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PRE 2010 DOCSCity of Fridley, Minn.. BUILDING PERMIT N°5 E 3 4 Date: ;Zt� Z Y Owner: Builder ---_— Address Address LOION OF BUILDING No. sStreet _"'Ar -__--_- Part f Lot Lot — Y#----' Block Addition or Sub-Divid1p Corner Lot _ Inside Lot Setback_aldeyard _ Sewer Elevation ___ — Foundation Elevation DESCRIPTION OF BUILDING T UsedXV ✓ Front Deptht' Height Sq. Ft. Cu. F9 -7e' Fr Depth Height ___ Sq. Ft. _ Cu. Ft. of Construction s `� rr�'"'j1e Type .�� .Est. Co .��,,� s,.�� .r... __ 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. 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 e 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 viola�ti,91jany of the provisions of said ordinances. -010-N_ Inspector NOTICE: This permit does not cover the construction, hutallation for wiring, plumbing, gas heating, sewer.or water. Be sure to see the Building hupeetar for separate permits for them items. 4 APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA Owner's Name Builder S a Address Address q;r ®6 ION. OF BUILDING No. � Street Part of Lot 2�1 Lot Block % � Addition or Subdivision Corner Lot Inside LotSetback �10 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: PW Front -2,q- Depth Height Sq. Ft. Cu. Ft. Front Depth Height Sq. Ft.Cu. Ft. Type of Construction F- Act e*_ Estimated Cosa 2— J-® a 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. 1-1_ DATE SIGNATURE (Schedule of Fee Costs can be found on the Reverse Side). Application for Power Plants and Healing, Coding, Ventilation, AeMgeration and Air Conditioning Systems and Devices PARTIAL RATE SCHEDULE GRAVITY WARM AIR: RATE TOTAL, 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 $ NECK. WARM ATR Furnace Shell & Duct Work to 120,000 BTU ............ 8.00 $ 8.00 each add. 60,000 BTU ....................... 2.00 $ Replacement of Furnace ............................. 5.00 $ Repairs & Alterations—up to $500.00 ................. 5.00 $ Repairs & Alterations each add. $500.00 .......:...... 2.50 $ gTEAM or HOT WATER SYSTEM ' Furnace Shell & Lines—to 400 sq. ft. EDR Steam ...... 8.00 $ " Furnace Shell & Lines --to 640 sq. ft. EDR Hot Water ... 8.00 $ Each add. 200 sq. ft. IDR 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 GAS BURNER (up to 400,000 BTU) ....................... 5.00 $ 5:()O GAS FITTING FEES: NO RATE TOTAL 1st 3 Fixtures x $1.50 $— Additional Fixtures ................. x .50 $ • Gas Range to 200,000 BTU ........... x 2.00 $ AIR CONDITIONING $ FAN HEATING SYSTEM See Fee Schedule VENTILATING SYSTEM $ 14.50 ALTERATIONS & REPAIRS TOTAL FEE $ ROUGH 10 FINAL Dept. of Bldgs. Phone SII 4-7470 Location 5477—.th St- X- F _ 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 Fridley, Minn_ 5 3-62 19 Philip Hirsoh Construotion Co. Kind of Building Used as Res. To be completed about 6-3-62 Estimated Cost, Old—New. Building Permit No. Permit No. DESCRIPTION OF WORK HEATING or POWER PLANTS–Steam, Hot Water, Warm Air—No- Trade ir—No Trade Name Westinghouse GUE-75 Size No- MM 75 Capacity Sq. Ft. E.D.R BTU___M H.P. Total Connected Load 35, 338Kind of Fuel --Gas BURNER — Trade Name Size No Capacity Sq. Ft. E.D.R. BTU H.P. (REMARKS -OVER) Signed FRED VOGT & CO. HEATING & AIR CONDITIONING By 6530 West hake. St�.ouis Park, Minnesota �w o 42 2M 7.59 Business Phone o HEAT LASS DEPARTIMENT OF BUILD 4GS Weadtentrips Guide Construction No. Windows Doors Reference Out. Wall lint.Waff I Ceiling I Roof Floor 9Ciad Iywzwo 19. F7 Room I Length Width M-;-kt1 / m Roam d Wiadowa and Dow--Crac6p and Area 00 �Sr wldtk otettt o. of MM AAs Eta of pans of ne lights of Crack ft. IPL � do if 1 ZS 1. — :/�7j All exp. wan Coat. Btu Ia�ratioa Ceiling -4 Gen Floor D 5 % 7 s �, wall e ✓ Z Alar a m. wail Int. wall Ceiling Floor 46/ Y Ism fie. fzga Rieguired sq. ft. E.D.R. or sq. in. W.A. Leader area FL L,egtt6 Width Height Windows and Doom -trackage sad Area eh a Llnpl ft. /fres Ni of pane of ne it*kL of eraek sq. ft. v � � / 7 Coat. � Iaikratioa - Ghm 3m Ex& wall 21m - Net exp, wan lat. wall Cell' Flow Tota! �. Revived sq. ft. E.DJL or sq. ims. W.A. Deader area Room I L rL Vickh� Windows and Doom trackage and'Area Lp�- , MM�M�M�I .� ��■■� f •I Widows and Doers.- Cn lx.te t Els. sf peesat of pans lt�l CA MINNEAPOLA 140M. Immsulatiaa How Applied WKm Hei ht and Area ft. Ares Crack sq. ft. Coef. Rta Infiltration p j. Glace �i--� Eap. wall — :/�7j All exp. wan �. Int. wall Ceiling -4 O S T O Floor D 5 % 7 s Total Btu. Required sq. ft. E.D.R. or sq. ms. W.A. Lander area I / FI -I Agdd Room I Length /.7— Width / / Height �. Windows and Doors—Craekage sad Area {Ar1Atk e�kt o of I.l8: rq No.o[ pace of 1 ate ereck n. -2 1 A w I ie 1 .9 ®r Glass Ew wall a•VIFVI Net nap. wall Iftt. wad Ceiling 7LI Floor Total Btf. Requiled sq. ft. E.D.R. or sq. itis. W.A. Lander area Rrssm I l Width P Hemet Windows and Doom—Crackage and Arae Width etgAt o. o Arcs Eto. of pane of sa It{�Au of track q a Infiltration Glass Exp. wall ? • Net exp. small sat. wall Ceiling 56— 11 1 otal E$tu. • skit3' Fridley, Y, Minn. e BUILDING PERMIT N® 6 769 O O F UILDING No. elf 't--y'Street /% — _ Part of Lo Lot ___ Block � Addition or Sub -Di on . Corner Lot --- Inside Lot fetback Sewer Elevation tion Elevation DESCRIPTION OF BUILDING To ���J� Front Depth Height �._.__ Sq..�1) Cu. Ft.�, i.-� `� • 'o a Z;MAe- - Depth Fr, Height _� Sq. Ft. Cu. Ft. Type of Construedo Est. 7 __ 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 compliance with 21 provisions of ordinances of the city of Fridley.� 1� az�-'�W F &u." 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 reg location, construct%n, alteration, maintenan pair and moving of buildings within the city limits and permit may be revoked at any tt�e upon lata n of any of the provisions of said ordinances. / dl Building Inspector • NOTICE: ihb perm* does not corer the construcdon, hutaWan for wb3ng, phmrbing, gas hoaft, sawer or water. Bo sure to sse tho Bonding hupecter for separate permhs for these hems. APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER ° S PIAT U DER w ADDRESS %I DESS LOCATION OF BU ING No. — � rest �• a P t of Lot �- LoY�'? FV °'' oc16Z Addition or Subdivisio 601 Corner Lot Inside Lot�etback Side Yard SEWER ELEVATION FOUNDATION ELEVATION Applicant attach to this form Two Certificates of Survey of Lot and proposed build- ing location drawn on these Certificates. DESCRIPTION OF BUILDING To be used as: Front -1-1.Z Depth Height Sq. Ft. o Cu. Ft. Front Depth Height Sq. Ft. Cu. Ft. Type of ConstructionEstimated Cost 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. A DATE__44-:S - _ SZCNATIME U (Schedule of Fee Costs can be found on the Reverse Side). 0 • City of Fridley, Minn. N. 7569 Date: Ysy 26, 1965 Omer: Gerald Goreeki Builder J. H. Franzen Conste, Address 5977 44th. Street N. E. Address Rt • #1 -Box 6136 E=elsior, Minn. LOCATION OF BUILDING No, 5977 Street 4th Street N. E, Part of Lot Lot 52 Block _14 Addition or Sub -Division It -de Park Corner Lot Inside Lot Setback Sewer Elevation To be Used as: Sideyard Foundation Elevation DESCRIPTION OF BUILDING Front Depth Height Sq. Ft. Cu. Ft. Front Depth Height Sq. Ft. Cu. Ft. Type of Construction Est. cost 3202.09.00 ____.. To be Completed Storm Damage Repair 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 a'll provisions of ordinances oP the city of Fridley. n s In consideration of the payment of a fee of1$ ©•00 , permit is hereby granted to J• H. Franzen Const.Co, 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 wiorthi nthe city limits and this permit may be revoked at any time upon violation of any of the provisions of said Building Inspector NOTICE: This pemilt does not ewer the com*mcdoe, hutallalien for whieg, phrmbinB, ges heating, sewer or water. Be sore to ses the Boildiag kapecter for separate permW for these inns. APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAME � F�rw lz'z— ,�/ BUILDER ADDRESS,y' ei ;;77— -V _Lf ST . A!--, ADDRESS CT &X AS- Oeat' LOCATION OF BUILDING No. %7 �< ' "�S� Street Pa t of Lots LOT tLIOCK ADDITION OR SUBDIVISION Corner Lot -;.ry Insi-de 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. To be used as; DESCRIPTION OF BUILDING Front Dept h Height Sq. Ft. Cu. Ft. Front Depth Height Sq. Ft. Cu. Ft. Type of Construction_d�fr,ryr, ,�"'� �,o,� Estimated Cost o l To be completed f -Ile= _111k' / 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.�� (Schedule of Fee Costs can be found on the Reverse Side). 97-84-416051 �;•. �,i FCF �L 1:'!Liti6 i,lu '"i:I%,I ,. ' I •r � 1 • t' v � N I cLA MI ; Li it _ 1 5977 4 strget SNE I � I,.t•,re ....rlr,c..tlor, �..,:rtr VIAL6r jch hsdt'e 5a 5977_4 Street NE Ilea [cr • it --,— Dcharunr:nt c>; b�t•!.11r��u •--' ;�5 aec C1 Ly of 1'r1d1�y Tel, 11571-�•15G Tho utrdoralgn,:d I..:Lety, r-::kca App 1Ic_L:ofzr c .raft f.r tho ..ark Lerc{:, epbclfled agrcl:ifig La da' e1! work lc sLr:et c;.:crJar. a r ttt, tl,+ Clt� and rullnys of the Ge:artfrent of B.t:d1re-! -ercrJ .1c lacer CteL el' thu facto acrd r.I,ru�„ctaLtonj e[atoJ s^ tL:a ,, t/LAO end 8-8-80 , lY I J L� r.acLcd with Sewer Hater t,u-:,L& I IAL„Lea IUL,IIe F:AcaIa L1.cr:f.] •e4 F1At.,Le, 31.1 Lpe salol IicALL;r - to 57,vJJ bl�' 030 bIU t,a ly :. O bTU later �.,fl�nar Iew L,LL.,rll.1 kin OId but1,11r.) .1L•LLII,; Natet IieeLer IIIIINC htES; .at 1 rIALuroe 1 I.II L 1 u.1 %I 11. Lipr,, .La 111,,.jp LG I$A,Ouu bTU PAIItti 4 AI.1EK-;TiuIIS I'I:at >Ik1u.OU tall 0.1.1, y1JJ.uO ..r [racuan Ito. RATEa TOTAL. x x $2.00 g ----, x ::. GO X $5.00 $ a $5.00 5 ® x $10.00 $ x 57.00 ed_ x 55.00 ; x 55.00 S x 5],00 5 x $1.00 ; T x Sto. 00 55:00 5 $2,00 SLata Surcharge 5 .50 TGi,.L t I.L 5 8.00 01-INER Gorocki _ KIND OF uUIL'ull;-i frame USED AS res. T TO BE COIInc—no ALJUf 8-15-80' ESMUMD CU5: OLD - IICH UUILCI:1,; hL6;•iIT 1pany � signet By TaI. Iia, ROUGH IIISP, D9 LJ FINhL IIISP. '-1-2F -%i Oatu hl•1'R(UVAL 1611 1-Lltr•1I'r -d MIIIIMUII I'L'L' II:1t 1.11' PLUcuillZ Pciu Ir IS 57. 51) PLUS 2.50 .TS.iC 6U[iCltxteGB SUBJECT City of Fridley 26932 AT THE TOP OF THE TWINS BUILDING PERMIT � NO. COMMUNITY DEVELOPMENT DIV. r 1 PROTECTIVE INSPECTION SEC. 1 � 1 . � NUMBER REV DATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 612-571-3450 910-F15 7/31/98 JOB ADDRESS 5977 5+7.7- 4th St NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 28, S$ 29, 1 Vac. Ale Hyde Park SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Gerald Gorecki 5977 4 St NE 571-1991 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Owner 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 IX REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof house and garage (19 Sq) Tear-off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with 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. OWLG. 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 $1584 .79 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. $51.25 Fire SC $1.58 PLAN CHECK FEE FEE TL53.62 SI NATURE OF CON' CTOR O AUTHORIZE AQENT IDATEI N O VALIDA THIS IS YO PER S S�GNATURE OF OWNERoF OWNER BUILDERi IDATEI BLD INSP MATE NEW [ ] Effective 1/1/98 ADDN [ J CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION j ConstructionAddress: Legal Description: Owner Name & AddressigfffZ+ , ��� ° Tel. # Contractor: V` It-'/l/Al MN LICENSE # Address: Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IlIZPROVEMENT LIVING AREA: Length Width Height Sq. Ft. _ GARAGE AREA: Length Width Height Sq. Ft. _ DECK AREA: Length Width Hgt/Ground Sq. Ft., OTHER: kF Construction Type: 'W Q ' (� �� Estimated Cost: $ Z/� (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: APPLICANT: ZZZei - Tel. CITY USE ONLY Permit Fee $ Fee Schedule on Reverse Side Fire Surcharge $ .001 of Permit Valuation (1/10th%) State Surcharge $ %9 $.50/$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: SUBJECT PR19FIT NO. City of Fridley 2 812 0 AT THE TOP OF THE TWINS U I L D I N G P E R M I T. 572-3604 B RECEIPT NO. ` ' COMMUNITY DEVELOPMENT DIV. - _____ r PROTECTIVE INSPECTION SEC. (06q I 01� NUMBER REV DATE PAGE OF APPROVED BY 1 /�"1 CITY HALL FRIDLEY 55432 �"""� 612-571-3450 910415 10/6/98 1013 ADDRESS 5977 4th Street NE 1 LEGAL f8T SQ /2 29ley BLOCK TRACT OR ADDITION 1Hyde SEE ATTACHED DESCR. wiMac .Al14 Park SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Gerald Gorecki971-1991 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Twin City Exteriors - 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 6 USE OF BUILDING e identia 7 CLASS OF WORK ❑ NEW 0 ADDITION ❑ ALTERATION REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Storm damaize repair 9 CHANGEOFUSEFROM TO STIPULATIONS TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REOUIRED 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 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 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $500 $.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 CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION $21.00. Fir SCi $.50 PLAN CHECK FEE TO L FEE Licen $5. 7.00 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI N P OP IS IS YT A IDA THISOU PE I BL INSR i flArt S-GNATURE OF OWNER..F OWNER BUILDERI IDATEI NEW [ `] Effective 1/1/97 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ...�ConstnlctionAddress • _ ' �% �-- L� ��' Legal Description: Owner Name & Address:�,�19 f_���,� G'C I Tel. # ,S17J—./ 99j Contractor: C 7-1 �X 1Dle-s n MN LICENSE# Address: lD C a ;?AcHv12Y .6) #�• ��v_ _%i�.r� .5,�3,� Te1. # x4a X73% 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: �J ptN ,Dfj/4/96'E )Q,4, Estimated Cost: $ Q (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: APPLICANT• Tel. # CITY USE ONLY Permit Fee $ off/. 00 Fee Schedule on Reverse Side Fire Surcharge .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1;000 Valuation SAC Charge $ $950 per SAC Unit License Surcharge $ S_-00 $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 [ ] ©d TOTAL $ �a STIPULATIONS: ---- - - -- _ f