AF - 45873City of Fridley
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PLUMBIiVr, PERf1IT APPLICATI�iJ
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Plumbin� Fixture Rates: N0. RATE TOTAL
Number Fiactures � x$2.00 S/a. a0.
Future Fixtures _� x $1.50 �� -SG
New Fixture-Old Open. x $1.50
Catch Bastn x $3.25
Water Heater-99,000 BTU x$3.Oo 3, Dt
Ground Run Old Bldg. x$3.25
Elec. Water Heater x $2.U0
Gas FittinQ Fees;
lst 3 Fixtures
Additional Fixturea
Gas Range-199,000 BTU
Repairs � Alterationa
Deacription; _
x $2.00 ,�, d't)
X $ .�s
X $5.0�
See
Code
IState Surcharse .50
,
I TOTAL FEE $ `� "'�
!The underaigned hereby makea application for a permit
for the woxk herein specified� agreeing to do all work
in atrict accordance with the City Ordinancea and rulin
of the Department of Huildiage� and hereby declare that
all'the facte and repreeentations atated in thie
application are true and correct.
�. __���-�., � �- . a
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,..-- � .��...�..�,�.._ � �_. ___.,.,�- ,-� . :__
�!.. . .... . . � � . � sueaecr � - . � � � _ IT NO. � � �.
.� '�City af Fridley t /'� ^ : 12���
. ATTHETOPOFTHETWINS � . . BUILDIN;V 1 �ERMIT •CEIP NO. .,
� �� � � _ COMMUNITY DEVELOPMEN� DIY. � - � � _
; � Y • � � PROTECTIVE INSPECTION SEC. � � . � � . �.^ !-p
o� W O
� � S /"'1��� CITY HALL FRIOLEV SSA32 NUMBER aEV. OATE >aGE OF APPROVEO BY �
. �--'��"F ,'� 612-580-3450 � . . � .
: 9io-Fi5 7/24/74 / /
ios naoaESS 526 Glencoe Stxeet N.E.
. . � 1 LP�QAL-�� �OTNO:. '� BLOCK '� YRAGTORADDITION � - � SEEATTACHED , .
°����s��� ���55�56.- � 2 Riverview Hei hts.Ad,dition ��s"EET � . . �
. 2 PROPERTYQWNEq � MAILADDRE6S � � �� � ZIP PHONE � � ��� �
<[3�a1ce Desi ns 7226 Rivesdale Road
� i�175iA�'IQR ' - � MAIIAflORf5$ .` � . � � . Z�P� �. PHONE LICENSENO. � .
� � l AqCF€Y'�CiORUEBICaNER MAILADDRESS � � -- ' . . Z�P � PHONE UCENSENO.
. 5 EN6INEER ��' � � � MAILADDAES6 � . � � �ZIV�� ��'PHONE LICENSENO. ' -
. 8 USE OF-BUILD[NG ( �� � . �. � , . . . � � � . � . � .
.. . R . � . . . . � . . . . .
7 CLASS OF WORK � � � � � - - � � �
� � � � � NEW: � ❑�. . ADDITION ❑ ALTEflATION ��❑ �REPAIR ❑ MOVE ❑ REMOVE :
.. �..'8 DESCRI6EWOFllC.' . . . . ... � .
Construct a Drvelling and a gazage
� 9 CMANGEOFUSEfROM � � � T� � � . .
ST1PUlA7fONS provide a hard;surface driveway. Provida a verifying survey before
` caPPin4•
SFFR�R IACATION:, 1Q1' East of Manht�le Ginv. 846.01)
Wye Elev: 84Z.25
_ Top of Footin4d 850.75 Minim�
Y7AT8A LOC,ATION:'1�' East of Sewer Service
SEPERATE PERMITS RE$li`IRED �t�R WI�2lNG,
H�A�'ING. PLUMBlNG ANO SIGNS. `
� ��� TYPEOPC6NST OCGUPANCYGROUP : OCCUPANCYLOAO
SEPAAAT&PERMITSARE REQUIflEO FOR ELECT:7IGAL, PLUMBING, MEATING,- � � � - �.
. VEN7{LATING OR Alfl CONDITIONING. � . � W "4 1$ ° � .
�THIS PERMIT BECOMES'NULL.AND VOID�IF�W�RK Ofl CONSTRUCTION ZpNINCa :� ���� S�.FL � ��CU.FT.. �
� AUTHORI�EO IS NOT'90MMEkGED WITHIN 90 DAYS, OR IF CpNSTRUCTION R 1� � - . � �
� .� pH WORK 13 SU$pENDED OR� ABANDONED FOA A PERIOD OF 120 DAYS AT � � �
- � " qdY iiME:AFTEfl-WOAK IS COMMENCEp.- �� . . . . � � NO OWLG:�UNITS � OFFSTREET PARNING �� �
� �� 4 HEAE81' EPR41EY7NAT-1 HAVE READ AND EXAM�NEO THIS APPLICATION � � �' �� �� -�STALLS-� GARAGES � � �
-�AkQiiELCJW�FfiJiB$pM@TQ.BETRU£ANDCOfiRfGT.ALIPROVI510N50FLAWS ypLUATION � . . . SUHTAX � . � . -
� .,P+NR.QR¢tNXNCES CaOVERN{N6 iHiS TYPE OF�WORK WtIL BE��COMPLfED �� � .
- WITH V¢Gt�=i�,ER SP � HEREIN OR NOT. THE GRANTING OF A PERMIT �� S1S�9�3 � 9.47 � .
DOES NOT`�� E T GNE AUTHORITV TO VIOLATE OR CANCEL THE� -pERMITFEE �. .. .. . SACCHAqGE .
.PpOVfS10N - F AN OTHER STAT OR iOC� LAW FlEGULATING CON, � �
�. � ST UCTI - ��OR T P�RFORMA F CO . UCTION. � ,�SS� S3E.00 � . yS�OO. OO � � �
PLANCHECKFEE �� TOTALFEE
$347.47 �
n'S� � n uREOFCONTRACTOaoanU*NORizEDaGErvi IDn1E1 WHENPROPEHLY ALIDAT iHIS GS�YO�Jfl PEPMIT
� _ �y
SI A UPEOf NEAIIFOWN€RBUILDERI � � IOATEI BLW.INSV OATE
1. , , _,
APPLICA'PION POR RESIDENTIAL, ALT�RATION,
OR AllDITION BUILDING PERMIT
CITY OF FRIDLEY, h1INNESOTA
° ��r� _r-
OWNER'S NAME:�.�.'C' ��S1Ca (JSBUILDER: c _
ADDRESS: /22� Y1��b'j]/!�'E �p. ADDRESS:
NO:. S Z�O STR�ET:
LOT: SS^d-S(v BLOCK: �— ADDITION:
CORNER I.OT
, v
INSIDE LOT: �-� SETBACK: ?v � SIDEYARD: % r
Applicant attach to this form 7tao Certificates of Survey of Lot a.nd proposed
building location drawn on these Certificates.
�ESCRIPTION OF BUILDING
° To Be Used As: �t 11�1� �BkNll�\� �'w��lHt�
l�
�S-� Front: Depth: Height
Square Feet: Cubic Eeet:_
��j(7�{�r Front: /2- Depth: 2�1 Height:_ ��
Square Feet; 2g 6 Cubic Feet: �& �
1�pe of Construction: ��AM� Estimated Cost: $ 20 000_�C'�
I 4' r' �
To Be Completed: ��/Z/%�i �
�
The undersigned hereby makes applicatinn for a permit for the woxk herein
specified, agreeing to do all work in stiict 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. .
DATE: �/��/%7 SIGNATCTRE:�
(See Reverse Side Por Additional Information.) �� ��,�j
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NaNNFAPOLdS. �1,
watherstnps n.a n v e Con+Uucean No. �"
Guide Iasulatiw ...,.�
��� I��_II Rcference Out. Wap Iat. Wa1l Cedin� Roof F1oor I Kind How Ap�Aad ����
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A.1 m Lenetk Width I�ht Fl.J Room Length 2_ Width Fje�
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t IUtR H�I�St No. et y�pNl f ArN .
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t= Ini. wali - �. _ l. O / 10 Nerexp. welf Q
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,��'� � Renm LeneYh � Width� Z He�ht �: � Hl.l . Ruoml Ler.,th '` .,P Width i�ht ��
Vr"indowa aud Uoon--Crac4age aod Area Windows aod +--Craekage and Ame
wiam � x.ye� No. oi 4q,.a r� w... �'ie. �
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COMMON VENT. VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When realacinst an existinp furance, the undersigned hereby verifies that the
venting has been examined and is free trom rust, deterioration, obsiructions,
and is securely supported and firestopped where required.
Yes (� No ( )
G�
The venting system is plastidPVC and meets 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 Central Furnace Venting Tables for fan
assisted and natural draft appliances.
The existina combustion air is sized and installed to meet the current codes
and manufacturer's specifications.
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacturer's specifications.
Yes�Q) No ( )
Yes� No ( )
Yes� No ( )
When installins� a new ventin� 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 Furnace
Venting Tables for fan assisted and natural draft appliances. Yes �}j No ()
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separateiy as per current codes.
Yes� No ( )
Appliance T4pe and SizelCommon Vent and Vent Connector Infomiation
Appiiance #1 Type BTU Input �� n Ass'ste r
Appliance #2 Type BTU Input,3�C8o Fan Assisted o at
Appliance #3 Type BTU Input Fan Assisted or a�
Total Appliances Total Btu Input ��
ii
Common Vent Type ia Vent Height Diameter� inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance #2 Vent Connector Height ft Length k Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS� (Describe)
HEATING CO:
Signed By: Date :
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Building
Inspections
763-572-3604
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
ppTE ( O— I I� O� YOUR E-MAIL ADDRESS
srtEa.��2ess �7G> Gi-ENCoE' ST� �'12iD�EY � MN
THIS APPLICANT IS: ❑ �WNER
Permit No.: �Qa� '
Received By:
Date Rec'd:
PROPERTYOWNER/ NpME: rOM � To�F+V LEbNA✓'�
TENANT ,�D�ess: S2 Co G t.<<_U CoE ST; CITY �'LO (-�� srn��!¢Ir�g 3 z-
PHONE: ']�2„� - 7g% - q 3 � .3
CONTRACTOR
SUBMIT A COPY OF
YOUR STA7'E LICENSE
WITH APPLICATION
PERMIT TYPE
STATE LICENSE N�
ADDRESS:� O �
rxoxe 612- (06
❑ SAIGLEFANIILY/Nf
❑ TWO FAMII,YlNEW
❑ ADDI170N
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I O��
DESCRIBE WORK BEING DONE:
SIZEOFIIvIPROVEMENT 1(oxZfl
R OF
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED I-IEIGHT:
- Z O o6 `F �� I £XP DA'rE
VLNL�l.uO� LANZ� NO . CITS
-�92� Far ���-.��06_0
❑ ROOF
�SIDING
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN Tll,E
❑ OTFIER
T�tn+�8 SS 32 7
24�` HEIGHT � 2
BASEMEtJT REMODELIIJG SUB�9T'
1. F..xisting Floor Plan
2. Roposed floor plan
3. List of structu=sl members to be used
SmING FOR NE W CONSTRUCTION INCLUDING DECKS,
�Viny� �OSoffit - ADDRIONS & PORCHES SUBMIT'
❑ Aluminum Trim L Site PIan/Survey showing @ie ezisting strucNres
❑ p�a � Fascia and proposed project.
WINDOWS 2. Two sets ofconstruc[ion plans
IN EXISTING OPENINGS �Yes ONo IACATION OF WINDOWS 3. Energy Cs{culations
OR FORNEW OPETIINGS-DESCRIBE STZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�78 `I S� OCCUPAIVCY TYPE
Permit Fee
Plan Review
Surcharge
Fire Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totel Due
See Back Page for Fee Schedule
65% of Building Peimit Fee
(.0005) times the Wtal job valuation — Minimum $.50
.001 x Permit Valuation (1/10%)
$5.00 (State Licensed Residential Contractors)
$1450 per SAC Unit (Plans to MVJCC for detemtination)
ft+6ft= ftx$20=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks oavable to: Citv of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PAOCESSED
I hereby apply for a building permit and I aclrnowledge tliat the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of t6e Ciry of Fridley and with the Minnesota Conshvction Codes; that I understand this is not a
permit but only an applicatio for a permit and work is not to start without a permit; that the work will be in accordance with the approved
plan in the case of all work ich re s review and approval of plans.
SIGNATUREOFAPPLICANT PRA7TNAME O�TEV�C �^��� DATE I�"`�t'��`�
,..... __ _...... .,,.�_. ........ From:u�known Page:2/2 Date:Bl11/200810:34:14AM ��„..
Building MECHANICAL Perm�tx�
Inspections R�i 5IDENTIAL APPLICATION Received
763-572-3604 CITY OF FRIDLEY Da�
7b3-502-4977 FA?C e,�a.,.,,,�, „�
SfIEADDRt3S f`�7� L\�Y
TTU3 APPLfCANT 1S: O OWNBR
OWNERJ
TENANT
NOTE: __._...'..' ...._._.y
SEPARATECITY CONTACTPERSOIV:
LiC@73H3 ARB STA'I'13 WCBNS$ N
R6QUIREO POR GAS
ANOHVAC. ���•�
SUBMITCOPYOFBOND �'_
ANDIMSURANCR
PBRMtT7'YP& '�°'^dLP.FAMILY
TYPEOFWORK: oNfiw '�i
YOUR &MNL
OTWOFAMILY OTDWNHOUSB
O ALTERATION/RHMODBI.
PER MB 16D.665 the permit fea is e miaimum ot S15.00 or SK of �6e Whl eoet op to 'S.500.011, whiohevx is groa[er, for tho
improvement, instelletion w repiacement of e residentid fixWre, excluding ihe fixturas. (This should rcflax only the cost of labor )
OR
[abor cost unda 5300 = S I 5.00. Lebor cost between 5300 to 5500 = cost of lebor x.OS =
FORPRQIECfSWHliR8LAB0R6XCEED8S300,FE8SAR8BASIiDONfI0.00P6RFIXTURH,EXCfiPfWHBREN07L'D. FIXTURES: (INDICATI;70TA1,
NUb1BER OF EACH BELON�
Equipmait(nsWlcd MFO: MODSL: Sf2PJB711
' 11/C i2S.W
Surcharge
TOTAL DUE
f15
Mf6:
MPG;
��
MlNIMUM $1'5.50
MODEL:
MOD[iL:
NumberoFflxtures�u SIUAU xSIU,W=
Number of fixtures Q S I 5.00 T, x S I5.00 =
OR Numbw of fixturcs (tA 525.00 x$25.00 =
Numbw of fixturcs (a3 535.00 � x S35A0 =
SNk Suraharge =
MtNIMUM S15.50 Total =
Tt11313 AN APPLICpTIQN ROR A PCRMIT-NOT VALID UNTIL PROCESSI3D
r n«eby e�y �ar e medwxai �a 1 ackmwladge ihu the iolb�metion ebove b oo�le0e and aoauam: Nu �he wo�k ua'il be ln coNormencc wtih the ordiimnca
onG wOm oP Ipo Cqy of Frbby eM nl� o Minnesotu Conswpion CoGe�; iht I undoreVnA Ihis B m[ e peimq brt on1Y en appJica�fon Ibr a permk en0 wmk Is noi a
a�art whla�x a pmni� tht Ihe wal� II 6e 'n acm�do� witl,� ep�royed q� M`Necave ofell work which �oquirea review�A upPmval af plana.
SIGNATURE OF
APPROVN.D BY
Cfty of Fridley
BaiMine Inspecfiona Departmeat
6431 University Avanue NE, Fridley, MN 35432
763-372-3604 PAX: 763-502�4977
DATE