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PRE 2010 DOCSCity of Fridley, Minn. UILDING PERMIT Date: 2,h".' It Tw Owner. .' Address N° (578'7 Builder Address LOT' N OF BUILDING Nor Street _ _. Part of t No...-----...__. '' Lot , J _, Block __ _ Addition or Sub -Division . Corner Lot _ A@0r7-- Inside Lot _ _ Setback k ____ ideyard -A �__._%_ Sewer Elevation Foundation Elevation DESCRIPTION OF BUILDING To be Used ,as:JAY, ata r Front Depth - Height Sq. Ft. �C Ft.6, "o Depth Sq, Ft. -. _ _ _ Cu. Ft. _ Type of Construction " %+ _ Esta Cost "�To be Completed _ In consideration of the issuance to me of a permit to construct the building described above, r 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. AP19 In consideration of the payment of a fee of $ s t , 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 buildings within the city limits and this permit may be revoked at any time upon violation, of any of the provisions of said ordinances. C Building Inspector 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 thea® bona. 4 ! ? LOV30 SUBJECT !T y�m APPLIC�+i'ION FOR BUILDING PERMIT G ?_, +�;.. J, CIS IDLEY, MINNESOTA IT � OWner s NameBuilder i. Address ° �^-. Address:+-: LOCATION OF BUILDING No. 1 �� 7 Street � � F �.,� g�� �� Part Of Lot Lot ,J - Block „ Addition or Subdiv�.sipn_ :a -L � Corner Lott Inside Lot setbackSide-YardQltl SEWER ELEVATION,,. yFOUNDATION ELEVATION Applicant attach to this form Certificate of Survey of Lot and proposed building location. To be used as s DESCRIPTION OF BUILDING FrontDepth Height Sq. Ft.--. �� � Q� � C11s �'t• a� �^� �* � o Front Depth , Height sq. . i M. Cud 1't, A.; Type of Construction - Estimated Costyt� To be Completed 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 ruling of the Department of Build- ings,, and hereby declares that all the facts and representations stated in this application are true and correct. Li • DATE �`�� y_,�� SIGNATURE F• r (Schedule of Fee Costs can be found on the Reverse Side). City of Fridley Application for Plumbing and Gas Fitting Permit Dept. of Bldgs. Phone SII 4.7470 DESCRIPTION OF WORK��° ��� . Number. Kind and Location of Fixtures Location / B PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: LL��ppN��O. RATE TOTAL Number Fixtures ...................... x $1.50 $ Future Fixture Opening ................ x 1.20 $ New Fixture Old Opening .............. x 1.00 $ Catch Basin ............................ x 3.25 $ Water Heater (Up to 200,000 BTU) ...... x 2.00 $ New Ground Run Old Bldg . ............ x 3.25 $ 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. SPR 2 61962 / /Fridley, Minn 19— Owner �J a /T A/ Kind of Building Used as //" 41 'l/ I— A P7. To be completed about /® ` ✓— 4 7� Estimated Cost, $ Old New Building Permit No. 07 Permit No. SignedLON ON PLUMMc 'j U0 By W Business Phone No ROUGH �^ f FINAL GAS FITTING FEES: NO. RATE TOTAL 9 �^- A (� (, -)— p 1st 3 Fixtures .......................... � x $1.50 $ /' Xd vJ � ` Additional Fixtures .................... x .50 $ �.rd Gas Range to 200,000 BTU .............. x 2.00 $ 2 - REPAIRS REPAIRS 8c ALTERATIONS—Refer to Code Description ................................................$ U %( TOTAL FEE $, / 42 2M � u 1 K <.. 3 <m m m Z N N K 3 1- Y oZ—e 02 K Z �� Z Q~Q� y lu �6n,'. w �QZ UN' ? �a O O ! F lY N WATER HTR. GAS ELEC. Base 3 3 3 / Z 3' l 1st ` e� / g 2nd e 3rd 4th ° Future Connection Openings New Fixture, Old Openings I Connected with Sewer El Cesspool El PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: LL��ppN��O. RATE TOTAL Number Fixtures ...................... x $1.50 $ Future Fixture Opening ................ x 1.20 $ New Fixture Old Opening .............. x 1.00 $ Catch Basin ............................ x 3.25 $ Water Heater (Up to 200,000 BTU) ...... x 2.00 $ New Ground Run Old Bldg . ............ x 3.25 $ 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. SPR 2 61962 / /Fridley, Minn 19— Owner �J a /T A/ Kind of Building Used as //" 41 'l/ I— A P7. To be completed about /® ` ✓— 4 7� Estimated Cost, $ Old New Building Permit No. 07 Permit No. SignedLON ON PLUMMc 'j U0 By W Business Phone No ROUGH �^ f FINAL GAS FITTING FEES: NO. RATE TOTAL 9 �^- A (� (, -)— p 1st 3 Fixtures .......................... � x $1.50 $ /' Xd vJ � ` Additional Fixtures .................... x .50 $ �.rd Gas Range to 200,000 BTU .............. x 2.00 $ 2 - REPAIRS REPAIRS 8c ALTERATIONS—Refer to Code Description ................................................$ U %( TOTAL FEE $, / 42 2M � u 1 Application for Power Ptants and Heating, Cooling. Ventilation, Reffigeration and Air Conditioning Systems and Devices PARTIAL RATE SCHEDULE GRAVITY WARM AIR: RATE TOTAL, 11 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 $ MECH. WARM AIR 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 $ STEAM or HOT WATER SYSTEM Furnace Shell & Lines—to 400 sq. ft. EDR Steam........ 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 y' GAS BURNER (up to 400,000 BTU) ....................... 5.00 GAS FITTING FEES: NO RATE TOTAb 1st 3 Fixtures ...................... x $1.50 $L-� Additional Fixtures ................. x .50 $ Gas Range to 200,000 BTU ........... x 2.00 $ AIR CONDITIONING $ FAN HEATING SYSTEM See Fee Schedule VENTILATING SYSTEM ALTERATIONS &REPAIRS TOTAL FF E $ ROUGH FINAL Dept. of Bldgs. Phone SU. 4-7470 -Ir77t9 ZX' 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. Owner Kind c Used a To be 10 19 � Estimated Cost, $ Old—New. Building Permit No. Permit No. 1C' DESCRIPTION OF WORK HEATING or POWER team 2t W , Warm Air—No 42I&C Trade Name Size No Capacity i 'i- 0 Sq. Ft. E.D.R. BTU H.P. Total Connected Loa 0 Kind of Fuel BURNER — Trade Nam Size No__SZ -Sr,0 Capacity 1 �° ® Sq. Ft. EM.R- 2S 10 -04 () 0-013TU H.P. (REMARKS -OVER) Std By WA 511 W. t , e . _ 4.42 IM 7-59 Business Phone No- City of Fridley, N BUILDING PERMIT x. _ szo2 ---) Date: Owners Builder Ad Address � LO TION OF BUILDING No. StreetV— -_�' Part of Lot Lot _. _ __ Block Addition or Sub- _ Corner Lot __M= Inside Lot _ _ Sack ideyard Sewer Elevation — Fo dation Elevation DESCRIPTION OF BUILDING To as: Front Depth Height Sq. Ft. Cu. Ft. SO Front DepthHeight Sq. Ft. Cu. Ft. Type of Construction _ .. Es - Type 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. do ALEASO 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 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 any of the previsions of said NOTICE: Ibbs permit don not cover the construction, installation for wbus, phnnbing, on heating, sower or wabr. Be sure to we the Buih m hapeator for spars% permit for these Mems. APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA Owner's Name d Builder Address Address LOCATION OFBUILDING No.�� ® Streeter ` Part of Lot Lot Block Addition 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 building location drawn on these Certificates. DESCRIPTION OF BUILDING To be used as: Front ', DepthHeight� Sq. Ft. Cu. Ft. to- -Front Depth Height Sq. Ft. Cu. Ft. of Construction Estimated Cost MCI- Type� To be Completed 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 (Schedule of Fee Costs can be found on the Reverse Side). d e SUBJECT PERMIT NO. City of Fridley AT THE TOP OF THE TWINS BUILDING P E R M I T RECEIPT NO. COMMUNITY DEVELOPMENT DIV. ______ I °� PROTECTIVE INSPECTION SEC. r , _ , ,'� CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF AP ROVED BV A � A L 612-571-3450 910 -FIS 4/7/94 JOB ADDRESS 5770 2 1/2 STREET NE 1 LEGAL OCK LOT NO=2-5 TRACT OR ADDITION SEE ATTACHED DESCR. Pt 26 1 Hyde Park SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE D 1 e E 42 St. Minneapolis—MN 612 722-8485 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. 4 A ITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO, 6 USE OF BUILDING Apartment 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof Garage Tear -off 14 Squares 9 CHANGE OF USE FROM TO STIPULATIONS 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 60 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 11 STALLS 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 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $1,050 $.53 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- SC $1.05 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. $27.00 Fire PLAN CHECK FEE TOTALFEE 28.58 CONTRACTOR ORAUTHO GENT IDATEI WHEN P 9LY VALIDATED THIS IS YOUR PERMIT BLDG INS nATE S" URE OF O ER IIF OWNER BUILDERI IDATEI e Prepaid Plan Check $ Estimated Cost $ Receipt # CITY OF FRMIEY R-3, COMMERCIAL & INDUSTRIAL BUE DING PERMY APPLICATION Effective 1/1/94 Construction Address P% U �? �� J '� �! Zoning Legal Description Owner & Address —3 L e1 � 'l Zz - A �4 CONTRAMOR & ADDRESS Tel . # Architect & Address --Peg.# Engineer & Address Reg.# TYPE OF WORK [] New [] Addition teration -Describe Applicant Signature Tel # Date Bi]II DING DIIKENSION.S Length Width Height Sq. Ft. # of Stories OFC. AREA: Length Width MSE AREA: IAmigth Width OTHER AREA: Length Width Height Sq. Ft. Height Sq. Ft. Height Sq. Ft. VAURMCN Sq. Ft. x $ Cast/Sq. Ft. = Valuation $ ) Sq. Ft. x $ Cost/Sq. Ft. = Valuation $ ) _ $ Sq. Ft. x $ Cost/Sq. Ft. = Valuation $ A TOTAL VALUE Building Use Construction Type Occupancy GrMW Air Conditioning []Yes []No Fire Protection Provided []Yes []No Performance Bond Amount $ See Reverse for Schedule Received []Yes Permit Fee $ % Ute, Plan Check $ Fire Surcharge $ L, O S� State Surcharge $ SAC Marge $ Erosion Control $ Park Fee $ Spec. $ Driveway Escrow $ o� See Fee Schedule on Reverse Side In Excess of Prepaid Amount - See Reverse Side .001 x Permit Valuation (1/10th %) $.50/$1,000 Valuation (See Sched. for > $1 Million) $800 per SAC Unit (Plans to NNCC for determination) $450.00 Conservation Plan Review Fee Determined By Engineering Agreement Necessary [] Not Necessary [] feet x $13.50/foot SUBJECT PE City of Fridley 3 01�6�8 AT THE TOP OF THE TWINS BUILDING PERMIT T NO. � • COMMUNITY DEVELOPMENT DIV. ___ V ------ PROTECTIVE INSPECTION SEC. r 1 6-6-?6� 1 � NUMBER REV DATE PAGE OF APPROVED BY i CITY HALL FRIDLEY 55432 612-571-3450 910415 9/3/99 JOB ADDRESS 5770 2 1/2 Street NE 1 LEGAL LOT NOPt. 2 BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 3 4 Pt. S 26 1 Hyde Park SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE 783-1656 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Michael R Oslund Roofing - 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 8 USE OF BUILDING Commercial 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION RC REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Re-roof 11 Unit Apartment (30 Sq) Tear-off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with the State Building Code. 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 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 $2622 $1.31 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 $83.25 FireAC $2.62 PLAN CHECK F TOT L EE ' .18 SIGNATURE OF CO O' CTOR OR AUTHORIZED AGENT DATEIHEN PRO V LI DA THIS7MIXR R dr S,GNATURE OF OWNEAoF OWNER BUiLOERi IDATEI BLR§ INS- gAiE Prepa±d Plan Check $ Estimated Cost $ Receipt # Effective 5/.10/99 CITY OF FRIDLEY R-3, COMMERCIAL & INDUSTRIAL BUILDING PERMIT APPLICATION Construction Address Zoning Legal Owner & Address -s'rr CONTRACTOR & ADDRESS Architect Reg.# "IV Engineer BUILDING CONSTRUCTION Tel# Tel# V? Reg.# TYPE OF WORK [] New [] Addition [] Alteration -Describe pG -Ly 1� OFC. AREA: Length Width Height Sq. Ft. WHSE AREA: Length Width Height Sq. Ft. OTHER AREA: Length Width Height Sq. Ft. APPLICANT Tel # %p� ��r6� Date VALUATION Sq. Ft. x $ Cost/Sq. Ft. = Valuation $ ) 4 6,�� Sq. Ft. x $ Cost/Sq. Ft. = Valuation $ Sq. Ft. x $ Cost/Sq. Ft. = Valuation $ ) 'TOTAL VALUE Building Use Construction Type Occupancy Group Air Conditioning [] Yes [] No Fire Protection Provided [] Yes [] No Performance Bond Amount $ See Reverse for Schedule Received. []Yes []No Permit Fee $S r See Fee Schedule on Reverse Side Plan Check $ c�d 6 In Excess of Prepaid Amount - See Reverse Side Fire Surcharge $ 1,2 ( .001 x Permit Valuation (1/10th o) State Surcharge $ $.50/$1,000 Valuation (See Sched. for > $1 Million) SAC Charge $ $1050 per SAC Unit (Plans to MCC for determination) Erosion Control $ $450.00 Conservation Plan Review Park Fee $ Fee Determined By Engineering Spec. Assessments $ Agreement Necessary [] Not Necessary [] Driveway Escrow $ feet x $13.50/foot TO'T'AL $ . ®� ATTACH STIPULATIONS 01 From: 7635379117._ Page: 1/1 Date: 11/24/2009 8:49:41 AM From: LAty of Fraley V .. I o: IOJ�00tCy`J rage. ut ua�e. i i rtottwa o.��.,,r rwi Building PLUMBING Permit No. 1 Inspections COMMERCIAL APPLICATION Rew"Ved By= 763-572-3604 Date Rec'd:�� 763-502-4977 FAX CITY OF FRIDLEY EFFECTIVE 1-1-09 rte. DATE " ✓ 0 � YO�UIZ E-MAIL ADDRESS (" �!•�� `.y��_ �� ' i ` a d GC r -d SITE. ADDRESS .�" 7 ' l r Y�+ 5 (� 7 L. G 1 ! V l R! Ir. 2'' - Ak a 55- *A TENANT SUITE NO. PROPERTY NAME: L TENANT ADDRESS: �• :% • �^ X ©_ CITY }^� i L STATERRGIP 5 . PHONE'– CONTRACTOR NAME: ✓ ; S R M IR O— y 5 L 4 - SUBMIT ACOPY OF YOUR STATE _ STATE LICESER N�� r `)J- I EXP DATE 11 3 P LICENSE, BOND AND PLUMBING BOND It EXP�D�/�'°'�TE pZ o � ] cgL 4*4R. R. CERTIFICATEOF ADDRESS: 0117*1 �i�K��L� •RI���C1TY ��� !