PRE 2010 DOCSCity of Fridley, Mm.
BUILDING PERMIT N° s,s
Date:
Owner: �__� Build b r
Address __ _ __ Address__—.—
AOCATION Wj LUP Its
No. "w Street '� 1 _..t._. P Lo
cl
Lot _ _, — _ .__ Block _ _ Addition or Sub-DivisionAW
Corner Lot . Inside Lot _ Setback__ _ Sideyard
-�
Sewer Elevation _ _ _ -- Foundation Elevation
DESCRIPTION OF BUILDING
To � ,fir
Front Depth 4 Height :- Sq. Ft. 'W4— Cu. Ft. ` t«:
a�=--
Frox DepthH ht Sq. Ft. Cu. _
Type of Construction ALA Est. T 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 fn 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 $ _+�'9 — ., 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
within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
NOTICE:
This permit does not cover the construction, installation for wiring, plumbing, .gas heating, sewer or water. Be sure to see
the Building Inspector for separate permits for these Nems.
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
Owner's Name ` Builder
Address Address
LOCATJON OF BUILDI
W
No. Street art
of Lot
Lot Block Addition or Subdivision
Corner Lot Inside Lot A--�4Wack Side -Yard e
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Two Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
To be used as;
DESCRIPTION OF BUILDING
o° ® Front Depth4/Z Height /e!9
Sq.. Ft, Cu. Ft.
Front Depth Height
Sq. Ft. Cu. Ft.
Type of Construction 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 representations stated in this application
are true and correct.
DATE SIGNATURE 2��� 47
(Schedule of Fee Costs can be found on the Reverse Side).
" . . o . . . s
City
Fridley, Minn.
of
i
_i 1 NG PERMITi t
Date:
4V, 4Pd
AddressOwner: Builder
a LO TIO Omio-r-
Lot
DING
No. Street62._ Fart of
Block �-2. Addition or Sub -Division J.- —
Corner Lot ._ Inside Lot Setback _ _ _ Sideyard
Sewer Elevation Foundation Elevation
DESCRIPTION OF BUILDING
To be Used .as: .
Front _ _ - Depth Height Sq. Ft. Cu. Ft.
Front - DepthHeight Sq. Ft. Cu. Ft.
t
Type of Construction Est. ._' 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 with adl provisions of
ordinances of the city of Fridley.
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
within the city limits and this permit may be revoked, at any time ups of any of the provisions of said
ordinances. ,�.t
NOTICE:
fids permit does not cover the construction, Instdieffen for Wiring, ph ting, oa heating, sever or crater. Be sure to see
the Building Inspector for soparato parmHs for thea item
APPLICATION LATHING AND PLASTERING PERMIT No.
Permit Fee $----------
Donald
------.%Donald A. Erickson, Inspector of Buildings.
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in stria accordance with the City Ordinances and
rulings of the Department of Buildings, and hereby declares that all the facts and
representations stated in this application are true and gOrect. -
'P --
Owner. ......... ll•• . � ...
Kind of Building �Floor.................................
.
1ROOM .................................
Usedas.• --••••-------••..................Z.4---...----•• --
Flat ...................................
Tobe completed about•--------------•--------•---•--------•----------•--••----•--•-•••---....------•...195......
Total Est. Cost, Lathing and Plastering,$........................................................
Old—New. Building Permit No ....................................................
INTERIOR PLASTERING EXTERIOR PLASTERING
............................................................ _Kind of Plaster. ---------------------- --------------
To be applied on----------------- ------------------- To be appliedon ............................... --•--
--------- ---------------- -----------------------------------------------
Number of yards----- ---------» umber of yards ......................... ...........
Estimated Cost $---- »_. Estimated Cost $ ......................................
Total number of yards Plastering ----------------------------- =................................................
INTERIOR LATHING ExTnitiog LATHING
Kind of Lath ------------------------------------------- . Kind of Lath ---
To be applied on ........... To be applied on -----
Number of yar...................................Number of yards--------- i �----.....---
Estimated Cost $ .........,Estimated Cost $
Total number of yards LathIng--------------------------- �---------�+-•---- /� :------------•.1 .
D-211955 r 4 Telephone ....................
f
City of Fridley
53-e4-s915a51
Application for Plumbing and Gas FitMng Permit
Dept. of Bldgs. Phone 560-3450
DESCRIPTION OF WORK 6141 Raninbow Drive ATS,
Number, Kind and Location of Fixtures I'hoa
M
y1
F
$
$
Future Fixture Opening ................
y�
1/�
12
N
New Fixture Old Opening ..............
