PRE 2010 DOCSSUBJECT
�111V11 I IV v.-�„
City of Fridley
X14528
AT THE TOP OF THE TWINS
BUILDING PERMIT
i 16
COMMUNITY DEVELOPMENT DIV.
-
PROTECTIVE INSPECTION SEC.
1 1 CITY HALL FRIDLEY 55432
IL
NUMBER
REV.
DATE
PAGE OF
APPROVED/BY
L----jk,. 612-560-3450
910-F15
112/22/77
JOB ADDRESS 1390 - 76th Avenue N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
1
2
Meadowmoor Terrace 2nd SHEET
2 PROPERTYOWNER MAIL ADDRESS ZIP PHONE
Gar -Jac Inc. 625 Highway #10, Blaine 786-8702
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
RM Residential
7 CLASS OF WORK
1 NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 50' x 46' Dwelling and a 22' x 23' Garage
0 SEVERATE PERMITS REQUIRED FOR WIRING,
9 CHANGE OF USE FROM HEATING, PLUMBINd AND SIGNS.
STIPULATIONS Provide a hard surface driveway. Provide sod in the front and side
yards. Provide a verifying survey before capping. Provide Combustion Air
to furnace area. Provide City with copy of truss design by 2/10/78.
SEWER LOCATION: 127' E. of Manhole (885.94)
WYE ELEV: 886.47 + 6.00 Riser = 892.47
TOP OF FOOTING: 895.97 Minimum
WATER LOCATION: 11' E. of Sewer Service
DRIVEWAY DEPRESSION COST: Applicable (next spring at revised unestablished
cost)
CITY OF FRIDLEY DOES NOT GUARANTE2 t??: W N'N6
ACCURACY OF UTILITY LOCATIONS AND ELEVATIC-i-,%. Before dl V
gg- call local
THIS DATA IS FOR INFORMATION PURPOSES ONLY ANS utilities
E
PERSONS USING IT SWULD VERIFY THE INFORIMATION TELEPHONE -ELECTRIC - GAS Etc.
REQUIRED FOR ELECTRICAL, PLUMBING,
TYPE OF CONST.
OCP�(j�gD
SEPARATE PERMITS ARE HEATING,
VENTILATING OR AIR CONDITIONING.
Wood Frame
VV ii
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
1302+506
27,532 Total
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.
WkT;, ! WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$41,275
$20.64
PERMIT FEE
SAC CHARGE
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISION OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION THE PERFORMANCE OF CO TRUCTION.
$110.13
$375.00
PLAN CHECK FEE
TOTALFEE
1
27.53
533.30
SIGNATURE OF C01CTOR OR AUTHORIZ AGENT (DAT)
WHEN. PRO ER/LYY VALIDATED THIS IS YOUR PERyMIT/�dy
70A
yj��
BLDG INSP DATE
SIGNATURE OF OWNER (IF OWNER BUILDER) (DATE)
• CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL BUILDING PERMITS
(NEW, ALTERATIONS, ADDITIONS, OR REPAIRS)
OWNER: BUILDER:�-
Address:����]�J '76"� Ni; Address:
/-3 9,40 .� JTel. No.:
No.:Street: ` \ / .
LOT: BLOCY.: �_ ADDITION:
CORNER LOT: L INSIDE IAT: SETBACK: 3S� SIDEYARDS: 24 4- IL/
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:
H 61n -e Front: s0
Depth: Height:
Cubic Feet:
Square Feet: /;Z XG
Front:
Depth: Height:
Square Feet: Cubic Feet:
Type of Construction:�/Y? Estimated Cost: $^0, 00
To Be Completed: Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired $ $
(SEE REVERSE SIDE OF SHEET)
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. See reverse side additional inform on.
DATE: /2 % SIGNATURE:
Stipulations:
137k)
�x y'
o
�$efi 11016-4
134 - 79
x
X's' _
ol
C
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f
3 66
3Gsl' a
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? 1
AM06 USUMMAN 5t06f) NE,
motmangtina
0
I )w L(4#F"Ad 1 Rw-op N1 *s6la 6.533?
ME]
Certificate of Survey for.� �A&-�-VWC &CA)5r A. ke.
25`
CAU T 104.
"VISION SAFETY CON RE"
0 CITY ANY-
@
0
kAC
DO NOT PLANT OR
C
30 DAY t4oyla THING IN THIS AREA T AP -
p F 10LEY.
DIV. 'EQU11RE.D FOR '�C_ G` I PROVAL OF THE CITY, F
(tEp N7
P.EPLACE
Aj. AND
DRIVEWAY OPE
AT GS
L.L1
LJ
Lr -
Es ko-f GUARANTEE,- I
F C)p FRIDLV DO NS AND MVATIO
CITY '0
ACCUIMCy Op UTILITY LOCA PURPOSES POSES ONLY A.4D
1.14A% DATA IS G
Vt INF)ULD FyTHE INFORMAlibt4PERSONS USNff OUIWJD
014 THE SITE
WARNING
PD. W Before digging can local gfiliges
TELEPHONE - ELECTRIC - GM Etc.
-REQUIRED BY LAW
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.moi i 1 v, i,_ -Li
APPLICATION FOR POWER PLANTS AND HEATING,
COOLING, VENTILATION, REFRIGERATION AND
Steam, Hot Water,
.AIR
CONDITIONING SYSTEMS AND DEVICES
PARTIAL RATE SCHEDULE
+
Size No. g< -
Capacity
Sq. Ft. EDR
GRAVITY WARM AIR:
RATE
TOTAL
Job Address
Furnace Shell & Duct Work '
$12.00
$
Replacement of Furnace
Repairs & Alterations -up t0 $500.00
7.00
7.00
$
$
Department of Buildings
Repairs & Alterations each add. $500.00
q,00
S_�-
City of Fridley
Tel. #571-3450
MECHANICAL WARM AIR:
Furnace Shell & Duct Work to 100,000 BTU
each add. 50,000 BTU
Replacement of Furnace
Repairs & Alterations -up to $500.00
Repairs & Alterations each add. $500.00
STEAM OR HOT WATER SYSTEM:
Boiler & Lines up to 100,000 BTU
each addn. 50,000 BTU
Boiler only up to 100,000 BTU
each addn. 50,000 BTU
OIL BURNER- to 3 gal. per hour
each add. 3 gal. per hour
GAS BURNER- from 100,000 BTU to 199,999 BTU
(over 199,999 BTU see Fee Schedule)
GAS FITTING FEES:
The undersigned hereby makes application for a permit for the work herein
$12.00 $-2.V •• specified agreeing to do all work in strict accordance with the City Codes
4.00 $ and rulings of the Department of Buildings, and hereby declares that all the
7.00 $ facts and representations stated in this application are true and correct.
7.00 $
4.00 $ Fr ey, Minn. ,•tet — �L, 19�(I
OWNER Cie!% f�i��
$12.00 $
4.00 $
7.00 $
6.00 $
$10.00
10.00
$10.00
1st 3 Fixtures x $ 3.00
Additional Fixtures x $ 1.00
Gas Range to 199,000 BTU x $10.00
AIR CONDITIONING
FAIN HEATING SYSTEMS See Fee Schedule
VENTILATI,`'G SYSTEMS
ALTERATIONS & REPAIRS
State Surcharge
TOTAL FEE
ROUGH INSP. REINSPECTION FEE
Date ($10.00)
FINAL INSP.
Date
APPROVAL FOR PERMIT
KIND OF BUILDING
USED AS
TO BE COMPLETED ABOUT
S
$ ESTIMATED COST Z-1 /' r�
OLD - EW BUILDIN ERMIT NO. PERMIT NO.
S
MINIMUM FEE FOR ANY HEATING PERMIT IS $7.50 PLUS $.50 STATE SURCHARGE
DESCRIPTION OF FURNACE/BURNER
BEATING or POWER PLANTS,
Steam, Hot Water,
Warm( Air- No.
Trade Name
+
Size No. g< -
Capacity
Sq. Ft. EDR
BTU HP
Total Connected Load
Kind of Fuel
BURNER - Trade Name
Size No.
Capacity
Sq. Ft. EDR
'IO—�HP
U Ition
8419 Center Drive
Company --
fog
Signed By
• Tel. No.
`� /•
�'iIi Ui rK1LLLf
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
Number Fixtures
Future Fixture Opening
New Fixture, Old Opening
Catch Basin '
Water Heater - to 99,000 BTU
100,000 BTU to 199,000 BTU
Water Softener
New Ground Run Old Building
Electric Water Heater
GAS FITTING FEES:
1st 3 fixtures
Additional Fixtures
Gas Range to 199,000 BTU
REPAIRS $ ALTERATIONS
First $100.00
each add. $100.00 or fraction
NO.
x
x
State Surcharge
TOTAL FEE
RATE
$3.00
$2.00
$2.00
$5.00
$5.00
$10.00
$7.00
$5.00
$5.00
'$3.00
$1.00
$10.00
TOTAL
$-21-0(j
$5.00 $
$2.00 $
$ .50
$
Job Address % 3 70 _ 17 t, /% (1
Department of Buildings
City of Fridley
Tel. #571-3450
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 Department of Buildings, and hereby declares that all
the facts and representations stated in this application are true and correc
Fridley, Mn. , 19
OWNER
KIND OF BUILDING n ,3 (-
USED AS �.
TO BE COMPLETED ABOUT _ 3 0 ( C6
ESTIMATED COST Its
OLD - NEW BUILDING PERMIT NO. PERMIT NO.
Company r
Signed By
Tel. No. -.3 IRS 0
ROUGH INSP.
�Date
FINAL INSP.
Date
APPROVAL'FOR PERMIT 4 #A
MINIMUM FEE FOR ANY PLUMBING PERMIT IS $7.50 pLUS $.So STATE SU2bMUME
REINSPECTION FEE
($10.00)
s
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lst
2nd
3rd
4th
(R) = Future Connection Opening
Connected with Sewer
(') - New Fixture, Old Opening
Water
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
Number Fixtures
Future Fixture Opening
New Fixture, Old Opening
Catch Basin '
Water Heater - to 99,000 BTU
100,000 BTU to 199,000 BTU
Water Softener
New Ground Run Old Building
Electric Water Heater
GAS FITTING FEES:
1st 3 fixtures
Additional Fixtures
Gas Range to 199,000 BTU
REPAIRS $ ALTERATIONS
First $100.00
each add. $100.00 or fraction
NO.
x
x
State Surcharge
TOTAL FEE
RATE
$3.00
$2.00
$2.00
$5.00
$5.00
$10.00
$7.00
$5.00
$5.00
'$3.00
$1.00
$10.00
TOTAL
$-21-0(j
$5.00 $
$2.00 $
$ .50
$
Job Address % 3 70 _ 17 t, /% (1
Department of Buildings
City of Fridley
Tel. #571-3450
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 Department of Buildings, and hereby declares that all
the facts and representations stated in this application are true and correc
Fridley, Mn. , 19
OWNER
KIND OF BUILDING n ,3 (-
USED AS �.
TO BE COMPLETED ABOUT _ 3 0 ( C6
ESTIMATED COST Its
OLD - NEW BUILDING PERMIT NO. PERMIT NO.
Company r
Signed By
Tel. No. -.3 IRS 0
ROUGH INSP.
�Date
FINAL INSP.
Date
APPROVAL'FOR PERMIT 4 #A
MINIMUM FEE FOR ANY PLUMBING PERMIT IS $7.50 pLUS $.So STATE SU2bMUME
REINSPECTION FEE
($10.00)
s
6431 UNIVERSITY AVENUE N.E., FRIDLEY, MINNESOTA 66432
TELEPHONE ( 612)571-3450
March 13, 1978
Mr. Gary D'Aigle
Gar Jac Inc.
681 North Highway #65
Cambridge, Mn 55008
Re: Final Inspection at 1390 - 76th. Avenue N.E.
Dear Mr. D'Aigle:
A reinspection was made on March 10, 1978 to final out the above address
and the following items were noted which must be completed before the
structure can be finaled out;
1. Provide sod in the front and side yards by June 15, 1978.
2. Provide a hard surface driveway by June 15, 1978.
3. Provide permanent support for the deck by June 15, 1978.
We will expect the above items to be completed by the scheduled date
when a reinspection will be made to determine compliance. If you have
any questions on these items, please contact me at 571-3450.
Sincerely,
DAR G. CLARK
Community Development Adm.
DGC/mh
0 V
SUBJECT
City of Fridley
23410
AT THE TOP OF THE TWINS
BUILDING
PERMIT
RECEIPT NO
'°�
' '
• _____ COMMUNITY DEVELOPMENT DIV.
r I I PROTECTIVE INSPECTION SEC ,
p4, ® LR
/'--I CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED Br
' 612-571-3450
910-F15
5/30/95
JOB ADDRESS 1390 76 Avenue NE
I LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DESCR.
1
2
I
Meadowmoor Terrace 2nd
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Ed Puchtel 1390 76 Avenue NE
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Addition & Remodeling Specialists 2618 Coon Rapids Blvd Coon Rapids MN 55433 1109
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 O ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X
6 DESCRIBE WORK
REroof (Tear-off) and Reside Dwelling
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.
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
ANY TIME AFTER WORK IS COMMENCED.
NO. DWLG. UNITS
OFFSTREET PARKING
I HEREBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS APPLICATION
1
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
$8,000
$4.00
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-
STRU THE P ORMANCE OF CONSTRUCTION
@
$99.00
Fire SC $8.00
/
PLAN CHECK FEE
TOTALFEE
L cense SC $5.00
116.00
SIGNA RE OF CONTRACTOR OR AUTN I' ED AGENT IOATEI
V DATED THIS IS YOUR PERMIT
ZW<N
BLDG iNSP
C
GATE
SIGNATURE OF OWNER OF OWNER BUILDERi (DATE,
0 V
NEW [) Effective 1/1/95
ADDN [ J CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
Construction Address: SQ%t l i P4,4R N'EZ
Legal Description:
Owner Name & Address:
Contractor: W[xcy dtl
Address: afQlt L
LIVING AREA:
GARAGE AREA:
Tel. #
MN LICENSE # I Cq
Tel. # 4 zn 933 B
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
Length Width Height
DECK AREA: Length
OTHER:
Corner Lot [ J Inside Lot [ ]
Type of Construction:
Approx. Completion Date: _
(Cost on Back)
Driveway Curb Cut Width Needed: Ft. + o Ft=4�L:
_ $
DATE: 5 APPLICANT: Tel. #
Width Houna _
Ft. Yd Setback Side Yard Setbacks
Estimated Cost: $ c n0
Sq. Ft.
Sq. Ft.
Sq. fit.
Permit Fee
$
Fire Surcharge
$ 0 o
State Surcharge
$
SAC Charge
$
License Surcharge
$ CCS
Driveway Escrow
$
Erosion Control
$
Park Fee
$
Sewer Main Charge $
TOTAL $ / .Ue)
STIPULATIONS:
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$850 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 [ ]
f
C17YOF
FRIDLEY
FRIDLEY MUNICIPAL CENTER - 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 - (612) 571-3450 - FAX (612) 571-1287
June 1, 1999
Teresa Puchtel
1390 76th Avenue NE
Fridley, MN 55432
Re: Final inspection at 1390 76th Avenue NE
Contractor: Marsh Heating & AC, Inc.
Dear Ms. Puchtel:
A mechanical permit was issued on June 15, 1998 for the property located at 1390 76th
Avenue NE for a new air conditioner. According to Section 305(a) of the 1991 Uniform
Mechanical Code a final inspection shall be performed on the mechanical permit. As of
this date no inspection has been called for.
You will be given thirty (30) days from receipt of this notice to respond. If we do not
hear from you, we will expire the permit and any inspections on this installation will
require a new permit.
Any questions can be addressed to myself at (612) 572-3603.
Sincerely,
Barry Riesch
Building Inspector
, _ X00-3
CITY OF FRIDLEY INSPECTION DIVISION Effective On January 1, 1998
6431 University Ave NE
Fridley, MN 55432 APPUCATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES ® f
�l
JOB ADDRESS 133/0 `7(®� Ave NC
RATE SCHEDULE
The undersigned hereby makes application for a permit for the work herein
Residential
Rate
TOTAL
specified agreeing to do all work in strict accordance with the City Codes and
Furnace Shell and Duct Work, Burner -
rulings of the Building Division, and hereby declares that all the facts and
Also Replacement Furnace
$ 30.00
$
representations stated in this application are tru and correct.
