AF - 47689BUII,DII�TG PERMIT
Village of Fridley, Mi_n.n. N� 211 �
• �. '
Date � �.�c:j.l�:............ ............
Owner .���� �': ''.'r';!�!: . . . . . �'�. �-'. . 6. . . . . . . . . . . Builder . .� :..•!e�' p'`.�r".`""� . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Address . +�,;; � . '�.�`. .��. �`�'.': . . � ��. . .�,t : �',/: . .�a�� Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LOCATION OF BUILDiNG
,.; � �f � ;�
No. ... �.�. � ... Street .r l.�t�C��C�f.�.. . �.-�.. . Part of Lot . .. . . ...... ...... . ..
.f � ��j
/ � „ ...
Loi ..... .,.��...... Block . �`s�r. ..... Addition or Sub-Division ..�if(...�:je��''.�.'..b!':��^:"_C _....
Corner Lot . . . . . . . . . . . . Inside Lot . . .�. . . . . . . Setback , �.; ~�,!�� Sideyard .�'.�ti. :'.�ff�4, , , , , , , , , , , , , ,
DES�RIPTIOI�! OF BUILD{NG
To be Used as: .
. � f D"�" �`�: i' . '. . . .,d,r'�. . p " ' :� g % .�iw'. . . . Sq. Ft. . . . . . . . . Cu. F't. . . . . . . . .
�5,; (,. Yc.: Front �. . De th . . ��. . Hei ht
• �'� �"'.�.�... ' . .
'°`.`� Front �,�,, . Depth . .� � . . Height . . . . . . . . Sq. Ft. . . . . . . . . Cu. Ft. . . . . . . . .
1�`� .�"4� .s r 11�� . ,�
Type of onstruction ;�� . �,{;, t ,,: . . Est Cost �3. �. . . . . .�,,. . . . . . . . . . To be Completed �F.:��.,�.-: �. � .�
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In consideration rrf the i�ssuance 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 �'ridley.
� `� �� � /
1 �
� consideration of the payment of a fee of $. ��. .., permit is hereby granted to ��,�� ��,�,r/: ,,
• r!.'.,. .�,/ . . . . . . . . . . . . . . . to construct the building or ad dition as described above. s pe t � ia �anted upon
the express condition that the person to whom it is granted and his agents, employees and worlunen, in all work
done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings with-
in the village limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances. j.
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. �rz{ „�,. . .. . . . .,�. . :� 1C. e�1l; '�J.A�1111f11T3g ZYLSp@CiOT
NOTICE:
This permit does not cover the construction, installation or alteration for wiring, plumbing, gas heating,
sewer or water. Be sure to see the Building Inspectbr for separate permits for these items.
�.
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sue�ecT IT NO.
City of Fridley � 16 3 7 7
AT THE TOP OF THE TWINS B U I L D I N G P E R M I T
r
; � RECEIPT NO.
� ' COMMUNITY DEVEIOPMENT DIV. �� �
� � �: — •
r � � PROTECTIVE INSPECTION SEC.
l� � �
-_-_ A �����,,, CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BV
i' � � 612-571-3450 910-F15 9/10/81 � �
JOB ADDRESS 6370 Jefferson Street N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 3 4 Christie Aeldition SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
Richard Ht. Blooau 6370 Jefferson Street N.E. 571-2377
3 CONTRACTOR MAIL ADDRESS Z�P PHONE LICENSE NO.
Elk Si ' & Oonstructi.�n 13977 - 91s.t Street N.E. Elk River 441-4877
4 ARCHITECTORDESIGNER MAILADDRESS ZIP PHONE LICENSENO.
5 ENOINEER MAILADDRESS ZIP PHONE LICENSENO.
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X
S DESCRIBE WORK
IriS'�31 S. � CZ �
9 CHANGE pF USE FROM TO
STIPULATIONS
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING. S'�EP.1
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. 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 ], STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $2/��Q $�'.24 •
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION O THE PERFORMANCE OF CONSTRUCTION. $3SsSO
asi�� ' ��/� PLAN CHECK FEE TOTAL FEE
� `�� $39.74
SIGNATUREOFCONiRACTOROR UT OR�2EDAGEN IDATEt WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
SIGNATURE OP OWNER �IF OWNER BUILDERI IDATEI -'r �°_� BLDG �NSP � DAT
CITY 0� FRIDLCY Effective Aug. 1, 1981
APPLICIITIQ,J FOft RCSIDEi�TI1lL QUILDIt1G PEfL'�ITTS
(�de►•l, Alter.�tions, Additions, or Repairs)
OtJCdER: �iG��/�Yi7 P�� ,�/a�IYI I3UILDER: ��,� ���(���f�� � G c�t/S�—
T..
ADDRESS: J�.3 �[� � c/—'F�f�.�'c�iY l�l� ADDRCSS: /.�i 7� ��s,�N� ��li�'[ �°1���
TEL N0: .r-'7 1�3 7� TEL ��d0: ca(�c� ��7,� _ 7s°� =��'� :g_
Consi:ruction Location
STRI�T NO : lOJ �(� STFtEET: c� ���SON
LOT: . � SLOQC : � ADDITION : C�Ft,�! S j / �., � D {�
Corner Lot: Insicle Lot: SetbacY.: Sideyards:
Ap�licant attach to this form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
DESCRIPTIOid OF COP�STRUCTIOPd
�S � Front: Depth: Height:
Square. Feet: Qibic Fcet:
Front: Depth: Height:
Square� Feet: Cubic I'eet:
����
7�y,pe of Construction : - ` - _
�
Zb 8e Q�r,�pleted:
EstimaL-ed Cost: $ ,���0 • � v
Alt. A Alt. B
Proposed Drive��ay Width If New Opening Is Desired: $' $
SE� REVERSE SIDE OF SHEET
ZRie undersigned hereby ma}:es application for a permit for the work�herein specified,
agreeing to c� .all work ir� strict accordance with the City of I'ridley Ordinances �azd
rulings of tlle De�-trl�t�n� of Buildings, and hereby declares that all the facts and
rapres�ntations stated in this application axe true and correct.
DI,T�: %y - %O �- c�� SIGNnTUFtE :
Stipulations:
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BUILDI•NG PERNlIT FEE SCHEDULE
The Inspector of buildings shall, before issuing permits for the
erection of any building or structure, or for any addition to any
bxisting buildinq or structure, or for any alteration or repairs
to any e$isting building or structure, upon application therefore,
require the payment by the applicant f or such permit of fees to the �
amount herein below set forth and in the manner herein provided to-wit:
TOTAL VALUATION
$1.00 t� $500.00
$501 t�o $2, 000
$2,001 to $25,000
$25,001 to $50,000
$50,001 to $100,000
FEES
$10.00 Minimum Fee $15.00 plus surcharge
$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 each
additional $�,000 or fraction 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 including $50,000
$283.00 for the first $50,000 plus $3.00 for
each additional $1,000 or fraction thereof, to
and including $100,000
$100,001 and up $443.00 for the first $100,000 plus $2.50 for
each. additional $1,000 or fraction thereof
PLAN CI�Qt: 25 percent of building peYmit fee
DRIVF�TAY D�EPRESSION ESCROW: Concrete C�rb Streets Only
Alternate "A": Removeal and replacement of curb and gutter only
Driveway width plus 6 feet x$13.50
Alternate "B": R�oval and replacement of curb and gutter and install a 3 foot
wide approach with 6 inch depth
Driveway width plus 6 feet x$15.75
VERIFICATION OF F4UNDATI�ON
Permits for construction will be issued a mini.minn of 24 hours fro�n the time of
application to allow for proper review of the pro,posed structure and di the
construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it
has been constructed will be required before proceed3ng with. the framing.
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THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
�OMM(]N VFNT, VFNT CnNNECT�R AND C(�ME3l1STInN AIR VFRIFI(:ATI(�N
� When r� �n acing an _xie in8 f�ranr_e, 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 plastiGPVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination.
The unde�signed 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 pY��+��A ceme�,.;t�en ��r is sized and installed to meet the current codes
and manufacturers specifications.
V1/hen required to inst��� a npw _emhu�en air�,it will be sized and installed
to meet the current codes and manufacturers specifications.
Yes �j�j No (
l�
Yes (�`� No ( )
Yes � No ( )
Yes (� No ( )
WhEf1 inctalline a new ��entina e�c�t�, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturers
specifications. This does inGude 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 ()
� • • . � ' • ' . � • - • 11 11 • � - � . � • ' / • � � ' M • � • �11 . 1 • �
Appliance #1 Type ,� � BTU Input f�T Fan Assisted or Nat � a�"
Appliance #2 Type BTU Input - Fan Assisted or Nat
'� Appliance #3 Type BTU Input Fan Assisted or Nat
o a ppliances -- — --- . "Total B�u Inpuf - - - - -
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
��� r - � r.► .- ..-
7356? CENT�iL AVE. �N.E.
HEATING CO: _ . ANOKA MW 55304
Signed By: -C�aden. � • �v�-�-- Date : � �' ���
-��-
HEATING
AIR CONDITIONIIVG
AND LECTRIC, INC.
ADDRESS � �—
OCCUPANT � �
HEAT LOSS DA,7`E HTG.BIA�ST.
SOLD BY e�s �e h! `h��eo
Elecuical Work By � 1 �
TYPE OF HEAT GA FA � HW STEAM SPACE HTR.
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9 � , t+ �
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��i. � , iy�������1���:�� �' �
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"� � ��4'Z�iL.,
CONTROL3
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61OUSE HEATING TESi FiECORD
�
APT. FLOOR CITY SUBURB
OWNER
INSTALLED BY � `�:°e P�
Gas Line By / 1 1
UNfT HTR. OTHER
�f
V@nt S'tZB
KIND OF LINER
-- Draft�fiood _
C«•12V'I���3[•721
SIZE �' NONE
Regulator
Filters Size Itc�J� :J-S x 1 Number
Chimney Location Inside �,,� o Outside
Heat Plug ^ Chimney Consvuction
Limit Setti � � �
Fan Settin
Pilot Type .�
Pilot Make �-
Pilot Nbdel
PilotTiming e%� 1°C
L.W. Cut Ott
Pressure �_ � � s � • Peraent COz
Input CFH�� .�� � Percent OZ �� o
Stack Temp. �� Percent CO S-i�'��%�
Smoke Bomb wring
Draft !� %� Test Tag
Door Pressure Lighdng Inst.
Date Tested � �`�-
Company Testing �
Name of Tester
Pressure Peroent COZ
Input CFH Peroent OZ
Stack Temp. Percent CO
From: Cityof Fridley To: 651-982-4587 Page: 4l5 Date: 7/2712006 3:37:06 PM
Builcling BUILDING P��t No.: �d�`� � �' ' °
Inspections itESIDENTIAL APPLICATI4N Received By:
763-572-3604 � CITY OF FRIl)LEY __ � vate R.ec'd:��.�
SITE .�T' DRESS �Q�L�_(� ��f�
THIS APPLICANT IS: ❑ GWNEIt
PROPERTY OVVNER/ N��:
TENANT �pD�ss:
CONTRACTOR
SUBMIT A COPY OF
YOL'R STATE LICENSE
VeTIH APPLICATION
PROPERTY TYPE
I � �1__;i�l��t� �'���1
YOURE-MAII. ADDRESS
�• :� I�.�.r.�--. rl�i L�SrI�
� ; �i �
- = /� —
' � � ' �%"�� ✓�.� � . .
i, � .� r .
❑ BASELIENT FII�IISH .�gOF
❑ DECK � SIDING
❑ S4\'IM.MING
TYPE OF `'VORK: I 4 ��'
S.z�' _��T't�1�'(�.�.._
U
r�.� Is C
EXP DATE J�'�
�%P �__CITY
�.��� %QZ���
stzE
sTOx�s
❑ v+�Il•1DOW5
❑ DRAIN TILE
❑ OTHER
��
STA'f�/� _��
— -- ---_ ----r-- -----
DESCRIBE WGRK BEING I�ONE: -
SIZE OF IIvIPRC��'E_LIENT ENGTH WIDTH HEIGHT
RO�FING � ❑ HOU3E ONLY
TE�Z}���`
Ft.
NUA4BER OF SQUARE3� _ ❑ HOUSE &(3ARAC�E HASEMENT REMQDELI�TC� SU$MTT:
GARAGES ❑ A1°TACHED GARAGE 1. Er.isting Floor Flan
PROPOS� SIZE: ❑ DETACHED GARAGE 2, Proposed flouC plan
PROPOSFA HEIGHT: 3. List of structural members to be used
SIDING FOR NEVV CONSTRUCTION INCLLTDING DECRS.
❑ Virryl OSnffit ADDITIOKS_ � PORCHES SUBMIT:
❑ Alumimiea ❑ Trim 1. 3ite PIan/Snrvey shoa ing the existing structures
❑ Ottier O Fascia and proposed project.
y��Dy�� 2. ltvu sets of conswcKion p!ans
IN EX[STII�Q OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3. Energ} Calculatiot�s
OR FOR NEW C�PENINGS-DESCR[BE SIZE OF
OPENING CHANGF� &
TYPE OF U4'NDOW TO BE INSTALLED NUMBER OF WA��OWS
ALL FEES ARE BASED O�T �ALLATION, INCLUDpNG THE COST OF LABOR AVD MATERLt1LS:
(USING "E 99 T; C FEE SCHEDULE)
TOTAL JOB VALUATION S� _ •�� .00CL'P.�11TC�' TYPE
Pamut Fae $ �� ,��' See Back Page for Fae Schedule
Plan Review $ 65% of Build'a�g Permit Fea
Fire Surcharge �}�' .OGl times tha tota.l job �aluatian
Surcharge $ �.� .0005 x Permit Valuation I�iinimum $.50
License Surcharga $ �.� �S.OU (State Licensed Residential Conttactora)
5AC Charge $ __ ___ ___ __ $1550 per SAC IJnit tPlens to M�ti'CC for determination)
f'urb Cttt Escrodv $ i{ + 6 ft= ft x$21 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Datarminad by Enginaering
5ewer Main Charga $ Agreemant necessary ( i Non Necessary ( j
Total Due $ � ,� Malce checks payable to: Cityo uf Fridley 4ttach Sdpalations
THI5 I3 AN APPLICATION FOR A PERyIIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that tha information aboye ia complete and accurate; that the wark will be in
conformance vPihh tha ordinances and codes of thz City of Fridley �d with the l�Zinnesota Construction Codes; that I understand this is not a
parmit but only an application for a parmit and evork ia not to start without a permit; that the work will be in accordance evith tha appro�ed
plan in the case of all work w i equiras re�iaw and a val of plana.
SIGNATURE OF APPLICANT _ ! �__ ���-L—PRfNT AAME __ DATE ------
—7—
From. Ciry of Fridley To: 651-982-4587
Page 2- Building Residential Application
Page: 5!5 Date: 7127I2006 3:37:05 PM
BUILDING PERIVIIT FEE S(;HEDLTLE
The Chief Building Official shall, before issuing permits for the erection of any building ar
stnicture, ar for any addition to any existing building or structure, or for any alteration ur repair
to any eaisting building or structure, upon application therefore, require the payment b}� the
applicant for such permit of fees to the amount herein belo�a� set forth and in the manner herein
provided to-wit:
� TOTAL VALL� ---T FEES -�
�$1 to $500 $23.50 (Vlinimum. Fee is $23.50 plus swchargz)
$501 to $2,000 �23r50 for 18` $SGO plus $3.05 for each additional $1 UO or fiaction, to and
includin $2,000
$2,G01 to $25,000 $69.25 for 1" $2,000 plus $14 for each additional $1,000 or fraction, to and �
includ'm $$25,000 �
$25,001 to SSO,OOG $391.25 for 1"$25,000 plus $10.10 for each additional S1,G00 or fraction, ,
to and includin SSO:OOU
$50,001 to S1011,000 $643.75 for 1°� $50,000 plus $7 for each additional $] ,000 or fraction to and
� ir.cludm $100,000
$100,001 to $SOO,UOcI $993.75 for 1$100,000 plus $5.60 for each additional S1,000 or fraction to
and includin $500,000
$500,001 to $1,U0(1,000 $3,233.75 for the 1�$SU0,0�)4 plus $4.15 for each additional �1,UC10 or
fraction to and includin $1,000,000
I$1,000,001 and up $5,608.75 for the 1"$1,000;000 plus $3.1 S for each additional $1,0(m or
fraction
VERIFIC:�TION OF FOUNDATIOn
Permits f�r construction will be issued a minimuin of 24 hours from the time of application to
allow for proper review of proposed shucture and of the construction site.
A Certificate of Survey of the lot, show-ing the location of the existing foundation witl be
required before proceeding with the &aming. New I€ouses Onlv
City of Fridley
Building Inspec�ions Departinent
6431 University Avenue NE
Fridley, MN 55432
763-372-3644
Fax: 763-502-4977