AF - 46058` _
Date:
Owner
Address
�
Village of Fridley, Mi.nn.
BUILDING PERMIT
�
I1T° 1856
.. ������. ... ...
� � �-�B`�'ld r ..............................................
...............� ........ .. . m e
...................................... Address .............................................
LOCATION OF BUILDWG
No. . . . . /�� 7. . Street . . . � .�. .1�.��� �,J . . . . . . . . . . . : . . . . . Part Lot . . . . . . . . . . . .
. . . .�f. . . . . Addition or Sub-Divisior►( . . . . . . . . . .� .�� ,,�
Lot ...��..... Block �f. ..� . . _
. .���'• ° �• •' • . �
Corner Lot . . . . . . . . . . . Inside Lot . . . . . . . . . . . Setback . . .�'�. . � �. Sideyard .�� � . • • .°S• ����I
�/
DESCRIPTION OF BUILDING
To b ed as: ° s �
. . . . Front . �� . Depth . �." . Height .�. . . . . Sq. Ft. /. .��° Cu. Ft . . . . . . . .
�.. ..... .... Front l 3'/a �, Depth .�.?�� ight .....�.� Sq. Ft.ti. a�!.. Cu. Ft. ........
�� a �.
Type of Construction C�`. . . . . . .. Est. Cost ��Do..� • • • • • • To be Completed ..... .. . . ... .... ..
% '
In consideration of the issuance to me of a permit to construct the building described above, I agree to do
the proposed work in accordance with the description above set forth and in compliance with all provisions of
ordinances of the village of Fri�ley. ,�
k. . .. ..�
A� � .. . �
. !�°�'�� :�
r�� ;
/"!� ermit is hereby granted t �
Tn consideratiion of the payment of a fee of $/cil. . p • • • • • • • • � • • • •
, ,.....''�. .... to construct the building or addition as described above. This permit is granted upon
ress condition that the person to whom it is granted and his agents, employees and worlunen, in all work
in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of
F'ridley, Minnesota. regarding location, construction, alteration, maintenance, repair and moving of buildings with-
in the village limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances. 6' . 9
�
�,1. ,��is, ./. . Building Inspector
�—
NOTICE:
�
Thia permlt does not cover th " nstruction, instaltation or aite�ation for wi�ing, ptumbing, gas heating,
sawer or water. Be sure to see the Building Inspector for separate permits for these items.
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��Y@� lJ� W� 5'0�1' ��i �� � Minnesota Well and Boring �
WELL OR BORING �OCA7i MI�ESOTA DEPARTMENT OF HEALTH Sealing No. � �����UI,
co�,cy rvame 1NELL AND BORING SEALING RECORD Min�esota u�iq�e No.
���� Minnesota Statutes. Chapter 1031 or W-senes No.
(Leave blank d no� known)
Tovmship Name Township No. Range No. Section No. Fraction (sm. � Ig.) Date Sealed e� A Approximate Date Well
�r�d1e 3� �.i L`! ��a}'��14Y��ra ��G���`�' orBoringConstructed i(���
Numencal Street Address or Fire Number and City of Well or Boring Location
1324 Hi 11 crest t�#v�, ��7 d� �� Depth Before Sealing ��� ft. Original Deplh 1-'�� fl.
Show euacl location of well or bonng �Sketch map of well or boring Static Water Level Q Accurate
in section grid with 'X-. , location, showing property lines,
roads, and buildings. ❑ Approximate
N
-' ' - � '-
r ' � � -�
�ingle Aqurfer ❑ Multiaquifer � k. x betow above land surface
�_ _ � _ _ i _ _� � � f � � CASING TYPE
W i � � � E � / ..«.Q.�....�.�
i i i i � �j
-r -ti- -r- -r f`�
i � � i hm.� 4 �;�� �teel ❑ Plastic ❑ Tile ❑ Other
i _ i _ _ � _�_ �
-i i i - i
� " Screen from ��� to ��� tt. Open Hole from to fl.
S '
�— � mj� —'� OBSTRUCTION/DEBRISlFlLL
� Obslruction ❑ Debris ❑ FII
PROPErRTY OWNER'S NAME
�� i �r��� Type of debris/obstruction ��� � ��# ���� �� p� � ���
Mailing Address il diHerent than property address indicated above.
Obstruction/Debris/Fill removed? �Yes ❑ No
PUMP
5larne
❑ Removed � Not Presern ❑ O[her
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF ��� TO
FORMATION
Diameter Depth Set in oversize holel Annular space initiaily grouted7
If not krrown, indicate estimated formation log from nearby well or boring. g
3 in. from J to ��� k. ❑ Y� �i+lo ❑ Yes ❑ No ❑ Unknown
in.from to fl. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in.hom lo ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
� No Mnular Space Exists
❑ Mnular space grouted with tremie pipe
❑ Casing Perforadon/Removal
in. from to k. ❑ Perforated ❑ Removed
in. from to ft. ❑ Pertorated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERULL
Grouting material 29� ��4 from `� ro ��� ft. yards �` bags
from to ft. yards bags
REMARKS, SOURCE OF DATA, DIFFlCULTIES IN SEALING
hom to ft. yards bags
from to ft. yards bags
UNSEALED WELLS AND BORINGS
O[her unsealed well or boring on properly? ❑ Yes � No
LICENSED OR REGISTERED CONTRACTOR CERTIFlCATION
This well or boring vras sealed in accordance with Minnesota Rules, Chapter 4725. The infortnation contained in this repoK is
true to the best of my knowledge.
t�rk �ell Co., Inc. fl213�
ConVacto � ss Na e License or Registretion No.
�%'''`�- 5�25=94 �
Authorized Representative Signature Date
52954 Randy D�nielsQn
LOCAL GOPY H Name ol Person Sealing Well o� Boring
HE-01434-01
Jun 21 06 12:48p
p.2
$Ul�t�l.tl�. ��L��(�''' PermitNo.:���'` �' �'''�'�''a
inspe��tions RESID�:N�`T'IAL APp'L]ECATI()N' �'°� �y:
7b3-572 3644 C�'TY' aF FRIDLEY ��e Rec'd: � _�' ��
( r.
DATG �".� 1"�/� GIJIt C•141AlL Af�I�RP,SS ...__ ...
g�,�,��� !�3 � -_F-J% �L.:�t:�:�.�- 1`�I� __-- ..._..__ ...... ._._ —.._
T!!4S AP�1,It:AN'I IS� D OWNER �Q�'qN1"R�1C'.'OR
TENILIY7'
CONTRACTOR
b'UBM(f A GOPY OF
YOUR STA'!E LLt:EN�L
wr�,•i npP��canoN
1'RVPT�RTY 1'1fPL�
I+ERMIT T'YPE
TYPi; OF WORK:
S1'A'1� L1CFdV�E E/fi� !-w�.,'�.`I_."�
FdV'
aotiaF.ss: ` ; i ��.'��..1 i
rr-crnac S i -�j �7 " ;�'��:�
�MGI� hAMILYMEW CO'+ES7':LU�CT[ON
a'erw� �A�u[.Yn�Ew c.oNS7RUC7 tomt
L7 Al)UlT WN � �3ARAl;i
q pASL•MCNTCINISIi I�ItWF
O DL�(:K � Q S1D�NC
O 4yYDrIM
U135CRiBC WORK BE1NG DONE:
sQUnttcs _? '�, ��
C;ARsGIb
PR4PQSEU 5Ct�:
PRC�ED HhiCiltr:
SID1lVC
Q Vinyl
o atuextmu�+
!7 (�tlta
WiN1tt)tYH
W EXt3'RNOODLNINGS DYce I]Na
l'►R FOA NL'W OIidVWC�S-DLSCIiRlG SIZL" UY
OPEP�U CFiANCES �
i.�� C�rx
�tia.isE � �_��er+a�
� A'1'f :hC:NE[7 (3ARAGE
O UE7'ItG�dEU CiARnGE
L]SolT�f
ar�
O K�du
LOCA710N 01' N+:MUf}WS
�.~_ f� ���`
SI'A'1'b U'
DATG _ / 1..( . :.� i
- �. I1' � cxTY. `,,,r� .�
�l -� =1 t `7-v� -7C�
su.�
!i7'URIES
01NAdDU .
0 uteAliv'ill.p
d ()i'HEIt
W!D'CII HEIGHT
�
n7� i,r.,,!?7-1C��-
Ras�MF]VT_RSMODELtNG SU�narr:
1. K�tiag PWur Akm
2. Prop�ed flaupfen
1_ L.lsc oPstmsuual m�nbias ta be oac �
Ft
POti NCW COAIS7RUGTl1�V INC,'LUDING Ls�Q(S.
$Qj�jZ',(QNS- dt FOItC1�S SUf3.bth':
1. Sife Nlmd!;urvey allowing tlia axisuub Wnwtucru
aad ProPo4ed proJac4
�. 7'wo 9c4 afconata�ctiou plans
3. Eewgy Calcalriti�s
ALL REES ARE BASLD OA1 VALlJAT1QN„ �rrc`�.i,fl)iNG 'fHYs C�(ib"II' UF LABOR
(USING__THE :l9!)7 U.B.0 FE� SCHEDULE)
Y
Plen Rewicw S _ � � •? � .�� .SS%ofBullding 1�ermit Fee . L,j' ��j'� � �',/ �
Faoe Suncharge S ��, �, �� 00I tim�s the wtal job val�mdnn c�i
5urcqargc S 1, �_._� .t1005xPermitValuaciun Miaimiaa�SO �I��''� fL� �;L�—
L�amro Surci�r $ �9 ;65.00 (Seat�: l.,i�ensed Rasideatial CotturoCtars) �����
SAC Chargc S .._� ;6155� perSAC Uait {Plans Lo MWCC for detorminatiun) �j�2..G_ I��
Curb Cnt Escrow S A+ 6 R= ft x� 1=� '�
Erosion C�ritrol � --- ;6450 Conscrvadon PI� Review � —7 ; � ,Z ��
T�ark Fee S � 1=ac, Dtlttdrmined by L'ngin��ring 1�{�:. �:1�
Sewer Main Ch+�rga S __, Agreerncnt neees�uy () Non Necas.kary () �
ToW Dae ..i ( O°% , a'? „�..r1Ylakc checic� b!� to: C' of F uach 5 Wtioa��
i7�11ti 1S AN APPLiC,�+Tl���N Fclk A�tMlT-NOT VAWL UN1'IL t�RCX%BSSED Y�-�
I hareby �pply for a buildinb permit aad I ackaowluig�; tl�ttt dm infcrrmati� alhove is compl�te and accut�ate; th►Zt tho work vrill be u�
canCaKmxnce wW� �e ordisaacas amd codea of �u Cit�� ot' Fridley and with eho Mia+rreyota Coastructinn Cod�:s: d,at ( uadersaund tbis is rroi a
permit bgt only an uppliwtion for o permit and worlc i:; n�oc u� sturt vvithout a p�rnit; that thw work will be ie ucCOrd�e with the apptuved
J�lan iti the cSS� e3Pt+l! wixk which reqnires Kw,iew aad a��,�rvul of plmts.
