AF - 47170�
City of Fridley, Minn.
BUILDING PERMIT
Date: . . . �`.A� . �. . � . � . . . . � �. . .
Owa�r ......................................
Addr�ss .....................................
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N° 3541
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Builder . . . . . �s�'r`�'�'?!� . . . . . . . . . . . .
Address ..... .......................................
LUCATIQ�11 OF BUILDINLa
No. �. /. .� .�. Street . . . .. . . . . . . . ..�� . . . . . . Part of Lot . . . .. . . . . . . . . . . . . . . . . . . . . . . .
Lot . . .�. . . Btock . . . . . �. . . . Addition or Sub-D4vision � . . � . . . . . . �,.,l.iLl.t�e,{�
Corner Lot .........
... Inside Lot ..�........ Setback ��.`, Sideyard . ��.°�.�...........
DESCRIPTION O� BUILD(NG
To be Used as:
,� � / /c � �
� . . .. . Fra�nt �� :'.;<. DePth �.�.:�14'� HeightJ. J .' �. Sq. Ft.��� .� Cu. Ft. � .��.� ��
.................... Front ........ Depth ........ Height ........ Sq. Fk ........ G�. Ft. ........
Type of Construc(3on . . . . . . . . . . . . . . . . . . . �et Cost. /�� �.�.�.� .f ."�'. . . . . To be Completed . . . . . . . . . . . . . . : . . . .
In considera.tion of 1�e issuance to me of a permit to
the pxoposed work in acc�rdance with the descriptton a
ondinances of the dty of Fridley. �
above, I agree to do
with all provis3ons of
..................................
/ � �_..
In c�nsideration of the payment of a fee o! .$.�... . . .. ., perinit is hereby granted to . .. .. .. .. .. .. .. .. . .
. . . .. .. .. .. . . . . .. . .. .. .. . to construct the building or addif3on as described above. This permit 9� granted upon
� the expre�s condition that the person to wham it is granted and his agents, employees and worl�nen, fn all work
a done in, around and ulmn said building, or any part thereof, shall conform in all respects to the ordinances of
Fridley, Minnesota regarding loc�tion, construction, alteration, maintenance, repa3r and moving of huildings with-
in the dty limits and this permit may be revoked at any time upon viola.tfon of any of the provisions of said
ordinanc�. _ _.
� _ _ _ c . B1IildiAg 7S18peCtOT
NOTICE:
Thls permit does not cover the conatructlon, Instailatlon o� alteratlon fo� wi�ing, plumbing, gas heating,
sewa� or wata�. Be sure to see the Bulldlrtg Inspecto� fo� separate permlts fo� thass Itema
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MINDER ENGINEERINC� CO., INC.
ENGI NEERS AND SURVEYORS
LANp BUQVEYINO
CIVIL �, MIJNICtDAL ENOINEERINp
6418-56T" AVENUE N.
MINNEAPOLIS 2"f, MtNN.
KE 7- 3637
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WE HERE9Y CERTIFY TNA7 TNIS IS A TRUE ANO CORREGT REPRESENTATION OF A SURYEY OF THE BOl)NDARiES OF TNE
LAND ABOYE OESLRIBED ANO OFTHE LOCATION oF ALL DUILDINGS, IF ANY, TNEREON , AND ALL VISIBLE ENCROACHMENTS,
�� �„r, FROM ORON SAID LAI�fD. MINDER ENGtNEERING CO., INC.
oCforev
OATED TM�S DI►YOF ���•��S�G'j �b��,jEERS AND Sl)RVEYORS
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City of Friclley, 1Vlinn.
BUILDING 1'ERMIT
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N° 5264'�
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Date: .�� '~' .!�_
Ovvaer: r� ,-^�` Builder _ _ . `� ���: r ���
Address �. Address —
�� LO TIOiV O I DIN9G
No. ���_ Street - �� ;�_.�l;�i��._/_ part of Lot
Lot .> >...._ Block '� �_ Addition or Sub- 'vis n_�_____._
Corner Lot � Inside Lot —�''� �iback =�Sideyard �_ �.7
Sewer IIevation .�.,. _. Foundation IIevation
DESCRIPTION OF BUILDING
T U
.: ...�_ Front �'~" Depth ��"'' Height �� Sq. Fi. '����: Cu. Ft ��-�
� Depth � H ight —. � Sq. Ft Cu. F�
7.'ype of Conatruction � Es� Cosi �C��__ To be Completed
In considera.tion oP tlze issuance to me of a permit to construct the building described above, I agree to do
the pro�sed work in accordance with the description above set forth and in compliance with all provisions oE
ordinances oY the city oP Fridley. �
In consideration of the payment of a fee of $.�_""'��- , permit is hereby granted to
the ress condition that the ���� �e building or addition as described above. This permit is granted upon
exP 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 oi
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildinga
within the city limit� and this permit may be revoked at any time upan violatiorcaP,any of the provislons of said
ordiaaacea _. , ,r�a � i
Building inspector
NOTICE:
ihh permit does nof eover the coestwetion, iestallation fo� wiriea, plumbmg, gas heating, sewer o� water. Be wn ro ses
ths Boildieg Uupeetor fe� separafe pem�ils fo� �hoss hems.
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1PPLICaTION FOR BIIILDING PERI�IIT
CITY OF F1�IDLEY, NQNNESOTA
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LOCATION OF BUILDING
No. � � �- t�
of I�t
Lot Block y Addition or Sul�livision
Corner Lot inside Lot Setbaek Side-3fard
SEWER ELEV&TION FOUAIDATION ELEIiATION
�pplicant attach to th3.a form Certificate of Survey of Lot a,nd proposed buildin�
location.
DF�SCRIPTION OF BUILDING
To be used as:
Sq. Ft. �( „/ (` � Cu. Ft. C� � d�
F`ront Depth Height
�
Sq. Ft. Cu. Ft.
Tyge of Construotion - Estimated Cost��4�� ��
To be Gompleted �� �.� ^
The underaigned hereby makea s.pplice,tion for a permit for the work here3n specif3ed�
agreeing to do all work in strict accorde,nce with the City ardinances and ruling of
the Department of Build9.n�s, and hereby declares that all the facts and representations
atated in this app7.3cat3on are true and correct.
DATE ,� � c� `� � I� SIGNgTURE �'-�,�
(A Schedule of Fee Costs can be found on the Reverse Side.)
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BIIILDING PERMIT FEE SCHLDOIE
Section 2. The Inepector of Buil.di.ngs ehall, 'before i�su3�ig any permit for the
erection of any building or structure, or for eny addit3�on to an�r existing build-
3ng or structure, or for an�r alteraticns or repa3rs to ea� existing building or
structure, upon application therefor, require the payment by the applicant for
such permit of fees to the a�nount herein below aet forth and in the aa'aaner herei.n
provided �to-wi�:
�.1. For aa� such permit for the er�ct3on of any fire-proof build3ag, bther than
a garage, warehouae, factory or grain eLeeator, or for the erect�.on af any► fire-
prooi addition, for similar occupancy, to any existing building shall be at ths
rate of $]..4A for each one thousand cubic feet, or fraction thereof, in such
cubical contents. .
2.2. For any such permit for the erection of any firepraof garage, warehouse,
factory or gra3n elevator, or for the erect�.on of any fireproof addition, for
sim3lar occu�pency, to any ex9.stin� building sha11 be at the rate of $1.25 for
each one thouaand cubic feet, class3�ied as �'fireproof" b�r Section 502 of the
Minnea.polis Buildi.ng Code.
HOUSES
2,3, For any such permit for the erect3on of an�r non-fireproof builcling o�her
than a garage, warehouse, factory or grain elevator, or any norr-fireproof
addit3on, for s3mi7.ar occupaney, to an�r existing build3ng. Permit $]..00 for
each one thousand cubic fset.
c�►c�s
2.4. For any such permit for the erection of any norr-fi.reproof garage, �tarehouse,
factory or grain elevator, or for the erection of any non-fireproof eddition, for
similar occupanc�, f,o an� existing building or for each such bvilding or a.c�dition.
Ninety Cents for ea.ch one thousand cubic feet or fraction thereof, in the c�ibice].
con�ents thereof with a m3nimum of $/�.00.
For the purpoae of computing feea for building permits the cubicel contenta of any
build3ng or addition to a un3form height throughout by multiplying the ground area.
covered from a point a3x (6) inches below the floor line of the basemen� or cellar
to the average hei�ht of the upper surface or to the average height of the roof
surface of the main gable of a pitched roof.
2.5. For repairs or alterations to an existing structure, the fee shall be at the
rate of �3.00 for each Five Hundred Dollars ($5�•00), or f'raction thereof in the
cost of all proposed work.
2.6. In no case sha11 the fee charged for ang perm3.t as set forth in Sectiori 2 be
lesa than �4•00•
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City of Fridley, Mi.nn.
BUILDING PEI�MIT
��: �ay 27, 1965
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N� �s8s
�r; �er C3kerstrom B„�� Iater Ci�y Garage Bu3lders t
Adaress �� Jaeksca �T: E. a� I�. 10, IKpls •� 33
LOCATION OF BUILDING
No. b7a� s�t Jackson st. N. E. p� t� Lot
Lot 5 _ Block 5 Addition or Sub-Division _BT�Okv3.ew Tei�race Addit3on
Coraer Lot — Inaide Lot Setback Sideyard
3eR'er �levat4on — Foundation IIevat3on
To be vsed es:
DESCRIPTION OF BUILDING
Frant I�pth Height Sq. F't. Cu. Ft
I+�ont Depth I�eight Sq. F't Cu. F't.
Type oP Constructlon F�e �t, eost �2, 996 • 00 To be Completed
$1;OPdl D8�18g8 �8p8�.T
In c�nsideratlon oP the fssueace to me of a permit to construct the building described above I agree to do
the proposed work in accordance with the d�escriptlon above set forth and in. comPlffence with afl pravisfons oP
ordinanoea oY the dty of FY1d1eY• a ./1 1
In camsideration of the �Yment of 8 fee OP $.],�1,�.�lQ , P�t ia herebY granted to �'�er Ci ta ,s�rmg@
��i � deT$ � to conatruct the building or addition as described above. Thia�ermi t is granted upon
the express c�ndit�on that the n to whom it is granted and his ageuta, emplo�yees an� workmen� 3n all work
a
done in, around and upon eai building, or any� thereof, shall conform in all respects to the ordinance� of
FridleY, �i�onesota regardlng laeation, conatruction, alteration, maintenance, repair and moving of bufldiage
wi�� dty limiffi and tbia permft may be �+evoked at any L�tme upon violation of aay of the provisiona oP eaid
Ht�ildin� Inspector
aonc�
Ylds peeedt doa eof eewe �6s eoesfeueN�, testal�dton for wirie8. P��9. Oa 6�8. a�r�r or wafK. B� wre te s�
��1din8 I�� ier s�Parafr ��or t6�p B�t.
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APPLICATYON F4R B���INC� PERMIT
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� CITY OF FRIDL�'Y� �i1�SOTA
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OWNL$ � N�1N1� . � `�/� �� BUYLDER �'�--�`� ° � � �
ADDBESS � ��
` �� � ADD1t�SS �� . �i
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LOC�Z"ION OF �DIIdG
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No. 6 %� � ,. St��et '� � � Part �f Lot
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Lot ,�� Biock <�� Addit.io�r or Subdat�istian ��,� ��-.-�,�-_,R- ��_��_" ��1 �� � C� "
_.-.---�-., ,-_„�,.-;
Corner Loe Inside �ot '��e�lr'a�k Side-Yard ,
SEWLR EbEVATIpN FOUNDATION II,�V'A'i'ION
Applica.nt atCach to t%.i� form,Two Certificates af,�Survey of Lot and proposed build-
ing 3.ocation d�°�wa o�1 these (;��'tificates .
DESCRIPTION OF Btr1LDING
�o be used �.s : ,
1ronC Depth Seight
9q. Ft. (:u. Ft.
�
FronC D�pth Hei$ht
� St�. Ft . Cu . Ft..
e ' , �
Type af Constructfoa _�ii` Esii:nated Coat�, ���
. .T� be ComP� _ �n�c��. o� f7 -
The undersigned hereby makes applieation for a pea�nit for the work herein specified,
agreeing �Ca� i�o a3,1 work f� str�.ct accordance wi.th the City of Fridley.Ordinances and
rulings v'� tlae Department� �of Buildings, and hereby declarea tfiat . all. the •fracts and
representationa stated in this application are true and correct.
�
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�Schedule of Fee Costs caa be found on the Reverse Sid�j.
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B1�ILDING PERMIT F8E SC��iJLE
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� Seetion 2. The Inspector of Buildin�s•shal�, be,�orQ ietui�g eay permit for
, th� erection of any buildiag or stru�t�.ure, �r for attq add,tti�, ts any euist-
, ing building or atructure, or foi. any a�,terat�t�n,s��`or� =epai�is to au�+ euiseing �.
. i�uildi�►g or structure, upon applicat�:o� �er,efor, ���aire the p,ayme� by �he
applicant for such permit of fee� �� �the amount �her�ip•below est 'forth._a�]
• �in the manaer hereia provided to-w�t: �`� .
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.:�.� -----. �.1. F�r any $uch permit �or the Q�re�tion •o�� aa� fire�-°p�f bu�ld�pg, cther �.
' �.:.; , -�laan a g,ar�ges �ra�ehouse, factvrY 'ox� g�i�t' �'�ev��;, .� �ar. Che e�ti�oa of `"
.' anq fi�e-��ot addi�ion, fa�c aia,�l;ar'°o��P,�ney• �b: a�,Y e,�cis��i�g bu�.l��g �•:: �. -
aha].1 be at the ra�e ## $�,.4Q for �ash�RSSC� thoue�nd Et�bi¢ feet, or�fr�ion
. a � .. ; thereof, ia such cubical c�ont�a�s , � . • � "`: . , � ` . . �
h. .
. `�. 2.2. For any su+eh germit-- f�...;��e erection a� any f9.rerproo� g�rara�.. ��•�^ ,
a��tory �r grain eievator, or ���the Q,acec_tior► �,f any�� �� E �•.a
. f�x' aimilar occupaacy, ,to aa exiet• �..
y � �a�3di�p,g sti�13,� •be �t .t ' e
. ...��fo�'�seh vne .th�usand cubic .feet;�.,cr�ae�i�ied .�L!'fixeproaf" �t� S�
the Mia�csr.p�L3.8..-Ba�f,i.ding �ot'��. ;�,.�,.�.,=� .' . � .
.' �''� HOUSES . , ' . � . . .
� � 2.3;. Fcir anyr such permi� for the er�eetion af any aon-Hrep}c�l�f b'�ildirag
':. �<: �'�than a gai�ge, warehouse, �actory or. grain elevator; br any 8od-fite�r�►f�'°�
additi�n, for sim��d� ocbup�lnCy; to an,y efti.stt�,g �buildia� - ge�mit $2,.�00 f�r ..
each �one thou�aln�l �c�bi.iC, fe�6.. . , . '
GARAG`ES . . . . � ' � . s�
�.. 4_ For any such pera�i,t ftsr the e=ection of any non-fireproof garag�, .
warehouae, factorq or grain elevator, o= for the erectioa of anq non-firepr�of`� '
�S� -f-0r-atmilar occupancq, to aax exiating build3ng br for eec� such '
-_,�,.;.-�iL�ding ox addition = ninety cents ($�0►90j for aach one thous�attd ce�bic feet .
or fi�t.ion thereof� in the cubical� coatents thereof witb a miaimum of $4.OQ.-
� •
For the purpose of computatag.fees for building permits,.th�.cub3cal cc�ritest� ��
of any bufldia�g or edditiaa Co a uniform hei ht throu hot�t �
� $ 't�y' multi��� �i�... - .
gronnd area �overed .fram� a�point six (6) fnch�fi bal�sw Ehe �loar 1�� t�f ..the__.. ��.
basement or oellar to th� aveitage height oi the upper au�face or to tlie �
aver�ge he3ght of the rpof $urface of the maiu gable of a.�38,tched roo€. . '.
. 2_ 5. • For repairs or a�,terations to an existitt� sCsuctt$r�..y �e gee s�a11 ,b��..��' "; .
. at the rate of $3,00 .per ea,ch Five I�uadred Do11a�s ..($g.�p$�sQ�)� qr �ractia� .
,Mtherebf i�t �h� co�t 'of •�l.l : prcposed work. . . . . _ ,; . . - .� . ' .
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2� In no case she13. �he d �:foz-.aa � , . . . . � . , �. 3
' Sectioa _2 be les�.�hen.-:�..Opg��.: �_ p- P��'� -�, se� fi�z'th �Ln . ,. . _ . .q.
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sue�ecr ERMIT NO.
City of Fridley 619 4
AT THE TOP OP THE TWINS g � I L D I N G P E R M I T
�
; � RECEIPT NO.
� `y � COMMUNITV DEVELOPMENT DIV. �/ ��
r � � PROTECTIVE INSPECTION SEC.
1 . �
� ` /'�'1 � CITY HALL FRIDLE� SS432 NUMBER REV DATE PAGE Of qGPROVEO BY
�----� • •,, 612-571-3450 9�aFi5 6/10/98 / /
JOB ADDRESS 6720 Jackson Street NE
t LEGAL LOT NO. BLOCK TRACT OFi ADDITION SEE ATTACFIEO
DESCF. S 5 Brookview Terrace SMEET
2 PROPERTY OWNER MAIL ADORESS 21P PNONE
Roger Okerstrom 6720 Jackson Street NE
3 CONTRACTOR MAII ADDRESS ZIP PMONE LICENSE NO.
Top Gun Inc 5014 Parrish Avenue NE, Ro ers, MN 55374 428-4559 3388
a ARCHITECT OR DESIGNER MAIL ADORESS ZIP PNONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PMONE LICENSE NO
B USE OF BUILDING
Residential
7 CLASS OF WOpK
❑ NEW ❑ ADDITION ❑ ALTERATION � REPAIR O MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof House (13 S Tear-off
9 CHAN�E OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBIN(i, FIEATIN(i, �PE OF CONST. OCCUPANCY GROUP OCCUPANCV LOAD
VENTII.ATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION IONING SQ. FT. CU. FT.
