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Q M � ���� Q��.� r. � � � ti �; l� �1+ M CD �� � � � � "F ���� � � � �' o � � C � 0. m � I � Fv I� rrr����...��� � O � � � � � � o�. �o � � vn � � � O � 0 c� � I � � � � 0 � � N I � o �� O A. �. 0 � � 0 � �' (�. � � � �• � A o io 0 W � � 6� � a a' � � � . � �' � S��' � �1 � �. � � � � � � F�" � 7Ao y � a O � � � � �. A � � � � � � A �� O ` O C �� � �� 7 � � � O �p 1� � ' � � <; s • �� � � � � � � O � � � � � � 7 � � � ' � � � rt H :P � Q. �• ' � y � f �. � ° � O 0 / \ � ro � � � � � � �0 . ., � �I � �• � M � � �► Ca ' ,� ��! ej��d wr�T�, 8-�-00 ���- � MINNESO A DEPARTMENT OF HEALTH Minnesota Well and Boring � ����� � WELLORBORINGLOCATION E AND BORING SEALING RECORD ��ngNo. H Counry wame Minnesota Unique Well No. : � ����� Minnesota Statutes, Chapter 1031 or�W� ��Nno. , � Township Name Township Na. Range No. Seclion No. Fractfon (sm. -s Ig.) Date Seated Date Well or Bonng Constructetl . . €' � � iL� ! �. �7�i�' 6�' tT � � ;� ��fi��� Numerical Sheet Address or Fire Number and Ciry of Well or Bonng Location �� Show exact la�tion of x�etl or boring in sectlon grid with °X'. N � � W E � � � � � � � � � � "f' _ i ' _�'_ '_'�'_ Y1Mle --�- -i-- -�-- --1-- � e(� f mne � �'� � Depth Before Sealing ' ! Sketch map of weil or bonng ApU1FER(S) loca�on, showing properry 1� Single Aquifer ❑ Multiaquiter lines, road ildings. � WELL/BORING ����q�� � � Water Suppty Well ❑ Monit. Well ��.i� ❑ Env. Bore Hole ❑ Other CASING TYPE(S) J'�Steel ❑ Plastic ❑ Tle ❑ Olhei CASING(S) Diameter Depth �' � in. trom � to in. from to '� �� �eAy owners mailing address if diHerent than weil location eddress irMicated above. in. from to R� ��� SCREEWOPEN HOLE Screen trom � to � � Original Depth it STATIC WATER LEVEL ,�Measured ❑ Estimated � ft �low ❑ above land surtace Set in oversize hole? � ry. ❑ Yes �No fl. ❑ Yes ❑ No ft. ❑ Yes ❑ No ft. Open Hole from to Annuiar epace initlally grouted? ❑ Ves ❑ No ❑ Unknown ❑ Yes ❑ No ❑ Unknown ❑ Yes ❑ No ❑ Unknown ft. WELL OVYNER'S NAME ❑ RodslDrop Pipe ❑ Check Valve(s} ❑ Oebris ❑ FlO �j No Obstruction Wen mmets meNrqy a�resa 8 Sdterant than PropeAY ownets aaaress indicated above. . Type of Obstructions (Dascribe) ObsWCtlons removed7 ❑ Yes ❑ No Descrfbe _'" Type HARDNESS OF ❑ Removed •�Not PreseM ❑ Other OEOLOOICAL YATERIAL . COLOR ` �R�nON FH06A TO If not Imown, tndimte esdmeted lomiation log trom nearby well oi buring. �THOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINaS, OR CASING � No Annuler Spece Exists O Annular space grouted with tremle pipe ❑ Ce�ng ParfaretloNRemovel in. from to k. in. from to ft. REYARKS, SOUNCE OF DATA, : w i � t Type of peAorefor p other GiROUTINO b1ATERIAL(5) (O (irouting Materiel �� �ri � ❑ Perforeted ❑ Removed ❑ Perforeted ❑ Removed beg ot cemeM = 94 tl�s., o�re 6ag M beMonite = SO fbs.) — trom � ro � �" e. � y� �'�4 �gy � from to tt, yards bagy — from to It_ Yards bagy _ hom to ft. yards pags OTHER WELLS AND BORINGS Other unsealed end unused well or boring on prapeAy? ❑ Yes � Nq How meny? �CENSEO OR REfi1STERED CONTRACTOR CERTIFICATION 'ihis well or boring wes sealed in exor�nce wfth Minnesota Rules, Chapter 4725. The informatlon eantained in Mis report ia true to the best ot my knowledge. $�#��� �@� � �B� � ��lC: ����$ � Name Liaense a Regis6atian f�n. ` � �f �i���� ! l �"-+� � � � :'�i.d' Aufhodzed resernaUve Signetwe p� BQti �#aA$�1�QI� Neme o/ Person Sealing WeAw Boring m 10/93/2091 08:10 �� m �� Z c''"D C� N � 'o ��,. r�n � Q: c� 1 � � �► � Z O� y .„ �• � n�'i � � bA � � � v o c�p O 3� v _' � 1 00 �p � a � �. � c' � a . �o 3 d 1 1 � � O c • rt za � O C� � • • .n � o � `v �- Wrn� W �c � O� z am � T �� � �rn �: .T � ? Z -„�-I O O � � z m `° z � � m m ='• -z-� °—' � v C1 _ F'% d 76353i �= � = N � ? 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OG• � � � � .� v�' ' o,� ° �a 'v_ Q, b' � a " -� v n�a y °o�o�n �'�' N p� � C y r' � � � � _ � � � o � . 3 � � o O � � ff Sr, � N � ..w 7� O � ^ v W � � � c � � • � � o . • Z . � � `� � � '� � � � O O ~ �"� O O � O O O p � CD '� !� $� �9 � � C "` a �o 1 . � a� .� d � _ � v_� tNp z 0 m' v � � --� p� O — C p, ° � � o � _ � 3 tD n� R � OD �� t � . � y �� � _ � O � C� � A n ro O � > > � � � � � �� � Q- (p o m � a�Z3 �o = � � �� � � G � v � 03 A �69 �f1 W � O � .� � m � � a 1' v� 0 � � Q � G � m � � � z 0 � � � ` � � � � s� � r PAGE 02, � � v��.p�. � � 0. @� � �� �/�B c79 tD �'° {� � �� �LT � N � � e ¢,w � ,c 'Ti � 01Z2D .� � � � g � O � �� � a� � � � m � V � O . � � � � � 0 � z C � O � W v � Q � O c � � N m . v � p.... _� � N "� � 4 � �. � Z � � 2 V' � � `'�" d � � � � •o r -- �� � � Zv f D � � � � �� � � � Z � `— ,�i- � �� �� �� �� d� �� �� Z � Z -��7 �� y �n r�*� Q . O �a r�i v� �� K�n N � � � � �• � � d � c N � 0 O o--• .C�MMON VENT. VENi CONNECTOR AND COMBUSTION AIR VERlFICATION ' When reolacinn an existin� furanc�, the undersigned hereby verifies that the venting has baen examined and ia free from rust, deteriora�on, obstructions, and is securety supported and �restopped where requlred. Yes �No () The venting system is plastiGPVC and meets alf current codes and manufacturer specifications (ncluding siZing, length, number of elbows and termination. Yes () No (y� The undersigned also verifies that the replacement unit is a listed assembly and meets the cumerit codes and manufacturer's specificattons. This does include AGr4-GAM�► Category I Central Fumace Venting Tables for fan assisted and natural draft appliancss. The existing combustion air is siied and installed to meet the currerrt codes and manufacturer's spacifications. 1Nher� rr�quired to Install a n�w combustion air it will be sized and installed to meet the cuRent codes and manc�facturers specifications. Yes (L,YNo ( ) Yes ( ) No (J�' Yes (,�No ( ) When installina a raew ventina svstem� the undersigned hereby verifies that it is a listed assembly and meets the current codes and manufacturers . spe�cifications. This does include AGA-GAMA Category I Cerrtral Fumace , Venting Tables for fan assisted and natural draft appliances. Yes (�No ( [s the common vent and vent connectors sized and inst�lled correct(y after an appliance has been removed frorrt the common vent and verrted separately as pe� current codes. Yes (�No () Appll�nce Tvpe and� SizelCommon Vent and Vent Connector Information Appliance #1 Type _��''0�"' BTU Input 7o,G'r� an�ssiste �or Nat Appliance #2 7ype Wnft�rt l.c�, BTU (nput �S'� Fan Assisted or ��� Appliance #3 Type BTU Input Fan Assisted or Nat . Total Appli�nces ____ Total Bfiu Input � . w Common Vent Type �SC Vent Height �� � Diameter � inches Appliance #1 Vent Connector Height ft Length �ft Diameter,,,_in Type � Appliance #2 l/ent Connector Height ft Length „ft Diameter in Type � Appliance �03 V�nt Connector Heighf ft Lc�ngth ft Diamet�r ____._in Type r„� ALTERATIONS: (Describe) � FiEATI{VG CO: %��SN �(� i�,�✓�p l�iS't �o,^s ��� i(�c Signed By; _ ��w� �� %��°"` � Date : %� / 3 �O I � ��0 3�Jtid �IIb '8 �JNIlb3H HS�IdW 9ZZ09E9E9L 0T �80 �00ZlE0/0i 10/03/2001 08:10 c PAGE 01� • � � ��•.��:,.�:..�tr;+�ra'r•'.:;:'., . .. �. . HEA.TiNG & QIR CONDIT[C7L�I�1�C C�-.,� [1'�IC. ,�48 lakalanQ Avmuss Nac�t - Suite t10 �saokryR P�arlc, MN 5��428 ' � ', � . Pliasse (T6.i� 5.86-06c'e � Fa:c (763) i36-0�6 0 aAr�� lv 3 0 � TO : �N �'( FROM' l ✓`' ��I�! , � °.s �! d ;,.�q i,�,r �N� FAX¢�3��7% "%z�7 _� SU6JEC"f': I� C C`�'5� � �`,/'2 ,� � .�-¢ c�.. a cor�QV-rs : Instali3uort PACE�OF� S air �etViC� EI�clr'lC31 �i 1 __ �- , \ -- � j � � \ � - ADDRESS: � � � .� �� � �� APT: FLOOR: CITY: � � ,�,1 � DATE: 8 � / � / o � OCCUPANT• OWNER• s�� ��aa P� a HEAT LOSS: HEATING INSTALLED BY: ���§ ELECTRICAL WORK BY: � P�� D� GAS LINE BY: ���..5 � TYPE OF HEAT: GA FA � ROOFTOP SPACE HTR UNIT HTR OTHER .GAS DESIGN MANUFACTURER: � � ��� � MODEL: � 5ou � � ��� • o °To SERIAL: � °�� � � �� INPUT: � � , CONTROLS THERMOSTAT: "� ° �'� VENT SIZE: � I � VALVE: �, KIND OF LINER: s�zE NONE �'' LIMIT: DRAFT HOOD: REGULATOR: LIMIT SETTING: FILTERS - SIZE: �� x ZS 5 NUMBER: d FAN SETTING: °�° ����� CHIMNEY -� INSIDE OUTSIDE PILOT TYPE: � � °� � � � ��� CHIMNEY CONSTRUCTION: � �' , ,�¢ �s PILOT MAKE: PILOT MODEL: SMOKE BOMB: WIRING:� K, PILOT TIMING: � ���, DRAFT: TEST TAG: N�l����1 L.W. CUT OFF: DOOR PRESSURE: LIGHTING INST: PRESSURE: `� � S �� % COZ a : � DATE TESTED: � � �' �� D INPUT CFH: °T � % 02 � e� COMPANY TESTING: � Qe� �. STACK TEMP: ��� % CO �' NAME OF TESTER�� �� � �RC e 6�. ;�o � � ,�,�� . CIlYOF FRtDLEY FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287 February 14, 2003 Matt & Jan Smigleski 319 Ironton Street NE Fridley, MN 55432 Re: Final Inspection at 319 Ironton Street NE Contractor: Marsh Heating & Air Conditioning Iac Dear Matt & Jan Smigleski: A mechanical permit was issued on October 4, 2001 to install a furnace at your address. According to the 1991 Uniform Mechanical Code a final inspection shall be conducted on the work authorized by this permit. As of this date the inspection has not been requested. The permit fee that was paid covers the inspection to make sure the work was completed according to the C�es. We will keep your pernnit open for another 30 days and if we do not hear from you within this tune to set up the inspection, we will mark the permit "no inspectaon called for by homeowner after notification" and take no further action. To set up the inspection or to have any questions answered, please contact the Building Inspection Division at (763) 572-3604. Y� DA Inspector DJ/mh � o : �� a S `o' i 3 ; j < oa� � o � a i m � ; � t < � : c� � o� �� � t o = c� `- � < � � < � �� Q � � � � � � 0 � 3 '-• � � \ � � m �` � Z „ � 7 � v � °+ m � w � m Z � � n _I � Z -n m m � � 0 0 � _ O � � � N �• UI C \ 3 °• N d � C m � °� � °o� o ai o � � o �° �i � � � O � Q �. r+ � � � � � _ m � °' o � �� o � m � 0 _ � � � �` � d � VI Z " oa x � a Z � � � O ,f � � � I� � �1 � G � \ � \ � �, � �C ��°' o� � � �'a � y ,\ � i. Q. m m o � i c �i 3 • a a � � N � N :°•cu� « 3 � � � a >� f W o � � r � O � i� °—' � . v — � ' <: o � rN.� ���� � 7 � � - � � * � � � 1 s � Q Q �`� a� i o- � c� ; � � � i °' � 3 �.� rt ,,�30 Z 7' r+ � ) � N 3 i fl? (7 � + 3 '� o �D o �' o °' � �,' � m � � � a a v � � — ' O � O � M �. m � � � m � � rn � � 3 ,��, D N. . N 3- tn �°— ° o � �• ° ° n N � o � c��u N.�3 � Q, o u, � � � � , �: �. °1 0 o � � cn m o v °, 0 �. °, D N � N o �� a � r+; O � � oa � � �° � N � v � m � v N _o a � oa Z � c � � m � m v � � 5 m � o� -n � o � v�i � � a � � � � � � � �p N m � � �Q c ° 1 C � � mv � 0 � m � � m R� a m � � m v � r c�i� o 0 o c�i� T °o °o °o °o °o Im � � � � � � � � -� d Im � � 3 m � 1 d a m z o� I� I � v� m �° � W 1 � m � Q °, m = z� � � m aa c � � � a O fp �? = O o �° fD _ = jI� � � a � o v a� _ °- o v�'� � � K O � � � � v � � D �"' m v 0 � � mT N � -� Z 0 � � � � � � W c a � aa C m a � � � �� � � �, � � �' � C� w��'�� � =` c w z � �� O Cii m, TI �P � � .�i N <v � � r Z � m w W � C � r � v � � � � � m � O Z �a m � � r � D m � —vi z zo a� z� vo a� � �� W � 'O ° 0 Z � � � O D � Z � �v � _ � � � Z !� m � � �. � Z O � p r Z v� G� � c� m y �� � � O Z � N N � N 0 � � � FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS COMMON VENT. VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When realacin�a an existina furnace, the undersigned hereby verifies that the venting has been examined and is free from n�st, deterioration, obstnactions, and is securely supported and firestopped where required. Yes (} No () The venting system is plasticlPVC and meets all current codes and manufacturer specifications including sizing, length, number of elbows and termination. Yes () No () The undersigned also verifles 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 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 wrill be sized and installed to meet the current codes and manufacturer's specifications. Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) When installina a new ventina 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 Venting Tables for fan assisted and natural draft appliances. Yes () Is the common vent and vent connectors sized and installed coRectly after an appliance has been removed from the common vent and vented separately as per current codes. No ( ) Yes ( ) No ( ) Appliance Tvae and SizelCommon 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 Tatal 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 : ADDRESS PIN LEGAL DESC PERNIIT TYPE PROPERTY TYPE CONSTRUCTION TYPE CITY OF FRIDLEY 6431 ITNIVERSITY AVENUE NE FRIDLEY, MN 55432 s�z-36u4 r�Ax: : 319 IRONTON ST NE : 033024240013 : AUD SUB NO 103 (REV) : LOT 23 BLOCK 0 : HEATING : RESIDENTIAL : ADDITION/ALTERATION ��r� � �►�t;�r� PERNIIT NO.: 0.�� 0676"� �, DATE LSSUED: OS/11/2004 VALUATION : $ 0.00 NOTE: AIR CONDITIONERS CAN NOT BE PLACED IN A SIDE YARD WITHOUT WRITTEN PERNIISSION FROM ADJOINING PROPERTY OWNER. COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. INSTALL AN AIR CONDITIONER # A/C UI�TITS #FURNACES # GAS RANGES APPLICANT MARSH HEATING & AIR CONDITIONII�TG 6248 LAKELAND AVE N BROOKLYN PARK, MN 55420-2937 (763)536-0667 OWNER SMIGLESKI, MATT & JANAE 319 IRONTON ST NE FRIDLEY, MN 55432 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 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 regulating construction or the performance of construction. Applicant ,,� Date , , 1 VALUE OF APPL OR WORK 0 # GAS DRYERS 0 Bldg Insp � ��d��- Dat� � l�Z�� HEATING PERMIT NIINIMUM FEE FURNACE SHELL/DUCT WORK GAS RANGE FEE GAS DRYER FEE AIR CONDITIONII�TG FEE HEATING REPAIRS/ALTERATIONS STATE SURCHARGE, MECH FLAT TOTAL PAID WITH CHECK # 70236 SEPARATE PERNIITS REQUIRED FOR WORK OTI�R THAN DESCRIBED ABOVE. � 0 0.00 0.00 0.00 0.00 25.00 0.00 0.50 25.50 � ADDRESS PIN LEGAL DESC PERMIT TYPE CITY OF FRIDLEY 6431 UNIVERSITY AVENUE NE FRIDLEY, MN 55432 572-36U4 l+'AX: : 319 IRONTON ST NE : 033024240013 : AUD SUB NO 103 (RE� : LOT 23 BLOCK 0 d PROPERTY TYPE . CONSTRUCTION TYPE . ELECTRICAL RESIDENTIAL ADDITION/ALTERATION 571-1Zif7 �+ PERMIT NO.: 200400748 `� � DATE ISSUED: OS/20/2004 VALUATION . I NOTE: ELECTRICAL PERNIIT BECOMES VOID 12 MONTHS AFTER PERNIIT ISSUE DATE. WIRE AIR CONDITIONER ' # INSPECTIONS 1 APPLICANT SPARK ELECTRIC 2114 WASHINGTON ST NE MINNEAPOLIS, MN 55418- � .0 I`-`/�I�� SMIGLESKI, MATT & JANAE 319 IRONTON ST NE FRIDLEY, MN 55432 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 know the same to be true and correct. All provisions of laws and ordinances goveming 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 regulating construcrion or the performance of construction. Applicant Date Bldg Insp Date ELEC PERNIIT FEE - MIl�T (RESn STATE SURCHARGE, ELEC FLAT TOTAL PAID WITH CHECK # 39767 SEPARATE PERNIITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE. 20.00 0.50 20.50 I ADDRESS IPIN LEGAL DESC CITY OF FRIDLEY 6431 iTNIVERSITY AVENUE NE FRIDLEY, MN 55432 57Z-36U4 FAX: : 319 IRONTON ST NE : 033024240013 : AUD SUB NO 103 (RE� : LOT 23 BLOCK 0 571-1287 PERNIIT NO.: 2004-01468 DATE ISSUED: 09/Ol/2004 PERMIT TYPE : ELECTRICAL PROPERTY TYPE : RESIDENTIAL CONSTRUCTION TYPE : ADDITION/ALTERATION VALUATION . NOTE: ELECTRICAL PERNIIT BECOMES VOID 12 MONTHS AFTER PERNIIT ISSUE DATE. INSTALL SAVERS SWITCH. # INSPECTIONS 1 APPLICANT HUNT ELECTRIC