PRE 2010 DOCSp 3 0
City of Fridley, Minn..° 9767
BUILDING PERMIT
Date: May 28, 1968
owner: Gary Fischer Builder _.._ Sussel Co.
Address 6378 Pin -rep St. N.R. _ Address 1850 Como Ave._
LOCATION OF BUILDING
No. 638— Street ___.. F.ia n e S f • H - B , . _ _ _ _ _ _ Part of Lot
Lot _._.._.12_--- Block _ Addition or Sub -Division .MQgre Lake Hiihlud ,Addn.
Corner Lot _ Inside Lot __X_ —.—Setback ___ Sideyard __
Sewer Elevation
Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
Garage Front 24_ Depth 24' Height _L0 � Sq. Ft. , 576 Cu. FL
5760
Front Depth . _ Height ._ Sq. Ft. cu. Ft.
Frame62 490.00 60 days
Type of construction Fit. Cost __ To be completed
In consideration of the issuance to me of a permit to constru4t the buil � described a e I agree to do
the proposed work in accordance with the description above rt f andr/,om.biazce�a'll provisions of
odinances of the city of Fridley. 14
In consideration of the payment of a fee of $ 9.00 .., permit is hereby granted to Sussel C
to construct the building or addition as described above. This permit is gran upon
the express condition that the person to whom it is granted and his agents, employees and workmen, in work
done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinance=s of
Fridley, Minnesota regarding location, construction, alteration maintenance, repair and moving of building
within the dty limits and this permit may be revoked at an�tune upon violation of o provisions of said
ordinanors. / l
CLARENCE BELISLE
NOTICE:
'This permit does not cover the construction, instalWon for whing, phnobing, gas heating, sewer or water. Be sun to we
the Building Inspector for separate permits for these hems.
APPLICATION FOR BUILDING PERMIT
CITY Op FRIDLEY, MIIINESOTA
04JlVE .' S. ;NAND�BUiLbER � �c�
AnDRSs_S nL�!—nI3REss_ i��
; . oCATIQN. o* mij)
NO. STREET__�_,�,,_
LOT i BLpCI . ,.i : - °. , c ADDTTIQ T: QR SUBDI*SION i q
COMER LOT IVSIDE LOT � SETBACK a % SIDFi=j: � --
SEWER ELEVATION TOP OF FOOTING
nn
Applicant.; attack., to. this. form Tvp, pe•rtiii. iate�t_ 4 Sur- of ,oft and proposed
building;; locatiop,,, drawn on these< Certificates . ; ::
DESggPTION DF. BVJMDIKG
To, Be Used As:
Front '1 'Defltti� : Aeieht
Square feet Cubic Feet _26 0
is • f:. " '. '' r Front Depth Seight
$quire feet. , Cubic., Feet
a�
Type of Construction---C--Estimated Cost
To Be Completed
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 represen ions stated in this application
are true and correct.
DATE_-�� —Z—SIGNATURE
r _
(Schedule of Fee Costs can be found on the Reverse Side).
cam'" r-
4 2�
-7E�A--"741-7
LOT
NAME /(��� `
SIZE y►/� L/p�
BLOCK
ADD(R//E..,,S��S
VALUE
ADD'N
M06 cze
AREA
TYPE
24.m. 17
Z41 -ire t-w-zia-
� sA
%-r-=PS s
' t Up oc®q �
1-7
�4FMW
- &�; - "r 3�*"-C"
VIM
` 90
K. �RR`� Ft�CrtEt2 "
,G3 75
City of Fridley
SUBJECT
h
PERM) NO. _
11o - 17,07
AT THE TOP OF THE TWINS
BUILDING PERMIT
' P
• _____ COMMUNITY DEVELOPMENT DIV.
r i � PROTECTIVE INSPECTION SEC.
1 S t
' r---� CITY HALL FRIDLEY 55432
612-571-3450
RE
NUMBER
910-F15
REV.
DATE
2/9/84
PAGE OF
APPROVED BY
JOB ADDRESS 6378 Pierce Street N.E.
1 LEGAL
DESCR.
LOT NO.
10
BLOCK
TRACTOR ADDITION SEE ATTACHED
Moore Lake Highlands 1st SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Gary Fischer 6378 Pierce Street N.E. 571-8295
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Modern Insulation Inc. 10779 - 93rd Avenue, -
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
8 DESCRIBE WORK
Reside Dwelling
9 CHANGE OF USE FROM TO
STIPULATIONS
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
TYPE OF CONST.
Steel
OCCUPANCY GROUP
OCCUPANCY LOAD
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
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
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$5000
$2.550
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-
ST ION OR THE PERFORMANCE OF CONSTRUCTION.
$50.50
PLAN CHECK FEE
TOTAL FEE
$53.00
4, �-d 2 - -
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGE (DATE)
WHEN PROPERLY VAt4DATED THIS IS YOUR PERMIT
}
•� BLDG INSP DAT
SIGNATURE OF OWNER tIF.OWNER BUILDER) (DATE)
CITY OF FItIDLCY Effective Aug. 1, 1981
'
APPLICATION FOR RESIDENTIAL BUMMING PLIM1ITS
(NCh/, Alterations, Additions, or Repairs)
OWHER: ► SC Iqf � BUILDER: 4 D-�-PLy
ADDRESS: 3 f �c4 Ul.1 ADDRESS:
TEL NO: 5 % — � � 95— TEL 110: L/ 2 J — 9 -
Construction
Construction Location
STREET NO: • ?j STJtEF.T: i f ►- C
LOT: BLOCK: ADDITION:
Corner Lot: Inside Lot: i Setback: Sideyards:
Applicant attach to this form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
DESCRIPTIONOF COi;STINCTIOH
t
Cr- Front: Depth: Height:
Square Feet: Cubic Feet:
Front: Depth: Height:
Square Feet: Cubic Feet:
"AVpe of cons tructio- � � L, Estimated Cost: S �® P
Zb Be Cbmpleted: ®
�— Alt. A Al t. B
Proposed Driveway Width If New Opening Is Desired: $ $
SEE P.E.VFRSE SIDE OF SHEET _
91le undersigned hereby makes application for a permit fcr the ::ork herein specified,
agreeing to do,all work in strict accordance with the City of Pridley Ordinances and
rulings of the Delwirtment. of Buildings, and hereby declares that all the facts and
represm-itatiens stated in this app)Arca�xn are true and correct.
L-
DATE: 2 ^ � - �� SIGNhTU%:
Stipulations:
d -T\ Minnesota Well and Boring H 29167 9
WELL OR BORING LO ON U MINNESOTA DEPARTMENT OF HEALTH -Sealing No.
County Name WELL AND BORING SEALING RECORD Minnesota unique No:
�Ap Minnesota Statutes. Chapter 1031 or W -series No.
.Irk ri (Leave blank if not known)
i? F
Township N me Township No. Range No. Section No. Fraction (sm. r Ig.) Date Sealed Approximate Date 71111/) p or Boring Constructed
F�o{ / I t` ®e,.. tie t la t fa
Numerical Street Address or Fire Number and City of Well or Boring Location pa -
4� 3 7 9 P i r- e -cc—. ; t � � p� a � � ) � � � Depth Before Sealing � ° ft! Original Depth i � � ft.
Show exact location of well or boring Sketch map of well or boring Static Water Level ❑ Accurate
roa
in section grid with -X-. location, showing property lines.
f4ndbuildings. 'Approximate
' N fl��
S
Screen from to
ft. Open flole'from
to h.
OBSTRUCTION/DEBRISIFILL
❑ Obstruction ❑ Debris ❑ Fill
o o
Type of debrislobstruction
Obstructiion/Debris/Flll removed? ❑ Yes ❑ No
Single Aquifer ❑ Multiaquifer
ft.�
below above land surface
t
-�-
t
t
- -
t
- i -
r
t
-
t
CASING TYPE
GEOLOGICAL MATERIAL
COLOR
yv
FROM
TO
It not known, indicat estimated to log from nearby well or boring.
t
-r
t
r
-�-
t
t
-r-
t
t
-r
t
110 t/Al Y .1K
[dSteel❑ Plastic ❑ Tile ❑ Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN_
L� No Annular Space Exists
❑ Annular space grouted with tremie pipe
❑ Casing PerforatlonfRemoval
in. from to
in. from to
Type of perforator
❑ Other
2 CASINGS, R CASING AND BORE HOLE:
ft. ❑ Perforated ❑ Removed
ft. ❑ Perforated ❑ Removed
S
Screen from to
ft. Open flole'from
to h.
OBSTRUCTION/DEBRISIFILL
❑ Obstruction ❑ Debris ❑ Fill
o o
Type of debrislobstruction
Obstructiion/Debris/Flll removed? ❑ Yes ❑ No
PROPERTY OWNER'S NAME
6 45% t %. C. P 1 �/'
Mailing Address if different than property address indicated above.
(�
fr.}IN`" Gni n
e
PUMP
.moved LotPresent ❑ Other
CASING _
Diameter Depth
J
- = e in. from to ft.
In. from to ft.
in. from to ft.
Set in ove e hole? Annular space initially grouted?
Sz
❑ Yes IgNo ❑ Yes ❑ No VUnknown
❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
GEOLOGICAL MATERIAL
COLOR
HARDNESS OF
FORMATION
FROM
TO
It not known, indicat estimated to log from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN_
L� No Annular Space Exists
❑ Annular space grouted with tremie pipe
❑ Casing PerforatlonfRemoval
in. from to
in. from to
Type of perforator
❑ Other
2 CASINGS, R CASING AND BORE HOLE:
ft. ❑ Perforated ❑ Removed
ft. ❑ Perforated ❑ Removed
GROUTING MATERIAL
Grouting material Bc Pit from
from
from
from
?,� to A it. yards bags
to ft. yards bags
to ft. yards bags
to ft. yards bags
REMARKS, SOURCE OF DATA, DIFFICUL71ES IN SEALING
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes YN.
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was seated in accordance with Minnesota Rules, Chapter 4725. The information contained in this report is
true to the best of my knowledge.
6,11
Contractor Business Names License orRegistration No.
m I
AWf5hzed
Representative Sig re
f=.1
N olPersonSealing�WellorBoring
Dae
5r
.�1.
LOM100"if
HE -01434.01
I /
91
SUBJECT
,
City of Fridley
32963
AT THE TOP OF THE TWINS
BUILDING
PERMiT
`
RECEIPT NO.
L'______ COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
11.7'j
� /
r -
NUMBER
EV
DATE
P AGE OF
APPROVED 8Y
ILCITY HALL FRIDLEY 55432
763-571-3450
910-F15
_[7E
18/6/02
JOB ADDRESS 6378 Pierce Street NE
1 LEGALLOT
NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
10
1
1 Moore Lake Highlands 1st SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Paul Evangelist 6378 Pierce Street NE
763-572-8461
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Rite Way Waterproofing 448 Lilac St, Lino
Lakes, MN 55014 651-786-0550
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO
B USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Install interior basement drain tile system
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.
Permit Inspection Cards
Will Be Mailed
To Homeowner To Post
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 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
$3,345
$1.67
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-
$97.25
Fire SC $3.35
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
PLAN CHECK FEE
TOTAL FEE
Cityce se j
102.27
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IOATEI
EN ROP ALID THIS IS OUR QERMI
S-GNATURE OF OVVNERJf OWNER BUILOERI IDATEI
Bl G INSo OAtE
I /
91
NEW [ ] CITY OF FRIDLEY Effective 1/1/2002
ADDN [ J 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp
ALTER SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: t- ; eALA.. �,.k . 0 g- �
Legal Description: - ;r, r 'Drag4 44L. &u s 4tAyN
Owner Name & Address:tom- 0,L)\ q__U. Wg=j ;5k Tel. # 71 U3 - 5? off- S'!(c
Contractor. Rite -Way Waternroofing MN LICENSE#
Address: 448 Lilac Street, Lino Lakes MN 55014 Tel.# 651-786-0550
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
OTHER: Sntprinr BasPmk-nt Drain Tilt- SlEatcam
Construction Type:Estimated Cost: $ 33 q
Driveway Curb Cut Width Needed: Ft + 6 Ft= Ft x $ _ $
DATE: -7-3c --crA APPLICANT: Tel. # to 5-1 --7n, -0SSV
Call (763) 572-3604 for Permit Fees if mailing in ap lication or Fax to 763-571-1287 if using credit card and we will
call you for card number.
CITY USE ONLY -
Permit Fee $ a1 • ods Fee Schedule on Reverse Side
Fire Surcharge $ 3.35 .001 of Permit Valuation (1/10th%)
State Surcharge $ t • (0-1 $.50/$1,000 Valuation
SAC Charge $ $1200 per SAC Unit
License Surcharge $ Uk $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'Engineedng
Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ]
TOTAL $ l)a• 9-1 STIPULATIONS:
M\ \)v k \T1 -mss
CITY OF FRIDLEY INSPECTION DIViSION
Effective On January 1, 2002
6431 University Ave NE
Fridley, MN 55432 ra�APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
(763) 572-3604 REFRIGERATION
AND AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS
RATE SCHEDULE
:P
OWNER
Residential
Rate
TOTAL
,
Furnace Shell and Duct Work, Burner -
BUILDING USED AS
Also Replacement Furnace
(Side Vent- Fill Out Back)
$ 30.00
$
P
ESTIMATED COST �7� PERMIT NO. ®1
Gas Piping (Needed with new furnace,
$ 10.00
$
but not replacement)
DESCRIPTION OF FURNACE AND OR BURNER
Gas Range
$ 10.00
$
No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Gas Dryer
$ 10.00.
'$
Trade Name Size No.
*Air Conditioning - All Sizes
$ 25.00
$�4Jv
BTU HP EDR
Fuel Total Connected Load
All Others/Repairs & Alterations (LIST ON BACK)
Burner Trade Name Size No.
1% of Value of Appliance or Work
$
BTU HP EDR
Commercial/Industrial
1.25% of Value of Appliance or Work $
State Surcharge $ .50
TOTAL FEE $ •�
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes an
rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and cor5ect.
HE
Sil
FA
Approved By
Rough -In Date
MR
�JA
Final Date Y& -C-�'
THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
COMMON VFNT�VFNT CONNECTOR AND COMRIISTION AIR VFRIFICATION
When re In acing an existing furance, 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 plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination. Yes () No ( )
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturers specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances. Yes( ) No( )
The avis ing eembustinn air is sized and installed to meet the current codes
and manufacturer's specifications. Yes () No ( )
When required to install a new enm6u_etien air it will be sized and installed
to meet the current codes and manufacturer's specifications. Yes () No ( )
When installing a new venting nystp-m, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturers
specifications. This does include AGA-GAMA Category I Central Furnace
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(
)
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
Total Appliances
Total Btu Input
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
HEATING CO:
Signed By: Date :
CITY OF FRMLEY PERMIT NO.: 2004-00090
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432 DATE ISSUED: 01/22/2004
ADDRESS 6378 PIERCE ST NE
PIN 133024310045
LEGAL DESC MOORE LAKE HIGHLANDS 1 ST
LOT 10 BLOCK 0
PERMIT TYPE ELECTRICAL
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION
NOTE: ELECTRICAL PERMIT BECOMES VOID 12 MONTHS AFTER PERMIT ISSUE DATE.
INSTALL XCEL ENERGY SAVERS SWITCH
# INSPECTIONS 1
APPLICANT
HUNT ELECTRIC CORP
2300 TERRITORIAL RD
ST PAUL, MN 55114-1614
(651) 646-2911
OWNER
EVANGELIST, PAULA
6378 PIERCE ST NE
FRIDLEY, MN 55432
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of worl
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
regulating construction or the performance of construction.
Applicant Date
Bldg Insp Date
ELEC PERMIT FEE - MIN (RESI) 20.00
STATE SURCHARGE, ELEC FLAT 0.50
TOTAL 20.50
PAID WITH CHECK # 113375
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
Building
PLUMBING
Permit No.: g -00l1 1
Inspections
RESIDENTIAL APPLICATION
Received By:
763-572-3604
CITY OF FRIDLEY
DadjAPI 2 "
763-502-4977 FAX
EFFECTIVE 1-1-08
DATE__Lf2A IQ 9 YOUR E-MAIL ADDRESS t c%&%6 tm O� tNsr%- c e^
SITE ADDRESS �'7 S NA
THIS APPLICANT IS:OWNER�,,� ❑aCONTRACTOR
PROPERTY
NAME: LArwg
OWNER/
ADDRESS: 63m P.Zo-7ec.F_ S7 )U6 CITY (—'a—Mm►G"( STATE AW ZIP 3ITLJ32
TENANT
PHONE: if, 3
CONTRACTOR
NAME:
SUBMIT A COPY OF
YOUR STATE
STATE LICENSE # EXP DATE
LICENSE, BOND AND
STATE BOND # EXP DATE
CERTIFICATE OF
ADDRESS: CITY STATE ZIP
INSURANCE
PHONE FAX
PERMIT TYPE
AINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK:
,NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK pop F2,,06% gAsy_i^Fw-T u`tzA z-r`i