AUTHORI2ED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOF A PERIOD OF 120 OAYS AT
ANY TIME AFTEH WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFV THAT I HAVE READ AND EXAMINEO THIS APPLICATION 1 STA�LS GAFAGES
AND KNOW THE SAME TO BE TRUE AND CORREC7. ALL PROVISIONS OF LAWS yALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIEO �y�q,�
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT � 1� O87 `�y+o-rv9 a.eJ�
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGUTATING CON- @
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. y�37.SO Fire SC �1.09
PLAN CHECKFEE TOTALFEE
License SC $5.00 $44.14
SIGNATUREOFCONiRACTOROFAUTMORI2EDAGENT IQATEI HEN PROPERIV V DATED THIS IS YOUR PERMIT
� @ �
SiGNATUREOFOWNERpFOWNERBU�LDEFii �OATEi 'gLOG NSP pFTE
NEW 11
ADDN �I
ALTER (]
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
Effective 8/ 1 /95�
(q�
�� �(��
ConstructionAddress: i� � � � ���� GYl �� , _
Legai Description: � _
Owner Nacne & Address: � ��� ��i Q�W� Tel. #•
Contractor: `T'� t-� C7 l� t� h- NC> , _ MN LICENSE � 3 3��
Address: 5� � �_ P__C�t i �S 1-� �-2 1�r �- ��S , �1 rl � el. � �I�� - �15 �_
LI�iING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Surv y o� �h�
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IM�'ROVEMENT
Length � � Width Height
Length Width Height
Length Width Hgt/Ground
_ Sq. Ft.. � , . . .
_ Sq. Ft.
_ Sq. Ft.
Corner Lot [] Inside Lot [] Ft. Yd Setback Side Yard Setbacks
Type of Construction• 1� ('�e�f � Estimated Cost: $_,`� �-
Approx. Completion Date: (� g `T�� l 0�`f', Ze
(Cost on Back) � J
Driveway C�urb C�t Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: � '� � APPLICAN'T: Tel. #
Percnit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
,�ITY USE ONLY
$ 7- �� Fee Schedule on Reverse Side
$ % �� .001 of Permit Valuation (1I lOth%)
$ . �Sf $.50/$1,000 Valuation
$ $850 per SAC Unit
$ 5 o e� $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [ ]
�
$ �. ��f
STIPULATIONS: - - � �
sue�ecr P
City of Fridley 2113 3
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
r
� � RECEIPT NO.
COMMUNITY DEVELOPMENT DIV. �� � � �
v PROTECTIVE INSPECTION SEC.
i _
� � __"-
r ; ;
� S /'�'1 � CITY HALL FRIDLE� 55432 NUMBEP REV. OATE PAGE OF APPROVED BV
�""� � �'� 612-571-3450 910-F15 10/24/91 / /
JOB ADDRESS 6720. Jackson Street NE
t IEGAL �OT NO. BLOCK THACT OR ADDITION SEE ATTACHED
DESCR. 5 5 Braokview Terrace SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PFIONE
Roger Okerstrom 6720 Jackson Street NE 571-6925
3 CONTRACTOR MAILADORESS Z�P PHONE LICENSENO.
Top Gun Roo�ing 9644 Ximines Lane, Maple Grove, N�T 55369 425-1455
< AFiCHITECT OR OESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAII ADDRESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Res identi.a,l
7 CLASS OF WORK
O NEW ❑ ADDITION � ALTERATION C� REPAIR ❑ MOVE O REMOVE
8 DESCRIBE WORK
Reroof House & Gaxage (20.Square�� Tear^o��'
8 CHANOEOFUSEFROM TO
STIPULATIONS Underlayment must comply with 3tate Suilding Code.
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING, �PE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. fT.
AUTHORI2ED IS NOT COMMENCED WITHIN 60 DAYS, OH IF CONSTpUCTION
OR WORK IS SUSPENDED OR ABANDONED FOH A PERI00 OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLO. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION �- STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALl PROVISIONS OF LAWS yqLUATION SUHTAX
ANO ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN O NOT. THE GRANTING OF A PERMIT +��- � O4O $. 'rJ2
DOES NOT P SUME TO GIVE AUT RITY TO VIOIATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISION F ANY OTHER ST O LOCAL LAW REGULATING CON- $2'], OO F1iG� SC $I..O4
TR CTIO OR THE PERFO E CONSTRUCTION.
PLAN CHECK fEE TOTAL FEE
$28.56
IGNATUR CON' CTORORAUTHORI� AGENT IDATEI WHEN PROPE A D THIS IS YOUR PERMIT
, _ - - C�-�-�� `i
SiGNATURE OF OWNER�IF OWNER BUILDERI IOATEI $G ql.TE
r�w � �
ADDN [ ]
AL'I'ER ( )
�
CTfY OF FRIDLEY
SINGLE FAMII.Y AND DUPLEXBS R-1 AND R-2
Building Permit Application
Construction Addre.ss: � � � D �c� � � C� /r� ���
Legat De.�cription: ,� �
Effective 1/1/91
Owner Name & Address: �%� �i„�_� �i /' S 7� �d G�/l %�� i Tel. ,# �7 / - �O�I�S'
C�: G u ��� � Tel. � i�� �.� =/�SS
Addr�ss: ? �r `{ y X�'�r �'�2 s c � �� � /�%,��� c�ro�� �/%H .�S_3 �
�
Attach to tLis application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IIKPROVEMENT
I.IVING AREA: Length Width Height
GARAGE AREA: Length Width Height
DEC% AREA: � Len Width Hgt/Grround
OTHER: � �d /� � (� � ( �C� � y � S 1� A-� - l'1��/=
Sq. Ft.
Sq. Ft.
�.�Ft
_ �
Corner Lot [] Inside Lot [] Ft. Yd Setback Side Yard Setbacks
Type of Construction: Estimated Cost: $ �
Approx. completion Date: / O ,�� �
taoe m a.�t�
Driveway G�rb C�t Widt�t Needed: Ft. + 6 Ft = Ft x$ _$
,
DATE: D� a ' 9� APPLICANT: G-- � Tel. # ya? S J�S �
Permit Fee $ � `�, C� �
Fire Surcharge $ 1 � D �
State Surcharge $ . ���
SAC Charge $
Driveway Escrow $
Park Fee $
Sewer Main Charge $
TOTAL
STIPULATIONS:
� ��•��
i�l�. � . L
Fe� Schedule on Reveis�e Side
.001 of Permit Valuation (1/lOth�)
�.50/$1,000 Valuation
$650 per SAC Unit
Alt. "A" or Alt. "B" Above
Fet Determined by Engineering
Agreement Nece.SSary [ ] Not Necessary [ ]
BUII.DING PERMIT FEE SCHEDULE
T'he Chief Building Official shall, before issuing permits for the erection of any building or structure,
or for azty addition to any exisrting bailding or structure, or for airy alt�ration or repair to any existing
building or stivcture, upon application therefore, require the �yment by t6e applicant for such permit
of fees tn 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
$540,001 to $1,000,000
$1,000,001 and up
FEF.S
�15 (Minimum Fce is $15 plus surcharge)
$15 for first 5500 plus �2 for each additional $100 or
fractiion thereof, to and including $2,000
$45 for first $2,000 plus $9 for each additional $1,000
or fraction thereof, to and including $25,000
�252 for first $25,000 plus $6.50 for each additional $1,000
or fraction thereof, to and including $50,000
$414.50 for first $50,000 plus $4.50 for each additional
$1,000 or fraction ther�f, to and including $100,000 _
5639.50 for first $100,000 plus $3.50 for each additional
$1,000 or �raction thereof, to and including $500,000
$2039.50 for the first $500,000 plus $3 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$3539.50 for the first $1,000,000 plus $2 for �ch additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
(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 replacement of curb and gutter and install a 3 foot wide
approach with 6 inch depth - Driveway width plus 6 feet times $15.75.
VERIFICATION OF FOUNDATION
peimits for construction will be issued a minimum of 24 hours from the time of application to allow
for proper review of the proposed slructure and of the construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has �en
constructed will be required before proceeding with the framing.
SUBJECT
City of Fridley
AT THE TOP OF THE TWINS g U I L D I N� P E R M I T
i�
� �
� • COMMUNITY DEVELOPMENT DIV.
' j L ���-- ,
r � � PROTECTIVE INSPECTION SEC.
� � �
� /�"1 � CITY HALL FRIDLEY 55432 NUMBER REV. OATE PAGE OF
�----� • •�� 612-571-3450 910-F15 5/8/84 � �
JOB ADDRESS 672fl Jackson Street N.E.
1 LEGAL LOT NO. BLOCK TRACT OH ADDITION
DESCR. 'rJ 5 Brookview Terrace
2 PROPERTYOWNER MAILADDRESS
R�er Okerstro� 6720 Jackson Street N.E.
3 CONTRACTOR MAILADDRESS
Nlilt�on L. Johnson Co. 2513 Central Ayenue N.�.
4 ARCHITECT OR DESIGNER MAIL ADDRESS
5 ENGINEER
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW
8 DESCRIBE WORK
A.1.13II1].ri13ICt S].
9 CHANGE OF USE FROM
STIPULATIONS
MAIL ADDRESS
O ADDITION
c1.T1$ '�] ltl
� ALTERATION
TO
ZIP
ZIP
ZIP
P
1748
R E�E+P�P16
/� � �
APPROVED BY
SEEATTACHED
SH.EET
PHONE
571-6925
PHONE LICENSE NO.
?81-9548
PHONE LICENSE NO.
PHONE LICENSE NO.
� REPAIR ❑ MOVE ❑ REMOVE
... --� --�-- �
A ATE PERMITS ARE RE�UIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING
AUTHORIZED IS NOT COMMENCED WITHIN 80 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
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINEO THIS APPLICATION �-
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT �`rJ �OOQ
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMITFEE
PROVISIONS OF ANY OT ST TE OR LOCA LAW REGULATING CON-
STRUCTION OR THE PERFO E OF CONS RUCTION. �`rJO. SQ
G PLAN CHECK FE
�� O
SIGNATUREOF fTSi CTOR AUTHOR12EDAGENT �D TEI WHEN F�Rf
SIGNATUREOPOWNERUFOWNERBUILDERi �DATEi �, B�OG INSP
OCCUPANCY GROUP OCCUPANCYLOAD
SO. FT. CU. FT.
OFFSTREET PARKING
STALLS GARAGES
SURTAX
$2.50
SACCHAFGE
TOTALFEE
��.��
RLY VALIDATED THIS IS YOUR PERMIT
i��i� � � � /A/��
�
CITY 01" FRIDLCY
APPLIGATID:1 FOf; RCSIDCf�TIR� [3U1LDIitG PCRi�fITS
(��c►�, A1ter.�Lions, AddiLions, or Rcpairs)
01iNER: ����� �1��' iPs � 2o�r,
ADJftESS: �7 �a J/� c k So.� �T. oV_� ,
TEL n0: s �/—�� a S
ST72I•TT NO : lr 7 °Z �
: Effective Aug. 1, 1981
�QUILDER: (�� �To � � e e� �ii�s e � �� _
ADDRCSS: �S/3 ��� 7�,��� 64 v d N�
TEL f10: 7 � � — �� �
Construction Location
STItEF.T: ��y�'p iJ S % a � �
LOT: BLOCK: ADAITION:
Corner Lot: Insicie Lot: SetbacY.: Sideyards:
Applicant attach to tl�is form two Certificates of S�rvcy of lot and
pzoposed building location drawn on certificates to scale.
DESCRIPTIO�� OF COI•JSTRiJCTIO�d
Front: Depth: Height:
Squarc Feet: Qibic Feet:
. Front: Depth : Heiglit:
Square Fe�t: Cvbic I'eet:
Rj►pe of Construction : �v � � % � i �� � l �L �yrj
Rb Be Obr.�pleted: �p � � �,,,�
' ��
Esiimated Cost: $ � �,
Alt. A Alt. B
Proposed Driveuay tr'idth If New Oper�ing Is Desired: $ $
. . S�� PEVF.RSf' SIDE OF SiIEET
ZSie undessigned hereb}► mal;c� applic�tion for a permit fcr the �:vrk herein specified,
agreeing to c� ,all work in strict accordanec t��ith the City of I'ridle}� Ordiiiances and
rulings of the De2k�rt�nr�at of Duilc3ings, and hereby declares that a the facts and
represen �ztions stated in this application are true and correc �
s -- �
D.'.TE: � y ',�I�1TA�?4`BI�E : ���
SLil�ulations :
��. S�
�. ��
��.00
�. . �
0
'1_.. � �' = Slu - - a� _� -
The Chief Building OPficial shall, before issuing permits for the erection
oP any building or structure, or for any addition to any e$isting building
or struature or Por any alteration or repairs to any e$isting building or
structure, upon application therePore, require the paymeat by the
applicant for such permit of fees to the amount herein belo� set forth and
._.in the manner herein provided to-Wit:
Total Valuation
�1.00 to �500.00
�501 to �2,000.00
�2,001 to �25,000
�25,001 to �50,000
Fees
�10.00 (Minimum �15.00)
�10.00 for the first �500 plus $1.50
� for each additional �100 or Praetion
thereof, to and ineluding $2,000
�32•50 Por the first $2,000 plus $6.00
for each additional $1,000 or fraction
thereof, to and including $25,000
�170.50 Por the first �25,000 plus
�4.50 for each additioaal �1,000 or
fraction thereof, to and including
�50,000
�50,001 to �100,000 �283.00 for the first $50, 000 plus
�3.00 for each additioaal $1,000 or
� fraction thereoP, to and including
$100,000
�100�001 and up $433.00 Por the first $100,000 plus
$2•50 for each additional $1,000 or
fraction thereoP
Plaa Cheak: 25 percent of building permit fee.
Driveway Depressioa Eserov: Conerete ourb streets°onlq.
Alternate "A": Removal and replacement oP curb and gutter only -
Drive�tay width plus 6 feet times �13•50
Alternate "B": Removal and replaeement of eurb and gutter and
install a 3 foot Wide approach with 6 inch depth - Driveway width
plus 6 feet times �15.75
]lerification Of Foundation
Permits Por eonstruetion will be issued a minimum of 24 hours Prom the
time oP applieation to allow Por proper review of the proposed strueture
aad oP the construction site.
A Certificate of Surveq of the lot, shoWing the loaation of the foundation
once it has been constructed will be required before oroeeedina with the
framing.
�
sue�etr � PE .
City of Fridle�► 2 8 312
AT THE TOP OF THE TWINS g u I L D I N� P E R nll I T
r
� .
� � .
� `v __�__ COMMUNITY DEVELOPMENT DIV.
r � � PIiOTECTIVE INSPECTION SEC. �� 9
1 . �
`-___ A ��"','; CITY MALL FRIOIE� SS�$2 NUMBBR REV OATH VAGE Oi APPqOVEO BY
L �� 612-571-3450 9/0-F15 10/20/98 � �
J08 ADDRESS
6720 Jackson Stre t N
t LEGAI LOT N0. BLOCK TiiACT OR ADDITION SEE ATTACNED
DESCR. 5 5 Brookview Terrac sHeer
2 PiiOPERTY OWNER MAIL AOORQS$ 21P PNONE
Ro er Okerstrom
3 CONTRACTOF MAIL ADORESS ZIP PMONE LICENSE NO
Milton Johnson Co. 525
d ARCHITECT OR OESIGNER MAIL ADDRESS ZIP PMONE LICENSE NO.
5 ENGINEER IqAll ADDRESS 21P PMONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WOFiK �
❑ NEW O ADDITION ❑ ALTERATION � REPAIR O MOVE � O REMOVE
8 DESCRIBE WORK
Sidin re air
9 CHANOE OF USE FROM TO
STIPULATIONS �
Call for building wrap inspection before covering.
SEPARATE PERMITS ARE FiEOUIREO FOR ELECTIi1CAL, PLUMBING, MEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIF CONDITIONING
THIS PERMIT BECOMES NULL ANO VOIO IF WORK Oii CONSTRUCTION 20NING SO. fT CU fT.
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CON$TRUCTION
OR WORK IS SUSPENOED OR ABANQONED FOFi A PER100 OF 120 DAYS AT "
ANY TIME AFTER WORK IS COMMENCED, ' NO DWLG. UNITS OFFSTFEET PARKING
1 MEREBY CEqTIFV THAT I MAVE READ AND EXAMIN�D THIS APPLICA710N STA�LS GARAGES
ANO KNOW TNE SAME TO 8E TF]UE ANO CORRECT. ALL PROVISfONS Of IAWS VALUATION SURTAX
AND OROINANCES GOVERNING THIS TVPE OF WQRK WILL �E CAMP�IED
WITH WHETHER SPECIFIED MEREIN Oti NOT. TME GRANTING OF A PERMIT $9�000 $4.SO
DOES NOT PRESUME TO GIVE AUTNOR�TY TO VIOLATE OF CAMCEL TME pEqMIT fEE SAC CMAqGE
PROVISIONS OF ANY OTMER STATE OR LOCAL LAW qEGULATING CON-
STRUCTION OF THE PERFORMANCE OF CONSTRUC710N 149. %S Fire SC $9.00
7 P�AN CNECK FEE TOT FEE
�- - � y.� ° �'�- /O l � �'� Lice 5 . 68 . 25
� ATUAEOFCON'AAC OAOA NOp�ZEDSGENT iO�iEi ME P O VALID Tr15 IS OUF1 P MIT
— c� �0-�-
$�GN4TUAE O� OWNEp��f OWNEA BU�lOEN� I�AfE1 ' BL �NS� - f�piF
N i:VV
ADDN
ALTI:R
� l _ ... , . -
� � ' CITY OF FRIDLEI'
I gl S(NGLE FAM[LY AND DUPLEXES R-1 AND R-2
BU[LDING PERMIT APPLIC}1TIO1V
Cffective 1 / 1 /97
q�t� ��
�I� �
ConstructionAddress: 6 7 2 0 Jackson S t. N. E. � ��
Legal Description:
Owner Name & Address: Roger Okerstrom ���mP1 Tel. 1{ 5Z1-�925
Contractor: Milton �Tohnson Co. Ml�i I.,jCENSE# 2083
Address: 525 Lowry .a,ve. N.E. , Mp1s. 55418 Tel. N
� --��� -Q��
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVIIVG AREA:
GARAGE AREA:
DECK AREA:
OTHER: .
