AF - 46617City of Fridley, Minn.
BUILDING PERII�IIT
nate: � ------.� ..^�--- �f.� �^�:._�.r_....�%._ ........................---
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Owner: ...._ -_::. - - � -- - `� -- --�- ---� �-- -- - -- �-- -- -
Address- ..............��-•---....._--�-----;�:: .._...__..__ _..____.-----•---••---�
Builder
Address
N° 4906 '
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..... �--''� ----���.._`._..----._......._.....-----------____.._
� OCATIO O� UILDING
. _. _.._...... Part of -�-- ---�-----�•------�•--�•--•-�-----....._._._... .�.
1 ' �'�- - � ---. .
No. .. .......-�---�--� -..... Street -- - -----�- - ���-�
..........._ .............._. Addition or Sub-Division ..._� � �
Lot ........_ .�.�......_........... Block ...__....._!-- ._... ._.... . - ----�-��-�L.�-�---
../ f t
Corner Lot -..L"''i._.._........ Inside Lot ......"�- .... Setback .....-;�..;�.........._........ Sideyard ...----�._..�......_....�...-f�----�—
Sewer Elevation
Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as
/'`� '� �
� ,(,(�-�`;,,� �.'s�. t`� ._ Front � � _'..- Depth _ �' �`_.. Height � �::..
F�. +1 p.
� � �
. t���. ,;��__a�� � . ...__ Front. _. �. ��s.... Depth ; ��_ ,�r .�:.-H ight �"+'! .. ....
�
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Type o��` Construction ���`s �'�,.�� -__ .... Est. Cost . ,/_ , ;,,,,: . ,..
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Sq. Ft. _,�f � �== cu.
/
Sq. Ft '� ...` � �:.. Cu.
To be Completed ..............
a
Ft. �' :r ����
�,.'�' �-��'
Ft. ..� _ _ t< .
In consideration of the issuance to me of a permit to construct the building described above, I agree to do
the proposed wo�k in accordance with the description above set forth and in compliance with all provisions of
ordinances of the city of Fridley.
-�---------- ---_.._.�----------
In consideration of the payment of a fee of $.- -.({1.-.-.-.- , 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 lixnits and this permit may be revoked at any time upon violation of any of the provisions of said
or8inances.
Building Inspector
NOTICE:
This permit does not eove� fhe consfruetion, installation for wiring, piumbing, gas haating, sewer or watsr. B� wre 10 see
fhe Building Inspecfor for separate permits foe these itema.
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� SUBJECT . . P . .
City of Fridley �-16 3 0 2'
AT THE TOP OF THE TWINS g U I L D'� N G P E R M( T
i�
� � �
� ; y �_���_ COMMUNITY OEVELOPMENT pIV. � �� �
r � � PROTECTIVE INSPECTION SEC.
� � �
1 � �'��1 � CITY HALL FRIDLEY 55432 NUMBER fiEV. DATE PAGE OF APPROVED B�
�"""� � �'' 612-571-3450 9i0-F15 7/28/81 / /
10B ADDRESS 100 Hartman Circle N.E.
1 IEGAI 40T NO. BLOCK TFACT OH ADDITION SEE ATTACHED
DESCR. 3 1 Sandhurst Ac1d. SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
lmbert & Beverl Thurston 100 Hartman Cir. N.E. Fridle -
3 CONTRACTOR MAFL ADDRESS ZIP PHONE LICENSE NO.
OWrlf31^
4 ARCHITEGT �R DESIGNER MAIL AODRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDfiESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
R@S 1C�iP.Iltld�.
7 CLASSOF WORK � NEW � ADDITION O ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRlBE WORK
Reroof
. 9 CHANGE QF USE FROM TO
STIPULATIONS
Roof can be second but not �hird.
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PWMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOlD IF WORK OR CONSTRUCTION ZpNING SO. FT. CU. FT.
AUTHORIZEO IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONEO FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NQ: DWLG. UNITS OFFSTREET PARKING
1 HEREBY CERTIFY THAT 1 HAVE REAO AND EXAMINED THIS APPLICATION STAILS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW FEGULAT�NG CQN-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE TOTAL FEE
ATUAEOFCONTRACTOAOf7 HOF12EDAGEN7 Dn�� WHEN PROP l AT D THIS IS YOUR PERMIT /
1 `.���'�
. �
� SiGNATURE NER IF EABUILDERI IDAT 1+.- � � BLOG WSP OFTE
0
_ .. . . _ . .._ ._ ... �. �. . . . .. ._. . i . _ . . ._:., .. , ' . . . . . _ _.�:rd
CITY Or FitIDLCY
0
/�PPLIC/1'fI�;1 f0(: l:ESIUL:i�ITJ/!i_ I3UIL[)It1G f'C{tifITS
(i�erl, tlllcrations, Additions„ or Repairs)
0
� Ot��i�Eit: YV . V� . r�ri Ui n�3UILUL-'R: (� W ln e r"' � -
ADDRESS: pc� �� � c /IDDRESS: � .SdyY�,'�
TEL h0: �,,h �L; ;� 7� TCL f�0: "
Construction Location `
` t .�
s��T rio :��� � s2�r T: ___ W_n �rn n�1 �� I f Q
i.o��: . _ � sr,oac : __L____ 1wnzTZOy : �,.,1 n ,n � u r.��r
Corner I,at: � Inside Lot: SetbacY.: Sideyards:
..___._�
Ap�licant attach to tliis form two Certificates of Survey of lot and
proposed building �ocaL-ion drawn on certificates to scale.
DESCRIPTIO�� OF CO�jSTR�JCTIO�J •
' Q^ Y"��_ Front: � Depth: Iieight:
Squane. �eet_ � C�ibic Feet:
�'ront :
Square� FeAt:
�P�=
Height: _ _ _ _ _
Cubic Teet:
�pe of Construction :� Esi-imaL-ed Cost: $�%7n (� � � l�
. , � , . •
Rb Be Q�r.�pleted: �
� � � Alt. A Alt. B
Proposed Drive��ay Width If New Opening Is Desired: $� $
' _ , S�� Re.VER: E SIDE OF SFIEET .
?Sie undersigned hereby makc� applicaticn for a permit fcr the �:�ork� hereisz specified,
agreeing to c� ,all work in strict accorc3anc� with the .Ci�y of I'ridley Ordinanees a�id
ruliiigs oi L-he DeZ�zrtmci�fi. of Buildings, and hcreby declares thzt all tlic tacts and
representatiens Stated u� t.his application are true and correct.
A.1Tr: � SIGNATUIS�:: 1,
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suaeECT PE .
City of Fridley � 16 3 0 7
AT THE TOP OF 7NE TWINS B U I L D I�� P E R 1. 1 I T
' ' RE
� � •
• COMMUNiTY DEVELOPMENT DIV.
' j L �"��', � � ��'
r � � PROTECTVVE INSPECTION SEC.
i � �
� � ����1 � CITY HALL FRIDLE� 55432 NUMBER REV. DA7E � PAGE OF APPROVED Bv
�"'""� � ��� 612-571-3450 910-F15 7/30/81 � f
JOB ADDRESS 100 Ha.rtman Circle N.E.
1 LEGAI. �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 3 ]. Sd11CZYl'l1�St SH EET
2 PROPERTY OWNER MAIL AODRESS ZIP PNONE
i�bert & Beverly Thurston 100 Hartman Circle N.E. 571-1736
3 CONTRACTOR MAII A�DRESS Z�P PHONE LiCENSE NO.
Same
4 AHCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
6 USE Of BUILDING
RLS 1.C�P•Yltldl
7 CLASS OF WORK
❑ NEW X ADDITION ❑ ALTERATION p REPAiR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 12• x 14' Addition to Rear of Dwellin
9 CHANGEOFUSEFROM TO
STIPULATIONS
Area can not be heated unless area meets the Sta.te Energy Code.
WA��1�G
SEPERAi`� PERMITS RE�U1REt� FOR VwtRifllG, Before Qi�inr cat! (ocal utilifie�
NEATING, PIUM�I(YG AOfQ SIGN�, fiE�EPN�NE-flf�TR1C-Gqg ��.
REQU�R�� �y �w
SEPARATE PERMITS ARE REQUIRED fOR EIECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTIIATiNG OR AIR CONDITIONING. WOOC3 FY'3IR@
THIS` PERMIT BECOMES NULL AND VOIO IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORI2ED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ].6S
ANY T4ME AF7ER WORK IS COMMENCE0. NO. DWLG. UNITS OFFSTREET PARKING
I HEFiEBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS APP�ICATION 1 STALLS GARAGES
AND KNOW 7HE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVEFiN�NG THIS TYPE OF WORK WI�� BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $Z�SOO yfi�..2S
DOES NOT PRESUME TO G�VE AUTHORITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY 07HER STATE OR LOCAL LAW REGULATIIJG CON-
STRUCTION OP THE PERFORMANCE OF CONSTRUCTION. $IS.00 None
- PI.AN CHECK FEE TOTAI FEE
3.75 20 00
NATURE FCONiRACTORpR uT OFlIZEDAGENT ton7E� WHEN PROPERL ALIDAT D THIS IS YOUR PERMIT
� ���.e L�� 7� ��/
SiGNATUR IIF 6 R BUILDER� IDAT 9LDG �NSP � nFTE
CITY �f FRIDLCY
tiPPLIC/1TI0iJ FO�t RCSIDLiVTIP1L E3UILDIi1G PEEL`�iTTS
(tde►�r, Al �er.�tions, Additions, or Renairs)
04JidER: , � r � � �UI LDER : �,j� w mQr^ �
t1DDP.ESS: pp � r , _ /10DRCSS: �
TEL h0: ��%� � 73(j,^� TEL t10:
Consi:ruction Location
n, iV
STI2�GT NO: � Q STREET: �[Yl l��'f' � Q .�.1 ��-
L07.': _� BLOQC: �_ ADnITION: �) U..YI �(1�
Corner Lot: _�� Inside Lot: SetbacY.: Sideyards:
Ap�licant attach to t2iis form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
DESCRIPTIOi� OF COPISTP.UCTIOPd
�� ` ��_ I'ront: /�. � Depth: �� , Height: f� /
Squane Feets ��_ Ctibic Feet:
Front:
Depth: Height:
Squar.e� FeAt: Cubic Peet:
I �i � ' = 2 �Z ° - z.�d�
Type of Construction: Estimated Cost: $ 0 d
Zb Be Oor.�pleted: S e p'� /
T Alt. A Alt. B
Proposed Drive��ay Lridth If New Opening Is Desired: $� $
SEE Rr^�VERSE� SIDE OF SHEET
�iie undersianed hereby ma}:e� applicaticn for a permit fcr the �:nrk hezein specified,
agreeing to c�o ,all work iri strict accordance with the City of I'ridley Ordiiiances and
ruliiigs of tlle Departmeizt. of Buildings, and hereby declares that all tlie �acts and
representations stated ui t.his �.pplication are true and correct.
D1:T�: '�� SIGNI,TUF.E:
Stipulations:
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MINDER ��TGINEERING C4.,INC.
ENGI NEERS AND SURVEYORS
��Ho auavEV�NO 8o«S TESTtNO
GIVI�, �. MUNIGIPAL ENOINEERIN3 LANO DLANNINO
6418-SGT" AVENVE N.
I�AINIJEAPOL�S 2T, MINN.
KE 7- 3637
�!'r�'i���L��i'i� •IF � �!�`IIC� -
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WE HERE9Y CERTIFY TNAT 7H15 IS A UE /W� CORREGT RE SENTAT►OtJ OF /'. SURVEY OF THE BOl)NpAR1E5 OF THE
�lWD ABOYE �ESCRIBED AND OF THE LoC OtJ OF ALL BUILDINGS, F A1JY, THEREON , ANCI ALL YtSlBLf ENCROACHMENTS,
�F ,►►,,,r, FROM OR ON 5N� UND. MINDE ENGINEERING CO., INC.
ONTED TN�S OwY oF t' �-- -. "� A.o. S
ENG�NEEQS AMD SVRvEYORS
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�'tl�.�� �
SuB�ECT
City of Fridley 3 012 9
AT THE 70P OF THE TW�NS g � �� D i N G P E R M I T
� , No.
, .
� ; v _.��_ COMMUNITY OEVELOPMENT DIV.
f � � PROTEGTIVE INSPECTION SEC. ��',
i . , v
�
� � �'�'1 � CITV MALL FRIOLE� SS132 NUMlEN REV O�iE v�GE O: A►vROvED er
�"""�" �'' 612-571-3a50 9�aF�5 8/27/99 / /
J08 ADDRESS 100 ar an Circle
1 LEGA� lOT NO. BLOCK TRACT OR A001TION SEE ATTACMED
oesca. 3 1 Sandhurst Addition SNEET
2 PROPERTY OWNER MAIL ADDRES$ ZIC PNONE
Robert Thurston 571-7450
J CONTRACTOR MAIL ADDRESS ZIP PMONE LICENSE NO
Owner
1 ARCNiTECT OR DESIGNER MAIL A�DqESS 21P PHONE LICENSE NO
S ENGINEER MAt� ADDRESS 21P PHONE LICENSE NO
6 USE Of BUILDING
Residential
7 CLASS OF WOpK
O NEW O ADOITION � ALTERATION �x REPAIR O MOVE O REMOVE
8 DESCRIBE WORK
Reroof house and ara e(20 S) Tear-off
8 CHANGE OF USE fROM TO
STIPUTATIONS
Underlayment must comply with the State Building Code.
TYPE OF CONST. OCCUPANCY GROUP OCCUPANGY �pAO
SEPARATE PERMITS ARE REOUIREO FOR ELECTRICAL, PlUM81NG. HEATING.
VENTI�ATING OR AIF COND1710NING
THIS PERMIT BECOMES NULL ANO VOID IF WORK OF CONSTRUCTION 2ONING SO. fT CU fT
AUTHORIZED IS NOT COMMENCED WITMIN 60 OAYS. OF IF CONSTpUCTION
OR WORK IS SUSPENOED OR ABANDONEO FOA A PEpIOD OF 120 OAYS AT
ANV 71ME AFTER WOfiK IS COMMENCED. NO DW4G. UNITS OffSTREET PARKING
I HEREBY CERTIfY THAT I HAVE REAO ANO EXAMINED TMIS APP�ICAYION STA��$ GARAGE$
ANO KNOW THE SAME Tp BE TRUE ANO CORRECT. ALL PpOVIS10N5 OF �AWS yAIUATION SURTAX
ANO OROINANCES GOVERNiNG TMIS TYPE OF WORK WILL BE COMPLIED
WITM WHETHER SPECIFIE� MEREIN OR NOT. TME GRANTING OF A PERMIT �1%�FH �.87
OOES N07 PRESUME TO GIVE AUTMORI7Y TO VIOLATE OR CANCEI THE pEqMITFEE SACCMARGE
PROVISIONS OF ANY OTHER STATE Ofi IOCAL LAW REGULATING CON-
STqUCTION OR 7HE PERfORMANCE OF CONSTRUC710N 63 . 1.5 r' lY0 �JCi � 1. 7.5
P�AN CNECK FEE T AL FEE
$65 7
S�GN�tUpEO�CON'AA�TOpO iHOp�2ED�GEHT �O�fE� N Pp OEpLr �TED M IS YO ii PERMIT �
�.��-w � �
�� �
$�GN�TU�7EO�OWNEA�i�OWNEpBU�IOEAi ���TE� B�p( Sp � r�ntt
NEV�[ ) "'
ADDN
ALTER
Effective 5/10/99
[ ] CITY OF FRIDLEY
[] SINGLE FAMII.Y AND DUPLEXES R 1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: JOF� �JA RT �'LAA1 C tRC LE3
Legal Description:
�q
� �3
� �
Owner Name & Address: P�aa � R'r" ��i U t�s � o►�J , 10o N A�Z�AU C ti R. Tel. #�6 ��.� $ 7I — 7��, �
Contractor: $ E L F MN LICENSE #
Address:
Attach to this application, a�Certificate of Survey of the
lot, with the .proposed construction drawn on it to scale.
DESCRIPTI4N OF Il1�II'ROVEMENT
Tel. #
LIVING AREA: Length Width Height 5q. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECB AREA: Length Width Hgt/Ground Sq. Ft.
OTHER: R L R c9 O fi i,� oUS E' f��Q AA 6� �� O S Q cl AR �S ~ TEA R o� �
Construction Type:
Driveway Curb C�t Width Neecled:
Estimated Cost: $ � � � 7 �
Ft. + 6 Ft = Ft x$
_$
DATE: �' ,� 7 9 APPLICANT: ����.m J ZT Tel. �l S' 7 I— 7 4�S �
Pemut Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
$ �.3 i�-
$ % �S
$ U%
$
$
$
$
$
$
$ �S �
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth%)
$.50/$1,000 Valuarion
$1050 per 5AC Unit
$5.00 (State Licensed Residential Contr�cters)
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
Building
Inspections
763-572-3604
DATE � � � —1 r Q �
srrE a,nDxESS l0
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
WITH APPLICATION
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
a owrrEtt
Permit Na 1
Received By:
Date Rec'd: j�
YOUR E-MA[L ADDRESS
r��Y. ��,r c�.� � t: c�. � Q`n v�r� r � ��i 3�'
a,nDxESS: t� '' �°<<fic�v� �' ��c� e ci� �"�f t C�'��-�-t sTn� Iv►�`�s� �f 3�
PHOxE: -� �� - S'va - (� � ��t
rr,v�� 'Z�.�fs lz.: cors � �.c -� ta +r
STATE UCENSE # ��I �� EJ� DATE
,�wn�ss: 1 C9 �'1 � 3 C.p �`'' �Pt u-2 i�l crrv S sTA� �zrn S��l f�
PHONE �\� � a'�''Q'1'' � f�'� 3 FAX
SINGLE FAMILYMEW CONSTRUCTION SIZE
❑ BASEMENT FINISH '�'ROOF
❑ DECK t�SIDING
❑ SWDvIM
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
R FING
NUMBER OF SQUARES a �
GARAGES
PROPOSED SIZE:
PROPOSED I-IEIGHT:
SID ��
❑ Aluminum
❑ Other
WINDOWS
IN FJQSI7NG OPENINGS OYes �Tlo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE 1NSTALLED
�E/REPAIR O REMODEL!
� �(' e d �-' C3�
LENGTH ,
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
0 DETACHED GARAGE
❑Sofftt
❑ Trim
O Fascia
LOCATION OF WINDOWS
❑ DRAIN 71LE
� OTHER
�S� -Q
�TH HEIGHT
BASEMENT REMODELING SUBMTT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be ased
Ft
FOR NEW CONSTRUCTION INCLUDMG DECKS,
ADDITIONS_ & PORCI�S SUBMIT:
1. Site Plan/Survey showing tfie existing suuctures
and proposed project.
2. Two sets of construction plans
3. Enetgy CaicWatiotis
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(LJSING 1997 U.B.6,�EE SCHEDULE)
TOTAL JOB VALUATION $ �� �•'� �'� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Chazge
Total Due
$
$ /
$ LS' 00
$ �7 , SO
$ s� o0
$
S
S
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum 5.50
�5.00 (State Licensed Residential Contractors)
51550 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftxS21 =S
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks qavable to: City of Fridle_y Attach
'fHIS IS AN APPLICATION FOR A PERMff-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclasowledge 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; that the work will be in accordance with the approved
plan in the case of all work w' requires r�pproval of plans. +� ,
SIGNATURE OF APPLICANT ��` PRINT NAME V �Q' �°`�� s�� DATE �— `�� °�
Building
Inspections
763-572-3604
763-502-4977 FAX
DA� I � i . U
SITE ADDRESS 1pb
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-i-2010
�^ I� YOUR &MAIL ADDRESS
�� I "N r 1�`�C�
�WNER OCONTRACTOR
NAME: � Y Q �
ADDRESS: %�U ��
PHONE: � ./ � a
NAME:
STATE LICENSE #
STATE BOND #
vY � � 7hu ►-�7vn
n G'k� CITY
ADDRESS: CITY�
PHONE _ _ _ FAX
SINGLE FAMILY
❑ NEW
O TWO FAMILY ❑ TOWNHOUSE
Jd REPLACEMENT
(
Permit No.f�UlJ�"��-''""'
Received By
����J�
STA�mhZ�P s�v3a
EXP DATE
EXP DA7�E
STATE ZIP
DETAILED DESC TION pF WORK �Z��T �t��y� �-� b � �a�ve ��d V W�1�'V U12�(/
� �h � Guu�tG�i �
FEES ARE BASED OI3 510.00 PER FIXTURE, EXCEP7' WHERE NOTED. FIX'TURES: (INDiCATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
535.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
^ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK ! WATER CLOSET BACKFLOW PREV. (S15)
DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
� WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is compiete 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 ase of all w hich requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME � teV �j �u � '- ' ` DATE I �2 � ' �V
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977