AF - 34908�
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City of Fridley, Minn.
BUILDING PERIVIIT
��; FBBgUABY 23, 1966
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N� ssgo
�: 80BERT T�LIEN �� S& W Construct3on Companq
�� � 1960 palley piew Lane
Mianeapolis, Minnesota 55432
LOCATION OF BUILDING
No. 7866. St�eet ALDBN WAY N.E. Part of Lot
Lot 1 Hlock 5 ABdittan or 9u�h-Divlsla� PEARSON' S CRAIGWAY ESTATES, 2ND
Corner.Lot g Instae r.ot � �tba�k 41' siaeyard 22� ADDITxON
8ewer IIevation �� �� II Att� id� � � O
�' �t ),/ � . � � _ �. ,.� �
DESCRIPTION
To be vsea as: /� 7� �� ��f � �
flOIISE �t 46 �� 32 ���t 20 �, � 1, 304 �� Z6, 080
GARAGE �t 22 � 22 ��t 10 �. � �� � 4,480 t� �A°
Type of Constructlon � Est. Cost � 23�000 To be Completad
Ia canslderatlon oP the i�nantae to me oP a per�nit to constnict the building des�lbed above I agree to do
th� propo�ed work in aexbrdance with the d�scrlptt� above set fo�p and ia c�apeliancs wlt1� a� pravlad�ne of
a�8iaanc� oR tbe city oP F�i�IIeY .� // ��� � y �1
Ia �mslderatlo� oP the p�yment oP a fee o! S¢ 31 •�� —, peranit is hereby granted to S& W CONSTRIII
COMt'ANY to cromstruet tbe building or adaittam as d�bed above. Tbis� t is giaated upa�
t�e exp�eas condittlon that the�pe�so� to vrhom it is �anted a�i his a�eate, �hp��� and workmen� ia a11 work
8a�e in, �� upon ��din� ar a�► thereo� s6a11 c�n4orm in- e11 r�pect� to the o�ainaac� aR
��3►� altera1�, matatenan�e, repair end maving oP buil�in�
wl� dty liaoite�� permit m�r be rsvc�ed at a�► t�me upa�a violatlon oP a�► a� tbe P� oY ea�d
ALIDEI� E�. JEIQSEN �S �
NOTIt�
1h� � doa ee� �r tb. �e, I�m 1'or �oY. P�► a�+ �. arra� or wd�. B� a� to n�
tla Ba� I� ter apara�a pumib ter flua N�. ,
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API'I.IGA�'t� FOR BUILDING PBRMIT
CiTY OF 1�R%DL�Y, MII9NESOTA :, ' ` -,
o��s � .�� � ��. T � �;P,� _ 8��:� � �/. " �'� �.�%/ � •
ADDRI.s -' �'' � � 1 l
ADDitBS S � . ��� i� � �
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� , LOCATION Ag BOII.DING
/ ' , . ,
N0. L� ��STRE�T , G�..�A PART OF. Lt3'� ,:
,, ��•:1��
L<Y�' BLOCR >�, ADDITTON OR SUBD SIO��� d�o ad �b � i q T
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CORNER LOT INSIDB LOT SETSACR � �,�, .-5�DE�YI�RD. .2�
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SEWER ELEV�ION � . : , FO�l1VDATIi>N ELE9ATT� � . �
...._. ..-
_ _ � ..��. . . . . r ' �+r.±R ±. r�r.�� .
Ap�licsnt �Ctach to this form K'wo Certifi�teei of� �i�y d� �,ot sad propo�ed �
building location drawn on thsse Certificates. ,
. , , DBSCRIPTIQN �dF BiTII,D�G. ` . . , .
To be used as;' �� - .
�., � �.:;� f • _..
-- ��' e ,� Front--`�-�-,--Depth_.�' z . flei�h�
sQ., Ft._/ 3��.` ,� cu� z�t_. �� �..
.� . , .
Front. Z �� �
� .��..
�....., Depth Z��Height �'+;
Sq. Ft�...e�.�y�+._� . Ft.� , _ �`� „/� �
, �
Type of Conatructioa�►/ o s oA �V�M � Estimated Cost , ��—t), .
