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PRE 2010 DOCSCity of Fridley, BUILDING PERMIT M(:5:5j3) Date: µ- Owner:Builder Address _-- _ __ Address --- r LOCATN OF BU DING No. r _ Street Lot _ __ Block _ _ — Addition or Sub-fv ision° Corner Lot w Inside Lot " Setback _ ..._ Sideyardf_ Sewer Elevation Foundation Elevation _ DESCRIPTION OF BUILDING To Used L/A1,05 Front _ _ Depth Height ' Sq. Ft. .. ,0 7 Cu. Ft.' _ rrnnv Depth49k.Ut Sq. Ft. _ _ cu. Ft. V or Type of Construction . e: Est. cost , a 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 all provisions of ordinances of the city of Fridley. In consideration of the payment of a fee of $-A'�, 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 buff Ings within the city limits and this permit may be revoked at any time upon lation.of of the provisions of said ordinances. .s"" 1./i V " m '. Inspector NOTICE: This permit does not cover the construction, installation for whing, plumbing; gas heating, sewer or water. Be sure to see the Building Inspector for separate permits for these items. APPLICATION FOR BUILDING PERMIT CITY OF FRIDIEY, MINNESOTA Owner's Name Builder �"Lae�Lc�c� C P Address AddressJ,��l LOCATION OF BUILDING No.�. Street a Part of Lot Lot Black �„ Addition or Subdivision li�V tv kW�+ Corner Lot Inside LotSetback .- Side -Yard SEWER ELEVATION FOUNDATION ELEVATION Applicant attach to this form Certificate of Survey of Lot and proposed building location. To be used as: W q. k z, DESCRIPTION OF BUILDING q1. Sq. Ft. O® C. U Cu. Ft. Front Depth Height i Sq. Ft. Cu. Ft. Type of Construction R\,� z Estimated Cost LAG o o� To be Completed (a a--% k\--. 5, The undersigned hereby makes application for a permit for the work herein 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. DATE 'qZxe A �_ 1 at (_1_ _ SIGNATURE %A (A Schedule of Fee Costs can be ford on the Reverse Side.) City of Fridley AWIcation fcw Plonbing and Gas Fisting Permit Dept of Bldgs. Phone SII 4-7470 DESCRIPTION OF WORK Number. Kind and Location of Fixtures Location PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ...................... x $1.50 $ `5 0 Future Fixture Opening ................ x 1.20 $ dew ? • R WATER HTR. � N -AS ELEC. 86 $Ci Catch Basin ............................ x 3.25 $ Water Beater (Up to 200,000 BTU) ...... ` x 2.00 $ ®� New Ground Run Old Bldg . ............ �d 190 $ Base e GAS FITTING FEES: NO. RATE TOTAL 1 6 0 1st 3 Fixtures .......................... x $1.50 $ Additional Fixtures .................... 1st .50 $ Gas Range to 200,000 BTU .............. x 2.00 $ 2nd 3rd 4th — Future Connection Openings Connected 'with New Fixture, Old Openings I Sewer Cesspool El PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ...................... x $1.50 $ `5 0 Future Fixture Opening ................ x 1.20 $ New Fixture Old Opening .............. x 1.00 $ Catch Basin ............................ x 3.25 $ Water Beater (Up to 200,000 BTU) ...... ` x 2.00 $ ®� New Ground Run Old Bldg . ............ x 3.25 $ GAS FITTING FEES: NO. RATE TOTAL 1 6 0 1st 3 Fixtures .......................... x $1.50 $ Additional Fixtures .................... x .50 $ Gas Range to 200,000 BTU .............. x 2.00 $ REPAIRS & ALTERATIONS—Refer to Code Description................................................$ TOTAL FEE $ City of Fridley: The undersigned hereby makes application for a permit for the work herein 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. Owner _ / o �i <>e� 19— Kind of Building 19— Used as o To be completed about Estimated Cost, $ Old—New. Building Permit No Sign aP By Business Phone No. 2- 11 POST 1M-12-58 AppEcatim for Power Pkmti and Heaft. Coolling. V9~0n. Ash i9ei uEN""I and Air Conditioning Systan and Devices PARTIAL RATE SCHEDULE DepL of Bldgs. Phone ISU. 4-7470 GRAVITY WARM Al2: RATE TOTAL, 1� Furnace Shell & Duct Work ........................... 8.00 Replacement of Furnace ............................. 5.00 $ Repairs & Alterations—up to $500.00 .................. 5.00 $ Repairs & Alterations each add. $500.00 ............... 2.50 $_ �­ 7 �4 Furnace Shell. & Duct Work to 120,000 BTU ............ 8.00 $ .each add. 60,000 BTU .................. 2.00 Replacement of Furnace .............................. �§.00 Repairs & Alterations—UP to $500.00 .... ............ 5.00 $ Repairs & Alterations each add. $500.00 ....... 2.50 $ Furnace Shell & Lines—to 400 sq. ft. EDR, Stearn....... 8.00 $ Furnace Shell & Line—to 640 sq: ft. EDR Hot Water ... 8.00 $ Each add. 200 sq. ft. EDR Steam ...................... 2.50 $ Each add. 320 sq. ft. EDR Hot Water .................. 2.50 $ OIL BURNER—to 3 gaL per hour ........................ 5.00 $ over 3 gal. per hour—See Fee Schedule GAS BURNER (up to 400,000 BTU) ....................... 5.00 $ GAS FITTING FEES: NO RATE TOTAL 1st 3 Fixtures ...................... x $1.50 $ Additional Fixtures ................. x .50 $ Gas Range to 200,000 BTU ........... x 2.00 $ AIR CONDITIONING FAN HEATING SYSTEM VENTILATING SYSTEM ALTERATIONS & REPAIRS ROUGH FINAL $ 4 �See Fee Schedule 9 TOTAL Fft M 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. Owner Kind a. Used ai To be c Estimatect cost, t OltL' oew. uilding Permit No: .,�/ Permit N.. DESCRIPTION OF WORK HEATING or POWER PLANTS—Steam, Hot Water, arm Air' N d'&u Trade Name- Size J, 1 VV Capacity. Sq, Ft. E.D.R- / (E-2) )21 — BTU H.1 Total Connected Load 7 < � -2- � Kind Of Fue ? f BURNER —*Trade Name Size No Capacity— __ - ____ Sq. Ft. E.D.R BTU— HI (REMARKS -OVER) Sign By -W_-4-42 2M 749 BusifiUfMQ*cV_1EAT1NG COMPANVINC; 293A FOURTH AVF- SO, , TA. 3.5209, MMULMM a MINNE5014 D-56 v •- Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft.,,� Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. HEAT LOStS CALCULATIONS DEPARTMENT OF BUILDINGS MINNEAPOLIS, MINN. Weatherstrips A.S.H.V.E, Construction No. 11 Infiltration Exp. wall Insulation 'r Guide Int. wall Exp. wall Ceiling Exp. wall Windows Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kind How. Applied Yes—No 1 Yes—No 19_ Ceiling Ceiling r XFl.l s� :,,. Room Length .`.. a Width $ � Height II � F1J � � .� z,r. ` Room I Length ; ; Width `,� Height Windows and oors—Crackage an Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft.,,� Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. � _-ALL Coef. Btu Infiltration p'" Coef. Btu Infiltration Exp. wall IInfiltration 'r Glass Int. wall Exp. wall Ceiling Exp. wall Floor'' Int. wall Net exp. wall Net exp. wall Floor �'•" r Int. wall Ceiling Ceiling Floor Floor "PA Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Fl.� z b Room I Length �> Width Windows and Doors—Crackage and Area Width Height No. of Lineal ft. Area No. of pane of pane llghts of crack sq. ft. Height Coef. Btu Infiltration Glass" . Exp. wall , Net exp. wall Int. wall Ceiling Floor_ Total Btu. - ; ,6 Required sq. ft. E.D.R. or sq. ins. W.A. Leader area , Room I Lenrtth 3 Width ice' Height '� Windows and' Doors—Crackage and Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft.,,� Width Height No. of Lineal ft. Area of pane of pane lights of crack sq. ft. Coef. Btu Infiltration p'" F, Glass' Coef. Exp. wall IInfiltration Net exp. wall Glass3� Int. wall Exp. wall Ceiling Net exp. wall Floor'' Int. wall Total Btu. s�>* Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Windows and Doors—Crackage and Area No. Width Height No. of Lineal ft. Area of pane of pane lights of crack sq. ft. Coef. Btu Infiltration$ Coef. Coef. Btu IInfiltration Glass Glass3� $ Exp. wall Exp. wall Net exp. wall $ Int. wall Net exp. wall Ceiling Floor �'•" r Total Btu. ri n •_ ' Doors—Crackage and Area Windows and Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. Coef. Btu Infiltration$ Coef. Btu Infiltration Glass .V' Exp. wall Glass`.n $ Net exp. wall Exp. wall Int. wall Ceiling Net exp. wall Floor Int. wall Ceiling Floor ��;��` Total Btu. Required sq: ft. E.D.R. or sq. ins. W.A. Leader area 1,s' Reem 1 Length Width ' .,Heiaht � Windows and Doors—Crackage and Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. Coef. Btu Infiltration$ . Glass .V' Exp. wall $ Net exp. wall Int. wall Ceiling Floor Total Btu. ; Required sq. ft. E.D.R. or sq. ins. W.A. Leader area �5 7017 QV of L. OWILDING PERMIT ,• 7243 Date: v 6� 4 el Owner: Builder -- Address Address D e LOCATI F No.Street (-2/-t -'f A:edd 77%ze I AT Lot _Block Addi on or Corner Lot Inside Lot _ �� Setback LDING Part of Lot 7 k Sideyard — _ . Sewer Elevation _. Fodation Elevation DESCRIPTION OF BUILDING 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 setforth and in compliance with aft provisions of ordinances of the city of Fridley. , // ,/° ,, 'L,_ _ 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 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 violatioaygf any of the provisions of said ordinances, 11 � f Building Inspector NOTICE: This permit does not sorer the construction, bstaWon for whtng, plumbing, gas heating, sewer or water. Be sero to see the Building Inspsetor for soperate permBs for than hoem a .APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAME I�___/_' ''� ; � '� C ��✓� BUILDER ADDRESS . , d C -T ADDRESS , (Z. LOCATION OF BUILDING No. __. Street Bart sof Lot Lot. Block,.. Additioa or Subdivision Corner Lot Inside Lot Setback Side -Yard - SEWER ELEVATION FOUNDATION ELEVATION Applicant attach to this form Two Certificates of Survey of Lot -and proposed build- ing•location drawn on these.Certificates. DESCRIPTION OF BUILDING To be used as: Front Depth. Height. Sq. Ft. Cu- Ft.. .. Front Depth Height Sq. Ft. -Cu., Ft --- -- Type of Constructione24'? Estimated •.Cost%' To be Completed The undersigned hereby makes application fora 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. jSchedule of Fee Costs can be found on the Reverse Side). SUBJECT City of Fridley ° 27763' 7763 AT THE TOP OF THE TWINS BUILDING PERMIT RECEIPT NO. COMMUNITY DEVELOPMENT DIV.® - PROTECTIVE INSPECTION SEC. r e 1 e NUMBER REV DATE PAGE OF APPROVED BY = CITY HALL FRIDLEY 55432 �`� 612-571-3450 910-F15 9/14/98 JOB ADDRESS 124 Rivers Ede Way NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 22 1 River Ede Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Raymond Rucinski Same 571-3963 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Joseph Paul Herzog 5538 Mayyiew Rd Minnetonka 553 933-7812 1596 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 IR . REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof house & garage (24SQ) Tear-off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with the 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 PAYS, 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 BE COMPLIED $2,056.80 $1.03 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOT FEE 114 L Yp xls� SC$ .00 $82.84 SIGN TU RE OF CONTRACTOR OR AUT AGENT (DATEI EN R VALIDAT& THIS IS 4 PERMIT BL G )NSP pa TE SIGNATURE OF OWNER OF OWNER BUILDER) IDATEI NEW [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: Legal Description: Owner Name & Address: Ra, yacry, Rt) _11A 15; ( Tel. # L- 39 �3 Contractor: 'PC , MN LICENSE # GQO ESQ 4 Address: Tel. # 'J33 -'JS t 2 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 GARAGE AREA: Length Width DECK AREA: Leng Width OTHER: J,Lol P'r— Construction Type: Driveway Curb Cut Width Needed: Ft. + 6 Ft = DATE: APPLICANT: Height Sq. Ft. Height Sq. Ft. Hgt/Ground Sq. Ft. Estimated Cost: $ (Fee Schedule on Back) Ft x $ = $ Tel. # . STIPULATIONS: CITY USE ONLY Permit Fee $ -'17 ® if 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 Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ] TOTAL $ s . STIPULATIONS: V CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 572-3604 Stories Basement Floor 1 Floor 2 Floor 3 Floor 4 PLUMBING FIXTURE RATES: APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR Bath Wash Drink Floor Catcst„` Auto. Urinal Tub's; Shower Sink; Tray Fount Drain Basin;:: Washer NO. RATE TOTAL Effective On January 1, 1998 Gas :Mist Water Heater Range Fixt Gas Elec JOB ADDRESS tZ�i���r ���� �ca.t,l New Fixtures $ 7.00 The undersigned hereby makes application for a permit 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 �� )MONIA UL � Water 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 $15.00 Reinspection Fee $42.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance -zcxco State Surcharge $ .50 TOTAL FEE $7-0 5'0 Building Used As Estimated Cost _ � 00 PERMIT NO. /a 3 -! PLUMBING COMPANY_'(hc- Gulp -r' ; st” S Approved By Rough -In Date f=inal MINIMUM FEE OR ANY PLUMBING GAS PER IT ,Dat$e 20.00 PLUS THE $.50 STATE SURCHARGE **COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE.6-A. MINIMUM SIZE 9 SQ INCHES. 01 SUBJECT City of Fridley 3 i 574 AT THE TOP OF THE TWINS BUILDING PERMIT r RECEIPT NO. i1r _-_-� COMMUNITY DEVELOPMENT DIV. : PROTECTIVE INSPECTION SEC. / CITY HALL FRIDLEY 55432 NUMBER REv DATE PAGE OF APPROVED By L 612-571-3450 910415 11/20/00 10B ADDRESS 124 River Edge Way NE 1 LEGAL LOT NO, BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 22 1 River Edge Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Raymond/Doris RUcinski 124 River Edge Way NE 571-3963 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Wellington Windows 3938 Meadowbrook Rd, St Louis Park, MN 55426 952-933-6300 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 ❑ ALTERATION CA REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Replace windows within existing openings 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. Puet Inspect a ;'* 10 Be a'Hed Tod Hamenwor To Pest 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 1 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 13,547 $6.77 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- Fire SC $13.45 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION PLAN CHECK FEE TOTA EE $A7.47 SIGNATURE OF CONTRACTOa OR AUTHORIZED AGENT iDATEi E p�VALIDATED HIS IS YOUR PERMIT , <iNS�MPI BL pAtE S.GNATURE OF ONEROF OWNER BUILDER, tD WATE� 01 NEW I l Effective 1/1/2000 ADDN [ ] CITY OF FRIDLEY (763) 572-3604 Bldg Insp ALTER [ J SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION L4 3 /LUC Construction Address: _)D4: �-(V�L Ple Legal Description: Owner Name & Address: G # cl Contractor: `I S Biu `( MN LICEEd E # eAqAddress: C(,b t # ��,� J�0, 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: Construction Type: Zt?fi L1, M W tL�istimated Cost: $L--/ S qZ Driveway Curb Cut Width Needed: Ft. + 6 Ft= Ft x $ _ $ ((\ `�� DATE: APPLICANT: CY Tel. # =�2s�v CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application Permit Fee $ �3a• 'S Fee Schedule on Reverse Side ,\ Fire Surcharge $ �� .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge $ $1100 per SAC Unit License Surcharge $—� t�7 $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 $ P��, STIPULATIONS��v�'/,,' , :.0"iFie '/'T����� .100�0405 ,moo asp ,14