PRE 2010 DOCSERMIT NO.
27172
SUBJECT
City of Fridley
AT THE TOP OF THE TWINS
BUILDING PERMIT
r
RECEIPT NO.
COMMUNITY DEVELOPMENT DIV.
� PROTECTIVE INSPECTION SEC.
9
r �
�
1
NUMBER
REV
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
612-571-3450
910-F15
8/13/98
JOB ADDRESS
1 S E
`
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Darc
572-9325
3 CONTRACTOR MAIL ADDRESS
Owner
ZIP PHONE LICENSE NO.
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 XX REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof (11 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 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
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
917.40
$.50
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING COW
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
$34.75
Fire SC $.92
PLAN CHECK FEE
TOTAL FEE
$36.17
0 DAGENT (DATEI
�0
S ATURE OF CONTRAL*..R1UUT1LDER)
WHEN PROPE VALIDATED THIS IS YOUR PERMIT
TE
BL G INSP DATE
SIGNATURE WNER OF D T I
ERMIT NO.
27172
NEW a [ ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Z
ConstructionAddress: � % o) Y7- AU Z
Legal Description:
Owner Name & Address: J),%e(5 Tel. # ~%off
Contractor: MN LICENSE #
Address:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Tel. #
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:
e�
Estimated Cost: $ %� �,��
(Fee Schedule on Back)
Driveway Curb Cut
Width Needed:
Ft. + 6 Ft = Ft x $ _ $
DATE �
®
APPLICANT:
R
Tel. #'.5 '9���
I
CITY USE ONLY
Permit Fee
$
3 L/ 75"Fee Schedule on Reverse Side
Fire Surcharge
$ �/ Z
.001 of Permit Valuation (1/10th%)
State Surcharge
$
.5-0
$.501$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
STIPULATIONS: