AF - 35528�....: _r -�
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Village of �ridley, Minn.
� ^ . BUILDING PERMIT �° � 18 4'7
�
Date: . .. . . . .. .. .. . . � �': .��rr.. ....... ..
Qwner . . . . . . . . . . Builder . . ��!�'x!:4'.`.''�-. . . . . . . . .. . . . . . .
. . . . . . . . . . . .. . . . . . . . . . . .. . . . . Address .�r. .7. . �� --v;`.�.
Address...................................... ....�.0..�{.`.�..... ... .......
AT[ON OF BUILDWG
No. .. �'�.�':�.. Street ....��'.��vZ�� ....................... Part of Lot ....... ... ..
Lot'.���.'. � �1 Block . . . . .�.. . . . . . . . . . Addition or Sub-Division .. i�.��°�'T/.+7?'�'. . c��.'':"r'.. • .. .
,/ ,� / � �. �
Corner Lot ........... Inside Lot ...!!...... Setback ..!�.�... Sideyard .. f...� ..... ..............
DESCRIPTION OF BUILD[NG
To be lise as•
� . . . . . . . . Front . .'�.� . Depth . �;1. :'.� Height . . !�.�. .`� Sq. Ft. . . . . . . . . Cu. Ft. . . . . . . . .
. . . . . . . . . . Front . . �. � . Depth . !2'.'�`: . Height . .�. r. .`S Sq. Ft. . . . . . . . . Cu. Ft. . . . . . . . .
. ��' . . . . Est. Cost . �. �. S� � . . . . . . . To be Com leted
Type of Construction . p ..••••••••••• . •.
Tn 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 �11 provisions of
ordinances of the village of Fridley.
.....................................................
�
[� �.
In consideration of the payment of a fee of $.� 1..... ., permit is hereby granted to ......... ...... ...
. . . . . . . . . . . . . . . . . . . . . . . . . to construct the building or addition as described above. This perniit 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, sha11 conform in all respects to the ordinances of
Fridiey, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings with-
in tne village limits and this pex�mit may be� revoked at any timz upon violation of any of the provisions of said
ordinances.
� .� ., .. .......... ......... Building Inspector
NOTICE:
This permit d'oes 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 #or these items.
sue�ecr P E
City of Fridley ° 4453
AT THE TOP OF THE TWINS B U I L D I N G P E R M I T;
r
' ' RECEIPT NO.
� �'-/3�/
� • COMMUNITY DEVELOPMENT DIV.
' j L ' "'-� .. . .
r � � PROTECTIVE INSPECTION SEG
1 � i � . � . . � .
� � ��"�'; � CITY HALL FRIDLEY 55432 NUMBER � REV. DATE �� PAGE OF APPROVED BY �
` -��'�' �� 612-560-3450
910-F15 llf 1/77 I �
JOB ADDRESS 6261 A�le Street N. E.
1 LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
oescR. 17 2 Moore Lake H1CJY11dIlCZS SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
George Heilman 6261 Able Street N.E.
3 CONTRACTOR MAIL ADDRESS Z�F PHONE LICENSE NO.
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE UCENSE N0.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
6 USEOF BUILDING
Residential
7 CLASS OF WORK
ClX NEW ❑ ADDITlON ❑ ALTERATION O REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 12' x 12' Shed in Yaack yard
9 CHANGE OF USE FROM TO
STIPULATIONS
Shed to be kept 8 feet from side lot line per owner.
� w��N�
SEPERAT� PERMITS REQUIREQ F`OR WIRING Be#ore diggin� �al� �z��:�I �E4���r�z;
r TELEPMQ�4E - EE.�'C . Zt�% -�„S �er,.
MEATfNG, PLUMBING ANfJ SiGNS. �������� �� �t��►
TYPE OF CONS7. OCCUPANCY GROUP OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOF ELECTRICAL, PLUMBING, HEATING, WO�
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 OFFSTfiEE7 PARKING
1 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 yS`SOO �.SO
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AWTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON'- •�, 5O
STRUCTION OR'THE PERFORMANCE OF CONSTRUCTION. $
PLAN CHECK FEE TOTAL FEE
yi8.��
I NATUREOFCONiRACTOR R THORIZEDAGENT IDATEI . . � HEN�PROP RLY� VALIDATE THIS IS YOUR PERMIT
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` C�-�C (, l ,.��/.�._.l� .
� iGNATUREOFOWN 1 fR UIL 1 � IDATEI �� . BLDG.INSP� � DATE�.�
CITY Of= f=fZIllLEY
' APPLIC/�TIOIJ FOR RESIDC(�TIf�L BUILDING PERt�IITS
�NEW, IILTERATIONS, ADDIT'IONS, OR REPAIRS)
OWN�R: � � ��� BUILD�R: � �) �,� �° ��
Address: Gi � (o / .�� (��_ �%� /iJ,�, Address: �
Te 1. . No . .
No.: Street:
LOT : � .7 BIACY.: �_ ADDITIOI3 : � p �., � f � ,N„ � � � I� /,� �
CORNER LOT: INSIDE IAT: � S;TBACK: SIDEYARDS:
Applicant attach 'to this foxm �ao Certiiicates of 5urvey of Lot and proposed
building location drawn on these Certificates.
DESCRIPTION OF BUILDING
To Be Used As:
r
S� � i� Front: ( t-- Depth: �'L Height: ��
Square Feet: I u t� Cubic Feet:
Front: Depth:
Square Feet:
Cubic Feet:
Height:
Type of Construction: � p p� Estimated Cost: $�CJ'p ^
Z+o Be Gompleted: �-- j'n ps � Alt. A A2t. B
Proposed Driveway Widt� 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 ��ith the City of
Fridley Ordinances and ruli.ngs of the Department oi Buildings, and hereby
declares �hat all the facts and represniltations stated in this application
are true and correct. See reverse sid for aclditional information.
. �
DATE: _ I I� t `��� SIGNATURE:
Stipulations:
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BUILDI(�G PER��IIT FEt SCHET)�!_L
SECTION 2. The Inspector of Buildings shall, before i.ssuing permits for the erection
of any building or structure, or for any addition to any existing building or structure,
or for any alteration or repairs to any existing building or structure, upon application
therefore, require the payment by the applicant for such permit of fees to the amount
herein below set forth and in the manner herein provided to-wit:
A,
NEW CONSTRUCTION: Single Family Homes and Garages: $4.00/1,000 cubic feet..
PLAN CHECK: 25 percent of building permit fee.
DRIVEWAY DEPRESSION: (Concrete Curb Streets Only) ,
Alternate A: Remov�l and replacement of concrete eurb and ':.
gutter only; Driveway width plus 6 feet x$11.75
Alternate B:'Removal and replacement of concrete curb and
gutter and install a 3 foot wide approach with
6 inch depth; Driveway width plus 6 feet x$15.40
:11 � ► �' p ��
For the purpose o£ computing fees for building permits, the cubical contents of any
building or addition, is determined by multiplying the ground area covered from a
. point six (6) inches below the floor line of the basement or th� cellar to the
average heights of the upper surface'or to the average heigh� of the roof surface
of the main gable of a pitched rnof.
For repairs or alterations to an existing structure, the fee shall be at the rate
of $3.00 per each five hundred dollars ($500.00) or fxaction thereof in the cost
o.f all proposed work.
Zn no case shall the fee charged•for any permit as set forth in Section 2 be less
than $7.50 plus $.50 state surcharge.
' � • • �_1�' �L
NQTE: Permits �or construction will be issued a minimum of 24 hours from the time
of application to allow for proper review of the proposed structure and of the
construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it
has been constructed will be required before proceeding with the framing.
CtRTIFICATE OF OCCUPANCY
Application for a Certificate of Occupancy shall be made ten (10) days prior to the
use or occupancy of any structure for which a°buiZding permit has been issued; and
said structure shall not be used or occupied until a Certificate of Occupancy has
been issued.
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sue�ecT PERMIT
City of Fridley
AT THE TOP OF THE TWINS B U I L D I N G P E R M I T
r
; � RECEIPT NO.
� • COMMUNITY DEVELOPMENT DIV.
r �~ � PROTECTIVE INSPECTION SEG �
� i
� �
i
i.-_. �,�/"'1,,, CITY HALL FAIDLEY SS4$2 NUMBER .� REV. DATE . PAGE OF APPROVED 8V
i �'� 612--571-3450 910-F15 4/24/85 � �
JOB ADDRESS 6261 A,ble 5txeet N. E.
1 LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. P't. 17,18 2 MOOY'2 Ld.ke H1C3Y11driC1S SHEET
2 PROPERTYOWNER MAI�ADDRESS ZIP PHONE
George Heilma,n 6261 T�ble Stxeet N,E. 571-3037
3 CONrRACTOR MAILADDRESS ZIP PHONE UCENSENO.
Lee's Siding & Trim R�pair Service 2461 Bunk.er Lake B1vd N.W., Andover 55304
4 ARCHITECT OR DESIGNER MAIL ADORESS 21P PHONE LICENSE NO.
755-5260
5 ENGtNEER MAILADDRESS ZIP PHONE UCENSENO.
6 USE OF BUI�DING
Residential
7 CLASS OF WORK
❑ NEW � ADDITION � ALTERATION � REPAIR O MOVE ❑ REMOVE
8 DESCRIBE WORK
Aluminiun t�im (�'acia & So��it & windows: (_
9 CHANGEOFUSEFROM TO
STIPULATIONS
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAO
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL ANO VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OF If CONSTRUCTION
OR WORK IS SUSPENOED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCEO. NO. DWIG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ ANO EXAMINED THIS APPLICATION STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORiiECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ,ORDINANCES GOVERNING THIS TYPE OF WORK W1LL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT y�`1. HrJ�. S. 92
OES NOT PRESUME TO GIVE AUTHORITY TO VIOIATE OR CANCEL THE pEfiM1T FEE SAC CHAFGE
OVISIONS OF ANY OTHER STATE OR LOCAI lAW REGULATING CON-
S U TION O HE PERFORMANCE OF CONSTRUCTION. tiS`3]-.00
� AN CHECKFEE TOTALFEE
,�-�� $31. 92
. S�GNATUfiEOPCONTRACTORORAUTHO Eon IDAT i WHEN PROPERI � ALIDATE THtS IS YOUR ERMIT ��
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SiGNATUAEOPOWNER11fOWNERBUILDERI � IDATEI BIDG WSP D E
N� [] City oP Fridley Effective 4/1/84
ADDN. [ J R-1 A1�D R-2
�I,TEp. [ J Building Permit Application
Construction Address
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Legal Deacription: `�" � � � l�, � � f �--` =z � v • � u u K � c--r-��c � �co�-r-uy-� ,�� - -
Owner l�mme i Address :��1^o R C� ���/� �.� 11� �S',Q M� Tel. � l-30
Contractor: � �,�5 � f� /NC. i'! /Y O .�.l�i�1����/'�' . S�/� I/�ic � Tel . # ��'" - S'�-6 d
Addreaa:�l�G 6 / �rJ�(/!�f � _.�� -r �� �/,O /1%�!�%� .�I✓�Dd/l.C=� S�S^3o' /
LI9IBG AREA:
GARAGE AREA:
DECI� AREA :
OTHER:
Attach to this applieation, a Certificate oP Survey of the
lot, with the proposed construction draWn on it to scale.
DBSCRIPTI011 OF IISPHOYEMENT
Length width Height Sq. Ft.
Length Width Height Sq. Ft.
Length Width Hgt/Gr?o�und Sq. Ft.
�i4 L//k �-� � a'„F ;�t �'7'� o�..P 71� ��— �i G c. M G d l� L: /�
Corner Lot [] Inaide Lot [] Ft. Yd. Setback Side Yard Setback
�.. d a
Type of Construction: Estimated Cost: �.� �s �
Approx. Completion Date:
Alt. A Alt B
Proposed Drivexay Width If NeW Opening Is Deaired: � �
See Back Page for Explanation
.
DATE: APPLICANT: Tel. �7 S�S � �� � �
CITY QSE OIiI.Y
Permit Fee
Plan Check
State Surcharge
3AC Cbarge
Park Fee
Se�r►ar Nain Charge
roT�.
STIPULATIONS:
_ �/. O d
a
3 ��
;
_
�
a �f 9�
Fee Schedule on Reverse Side
25f of Building Permit Fee
=.50/a1�000 Valuation
=425 per SAC Unit
Fee Determined by Engineering
Qgreement Necessary [ ] Not Hecessary [ ]
Y � s �.
BIIILDIIiG PBRMIT FEE SCA$DIILE
The Chief Building Official ahall� before issuing permits for the erection of any
building or structure, or for any addition to any existing building or structure, or
for anq alteration or repair to any existing building or structure� upon application
therefore, require the payment Dy the applicant for such permit of fees to the amount
herein belo� set forth and in the manner herein provided to-Wit:
?otal Yaluation
�1.00 to =500.00
Feea
�10.00 (Minimum Fee is =15.00)
�501.00 to ;2,000.00 =10.00 for the firet =500 plus �1.50 for each
additional a100 or fraction thereof, to and including
�2,000.
=2�001.00 to �25,000.00 =32•50 for the first �2,000 plus �6.00 for each
additional �1�000 or Praction thereof, to and
inaluding ;25,000.
�25,001.00 to a50,000.00 =170.50 for the first ;25,000 plus �4.50 for eaeh
additional a1,000 or Praction thereof, to and
including #50,000.
:so,00,.00 to a,00,000.00
�100,001.00 and up
#283•00 for the firat a50�000 plus �3.00 for each
additional �1�000 or f raction thereof, to and
including �100�000.
�433.00 for the first �100,000 plus �2.50 for each
additional �1,000 or fraction thereof.
DRIYEiiAY DEPRBSSION ESCROiii
(Concrete Curb Streets Only)
. Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus
b feet times �13•50
Alternate "B": Removal and replacement of curb and gutter and install a 3 foot wide
approach t�ith 6 inch depth - DriveWay width plus 6 feet times �15.75
YBRIFICATIOA QF FODNDATION
Permits for construction Will be issued a minimum of 24 hours from the time of
application to al1oW Por proper revieW of the proposed structure and of the
aonstruction siLe. -
A Certificate oP Survey of tbe lot, ahowing the location of the foundation once it
haa been oonstructed aill be required before proceeding with tbe framing.
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SuB�ECT
c�ty of Fridley
AT THE TOP OF THE TWINS B U I L D I N G P E 1� M I T
' �, �72-3f t�4
� `y��____ O MUNITY DEVELOPMENT OIV.
r � � PfiOTECTIVE INSPECTION SEC.
1 . �
� � i"'1 � CITV MALI FRIOIE� SSIJ2 NUMBEN
�""�" ,'' 612-571-3450 910-Ft5
lOB ADORESS
6261
t LEGAL ��T�L'. Of BIOCK TRACTORAOC�TION
DESCR. 17 & 1$
2 PROPERTY OWNER MAIL ADORESS
Geor�e Heilman
3 CONTRACTOR MAIL AODiiESS
Gates Roofing 4640 XiminPs L�n Pl�ut� '
� ARCNITECT OR OESIGNER MAII AD�FESS
5 ENGINEER MAIL ADORESS
6 USE OF BUILOING
Residential
7 CLASS OF WORK
REV O�TE PAGE OF
12/1/98 / /
28690
R O.
���s
APPROVEO BY
SEE ATTACNED
SNEET
ZIP PHONE IICENSE NO
ZIP PHONE LI N0.
ZIP PHQNE UCENSE NO
O NEW O AODITION O ALTERATION � REPAIR O MOVE O REMOVE
8 OESCRIBE WORK
Reroof house and garage (27 Sq) tear-off
9 CHANGE OF USE FROM
TO
STIPULATIONS
Underlayment must comply with the State Building Code.
rrre vr c vn�� .
SEPARATE PERMITS AqE FEOUIqEO FOR ELECTRiCAL, P�UMBING, HEATING.
VENTI�ATING OR AIF CONDITIONING
THIS PERMIT BECOMES NULI AND VOIO If WORK OR CONSTRUCTION ZONING
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOF A PERI00 OF 1Z0 DAYS AT
ANY TIME AFTER WORK IS COMMENCEO. NO DWLG. UN17�
1 HEREBY CERTIFV THAT I HAVE READ AND EXAMINED 7MIS APPLICATION
AND KNOW TME SAME TO BE TRUE AND CORRECT. ALl PROVISIONS Of LAWS VAI,UATION
ANO ORDINANCES GOVERNING THIS TYPE Of WORK WI�� BE GOMP�►EO
WITH WME7MEFi SPECIFIED HEREIN OFi NOT. TNE GRANTING OF A PERMIT $2313
DOES NOT PRESUME TO GIVE AUTH TV TO VIOLATE OR CANCEL THE pEqMIT FEE
PROVISIONS OF ANY HER ST R IOCAL LAW REGUTATING CON-
STRUCTION O TH EFiFO N OF CONSTRUCTION �]�F. %S
PLAN CNECK f EE
License SC
S�GNIIUQEO�CON'RACTOpOQ�UTMOA�ZEO�GENT IOATEi WMEN PR
I
S�GH�iUAE O� OWHEQ ��� OWNEA 8UR0@A� � �O�TE�� e� n �aeo
\
Sa.
STA�LS
OCCUPANCYLOAO
CU FT.
f PARKING
GARAGES
$1.16
SAC CHARGE
Fire SC $2.31
TOTA�FEE
$83.22
D TMIS IS VOUii PERMIT
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NEW ( ]
ADDN [ ]
ALTER [ ]
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: ��(d �
Legal Description:
Owner Name & Address:
Contractor: L-`7G1 �� :
Address:
_ �/� ,
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Effective 1 / 1198
�Q�
�� �6��
Tel. #
'ENSE #
Tel.# �����y�
LIVING AREA: Length Width Heighf Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: I.ength Width Hgt/Ground 5q. Ft.
OTHER: %grc�� �x��s� o� � �� � rroo� h�s � a � �z .
a--
Construction Type ��/^1 � d- I'�'1'��� Estimated Cost: $`'t' o?��
�..
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: �� / � APPLICANT:
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
$ � .��
� o?. 3�
$
$
$ ^� UU
$
$
$
$
$ c�3 ��
Tel. # S�� O d ��
CITY USE ONLY
Fee Sehedule on Reverse Side
00 L of Permit Valuation (1 / l Oth %)
$.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 [ ]
BUILDING PERMIT FEE SCHEDULE
K w
The Chief Building Official shall, before issuing permits for the erection of any building or structure, or for
any addition to any existing building or structure, or for any alteration or repair to any existing building or
structure, upon application therefore, require the payment by the applicant for such permit of fees to the amount
herein below set forth and in the manner herein provided to-wit:
TOTAL VALUE
$1 to $500
$501 to $2,000
$2,001 to $��,f�00
$25,001 to $50,000
FEES
$21 (Minimum Fee is $21 plus surcharge)
$21 for first $500 plus $2.75 far each additional $100 or
fraction thereof, to and including $2,000
$62.25 for first $2,000 plus $12,50 for each additional $1,000
or fraction thereof, to and including $25,000
,
$349.75 for iirst $25,000 plus $9.00 for:each additional $1,000
or fraction thereof, to and including $50,000
$50,001 to $100,000 $574.75 for first $50,000 plus $6.25 for each additional
$1,000 or fraction thereof, to and including $100,000
$100,001 to $500,000 , $887.25 for �rst $100,000 plus $5.00 for each additional
$1,000 or fraction thereof, to and including $500,000
$500,001 to $1,000,000 $2887.25 for the first $SOQ,000 plus $4.25 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$1,000,001 and up $5012.25 for the first $1,000,000 plus $2.75 for each additional
$1,000 or fra�t��� thereof
DRIYEWAY DEPRESSION ESCROW
(Concrete Gurb Streets Only)
Alternate "A" : Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50.
