PRE 2010 DOCSCity of Fridley, Minn.
BUR DING PERMIT
. .
Date: ........................................
Address ......................................
N® 3.252
Builder Vc :' "
Address...6 ........................................
LOCATION OF BUILDING
No. " I s� * F�
............ Street �%I�� '�/ ............... Part of Lot ..... ... ........... .
Lot ............ Block ...... ::......... Addition or Sub -Division ./V Vii'.
Garner Lot ............ Inside Lot ............ Setbacks..... Sideyard Zn .... �:�'. a.:7' . Q .........
DESCRIPTION OF BUILDING
To be Used as:
®....
X..
�Y
......
Front
Depths ,i.. -n. Height ....
Sq. F't./Q:
....................
........
Depth ........ Height . , ..•...
Sq. Ft. ........
Cu. Ft. ........
Type of Construction
_17nt
'::A:: ': .... Mat. Cost. .I ® ` ' ��.. ...
To be Completed ? rz. r= "
In consideration of the issuance to me of a permit to construct the building desribed 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 city of Fridley.
,)( ..................................................
„ �,�.
• •In•consideration of the payment of a fee of $ .., permit is hereby granted p �u .
............... to construct the buildingor aThis eras
...ddition as described above. is granted upon
the express condition that the 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 of
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings with-
in the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
� Building Inspector
NOTICE:
This permit does not cover the construction, Installation or alteration for wiring, pTumbing, gas heating,
sewer or water. Be sure to see the Building Inspect* for separate permits for these Items.
MxNDER ENGD EM1 NG Co., INc e
ENGINEERS AND SURVEYORS
LAND awavayiNe SOILS TESTING
CIVIL Au KAUt4lClP^L ENGINEEMING LAMO PLANNING
4418-54'ru AVENUE N.
MINNEAPOLIS TL MILAN.
KE *T- SG37
V,
R
C)
I
by Building lln
- ---------
Z-' o 1-7— 5—z- -9
WE HERESY CERTIFY THAT THIS IS A TRUE AND CORRECT REPRESENTATION OF X SURVEY OF THE BOUNDARIES Of THE
LAPID ABOVE DESCRIBED AND OF TRE LOCATION OF ALL BUILDINGS, IF ANY, THEREON, PAID Mir VISIBLE ENCIZOM14MENTS9
IF ANY, FROM OR. ON SAID LlkNO. MENDER ENGINEERING CO." INC.
OATrLp -mls_ my CF EM014REMS MID st)"llyov-s
er 7 qta
City of Fridley, Minn.
BUILDING PERMIT x? s?s1
Owner: 42�.9 � Buffle-1
Address Address
YCATION UI DING
No. A&- :Street ' Part Lo
Lot 81ock Addition or Sub- on
Corner Lot Inside Lot _ **back Sideyard Ale
fAC
OF
Sewer Elevation Fo dation Elevation
DESCRIPTION OF BUILDING
AW E To T, d
Front Depth Height Sq. Ft. Cu. Ft
DepthHeight Sq. Ft Cu. Ft
40 dowse—MM
Type of Construction A isr- Est–CuP &M—W–ro be Completed
In consideration of the issuance to me of a permit to construct the building described above I agree'to
do
the proposed work in accordance with the description above set forth and in compliance with ail provisions of
ordinances of the city of Fridley.
.T"
In consideration of the payment of a fee of $ permit is hereby granted to
to construct the building or addition as described above. This permit is granted upon
the express condition that the person to whom it is granted and his agents, employees and workmen, in all work
done n, around and upon said building, or any pari thereof, shall conform in all respects to the ordinances of
Fridley, Milmesota regarding location, construct%n, alteration, maintenance, repair and moving of buildings
within the dty limits and this permit may be revoked at any time upon vion of any of the provisions of said
ordinances
;,r !'' � "mss"' ,- =..a.� � � • -
NOTICE:
'fids pwmh den not cover the conn miloe, huhlWm for wiHM phnnbing, gn haating, saver or water. Be sure to sae
the Building bupeder for spm to pwmhs Por thea hams.
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNER' S NAME EA M is . H l I U S t ft BUILDER
ADDRESS ) % - /n- A.& ADDRESS ,c r / 3 �( - 7` /i n1 /1- s At 61
OF BUILDING -
No. :'' 'Y'3-
Past of . Lot
Lot Block Addition or-Subdivisi
Corner Lot AOOO" Inside Lot Setback Side- d
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Two Certificates of Survey of Lot and proposed build-
ing location drawn on these Certificates.
DESCRIPTION OF BUILDING
To be used as:
Front Q Depth Height -�
Sq. Ft. 11410 Cu. Ft. 1
Front I Depth Height
Sq. Ft. Cu. Ft.
Type of Construction Lt A. in .P Estimated Cost
To be Completed 19 CIO—
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.
DATE ® — _ 4/,SIGNATURE �- U 13 19 -1 /2,3. / At C
(Schedule of Fee Costs can be found on the Reverse Side).
City of Fridley
AT THE TOP OF THE TWINS
suB�Ecr
BUILDING
PERMIT
PER NO.
_ 110.
500
COMMUNITY DEVELOPMENT DIV.
r 1 PROTECTIVE INSPECTION SEC.
1 = �
CITY HALL FRIDLEY 55432
L 612-571-3450
R EIPT NO
It
NUMBER
910415
REV.
DATE
8/12/86
PAGE OF
APPROVED BY
JOB ADDRESS 6851 Madison Street N.E.
1 LEGAL
DESCR.
LOT NO.
1
BLOCK
4
TRACT OR ADDITION SEE ATTACHED
Rice Creek Terrace Plat 6 SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Joseph Hrncir 6851 Madison Street N.E.
571-1170
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
Modern Insulation Inc. 10779 - 93rd Avenue North,
Osseo 55369
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 JJ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reside & insulation
9 CHANGE OF USE FROM TO
STIPULATIONS
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
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
ZONING
SQ. FT.
CU. FT.
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
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
VALUATION
$8,000
SURTAX
$4.00
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-
S\9VCTION OR THE PERF RMANCE OF CONSTRUCTION.
$68.50
PLAN CHECK FEE
TOTAL FEE
$72.52
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENTIDATEI
_
WHEN PROPERLY
BLDG )NSP
ALI DATED THIS IS YOUR PERMIT
o A CJ,
OAA E
SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI
NEW [ ]
City of Fridley Effective 4/1/86
ADDN. [ ] R-1 AND R-2
ALTER. [ ] Building Permit Application
Construction Address:
Legal Description: t-1
I
5 1
vc-
6 0 A/ V!
Owner Name & Address ti W� y < Tel. # ���� ��
Contractor: D 2 X741 S U k %r oy `�' y !rel. #
Address:
r�'?A!)d
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Corner Lot [ ]
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width _ Height Sq. Ft.
Length
Width
Height
Sq.
Ft.
Length __
Width ,__.
_ Hgt/Ground
Sq.
Ft. _—
Inside Lot [ ]
Ft. Yd. Setback
Type of Construction: Sr Chi
Approx. Completion Date: ri
Side Yard Setback
®�O
Estimated Cost: $ "o
Alt. A Alt B
Proposed Driveway Width If New Opening Is Desired: See Back Page for Explanation
�
DATE. APPLICANT: Tel.
CITY USE ONLY
Permit Fee
Plan Check
State Surcharge
SAC Charge
Park Fee
Sewer Main Charge
STIPULATIONS:
$ �,� �,. c,ze Fee Schedule on Reverse Side
253 of Building Permit Fee
$.50/$1,000 Valuation
$ $475 per SAC Unit
$ Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [ ]
$ 17.? _ s�
SUBJECT
P ,
City of Fridley
2
6 6
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
IE8 NO.
1 • COMMUNITY DEVELOPMENT DIV.
I L PROTECTIVE INSPECTION SEC.
e
q6 72
r
NUMBER
REV
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
612-571-3450
910-F15
7/29/98
JOB ADDRESS 6851 Madison
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
4
Rice Creek
Terrace Plat
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Pat Hrncig
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
D & B Home Improvement784-nS??
7773
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Reisdential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION OX REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and garage
9 CHANGE OF USE FROM
TO
STIPULATIONS
Underlayment must comply with 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
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
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
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
2001
$1.00
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOC - LAW EGULATING CON-
STRUCTION OpR T PERFORMAN FCO T U 1 N.
$74.75
FivG SC $2.00
PLAN CHECK FEEZ/2.75
FEE
%
AJNAR
Licen S
5.
CONTRALTO o A O NT IDA I
EN R P
I N S P
V LI T THIS IS OUR PERMIT
S.GNATURE OF OWNER OF OWNER BUILDER) IDATEIMK
NEW [ ]
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: / 5-I
Legal Description:
Owner Name & Address:
Contract
Address:
Tel. #
ENSE #273
Tel. # 7F
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
Effective 1/1/98
� 66 73
a zj&
DESCRIPTION OF IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE -AREA: - Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER:
Construction Type: Orr Estimated Cost: $
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ _ $
r
DATE: `'C;) APPLICANT: Tel. #
STIPULATIONS:
r
CITY USE ONLY
Permit Fee
$ �` ��
Fee Schedule on Reverse Side
Fire Surcharge
$
.001 of Permit Valuation (1/10th%)
State Surcharge
$
1. CQ
$.50/$1,000 Valuation
SAC Charge
$
$1000 per SAC Unit
License Surcharge
$
C)
$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 [ ]
6
TOTAL
$
STIPULATIONS:
r
SUBJECT,PIIT
NO.
