PRE 2010 DOCSVillage of Fridley, Mum.
ix �::I. n
1\T® 440 ice of WSPEM01 OF BUHMMGS
Owner,
Architec„,,� Fridley,
.Builder ”
LOCATION OFA BIDING
NO. Street a *. Part of Lot
-
k
Lot Block Addition or Sub -Division
- e 4---j -- t
Front �'1 Dep�h Height, _ Stories_ _ Manner of Construction P#.
9
a LY
TO be used as ZS
y� q ,o,,,,r To be completed° Estimated Cost
Permit is heregran ted to, - to d i' 4`
the building , described in the above statement.- This permit is granted
upon the express condition that the pe on to whom it is granted, and his agents, employees and workmen, in all
the world done in -'around and upon sffld building, or any part thereof, shall conform in all respects to the ordi-
nances of Fridley, Minn., regarding the construction, alteration, maintenance, repair and . moving of buildings
within the city limits_, and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.m
1&�
,t
ector of Buildings.
AGREEMENT AND SWORN STATEMENT
In consideration of the issue and delivery to me by the Impector of Buildings of Fridley 9f
the above permit, I hereby agree to do the proposed work in accordance with the description
above set forth and according to the provisions of the ordinances of li'ridley, and, being first duly
sworn, I hereby state and say that the facts stated by me and contained in the above permit are
true as therein stated. M
Subscribed and sworn to before me at. Fridley, Mi nesota, t '
day ojotA. D. 19 w
p
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a
t !-!a:t'J:.Y A.
1 . ,J-�::.:27'1NtvF;iT
SURVErS
P�7.a 3rMSh(i T -4E WZtCP-0S 07
-W'-
e.tri. ,.V�=. N. E. Rs 'aAST RIYiA RD
E. P. E
/'� l��J /'� �+
- Z. MItL-E$T491:9N5p 1896 _
���il SURVEYORS
E*�1J�J
-•>TEPLI.40 2301
C. F• 3iV0"aar. ESTAaU;5btmO 1348
!
`! ;-IAROLO R. OLSON
!tEG13 I fiRsD L/.V� i'N. �•-\'rVi f.:= :i'f AT.�-_ OF MINNESOTA ;9%q.z4 NAQ,SON. ESTABLISH= 1922
�tcENScQ By MINMEAPOL15
BOX 174, R09T$1
LK=UaTRIAL
-NESTW000 SNORES
:37 PLYMOUTH 3JILDI`6; LINICOLN 372t BUSINESS -
!
!40JNO. ?AIN.NE3OrA
'
I
or $NRv6YS
Ammepor's +.certificate LAx�SI,Otat�
tA0'.1N7 �48M
PLATTIM<;
Carl :.arson
I 9931
5nv. 75
-cote: This surfey
for loan
for any other use.
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t ;�F: _ ; `� :tu:_;, :: .�.�.:�. 21
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ia
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Ir
SUBJECT
PER
- City of Fridley
1*C,.
AT THE TOP OF THE TWINS
BUILDING PERMIT
t
S
NO.
COMMUNITY DEVELOPMENT DIV.
/RECEIPT
r PROTECTIVE INSPECTION SEC.
1 = �
CITY HALL FRIDLEY 55432
,`1
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
`•"' 612-580-3450
910-F15
5/3/79
10B ADDRESS 6663 Lucia Lane N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
5E
Auditor's Sub. #21 SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Carl Swanson 6663 Lucia Lane N.E.
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Same
4 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
❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X
8 DESCRIBE WORK
Construct a 5' x 12' Entry d an 18' x 12' Addition
9 CHANGE OF USE FROM TO
STIPULATIONS
WARNING
84fore digging call 10cal utilities
TELEPHONE - ELECTRIC - GAS Etc.
REQUIRED BY LAW
SEPERATE PERMITS REQUIRED FOR WIRING,
HEATING, PLUMBING AND SIGNS.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING. Wood
Frame
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
+ 216
1200 + 4320
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
60
ANY TIME AFTER WORK IS COMMENCED.
NO. DWLG. UNITS
OFFSTREET PARKING
'HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1
STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
VALUATION
SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED.
$4.20
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$8,400
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$51.00
NONE
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
$12.75
$67.95
SIGNATURE OF CONTRACTOR OR AUT-H2O,R,IIZEID AGENT (DATE)
WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
BLDG INSP I -QjkTE
1f SIGNATURE OF OWNER (IF OWNER BUILDERI (DATE)
CITY OF FRIDLEY ,
APPLICATION FOR RESIDENTIAL BUILDING PEMITS
PEW, ALTERATIONS, ADDITIONS,' OR REPAIRS)
OWNER:C- ��'��'' �� � �.�. BUILDER:
Address: G3 =® Address:
Tel. No.
