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,t�e }a�ldin� ` : � �a' � _ sleaeribed�ia tise-.alxive atatemen� -'t� per�iti #s �rante�l .°
� upcin _xhe e�press coacli�iaa that the pe�eson to �vhom it is -�ted; and hls agent� emgloyees ..a�nd wor�n� in a11 ,,
�. tixe work done in, aa�onnd amd upon eaid i�iildin�, Qr �n9 Pas°� �iaereiaf� �a11 con:Porm; ix�, a11 reape+cta to ihe Q�ti
.� n�cces af .F'rid%y, �inn� regasding tl� csoastructiori� alt�raf3on, mai�tenanc�e, �repa� ana �zavin� of- but�s'iings ": _ -
, � �vith�i. t't� etty "umtts; a�#a this� p�rmit s�a�r �e revogea a,t aay "iirrie upon vio]�,faton, of aay. ar tlie' provtsiana oP �ata :
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-. In co�ta.ider�.tion �� fihe i�sue��d �leliver3r to' me by �he Inspe+etor of` �uilldia�s of Fridley of �
t�e above l�ermit, � hereby agree to do. �Tie prog�sed �►ork in �,ccordance �th �he ; descript�n .
abov� sei forth �nd aecord'nag. �o t'�e provisions of the ordin�:nces of Fricll.ey, as�d., b�in� fir� dtily ; '
aworn, . I;�ex eby state a�d say. �at :the fact� s��ed by.' mE a�d eo��ecl � t.he abov� ge�it are - ��
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CHIMNEY AND STACK V$RIFICATION
The undersigned hereby verifies that the existing chimney or stack:
l. Has been carefully examined Yes (� No ()
2. Is free from rust or deterioration Yes (�j No ( j
3. Has no foreign objects lodged within Yes (� No ()
4. Is securely supported Yes (�) No ()
5. Meets all current Code requirements for
size and total BTU's connected Yes (� No ()
6. �ias total hea�ir�g -$Tii's of @9 � � - .
_ All other BTII' s 7�� W� � �
TOTAL BTII' s ! �� . �� .
I,ist Alterations Beinq Done:
HEATING COMPANY
Signed By
Date
0
HOUSE HEATING TEST' RECORD
�� P � � f '� � ' � ^'- . P j
ADDRESS ��"�r' �,� !.�����'`���-'( �-'��� ��°�'� APT..—��FLOOR CITY SUBURB `' i�;`���ft'�
OCCUPANT � � OWNER � ' f�'�"��'-�� "�� � ''�'�`-
HEAT LOS�, `' f �'F � DATE HT4G. INST. `-" ' f�'� r
SaLD BY� r ��'� �� �s..�+�11;�� �l �.6�i6-i � lj =�° ` ' ,�..L '_-�`�--''`�� INSTALIEDa$Y --� �t�i,�"i,� .
Elsct►icol Work By �� Goa Lins`B�r��s�'/9°���+
TYPE OF HEAT GA —_ FA T�HW STEAM SPACE HTR. UNIT HTR. OTFtER .,
° GAS DESIGN CONVERSION. �
MAKE .���' � '-� �� ~ .MAKE OF BURNER �
Model ,c ��. �� � �``� `� �� �`� � F%� f �% Modsl
Ssrial � �' �" � �^"���� -`� � �� Maz. BTU Rating
INPUT � �"�' " � � � ' MAKE OF FURNACE �
Model
�CONTROLS
%� ,� /�
THERMOSTK "�� Heat Plug Vsnt Sise
��� ��,' ° � � �
Vclvs � KIND OF IINER '� "��� SIZE � NONE
Limit � � �F Oraft Hood ��'�"�-���.�?-�" � Reqularor �'�
Limit Setting � Filters Si:e ��..c.`�-,� �Tlumbsr �
Fcn Setting 9 `�" Chimnsy Loeation � sids - r.� _ Outaids
Pilot Type �`' '�/�� � � -� Q�imney Construetion ������' "�'�y ,T
Pilot Moke �'���=''��. ;r�✓
a i
PilotModel _��`������r«''�'�'�' _ $mokeBomb �` Wiring �
Pilot Timing ` ��', ' ^`Draft �� �Test Tag l``
L.W, Cut Off , Door Pressure � Lightiny Inst. �
.�-
Prossure � �� Pereent CO� �� Dats Tsstsd �+ r• ��`
� �.
input CFH '",� �'�:�• Peresnt OZ_� Company Tesfing ..�s"'�� ��
Stack Temp. �°� Paresnt CO N Nams oF Tester °: �°
Form 235
sua�ecT PE : -_
City of Fridley � 9 5 4 0�
AT THE TOP OF TME TW�NS g � I L D I N G P E R M I T
r
; � RECEIPT NO.
� `y � COMMUNITY OEVELOPMENT OIV. ���
r � � PFiOTECTIVE INSPECTION SEC.
� j �
� /"'1 � CITY NALI FRIOLE� SS�,i NUMBEF pEV OATE VAGE Oi AVpROVEO BY
�°�'� � �'' bt2—s��-3450 s�aF�s 5/24�'99 / /
JOB ADDRESS 6611 Ar•thur Street NE
1 LEGAL �OT NO. BLOCK TRACT OR ADOITION SEE ATTACHED
DESCIi. 1( 17 1H 3 ak r dd� 1 SMEET
2 PROPERTY OWNEF MAIL ADDRES$ 21P PMONE
Gwen Ha en
3 CONTRACTOR MAIL ADDRESS 21P PMONE LICENSE NO
Premium R���fx oo i -
d ARC►11TECT OR DESIGNER MAIL AOOqESS ZIP PMONE LICENSE NO.
S ENGINEER MAII ADDRE33 2�P PMONE LICENSE NO
8 USE OF BUILDING
Res�dential
7 CIASS OF WORK
� NEW O ADDITION O ALTERATION � REPAIR ❑ MOVE O REMOVE
8 DESCRIBE WOEiK
Reroof house (13 S ) Tear-off
9 CNAN(3E OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
TYPE OF CONST OCCUPANCY GROUP OCCUPANCV LOAD
SEPARATE PERMITSARE REOUIRED FOii ELECTRICAL. PLUMBING. HEATING.
VENTILATING OR AIR CONDITIONING
THIS PERMIT BECOMES NULL AND VOIO IF WORK OR CONSTRUCTION 20NING SO. FT CU FT.
AUTHOR12ED IS NOT COMMENCED WITHIN �0 DAYS. OF IF CONSTRUCTION
OR WOiiK IS SUSPENOED OR ABANOONED FOR A PERIOD OF 120 DAYS AT
ANV TIME AFTER WORK IS COMMENCED. NO DWLG. UNITS OFiSTREET PARK�NG
I MEREBY CERTIFY TNAT I MAVE FEAD AND EXAMINEO TMIS APPLICA710N STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING TNIS TYPE OF WORK WILL BE COMPLIED C111(i �.56
WITH WHE7HER SPECIFIED MEiiEIN OF NOT. TNE GRANTING OF A PERMIT 'P
OOES NOT PRESUME TO GIVE AUTMORITY TO VIOLATE Ofi CANCEL THE pEpM17 fEE SAC CMAFGE
PROV�SIONS OF ANY OTMER STATE OR LOCAL LAW REGUTATING CON- d�(�p . HJ F� e SC � 1. 11
STRUCTION OR THE PERFORM NCE OF CONSTRUCTION .D �+
PLAN CMECK FEE T TA� FEE
� ;�y'ej Lice C $5.0 51.52
S�GNATUAEOFCON'FACTOpOpeUTMORiZEDAGENT �O�iE� HE P Y VALI D TMIS 1� PERMIT
� V
S�GN4TUAE O� OWNEA��F OWNEABWLDEAi �D�iEi B G�NS� f��if
�[ ]
ADDN [ ]
�,�R Il
Effective 5/10/99
CITY OF FRIDLEY
SINGLE FAMII.Y AND DUPLEXES R-1 AND R-2
�
V)
BUII.DING PERNIIT APPLICATION �►� ��
� 0
Construction Address: L��� �¢'t,[(Ur�- Sr �
�
Legal Description: /Rp� /_ //�(�
Owner Name & Address: ��a��� � �l-�►��� Tel. #
Contractor: �/r'��/t����sv� /��i yI/lJ� MN LICENSE # �Q°/%�
Address: �o���(� �G�G I J4 G �, / T � ,S S �� Tel. # � �l -.�°f 7.3
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTI�R:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
I.ength
Length
Length
DESCRIPTION OF IMPROVEMENT
Width Heighf _
Width Height
Width Hgt/Ground
Sq. �t.
Sq. Ft.
Sq. Ft.
e
�( / b
Construction Type:���� ���� ���'�� Estimated Cost: $
Driveway C�rb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: �S ° � APPLICANT: ����.v ����G� Tel. #� %%' � ��
Permit Fee
Fire Surcharge
State S�rcharge
SAC Charge
License Surcharge
Driveway Fscrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
$ �� ��
$ �ll
$ �o
$
$ ���d`!�
$
$
$
$
$ �l-.�"�`-
CITY USE ONLY
Fee Sched'ule on Reverse Side
001 of Permit Valuation (1/lOth%)
$.50/$1,000 Valuation
$1050 per SAC Unit
$5.00 (State Licensed Residenti�l Contractors)
Alt. "A" or Alt. "B" Above
$450.00 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 erecrion of any building or structure, ox for any
addidon to any existing building or structure, or for any alteradon or repair to any existing building or structuge9
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 $25,000
$25,�1 to $50,000
$50,�1 to $100,000
$100,�1 to $500,000
$500,001 to $1,OOD,000
$1,000,001 and up
FEES
$23.50
$23.50 for first $500 plus $3.05 for each additional $100 or
fraction thereof, to and including $2,00�
$69.25 for first $2,000 �lus $14. � 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 $1,000
or fraction thereof, to and including $50,000
$643.75 for first $50,000 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
$1,000 or fraction thereof, to and including $500,000
$3,233.75 for the first $500,000 plus $4.75 for each additional
$1,000 or fraction thereof, to and including $1, 000, 000
$5,608.75 for the first $1,000,000 plus $3.15 for each additional
$1,000 or fraction 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 foot 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 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 co��c�l will
� be required before proceeding with the framing.