Z
o
y,
2rK�
uZ
C Z
S
Q Z
U
p�
O=
4 3
U�' d
W
�U' �a
a
?
0U' O
O
F
t
N
WATER HTR.
GAS
ELEG
Base
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ...... ...... ............
1 x $2.00
$---2-.-()0
Additional Fixtures ....................
x $ .75
$
Gas Range to 199,000 BTU ..............
x $5.00
$
install (1) gas grill
3.00
REPAIRS & ALTERATIONS --Refer to Code
1st
2nd
3rd
4th
• Future Connection Openings
New Fixture, Old Openings
Connected with
Sewer
Cesspool
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures ......................
x $2.00
$
Future Fixture Opening ................
x $1.50
$
New Fixture Old Opening ..............
x $1.50
$
Catch Basin ............................
x $3.25
$
Water Heater (Up to 99,000 BTU) ......
x $3.00
$
New Ground Run Old Bldg . ............
x $3.25
$
Electric Water Heater
s $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ...... ...... ............
1 x $2.00
$---2-.-()0
Additional Fixtures ....................
x $ .75
$
Gas Range to 199,000 BTU ..............
x $5.00
$
install (1) gas grill
3.00
REPAIRS & ALTERATIONS --Refer to Code
Description ........................ .......................$
TOTAL FEE $ 5.00
City of Fridley:
The undersigned hereby .makes application for a permit for the work herel
specified, agreeing to do all work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the facl
and representations stated in this application are true and correct.
Fridley, Minn June 30p 1970 , 19_
Owner Wm Hart
Kind of Building frame
Used as residence
To be completed about July 3, 1970
Estimated Cost, $ 30.00
Old NNew. Building Permit Permit No.
By.
Business Ph APOLIS GAS (j
ROUGH
FINAL Z4 - IAI-
Cit;"r iiftGi^.N -
c.-, 0-3 L.%zz 'NI* �'•ce�c:'.•;S
Dopt. of Bld7z. Phono $cam -3450
BrsC?�Ip•:Iozi G"%, V-,Gl,i. �
+_ � li� r�
K:--Aes.d L cr_icn o° Fix`.'res Locr`e�� _ .
city of Pr.d:cy:.
The urdcrsigncc hereby rn.2kes spp•!cation for a ;,ermit fer t.`:e• -c:l: t erri
specified, a,—ce:ng to do all in strict acco:-dcrce w:th t`e Ci;T 0-d:--ncl
a^.d n_'ing of the D-.Partr:ent of '.:iiy'n , and hereby deciarel that ;Cl L`.e im=
and re-p:esc-ntations stated in this 2PP'-icatian s --e tr_e zrd come•-*
L7
Owner
Kind o. B:.ildi^.z
Sw ar ❑ Used as
Cc --.pool ❑ _ /
To be completed ahout C) %
' F� • d C t S ,� —-�
Sr` 'E DU
v��/
PAr. i lAI RATE i-1
ti
i,
�- #
3
�;. +:•d ::l^� FIXAU1',ATES:
2iG. d,AiE
I L(
_ t
� o
'<';7 h �7
c�
u -
ot
Warta MIN.
�TI1-Wc.
j�
4 •p'
..._____.___� x
,i � � � � `< < i�
� !7
v
w
c..,
3 •
*
By —t±
I------�
New P iX:L':c' 0""1 CV-,^ing..........
5+..,0�(
I� i
l i •i
Catch Basin ............... • .. 6 .
x53.25
I
�
_
•,
Z4atcr Heater'U;> to 990,..000 B11J). • • r
x 53 A
3
ROTJGH •
New GrGsnd Run Old S:dg. • • • • ... Y
x :3. �
5 -------
S f, --:fie: Water Har.l.ar.....:........
a S2.03-
2.GJJ
ei • • e • • . • e • s e • s a • • a •
3Fixtures
��...�. X S2.G.1
V
� � .
Fxtures
.75
-LE7Tfi
.�+--- x vJ.li•J
V .i.:
city of Pr.d:cy:.
The urdcrsigncc hereby rn.2kes spp•!cation for a ;,ermit fer t.`:e• -c:l: t erri
specified, a,—ce:ng to do all in strict acco:-dcrce w:th t`e Ci;T 0-d:--ncl
a^.d n_'ing of the D-.Partr:ent of '.:iiy'n , and hereby deciarel that ;Cl L`.e im=
and re-p:esc-ntations stated in this 2PP'-icatian s --e tr_e zrd come•-*
L7
Owner
Kind o. B:.ildi^.z
Sw ar ❑ Used as
Cc --.pool ❑ _ /
To be completed ahout C) %
' F� • d C t S ,� —-�
Sr` 'E DU
v��/
PAr. i lAI RATE i-1
Es..rra p os .
t •d'irZ it ,:o.
Old—New. F3ui. a -,r--
�;. +:•d ::l^� FIXAU1',ATES:
2iG. d,AiE
TOTAL
Signed
;:;.•:,�z F1rtur2s ..... • ......... e
..._____.___� x
,.
Ruture F :xtu: e Ot,cr.i^g e .., .... e ...
•x
.._.. _--- x 51.50
3 •
*
By —t±
I------�
New P iX:L':c' 0""1 CV-,^ing..........
5+..,0�(
--
-
Catch Basin ............... • .. 6 .
x53.25
3
_
•,
Z4atcr Heater'U;> to 990,..000 B11J). • • r
x 53 A
3
ROTJGH •
New GrGsnd Run Old S:dg. • • • • ... Y
x :3. �
5 -------
S f, --:fie: Water Har.l.ar.....:........
a S2.03-
2.GJJ
ei • • e • • . • e • s e • s a • • a •
3Fixtures
��...�. X S2.G.1
V
� � .
Fxtures
.75
.: s.. iZ ' •i 159.000i U ....... . . s.
.�+--- x vJ.li•J
V .i.:
•
�
50
` e e
State SLLcha ge
�•�S
�C d:}.=.'ret�i l•:S��dr•6:Ci CO•d�
�q•� �::: ALT :O
Y
-
•5
J.UO
.,�Je:yC:ij:r=vn • e . • a o e • . • r . e e . w e . •..
.
e • • a.• s .TeO/•�•�••�• •��+•}w�
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City of Fridley
AT THE TOP OF THE TWINS
SUBJECT
UILDING PERM
BUILDING
` 27088
`
COMMUNITY DEVELOPMENT DIV.
1 1 ~ PROTECTIVE INSPECTION SEC.
CITY HALL FRIDLEY 55432
�'' 612-571-3450
RECEIPT NO.
NUMBER
910-F15
REV
DATE
18/10/98
PAGE OF
APPROVED BY
JOB ADDRESS
6141 Rainbow Dr
1 LEGAL
DESCR.
LOT NO.
13
BLOCK
2
TRACT OR ADDITION
1 Sylvan Hills
SEE ATTACHED
SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP
PHONE
William Hart 6141 Rainbow Dr
571-2128
3 CONTRACTOR MAIL ADDRESS ZIP
PHONE LICENSE NO
Owner
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 gk REPAIR
❑ MOVE ❑ REMOVE
6 DESCRIBE WORK
Reroof house and garage S Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with 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
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
ZONING
SO. 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
VALUATION
SURTAX
WITH WHETHER SPECIFIED HEREIN OR NOT, THE GRANTING OF A PERMIT
2085
$1.04
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.
$74.75
Fire SC $2.08
PLAN CHECK FEE
TOTAL
SIGN�jATUR FCsONTRA/CTTOR OR AUTHORIZED AGENT MATE
pE
P OP IDAT
BL INSP
IS IS Y UR PERMIT
MATE
SIGNATURE OF OWNER 0F OWNER SUILOERI I ATEI
k /
NEW [ ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: / "fle G
Legal Description:
Owner Name & Address: A 'OV e- CVIA e I- 1/k /,/�,�/•ael. # _5'_7/ 2 -
Contractor:
Contractor: MN LICENSE #
Address:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF E%IPROVEMENT
Tel. #
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER: A-� /AT;/ tom- Aru'_ a` /A�' 2>
Construction Type:
Driveway Curb Cut Width Needed: Ft. + 6 Ft =
Estimated Cost: $ "'?( COD�-
(Fee Schedule. on Back)
Ft $ _$•
DATE: ,m APPLICANT: d'�/�i` Tel. # 57 / z /a
Permit Fee
Fire Surcharge
$ . '-�- o v
State Surcharge
$ 1 G
SAC Charge
$
License Surcharge
$
Driveway Escrow
$
Erosion Control
$
Park Fee
$
Sewer Main Charge $
TOTAL $ f s U
. STIPULATIONS:
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%) -
$.50/$1,000 Valuation
$1000 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 [ ]
�O /o/ AMIU low
COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacing an existing furance, the undersigned hereby verifies that the
4enting 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 manufacturer's specifications. This does
include AGA -LAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances.
Yes No( )
The existing combustion air is sized and installed to meet the current codes
and manufacturer's specifications.
