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CITY OF FRI�LEY
qpPLICATION FOR HEATING REPLACEyIENT
CHIMNEY ANO•STACK YERIFICATION
TNIS FORt4 MUST ACCO��PA�JY STR�JD4R0 APPLICATIOP� FOR IIEA7IP�G PERMI7 FORt�1.
,
LOCAT ION �� C� f��-�� ��.-��? r� ��I DATE �- o- 5-��
F
OWNER /� ' �� � � �� �i ADDRESS ��«�°�'
The undersigned f�ereby verifies th.at the existing chimney or stack:
1. Has deen carefully examined
2. is free from rust or det�riora�i�n
3. ��o foreign objects are lodged within
4. ttat it is securely supported
5. That it meets all current Code requirements
f�r size and total BTU connected
6. Total N�at i ng B7U ��� �' e' ��
All Other B7U
c f' s�• d c:� ;��
�
TOTAL � �v � � � � �
q j
,�. �� � �i
�
a�%w�K$ � �� �iCa � ��"��, ;�! l,�-�
� `� �� � /
HEATING PERMIT #
�
SIGNEO � � ���t.r�-�r ��-��'�4-� ��
� � � Licensee
by ��;�� ��� �
Addres s �c � .� � - �% �- -����' �
7elephone � � �- �" �� �
Fridley City Licertse �
0
❑
����i
0 ,r.,. �,T�Goe y-3Q- �j b �. , �-r� , � ;
wELL OR eoRlNO LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H� 0 2 7 2 4 �
County Name WELL AND BORING SEALING RECORD Sealing No.
Minnesota Statutes, Cha ter 1031 M i n n e so t a Unique No.
�Q�¢,� P or W-series No.
(Lea�re Blsnk n �rot Imown)
Township Neme Trnmshfp No. Range No. Secdan No. Fracdon (sm. -s Ig.) Date Seated Date Well or Boring Constructed
�ridi�y 3p 23 �.3 N� SE�t�R� �`��-9�
Numedcal SVeet Address or Flre Number and City of Well or Boring Locatlon
6�a9 +�h�t�ne3 Rr�a�, FT`idi�3t' DepthBeforeSealin9 '�! tt OrlginalDepth �� n.
Show euact locatlon of well or bodng Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL
in sectlon grid wlth °X°, loptlon, showing property ingle Aquifer ❑ Multlaquffer
Iines, roads, end bufldings.
N WELLBORING �Measured ❑ Estlmated
� I � ; [�Water Supply Well ❑ Mon(t Wetl
'T_ 'T_ _'T' " I_' ��
i ❑ Env. Bore Hote ❑ Other ft. C+� below ❑ above Iand surtace
W -� � -i -� E CASING TYPE(S)
� � � �
- '-- --
--� - � �-- --i- �.Steel ❑ Plestic � 111e � Otfier
Y� mue
--'r- --�- --�-- ---I-- � CASING
S Diametar Depth Set In oversize hole7 Annualar space initlally groutedT
�&-- t mue� � in. fram � �to �� ft. ❑ Yes [� No ❑ Yes ❑ No ❑ Unlmown
PROPERTY OWNER'S NAME in. from to R ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unlmown
Property owmers maWng eddress If differerrt llmn weA locetlon address htdirated above. in. from ro iL ❑ Yes .❑. No ❑ Yes .❑ No ❑ Unimown
SCREEWOPEN HOLE
Screen from �`� to �� R Open Hole hom to ft.
OBSTRUCTION/DEBRIS/FlLL
WELL OWNER'S NAME Obstructlon
� ❑ Debds ❑ FII ❑ No ObsVUCtlon
Well owner's mailing eddress ff difterent than property ownePa eddress Indicated above. Type of ObsWctlon/Debris/FlII ��+ ���� �' C' ��� � b
Obstrucdon/Debris�Fill remwed? � Yes ❑ No
PUMP
� lype _ ��� . �l �
CiEOLOGICAL MATERIAL COLOR '��NESS OF �OM TO Removed ❑ Not Preserd ❑ Other
FORMATION
If not known, Indicate esdmeted {ormatlon log hom nearby well or hodng. ��OD USED TO SEAL ANNULAR SPACE B6TWEEN 2 CASINGS, OR CASING ANp BORE HOLE:
> -' � No Annular Space Exifs
❑ Mnular space grouted with tremie pipe
❑ Casing PerforeBon/Removal
, _. _
in. from � ft. ❑ Perforated ❑ Remwed
in. from to n, ❑ Pertorated ❑ Removed
Type of pertorator
❑ other
�ROUTING MATERIAL(S)
a
GroutingMaterlal I��' ��� from � to �� ft. yards � 6ags
from to it y�g �gg
�m m ft. yards bags
from ta ft. vards haas
IREMARKS, SOURCE OF DATA, DIFFlCULTIES IN SEALIN�
ILOCAL COPY I �-[ ������
HE-01434-02
UNSEALED WELLS pND BORINGS
Other unsealed well or boring on prapertyt ❑ Yes � No
LICENSED OR REGISTERED CONTRACTOR CERTIFlCATION
This weil or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The InfarmaUon coMained in this report is
6va to the beat of my Imowledge.
iin� �
� ��
Authorized Representetive Slgns6�re
�C'c�� �7C��
Name of Per�n Sealing Well or BoNng
� �v9�;�►���'�0
or
�
��
10/95R
SuBJECT
City of Fridley 2 6 3 6
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
;,
' �� RECEIPT NO.
� ; L __�e COMMUNITY DEVELOPMENT DIV. �� ��
r � � PROTECTIVE INSPECTION SEC.
' i '
L----� �r���,•, CITY HALL FHIDLEV 55432 NUMBER REV DATE PAGE OF APPROVED BY
L 612-571-3450 910-F15 6/26/98 / /
JOB ADDRESS 6609 Channel Road NE
1 LEGAL LOT NO. BLOCK TRACT OR AODITION SEE ATTACHED
DESCR. Pt 4G Second Rev. Aud. Sub. 4�'21 SHEET
2 PROPERTY OWNER MAIL ADD1iESS ZIP PHONE
Ra.ndy Moehlman 6609 Channel Road NE 449-4988
3 CONTRACTOR MAIL ADDRESS Z�P PHONE LICENSE NO.
Bo's Construction 2218 22 Ave S, M ls., MN 55404 709-5037
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PNONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION O ALTERATION � REPAIR O MOVE O REMOVE
8 DESCRIBE WORK
Reroof House & Garage (18 Sq) Tear-off
8 CHANOE OF USE FROM TO
STIPULATIONS
, Underlayment must comply with the State Building Code.
SEPARATE PERMITS ARE REOUIREO FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTqUCTION ZONING . SQ. FT. CU. FT.
AUTHORIZE,D IS NOT COMMENCED WITHIN 80 OAYS. OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONEO fOR A PERIOO OF 120 DAYS AT
ANV TIME AFTER WORK IS COMMENCEO. NO. OWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFV TMAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORREC7. ALL PROVISIONS OF LAWS yALUATION SURTAX
AND OROINANCES GOVERNING THIS TYPE OF WORK 1NILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN Oii NOT. THE GRANTING OF A PEFMIT �l�SQl �.]5
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUC ION OR THE PERFORMANCE OF CONSTRUCTION. �51.25 Fire SC �L.SO
t�`�Q�� r���` ( PLAN CHECK FEE TOTAL FE :
� Licens .00 8.50
- SIGNATUF7E OF CON7RACTOA OA AUTN0�:12ED AGENT IDATEI pq PE DATED IS YO R PER IT
)
SiGNATURE OF OWNEA UF OWNER BU�LDEAi IDATEi a*/'��� `��- G NSP /ptiTE
�.r . -'�Y � ,
NEW
ADDN
ALTER
[l
[l
[l
ConslructionAddress:
Legal Description:
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
I
/ (0^cPV 1 e�-i', �/V
Effective 1/1/98
��� �
�(� �bq
Owner Name & Address: �rny�r) � n � � � Tel. # � � �f - � � $ S�
Coutractor: �jt� S (�-rt 5"Fr�c°� �`� MN LICENSE # �� / ��,��
Address:�� r ► �� ,/�. ,,,P � %�lf�ls d�� SS �j�! Tel. # �%O 9- SO.��
��
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:
OTHER:
Length
Length
Length
DESCRIPTION OF IMPROVEMENT
Width Height
Width Height
Width � Hgt/Ground
� a� �
�
Sq. Ft.
Sq. Ft.
Sq. Ft.
Construction Type:�e -�bo� Estimated Cost: $ �� D�6
(Fee Schedule on Back)
Driveway Curb C�t Width Needed: Ft. + 6 Ft = Ft x$ _$ f�-� ��
� �
DATE: � �'C�� "% � APPLICANT: ��Ca S�e.c /5-�� Tel. # 70�1 � �3"7
Permit Fee
Fire Surcharge �
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
. STIPULATIONS:
$ ��� o��
� ! So
$ � ,�5�
$
$ ��
$
$
$
$
$ ��°-Sc�
CITY USE ONLY
Fee 5chedule on Reverse Side
.001 of Permit Valuation (1/lOth%)
$.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 [ ]
w _-
� _ �.
BUII.DING 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 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
$25,001 to $50,000
$50,�1 to $100,000
$100,001 to $500,000
$500,001 to $1,000,000
$1,000,001 and up
FEES
$21 (Minimum Fee is $21 plus surcharge)
$21 for first $500 plus $2.75 for 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 first $25,000 plus $9.00 for each additional $1,000
or fraction thereof, to and including $50,000
$574.75 for `�first $50,000 plus $6.25 for each additional
$1,000 or.fraction thereof, to and including $100,000
$887.25 for first $100,000 plus $5.00 for each additional
$1,000 or fraction thereof, to and including $500,000
$2887.25 for the first $500,000 plus $4.25 for each additional
$1,0(}0 or fraction thereof, to and including $1,000,000
$5012:25 for the first $1,000,000 plus $2.75 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 $13.50.
n n
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 tnnes $15.75.
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 constructed
will be required before proceeding with the framing.
�,,
�uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE �'� ° � `� - �` �
SITE ADDRESS � �P � �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
aPPiicATTON
PERMIT TYPE
�rE oF wo�:
lYII�C�l�TICAL
�5��+ NT'�L �I'I.��A'�'I�Jl�T
CITY OF F�I.EY
EFFECTIVE ]-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER
Permit No.
..--.; �����
� ,;
�. � x
;it �ii�i' -_-_ - '�'� � �
NAME:_�.sl ti/ �Cae. 9 Q �� 5��� _
aDDxESS: �`� � Q C°L.�� ��l � ��-- cr� �`e@l1i�d� • STATE �`�ZIP � J VSb.
PHONE: '���' �`,/- �gSI�
COMPANY NAME: ��i e� �✓ � GR L..� D�� c� 9
CONTACT PERSON: ��n e- � �a , .� .�
STATE LICENSE # EXP DATE
ADDRESS: F�� 9""�2i_��s :�� Lu� CITY ,�/Zt�� �_STATEE°�.r'Zip,�`� ��;
PHONE ��.�{ � S°� oL ! q 9 FAX -
❑ SINGLE FAMILY ❑ TWO FAMII.,Y
❑ NEW �2EPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
��L
FEES ARE BASED ON $10.� PER FII�TURE, EXCEpT WH�gE NOTED. FIXTIJRES: (INDICATE TOTAL NUMBER OF EACH BELO�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2(MI6 ASffitAE HANDBOpK,
Equipment Installed MFG: ����'e.. MODEL: i�°!a /��p / A c�. � SIZE/gT[J oi. �'V a�
MFCT: MODEL: SIZE/gT[J
MFG: MODEL: SIZE/gT[J
AlC.$25.00 _FIItEPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 _FURNACE $35.00 _GAS iINIT HT'R $10.00
—CHININEY LINER $10.00 _GAS DRYER $10.00 � POOL HEATER $35.00
_ DUCT WORK $10.00 GAS PIPING $10.00 _VENTILATOR $15.00
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
confortnance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; thaY I understand 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.
SIGNATURE OF APPLICANT ` � � `=j -P PRINT NAME � �"� ✓ ` J 1'�P'� ,d ' DATE �- � c� ~ / �
7e� e ..t. _
�iI,
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977