Si(iNATURE OF AFPIICAN7/�.�, f''? �,� �-ct" ��i�� .'�,�PRfl�(1' NAML' 11�%L �T � DATC / �. �..�,.,^_
Zd WtiS� : LS 9002 LZ '�^f ZBZT iL�L :'ON }id� �'ai Fs �j Jo �'� F�: ��
From: City of Fridley Ta 763754290"c Page: 414 Daie: 4I16/2009 11:00:10 AM
�SU11C1]11� ��,���L��r Permit No.. �Q '
' �nspections ' ��S���I�TT�A.�. �.�PL����.���l�T Received Bv:
�6;-��-�eo¢ � . _ ' �9
I � ::�- `. �:�'�`�� �� ���.���i ' Da�'d� �
%b �-JO�-a�% � F.�,. �
� �NH�,CTIV�:3-14�-Q�?
llAT6 J�b�V`I
51T� AUllR�:55 � �
�. HIS APPLICANT 15:
PROPER`I'1'
OWNER/
TENAN'I'
CONTRACTOR
SUBMITA COPY UF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
[NSURANCE
PERMIT TYPE
YOUI: �-NIA1L AlllllttS�
1�'� I I car��'--[)-Y N E '
❑ C)WNER ''bNTRACTOG:
NAMt:� V��Pi1/I �!��q,i.L�
.,llll���ss: �3Zy Nillc�e5� �r �►E
PHON�: 'Iv�� �I� �i�°iO
NAMt: 1�1VQ.✓ �,� ��1 � � IAIiV1�1 /ti{9 r%9 �
STAT� LIC�NS�. r!
STATE BON U it
ADllRr,S5: D�%i�,o YV �d�l/� s� N,�' ��"1
PHQNt ��1' �li�� iil�(�
TYPE OF WORK: I� Ntw
C1Tl' �!{�1r� Ki�] STAT��'Ll!'CJ5 '?✓' v
HAX
NAMILY ❑ TWO NAMLLY O TOWNHOUSE
QO R�PI.AC�M�N'f
/�
�.xr �at�
�XP DAT�
-r� t�"LIP r �a
DETAILED DESCItIPTION OF WORK T�y��,�IA�'�'ri D-�_d�p(�cC f�1i�p��1l�Z� �
Hr�S Altt BASf.D ON $]0.00 P�R NIXTUR�, �XC�PT WHtR� NOT�D. HIXTUR�S: ('INDICAT� TQTAL NUMBrR ON �ACH H�LOW). MINIMUM FE�
$35.50.
HATH S1NKlLAV NLOQIt DRAINS SHOWtR WAT�R PIAING
BATHTUI3 GAS PIPING ('NtiED CITY LIC} SWIMMING POOL WA'fERSONTN�R ($35)
CL.OTH�S WASH�K KITCH�.N 51NK WAT�ItCLOS�.T IiACKH1.OW PREV. ($15?
_ DISHWASHEK _ LAUNDRY TRAY �WATER H�A'f�R ($35) NOR 1RRIGATION
WATtR Mh7tft OTH�R
THiS IS AN AAPLICATION FOR A P�RM1T-NOT VAL1D UNTIL PROCtSSED
I hcrcby apply for a plumbing permit and I acl:nowlodgc that thc information abovc is camplctc and accuratc; that thc work will bc in
canformancc with thc ordinanccs and coda5 af thc City of Fridlcy and with thc Minncsota Construction Codc,.w; that I undcrstand this is
not a permit but only an application for a permit and work is not to start without a permit on sitc; that thc work will bc in accordancc;
with thc approvul plan in thc casc af ail work which requircti rcvicw and approval of pLans.
SIGNATUIZ�.OFAPPLICANT ���i/�'/v' ��d� P1LINTNAMt'VIGI� ��� UAT� �l�lDel
�aty �� Fa-bdley
�uilding �inspec�i�ns �epartment
6431 UuiversiryAvenue i�1E, Fridley, ivII� ��432
763-�73-3b0�
FA�i: �63-�0?-�977