PRE 2010 DOCSCity of Fridley, Minn.
BUILDING PERMIT
Date:
Owner:A " p 4'- �a8uilder
Address Address
r
TION OF UILDING
Streett4 Parc o Lot ,
Lot c — Block yrs Addition or Sub-Dividon 07 '" ' r
Corner Lot _ Inside Lot !"' Setback / -- Side;ewd
Sewer Elevation _— Foundation Elevation
DESCRIPTION OF BUILDING
Toiri Used ��
Front Depth Height =1~ _ - Sq. Ft. 4 i-4� Cu. Ft.
Depth Height Sq. Ft. Cu. Ft.
Type of Construction Est. Cost �.,. __ _.__ ........... __ 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.
CIO
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
=ceee city limits and this permit may be revoked at any time upon violation of any of the provisions of said.
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 theta Items.
16
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDIEY, MINNESOTA
y
Address Address
LOCATION OF BUILDING
No. :r 7 oZ Street 6 -c- Part of Lot T�
Lot Block Addition or SubdivisioIL-WA-
Corner Lot Inside Lot Setback 6 - 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;
Front Depth_„_, Height_
Sq. Ft. �� �-� % Cu. Ft.
Front Depth Height
Sq. Ft. Cu. Ft.
00
-
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 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.
DATE SIGNATURE
(A Schedule of Fee Costs can be found on the Reverse Side.)
Ya •
■w � N .
City of Fridley
Application for Plumbing and G= Fitting Permit
Dept, of Bldgs. Phone SII 4.7470
DESCRIPTION OF WORK — _ `S y �U4
Number, Kind and Location of Fixtures Location
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL CB
Number Fixtures ...................... x $1.50 $-1 e, SU
Future Fixture Opening ................
x 1.20 $ 7- /O
New Fixture Old Opening .............. x 1.00 $
Catch Basin ............................ x 3.25 $
Water Heater (Up to 200,000 BTU) ...... x 2.00 $ y'
New Ground Run Old Bldg. ............ x 3.25 $
GAS FITTING FEES: NO. RATE TOTAL
1st 3 Fixtures .......................... x $1.50 $--Z' So
Additional Fixtures .................... x .50 $
Gas Range to 200,000 BTU .............. x 2.00 $
REPAIRS & ALTERATIONS—Refer to Code
Description ................................................$
TOTAL FEE /Q
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.
Fridley, Minn MAR 2 7 1961 1s_
Owner / 1 A/ /4 L Q.A ltl,4-r L�
Kind of Building
Used as
To be completed about
Estimated Cost, $ / /
Old—New. Building Permit No Permit No. Z Cr C1 CO
Signed L O D 0 N PLUMBING C O ..�
Bya�''�.
Business Phone No
ROUGH y — 3 4,1
FINAL
42 2M 749
z
z
'a7
C 'z
ul
�?
O
J
W
O
(N9
Z
z
7 aO
F
N
WATER HTR.
GAS
ELEc
Base
0/
1st
!
/
/
2nd
_
3rd
4th
I
�
• Future Connection Openings
Connected with
Q
Sewer
New .Fixture, Old Openings
Cesspool El
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL CB
Number Fixtures ...................... x $1.50 $-1 e, SU
Future Fixture Opening ................
x 1.20 $ 7- /O
New Fixture Old Opening .............. x 1.00 $
Catch Basin ............................ x 3.25 $
Water Heater (Up to 200,000 BTU) ...... x 2.00 $ y'
New Ground Run Old Bldg. ............ x 3.25 $
GAS FITTING FEES: NO. RATE TOTAL
1st 3 Fixtures .......................... x $1.50 $--Z' So
Additional Fixtures .................... x .50 $
Gas Range to 200,000 BTU .............. x 2.00 $
REPAIRS & ALTERATIONS—Refer to Code
Description ................................................$
TOTAL FEE /Q
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.
Fridley, Minn MAR 2 7 1961 1s_
Owner / 1 A/ /4 L Q.A ltl,4-r L�
Kind of Building
Used as
To be completed about
Estimated Cost, $ / /
Old—New. Building Permit No Permit No. Z Cr C1 CO
Signed L O D 0 N PLUMBING C O ..�
Bya�''�.
Business Phone No
ROUGH y — 3 4,1
FINAL
42 2M 749
14 Application for Pourer Plants and Heating, Cooling, Ventilation. ReMgeraflon and
'fV 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 $
MECH. WARM AIR
Furnace Shell &Duct Work to 120,000 BTU ............
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 $
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 BTL) ....................... 5.00 $
'GAS FITTING FEES: NO RATE TOST`AVL
1st 3 Fixtures ...................... x $1.50 $--J—
J 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 FEE $.
REMARKS:
Dept. of Bldgs. Phone SU 4-7470
Location
City of Fridley:
40
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 /rrect.
,�/�
Fridley, 1 `� 195_
Owner � G � yy 19 P 195—
Kind of Building �"' 195—
Used as ie
To be completed about
Estimated Cost, $
Old—New. Building Permit No. \6-6F 1.6
DESCRIPTION OF WORK
HEATING or POWER PLANTS—Steam, Hot Water, 4Q No
Trade Name --C— 169 Y'�, �bEff 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.
Signed (!?IV °
B&23i'
3
11 POST 1M-12-58 Business Phone No_ �%� �` L _
,S-,7 2 -may a -e -NE.
el,C13Y
HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS J FRIDLEY MINN
Weatherstrips*
S.H.V.E, Construction No.
Guide
Windows D ors Reference Out. Wall Int. Wall Ceiling Roof Floor
es I No es No 19_
/ F1.1 L G V Room I Length Width Heiitht II / FI.I 317
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
No. of Dane of pane llghts of crack - sq. ft.
2 q 2 L 3
2
Coef.1 Btu
Infiltration
Coef.
Btu
]Infiltration
,2-/
qoQ
Net exp. wall
Glass
L/
/G
G O
Exp. wall
Floor
2 -
Net exp. wall — / 2
Ceiling
10
/0
Inc. wall
SO
/ Ps
2�ry G d
Ceiling
3
/0
Floor
2
1 71®
G ( 6
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
/ F1.1 Po- / Room I Length Width Height
Windows and Doors--Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
No. of Dane of pane ---lights of crack sq. ft.
2
2
Coef.1 Btu
Infiltration
-/Q
Glass
Infiltration
Exp. wall 2
Val
Net exp. wall
(f
Int. wall
/G
Ceiling
lo 13 2-o
Floor
2 -
Total Btu. I -
Required sq. ft. E.D.R. or sq. ins. WA. Leader area
t M1 1 a_ •i D�� I I ......L / n R/:�aL / n i/ t7�:_L.
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
No. of Dane of pane ---lights of crack sq. ft.
2
2
Coef. Btu
Coef.1
Btu
Infiltration
S51
Val
/ 0
Glass
?-r/
/G
Net exp. wall
Exp. wall
1 /0, 1130
Int. wall
Net exp. wall
Ceiling
10
/0
Int. wall
SO
IS6
Ceiling
/�1
Floor
I /Sv
1 71®
0 Sav
Tbtal Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area�0 3 Q
Insulation
Kind How Applied
Room I Length /2'G Width / S—Height
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack eq. ft.
2
2
Coef. Btu
Infiltration
d
Ya / % to
Glass
-2-
ST/13
Exp. wall
?-r/
/G
Net exp. wall
P73
1 /0, 1130
Int. wall
Ceiling
Ceiling
-ZP—'
/0
Floor
SO
Total Btu.
Required sq. ft. E.D.R. or sq. ins. WA. Leader area 112-3
/ M-1 Room I Length C' Width 9 Height Sr
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack eq. ft.
2
2
Coef.
Btu
Infiltration
/
vo
(o
Glass
Exp. wall
Net exp. wall
/G
gelo
Int. wall
2/
Ceiling
/7/1/0
-ZP—'
0
Floor
SO
IS6
Total Btu.
Required sq. ft. E.D.R. or sq. ins. WA. Leader area 3 j 2 7
F1.1 Y, 7— Room I Length / I/ Width 12- Height P
Windows and Doors--Crackage and Area
Width HeightNo. of Lineal it. Area
No. of pane of pan Ifghto of crack eq. it
/
2
Coef.
Btu
Infiltration
vo
RV
Glass
SD
Exp. wall
2/
Net exp. wall
/7/1/0
l
Int. wall
Ceiling
Floor
S
1 2 2
Total Btu.
Required sq. ft. E.D.R. or sa. ins. WA. Leader area I S? -P / <-
i
Application for Power Plants and Healing. Cooling, Ventilation, Refrigeration and
Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR: RATE TOTAL
Furnace Shell & Duct Work ........................... $10.00 $
Replacement of Furnace ............................. 6.00 $
Repairs & Alterations—up to $500.00 .................. 6,00 $
Repairs & Alterations each add. $500.00 ............... 3.00 $
MECH. WARM AIR
Furnace Shell & Duct Work to 120,000 BTU ............ $10.00 $
each add. 60,000 BTU ....................... 3.00 $
Replacement of Furnace ............................. 6.00 $
Repairs & Alterations—up to $500.00 ................. 6.00 $
Repairs & Alterations each add. $500.00 .............. 3.00 $
STEAM or HOT WATER SYSTEM
Furnace Shell & Lines—to 400 sq. ft. EDR Steam . .... $10.00 $
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ... 10.00 $
Each add. 200 sq. ft. EDR Steam ... .................. 3.00 $
Each add. 320 sq. ft. EDR Hot Water .................. 3.00 $
OIL BURNER—to 3 gal. per hour ........................
6.00
$
over 3 gal, per hour—See Fee Schedule
GAS BURNER (up to 199,000 BTU) .......................
5.00
$
-Teo
over 199,000 BTU See Fee Schedule
GAS FITTING FEES:
NO RATE
TOTAL
1st 3 Fixtures ...................... x$ 2.00
$
�y
Additional Fixtures .................
x .75
$
Gas Range to 199,000 ...........
x$ 5.00
$
AIR CONDITIONING
FAN HEATING SYSTEM
VENTILATING SYSTEM
ALTERATIONS & REPAIRS
ROUGH
FINAL
See Fee Schedule
TOTAL FEE $ o
Dept. of Bldgs. Phone 860-3480
1-0 T�
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.
Fridley, Minn_ %tet 190
Owner d` ltd �}-GtfL
Kind of Building
Used as
To be completed about
C
Estimated Cost, $ , �6 V'�
Old New. Building Permit No. Permit No. 6
DESCRIPTION OF WORK
HEATING or POWER PLANTS/-�Steam, Hot Water, Warm Air—No
Trade NamZ., — �
Capaci 1j
Total Connected Load Kind of Fuel
-
BURNER — Trade Name Size No
Capacity Sq. Ft. E.D.R BTU H.P.
(REMARKS -OVER)
SUBJECT
City of Fridley
2 8548
F THE TWINS
BUILDING
PERMIT
��7.2__-36
DEVELOPMENT DIV.
_ __ COMMUNITY INSPECTION'
PROTECTIVE INSPECTION SEC.
� „
r
01/
NUMBER
REV
111/9/98
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
612-571-3450
910-F15
JOB ADDRESS
572 54th Avenue NE
1 LEGALLOT
NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
3
1
1 T@Wle Terrace 2nd Addition
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Rita Furlong
-
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Warner Construction
-
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 O ALTERATION gx REPAIR 0 MOVE 0 REMOVE
8 DESCRIBE WORK
Reroof house and garage 14 S Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
SEPARATE PERMITS ARE REOVIRED 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
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
1199
.60
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-
STR CTION OR THE PERFORMANCE OF CONSTRUCTION
$40.25
Fire SC $1.20
PLAN CHECK FEE
TOTAL FEE
License SC
$5.00
47.05
S1G NAT UNE OF CONTRACTOROR AUTHORIZED AGENT MATE,
WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
S-GNATURE OF OWNEROF OWNER BUILDER, IDATE1
BLDG INSP
DATE
NEW [ ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress. 7 X "�-Y f-z�
Legal Description:
Owner Name & Address: .2 , -�-rue- L 5 7 L -'g-c/4-t7 Tel. # 7
-h),
Contractor: W& tr ti c 2 Cid A,) s fr e, t, MN LICENSE # a d / X-7 a, a-0
Address: S-77 &-Y�-A -U6- '*Al *Al Tel.# 5 -7 L/-'�/ 9L,)
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. f ��
GARAGE AREA:
Length
Width Height Sq. Ft. —"
DECK AREA:
Length Width Hgt/Ground Sq. Ft.
%�
OTHER:
��=Y��e I �- � �� c� _/-i?
Construction Type: P-cu,zwve, ct-A IZePCucle 9CO F Estimated Cost: $
(Fee Schedule on Back)
Driveway Curb Cut Width Needed:
Ft. + 6 Ft = Ft x $ _ $
DATE: I _ cl APPLICANT:
i�olaet-4- L 1orxl er Tel. # S 7 L/^
CITY USE ONLY
Permit Fee
$
Fee Schedule on Reverse Side
Fire Surcharge
$ /, ,,) V
.001 of Permit Valuation (1/10th%)
State Surcharge
$ ( Q
$.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
PERMIT NO. _
City of Fridley
AT THE TOP OF THE TWINS
BUILDING
PERM l
2 8 5 8 4
i 572-3
�` , ITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
I CITY HALL FRIDLEY 55432
1 612-571-3450
RECEI
� 7�
NUMBER
910-F15
fRE7DATE
11/16/98
PAGE OF
APP ROvED By
JOB ADDRESS
572 54th Avenue NE
I LEGALLOT
DESCR.
NO. BLOCK
3 1 ITemRle
TRACT OR ADDITION SEE ATTACHED
Terrace 2nd --Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Rita Furlong
-
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Warner Construction974-9190
20127220
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
B DESCRIBE WORK
Reside house
9 CHANGE OF USE FROM
TO
STIPULATIONS
Call for building wrap inspection before covering.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING. HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCYLOAD
VENTILATING OR AIR CONDITIONING
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS. OR IF CONSTRUCTION
ZONING
SO. FT
CU FT.
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
STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
VALUATION
SURTAX
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
2200
$1.10
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
PERMIT FEE
SAC CHARGE
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
$74.75
Fire SC $2.20
PLAN CHECK FEE
TOTAL FEE
�"�--License
SC $5.00
83.05
SIGNATURE OF CON'RACTOR OA AUTHORIZED AGENT iDATEr
WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
BLDG -NSP OATE
S,GNATURE OF OWNERoF OWNER BUILDER, DATE'
NEW [ ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION l
9_1
ConstructionAddress: s ZX 15 Ll �/l lq-r/e/c
h
(lam$ �
Legal Description:
Owner Name & Address: ' 5A Tel., Q/
Contractor: , I = �0 �- `d MN LICENSE # o_Z6 l c2 ? a D, -
Address:
Address: S7 7 S Y I- `z Tel. # 7
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 2 Z Width Height Sq. Ft. g�
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground ° Sq. Ft.
OTHER:
Construction Type: lZeove ,fie (9,e s e,-73 a Estimated Cost: $ 2 02 6
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ = $
DATE: 1 -16 `W
Permit Fee $
Fire Surcharge $
APPLICANT: - /--�-� (�G Tel. #
State Surcharge
SAC Charge
$
License Surcharge
$ syy
Driveway Escrow
$
Erosion Control
$
Park Fee
$
Sewer Main Charge $
TOTAL
STIPULATIONS:
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1000 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Fee Determined by Eng[neermg
Agreement Necessary [ /] Not Necessary [ ]