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PRE 2010 DOCSCity ®f Fridley, Yffim N° 7677 PERMITBURDING Date: _ June 2, 196 owner: Walter Raser Builder P. D. Q. Claim Se c! Address 6160 Rainbow Drive N. E. Address (1305B=- a -at Ave- South LOCATION OF BUILDING No. 6160 street Rainbow Drive N. E. Part of Lot Lot 2 _ Block - 3 Addition or Sub -Division Sylvan Hills Corner Lot Inside Lot Setback Sideyard Sewer Elevation Foundation Elevation DESCRIPTION OF BUILDING To be Used as: Front _____ _r Depth Height Sq. Ft. Cu. Ft. Front Depth Height Sq. Ft. Cu. Ft. Type of Construction Est. Cost 2' •80 To be Completed Storm Damage Repair In consideration of the issuance to me of a permit to construct the building described above I agree to do theproposed work in accordance with the description forth and in ,compliance with a'll provisions of ordinance: of the city of Fridley. /Af In consideration of the payment of a fee of $— , permit is hereby granted togs D• Q• Claim - Service to construct the building or addition as described above. This permit is granted upon the express condition that the person to whom it is granted and his agents, employees and workmen, in all work. done in, around and upon said building, or any put thereof, shall conform in all respects to the ordinances of Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. A11en Jensen Building Inqwtor NOTICE: ihb pwmb don not aoser dw coadmcUon, hutAMan for wkk& plumbing, gas h"dng, wwa or water. Bo airs to me do BaUdtng Inape for fee sapnata parmha for then Items. v OWNKR' S NAME No. APPLICATION FOR B -^ M, PERMIT CITY OF FRIDLEYi 1IMSOTA, ® BUILbER Lf A11DItSS LOCATION OF BIDING Lot �� Block Additiore or Subdivisian Corner Lot Inside Lot .$etVgtk Side -Y SEWER ELEVATION FOUNDATION ELEVATION. Fart of Lot. a> Applicant attach to thi-A form Two Certificates of.Survey of Lot.and proposed build ing location dr'A.wn on these CA-ttificates . To be used do: DESCRIPTION OF BUILDING d front Depth Height - Sq. Ft. Cu. Ft. Front Depth Height Sq. Ft. Cu. Ft. Type of Construction Estimated Cost jgr;Z2,, '® y. The undersigned hereby makes application for a permit.for the work herein specified, agreein-g to do all work ii! 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. _Ochedule.of Fee Costs can be found on the Reverse Side). g SUBJECT City of Fridley 21259 AT THE TOP OF THE TWINS BUILDING PERMIT r ECEIPT N COMMUNITY DEVELOPMENT DIV. �0 _ r PROTECTIVE INSPECTION SEC. !� CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY ,`� 612-571-3450 910-FlS " 4/6/92 % JOB ADDRESS 6160 Rainbow Drive NE 1 LEGALLOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 2 3 Sylvan Hills SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Michael Johnson 6160 Rainbow Drive NE 572^0789 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 Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION � ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Remodel . Basement 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. ZONING SQ. FT. CU. FT. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT NO. DWLG. UNITS OFFSTREET PARKING ANY TIME AFTER WORK IS COMMENCED. I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION STALLS GARAGES VALUATION SURTAX AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED $7 $3 a50. WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT fQQQ PERMIT FEE SAC CHARGE DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- $90., 00. Fire SC 7. 00 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE $100.50 SI NATO F C - THORIZED AGENT IDATEI PR P L ALIDATED THIS IS YOU PE"IT / kATE pn SiGNATU E OF229EROF OWNER BUILDERI ..i?t?iYilth;t;2,t;i2i2id:i2iiib:?2Y21:j2>.i:ih. 32t?2tiYCY�.............:Ytti?Rt wibti?i;i?i?i,..n,.a:.bb:..:•252i:ii.:i.t2s... >.ibhb2.......... ......... 2>2... ..... ...., ... , .... ... .._ ... ,.. . ... ,. ,........ . NEW j Effective 3/1/92 ADDN [ ] CITY OF FRIDLEY ALTER j ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Building Permit Application Construction Address: 6& ® �-r.✓ V.,Lo AJ 6 J5, Legal Description: 44- Z - .64o r-� -r�°/rs � � Z1_3 Owner Name & Address: i0W,4,,,,-,/ Ors � Tel. #cr7a�� Contractor: S•17wc. _ MN LICENSE # Address: Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF HAPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: Corner Lot j . ] Inside Lot j ] Ft. Yd . Setback Side Yard Setbacks Type of Construction: Estimated Cost: $ 7& 00 Approx. Completion Date: Driveway Curb Cut Width Needed: APPLICANT'. CITY USE ONLY DATE:C Ft. + 6 Ft = (Cost on Back) Ft x $ = $ Permit Fee $ 90,00 Fee Schedule on Reverse Side Fire Surcharge $ 7,,00 .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge $ — $700 per SAC Unit License Surcharge $ $5.00. (State Licensed Residential Contractors) Driveway Escrow $ Alt. "A" or Alt. "B" Above Park Fee $ Fee Determined by Engineering Sewer Main Charge $ '� Agreement Necessary j j Not Necessary [ ] TOTAL STIPULATIONS: $ 166, pro CITY OF FRIDLEY INSPECTION DIV. Effective On January 1, 1991 / e!5 7 6431 University Ave NE Fridley, MN 55432 572-3604 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 NO. RATE TOTAL W_' Gas Range Gas Dryer Back Flow Preventer Required ( )Yes () No Type $ 7.00 $ 4.00 $ 5.00 $ 7.00 $ 7.00 $ 7.00 $ 7.00 $10.00 $ 7.00 $10.00 $10.00 $10.00 ` $5.00 Reinspection Fee $30.00 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1 % of Value of Fixture or Appliance _ JOB ADDRESS 0'-A-®— �w�, 4.z The undersigned hereby makes application for a permit for the work herein ,UG specified agreeing to do all work In strict accordance with the city codes and rulings of the Building Division, and hereby declares that all the facts and representations stated In this application are true and correct. State Surcharge 1 .50 Y — 7 ,199 Owner������y- Building Used As J Estimated Cost / • PERMIT NO. ✓ "�d PLUMBING COMPANY��el - SIGNED BY A�G�-! ve�e�_ _ TEL N0. Final Date Q Approved By' Rough -In Date MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 TOTAL FEE $ PLUS THE $.50 STATE SURCHARGE /� t Shower r W sh TraYStories ................... Floor Drain .B...''`'' i.1......... a sher rAuto. Gas Water Heater Gas EI e c ....:........:.... .::..p'''''P''...'.'....Ran a '....... Base e m n< Floor 1 :> Floor 2 :::i:: FI or 3 0 F r4 loo 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 NO. RATE TOTAL W_' Gas Range Gas Dryer Back Flow Preventer Required ( )Yes () No Type $ 7.00 $ 4.00 $ 5.00 $ 7.00 $ 7.00 $ 7.00 $ 7.00 $10.00 $ 7.00 $10.00 $10.00 $10.00 ` $5.00 Reinspection Fee $30.00 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1 % of Value of Fixture or Appliance _ JOB ADDRESS 0'-A-®— �w�, 4.z The undersigned hereby makes application for a permit for the work herein ,UG specified agreeing to do all work In strict accordance with the city codes and rulings of the Building Division, and hereby declares that all the facts and representations stated In this application are true and correct. State Surcharge 1 .50 Y — 7 ,199 Owner������y- Building Used As J Estimated Cost / • PERMIT NO. ✓ "�d PLUMBING COMPANY��el - SIGNED BY A�G�-! ve�e�_ _ TEL N0. Final Date Q Approved By' Rough -In Date MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 TOTAL FEE $ PLUS THE $.50 STATE SURCHARGE /� CITY OF FRIDLEY INSPECTION