PRE 2010 DOCSCity of Fridley, Minn.
]BUILDING PERMIT
Date: June 5, 1969
Owner: Charles Johanson Builder
Address 580 69th Ave. N. E. Address
Same
Same
LOCATION OF BUILDING
C/9�j
N9 10261
No. - 541 Street - - Rice Creek Blvd.. ___ part of Lot
Lot 5 _ _ Block 2 Addition or Sub -Division .____ Holiday Hips
Corner Lot Inside Lot — X Setback 40' _ _ _ Sideyard 10' 61
Sewer Elevation __ 826.79 829.79
Top of Footing
DESCRIPTION OF BUILDING
To be Used as:
Dwelling_ Front 5 0' 6" Depth 26' Height 20' Sq. Ft. 1420 Cu. Ft. 28400
Garage Front 24 . Depth 24 7cTeight 10, Sq. F,t, 576 5 76 0
Cu. Ft.
Type of Construction Fum Est. Cost —•_. $24., 0 -0..s.0 -c -L To be Completed
SEWER LOCATION 166' South of Manhole
WATER LOCATION 154.5' South of Manhole
In consideration of the issuance to me of a permit to construct th building descri ed bove, I agree to do
the proposed work in accordance with the description above set�orOj%and incomplian th /all provisions of
ordinances of the city of,Fridley. Op !i /
100.OG Sewer Connnectio �e
In consideration of the payment of a fee of S 51 a 00 , permit is hereby ted to Charel es Johanson
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 o themprovisions of said
ordinances.
i
a
Clarence Belisle
NOTICE:
This pemmit does not cover the construction, Installation for whing, phmhing, gas henthM sewer or water. Be aura to see
the Building Inspector for wparate permits for then items.
ft _ ' -+
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNM 'S NAME 1�1 I A *1^r%rLj BUILDER(!UADI 17CZ P lnwkU�,QN INC.
CHIAM-F-0 Lt, . Me. -
ADDRESS 580 69th Avenue N. E. 530 69th Avenue N. E.
S Fridley, Minnesota 55 i ADDRESS -r. (Fids 55432
LOCATION OF BUILDIRTC,
NO. STREET�-f
LOT— BLOCK ADDITION OR SUBDIVISION 141e. -z
CORNER LOT IFSIDE LOT
___A_SETBA(=',Y YC 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.
To Be Used As:
P a s , Front
DESCRIFTION OF BUILDING
Depth Height
Square feet /:Z A o Cubic Feet a '-'Z cz.bi
Ah, Front— '1�j Depth Height -
Square feet �76 Cubic Feet
Type of Construction :9A nr Estimated Cost --Zi ale', C,
To Be Completed 1::'c, 7- - f e
The undersigned hereby makes application for a permit for
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. 0
DATE —SIGNATURE LS46--�
(Schedule of Fee Costs can be found on the Reverse Side.)
$%
NO. RATE
TOTAL
Number Fixtures
/_ x $2.00
$
Ya
O
Future Fixture Opening .. .. ....
z
D
Z
U@
3
O 6
w
��
p
F
N
x $3.25
GAS
ELEC.
Water Heater (Up to 99,000 BTU)
'16' x $3.00
$
New Ground Run Old Bldg.
x $3.26
$
Electric water Heater
: $2.00
$
2.0-0
GAS FITTING FEES:
NO. RATE
TOTAL
1st 3 Fixtures ..... .... .....
.. x $2.00
$
Additional Fixtures ..... ..............
x $ .75
$
Gas Range to 195,000 BTU ...............
x $5.00
$
2nd
3rd
4th
_
--
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)
'16' x $3.00
$
New Ground Run Old Bldg.
x $3.26
$
Electric water Heater
: $2.00
$
2.0-0
GAS FITTING FEES:
NO. RATE
TOTAL
1st 3 Fixtures ..... .... .....
.. x $2.00
$
Additional Fixtures ..... ..............
x $ .75
$
Gas Range to 195,000 BTU ...............
x $5.00
$
REPAIRS & ALTERATIONS—Refer to Code
Description .................................. ........
TOTAL FSE $ "
City of Fridley:
The undersigned hereby snakes application for a permit for the work herei
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 fact
and representations stated in this application are, true and correct.
Fridley,
Owner Al -4-R�' (ZL
Kind of Building X/ K 5 L
Used as
I
To be completed about
Estimated Cost, $ - 0 r,
Old—New. Building Permit No.r (O 4 _;X0 1 __Permit,5�. 44 6
Signed &9 I2 1
ROYJG*
FINAL %/
By-- —•
Business Phone No --:i5 5 � 2 9
52-84-5915.51
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 Beater
= $2.00
$—
GAB FITTING :
NO. RATE TOTAL.
1st 3 Fixtures ....... ..................
x $2.00
$
Additional Fixtures . .......... ,.......
x $ .75
$
Gas Range to 199,000 BTU ..............
1 x $5.00
$-3-00
MENEM
0
ME
1M
M
ME
ME
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 Beater
= $2.00
$—
GAB FITTING :
NO. RATE TOTAL.
1st 3 Fixtures ....... ..................
x $2.00
$
Additional Fixtures . .......... ,.......
x $ .75
$
Gas Range to 199,000 BTU ..............
1 x $5.00
$-3-00
RWAIRS R ALTERATIONS—Refer to Code
Description ................................................$
TOTAL FEE $ 3.00
City of Fridley:
The undersigned hereby makes application for a permit for the work herei
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 fact
and representations stated in this application are true and correct.
Fridley, Minn- 10-8-69
19_
Owner C Johnson
Kind of Building fram
Used as res
To be completed about 10-13-69
Estimated Cost, $ 101 00
Old—New. Building Permit No.—".—PIT
PI it . ®.
Signe
By mipgMEAPOLIS GAS CO.
Business Phone No _
ROUGH
FINAI, '
Application for Power Plants and Heating. Cooling, Ventilation. Refrigeration and
Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR:
RATE TOTAL
Furnace Shell & Duct Work ..........................$10.00
$
Replacement of Furnace .............................
6.00 $
Repairs & Alterations—up to $500.00 ..................
6.00 $
Repairs & Alterations each add. $500.00 ...............
3.00 $
MECH. WARM AIR
q�F�ts
Furnace Shell &Duct Work to 120,000 BTU ............$10.00 $ d-�°
each add. 60,000 BTU ....................... 3.00 $
Replacement of Furnace ............................. 6.00 $
Repairs & Alterations—up to $500.00 ................. 6.00 $
Repairs & Alterations each add. $500.00 .............. 3.00 $
STEAM or HOT WATER SYSTEM
Furnace Shell & Lines—ta 400 sq. ft. EDR Steam ......
$10.00
$
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ...
10.00
$
Each add. 200 sq. ft. EDR Steam ......................
3.00
$
Each add. 320 sq. ft. EDR Hot Water ..................
3.00
$
OIL BURNER—to 3 gal. per hour 6.00 $
over 3 gal. per hour—See Fee Schedule
GAS BURNER (up to 199,000 BTU) ....................... 5.00 $
over 199,000 BTU See Fee Schedule
GAS FITTING FEES: NO RATE ssT��OT++A��L
1st 3 Fixtures ...................... x$ 2.00 $—
Additional Fixtures ................. x .75 $
Gas Range to 199,000 ........... x$ 5.00 $
AIR CONDITIONING
FAN HEATING SYSTEM
VENTILATING SYSTEM
ALTERATIONS Be REPAIRS
ROUGH
FINAL -/-L4- 7-7/
See Fee Schedule
0.
