AF - 45845�
City of Fridley, Minn.
BUILDING PERMIT
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Date: .. .... ..........
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Addre� ......................................
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N° 3fi1�.
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Builder . :: . ����o�� .. �" .. :�.. . . . . . . . ...
Address .............................................
LO�CATIQ�1[ OF BUILDING
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No. . /. � � �. . . Street . . ��
%0 � . . . . . . . . . . � . ���!`.�. . . . . . Part of Lot . . . . . . . . . . . . � �„ .,�� .
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I.ot . . . . . . . . . . . . Btock . . . . . . . . . . . . . . . . . . Addit4on or Sub-Dfv3sion . . . . . . . . . . . . . . . �. . . . .
......
Corner Lot . . . . . . . . . .. . Inside Lot �i. .. .. . . .. . Setback �: . � �. . Sideyard .��.'. .�'.°,..� . .. . . . . .. .. .. . .
DESCRIPTION O�' BUILDING
To Used as:
�/ 0 �/ � /p � I °y �9�j
...... ... Fro� �� �! DePth .�.�. �7 Height / 1.'0 � Sq. Fk d� �p.�. Cu. Fk ��4G.�/. /' a�c?�e
�,�: . . r�om �.�: :� �' nentn .� �. : :� H��r,t !9. : .�w' sQ. Ft. �'� �. ct�. �. �� � �. °° ��.
��s�sn .g�.0 . Pt
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Zj�pe of Co ct[on ................... �st. Cast..................... To be Coaipleted ..............:.... ���.
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In consideration of 1�e fs�ance to me .oE a permit to construct the bwllding desribed above� I agree to do
the proposed work in accmrdanc�e with the descriptlon above aet forth and in com�liance with all prov�tsions of
ordinances of the dty of Fridley.
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In consideration of the payment of a fee oP $. � . . . . . . . ., permit is hereby granted to . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . to construct the buildiug or addition as described above. This permit 9a granted upon
the express condition that the person to whom ft is �aanted and lnia agents� employees and worl�nen, in all work
dane in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances oP
Fridley, B�Iinnesota. regarding location, conslruction. alteration, ma3ntenance, repair and moving of iruildings with-
in the city limits and this permit may be revoked at any time ugon violation of any of the provisfona of said
ordinances. �. �
NOTICE:
This pe�mlt doea not cover tha construction, Instailatlon or alteration To� wl
eewe� or water. Be sure to see the Bulldlna Inepeator fo� separate pa�mN� for
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gas heating,
iNOUSneu�
wo�KCSs
GTY LOTs
TOIOORArHIC MAPPINO
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C. E. COU LTER
LAND SURVEYOR
REGISTERED UNDER LAWB OF STATE OF MINNESp7A
L[GCNSED !Y ONDINANO[ OP CtTY OP MINNlAPOL16 '
3300 LYNDALE AVE. 50. ' MINNEAPOLIS 8. NIINN.
TAYLOR 4-0370
S URI' LL/ FQ/� �T T� L/ .7 �r��Ji�i�
�ttrnrqar's (IIn�t�r�rtr
N�urr�No
FAPM SYRVEY6
LAKpMOR[
JYDICIAL
ScA«-� /'= 30"
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I hereby certify that the above is a true and correct plat of a survey of�
Lot Eleven (11), Block Une (1), OSTf�`,�N'S THI�.D ADDITIUPI� anoka Coun�ty,
ti'iinnesota.
As surveyed by me this 19th day of November 195a A.D.
Signed � <�. �c ��+°,.��-�.
h�innesota �.egistr�tion No. 258�?
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HEAT LOSS CALCULATIONS DEPART�IVIENT OP BUILDINGS fRIDLEY, MINN. 4
Weatherstrips A.S.H.V.E, Conshvction No. Insulation
Guide
Windows I Doors Reference Out. Wall Int. Wall Ceiling Roof F7oor Kind How Applied
Yea—No Yes—No 19—
F1.� Room � Lengch � 2� W;dth /� Height �• / FI.��.�� Room Leagth � o Width �'�/ Height�:
Windows and Doors—Crackage and Area Windows and Doora—Crackage and Area
�Vldth Helgdt No. oL Llneal f. Area Wldth Helght No. ot Llneal tt Area
No. ot pane ot Dane lighte ot crack eq. tt. No. ot pane of De.ne lighte of crack ea. it
Coef. Btu
IaSltration /_�, 3 K '�Sjl�
Glass 19P � �
Fap. wall / 7�
Net exp- _wall - - !S
Int. wall
Ceiling ,� �.� ,
Floor ,
Total Btu.
Required sq. ft. E.D.R. or aq. ias. W.A. Leader area
/ Fl•I ��� . R�m ( �p� / � Widch
Windows and Doors—Crackage and Area
Widlh Height No. of Lfneal 1t Area
No. ot pane ot pane IlBbts ot crack eQ. it,
/ -�t �� � l��i /7, % l2,r►'
v V
2 /i
Coef. Btu
In6ltration � 7 �� ��
Glaaa /� H/ ��
Eup. wall .Z X' X X
Net ezp. wall S,y �� i�
Int. wall 'V Y �t 1l
Geiling - r� /� - /- O�
Floor � f s/�'
Total Btu. d
Required sq. ft. E.D.R. or aq. ina. W.A. Leader ana
Ft, � oom'� Length /� Width / z- Height �=
Windowa aad Doors—Crackage and Area
Width Heig6t No. ot Llneal tt Area
No. of Dene ot Dane Ilghts ot crack W. tt
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� 2� G� 1�' at.Y- Zv, � �, %
Coef. Btu
In6ltration '� � ' D
�, � y/
_ii v
Gtaas
�p. Wau
Net ezp. waU
Int. wall
Ceiling
Floor
Tbtal Btu.
Required aq.
��Sf �/ / �
� � X
�Sf /Z � //D
ft. E.D.R. or aq. ins. W.A. I.eader area
/ �/yf �G � T,J Zrs. ° y
� /L � �-�/ � Pr s . � 3, y
3 `= 6 � �vy, a..�. � �c'.�
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L�filtration � 3. s'
Glaaa 7-�
Fap. wall
Net-eap. wall � Z
Tn� wall Y
Ceiling p
Floor ,�c �
Total Btu.
Required sq. k. E.D.R. or aq. ins. WA. l.eader aree
Ft.I T�Q T/,� Room ( l.ength � Width ;
R/indows and D�rs--Crackage and Area
Wldth Helght No. ot Llneal 1L Area
No. ot Dane of pane I16b�e ot crack eQ. fG
i z 5i /� �7rY. /3_ � 7. Y
ef. Btu '
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'/ 3 7D
� �c X
�t Y Y
/2 � � (Pd
/y '�,�3�
H��hc � I
Infiltration /3, 3 � ,S/O
Glaas % L1/ c�a
Eap. wall �'� 1� v Y
Nec eap. wa11 8'0� /� .S3 �
Int. wall V � � v
- Ceilins .�i6 / a- %7 2
Floor �� �
Total Btu. �- l� �
Required aq. k. E.D.R. or aq. ins. WA. Leader aree
/ F7.� %� . Room I Length / Width �i
Windowa and Doors—Crackage aad Area
Width Hef6bt Na ot Llneal [G Ares
No. o! pane ot.yane Ifghts ot arack sQ. tt
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� �� > G Z 71.s/ i� 9 d�
o�c�
;i�ht �
Coef. Btu
0
Infiltration %': 3 3�/ �8'C� •
c�a� �y o �� ��
Fsp. wall /'�'-� � �[ �C Y
Net esp. wall / 1 � oD
Iat wall �f �l x }�
Ceiling /y3 /2 �s
Floor t/ / � � �
Total Btu. ' y �
Required aq. k. E.D.R. or sq. ias. WA. l.eader area
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HEAT LOSS CALCULATIONS DEPART�INENT OP BUILDINGS FRIDLEY, MINN. �
Weatherstrips A.S.H.V.E, Coastructioa No. Insulation
Guide
Windows ( Doors Reference Out. Wall Int. Wall Cxiling Roof F7oor Kind How Applied
Yes—No Yes—No 19_
Fl•� ,�%., ,Room � Length (� Width � Height �'! Fl.� Room Lengt6 Width Hei
Windows and Doors—Crackage aad Area Windows and Doora�rackage and Area
�Vldth Helght No. o[ Llneal f. Area Wldth Halght No. ot Llneal !t Ares
No. ot Dane ot Dane Iighte ot crack eq. tt. No. ot pane ot pane Ifghte o! crack eq. ft.
Coef. Btu
lnfiltration 9C y k
Glass '�t v �r y
Eap. wall �( y �r Y
Net esp_ wal� -_ X _v X_
Int, wall Y 5� X
Ceiling /� ! �– ��
Floor / / .g �S
Total Btu. �
Required sq. k. E.D.R. or aq. ws. W.A. Leader ana
Fl.� • Room � Length Vf/idth Height
Windows and Doora—Crackage and Area
wtatn Hetght No. o[ Llaeal ft Area
No. ot nane oL oane IlRhte ot crack sa. !L
�
In6ltration
Glaaa
Eap. wall
Net eap. wall
Int. wall
Ceiling
Floor
Total Btu.
Required sq. k. E.D.R. or aq. ina. W.A. l.eader area
Fl.� Room � Length Width
Windows and Doora—Crackage and Area
Wldth Helght No. oL Llneal tt Area
No. of nane ot vaae Ifehts of crack sa. it.
�
, Infiltratioa
Glaaa
Eup. wall
Net exp. wall
Int, wall
Ceiling
Hloor
Tbtal Btu.
aq. ft. E.D.R. or aq. ias. W.A. Leader ana
B�B
Bi11
Btll
Infiltration
Glaas
Eap. wall
Net ezp. wall
Tp�. Wau
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or aq. ins. WA. Leader area
FI.� Room � Length Width
Windows and D�ra—Crackage and Area
�Wldth 8e16ht No. of Llneal tt. Area
No. o[ nane of pane llBhts o! crack ep. tt
Infiltration
Glasa
Eap. wall
Net e�. wall
Int. wall
Ceiling
Floor
1'otal Btu.
Requued aq. k. E.D.R. or sq. ins. W.A. I.eader area
Fl.� Room I LenSth Widt6 Height
Windowa and Doore—Crackage and Ana
Wldth Hefght No. ot Ltneal [G Ares
Na o! usne ot.pane 116hte ot c�ack eQ. tt
In6ltration
Calaaa
Esp. wall
Net eap. wall
In� wall
Ceiling
Floor
Total Btu.
Required aq. k. E.D.R. or aq. iaa. WA. l.eadec area
Biti
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Caity of Fridley, Minn..
6431 University Ave. N. E., Mianeapolie, Minn. 55432
BUILDING PERMIT
��: Segtemb�r 7_a,�71
_11170
�
Owaer: ThoTMSs I�ale�= Bwtlder Ex-teri�ox�lesi�A Services
�� �H 7p19 Hickorv Drive N.E. Addres9 6391 Monroe Str.eet N.E.
LOCATION OF BUILDII�G
No. 7019 s�t Hickory Drive N.E. � _ p� of Lot
Lot � � Slock
Addition or Sub-Division
Corner Lot Inside Lot X Setback Sideyard
d3eWer IIeval3on Foundation IIevation
DESCRIPTION OF BUILDING
To ?� IIsed as:
Re$iding H& G �'ront Depth Height Sq. Ft. G�. Ft
Front Depth Hei�Y►t Sq. Ft Cu. Ft
'l�ie of Construction S,teel �.� �.� _ $2,600.00 To be Completed Oct. 1, 1971
In consideratioa of the issuance to me of a permit to construct 'the building described above, I agree to do
�ig proposed work in accordance with the d�aription above set forth and ' compliance with all provisions of
Orc7inances of the dty of Fridley. �
� J , / / ��°-. � �i '" '� `��
In con�tderation of the payment of a fee of $.____1.�..Q�_, permit is hereby granted to x erig� D_. e_si�n Seiw.
to construct the building or addition as described above. This permit is granted upon
the express condition that the person to whom it is granted and his agents, employees and worl�nen, in all work
done in, around and upon said building, or any part thereof, shall conform in all respects •to the ordinances of
FTYdley, 1123nnesota regarding location, consixuction, alteration, maintenance, repair and moving of buildfilg8
�� dty ]imit� and this permit may he revoked at any time upon violation of any of the provisions of 8aid
�
,���_� ���e�� �`� Buiidin8 Inspector
HANR � �iJ�iICH
�. '
NOTICE:
ffiis permit do� not eover the eoastruction, inatallaHon for wirins, plumbing, ges heatiag� sewer or water. Be soro to ses
t6s Batlding Inspector for aeparate permih fo� these items.
a
AP.PLICATION FOR RESIDENTIAL, ALTERATION,
OR ADDITiON BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNER�S N�AME' ���i �5 f7 �l� y BUILDER: �5l�e0`/af �srSno Seo�u�c�S
. ' eT '
ADDR�S$ : oll�jliG/�o/' Y D!' �iDDRF.SS .� 3�%/ �pil/�D e. �%E
�0:. STREET' 7�l � �t c.�r�r"'1 .�r.
L0� ;��„ BLOCK; I ADDITION :� c� �%r �u, 3``d� c�e� Q� J.
CORNER LOT: � INSIDE LOT:�_SETBACR: SIDEYARD:
�i,ppllcaat attach to thie foan �io Certificates of Survep of Lot and proposed
buildin$ locatior� dxawa on theee Certificates.
