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PRE 2010 DOCSSUBJECT EBA City of Fridley 16548 AT THE TOP OF THE TWINS BUILDING PERMIT r R I `v COMMUNITY DEVELOPMENT DIV. r PROTECT VE INSPECTION SEC. CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 1 612-571-3450 910-F15 4/28/82 JOB ADDRESS 5423 - 4th. Street N.E. 1 LEGAL LOT N0. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 20,21 11 Hamilton's Addn. to Mechanicsville SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Steve Smith 5423 - 4th Street N.E. 572-8193 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Same 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE x 8 DESCRIBE WORK Construct a 22' x 24' Garage 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. Wood Frame 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 STALLS GARAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION g SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIEDoo— $2.49 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT s 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- $50.50 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE $52.99 GNATURE OF CONTRACTOR AUTHORIZED AGENT (DATE) WHEN PROPERLY ALI DATED THIS IS YOUR PERMIT b® �� BLDG INSP DATE '' IGNATURE F OWNER IIF OWNER BUILDERI (DOTE) CITY OF FRIDLEY Effective Aug. 1, 1981 APPLICATI94 FOR RESIDENTIAL BUILDING PE•RijITS (New, Alterations, Additions, or Repairs) ONINER: �T� �� BUILDER: S e— ADDRESS: 5��� �4�-� ADDRESS: TEL NO: C— 7a~ Si TEL NO: Construction Location STR=T NO: STREET: LOT: BLOCK: ADDITION: Corner Lot: Inside Lot: ✓/Setbackc: Sideyards: Applicant attach to this form two Certificates of Survey of lot and proposed building location drawn on certificates to scale. DESCRIPTION OF CONSTRUCTION Front: Depth: Height: Square Feet: Cubic Feet: Front: Depth: Height: Square -Feet: Cubic Feet: Type of Construction: rrAA?e' 206 c?. �,D Estimated Cost: $ To Be CUripleted: �/+�i�ii �`� S Alt. A Alt. B Proposed Driveway Width If New Opening Is Desired: $ $ SEE MVERSE SIDE OF SHEET Mie undersigned hereby makes application for a permit for the %:'ork* 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 represcintations stated in this application are true and correct. DATE: ����m � SIGNATURE: Stipulations: 9'0 ` Lt Co fist t d Orn-_ wp-aftNi , WELL OR BORING LOCATION MINNESOTA DEPARTME OF HEALTH Minnesota Well and Boring H 114455 County Name WELL AND BORING SEALING RECORD Sealing Minnesota Unique No. Minnesota Statutes, Chapter 1031 or W -series No. Anoka(Leave blank If not laumn) Township Name Township No. Range Np. Section No. Fraction (sm. -> Ig.) Date Sealed Date Well or Boring Constructed Fridte 30 23 23 HV SEA SW 2-5-97 Numerical Street Address or Fire Number and City of Well or Boring Location 48 5423 4th St., Fr i d i ey I Depth Before Sealing ft. Original Depth ft. Show exact location of well or boring Sketch map of well or boring AOUWER(S) STATIC WATER LEVEL In section grid with °X°. location, showing property Wingie Aquifer ❑ Multiaquffer lines, roads, and buildings. N WELLIBORING R)tAeasured ❑ Estimated W uuuu '7- in. from 5 to ft. El Yes [X No ❑Yes ❑ No ❑Unknown I uuuu ❑ No ❑ Yes ❑ No ❑ Unknown uuuu J.R.S. ConStructinn uuu ❑ No ❑ Yes ❑ No ❑ Unknown Property owner's mailing address ff different than welllocation address Indicated above. 23555 ` Man)„llD e f St. HE gb(Nater Supply Well ❑ Monit Well ❑ Env. Bore Hole [IOther �' ft. [below ❑ above land surface E CASING TYPE(S) TSteel ❑ Plastic ❑ Tile ❑ Other Ya m0e CASING Diameter Depth Set in oversize hole? Annualar space initially grouted? l' S ���""" 1 mite fgrm '7- in. from 5 to ft. El Yes [X No ❑Yes ❑ No ❑Unknown I In. from to fL ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown PROPERTY OWNER'S NAME J.R.S. ConStructinn In. from to tL ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown Property owner's mailing address ff different than welllocation address Indicated above. 23555 ` Man)„llD e f St. HE SCREEWOPEN HOLE P� a+� d East Bethel, NN 55005 Screen from 44 to 4.8 ft Open Hole from to n OBSTRUCTION/DEBRISIFILL U,Obstructlon ❑ Debris ❑ Fill ❑ No Obstruction WELL OWNER'S NAME Type of Obstructlon/Debris/Fill 3111 A Is d . p • & Jet Well ownees mailing address If different than property !owneTs address Indicated above. Obstruction/Debris/Mll removed? WXYes ❑ No PUMP t Type stat Removed ❑ Not Present ❑ Other GEOLOGICAL MATERIAL COLOR HARDNESS OF FORMATION FROM TO If not known, indicate estimated formation log from ne0y well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, K No Annular Space Exits OR CASING AND BORE HOLE: ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal In. from to In. from to Type of perforator ft. ❑ Perforated ❑ Removed fL ❑ Perforated ❑ Removed ❑ Other GROUTING MATERIALS) tdt CMA 43 11 Grouting Material from5 to k. yards bags from to from to from to ft. yards bags ft. yards bags ft yards bags REMARKS, SOURCE OF DATA, DIFFICULTIESI N SEALING UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑ Yes EkNo tri P �f LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The Information contained In this report Is true to the best of my knowledge. X' Mork Well Co.- Inc. 02658 Con us ass Name ` License or Registration No. 2-5-97 Authorized presentative Signature Date Tim Chouinard LOCAL COPY H 114455 Name of Pennon Sealing Well or Boring HE -01434-02 10/95R City of Fridley SUBJECT 28942 AT THE TOP OF THE TWINS BUILDING PERMIT f REC� � COMMUNITY DEVELOPMENT DIV. SEC /1 40 PROTECTIVE INSPECTION 1 i CITY HALL FRIDLEY 55432 NUMBER qEv GATE PAGE OF APPROVED Br 612-571-3450 910-F15 2/25/99 JOB ADDRESS 5423 4 Street NE I LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 20,21 11 Hamilton's Addn. to Mechanicsville SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE James/Carol Staysvick 5423 4 Street NE 574-9345 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO K Designers 1310 Hwy 13, Burnsville, MN 55406 894-3600 20138685 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO B USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW O ADDITION ❑ ALTERATION REPAIR O MOVE O REMOVE 8 DESCRIBE WORK Reside House & Garage 9 CHANGEOFUSEFROM TO STIPULATIONS Call for building wrap inspection before covering. 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 I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION j 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 @ $8'30 WITH WHETHER SPECIFIED HE IN OR NOT. THE GRANTING OF A PERMIT $16,610 DOES NOT P SOME TO GI AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISION F AN O STATE OR LOCAL LAW REGULATING CON. STRUC�TI TH $249.75 Fire SC $16.61 P MANCE OF CONSTRUCTION PLAN CHECK FEE TOTAL FEE License $5.00 79.66 .TW !;GN U C ACTOR OR AUTHORIZED AGENT iDATEi EN OPE LIGATE HI Y R PERMIT d BlD -NSo pAtE SjGNATURE OF OWNE Anv OWNER BUILDER, iDATE NEW [ ] Effective 1/ 1/99 ADDN [ ] CITY OF FRIDLEY ALTER [ J SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION C onstructionAddress: Legal Description: Owner Name & Address: Tel. Contractovile /JP.,- MN LICENSE Address: 4,1 2; ; ,, s, ,, !- Tel. # A tach 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: R, 5�4 Estimated Cost: $ ��U O (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. +fiyt = ��t _ $ DATE: 1? 5" % � Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: Tel. # P'`/— 3�0 G CITY USE ONLY $ �% %�� Fee Schedule on Reverse Side $ / 6 . o / .001 of Permit Valuation (1 / 10th %) $ 9.3O $.50/$1,000 Valuation $ $1050 per SAC Unit $ .5-66 $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 [ ]