PRE 2010 DOCS*City oFridley, , Minn. `
BUILDING PERMIT N® 4271
Date: ..._14 ... ......./..... ....... ............ _............. _..
Owner: ............................................................. _........ _._.._. ----------- ------------_------- Builder ........-------............_...._............... ...._...._......._..4....._._ ........ ...
_...—
Address....._ ............._.......__..-------_...._......_ ._.. _ _.._.... Address ........................................ ........................ _................ _. _......._......._...___ _
TIO OF B II D�1 G
No......_..- .......... Street ------•--•-- (�� ..-..�_... - .... ..._ .._. Part of Lot • .................. _......._.
....._..._.
Lot ....._......................... Block _.. -................... Addi nor Sub -Division tSieyard
�,a::E .....
Corner Lot ................. _........ Inside Lot ..__ ................................ Setback .S..r ...�--t:: �........�
- ...-
Sewer Elevation ..... . ............................ -............. ........ _.... .............. ---.............--...... Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
.. .................................... ..... Front..Y.e2: C Depth Height Sq. Sq. Ft.liq...71.. Cu. Ft..`..o.3 7
r r
� ................ .. Front f '...% Depth ... �..... �. �' Sq. Ft ..Y�....P,� Cu. Ft..........%�.
Typeof Consn.................. ................................. ........ Est. Cosmo .......... ...... .Z..To be Completed ..................................................
In consideration of the issuance to me of a permit to cons ct the building described above, I agree to do
the proposed work in accordance with the description above t 4orthVcoqi1anc.e withall provisions of
ordinances of the city of Fridley.
.... .__.__._. ._...___..__.__..._._..__.
In consideration of the payment of a fee of $..4
�. ....... 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
within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
Building Inspector
NOTICE:
i This permit does not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sure to see
n ^ ` the Building Inspector for separate permits for these Items.
ISb
��
p Application for Power Plants and Heating, Cooling, Ventilation. Refrigeration and
r Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR:
Furnace Shell & Duct Work ..........................
Replacement of Furnace .............................
Repairs & Alterations—up to $500.00 ..................
Repairs & Alterations each add. $500.00 ...............
MECIL WARM AIR
Furnace Shell & Duct Work to 120,000 BTU ............
each add. 60,000 BTU .......................
Replacement of Furnace .............................
Repairs & Alterations—up to $500.00 .................
Repairs & Alterations each add. $500.00 ..............
RATE TOTAL
8.00 $
5.00 $
5.00 $
2.50 $
8.00 $ , 04
2.00
$
5.00
$
5.00
$
2.50
$
STEAM or HOT WATER SYSTEM
NO RATE TOTAL
1st 3 Fixtures ......................
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 FEE
$ r—
REMARKS:
Dept. of Bldgs. Phone SII 4-7470
Location 1�— 61';' �- X,
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 ! / , 195-92- U
Owner �� �� 2A F`d�i 195—
Kind of Building '`p' ' G> 24 A_'-= 195—
Used as
To be completed about
Estimated Cost, $��
Permit No.
DESCRIPTION OF WORK
HEATING or POWER PLANTS—Steam, Hot Water, Warm Air—No
1//
A r,
Trade Nam t �' C! Y L •v �/ Size No 3c:"
Capacity Sq. Ft. E.D.R-// BTU H.P.
Total Connected Load q -57i t? 90 P 9` t� Kinn of INIA, XJ4 -,, Fj/ S
BURNER — Trade Name �'� (9 z z 1�� a ,size No
Capacity Sq. Ft. E.D.R 024 C ('' BTU H.P.
Sign l� C� rL.)� Al
By P
11 POST 1M-12-58 Business Phone No. / ►�
0 G,f�
�lCity of Fridley
ApPCcation for Plumbing and Gas F'h ing Permit
DepL of Bldgs. Phone SU 4-7470
DESCRIPTION OF WORK / f
Number. Kind and Location of Fixtures Location
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 195
Owner /4/0 19—
Kind of Building /117"117 ' 19—
Used as lgdlc�
To be completed about
PARTIAL RATE
SCHEDULE
Estimated Cost, $
New. ding Permit
PLUMBING FIXTURE RATES:
N
oS
N
Number Fixtures ......................
�U' °d
m
Z
�U'
•
R
O
N
WATER HTR.
GAS
ELEC.
W
$
Business Phone No-
o
Catch
Catch Basin ............. ..........
.. ... x 3.25
$
Water Heater (Up to 200,000 BT[A ......
x 2.00
$ A7
3
x 3.25
$
O
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................
Base
$ LS U
Additional Fixtures ....................
x .50
$
Gas Range to 200,000 BTU ...............
x 2.00
$
1st
2nd
3rd
4th
• Future Connection Openings
Connected with
New Fixture. Old Openings
I
Sewer E]
Cesspool El
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 195
Owner /4/0 19—
Kind of Building /117"117 ' 19—
Used as lgdlc�
To be completed about
PARTIAL RATE
SCHEDULE
Estimated Cost, $
New. ding Permit
PLUMBING FIXTURE RATES:
NO. RATE TOTALOld
Number Fixtures ......................
x $1.50
$ To.e. -
Signed
Future Fixture Opening ................
x 1.20
$ A y G
By
New Fixture Old Opening ..............
x 1.00
$
Business Phone No-
o
Catch
Catch Basin ............. ..........
.. ... x 3.25
$
Water Heater (Up to 200,000 BT[A ......
x 2.00
$ A7
New Ground Run Old Bldg . ............
x 3.25
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................
x $1.50
$ LS U
Additional Fixtures ....................
x .50
$
Gas Range to 200,000 BTU ...............
x 2.00
$
REPAIRS & ALTERATIONS—Refer to Code
Description................................................$ ,/
TOTAL FEE $ .1 72 () Q0,11 POST IM -12-58
SUBJECT
PER T
City of Fridley
o 19193
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
RECEIPT NO.
i L'______ COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
/
1 . �
i ".--I CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
F
APPROVED BY
--_-
L 612-571-3450
910-F15
9/28/87Fr'
JOB ADDRESS 10 - 66th. Wa N.E.
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DESCR.
1
5
Edgewater Gardens
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Marshall B'orklund. same
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
Richard Hastin s 6331 Riverview Terrace N.E. Fridley
574-9966
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 - 21 squares
9 CHANGE OF USE FROM TO
STIPULATIONS
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 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
$1 050
$.53
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.
$19.00
%AZ ?/,? %
PLAN CHECK FEE
TOTAL FEE
$19.53
SIGNATURE OF CONTRACTOR OR AUTH IZED AGENT (DATE) ..
WHENMPRP
Y V LI TED THIS IS YOUR PERMIT
BLDG INSP
DATE
SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI
NEW [ ]
ADDN. [ ]
ALTER. [ ]
Construction Addri
Legal Description
City of Fridley
R-1 AND R-2
Building Permit Application
Effective 4/1/86
Owner Name & Address: AAA9,54 A L t L u /� �� "`� `� Tel. #
Contractor: N. c- kA R b 44 � i-, AJ6s Tel.
Address: Z, d'E2 v
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVING AREA: Length
GARAGE AREA: Length
DECK AREA: Length
OTHER: 0 r
DESCRIPTION OF IMPROVEMENT
Width
Height
Sq.
Ft.
Width
Height
Sq.
Ft.
Width
Hgt/Ground
Sq.
Ft.
Corner Lot [ ] Inside Loot [ ] Ft.. Yd. Setback Side Yard Setback 1
Type of Construction: Jt Cit00F (9 l �,� Estimated Cost: $ l e) s—A
Approx. Completion Date:
Alt. A Alt B
.10
Proposed Driveway Width If New Opening Is Desired: $ $
See Back Page for Explanation
�( ��� 8
APPLICANT: �
� � �
Tel. #-f-7 7
r6
DATE:
CITY
USE ONLY
Permit Fee
$ .o
Fee Schedule on Reverse
Side
Plan Check
$ '
25% of Building Permit
Fee
State Surcharge
$
$.50/$1,000 Valuation
SAC Charge
$
$ 525 per SAC Unit
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$ .�
Agreement Necessary [ ]
Not Necessary
[ ]
TOTAL
$
STIPULATIONS:
ld �'
SSD U
/0
NEW [ J
ADDN [ J
ALTER ( J
xConstruction Address:
Legal Description: _
XOwner Name & Address:
P#6�5-1�
CITY OF FRIDLEY Effective 1/1/2002
6431 University Ave NE, Fridley, MN 55432 (763) 5723604 Bldg Insp
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
6
Tel.# 7G3 -19- `I V-736/
Contractor. v MN LICENSE #
Address: Tel. #
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length Width Height Sq. Ft
Length Width Hgt/Ground Sq. Ft
Construction Type: Estimated Cost: $
CrC�
Driveway Curb Cut Width Needed: �� Ft + 6 Ft = �4� Ft x $ _ _ $
DATE: ®`/ Ld y APPLICAN a 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
P
CITY USE ONLY -
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.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 [
TOTAL $ STIPULATIONS:
SUBJECT
City of Fridley
33772
AT THE TOP OF THE TWINS
BUILDING PERMIT
r
RECEIPT NO.
COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
�tr�
1
REV
DATE
PAGE OF
APPROVED 8Y
i CITY HALL FRIDLEY 55432
--_- ��"'T;•�
L 763-571-3450
JNUMBER
910415
8/6/03
10B ADDRESS 10 66 Way NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
1
5
Edgewater Gardens SHEET
2 PROPERTYOWNER MAIL ADDRESS ZIP PHONE
Marshall Bjorklund 10 66 Way NE 763-574-7381
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO
Stadard Water Control 5337 Lakeland Ave N, Crystal, MN 55429 763-537-4849
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
1522
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO
6 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW ❑ ADDITION Q ALTERATION O REPAIR O MOVE O REMOVE
B DESCRIBE WORK
Install drain the system
9 CHANGE OF USE FROM TO
STIPULATIONS
Permit Inspection Cards
Will Be Mailed
®HomeownerTo P®st
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 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
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
$3,500
$1'75
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
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-
$97.25
Fire SC $3.50
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
PLAN CHECK FEE
TOTAL FEE
Lic-giks4 SC $5.00
$107.50
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
EN PROPERLY VALIDATED THIS IS YOOJR PE MIT
S,GNATURE OF OWNEROF OWNER BUIEOERI IWE,
FROM : FAX NO. : 7635371882 Jul. 31 2003 07:15AM P1
NEW [ ] CITY OF FRIDLEY Effective 1/1/2003
ADDN [ ] 6431 University Ave NE, Fridley, MN 55432 (763) 572.3604 Bldg Insp
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax
BUILDING PERMIT APPLICATION
Construction Address: / Q �D Way NE
Legal Description:
Owner N
Contract,
Address:
Tel. 2??/
MN LICENSE # Z4�V,�,
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTIO.N OF IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width HgtlGround Sq. Ft.
OTHER:
Construction Type: Estimated Cost: $ . i 06)
Driveway Curb Cut Width Needed: Et. + 6 Ft w Ft x
DATE: APPLICANT: Tel. # -
Call (763) 572-3604 for permit Fees if mailing in application. Fax to 763571-1287 if using credit card and we will
call you for card number.
Permit Fee
Fire $urcharge .
State Surdharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL ..
CITY USE ONLY -
$ % . �® Fee Schedule on Reverse Side
.001. -of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$ $1275 per SAC Unit
$ 4 (go $5.00 (State Licensed Residential Contractors)
$. Alt. "A" or Alt. 'B" Above
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
Agreement Necessary[ J Not Necessary [ j .
0aa (�u S-�l OD -k d
A
SUBJECT
City of Fridley(/33869
AT THE TOP OF THE TWINS
BUILDING PERMIT
• _ COMMUNITY DEVELOPMENT DIV.
fr
PROTECTIVE INSPECTION SEC.
r
1 . .
CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED By
763-571-3450
910-Fl5
9/10/03
JOB ADDRESS 10 66 Way NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
1
5
Edgewater Gardens SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Marshall Bjorkland 10 66 Way NE
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO
Charles Michael Company PO Box 457 Anoka MN 55303 612-490-4538
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
20314293
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO
6 USE OF BUILDING
Residential
7 CLASS OF WORK ❑
❑ NEW ❑ ADDITION ❑ ALTERATION X REPAIR ❑ MOVE ❑ REMOVE
X
B DESCRIBE WORK
Reside House; Replace windows within existing openings; Replace Exterior Door;
Install soffit fascia & trim
9 CHANGE OF USE FROM TO
STIPULATIONS
Per Section 1402, 1997 Uniform Building Code, requires that a weather resistive
barrier be placed over exterior sheathing to protect the interior wall covering.
Exceptions for this provision would be if sheathing is an approved weatherproof
panel or when the siding is an approved weather barrier. Vinyl siding is not
a weatherproof covering unless the manufacturer states this in their application
guidelines. Call for inspection of wrap before covering or take pictures. Caulk
and flash all exterior openings. Install soffit ventilation to meet the State
Building Code.
Provide smoke detectors in all sleeping rooms and on all levels of the dwelling
per Section 310.9.1.2 of the 1997 Uniform Building Code. Caulk and flash all
exterior openings.
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 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
1 HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
I
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
$18,241
$9.12
WITHWHETM PECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES N PR UME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROM ONS F ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$307.25
Fire $18.24
STR TIO ME R TE ORMANCE OF CONSTRUCTION
.SC
PLAN CHECK FEE
TOTALFEE
/6
en SC $5.00
1 $339.61
$ ATURE N C A OR AUTHORIZED AGENT iOATE,
N PROPERLY VALIDATED THIS IS YORrP{EA IT,
ll
YAM NOM Y �" V'
S-GNATURE OF OWNER,.F OWNER BUILDER. DATE,
BLft MATE
NEW [ ] CITY OF FRIDLEY Effective 1/1/2003
ADDN [ j 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax
BUILDING PERMIT APPLICATION
Construction Address: �` ® �°
Legal Description:
Owner Name & Address: Auar,shg 11 /310vkf �l�l, Tel. #
Contractor. eV CA4—o-'/FSMN LICENSE#
Address: /S3U GIJ �l4/l/l� /1/I //'/f%iU 5��� Tel. #
A01114, pe)catio "A, X530 3
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: A0 Wit i do u -J (6, � �= iopoor -s'Offil
Construction Type: Estimated Cost:
Driveway Curb Cut Width Needed:. 6 Ft = Ft x $ _ $
DATE: '1//0/0-!5 APPLICANT: Tel. #
Call (763) 572-3604 for Permit Fees if mailing in application. 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
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL $
CITY USE ONLY -
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1275 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 [ ]