DIV. Effective On January 1, 1991 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, 572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES ,s brTC 0 JOB ADDRESS l0t K-c� I V7\ I-) RATE SCHEDULE The undersigned hereby makes application for a permit for the work Residential Rate TOTAL herein specified agreeing to do all work in strict accordance with the Furnace Shell and Duct Work, Burner - city codes and ruling of the Building Division, and hereby declares Also Replacement Furnace $ 20.00 $ that all the facts and representations stated in this ap plic tion e true and correct. 5a ,199% 5-7 ( " Z o'? J Gas Piping (Needed with new furnace) $ 10.00 $ vP OWNER C� 572 - ® 759 Gas Range $10.00 $ BUILDING USED AS Gas Dryer $10.00 $ - 4,1- ESTIMATED COST Iy PERMIT NO. *Air Conditioning - All Sizes $10.00 $ DESCRIPTION OF FURNACE AND OR BURNER All Others/Repairs & Alterations (LIST ON BACK) 1 % of Value of Appliance or Work $ No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air) Trade Name Size No. Commercial/Industrial BTU HP_ EDR 1 % of Value of Appliance or Work $ Fuel Total Connected Load State Surcharge $ .50_ Burner Trade Name Size No. IS"15BTU HP EDR TOTAL FEE $� HEATING COMPANY Oft t -s e- 1 MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS $15.00 Signed By % Tel No. PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $30.00 Approved By Rough -In Date 3` ` Z -Final Date t/// a I2- *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE CHIMNEY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack: 1. Has been carefully examined Yes ( ) No ( ) 2. Is free from rust or deterioration Yes ( ) No ( ) 3. Has no foreign objects lodged within Yes ( ) No ( ) 4. Is securely supported Yes-( ) No ( ) 5. Meets all current Code requirements for size and total BTU's connected Yes ( ) No ( ) 6. Has total heating BTU's of All other BTU's TOTAL BTU's Remarks List Alterations Beinc Done: HEATING COMPANY Signed By Date CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 572-3604 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR Effective On January 1, 1997 PLUMBING FIXTURE RATES: NO. RATE TOTAL JOB ADDRESS 6 I �® k4l 6y 1N Ok /y E, New Fixtures $ 7.00 The undersigned hereby makes application for a perm it for the work herein Old Opening, New Fixture $ 4.00 specified agreeing to do all work in strict accordance with the city codes Beer Dispenser $ 5.00 and rulings of the Building Division, and hereby declares that all the facts Blow Off Basin $ 7.00 and- representations stated in this application are true and correct. Catch Basin $ 7.00 Rain Water Leader $ 7.00 .1998 Sump/Receiving Tank $ 7.00 Water Treating Appliance $10.00 Owner Water Heater —Electric $ 7.00 Water Heater — Gas** _� $10.00 Building Used As&15.5 Gas Range** $10.00 % Gas Dryer** $10.00 Estimated Cost PERMIT NO. G �� Back Flow Preventer Required ( )Yes () No Type $15.00 PLUMBING COMPANY MR. ROOTER OF ANOKA COUNTY 6250 nusAve. Reinspection Fee $42.00/Hr SIGNED" Ramsey, MN 55303 TEL NO. ALL OTHERS ANO/OR REPAIRS AND ALTERATIONS 421-6140 1.5% of Value of Fixture or Appliance 1 , 421 -6198 -FAX Approved By Rough—In Date Final Date State Surcharge $ .50 TOTAL FEE $.440157) PLUS THE $.50 STATE SURCHARGE **COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6—A. MINIMUM SIZE 9 SO INCHES. M SUBJECT O• City of Fridley 26704 AT THE TOP OF THE TWINS BUILDING PERMIT zR r 1 RE COMMUNITY DEVELOPMENT DIV. tr ------PROTECTIVE INSPECTION SEC. 437' r 1 � 1 . � NUMBER REV DATE PAGE OF APPROVED BY 1 = /'�'1 CITY HALL FRIDLEY 55432 A "'j 612-571-3450 910-Ft5 /20/98 JOB ADDRESS 6160 Rainbow Dr. NE I LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 2 3 1 Sylvan Hills SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Michael R. Johnson 6160 Rainbow Dr NE Fridley MN 55432 572-0.789 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 M REPAIR ❑ MOVE ❑ REMOVE B DESCRIBE WORK Reroof house and garage (24 Sq) Tear-off 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 $1.00 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $2001 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- Fire SC $2.00 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. $74.75 PLAN CHECK FEE TOTAL FEE $77.75 A CO A R HO AC �EI WHEN PROPERLY BLD INSP LIDATED THIS IS YOUR PERMIT BATE SIGNATUREO WNERtIF OWN UILD RI IDATEI M NEW [ ] ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION 4ConstructionAddress: `�° ® �B-/,���vr J�o �� /?�a Legal Description: Effective 1/1/98 �O� Owner Name & Address: ,j �� �.�.i.� �� Tel. #��� Contractor: mss' �� MN LICENSE # Address: Tel. # 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: Sq. Ft. OTHER:_ HeVGround Width Height Sq. Ft. Width Height Sq. Ft. Width HeVGround So. Ft. a �C/-i� g - Wyk- � Construction Type: W�tj A10 0-10 Estimated Cost: $ "(Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: �' `" �� APPLICAN Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: $ S 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 [ J ' .. SUBJEtT City of Fridley 2 9 � 15 AT THE TOP OF THE TWINS BUILDING PERMIT r -FTECEIPT NO. ______ COMMUNITY DEVELOPMENT DIV. L r � � PROTECTIVE INSPECTION SEC. '! /✓� a ��'��,•, CITY HALL FRIDLEY 55432 i NUMBER REV GATE T716/99 PAGE OF APPROVED BY .--. L J` 612-571-3450 9110-F15 JOB ADDRESS 6160 Rainbow Drive 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED OESCR. 2 3 Syl van Hills SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Mike Johnson 572-0789 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Best Siding 1310 154th Ave NE Ham Lake MN 55304 786-1888 2846 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 O ADDITION ❑ ALTERATION OX REPAIR ❑ MOVE ❑ REMOVE B DESCRIBE WORK Reside 9 CHANGE OF USE FROM TO STIPULATIONS Call for building wrap inspection before covering 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 I HAVE READ AND EXAMINED THIS APPLICATION 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 ISE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GR NTING OF A PERMIT 5260 2,63 DOES NOT PRESUME TO GIVE AUTHORITY TO VIO TE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF ANY OT ER STATE OR LOCAL W REGULATING CON - TR% CTION OR 7}�E P OCE CONS TION 125.25 Fire SC $5.26 10 d PLAN CHECK FEE TOTAL FEE _x 133.14 S-GNAfURE OF CONTRACTOR OR AU NORi2ED G T iDATE, WH DPERLY VALIDATED THIS IS YOUR PERMIT A, Od SNS - OA Tk SIGNATURE OF OW NER,iF OWNER BWLOE Rj IOATEi ERMIT NO. NEW' ] Effective 5/10/99 ADDN [ ] CITY OF FRIDLEY ALTER [ J SINGLE FAMH.Y AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Construction Address: (a 0 ? A/ A/ 43 ed -Al Q K , /4 /f ( 01 Legal Description: Owner Name & Address: /` ✓1 -a���/g d �/ Tel. # 7+` �� �7 Contractor: d ij,y Z' 6e4e4 /,*,, s MN LICENSE Address: 6 4d"e - .4t/e i✓rz' /� Tel. # -2& Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF EMPROVElVIENT 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: 4g: S o 12 /rz_ Estimated Cost: $ cJ , Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ = $ DATE: APPLICANT: 44 qAM' i �� - Tel. #Y 42 STIPULATIONS: CITY USE ONLY Permit Fee $ /0� 5 aS Fee Schedule on Reverse Side Fire Surcharge $ a(® .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge $ $1050 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 $ 133.l STIPULATIONS: