PRE 2010 DOCSCity of Fridley, Minae '
BUILDING PERMIT
N 4959
Date:
Ae
Owner: _.__-s¢"='� Builder _�_-....._. �._--•---•--__ _ _ .._ _ ____......
_
Address _ .._±•`zt ' _ Address
LO 1 N OF BUILDING
NO. .. Street J1 /Q, ._J.... •*f+' �-•---- .... _Part of Lot
Lot-----.�. ........... Block ._..__..._...._................ Addition or Sub -Division _....... _..._ _._.�_.
Corner Lot ------ ................... _...... .. Inside Lot ..... _......... Setback ..... ...ar!.................... Sideyard .--- ..
Sewer Elevation....._............._...........__......._...._...................._......_............._......_ Foundation Elevation
DESCRIPTION OF BUILDING
To Used as
r .... lets .------�4
... ... ....,. Front ..... ....,�_.. Depth .,�..��....�,,,..Height ......... Sq. Ft. leo ..__ Cu. Ft.
..............._of Construc ........ ....._................. -- p ......1�°"t,<�--- ......... Sq. Ft....................... Cu. Ft......_...............--
........... .
Front � Depth ....._....... ight ....._.
Type tion[..:.. Est. Cos .. ..� 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 $.p '_"rpermit 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, rep and moving of buildings
within the city limits and this permit may be revoked at any tim o viyplation oof the provisions of said
ordinances. //�� f
Inspector
NOTICE:
This permit does not cover the construction, Installation for wiring, plum' bing,' gas heating, sewer or water. Be sure to see
the Building Inspector for separate permits for these items.
•
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA r
Owners Name Builder, -
Address—Address—
._....
LOCATION OF BUILDING
No.a3 Street____ l- Part of Lot
LotV Block .� Addition or Sub.Div.
Corner.Lot , In;ide Lot Set Back =5 Side -Yard
SEWER ELEVATION FOUNDATION ELEVATION --
Applicant attach to this form Certificate of Survey of Lot and proposed building
location.
DESCRIPTION OF BUILDING
To be used as:
s
Front Depths Height
Ile
Sq. Ft. r Cu. Ft.�
Sq. Ft.
Type of Cons
To be
Front Depth Height
. Ft•
ted Cost �= t" /0
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 representa-
tions stated in this application are true and co3l4rect.
2a SIGNATURE_
DATE•- _ -- - ..,
(A Schedule of Fee costs can be found on the Reverse Side.)
r
Application for Power Plants and Heating, Cooling, Ventilation, .Refrigeration and
Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE Dept. of Bldgs. Phone SII. 4-7470
GRAVITY WARM AIR: RATE TOTAL, Location—
Furnace Shell & Duct Work .......................... 8.00 $ City of Fridley:
Replacement of Furnace ............................. 5.00
The undersigned hereby makes application for a permit for the work herein
Repairs & Alterations—up to $500.00 .................. 5.00 $ specified, agreeing to do all work in strict accordance with the City Ordinances
Repairs &Alterations each add. $b00.00 ............... 2.50 $ and ruling of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
MECH. WARM AIR
Furnace Shell & Duct Work to 120,000 BTU ............ 8.00 $
.each add. 80,000 BTU ... .................. 2.00 $
Replacement of Furnace f§.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 /
GAS BURNER (up to 400,000 BTU) ................. / ... 5.00 $
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
$ _
ALTERATIONS & REPAIRS
TOTAL ME
$ to
ROUGH—
OUGH
FINAL—
FINAL
Fridley,
Fridley, Minn A
Owner agY4=t. -,
Kind of Building
Used as
To be completed about
Estimated Cost, $ J�
Old New. wilding Permit No. /7/ Permit No.
DESCRIPTION OF WORK
HEATING or POWER PLANTS—Steam, Hot Water, Warm Air—No
Trade Name Size No
Capacity Sq. Ft. E.D.R. BTU H.P.
Total Connected Load Kind of Fuel
BURNER — Trade Name . Size No
Capacity Sq. Ft. E.D.R BTU H.P.
(REMARKS -OVER)
42 2M 7.59 Business Phone No
0
•
11
City of Fridley, Minn..
BUILDING PERMIT
Date: August 6,. 1965
Builder
WARREN OSBORN
Address 7534 — 4th Street N. E. Address 7565 University
Fridley, Minnesota Fridley,. Minnesota
No. 7534 street
LOCATION OF BUILDING
4th Street N. E. Part of Lot
Lot 22 _ Block 2 Addition or Sub -Division Osborne Manor
Corner Lot Inside Lot —. X Setback 72 Sideyard 101
Sewer Elevation Foundation Elevation
DESCRIPTION OF BUILDING
No 8325
To be Used as:
Dot. Gamgee Front 20 Depth 22 Height Z 10 sq. Ft. 44P cu. Ft 4400
Front Depth Height Sq. Ft. Cu. Ft.
Type of Construction Wood Est. Cost $1,300*00 _ To be Completed
New Detached Garage
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 ab7;ni2=7�=
of
ordinances of the city of Fridley.
In consideration of the payment of a fee of s 4.00 . permit is hereby granted to WARREN OSBORN
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
ing location, ccttiippaarrtt thereof, shall conform in all respects to the ordinances
Fridof
within e cit Mmota this permit � revoked,. t any time upon violation off any of t and provisions of said
ordinance. city limits and
ALLEN 0. JENSEN Building inspector
M(MC&
"Is pe mb den net cover the conatruatlon, iestalkilan fee whiny, plumbing, gas hating, Bawer or water. as sun to no
fhe Building Denier for separate rmnlM for thea hems.
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
r
OWNER'S NAME BUILDER
ADDRESS__.L C ADDRESS
LOCATION OFBUILDINGBUILDING
s' r a 4 11 k ,
NO. STREET r PART OF LOT
LOT BLOCK ADDITION OR SUBDIVISION
CORNER LOT INSIDE LOT SETBACK SIDE YARD 9
SEWER ELEVATION_ FOUNDATION ELEVATION s
Applicant attach to this form Two Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
DESCRIPTION OF BUILDING
To bA used as;
Front Depth! Height
Sq. Ft.-- ey �� l Cu. Ft 1 < <'
Front
Sq. Ft:
Depth Height
Cu. Ft.
Type of Construction Estimated 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.
DATESIGNATURE
_--C
r'
(Sc*d�4e'of
Fee
Costs
can be found on
the Reverse
Side). fL
City of Fridley
Application for Plumbing and C%n Fitting Permit
Dept. of Bldgs. Phone 560-3450
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
C1
x $200
$
Future Fixture Opening ................
x $1.50
12i^
New Fixture Old Opening ..............
i �i
o2r
z
InU
<� z
�
O�j
<
� d
z
C�9 o4
z
z
009 0
F
N
WATER HTR.
GAS
ELEC
Base
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ...... ...................
2 x $2.00
$_ 2.00
Additional Fixtures ....................
x $ .75
$
Gas Range to 199,000 BTU ..............
x $5.00
$
install (2) gaslites
6.00
1st
2nd
3rd
4th
• Future Connection Openings
New Fixture, Old Openings I
Connected with
Sewer
Cesspool �
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures ....... ..............
x $200
$
Future Fixture Opening ................
x $1.50
$
New Fixture Old Opening ..............
x $1.50
$
Catch Basin ............................
x $3.25
$
Water Heater (Up to 99,000 BTU) ......
x $3.00
$
New Ground Run Old Bldg . ............
x $3.25
$
Electric Water Heater
a $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ...... ...................
2 x $2.00
$_ 2.00
Additional Fixtures ....................
x $ .75
$
Gas Range to 199,000 BTU ..............
x $5.00
$
install (2) gaslites
6.00
REPAIRS & ALTERATIONS—Refer to Code
Description ..... ........ ..............................$
TOTAL FEE $ 8.00
L mflon 7K31'IE. 4 St.
City of Fridley:
53-84-x915.51
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.
Fridley, lYl"inn_ June 26, 1970 019 -
Owner
19_
Owner Charles Jordand
Kind of Building fraMe
Used as residence
To be completed about June 30, 1970
Estimated Cost, $ 20.00
O1c-New. Building Pe o Permit No.
By
ROUGH
FINAL
42
MM EGASCO
53-84-s-915-51
City of Iridiay
Applicelcn for Plumbing and Gas Milmpn y Pormlt
Dept. of Bldga. Phone 560-3450
DESCRIPTION OF FIOM-4 7534 4th Street N. E.
Number, Kind and LocaKrn of Fixtures
Location
i
NO. RATE TOTAL
S►
x $2.00
p
Future Fixture Opening ............
x $1.50
S _.
New Fixture Old Opening..........
V
0.
N
Vis
i
N
WATE4 NTR.
GAS
[lEG
r
x $3.25
$
Electric Water Heater ..............
a $2.00
$
LS FITTING FEES:
NO. RATE TOTAL
Ist 3 Fixtures ............ • • • • • •
x $2.00
$ .
Additional Fixtures ...............
x $ .75
$
Gas Range to 199.000 BTU . ..... .....
x5.5.00
S
InstJ11
Us Gr
L11
f
Futuro Congaed-: u OpaningsI
Sewer []
X*w Fixturv. Old Openings Cerspool 0
PARTIAL RATE SCHEDULE
-UMBING FIXTURE RATES:
NO. RATE TOTAL
Number Fixtures ................
x $2.00
$
Future Fixture Opening ............
x $1.50
S _.
New Fixture Old Opening..........
x $1.50
S_ --
Catch Basin ....................
x $3.25
$
Water Heater'L'p to 99.000 BTU). • • •
x $3.00
$
New Ground Run Old Bldg.......:.
x $3.25
$
Electric Water Heater ..............
a $2.00
$
LS FITTING FEES:
NO. RATE TOTAL
Ist 3 Fixtures ............ • • • • • •
x $2.00
$ .
Additional Fixtures ...............
x $ .75
$
Gas Range to 199.000 BTU . ..... .....
x5.5.00
S
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 -
Fridley, Minn 5-6-75 19—
Owner _ Charles D. Jordan
Kind.of Building Frame
Used as 'RA -Re
To be completed about 5-13-75
Estimated Cost. $ 10.00
Old—j%K Building Permit No. Permit No.
Signed-
By
igned-By MIN N IPGASC�' -'
Business Phone No
ROUGH
EPAIRS & ALTERATIONS—Rafor to Code .50 State Surcharge
-Description ....... SP014.1 . G ..Grp-lh........:....3 5.00
TOrICAL FEE 5.50 --
lass
0 lass uW1 Surcharge ,50¢
c
1__j
SUBJECT
P
City of Fridley
22769
AT THE TOP OF THE TWINS
BUILDING PERMIt��
RECEIPT NO.
_ COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
612-571-3450
910-F15
8/2/94
JOB ADDRESS 7534 4 Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
22
1 Osborne Manor SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
John Courneya 7534 4 Street NE 786-0234
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Same
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 ❑ ADDITION ❑ ALTERATION ❑% REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof House (16 Squares) 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.
ZONING
SQ. 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
1
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
$1,200
$.60
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$29.00
Fire SC $1.20
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTALFEE
AI
$30.80
SIG ATURE F co ACTOR OR AUTHORIZED AGENT (DATE$
W N RLY VALIDATED THIS IS YO R PERMIT
-WNArdAe OF OWNER OWNER BUILDER$ IDATEI
BLDG $NSP DATE
1__j
NEW {) Effective 1/1/94
ADDN { ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
Construction Address: 7S-3 V V`riS7 'vc
Legal Description:
Owner Name & Address: Tel. #
Contractor: S E 1 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: �� /food
�ITiS` Jamie o�G
/�cyS�
�� scvaS
Corner Lot [ ] Inside Lot [ ]
Type of Construction:
Approx. Completion Date: _
Ft. Yd Setback
Side Yazd Setbacks
Estimated Cost: $
(Cost on Back)
Driveway Curb Cut Width Needed: Ft. + 6 t = Ft x $ — $
DATE: a - APPLICANT: Tel.. #Dz93
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$800 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 [ ]
SUBJECT
IT N(3.
City of Fridley
3 2 7 5 7
AT THE TOP OF THE TWINS
BUILDING
PERMIT
�
RECEI NO.
COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
I �
NUMBER
REV
DATE
PAGE Of
APPROVED BY
= CITY HALL FRIDLEY 55432
612-571-3450
910415
7/8/02
JOB ADDRESS 7534 4th St NE
i LEGALLOT
NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
22
2
Osborne Manor
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP
PHONE
Doreena Cisewski, 7534 4th St NE, Fridley, MN 55432
763-717-4197
3 CONTRACTOR MAIL ADDRESS
ZIP
PHONE LICENSE NO
Doreena Cisewski (same as above)
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 0 ADDITION 0 ALTERATION 0 REPAIR
0 MOVE 0 REMOVE
8 DESCRIBE WORK
Install egress window on rear of house.
9 CHANGE OF USE FROM 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 CONSTRUCTIONZONING
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
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 13E COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$750.00
$.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
$3.2.65
$.75 Fire SC
PLAN CHECK FEE
TOTAL FEE
11�
/.
$33.90
URE OF CO"GT AUTHORIZED AGENT iDAfEi
—�
WH PRO
Y VALID ED THIS IS YOUR PERMIT
Na EO�OW NEA oOWNER BUILDER, �ME
qfDG INS
OAfE
NEW [ ] CITY OF FRIDLEY Effective 1/1/2002
ADDN [ J 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: �'h(P2t � 16A
Legal Description: e W S le LJ
Owner Name & Address:i'�e C\r� Tel.
Contractor. 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 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: rec'-f�- ` \j i I"fEstimated Cost: $
Driveway Curb Cut Width Needed: Ft + 6 Ft = Rx $ —=$
DATE:
APPLICANT:
Tel. #
Call (763) 572-3604 for Permit Fees if mailing in application or Fax to 763-571-1287 if using credit card and we will
call you for card number.
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
CITY USE ONLY -
Fee Schedule on Reverse Side
$ e 76 .001 of Permit Valuation (1/10th%)
$ '50 $.50/$1,000 Valuation
$ $1200 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 [ ]
$ 3390 STIPULATIONS:
Building
PLUMBING
Permit No.: alao7
Inspections
RESIDENTIAL APPLICATION
Received By:
763-572-Q3604
CITY OF FRIDLEY
10 ' I8 "0 7 d c-is�y�K� @ r�esg tn� rdy�t s • ccm
DATE YOUR E-MAIL ADDRESS
sITE ADDRESS 7S 34• 4M SWe,41- N6
THIS APPLICANT IS: ieOWNER OCONTRACTOR
PROPERTY
NAME: DOIC66914A Gy1.S� Ec,W,�$i�l
J
ADDRESS: ZC$ 7 • �7! r ee.Jt AffLO , CITY Ani�Gf 1 e y STATEN ZIP�Z,.
OWNER/
TENANT
@q'1`
PHONE: 163 q59— 12476
CONTRACTOR
NAME:
STATE LICENSE # EXP DATE
SUBMIT A COPY OF
YOUR STATE
ADDRESS: CITY STATE ZIP
LICENSE WITH
PHONE FAX
APPLICATION
PERMIT TYPE
SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK:
❑ NEW WfiPLACEMENT
DETAILED DESCRIPTION OF WORK LeM InaD � M
PER MS 1613.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor )
Labor cost under $300 = $15.00. Labor cost between $300 to $500 = cost of labor x.05 =
FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL
NUMBER OF EACH BELOW)
BATH SINK/LAV DRAINS —SHOWER —WATER PIPING
_ _FLOOR
_ GAS PIPING pvEEv crrrtrcEtvse) _ SWIMMING POOL —WATER SOFTNER ($35)
—BATHTUB
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
_ _
_ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
—DISHWASHER
WATER METER OTHER
PERMIT FEE PROJECTS FOR UNDER $500 `
PERMIT FEE FOR PROJECTS OVER $500
Permit Fee $ OD
Number of fixtures @ $10.00 x $10.00 = $
Surcharge .50
Number of fixtures @ $15.00 x $15.00 = $
Number of fixtures @ $35.00 x $35.00 = $
TOTAL DUE $
State Surcharge = $ .50
Total = $
THIS IS AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED
I hereby apply for a building 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 and with the Minnesota Construction 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; that the work will be in accordance with the
approved plan in the case f all work wl ' re fres review and approval of plans.
r- DOrMA `"' "•' Imo• DATE 10-18-07
SIGNATURE OF APPLI f PRINT NAME
PLEASE NOTE: SEPARATO PERMITS ARE REQUIRED FOR BUILDING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977