Altemate "B" : Removal and replacement of curb and gutter and install a 3 foot wide
approach with 6 inch depth - Driveway width plus 6 feet times $15.75.
VERIFICATION OF FOUNDATION
;
,
Permits for construction will be issued a minimum of 24 hours from the time of applic�tiQn to allow for proper
review of the proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed
will be required before proceeding with the framing. '
CITY OF FRIDLEY INSPECTION DIV.
6431 University Ave NE
Fridley, MN 55432
572-3604
APPLtCAT10N FOR PLUMBING AND GAS FITTING PERMIT
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH F� nnR
Effective On Jan 1, 2000
PLUMBING FlXTURE RATES
NO. RE�TE TOTAL
New Fixtures �
Oid Opening, NewFixture
Beer Dispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Water Heater -Electric
Water Heate� - Gas'" �_
Gas Range** �
Gas Dryer""
Back Flow Preventer Required OYes O No
Type
$ 7.00
$ 4.00
$ 5.00
$ %.0�
$ 7.00
$ 7.00
$ 7.00
$10.00
$ 7.00
$10.00
$10.00
$10.00
$15.00
Reinspection Fee $47.00/Hr
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture or Appliance
State Surcharge
� .50
TOTAL FEE $�►�/•� P�llS THE 5.50 STATE SURCHARCF
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE
JOB ADDRESS �� �'s at����.
The undersigned hereby makes apptication for a permit for the work herein
specified agreeing to do all work in strict accordance with the city codes
and rulings of the f�uilding Division, and hereby declares that all the facts
and repr���^*�f�^^^ �•�a-a °- iL0- =—" �� 've and correct.
HEILMAN, TIM
6261 ABLE STREET N(:RTHEAST jl ��� ' 20 ��
FRIDLEY, MN 55432 �
(763)571-3037
Owner _
_ . Building Used As �'ES1��lV Ci�
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_ Estimated Cost � PERMIT NO. ,`� 7( /
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PLUMBING COMPANY OIZ��I� ZU/✓I�11/l�� �
SIGNED BY ��' TEL NO.�[ Z'S�'�O � 7?
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,_ _ Approved By . Rough-in Date Final Date � �� ���
COMMON VENT VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When reqlacin� an existin�t furance, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes O No O
The venting;,system is plastic/PVC and meets all current codes and manufacturer '
specifications ,including sizing, length, number of elbows and termination. � ' Yes O` No O
The undersigned also verifies that the repiacement unit is a listed assembly
and meets the current codes and mar�ufacturers specifications. This does
include AGA-GAMA Category I Centr�i Furnace Venting Tables for fan
assisted and natural draft appliances.
The existin� combustion air is sized and installed to meet the current codes
and manufacturer's specifications.
YesONoO
Yes ( ) No ( )
When required to install a new combustion air, it wiH be sized and installed
To meet the current codes and manufacturer's specifications. Yes O No O
When installin a new ventinst svstem, the undersigned hereby verifies that
it is a listed assembly and meets the c:urrent codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Furnace
Venting Tables for fan assisted and n�tural draft appliances. Yes O No O
Is the common vent and vent connectors sized and installed correctly after
an appliance�:has been-removed from the common vent and vented
separately as:per current codes. Yes O No O
Appliance Tvpe and Size/Common Vent and Vent Connector Information
Appliance #1 Type BTU Input Fan Assisted or Nat�
Appliance #2 Type _ BTU Input _ Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances Total Btu Input
Common Vent Type _ Vent Height Diameter inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance #2 Vent Connector Height �ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS• (Describe) -
HEATING Cb: i
Signed By: ; Date :