DESCRIPTION OF IMPROVEAZENT
�n� Widdl Height �
�ng� Width Height
�n� Width Hgt/Ground
Sq. Ft. .
Sq. Ft.
Sq. Ft.
Construction Type: Sidin • Repair � Fstimated Cost: $ 9;�000. 00
(Fee Schedule on Back)
Driveway G�rb G�t .Width Needed: Ft. + 6 Ft = Ft x $ � -. � _ � � .
DATE: ��, �S .-y d� APPLICANT: '`f �' °'�° , �' - � t ���� ��� T . . '
el. � �si-�sas
�, -
� ": .
Permit Fee
��ire Surcharge
�tate Surcharge
iAC Chatge
:.icense Surcharge
)riveway Escrow
:rosion Control
'ark Fee
�ewer Main Chargc
TOTAL
'C[PU(.A"I'[ONS:
$_ ��`f9 ?s,
� � v�
$
$
$ S,�dU
$
$
�
$
� /��.��
CI'1"Y USE ONLY
Fee Schedule on Reverse Side �
.001 of Permit Valuation (1/lOth%) �
$.50/$1,000 Valuation �
$950 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above •
�$450.00 Conservation Plan Review
Fee Determined by Engineering
Agreement Necessary [ ] Not 1Vecessary [ ]
. ;.
. '. '�
au��,u�,vc. ���:�t�irr rr:c sc�{cuc.��.��. _ � - --
'l'hc Clii�f I3uilding Ofticial shall, bcfore issuing pem�its for the erection c�l' any building c�r cwcwre, or 1i�r
any addition �o any cxisting building or stnicturc, or for any alteration or repair to any cxisting building or
stivc;iure, upon application tlierefore, require the payment by the applicant ii�r 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,OU1 to $25,000
$25,001 to $50,000
$50,001 � to $100,000 .
$100,001 to $500,000
$SOO,OOI.to $1,000,0� •
FEES
.$21 (Nliaimum Fee is $21 plus surcharge)
$21 for fust $S00 plus $2.75 for each additional $100 or
fraction thereof, to and including $2,Q00
562.25 for first 52,000 plus $12.50 for each addi[ional $1,000
or fraction thereof, to �and including $25,000
$349.75 for first $25,000 plus $9.00 for each additional �1,000
or fraciion thereof, to and including $�0,000
$574.75 for first $50,000 plus' $6.25 Cor each additional
$1,000 or fraction thereaf, to and including $100,OQ0 �
.$887:25��for fust $100,000 plus $5.00. for each additional
$1,OOO�or frdr.�ion thereof, .to an�d �including $SOO,OQO
$2887.25 for die first $500,000 pius $4:25� for eacli .additioffi1 . . . . � .
$1,Q00 or fiaction ther�f, to and including $1,000,000 `� '
$1,000,001 and�up � $5012.25 for �e first $1,000,0� plus $2.75 for each additional
$1,000 oc fraction thereof
DRIVEWAY �DEPRESSION ESCROW � . .
(Concrete (�rb Streets Only)
�lternate "A"�: Removal and replacement flf curb and gutter only =�Driveway width plus 6 feet times $13:50.
(ternate "B": Removal and replacement of curb and gutter and iastall a 3 foot wide �
approach with 6 inch depth�- Driveway width plus 6 feet times $15.75.
VERIF[CATION OF FOUNDATION
. •,•
.:rn�its for construction will be issued a minimum of 24 hours from the time of applic;ation to atlo�u for prop�r
:��ie�+� ol' the �r��Posecl su-ucture and of d�e constcvction site.
.��rtilic:ite of Survcy ci(� the lo[, showin, the location oi''tlie foundation t�nce it h3s it ha.rhe:cn constr-uctcc!
•'� :!�. r���uirccl 1�r9��r� n����r.�:��din�: ��•ith thc framin�.
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aTHE BELOW MUST BE FILLED IIV VIMEN REPLACI(VG FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
C(�MMC)N VFNT, V NT .C�NN CTOR ANI� COMBIISTInN /�IR VFRIFIGATI(�N
When !� �n acin,� an �xic4in4-f �i �ran�p, the undersigned her�by verifies that the �. ..
�- venting has�been exarriined.�nd is free from nast, deterioratior�; obstructions, � -
� and is securely supported-.and firestopped where required. � '" Yes O�No (;) ;
.
The venting system is plastic,/PVC and meets all current codes and manufacturer �
specifications including sizing, length, number of elbows and tennination. Yes () No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specfications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The pYi�n� cemh��en air is sized and installed to meet the current codes
and manufacturers specifications. .
When required to in�u a r, w_emh �cfien air�itwill be sized and installed
to meet the current codes and manufacturers specifications.
Wh@Ct installin4e a new ventina e�c4em, t►-ie undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does indude AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances.
Is tfie common vent and vent connectors sized and installed correctly :after
an appliance has been removed from the common vent and vented
separately as per cuRent codes:
YesO NoO
Yes( ) No( )
Yes( ) No( )
Yes ( ) No ( )
Yes( )No( )
� � � . � � ' l� " , � •. � • 11 -11 • 1 - U , � •LT'[..-)�1� • � � ' y •: � • �11 . • ��
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
Tota! Appliances Total Stu Input
Comm�n 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
AI TFRATIONS• �Deccri6el
HEATING CO:
Signed By: • Date :
0
�- ����
/e� .�h G��r�-�i��m . �
��
THE �EL W MUST BE FILLED IN WHEN REPLACtNG FUEL BURNING APPLIANCES OR THE
APPUCATION WILL BE RETURNED
•ii�i�► ► I ► •►► •: �►� •��� 1•► _ ' I : � •►
., When � �n acing an �riet�n�;f�rance, the untlersigned her�by verifies that the . :�
- _. . �:
�� venting has-t�een ex�rriined _�nc# is free from rust, deterioration; obstructions, `;
.. and is securely supporte��and firestopped where required. � �=;Yes O No (':) _,
. The venting system is plasticlPVC and meets all current codes and manufacturer � �
specifications including sizing, length, number of elbows and termination. Yes () No ()
The undersigned also verifies thai the replacement unit is a listed assembly
and meets the cuRent codes and manufacturers specifications. This does
include AGA-GAMA Category I Central Fwmace Venting Tables for fan
assisted and natur�t draft appliaaces.