(Side Vent - Fill Out Back)
�, /S 1998
Gas Piping (Needed with new furnace)
Gas
$10.00
$
OWNER 9.5 A Uc- A k I
Gas Range
$10.00
$
BUILDING USED AS Me
Gas Dryer
$10.00
$
#190(3.o,, % `
ESTIMATED COST PERMIT NO. ID -1A),
*Air Conditioning - All Sizes
$ 25.00
$ Z6 , co
0 Z 7- 0 3 c tex4A Z IZ /�-J
DESCRIPTION OF FURNACE AND OR BURNER
All Others/Repairs $ Alterations (LIST ON BACK)
I% of Value of Appliance or Work
$
No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Trade Name Size No.
Commercial/industrial
BTU HP EDR
1.25% of Value of Appliance or Work
$
Fuel Total Connected Load
State Surcharge
$ .50
Burner Trade Name Size No.
BTU HP EDR
TOTAL FEEZ$
S. 6-u
MINIMUM FEE FOR ANY HEATING/COOUNG"TILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $42.00/Hr
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
HEATING COMPANY /J AASH 9641i,46 AT'D A/A
Signed By Xq&vk Tel No. 536 _ O&O
Approved By Rough -In Date Final Date �f
FILL OUT BACK SIDE FOR ST K VERIFICATION ON
REPLACEMENT FURNACE
6 Has total heating BTU's of
All other BTU's
TOTAL BTU's
7. Has a liner been provided for water heater Yes ( ) No ( )
8. Has combustion air been provided for water heater Yes ( ) No ( )
Remarks:
List ALTERATIONS Being Done:
HEATING CO:
Signed By:
Date:
., .
CHIMNEY AND STACK VERIFICATION
The
undersigned hereby verifies that the existing chimney or stack:
1.
Has been carefully examined
Yes ()
No
( )
2.
Is free from rust or deterioration
Yes ()
No
( )
3.
Has no foreign objects lodged within
Yes ()
No
( )
4.
Is securely supported
Yes ()
No
( )
5.
Meets all current Code requirements for size
and total BTU's connected
Yes ()
No
( )
6 Has total heating BTU's of
All other BTU's
TOTAL BTU's
7. Has a liner been provided for water heater Yes ( ) No ( )
8. Has combustion air been provided for water heater Yes ( ) No ( )
Remarks:
List ALTERATIONS Being Done:
HEATING CO:
Signed By:
Date:
., .
NEW
ADDN
ALTER
[ ] CITY OF FRIDLEY Effective 1/1/2003
[ ] 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp
[ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax
BUILDING PERMIT APPLICATION
Construction Address:
Legal Description:
Owner Name & Address:
Contractor:
Address: 5555 A' Z16,r./l/7 PAX� 553Y3 Tel. # 95Z - 936* %6"F
9
95Z - 1-3-T • 15-eIV
Attach to this application, a Certificate of Survey of thb
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:enotth Width Hgt/Ground Sq. Ft.
OTHER: QJxl-u 0) s�ZD him- /A "al shO �
_k&i�� �
Construction Tvpe: Estimated Cost: $ ;1 A707-0"
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: f Z m-6 s- APPLICANT:�/Iiv- Tel. # tZ'✓ I / q
-
Call (763) 572-3604 for Permit Fees if mailin in application. Fax to 763-571-1287 if using credit card and we will
call you for card number.
CITY USE ONLY -
Permit Fee $ �� ,ZSR Fee Schedule on Reverse Side
Fire Surcharge $ Z T71 .001 of Permit Valuation (1 /10th%)
State Surcharge $ �5 $.50/$1,000 Valuation
SAC Charge $ $1275 per SAC Unit
License Surcharge $; 00 $5.00 (State Licensed Residential Contractors)
Curb Cut Escrow $ Alt. "A" or Alt. "B" Above
Erosion Control $ $450.00 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ AgTepment Necessary[ ] Not Necessary[ J
TOTAL $ "GZ' RTIPULATIO
l