City of Fridley
2667
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
`
RECEIPT NO.
w _ COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
r
1
NUMBER
REV
DATE
PAGE OF
APPgOV BY
CITY HALL FRIOLEY 55132
612-571-3450
910415
6/6/02
JOB aooREss 6851 Madison Street NE
1 LEGAL
LOT NO.
BLOCK TRACTOR ADDITION
SEE ATTACHED
DESCR.
1
4 Rice Creek Terrace Plat
6 SHEET
2 PROPERTY OWNER MAIL AODRES$
ZIP PHONE
Patricia A Hrncir 6851 Madison Street NE
763-571-1170
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
B USE OF BUILDING
RM Residential
7 CLASS OF WORK
Q
❑ NEW [I ADDITION x ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Install sliding glass door
9 CHANGE OF USE FROM TO
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. See notations on plan.
SEPARATE PERMITS ARE REOUIRED 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
S0. FT
CU FT
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
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
$1,389
$.70
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-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
PLAN CHECK FEE
TOT FEE
3.04
SIGNATURE OF CONTRACTOR OR A TNORi ZED AGENT iOATEi
HE ROP
L VALID T THIS IS YOUR PERMIT
A7- a010
KO
X*111-&-T.-Ey01
Bl ..NSP
�
qA E
OWNER dF OWNER BUIL DE R� iDATE,
NEW [ ] CITY OF FRIDLEY Effective 1/12002
ADDN [ J 6431 University Ave NE, Fridley, MN 55432 (763) 5722604 Bldg Insp
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: fi ��� —�!% Xtd , S o .,V S7-,
Legal Description:
Owner Name & Address: rc� Pr J4 • Rte1:;C Tel. # S7)— ) 170
Contractor. L11 1,,)(6 , MN LICENSE #
Address: Tel. #
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft
Length Width Height Sq. Ft
Leng Width HgVGround Sq. Ft
1 v Qd
Construction Type: Estimated Cost: $ 't/ 3 r% Xt
Driveway Curb Cut Width Needed: Ft + 6 Ft = Ft x $ = $
DATE: APPLICANT: &7"-/Z i e .� • /-/A NG 1 JZ Tel. # 763 -571 -// 7D
Call (763) 572-3604 for Permit Fees if mailing in application or Fax to 763-571-1287 if using credit card and we will
call you for card number.
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
CITY USE ONLY -
3 �SU. 95
S�S
S
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1200 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 Necessary [ ]
STIPULATIONS:
SUBJECT
R
City of Fridley
3470
AT THE TOP OF THE TWINS
BUILDING
PERMIT
a•
`
RECEIPT NO.
COMMUNITY DEVELOPMENT DIV.
_ _
1 INSPECTION SEC.
(21 //&0PROTECTIVE
I . F
NUMBER
REV
DATE
PAGE OF
APPROVED BY
CITY MALL FRIOLEV 55432
I'' 763-571-3450
910415
4/25/03
10B ADDRESS 6851 Madison Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
j
4
1 Rice Creek Terrace Plat 6 SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Pat Hrncir 6851 Madison Street NE
763-571-1170
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO.
-9" ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO
6 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW j] ADDITION ❑ ALTERATION O REPAIR O MOVE O REMOVE
B DESCRIBE WORK
Construct a 20' x 16' Deck
9 CHANGE OF USE FROM TO
STIPULATIONS
See notations on plan.
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
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
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
@
$1.98
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$3,968
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SACCHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
PLAN CHECK FEE
TOTALFEE
$103.20
NAT RE�OFC%ONu'JRACTORORATMORGAGAsTE,-
W EN PROPERLY VALIDATED THIS IS YOUR PERM T
_ aiD
a
a5o
S-GNATURE OF OWNERJF OWNER dUlLbER, iDATE.
BL5D
PATE
NEW [ ] CITY OF FRIDLEY
ADDN [ ] 6431 University Ave NE, Fridley, MN 55432
ALTER [ ] SINGLE FAMILY AND DUPLEXES R4 AND R-2
BUILDING PERMIT APPLICATION
Construction Address:
Legal Description: IU
Owner Name & Address:
Contractor:
Effective 1/11/2003
(763) 572-3604 Bldg Insp
(763) 571-1287 Fax
Tel.# 763-5-7/-/170
MN LICENSE #
Address: Tel. #
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length Width Height Sq. Ft.
Length Width Hgt/Ground Sq. Ft.
aG
Construction Type: �Estimated Cost: $ -I
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: `7' �Z`� ' a APPLICANTS /moi Y il,,,/yryt' Tel. # `� 3 57I 700
Call (763) 572-3604 for Permit Fees if mailing in application. Fax to 763-571-1287 if using credit card and we will
call you for card number.
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL $ 0 13=0� 0
CITY USE ONLY -
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1275 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 Necessary [ ]