TOTAL FEE $ 3
Dept. of Bldgs. Phone 560-3450
Location
City of Fridley:
The undersigned hereby makes application for a permit for the work hereir.
specified, agreeing to do all work in strict accordance with the City Ordinances
and ruling of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
Fridley, Minn 19 6_6
Owner
Kind of Building�-
v% A � n
Used as
To be completed about
$ �
Estimated Cost, / !y 70
—New. Building Permit No. Permit No. cQ %.-2-j
DESCRIPTION OF WORK
BEATING or POWER PLANTS --Steam, Hot Water, Warm Air—No
ha
Trade Name d � Size No-, 1 -
loa, ®� '1�
Capacity. Sq. Ft. E.D.R- E-4. 6 �° BTU } _ H.P.
Total Connected Load S/ Ifo Kind of Fue
/06,
BURNER — Trade Name �`��'�� Size No_ ea, ®� d
Capacity Sq. Ft. E.D.R I BTU H.P.
(REMARKS—OVER)
Signe h
as Business Phone No- W- �-5-2 9f/%
Original
PERMIT for Power flants and Heating. Cool-
ing. ventilation. Refrigeration and Air
Conditioning Systems and Devices
DESCRIPTION OF WORK
No. of Pleating Plants to b 'Hata ltered—repaired
MakeSize—;!!90-
�/-/O® .
Sixe /�� �%a �P� ,
Oil fired—,- Coal fired—,- Gas fired ; Gas Authorization No.
Remarks
Approved
Final Inspection
19_
Inspector
-�-c316
Permit N° 4672
Fee $ o5.7.
Office of the Inspector of Buildings
City of Fridley
City of Fridley, Minn., 1221AA a_ , 191-0
Owner
Location cn (/ " )& je- .
Kind of Building �(� 4
Aan
How Occupied �1,w-
Work to be Commenced—, 19
To be Completed ,19_
Estimated Cost, $ /AI/%G•d 0
(9DVew, Building Permit No.
Permission is hereby granted l Y � --h'�to install---erect—use the material and devices described in the
above statement. This permit is granted upon the express condition that the person to whom it is granted, and his agents, employees and workmen, in all the work
done and materials used under this permit, and in the operation of the devices herein mentioned shall conform in all respects to the ordinances of the City of Fridley
relating to or governing the work to be done and the operation of the devices herein named, and to the specifications set forth in the approved application for this
permit on file in the office of the Inspector of Buildings.
UIA-Q-E A .,rJ, �'�a � , Inspector of Buildings
42 2MIWb
In AM, N® 497
Original Permitr IFLUMBING AND GAS FITTING
N.B. When work covered by this permit is ready, the Plumbing Ordinance requires that request for . I �00
inspection shall be phoned in to the plumbing Inspector, 560-3450 giving number of this permit.,
DESCRIPTION OF WORK
Number, Sind and Location of Fixtures
City of Fridley Q
E W 4 to S4F W
Stories
F�
O
Q -1
U
Z
a
7
x m
F m
4❑
M F
t
W
Q
m
Y
?
N
� r
Q
4 E
F
Z Z
❑
E O
❑ LL
$
O
Z
(p
O Z
O 4
J M
LL p
U Z
F m
Q Q
U W
Z m
C
Q❑
E -1
v
G %
E LL
.1
an d
Q u.
G Q
W
O
0 Z
Q Q
C9 tC
WATER HTR.
GAS
ELEC.
Basement
iL
ist
s
a
2nd
3rd
4th
Connected with Sewer -Cesspool Gas Piping
Permission is hereby granted to do the plumbing and
gas fitting in the building described n the statement hereto attached, upon the express condition that
the person to whom this permit is granted, and his agents, employees and workmen, in the plumbing
or gas fitting of said building shall conform in all respects to ordinances of the City of Fridley, and
this permit may be revoked at any time upon the violation of any of the provisions of said ordinances.
By Order Of The Inspector Of Buildings
Roughing in Inspection Date
Inspector.
Final Inspection Date
Inspector.
az JM -6-65-V
Owner —�
Location
Kind of Building
Used as
To be Completed
Estimated Cost
Old -New. Building Permit No. n 0 -2 (2
Date
Inspector of Buildings.
CITY OF FRIDLEY INSPECTION DIV. Effective On January 1, 1991
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
572-3604
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
1/yater
ries Urina
::_::.:.:.....:
....:.::::
w r
NOT
.
Wash
Floor
. Drain
tc>:: Auto.:::<:::
.
Gas
Range
ItiS�X<� l� Water He
Gas ElecSt
Basem n
Rain Water Leader
$ 7.00
Sump/Receiving Tank
$ 7.00
Water Treating Appliance
$10.00
Water Heater -Electric
$ 7.00
Floor 1
$10.00
Gas Range
$10.00
Gas Dryer
$10.00
Back Flow Preventer Required ( )Yes () No
:;.
r
Floor 2
�I
Floor 3
FI r
00 4
PLUMBING FIXTURE RATES: NO. RATE TOTAL
New Fixtures
$ 7.00
Old Opening, New Fixture
$ 4.00
Beer Dispenser
$ 5.00
Blow Off Basin
$ 7.00
Catch Basin
$ 7.00
Rain Water Leader
$ 7.00
Sump/Receiving Tank
$ 7.00
Water Treating Appliance
$10.00
Water Heater -Electric
$ 7.00
Water Heater - Gas _
$10.00
Gas Range
$10.00
Gas Dryer
$10.00
Back Flow Preventer Required ( )Yes () No
Type
$5.00
Reinspection Fee $30.00
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1 % of Value of Fixture or Appliance _
State Surcharge .50
TOTAL FEE $_VaSo
JOB AD
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
and rulings of the Building Division, and hereby declares that all the facts
and representations stated in this application are true and correct.
--1 .1991
Owner t -0F'_1 1,
Building Used As r,e mac- oo -
Estimated Cost .PERMIT NO. IiLlq
PLUMBING MIAPAW1ttfl,
700 W. Linden Avenue
SIGNED BY�n Box 1165 --TEL N0.
Minneapolis, MN 55440-1155
Approved By Rough -In Dae' °
MINIMUM FEE FOR ANY PI I1MRINrrtr,Ac P9=0hAtr IC AtIM nn
PLUS THE $.50 STATE SURCHARGE
CITY OF FRIDLEY INSPECTION DIV.
Effective On January 1, 1995
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER
PLANTS AND HEATING, COOLING, VENTILATION,
572-3604 REFRIGERATION AND
AIR CONDITIONING SYSTEMS AND DEVICES
�L
JOB ADDRESS 1 C
RATE .SCHEDULE
The undersigned hereby makes application for a permit for the work herein
Residential
Rate
TOTAL
specified agreeing to do all work in strict accordance with the City Codes ar
Furnace Shell and Duct Work, Burner —
rulings of the Building Division, and hereby declares that all the facts and
Also Replacement Furnace
$ 20.00
$ �U
representations stated in this application are true and cgrrept.)�
L�1995
(Side Vent — Fill Out Back)
Gas Piping (Needed with new furnace)
$10.00
$
OWNER__
Gas Range
$10.00
$
�%� L6
BUILDING USED AS d __
Gas Dryer
$10.00
$
r
COST �®® PERMIT NO._
- 144
*�ir Conditioning —All Sizes
$10.00
/ESTIMATED
$ 00
-�
DESCRIPTION OF FURNACE AND OR BURNER
All Others/Repairs & Alterations (LIST ON BACK)
�ar
1% of Value of Appliance or Work
$
No. of Heating Units Circle One (Steam) (Hot Water)
?'15 Size No.
Trade Name
Commercial/Industrial
BTU SbC®® HP EDR
I% of Value of Appliance or Work
$
Fuel , Total Connected Load
State Surcharge
TOTAL FEE
1
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $15.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $30.00
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
Burner Trade Name Size No.
BTU HP EDR
HEATING COMP
igned B �S�
Approved B Rough—In Date Final Date
— 44 r
FILL OUT BACK SIDE FOR STACK VERIFICATION ON
REPLACEMENT FURNACE
NOTE: #1 through #8 required when using a side vent furnace.
CHIMNEY AND STACK YERIFICATI�
The undersigned hereby verifies that the existing chimney or stack:
1.
Has been carefully examined
Yes {)
No
( )
2.
Is free from nest or deterioration
Yes ()
No
( )
3.
Has no foreign objects lodged within
Yes ()
No
( )
4.
Is securely supported
Yes ()
No
( )
S.
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
7.
Has a liner been provided for water heater
Yes (
)
No
( )
8.
Has combustion air been provided for crater heater
Yes (
)
No
( )
Remarks:
HEATING CO:
Signed By:
Date:
NOV-16-2004 10:25 CITY OF FRIDLEY
Ntvv1 I.1/ AIp4 1
ADDN [ j V I ✓ J 6431 University Ave, NE, Fridley, MN 55432
/�
ALTER j j � 1 SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Addre
Legal Description:
(763) 572604 Bldg lnsp
(763) 571-1287 Fax
Owner Name & Address: V)D Tel, #
Attach to this application, a Certificate of Survey of the
bt, with the proposed construction drawn on into scale.
DESCRIPTION OF IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA; Length Width Height Sq_ FL
DECK AREA:
OTHER:
Width
Hot/Ground
Sq. Ft.
Construction Type: Estimated Cost: $ 3s l oo
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ =$
DATE /90 APPLICANT: Tel.# 151 rL-X3®6
Call (763) 572.3604 for Permit Fees if mai ing in application. Fax to 763-5714287 if using credit card and we will cail
you for card number.
Permit Fee
Plan Review
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
S— tof f i 1,000 VNLT -
$ Fee Schedule on Reverse Side
$ 65% of Permit Fee
$ 3 • Co r .001 of Permit Valuation (1/10th%)
$ $.50/$1,000 Valuation
$ $1350 per SAC Unit
$ S - c�� $5.00 (State Licensed Residential Contractors)
$ Alt. °'A" or Alta "B" Above
$ $450:00 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [
STIPULATIONS:
From: City of Fridley To: 7r-.�7542908 Page: 414 Date: 4116/2009 11: 00:10 AM
Buiiciin PLUMBING
inspections R. SID1 TLA.L APPLICATION
76_ -:S_7`? -36.0 - CITY CSP F , LES''
1763-502-4977 F.Al;
EFFECTIVE 2-19-09
Permit Na'
Ree ti
Date e _
DATE. I�� I�� f�trp { YOUI' H -MAIL ADDRESS
SITE ADDRESS
HIS APPLICANT IS: El OWNER "ONTRACTOk
PROPERTY NAME: 4kt garne ife
OWNER/ N ADDRESS: !s Lii gat' CV2L1�- Pay 1415 CITY i YI �9 STAT> LIP ✓ �2
PHONE: YS5
CONTRACTOR NAME: I7,1Y21' Gi�y �`I�Lrl1%1�v1 Cd
SUBMIT A COPY OF
YOUR STATE STATE LICENSE if EXPDATE
I
LICENSE, BOND AND STATE BOND /l EXP DATE
CERTIFICATE OF ADDRESS: Siq'p 01t i 1() clt kuI "11 CITY �'o4e STATE ZIP MqZ
INSURANCE PHONE '_V5- 15-f- FAX VV5- Jdi 2`l
PERMIT TYPE SINGLE FAMILY M TWO FAMILY ❑ TOWNHOUSE
11 TYPE OF WORK: 113 NEW (REPLACEMENT
DETAILED DESCRIPTION OF WORK JIASi'U11 MV1V
FEES ARE BASED ON $10.00 PER FIXTURE EXCEPT WHERE NOTED. FIXTURES: ('INDICATE TOTAL NUMBER
OF EACH BELOW). MINIMUM FEE
$35.50.
DRAINS
_WATER PIPING
_BATHSINK/LAV
_FLOOR
GAS PIPING (NEED CITY LIC)
_SHOWER
POOL
WATER SOFTNER ($35)
_BATHTUB
WASHER
_
KITCHEN SINK
_SWIMMING
WATER CLOSET
BACKFLOW PREV. ($15)
_CLOTHES
DISHWASHER
_
LAUNDRY TRAY
_
I WATER ($35)
FOR IRRIGATION
_
_
WATER METER—OTHER
THIS IS AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes: that I understand this is
not a permit but only an application for a permit and work is not to start without a permit on site-, that the work will be in accordance
with the approved plan in the case of all work which requires review and approval 1of plans.
SIGNATUREOF APPLICANT 'V vl/4G PRINT NAME (�-1` DATE
i
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, TMN 55432
763-572-3604
FAX: 763-502-4977
M
'Building
BUILDING
Permit No.:
InspectionsRESIDENTIAL
APPLICATION Receiv ed
763--4
572
LU
CITY OF FRIDLEY
,B
Da PVJ
763-SQ2-4977
977 FAX
EFFECTIVE 1-1-2010
DATE �� ®
YOUR E ADDRESS
SITE ADDRESS ofe
cl - 43!4E da Alt
THIS APPLICANT IS:
❑ OWNER X ONTRACTOR
d
PROPERTY OWNER/
NAME: e
TENANT
ADDRESS:�yw drAr"'g' yo/ CITY
e STATE& .�Si
PHONE: �� � �"� � Q f'',�
CONTRACTOR
NAME:a%.tz,1s,V "-
SUBNVIIT A COPY OF
YOUR STATE LICENSE
STATE LICENSE # EXP DATE
AND CERTIFICATE OF
ADDRESS:3 4 M- /% &,W _
aAre'ow
INSURANCE
PHONE 9 r-2— 17 91 4 3470 FAX
PROPERTY TYPE
SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMU Y/NEW CONSTRUCTION STORIES
PERMIT TYPE
❑ ADDITION ❑ GARAGE/SHEDWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK:
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
LENGTH WIDTH
HEIGHT SQ FT
O
11 HOUSE ONLY
BER
NUMBER OF SQUARES
❑HOUSE &GARAGE
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES
❑ ATTACHED GARAGE
2. Proposed floor plan
PROPOSED SIZE:
❑ DETACHED GARAGE
3. List of structural members to be used
PROPOSED HEIGHT:
SIDING
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl
❑Soffit
ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum
❑ Trim
1. Site Plan/Survey showing the existing structures
❑ Other
❑ Fascia
and proposed project.
WINDOWS \
2. Two sets of construction plans
IN EXISTING OPENINGS dKes
❑NoATIO OF WINDOWS
3. Energy Calculations
FOR WINDOWS - PROVIDE U -VALUE AND
OR FOR NEW OPENINGS -DESCRIBE SIZE OF /�d�C/�
MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED d 1:&0q, NUMBER OF WINDOWS
♦ T T TTT.1C
zsa rrGa Axe nAaLL VIN VA1.UXHL O1V, INCLUDING THE COST OF LABOR AND MATERIALS:
— -(U-WG THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
./7&'V OCCUPANCY TYPE
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ , 001 times the total job valuation
$ o 0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= f.x$22=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ 104 Agreement necessary ( ) Non Necessary ( )
$ ® a Make checks payable to: City of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the2ofy and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and wstart without a permit on site; that the work will be in accordance with the
approved plan in the case of all wor hich req ' pproval of plans.
vSIGNATURE OF APPLICANT RiNI NAME ��'v ®� o Id DATE /Z r