AF - 348981 1
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City of Fridley, Minn.
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T11 CO218�dBT8�{OA Oi �},l@ �U&IIC@ t0 Il� Of 8 jJQTn1�t t0 CO118'b
tht� proposed work in ac�r8ance wlth the d�rlption above set
ordinanaea oP the dty of Frldley. /
Ia camaideratton of the �►m�nt of a fee of
e builaing de�ibed above I a�ree to do
and in cromnplian�ae wi af 1 provisions oP
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Permit 9s hereby granted to
to t�atract the buflding or addition as descTibed above. Thispermi t is granted upon
the exArese c�ndition that theperson to wham it is granted and his a�ente, employees and workmen, fn all work
done in� asaimd and upoa said building, or any thereo� shall conform itt aII r�peclB tfl the ordinanc� of
FridleY� �ta �g lacatlo�, vaaslt�uc� alteration, maintenaac� repair aad movittg oP bt�il�s
wl�� dty limitai� thia permtt m�► be revaked at an�ae u� vi�an of aay af the P��� oP ea�d
e�
F:,�rit{T� �_�'�'�K�
,� No�nc�
'll�. � aou �t eera, t6s �, � t�:vrleiea P�s. s�+ �. ,ar� � waM. 6. ar. te ,..
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06�it' S NAME�
ADDRES3
.. APPLICATION F08 BOILDING, , FER1�T
.' CITY `OF F$iDLEYi; �SC'�A '_
; G�E��
' : , � °�Ann�iss . 6
. _ _,.....
L(1CATION OF BOII.DII�.
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,�� .- � �..�'� �: �;
No._�;,v �� Stxeet G����� �'° .- � grt of Lot
, .� � �
Loe � Block � Additica o�c Subdivieion . +� ` �� � �'� � "�
_ �
Cosrer I;ot � Inside L.oC�_S�tbqck ���, � ; .S3de Yerd - , � �� �-' ��
SBWER ELSVATION �.'FdUNDATION ELE9ATION
App�icant attach to thia form_Twa Cert�ficates of 3urvey.of Lot and proposed build-
ing location' dratan on these Certificates .`.
,, .
DESCBIPTIO� OF BDII.DING
To be used as: (
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D���-�— Fraat � Depth , . .He��ht D
1. Sq. Ft. � Cu. Ft.
- �Front � ' Depth�� Height �' /
, .
Sq. `Ft . Cu . Ft . ,
Tppe of Conatruction ��.���tS��' ' P Tstimated Cost
_...�....�_. =. r
To be Completed_ _ �� �
The undersigned hereby makes applicat3on �or a,parmit,for the work;herein specified,
agreeing to do all work in strict accordance raith the City of Fr3dley Ordinances and
ruiin�s of the Departmen� of Buildi�qgs,, and .h�reb.y �declaxeQ,� ��aa��."al]. �he facte aad
represeatations atated 3n this applicetiori are true.as�d corzect.
DA�E Ce��i�� ��� I9�� Si[l1�tATtt�� � �.. /����� ����'�'� • �.
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(Schedule of Fee Coats cen be found on �fie He re Side).
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BUILDIA� PEIi1+�T FEE SC.HEDi1I.S
SeGtion 2. The Inspector of Build9.nga shall, before 18suing any perm�t for
t�ie erectioa of aay buildin� or structure., or for anq addition to any euist-
ing buildiag or struceure, or fos� euy alterations or repaiTs to any e�isting
bu3lding or seructure, upoa agplication therefor, requira the paymen� by the
applicant for auch permit of feea te the amo�t herein below set forth end
in the mannes hereia provided to-wft:
2.1. For any su.ch permit for,the erection c�r anq fire•proof buildiag, othex
than a gara�e�-warehouse, �#actory��or �raia�elevator, or for the erectioa of
aay iire-proof additioa, for similar occupancy, to any exiating building
ahall be at the rate of $1.40 for each one thouaand cubic feet, os fractioa
�hereof, in such cubical Coriteat�'.
2.2, For any auch perinit �or the erection of any fire-proof garage, iaareh�use,
- factory or �rain elevator, or for the erectioa of an�r fire-proof �slditioa,
. for simiYar occupaacp, �o eap exfeting buildiag shal� be at the rate of �1.25
for each one thousead cubic ieet, claeaified as °1fiseproof" bq Section 502 of
the Mi.aneapolta Butiding � C�le. . � .
�AUSSS .
�,.
2.3. Far aay sucb parmit`�or the erectioa of any nan-fireproof buildin� other
than a gara�e, warehouse, faotorp or �raia elavator, or aay noa-firegroof
addition, for eimilar occupancy, to anq existin$ build3n� - permit $1.00 for
each one thousand cubic.feet.
GARAGES
2.�. For anq such permit for the�e�ae�tion of aay-noa-fireproog gara�e,
warehousa, factory-or graia elevator;--or for Che erectioa-of aa� non-fire�soaf
addit3o�►, for �.imi.lar occupancq, to any esistia� bu3lding or for each such �
bu�lding or addition - nisety cents ($0.90) for each one thousan�d cubic faet
ox fractian thereof, ia th� cubicai caoateute thereof with a minf�um of $4.00.
For the purpose of computiag iees for build,ing permita, the cubical coatents
of aay buildiag or add3tioa to-a uuiform iiei�bt throu�hout by muLtipiyia� the
�rouad area covered fr� a poime eis (6) iaches below �he flocr i�ae of tbe.
b�semeat ar. cellai to the aver�e height ofJ tt►e uppes surface or to the
average height of the roof surface of �he maia �able of a pitched roof.
2.5. For repairs or alterations to aa existing structure, the fee aha11. be
aC the rate of $3.00 per each Five Hundred Dollara ($500,00) or fraction
th�reof 9.n the cost of all propc>sed' work.
2.6. Itb tto CBSe�sliall the fe�, chaxgc�d for a�y permit ae set forth ia
Section 2 be less tban $4.00.
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M��F.�2. ENGII�r:�RIN(� CO. INC..
ENGINEERS_ �ND SVRVEYORS �
u►ND avavev�NO 801��8 TESTINO
CIVIL A�, MVNIGIPAL EN01N6HRINp LANO P[.,ANNINB
6418-56T" AVENUE N.
" MIMNEAPOLIS 2T. MtNN.
KE 7- 363T
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WE HERE6Y C�RT�FY iNAT TMIS t5 A TRUE A1dD CORREGT REQRESEN�?1TION OF A S�RVEY OF THE BOl1NOAR1E5 OF 7HE
u►NO ABovE DESCa�BED AN� OFTHE L�ATION OF ALL BUItDINGS� �F AuY, TKEREON, ANO P.t�;v�S18tE Er�CRoACHMEt+1T5,
IF MtY, FROM OR ON 5MD LAND. ``
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�►� � Conetruccioa No.
Wi�o�w Da►» Refereaoe 0�. �N�II Int. Wall CeJie� Roof Floor ICiod
' Y�Ae �0 19_
.Roam Leasth Width Heig6t / Fl.1 �.�Q . Room I L
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en a�e e. i. wre. �/ ia� x• aee Ho.
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Coef. �tn
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F�p. �.atl �
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R. EDR or p. ins. WA. Leadrr area '
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aeed Door�—Cracka�e a� Area
t a �rr
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IN� esp. vv�
lat. waU
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F�r
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C�laa
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Ne4 esp. wa�
Iat. wall
Ceilio
Floor
Total &u.
m
t�v.
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lnaulateo�n
HoMr
Width
ed �q. k. E.D.R. er �q. inso WJ�. l.eader ans
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�ad DoorO--Craeka�e and Area
th e � t a o[ ne�i roa
ot e� e! ��s� Il�hb ot eriak p. [t.
