AF - 36105Village of Fridley, 1Vlinn.
BUILDING P�RNdIT
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Date: ..�. . .. ... .... ....
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Owner . � .�� . .�� �c�"�'
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Address . . ;� !�° '� . . . .�G��� �:�: .�."�.`�
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�i° 1655
Buiider............� ...........................:......
Address.............................. ............
� L .�C [O�,N pF BUILDING
No. �. �. :�� . . Street . . . . . ��. . .�. �� . . . . . .�.�. :`. . . . . . . . Part of Lot . .�. . . . . . . . . . . . . . . . . . . .
� . .`l�J�-�? .�9�rv�.r. . . . . . .
Lot . .. . . .. .. .. .. . Block . .. .. ... . .. .. . Addition or Sub-Division .
Corner Lot .... ..... Inside Lot .. �.... Setback ........... Sideyaxd .............................
DES,� R[P 10�1 OF �,UILDI�aiG "'
To be Used ,�s: �"� �t' � +� : �9.r� .�rc #� ��z'.�,z'.�°' � ,,.;�'�� �'�'� �
�� �� . . . . . . Front . . . . . . . . Depth . . . . . . . Height . . . . . . Sq. Ft. . . . . . . . . Cu. Ft. . . . . . . . .
.............. . .... Front ........ Depth ........ Height .... . Sq. Ft. ........ Cu. Ft ........
Type of Construction .................. Est Cost ..................... To be Completed ..................
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on de n. of the is�uance to me of a permit to construct the building described above, I agree to do
th roposed work in accordance with the descriptian above set forth and in compliance with all provisions of
ordinances of the village of Fridley.
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Tn considerafaon of the payment of a fee of $. :� ......., permit is hereby granted to .'�°F:�� .. .
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. . . . . . . . . . .. . . . . . . to construct the building or addition as described above. This permit is granted upon
the express condition that the person to whom it is granted and his agents, em.ployees and worl�nen, in all work
done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of bwllaings with-
in the village limiis and this permit may be revokecl at any time upon violation of any of the provisions of said
ordinances.
� : .�.�. . . .� � . Building Inspector
.. ����i .• .��..•
NOiBGE:
7his permit does not cover the constructian, installation or aiteration for wiring, plumbing, gas heating,
sewer or wafier. Be sure to see �,Building Inspector for separate permits for,�,se items.
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CIIYOF
FR[DLE,Y
FRIDLEY MUr1ICIPAL CENTER • 6431 UTIIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287
May 6, 2002
Donald Nelson
5971 Central Avenue NE
Fridley MN 55432
Re: Paved Driveways
Dear Mr. Nelson:
In 1997, the City Council adopted an ordinance declaring gravel driveways a public nuisance.
They were declared a public nuisance for a number of reasons, such as: they can cause
erosion, contaminate soil with oil and other vehicles fluids, and deposit soil and gravel in the
City's storm sewers and detention ponds. When gravel driveways were declared a public
nuisance, the City Council gave property owners five years to have their gravel driveways
paved. The five-year deadline is quickly approaching, which means all gravel driveways within
the City of Fridley must be paved with approved concrete or asphalt by December 31, 2002.
If on December 31, 2002, your driveway hasn't been paved a citation will be issued and filed at
the Anoka County Cou�thouse. A misdemeanor citation is a criminal offense and is punishable
by up to 90 days in jail and/or a$700 fine.
If you've already paved your driveways, Thank you! Please call me at 763-572-3595, so I can
update our files.
For your convenience, a brochure on the City's loan program has been enclosed. You can use
this loan program to acquire financing for your driveway improvement project. Please call Jim
Hesnik at 612-335-2651, if you have any questions regarding this program.
Thank you for your cooperation! As you successfully complete your driveway improvement
project, please call me at 763-572-3595, so I can do an inspection of your property and update
our files. If you have any other questions, please feel free to call me at the above number.
Sincerely,
Stacy St mberg
Planner
C-02-53
_
_
CITYOF
FRiDLEY
FRIDLEY MIINICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287
May 6, 2002
Beverly Nelson
37438 Dolphin Street NW
Princeton MN 55371
Re: Paved Driveways — 5971 Central Avenue NE
Dear Ms. Nelson:
In 1997, the City Council adopted an ordinance declaring gravel driveways a pubiic nuisance.
They were declared a public nuisance for a number of reasons, such as: they can cause
erosion, contaminate soil with oil and other vehicles fluids, and deposit soil and gravel in the
City's storm sewers and detention ponds. When gravel driveways were declared a public
nuisance, the City Council gave property owners five years to have their gravel driveways
paved. The five-year deadline is quickly approaching, which means all gravel driveways within
the City of Fridley must be paved with approved concrete or asphalt by December 31, 2002.
If on December 31, 2002, your driveway hasn't been paved a citation will be issued and filed at
the Anoka County Courthouse. A misdemeanor citation is a criminal offense and is punishable
by up to 90 days in jail and/or a$700 fine.
If you've already paved your driveways, Thank you! Please call me at 763-572-3595, so I can
update our files.
For your convenience, a brochure on the City's loan program has been enclosed. You can use
this loan program to acquire financing for your driveway improvement project. Please call Jim
Hesnik at 612-335-2651, if you have any questions regarding this program.
Thank you for your cooperation! As you successfully complete your driveway improvement
project, please call me at 763-572-3595, so I can do an inspection of your property and update
ourfiles. If you have any other questions, please feel free to call me at the above number.
Sincerely,
Stacy Stromberg
Planner
C-02-53
_
_
�.1� OF
FR[DLEY
FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287
July 2, 2002
Donald Nelson
5971 Centrai Avenue NE
Fridley MN 55432 .
Subject: Paved Driveway Reminder
Dear Mr. Nelson:
This letter is a friendiy reminder that all driveways within the City of Fridley need to be paved by
December 31, 2002*.
As you are aware, the City Council adopted an ordinance declaring gravel driveways a public
nuisance. They were declared a public nuisance for a number of reasons, such as: they can
cause erosion, contaminate soil with oil and other vehicles fluids, and deposit soil and gravel in
the City's storm sewers and detention ponds. When gravel driveways were declared a public
nuisance, the City Council gave property owners five years to have their gravel driveways
paved. The five-year deadline is quickly approaching, which means all gravel driveways within
the City of Fridley must be paved with approved concrete or asphalt by December 31, 2002'`.
If you've already paved your driveways, thank you! Please call me at 763-572-3595, so I can
update our files.
For your convenience, a brochure on the City's Ioan program has been enclosed. You can use
this loan program to acquire financing for your driveway improvement project. Please call Jim
Hesnik at 612-335-2651, if you have any questions regarding this program.
Thank you for your cooperation! As you successfully complete your driveway improvement
project, please call me at 763-572-3595, so I can do an inspection of your property and update
our files. If you have any other questions, please feel free to call me at the above number.
Sincerely,
Stacy St mberg
Planner
*If on December 31, 2002, your driveway hasn't been paved a citation will be issued and filed at the Anoka County Courthouse. A
misdemeanor citation is a criminal offense and is punishable by up to 90 days in jail and/or a$700 fine.
C-02-83
_
_
CI"iYOF
FRIDLEY
FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287
July 2, 2002
Beverly Nelson
37438 Dolphin Street NW
Princeton MN 55371
Subject: Paved Driveway Reminder
Dear Ms. Nelson:
This letter is a friendly reminder that all driveways within the City of Fridley need to be paved by
December 31, 2002*.
As you are aware, the City Council adopted an ordinance declaring gravel driveways a public
nuisance. They were declared a public nuisance for a number of reasons, such as: they can
cause erosion, contaminate soil with oil and other vehicles fluids, and deposit soil and gravel in
the City's storm sewers and detention ponds. When gravel driveways were declared a public
nuisance, the City Council gave property owners five years to have their gravel driveways
paved. The five-year deadline is quickly approaching, which means all gravel driveways within
the City of Fridley must be paved with approved concrete or asphalt by December 31, 2002*.
If you've already paved your driveways, thank you! Please call me at 763-572-3595, so I can
update our files. ,
For your convenience, a brochure on the City's loan program has been enclosed. You can use
this loan program to acquire financing for your driveway improvement project. Please call Jim
Hesnik at 612-335-2651, if you have any questions regarding this program:
Thank you for your cooperation! As you successfully complete your driveway improvement
project, please call me at 763-572-3595, so I can do an inspection of your property and update
our files. If you have any other questions, please feel free to call me at the above number.
Sincerely,
Stacy St mberg
Planner
"If on December 31, 2002, your driveway hasn't been paved a citation will be issued and filed at the Anoka County Courthouse. A
misdemeanor citation is a criminal offense and is punishable by up to 90 days in jail and/or a$700 fine.
C-02-83
�
_
CITYOF
FRIDLEY
FRIDLEY NtUNICIPAL CENTER • 6�31 UNIVERSITY AVE. N.E. FRIDLEY, �IN 5�-�32 •(763) �71-3450 • FAX (763) 571-1287
December 13, 2002
Don Nelson
5971 Central Avenue NE
Fridley, MN 55432
Subject: Last & Final Paved Driveway Reminder
Dear Mr. Nelson:
This letter is your last and final reminder; all driveways within the City of Fridley need to be
paved by December 31, 2002.
As you are aware, the City Council adopted an ordinance declaring gravel driveways a public
nuisance. They were declared a public nuisance for a number of reasons, such as: they can
cause erosion, contaminate soil with oil and other vehicles fluids, and deposit soil and gravel in
the City's storm sewers and detention ponds. When gravel driveways were declared a public
nuisance, the City Council gave property owners five years to have their gravel driveways
paved. The five-year deadline is quickly approaching, which means all gravel driveways within
the City of Fridley must be paved with approved concrete or asphalt by December 31, 2002.
If you've already paved your driveways, Thank you! Please call me at 763-572-3595, so I can
update our files.
The City Council has agreed to allow an extension until June 15, 2003, to those of you who
haven't paved your driveway and/or can't get a contractor to do the project until spring. In order
to be eligible for this extension, proof of a signed contract from your concrete or asphalt
contractor stating that they will pave your gravel driveway by June 15, 2003 must be filed
at the City by December 31, 2002. You as the property owner will also be required to sign
the statement on the next page, ensuring the driveway will be paved by June 15, 2003.
Failure to do so will result in a criminal citation being issued on January 3, 2003 and filed
at Anoka Countv.
Thank you for your cooperation. If you have any other questions, please feel free to call me
763-572-3595.
Sincerely,
Stacy St mberg
Planner
C-02-150
SuB�ECT -- ,
City of Fridley 3 3 8 41 �
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
�
; � RECEIPT NO.
� • COMMUNITY DEVELOPMENT DIV.
� LV ����� � ���/
r � � PROTECTIVE INSPECTION SEC
1 ; �
� � �"'1 � CITY HALL FRIDLE� SS1JY NUMBER REV DATE VAGE OF APGqOVEO B�
�""-'� � ��� 763-571-3450 910-F15 8/29/03 / /
10B ADDRESS 5971 Central t�venue NE
t LEGAL ��7 NO. BLOCK TRACT OR AODITION SEE ATTACMEO
oesca. 9 1 Meloland Lakeview SHEET
2 PROPERTY OWNER MAIL AODFiESS 21P PHONE
Patricia Kilian 5971 Central Avenue NE 763-572-9202
3 CONTRACTOR MAIL ADDRESS ZIP PMONE LICENSE NO
Same
4 ARCHITECT OR DESIGNER MAIL ADORESS ZIP PMONE LICENSE NO
S ENGINEER MAIL ADDHESS ZIP pHONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
0 NEW ❑ ADDITION D ALTERATION � REPAIR O MOVE O REMOYE
8 DESCRIBE WORK
Reside gable ends of house; Reroof house & garage (18 Sq) tear-off; Replace all
windows wit in existing openings
9 CHANCiE Of USE FROM TO
STIPULATIONS
Per Section 1402, 1997 Uniform Building Code, requires that a weather resistive
barrier be placed over exterior sheathing to protect the interior wall covering.
Exceptions for this provision would be if sheathing is an approved weatherproof
panel or when the siding is an approved weather barrier. VinyZ siding is not
a weatherproof covering unless the manufacturer states this in their appZication
guidelines. Call for inspection of wrap before covering or take pictures. Caulk
and flash all exterior openings. Underlayment must comply with State Bldg Code.
Provide smoke detectors in alI sleeping rooms and on all levels of the dwelling
per Section 310.9.1.2 of the 1997 Uniform Building Code. Caulk and flash all
exterior openings.
SEPARATE PERMITS AFiE REOUIRED FOF ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GiiOUP OCCUPANCV LOAO
VENTILATING OR AIR CONDITIONING
TMIS PERMIT BECOMES NUIL ANO VOID IF WOFK OR CONSTRUCTION 20NING SO. F7 CU FT
AUTHOR12ED 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. UNI7S OFFSTREET PARKING
I MEREBY CEHTIFY THAT 1 HAVE READ AND EXAMINEO THIS APPLICA710N 1 STA�LS GAiiAGES
AND KNOW THE SAME TO BE TiiUE AND CORFECT. ALL PROVISIONS OF LAWS yqLUATION SURTAX
AND ORDINANCES GOVERNING THIS TVPE OF WORK WILL BE COMPLIED @
WITM WHETHER SPECIfIEO HEREIN OR NOT. THE GRANTING OF A PERMIT W1O�000 �S.00
DOES NOT PRESUME TO GIVE AUTMORITV TO VIOLATE OR CANCEL TME pERMIT FEE SAC CHARGE
PROVISIONS OF ANV OTHER STATE Oii LOCAL LAW REGULATING CON- �181.25 Fire SC �LO.00
STRUCTION OR THE PERFORMANCE OF CONSTFUC710N
PLAN CM CK FEE TOTAL FEE
F�a. e SC $N/A $196.25
S N4T E OF CON'RACTOA O nu i2ED 4GENi �D�rEi NEN PROPERLV VALIDATED THIS IS Y R PER IT
. � q �� �
S�GN4tUqEO�OWNEQ��FO EABUiIDERi iDA E� BL G ihS� r���E �
NEW
ADDN
ALTER
[] CITY OF FRIDLEY Effedive 1/1/2003
[] 6431 Unive�sity Ave NE, Fridley, MN 55432 (763) 572-3604 Bidg Insp
[] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax
BUILDING PERMIT APPLICATION
Construction Address:
Legal Description:
� � � l ���� %�'-YL /TY � /�" �
Owner Name & Address: Y'�/�f:fl� 1�-� �/� Tel. #��3 ��v�'�c�
Contractor. � CN� � MN LICENSE #
Address: Tel. #
LIVlNG AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this application, a Certificate of Survey of the
lot, vaith the proposed construction drawn on i# to. scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height
Length Width Height
Hnt/Ground
��
� �� �
S . Ft. �' �
4 ���
.
Sq. Ft
Sa. Ft. !
Constnaction Type: �� Estimated Cost: $�l�i ���
Driveway Curb Cut Width Needed: Ft. + t= Ft x$ _$
DATE: �/� ��� APPLICANT: l f Tel. #7103 � 70� �/�� �
Call (763) 572-3604 for Permit Fees if mailing in application. Fax to 763-571-1287 if using credit card and we will
call you for card number.
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
��lt�
� ����5.�
$ � � C�D
$ ,
$
$
$
$
$
$ `,
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1275 per SAC Unit
$5.00 (Stat� Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
$ l K �
�
_..
BUILDING PERMIT FEE SCHEDULE
The Chief Building O�cial 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 pernut 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
$25,001 to $50,000
$50,001 to $100,000
$100,001 to $500,000
$SOU,�1 to $1,0�,�
$1,(}00,001 and up
FEES
$23.50
$23.50 for first $500 plus $3.05 for each additional $100 or
fraction thereof, to and including $2,000
$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,Q00
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 $500,0� plus $4.75 for each adciitional
$1,000 or fraction thereof, to and including $1,000,000
$5,608.75 for the first $1,000,�0 plus $3.15 for each additional
$1, 000 or fraction thereof
CURB CUT ESCROW
(Concrete Curb Streets Only)
Removal and replacement of curb and gutter only - driveway width plus 6 feet, times the annually determined
rate.
Permits for construction will l� 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.
VERIFICATION OF FOUNDATION
A Certificate of Survey of the lot, showing the location of the existing foundation will be required before
proceeding with the framing. New Houses Onlv
�
SuB�ECT �°{� -
City of Fridley 387 �
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
�
; � CEIPT NO.
� `y �����_ COMMUNITY OEVELOPMENT DIV. `^�
r � � PiiOTECTIVE INSPECTION SEC. �6iI ��
1 ; i
� � r'�'1 � CITY NALL FRIOLEV SS��Z NUMBER REV DATE PAGE Oi APPROVED BY
�'""� � ��' 763-571-3450 910- F 15 9/ 12 / 03 / /
J08 ADDRESS 5971 Central Avenue NE
t LEGAL LOT NO. BLOCK TRACT OR ADOITION SEE ATTACMED
DESCR. 9 1 Meloland Lakeview SNEET
2 PROPERTY OWNER MAIL AOORESS ZIP PHONE
Pat Kilian 5971 Central Avenue NE 763-572-9202
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO
Donnelly Stucco 2500 E 25 St, Minnea olis, MN 55406 612-722-4200 202 68435
4 ARCHITECT OR DESIGNER MAIL AODRESS ZIP PMONE LICENSE NO.
5 ENGINEER MAIL AODRESS ZIP PHONE LICENSE NO
8 USE OF BUILOING
Residential
7 CLASS OF WORK
❑ NEW O ADDITION 0 ALTERATION �7 REPAIR O MOVE ❑ FiEMOVE
8 DESCRIBE WORK
Patch and redash house & garage
9 CHANOE OF USE FROM TO
STIPULATIONS
� �' �� �r�� e�to�n Cards
ill � ip�
0 o eo ��r To P���
SEPARATE PERMITS ARE FE�UIRED FOR ELECTiiICAL, PLUMBING, MEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCV LOAO
VENTILATING OR AIR CONOITIONING
THIS PERMIT BECOMES NULL AND VOIO IF WORK OR CONSTRUCTION 20NING SO. FT CU FT.
AUTMOiiIZED IS NOT COMMENCEO WITHIN 60 OAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERI00 OF 120 DAYS AT
ANY TIME AFTEii WORK IS COMMENCED. NO DWLG. UNITS OfFSTREET PARKING
I HEREBY CERTIFY THAT I MAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SUR7Al(
AND ORDINANCES GOVERNING THIS TYPE OF WOFK WIIL BE COMPLIEO @
WITH WHE7HEA SPECIFIED MEREIN OR NOT. TME GRANTING OF A PERMIT y�S�9OO ��F.�FS
DOES NOT PRESUME TO GIVE AUTMORITY TO VIOLATE OR CANCEL THE pEqMIT f EE SAC CMARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR TME PERfORMANCE OF CONSTRUCTION �167.ZS Fir SC �H.9O
PLAN CNECK FEE TO L FEE
Lice SC $5. 0 185.60
S�GN4TU�7E OF CON"AACTOR OA AUTMOA�ZED 4GENT IOATEi HE PF� V VALI T D THIS IS R ERMIT
S�GNniuqE O� OWNEAiii OWNEABUILDEAi iOATE� �� B G�h5� q`i
SEP-09-2003 09�29 FROM CITY OF FRIDLEY TO 6127212091 P.0�i05
NEW (] C1iY OF Ff�lDLEY Effedive 111/2003
ADDN [ J 6431 UniversRy Ave NE, Fridtey, MN 55432 (763? 572-3604 Bidg Insp
ALTER [] SINCLE FAMILY AND DUPLEXES a-9 AND R-2 (763) 5'�1-1287 F�x
BUILDlNG PERMIT APPLECAT[ON
Constructian Address_
Lega( Description:
Owner Name 8� Address:
Contr�ctor. �D �(?F
Address: � `J (7 � �
LIVING AREA:
GARAGE AREA:
C1�CK AREA:
OiHER:
��
�
r�
��
�� Te1. # � 7 — ZO�
� MN LICENSE #� C Z� p?j�
�.=f�,� � Tel. # � ��- 7�� �7Z�
Attach fia t��is application, a Certificate af Survey of the
lot, with th� praposed construction drawn on it to scale.
DESCRIPi'ION �F IMpFtOVEMEIiiT
Length _ Width Height Sq. Ft_
Length Width Heipht Sq. Ft.
Length Width Hgt/Ground Sq. Ft.
Constructian T e: �� � f"� `�
yp L�r� !f �� � Estimated Gost: � ��l.t�s
f3rivewa�y Curb Cut �dth Needed: Ft. + 6 Ft = Ft x$ =$
DATE: �J _ APP�.IGANT: t z7�-, Tel. #�l�' %� Y��
CaI! (T83) 572-36�p4`far Permit Fees if mailing in application. Fau to 763,579-7257 ii using credit card and w� will
calt you far card r�umber.
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
E.icen�e Surcharge
Curb Cut Escraw
Erosion Contral
P�rk Fee
Sewer Main Charge
TdTAL
CI`CY USE ONl.Y -
� ��%�„
$ � • l�
$
$
$ � �c�
$
$
$
$
$ 1��: �6 .
Fee Schedule on Reverse Side
.001 af Permit Valuation (1 /10#h%}
$.50/$1,000 Valuation
$1275 per SAC Unit
$5.00 {State Licensed �
Alt. °'A" or Alt. "�,° Abov � ��� �
$450.00 Cons�nration I
F�e Determined by Enc tt•� �' ��
,
,� � ��-��
c ° �-'-�
Agreement Nece�sary j �. � �uv ���c�.
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APR.27.2005 9�3aAM MCG�IRE& SONS
N0.70S P.3/3
��
FILL IN COMPLE7ELY FOR REPLACEMENT FUEL BUF�NING APPLIANCE PERMITS
COMMQN V�NT, VENT CQNNECTQR ANQ �QMQ41S'TIQN AIR 1/�RIFICATIQN
When _r_e�lacinp_a�n �xisdng t��, the undersigned hereby verifies that the
venting has heen examined and is free from rust, deterioration, obstructions,
and is secu�ely supported end firestopped where required. Yes () No ()
7he venting system is plasticJPVC and meets all current codes and m�nufactur�r
speCifications including sizing, length, number of elbows and terminatibn. Y�s () No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacture�'s sp�acfficatians. This dbes
include AGA GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliancas.
The existins� cnm6ustlon ai is sized and instelled to meet the cuRent codes
and manufactur�er's specifications. '
Vlfhen required to i�tall � neKr comdustion at,ryit will be sized ar�d instaped
to meet the current codes and manufacture�'s specifications.
Yes ( ) No ( )
Yes ( ) Na ( )
Yes ( ) No ( )
When ir�s�.allin� a n�w ventinA svstem, the undersigned hereby verifles that
it is a listed assembly and mests the current codes and manufacturer's;
s�ecifications. This does include AGA-GAMA Category ( Central Fum�ce
Venting Tables for fan assisted and natural draft appliances. � Yes ()
Is the common vent and vent connectors sized and installed cotrecfly �ftar
an appliance has been �emoved from the oommon vent and vented
separately as per current cades.
(Vo ( )
Yes ( ) Na ( )
Appliance Tvae and Si�e/Common Vent and Vent Connector Information
Appliance #1 Type ' 1„ bi �2✓ � BTU Input l0� � Fan Assisted o� Nat �,55i 5�
Appliance #2 Type B7U Input � Fan �ssisted or Nat
Appliance �13 Type ' BTU Input,� Fan Assisted or Nat �
Total Appliances Total 8tu lnput
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: (pescribe)
,,. , ,
HEATI NG CO: ( r`�(,'t,(,� I' � r'�1,1/l� c��?Yl S
Signed By; ���� D .�'p � �}� Date . _�{-02�-� d .S'�
JUL-28-2010 �ED Q9:01 AM
E�a��eerin.g
763-572-3552
7�3-571-X287 fax
�/ �v
WA1�� .A�TII SEWER
��lIT APP�XC,A.'TION
��TY UF Fi?�3�.,�X
�xx�c�vE �izrxo�o
P• 00
� —c�f� s`-�
Pe�t
Received By; (
Date Rec'd: ��
AFPLI�,A.'��OiV DATE�,a� t _'-� G" � �C� YQUR E-MAIL/FAX:
THI3 ,APPLIC.�,iV'�' IS: Cf OWNER COANfRACfQ�t —
JOB ADDRESS: �d � G� C'r1 '`°t .s� v xt ./�.�'�
N&W CO'NS'�'RUCTION PERM!'1'fi� (IF t4PPLICABL�}: _
�'�tQpERTY
OW��/
TENAN'�'
�
nnn�ss _S� q 7'/ � e v+.� -� f ..�'9� e.
�ONE: � - - Q 0 G/ s�-�
'��
C;UNTRACTOA NA�:�%`p a M f dc+•,�St 1�•ar� d�l'� ' Pr� ��i�J�.�7 i�'!�� �•, f: �.�ci
SITBMl?'.� G+P�PX OF ADDRE3S: Y' — _
YOU�i'S�'it� " � �''Y'"�' CITY_. �j„+� f� � STAT��'�xp ��5'�//
�,tc',�avs;� wl�t �torr� !,z :�'�} ,� ` S� q.� cs�.L.�aor�:
�PP�(CAT'!ON STATE LIC # � ��v� � � ��. f
S'1'ATB BONB: B33� z]AT'E: .�e� �
X. �ia � tzvclwMttea desc�ni�tion:
�' vv�t.f'_' r� ` �
• e�� I " � � �• t''�l �'1'�'v
�` t n. o r ' ..-� a � .�I'/�' �-r , •
2. PIeaae e e1� skede show�ing curb line, ntlIity � me, build' , et�e. witl� d�sta�nces on bac page.
�. St��uistions• � � / ,--� �� -� _ � � � —� � 5 � ��C��
1�iflTE:
G��� ' '. �� � 7 � � 35� S � �
j . ��..�,�: � �-L.�-�-$�r�. �1 5�u--���� .d �.-�
`� �*E�itVQT TYPE
❑ SEWW��t CONN��TION �E�'
Q WATER CO��'�(]N P�IZMIT
❑ W,A.'�R LINE kE�,q,�
�SE�VER I��1VE RBPAYR
�AbD ST�i'�,`� SUkkCHARGE
S.A,C C�A,RGB @ $2�OQ =
$�0
$50
�40 ""
$40 � C�id
�5.uo - o s�
o �' ".`
'�U'�A,L � �� � C�� �
OTHE�t CHA.RGES (IF A�'L�CA.Bx.�) pAY Ta IJ',['�L�T�' H�LIlYG
I�W W��'E�i 11+�TBR C05T – S�B U'��.ITY $YLLING
_ SPEC�A.L A,SS�SSMEIV'I'S – SEE �,iN.A�rTCE
WATER TAP , SE� �I�TGIIVEETtING
'A,�i, INSP OR SI�T1T C1k�' / EV�TrTINGS, WFB�1VpS 8c HOLIDAY9 � �� s runr rn�u rr r,�„
'�"�II55 IS AN APPLICp�'IQfi[ k'pR A PERMIT NOT VA,I.Ip i1A}TII. PROCE55EI3
� b�ereby a�ly for a wate;r vx sewer (new cohu�ection vr repair) pexmit aa�d I aclmowledge that ttae iu�fo�matioa above is contp�ete and
accurate; tlaat t�z� w�ric will be �a caz�farmance witb� the �xdinances and cades c►�"the City of Pndley. Y understarAd this is not a pe�rxnit but
only an a�rplication fox a permit and work is mot to st�rt wi�hvut a pez��t.
S�GNA,'�URB l'�k' APPLIC '' "� ,�,� �.".
PRINT NAMfi� � �/ /F C 9 r, �i�F+ pA'�:� ��•i�--
A.P�ROV�3b HY; �L ' �}AITE: � Z � `C�
COPY ��N �� U'�' TY BII,LING (oaay if new meter) O�I1�C WOIi,KS ❑ E�TC�IT�ERAYG
City o� �'x�dley
�aa�i.neering De�aaxtment
6431 U�iversify Avenue NE, Fz�d�ey, MN' S5432 �
763-572-3352
FAX: 763�571-12$7
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i�illa�e : g� : �i���e�, ��. ^
' . #�I3�lC���6 $'!��� . ;
�T�' S� 6 ���� af n����� �� su�n��s
�; ��r �_��-
O�vner �ir�+�,► ;
Arc�itec't� �'rid'ey, Minn., �� ��� ; 1e,��
Suilder
. LOC��.'IQI� ,OF �3 . TI�TG ; �,;.. `; . :
No. Stree€ ��,�+`��� � � Part afi Lot
�'"
Lot.„ Biock Adclttion or S b-D3vision °
' �a�„� �' �►q�"��T'�CY I��'���i G`E+' �LTIL�3�I'v`G ", .
Fron�.� L)epth._,�,_ I3ei�ht� �toaies__� Manner of Cc�nstructicnc�,
fifl �e u�ed as�� �o be completed � ;" Est�n$ted Cost
_ . , > . .
_ _
✓ _ .vY, � ;;
;` ,�#
Fermit i� 2xereby granted to `��i�etidiii'�;,.�� t(� �,`��p���._._
the buiici�a�� � dvseribed in the aba�re sta�mEnt. TM� .�ermit is grt�nted
upon the .expr€sa Co�dition that the <person to who� it is ar�,nied, and liis agenta, e�tpioyees aaid vP'orkmen, in ai2
the work doAe in, aroun� and upon said building, or an� part thereof, �.shall conform in a.11 respects to i3�e qrdi-
nances of Fridiey, �Iinn., regarding the constatzetiax�, aiter�.tion, maintena�s�; repa.ir a�d maving; of �u�I�gs
within ttre city limzts, and this perrnit ma� �e revoked at any time upon; vio 'on oi any of the g�ravis4gas nf s�i�
ordtaances. ` . .
spector of �uiidin�`s; ,
, �� � � � � � � � .
AGRE�iFI>IT Al�1D S'�VdRR� S�'`�T�Pk�NT , °: .
I� .con�ideration mf: the assue a�d d�livery to LL;�e b�r the In<��ete� of ���i?.d�n�s of �id�� �f
t�e ahove pe�nii, I herEby �rree to dc� th� prQ���e� �or�i in �ccc�rc��.�ce v�it.�i the des�ptzt�n'
aboye set fo�h anc� acr;��di�ag to the �rc�visioz�s c�' t��e o�c�i�a ��c�w of 1�'rie�ley, a�.d; b�ing �� dul�
swarn, � he�eby s�ate a.rid s�y'that the.��et� st�tcr� bq me an� �ts��ai�ec� ��.�he �.i�o�e perr�s�t a�e
true as therein stated. '
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