�_��`. _ , .
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To be completed r�. � % � ' , .
,
! r � . � - : � i --..-.�.
The undersigaed hereby makes ap�i],icatioa for a permit for tlie work }be�ein
specified, agreeing to do all work ia atrict accordaace with the Gity of -
Fridley Ordinanaes and, rul,�s o� the Degartmeat of �Hu3;ldi�s, ,and hereby ,;� .F .
declares that a],1 the �acts and represeafatione statesd in th`is appli.cation
are true and correct. ` .
DATE 2— Z/ -� G SI��NATQ� � •
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(Schedule of Fee Costa cam be found on the Reversa Side). �
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BIIILDING PER'MI� 1�EE SCHEDULB
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SECTIOA 2. The Inspector of Buildings sliali, before iseuing any permit for
the erection of any buildiag oir�stru�t�re� or for aay �d8ition to 8ay existing
buildin� or structure, or for any'alterations or repairs to any exi�ting
building or structure, upon application therefore; require the paymeat by the
applican.t__#o�._�e�ch �p.�xmit .af_��ees.-fio 'the. �ovnt_ he�ei�a. below set .fvrth and in
ehe msnner herein provided to•wit:
2.1. For auy �uch permit for the arection of anq fire•proof building,
othei th a garagef warehouse, fac'tor� or grain�e�.eva�or, or for the ereceion
of any fire-proof additioa, for eimilar occupancy, to any esieting building,
ahall b� e,t._fihe ratie �of "�1.40.for each..one thousand .cuhi� feet,- or fraction . �
thereof, in such cubical contenta.
2`2,_ For any, _such ,permit for the erectioa of" any f�.re-praof garage.,
warehouae-f---fac�os�r-flr"�rain e�-ava�or, oi� for the erection of ady fire•proof'
8ddition, for similar,occupa��cy�»�o any eaistiag buildin� shall be at the
rate- o€� �1.23 -for each one ths�ueand cubic �eet; :cl$e�sffied ae "fireproof"
bq Sectioa 502, of the .l�iuueapolis Buildin,� ,C�ie. ,
flOIISES �- . . � .
2` For any such permi� for. tbe,-erectioa of aay aoa•�ireproof
building, other thaa a�ara�e, wa�e�ouse,`factary or'�rain elevator, or
any aoa-fireproof add3tion, for e3milar occupancy, to any euiating building - ,
permit $1.00 for each one thousand cubic feet.
, . � .. .
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_. � .
GARAGES- ,. �. . __ _.. __, _:.__.. . _. � __ ---
—_
��2.4-. --�'o� any auch permit for the e�rec�ion of aay non»fireproof garage,
warehouse, fact�ry or �rain �levator, or for the erection of any nan-fire-proof
additicac�,� foi sYmilar occupancq, ta any- e��sting buildisg ar for each°-such � .- -
building ar addition - a9.nety cents ($0.90) for each one thous.and cubic feet
or fractio� �he�ea€, in tihe cubicg� coateats tlie=eof with the miaimuan of $4.04.
For �the -purpose- of eamsputfn$ fees for `buil°ding- �permits, the cubical contenCs
of any buildiag or addition to a uniform height throughout by multiplying the . -
8rouud-- a�ea-eover-ed-€rom a� point s#x (-6)-- ft�c�hea balow the floar 2ine of the
basement or cellar to the average h�fght of the upper surface or to the average
height of tbe roaf surface of the maia gable of a pit�hed roc�f.
2_ 5. For :repa�:rs or �alterations to an esisting ets�}cture, the fec� ah,ell _
be at the rat�'of $3:00 per�ea�h Pive'Hundred Do2lar.e.�$500.00} or 'frEC4i�n ..
thereof ia �t�e'' cost of a11 proposed work. �
2.6. In no case �ha11 the fee charged for any permit as set forth in
Section 2 be lesa than $4.00.
..
. ._ _ . _..__..___... ,__ ,__ . �_ � _.. - -_ _ - - - .
s - .
