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PRE 2010 DOCSBUILDING PERMIT Village of Fridley, Minn.? 2575 Date ...... .: .. �. ` ......... Owner .. Builder .�. ....:...... ............. .............. .......... Address Address .......... LOCATION OF BUILDING No.. ... Street ... �. .. .... Part of Lot ........................ -, Lot ................ Block ................ Addition or Sub -Division , , , , , ........... Corner Lot ............ Inside Lot . Setback - . Sideyard .. DESCRIPTION OF B ILDING To be Used as: Front ... .� Depth . �.. Height ::. Sq. Ft.. .. Cu. Ft, ........ Front ........ Depth ........ Height ........ Sq. Ft......... Cu. Ft........ . Type of Construction Est. Cost 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 village of Fridley. X� .............. In consideration of the payment of a fee of $., , :.. , , permit is he to construct the building io d dition as described abovvee the express condition that the person to whom it is granted and his agents, employees and workmen, in all wor done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of Fridley, Minnesota regarding location, construction, alteration, maintenance, repair' and moving of buildings with- in the village limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. Building Inspector n� NOTICE:' This permit does not cover the construction, installation or alteration for wtOng, plumbing, gas heating, sewer or water. Be sure to see the Building Inspector for separate permits for these items. 3rd. 3200 FRANCE AVE. S0. STREET N.E. I : N !$A:-- "419"W"92.2 13 70 of= 4 N 976 75 .2 4994 75 t0d 2 4952/N�N 75 40.2 4840 78 40.2 V4"i228 N N 79 is .2 1 �--- ///j . N' V 918 I 21 lI ;_- ... N N iw X0.2`Y 7.1 N !I� V te.1 •p r N •+ ir. 262 N ... p I .I - T- - - - i � 14 26.2 s 15 16 IT 3 Drlin9 e $ 04r 18 4;0 Fise" of 19 20 yb L— —43 — — — 76— — — 7!— — --79 — —75---- —76-- —g0-- — 26.2 1 n ► I _2410 .9_ 24.2 1 M77771 . j � o N I 1 0 l4p 40. b A04N 49 77 N 14 40 2 a 48 85 N �q 9_ 40.2 N Igo 4 b 3 N s 40 2 N-14.1 9 494 Iv 2 -Z[1,44 40.2 I I 95.2 - 0Q9N 4 N a 314 l r4�817 4 N a - ' 7 -�e e a .^ 1 B w 84 ' 70 '73 71 at off~ 70+ --- ROMAN . I hereby certify that the above is a survey of Lata One (1) through Twenty (20). Block Three (3).,CARLiONIS.9 OUT MANOR SOUTH ADDITION• Anoka County, Minnesota. showing the location of the houses on said lots. As surveyed by me this 18th day of April 1955 A. D. Signed �. Minaeaoto Registration No. 2c84 a' ROAD ij Z W Q .0 4M• SUBJECT - PERMIT NO. City of Fridley ® 13150 AT THE TOP OF THE TWINS BUILDING PERMIT RECEIPT NO. COMMUNITY DEVELOPMENT DIV. INSPECTION r � � PROTECTIVE SEC. �� 1 � � CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 812-560-3450 910-F15 8- JOB ADDRESS 4917 ROMAN ROAD N.E., FRIDLEY MINNESOTA 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 4 3 1 CARLSON' S SUMMIT MANOR SOUTH ADDITION SHEET 2 PROPERTYOWNER MAIL ADDRESS ZIP PHONE THOMAS KELLY, 4917 ROMAN ROAD N.E. 3 CONTRACTOR MAILADDRESS ZIP PHONE LICENSE NO. D.W. CONSTRUCTION, INC. 8804 LEXINGTON AVENUE NEW BRIGHTON MINN. 55112 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING RESIDENCE 7 CLASS OF WORK ❑ NEW XX ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK CONSTRUCT PATIO DECK & CABIN ETS 9 CHANGE OF USE FROM TO STIPULATIONS WA RNONG Before digging call local utilities TELEPHONE - ELECTRIC - GM Etc. REQUIRED BY LAW SEPERATE PERMITS REQUIRED FUlt VV iA14G, HEATING, PLUMBING AND SIGNS. TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. FRAME 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 R-1 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. $1.25 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $2,500 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SACCHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. $15.00 / PLAN CHECK FEE TOTALFEE '2 - 16-.25 SIGNATURE OF CONTRAC ORAUTHORIZEDAGENT (DATE) HEN PROPERLY V DATED THIS IS YOUR PERMIT 8-22-75 BLDG INSP DATE SIGNATURE OF OWNER (IF OWNER BUILDER) - (DATE) I • ' APPLICATION FOR RESI'DE'NTIAL., ALTL'ItATION, OR ADDITION•BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAriE . BUILDERL�Z�; ADDRESS : 2 s ADDRESS : o %. A ®. R z NO:. STREET: LOT: d_ BLOCK: ADDITION.: CORNER LOT: INSIDE LOT: SETBACK: SIDE -YARD: Applicant attach to this form, Ttao Certificates -If Survey . of Lot and . proposed building location c:.tawn on these Certificates. DESCRIPTION OF BUILDING To Be Used•As: SCK Front: J 2 Depth : eight: Square Feet: Cubic.Feet: Front: Depth: Height: Square Feet; Cubic Feet: Type of Construction: Estimated Cost: $ To Be. Completed: 6 o 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: (See Reverse Sidb For Additional Information.)' 2,500 X 6.00-C. �S�o K ,so /ate SUBJECT PERMIT NO. City ®f Fridley2 ®6 5 3 AT THE TOP OF THE TWINS BUILDING PERMIT r COMMUNITY DEVELOPMENT DIV. *' _ PROTECTIVE INSPECTION SEC. �� n (� _ , CITY HALL FRIOLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY I.J 612-571-3450 910-F15 10/31/90 JOB ADDRESS 4917 Roman Road N.E. 1 LEGALLOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 4 3 Carlsonts summit Manor South Addn. SHEET 2 PROPERTY OWNER MAILADDRESS ZIP PHONE 572-8686 Tom Kelly 4917 Roman Road N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. D & D Home Improvement 7401 Central Avenue N.E. 784•-7543 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 3V ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof Dwelling (18 Squares) Tear -off 9 CHANGE OF USE FROM TO STIPULATIONS tear -offs and replacement roofs, �n all new roofs or that 2 l of 15 1b. 24 ii ches State Code requires b.9 install d 10 the mapnsd together, use of other �r up from eacterior wall line, approved underlayment membrane. TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. ZONING SO. 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 Z ISTALLS 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 $9010, $.50 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT PERMIT FEE SAC CHARGE DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PRO VIS S OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- � $23. QQ STRU 10 OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTALFEE 4 F re Sc $.90 $24,40 SIGNATURE OF CONTRACTOR OR AblffORTZED AGENT (DATE)EN WHPROPERLY VALIDATED THIS IS YOUR PERMIT s /o 6 BLD ;FISP FIAT SIGNATURE OF OWNER OF OWNER BUILDERI IDATEI NEW [ ] Effective 8/16/90 ADEN [ ] R-1 AND R-2 ALTER [ ] Building Permit Application Construction Address: Legal Description: Owner Name & Address: Tel. #��=� ( Contractor:D ' /��_. /��,�, Tel. # 7 Address:, Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. LIVIM AREA: Length Width Height Sq. Ft. GMRAGE AREA: length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. Off: Corner Lot [ ] Inside Lct d tback Side Yard Setbacks Type of Construction: `� -�1�i ,� Estimated Cost: Approx. Coppletion Date: ® l� Proposed Driveway Width If News Desired: Ft. $ $ �ry Width + 6' See Back Page DATE: X AC.� APPLICAt� T: Tel. # CITY USE ONLY Permit Fee $_<� Fee Schedule on Reverse Side Fire Surcharge .001 x Permit Valuation (1/10th %) State Surcharge $.50/$1,000 Valuation SAC 0mrge $ $600 per SAC Unit Driveway Escrow $ Alt. "A" or Alt. "B" Above Park Fee $ Fee Determined by Engimering Sewer Main Charge $ Agreement Necessary [ ] Not Necessary.[ ] TOTAL STIPULATIONS: CITY OF FRIDLEY Effective Date May 1. 1988 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND D7: as RATE SCHEDULE RESIDENTIAL � RATE Furnace Shell and Duct '`tort. Burner (Also replacarent furnsee) $ 20.00 Gas Piping 10.80 (piping needed titk mw furnace) Gas Range $ 10.00 Gas Dryer $ 10.00 Ain Conditioning (all sizea) $ 10.00 All Others/Repairs and Alterations It of Value of Appliance or Mork COMMERCIAL INDUSTRIAL 11 of Value Of Appliance or Mork State Surcharge Tarxz PER Reinspection Fee ($15.00) Rough Iasp. Date Q Final Insp. Date Approval for Permit 11INIMum PEE FOR ANY HEATING PFA41T IS $15 -00 - PLUS $.5o STATE SURCHARGE •Air Conditioners can not be placed inside yard without vcitten paraiuton fros adjoining neighbor. s $ $ .50 $ Job Addreall hza WA Department of Buildi"a, 6431 university Ave. N.E., Fridley. K" SS432 City of Fridley Tel. 4571-3450 The undersigned hereby stakes application for a pecaLt for the woak herein specified agreeing to do all work in strict accocdanas with the City Codes and rulings of the pepartstent of Buildings, and hereby dsclaces that all the facts and representation* stated in this applicatijj10onare trw and aorract). Fridley. Minn. -2�z . 19ll OWER XIND c USED 0 TO a8 ESTIMATED COST ( ' oin - NEM BUILDINiG PBBNIT No. PERIIr!' NO. U(d f DEWRIPTIOM OF FUFXACE/43U3=R HEATING or POWER PLANTS, Steam. not Stater Starr Jsir-'No. I t,• Trade Naas 1 V �`l l C� LA 1 Size no Capacitysq. Pt. EUR 4nv ----^ VJ LL Total Connected Load f " ^+ Kind o! Fuel BURNER - Trade Haas Size No. Capacity Sq. Ft. EOR Bill up - C-4 - � J �3 Signed by Ali � d}L Tel. No. � (JI Fill out back side for stack verification on replacement furnaces a CHIMNEY AND STACK VERIFICATION The undersigned hereby verifies.that the existing chimney or stack; I. Has been carefully examined Yes (,) No ( ) 2. Is free from rust or deterioration us t } No ( } 3. Has no foreign objects lodged within Yes ( No ( } Q. Is securely supported Yes ( } No ( } 5. Meets all current Code requirements for size and Yes ( No ( ) total BTU connected 6. Has Total heating BTU's of (0 Utz i All other BTU's TOTAL Com.pa ny Signedly pate%(J— suedEcr IT N0. City ®f Fridley 26957 AT THE TOP OF THE TWINS BUILDING M I T P T NO. COMMUNITY DEVELOPMENT DIV. ~ OI PROTECTIVE INSPECTION SEC. r 1 � � NUMBER REV DATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 j L 612-571-3450 910-F15 8/3/98 JOB ADDRESS 4917 Roman Rd 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION Carlson T s Summit Manor South SEE ATTACHED DESCR. 4 3 S.M.S. Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Tom Kell 572-8686 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO R & B Construction 1814 214 Ave NE Cedar 434-1206 20072653 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 NJ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof house and garage (20 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 1 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 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $1668 $.83 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. SXM $54.00 Fire SC $1.66 PLAN CHECK FEE TFEE Licen $5.00 1$749 IF SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATEI IVP P ALIDATE THIS IS R P MIT lI I d I P' ryATE SIGNATURE OF OWN ERPF OWN ERSUIL DER) [DATE, NEW [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION 0�6 ConstructionAddress:� Legal Description: Owner Name & Address: Z3 w, /�(e t 1, y Tel. # Contractor.. iS L �v s v 1.' 0 MN LICENSE # ),007A631? Address: 1 f l � I t !"' j4V& 4,1 C ecl c f t.,., , x Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF EMPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: T �� { ® . �� c r < �� , I e ),Q .s r Construction Type: Estimated Cost: $ (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: 'J;�-3APPLICANT: /A Tel. #— Z06 Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: CITY USE ONLY $ 6e Fee Schedule on Reverse Side $ .001 of Permit Valuation (1/10th%) $ $.50/$1,000 Valuation $ $1000 per SAC Unit $ .S . On $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 [ ] SUBJECT PE City of Fridley 11715 AT THE TOP OF THE TWINS BUILDING PERMIT ` RECEIPT NO. COMMUNITY DEVELOPMENT DIV.672-3604 v INSPECTION SEC. d A�1 r PROTECTIVE E E S CITY HALL FRIDLEY 5 432 IL �� NUMBER REV DATE PAGE OF APPROVED BY --"'11.0 612-571-3450 910-F15 4/2/01 JOB ADDRESS 4917 Roman Road NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 4 3 Carlson` s Summit Manor South Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Thomas/Marilyn Kelly 4917 Roman Road NE 763-572-8686 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Quarve Con tracting Inc 8427 Center Dr NE, Spring Lake Park, MN 55432 6016 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 763-785-1472 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 6 USE OF BUILDING Residential 7 CLASS OF WORK O NEW 0 ADDITION 0 ALTERATION CR REPAIR 0 MOVE 0 REMOVE B DESCRIBE WORK Install replacement windows & doors 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. Caulk and flash all exterior openings 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 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 $8.00WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $16,000 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHAR E PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- Fire C $16.00 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION $265.25 PLAN CHECK TOTAL E FIE Lice eC $5.0 $194.25/ SIGNATURE OF CON'RACTOR OR AUTHORIZED AGENT (DATE. HE MRPALIDAT S IS Y PE;MIT� /%' • S-GNA TUBE 09 OWNERpF OWN ERBU0.0ERi iDATEI BL NSP DATE NEW [ ] Effective 1/1/2000 ADDN [ ] CITY OF FRIDLEY 612-572-3604 Bldg Insp ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Construction Address: H Ir] ROrnan R00c1 , r(dle,� ITIN 551421 Legal Description: Owner Name & Address: TlndmQc- M(xv' \yro i�e,lly C (* Q60"e) Tel. Contractor: Cerdw MN LICENSE # SpIng Lakeawx PM 55= I6 5'- 13S -1q I 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 Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: Construction Type 11%66 N -W WI nam i f '} `o 4, Estimated Cost: $ I (®i ' 0�6 Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ —=$ DATE: O I APPLICANT: �° " ' J �' _ Tel. # 10- ate. CITY USE ONLY - Call (612) 572-3604 for Permit Fees if mailing in application Permit Fee $ a(S5'a5 Fee Schedule on Reverse Side Fire Surcharge $ 110" to .001 of Permit Valuation (1/10th%) State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control $ $.50/$1,000 Valuation _ per SAC Unittl160 _$5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above $450.00 Conservation Plan Review Park Fee $ Fee Determined by Engineering Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ] TOTAL $ 2Q4' D 6 STIPULATIONS: 5"";;Z01'eA5110, -S Building PLUMBING Permit No.• Inspections RESIDENTIAL APPLICATION Received By: 763-572-3604 CITY OF FRIDLEY Date : J UN 5 220 37 DATE / O7 YOUR E-MAIL ADDRESS SITE ADDR s 5aw►t as Q�rrG✓ Thomas Kelly THIS APPLICANT IS: ❑ OWNER j6CONTRACTOR PROPERTY4917 Roman Road NAME: Fridley, MN 55421 OWNER/ TENANT ADDRESS: 7635728686 TE ZIP PHONE: CONTRACTOR NAME: NORBLOM PLUMBING CO, SUBMIT A COPY OF STATE LICENSE # SOLOS '-' , (6��E 033 YOUR STATE ADDRESS: 'OOngSTATE ZIP LICENSE WITH PHONE APPLICATION �INNLAPUI JR- RA19 55408 PERMIT TYPE XSINGLE FAMILY a TWO FAMILY O TOWNHOUSE TYPE OF WORK, ❑ NEW REPLACEMENT DETAILED DESCRIPTION OF WORK ��plGtc,�, GtJaILe✓ I�at✓ PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00; whichever is greater, for the improvement, installation or replacement of a residential fixture, excluding the fixtures. (This.should_reflect only.the cost of labor ) Labor cost under $300 = $15.00. Labor cost between $300 to. $500 = cost of labor X.05 = -.FORXROJECTS WHERE LABOR EXCEEDS•$500;_-EES ARE BASED ON $10.00 PER FIXTURE,EXCEPT-:WI�REND.TEI)t:FIXT :,.(ATDIGATE TOTAL ' NUMBER OF EACH BELOW) _ BATH SINK/LAV FLOOR DRAINS _ SHOWER _ WATER PIPING —BATHTUB GAS PIPING a4m)cmuczvsE) _ SWIMMING POOL _ WATER SOFTNER ($35) _ CLOTHES WASHER _ KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15) —DISHWASHER _LAUNDRY TRAY TWATER HEATER ($35) FOR IRRIGATION WATER METER OTHER sm Permit Fee $ Number of fixtures @ $10.00 x $10.00 = $ Surcharge .50 Number of fixtures @ $15.00 x $15.00 = $ TOTAL DUE $ Number of fixtures @ $35.00 x $35.00 = $ 35. State Surcharge = $ 50 Total = $. SD 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an app ' 'on for a permit and work is not to start without a permit; that the work will be in ,accordance with the approved plan in the case rk w ' ires review and approval of plans. �J� /� SIGNATURE OF APPLIC PRINT NAME Jell Yaae,,ilOW DATE 4e 17 City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977