AF - 46178Villa��= Fridley, Minn.
BUILDING PERMIT
�T° 1514
Date: : �..�-�:r P'�`� ��,�� . . .
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Owner � ,:. .�t. x .�l�,�.�.-� �'.�'�.� Builder°':� �'� ;�e^�':"�'. .. '�`� �. .'' :�°��':�`-..r.
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Address .............. ....................... Address .. "�t s`r�
�'�' . �'. :'�.. � � . . �� . �:�,. �. �:.�: . . . . . . .. .
� LOCA� �F BUILDINC.�
No. I. �:� .'f'�. . . Street �F ��. � � :`�� . , � .�;''� . . . . . . . Par of Lot . . . . . . . . . . . . . . . . .
Lot . . . . �.,.��. , . . Block . . . . .L.�. . . . . . . . . Addition or Sub-Division .�r� �. . �.� ��.�� .. . . . . .
�t �-
Corner Lot . . . . . . . . . . . Inside Lot . �t'�. . . . Setback . a� � . . Sideyard d � . . . . . . . . . . . . . . . . . . . . .
DESCRIPTION OF BU[LDING
'�'a,be Used as� �
� B � �'
� f
t�r_,��. . . . � . . . . Front .��j . . . Depth �,�i . . . Height /. ����Sq. F�t . . . .. . . . Cu. Ft. . . . .. . . .
..................... F ont ........
Type of Construction . •!���:"+�".�r. . . . .
#'a'
Depth . Height ........ Sq. Ft. ........ Cu. F� ........
,�{� �
Est. Cost . �i? r. ��.4�.... . .. . To be Completed .�':3.`: :�... .. ..
In consider�tion of the issuance to me of a permit to construc�`th�; building described above, I agree to do
the proposed work in accordance with the description above set ��5rt�r' anc� in co�yp�nce �vith� ��rovisions of
ordinances of the village of Fridley. `- �` ;�" "�~�=- �'� - t°" _-
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Tn consideration of the payment of a fee o$ .�!.�'.., permit is hereby granted to `"'� �
�
t• •� �'1�'�"':`"�'.`�`:` io construct the building or addition as described above. This permit is granted upon
� the express condition that the person to whom it is gra.nted and his agents, employe�s and worl�nen, in all work
done in, axound and upon said building, or any part thereof, shall conform in all respects to the ordinances of
Fridley, Minnes�ta regarding location, construction, alteration, maintenance, repair and moving of buildings with-
in the village limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
. . . R`° r.a ,��1:'� �� ��F"":�':�'.�: . . Btlilding Inspector
NOTICE:
7h1s permlt does not cover the construction, installation or alteration for wlring, plumbing, gas heating,
sewer or water. Be sure to see '�Building Inspector for separate permits for�'se items.
sue�ecT PERMI .
City of Fridley o 18 8 71
t ` AT THE TOP OF THE TWINS g U i L D I N G P E R M I T REC .
r
� • COMMUNITY DEVELOPMENT DIV. �� d J�
r � L PqOTECTIVE INSPECTION SEC. o� 7
� ;
1 ` �
l•-_.� �����,•� CITY HALL FFiIDLEY SS432 NUMBER REV. DATE PAGE QF APPROVED BY
i 612-571-3450 910-F15
4/10�7 � /
JOB ADDRESS 1354 Hillcrest Drive N.E.
t LEGAL LOT NO. BLOCK TRACT OR ADDITION
SEE ATTACHED
DESCR. 12 3 Maore Lake H].�.�.5 SHEET
2 PROPERTYOWNER MAILADDRES$ ZIP PHONE
Qyde/'Betty W�rner 1354 Hillcrest Drive N.E. 571-3505
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Sante
4 ARCHITECT OR DESIGNER MAIL ADDRESS 21P PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
8 USE OF BUILDING �
Resi dentia 1
7 CLASS OF WORK
❑ NEW X ADDITION ❑ ALTERATION O REPAIR O MOVE ❑ REMOVE
8 DESCRIBE WOHK
Construct a 33' x 14t Addition to Darellin
9 CHANOE pF USE FROM TO
STIPULATIONS combustion
See notations on plan. Provide products of cenau3as�isa fire alarms
in basement a,nd hall near bedrooms
SEPqRAi"E pE�N�IiS WA�������
�������� �'�A7'li��;� �a��MB�I�E� FQ� �efore digging call lac�1 utQs'�f;t�
TELEPHONE - ELECTRIC � GAS ���,
�N� �1ND S[�NS. �E�L�'�iE� ��° L�����
SEPARATE PERMITS ARE HEOUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT. CU. FT.
AUTHORIZED IS NOT COMMENCEO WITH�N 60 DAYS, OR IF CONSTRUCTION
OH WORK IS SUSPENOED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. • NO. OWLG. UNITS OfFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION �- STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ,ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIEO HEREIN OR NOT. THE GRANTING OF A PERMdT 527��-00 tiS`].3. rj�j
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-
STRU TI OR THE PERFORMANCE OF CONSTRUCTION. tiSI.BS. SO
PLAN CHECK FEE TOTAL FEE
- '$� 4�1.13 $249.18
Si uaEOFC rv�RACT THO 12EDAGENT IDATEI WHEN PqOPERLY DATED THIS IS YOUF PERMIT
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ATU f O ER�Ii OWNER BUILDERi IOATEI BLDG �NSP - ��
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CHIM�JEY AND STACK VERIFICATION
The undersigned hereby verifies that the existing chimney or stack;
1. Has been carefully examined Yes (,)
2. Is free from rust or deterioration . Yes ()
3. Has no foreign objects lodged within Yes ()
4. Is s�curely supported Yes ()
5. Meets all cu�re�-�t Co�e requirements for size and
toial BTU co�nected
6. Has Total hea ting BTU's of
All other BTU's
TOTAL
Rer�a rk s
No ( )
No ( )
No ( )
No ( )
. Yes ( ) ivu ( /
Com pa ny
Signed By
Ca t�
�
�
�
sue�etr P
c�ty of Fridley 3110
AT THE TOP OF TME 'fiNINS � � �� D i N G P E R M I T
r
; � RECEIPT NO.
COMMUNITY DEVELOPMENT OIY.
i •y �"��'� .
r � � PROTECTIVE INSPECTION SEC.
i� j .
---.� ��"' �,� CITY HALI FRIOLEY SS�32 NUMBEp pEV O�TE v�GE O� AvvqOVED e
t 612-571-3450 9/a-F/5 6/22/00 � �
JOB AOpRESS 1354 Hillcrest Dr. NE
t IEGAI �OT NO. BLOCK TRACT OR AODITION SEE ATTACMEO
oescA. 12 3 Moore Lake Hills SNEET
2 PROPERTY OWNER MAIL AODRES$ 21P PMONE
Elizabeth Zaerner 1354 Hillcrest Dr. NE 571-3505
3 CONTRACTOR MAIL ADORESS ZIP PMONE LICENSE NO
Jack Pixley Sweeps, Inc. 4179 - 149th Ave. NW Andover, MN 55304 763-422-0481
d ARCNITECT OR DESIGNER AIL ADDRESS ZIP PHONE LICENSE NO.
20183369
5 ENGINEER MAII ADOFiESS 21P PMONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW O ADDITION O ALTEfiATION � REPAIR ❑ MOVE O REMOVE
8 DESCRIBE WORK
Rebuild top of masonry chivmey for fireplaces up and down
9 CHANOE Of USE FROM TO
STIPULATIONS
SEPARATE PERMITS ARE REOUIRED FOp ELECTRICAL, PLUMBING. FIEATINa, TYPE OF CONST OCCUPANCY GROUP OCCUPANCV LOAO
VENTILATING OR AIR CONOITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK Oq CONSTpUCTION 20NING SO. fT CU FT
AUTHOR12ED IS NOT COMMENCEO V�IITHIN 60 OAYS. OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANOONED FOR A PERIOD Of 120 OAYS AT
ANY TIME Af7ER WOqK IS COMMENCED. NO DWLG. UNITS OFfSTREET PARKING
I HEFEBY CERTIFY TMAT I HAVE READ ANO EXAMINEO THIS APPLICATION 1 STALLS GARAGES
AND KNOW TNE SAME TO BE TRUE AND CORFIECT. ALL PFOVISIONS Of LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING TMIS TVPE OF WORK WILL BE COMP41E0 �'3,746.00 ��..8%
WITH WHETMER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESU TO E AUTMOqITV TO VIOLATE OR CANCEL TNE pEqMIT FEE SAC CHAFGE
PROVISIONS OF V HER TATE OR LOCAL LAW REGULATING CON-
STRUCTION OR P RFORM NCE OF CONSTFiUCTION �9%. ZrJ F� e SC $3. %rJ
'c �� DO P�AN CNECK FE TOT L FEE
Lice $5.00 07.87
S�GN uA M RIjEDA ENi �OATEi MEN ROP VALID T TNIS IS V UR PERMIT
�•' ♦
S�G UAEO�OWNEAi�fOWNEABU4DEp� �0�1E� Bl0 �NSp' q6fE
� �
NEW
ADDN
ALTER
[l
I]
[l
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
� � //o�
�
Effective 1/1/2000
(763) 572-3604 Bldg Insp
Construction Address: % 3 .� �' �%% c v1er � ��� � E �
Legal Description: � � �- � - ~
Owner Name & Ad ress: �l t Z`�� �"�` (/�%� r fne r Tel. # �7/ -- 3S"�.I�
Contractor. A�Jc �l xl ' Swe � He : MN LICENSE #_ �� l�3� � 9
Address: P}//"��i -J�� � � ��.v , ��,�dcJf/Z � S�� Tel. # �s� �2 z� v ��'/
LIVING AREA:
GARAGE AREA:
DECK AREA:
Attach to this application, a Certificate of Survey of the
lot, witk�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
OTHER:
�.�,�i 1 � �-�� � �1 �S�„� y�.d.,�„�� -� � �
Construction Type:_ F����'eS �,►a °'�' �°"'�"' Estimated Cost: $_ � �% �"�
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: ,^r� � Z� APPLICANT: � Tel. # �� 3 r �%2 z -O � �/
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
Call (763) 572-3604 for Permit Fees if mailing 1n application
$ ��� Fee Schedule on Reverse Side
$ 3.�$� .001 of Permit Valuation (1/10th%)
$ /.. � $.50/$1,000 Valuation
$ � $1100 per SAC Unit
$ v�.��v $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 [ ]
� �6��%
STIPULATIONS: _ /'♦ �����
�� (�
�
BUII..DING PERMIT FEE SCHEDULE
The Cluef Building Official shall, before issuing permits for the erection of any building or structure, or for any
addition to any existing building or st�ucture, or for any alteration or repair to any existing building or structute,
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 $25,0�
$25,001 to $50,000
$50,001 to $100,000
$1(�,001 to $500,000
$500,001 to $1,000,000
$1,000,001 and up
FEES
$23.50
$23.50 for first $500 plus $3.05 for each additional $100 or
fraction thereof, to and including $2,OOQ
$69.25 for first $2,000 plus $14.00 for each additional $1,000
or fraction thereof, to and including $25,OQ0
$391.25 for first $25,000 plus $10.10 for each additional $1,000
or fraction thereof, to and including $50,000
$643.75 for first $50,000 plus $7.00 for each additional
$1,Ot� or fraction thereof, to and including $100,OQ0
$993.75 for first $100,000 plus $5.60 for each additional
$1,� 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,OOO,Q00
$5,608.75 for the first $1,000,(�0 plus $3.15 for each additional
$1, �0 or fraction thereof .
DRIVEWAY DEPRESSION ESCROW
(Concrete G�urb Streets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $15.50.
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 times $23.25.
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper
review of the proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructeci will
be required before proceeding with the framing. New Houses Onlv
SUBJECT ,
City of Fridley 3131
AT TME TOP OF THE TWINS g � I L D I N G P E R M i T
r
; � RECEiPT NO.
i LV ����� �
COMMUNITY DEVELOPMENT DIV.
r � � PFOTECTIVE INSPECTION SEC.
i . ,
i--__�; �"' �•� CITY HALI FRIDLE� SS132 NUMBEA pEV D�iE v�GE OF �6nnOVEO Br
L 612-571-3450 91a-F15 8/15/00 � /
lOB ADDRESS 1354 Hillcrest Drive NE
1 LEGAL L07 NO. BLOCK TRACT Ofi ADDITION SEE ATTACMEO
oescR. 12 3 Moore Lake Hills SHEET
2 PfiOPERTY OWNER MAIL ADDRES$ ZIP PMONE
Betty j'Verner 1354 Hillcrest Drive NE (763;571-3505
J CONTRACTOR MAIL ADDRESS tIP PMONE LICENSE NO
Reliable Roofing Co. 9110 Grand Ave S Bloomington, MN 55420 952-888-4545
A ARCHITECT OR DESIGNEfi MAIL AODRESS ZIP PMONE LICENSE NO.
20218872
5 ENGINEER MAIL ADDFESS 21P PHONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW O ADDITION O ALTERATIOIY C� f1EPAIR O MOVE O REMOVE
8 DESCRIBE WOfiK
Reroof House and Garage 24 sq Tear-Off
9 CHANOE OF USE FROM TO
STIPULATIONS
Underlayment ta compl� with the State Building Code.
Perr�i�it ���������� ��rds
9��19 �� ���i�tl
To Ham���ner �'� ����
TVPEOFCONST OCCUPANCVGROUP OCCUPANCYLOAD
SEPARATE PERMITS ARE REOUIREO fOR EIECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING
7MIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT CU FT.
AUTMORI2ED IS NOT COMMENCED V�IITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PER100 OF 120 DAYS AT
ANY TIME AF7ER WOpK IS COMMENCED. NO DWIG. UNITS OffSTREET PARKING
1 HEREBY CERTIfY THAT I HAVE REAO AND EXAMINEO THIS APPLICATION ]. S?ALLS GAfiAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS Of LAWS yp�VATION SURTAX
ANO OROINANCES GOVERNING THIS TYPE OF WOFK WILL BE COMP�IED
WITM WHETHER SPECIFIED MEREIN OR NOT. TME GRANTING OF A PERMIT .�Z�O9H.00 ��..OS
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL TME pEqMIT FEE SAC CMARGE
PROVISIONS OF ANY OTMER STATE OR LOCAL LAW REGULAT�NG CON-
STRUCTION OR THE PERfORMANCE OF CONSTRUCTION $3.25 Fl 8 SC �ZsIO
PIAN CNECK F TOT L FEE
Lic e. C $ . 0 $91.4U
S�GN4TU�7E OF CON-NACTOp Op 4UTMOp�ZED OGENT �D4TEi HEN PR P L VALIDAT�7HIS I�R P�RM-
i /
��
- ,� �
S�GN4IUAEO�OWNEAi��OWNEABU4DEp� �D�TE� BLO �NS� � � pciE
AUG-11-2000 09�37 FROM CITY �F FRIDLEY TD
NEW �
ADDlV [ l Gl'CY �?F FRJDlEY
A�TER [] SINCsLE �AIVliLY AND DUPLEXES R-'l AND R 2
�UILDi(dG PERMIT APPLIC�►T{QN
Constrttc�i�n Addres�: ��i` 9�/C LC`,�.°E"cST S�
9528881011 P.01�04
Effecave 9/'iPZQ00
(763) 572-3604 Bldg Ittsp
�����
i�egal C�escription:
Owmer Name & Address: ���7'T�/ L!/EJ�°i?�/� TeJ. # 7�'vr7/ �S4 S
, ,�
.Contractor. �EL/�13L� ��IFi�J� �'ar,�Ny _ nn�v ircENS� # �C_l� !�'� 7Z
,
Aadress: �l//D �,Ci�///> �11�5 �C�X1/yJ�t�T��'/' /�l/f/ uS�ZG Tei_ # 9v�� • �����5'�
LMNG AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Attach to this applicatiort, a Cert�fic�te t3f $uroey of the
ltrt, wihh th� propc��d con�cti4n �drawm on it ta scale.
DESGRIRTION OF IMPROVEMENT
Lbngth Width ---- - Height St�. Ft
Leng�1 Wid�t � Height
Length � Vifidfh �� Hyt/Ground
$q. Ft
Sq. Ft.
v �
�..`QF1StCUGtlOi1 Ty�E: � �C�� -.-_-.-,- ----..... . . _ ES�IP11�#Q.f� ('iQS� $ ! O/ O -
a���y cur� +��t wa�r, N�ea: �t. + G Ft = Ft x$. _�
DATE:
GITY USE �NLY �
Permit F�e
Fir� Surcharge
�tate �urcharge
S�►C Charsge
ae
License Surcharge
Driveway Escrow
Ervsion Can#rol
Pa�c Fee
Sewer Main Charge
TCiTAL
STIPULATIONS:
ARPLI+CAPIT: Tel. #
Cali (963) 372 3604 for R'errr�it Fees if mailing in apAGr�ttion
$. _��� o7s Fee Sc,�edule an Rev�r� S�de
$ c� • /D .001 of Permit Valuation ('[l10th°!o)
$ /. 0$ �.501$1,00{� Valuatian
$ $9'f00 pee SAC Unit
$ V, 0(j $5.00 (State Lic�ensed Residential Contractors)
$ Alt. "A" ar Aft. "B" Abave
$ $450.00 Consen►ation Plan Review
� Fee �etermined by Engineering
$ Agreement weces�arY [ l Not Nec�s�rY []
� /. �o
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CI7YOF
FRIDLEY
FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(612) 571-3450 • FAX (612) 571-1287
August 9, 2000
Elizabeth Werner
1354 Hillcrest Drive NE
Fridley, MN 55432
Re: Final Inspection at 1354 Hillcrest Drive NE
Contractor: Sedgwick Heating & Air Conditioning Co.
Dear Ms. Werner:
A mechanical permit was issued on June 14, 2000 for the property located at
1354 Hillcrest Drive NE to install a 4 inch class B flue and to revent the water
heater. According to Section 305(a) of the 1991 Uniform Mechanical Code a
final inspection shall be perFormed on the mechanical system. As of this date no
inspection has been called for.
You will be given thirty (30) days from receipt of this notice to respond. If we do
not hear from you, we will expire the permit and any inspections on this
installation will require a new permit.
Any questions can be addressed to myself at (763) 572-3603.
Sincerely,
�/
i .� � �. � � ��/
� �7 . �
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COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When repiacing an existing furance, 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 (� o()
The venting system is plastic/PVC and meets all cuRent 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 manufacturers specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The existinp 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 (�No ( )
Yes ( �No ( )
Yes( ) No( )
When installina a new ventina system, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specification�. This does include AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances. Yes () No ()
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes (✓�No ()
Appliance Tvpe and Size/Common Vent and Vent Connector Information
Appliance #1 Type BTU Input Fan Assisted or Nat
Appliance #2 Type BTU Input Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances Total 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) r`�c�l� 10�r% � �,�� /�CyJ��}��<<,, -�,�
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HEATING CO: �-�?E�l R �OfViRA�'T�R� tl��":
Signed By: ' � Date : /�—��–�v
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' FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT. VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
. When replacin�a an existins� furnace, the undersigned hereby verifies that the
venting has been examined and is iree from rust, deterioration, obstru�tions,
and is securely supported and firestopped where required. Yes () No ()
The venting system is plastic/PVC and meets all current codes and manufacturer
spec�cations 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 Fumace Venting Tables for fan
assisted and natural draft appliances.
The existins� combustion air is sized and installed to meet the current codes
and manufacture�'s specifications.
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacture�'s specifications.
Yes ( ) No ( )
Yes() No()
Yes ( ) No ( )
When installin�a a new ventina svstem, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
spec�cations. This does include AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances. Yes ()
Is the common vent and vent cflnnectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current cmdes.
No ( )
Yes ( ) No ( )
Aaaliance Tvpe and Size/Common Vent and Vent Connector Information
Appliance #1 Type BTU Input Fan Assisted or Nat
Appliance #2 Type BTU Input 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: (Describel
HEATIfdG CO:
Signed By: Date :
CITY OF FRIDLEY
6431 iTNIVERSITY AVENUE NE
FRIDLEY, MN 55432
572-36U4 FAX: (7631571-1287
___�_�
PERMI o.: 2004-01584 �-,,
Y;
DATE ISSUED: 09/13/2004 '
ADDRESS : 1354 HII.,LCREST DR NE
PIN : 243024120033
LEGAL DESC : MOORE LAKE HII,LS
: LOT 12 BLOCK 3
PERNIIT TYPE : PLUMBING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION : $ 0.00
NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC CHAPTER 6 AND TABLE 6-A. INSTALL A GAS WATER
HEATER
# ELEC WATER HEATERS 0 # NEW FIXTURES (EXIST OPEI�TINGS) 0
# GAS WATER HEATERS 1 # GAS DRYERS 0
# GAS RANGES
VALUE (FOR MINIMUM CALC)
APPLICANT
NORBLOM PLUMBING CO
2905 GARFIELD AVE S
NIINNEAPOLIS, MN 55408-2173
(612) 827-4033
� .L�!_ ._
WERNER ELIZABETH A
1354 HII.,LCREST DR NE
FRIDLEY, MN 55432
0 # OF NEW FIXTURES
400 # WATER TRMT APPLIANCES
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
application and laiow 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 y other state or local law
regulating construction r the perf ance f construction.
Applicant _ � Date / ,
Bldg
PLBG PERNIIT MINIMUM FEE
PLBG FIXTURES (NEW OPENINGS)
PLBG FIXTURES (EXIST OPENINGS)
WATER TREATMENT APPLIANCE
WATER HEATER - ELEC
WATER HEATER - GAS
GAS RANGE FEE
GAS DRYER FEE
STATE SURCHARGE, PLBG FLAT
TOTAL
PAID WITH CHECK # 29032
SEPARATE PERMITS'ItEQLYI�2ED FOR WORK OTI�R THAN DESCRIBED ABOVE.
0
0
0.00
0.00
0.00
0.00
0.00
35.00
0.00
0.00
0.50
35.50