STOIiM RBPAIR DAAqAGE FEES : - . . _ . . � _,
Residential t 13sti�aated Cost of work up t� S,�A, i?0 - S i. na
Eatimated Coat of wos:� e���r ;::� �:�t_�;il > j::;,,{y0
_ Ccmm►ercial; EstimBted�'^�et of. �s:��• ic u; ^"} �;1?'�� S i,t'� -,^?i,��
', Estimated rJ3t of wor�C over $5�'L+. Jt1 -$�U..,J ,
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sua�ecr PERIVI
City of Fridley �-- 7 4 2'`
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T �
r
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� • COMMUNITY DEVELOPMENT DIV.
� ��.-------� � ���I!
r � � PROTECTIVE INSPECT�ON SEC.
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� �'���1 � CITY HALL FRIDLEY 85432 NUMBER REV. DATE PAGE OF APPROVED BV
�'----� • •�� 612-571-3450 9t 0-F15. 3/19/84 / /
JOB ADDRESS �866 AYden Way N, E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACH€D
DESCR. j rj P�c1r30II� $ Cra:i.gway Fostates ZI3C1 SHEET
2 PROPERTY OWNER MAIL ADDRESS 21P PHONE'
Ron I�oaey 7866 Alden Way N.E.
3 CONTRACTOR MAILAODRESS ZIP PHONE LICENSENO.
3telle Construction 3941 - 10th Avernie South MPIs. I�9N 55407 82 -7 7
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
B USE OF BUILDINCi
Residential
7 CLASS OF WORK
❑ NEW O ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X X
8 OESCRIBE WORK
Construct a 15' x 14` Addition a 1' x 14' Deck d a 21' 1'
Alterati.ons to exi.sting bathrooans
9 CHANGEQFUSEFROM TO
�':..STIPULATIONS See notations on plan.
, i�� SEP�RATE F'ERMITS REQCItR�'t� Fp�► ����p��;
�i�R�1 �F�aTtr��. P�.�jn���Nr., a�� ��r�v�
8��� � cau bcal uti�itio�
���p� - ELECTRIC - GAS �t�.
REC��J�RE� �Y L�V�I
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, �PE OF CONBT. OCCUPANCY (iPOUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. F7.
AUTHORIZED IS NOT COMMENCED WITHIN 80 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 �- 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 SPECIfIEO HEREIN OR NOT. THE GRANTING OF A PERMIT $38►OOO �S`�.9.00
DOES NOT PRESUME TO (iIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMITFEE SACCHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW RE(iULATINO CON-
TRU TION OR THE PERF RMAN CONSTAUCTIO . $229. UO
PLAN CHECK FEE TOTAL FEE
� � $ 57.25 � $305.25
SIGNATUREOFCONTRACTORORAUTHORIZEDA6ENT IDATEI WHEN-PROPERL VALIDATED THIS IS YOUR PERMIT�
SIGNATUREOFOWNERtIFOWNERBUILDERI IDATEI r� `~ BLDG WSP �qA F�
• Effective Aug. 1, 1981
CITY or fltlOtCY
I�PPLIW1TIa1 f0(t RCSIDCf�TIR� Bl�1LDIf:G PL(v�iITS
tl�ch�, Alterations, ,Additions, or Repairs)
Ob�NER: �_01� �'bs�� �BUILDER: �P�I.r� �l4 ��� �
ADJRESS: ADDitCSS: `�-�,� 1 1 D���NL°S° J�J� �"(� ��
TEL A0: TEL 120: ��'7, �%� Z
Construction Location
STJi1�T NO : � S�� STJtEF.T:
i,o�': �_ si.oac: '�
1
�niTiot, : C 3-v'S � l�S �� �. Z
Cozner Lot: �_ Insiile Ipt: _ Sctback: Sideyards:
Ap�liclnt attach to tl�is form 4.�o Certificates of Survey of lot and
pzoposed building locatian drawn on certificates to scale.
DESCRIPTIO�� OF CO��.STF�.ICTIOr�
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�`{' t� ��� -��' _ Fzont: t� � DePth: 1 Height:
�V r�-'�► ��"� po�"' � Squarc i'eet: Gibic Feet:
-4 (� ObfL 9 `� �IC �A L� '. .
.`��, . Front: �,_ Depth: i� Neight: �I�p'i
� :. _: '��: Square Fe�t: Cvbic Feet:
���o� ��-������s ���aQ .
� ��;� � a�
'a'ype of Cor,�.tructio� : �� C6 ��d'o'� ` Estimated Cost: S � �Q �
Rb Be mr.�pleted: �� �OS�
Alt. A Alt. 8
Propos�d Orive��ay tiidth If New Opening Is Desired: $ S
Q
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SE� P%VF:R;L•' SIDE OF SiIEET ,
9i�e ursdersiancd hereby ma):c:a applictticn foz � pernit fcr the �:ozk heyein specified,
agrcein� ta �o .all �ork i:� striet accord.�nce with the Ci�y of Tridley Ozdin�nces e�id
sulin�� of the De�k�rtm�t. of Dui2c]ings, and hereby decl�zes that all tl�c• facts and
repr�sr��itiens stated � this appl.ic.�tion azE true and co�re�t.
o.��: � b sic�rnlv� :
Stil�ulatio»s :
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?he Chief Buildir�g Olficisl sDall� before issuiag permits for the erection
oP any building or atructure� or for any addition to any ezisting building
or atructure or tor any alteratioa or repairs to aay existing building or
structure�,upoa�application Lherelore� require t6e payment Dy tbe
spplicant for auch pe�it of fees to tbe amount herein below set lortb and
ia tbe manner hereia provided to-vit: �
Sotal Valuation 0
=1.00 to =500.00
=501 to �2,000.00
=2�001 � t0 ��25,000
`=25�001 to =50�000
Fees
=10.OQ (Miaimum �15.00)
=10.00 for the lirst �500 plus �1.50
!or each add�tional a100 or fraction
tbereof� to and iacluding a2�000 '
=32•50 for tDe first a2�000 plus a6.00
tcr each additional �1,000 or fraction
thereof� to and iacludiag a25,000
=170.50 for tbe firat =25 � 000 plus
=4•50 for each additional �1�000 or
Praction thereof� to and including
i50�000
�50�001 to =100�000 =283.00 for the first �50 � 000 plus
=3.00 for eacb additional �1�000 or
fraction thereof� to aad including
;100.000
=100�001 and up =433.00 for Lbe first �100,000 plus
=2•50 for each additional �1,000 or
• traction tbereof
plan Check: 25 �rcent of building permit fee.
Drivevay Depres�ion Escrov: Concrete curb atreeLs only.
Alternate •A": Aemoval aad replacement cf curb and gutter oaly -
Driveway vidt6 plus 6 feet times =13.50
, Alteraate •B": Removal aad replacement of c urb and gutter and
iastall a 3 foot Wide approach Wstn 6 iach depth - Drivexay t+idth
plus 6 feet times =15.75
� 9erifiaation Of Foundat on
permita for construotioa rill be issued a minimum ot 2� hours from the
time of application to allow Por proper revisW of tbe proposed structure
aad of tbe construction aite. �
A Certificate of Survey of tbe lot� ehowing the location ot Lhe toundatioa
once it has Deen Qonstructed vill be required before croeeedina vith the
Praming.
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-- En9ineers E Surve�/ors —
G87S-N� �ts u.E.
— Mim�ewla
.fliist/4-�065
cetti�scate o� sszssre �o: ',��►�A! F1' �o�slr�c�;or �o.
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-- ANOKA CouNTY --
/�v�edrJ cerii�'y 11�of �rs �'s o hr�s ord mrrtcf npvrssn%/'ion o�'a .sr�t, �'iL�.► �w�d�s �'l16r a6n,r oLsu+ibrd larnd,ad
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�-� � SUB uRBAN ENG/N R/NG , laC.
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sue�eCr � ERMIT N .
City of Fridley 2 9 9 28
�
AT TFIE TOP OF TNE TWINS � � I L D 1 N G P E R M I T
' � COMMUNITY DEVELOPMENT OIV. , /'� �.,0�
r � L � PROTECTIVE INSPECTiQN SEC. ���• �J
� _ ,
� �'�'1 � CITY NAII FRIOLEY 5�32 NUM�EF pEV DATE PAGE Oi APPROVHO Br
�----� • •,, 612-57�-3460 s�aF�s 7/23/99 / /
�oe aooaess 7g66 Alden Way ATB
t LEGAL �OT NO. dLOCK TRACT OR Ab01TION SEE ATTACNED
oesca. 1 5 Pearson's Craigway Estates, 2nd SNEET
2 PROPERTY OWNER MAIL q10DQ�$$ ZIP PMONE
Ron Losey
3 CONTRACTOR MAIL ADORESS Z�P PMONE LICENSE NO
B� B Roofing 6760 A9adison St. Fridle MN 55432 571-0248 9042
d ARCMITECT OR DESIGNEp MA1 AODRE88 IIP PMONE LlCENSE NO.
S ENGINEER MAII AOpRE$8 . ZIP PMONE IICENSE NO
8 USE Of BUILOINd
Residential
7 CLASSOFWORK � N� O AODITION O ALTERATIpN � pEPAIR O MOVE O REMOVE
8 OESCRIBE WORK
9 CHANdE Of USE FROM TO �
STIPULATIONS
Underlayment must comply with the State Buildi.ng Code.
SEPARATE PERMITS ARE REOUIREO POR ELECTRICAL, PIUMBiNG, MEATING, �P� �F CdNST. OCCUPANCY dROUP OCCUPANCV LOAO
VENTIIATING OR AIR CONDITIONIN<3.
THIS PERMIT BECOMES NULL ANO VOIO iF WORK OR CpNSTRU�TION 20NING SO. fT CU FT.
AUTHOp12ED IS NOT COMMENCED V�fITHIM 80 OAY9. OR IF CONSTRUCTION
ON WORK IS SUSPENOED OR ABANDONEO fOR A PERIOD OF 1T0 DAYS AT
ANY TIME AFTER WOqK IS COMMENCED. NO. DW4Ca. UNITS OfFSTREET PARKING
I HEREBY CERTIfY TMAT I NAVE REAO AND �XAMIN�O THIS APPLICATION STAILS GARAGES
AND KNOW THE SAME TO 8E TRUE ANO CORREC7. ALL PROVISIONS OF LAWB p�UATION SURTAX
AND OROINANCES GOVERNING THIS TYPE OF WpRK WILL �E COMP�IEO
WITH WMETMER SPECIFIED NEREIN OR NOT. TNE tiRANTING OF A PERMIT �2797 .��-.�'O
DOES N07 PRESUME TO GIVE AUTMORITY TO VIOLATE OR CANCEL TME pEiiMIT fEE SAC CMARGE
PF NS OF ANY OTHER STATE OR LOCAL LAW REGULATIN�i CON•
S UC ON OR THE P FOfiMANC OF CONSTRUCTION �53.25 Fire $2. $U
PLAN CNECK fEE TOTA� F E
� ��� � License .00 9 :45
S�GN UpE OF CQN'NACTOp ON AUTMOp�2ED OGENT i0�t � p PE k. IOATE �S Up i�
/
S�GNATUAE O� OWNEpn� OriNEpBWLOEp� � i AT�t g�pG gp � OaTE
NE�V [ ] �
ADDN
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[l
Il
Construction Addre;
Legal Description:
Effective 5/10/99
CITY OF FRIDLEY Q �
SINGLE FANIILY AND DUPLEXES R 1 AND R 2 /� �
BTJII..DING PERMIT APPLICATION "t� �
�� ��
Owner Name & Address: K 0 /V �. � .� � � Tel. #
Contractor: � �� /�C�� /fi�° MN LICENSE # �U �o°�-
Address: �o�� �i%�i9�%�/—�'Jyl � / Tel. # � �/—'t�� �
� ,
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVING AREA:
GARAGE AREA:
DECB AREA:
01'HER:
DESCRIPTION OF IlVIPROy�:MENT
Length Width Height
Length Width Height
Length Width Hgt/Ground
Sq. Ft.
Sq. Ft.
Sq. Ft.
Construction Ty�: ��� ,�t�L/�"-G �� Estimated Cost: $ � l` l
IIriveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$ �
DATE: `�� �'� APPLICANT: �/� S� `J' i/%��L Tel. #,5 7��00�5��
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
5ewer Main Charge
TOTAL
STIPULATIONS:
$ 3. as
$ �tvU
$ /, D
$ �
$ S soU
$
$
$
$
, �.,.,.
$
CI1'Y USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth%)
$.50/$1,000 Valuation �
$1050 �r SAC Unit
$s.00 (state Licensed Residential contractors)
Alt. "A" or Alt. "B" Above
$450.� Conservation Plan Review
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
�. , „
BUII.DING PERMIT FEE SCHEDULE
The Chief Building Official shall, before issuing permits for the erection of any building or structure, or for any
addition to any e�tisting 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 $5�
$501 to $2,000
$2,001 to $25,000
$25,001 to $50,�
$50,001 to $100,(m0
$100,001 to $500,000
$500,�1 to $1,000,000
$1,000,�1 and up
FEES
$23.50
$23.50 for first $5(m plus $3.05 for each additional $1(?0 or
fraction thereof, to and including $2,000
$69.25 for first $2,000 plus $14.00 for each additional $1,000
or fraction thereof, to and including $25,000
$391.25 for first $25,000 plus $10.10 for each additional $1,�
or fraction thereof, to and including $50,0�
$643.75 for first $50,(m0 plus $7.00 for each additional
$1,000 or fraction thereof, to and including $100,000
$993.75 for first $100,000 plus $5.60 for each additional
$1,(�0 or fraction thereof, to and including $500,0�
$3,233.75 for the first $500,000 plus $4.75 for each additional
$1,000 or fraction thereof, to and including $1,000,�
$5,608.75 for the first $1,(�0,000 plus $3.15 for each additional
$1,000 or fracdon thereof
DRIVEWAY DEPRESSION ESCROW
(Concrete Curb Streets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $15.50.
Alternate "B": Removal and replacement of curb and gutter and install a 3 faot wide
approach with 6 inch depth - Driveway width plus 6 feet times $23.25.
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum, of 24 hours from the time of application to allow for proper
review of the proposed st�ucture and of the construction site.
A Certificate of S�uvey of the lot, showing the location of the foundation once it has it has be�n co�cted will
be required before proceeding with the framing.
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FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT. VENT CONNECTOR AND COMBUSTIOPI AIR VERIFICATION
When reqlacin� an existins� fumace, the undersigned hereby verifies that the
venting has been examined and is free from nast, deterioration, obstn�ctions,
and is securely supported and firestopped where required. Yes () No ()
The venting system is plastic/PVC and meets all current codes and manufacturer
specfications including sizing, length, number of elbowrs and termination. Yes () No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances. �
The existin� combustion air is siz� and installed to meet the curren# codes
and manufacturer's specfications.
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacturers specifications.
Yes ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
When installin�a a new ventina svstem, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specfications. This does include AGA GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances. Yes ()
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.
No ( )
Yes ( ) No ( )
Apaliance Tvae and Size/Comrnon 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 Tatal 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 CO:
Signed By: Date :
PLUM�IlV�
�ES���Nr�� a�p�,icar�aN
�ity of Fr�t�ley
n�orE: iF PROP��r�r rs Nor
nwre a - ac - �,
snE��g'GrG� /f
tHe n�ucavr �s: �ct� o�+tt�
�op�rr c��t
T�NANT
��
�a 7�;��
A LIt�NBED CONTRACTOR M118T OBYAIAI THE pERMIT.
irouR �-�u�. �noaESs
- - - -_- ,.,
ovv�t
�7'O ff/V
. - �.
�N�
naoRF� � tv (�+ �t[� �7✓ lrt/
CI'IY STATE
P'HONE �
NAAiB .
C�INTRACTOR MDIi�
crrv,_
PHONE
PERMff TYPH
TYPE OF NtORK � f] N6W
t�e�/ �`-N -�#
� '�i�� �
��i,c.�s
?/ � t�
F��tv
�
LICBN$� p
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�1TATE�/V �a ��"�{O ']
Fax� / - 7�/ -8U y i
FAIAILY
� R�?L.AC6AAEMF
D�TAILED DEBCRtPTWN OF WORK F7./�/�i��'��� � t/Y�.Tj�LEQ L�U f Ar�i,. /Y/¢ /f
� �V/4 �/p.. �
FEES ARE BA�S@D ON =�{O.QO PER Fl7CY1fRE� f7C(�PT WNERB NQ'tED
pDtT1JRE$: QNDICAI'6 TOTAL NU�ABE� QF FAG1f}
BATH �INK/LAV FLOOR DEtNNS $HOWER WAT�R PIPING
_ B/ITHTLJS GA�S P'tRIN3 (Ne9d Cily LIC8t1se) _„SWIMMWG POOL — WATER SOFTENEI� (S35f
CLQ7'F1ES WASHER IQTCFiHN SINMC WATLR GLQBE� BIICKPLdW PRkV. is73i
DISi�WABFIER L/WNDRY TRAY �,,,WATER HTR (�j FOR IR(tIGA'ilOtN
WATEa �l6R 0'tH�R
Perr�lt Fee
Ptan Revlew
�urch�rg�
TOTAL DUE
S .3�.�,lJU
x
5
�
� - .��
WIiP11MUM: $15.00 ar 8�0 of cost ot the improveme�rt.whichave� le�
grsater an work les� than $300
Make chaClcs payable tc�: City of F�#dl�ay
�-.vr� � wn rrn A reRA� �— ryV a YALIU {�� t IL f�KUGC��'i�D —
� �+�I► �r � e p�� �►rsage n,s� fh9 (nfom�anor► at�ve E� c�mp,ete and soa,r�te: u,ac n�e,�k �qn r�e in eonu�n„e„ce wifh
tl�e a�nanoes and aod� a� tl+e City �` FrtdlE�y and w1�1 tl�e Mi�r�Ea Ca�sirucfMn Codeg: th8t I under.�t�! tld5 � not e permit 6ut �ly an
3pplie�on (or a pPam[# and work is not ta 83art Y�hOUt e pemd� th8t t�e w'id be ir1 ac�rdan� wi�l C�e appr�OVea plan � fhe caae ot+ap work wMch
r�wt� r�► �,a aap� ��. .�RM S r�iv6�
���� oA,�_�-�-a�
3�GNATURE OF
643t uN1V�$tN AVBNUE NE. F'R(L►LEIf. � 53432
R83f !i�-980�
Building
In.spections
763-572-3604
SITE ADDRESS ,_
1TiI5 APPLICANt IS:
PROPERTY
OWNER�
7: ENAIVT
CpNTRACTOR
SUgMIT A COPY OF
YOUR STATE
LICENSE WIT'H
APPLICAT'ION
PERMIT TYPE
�rYrE oF woxx:
t•
MECHANICA.L
gESmEN'I`TAT APPLICATION
CI'T� C1F FRIDLE�
� � YOUR E-MAIL ADDRESS
!�(P I e t'`'�-
0 OWNER �CO CfOR
^
PHONE: %�0 3' +-�' � �� � a'� �
CAMP'A2•1TY 13AA'�:�
CUNTAGT PFRSON: d6a Fin
STATE LiCF.�SE � UCens9
PHONE
�INGLE FAA�.Y ❑ TWO FAMILY
�t�w ❑ �uc�r
DETpII,ED DBSCRIPTTOAI OF WORK
Permit
Received By:
_
STATE ZIP,
�_ EXP DATE
( CITy S
FAX
,
D TOWIdI-10USE
o �,nowxr�onn.
� l .�� � F•^,eP��� c.-e
pER MS 16B.665 the p�rmit fee is a minimnm of $1�.00 or �% of the totaf cost np to SS00.00, whichever is gre�.ter, for the
unprov�nent, installation or r�placement of a residential fixture, excluding the fnctures. (This shonld reflect anly the cost of labor )
Labar cost under $3� _$15.00. I.abor cost hstw�n $300 to $S00 � cost of labor x.OS °
FOR PRO)EG'TS WF�RE IABOR EXCEEDS 5500. FEFS ARE BASID ON $ IO.� PER FIXTURE� EXCEPT WHERE NOTED. FDCTURF•S: (INDICATE TOTAL
r�B� oF Eacx B�a.ov� � e,� a�-�e x T s�Bru 3� v�''r-'
Equipment installed , MFG: i'r'e t� �- °� L I n MODEL: g�g/gTU
�: �_ MODEL: SD�/B,I,V
k1FG: MODE1.:
NC 525.00 �LACE (GAS) $15.� GA5 RANGEIOYEN 510.�
AIR TO AIlt EXCHANC�EER $15 FIR�PIACE (WOOD) $35.00 TiEW GAS GRILL $10.�
BOII.ER $35.00 • _FURNACE 535.00 GA5 UNTf H'1'R $10.�
CI-IDv�IEY L1NER $lO.OD GA5 DRYER $10.� P�L HFA1'ER $35.00
DUCT WORK $IQ00 _ =GAS PIPING SI0.00 VE1�TII..ATOR 515.00
Pemut Fee $ Number of f xtures @$10.00 � x$1 Q.00 =$�
Surcharge $ .50 Number of fuch�res @$15.00 �, x$15.Q0 = S_�1_____
TOTAL DUE $ Number of fixtures @$25.00 x$25.00 =$
Number of fixtures ([� $35.� x $35.00 = $
State Surcharge � $ .50
Tota] _ $�
'�IIS LT AI•i AppLICATION FOR A PERNRT NOT VALID UNTII. PROL'ESSF.D
I hereby apply for a building �rmit 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 Mfr�nesota {;onstruction Codes; that T undershand this is
nat a permit but only aa application for a permit and work is not to start without a permit; that the work wiII be in accordance with the
approved plan in the case of aIl work which requires review and appro��al of plans.
SIGNATURE OF APPLICANT
- ��,sC � PR1NT NAME /�t°✓ � �, ��r 3 � i � DATE � � �
City of Fridley
Building Inspections Department .
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
•.-
REQUIRED INFORMATION NEEDED TO PROCESS PERMIT
p � � � RESIDENTIAL PERMIT APPUCAT{ON tiVAC
❑ NEW HOt�ESIADD{�'IONS ❑ EXtSTING HOME ❑ ���-UP �R
REQUIRED FOR NEWlEXISTING HORIfES ,��� �M �, t
1.
z.
•ei8a��� ;,.
Combusti.on Air (See note below) •.�1��� N ca.,
a,. Oil ar s�olid fuel ]MC Cha�iez' 7 wifh MN Am�e� � �rga
b. Nafiu a1 Gas or Propan�GC Cha�ter 3 with MN Amendmenrs '
Ma�e up Air (See note below)
�, nvlc cc�� s �.� �t ��.am.�
3. V�.g
� Cas appli.ancss IFGC Gha�ter 5 with RgN �mendm�s
' b. Fu.�I oi�.ear th.aa gas IMC Ch�pfer 8 with MN Amendm.enl�
REQUIRED FOR NEW HOI�flES
r.
4. Heai loss & cooling load per room
� gequired on ne�v conshuction IlVlC 1346.03 I2
5. Ventilafiion .
a, per MN Energy Code 76'�0 or 7672
;
6. Duct Design Per TA�IC 1346.0603.2
a. AC�CA Maxwal D
NO'I'�: Centerpoivat Energ� Mecha.nical Code Guidelines soffware may be nsed for �
_ .
comb�'usiion aiad make up air calculahons .:
; .
0