CORPORATION 2300 TERRITORIAL RD ST PAUL, MN 55114- OWNER SMIGLESKI, MATT & JANAE 319 IRONTON ST NE FRIDLEY, MN 55432 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 lmow the same to be true and correct. All provisions of laws and ordinances governing this type of worls 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 regulating construction or the performance of construction. Applicant Date Bldg Insp Date ELEC PERNIIT FEE - MIN (RESn STATE SURCHARGE, ELEC FLAT TOTAL PAID WITH CHECK # 117431 SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVL�. 20.00 0.50 20.50 Building PLUMBING Permit 1vo.: ���.�,� I� � Inspections RESIDENTIAL APPLICATION Received By: , � 763-572-3604 CITY OF FRIDLEY Date Rec'd: ��.11 p�.`� �% DATE %�//� O 6 YOUR E-MAIL ADDRESS Sr[� nnDttESS °3 f 9 Ti��» �- 111 L- 7'FIIS APPLICANT IS: �WNER OCONTRACTOR PROPERTY Np�; J o � %h. �� OWNER/ ADDRESS: 3 1 9 i.sm � v� �/�%� CITY �r� cJ C4. �r STATE�ZIP sSy3.Z TENANT pHONE: `7� 3 3 70 S��,13 CONTRACTOR NpME: SUBMIT A COPY OF STATE LICENSE # EXP DATE YOUR STATE ADDRESS: CITY STATE ZIP LICENSE WITH PHONE F,47� APPLICATION PERMIT TYPE b'DU�GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE TYPE OF WORK: �w 0 REPLACEMENT DETAILED DESCRIPTION OF WORK .f�, S�/l�,�F�°pG., a.�' L.�; ( i h,�, 6,•,o�.e t��p/� ,��,es�,,,� V'e+ C,�ti/� �„�� k�r PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the improvement, installation or replacement of a residential fixture, excluding the fixtures:. (This_shnuidreflect only the cost of labor ) Iabor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor x.OS = FOR PROJECTS WI�RE LABOR EXCEEDS $500; FEES ARE BASED ON $10.00 PER FIX3'[JRB• €�X�T_�� l�If3r'FED.: FIXTUIt�S: �IGATE TOTAL -. -•+_ NUMBER OF EACH BELOVI� BATH SD�iK/LAV _FLOOR DRAINS SHOWER WATER PIPING BATHTUB GAS PIPING f��o c�rr�c�) SWA�NIII�G POOL WATER SOFINER ($35) _ CLOTI-IES WASHER _ KITCHEN SINK WATER CLOSET � BACKFLOW PREV. ($15) DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION _ WATER METER _ OTHER � � , . .. � ` '� � � � � �,� � , � ������ � � �s , � � � � _. '�.� �� ,y.-x .. � < , . „ ,.� .„��. M � �,,. �_.��: ;, , �.�,. � . ._. .>�-.� . �,M�� � � , r�` �'' t� � �� ;� �'' ` � � ,�,£ . Permit Fee $�t s. pCD Number of fixtures @$�10.00 � x$10.00 =$ Surchar e .50 Number of fixtures @$15.00 x$15.00 =$ TOTAL DUE $�. S� Number of fixtures @$35.00 x$35.00 =$ State Surcharge = $ .50 Tota1= $ THIS IS AN APPLICATION FOR A PERNIIT-NOT VALID UNTIL PROCESSED I hereby apply for a building permit and I aclrnowledge 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 a11 work which requires review and approval of plans. SIGNATURE OF APPLICANT i��s•-.- �� PRINT NAME "�T "e �� T: °�.9 DATE_ %�/ 1�� C� `�c -� �`r ' � _ � Q. � £ > �N , �� �� � � "� _.�6- . .........:: .�.,._�..-.., w �..�.�...r . �: � f '' n, � .> .. u..:,�,. _e . ...•, .�w.. ..�- a _ ' ' _' ' ,,. _ a w S t� ,.�.._.,.�_ _..... . ...y....__,1"�:... _.� � - . City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, NIN 55432 763-572-3604 FAX: 763-502-4977