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City of Fridley, Minn.
BUILDL�TG PERMIT
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N° ?088
Date: °
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Oaraer: � Buflder s
Adc7reas Address
LO�:ATIOIN,�F UILDING
Ne. �� st�et _.�y�r� � e Part of Lo
Lot ._._ �__ Slock Addition or Sub-Divisfan .�a�t... �^��1 �i�Z�'o��
Corner Lot — �Inaf�ie Lot 5etback �V� Sideyard � ,� � �>
Sewer IIevation .—��� � _--- - . �Ats�„ �_ °� cl � �
DESCRIPTION OF BUILDING
ee v�a � '�
F'ront ,e��. Depth .� Hefght �� Sq. F'k �d� Cu. F't
t Depth "�ost I�eight Sq. Ft Cu. F�
Type oP Constructio �
�--- F%s�. ��e�� To be Gmpleted
In consideration of the issuance to me of a permit to c�
tt►e ProPosed work in acc;ordance with the deacription above
or�iinaaoes of the dty oP Frfdley.
In �onsideratton af the payment of a fee of $��_ ,
����ce wit�h ae'll � a� to do
provls�ttona of
herebY granted to
to construct the buflding or additfon as described above. Thiape rmit is granted u�n
t�e euPresa �ndition that theperson to whom ft is granted and his agent�, employees and worl�en, in a11 work
done in, around and upon eafd building, or anypa� thereof, shhall oonform in all respects to the ordinaac� of
Fridley� Mfnnesota g la:ation, constructTon, alteration� maiatenance, repair and mov3ng of buildings
�thin th�e dty limffts�and�thia permft may be revoked at aqy time upon violation of aay oE the P�visiona of said
NOTICE:
ihb psrmit doa not eowr t6s coes�rueH�, testalladon /oe �l�ey. P�+�O, 9� 6�8. mr�r er watsr. B� sme to a�
iM Batldlne Im�Or to� pPu+f+ p�rmNa Ior tltas �ms.
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APPLICATION FOR HII]ZDING P�MIT
CITY OF' FRIDI�Y, MINNE.Sa'TA
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Owner's Name �` ��G� Builder
�ddress ---- --- Address sa��l� G
LOCATION OF BUILDING
No. Street Part of Lot
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Lot ,� Block � Addit3on or Subdieieion��r,�a?�rt�G�
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Corner Lot !/ Inside Lot Setbaak ,�"S L� Side-Yasd .,�� 9� ��
SEWER ELEVATION FOUNDATION ELEVaTION
�pplicant atta.ch to this form Certificate of Survey'of Lot and proposed bui].din�
locat3on.
DESCRIPTION OF BIIILDING
To be uaed as:
. Sq. Ft. /�.S � Cu. Ft.
Type of
To be Gompleted
Front Depth Height
Sq. Ft. Cu. Ft.
_. . � /".,r/�/.
The undersigned hereby makes applica.tion for s permit for the work herein specified,
agreeing to do all work in st�rict accordance with the City ardinences and ruling of
the Department of Buildings, and hereby declares that all the facts and re resentations
stated in this appl3ca. 3on e true and correct.
DA� SIGNgTURE
(A Schedule of Fee Costa can be found on the Reverse Side.)
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Buzr.�nvc �aT � sc�ur.�
Section 2. The InePector of Bu�.ldings shall, before iseuiug aAY pex'mit for the
ereation of any building or atsucture, or for any addition ta eny �.�tin8 build-
3ng or s"�rructvre, or for any alterations or repairs t,o ang ex3at3ng buildin� or
structure, ugon e.gplic�.tion tharefor, require the payment by the epplicant fpr
such permit of fees to the amount herein below set forth and in the �ner here3a
provided to-wit: �
2.1. For eny such permit for the erectfon of a�y fire-proof building, othe� '�an
a ger�ge� warehouse, factory or grain elevator� or for the er�ct3eu oS a�y fire-
proof e.ddition, for similar accuparrcY, 'to e.n,Y e�.st3n� bu�7-ding sh�l.l be at the
r��t,e of �]..4A for each one thousand cubio feet, or f�eation thereo�, in suc�h
cubioel cont�enta.
2.2. For eay such pes�m3t �or the erection oP ar�t Pirepreof garege, �exehouse�
factorg or grein elevator, or for the ereotion of any Pireprao! additivn, gor
aim3lar occuPanccY, to any exi�ting building s� be at the rate ot �i.a23 f0�
each oae thousand cubie feet, clagsif%d as '�f3reprooftt by Sectio� �02 of t�
Minneapolis Buildin� Code.
. ���
2.3. For ex�y such permi.t Por the
than e gera�e, wareYiouse, factory
addit3on, £or similles ocoupanoy,
ee,eh one thouser�d cubia feet.
tsrA�tAGES
erec�ion of anq non-lireprooP build�g �th�s
or grain elevator, or a�r no�Pireproot
t,o aug exist3ng bui7.8i��. Perm3t �77.,00 tox'
2.l�. For er�y such permit Yor the erection of any no�fiseprasf ge.r�ge� �re►r'ehouse,
factory or grain�elevatot, or for the erection oP any ae�fireP='o0� addition, for
simj.7.ar occupanay, to �p existing build3.ng or for eaoh suoh buildin8 or additioa�,
Ninety Cents for ea.ch one thausand cubic Pest or �`raation thex�f� in the cubical
coa�ents thereoi w3th a min3mum of $k.00.
For the purpose of comput3a� feea for build3n� perm3ts the cubical coa'teb'�e o� �Y
building o�' &dd3tion to a un�form height throughout by mul.tiplying the ground esee,
covered f'rom a poi.nt. s3ssc., (6) iaches below the floor line of the basement or oellst'
�to the'avsrage heigh�. o�'tMe upper surface or to the avere.ge height of the roe�
surface o� the main gable o� a pitched roof.
2.5. Fot� reps3rs or alterat3.one t� an esc5.stin� atruc�ire, the fee �hea.l be et 't1�4
ra�.e of �3+db for �each F#.ve I�undred Dollera ($500.00), or �ractioa thereoP in tlze
cost o�` sll propoaed work.
2.6. In ao cese aht�l]. the Pee char�ed Por s�ny perm�-t as set �'orth � Section 2 be
leas than �+4•00.
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City of Fridley, Mirm.. �jo �.0176
BUILDING PERMIT
Date: -_4�P�i1 9, 1969
p�r; John P. Velin �� Inter City Blders.
Adaress _ ,51 OS Nnri � on Tlr_ i t�p Ad� 25 00 Murray Ave . N. E.
LOCATION OF BUILDING
No. 5105 S�t I3orizon Drive � p� of Lot
I.ot --..6 .__.__ Block z Addition or Sub-Divisian ____ �ar$sons � Stxmmit Ma.nor Annex 2nd
Coraer Lot _ Inside Lot _._. Setback —..� Sideyard
Sewer IIevation � _ Foundal3on IIevatton
DESCRIPTION OF BUILDING
To be Used as:
Garage �t 24' �p� 14' H��t 10' �. � 336 �� 3360
Front Depth ._.._ FTeight Sq. F� Cu, �'t,
Type of Conatruction Frame �� �$ 1800.00 _ To be Completed
In consideratlon o4 the issuance to me o4 a permft to construct the buildiug descri above, I agree to do
the proposed work in acc�rdance with the d�escription above aet forth aad in complian� all provisions of
ordinances oP the dLy of FrYdley. , �, y
In conafderation of the payment of a fee of $ � 5' �, permit fs hereby granted to Inter C3ty Blders .
to construct the building or addition as described a'bove, Thispe rmit is grented upon
the egpress condil3on that the peraon to whom it is granted and his agents, employees and worlmien, 9a ali work
done fn, around and upon said building, or any part thereof, shall conform in all reapects to the or8inaac� of
FridleY, M3nnesota regarrling location� construction, alteration, maintenance, repair and moving of bufldinga
within the dty limits and tvis permit may be revoked at a�y time upon violation of aay of the provfaions of said
ordinances.
- Official
B�8 �
� NOTIC�
'19ds psemh dees eet eovs� fhs eoestrnefloe, testallaHon h� wirlae. P�+�e. 6b 6e+�e� ssrwr er vtlsr. B� sun to �
f6a Boildin8 le:ptete� tor separat� parmi» Po� thas (tfmi. .
_ _ � �- .'