� T�KK sTATE7r1d xjp i5,4 -Lf ` INSURANCE PHONE.1.3 . u - -T go''?e ? PAX PERMIT TYPE D INSTITUTIONAL XWULTl-FAMILY ❑ SWIMMING POOL 0 TO WNHOUSE 0 COMMERCIALIINDUSTRIAL 0 OTHER TYPE OF WORK-- 0 NEW AREPLAC'EMENT 0 ALTERATIONIREMODEL [DETAILED DESCRIPTION OF WORK T7�.)R M LIE:::.:..: :..::::::::::::::::: :::::::::::: :::::::::::::::::>1O7iilith$e1121}A.:.,... . _ CLOTHES WASHER _ FLOOR DRAINS _ RPL VALVE URINAL —DISHWASHER _ `GAS PIPING BACK! -'LOW PREY, WATER HEATER DRINKING FOUNTAIN ___.GREASE TRAP —ROOF DRAINS WATER METER —FAUCET _KITCHEN SINK —SHOWER WATER PIPING —FLAMMABLE WASTE TANK _ LAUNDRY T1tAY _SLOPSINK �WATER SOFTENER LAVATORY _SWIMMING POOL _WATER CLOSET ::::.:::::::::::::•:::::::::::::::::::::::'i:::::::::::::c:•::::........::::::....`.......:':'::::::::::::::i::::::::::::::::::::::::::�::::':::::?:::::::':::::i:::.:::::::::::::::::::::::lei:i::::::�:::::::................ Total Job ............ ..................: :.:::::::::::::::::::::::::.....::::::::::..:......::::::::::::::::..;....:::::::::.....::...:;,.;,. �::::: $ .3Ss - c►y Alt fees are based on valuation, including the cost of labor and materials. Valuation Permit Fee + $-35,00 (1.25%of Job Valuation / Minimum fee: $35) Surcharge $ - Valuation X.0005 Total Due $ Malec Checks Payable to: City of Fridley THIS IS AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED I hereby apply for a plumbing permit and t 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 Conduction 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 tic case of all work whi/c�h� requires review and approval of plans: NAME OF APPLICANT �eGi C t 1�'J /jlbi J�1 �! SICrNATURE OF APPLICANT DATE ;..IJ ;S h1Q. ';-`9E-PA-RATE PFRti+)il i1 ) E I :FOI Blifl; f<ttar�: l TI IOtk '. AID It+EE T(l All ►141i ::=:€ .... %-HY 01 r'rlatey Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-5024977 Engineering WATER AND SEWER Permit No.: 'i10 IP 1) 763=572-3552 PERMIT APPLICATION Received By:0) 763-571-1287 fax CITY OF FRIDLEY D ' P � 201 EFFECTIVE 7/1/2010 APPLICATION DATE: 6 a ® YOUR E-MAIUFAX: THIS APPLICANT IS: ❑ OWNER EriONTRACTOR JOB ADDRESS: en a 2 S f f 0577 NEW CONSTRUCTION PERMIT# (IF APPLICABLE): PROPERTY NAME: /1-4-0 &0 ADDRESS: C�III� GtJ� o d /%%cs CITY 6. 14 .P- STATE ZIP s r TENANT -6%0 PHONE: CONTRACTOR NAME: SUBMITA COPY OF /y STATE DRESS: PITY YOUR STATE --6 LICENSE WITH PHONE -26:j 5:4iF -691-L- CELL PHONE: 4> 9 9 APPLICATION STATE LIC # STATE BOND: EXP DATE: 1. Narrative/written description: C- 2. Please attach sketch showing curb line, utility line, building, etc. with/distances on hack page. 3. Stipulations: , ✓CepC C�e.�.�JC� 3.to . -6 �kw" P RMIT TYPE ❑ SEWER CONNECTION PERMIT $50 ❑ WATER CONNECTION PERMIT $50 ❑ WATER LINE REPAIR $40 0 ❑ SEWER LINE REPAIR $40 ❑ ADD STATE SURCHARGE $5.00 ❑ SAC CHARGE @ $2100 = TOTAL $ OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING NEW WATER METER COST - SEE UTILITY BILLING SPECIAL ASSESSMENTS - SEE FINANCE WATER TAP - SEE ENGINEERING NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/11OUR-BILLED THIS IS AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED I hereby apply for a water or sewer (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 permi d work is not to start without a permit. SIGNATURE OF APPLI N %' r2) � DATE: APPROVED BY: DATE: 0 COPY G O: LI BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENG EER G City of Fridley Engineering Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3552 FAX: 763-571-1287 M cc s e �1