t acq�ired by
t,;c z�eaecn �f snoh nort�s�;e. It is undcrstood an3 a�reed no Taonursent� havo becr.
:.lac-�� fcr the Fa:ro:,e of ostablishiag let lines or bou rf corne�s. As,�urve,�ned
r;; .:c :: `s �Oth d&f c. July� 1959: s�c���' .. -^ - -�< �.l—
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ADDRESS
PIN
LEGAL DESC
PERMIT TYPE
PROPERTY TYPE
CONSTRUCTION TYPE
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
�i�-suu4 r.�:
: 115 GLEN CREEK RD NE
: 103024140008
: UNAVAILABLE
: LOT BLOCK
: BUILDING
: RESIDENTIAL
: ROOFING
� ii-tza i
PERMI O.: 2004-00888
DATE ISSUED: 06/10/2004
VALUATION : $ 3,357.00
NOTE: UNDERLAYMENT AS PER STATE BUILDING CODE. REROOF HOUSE & GARAGE (29 SQ) TEAR-OFF
STATE LICENSED CONTRACTOR 1
APPLICANT
HASTINGS RICHARD CONT (4051)
6331 RIVERVIEW TER NE
FRIDLEY, MN 55432
OWNER
HERZOG NORMAN J& MARY K
1 IS GLEN CREEK RD NE
FRIDLEY, MN 55432
ACREEMENT AND SWORN 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 tune after work is commenced.
I hereby certify that I have read and examined this
applicarion and know the same to be true and correct. All
provisions of laws and ordinances governing this type of wor4
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate ar cancel the provisions of any other state or local law
regulating� c�tSuc 'on or e pe�n'e of constructiop.
Annl' ��d Date ��Io/O+/
Bldg
SF.PARATF. PF.RMITS REOUiRED FOR
BUILDING PERMIT FEE
FIRE SURCHARGE
STATESURCHARGE,VALUE
LICENSE SURCHARGE
TOTAL
�THF.R THAN TIF.SCRiRED ABOVE
9725
336
I .68
5.00
l OZ29
NEW
ADDN
ALTER
[1
I1
I1
CITY OF FRIDLEY
6431 University Ave NE, Fridley, MN 55432
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Effective 1/1/2003
(763) 572-3604 Bldg Insp
(763) 571-1287 Fax
�op� aDB��
Construction Address: %�S 6LF,<l c�� F'1�' �Z.D _
Legal DescripUon:
Owner Name & Address: No��KAN ��+ZZ o� Tel. #
Contractor: f � � � � � p � ��� � � � S MN LICENSE # �p C /
Address: �53 1 2� v�Z�7� �� T`�- (Z � Tel.# 57 U"5�.66
LIVING 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
Length Width
Z.9 s�
Height Sq. Ft.
Hgt/Ground Sq. Ft.
Construction Type: `t.�'A ���F � 2�� o o F Estimated Cost: S �S�
Driveway Curb Cut Width Needed: _Ft. + 6 Ft =_Ft x S =
DATE: G � APPLICANT: �- � ���_ Tel. #'��y-� "/���
Call {763) 572-3604 for Pertnit Fees if mailing in application. Fax to 763-571-1287 if using credit card and we will
call you for card number.
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
I
.
a. �i .
r
,, �
;,
/
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th°�)
$.50/$1,000 Valuation
$1275 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 Necessary [ ]
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CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
a�z-sau4 raa:
ADDRESS : I I S GLEN CREEK RD NE
PIN : 103024140008
LEGALDESC : UNAVAILABLE
�CiTi�e)�[�Z�1;�
PERMIT TYPE : HEATING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION .
a ii-i�a i
PE O.: 2004-0190�-
�_
DATE ISSUED: 10/18/2004
NOTE: ELECTRICAL PERMIT BECOMES VOID 12 MONTHS AFTER PERMIT ISSUE DATE. 100 AMP SERVICE
UPGRADE.
# NC UNITS 0 VALUE OF APPL OR WORK
# FURNACES 0 # GAS DRYERS
# GAS RANGES 0 VALUE (FOR MINIMUM CALC)
APPLICANT
PRACTICAL SYSTEMS
4342B SHADY OAK RD
HOPKINS, MN 55343
OWNER
HERZOG NORMAN J& MARY K
115 GLEN CREEK RD NE
FRIDLEY, MN 55432
AGREEMENT AND SWORN 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
applicatiou and lmow the same to be true and correct. All
pmvisions of laws and ordinances goveming this type of wor}
wilJ 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 othar state or local law
reguJat�ieg.constrpction or the performance of construction.
HEATING PERMIT MINIMUM FEE
FURNACE SHELL/DUCT WORK
GAS RANGE FEE
GAS DRYER FEE
AIIt CONDITIOATING FEE
HEATING REPAIRS/ALTERATIONS
STATE SURCHARGE, MECH FLAT
TOTAL
PAID WITH CHECK # 1861
f �� ^�
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0
10.00
0.00
0.00
0.00
0.00
0.00
0.50
10.50
� 1 �
��SL�� � ' ��-i�iZ1�
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
Builaang
Inspections
763-572-3G04
��,� �,—.�r�•
$1'I'H Al)UI(1iJ9 �
1'HI$ Al'PLI(;AIYI" IS.
TC� NAIYT
1 `��� �
$Ujj,bI1�TG Permit No.�
RESIDENTIAL APPLICATI�N Received By;_
CITY OF FRIDLEY Uat� x��'a:--2
&MAIL AUUItkiAS
CIUWNER .'�nNTR4CftM
ADDRE5SJ..L..S.. _..._C�"GC��
PHONE; 7G�,— -S"7/ — _�Q�..... .
_.. . ...�TATF !(jiW.,IP .tsy.3�
l.:asPill[RI:IUK NAME:.,,�.c. - Lt.7 ✓ _____—
_..........._. _.
..........
SUBMI7A COPY OF STATC LIl'BNSE # XP D�1TE
_.... , .., .'_.'_.
YOURSTATELICENSE ADDRE59:_/�..GIGrr_.Cwpo� � CITY : ,. STAT��fN i�y�a
WITH APFLIL'ATION pHpv�; /— FAX �' � � '
YROPERTY TYPE �7 S�NGL6 FAM[LY/NEW CONS'C2UCTION s�Lr:
❑ BASEMFN'I' NINISH O ROOF
C] DLtC:K ❑ SmING
DESGRIBE WORK BF.ING
GA�lAQEB
PRUPU4PA SIZE:
PROPOSGU IiCi61�1T: _....�
�YiQ]�L[
❑ Vlnyl
l7 Apiminum
❑ Other
❑ HCXI.YH �@ GAxAGB
❑ A7'I"ACH EU 4AItAGE
❑ vcrnci•sn ann.aa�
f7Svffit
❑ Tcim
a ra.+c+a
W�DWC
MP.XL9'�'INCUPE:NINGg qyp [1No LOCATIONOF WINDOWS
OA POR NEW OPGN7NQ3-D�SCIkI�F SIZCi OF
nPF?NINC CHANCiH5.4
Plan Rnviaw
Fite Suroharge
Surchaxge
License Surcharge
SAC Cherge
Curb Cut Bscrow
Eroeion Controt
Park Fee
Sewer Main Charge
1997 U.&C FEE SCHEUULE)
c� „r..,.........,
DRAIN'fILH
f71'HHR
i, I �1Csi.YY
pASEMENT REMO�BLSNG : 1HMf1':
1. Exia[uigPlonrPlan
2. Vnmunrdfluurpinn
3. L'ut ofsVUYUraI mzrMfets W be us�x)
POR NEW CONSTRUCTION INL'LllD W C; UF(7KS,
dD.A,lIL4l9,5..$.�RL}La SSfBbllT�
1. SiKPlan/$urveyshowingtheaciningsuuctures
md pwp�sbd p%ja:l.
2. Twa xts of consauction pla��s
3. EnagyCalculatimis
ANp MA
See Bttck Page tor Fee Schedule
65°h of IIuiMing Permit Pee
.001 times the wtal job valuation
.0005 x Permit Valuation Minimum $.50
55.00 (State Licensed Residential Contractors)
$ I55� per SAC Unit (Plans to MOVCC for determinatlon)
1�+bft= Rx$2l=$
$450 Conservatiai Pla�i Iieview
Fee Determined hy EngineeYing
AKreeement necessary { ) Non Necessery { }
'1'HIS IS AN APPLSCATION POR A PERMR'-NOT VALlD IINTIL PROCESSRp
I heroby apply for e builcimg permit and I
conformanc� wirh the ordineneoa and c �
pemtit btd only sn opplication a rm' a
plan in the case ofall work � ' s[�
s�pNanrne or•
edge that tho infarmauon abowe is cumplate and accurate; that tiie work wil! be in
y of Aridley and with the Muwesotn Conswotion Cod�s; lhut I understund this is not a
is nat to start without a pe�luit; that the work will be in accordnnce with tho apprnved
aPProval qf'plans. e i /7 ,