PRE 2010 DOCSCity of Fridley, Minn.
BUILDING PERMIT
Date: March 21, 1969
Owner: Jerome W. Petefson Builder Same
Address 6893 M adis on St. N. E. Address Same
No. 6893 Street
Lot _.. 2 __ Block
Corner Lot --
Sewer Elevation
N° 10146
LOCATION OF BUILDING
Madison St. N. E. — part of Lot
4 Addition or Sub -Division _ Rive Creek Terrace Plat 7
Inside Lot — x Setback — _ Sideyard
Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
Garage Front 20' Depth 26' Height 10' Sq. Ft. 520 Cu. Ft. 5200
Remodel Kitchen Front Depth Height _ _ Sq. Ft. r Cu. Ft.
Type of Construction Frame Fst Cost $975.00 To 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 wit" provisions of
ordinances of the city of Fridley. Z/1„ T7 ZI/
In consideration of the payment of a fee of $__14. PO , permit is hereby granted to Jerome Peterson
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 in, around and upon said building, or anypart thereof, shall conform in all respects to the ordinances of
Fridley, Minnesota regarding location, 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.
YBuilding
OfficialMagam
Muhich
NOTICE:
This permit doer not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sura to sae
the Building Inspector for separate permits for these items.
r - w
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, NNESOTA
OWNER ' S NAME UILDER
ADDRESS 49.3 ADDRESS
LOCATION OF BUILDING
NO . - STREET
LOT ,� BLOCK ADDITION OR SUBDIVISION �t �
CORNER LOT INSIDE LOT ✓ SETBACK SIDEYARD
SEWER ELEVATION TOP OF FOOTING
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:
Gi y a 'P Front Zee Depth 2-6 Height / b
7f7 Square feet�Cubic Feet
Front Depth Height
Square feet Cubic Feet
Type of Constructio.nmlx4e l RewaAPAstimated Cost �7 �-
To Be Completed A.) �--�—
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 -3 - .2 / - % SIGNATURE
(Schedule of Fee Costs can be found on the Reverse Side.)
Re wol
SUBJECT
PER-_
City of Fridley
1 � 521
AT THE TOP OF THE TWINS
BUILDING PERMIT
r
REC
• COMMUNITY DEVELOPMENT DIV.
r i PROTECTIVE INSPECTION SEC.
CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED BY
612-571-3450
910-F15
6/1/84
�
JOB ADDRESS 6893 Madison Street N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
2
4 L
I Rice Creek Terrace Plat 7 SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Jerome Petersen 6893 Madison Street N.E. 571-3707
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Acme Concrete 3612 - 10th Avenue South,.Mpls.., MN 55407 825-1881
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
Re -place old footing and foundation wall in northeast corner (approx. 22 feet)
9 CHANGE QF USE FROM TO
STIPULATIONS
Call for footing and soil check before pouring new footing.
SEPERATE PERMITS
REQUIRED
HEATING, PLUMBING
Fps WIRING,
a
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
ISTALLS
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
$3,lOO
$1.55
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-
$44.50
STOR INCE OF CONSTRUCTION.
RU 10
PLAN CHECK FEE
TOTAL FEE
--1--�-
$46.05
SIGNATURE OF CONTRACTOPIr AUTHORIZED AGENT (DATE)
WHEN PROPER VALIDATED THIS IS YOUR PERMIT
6
BLDG 11SP ry TE
SIGNATURE OF OWNER IIF OWNER BUILDERI (DATE)
NEW [ ]
City of Fridley Effective 4/1/84
ADDN. [ ] �R-1 AND R-2
ALTER. [ ] Building Permit Application
Construction Address:(� 9 3 A k11 5- 40A/ -Ay-= A`
Legal Description: �' �y
Owner dame &Address: eY�®�yl �' �Rse� M 1sD.G /� ; Tel. # 7 -24_7
Contractor: Acme eey c?Cr,2�i Tel . #
Address: l —LV AY 11D7
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
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.
e - d a
OTHER: e e E,C z
Corner Lot [ ] Inside Lot [ ] Ft. Yd. Setback Side Yard Setback
Type of Construction: 0gNe ° A'' -N Ry Estimated Cost: $
Approx. Completion Date: Z' —36)—g L/
Alt. A Alt B
Proposed Driveway Width If New Opening Is Desired: $ $
See Back Page for Explanation
DATE:` 3% if APPLICANT:
Tel. # "� � 941i
CITY USE ONLY
Permit Fee $ Fee Schedule on Reverse Side
Plan Check $ ® 25% of Building Permit Fee
State Surcharge $ �� S $.50/$1,000 Valuation
SAC Charge $ $425 per SAC Unit
Park Fee $ ® Fee Determined by Engineering
Sewer Main Charge $ �
Agreement Necessary [ ] Not Necessary [ ]
TOTAL $
(� e_
STIPULATIONS: pS
C:
City -of Fridley, Minn.
BUILDING PERMIT N® 3405
Date: . . ..R R. 9 ... 'S`... ........
Owner ....................................... Builder &
..... ... lil�... ...........
Address ...................................... Address.............7................................
LOCATION OF BUILDING
p '
No(P ..x+79�3.. Street ...W.. . f : . .. ............... Part of Lot ..................
Lot ....rte( ..... Block .... .......... Addition or Sub -Division �yZ.P.. � . ���r� A /
X� '///7
Corner Lot ............ Inside Lot ........ Setback . J.1. _ Q."Sideyard ..//0.:.0 ...............
DESCRIPTION OF BUILDING
To be Used as:
Age, A ... Front � y Depth 074: 14 Height /. 7 r0 Sq. Ft. /.1� � . , J' Ca Ft.
.................... Front ........ Depth ........ Height ........ Sq. Ft. ........ Cu. Ft. ........
Type of Construction ................... Not Cost. A5OT...77.777 To be Completed ....................
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-a}nd � c�liance with all provisions of
ordinances of the city of Fridley. / / C/
:IV. -4�44ir.....................
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 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.
a:lAa,11e_l
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 Inspector for separate permits for these Items.
SUBJECTP
City of Fridley
I84 6
AT THE TOP OF THE TWINS
BUILDING
PERMIT
MF
r
R .
',,
• ______ COMMUNITY DEVELOPMENT DIV.
L PROTECTIVE INSPECTION SEC.
S
r
�
`1• i
��"",•� CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
TPPROVED BY
---.
L 612-571-3450
910-F15
5/2/86
JOB ADDRESS 6893 Madison Street N. E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
2
4
Rice Creek Terrace Plat
7 SHEET
_T PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Jerome Petersen 6893 Madison Street N.E.
571-3707
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.
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION f ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof Dwelling
9 CHANGE OF USE FROM TO
STIPULATIONS
Roof can be the 2nd layer but not the RIX 3rd.
Irstall ridged galvanized
valleys.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
Fiberglass
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SQ. 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
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
600
$.50
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
TOTAL FEE
$15.50
SIGNATURE OF CON RACTORO AUTHORIZED AGENT (DATE)
WHEN PROPERLY V D TED THIS IS YOUR PERMIT
I.
GNA URE OF OWN N ILDERI ,#A(DATE)
BLDG )NSP
0 TE
NEW [ ] City of Fridley Effective 4/1/86
ADDN. [ ] �R-1 AND R-2
ALTER. [ ] Building Permit Application
Construction Address:
o9F--*:�
1-1A ��Sa-N'
S/
Legal Description: A
o%� ?
Owner Name & Address: �� �'`4 la Tel. #
Contractor: Tel. #
Address:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
LIVING AREA: Length
GARAGE AREA: Length
DECK AREA: Length
OTHER: 9z - S 4 ; ti:� 1,
Width Height Sq. Ft.
Width Height Sq. Ft.
Width Hgt/Ground Sq. Ft.
A
Corner Lot [ ] Inside Lot [i-] Ft. Yd. Setback Side Yard Setback
Type of Construction•Estimated Cost: $ 'g� o c
Approx. Completion Date:
Alt. A Alt B
Proposed Driveway Width If New Opening Is Desired: $ $
See Back Page for Explanation
DATE: ��a�� APPLICANT: Tel. #
Permit Fee
Plan Check
State Surcharge
SAC Charge
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
CITY USE ONLY
$ /,5-, 6)a
$
$ Z�L-
4-6
Fee Schedule on Reverse Side
25% of Building Permit Fee
$.50/$1,000 Valuation
$475 per SAC Unit
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
SUBJECT
I
City of Fridley
2 6 5 7
AT THE TOP OF THE TWINS
BUILDING PERMIT
i
RECEIPT NO.
DEVELOPMENT DIV.
/ /��
-------COMMUNITY
PROTECTIVE INSPECTION SEC.
l
NUMBER
REV
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
612-571-3450
910415
7-13-98
JOB ADDRESS
6893 Madison St.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
2
4
SHEET
Rice Creek Terrace Plat 7
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Virgil Nelson 571-5272
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO
Four Seasons Roofing & Remodeling, 7930 University AVE, Fridley, 55432, 795-9410
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
20138780
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION F9 REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Remove & Replace 22 Sq of Shingles
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
SQ. 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
$1,834
$.92
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
PROVISION F ANY O TATE OR LOCAL LAW REGULATING CON-
Fire SC $1.83
STRUCTIO R THE FIERFORM CE OF CONSTRUCTION.
$59.50
/fox
PLAN CHECK FEE
TO ALFEE
$Lic nse $5.
$67.25
SIGNATURE OF CONTRA ROR AUTHORIZED AGENT IDEI
QP VALI A D THIS IS YOUR PERMIT
• /�
a SP GATE
_
SIGNATURE OF OWNER IIF OWNER BUIEDERI IDATEI
NEW [ ]
ADDN [ )
ALTER [ )
Effective 1/1/98
CITY.OF FRIDLEY .
t SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: 123 MadIsvn 5+
Legal Description:
Owner Name & Address: V i r c, I I AJ P,I S 4 in Tel. #Jam`%/—J o� %o:
Contractor: Pbo r 5,e4son5 iW OD�-lna at. 1�e�Yl dal e� n L[ GMN LICENSE #
Address: 1'7 36 Un ty.e.,rs LL, e- Tel. # 795 9�1d
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVENWM
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width . Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft..
OTHER: R-Q.movc 4- Re_01& � "2A 54 onpS lnr/e_5
STIPULATIONS:
Construction Type:P
emp Ve..
Estimated Cost: $ A�3
-,
(Fee Schedule, on Back);
Driveway Curb Cut Width Needed:
Ft. ' + 6 Ft = Ft x $ _ $
DATE:. 7-15
- APPLICANT:
Tel. # `%1�— l�
CITY USE ONLY
Permit Fee
$ �.
Fee Schedule on Reverse Side
Fire Surcharge
$-
.001 of Permit Valuation (1/10th%)
State Surcharge
$
$.50/$1,000 Valuation
SAC Charge
$
$1000 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 r
Sewer Main Charge
$
Agreement Necessary [ ] Not Necessary [ )
TOTAL
STIPULATIONS:
NO.
SUBJECT
City of Fridley
=15
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
`L __�___ COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
CITY HALL FRIOLEY 55132
NUMBER
REV
DATE
PAGE OF
APPROVED BY
612-571-3450
910415
12/5/00
JOB ADDRESS 6893 Madison Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
1 2
4
Rice Creek Terrace Plat 7 SHEET
2 PROPERTY OWNER MAIL ADORES$
ZIP PHONE
Virgil & Marion Nelson 6893 Madison Street NE 571-5272
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Windows America of MN 7928 University Ave
NE Unit C, Fridley, MN 55432 20248265
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO.
763-786-8115
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION jJ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Replace windows
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.
Will BILI
F�
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCYLOAD
VENTILATING OR AIR CONDITIONING
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SO. 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
@
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$1,800
$ • 90
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-
$63.15
Fi SC
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
a $1.80
PLAN CHECK FEE
TOT L FEE
Lice C $5.
$69.05
SIGNATURE OF CON TRACTOR OR AUTHORIZED AGENT IDATE,E
PR P VALI AT THIS IS yQyR PQMIT
-6
_
�
/0 7
8l G INS BATE
S�GN4TURE OF OW NER �rt OWNER BU�IDERi IDATE�
NO.
APR -24-2000 1534 FROM CITY OF FRIDLEY TO 7668125 P.02/03
NEWEffective 1/1/2000
ADON [ J [I CITY OF FRIDLEY (763) 572-3604 Bldg Insp
ALTER [ J SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: �%, M 7�
Legal Description:
Owner Name & Address: I� Tel. S -c�oZ 7a
Contractor: - MN LICENSE # k aOD 49J
Address: Tel. �2—
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft
Length Width Hefght Sq. Ft.
Length Width Hgt/Ground Sq. Ft
Construction Type: - - Estimated Cost: $ / Foa 00
Driveway Curb Cut Width Needed: Ft + S Ft = Ft x $ =
DATE: r I APPLICANT: Tel 7 1-11i6
CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application
Permit Fee $ 3. Fee Schedule on Reverse Side
Fire Surcharge $v 1, ���� .001 of Permit Valuation (1/10th%)
State Surcharge $ d 10 $.50/$1,000 Valuation
SAC Charge $ $1100 per SAC Unit
License Surcharge $ �, 0 _$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 $& / V
STIPULATIONS:
1—;Z�C ivIO& ��lO�� 1� �/-wje
452
State o�"irmesoia fl ari+rte :Ct mmerce t icstasi g Division
. ` A�az6ttoterce:
133East.S.^s Tarte .(854
E:..
s estaEs.ma.us
St aw. MN 5516r �p��{�����
9 Webske address. .1JtIt.tLS