.� _10V
No.: t-/, G6 o/ _3 Street:
LOT: ,j'
BLOCK.:
ADDITION:
®lam
CORNER LOT:
INSIDE LOT:
SETBACK.:
SIDEYARDS:
Applicant attach 'to this form Two Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
DESCRIPTION OF BUILDING
To Be Used As:
Front: a Depth: `i. Height: a
Square Feet: & Cubic Feet:
Front: I*19 Depth: �'L Height: Z O
Square Feet: '�� �•• Cubic Feet: �®
Type of Construction: �n�-y �. Estimated Cost: $ 40d
To Be Completed: Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired $ $
(SEE REVERSE SIDE OF SHEET)
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City of
Fridley Ordinances and rulings of the Department of Buildings,, and hereby
declares that.all the facts and representations stated in this application
are true and correct. See reverse side for additional information.
DATE:� 2 —,)q SIGNATURE: 61 la
Stipulations:
1466 if
IL,1s"00
20
�.
CITY OF FRIDLEY
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND
AIR CONDITIONING SYSTEMS AND DEVICES
PARTIAL RATE SCHEDULE
GRAVITY Y,AR}i AIR: RATE TOTAL
Furnace Shell & Duct Work $12,00 $
'R.eplace_-ant of Furnace 7100 $
Repairs & Alterations -up to $500.00 7.00 $
Repairs & Alterations each add. $500:00 4.00
DIECHANICAL WARM AIR:
Furnace Shell & Duct Work to 100,000 BTU $12.00
each add. 50,C00 BTU 4.00 $
'Raplaceye:t of Furnace 7.00 $
Repairs & Alterations -up to $500.00 7,00 $
Repairs & Alterations each add. $500,00 4,00 $
SII..:_•i OR IDT 1' AyTE.R SYSTE is
Boller & Lines, up to 100,000 BTU
each add-. 50,000 BTU
Boiler only up to 100,000 BTU
each adds. 50,000 BTU
OIL BU:LNEF.- to 3 gal. per hour
each and. 3 gal. per hour
$12.P0
4.00 $
7. OR $
P.- PP s
q?q•G4
}q.Aq
GAS BURNER- from 100,000 BTU t.0 19,9,jjj RTR S1Q:qq .
(over 139,999 BTU see Fee Schedule)
GAS FITTING FEES:-.
1st 3 Fixtures ?t $ $.AQ
A:!4-tional Fixtures
Gas Range to 199,000 BTU i6 �IA;aA
AIR CONDI T IO\I2iG,
X FEATI `:G SYSTEMS See Fee Schedule
VEN ILAIING SYSTEMS
ALTERATIONS 4 REPAIRS
State Surcharge
TOTAL FEE
F=mi LtiSP. REINSPECTION FEE
Date ($10.00)
FI::AL I:iS2. — i -p 'Z
Dal te
APPnOV.'L FOR PERMIT .
$
q
FOR A2.Y HEATING PERMIT IS $7.50 PLUS • $. 50 STATE SURCHARGE
°:.t:ae':e3 stack verifiea-,•ion fora
Uob Address
Department of Buiidinga
C;ty of Fridley
Tel. #571-3450
The undersigned hereby makes explication for a permit for t%e work herein
specified agreeing to do all work in strict accordance with the City Ccdes
and rulings of the Department of Buildings, and hereby declares that all the
facts and representations stated in this application are true and correct.
a
Fridley, Minn. ( e --ems• 19�
014NER 6 -Lk
;aND PF BUILPIIJG
TA Pr OQMFLETFQ WTIT / Q ` 1-2-- `o S-0
FSTTM !Tpp PM � �S 0
TR
JG r
OE4CRTPTIQN QF FUR'N'ACE/TURNER
PAT$NP A; pgw;N ?ANT.s( Sfe4?p, NPI: W4par; wary} Air- ljo.
Tricia Name size No. e C,9-0 - �2C__Sr
Capacity q. Ft. EDR BTU :'w
Total Connected Load Kind of Fuel
BURNER - Trade Name Size No. %00' Q e
Capacity Sq. Ft. EDR BTU HP
Company
p a Signed By
Tel. No. -7 f�l j ` Y
CITY OF FRIDLEY INSPECTION DIV.
6431 University Ave NE
Fridley, MN 55432
572-3604
Effective On January 1, 1991
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
PLUMBING FIXTURE RATES:
New Fixtures
Old Opening, New Fixture
Beer Dispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Water Heater -Electric
Water Heater - Gas
Gas Range
NO. RATE TOTAL JOBADDRESS Loi��� /2('J.�? A2
Gas Dryer
Back Flow Preventer Required ( )Yes () No
$ 7.00D The undersigned hereby makes application for a permit for the work herein
$ 4.00 specified agreeing to do all work In strict accordance with the city codes
$ 5.00 and rulings of the Building Division, and hereby declares that all the facts
$ 7.00 and representations stated in this application are true and correct.
$ 7.00
$ 7.00N '1991
$ 7.00
$10.00 Owner M'1-4 t AdXn e iPR4 �5
$ 7.00
$10.00 Building Used Ash
$10.00 ,
$10.00 Estimated Cost > `�� ° PERMIT NO.
Type $5.00
Reinspection Fee $30.00
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS C�I
1 % of Value of Fixture or Appliance
State Surcharge $ .50
TOTAL FEE
7/U
//0
PLUMBING COMPANY_,A 0e_A P "/, d i 0-55 oj,i 2.15% 1 • c� •
SIGNED�TEL N0.
Approved By Rough -In Date Final Date
MINIMUM FEE FOR ANY_PLUMBING/GAS PERMIT IS $15.00
PLUS THE $.50 STATE SURCHARGE
/ater>
11*.
U a I
Bdi
`< Shower
Tf.:::::
Wash
<.; '` Tr
:iC.::.. ay
Drcrtii. : Floor
D i
1.::.:. ran
[t11: Auto.
'` W sher
BiSt::.. a.:1.::.::.
h; :Gas
":`<>
Ran a
g
MSCx.... Water Heater
ririn
Sto esi.'dst::
Ga EI
s ec
Bas emen
Floor 1
Floor 2
Floor loo 3
Floor 4
PLUMBING FIXTURE RATES:
New Fixtures
Old Opening, New Fixture
Beer Dispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Water Heater -Electric
Water Heater - Gas
Gas Range
NO. RATE TOTAL JOBADDRESS Loi��� /2('J.�? A2
Gas Dryer
Back Flow Preventer Required ( )Yes () No
$ 7.00D The undersigned hereby makes application for a permit for the work herein
$ 4.00 specified agreeing to do all work In strict accordance with the city codes
$ 5.00 and rulings of the Building Division, and hereby declares that all the facts
$ 7.00 and representations stated in this application are true and correct.
$ 7.00
$ 7.00N '1991
$ 7.00
$10.00 Owner M'1-4 t AdXn e iPR4 �5
$ 7.00
$10.00 Building Used Ash
$10.00 ,
$10.00 Estimated Cost > `�� ° PERMIT NO.
Type $5.00
Reinspection Fee $30.00
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS C�I
1 % of Value of Fixture or Appliance
State Surcharge $ .50
TOTAL FEE
7/U
//0
PLUMBING COMPANY_,A 0e_A P "/, d i 0-55 oj,i 2.15% 1 • c� •
SIGNED�TEL N0.
Approved By Rough -In Date Final Date
MINIMUM FEE FOR ANY_PLUMBING/GAS PERMIT IS $15.00
PLUS THE $.50 STATE SURCHARGE
U
011
SUBJECT
PE
City of Fridley
1
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
RECEIPT NO. -
rr COMMUNITY DEVELOPMENT DIV
r PROTECTIVE INSPECTION SEC
437
1 �
= CITY HALL FRIDLEY 55432
NUMBERREV
DATE
PAGE OF
APPROVED BY
612-571-3450
910-F15
9/16/96
JOB ADDRESS 6663 Lucia Lane NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
Pt 5
1
1 Auditor's Subdivision X621 SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Carl Swanson 6663 Lucia Lane NE
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
Richard Hastings Contr 6331 Riverview Ter NE, Fridley 55432 574-9966 4051
4 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
❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X
B DESCRIBE WORK
Reroof House & Garage (22 Sq) Tear -off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State
Building Code.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SQ. FT.
CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED,
NO. DWLG. UNITS
OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1
STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
VALUATION
SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$1,815
$.91
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$59.50
ire SC $1.82
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
/
l6
PLAN CHECK FEE
O AL FEE
T / ��
Licens SC
.00
$67.23
SIGNATURE OF CONTRACTOR OR AUTHOG'ZED AGENT IDATEIMeAL.G
LY V I ED THIS IS YOUR PERMIT
DATE
SIGNATURE OF OWNER SIF OWNER BUILDERI IDATEI
U
011
NEW [ ] Effective 3/1/96
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
ConstructionAddress: 616 3 L� c ,',g by
Legal Description:
Owner Name & Address: C A RL Tel. #
Contractor: 9,c R D /49 f/,V G MN LICENSE # Z,/0 S
Address: G 33 t RcyP- JZ U i e � t -'E i2, Tel. # .S"7 - G
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF EWPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER: 22 so, _
Comer Lot [ ] Inside Lot [ ] Ft. Yd Setback Side Yard Setbacks
Type of Construction:
FF
R A= 9 o o F Estimated Cost: $
Approx. Completion Date:
14c a S -L- q,2a c e
(Cost on Back)
Driveway Curb Cut Width Needed:
Ft. + 6 Ft = Ft x $ _ $
DATE: _ � 16`16 APPLICANT:
Tel. # 5 7 9 2' e AC
CITY USE ONLY
Permit Fee
$
Fee Schedule on Reverse Side
Fire Surcharge
$ f . 9_�2
.001 of Permit Valuation (1/10th%)
State Surcharge
$ 9/
$.50/$1,000 Valuation
SAC Charge
$
$900 per SAC Unit
License Surcharge
$
$5.00 (State Licensed Residential Contractors)
Driveway Escrow
$
Alt. "A" or Alt. "B" Above
Erosion Control
$
$450.00 Conservation Plan Review
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement Necessary [ ] Not Necessary [ ]
TOTAL $ �_ 3
STIPULATIONS:
l
SUBJECT
PERMIT
City of Fridley
3 1468
AT THE TOP OF THE TWINS
BUILDING P E R
M I T
E �
R
COMMUNITY DEVELOPMENT DIV.
r � � PROTECTIVE INSPECTION SEC.
l�
E . �
NUMBER
REV
DATE
PAGE OF
APPROVED BY
i A CITY HALL FRIDLEV 55432
--_. ,��'�',•�
L J` 612-571-3450
910-FlS
1.0/11/00
JOB ADDRESS 6663 Lucia Lane NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
Pt 5
1 Auditor's Sub. #21
SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP
PHONE
Carl Swanson 6663 Lucia Lane NE
763-571-9660
3 CONTRACTOR MAIL ADDRESS ZIP
PHONE LICENSE NO
Midwest Restoration 6319 Hwy 65 NE, Fridley, MN 55432
502-1082 5267
4 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
❑ NEW ❑ ADDITION ❑ ALTERATION REPAIR
❑ MOVE ❑ REMOVE
B DESCRIBE WORK
Repair Roof (5 Sq) Tear -off Tree Damage
9 CHANGEOFUSEFROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING
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 1 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 GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$511
$
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
.50
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OT A E CAL LAW REGULATING CON -
$26.55
Fi SC $
RUCTION OR T FORMA CE OF CON TRUCTION
.51
PLAN CHECK FEE
T AL FEE
Licens_e,,SC
y$32.56
$IGNATUR CONT TORO AUTNORQEDAGENT
H PRO Y VA 10 ED THIS IS YOUR PERMIT
�TE�
8 G NSR
f•/ !!DATE
-2
S,GNATUREOFOWNEROFOWNER BUILDERi IOATEt
l
NEW [ l Effective 1/1/2000
ADDN [ ] CITY OF FRIDLEY (763) 572-3604 Bldg Insp
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: (o f �yG/� '4;ywe
Legal Description:
Owner Name &Address: r,5Gf�i�/I%f% Tel. #
Contractor: -f2��/-J G'�j�'��p��jJ MN LICENSE #
Address: Tel.# J02 ® Z
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
TOTAL $ S
STIPULATIONS:
DESCRIPTION OF IMPROVEMENT
LIVING AREA:
Length
Width Height Sq. Ft.
GARAGE AREA:
Length
Width Height Sq. Ft.
DECK AREA:
Length``_
Width Hgt/GroundSq. Ft.
OTHER:
Construction Type:
Estimated Cost: $
Driveway Curb Cut Width Needed: Ft. + 6 Ft= Ft x $ _ $
DATE. DO APPLICAN
Tel. #�'
CITY USE ONLY -
Call (763) 572-3604
for Permit Fees if mailing in application
Permit Fee
$ • �S
Fee Schedule on Reverse Side
Fire Surcharge
$
.001 of Permit Valuation (1/10th%)
State Surcharge
$O
$.50/$1,000 Valuation
SAC Charge
$
$1100 per SAC Unit
License Surcharge
$ S-'00 $5.00 (State Licensed Residential Contractors)
Driveway Escrow
$
Alt. "A" or Alt. "B" Above
Erosion Control
$
$450.00 Conservation Plan Review
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement Necessary [ ] Not Necessary [
TOTAL $ S
STIPULATIONS: