AF - 42237sus�ecT P T N O.
c�ty of Fridley � i3343
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T •
i �
COMMUNITY DEVELOPMENT DIV. RECEIPT NO.
�
� j y �������
r � PROTECTIVE INSPECTION SEC.
� �
1 ; �
l_-_• A ����';,� CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BV
L J � 612-560-3450
910-F15 12/31/75 � �
�oe aooRess 1321 Fireside Drive N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. ],L,� Auditor's Subc3ivision #129 (Parcel 925) SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
5wedish Builders 8804 Lexington Avenue
3 CONTRACTOR MAILADDRESS ZIP PHONE LICENSENO.
D. W. Construction 8804 Lexington Avent�e, New Brighton 784-0938
4 ARCHITECTORDESIGNER MAILADDRESS ZIP PHONE LICENSENO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
e USE OF BUILDING
Dll �.CX
7 CLASS OF WORK
X NEW O ADDITION � ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK ,�, ��y w,T�
F'90��
Construct a 47'8" x 29'8" Du lex and a 20' x 30' Ga.ra e
DlVISION REGARDING CURB
8 CHANGE QF USE FROM T� AT DRtVEWAY OPENtN�S,
STIPULATIONS Provide a hi�xd surface driveway. Provide a verifying survey be£ore
capping. Provide sod in the front and side yards.
SEWER LOCATION: (Approx. 9' Deep) Possible Wye Only
149' East of Manhole (E. Inv. 883.24)
Wye Elev: 884.09
Top of Footing: 887.09 Minimum with 35' setback.
WATER LOCATION: MUST BE TAPPED 6" watermain, 15' south of south property line of
Lot 14
s����aTE P���� ����6��G
t� ��(�UIRE[� �OR ���IN�, �efore d4,��ing cafl local ufilitie
HEATtIVG, PLUAA�ING ANL� St�IV�. TELEPHCiN� - C��.�Tt�►C � G�s Et�.
� �� �
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPA '�� p' y �
VENTILATING OR AIR CONDITIONING. WOOC; FY�@
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING S�. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT �.440 -I- GOO �O�S�.�. -{- 6000
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 2 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LSWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED $77�O�.Z.00 yS4],.69
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING coN- $650.00
STRUCTIO OR THE PERFORMANCE OF CONSTRUCTION. ' $'1'07.47
� � � PLAN CHECKFEE TOTALFEE
��� ��� � $799.16 �
G�ATUREOFCONTRACTOFlORAUTHORIZE AGENT �DATEI WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT,'"- g
. .� s� n � .CRJth Q � (1(�.Y�st.l'L� ! �l� -'1�.�.s
``JjO SIGNAI� RE OF OWNER UF OWNER BUILDERI IDATEI BLDG. INSP DATE �
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.41'PLICATION POR RESID�NTIAL, ALTERIITION,
OR AllllITION BUILUING PERI�IIT
CITY OF FRIDLEY, MII�NESOTA
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NO.. �,� � � STREET: �/�� �1��
LOT° j � BLOCK:
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CORNER ZOT: INSID� LOT:�SETBACK: SIDL'YARD:
r�pplicant a�tach.:o this fozm �ao Certificates of Suxvey of Lot and proposed
building location drawn on these Certificates.
DESCRIPTION OF BUILDING
To Be Used Aso
v�-�� �� Fxont :_ �i 7 r g11 Depth :�g' �" Neight o�,� �
��'§ � � Squa�re Feet : d Cubic Feet :�a � � �
— -- ��2�� � Fxont : �C� ]3epth : �CJ Height : /(�
Square Feet; Q(� Cubic �eet s �p QQ
�pe of Construction: Estima,ted Cost:_$
To Be Completed: ��_ � �e
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��?7',�� �,ad
The unde�csigned her�by makes appli.cativn fox a permit fox �he wo�:k herein
apecified, a.gxeeing to do all work in sti�.c�t accord.ar�ce with the Gity of
Fridle,y Ordinances and xulings of �he Departm�nt of Buildings, and 1lereby
declares thai: a11 ihe facts and repxesentations stated in this application
�.re true and correct. � '� �
DAT� t SIGNA'P[TRE °
�See Reverse Side For Additional Tnformation.)
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BUILllING PERMIT FEE SCHEllULE
SECTION 2. The Inspector of Buildings �hall, before issuing permits for the
exection of any building or structure, or for any addition to any existing
building or structure, or for any alteration or repairs to any existing
building or structure, upon applica�ion therei-ore, 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:
UNIFORM BU.T.LDING COD�: Type 1, 2& 4-$2.15 for each one thousand cubic
feet, ox fraction thereof, in such cubical contents. Type 3& 5-$1.85 for
each one thousand cubic feet.
ADDITIONAL INFORMATION
Fox the purpose of computing fees fox building permits, the cubical contents
of any building or addition, is determined Uy multiplying the gxound area
covexed from a point six (6) inches Uelow the floor line of the basement
or the cellar to the average heights of the upper surface or to the average:-
height of the roof surface of the main gable of a pitched roof.
For repairs or alterations to an existing structure, the fee shall be at the
xate of $3.00 per each five hundred dollars ($500.00) or fraction thereof in
the cost of all proposed work.
In no case shall the fee charged for any permit as set forth in Section 2 be
less than $5.00.
V ERIFICATION OF FOUNDATION
NOTE: Permits for eonstruction will be issued a minimum of 24 hours fxom.the
time of application, to allow for proper review of the pxoposed structuxe and
of the construction site.
A Certified Sar��ey of the lot, showing the location of the foundation, once i�
has been constructed, will be xequixed before proceeding with the framing.
CERTIFICATE OF OCCUPANCY
Application for a Certificate of Occupancy shall be ma.de ten (10) days prior
to the use or occupancy of any.structure for which a building permit has been
issued; and said structure shall not be used or occupied until a Certificate
of Occupancy has been i.ssued.
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�' +�ENEBY CERiIRr TM�T TH� AepV� 18 w TRUa ANO CpRqEC7 PLAT �pF�A SuRV�Y`Q� , , , . �
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. � Lot 14,�ud3tor►� �Tlbdivision ��iya. 1ti�,' ' � .
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1lEYEL. BY, ME T1118 ::.: . �!11�54 DAY' Cl�_ •L��i • ' :.� . A � . 1� fj� . . ' . � . /°I %"`� � . .
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HOUSE HEATING TEST RECORD �
ADDRESS "'�� � � ��� � APT. FLOOR CITY SUBURB
OCCUPANT � �'" � `'� OWNER
HEAT LOSS DATE HTG. INST.
SOLD BY INSTALLED BY
Electrical Work By � Gas Line By
TYPE OF HEAT GA FA �HW STEAM SPACE HTR. UNIT HTR. � OTHER '
GAS DESIGN ' CONVEk510N
MAKE MAKE OF BURNER
Model � � � �� Model
Seriai Max. BTU Rating
INPUT MAKE OF FURNACE
Model - --
CONTROLS /�' I�
THERMOSTAT eat Plug Vent Size `�
Volve - KIND OF LINER SIZE NONE 't-�r
Limit Drah Hood ��� Regularor
Limit Setting �`� Filters Size Number
Fan Setting Chimney Location �ide Outside — ,
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Pilot Type Chimney Construetion B.. �0 L�' "� P�
Pilot Make -
Pilot Model Smoke Bomb Wiring �
Pilot Timing ���rd-�D� Draft Test Tag =�°
L.W. Cut Off Door Pressure Lighting Inst. �'�
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Prossure�� �"��° Percent CO ` Date Tested "`�
Input CFH� ��! � Percant 02 �� mpany Testing • �' 6
�"'�+ek Temp.� �' � Percent CO '� � Name of Tester
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� ATTENTION OF:
� , � _ _ _ _ - _ _ _____ _ _ _ _ . ___ _ . _ __ -�
TO �$e'� �1��
` CITY OF FRIDLEY
6431 University N. E.
Minnecpolis Minn. 55421
612-560-3450
_ _ -___ _ -- -
_ _ _ _ -- __ ---_ _ . J
SUBJECT �fl�� ��o��F 1�P�SB3[�Y! t�i8'� Zitd DATE �S? ��i ��
[b�.1.B�3.OTi 1?i �dd�.�isia�9. �x�.t.$3IIQ i�8rm3.t I�`et�
__ _ ��.�� sa�� . �u�__�a r�+r�k i� fi�e �m�� �' __���7r� ��i�,�_ .i�a. i3._ W. __4�s�'�3a!nR -
__ _88fl� _i�qt�a_gg�. Ne�_ Brigbt,�s�__�n. .�53).2,_ �.a pa�ment �or a__re_faad_�cf a____ --_______ ---- _
_ __ _ _
ds�.v�y degse�ica cos� �ed h�.m__%3.� ac�3.3.#�t�al btai��dingg�.� _f�e dnei _Dut _______
__ _ _ _ __ _ _ _.
_. _waa_r�t g�+essary. 8�so �aasfet �4tis�4 fra�c_�e d�atvesaa.g degress$�mm fi�d ar� __
_ _ _ _ _ _ ._
_._ _ _ _P�� � �� _P�� �a-_ __ �}.so__�tasfe� _�.96 €z+�m _s��harge ftzr3d 3rsto ____ -- -- .
'--- .. b�ieii permit_ fuad,, A%�. _ a�e aeti±��s as+a oa 3.�21—]323 .� F9s�s3de _. �3.ve_ �T. E...
; :. _— ___ Snilt�ing I�el�ui� _ �13, 3G7.. __ _ ___ _
_ _ _ _ __---
F
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_.__a ......_.. .... ...... ..____'.... -__.. ._. _._.���. ___.._. _.._. .......__ ...... . ....._. .,.�__ .........._ .-____... _...._..__.__...
cir_�eT��oG sJ � � / 0�
REPLY: '
____ - _ _
;
DATE, SIGNATURE
�fl�pPaRFfIA�i �R — fI��YA�k'�Y ,(ol�iY� G� k�'��hB
�
�
� _ _ .� �_..�
y � City of Fridley S�B�E�T E�TENSION
AT THE TOP OF THE TWINS g � I L D I N G P E R M I
;,
� �
� ` _�_ COMMUNITY DEVELOPMENT DIV. �
� L � PROTECTIVE INSPECTION SEC.
r , ,
' i '
�` �""1 � CITY HALL FRIDIE� 55432 NUMBER REV.
L""'�'� ,'� 612-560-3450
910-F15
JOB ADDRESS 1321-23 Fi res i de Dri ve
1 LEGAL LOT NO.� (4 BLOCK TRACT OR ADDITION
DESCR. , Aud. Sub #129
2 PROPERTYOWNER MAILADDRESS
Swedish Builders 8804 Lexingto
3 CONTRACTOR MAILADDRESS
$�X D. W. Construction 8804 Lexina�
4 ARCHITECT OR DESIGNER MAIL ADDRESS
5 ENGINEER MAILADDRESS
8 USE OF BUILDING
DATE PAGE OF
3/24/77 � � �
'° 13961
RECEIPT NO. .
APPROVED BY
SEE ATTACHED
SHEET
ZIP PHONE
Ave�ue
ZIP PHONE LICENSE NO.
n Avenue. New BricLhton 784-09:
ZIP PHONE LICENSE NO.
ZIP PHONE LICENSE NO.
7 CLASS OF WORK
�] NEW ❑ ADDITION ❑ ALTERATION O REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBEWORK �tension permit for Permit 13,343 issued 12/31 7
for a 47'8" x 29'8" Duplex and a 20' x 30' Garaae
8 CHAN�E OF USE FROM
STIPULATIONS
Stipulations same as 13,343
�
TO
POR CURB
REMOV�►�. �NV iCiLl��.rn.... . -
pY DRIVEWAY OPENINGS•
Tota� 392.05
less credit from permit 13,343
� - , -
�'E.Fi.� t� �"- i 9- �'�
SEPARATE PERMITS ARE RE�UIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPA
VENTILATING OR AIR CONDITIONING. WOOCI F1'�Ne
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTIOId ZONING SQ. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 720 DAYS AT R-1 1440
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS
1 HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION ��n10 STALLS
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT Re,pOlteCl Ori #�.3 �
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE
PROVISI NS OF ANY OTHER STATE OH LOCAL LAW REGULATING CON- '� �!� �/,
STRUCT N OR THE $ERF RMA F ONS RUCTION. �
° a PLAN CHECK FEE
� � ����
IG ATURE OF CONTRACTOR OR AUTHORIZED AG NT (DATEI � + 'W N PRO RL VAL
1 �
SIGNATURE OF OWNERIIF OWNER BUIL�ERI IDATEI ai nr, INS re
CY GROUP OCCUPANCYIOAD
CU. FT.
+ 600 40,811 + 6000
OFFSTREET PARKING
GARAGES
SURTAX�t�/% �F dO./�, %,
34 Paid on #13,343�a
SAC CHARGE
Paid on #13,343
TOTALFEE -�p
._�-�r:'�O �oZ�Ca • �
DPTED,THIS IS�'j0 R PEFJVIIT
r
CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL BUILDING PERMITS
�NEW, ALTERATIONS, ADDITIONS, OR REPAIRS) _
OWNER: � J � BUILDER:
• , r
Address : ,��(/� �C��z��/� Address :
Tel. No.
No.: /3oZ.1- �3 street: ��l�t�r��/ o�!��
LOT: BLOCK: ADDITION: � / , ��c.� . �� �
CORNER LOT: INSIDE IAT: SyTBACK: SIDEYARDS:
Applicant attach to this form �tao Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
DESCRIPTION OF BUILDING
° To Be Used As : ��
, k!��� � /3� � �� -
�
��2� Front: De�th: Heisht:
Square Feet: Cubic Feet:
Front: Depth: Height:
Square Feet: Cubic Feet:
Type of Construction:
Estimated Cost: $
7.b Be Completed: �'
/Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired $ $
(SEE REVERSE SIDE OF SHEET)
• The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City of
Fridley Ordinances and rulings of the Department of Buildings, and hereby
declares that all the facts and representations stated in this application
are true and correct. See reverse side r additional infozmation.
�
' DATE: SIGNATURE:
5tipulations: - �
. � ,31Z� �� .
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C ��C �i � . ���� �i3�1y
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BUILDIt�G PERf�7IT FEt SCHEDULE
SECTION 2. The Inspector of Buildings 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 repairs to any exis ting 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:
NEW CONSTRUCTION: Single Family Homes and Garages: $4.00/1,000 cubic feet..
PLAN CHECK: 25 percent of building permit fee.
DRIVEWAY DEPRESSION: (Concrete C�rb Streets Only)
Alternate A: Removal and replacement of concrete curb and
gutter only; Driveway width plus 6 feet x$11.75
Alternate B: Removal and replacement of concrete curb and
gutter and install a 3 foot wide approach with �J�
6 inch depth; Driveway width plus 6 feet x$15.�
� 1 1 • � \ � ' : � \
For the purpose of computing fees for building permits, the cubical contents of any
building or addition, is determined by multiplying the ground area covered from a.
point six (6) inches below the floor line of the basement or th� cellar to the
average heights of the upper surface or to the average height of the roof surface
of the main gable of a pitched roof.
For repai.rs or alterations to an existing structure, the fee shall be at the rate
of $3.00 per each five hundred dollars ($500.00) or fraction thereof in the cost
of all proposed work.
*
In�no case shall the fee charged for any permit as set forth in Section 2 be less
than $7.50 plus $.50 state surcharge.
VERIFICATIO� OF FOUNDATION
NOTE: Permits for construction will be issued a minimtun of 24 hours -from the ti.me
of application to allow for proper review of the proposed structu,re and of the
construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it
has been constructed will be required before proceedi.ng with the framing.
CERTIFICATE OF OCCUPANCY
Application for a Certificate of Occupancy shall be made ten (10) days prior to the
use or occupancy of any structure for which a building permit has been issued; and
said structure shall not be used or occupied until a Certificate of Occupancy has
been issued. -
� �%
,,.� �-�•�� - - , 515
� CITY OF FRIDLEY
PUBLIC WORKS DEPARTMENT
TAPPING APPLICATION AND PERMIT
FOR INSTALLATION OF WATER & SE�VER SERVICE
I) This form to be completed before a tap is made to any esisting water or
sewer line.� �� ` „ /, % .i _
Addtess �–
Owner � .
i
Plumber
CHARGES TO BE PAID BEFORE TAP IS E— WHERE
ASSESSMII�TT HAS NOT BEEN LEVIID AGAINST PROPERTY
II) Water & sewer connection permit must be registered before this Tapping
Permit can be issued.
City supplies all material and labor for 1" or under water tap. Con-
tractor supplies all material and labor for water tap over 1", and all
sewer taps.
WATER TAP: Materials Used: $_ /�� �
Street Patch: ��: $ � � ` �
TOTAL: $ � ��e �
SEWER TAP: Street Patch: =��: $�'�'
III) If this property has not paid a fiill Lateral Charge for its shaze of the
water and sewer system, additional charges will be placed against it.
This will be in addition to the normal connection and tapping permits,
meter deposits, etc.
Water
ASSESSMENTS TO BE LEVIED: Lateral: $
C7erks
Supt. a
Sewer Lateral: $
TOTAL ASSESSMENT: $
M/P 3/76 Whfle P.W. Canary Finance Pink Prop. Owner Goldenrod Plumber
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August l, 1977
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6431 UidIVEFiStTY AVEPIUE id.E., FRID! �Y, F�i1lBdid��OT� 55432
D. W. Construction
8804 Ler.ington P.venue
New.Brighton, Mn. 55Z12
TELE�ii�iVE ( 612)57 �-345a
Re: Final Inspection at 1321-1323 Fireside Drive N.E.
Dear Sirs:
A final inspection was made on July 29, 1977 of the above address and the
following items were noted which must be completed before the structure
can be finaled out;
l. Provide sod in the front and side yards by October 2, 1977.
2. Provide house numbers on stxucture by August 10, 1977.
3. Provide joist hangers at stairwell header in basement by August 10, 1977.
4. Call for final plumbing inspection by August 10, 1977.
�. Seal around vent pipe penetration of common wall by Auqust 10, 1�77.
We will expect the above items to be completed by the scheduled dates when
reinspections will be made to determine caapliance. If you have any �
questions on these items, please feel free to contact me at 571-3450.
Sincerely,
ROTd HOLUEN
Building Inspector
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6431 UNIVERSITY AVENUE N.E., FRIDLEY. MINMESOTA 55432
TELEPHONE ( 612)571-3450
14ugust 15, 1977
D. W. Construction Company •
8804 Lexington Avenue
Wew Brighton, Minnesota 55112
Attention: Don Wehlast
Dear P1r. Wehl ast:
Enclosed is a bill for $65.00 for additional street patching at
1321-23 Fireside Drive Northeast, Fridley. The Water and Sewer
Permit and Tapping Permit were taken out under Dean's Plumbing
Company and signed for by Dwayne Cardinal.
Dean's Plumbing informed us that they did not do the outside
sewer and water work, nor the tapping. Also, Dwayne Cardinal
is not licensed with the City.
The home is now being occupied, and no meter has been installed.
In view of all these probl.ems, we must insist that ;�ou come in
to resolve these matters or we may have.to revoke your license.
Sincerely,
v ����'�wz-�-_
����
RALPH VOLKMAN
Superintendent of Public Works
RV:ik
Enc. 1
cc: Darrel Clark ✓
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CITY O� FRI�iLEY —� �°�a� =�
INVOICE�`,�� ���� ;���
6431 University Avenue N.E. '`���� ri��_� -�''
Fridley, Minnesota 55432 INVOICE DATE 8-15-77
Telephon�: 56Q-3450 cuST. ORDER NO.
� �
To Mr. Don Wehlast
D.W. Construction Companu
88Q4 Lexington Avenue
� New Brighton, Minn. 55112 �
Pleass return IMVOICE with your remittence NO STATEMERIT WILL BE SENT.
TEM CITY
CODE DESCRIPTION
NO.
Street Patch at 1321-23 Fireside Drive N.E., Fridley, Minn>
Nate: Paid for 5' x 9' street patch (5 sq. yds.)
Street Dept. patched 5' x 21' hole (112 sq. yds.)
Charge for additional 62 yds. @$10 per sq. yd.
�
Amount Enclosed
AMOUNT
$65.00
White copy — return City of Fridley — Yellow copy Acct. Dept — Pink capy Cashier's Copy — Goldenrod Customer Copy
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8431 ll�dIVE�S�IYY A,1dERlli� PE.E., FWI�L�Y� AflINR1E�t�T� 5543�
TELE�640NE ( �92)571-3450
Mr. Clarence Larson
1150 - 107th Avenue N.E.
Blaine, MN 55434
Dear Mr. Larson:
Qctober 17,�1980
RE: 1980�81 License Application for the Residential Rental
Property located at 1321-23 Fireside Drive PJ.E.,
Frid'iey, MN
At the end of July9 1980 you were m�iled an application to
li��ns� ,our resi��n+ial rental prc��rty. As af the date of
this letter., the City has not received tl�e application and
appropriate fee.
Therefore, we are again mailing out the enclosed application
which must be completed, signed and returned with the license
fee plus the 50/ late penalty no later than 11-3-80.
Your prompt attention to this matter is appreciated.
SJO/kw
Enclosure (1)
Very truly yours,
STEVEN J. OLSON, R.S,
Environmental Officer
. o
0069A/USO7A
City of Fridley
AT THE TOP OF THE TWINS
r
� �
� �
� • COMMUNITY DEVELOPMENT DIV.
� VV � ��
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� � �"'1 � CITY HALL FHIDLEV 55432
�'""� � �'� 612-571-34b0
SUBJECT
BU ILDING PERMIT
NUMBER REV OATE PAGE OF
9t0-F15 6/29/93 / /
JOB ADDRESS 1321-23 Fireside Drive NE
t LEGAL �OT NO. BLOCK TRACT OR ADDITION
oesca. 14, Parce 925 Audi.tor�s Sub-division #129
2 PROPEHTV OWNER MAIL ADORES$ Z�P
Anna Broton 1321 Fireside Drive NE
3 CONTRACTOR MAIL ADDRESS Z�P
Durabilt Associatqs 7343 Ann Court, Eden Prairie MN 55346
4 ARCHITECT OR DESIGNER MAIL ADDRESS Z�P
5 ENGINEER
MAII AODRESS
� •��
����
APPROVED BY
SEEATTACHEO
SHEET •
780-0342
PHONE LICENSE NO.
938-9350 3004
PHONE LICENSE NO.
ZIP PHONE LICENSE NO.
8 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW C� ADDITION � ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 22� x 12� Adclition to Ga]:a�e
9 CHANGE OF USE FROM
TO
STIPULATIONS
See notations on plan, �xcavi,cle a hard sur,face driveway. Install smoke
detectors a,s per UBC 1210� adjacent tp all sleeping areas and in basement.
�A�NING
Before diggi�g call for
a�� Ut���tY locations
454-0002
EQUIRED BY LAW
SEPARATE PERMITS REQUIRED FOR
IIVIRING, H�ATING, PLI�M�iNG AND S1GlVS,
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORI2ED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONEO FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WOFiK IS COMMENCED.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
AND KNOW THE SAME TO BE TRUE ANO CORF;ECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISIO S OF AN , OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCT_I� OR THE�ERFOF;MANCE pF CONSTRUCTION.
TUiiE O CONTRA TO R AUTHOR12ED AGENT � IDATE�
� �DATE� � J
i.
E OF CONST. OCCUPANCY GROUP
IN(i SO. FT.
DWLG. UNITS OFFS
1 I STALLS
1LUATION
$4 �224
:RMIT FEE
$72 �OQ
.AN CHECK FEE
Li.cense SC $�.OQ
c� ROP LY VA
BLOG iNSP
a
PANCYLOAD
CU. FT.
' PARKING
GARAGES
$2, Z�.
AC CHARGE
Fire SC $4.22
OTAL FEE
$83.33
� THIS IS VOUA PERMIT
� SO-��
ATEW � Effe�tive 5126/93
ADDN [�.]� CITY OF FRIDLEY
ALTER j] SINGLE FAMII.Y AND DUPLEXES R-1 AND R-2 �p���
Building Permit Application
Consbruction Address: 1�j a•I�F�Y L� t� �- � r iv L Na� �o�S+
Lega1 Descriprion:
Owner Name & Address: �r�inq� ��'o�oh ��a�`-a-� ��r�i���- i�rtd�. �f. j'G. Tel. #$0' 034:�
Co�ractor: �t3i o�,b �«�S i 0[.ta�s S�'� l�� :ti �o� ��' �, P• S S'j�� MN LICENSE � � 0
Address: Tel. # -� �
Adach �o this application, a Certiftcate of Survey of tt�
lot, wittt die proposed construction drawn on it to scaie.
DESCRTPTI4N OF IIyIPROYEMENT
LIVING AREA: Length Width Height
GARAGE AREA: I.ength a a' , Wi�h l'�� Height g
DECK AREA: T.engt6 Width HgtlGra�ci
� ��. ,
sq. Ft �
�. Ft. �m
�- �c.
� � . �
Corner Lot [ j Inside IAt F� Yd Setback _�_ Side Y�d �cks �
Type of Conslruction: �/� ��. Estimated Cost: $�, OQd,�c�
Approx. Completion l�ate: � �-�/� ,��
(Cost on Back)
Driveway Curb Cut Widt6 N�ed: Ft. + 6 Ft = Ft x$ _$
DATE: �p a .a►PPLICANT: Tel. # q3 g� �� S�
Permit F�
Fire Surcha�ge
State Surcharge
$ ��d. C�C�
$ ���
$ �• / l
+�.Y 11. ' � �1_ .
Fee Schedule on Reverse Side
.(�1 of Permit Valuation (1!1(}th%)
$.SQ/$i,000 Valuation
SAC Charge $ $'ISO per SAC Unit
License Surcharge $ �-�� C� $5.00 (Staie Licensed Residential CoMractors)
DtlYC�'dy ESCiO�V $ AIt. °A" OT A�t. �B° A�VC
Erosion Control $ C'onsen►atian Plan Review $450.�
Park Fee $ Fee l�min� by Engineering
Sewer Main Cha.rge
TOTAL
�
$ `"� .� � �
��� ��
Agreement Aiecessary [ ] Not Na�ary [ ]
STIPUI.ATIONS:
�,
: I 1 I �':�' I :�' C I' 1
�
4�
The Chief Building Official sha11, before issuing pe�nits for the erection of any building or struckure,
or for any addition to any existing bnilding or structure, or for anry alterrdttiton or repair to any existing
building or structure, upon application-a�lile�efore, .�uire the pay�a� fi�,the ap�ilicant for such permit
of fees to the amount he�ein below set forth and in the manner herein provid� to-wit
. t a � . TOTAI." VoALUE _ . ; � ' , �� : , , � . � , � r � , . ' � :., ��
, , .
! ' _ P � ' � . � i
$1 � to $500 � '�� $15' �M°�m�m Fe�'iis� $i5 plus sur�harge) � ^ �: . . ." � .f
. �. . -
� ,.
$501 to $2,000 $15 for fu� $500 plus $2 for each additional $100 or
fraction thereof, to and including $2,000
$2,001 to $25,000 .$45 for fust $2,000 plus $9 for e�ach additional $1;000
. or fraction thereof, to and includiag $25,000
$25;001„ �r� $50,000
$50,001 to $100,t�0
� .
, �" � ^ +��
$100,�1 to $500,0�'' w . � t �
$5�,001 to $1,0�,0�
' $252 for first� $�5,� pl�as $6.50 fo� each additional $1,000
or fraction thereof, to. and including $50,000 -
$414.50 for first $50,000 plus $4.50 for each additional
$1,000 or fraction the�eof, to and including $100,�0
;:� -
;�:-�� � . .
$639.50 for first $100,00Q plus $3,�� .fo� `e�ch � additional
$1,000 or fiacfion th�eof, to and in�cl�ding,► �$500,�0
. , . , ,.
$2039.50 for the �$500,000 plas $3 for each addit[onal
$1,000 or fraction thereof, to and iacluding $1,(�0,0(�
s
$1,D00;001� �nd up $3539.50 for;.t�he; f�rst: �1°,0(�,OQO plus $2 for each additional °
$1,000 or fraction thereof � , `
DRIVEWAY DEPRESSION ESCROW
(Concrete C�rb Stre�ets Only)
Alternate "A": Removal and replacemem of curb and gutter only - Driveway width plus 6 feet times
$13.50.
Alteinate °B" : Removal and replacement of curb and gutter aad install a 3 faot 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, showiag the l�on of the foundation oace it has it has been
constructed wiil be required l�fore proceeding with the framing.
,�
. -
l��'
_, � _ s �,' � ,. ,
�
dwrobilt
8a�ti008�gdi8a68
JOB
SHEET NO. OF_
CALCULATED BY DATE
�llZ'Q�lxt O�dQOCl��� �%1C. CHECKED BY DATE
7343 ANN COURT EDEN PRAIRIE, MINNESOTA 55346 938-9350 SCALE �� `�' O
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SuB�ECi
c�ty of Fridley
AT THE TOP OF THE TWINS g � I L D I N G P E R M I T
r
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� ' y __�__ COMMUNITY DEVELOPMENT DIV.
r � � PROTEC7IVE INSPECTION SEC
i . �
i--_- A �'�','� CITY MALL fR10LE� SS132 NUMBER REV DATE
t �� 763-571-3450 9�aF�s 5/21/03
J08 ADORESS 1321 Fireside Drive NE
1 LEGAL �OT NO. BLOCK TRACT OR ADOITION
oescR. 14 Auditor's Sub �i�129
2 PiiOPERTY OWNER MAIL AODRESS
Anna Mae Broton 1321 Fireside Drive NE
3 CONTRACTOR MAIL ADORESS
Roncor Construction 10740 Lyndale Ave S��11E, Bloomi3gto
0 ApCHITECT OR DESIGNER MAIL AODRESS
5 ENGINEER
8 USE OP BUILDING
Residential �
7 CLASS OF WORK
❑ NEW
MA1L AODRESS
v�GE OF
/ /
3353�
RECEIPT NO.
V'���
APPROVEO BY
SEE ATTACHED
SNEET
763-780-0342
Z�P PMONE LICENSE NO
, MN 55420 2337
ZIP PMONE LICENSE NO
952-888-5578
21P PMONE LICENSE NO
C� ADDITION O ALTERATION ❑ FIEPAIR p MOVE ❑ REMOVE
B DESCRIBE WORK
Construct an 18' x 12' Three Seasoa Porch
9 CHANGE OF USE FROM
STIPULATIONS
See notations on pian.
P��rnit 9nspection Card�
Nlill �e Niailed
To Hom�o�un�r To Post
TO
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SEPARATE PERMITS AqE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING. �
VENTILATING OR Alq CONDITIONING
TMIS PERMIT BECOMES NUIL AND VOID IF WORK OH CONSTRUCTION 20NING
AUTHORIZEO IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONEO FOR A PERI00 OF 120 DAYS AT
ANV TIME AFTER WORK IS COMMENCED. NO OWLG. U
I MEFiEBY CERTIFV 7NAT I NAVE READ AND EXAMINEO THIS APPLICATION 1
AND KNOW TME SAME TO BE TRUE AND CORRECT. ALl PROVISIONS OF LAWS yp�VATION
AND ORDINANCES GOVERNING THIS TVPE OF WORK WILL BE COMPLIED
WITM WHETMER SPECIFIEO MEREIN OR NOT. TNE GRANTING OF A PERMIT �8 f 778
DOES NOT PRESUME TO GIVE AUTMORITY TO VIOLATE OR CANCEL TME pEqMIT FEE
PqOVISIONS OF ANY OTMER STATE OR LOCAL LAW REGULATING CON-
�TRyCTION OR THE P�,fiFOfiMANCE OP CONSTFiUCTION �iC)%.ZS
SC
S�GNOTUpE O� CON'bACiOp OA oU1MpQIZED AGENT IDATE� � ..
S�GNOTUAE O� OWNEA i�F OWNEA BU4DEA� - �O.�TEi �� �
SQ. f T
STA��S
.00
.V VALI
GROUP IOCCUPANCVLOAD
OFFSTREET PARKING
IGnRAGES
$4.39
�AC CMARGE
Fire SC $8.78
OTAL FEE
$185.4
i TMIS I�� R PER IT �
r��tk
NEW [] CI1Y OF FRIDLEY Effective 1/1/2003
ADDN [] 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp
ALTER [] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax
BUILDING PERMIT APPLICATION ����
���
,/� � �
Construction Address: 4 3� � �� R� S��to fv /� r�-�
Legal Description:
Owner Name & Address: �%,� � � a-P � r�o '� w Tel. # lG �° 7� �� b 3 j� a
Contractor: �� w���2 C-- �``� g� MN LICENSE # a 3 3�
Address: at� `7 `iv '� �-r n_c�%�- �-� l�v-e � o� Tel. # Cl S a,-`� ��° � S'7�
LIVING AREA:
GARAGE AREA:
Attach to this application, a Certificate of Survey of the •
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
_ _.__._. __�
Length l Width � a- Height � . Ft. �� �
Length Width Height Sq. .
DECK AREA: Length
Width HgUGround Sq. Ft.
OTHER:
� �C?� � `�� .o� 9
Construction Type: � 5 � '� 5 ° `'`' �� �ei�Estimated Cost: $ � 7�CJ, l�
Driveway Curb Cut �dth Needed: Ft. + 6 Ft = Ft x� _$
�c �'a � r7`
�ATE:�" � ' � � A��LICANT: � � Tel. # ��' �-�� � � � �
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
$ G�? ��
$�� .�$
W � a � 1
$
$ 'S . C�Ca
$
$
$
$
TOTAL $ � '�'I
1 �� � 2 �'
�
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th°/a)
$.50/$1,000 Valuation
$1275 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 [ ]
�3�11illr�ri7��3i
, _
, ,.
BUIIrDING 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
$1 to $500
$501 to $2,0�
$2,001 to $25,(�0
$25,001 to $50,000
$50,001 to $100,000
$1�,001 to $500,000
$500,001 to $1,000,000
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.Q0 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,�0
or fraction thereof, to and including $50,0�
$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,�0 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 $1,0OO,OUO
$1,000,�1 and up $5,608.75 for the first $1,0�,000 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 $17.00.
Permits for constivction will be issued a minirnum of 24 hours from the time of application to allow for proper
review of the proposed structure and of the construction site.
VERIFICATION OF FOUNDATION
A Certificate of Survey of the lot, showing the l�ation of the existing
proceeding with the framing. New Houses Onlv
�- .
= ti � �
foundation will be required before
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dur+a6ilt
ad�i0II8�98i8gQ8
�u�a$lBt o�eeoclated, 9ac.
7343 ANN COURT EDEN PRAIRIE, MINNESOTA 55346 938-9350
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SHEET NO. OF
CALCULATED BY DATE
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sue�ecr PERMIT"N0. � '' -
City of Fridley ;� � � � �, � � � �`��
AT THE TOP OF TFIE TWINS g U I L D I N� P E R M I T � '
� , „_.:_� , _ �_.: _
; � RECEIPT NO.
• COMMUNITY DEVELOPMENT DIV.
� �.; - �� � l � �.'� � ��
r � � PROTECTIVE INSPECTION SEC.
i . �
� � �"'1 � CITY HALL FRIOLEY SS132 NUMBER pEV D�TE P�GE OF �PVRpvED Br
�'"'"�" �'' 763-571-3450 s�aF�s 5������ / /
JOB AODRESS Z� p l ��Y,t�.� �f��� d�i�„�,tqa ���
1 LEGAL �OT NO. BLOCK TRACT OR AODITION SEE ATTACMED
DESCR. L�b �±.'Li�.� � :� r �' �LP�� �� � .�;+ SNEET
2 PROPERTY OWNER MAIL ADORESS 21P PHONE
L8.�1$�c� .69��C,.' ��",�'G�i� S�c:� ��i%te�41k. :.s;�'��"JF- �nF', �F!� %G:���•��ESt��i�,
3 CONTRACTOR MAIL AODRESS Z�P PMONE LICENSE NO
����aT��=fi�;�' ��?F`�a�;�"A2�fi�'�R°��<, ���d�6�` _�.f;��4.�K': �'F3rr �o .i��,�.�3 �i?:;;�*n�����A�;��!�:�.?� j''�"_�*t.a ���9��k�+ 4�'.��6�
a ARCHITECT OR OESIGNER MAIL AODRESS ZIP PMONE LICENSE NO.
• i_ " ��.. C�-, ti; r 61
U ���L������, ��`�
5 ENGINEER MAIL ADDRESS ' ZIP PFIONE UCENSE NO
B USE OF BUtLDING .
itt; `a.�.C6fsTC'�.:lak.l'L
7 CLASS OF WORK
O NEW �� ADDITION O ALTERATION ❑ REPAiR O MOVE O REMOVE
��
- 8 DESCRIBE WORK
����.: ����,t ��. 1�� 1.�,: `��t�c_-� 5�.����� S��t:�:1-�
2 l� �.
9 CHANGE OF USE FROM TO
STIPULATIONS ,
S�c: x�c���.tiar�a �+s� gP�'s�4i1e
�� f � ���� +
�� � ���
TYPE OF GONST. OCCUPANCV GROUP OCCUPANCV LpAD
SEPARATE PERMITS ARE fiEOUIRED fOR ELECTRICAL, PLUMBING, MEATING,
VENTILATING OR AIF CONOITIONING
TMIS PERMIT BECOMES NULL ANO VOID IF WORK OR CONSTRUCTION 20NING SO. FT CU FT.
AUTMORIZED IS NOT COMMENCED WITHIN 80 OAYS. OR IF CONSTRUGTION
OR WORK IS SUSPENOED OR ABANDONEO FOR A PERIOD OF 120 pAYS AT
ANV TIME AFTER WORK IS COMMENCED NO DWLG. UNITS OFFSTREET PARKING
I MEREBY CERTIFV THAT I HAVE READ AND EXAMINEO TH�S APPIICATION � S7ALLS GARAGES
ANO KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF �AWS VALUATION SURTAX
AN� ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPUED r��a ��� �� •��
WITM WHETMER.SPECIFIED HEREIN Oii NOT. THE GRANTING OF A PERMIT �—-"
DOES N07 PqESUME TO GIVE AUTMORITY TO VIOLATE Oii CANCEL TME pERMiT FEE SAC CMARGE
PROVISIONS OF ANY OTHEA S7ATE OR IOCAL LAW REGULATING CON• -,,�T ���� .:�� ���� ��; �� r 1��^
S'�TRUCTION OR THE PERPORMANCE OF CONSTRUCTION
' � � PLAN CNECK fEE TOTAL FEE
� f � � ` � t a E
1� �A� ,. � - p`� � ���'r'��.�uf` �� :?�oL�lJ �a bL�1o�S :
S�GNATUAEOFCON'AACTOpOAAUTMOp�ZE04GENT IDATEi -- ; WHEN PROPEfiLV VALIDATEO THIS IS YOUp PERMIT -
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� FILL IN COMPLETELY FOR REPLACEMENi FUEL BURNING APPLIANCE PERMITS
COMMON VENT VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When repiacin� an existina furnace, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes () No ()
The venting system is plastic/PVC and me:ets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination. Yes () No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Centrai Fumace Venting Tables for fan
assisted and natural draft appliances. .
The existina coe�nbus�i�� �6c is siaed and in�talled to meet the cuRent codes
and manufacturer's specrfications.
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacturer's spec�cations.
Yes ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
When installln�a a new ventins� svstem, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This. does include AGA-GAMA Category I Central Fumace Yes () No ()
Venting Tables for fan assisted and natural draft appliances.
Is the common vent and vent connectors sized and installed correotly after
an appliance has been removed from the common vent and vented Yes () No ()
separately as per current codes.
A liance T e and Size/Common Vemt and Vent Connector Information
Appliance #1 Type BTU Input Fan Assisted or Nat _
Appliance #2 Type BTU Input e Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat _
Total Appliances ,_ Tdal Btu Input
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: Describe
HEATING CO:
Signed By:
Date :
CITY OF FRIDLEY PERMIT N� 2004-01695 ',r''
6431 UNIVERSITY AVENUE NE -
FRIDLEY, MN 55432 DATE ISSUED: 09/29/2004 - r
572-36U4 FAX: (763) 571-1287
ADDRESS : 1321 FIRESIDE DR NE
PIN : 123024130010
LEGAL DESC : UNAVAII,ABLE
: LOT BLOCK
PERMTT TYPE : PLUMBING
PROPERTY TYPE : DUPLEXES
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION : $ 0.00
NOTE: COMBUSTION AIlZ SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. INSTALL A GAS WATER
HEAT'ER.
# ELEC WATER HEATERS 0 VALUE OF FIXTURE/APPLIANCE 0
# NEW FIXTURES (EXIST OPENII�TGS) 0 # GAS WATER HEATER5 1
# GAS DRYERS 0 # GAS RANGES 0
# OF NEW FIXTURES 0 VALUE (FOR NIIl�TIMUM CALC) 400
# WATER TRMT APPLIANCES 0
APPLICANT
NORBLOM PLUMBING CO
2905 GARFIELD AVE S
NIINNEAPOLIS, MN 55408-2173
(612)827-4033
OWNER
' BROTON ANNA MAE TRUSTEE
1321 FIltESIDE DR NE
FRIDLEY, MN 55432
AGREEMENT AND SWORN STATEMENT
This permit becomes nu11 and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and lmow the same to be true and correct. All
provisions of laws and ordinances governing this type of wor�
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
regul ' o ction or the perFormance of construction.
Applicant _ Date , I
i: � : � , "��'��.1��'1t! _1.� � . -
PLBG PERMIT MINIMUM FEE
PLBG FIXTURES (NEW OPErTINGS)
PLBG FIXTURES (EXIST OPENII�TGS)
WATER TREATMENT APPLIANCE
WATER HEATER - ELEC
WATER HEATER - GAS
GAS RANGE FEE
GAS DRYER FEE
PLBG REPAIR/ALTERATIONS
STATE SURCHARGE, PLBG FLAT
TOTAL
PAID WITH CHECK # 29179
SEPARATE PERMITS REQUIRED FOR WORK OTI�R THAN DESCRIBED ABOVE.
0.00
0.00
0.00
0.00
0.00
35.00
0.00
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�. FILL IN COMPLETELY FOR REPLACEMENi FUEL BURNING APPLIAIdCE PERMITS
COMMON VENT VENT CONNECTOR AI�D COMBUSTION AIR VERIFICATION
When reolacin�a an existins� furnace, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions, No ()
and is securely supported and firestopped where required. Yes ()
The venting system is plastic/PVC and meets all current codes and manufacturer
spec�cations including s'izing, length, number of elbows and termination. Yes () No ()
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances. .
The ex6�tir�a co�bs�s�6on-alr is si�ed and ins�alled to meet the current codes
and manufacturer's specrfications. �
When required to install a new combustion air. it will be sized and installed
to meet the current codes and manufacturer's specifications.
Yes ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
When installing a new ventins� svstem, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This. does include AGA-GAMA Category I Central Fumace Yes ()
Venting Tables for fan assisted and natural draft appliances.
No ( )
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented Yes () No ()
separately as per current codes.
A liance T e and Size/Common Veo�t and Vent Connector Information
Appliance #1 Type BTU Input e Fan Assisted or Nat
Appliance #2 Type BTU Input e Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat __
Total Appliances ____._ Tdal Btu Input
Common Vent Type Vent Height Diameter _, inches
Appliancs #1 Vent Conne�tor 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: Describe
HEATING CO:
Signed By:
Date :
ADDRESS
PIN
LEGAL DESC
' � ; u_�r M1�
PROPERTY TYPE
CONSTRUCTION TYPE
CITY OF FRIDLEY
6431 iTNIVERSITY AVENLTE NE
FRIDLEY, MN 55432
572-36U4 l+'AX:
: 1323 FIRESIDE DR NE
: 123024130010
: UNAVAII,ABLE
: LOT BLOCK
: PLUMBING
: DUPLEXES
: ADDITION/ALTERATION
571-12if7
!�: "°,
PERM N0.:2004-01694
� �'�
DATE ISSUED: 09/29/2004
VALUATION : $ 0.00
NOTE: COMBUSTION AIlt SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. INSTALL A GAS WATER
HEATER
# ELEC WATER HEATERS 0 VALUE OF FIXTURE/APPLIANCE 0
# NEVJ FIXTURES (EXIST OPENINGS)
# GAS DRYERS
# OF NEW FIXTURES
# WATER TRMT APPLIANCES
APPLICANT
NORBLOM PLUMBING CO
2905 GARFIELD AVE S
NIINNEAPOLIS, MN 55408-2173
(612) 827-4033
�� .I�� :
BROTON ANNA MAE TRUSTEE
1321 FIItESIDE DR NE
F'RIDLEY, MN 55432
0 # GAS WATER HEATERS
0 # GAS RANGES
0 VALUE (FOR MINIMUM CALC)
0
WATER HEATER - GAS
PLBG PERMIT NIII�TIMUM FEE
PLBG FIXTURES (NEW OPENINGS)
PLBG FIXTURES (EXIST OPENII�TGS)
WATER TREATMENT APPLIANCE
WATER HEATER - ELEC
GAS RANGE FEE
GAS DRYER FEE
PLBG REPAIR/ALTERATIONS
STATE SURCHARGE, PLBG FLAT
TOTAL
PAID WITH CHECK # 29179
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
applicarion and l�ow the same to be true and correct. All
provisions of laws and ordinances governing this type of worl�
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
re ug�lating constru�tion or the performance of constr�}ction.
Bldg Insp.
Date
SEPARATE PERMITS REQUIR�D FOR WORK OTI�R THAN DESCRIBED ABOVE.
1
0
400
35.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.50
35.50