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PRE 2010 DOCSCity of Fridley, Minn. BUILDING PERMIT N® 3053 Date: ....C�/... � ...� . ®....... ...... . Builder .......... ... . Address ....... o.::. �,/.. .. Address ®� ... ............ . LOCATION BUIL® OF' No. .! ..-. Street . �o / .. Gz�.gs�rart off Lot ....... .. .............. . Lot ......9.... Block .. ......... Addition or Sub -Division . (!�. Corner Lot ............ Inside Lot .. ...... Setback ... Sideyard 9,.,�. P p_ it DESCRIPTION OF BUILDING To be Used as:- 1 9 // p ....... A Front .. Depth e.. Height o.Ot*6 Sq. Ft. Cu. Ft. ........ ... ....... Front .f a .. Depth -4O Heii ht ...a Sq. Ft. ..� � Cu. Ft. e of Construction Fort. Cos�r.(ca.. ®.To be Completed . 4 .. yZ "' In consideration of the issuance to me of a permit to construct the building desribed 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. ,�?... ............... A4'9 ®, 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 with- in the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. NOTICE: This permit does not cover the construction, Installation or alteration for wiring, plumbing, gas heating, sewer or water. Be sure to see the Building Inspector for separate permits for these Items` - I W NAWIMMMAJ WAMAW4 City of Fridley Application for Plumbing and Gas Fitting Perndt DESCRIPTION OF WORK Number. Kind and Location of Fixtures PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL <) Number Fixtures ...................... x $1.50 $ C,< Future Fixture Opening ................ x 1.20 $ New Fixture Old Opening .............. x 1.00 O t7 z O F N WATER HTR. GAS EIEG � x 3.25 $ GAS FITTING FEES: NO. RATE TOTAL u7 Base 1st 2nd _ 3rd _ 4th • Future Connection Openings Conne�ed wRh Sewer ❑ New Fixture, Old Openings Cesspool C essp ❑ PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL <) Number Fixtures ...................... x $1.50 $ C,< Future Fixture Opening ................ x 1.20 $ New Fixture Old Opening .............. x 1.00 $ Catch Basin ............................ x 3.25 $ Water Heater (Up to 200,000 BTI) ...... x 2.00 $ New Ground Run Old Bldg . ............ x 3.25 $ 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 $ REPAIRS & ALTERATIONS—Refer to Code Dept. of Bldgs. Phone SII 4-74700��D Location 0171.0 0 e G `/ 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 areetrue and correct. Owner Kind of Used as ..,, __ 0, le/ To be completed about Estimated Cost, $ .1 / ✓ 9 Old— ,nalOr Building Permit No - —3 Permit No. 7 � Signe By �� Business Phone No.T ROUGH DEC 31 loan FINAL Description ................................................ TOTAL FEE:T, 06 42 2M 7.89 196 - City of Fridley, Minn. BUILDING, PEST Date: Address 10 Builder _-- -- Address L„9 � N BUILDING No. _ Street t=� i +� r Part of Lot Block Addition or Sub- ij--4sgon ..... !M & It — Corner Lot Inside Lot _ _ &eack ,-41,` SideYardjp _ Sewer Elevation Foundation Elevation r DESCRIPTION OF BUILDING To 1% Used as: s� /-4"P Front Depth Height , � Sq. Ft V r} cu. Ft�zd �-% FreAt Depth ,Height Sq. F't. Cu. Ft. _.._.. Type of Construction! ta" 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 ordinanoes 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 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 ordinances. city limits and this permit may be revoked at any time upon violyrt= of any of the provisions of said ordinances. rs A / 11 Building Inspector NOTICE: This permit does not cover the construction, installation for whing, plumbing, gas heating, sower or water. Be are to we the Building Inspector for separate permits for thesis hems. 4 APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA 9 Ye Owner's Name Ja--C�6 rBuilder Address �% r'� /V Address X, LOCATION OF BUILDING No.� Street Part of Lot Lot Block Addition or Subdivision Corner Lot Inside Lot Setback Side -Yard SM?ER ELEVATION FOUNDATION ELEVATION Applicant attach to this form Certificate of Survey of Lot and proposed building location. To be used as: DESCRIPTION OF BUILDING Front__ -? Depth V Leight Y Sq. Ft. -1- 99 P Cu. Ft. 13 ®y � FrontDepth Height Sq. Ft. CU. Ft. Type of Construction cw�-�E �'�=� Estimated Cost 1600 To be Completed N® v, j 6 '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 ruling of the Department of Build- ings, 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 t�e-'dReverse Side) . 4: sueJEcr PE City of Fridley A�R AT THE TOP OF THE TWINS BUILDING PERMIT ,'706 RECEIPT NO. COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. 1 . � CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 812-580-3450 910-F15 1(9/5/74 JOB ADDRESS 430 - 67th Avenue N.E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 9 5 Rice Creek Terrace Plat 3 SHEET 2 PROPERTY OWNER MAILADDRESS ZIP PHONE Jack Kirkham 430 - 67th Avenue N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Leif Henriksen 6434 Riverview Terrace N.E. 4 ARCHITECT OR DESIGNER MAILADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION EX ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Enclose screen porch to provide additional living area 9 CHANGE QF USE FROM TO STIPULATIONS SEPERATE PERMITS REQUIRED FOR WIRING. HEATING, PLU.MBJNG AND SIGNS. TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, Frame VENTILATING OR AIR CONDITIONING. Wood THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. 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 R-1 ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 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. $2�SOO 1.25 WITH WHETHER SPECIFIED HEREIN OR OT. THE GRANTING OF A PERMIT DOES NOT PRESUMETO GIVE AUT ITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS ANY OTHER ST OR LOCAL W REGULATING CON- STRUCTIO TH E OR NGS OF CON CTION. $lS.00 PLAN CHECK FEE TOTALFEE $16.25 SIG TUR TRACTOR OR AUTHORIZED AGENT (DATE) WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT .. 9 -5-_ qt( BLDG INSP DATE SIGNATURVOF OWNER (IF OWNER BUILDER) (DATE) APPLICATION FOR RESIDENTIAL, ALTERATION, OR ADDITION BUILDING PERMIT CITY OF FRIDLEY, MINNE OWNER'S NAME: 5atc<< K i RK N w" BUILDER ADDRESS:— L110 (,'7Iz� fi,�rt_ ADDRESS NO:. y 3c) STREET: ( 7 7W A -u i,. LOT: q BLOCK: 6- ADDITION: ic,rz 0_y_rvu,L `TX RdL, p� CORNER LOT: INSIDE LOT:_SETBACK: SIDEYARD: 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: CN c LM) k3 C. •5cn�17 90&C v. lb Front: J Z Depth: Height: Pao0,�� Rootlrt -� Ltu% u Square Feet: Cubic Feet: Front: Depth: Square Feet; Cubic Feet: Height: ✓ S%OQ y Type of Construction: Estimated Cost: To Be Completed: %0 MYS 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 stated1�7 s application are true and correct. /'?. - <- /? DATE: _XaZ �t_ !9. 1614 SIGNATURE: ( A (See Reverse Side For Addition ^z oZ�ou XQ id c i CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 572-3604 Stories Basement Floor 1 Floor 2 Floor 3 Floor 4 PLUMBING FIXTURE RATES: Effective On APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR fit... Wash '?' :..>:;.;: Floor r a1l> Auto. Gas r U ina Shower >': S o h .� rain • .........::::: ..........:::. _ Y_ Washer Ap'p(�>��� Ran NO. RATE TOTAL New Fixtures $ 7.00 Old Opening, New Fixture $ 4.00 Beer Dispenser $ 5.00 Blow Off Basin $ 7.00 Catch Basin $ 7.00 Rain Water Leader $ 7.00 Sump/Receiving Tank $ 7.00 Water Treating Appliance $10.00 Water Heater -Electric $ 7.00 Water Heater - Gas $1.0.00 Gas Range $10.00 Gas Dryer $10.00 Back Flow Preventer Required ( )Yes () No Type a- -$5.00 Reinspection Fee $30.00 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1 % of Value of Fixture or Appliance /6 --Go State Surcharge $ .50 TOTAL FEE $ J,50 Elec wo(e �I L JOB ADDRESS - XkO (J" The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the city codes and rulings of the Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. �5� '1996 Owner Estimated Cost L10 . OD -PERMIT NO. :""13 PLUMBING CO PANY, SIGNED BYW-ra TEL N0. Approved By Rough -In Date Final Date MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 PLUS THE $.50 STATE SURCHARGE �. U SUBJECT City of Fridley 93 AT THE TOP OF THE TWINS BUILDING PERMIT RECEIPT NO. Ir? 06 • COMMUNITY DEVELOPMENT DIV. `577 r : � PROTECTIVE INSPECTION SEC 1 � � CITY HALL FRIDLEY 55432 NUMBERDATE REV PAGE OF APPROVED BY 612-571-3450 910-F15 9/24/96 / / JOB ADDRESS 430 67 Avenue NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 9 5 1 Rice Creek Terrace Plat 3 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Corine Kirkham 430 67 Avenue NE 571-3168 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. D & D Home Improvement Inc 7401 Central Ave NE Fridley MN 55432 784-7543 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 4840 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION QA ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE R 6 DESCRIBE WORK Sheetrock existing walls and ceilings in basement' install window 9 CHANGE OF USE FROM TO STIPULATIONS Provide smoke detectors on every level of dwelling and in each sleeping area. SEPARATE PERMITS REQUIRED WIRING, HEATING, FOR PLUMBING AND SIGNS. 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 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 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 $9,000 $4.50 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 PERFORM NCE OF CONSTRUCTION $149.75 A Fre SC $9.00 T PLAN CHECKFE AL FEE Li C .00 $168.25 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI P L VA D EDTHIS IS UR PE IT pZ LDG INS TiATE SIGNATURE OF OWNEROF OWNER BUILDERI IDATEI U NEW [ ] Effective 3/1/96 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Building Permit Application ConstructionAddress: 7' A Ve , IV6' Legal Description: Owner Name &Address: c r ih� [S c4 t k hm K j . Tel. # Contractor: D & D Home Improvement, Inc MN LICENSE # 4,q 4 o Address: 7401 Central Ave NE Fridley, MN 55432 Tel. # 784=7543 Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. LIVING AREA: GARAGE AREA.- DECK REA:DECK AREA: OTHER: DESCRIPTION OF IMPROVEMENT Length Width Height Sq. Ft. Length Width Height Sq. Ft. Length Width Hgt/Ground Sq. Ft. Corner Lot [ ] Inside Lot N Ft. Yd Setback Side Yard Setbacks Type of Construction: �� one $ is -%,4Sc-6y1 ertT Estimated Cost: $ CV0-,' Approx. Completion Date: 10-3j--5 ,(Cost on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: APPLICANT: Tel. Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL $ /0 7.r $ 37,40 $ .Sb CITY USE ONLY Fee Schedule on Reverse Side .001 of Permit Valuation (1 / 10th %) $.50/$1,000 Valuation $900 per SAC Unit $_ _�; dU $5.00 (State Licensed Residential Contractors) $ Alt. "A" or Alt. "B" Above $ &29.ss $450.00 Conservation Plan Review Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] STIPULATIONS: CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 572-3604 Stories Basement Floor 1 Floor 2 Floor 3 Floor 4 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR h.... Was1.h ;Orirll4::::;: Floor :011::;:;::: Auto. Urinal Tui ;€ :Shower S OR. Tray 1"111# ' :Drain ` i a >' Washer PLUMBING FIXTURE RATES: NO. RATE TOTAL New Fixtures % $ 7.00 /700 Old Opening, New Fixture $ 4.00 Beer Dispenser $ 5.00 Blow Off Basin $ 7.00 Catch Basin $ 7.00 Rain Water Leader $ 7.00 Sump/Receiving Tank $ 7,00 Water Treating Appliance $10.00 Water Heater —Electric $ 7.00 Water Heater — Gas** $10.00 Gas Range** $10.00 Gas Dryer** $10.00 Back Flow Preventer Required ( )Yes () No Type $15.00 Reinspection Fee $42.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance ' State Surcharge $ .50 TOTAL FEE $ 0,0_ SC� Effective On March 1, 1996 Gas ::Mase::;::::: Water Heater Range ... Gas Elec JOB ADDRESS_ (-qo (p TA f}L,,,e t—ja The undersigned hereby makes application fora permit for the work herein specified agreeing to do all work In strict accordance with the city codes and rulings of the Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. c1—d0 , 1996 Owner ��� c �j � 5^ 7/ — 3 / (MI? Building Used As t, —// Estimated Cost 0� = PERMIT NO,126Q_ PLUMBING COMPANY P1,,,16, lr Co SIGNED Approved By TEL NO. 591-155(3 **COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6—A. MINIMUM SIZE 9 SQ INCHES. SUBJECT P City of Fridley2 8 249 AT THE TOP OF THE TWINS BUILDING PERMIT DIV. ,572-3O ITY DEVELOPMENT r E v PROTECTIVE INSPECTION SEC. CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY 612-571-3450 910-F15 10/14/98 JOB ADDRESS 430 67th Avenue NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 9 5 1 Rice Creek TErrace Plat 3 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Jack Kirkham 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO 0 St fter Bros Const Inc 3445 219th Ln NW Anoka 55303 753-5413 20064402 A 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 Qx REPAIR ❑ MOVE ❑ REMOVE B DESCRIBE WORK Reroof house and garage (28 Sq) Tear-off 9 CHANGEOFUSEFROM TO STIPULATIONS Underlayment must comply with the State Building Code. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCYLOAO 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 1 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 $2399 $1.20 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CRGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION $74.75 FirH SC $2.40 PLAN CHECK FEETOT l FEE Licen C 5.0 3� 35 ORORAUTHORIZED AGENT iDATE- NPR HIS ISR�7PEIT gSnO BlD SP - Q E aTURE OF OWjTER,IF OWNER BUILOERi iDATE, NEW [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: '�{ 30 Legal Description: Owner Name & Address: c ? �ca Tel. # Contractor: :2 42L r B f,0 5 ( c�, IX -5). ,,c. MN LICENSE # 906 6e1g6 Z Address: 3 y�iS j �'( /"1` ve �'l/, (,✓ ,moo �� �=� 30� Tel. # 75-3-. 2Z/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: $ $5.00 (State Licensed Residential Contractors) Driveway Escrow $ Alt. "A" or Alt. "B" Above Erosion Control $ 2, 3 Construction Type: e� a� R e t`o a Estimated Cost: $ $ Agreement Necessary [ ] Not Necessary [ ] TOTAL $ (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: APPLICANT: //-,� Tel. # CITY USE ONLY STIPULATIONS: Permit Fee $ ✓ V If Fee Schedule on Reverse Side Fire Surcharge $ . G .001 of Permit Valuation (1/10th%) State Surcharge $ $.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: