PRE 2010 DOCSCity of Fridley
Application for Plumbing and Csas fitting Permit
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
pp
G1
C
$
Future Fixture Opening ................
Y
F a
Yui rz�c� �8Z taTiZ
w
OS
w
Z
�O
F
«
N
WATER HTR.
GAS
ELEC.
$
Water Heater (Up to 200,000 BTU)
..... x
2.00
$
New Ground Run Old Bldg . ............
x
3.25
s
$
Base
1st
°
2nd
3rd
4th
• Future Connection Openings
Connected with
e New Fixture, Old Openings
Sewer
I Cesspool
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. 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
s
$
GAS FITTING FEES:
1st 3 Fixtures ..........................
Additional Fixtures ....................
Gas Range to 200,000 BTU ..............
REPAIRS & ALTERATIONS—Refer to Code
NO. RATE TOTAL
X $1.50 $
x .50 $
x 2.00 $
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Location. 1374- 6 6 �--
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.
1 r Fridley, ]VCinn 19�
Owner %/•� %� & 'q L if
Kind of Building
Used as
To be completed about
Estimated Cost, $
Old—New. Building Permit No Permit No. _
SigneZIA
By Q
Business Pd/one No
ROUGH
FINAL
Description ................................................$
TOTAL FEE $,,— 42
STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED WELL RECORD
1. LOCATION OF WELL MINNESOTA UNIQUE WELL NO.
County Name AN 0 KA (leave blank if not known)
Township Mame
FRIDLEY
TownshipNum
N
30 sr
Range Number
E
24
Section No.
13
Fractionof
h k k
NWSWNE
4. WELL DEPTH (completed)
-75 ft.
Date sealed
PA.Tic; . 2 5 0 1531 9.2
Numerical Street Address and City of Well Location or Distance from Road
Interseetian
S. DRILLING METHOD (if known)
Cable tool 40 Reverse 7[] Driven ICO Dug
1376 6 6TH AVENUE
20 Hollow Rod 50 Air 80 Bored 110
30 Rotary 60 Jetted 90 Power Auger
Show exact location of well
(in section grid with "X") N Sketch map of well location
. _ ._� U p _
6. OBSTRUCTIONS
Well obstructed 0 Yes No
Obstructions removed Yes 13 No If obstructions cannot be
�i•�':
removed, contact MOH
E �ft,:l
_ _ T
_ I a
before sealing.
7. USE
1�Domastic 40 Monitoring 8[3 Heat Loop
220 irrigation 5O Public 90 Industry
3E3 Test Well 60 Municipal 100 Commercial
70 Air Canditicnin; 110
2. PROPERTY OWNER'S NAME
DOUG & BETH
NYB E RG
Mailing Address if different than
property address indicated above
1376 6 6TH AVE.
F R I D LE Y, MN . 55432
8. CASING(S)
IKBlack XThreaded 70
20 Ga IV. 5C3 Welded
30 Plastic 60 Stainless Steel
3 in. to 7 2 ft.
in, to ft.
HARDNESS OF
3. FORMATION LOG COLOR FORMATION FROM TO
if not known, indicate formation log from new well or nearby well,
SAND
3ROWN.
0
26
9. SCREEN
screened well from 7 � ft. to 7 5 ft.
(lf known)
0 Open Hole from _ ft. to _ ft.
SANDY CLAY
RAY
26
110
SAND, CLAY, ROCK
RAY
110
123
10. STA WATER LEVEL
ft.below 0 above
land su ace Date Measured 8 — 2 5 — 9 2
SAND,GRAVEL,LIME
123
127
LIMEROCK
TA14
127
138
11. WELLHEAD COMPLETION
10 Pitless Adapter 40 Found Buried
KBasement offset 50
30 Well Pit
16. REMARKS. ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC.
GEOLOGY WAS TAKEN FROM THE WELL AT:
12. GROUTING INFORMATION 3 BAGS
XNeat Cement 20 Bentonite 30
69TH AVE. NE & OLD CENTRAL AVE . , FRIDLEY
WATER LEVEL IN THE ABOVE WELL: 58'
Grout materialPORTLAND from7 5 tPURF •cu. yds
NEAT GROUT
DATE WATER LEVEL WAS TAKEN: 5-21-84
13. NEAREST SOURCES ff CONTAMINATION
48 feetdirection...���.,,CITY SEWER type
Well disinfected bsealing? es
efore fir
14. PUMP Removed 0 Not Present
Type: 1[( Submersible 30 L.S. Turbine E0 Reciprocating
XJet 40 Centrifugal 60
A A
2-5,1992-1
15. EXISTING WELLS (Please sketch locations of abandoned and
u
n 1 7
� ��
SEALELJ17.
active wells 1n remarks section or on back.)
Other unused well(s) an property? 0 Yes No
Abandoned: 0 Permanent 0 Temporary ealed
WATER WELL CONTRACTORS CERTIFICATION
This well was sealed under my jurisdiction and this report
is true to the best of my knowledge and belief.
According to MN State Regulations
E.H. RENNER & SONS INC.
Licensee Business Name LicenseeNo. No.
1
AddEL VER M 55330 427-6100
signed Date 8-27-92
WAYNE BR STE Date 8-25-92
Name of Driller
OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer)
ZXJPMrAsr: PZLs WZ2T DMM
F: E V I N H O P P E
SUBJECT
PE.
City of Fridley
26710
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
RECEIPT
COMMUNITY DEVELOPMENT DIV.
L
r I PROTECTIVE INSPECTION SEC.
NUMBER
REV
DATE
PAGE OF
APPROVED BV
CITY HALL FRIDLEY 55432
612-571-3450
910-F15
7/20/98
JOB ADDRESS 1376 66th Ave NE
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DEscR.
6 & 14 Par
el 1640
Aud. Sub 410
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Steve Scherber 1376 66th Ave NE
572-2455
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 rA REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and garage 20 SO tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with StateBuilding Code.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED 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 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
1
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
$1668
$.83
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-
Fire SC $1.66
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
$54.00
PLAN CHECK FEE
TOTAL FEE
$56.49
SIGN TUREOFCONT RORAUTNORIZ AGEN iD TE)
WHEN PROPERLY LIDATED THIS IS YOUR PERMIT
G URE OF OWNER OF OWNER BUIL DATE
BLDG iNSP
f)ATE
NEW [ l Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: 13-7 Ug (,? J" )Pa -ye.
Legal Description:
Owner Name & Address: Tel. # S 7 Z. - 2- 4 S S
Contractor:` MN LICE
Address: Tel. #
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF BIPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER: PC .--RU-)YAfx ASre - - G,� f'�C�� �, �
�r-e�-p_-0Fr .
Construction Type: Estimated Cost: $
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: 7 APPLICANT: ZS±9 A,, -e 5z� (- 12 Tel. # S 7 2. - Z HSS, -
Permit Fee
$ ��� 0
Fire Surcharge
$ (�
State Surcharge
$ t �°
SAC Charge
$
License Surcharge
$
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 Engineering
Agreement Necessary [ ] Not Necessary [ ]
'j�-