S•�
:9 C � z• l� .e�
B� _
, � e . In6lteaeion
i�' �. . Glau
Eap. wall �� /
/ Q.S.�. Nct e:p. w�ll
lat. �►�1!
: D Ceiling .r t,�,/ a
I % � Floor
T�al &e.
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h. ED.R. or q. ina. WA. Leeder area Reqp�iced p. k. E.D.ft. or sq. ies. W.A. Lea�r ae+� /
t� �� w� �� � t� � e�� w� �
and �n--Crackage aod Area 1�/'�vs and Doon�--Craekage aad Area
ds e e. or tc. wna t asee a ot tdeea� rc. wr.s
� st oaM t{<DU o[ enei p. [t. No. ot oao� o� sau� It�AU ot encic so. !t.
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Tetal Btn.
Req�eed �. h. ED.R or p. ies. WA l.eader a�ea
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� In6ltratioo
3 � e , Glaa
Es�. wall �' .
� Net e:p. wall
P
Int. drall
�'/ y� Ceiling .�.i 3
Floor
Total &n. ' �
R�d W. h. ED.R. � �q. w�. �IA. Lcader area
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l�/� l��.�7LA.VLl\�V1�7 VGI'M 11�1G1\ 1 V�' �VliLllAa7 l�ldl\1\rJ'�f"6JL.Is7e �.
Wea�rttrips �� Conatructioet A(o. �eulat�n
W� Diaora Refuaace Out. WaU lnt. WaU Ce�iios Roo� Floor Kind l�w
Do 0
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Fl. ° . Room L.eeath Width Haight � Fl.� , Room Le4QCh VVi�h
Wendowe arid rs—�CrackaQe and Area Wiadows and Door�—Ctaekage a�d Area
Idth a1�At No. s! Lin�al t. Ares WIAtA Hel�st Na ot lo�ai tt. ♦rsa
No. of a� ot pane 11 bt� ot er�ck �. tt.
� Ne. ot pans ot pae� Il�st� ot araot p. tt.
, c � `, ���Q(� '
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Coef. &u
l�hration
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f�p. waU �
Nat esp. wal! I �
, In� wall
Ceiliag
f7oor
'fotal Btu. •
Requ�ed W. ft. E.D.R. or p. iaa WA. L.eader area
, Fl. E3ooa► Leegth Widtl�( . He�
W ied Doon--Crackage aed Area
t N� t No. o ee Area
_ Na o[ pap of pa� Il�bt� ot crset �a. !t.
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l�tr�tildi
Ciaa
Etp• wall ZS' °
1Vmt esp. wall
let. �rall
Ceilieg �_
F�r t� y�_
Total �tn.
. k. E.D.R. or �q. in�. W.A. i..eader area
— Wiedowr aad Doon--Crackage end Arca
Wth ![N�ht No. ot Lfneal tt. Aret
_ l�a ot y�as ot p��a II�Ab et crack w. tt.
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Ist. waq /6� �
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Total i�. ,
Reqiured sq. fe. E.D.R. ot p. ias. Q/.A. L.eader are. /
�� Glsa
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Fap. wall 3 1 �
I�et esp. wall
Ia� waU
� Ceiliag
� Floor
� Total &n.
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IRaryired �q. k. E.D.R. or �q. ms. WA Leader �na
Fl.I Room I 1.,eaQth �Vi�h
Wiadowa aad Door�—Craekege and flrea
1dtA el�t►t o. ot a�al t. Ara
No. o[ y�ne o[ paTe� Il�bts ot c�ack p, tti
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&n
7�
4o s
In6ltration
Glaa
Fsp. waU
Net e:p. wall
Iet. wall
Ceiling
Floor
Tocal Bcu.
Requued eq. ft. E.D.R. or aq. me. WA. Leader �rea
Fl. Rooa� I Length Widch Heiehc
Window� and Doon--Craekage and Area
IdtA e1�At No. ot Llneal tt. A�ea
No. ot pan� ot yan� Il�bq ot er�ck p. tt.
Infiltration
Glasa
�. Wa��
Net ezp. wal)
Int. wall
Ceiling
Floor
Toea) �cu.
Required �q. h. ED.R or p. ias. W.�l. l.eader aeea
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TfIE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIA(1SCES OR THE
O�ePPLICATION WILL BE RETURNED � �
•,,,,•. i .r � .r �►► •: �►� •,,: r•► � - ��cII�T : i��►
�Q�j �DI9[`Ir1Q'a17 PY�CtIr19 ,ran __, the undersigned hereby verifies that the
venting has been examined ar�d is free from rust� deterioration, obstrudions, �
and' is secure(y suppo�ted and firestopped where required. Yes � No (
The venting system is plastic/PVC and meets all cx�rrent codes and manufacturer
speafications inciuding s¢ing� length� number of elbows and termination. Yes ('� No ()
The undersigned also verifies that the replacement unit is a Gsted assembly
and meets the currer�fi codes and manufadurers speafications. This does
indude AGA-GAMA Category I Cer�tral Fumace Venting Tables for fan
assisted and natural draft appliances.
'me �ce�r,Q _err, -���+r± �ir �s sized �nd instaUed to meet the curreni codes
and manufac�urers speciflcations.
Wh@f1 �QUl�2d t0 ����� a new cemh�_c±ien ai� it will be sized and installed
to meet the current c�des and manufadurers speafications.
.
Yes (� No ( )
..
Y���110 ( )
Yes � No ( )
When in�,�+atl�n�a new ventin0 � �„� the undersigned hereby verifies that
it is a I'isted assembly and meets the cxarrent codes and manufadurers
specifications. This does indude AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appiiances. • Yes (� No ()
Is the common vent and vent connectors sized and installed e:orrectly after
an appGance has been removed from the common vent and vented'
separately as per cx�rrerrt codes. Yes�No ()
� . . . . «- ,.�- . � . .,- . �� �� . . - . _ . . - .� . . . �.,�. �<<.:�,� .�, . .
AppGance #1 Type BTU Input Fan Assisted or Nat
Appliance #2 Type BTU Input Fan Assisted or Nat
App(iance #3 Type BTU Input Fan Assisted or Nat
Total AppGances Total Btu Input � .
Common Verrt Type
Verrt Height Diameter - �c�$s
AppGance #1 Vent Connedor Fi�eight � ft�gth ft Diameter in TypB
AppGance #2 Vertt Connedor Height ft Length ft Diameter in Type
Apprance #3 Verrt Connedor Height ft Length ft Diameter in Type
� - 1 • ► �:- . .:-
-- i ---- - - .. _ � '
Center Point Energy MGCO °� -
13562 C,entral Ave NE . '
HEATING CO: �ka, n�nv s�oa - � .
. �
Signed By: �' Date :-� o� ltJ ..3
: M
� = ---- -- _ � . _. _ _ _ _
HEATING
AIR CONDITIONING
AND ELECTRIC. INC.
AQDRESS � �10�
OCCUPANT �
HEAT LOSS DATE HTG. INST. �' U
SOLD BY � �✓i
Elecvicel Work By
TYPE OF HEAT GA FA HW STEAM SPACE HTR.
�.- � • �,
: .�l t -
.�:
S!' ' �
`i�' �r�i� � i ,.�?�
; ; i i1 �
CONTROLS
HOUSE HEATING TEST RECORD
APT.-� FLOOR CITY� d SUBURB
OWNER �w�LQ
INSTALLED BY � /� `�
G� Lirre By
UNR HTR. OTHER
CONVERSION
�.
Vent Size
KIND OF LINE� SIZE �S�` � NONE
Draft Haod Regulator
Filtera Size 9e� Nu��
Chimney Locedon Inaide Outaide
Heat Plug_ Chimney Conatructian
Umit Setti �
Fan Setd
Pilot Type !A �
Pilot N�ke
Pitot AAodel
Pilot Timing �GC� _
�..W. CiUi Qn
Pressure S`l � PeroentCOa �
InputCFH �j�_0�9� Percent0l 7a
Stack Temp. �eQ � Peroent CO: ����_
�s
Smoke Bomb Vlfiring [�
Dratc Test Taa i
DQor Preasure Lightir� Inst
Date Tested
Company Testlng '�
Name of Tester
. �4
Presaure Peroent COa
Input CFH Percent OZ
Stadc Temp. Percent CO
i.
Building lYI�CHAI�TICAL Pe�t No.:
Inspections RESIDENTIAL APPLICATION Received By:
7. 63-572-3604 C�y OF FR�LEY Date Rec'd: ��a �
DATE 5�- � I�-D CO YOUR E-MAIL ADDRESS
SITE ADDRESS �I �! �,� �1'V �!� ��
THIS APPLICANT IS: ❑ OWNER 'L�60NTRACTOR �
PROPERTY Np�; L'i��6rb
OWNER/ ADDRESS: ��Yn'R CITY I� STAT�J�,ZI��3 Z
'rEN�v'r Pxor�: �'I/ 3_�71- 3 �o �'
corr�c�roR con�Ax�r ru�: Riv�r Ci Sh��t �, nc.
SUBMIT A COPY OF ��TACf PERS�N: 2g0 AAsin St. N.E., u�
YOUR STATE STATE LICF.I�ISE � Fridley, IV1l�
LICENSE WI'I'H ADDRESS: /7�R'dl 7�.2'i9� FaJ( 4763) ��`2� � STATE ZIP
APPLICATION PHO� FAX
— - ---- -- -- - --- , — - --
PERMIT TYPE ��GLE FAWIILY 0 TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � � �LACEMEN7' ❑ a,LTER/+.TTON/REMODEL
DETAII.ED DESCRIPTION OF WORK '�' �' �-
PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the totsl cost up to $50Q.00, whichever is greater, for the
improvement, installation or replacement of a residential frxture, excluding the fDCtures. (This should reflect only the cost of labor )
Labor cost under $300 a$15.00. Labor cost between $300 to $S00 = cost of labor x.OS �
FOR PROJECTS WHERE IABOR EXCEIDS $SOD, FEES ARE BASID ON $10.00 PER FIXIVRE, EXCEPT VV�iERE NOTID. F1X1'URES: (II�IDICATE TOTAL
NUMBER OF EACH BELO�
Equipma►t InstaUed . MFG: �_ MODEL: �� � SIZFJBTU ��X%
MFG: MODEL: SIZFJBT(J
�� N1FG: MODEL: SIZFJBTU
� H/C $25.� _FIREPLACE (GAS) $15.� . _GAS RANGFJOVENI $10.�
AIR TO AIIt EXCHANGEER S15 FIREPLACE (WOOD) $35.00 NEW GAS GRII.L $10.�
BOII.ER 535.00 FURNACE $35.00 _GAS iJN1T HTR $10.00
CF�NIlVEY UI�IER $10.00 GAS DRYER $10.00 Pt30L iiEATER $35.00
DUC7' WORK $10.00 QAS PIPING $10.00 ' VENTILATOR $15.00
— —
. . . ... .,. . .... . _ . . _ , _ .. . . .�.. - .. -
3
•�.. . �.. ., AN � . .. . . . ' �. .. ., ..:.. �. �. . . .. ' . . . .. .
Permit Fee $ 4 Number of fixt�ues (n� $10.00 x$10.00 =$
Surcharge $ .50 Number of fxtures @ $15.00 x $15.00 = $
'TOTAL DLJE $ Number of fixtures @$25.00 l x$25.00 =$��-dG
Number of fixttues @ $35.00 x $35.00 = $
State Surcharge = $ .50
Tota1= $ . S
THIS IS AN APPLICATION FOR A PERMIT NOT VALID UNTIL PROCESSID
T hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
confomiance with the ordinances and codes of the City of Fridley and with the Minnesota-Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a germit; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT %%� �% p�NT NAME� � S ��� DATE � 3/ /�%G
.A ... ......y,. . . ... . ... . �. .. ., ._ � -
'. _ . ����, ��.'..
,
,
, -
(:ity ot r�ria�ey
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
�.�
- � REQUIRED INFORMATION NEEDED TO PROCESS PERMIT
RESlDENTIAL PERMIT APPLICATIDN HVAC �
❑ NEW HOMES/ADDlT(ONS ❑ EXISTlMG HOME � ❑ MAKE-UP AlR
�
REQUIRED FOR NEVN/EXISTING HOMES
1. Combustion Air (Se,e note below) .
a. Oil or solid fuel IMC Cb.a�ter 7 with MN Amend.ments
b. Nahu�al Gas or Propane/IF'GC Chapter 3 with MN Amendments �
2, Make-up Air (See note below)
a. IMC Chapter 5 with NIN Amendmen.ts �
3. Ven.ting
a. Gas appliances IFGC Chapter 5 with MN Amendments
b. Fuel other than gas IMC Chapt�r 8 with MN .Amendments
REQUIRED FOR NEW HOMES
4. Heat loss & cooli.ng load. per room
a. FZequired on new construction IMC 1346.0312
5. Ven.tilation . �
- a. - �erMN E�erg�-��e 7�70 or �672
6, �uct Design Per IMC 1346:0603.2
a. ACCA Manual D �
NOTE: Centerpoint Energ� Mechanical Code Guidelines software may be u�ed for
comb.ustion and make up air� calculations
Building PLIJMBING � Permit lvo.•� - o��
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY UF FRIDLEY Date�f��:� Q 4 2 7
DATE �� D% YOUR E-MAIL ADDRESS /C. ��C� �� �'H �' N
SITE ADD S � /
THIS APPLICANT IS: OWNER �CONTRACTOR
PROPERTY NpME: � .g �' Z' �.
��E� ADDRESS: 7 (i{%' CITY {rl, "� fi1 STATE /' d
TENANT PHONE: CO� `3l'°% ,�J D �
CONTRACTOR Np�;
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE ADDRESS: CITY STATE ZIP
LICENSE WITH pHONE FAX
APPLICATTON
PERMIT TYPE SINGLE FAMILY O TWO FAMILY 0 TOWNHOUSE
TYPE OF WORK: � �W REPLACEMENT
DETAILED DESCRIPTION OF WORK � �P�.t.� O� G. O�� !�-[ 11e- O 7/i.
� �
PER MS 16B.665 the permit fee is a minimnm of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor )
Labor cost under $300 =$15.00. Labar cost between $300 to $500 = cost of labor x.OS =
FOR PROJECTS WHERE LABOR EXCEEDS $5�, FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WI-IERE NOTED. FIXTURES: (WDICATE TOTAL
NUMBER OF EACH BELOVi�
BATH SDQK/LAV FLOOR DRAINS SHOWER WATER PIPWG
BATHTUB GAS PIPING �n crrrucFrvsE) SWIMMWG POOL WATER SOFfNER ($35)
CIATHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER ME'fER �C OTHER
� � � �`- - � �,.
2 , �
Permit Fee $�_. Number of fixtures @$10.00 x$10.00 =$
Surchaz e .50 Number of fixtures @$ I 5.00 x$15.00 =$
TOTAL DUE $ S.� Number of fixtures @$35.00 x$35.00 =$
State Surcharge = $ .50
Tota1= $
THiS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I wnderstand this is
not a permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of a11 work which requires review and approval of plans.
SIGTIATURE OF APPLICANT -� /.L�����P�� PR1NT NAME �o �/'� J, G/Gt.�� �,� �� �� !��
.�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 '
FAX: 763-502-4977