YesK)No( )
0'`
When required to install a new combustion air, it will be sized and installed
To meet the current codes and manufacturer's specifications.
Yes K No( )
When installing a new venting system, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Furnace
�/
Venting Tables for fan assisted and natural draft appliances.
Yes (,f) No( )
f
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.
YeO(� No ( )
Appliance #1 Type LO, Cf— BTU Input®� an A siste r N
Appliance #2 Type m ����, BTU Input Fan ssised a
Appliance #3 Type BTU Input Fan Assisted o at
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 Carf
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS: (Describe) feds�it��'� ' I5 fL,4/D &lji M,57kzcO
HEATING CO: /(// eli' l�f/'Y �/�i�i��C�%' P"�/®��%� r��
Signed By: Date
WILL
Pq
CITY Oh FRIDLEY INSPECTION DIViSION
6431 University Ave NE
Effective On January 1, 200(
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
572.3604
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS 1 eAlV&q, J:)2 MW
RATE SCHEDULE
OWNER1 u. t �YYI —r
Residential Rate
TOTAL
_14-0-r
Furnace Shell and Duct Work, Burner
r,�
BUILDING USED AS . a),t LLi ►!—
Also Replacement Furnace $ 30.00
$34.40
(Side Vent - Fill Out Back)
Gas Piping (Needed with new furnace, $ 10.00
$
v
ESTIMATED COST -77®0 d' PERMIT NO.
but not replacement)
Gas Range
DESCRIPTION OF FURNACE AND OR BURNER
$ 10.00
$
Gas Dryer $ 10.00
$
No. of Heating Units Circle One (Steam) (Hot Water)arm
i6i
Trade Name Size No.,! C;- -Oly- /7�k--
*Air Conditioning All Sizes $ 25.00
$
�-° r�
BTUT� HP EDRFuel
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
$
The undersigned hereby makes application for a permit for the work herein
State Surcharge
$ .50
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
TOTAL FEE
$ . S^®
representations stated in this application are true and correct.
DATE �PR'D
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
HEATING CO Siyf0 44v -AL
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
Q a -g
Signed .�.o TEL # 70 —M -21f9 X33
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard without
written from
Approved By Rough In Date Final Date ��<�/
permission adjoining property owner.
CITY OF FRIDLEY PERMIT NO.:
2004-02126
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432 DATE ISSUED: 11/18/2004
763) 572-3604 FAX: (763) 571-1287
ADDRESS : 6141 RAINBOW DR NE
R 608 8
PIN : 143024330028
LEGAL DESC : SYLVAN HILLS
: LOT 13 BLOCK 2
PERMIT TYPE : BUILDING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION : $ 1,800.00
NOTE: SEE NOTATIONS ON PLAN.
CALL GOPHER STATE ONE AT 651454-0002 FOR UTILITY LOCATIONS.
PROVIDE SMOKE DETECTORS IN ALL SLEEPING ROOMS AND ON ALL LEVELS OF THE DWELLING
PER R317 OF THE
2000 INTERNATIONAL RESIDENTIAL CODE.
APPLICANT
BUILDING PERMIT FEE
FIRE SURCHARGE
63.15
1.80
NORTHERN CREST INC.
7401 CENTRAL AVE NE
STATE SURCHARGE, VALUE
0.90
FRIDLEY, MN 55432
TOTAL
65.85
PAID WITH CHECK # 5653
OWNER
HART WILLIAM L & NORMA L
6141 RAINBOW DR 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 work
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
recons oar o ance of construction.
Ap;licant Date
tlo
d
Bldg Insp Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
NEW s [ ] CITY OF FRIDLEY
ADDN [ ] 6431 University Ave NE, Fridley, MN 55432
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: &/ / god
Effective 4/1/2004
(763) 572-3604 Bldg Insp
(763) 571-128 9.
ax
C �
Legal Description:
Owner Name & Address: Tel. #
Contractor. Ce°C3 01 a MN LICENSE # 2 00 q gq1
Address:�qU 6QA( �l�e �/ ��Cc i� Tel. # 7bS P q q�
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:
r '�f/ o 0,
Construction Type: ka(65 � 1 Estimated Cost: $
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ p
DATE: "� APPLICANT: Tel.# f 6 )4 641
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.
CITY USE ONLY -
Permit Fee
Plan Review
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
$
Fee Schedule on Reverse Side
65% of Permit Fee
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1350 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:
lqcI
nq � arc s 1-i kv W1��o�
Cu S-ei 0,L t w t l(-�o be -
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