AF - 46202�
•
.
� City of Fridley, Minn.�
BUILDING PERMIT
. .
, �1,_i ,,!, / �� //
/ i
No. �� �
_� Street
TION O
Iat _..._.... __._.__ Block _.._._.....,,] ..__ Additi� or 3ubx/�!�i on ���T¢!S.�
Corner Lot _.__._.._.._...� Inaide Lot ....._..��_..... _. �E§acd;q���F.�S.. Sideyerd
/
Sewer IIevation .---._.._._.....---...._._...._.._...._ F tindation Elevation ...._......._
�l�%� �
N° 6464
/
DESCRIPTION OF BUILDING
To U � FYront �.�.. DePth`.p(_.f__ HeiBht ��_.. S4. FL 7���1. Ft 7�
__.—_.__�_____�_ Front .._._ _.._ Depth _...__. t__ 9q. Ft .---..._.— G�. Fk _..._:._..._._
lype of Conahuctlon ��.. Es� C��e��.�_ To be Co¢ziPleted ......_.__...__..._.._..__.—
Y
In cafaideratlon of the issuance to me of a perm4t to rnnstruct The building described above, I agnee to do
the propoced work in acooidance with the deacription above set forth and in c�pliance with ,a.11/ prwisions of
a�'dinances oP the city oP FrfdleY. _ /1�� _ ,!' Y e .
In caoslderation of the paYment of a fee of
permit ia Lereby �anted
to construct the building or additt� as described above. This pernut is granted upon
the expnes condition iLat thepersa� to whom it is granted and hie agents, employees and worlmien, in all work
done ia, airound and upaa said YWliing, or any part thereof, shell confoim in all reapects W the ordinancee oR
Fridley. Minnesota regeiding locatlon, camstruction, alteration, maiatenenee, repair and muving of btildin�
ordtnancea dCY limfffi end this Ba'mit may be revoked at �:p � vio]pBhVn of any oP the Pmv3sims d seid
/ I
Buitding Inspectas
I�TICE:
ThY P�M dea nW eewr � eemhuaitoe. 6ue�Iltlien far vrYinY. P��Y. Yn A�inY, awa ee wanr. M wn b e«
th� BuilNey InyMer fer aWraM pa�aW fer tiw h�.
OWNER'S
ADDRESS
� APPLICATION FOH BUII.DING PSRMIT
RI79F OF FRIDLBY, MINNESOTA
' LOCATION OF SVII.DING
i �%
No, �� 5 . � Streeti /�l� — �� � o �Lot
�� ,
Lot Block Addition or Su6divieion
Comer L6t�_Inaida Lot I�� Setback�_Side-Ya;d ,
SBWER ffi.EVATION , FOUNDATION ffi.SVATION
^ , �
Applicant attach to thia form 11ao Certiffcates of Survey of tot and proposed build-
ing location drawn on theae Certificatee.
To be
n : ��� � ,.
v
Sq. �t. �. �.
Front Depth Aeight
Sq. Pt. ° Cu. Ft
Type of Construction gstimated Cost
To be Completed
The undersigned hereby makes application for a perait for the �..ork herein specified,
agreeing to do all work in atrict accordance rith tha Citq of Fridley Ordinances and
rulings of the Department oi Buildinga, and berebR detlazeA,that a11 the facta and
repreeentations atated in this application are true and correct.
u • � s�
/
(Schedule of Fee Coata can be found on the Heverse Sfdej.
t:r � � ...
��. � sueaecr � -� � PERMI7 . '
�City of Fridley 1330'
"TT"E'°P°FT"E7'"'"S gUI�D1NG PERMIT
�� �.i � . . � RE .
�� ` __ COMMUNITY ➢EVELOPMENT DIV. . � � ��
� 'r. ��Y PROTECTIVE INSPECTION SEC. �
1
� i � /"1'� CITY MALL FRIOLE� �JS/32 NUMBER� � MEV. DRTE PAGE Oi FFVfiOYED BY
�..__J\.-' ' `.� su3so-a�so 910-F15 11/10/75 � �
�os nooAESS 5853 Hackmann AVenue N.E.
�1 LE6AL �OTAO. BLOCK THACTORADDITION SEEATTACMEO
DESCR. 3� 3 Parkview Manor SHEET
�: 2'�PROPEHTYOWNEN MAILADDRESS 21P PHONE .
Ee�nitt 0'Neill 5853 Hacl�arui Avenue N.S., Fridley
3� CONTRACTOR MAILAD�RESS � Z�P PHONE LICENSENO.
Rite-Way Waterproofing 2654 Lyndale Avenue South
-4� ARCNITECTOROESIGNER MAILADDRESS ZIP PHONE UCENSENO.
5 ENGINEER MAILADOHESS - ZIP PHONE LICENSENO.
-� �.B �-USEOFBUILDING
Fesidential
� c�nss oF w�K
. ❑ NEW ❑ ADDRION ❑ AITERATION fjj REPAIR ❑ MOVE ❑ REMOVE
B qESCRlBE WOqK �
FlatarProof basement
9� -0HANGE QP USE FROM � . TO -
� � �:STIPULATIONS � � . . �
� SEPARATE PERMITSARE REOUIRED POR ELECTRICAL, PIUMBING, HEATING, ryPE OF CONST. OCCUPANCV GROUP OCCUPANCV LOAD
VENTIlAT1NG OR AIR CONDITIONING. �
THIS PERMIT BECOMES Nl1LL ANO V01D 1F WORK OH CONSiRLIGTION ZpNING SO.FT. CU.FT.
.AUTHORREp IS NOT CAMMENCED WITMIN 60 DAYS, OR IF fANSTRUCTION
OH WORK IS SUSPENOED OR ABANDONED FOR A PERIOD OF /20 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWIG. UNITS OFFSTREET PARKING
� 1 NEREBV CERTIFV TNAT I�HAVE READ AND E%AMINED THIS APPLICATION 1 STALLS GARAGES
ANOKNOWTHESAMETOBE.TRUEANDCOARECT.ALLPROYISIONSOFLAWS yq�UATION SURTax
�ANO ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPUED
WITN WNETHEP SPEG�F�E� HEPEIN OR NOT. THE GRANTING OF q PERM7T SZ � ZOO Z. ZO
DOES�N0.T PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMITFEE SACCHARGE
PNOV1510NS OF ANY�.OTNER STATE OR LOCAL LAW REGUTATING CON-
STRUCTION OR TNE FEflfOPMANCE OF CONSTRUCTION. � S�-S.00
�. " ���� PI.ANCHECKFEE TOTAIFEE
/' l //'/e- i5� $16.10
IGNATUPEOrCONifUGTONOFAUiHOR�ZEDAGENT IOATE� WHEN PflOPERLY VAUDA�ED,TH!IS IS VOUR PEHMIT
�.� �/uV %�-i0 -�a.
SIGNATf}qEOFOWNENIIFOWNER9VILDERI IDAiEI 9LW �NSP OPTE
).
.APPLICATION TOR RESI'D�IJTIAL, ALTL'RATION,
OR AllllITION.BUILDIhG P�RhiIT
CITY OF FRIDL�Y, h1INNESOTA
.
�
OWNER�S Nt14f�: � rv+M ��� d� �e� � � BUILD�R: ��` �'�e. - W^��! (%l� �� c��J'co�'n�
, ADDRESS: 5853 Na�km..�� I4„�, nnrn�ss: �c, s�l �vh��./� A��, sa.
,
NO:. S�S 3 STREET: i1� -Kmo.+n
j,pT • 3 BLOCR • 3 ADDITIOn :,, P F f� v� c�.0 �1 �. n a r
C�RIQER LOT: INSIDE LOT: ✓ SETBACK: SIDE`iAP.D:
Applicant 2.ttacl: to this form ltao Certificates ?f Survey.of Lot an3.proposed
building location dracan on these Certific�tes.
To Be Used As:
BESCRIPTION OF BUILDING
c
(,� a�t r�,s cea� 6e.5<mt�nY • Depth •� Height •
Square Feet: Cubic.Feet
Front: Depth:. Height
Square Feet
Cubic Feet• '
Type of�Construction: Estimated Cost: $ °a°�oo
To Be Completed: J w Cc k • .
' The undersigned hereby makes applicatian for a permit for the work herein
specified, agreeing to do all worlc in st'rict accordance with the City of
Fiidley Ordinances and rulings of the Department of Buildings, and her�by
declares that ali tUe facts and representations stated in tliis application
ate 'true and carrect.
� • nAx�: 1 ! - i a - � s- sicr�niv� : </u.�ru� !1 �..a-�J��
(See $everse Side For Additional Information,)
�S.UU .
/.�� .
i U .sr
�' . �
6
.
i
�
-.;
� sue�ea � PERM .
'��City of Fridley 20051
ATTNETOPOFTNETWINS� BUILDING. �ER�IT �
� �
� COMMUNITV DEVELOPMENT DIV.
i jy"
r �.. •� PqOTECTNE INSPECTION SEC. ? 3� 7�
� .J
� � �'��l � CITV MALL FRIOLEV 55IJ2 NUMBER AEV. D�iE VAGE O� APPFOVE� BY
ti..__Jl.• ••� 612-571-3450 9t0-Fi5 8/10/89 / /
J08 ADDRESS 5853 Hackmann Avenue N.E.
1 LEGAL �OTNO. � BLOGK TRACTORADOITION SEEATTACHED
DESCR. 3 3 Parkview Manor SHEET
Y PROPERTVOWNER MAILADDRESS . ZIP PMONE
Emnitt Oneill 5853 Hackmann Avenue N,E. 571-2179
3 CONTRACTOR MAILADDRESS ZIP PNONE LICENSENO.
D& D Home.Ilnprovement 7401 Central Avenue N.E. 784-7543
a ARCHITECTORDESIGNER MAILA�ORESS ZIP PHONE LICENSENO.
5 ENGINEEH MAILADDRESS ZIV PHONE LICENSENO.
8 USE OF BUILO�NG '
IZES7.(iEiltld].
7 CLASSOFWORK
❑ NEW ❑ ADDI?ION ❑ ALTEFATION C� REPAIR ❑ MOVE ❑ FEMOVE
8 DESCHIBE WORK
Itemo£ over 1 layer (�House & Garage� 25 Sqnares
9 CHANGEOFUSEfROM TO
' STIPULATIONS �
Fuo� can be the 2nd layer but not the 3rd. Install ridged galvanized
valleys.
SEPARATEPERMITSAREREOUIREDFORELECTRICAL,PLUMBING,HEATING. ryPEOFCONST. OCCUPANCYGROUP OCCUPANCY40AD
VENTIIATING OH AIR CONDITIONINCa. �
TNIS PERMIT BECOMES NULL AND VOID IP WORK OR CONSTRUCTION ZONIN6 � SO.FT. CU.FT.
AUTMORIZED IS NOT COMMENCED WITHIN 60 OAVS, OR IF CONSTRUCTION �
Ofl WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT �� �
ANY TIME-AFTEP WOHN IS COMMENCED. � NO. OWLG. UNITS OFFSTREET PARKING
I HEREBV CERTIFY THAT I MAVE READ AND EXAMINEO TNIS APPLICATION 1 STAILS GARAGES
ANDKNOWTMESAMET08ETRUEANDCORRECT.ALLPROVISIONSOFLAWS yALUpT10N SUHTA%
AND ORDINANCES GOYERNING THIS TYPE OF WORK WILL BE COMPLIED $j.�2SO
WITH WMETNER SPECIFIED HEREIN OR MOT. THE GRANTING OF A PENNIT $.63
DOES NOT PRESUME TO GIVE PUTHORITY T� VIOIATE OR CANCEL TME pEHMRFEE SACCHARGE
GFOVISIONS OF ANY OTHER STATE OR IOCAL LAW REGULATING GON- $3j..00
STRUCTI OR iHE PEHFORMANCE OP NSiRUCTION.
/J�/ FLANC4IECKFEE TOTALFE
(�//��/�����/!�/ $31.�3
SiGN��UaEOiCON�RnCfO" Rbnau oa¢EDn �OnTEi WHEN PR�PERIY �IDATEO IS IS YOUR PERMIT
�_ ,i
SIGNPTpPEOFOWNERtlFOWNERBUILDEPi IDATE� LOGIN$> !
� �E
NEW [ j
ADDN L) R-1 AND R-2
AL'PER [ ) m,;�dinq Permit Applicati�
c���� aaa�• ��g�S_3 d��+r�k�n,4�r/ � /1�
Lega1 �escription: Lo i
✓
• _� - �..� w i/�! lt�;/�/1:�11 -
Contractor:
�.. - /' �✓" � �
��� �i
GARAQ; ARF�:
II�CIC ARF�:
OTi�R:
Effective 5/1/88
Z�el.
# �7/�'Z�%9
#_..L�34�7�
Attach to this application, a Certificate of Siuvey of the
lot, with the p� �structioai drawn � it to scale.
I�'::4� �JY �l� �1' ��IY.��i/+v�+�,l
Lexr3th Width
Length Width
Iength Wi.dth
H�eic�t Sq. E't.
Heic�t Sq. Ft.
Fk�t/C�+oimd _ Sq. Ft.
Corner iat [] Inside Iat [] Ft. Yd Setback Side Yaxtl Setbacks
Zype of Construction: /Qe-1�97F o�t1 �i LAKti� Fstimat:ed Cost: S�/� /�7s 6
Approx. Ccxiq�letion ik�te: � 3/-S�' � f�o!!Se o:- �iRE�gC �s
Proposed Driveway Width If New Opening Is Desired: Ft. $ $
�f. th + 6' See BaCJC Pdge
OATE: 7� _�O-gY APPLICANr: �j//i � � 'i1P1. # 7� %��
Y
Permit Fee $ � /. 0 O
State Surd�arge S �3
SAC C'harqe $
Driveway Escraw $
Park Fee $
Sewer Main Qlarge $
zrrra� $ ��, (�3
CITY iIBE �,Y
Fee Sd�edule a� Itevecse Side
S.5o/Sl,000 valuatiari
$575 per SAC Unit
Alt. °p,° or Alt. °go p,bove
F'ee DEt2Im171ed by �i rr.pri xr
Ag�ent Ne�saxY L I � Ne�iY I l
... r�
m
T
N
:
aq°%
O
i
Y
�
w
W
J
0
C
LL
LL
O
�..1
O
_
a
z
O
f-
6
C
W
�
�
LL
W
�
_
0
�Q
J N
W
u
> O
fl
2 q
J N
O S
U H
N
t�� Y
Z N{�
!- Z
2 O
2 ~
Q G
�.
N p
a �..�
g �
a�
�
a
O
d
m
� �
O S
F- N
U W
J Q
� �
a
O
Y
�
.,
n
e
N
�
0
�
V
�
2
>
�
u
n
>
w
�
b
g
�
�
�
W ti Y1
o �o a
w n
Y 4 1
C n. .�
r
�a:
M1�
yY'1
a��
0
S r rJ �
tci e � �
M
w u e E
gu.t+e
C
L0 o s a
Y y N O
Y C M Y
o.+Y�
w r
a+ s � y
E m � a
U
C 0
G Op L Y
Y {� C �
W 4 4 p.
Y a
C M mp� ■
1 4 C W C
ewo2 tii
u .+ u
.�+ i � c !.
a m.+ o
4 4w 9 'O
X � yC J � r
9 ^1 Y 0
e o � q
Y � GM
ms�:
a �ra
O +� V q
+�pi M O G £'
Y S m Y �• �
7 Cq w
� $ � a
m r M • iC
� � e �.°. �
FI \� I I �
N tll N N
�! �I �l �I �1
N (? N 1?
i � � 2
�Y .�
M
^J°� i
p G
�� 5
� ' 0 � S
� N a
,, , 9
m ■
rl t=A � f�. e m la
+� O� •
a
� g e ° °'� c
M1�1 7 7 �04� O
a� m m v u"� o
I I
t? N
o�
0
0
..
0 Y
■ YI
C O
wa
4 �
m o0
H 4 a
, O.�A+
a q4
a
a -�+ o
e a
� o�
�.�1 \ O
.~i M �
C C p
u o�
�.�1 .-~1
t t
ui
w
0
0
�
{
a�
�
�
O �
Y O
� F
�
�
g
M
�
a
J M
� �
_
N �
� �
O S�
� a
� o
O �
� �1 I �
N N N N
0
a
_ __. L _
4
L
u
X M (q
� w �;
N u .�
O q �+
O �N �
� -
�
4+ 6
� �
� O
O
H �
.-1
� �
� O
� •
u �
O
O
�
.�
�
0
d
O
H
Y
6-
•
C
m
a
�
�
�
i'
�
�
6
�
0
�
o°
6
•
M
C
P
a
Q �
I
� �p �
F O
� m C
S I Y
w I{
1
a
w
a
_ _ y1
Vl
�
a ,,
s'
0
Y
u
a
Z » �
Y U ti
� � �
$
M
m
°s
z
9
a
F
�
�
W
�
0
x
m
I �
�a
C
� �
�
N
a
a
s
0
0
�
N
N
� �
� �
, a
� ��
� 1 .-.- .. Fo�G
. . v � . ' =g
i
o � v
° e e u�i
� � d
W OH
4 �F
d W 47 y
M q � S�
�+ O E y
r-� y
'1 d M rl
m �e s d
�
F
✓
�
;
E�
T
d Y
y$
N
C P
e gu
.�1 C
G�
� a
�
S8
: V
u o
E m
�w
y
qY 4
C i
c
8 Y
Y
Y y
< 3
.
Dec. 1, 1999
To: City of Fridley
Dear Sirs:
� ����L
��� ���U�
�
I am giving permission for Thomas Carney, 5853 Hackmann Ave. N.E., to
add to the width to the southwest side of the driveway at that address.
We have agreed that all snow will be moved to the opposite side of the
driveway.
� �
����' � �
Building
Insp�et[ons
763-572-3604
DATE (Zf�J- /'
SITE ADDRESS �
THIS APPLICANT I5:
ERTY OWNER/
TENANT
SUBMIT A COPY OF
YOUR STATE L[CENSE
WI"i'H APPLICATTON
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL
�COMRACfOR
STATE
��a.�� �, ro
ADDRESS: CITY
❑ BASEb�N'f FINISH ❑ ROOF
❑ DECK ❑ SIDIIdG
TSrrE oF woxx: I o
❑
DESCRIBE WORK BEING DONE: �Fq� £5�
SIZE OF IMPROVEMENT �F`h�� �`' � in
NUbffiER OF SQUARES ��
GARAG A—
PROPOSED SIZE: N 7 �
PROPOSED HEIGHT:
❑ HOUSE k GARAGE
O A'ITACf$D GARAGE
❑ DEI'ACHED GARAGE
O DRAIIJ 7'ILE
❑ OTFIER
' - � ,,1�'� " „�5."{!
�
' - -. : .��
� . ' � � �li�
-- __ --
�, �
n �.
BASEMENf REMODELING SVBMIT:
1. Facisting Floor Plan
2. Proposed flmr plan
3. List of itruc0usl manbas to be used
Ft.
SID . FOR NEW CONSTRUC(lON RJCLUDING DECKS,
❑ Vinyl OSOffit � ADDCffONS. & PORCHFS SUSA�U7':
❑ Aluminum � . ❑ 7rim 1. Site PIuJSiuvry showinB tlr acisting strucWres
❑ Ortxr . � ❑ Fascia md P�� MoJ�-
WII4DOW5 2. Two sds ofconstrucaon plans
INEXIS7INGOPFNQ�IGS OYes ONo IACA770NOFWQdDOWS 3. FicergyCalcvlsaions
OR FORNEW OPENINGS-DFSCRBE SIZE OF
OPENPIG CHANGES &
TYPE OF WINDOW TO BE AISTALLED NUI�ER OF�WRJDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION g�j �n1997 U.B.0 FEE SC��DUMLE� TYPE
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
�rb Cut Escrow
Erosion Control
Pazic Fee
Sewer Main Charge
a
$
$
$
$
$
$
$
$ _
See Back Page for Fee Schedule
65% of Building Pertttit Fee
.001 times the tots( job valuazian
.0005 x Permit Valuation Minimum 5.50
$5.00 (State Licensed Residential Contracton)
$1b75 per SAC Unit (Plans to MWCC for determinarion)
ft+6ft= ftx$21=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
checks oavable to: Ciri of
THIS S$ AN APPI.7CATION FOR A P£RMIT NOT V ALID UMIL PRO(:ESSED
I hereby apply for a building permit and I aclmowledge that the information above is complete and accurate; that the work will be in
confoimance with the ordinances and codes of the Ciry of Fridley and with the Minnesota Construction Codes; that I understand Uus is not a
permit but only an app(ication for a permit and work is not to start without a permit; t6at the work will be in acwrdance with the approved
plan in the case of,all work /wh�ich requires review and approval of plans. �{/
SIGNATURE OF APPL[CANT � YI !yUALVI �,�J�PRINT NAME I V� �� ��Y V�'4�DATE R � a l o�
1�-`v�7---
.-
%
�4,
�
�
y
,�
'�
�3
� � �
•� J V
�L
v �
U
�
��J
Z
S
�
�
�.
,
s
0
J
r �
�
��� �
_ .�. s �
� �
����
7
�
� �--� I
�- �
� � _ _ _ _ _ _ _ � � 1
3 ,
� �
�
.� ,
�
-- =--�
� �� �
� y t
3
�
��
� =
C �
�
c�t'
�
ci
�,_.
_��
� �
�
�s
3�
� � �c�y
�� �
.
���
<�
W '0
��
W �
--�" � r
� M
2 --� A�
� �
�
�
�
�
�
�
Building
Inspections
963-572-3604
763-502-4977 FAX
S17'&ADDRESS
l4i[SAPPI.ICAN7'IS: `
PROPERTY
OWNER!
TENANT
CONTRACI�OR
xmE:
SFPARAIE Q7'Y
LCENSESpRE
RBQUDtPD PORGAS
AND NVAC.
sus�arcorroe�+n
uro arsuRnrtce
PERMif TYPE
TrrE oawoxx:
a • d•
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
!'6:I17�S/.ti . �.i.: r
P�,�►�t
����a
A°'�3� � srntE zW
COMACT PERSON:
SCAITi LICEN3E N fVL Of1�-� x r�! Z c
Aoote�ss: I(D I cl .�fY� /�V�I
Pxw,� ( o l�'� i q 10 4 �l
�SWGLEFAt�LY o�oFnbm,r
�NNeW �RpPIAC9�fflIT
DETAIi,ED DESCRIPTION OF WORK
��� :� �
. u ,�... y
l� . �a:: �.�.. �: �, .�.� o
PFR M516B.665 tl�e peamit fee is a�w of SI5,0� ur 59L u(tk buW ao� rp bp sgpp,ap, wAicl�ever is gmter, for the
improvm�t, inst�latioe or replaccanent of a residd�tial fixture, ocludng the fuchaes. ('fhis shonld re9at only 9�e oost of tabor )
Labor oost uwler S300 = SI5.00. Labor cost betwaeo 5300 m 5500 = cou of lalwr x.OS =
FORPROIE(.75W}IPR6I.ABOR&XC&EDSSSOO.ASFSAREBAS�ONfi0.00PFBFIXRIRS.EXCEPI'Wf�RCNOT6D. FlXiilRES: �IDICATEiO7AL
N[)�A86& OF FAC7SBEIAVJ)
FAo���linhlled AQPG: �Y�, A,%]Dfil.:
S�ZP�B7U � ti�1
MFG: MOD6L: S�ZBIB7IJ
MFCr. MOD&.� S2FJ61V
A/C 325.00 FIXkTI,ACE (GAS)fIS.OD Cn4S RAtiGFJOVFN 510.00
AIRIVAIRIXCFIANGS61tL5 �ACES'iS.OD DIt35.00 HEWfsAS(Htt1.LS10.OD
HOII.E7t f35.00 GAS [RU'I F7IAS10.00
CHA�76Y[]NERSID.OD _GASDRY�[SI0.00 orrfr.tms�osacm
- ------ •� ,.umoera�naaaes�siu.w_xSlo.00=s
S� -�Q Tlomba of fixnrtes � E15.00 _ x 515.00 = S
TOTAL DLJE S�x , OR Nimmber of 6xhees � 525.00 x 525.00 = S
1Vumber of SxMes � 535.00 _ x 535.00 = S
MIMMUM Z15S0 � S�� ° S SO
1�D1�1MOM S1S50 Tom1= S
'[4IIS LS AH APPI]G31dN P(NtA PER111T-titff VAIID I1N171. PROCESSED
I hc+ebY app1Y for a'oalasiral prsmit md i edieowk�e met flrc mfotmti� eLove's om�piee aod aocmaie; th.t 18e wak vi0 be m wofa'mnrs wilh mc o�d'mmom
aod wtlm of tAe Cily dFriAlry aod wiW me hSeresota CanWemo Coda; Me1! mda�dod Nia it oo[ a Pv+ak h�9 aoty m apptiration (ora prmirt and uvk 6 mt m
ala�t wi[homa pnmit 8W Ihe woik wi8 6e in atoo[daocC wiTh �heappwvM pin ie Ihe me ofaM xodc whidl �eqme+2vieasod epymval otp4ro. ,.,!'
SIGNA'[ZIRE OP APPI,ICANT ��Yi'/K�li I7�--�� PRTNTUen.� I4� l Y..� �1n 7 i I: I ,�..,��-A-i 7f
APPROVED BY
Ctey of FeMie.y
Boldia6lospee4oes DeparWe�t
643I Univessity Avenue NS, Fridky, MN 55432
763-572-3604 FAX: 763-502-4977
DATE
t.-1 . 4......��.. � r J�.�...�. .... r� _I-.�.
Wd LO Sl Z 900Z/OLl6 ale0 Z!L a'Bed w�wu�un :waa�'