H�SCRIPTION OF BUILDING
To Be Used As:
�es r �e.+/� F�oIIt : Depth : Height :
^ r
�� �a�.� � � Squa�e Feet: Cubic Feet:
%RI �� Fxont; Depth: HeighC:
Squaxe Feet; Cubic Feet:
�ipe of Conetruct�on: � f S,d�n�� Estimsted Ccet; �$ v?6Qo �
s
7.°O B@{ COmplBted; �C% ��.�1 �% %�
�., � � �'
�;,�
The uade�sigaed hereby makee applicatimn for a�ermi.t �or the work hereiu
epeciiied, agreeing to dv all woxk in sttict accordaace w�.th tt`e C�ty �f
$�ridley Osdin�aces and suliuge of the Departm��nt of Building�, and hersby
dec].�tres that all the facto and repreeeatatiane stated in this applicatiou
are tsue aad corsect.
DiATE: ��! 7 SIGNATORE: ae�-� c"-�•
(See Sav�sse Side For Additio�nal Imformation.� �
_ . .. ,� .�- . _..,. / !-' .. ` P
/
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w ' � l _� .._� ....`_Ya �. _
ls.: ' r - k�_o /�� • � ' =d�
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BUILDING PERMIT FEE SCHEDULE
SECTION 2. The Inspector of Buildiags shall, before issuing peYmits for tt►e
erection of any building or atructure, or for any addition to any existing
building or structure, or for aay alteration or repairs to any existing
building or structure, upon application therefore, require the payment by the
appl;tcant fur such pern�it of fees to the amount herein below set forth and in
the auaaner herein provided to-w3ts
UNIFORM BUILDING CODE: 1�ipe 1, 2� 4-$2.15 for each one thousaad cubic
feet, ox fraction thereof, in such cubical conteata. Type 3� 5-$1.85 for
each oae thousand cubic feetm
ADDITIONAL INFORMATION
Foz the purpose of camputing fees for building permits, the eubical contents
of any building or addition, ia determined by multiplying the ground area
covsred from a point six (6) inches below the floor line of the basement
or �he cellar to the average heighte of �he upper surface or to the average�
hei�ht cf the roof eurface of the main gable of a pitched roof.
For xepair� or alterations to an existing structure, the fee shall be at the
rate of $3.00 per each five hundred dollars ($500.00) or fraction thereof in
the cost of all proposed work.
In ao case ehal� the fee charged for any permit as set forth ia Section Z be
lesa thaa �5,5 � 00.
V�RIFICI�ITION OF FOUNDATION
NOTE: �etm�ts for Qonetrustion will be issued a minin�m of 24 hou�a from the
ti.�e of applicatioa, to allaw.for proper review of the proposed structure �tnd
of the conatsuction site.
A Ce7cti�3ed Survey of the lot, ahawing the location of the foundation, ouce it
has.been canstsucted, will be required before vraceedina with the framiag.
CERTIFICATE OF OCCUPANCX
Applicatiom for a Certificate of Occupaacq shall be made teq (10) daye prior
to the uae or occupancy of any atructuse for which a building pexmit has been
iasued; and eaid atructure shall not b� used or occug�ed until a Certiricate
of Occupancy haa been issued.
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HOUSE HEATING TEST RECORD
ADDRESS / � � � ��f �Lf dy' V �3"t �� �.. APT. FLOOR CITY SUBURB �
OCCUPANT ��- ` �" � OWNER `�
HEAT LOSS AT HTG. 1 T. �
SOLD BY 7�� � ��� INSTALLED BY ��
Eleetrical Work By Gas Line By ��
TYPE OF HEAT GA FA e'' HW STEAM SPACE HTR. UNIT HTR. OTHER
/i� GAS DESIGN CONVERSION
MAKE L�(��� `�-�+-°- �. MAKE OF BURNER
M�e� ° Modal
Serial � `� � � �/� � Max. BTU Rating
INPUT I��� °��, MAKE OF FURNACE
Model
�� CONTROLS �jd °/
THERMOSTAT �"� �` Heat Plug )�� Vent Size �`�
Valva. �''�+�.- - KIND OF LIN R%�'�i'�`� SIZE ���� NONE
Limit � � %� - Drak Hood � � �"— Regulator � � ~�
Limit SeHing �-� � Filters Size,���� ��umber �
Fan Setting / � � `� �/"� , Chimney Location Insid� ' �Outaide
Pilot TYpe �.��+�� � Chimney Construetion '�
Pilot Make �' `� '
Pilot Model Smoke Bomb
PiloT Timing p "�'� ' Draft
Wiring �'°
.Test Tag �'"
L.W. Cut Off Door Pressura Lighting Inst. �"
� � � ,.s�
Pressum � �' Pereent CO2 � Date Tested � � �'` � �
Input CFH 6 B� Pereent OZ � Company Testing �
Staek Temp. � Pereent CO U Name of Tester `
Form 235
sue�ecr PER
City of Fridley ° 17 6 0 7,
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
r
; � ECEIP
� • COMMUNITY DEVELOPMENT DIV. I y/� n
r � y � PRO7ECTIVE INSPECTION SEC. �� ��
� _ �
� /'�'1 � CITY HALL FRIDLE� BS432 NUMBER REV. DATE PAGE OF APPROVED BV
1""'"� � ,`� 612-571-3450 910-F15 7/11/84 � �
JOB ADDRESS �019 Iiickory Drive N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. ].]. 1 Ostman's Third Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS 21P PHONE
Robert Faulkner 7019 Hickory Drive N.E. 571-4597
3 CONTRACTOR MAILADDRESS Z�P PHONE LICENSENO.
Greco Constructi.on 41 - 70th Way N.E. 571-1914
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
8 USE OF BUILDING
Residential
7 CIASS OF WORK
❑ NEW ❑ ADDITION [� ALTERATION � REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof Dwelling
9 CHANGE OF USE FROM TO
STIPULATIONS
Roo� can be the.2nd layer but not the 3rd. Install ridged galvanized
valleys where necessary. �
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
SEPARATE PERMITS ARE REDUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SUfiTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED �`],�600 S•8�
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING coN- $26. SO
STR N OR THE PERFO M NCE OF CONSTRUCTION.
PLAN CHECK FEE TOTAL FEE
� � �'/ /��� $27 .30
°" Si ATUREO TRACTORORA�THORI2EDAGENT ��ionTE� d- WHEN PROPERLY LIDATED THIS IS VOUR P RMIT
�� � � I �
SIGNA7URE OF OWNER IIF OWNER BUILDERI IDATEI BLDG iNSP �ATE
NEW L �
City of Fridley Effeetive 4/1/84
ADDN. [ ] R-1 AND R-2
pLTER. � J Building Permit Application
Construction Address: ��/ `� �'��°� � �� ��
Legal Description: �7 /I +��- / ����'S �� ��N�
Owner Name & Address:
������� ���/�� ' Tei. � ��1� ���r �
Contraotor:
�r� �r� �..��-� � � Tel. # �7� ��
Address: �t � �0�� �t/� �'�� -
LIVING AREA:
GARAGE AREA:
DECH AREA:
OTHEa:
Attach to this application, a Certificate of Survey of the
lot, with the proposed eonstruetion drawn on it to scale.
DESCRIPTION OF II�IPaOYEMENT
Length _ Width Height Sq. Ft. _
Length _ Width _ Height Sq. Ft.
Length width _ Hgt/Ground Sq. Ft. _
Corner Lot [] Inside Lot [] Ft. Yd. Setback __ Side Yard Setback
�
Type of Construction: � � Estimated Cost: $ ��� �
Approx. Completion Date: �5��� � ��`�
Alt. A Alt B
proposed Driveway Width If New Opening Is Desired: $---- $ -
See Back Page for Explanation
� /G��
DATE: ��� APPLICANT: � Tel. #.�� �
CITY IISE ONLY
Permit Fee
Plaa Check
State Surcharge
SAC Charge
Park Fee
SEwer Main Charge
TOTAL
STIPULATIONS:
� ��-5�
�
$ -- U�O
�
$
�
$ o`� �. �Li
��
�a . � 0
Fee Schedule on Reverse Side
25� of Building Permit Fee
�.50/$1,000 Valuation
$425 per SAC Unit
Fee Determined by Engineering
Agreement Necessary [ ] Not Neeessary [ ]
., a .
. BIIII.DIAt's PERMIT FEE SCH$DIILE
The Chief Building Official shall, before issuing permits for the erection of any
building or structure, or for any addition to any existing building or structure, or
for any alteration or repair to any existing building or strueture, upon application
therefore, require the payment by the applicant for such permit of fees to the amount
herein beloW set forth and in the manner herein provided to-Wit:
Total Yaluatioa
�1.00 to �500.00
�501.00 to $2,000.00
�2,001.00 to $25,000.00
�25,001.00 to $50,000.00
$50,001.00 to $100,000.00
$100,001.00 and up
Fees
i
$10.00 (Minimum Fee is �15.00)
$10.00 for the first $500 plus $1.50 for each
additional �100 or fraction thereof, to and including
�2,000.
$32•50 for the first $2,000 plus $6.00 for eaeh
additional �1,000 or fraetion thereof, to and
including $25,000.
�170.50 for the first $25,000 plus $4.50 for each
additional �1,000 or fraction thereof, to and
ineluding $50,000.
$283.00 for the first $50,000 plus $3.00 for each
additional $1,000 or fraction thereof, to and
ineluding $100,000.
$433.00 for the first $100,000 plus $2.50 for each
additional $1�000 or Praction thereof.
DRIYEi1AY DEPRBSSIOA ESCRW
(Concrete Curb Streets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus
6 feet times $13.50
Alternate "B": Removal and replaeement of eurb and gutter and install a 3 foot wide
approaeh With 6 iach depth - DriveWay width plus 6 feet times $15.75
VERIFICATION OF FOIINDATION
Permits for construetion �ill be issued a minimum of 24 hours from the time of
application to a11oW for proper review of the proposed structure and of the
construction site.
A Certificate of Survey of the lot, showing the location of the foundation onee it
has been construeted will be required before proceeding With the Praming.
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�'THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNiNG APPLIANCES OR THE
APPLICATION WILL BE RETl1RNED
r•► � � r•►
• : ' ► � � �� : - -
�Gmnrii:,:�� : _ !—� -- -• ► ► '- —
When ' , the unde�signed hereby verifies that the
ven�ng has been examined and is free from rust, deterioration, obstructions, Yes (X► No ()
and is securely supported and firestopped where required.
The venting system is plasticlPVC and meets all current codes and manufacturer Yes XI No ()
specafications including s�zin9� �ength, number of elbows and termination. i
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codeS and n�l Fumace V nti gCTaUles fo' f noes
i n c l u d e A G A- G A M A C a t e g o ry I C Y e s (� ) N o ()
assisted and natura� draft appliances.
�e is sized and installed to r�e�t the c�+�rer�t codes Yes �) No O
and manufacturers specifications.
When required to �^�'"�� "��'� cemh�c_fien air_ it Will be Slzed and 'I�stalled Yes �) No ()
to meet the current codes and manufacturers specifications.
When iostallia" ""°�•••°ntina c� _ct�m, the undersigned hereby verifies that
it is a listed assembly oes i clude AGA-GAMA Cat gory I C ntral Fumace
s p e c i fi c a U o n s. Th i s d Y e s �) N o ()
Venting Tables for fan assisted and natural draft appliances.
Is the commo as been emoved from the commonv en alnd ented�y after
an appliance h Yes (x) No ()
separately as per current codes.
� • • . 1 / • ' . 1 �
• 11 11 • 1 - � . � � - 1 • � 1 - H • � • �11 . 1 • �
Appliance #1 Type ���� ��- BTU Input �o� ��
Appliance #2 Type �✓° �°� �' � �� B-� Input �y �
APPIi�� �'' Ty� - Total Btu Input ��
Total Appli�nces _____.__-
Fan Assisted or Nat t�
Fan Assisted or Nat � �"
Fan Assisted or Nat
Vent Hei ht %8 / Diameter `% �� inches
Common Vent Type �-�-�� 9
qp liance #1 Vent Connector Height 3� ft Length s Diameter '`� p• in Type c%.�
p ' ft Length =ft Diameter �in Type ��
Appliance #2 Vent Connector Height _L
Appliance #3 Vent Connector Height = Length ft Diameter in Type .M
.
� ��.c���.,►,�..�-�-.- _
13562 Central Ave NE, Anoka, MN 55304
EATING CO: CenterPoint Ener��1�liiane$�s�e ,
. ` :" i�t - '
. : . �� .. _ -:�r
�_ - -
.. ��
ADDRESS
PIN
LEGAL DESC
PERMIT TYPE
PROPERTY TYPE
CONSTRUCl'ION TYPE
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
163) 572-3604 FAX: (763) 571-1287
: 7019 HICKORY DR NE
: 103024440023
: OSTMANS 3RD ADD
: LOT 11 BLOCK 1
: HEATING
: RESIDENTIAL
: ADDITION/ALTERATION
PERMIT NO.: 2004-0�1240 e�� j
DATE ISSUED: 02/20/2(�04
VALUATION .
NOTE: AIR CONDITIONERS CAN NOT BE PLACED IN A SIDE YARD WITHOUT WRITTEN PERMISSION FROM
ADJOINING PROPERTY OWNER
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A
REPLACE FURNACE (WARM AIR, CARRIER, 60,000 BTU'S)
# A/C UNITS 1 VALUE OF APPL OR WORK
#FURNACES
# GAS RANGES
APPLICANT
CENTERPOINT ENERGY/MINNEGASCO
13562 CENTRAL AVE NE
ANOKA, MN 55304-
(763)757-6202
OWNER
FAULKNER ROBERT J & DEBORAH
7019 HICKORY DR 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
applicadon and know the same to be true and conect. All
provisions of laws and ordinances governing this type of worN
will be complied with whether specified herein or no� The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
regulating construction or the performance of construction.
App11C�13T�� Date .
Bldg
1 # GAS DRYERS
0 ENTER VALUATION
HEATING PERMIT MINIMUM FEE
FURNACE SHELL/DUCT WORK
GAS RANGE FEE
GAS DRYER FEE
AIR CONDITIONING FEE
HEATING REPAIRS/ALTERATIONS
STATE SURCHARGE, MECH FLAT
TOTAL
PAID WITH CHECK # 5359
SEPARATE PERM(TS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
0
0
5900
0.00
30.00
0.00
0.00
25.00
0.00
0.50
55.50
= Ce�l%IPtll%:r�
Enerr�qyy
Minne asco
ADDRESS �! �L t7� �� ��
OCCUPANT L �
HEAT LOSS Yes DATE HTP. INST.
SOLD BY CenterPoint Enerav inn asco
Electrical Work By � i / i
TYPE OF HEAT FA a/ SPACE HTR.
CiAS DESIGN
MAKE. � r� �+
Model � f,��
Serial ` �
NPUT ' c� � •� - --
CONTROLS
THERM TA ��� ��f '1'� Heat Piu�_
Value iv�i�� ��
Limit yl C•�
Limft Settin
Fan Settina �i'a7 e
Pilot Ty� �/.S� .�
PUot Meke �� �"� °'+ �
PAot Model � /"1
PUot Tim(n��_,_,�� �
Pressure o � � Percent COZ
nput CFH �O � � � � Percent OZ
Stack 7emp. � i Perc�nt CO�� u,.� ,,n
�"_
��us� ��`��tv� �'�s� ���o��
APT. �LOOR CITY � ��
01flINER _
INSTi4LLED BY CenterPoint Enereay Miy nneaacro
Gas Line By � r �' '
UNIT HTR. OTHER
COIdVER�ION
Vent Siae
` � J �-
KI�ID O� LINER � SIZE � �' -
NONE
Draft Hoad Regulator �v �YP,�e D' e
FNters Size � ,� Number �
Chimn�y Location Inside �./' Outside
Chimney Construction _�� S S �
Wirirsg � e
Test Tag o/
LighUng inst. P/
Date Tested � d- O
Company Testlng i�
Name of Tester � � �
s;.
ADDRESS
PIN
LEGAL DESC
PERMIT TYPE
PROPERTY TYPE
CONSTRUCTION TYPE
i
CITY OF FRIDLEY
�a�� rnvrvFUCrrv evF�vr� x�
FRIDLEY, MN 55432
572-3604 FAX: (7631571-1287
: 7019 HICKORY DR NE
: 103024440023
: OST'MANS 3RD ADD
: LOT 11 BLOCK 1
: ELECTRICAL
: RESIDENTIAL
: ADDIT'ION/ALTERATION
PERMIT NO.: 2004-00241
DATE ISSUED:
VALUATION .
NOTE: ELECTRICAL PERMIT BECOMES VOID 12 MONTHS AFTER PERNIIT ISSUE DATE.
REPLACE FURNACE AND AIlZ CONDITIONER
# INSPECTIONS
APPLICANT
CENTERPOINT ENERGYMIlNNEGASCO
13562 CENTRAL AVE NE
ANOKA, MN 55304-
(763)757-6202
OWNER
FAULKNER ROBERT J & DEBORAH
7019 HICKORY DR NE
FRIDLEY, MN 55432
AGREEMENT AND SWORN STATEMENT
This permit becomes nu11 and void if work or consttuction
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
application and l�ow the same to be true and conect. All
provisions of laws and ordinances governing this type of worl�
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 provisions of any other state or local law
regulating construction or the performance of construction.
Applicant Date
Bldg Insp Date
1
STATE SURCHARGE, ELEC FLAT
ELEC PERMIT FEE - NIIN (RESn
TOTAL
PAID WITH CHECK # 5359
SEPARATE PERNIITS REQUIltED FOR WORK OTI�R THAN DESCRIBED ABOVE.
0.50
20.00
20.50
OCT-17-2005 13�04 CITY OF FRIDLEY
��.ildiu�g
r�spections
'G3-57�-3G04
a��
ITE ADDRESS r
HIS •'•ppLIC.4N� IS:
TEN,t�NT
�TJ�I.DiNG
R.�S�D►ENTI,�L AP�"LYCA'TIt�N
C�Y ��' FRID���
XOLIR E-MAii. AAa7RESS _
�` u %�.
❑ O �CGNTRAGTOR
NANIE; . �l—�/—P!� %�--
ADDR�SS� � p i' .
�a�:, S l-� 3 5- �vl� �
n�eu,rF• 1 /.�.h�nP�� �k%d�v!'�
P.02iL4
Permit No.: � ' �L" �-' l
�����a gy: -
D�.te Rec'd: ��_ ' - _� ��i�'
Z
SUSMTI' A COPY OF STATE J�ICENSE � �' DATE
�rovR s�ra� �cnvs� .Ew��: 2 7�� AJ � F�-� v�/� c.v _ crrx�� lZ �� /c.� sra� zrn -S'S/i 3
R'ITH APpY.ICATION p�o� -!� 9.� � v FAx 5/ - 2�°� -v/ y5
PROpERTX �'Y�E
PERN�'1' T'YPE
T"YpE QF �Vd�tK:
O �uts
O BASEIv�Ni' Fu�t[SH
❑ DECK
�ESCRIBE QVO�ttC �EING
ST�E OF II1�KOVE1b�fT_
JIIM'�ER OF SQUARES
�.=Ai�AGE$
�ROFO5ED SIZE:
�tOPOSID i�1GHT: —
So��r f �
O ROOF
o SIDWG
O SwWt�ID�TG POOL
D AI�DITION
� REMOD�G
i; S�-e'� C�,
l� HOUSE & GARAG�
G ATPACFffA GARAG�E
❑ DETAC�D CrARAGE
o nn�t zwE
��� 50�7 � �Cl.SL�G� C� �l f�lo,("
e �.S
I�iGHT
$�13�2QbEt�vcr susMrr:
1. �g F1oor Pl�
Z. Pfopo^.�ed tloor plan
3. L�2 of strucleual r�nbers to be us�d
51riYNG FOR NEV+► CONSTRUClTON IltiCX.L1DING DECKS,
� vimyl OSoffrt ADDIT[ONS_ &,RORCHES S[1BNIlT:
� Alltelinua► 0 Ttim 1. Siec PianlSurvey showing the existit�g sd-t�res
❑ � D Fastia �d propased prc.ject
2. Two set� of wnstructiae plans
Q.1� OP�7+1IN6S [3Yes �li�lo I.C)CATIaN dF a'IlJDC)WS 3. En�gy Caiculations
pR FOR TiEW OPENINGS-DES�E SiT� OF _ _
a�r cxa�a� &
TYP� OF WINDOW'PO BE MSTALLED NUMBIIt O�' WA�1pOW5
ALL k'E�S Alt� EASEb ON vAY.UATTUN, YNCLUAA�iG'Y'HE C4ST OF LA�Q�.t AN� MA�`E�tIALS:
(U�iG T'AE 1997 U.B.0 FEE SC�riUL�
71'�'TAY. JOJ� �ALilA?AQN � �� U� _ �LE1PA1lfC� _ �°4'P� _ .—
Permdt Fee
Plan Review
Swcharge
Fire Swcharge
�.1CCriS8 SSYG}i8l"��
SAC Cbarge
Curb Cut Escrow
Erosion Cantrol
Park Fae
Sewer Main Charge
Total Due
� }�' 3. a
$
�
� .�aa
$ •�
$
$
�
_S
$
$ °l/.SS --
See Back Page for Fee Scbcduie
65°h of Btulding Fennit Fee
{.0005} times t'�e total jok► vai�ioA �- Mi.aimum �.59
.00 � x i�ermit Vatussion (1/l0%)
$SAO (St3�te Licensed �t.esidearial Co�tractors}
$1450 per SAC Unit (Plans t4 MWCC for detcrmiaariQn}
�t+6ft= $x�20=$
$450 Conservation Plan �CView
Fee Detern�iaasd by �agineering
Ageement necessaiy ( ) Nom Ne�essary ( )
7'�IIS IS AN APPLICATION FOR A PERN1Ff—N4T VALID UNTII. PRIX:L$$�D
I hereby apply for a build3rn,� perrr�it and i ac�wl�ge tiaat the informatian above is carnple#e and ace�trate; that the wark wi�ll be in
con�ormance with thd ordinances gnd codes di the City af �ridley and with t4�e Minnes�ta Construction Cades; that I understwd this is not a
permit but o�y an application far a pern�it and work is not ta statt without a penmit; that the wprk wili be in accerdar�ce wit.� th� approved
pian ia the case of all work which requires revier�v and a�proval of pians.
SIGNATJiLEOFAPPLICANT./J%�C��� �dL11G����"��PR�iTNAME �LJ%.P,%ZfG�Ce IO�1�'Y�l��' �� 3/0 L
OCT-17-2005 13�04 CITY OF FRIDLEY
3uilding
CiSpectibnS
'63-572-3G04
[TE ADDRESS __.L!
HIS APPLICANT 1S:
��
�U�LDING
RES�DENTLAL APl"LYCATIC3N
CYTY U� FRID��Y
. � . . tx�
p OyVNER, �G'NTRAG'tOR
S 1-
P.02iO4
Permit No. • �� � � % �
�t����a �y:
Date Rec'd: � -�' �? � �
r ,� ��-
corrrxac�-v� sv,v�: /�t��- �t(�� o�-s - -
SUEMIT A COPY OF STATS 1.iCEDISE � f� DATE
�rornt s�ra� �tcnvs�E �wn�ss: 27 8lr N• �"a � vrii c u> crrr� Fe u�!l e_srA� z� 5 S/ l3
WITH A�'Y.ICATION rHO� !� 5 �-[o G S- 3(� � c� . FAx !� S/- Z� 7-o i y.r
PROPERTX TYPE
T�ERN��' Ti�PE
i"YpE QF VVO�tK:
OBA5EN�Ni'FWISH �RaOF
❑ DECIC � SmIIVG
Q S�
�ESCRIBE �VORK BEING Dt7NE: i'� !�U t� � O.{ Lf
�T�E OF
sQu,v�s . � D -
:�E�
?ROFOSEA S1ZE:
''ROPOSID i�TTGHT: - —
eroYNG
� vimyl
� Alumim�m
o mi►a
� OPEf3IIdG�S C3�ies �No
OR FOR NEVii OPENII3GS-DFSGRISE SIZE OF
OPENYNCr CHANG$S &
TYP� OF W�DOW TO BE �STALLED
l7 HOUSE & GARAG�
Q ATfACFIED GARACrE
O LETAC�D CrAiielG�
OSoffit
0 TEVn
0 Fascia
Wca,3�aN OF wavnows
■ .• � �
■ • _�.r��•
I�IGHT
BASENID�T'i' RF1IV�ODELING SUBMiT:
1, �g Flaor Pl�
2� i�aposcd floor pfan
3. Lgt of str�cpua{ manbe�s to be us�d
�'t
FOR.NEW CONSIRUCITON INCL.UDING DFClC5.
�1DIl'lONS_ & PORCHES SCiBl�RfL:
1. $iee Pian/5urvey shvaing �t existing spvcmre5
�d propo�d pro�ect
�. Tvao set� of co�avc,�on pim►s
3. Encrgy Calcula�iots
AL� l�'E�S AR� �AS�D ON YAY.UAT'�UN, nvcr,v�a�� � cosT a� L,vao� arm �vr.�►��ua�s:
(USA�TG T�YE 1997 U.B.0 FEE SC�riITLE7
�►�ay, ,ro� ���A'��� � �l���A t����aavc� ��
Permit Fee
Plan R,eview
Surcl�arge
Fire Surcharge
�.icense S�charge
SAC Cb�arge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Mam Charge
Total Dne
$ �S3 a� See Back PagC for Fee Scbrdi�le
$ 65% Of Builcimg PeTmit Fee
$ (.�057 times the total,job vaivation � M�nimum 5.54
$ . �{ .QO1 x i�ermit Vatuation (1/10%)
$ �,Q�j $SAO (State Licensed �Lesidential Cvr�tr�actors)
$ $1450 per SAC U'nit (Plans to M'WCC for deterrn3nation)
$ R+6ft= ftx�20=$
$ $450 Coffiervatian Plaa ZLeview
$ Fee Detenr�i�oed by Enginee�ring
$ Agreement necessary ( ) No�a Necsssuy ( )
S Make el�ecks payable to: City of F�idle� Attach
TFIIS IS AN APPLICATION FOR A PERMff NQT VALiD C3Nl'IL PROC�SS�D
I heTeby apply for a buflding permii �d i ac�wlet3ge tt�at Lhe informati�n above is cample#e and accurate; that the work will be in
con�ormance with the ordmances and codes di the City of k'ridley and witt► the Mianesota Construction Codes; that I understand this is not a
pzrmit but o�y ea application for a petn�it and work �s not so stact without a penaoit; that tbe work will be in accordance wit�a the approved
plan ia the case of all work whioh requires revie d approval of pians.
