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SEDGWICK HEATING & AIR CONDITIONING CO. HEATING JOB NO �'�/ -.��?,..�
8910 WENTWORTH AVENUE SOUTH • MINNEAPOUS, MN 55420 •(612) 881-9000 '�� RECORD .
ADDRESS �i2� ?(-� CB�h G � � �'1 ' CITY �^ � � ��°,f �
OCCUPANT �'kK �� o b
SOLD BY �5�� w•'° ��
MAKE 1 e h� a y
OWNER
INSTALLED BY
MODEL C%'?OQ3E �s
�R9S �� I��D% INPUT °7SiDco
SERIAL NO. �
• � !'
THERMOSTAT ��� fi e� Ib� �� VENT SIZE
VALVE ia,+ � wd II 7YPE OF LINER �%-Ueh '�
/ c /�
LIMIT `�. ��l � o:° LINER SIZE d
LIMIT SETTING �� o° FILTERS: SIZE i6 ����� NUMBEEi �
FAN SETTING f `�� e �
PILOT TYPE �%� G'�/' r `�
IGNITION MODEL '�e/� H Q ti
PILOT TIMING �a '� er' m �� �° '
PRESSURE 3� S G �� C PERCENT COZ B�O
INPUT CFH �� PERCENT OZ � lp
STACK TEMP. ~ Y� o PERCENT CO O�Q
FORM 235 (REV. 11/89)
WIRING �G /'/'r'3o �'l
TEST TAG 1I�
LIGHTING INST. V
DATE TESTED � �'� �� ` ��
COMPANY TESTING S �� �',' �
NAME OF TESTER �� t� G�'ti� �i4.. -,
FORM DISTRIBUTION: WHITE COPV - JOB FILE YELLOW COPV - CIT'I
� . � . . � .s _.. � � . � . .. . : .: . , . . -...;' • ',' ' ..�.. � �..... �. :, V,� p. y� h i , "F.•�a �.A°'45,:: �.:i"� c+- �JF.v: l�i.i.ja2 ,�54.,�.F -i'4#�' � ��°�. Ai,y^F�� TTF1��
S J
. . . _ . - - � . .., a , `�?''� . , k , , r. � `�'�r' ,.
c�ty of Fridley
A7 THE TOP OF THE TWINS
r
� �
� ; y _.___ � COMMUNITY OEVELOPMENT OIV.
r � � PROTECTIVE INSPECTION SEC.
� _ �"'1 � CITY M���OL`@��•�3
�"'"� � �'' 612-571-3450
10B ADDRESS 6270 Comet Ln NE
SuB�ECT
�U ILDING PERMIT
910-F1$
t LEGAL LOT NO. BLOCK TiiACT Oli ADDITION
DESCR. 15 2 $y].VSri H�
p PROPERTY OWNEFi MAIL ADOFiES$
�t��� Paul Boblett
3 CONTRACTOR MAIL ADDRESS
Owner Same
A ARCHITECT OR DESIGNER MAIL ADORESS
5 ENGINEER MAILADDRESS
8 USE OF BUILDING
Residential
7 CLASS OF WOFiK
O NEW ❑ ADDITION
B DESCRIBE WORK
Finish Basement
9 CHANC3E OF USE FROM
STIPULATIONS
See notations on plan.
REV I OATE
ZIP
PAGE O:
� �
PFIONE
PMONE
PHONE
P£RMIT NO.
2786;
RECEI NTP O.
� ��
4PPROVED BY
SEE ATTACMED
SNEET
LICENSE NO
LICENSE NO.
LICENSE NO
C� ALTERATION ❑ REPAIR ❑ MOVE O REMOVE
TO
TYPE OF GONST. OCCUPI
SEPARATE PERMITS ARE REGUIREO FOR ELECTRICAL, PIUMBING, MEATING.
VENTILATING OR AIR CONOITIONING.
TMIS PERMIT BECOMES NULL AND VOID IF WOFK OR CONSTRUCTION 20NING SO. FT
AUTMORIZED IS NOT COMMENCEO WITHIN 80 DAYS. OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANOONEO FOR A PERI00 OF 12p DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO DWLG. UNITS
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINEO TNIS APPIICATION STAILS
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS yp�UATION
ANO ORDINANCES GOVERNING THIS TVPE OF WORK WILL BE COMP�IEO $5,500.00
WITH WMETMER SPECIFIEO MEiiEIN OF NOT. TME GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTMOfiITY TO VIOLATE OR CANCEL TME pEpMIT FEE
PROVISIONS OF ANY OTHEF STATE OR LOCAL LAW REGULATING coN• $112.ZS
STRUCTION OR TME PERFORMANCE OF CONSTRUC7�ON
V �N4TUpE OF CON:AA Op OA AUTMOA�2E0 AGENT
��Y • _ .- .
UILDEAi
IDATE�
��t��q� �-1
iD�TE�
�
OCCUPANCVLOAD
CU :T.
fREET PARKING
IGARAGES
AX
2.75
;MARGE
Fire SC $5.50
LFEE
�'$120.50
S'IS)�Q)1R P R ITV/�s
yP � //
r�w
ADDN
ALTER
[]
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ConstructionAddress :
Legal Description:
������
CITY OF FRIDLEY �
SINGLE FAMII,Y AND DUPLEXES R-1 AND R-2 �I
BUILDING PERMIT APPLICATION �i Il�
��� �� '�. _ � .
� ��� •
� ,
/
Owner Name & Address: ��,,, j � �l, � e-�' �2� ��,�,t �,,,,�, N� Tel. # ��(- ��,� �-
Contractor: '��„ 1 � �s �� ��� , l MN LICENSE#
Address:
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Tel. #
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length Width Height Sq. Ft.
Length Width Hgt/Ground Sq. Ft.
� � !� J
�1+��S�n 1)iclr-tr�`,'
Construction Type: 1,� ab�. ��.„'.�, Estimated Cost: $ S�'oa
(F'ee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
�,s�- �l . ��— Tel. # �'� �l �- 2 � °� �
DATE: 11 - ► a� - � � APPLICANT: �
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
� l �. �
$ �- 7``�
$
$
$
$
$
$
$
$ ,�
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1 / l Oth %)
$.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 [ ]
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 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
$ i to $500
$501 to $2,000
$2,001 to $25,000
$25,001 to $50,000
$50,001 to $1Q0,000
$100,001 to $SQ0,000
$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
$1,0(?0 or fraction thereof, to and including $500,000
$2887.25 for the first $500,000 plus $4.25 for each additional
$1,000 or fraction thereof, to and including $1,Q00,000 �
$5012.25 for the first $1,000,0(}0 plus $2.75 for each additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
(Concrete Curb Streets Only)
Altemate "A" : Removal and replacement of curb and gutter only - Driveway v�°idth plus 6 feet tunes $13.50.
Altemate "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 $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.
�9- 'S4 i" 5��� '� . .� � - . � ' � ' � V
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ADDRESS �"%� � (�-
OCCUPANT f'
HEAT LOSS_ Yes DATE {iTG. INS% !J
SOLD BY
Electrical Work By
TYPE OF HEAT FA SPACE HTR.
(3AS DESIAN
MAKE
nnodei
se�ai 3Q�F,3�'��- �
NPUT G�'l �
Heat Plug
Limit Settin 1 �
Fan Settin
Pilot Type
Pilot Make
Pilot Model
Pilot Timin� � �
rressure -' Percent CO2
nput CFH , f.� fi Percent OZ _
Stack Temp. 6, Percent CO
HOl1SE HEA7iNG iEST RECORD
�T oc�R cirv �_
OUVIVER PL i�
INSTALLED BY _ �enterPoint Enerc�y Minngq�,^�
Oas Line By ��Q
UNIT HTR. OTHER
CONVERSION
i(
ver� s�e •
KIND OF LINER SIZE
NONE
Dreit Hood �,�1 � Reguletor
Fifters Size �Number
Chimney Locatlon Inside Outside
Chimney Constructlon
Wiring v
7est Tag /
Lightlng Inst
Date Tested
Company Testing __ CenterPoint Energy Minnega�
1Vame of Tester
�.
Building MECHANICAL Permit No.� � ' �� ' `
Inspections itESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY Date Rec'd: U�-��
DATE - ' � YOUR E-NiAIL ADDRESS
SITE ADDRESS C1 �i
THIS APPLICANT IS: � OWNER COMRACTO
PROPERTY NpME: " / � , �
OWNER/ ADDRESS: J��� GQ�(�r ��2—CITY �n��v, STATE�ZIP �y _
TENANT PHONE• 2��� r�7/��9j�J
CONTRACTOR CoMPnNY N,vvc�: / �
SUBMIT A COPY OF COMACT PERSON: �/
YOUR STATE STATE LICENSE # E7� DATE �,��(�
LICENSE WTCH ADDRESS: /.3�ll��d�.� / f�i1 ii�.� CITY %9hG �"' STATE%�✓ ZIPi2,�" %
APPLICATION pHONE � 3• �° lo �'0�- � FAX
,
PERNIIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: ��W O REPLACEN�NT �ALTERA7'[ON/REMODEL
DETAILED DESCRIPTION OF WORK � /,' `��G�1 S G
PER MS 16B.665 the permit fee is a minimum of 515.00 or 5% of the totat 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. Labor cost between $300 to $500 = cost of labor,� x.OS =
FOR PROJECTS WHERE LABOR EXCEEDS $500, FEFS ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. Fi}CfURFS: (INDICATE TOTAL
NUIvIBER OF EACH BELOV�
Equipment InstaUed . MfG: MODEL: SIZFJBT'U
Ivv1FG: MODEL: SIZFIBTU
MFG: MODEL: SiZFJBTU
A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGFJOVEN 510.00
AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRII.L $10.00
BOILER $35.00 FURNACE $35.00 GAS UMT 1-TfR $10.�
CHIMNEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPiNG $10.00 VENTILATOR $I5.00
..,, _.
;���3 �F����� 4 4 .. M1�(�R.��R�$�00.�:, ' �������x,�`4.:��� �� ' � .: " ` ��''� . .. � L . �. �O'�R��SO:�¢
__ _ . . _ ..
Permit Fee $ Number of fixtures @$10.00 x$10.00 =$
Surchazge $ .50 Number of fixtures @ $15.00 x $15.00 = $
TOTAL DUE $ �. � Number of fixtures @ $25.00 x $25.00 = $
Number of fixtwes @ $35.00 x $35.00 = $
State Surchazge = $ .50
Tota1= $
THIS IS AN APPLICATION FOR A PERMI7'-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 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 all k which re ires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME 1'��5i4 � L�L�L,SG�'Glt3 DATE L�4� �I
, �:�� J��"SE�1'b�,;SE ',. _� �,'E��ERMITS��iR���tE:rL�IRED�FQ��[��L:DINC'r,�tEL�C'T1tTG°,�`�',�TID,IVIE!�. .` � CAI��4'���
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
RESIDENTIAL PERMIT APPLICATION HVAC
❑ NEW HOMES/ADDITIONS ❑ EXISTING HOME ❑ MAKE-UP AIR
REQUIRED FOR NEW/EXISTING HOMES
1. Combustion Air (See note below) .
a. Oil or solid fuel IMC Cha}�ter 7 with MN Amendments
b. Natural Gas or Propane/IFGC Chapter 3 with MN Amendmen*,s •
2. Make-up Air (See note below)
a. IMC Chapter 5 with MN Amendments . .
3. Venting
a. Gas appliances IFGC Chapter 5 with MN Amendments
b. Fuel other thau gas IMC Chapter 8 with MN Amendments
REQUIRED FOR NEW HOMES
4. Heat loss & cooli.ng load per room
a. Required. on new conslruction IMC 1346.0312
5. �entilation
a. Pez MN Energy Code 7670 or 7672
6. Duct Design Per IMC 1346.0603.2
a. ACCA Manual D
NOTE: Centerpoint Energy Mechanical Code Guidelines software may be used for
combustion and make up air calculations
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 8-19-09
YOUR
❑ OWNER
STATE LICENSE
L°
PHONE�j�� ,S(� '��.-- �(4 �/
�INGLE FAMILY/NEW CONSTRUCTii
TWO FAMILY/NEW CONSTRUCfION
O BASEMENT FINISH �(ROOF
❑ DECK ❑ SIDING
C[TY
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCT(ON ❑ ADDTI70N
MAINTENANCFIREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ��p � �
SIZE OF IMPROVEMENT LENGTH WIDTH
OOFING �HOUSE ONLY
NUMBER OF SQUARES �� ❑ HOLJSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Virryl
❑ Aluminum
O Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
wnvnows
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINBOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
Permit No.:
Date
� �I� �
EXP DATE �Gj `S�� .i(%/(J
CITY��' //!y p STAT'�IP�
❑ WINDOWS
❑ DRAIN TILE
O OTHER
BASEMENT REMOpELING SUBMIT:
1. Existing Fl�r Plan
2. Proposed floor plan
3. List of strucdual members to be used
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
ADDITIONS_ 8c PORCHES SUBMIT:
1. Site Plan/Survey showing the existing strucwres
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE ST[CKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
S THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ _� � ,. OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surchazge
SAC Chatge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$ _
See Back Page for Fee Schedule
65% of Building Permit Fee
.QO1 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2000 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$22=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks p�yable to: City of Fridley Attach
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 understand this is not a
permit but only an application for a p it and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of ork ich r ' es re iew and approval of plans.
SIGNATURE OF APPLICA RINT NAM�UIZ���/ �Co /t/ � DATE / � / � '�j
0
Page 2- Building Residential Application
BUILDING PERNIIT FEE SCIiEDULE
The Chief Building Official 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 FEES
$1 to $500 $23.50 (Minimum Fee is $23.50 plus surcharge)
$501 to $2,000 $23,50 for 1� $500 plus $3.05 for each additional $100 or fraction, to and
includin $2,000
$2,001 to $25,000 $69.25 for 1�` $2,000 plus $14 for each additional $1,000 or fraction, to and
includin $$25,000
$25,001 to $50,000 $391.25 for l� $25,000 plus $]0.10 for each additional $1,000 or fraction,
to and includin $50,000
$50,001 to $100,000 $643.75 for 1� $50,000 plus $7 for each additional $1,000 or fraction to and
includin $100,000
$100,001 to $500,000 $993.75 for l�` $100,000 plus $5.60 for each additional $1,000 or fraction to
and includin $500,000
$500,001 to $1,000,000 $3,233.75 for the 1� $500,000 plus $4.75 for each additional $1,000 or
fraction to and includin $1,000,000
$1,000,001 and up $5,608.75 forthe l� $1,000,000 plus $3.15 for each additional $1,000 or
fraction
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 proposed structure and of the construction site.
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
City of Fridley
Building Inspections Department
6431 University Avenue NE
Fridley, MN 55432
763-572-3604
Fax: 763-502-4977