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PRE 2010 DOCSCity of Fridley, Mm. 64311 University Ave. BUILDING .N. E., Minneapolis, Minn. 55432 nPr P_mh R -r 97, 1972 Omer: Don Mathis Builder Same ,Address 7969 Jackson Street N.E. Address Same LOCATION OF BUILDING . No 3.255 Street W Q ington Street N.E. Part of Lot Ut 15,Pt.16 Block 4 - Addition or Sub -Division Adams Street Addition Corner Lot Inside Lot X Setback 35' _ — _ Sideyard 10' & 6' 8" Elevationa5. 6_. 82 >i% ri itro�i�e%� 6� _ $59.82 Minimum' Wye Top of Footing To be Used as: Duelling Front 28' Depth 40' Height20' Sq, Ft, 1120` Cu. Ft, 27,210 Total Oa,ra�e Front22 '4 ' Depth -__?. -' . Height 10' Sq. Ft. ___... 481' Cu. Ft.. /4, 81.0. Type of Construction Wood Frame Est. Cost — $21, 274 _ 9-3 To be Completed Marnb , 1973 Stipulations: Provide a hard surface driveway. Provide a verifying survey before capping. Need agreement for sewer lateral pending (Approx. $936.00). WATER LOCATION: stop box 10' North of Sewer SEWER LOCATION: 145' North of Manhole 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. l 7 a 10.64 State Surcharge In consideration of the payment of a fee of $_ 51.00 , permit is hereby granted to Dona 1 d Ma tb i c 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 Ridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings odt a city limits and this permit may be revoked at any time upon violation of any of the provisions of said �)A -- UBuilding Inspector DARREL C I ARK 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 items. APPLICATION FOR RESIDENTIAL, ALTERATION19 OR ADDITION BUILDING PERMIT CITY OF PRIDLEY e MINNESOTA O i $ e •., • 1 I P11•e I I IIP !IlGI .11 ADDRESS:jo Z ADPi8ES3: ,- 9 , 4,2 1, I I�.q• . 1 L $LOCK �e� ION3�Q � �SETBACK: j� SIDEY�,RD �. a�Qli�iER LOT: ==LOT; , Aptiv,mt attach to ChU fv=_Vo Certificates of SuxveX of Lot and proposed .I.da% joeatien drwR on hese Certificates, DESCRIPTION OF BUILDING ToBeUOPA AS: nth, �� Height: Square Feet; � � ��„ Cub% Feet ovc'rcxnt ` Depth, Height• Square deet, ! „P Cubic Feet: fi l { of Construct. Estimated Cost: v� a, r'^ '.�� iit+i ►i�itsd3 �-� TM uWarsione4 hereby makes application for, a pemit for the work herein #p4wjf W. agreeing to dry all work in attict accordance with the City of tldIvy or4taxuces 4u4 ruttW pf Oe Department, 9f Buildi.ngs, and 'hereby +.area oat all the facts and representations stated is this application exe true as4 correct, Sjr • IS ■. 1 G 1 IR (Oft Ravene S*de For Addtf4onal Inforjtiation.) C E BUILDING PERMIT FEE SCHEDULE SECTION 2, The Inspector of Buildings skull, before issuing permits for the erection of any building or structure, or for any addition to any existing buildimg or structure, or for any alteration or repairs to any existing uil dtn$ or structure, upon application therefore, require the payment by the applicaAt for such permit of fees to the amount herein below set forth anal in the manlier herein provided tomwi,t t UNIFORM BUILDING CODEr Type 1, 2 & 4 - $2.15 for each one thousand cubic fest, or fraction thereof, in such cubical contents. Type 3 & 5 4 $1.85 for each one thousand cubic feet. ADDITIONAL INFORMATION For the purpose of computing fees for building permits, the cubical contents of any building or addition, in determined by multiplying the $round area oovered.f om a point six (6) inches below the floor line of the basement or the cellar to the average heights of the upper surface or to the average, 3,t of Oe .roof surface of the mann gable of a pitched roof. J= reVairs or alterations to an existing str%Kture, the fee shall be at the rate of $3,00 Per each five h�mdred dollars (WO.00) or fr tton thereof in the coat of .all proposed work.,. In so case shall the fee charW for =W permit as set forth in Section 2 be 1440 Uhan $5,00, VVRIFICATION OF FOUNDATION N=4 permits for construction will be issued a minimum of 24 hours from the > of application, to allow for proper review of the proposed struotare and of Oe construction site. A certifie4 Survey of to lots ribmdmg the locatim of the foundation, owe it hag be= 4o,nstructed,0 will be required before orocoeedbg with the framing, CERTIFICATE OF OCCUPANCY Application for a Certificate of, Occupancy shall be made ten (10) 4aye prior to the use or occupa=y of my struetare for which a building permit has been issued; 4md said structuxe shall, not be used or occupLed until a Certificate of Occupmcy has been ivwm d, Base PARTIAL RATE SCHEDULE PLUMBING FIXTUM BATESa� TETOTAL. A e c= "`°' Number Fixtures ....... ®.. • . e e . • x $ $� Future Fixture Opening ........... x $1.50 $ New Fixture Olaf Opening .......... x $1.60 5 - Catch Basin .... a ............... x $3.25 $ Water Beater :gip to 99.000 BTtJ1.... � x $3.00 $—.3, D 0 New Ground Bun Old Bldg......... x $3.25 3 Electric dilater Heatere ............. a $100 $ GAS FITTING FEES. NO. RATE TTO,T//AIL��� lot 3 Fixtures .. e • . • • ... • • • . • ... x $2.00 $-0— Additional Flatums• ..... • ...... a .. x $ .7766 $ Gas Range to 199.000 BTU . e �..... a •.• x $5.00 $ State Surcharge $ • 50 REPAIM A AL TIO fer ft Cc&_ Description eoe �o�ee oo..e©a.e ..o ow..•.o.a.•••.. •.a•e.•.� e TOTAL i $ City of Fridley: I The undersigned hereby ~Hakes application for a permit for the work here!~ specified, agreeing to da all work in strict accordance with the City Ordinance and nnling of the Department of Buildings, and hereby declares that all the fact and vepresentations stated in this application are true and correct Fridley. Minn 02 To be completed about_ -0-30. - �3 0 . ',-1-3Estimated Cost. $ c Old ew Building Permit No. nPermit N ( -1'7� . ROUGH Signed Business Phone for Pe~ Plank and H °Caffm �'�"' !a Coang. VlnfflQflons Reft oailOn and Air Conditioning Sysftm and Davicu GRAVITY WARM AIR: RATE TOTAL. Furnace Shell &Duct Work .......... ..... $10.00 $ Replacement of Furnace 6.00 $ Repairs & Alterations—up to $500.00 8.00 $ Repairs & Alterations each add. $500.00 3.00 $-- - _ f Furnace Shell & Duct Work to 120,000 BTU ... .. $10.00 $ U --o each add. 60,000 BTU .................... .. 3.0U ; Replacement of Furnace 8.00 Repairs & Alterations—up to $500.00 6.00 $ Repairs & Alterations each add. $500.00 .... .. 3.00 $ STEAM or HOT WATER SYSTEM 6.00 Furnace Shell & Lines—to 400 sq. ft. ZDR Steam $10.00 $.---- . ___Furnace FurnaceShell & Line—to 640 sq. ft. EDR Hot Water 10.00 $_ Each add. 200 sq. ft. EDR Steam Each add. 320 sq. ft. EDR Hot Water 3.00 $— OIL BURNER—to 3 gal. per hour over 3 gal. per hour -wee Fee Schedule GASB (up to M,000 BTU) 6.00 $ u ✓ over 199,000 BTU See roe schedule GAS FITTING FEES. NO RATE TOTAL 1st 3 Fixtures x$ 2.00 Additional Fixtures x .76 $ Gas Range to 199,000 x$ 5.00 $ • ': " LIJ r_, FINAI. •y® 7- $ see Foo schadulbo $ TOTAL rim $ 7..d ✓ (SURGIVIARGE $ _050-)7, j -7 �l " Dept. of Bldg. Pham L 5755 Washington St. N.E. 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- �"— / ` 1971, Owner — Don Mathis Kind of Building Frame Used as - --- - --PW—CJ-1 ------ To be completed about Estimated Cost, Old—NeWX Building Permit No. Permit No. L HEATING or POWER trsnn, Not Water, Warm AirX No 1 Trade Name Singer No GB 1104—OHD Capacity Sq. Ft, E.D.R_ 8 0 , 0 0 0 BTU Np Total Connected Load 36,500 Kindof Fuel Nat . Gas BURNER — Trade Name Size No Capacity Sq. FL EM.R BTU ISP. (REMARKS—OYER) Sim Mill City HEating Co. BudnessphweNo 544-1501 --V4 Infiltration Glau HEAT LOSS CALcULATIONS wall N t exp. wall DEPARTMENT OF INSPECTION MUNEAPM3. Weatherstrips A.S , two Guide Doors Refereacc out.wall Construction No. lat.wall Insulation --T— 7170 ol—I 19— Ceding Floor Kind How Applie, Windows and rs—Crackage and Area -A Width Height No.ot Lin dows and Doom—Cracka and Area Infiltration Glass Infiltration Infiltration r Infiltration Glau wall N t exp. wall Int. Wall Ceiling Floor Infiltration Glass Exp. wall Not exp. wai Btu Infiltration Glaw Esp. wall Net emp. wall Int. wall Ceiling Floor Total Btu. Required eci. ft. MRL or sq. ins. W.A. Leader area impectora notest. Infiltration Glass En. —wall Net elp. wall Int. wall Ceiling Floor ANN. Insulation How Applied Width Height ad Area Deal t. crack ra It sq. Required Sq. ft. E.D.R. or sq. ins. W.A. Lader area Fl.1 m Len Le =zth � Width Hei Roo_ boors- - and Area Windows and Doors—Cracliase and Area MCa Width Height N;. of Lineal ft. ArOm Me width It him of crack sq. ft. No. of pane of Vane Infiltration Glass Esp. wall Net esp. wall lat. wall Ceiling Floor Total Btu. Rewired-*a. ft. E.D.R. or sq.KO—S-W area LIM e Q FY OF FREDLEY 4 2 0 Application for Installation of Water and Sewer Service This form to be completed before a tap is made to any existing water or sewer line. Lot ----- Block .......... �./ ........ Addition Address .... \ '00 Owner ... Plumber . ..... (this portion of form to be completed by person requesting tap) CHARGES TO BE PAID BEFORE TAP IS MADE — WHERE ASSESSMENT HAS NOT BEEN LEVEED AGAINST PROPERTY Sewer Connection fee *Street patch — U uu U Water Connection fee .00 W Meter deposit .00 (I Materials used 10D *Street patch 6 Z Where applicable $96. j The above applies for all regular residential e 3services IF LATERAL ASSESSMENTS HAVE BEEN LEVIED AGAINST THE PROPERTY, THERE WILL BE NO CHARGES OTHER THAN CONNECTION PERMITS AND METER DEPOSIT The Cit furnish materials for water service and the plumber Will bill Sewer, not to exceed $3.00 a foot or a maximum of $60.00. ASSESSMENTS TO BE LEVIED Water Lateral Credit for material Total assessment Sewer Lateral Credit for material $------------------...– - -- ...... $- - - .... - - --------------------- Total assessment Clerk's signature_..... ------------------------------------------------------- I -- Vea hereby authorize- �o e tap 1st copy—Public Works Director of Public Works -------------- 60.00 CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 612-3604 RATE SCHEDULE Effective°OnuguFtA'195 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES e_1 — JOB ADDRESS The undersigned hereby makes application for a permit for the work herein Residential Rate TOTAL specified agreeing to do alk work in strict accordance with the City Codes and Furnace Shell and Duct Work, Burner — rulings of the Building Division, an6hereby declares that all the facts and Also Replacement Furnace $ 30.00 $ ®. representations stated in this application are true and correct. (Side Vent —Fill Out Back) ,199° Gas Piping (Needed with new furnace) $10.00 $ Gas Range Gas Dryer *Air Conditioning — All Sizes All Others/Repairs & Alterations (UST ON BACK) 1 % of Value of Appliance or Work Commercial/industrial 1.25% of Value of Appliance or Work $10.00 $ $10.00 $ $ 25.00 $�� $ ` State Surcharge x.50 TOTAL FEE Tip�� MINIMUM FEE FOR ANY HEATING/COOLINGIVENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00 PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $42.00/Hr *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. 1 01 BUILDING USED AS a ag=g2&�� ESTIMATED COST PERMIT NO. 1 DESCRIPTION OF FURNACE AND OR BURNER No. of Heating Units Circle One (Steam) (Hot Water) arm Air) Trade Name �® Size No. BTU '7�j () ®® HP EOR Fuel �_ Total Connected Load Burner Trade Name Size Na. BTU HP EDR DEPEND INDOOR AIR QUALITY. INC. HEATING COMP NY 2619 COON LEVARD Approved By Rough—In Qate Final FILL OUT BACKSIDE POR STACK VERIFICATION ON REPLACEMENT FURNACE 1� 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 S_�� 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** Gas Range** Gas Dryer** Back Flow Preventer Required ( )Yes () No Type- $7.00 ype $7.00 The undersigned hereby makes application for a permit for the work herein $ 4.00 specified agreeing to do all work in strict accordance with the city codes $ 5.00 and rulings of the Building Division, and hereby declares that all the fads $ 7.00 and -representations stated in this application are true and correct. $ 7.00 $ 7.00 „A .1998 $ 7.00 - $10.00 Owner ��.� � ®� S .3 $ 7.00 �1 $10.00 Building Used As $10.00 $10.00 Estimated Cost 432�1 PERMIT NO. $15.00 Reinspection Fee $42.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance State Surcharge $ .50 TOTAL FEE $ PLUMBING COMPANY SIGN ED BY TEL NO. Approved By Rough -In Date Final Date MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $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. SUBJECT PERMIT NO City ®i Fridley 2733 AT THE TOP OF THE TWINS BUILDING PERMIT � RECEIPT NO. COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC.��� NUMBER REV DATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 612-571-3450 910-F15 8/21/98 JOB ADDRESS 5755 Washington Street NE 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 15,Pt.16 4 Adams Street Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Mike Phel s�,{{ - 5923 3 CONTRACTOR MAIL ADDRESS JS 112 PHONE LICENSE NO. Jayson Lindsay Roofing 2638 Clearview Ave Mounds Vie1112----792-1857 20098263 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 ]a REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof house and garage (23 s 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 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 BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $1918 .96 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF ANY OTHER ST EOR LOCAL LAW REGULATING CON- STRUCTI N OR THE PERFORM C F CONSTRUCTION. 62,25 Fire SC $1.92 rr PLAN CHECK FEE TOT EE 1`� License 5.00 .13 $IGNATU EOFCONTRACTOR ORAU. IZEDAGENT IDATEI EN ROP ALIDATE TNI$ IS R PERMIT G INSP DATE SIGNATURE OF OWNERIIF OWNER BUILDERI (DATE) NEW -4 - [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: "� y 5T 'J D Legal Description: Owner Name & Address: Xj ® C' Tel. # Contractor: d MN LICENSE # U`/,9 9 6S Address:1.4 'Age C, U Le"i p��®j,��i'�y/ � , Tel. # P��1`S -7 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: Construction Type: Estimated Cost: $— 1918 - (Fee 918(Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $/, = $ DATE: a- '; 1 9 0 Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee $ Sewer Main Charge $ TOTAL STIPULATIONS: Tel. # i9,? /,a s-% CITY USE ONLY Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th%) $.501$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 [ ] BUILDING PERMIT FEE SCHEDULE The Chief Building Official shall, before issuing permits for the erection of any building or structure, or for any addition to any existing building or structure, or for any alteration or repair to any existing building or structure, upon application