SIGNAJURE OF APPa.1CA3JT ;� _ Cl/7G���1�'�mrr rra�0 /e�'/e I��11I�iOd�DATE ���.� f D 6
�°o
'�
OCT-17-2005 13�04 CITY OF FRIDLEY
3uildiu�g
tiSpectibn5
'63-57�-3f 04
rrE ,a►t�oxESS ,,,�C(,
Eii5 APPLICA,IVT YS:
_f�.►�li!
�3U�LD�TG
RES�ENTI,�.L A.P�'LYCA,.TICaN
Cr'i'Y {Jk` FRID��Y
�ovR. �-�r,vr.,�,p�ss _
Y� .
❑ avdxEx �ea:wrRa►c'rox
P.02/04
Permit No..
�t���ea By:
L7ate R.ec'd:
,� z���43�
SUBMIT A COPY OF STATS L10Etd5E � E7� DATE
�ovR s�rA� r�cnvs� ���: 27 Sf� �•�e'.� r v� �c� crrx� �/�1�, srA�7f1� S//3
WITH APp"y.ICATTON rxor� (�St -(�__95 -3l� �3� F.�x !� SI - a �� -O I �s
'!"YPE �vLh rAtvut. zuvaw wr�a ixu�., i.vN
. ❑ TWO FAIVIII.Y/1��'9V CONSTRUC7i0N
'�� O �+,$£iTt3$�I O �A�,,4
O $ASEIvIDVT F�TISH O ROOF
❑ DECK �SfDIIVG
G S'�VQvIIvJ
QF
�ESCRI�E oVOZLtC BEING Dt7NE:
3T�E OF II�1tOWE�`1' _
SQUAR$S ^,
�_a�srPC,
�
�ROFO5ED SIZE:- —
'TtOPOSID i�11GHT: —
8t17ING
� v;my1
� Alumirnm�
❑ Qthet
� OPENINCvS C3Yes �No
OR FOR NEW OPENB3GS-D�SC,RIDE SiZE OF
�i'ENTiVCx GHAIVGES &
TYPE OF WTI�t�0�1 TO BE Il4ISTALLEi7
ALL �'E�S AR�
Permit k'�
Plan R,eview
Swci�arge
Fire Surcbarge
License S�cha�rge
SAC Charge
Curb Cut Escrow
Erosir,n Control
psrlc Fee
Sewer Main Charge
n
l� HGIUSE & GARACsE
G ATTACFIED GARACrE
❑ LETACHED GARAGE
C]Soffit
0 T�t
O fss�ia
LACATTa�N OF w�mows
OP
❑ DRAW TIL�
O O'�IER
T�EIGHT
BA�7' RRMODE111VG_SiiBMt7':
1. �g Floor Pian
2_ I�oposed 9oor plse
3. Lgi of struct�ffi marnbc�s to be used
FOR NEvJ C4NSTRUCTiON INCi.UDING DF.C�CS.
ADDfl70NS_ & P(�RCHFS SLTBNIlT:
1. Si� PimUSuevry shoaing tht eatistirtg sprucmres
�d proposed pra�ea.
2. 7wa sets of coaad'ac�bn plans
3. Enqgy Celculatietfs
ON VAY.UAi`�4N, YNGZUA�N'G'Y'iiE COST OF LA�OR AN�t MA,�xtTALS:
(U�i Z'FiE 1997 U.B.0 FEE SCSEriU3+�
►TIUN S � � � �__ O�CUPANC� _ T'i'p�
$ �� � S° � See Sack Page for �'ee Sch�dule
$ 65°/a Of 8uflding Per�nit Fee
,$ .?� {.0045) tinaes the total job valuatiam � M'vnimum �.SO
$ s�� AO a x i�ermit Valuation (1/10%)
$ l� $�.00 (State Licensed �tesidengal Gvutractors)
$ $ I450 per SAC L?nst {Plans to M'OiiCC far deterrnination)
� R+6ft= 8x$20=$
$ $450 Conserx+arioa Pian Zteview
$ Fee Det�en�i�oed by Engmt�ring
$ Ageement necess�y ( ) No�a Nets�sseuy ( )
� � S 7 1V1ake checks oavable to: C'rto of Fridfen Attac
Tf�II3 I3 AN APPLICATION FQR A PERMCE NOT VALID i3N1`IL PROLES5FI5
I hereby apply for a build�g permit and I ac�wledge tha� the informatiq� above is cample#e and. accurate; that the work will be in
con;formanc� with the ord'm�ances and codes af tlie City of �ridley and wiitb the Minrnesota Constnuction Cades; t�at I rmderstand this is not a
permit but o�y sn application for a peru�it and work �s nat w start without a permit; that the w�►rk will be in accordance witb the approved
p}.aa ir� the case of all work whiah requires revi�wv and a�proval of pia�s.
s��ra�.n� oF ,��.tc�' �QA? i/�G� Na� !.C�.� iC /l � Va/1 �� �� 9 -l�� %
�uilding �j,���� Permit No.:
Inspections ����N��, �p�,ICA'I'I�1V Received By.°�
763-572-3604 ��►�� �g, ��� D��.'�'c� E P 2 2�Q 8
763-502-4977 FAX EFFECTIV� 1-1-08
DATE YOUR E-MAIL ADDRESS
SITEADDRESS � . �.
THIS APPLICANT IS: ❑ OWNER °�QNTRACTOR
PROPERTY NAME:
��� ADDRESS: CITY STATE ZIP
TENANT PHONE: � �] I ` S� �I
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE ��r um ng Q EXP DATE
YOUR STATE
LICENSE, BOND AND STATEBOND #�a90 ���� ��. N.�., # 38 EXP DATE
CERTIFICATE OF ,�D�SS: �ridl�y, �� 5�jt "�2 CITY STA1'E ZIP
INSURANCE PHONE ��) 7`�-2199 Fa�t (763) 754-'��� FqX
PERNIIT .l�.,pE ❑ SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � N� ��PLACEMEtv'r
DETAILED DESCRIPTION OF WORK -
PER MS 16$.665 the permit fee is a mmimum of $15.00 or 5% of the total cost np to $500.00, whichever is greater, for the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor x.OS = plus .50 surcharge
OR
FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON $l O.Ofl PER FIXT[JRE, EXCEPT WI�RE NOTED. FIXTURES: (INDICATE TOTAL
NUMBER OF EACH BELOVi�. NIINIMUM FEE $ I5.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED QTY LIC) SWIlVIMING POOL WATER SOFfNER ($35)
CLOTi�S WASHER KTTCHEN SINK WATERCLOSET BACKFLOW PREV. ($I�
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IILRIGATION
_ WATER MET'ER _ OTF�R
.... _.. ., �.. _..._ _
, .
w Y � � � ��... .i.- . � -: 1. i' } .�y?Y s� '}, 9 'ti ��' { '
f �4 �,� f �K ��Yes, z s. e.Fw . `33:" .7 �l .a� . �uz�' � = t�i��°�^;
� . _ . , , . . ,. ' . ,. _„a. ..<.,,k �., . _ . r . ., u , f. . . , - ._:; r,
Permit Fee $ Number of fixtures @$10.00 x$10.00 =$
Surchar e .50 Number of fixtures @$15.00 x$15.00 =$
TOTAL DUE $ OR Number of fixtures @$35.00 x$35.00 =$�_
(MINIMUM $15.50) State Surcharge = $ 50
(MINIMUM $15.50) Total = $ �—
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 complete and accutate; 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 a11 w�k which requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME �,1� ��'��'D�DATE ( � / � �C
APPROVED BY DATE
.
t c 3� � ,3�/ "�����' �� � b
'��.r�.�"��.��. , �'�.�'" , .
, , � s ,�� : <: � `y=�i�'�`� '�.' � ',�.�s° �� r���a
City of F�idley
�uilding Inspections Department
6431 University Avenue NE, Fridley, MN �5432
763-572-3604
FAX; 763-502-4977
Building
T11S��@Ct10riS
"1FG63-572-3604
763-502-4977 FAX
DATE J V rw,,,
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
PROPERTY TYPE
� , uir r��
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
IDIN
❑ Vinyl
❑ Aluminum
❑ Other
❑ OWNER
I � � 1 1�
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-08
'j'� YOUR E-MAIL ADD
OrC �I �4. 11! +' . �� rj
��
�/..
{ �
PHONE �LJ • 7�-7f�30 I� VL7.d .s3� � yy��
STATE LICENSE # �p �ZCf ^l EXP DATE
�SINGLE FAbIILY/NEW CONSTRUCfION
TWO FAMILY/iVEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
O NEW HOME CONSTRUCTION O ADDIITON
0 MAIIV1'ENANCE/REPAIR �REMODEI.1
�Lt%��'1�i ��ap�ir, i� ��Gifjlr
' I.EI�IGTEI g f WII
❑ HOUSE ONLY
❑ HOUSE 8c GARAGE
O ATTACHID GARAGE
❑ DEI'ACHED GARAGE
❑Soffit
� Trim
❑ Fascia
SIZE
STORIES /
wnvnows
IN EXIST'ING OPENINGS ❑Yes DIVo LOCA1'ION OF WINDOWS
OR FOR NEW OPII�IINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WII�iDOW TO BE INSTALLED NUMBER OF WIIVDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF
fOTAL JOB VALUATION ��i, s� ��G THE 1997 UBC FEE SCHED �)
Permit F�
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Dne
❑ DRAIN TII.E
O OTI-IER
@
Permit No. o�
Received By:_
Date Rec'd:0
�z� f/� Z-.
�SS�/3'L„
HASBMENT REMODELING SUBMIT:
1. Exi.�ting Floor Plan
2. Proposed floor plan
3. List of structuial members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
�DD1TiONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing d�e e�dsting structures
� ProPo� P�J�
2. Twa sefs of constrnction plans
3. Energy Calculations
lu�l Y �l� /:`iC�
� S Sce Back Page for Fe� Schedule
$ 65% of Building Pern►it Fee
$ .001 tim� the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Conlractors)
$ $1825 per SAC Unit (Plans to MWCC for detetmination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Nece�aty ( )
$ __� l iViake checks payable to: Citv of Frldlev Attac
THIS IS AN APPLICATION
I hereby appty for a bu�ding permit and I ackno ledge that the
of ifie City of Fridley and with die Minn�sota ishuction Co
ish
perniit on site; d�at tlie work w�71 be in accordan wi� the�
SIGNATURE OF APPLICANT � _C , /,
APPROVED BY
A PERMIT NOT VALID UNTIL PROCESSED
ve is complete a� accarate; that the work wi7l be in canformance with the ord'mances and codes
t6is is not a permit but only an applic�tion for a permit �d work is nat w start without a
the o which reqai�es review and approval o plaas. �
��e
PRINT NAME��°�.$� • I�:� Z.. DATE e�4�
1 _ ,-
DA �
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Building PLUMBING Pernut No.: �;�°1 ��1 ��
Inspections RESIDENTIAL APPLICATION Receivecl By:
763-572-3604 CITY OF FRIDLEY Date Rec'd: f
763-502-4N%% FAX EFFECTIVE 1-1-09
DATE � YOUR E-MAIL ADDRESS
SITE ADD SS 0 : 0'e'l
THIS APPLICANT IS: ❑ OWN B�ONTRACTOR
PROPERTY Nq�: �� ��, �/���,,,
OWNER/ �DRESS:���/ CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR Np�: '—'� ' j
SUBMTT A COPY OF STATE LICENS # �J��,� EXP DATE �
YOUR STATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF pDDRES % �.ri�-�c>o� �v� CITY �%y�� STATE y/ � ZIP D�3
INSURANCE PHONE iC�- ot�j�- 'S�tI�IP� FAX �<� �
� �d°� 6
PERMIT TYPE ��GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW 0 REPLACEMENT
DETAILED DESCRIPTION OF WORK � �
.`n/ �,�Jr�rv�
PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor )
Labor cost under $300 =$I5.00. Labor cost between $300 to $500 = cost of labor x.OS = plus .50 surcharge
OR .
FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL
NUMBER OF EACH BELOV�. MINIMUM FEE $15.50.
1 BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY L1C) SWIMMING POOL WATER SOFI'NER ($35)
CLOTHES WASHER KITCHEN SINK 1 WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER ! LAUNDRY 7RAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
. �: �:������ i�; ��� : R � ���� � ���, �, � � � ��,. � ��F�>� � �.���� ',.���3� `��;� �,ib � ` �ci :;
,� . � . ...� �r��a . , � . .
Permit Fee � $ Number of fixtures @$10.00 x$10.00 =$
Surcharge .50 Number of fixtures @$15.00 x$15.00 =$
TOTAL DUE $ d I.� Number of fixtures @$35.00 x$35.00 =$
c Sta.te Surcharge = $ .50
INIMUM $15.50 � J� (MINIMUM $15.50) Total = $
THIS IS AN APPLICATION FOR A PERMiT-NOT VAL1D LINTIL PRQCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
confortnance 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 �,2�,�,,,��%O�,¢ �W PRINT NAME �� � �''Ll`Ltiy1/ DATE 0 �.��
�� ���✓X"7�. �-..� 4 ,...�, � i� ��� ��"�S ����i}.��.�������i`.�., ���'.��._. �" � ....� �5� t..
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977