The Px��ne ceme ,�en air is sized and installed to meet the current codes
and manufacturers specifications. .
When required to ir,s±�n a new _emh �etien air�it �nri�� be sized and installed
to meet the current codes and manufacturers specifications.
Yes ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
When in�� a nPw ventine s�m, the undersigned hereby verifies that
it is a listed assembly and meets the cuirent codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Fumace
_ Venting Tables for fan assisied and natural draft appliances. Yes O No (}
Isthe common vent and vent conne�tors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current cfldes. � Yes () No ()
_.. ...,- .- ... - .����.. -. ,�. -�� ...-.,. . .Q��.�..
Appliance #1 Type _�UR��1 A�G BTU Input � Oa� Fan Assisted or Nat �A►�
Appliance #2 Type �6$- a�� BTU Input �a�► v� Fan Assisted or Nat �
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances -a. Total Stu Input �� o� �� c�
Common Vent Type _���� Vent Height L� Diameter _�,�_ inches
Appliance #1 Vent Connector Height � 9_ ft Length Z'�2ft Diameter �� D in Type �
Appliance #2 Vent Conneetor Height,,,� � ft Length � ft Diameter �fl'9 in Type ��� S�� �r.�
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
. . � _ �
� � e.��d�u�s.���a a�._�a-� ud� � u p '�9'a'�;����c �
�� � €��;���.1 ��':enfi�vorth Av�. So. �
� is,
HEATING CO: ��2) 83�-�000
Signed By: � , Date : �o�/%/�dZ,
SE�GWICK HEATING & AIR CONDITIONING CO. HEATING ,IOB NO. ���'��
8910 WENTWORTH AVENUE SOUTH • MINNEAPOLIS, MN 55420 •(952) 881-9000 TEST RECORD
ADDRESS �� �� J ��-�'� � �� � �
OCCUPANT � ��' � � d'� �
SOLD BY� r���/
MAKE � ����
SERIAL NO. ����' / �I� �i
THERMOSTAT �✓//l�P// / Q h'C��
VALVE �rV(,� 1�,I/
LIMIT �XG�
LIMIT SETTING ��� �
FAN SETTING J ���,(Y
PILOT TYPE �� �� � � � C -
IGNITION MODEL ��O � �/�
PILOTTIMING ��JS�`!>
PRESSURE �•s/��� PERCENTCOZ �
INPUT CFH �� PERCENT OZ `�
�
STACK TEMP. � PERCENT CO
ci,v �t'�.�i � �� � S N��
OWNER
INSTALLED BY
MODEL -�� VVL�� � � (�{�r- - O ��� � �
INPUT ��; [�taV I���
� f/'
VENT SIZE
TYPE OF LINER �y;
r�
LINER SIZE �
FILTERS: SIZE. �` �� NUMBER
WIRING -- _ ��'�� �� CGQ
TEST TAG
LIGHTING INST.
DATE TESTED �� I L� �
1 `. //�
COMPANY TESTING �� e �i"P
NAME OF TESTE �
FORM 235 (REV. 11/89) FORM DISTRIBUTION: WHITE COPY • JOB FlLE YELLOW COPY - CITY
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N011t/�I�RI3/1211b� NOIlSf18W0� aNtJ 2101�3NN0� 1N3A 1N3A NOWWO�
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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �"S" L �i' �
SiTE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-08
YOUR E-MAIL ADDRESS
J ��'�-� n `
❑ OWNER �C'iONTRACTOR
•_ � � 1�;�� ,- 'y,
� - - -. : F
�1����
,
�.� � ��� �� . � i � •
PROPERTYOWNER/ NAME: ��C7e9�r U����•��
TENANT p,DDRES� CITY STATE Z1P
PHONE:
CONTRACTOR ADDRESS:�
SUBMIT A COPY OF pHONE �
YOUR STATE LICENSE
STATE LICENSE #
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
FAX
CITY
EXP DATE
�MGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WMDOWS
❑ BASEMENT FINISH �tOOF ❑ DRAIN TILE
❑ DECK ❑ SIDIAiG � OTHER
O SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
1�tvIAINTENANCFJREPAIR ❑ REMODELING
ROOFING �
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXIS7'ING OPENINGS OYes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED_
ALL FEES ARE
TOTAL JOB VALUATION $
Pertnit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
ED ON
I�IXI
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
A
F'f
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project
2. Two sets of conswction plans
3. Energy Calculazions
LOCATION OF WINDOWS
NLTMBER OF
- _ _
TION, INCLUDING THE COST OF LABOR AND MATERIALS:
; TIiE 1997 UBC FEE SCIiEDULE)
�� OCCUPANCY TYPE
$" �� ,,� � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � .001 times the total job valuation
$ i .0005 x Permit Valuation Minimum $.50
$ .� " $5.00 (Sta.te Licensed Residential Contractors)
$ $1825 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �; .`1 = Make checks payable to: Cityo uf Fridle_y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge 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 Minnes Conswctio Cod , that understand this is not a pertnit but only an application for a permit and work is not to stari without a
permit on site; that the work will be in ac ance with ap ed in th of all work which requires review and approv f ans.
SIGNATURE OF APPLICANT l PRINT NAME �/��� ���` U�.� DATE �"� �U
APPROVED BY � DATE
Page 2- Building Residential Application
BUILDING PERMIT FEE SCHEDULE
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 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 for each additional $100 or fraction, to and
including $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 $391.25 for 1�` $25,000 plus $] 0.10 for each additional $1,000 or fraction,
to and including $50,000
$50,001 to $100,000 $643.75 for 15` $50,000 plus $7 for each additional $],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 including $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 includin $1,000,000
$1,000,001 and up $5,608.75 for the l�` $1,000,000 plus $3.15 for each additional $1,000 or
fraction
VERIFICATION OF FOUNDATION
Pemuts for construction will be issued a minimum of 24 hours from the time of application to
allow for proper review of proposed structure and of the construction 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 Oniv
City of Fridley
Building Inspections Department
6431 University Avenue NE
Fridley, MN 55432 "
763-572-3604
Fag: 763-502-4977