therefore, require the payment by the applicant for such permit of fees to the amount herein below set forth and in the manner herein provided to -wit: TOTAL VALUE FEES $1 to $500 $21 (Minimum Fee is $21 plus surcharge) $501 to $2,000 $21 for first $500 plus $2.75 for each additional $100 or fraction thereof, to and including $2,000 $2,001 to $25,000 $62.25 for first $2,000 plus $12.50 for each additional $1,000 or fraction thereof, to and including $25,000 $25,001 to $50,000 $349.75 for first $25,000 plus $9.00 for each additional $1,000 or fraction thereof, to and including $50,000 $50,001 to $100,000 $574.75 for first $50,000 plus $6.25 for each additional $1,000 or fraction thereof, to and including $100,000 $100,001 to $500,000 $887.25 for first $100,000 plus $5.00 for each additional $1,000 or fraction thereof, to and including $500,000 $500,001 to $1,000,000 $2887.25 for the first $500,000 plus $4.25 for each additional $1,000 or fraction thereof, to and including $1,000,000 $1,000,001 and up $5012.25 for the first $1,000,000 plus $2.75 for each additional $1,000 or fraction thereof DRIVEWAY DEPRESSION ESCROW (Concrete Curb Streets Only) Alternate "A": Removal and . replacement of curb and gutter only - Driveway width plus 6 feet times $13.50. Alternate "B": Removal and replacement of curb and gutter and install a 3 foot wide approach with 6 inch depth - Driveway width plus 6 feet times $15.75. VERIFICATION OF FOUNDATION Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper review of the proposed structure and of the construction site. A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed will be required before proceeding with the framing. May 20 2010 3t30PM HP LASERJET FAM 6517622500 p.1 Enoeering WATER AND SEWER permit No.3 L N 763-572-3552 PERIVW APPL,ICATZON Received By: 763-571-1287 fax C rY OF FRIDLLY , EP"=VE I11=1D APPLICATION DAM: YOUR E-MML/FAX: THIO APPLICANT IS: O OWNER 8 CONTRACTOR S 7SS 108 ADDRESS: LJ+eeuz.io, St NEW CONSTRUCTION PBRmaw (iF APPLi CABLE}: PROPERTY NAME: e AK n TENANT ADDRESSi s �*'�5 .,,, i�g S} crrx STATE ---71P PHONE; CONTRACTOR NAME: SUBM17A COPY OF YOU,RSTATE ADDRESS: +•d.,jait CITY 40 1- STATE�ZIP rLYlts LICISNSE HIM PHONE & f!". 7,6.7-a Soo _CELLPHONE: APPLICATION 9T TE LIC S g S STATE BOND; (&W -04-2A EXP DATE: !.'1 'l� -]'1 1. Narrative) vrMen description: l.e,.� L.9 wi,G r a� �• B i.� � {�, l � �fl � I i G 2. Please attach Bketch:sh wing curb line, utility line, building, etc. with distances on hack page. 3. Stipulations; ��/l•-� ii ted" f'tr?�t? C-�t_ (-76 3 - 5 72- -3!;S 2 Id PERMIT T"E ❑ SEWER CONNECTION PERMIT $50 IJ WATER CONNECTION PFR1b1IT $50 MP WATER LIM REPAIR $40 ❑ SEWER LINE REPAIR $40 Q ADI] STATE SURCHARGE $.50 0150 n SAC CHARGE, $2100 TO'N'AL $ OTHER CHARGES (IF APPLICABLE) PAY TO I:TILTrY BILLING NEW WATER METER COST - SEE UTILITY BILLING SPECIAL ASSESS.MSNTS - SEF NWANCE WATER TAP - SEE ENGINR$RING NOTE: WATER METER REAATR- tNQD M Curry -nue v.rvwm r.Y� ,.,,..,... _ - • --- . _- ---- -- _ — THIS IS AN APPLICATION FOR A PERMIT NOT VALID UNTIL PROCESSW I hereby apply for a water or sower (new connection or repair) 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. I understand this is not a permit but only an application for a permit and work is not to start without a permit. SIGNATURE OF APPLICANT 1 '7 PRINT NAME: /)?,At �!' �+ DATE; 5 �: 2 G - 10 APPROVED 13Y;DATI3: l ®� COPY GWiN T6❑ UI'IL,ITY BILLING only if new meter ❑ PUBLIC WORKS ❑ ENGINEERING. City of Fridley Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3552 FAX: 763-57I-1287 May 20 2010 3:3OPM HP LASERJET FAX A 6517622500 p.2