9P�'LICATION FOR BUILDING PERNBT
CITY OF FHIDI,EY, MINNESOTg
owrrgt ►s N�s�� %�l f� !�� � i� �az�u� l�i ���- � ��� T,�� D�� S
�. �, � .
gnp�s S' l � s°��o /� � � o �/I� � . �n�xESS a sQ a /�iv� � 1/ �I �e 1� � -
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LOCgTION OF BIIILDING
N0. STREET
LOT � �LOCK �- ADDITION OR SIIBDTPISION � q�� S �� 5� a,� .
�
CORNER LOT____��^INSIDE LOT SE°I'BACK SIDEY�RD,_�
SEWER Ei,EVATION TOP OF FOOTING
�pp7.iaant a�t�ach to this form Two Certificatea of Survey af Lot and
groposed bu�,ld� location dsawn on th�se Certificatea.
DESCRIPTION OF BIIILDING
'�o. Be IIaed As: �j-�] J�t �i, � �: , � _.
Fxqnt Depth Height
, ... �qua�e feet Cubic Feet
�Front � L� Depth ,;- Height �
�
Square feet Cubic Feet
Type of Cpnatruction �� /� �� Estima.ted Cost �� �� <
�
To Be Completed
The undex�i�p,ed �e�eby makes application for a p�rmit ior the work
herein apeoif�.ed, agpeeing to do all work in atrict accordance with the
City of Fridley Ordi.r�.e.nces and rulixigs of the Depaxttnent of $uildix�,gs,
and hereby deo�.are� that all the �acte and repre�entations $tated in
th�.s appliQation axe true and correcte
DA.TE '� (� SiGNATURE u, 1
(Sche ule of Fee Coets can be fourid on th Rev r�e Side.)
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BIIILDING PFRMIT�FEE SCHEDIILE
SECTION 2, The Inspector of Buildinga sha,ll, before iss�uing permita
for the E�ection of any building or structure9 or for any addition to any
��ci�ting �tru.cture or buildin.g, or .for an.y alteration or repai7�s to a�,y
existing building or st�uucture, upon application therefore, require the
payment by the �.ppliea.nt for �uch permit of fee� to the amount herein �
below set iorth and in the mant�.er herein provided to-wit:
Uniform Building Codes_ Type 1, 2, & 4-$1075 for each on.e thousand
cubic feet, or fraction thereof, in auch cubical c.�ontents. Type 3& 5-
$1a50 for each one thousand cubic feeto
For the purpoae of computing.fees for building perm,ita, the cubical
° ' �`ortt�nts o�f 'at�.°y'�b�i�.�i. aciclitio�.°�'°a uni'form hei�t�th�u�h:otit °�y � '
multiplying.the ground area covered from a point six (6) inchea below
the iloor line of the basement or the cellar to the average'�.eight of
the upper surface or to the average height of the roof sur�ace of th.e
ma,in gable of a pitched roof .
For repairs or alteratione to an eacisti.ng atructure, the fee shall be
at the xate of' $3.00 per each five hundred dollaxs ($500.00) or
fraction thereof i�. the cost of all proposed worka
In no caae shall the fee charged for any permit as set forth in Seatio�
2 be lese thars $50000
NSSSD Connection Charges baaed on location - Area 1 or 2.
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BUSINE�fi
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TOPOGRAPMIC NAPPING
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C. E. COULTER
LAND SURVEYOR ;:���� ��' � �
REGISTERED UNDER LAWS OF STAtE OF�,MA-NNESOTA y��
LICENSEO EY OpDINANCfB Oi CIT`! OF MIN`f!IEAP0119 �� j
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I hereb� aertifg that the �bove 3s a true and correct plat of a svrvey ofs
PIATTIN6
FARM BUpVEY�
LAKE6M011!
JU�IC�AL
Lot 6, Block 2, C�iR,LSON�S SLit��:IT I�.ANO�i ANll�% SECOTID ADDITIQId, Anoka Count�, Niin�e�of.a,
A� s�eyed bg me t,his 1/�.th day of Februa=g 1963 �. D.
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C�..�M�OI�J � '� 1.iC, �
Signed_ • � �� ���°�
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r�nnasota Registration Nt�. 25g1,,
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INDVStN�4L , •
OuS�NE55 �
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�OPOGRAV�y�C M1�POiry�: '
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- � C. E. �OULTER
LAND SURVE'/i�c� ( � ''
REGISTERfiD L'NUER L4W5 OF ST4tE OF,MtNNESOTA
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' LICENSE❑ 0� OAD.h�I�.:fb OF CIL! O� r'"��MEAVOI.�S
3300 LYNOALE AVE 50 . MINNEAPOLIS 8. MINN
. TAYLOFt 4-0370
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I hereby certif� t::at the above is a tru3 an.l c�- rect � plat of a sia�-Jay oi':
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TO: Scott Erickson, Assistant Public Works Director
FROM: Paul Lawrence, Superintendent of Public Works
DATE: July 7, 1994
FROM: Water Quality Problem 5105 Horizon Drive
I discussed the memo you received from Lisa Campbell, regarding
Jack Velin, 5105 Horizon Drive water quality complaint with Jim
Saefke. Jim feels the problem is caused by the high levels of iron
and manganese in the City's water supply. This is a particular
problem in the Horizon Drive area as most of the water in this part
of the city comes from well 13 that is not treated for iron and :
manganese removal. �
Jim has made arrangements for City personnel to test Mr. Valin's
water for iron and manganese and to also use his home as a source
for one of the City's routine bacteria test.
I _
s
I
DATE:
TO:
FROM:
3IIBJECT:
� L� J
Community Development Depar�ment
�LANNIIiTG �IVI�ION
City of Fridley
June 29, 1994
�,�cott Erickson, Assistant Public Works Director
Lisa Campbe�lanning Associate
Water Problem at 5105 Horizon Drive
Environmental Quality & Energy Commission member,�Jack Velin of
5105 Horizon Drive, reported at the June 21, 1994, Environ�nental
Quality & Energy Commission (EQE) that he has been experiencing a
problem with City water for the last six months. Apparently, there
is a slimy film in his water. He has requested that the City
investigate this decline in the water quality and has asked that
I forward this matter to you for further action.
If you have additional questions, you may reach Mr. Velin at �572-
9607. Thank you for your careful consideration of this request.
If my assistance is needed, please feel free to contact me at
extension 594.
LC:ls
cc: Barbara Dacy, Community Development Director
Jack Velin
M-94-358
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sue�ecr PER �_.
CitY of Fridle �
AT THE TOP OF TME TWINSy g U I L D I N G P E R M I T �� ���
r
��� RECEIPT NO.
� i y�_��� COMMUNITY OEVELOPMENT DIV.
r � � PROTECTIVE INSPECTION SEC. �—
� �
�. �
� t �"�'\ � CITY HALL FRIDLE� 55432 NUMBER REV OATE vpGE OF pPpqOVED Br
�""'�� ��J 612-571-3450 9t0-Ft5 5/21/96
� �
JOB ADDRESS 5105 I3orizon Drive NE
t IEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCFi. �j � 2 cX Carlson's Summit Manor � Annex 2nd SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Jack/Ginny Velin 5105 Horizon Drive NE 572-9607
3 CONTRACTOR MAIL ADDRESS Z�P PMONE LICENSE NO
Caribou Construction Inc 180 Transit Ave, Roseville MN 55113 483-8346 5903
A ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP pHONE LICENSE NO
6 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW 0 ADDITION p ALTERATION O REPAIR O MOVE ❑ REMOVE
X
8 DESCRIBE WOHK
Ritchen Remodel
9 CHANGE OF USE FROM TO
STIPULATIONS
See notations on plan.
- �� RA"�'E PERMITS REQUIRE �NC� S1G�iS•
S�P� '
VVIRING, N�ATINC, �'I.UM�I�
TYPEOFCONST. OCCUPANCYGROUP OCCUPANCVLOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBINCa, HEATING.
VENTILATING OR AIR CONDITIONING.
THI5 PERMIT BECOMES NULL AND VOID IF WOFK 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 WOiiK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIfV 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 SURTAX
AND ORDINANCES GOVEFiNING THIS TYPE OF WORK WILL BE COMPLIED @
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT y�iB�OOO �9.00
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOC LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CON RUCTION �262.ZS Fire SC �iB.00
���/I PLAN CHECK FEE TOTAL FEE
'° � s`G'� ` =�'` � � `�°� License SC $5 . 00 $294 . 25
SIGNATUAEOFCON'RACIOAORAUTMOAIZEDAGENT IDATEI WHEN PqOP V VALIDATED THIS IS YOUR PERMIT
S�GNaTURE OF OWNER�iF OWNER BUILDER� iDATE� � � � � �
�� B G �N50 GTE
NEW
ADDN
ALTER
Cl
��
CITY OF FRIDLEY
SINGLE FAMII.Y AND DUPLEXES R 1 AND R 2
Buiiding Permit Application
ConstrucrionAddress: j! �� � o/� � Z t� K,► /V a�_ �'y ,�/��,
,�
Legal Description:
Effe�tive 3/1/96
Owner Name & Address: �] �L� �- �, �,,l.� lJe. i� n1 Tel. # S�L — g�� � 7
Contractor: �2�6� c> � �,� � � n� C, _ MN LICENSE # ��.3
Address: / g� �/���� � ���- , �OS��'- � ��// � Tel. # _� � ��3��►'3 4��,
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
DESCRIPTION OF IlVIPROVEMENT
�ng� Width Height Sq. Ft.
Length Width Height Sq. Ft.
�ng� Width Hgt/Ground Sq. Ft.
KI e�lf �h� Kef�O 9P l-
Corner Lot [�v]�Inside Lot [] Ft. Yd Setback
Side Yard Setbacks
Type of Construction: Estimated Cost: $�� �� C� `�
Approx. Completion Date: �
(Cost on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: s l�--�r ` APPLICANT: �/L/ f�,�L ��/J��.� j,�c� Tel. #���°'l��a�f
Permit Fee
Fire Surcharge
Sta.te Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Pazk Fee
Sewer Main Ghazge
TOTAL
STIPULATIONS:
._ • -
, �- � ,,. .
, -��=�r,
I � �
CITY USE ONLY
Fee Schedule on Reverse Side
.�1 of Permit Valuation (1/lOth%)
$.50/$1,000 Valuation
$900 per SAC Unit
$ _�1 � � � $5.00 (State Lic�nsed Residential Contractors)
$ Alt. "A° or Alt. "B" Above
$
$
$
� y ��
$450.� Conservation Plan Review
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
�1s/L/ Z ��
BiJILDING PERMIT FEE SCHFDULE
The Chief Building Official shall, before issuing permits for the erection of any building or stcucture, or for
any addition to any existing building or structure, or for any alteration or repair to any existing building or
structnre, 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 VALUE
$1 to $500
$501 to $2,000
$2,001 to $25,000
$25,001 to $50,000
$50,001 to $100,000
$100,001 to $500,000
$500,001 to $1,000,000
$1,000,001 and up
���
$21 (Minimum Fee is $21 plus surcharge)
$21 for first $5� plus $2.75 for each additional$100 or
fraction thereof, to and including $Z,O(�0
$62.25 for first $2,� plus $12.50 for each additional �1,(�0
or fraction thereof, to and including $25,000
$349.75 for fust $25,000 plus $9.(� for each additional $1,000
or fraction thereof, to and including $50,(�0
$574.75 for first $50,�0 plus $6.25 for each additional
$1,000 or fraction thereof, to and including $100,000
$887.25 for fust $100,000 plus $5.� for each additional
$1,�00 or fraction thereof, to and including $500,000
$2887.25 for the first $500,000 plus $4.25 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$5012.25 for the first $1,000,0� plus $2.75 for ea.ch additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
(Concrete C�rb Streets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50.
�lternate "B" : Removal and replacement of curb and gutter and install a 3 foot wide
approach with 6 inch depth - Driveway width plus 6 feet times $15.75.
VERIFICATION OF FOiJN�ATION
Permits for construction will be issued a minimum of 24 hours from the time of applica.tion to allow for proper
review of the proposed structure and of the const[uction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed
will be required before proceeding with the framing.
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City of Fridley
AT THE TOP OF TME TWINS � � � L D I N G P E R M I T �
�
i �
� �
� `� _____ COMMUNITY OEVELOPMENT OIV.
r � � PROTECTIVE INSPECTION SEC.
`_--_ A �����,'; CITY MALL FRIOLE� SS�3Z NUM�EN REV DATE PAGE OF
L �� 612-571-34b0 910-Ft5 12.5.00 / /
JOB ADORESS 5105 Horizon Drive NE
1 LEGAL �OT NO. BLOCK TRACT OR AOOITION
3 i 590
�-`°'
RECEIPT O.
7�6
�PPROVED 8Y
SEE ATTACMED
oescA. 6 2 Carlson's Summit Manor Annex 2nd SMEET
2 PROPEATY OWNER MAIL ADORES$ 21P PHONE
Virginia Velin 5105 Horizon Drive NE 572-9607
3 CONTRACTOR MAIL ADDRESS 21P PHONE
Wellington Windows 3938 Meadowbrook Rd, St Louis Park, MN 55426
4 ARCHITECT OR DESIGNER MAIL ADDRESS 21P PMONE
933-6300
5 ENGINEER MAIL AODqESS 21P PIiONE
8 USE OF BUILDING
Residential
7 CLASS OF WOFiK
O NEW ❑ ADDITION � ALTERATION
B DESCRIBE WOFiK
Renlace windows
9 CHAN(iE OF USE fROM
TO
IICENSE NO
City
LICENSE NO
LICENSE NO
�7 REPAIR O MOVE O REMOVE
STIPULATIONS
Provide smoke detectors in all sleeping rooms and on all levels of the
dwelling per Section 310.9.1.2 of the 1997 Uniform Building Code.
�ermi� �nsp�c���� �a���
Will �e Ma�led
To H�������� �� ����
SEPARATE PERMI7S ApE REOUIRED FOR ELECTRICAL, PIUMBING. MEATIN(3, ' rrc a�r vvi
VENTI�ATING OR AIR CONOITIONING
THIS PERMIT BECOMES NULL AND VOIO IF WORK Op CONSTRUCTION IONING
AUTHORIZED IS NOT COMMENCED V�IITHIN 80 DAYS. OR IF CONSTRUCTION
OR WOiiK IS SUSPENDED OR ABANOONED fOR A PERI00 OF 1� OAYS AT
ANY TIME AF7ER WORK IS COMMENCED. NO DWLG.
I HEREBY CERTIFY 7HAT I HAVE READ ANO QXAMINED THIS APPUCATION 1
AND KNOW TNE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF �AWS VALUATION
AND ORDINANCES GOVERNING TMIS TYPE OF WORK WILL BE COMP�IEO
WITH WHE7MER SPECIFIEO MEREIN OFl NOT. TME GRANTING OF A PERMIT �2,926
DOES NOT PRESUME TO GIVE AUTMORITY TO VIOLA7E OR CANCEL TNE pEWMITfEE
PROVISIONS OF ANY 07MER STATE OR LOCAL LAW REGUlA71NG CON-
STRUCTION OIi 7ME PERFORMANCE Of CONSTRUCTION �H3.ZS
Ci
SiGN4iUNE OF CON7iiACTOp Op AUTtiOAIjEO 4GENT IOAYEi
— �D�rE� I ="'�,
SO.
S7ALlS
GROUP �OCCUPANCV�pAD
CU fT
GAFAGES
$1.46
SAC CMARGE
Fir SC $2.93
roT ee
7.64
R PERMi
► �1°,
NEVV [ ]
ADDN []
ALTER [ ]
Construction Address: _ � �
Legal Description:
Owner Name & Address: `
Contractor: W Z � i n.� '
LNING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Cl�lf OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
`
�„- _ t ►_,� �
6� �i�o
Effective 1/1/2000
(763) 572�3604 Bldg Insp
Tel.# J/d" 6i
MN UCENSE # ll�s�-i�
Tel. # , ��� � ���
Attach to this application, a Certifi�ate of Survey of the
lot, with the proposed construction drawn on it to scale.
- --- �IE�Rl�TlO(e! �F IEl1lA!?�9/€ME,''�'� -- � - —
Length Width Height Sq. Ft.
Length Width Height Sq. Ft
Length Width Hgt/Ground Sq. Ft
Construction Type: I e 6Gtce e� I�tJ �c�-�� o�
� d � � Estimated Cost: $ I�
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: � � � APPLICANT: 6/� / v � Te�, # � / JJ °`j,j GC�
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Call (763) 572-3604 for Permit Fees if mailing in application
� ��
$ �� - Fee Schedule on Reverse Side
$ ��� .001 of Permit Valuation (1/10th%)
$ d.yG $.50/$1,000 Valuation
$ $1100 per SAC Unit
$� 1�1c�i Pr� $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$
$450.00 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement Necessary [ j Not Necessary []
TOTAL
STIPULATIONS:
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BUILDING PERMIT FEE SCHEDULE
The Chief Building Official shall, before issuing pernuts for the erection of any building or structure, or for any
addition to any existing building or structure, or for any alteradon or repair to any existing building or structure,
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 VALUE
$1 to $500
$501 to $2,000
$2,001 to $25,000
$25,001 to $50,000
$50,001 to $100,000
$100,001 to $500,000
$500,001 to $1,000,000
$1,000,001 and up
FEES
$23.50
$23.50 for first $5(� plus $3.05 for each additional $1(� or
fraction thereof, to and including $2,000
$69.25 for first $2,000 plus $14.00 for each additional $1,000
or fracdon thereof, to and including $2�,000
$391.25 for first $25,000 plus $10.10 for each additional $1,000
or fraction thereof, to and including $50,000
$643.75 for first $SO,Q00 plus $7.(}0 for each additional
$1,Q00 or fraction thereof, to and including $100,000
$993.75 for first $100,000 plus $5.60 for each additional
$1,000 or fraction thereof, to and including $500,000
$3,233.75 for the first $500,000 plus $4.75 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$5,608.75 for the first $1,0(}O,Q00 plus $3.15 for each additional
$1,000 or fracnon thereof
DRIVEWAY DEPRESSION ESCROW
(Coi�crete C�arb Stre�is Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $15.50.
Alternate "B": Removal and replacement of curb and gutter and install a 3 foot wide
approach with 6 inch depth - Driveway width plus 6 feet times $23.25.
�ERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of application to allow 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 once it has it has been constructed will
be required before proceeding with the framing. New Houses Onlv
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COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacina an existina furance, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes (�'No ()
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination. Yes (�No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturers specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The existing combustion air is sized and installed to meet the current codes
and manufacturer's specifications.
When required to install a new combustion aBr, it will be sized and installed
To meet the current codes and manufacturers specfications.
Yes (�No ( )
Yes (�—No ( )
Yes ( �No ( )
When installing a new venting system, the unde�signed hereby verifles that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances. Yes (.a-No ()
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes (�o ()
A�pliance Type and Size/Common Vent and Vent Connector Information
Appliance #1 Type BTU Input Fan Assisted or Nat
Appliance #2 Type BTU Input Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances Total Btu Input
Common Vent Type Vent Height Diameter � inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance #2 Vent Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS• (Describel
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COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacing an existing furance, the unde�signed hereby verifies that the
venting has been examined and is free from rust, deterior�tion, obstructions,
and is securely supported and firestopped where required. Yes () No ()
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows �nd termination. Yes () No ()
The undersigned also verifies that the �eplacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The existina combustion air is si�ed and installed to meet the current codes
and manufacturer's specifications.
When required to install a new combustion air, it will be sized and installed
to meet the cuRe�t codes and manufacturers specifications.
Yes ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
When installina a new venting system, the undersigned hereby verifies that
it is a listed assembly and meets the cuRent codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances. Yes () No ()
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes () No ()
Appliance Tvqe and Size/Common dent and Vent Connector �nformatian
Appliance #1 Type BTU Input ' Fan Assisted or Nat
Appliance #2 Type BTU Input Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances Total Btu Input
Common Vent Type Vent Height Diameter inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance #2 Vent Connector Height ft Length ft Diameter in` Type
Appliance #3 Vent Connector Height ft Length ft Diameter in "fype
ALTERATIONS• (Describe)
HEATING CO:
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FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMI`tS
COMMON VENT. VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacinq an existinq furnace, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes () No ()
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination. Yes () No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The existina combustion air is sized and installed to meet the current codes
and manufacturer's specifications.
When required to install a new cambustion air, it will be sized and installed
toameet the current codes and manufacturer's specifications.
Yes ( ) No ( )
Yes( ) No( )
Yes ( ) No ( )
When installina a new ventinq svstem, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Furnace
Venting Tables for fan assisted and natural draft appliances. Yes ()
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
sep�rately as per current codes.
No ( )
Yes ( ) No ( )
Appliance Tvpe and Size/Common Vent and Vent Connector Information
Appliance #1 Type BTU Input Fan Assisted or Nat
Appliance #2 Type BTU Input Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances Tatal Btu Input
Common Vent Type
Vent Height Diameter inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance #2 Vent Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS• (Describe) --
HEATING CO:
Signed By: Date :
Building
Inspections
763-572-3604
DATE `�
SITE ADDRESS _
THIS APPLICANf IS:
�
PROPERTY O�VNER/
TENANT
CONTRACTOR
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
�-1 D iZ[ /_
❑ OWNER
YOUR E-MAIL ADDRESS
(�ONTRACTOR
Pernui No.: � -G0.
Received By:
Date Rec'd:� Lc� O
N,v�: �',Z► c l� li E L a 14/
n.��xESS: �' I� S �a �e T� ,���i 171� crrY �2 , d �� sra� z�,
PHONE: S > � — % � � 7
SUBMIT A COPY OF STATE LICENSE # �{ b.S I � DATE ��� b��
YOUR STATE LICENSE ADDRESS: � �.� ) �� �'i� �2 �� i� ;__ ; Cj'E %Z , CITY ��12-� � �-i-= 7� _STATFJ��' ZIP�� � �
WITH APPLICATION pHONE 7-- �� 6� FAX
PROPERTY TYPE
PERMIT TYPE
�E oF woRx:
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDTITON � GARAGElSi�D ❑ WAIDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTE�R
0 SWIlvIIvID�IG POOL
0 REMODELING
DESCRIBE WORK BEING DONE: °r� ai`�Z 2s 1— � �'�� 1Z c7 0�
SIZE OF IMPROVEMENT I� S�L . LENGTH WIDTH HEIGHT Sa. Ft.
OF SQUARFS ��
GARAGES
PROPOSED S1ZE:
PROPOSED HEtGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE & GARAGE
❑ A'ITACI�D GARAGE
❑ DETACHED GARAGE
❑Soffit
� Trim
0 Fascia
wnvnows
IN EXISTIAiG OPENINGS OYes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF �
�ASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION 1NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMTT:
1. Site Plan/Survey showing the e�cisting struciaues
and proposed project
2. Two sets of construction plens
3. Energy caloalations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Surchazge
Fire Swchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Dne
$
� a- 33
$ l• l7
�S.U7,�
$
$
$
$
$
$ /.75
See Back Page for Fee Schedule
65% of Building Permit Fee
(.0005) times the total job valuation — Minimum $.50
.001 x Permit Valuation (1/10%)
$5.00 (State Licensed Residential Contractors)
$1450 per SAC Unit (Plans to MWCC for determination)
$+6ft= ftx$20=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessazy ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
TfIIS IS AN APPLICATTON FOR A PERMIT-NOT VALID UNfIL PROCESSED
I hereby apply for a building pemut and I aclmowledge 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
pemut but only an application for a peraut 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 which re uires revi w an roval of plans.
SIGNATURE OF APPLICANT -c� _�.l� /�=�"�`�' ° PRINT NAME � C �` � �Z � /� Q � r t�� � DATE � S� '
Page 2- Building Residential Application
BUILDING PERNIIT FEE SCHEDULE
T'he Chief BuildSng Official sha11, before issuing permits for the erectioa 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 structure, 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 VALUE FEES
$1 to $500 $23.50 (Minimum Fee is $23.50 plus surcharge)
$501 to $2,000 $23,50 for 1�` $500 plus $3.05 fo� each additional $100 or fraction, to and
includin $2,000
$2,001 to $25,000 $69.25 for 1�` $2,000 plus $14 for each additional$1,000 or fraction, to and
includin $$25,000
$25,001 to $50,000 $39125 for 1�` $25,000 plus $10.10 for each additional $1,000 or fraction,
to and includin $50,000
$50,001 to $100,000 $643.75 for 1�` $50,000 plus $7 for each additional $1,000 or fraction to and
includin $100,000
$100,001 to $500,000 $993.75 for 1� $100,000 plus $5.60 for each additional $1,000 or fraction to
and includin $500,000
$500,001 to $1,000,000 $3,233.75 for the 1�` $500,000 plus $4.75 for each additional$1,000 or
fraction to and including $1,000,000
$1,000,001 and up $5,608.75 forthe 1$1,000,000 plus $3.15 for each additional$1,000 or
fraction
VERIFICATION OF FOUNDATION
Pernuts for construction will be issued a min;mum of 24 hours from the time of application to
allow for proper review of proposed structure and of the constcuction site.
A Certificate of Survey of the lot, showing the location of the existing foundation will be
required before proceeding with the framing. New Houses Onlv
Ciiy of Fridley
Building Inspections Department
6431 University Avenue NE
Fridley, MN 55432
763-572-3604
Fa�c: 763-502-4977