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Lot .� . ,,� F.• BI�� �.�... Addit��� �ar Sub�-Dixision � �
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:�n ec��.side���bn of th� 3ssuaittce to 'me of �a permit t� con.�t�`uct the bu#i�ing. de�i�ed a�y�, ����� �
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tYie •+e�cpres� eondfiinn. tht�t tt�e �an tv wham it is. granted and �iS agents, emA�3!�s and worlartea, ir► alI r�%ork {;
do�� �in; arpund �nd.upoa �aic�=bi�ldirig, or any' P� thereof, :tshal.t conform in aii resp� to tl�e ordinaac�e..a:. �p
�id�eY, ,Miinnescata rega�d#�� lc�atiaa, apn�truc#or�, �lterafiion; z�ai�ntenar�ce; �eFa3r and movi�s af b k V
� in :th� v�ta;ge li�it� and �h% p�rmit ma.y be revoked at g ��� with
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9, ptumb#n�t gas hea#ing,
sBwEror xnrafiet�. Be sure to seb �he u�tdtrtg fnspector for se�ra�e permits t`ar" t�i��ms. .< '
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CD
HOUSE HEATING TEST RECORD
ADDRESS � ; y ,
OCCUPANT APT. FLOQ#2 CITY �
HEAT LOSS OWNER� C� SUBU����'
----_.DATE HTG. INST.
SOLD BY GAS C0. METER Bq E#
� Eleetrical Work By INSTALLED BY
TYPE OF HEAT GA pq � Gas Line By
STEAM SPACE HTR. UNIT HTR,
GAS ESIGN OTHER
MAKE _ , - � CONVERSION
M°de� MAKE OF BURNER
-�_�.,
Serial ���� � � � � Model
INPUT Max. BTU Rating
MAKE OF FURNACE
CONTROL S ModeO
THERMOSTA �" �
Valve e H.r Plug Vent Size �
Limit � KIND OF L�NER/i'°���.. �mp�;��.i �.
Limit Sefting
� Drah Hood ���F � NUNE_�__
Fan Setting � t.,n,��'� Filters s—�Regularor
Size
Pilot Type Chimney Laeation u �
�� Inside
Pilot Make Chimne �--Outsida
, Y Construetion
Pilot Model
Pilot Tim(ng Smoke Bomb � ��
L•W. Cut Off �raft � Q� Wiring
Door Pressure _ TesT Tae
Pressure�� �_ �� =�C�%'�r�� Lighting Inst. �
Pereant CQ Dute Tasted - ��' ��
Input CFH Per��� � �.
Sfaek Temp, Pereent CO �, �� CO1"P°ny Testing _
Form 235 Nama of Tester
Building
Inspections
763-�72-3604
�.4Tc � �'
SITE .hDDR.ESS �
TH]S APPLICANT IS
� MECHA.NICAL
RESIDENTIAL APPLICATIQN
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
O OWNER �CONTRAC7'OR
PROPERTY Nqt,,�:�
OWNER/ .a,DDRESS:
TEN AI�'T
PHONE:
CO�'TRACTOR
SUBNIIT .4 COPY OF
YOUR STATE
L�cENSE wrTx
APPLIC.ATION
PERMIT TYPE
TYPE OF WORK:
C1TY
Permit No.
Fceceived By.:
Date Rec'd:� 0 � °b��
COMPA2�'Y NAME: '
CONTACT PERSON: ii"�%GfJ Anderson Heating and Air-Conditionmg
A
STATE LICENSE 11 N/� 4347 Central Ave N.E. —
.4DDRESS: � _STATE ZIP
rxo� 7���-%?�s"/- �-S"// ��,�� Col. Hts, Mn 55421 �
'�SINGLE FAMILY ❑ TWO FAMILY
i
❑ �W I� REPLACEMENT
r-
DET,AILED DESCRIPTION OF V+'ORK
❑ TOWNNOUSE
❑ ALTERA7"]OTJ/REMODEL
���
PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the total cost up ta S500.00, whicbever is greater, for the
improvetnent, installation or replacement of a residential ftxture, excluding the fixtures. (This should reflect only the cost of ]abor )
Lzbor cost under $300 =�15.00. Labor cost between $300 to $500 = cost of ]abor x.OS =
FOR PROJECTS WI-�RE LABOR EXCEEDS $500, FEES ARE BASED ON � 10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: {INDIC� E TOT.4L
w.1Li!JIBER OF EACH BEL0�7 SIZE/BTU��+ �_
�qui�ment Installed MfG: MODEL���
J�G: MODEL: SIZE/BTU
�G: MODEL: SIZEBTU
,�..'C i25.OG FIREPLACE (GAS) $I5.00 GAS RANGE/OVEN $10.00
�A.IR TO A1R EXCHANGEER i15 . FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER S3S.00 �URNACE $35.00 _GAS UNIT HTR $10.00
CHIMNEY LINER $10.�0 " CiAS DRYER 510.00 _,POOL HEATER $35.00
_DUCT WORK $10.00 GAS PIPING $]000 VENTILATOR $15 00
: � ' .
. . .. . . ;a'nt,y ,,,i:.. v.y�y ��qz`k � zr «. R Nr "��,'i� c. a
PER3��II�'�FEE�PR�7EGTS F,OR fi:JNDER�$3D� ;,,�r, .g, , ; :.-�; <:� � k; .��. �:��"������,�������.�O�i'����CTS OVER �500:
Permit Fee i_°�_.,�. Number of fixiures @$14.00 x$10.00 —$
Surcharge $ .50 Number of fixtures @ $15.00 x $15.00 = $
TOT.AL DUE ��•� Number of fixtures @$25.00 x$25.00 =$
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ .50
Total = $
THIS IS AN APPLTCATION FOR A PERMIT-NOT VAL1D 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 i
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Cor,struction Codes; that I understand this is I
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 work which requires review and approval of plans. ;
C. L(/l�l�(,P�'�G�-�i1 �_PWNT NAMEC � GC�/! i�1' E/J �� f''Gj L/�' DATE I I��6 �
SIGNATL'�tE GF 6.PPLICA1v'T I
City of Fridley
Suilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
'• 763-502-4977
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WELL OR BORING LOCATION
County Name
Name �Township No. �Range
MINNESOTA DEPARTMENT OF HEALTH
WELL AND BORING SEALING RECORD
Minnesota Statutes, Chapter f031
tion No. FracGon (sm. � Ig.) Date Sealed
�....: �--�e _.�-q--��_ Q: --,...���.^
Minnesota Well and Boring I,,' ���
Sealing No.
Minnesota Unique Well No.
or W-series No.
n� nmu� n �c �>
Date Well or Boting Constructed
GPS ��de degrees_ minutes seconds Depth Before Sealing 1�� ft. Ortginal Depth_ 1 LC
LOCATION: Longitude_ degrees_ minutes seconds ��T
— � R(S) S�WATER LEVEL
Numerlcal Street Address or Flre Num6er and City at Well or Boring Locatlon ngle Aqu'rfer ❑ Multlaqu'rfer
501 ELY S't'1tFF't' � ��ORING as��� ❑ Estimated oete
W t S
iow exact Iocatlon of weli or bodng
section grid with °)(."
N
W. . � �ET
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s
—= ,—imna--t— -
PROPERTY OWNER'S NAME/COMPANY P
a
2� forest Ave �
Mahtomedi, MN 55115
_L OWNER'S NAME/COMPANY NAME
Sketch map of well or boring
loc�tlon, showing properlq
lines, roads, and butldings.
addresv
a er- upply Well 0 Monit. Well
❑ Env. Bore Hole ❑ Other
CASING TYPE(S)
❑ Steel ❑ PlasKic ❑ llle ❑ Ot
Outstde: ❑ Wetl House ❑ At Grade
❑ Pitless AdapterNnit � B°��
❑ wan P�
� ou,a.
CASWG(5)
Dlameter Depth
�in.hom� to�pft.
1 VlJ
in. tram to ft.
in. from to ft.
❑ elmve land surtace
�
Inslde: semerrt Offset
Well PR
❑ s���
❑ otner
Set in oversize hole? Annular space Initlally grouted7
❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
❑ Ves ❑ No ❑ Yes ❑ No ❑ Unknown
WeII owneYs malling address H differerrt than property ownePs address inmcated above �reen from_ 1 LA to 1 LGft, Open Hole from � tq n
—�OC/ —�QJ
. OB TRUCTIONS
�rop Pipe ❑ Check Valve(s) ❑ Debris ❑ FlII ❑ No Obstruction
�
Type of Obstructions (Describe) pinp �n���
P'
GEOLOGICAL MATERIAL COLOR �DNESS OR FROM TO Obstructions removed? s
FORmunON ❑ No Descrlbe ��
If not known, indicate esdmated formaBon log from nearby well or boring. PUMP
�
MARKS, SOURCE OF DATA, DIFFlCULTIES IN SEALING
Geology above from: 470 Ely Street
Water Level in Above Well: 19'
Da.te Water Level Taken: 9/23/1949
Unique 206647
Hired by Michelle Nelson
• LGCr".� r�py � �"�
HE-01434-11 IC# 140-0423
Remwed Present ❑ Other
METHOD USED TO S ANNULAR SPACE BErWEEN 2 CASINGS, OR CASINO AND BORE HOLE:
Annutar Space Exists ❑ AMnular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal
in. from to ft. ❑ Perforated ❑ Removed
in. from to ft. 0 Pertorated ❑ Removed
Type of Pertorator
! � Other
GROUTING MATERIAL(S) (One bag of cement = 841bs., one bag of beMOnite = 50 t6s.)
Groutlng Material--�T$�–.(3�'A� from_A to��3, yards_� bagy
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑ Yes How manyl
LICENSED OR REGISTERED�CONTRACTOR CERTIFlCATION
This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The infortnalion contained in this report
is true to the best of my knowledge.
�j(]��'j I Kevin Scheiterlein
Name of Person Sealing WeII or Boring
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