AF - 47370Date:
Owner
Addr
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City of Fridley, Minn.
�
BUII.DING PERMIT N°- 3'7 0 2
....3.:-.�..:...�.. ....
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.!.`!%��Zi%Ll�...�..�• uilder .................. .........................
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ess ...ti.l..%.� "�......p�.� .. !.L Address .............................................
��/ rr�i. 0. �/. :9.'�s��
Corner Lot ............
� 3 d� LO�CATION OF BUILDING
. . .�� �f..� Part of t ......... ... ............
................ Addition or Sub-Division .... .. . ��..�.............
Inside Lot ............ Setback ............ Sideyard . ..... .......
.. ............
DESCRIPTION OF BUILDING
To be Used
a /t / /��c �
� . . . . . Front �0. .-,� I 'Depth .�{P :� Height ! ��� ' Sq. Ft. /�1.V. � G�. F't./�Q �.� �y
. . . . . . . . . . . . . . . . . . . Front � J . G y Depth � � : : fl'`Height . �Q. . � Sq. Ft. � .��. . Cu. Ft. � � 7 Q 7` O�'o—
_�--
Type of Construction ................... �� Cost..................... To be Completed ...................
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In consideration of tihe issuance to me o! a permit to construct the building desribed above, I a�ee to do
the proposed work in accordance with the description above set forth and in compHance with all provisiona of
ordinances of the city of Fridley.
.�. .���. . 4� . .. � .�.�.1. . . . . . . . . . . . . .
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In consideration of the payment of a fee of $��......, permft is hereby granted to ..............:....
. . . . . . . . . .. . . . . . . . . . . . . . . to construct the building or addition as described above. This germit ie granted upon
the express condition that the person to whom it is granted and his agents, employees and worlunen, in all work
done in, around and upon said buiiding, or any part thereof, shall conform in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings with-
in the city limits and this permit may be revoked at any time upon violation of an�f the provisions of said
ordinances. � / '
NOTICE: - .
� .
This permit does not cover the construction, inatallation or alteration tor
sewer o� water. Be sure to see the Buildinp Inspector for separate permits
�
itema
�aa heating,
APPLIC�.TION FOR $UILDIldG PERMIT , , �
GITY OF FRIDLEY, MINNESQT�..
Owners Name .12 -�+ v i�- 6 <T�l,� Builder ,� �i�M �,
S� N-c.. �
Address �_� � 1-- � `_� _.. ._ Address .,.,. � � � .
. _ � � LOGATION OF BUILD.ING.. : . . . .
, ����-C t� ' � ' i� � -� - Z , �
No. Street S.� � Part of I�ot 1� _._.---_.._,�
Lot ,,,,�� Block . � Addition or Sub. Div. �� � R-„�TE �„� ��-jL.
Co2ner Lot �'., insid� Lot. !� .._ Set Bsck ,
App].ican�., a�itach � to thi� form Ce�^tificate of � Survey of Lot and px�oposed . .
building location. �
DESCRIPTION OF BUILDING
To be used �as . .
. P 5 �'4' . ` , � ..
�� � s , D � � �t;, F�ont �.-.,�.a-...t= Depth ��Height � � �J�4- �.0 S _
Sq. F�. ._ � Cu. �''t. � ��
. . . F�ont �� Depth . r-. Height . ,
5q. F`t. Cu. Ft. .._..__._._,_ : �/
� ��
�pe of Construction .�'��'�'�- Fstimated Cost 1�� ��
To be completed � � `- ( �,� � �
The undersigned hereby makes application, for, a, pe�m,it for. the woz'k ' .
herein specified,�agreeing.to.do all work in atrict.accordance with t�e
�
�S'. _� o " ���_
City Qrdinances and ruling of the Depaxtment of Buildings, and hereby
declares that all the facts and.representa.tions sta�ted in th�.s applica�ion
are true and correct. '
De.te � .`. � - � cr � Signature
(l Schedule of Fee Costs can be found on the Reverae Side)
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Application far Rawer Ptants and He�ting, Coo�ing. Ventilatian, Refrigeratio�n and
Air Canditian�ng Systems and Devic�s
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR: RATE TOTAL
Furnace Shell & Duct Work . . . . . . . . . . . . . . . . . . . . . . . . . . 8.00 �
Replacement o! Furnace ............................. 5.00 �
Repairs & Alterations—up to $500.00 . . . . . . . . . . . . . . . . . . 5.OQ $
Repairs & Alterations each add. $500.00 . . . . . . . . . . . . . . . 2.50 $
MECH. WARM AIR
Furaace Shell & Duct Work to 120,000 BTIT . . . . . . . . . . . . 8.00
each add. 60,000 BTU ............. .. ....... . 2.00
Repiacement of �rnace . . . . . . . . . . .. . . . . ... . . .. . . . .. . 5.00
R.epairs & Alterations—up to $500.00 . . . . . . . . . . . . . . . . . 5.00
Repairs & Alterations each add. $500.00 . . .. . . . . . . .. . . 2.50
STEAM or HOT WATER $YSTEM
Furnace Shell & Lines—to 400 sq. it. EDR Steam ...... 8.00
F�rnace Shell 8c Line—to 640 sq. ft. EDR Hot Water ... 8.00
Each add. 200 sq. ft. EDR Steam . . . . . . . . . . . . . . . . . . . . . . 2.50
Each add. 320 sq. ft. EDft Hot Water . . . . : . . . . . . . . . . . . . 2.50
$ $: D d
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$
$
�
$
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OIL BIIRNER—to 3 gal. per hour . . . . . . . . . . . . . . . . . . . . . . . . 5.00 �
over 3 gal. per hour—See Fee Schedule
GAS BURNER (up to 400,000 BT[T) . . . . . . . . . . . . . . . . . . . . . . . 6.00 ��
GAS PIPING (Up to 3 Fixtures) . . . . . . . . . . . . . . . . . . . . . .. . . . 1.50 � 1.� V
(Add 50c each over 3>
AIR CONDITIO1�iIl�d
FAN HEATING SYSTEM
YENTILATING SYSTBM
ALTERATIONB 8c RE�AIRS
�
See Fee Schedule
$
TOTAL FEE ���2'�
RE�IAAS&
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Dept. of Bldgs. Phoae 3II 4-7470
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City of Fridley:
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The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City Ordinances
and ruling of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
Fridley,
Owner
Kind of Building
Used as
To be completed about �
Estimated Cost, $
Old ew. uilding Permit No. �� /'" d�
DESCRIPTION OF 1AOR8
195�.
195.�
195�
HEATING or POWEft PLANTS—Steam, Hot Water, Warm Air—No
Trade Nam (��ac�. Size No,.��D �
s
'�a�`it'y� Sq. .+�S�H!R %.�0 � D B � H.P.
Totai Connected Load—._�/ ��j Kind of Fue
BURNER. — Trade Nam Size No
Capacity Sq. F't. E.D.R BTIT H.P.
11 Pp� t M-8-58
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n.S6 ��9 / C� �/'� / C% t�.�� � a O
HEAT LO,,SS CALCULATIONS DEPARTMEIVT' OF BUILDINGS MINNEAPOLIS. MINN.
Weatherstrips A.S.H.V.E, Construction No. Iasulation
Guide
Windowa Doors Reference Out. Wall Int. Wall C.eiling Roof F1oor Kind How Applied
Yes—No Yes—No 19—
! Fl.� ` ° Room Length ,,r .� Width Height � ' Fl.� Room Length Width ,� Height
Win ows and Doors—Crackage and Area Windows and Doors—Crackage and Area
�Vidth Height No. of Llneal ft. Area , Wldth Height No. ot Llneal ft. Area � .
No. of pane of pane lighta o[ crack eq. tt. No. ot Dane ot pane llghte � ot crack eQ. tt.
�^o �3 ..L ..z .2 �/ �
.? a? o � �. .3 0
�z x � �
3 � ��" ,s� `� ,yd Coef. Btu Coef. Btu
Inhitration ' � �.� C� � In6ltration / � 8
Glaas �D d Glaas b
Exp. wall � b' %,L Exp. wall �,.? )( �
Net exp. wall I> O Net esp. wall p Q
Int. wall Int. wall
Ceilin Ceiling
Floor Floor
Total Btu. Tocal Btu. �
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
Fl.� Room � Length ' Width Height � FI.I Room ( I.ength � Width // Height
Windows and Doors—Crackage and Area Windows and Doors--Crackagt and Area
Wldth Helght No. of Lineal ft. Area Wldth Height No. of Lineal tt. Area �
No. o[ Dane of Dane lighta ot crack eQ. ft. No. of Dsne ot Dane Ilghte ot crack aq. tt.
°� � �' �` ..? 3 � / r_ � 3 � t �'t
Coef. Btu
In6ltration 3 ,y ,3 ,�
Glasa ,� D d a
Exp. wall ,R' �
Net exp. wall ,5 / b ~(,
Int. wa�!
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
Fl. Room � L.ength �,, Width Height
Windows and Doors—Crackage and Area
Width Helght No. o[ Lineal tt. Area
No. ot pane ot pane Iighte ot crack eq. ft.
2 , �- � % � �/ /A
Coef. Btu
In6ltration 3/ g �' / -
Glaaa � �
Exp. wall ,� �
Net eap. wall v
Int. wall
Ceiling
Floor
Tota) Btu.
Required aq. ft. E.D.R. or sq. ins. W.A. Leader area
Infiltration
Glaas
Exp. wall �„�
Net exp. wall
Int. wall
Ceiling
Floor
'I'otal Btu.
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Required sq. ft. E.D.R. or aq. ins. W.A. Leader area �
/ Fl•� Room I Length /� Width � Y Height �(
Windowa and Doors—Crackage and Area
Width Helght No. ot Ltneal ft. Ares
No. of pane ot�psne Iighta ot crack ep. tt.
�i8� P 8�1
.aZ .7 � i� O J �
/ .Z �-r� z
Coef. Btu
Inhltration G'% 3,� � S L
�� Glass
Exp. wall .,?
( � S � Net exp. wall
Int. wall
� Ceiling
Floor
�—(� ..Z� Total Bm.
' o s� � — b o
� / o ! d'�- o
ft. E.D.R. or sq. ins. W.A. Leade� area
.�6 . •
�� C�ty of Fridley
App�ica�ian for Plumbing cmd Gas Fitting Re�rmit
Dept. of Bldgs. Phoae SU 4-7
DESCRIPTION OF WORK QQ / _ /%
Number, Kind and Loeatioa of Fixtures Locatio ✓ / �✓
'n � U' � WATER HTR.
��� i x z u xy zz �8�Z �Z o= � c� Z• *
� 3U � e�o� � in 3� a� =i u.o U� <3 C�9t �4a �p F N GAS ELEC.
�
Base � � � � � %
�St ! 1 l l
2nd
3rd
4th
• Future Connectioa Openin�s
� New Fixture, Old Openiags
PARTIAL RATE SCHEDULE
Sewer H
Cesspool n
PLUMBING FIRTURE RATES: NO. RATE TOTAL
Number Fixtures . . . . . . . . . . . . . . . . . . . . . .—� x $1.50 $ % 0 • 5 �'
Future Fixture Opening ................ � x 1.20 $ � y a
New Fixture Old Opening . . . . . . . . . . . . . . x 1.00 $
Catch Basin ............................ x 3.25 $
Water Heater (Up to 200,000 BTLT) ...... r x 2.00 $ � d a
New Ground Run Old Bldg . . . . . . . . . . . . . x 3.25 $
GAS FITTING FEES: NO. RATE TOTAL
lst 3 Fixtures ...............:.........._L x$1.50 $ 1 S�
Additional Fixtures .................... x .50 $
Gas Range to 200,000 BTiT . .. . . . . . .... .. x 2.00 $
REPAIRS 8t ALTERATIONS—Refer to Code
Description ........................ $ .
......................
�roT�, r� $ � � O
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0
Clt3' O� �'1C�2y: L,, `
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The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City Ordinances
and ruling of the I?epartment of Buildings, and hereby declares bhat all the facts
and representations stated in this applicatian are true and correct.
r�iaiey, .ivr�n�. 2 , i s s:�'
, � �
C�Z'��/�ll. �
Kind of Building
Used as
�
To be completed about
� 4/ V
Estimated Cost, $ `�,�5 f �`
Old ew Building Permit No. �� /`' �
Signe�
7
By
Business Phone No. 2 Z�
JUN 3 1959 Rough
11 POST 1M-12-58
19_
19_
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CITY OF FRIDLEY
Effective Date May 1, 1988
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND
AIR CONDITIONING SYSTErqS AND DEVICES
FATE SCHEDULE
QESIDL�iTIAL
Furnace Shell and Duct Work,
Burner (Also replacement furnace)
Gas Pipinq ;
(pipinq needed with new furnace)
Gas Ranqe
Gas Dryer
* Air Conditioning (all sizes�
All Others/Repairs and Alterations
18 of Value of Appliance or work
COMMERCIAL/INDUSTRIAL
18 of Value of Appliance or Work
RATE TOTAL
$ 20.00 $ z�. `C'
S lo.00 $�
$ 10. 00 $
$ 10.00 $
$ 10.00 S�i�°°
$
S �
State Surchazge
TOTAL �E
Reinspection Fee ($15.00)
Rouqh insp.
Date
Final Insp. �— ( —�(/
Date
Approval for Permit ___`��
MINIMUM FEE FOR ANY AEATING PERMIT IS $15.00�
PLUS $.50 STATE SURCHARGE
$ .50
$ � ` �
$
Attach stack verification foffi with. replacement furnace peanits
+�Air Conditioners can not be placed in side yard without
written peiai.ssion fran adjofafng neiqhbor,
�
Job Address � �C % 11.0 � � �,,,_�. T'i" �i
�
Department of Suildings. 6431 Universfty Ave. N.E., Fridley, MN 55432
City of Fridley
Tel. #571-3450
The undersiqned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes
and rulinqs of the Department of Buildings, and hereby declares that all the
facts and representations stated in this application are'true and correct.
Fridley, Minn. '�9' , 19�
OWNER C/f'd:� �S �a'� t"' S
KZND OF BUILDING ,� � Ge�,�_
USED AS �2�5� �:�u •
TO BE COMPLETED ABOUT �/�s-- /��
ESTIMATED COST .�2 3(,rj• �
OLD - NEW BUILDING PERMIT NO. PERMIT NO. I C�� �
DESCRIPTION OF FURNACE/BURNER
'HEATING or POWER PLANTS, Steam, Hot Water Warm Air No.
Traae Name size No. � 3 f.�'- / �
CBpdCity Sq. Ft. EDR BTU `�.dL?d HP
Total Connected Load ��, C�CC- Kind of Fuel � rn? GiY__ �.
BURNER - Trade Name Size No. `
Capacity Sq. Ft. EDR BTU HP
�p�►y Standard Hea�tina & A/C
Siqned Hy
Te�. xo. _ 824-2656
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0
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•
CHIM�JEY ANJ 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 securely supported Yes ��\
5. Meets a11 current Code requirements for size and
total BTU connected
6. Has To ta 1 hea ti ng BTU' s of � �
Ail other BTU's `3`i-, � o
TOTAL 3 4 � �� �
Rema rk s
Ye s �)
No ( )
No ( )
No ( �
No _( )
No()
,
Com pa ny �
Siqned By .
Da te ,•����
410 W. LAKE ST. 1072 PAYNE AVE.
MINNEAPOLIS, MN 55408-2998 ST. PAUL, MN 55101-3892
612/824-2656 HEATING AND AIR CONDITIONING C0. 612/7 72-2449
�cServina The Twin Cities Siace 1930'
ORSAT TEST RECORD
ADDRESS 3[�� 6lr _�, cn/^ CITY
OCCUPANT
OWNER
DATE HTG. INST. INSTALLED BY �,
GAS LINE BY �t� � �
TYPE OF HEAT: GA FA HW S� SPACE HTR.
GAS DESIGN
MAKE MAKE
MODEL g MODEL
SERIAL b ��c�� )�� MAX.
INPUT ��j �� MAKE
CONTROLS
MODEL
UNIT HTR. OTHER
CONVERSION
OF BURNER_
BTU RATING
OF FURNACE
THERMOSTAT HEAT PLUG �� VENT SIZE 2��
VALVE !ti%� KIND OF LINER �l/G SIZE�`�NONE
LIMIT ����� DRAFT HOOD r RErULATOR
LIMIT SETTING / 7p CHIMNEY CONSTRUCTION �/ G
FAN SETTING �;-. DRAFT��IG ��.�.,,,�TEST TAG�a� �s �' G
A
PILOT TYPE �./ LICHTIN� rNST. �'i.L
PILOT MAKE
PILOT MODEL
PILOT TIMING � s7 .{�-.,,_,
PRESSURE � PERCENT CO2 DATE
INPUT CFH��__PERCENT 02 � %
STACK TEMP.��PERCENT CO /� � -� NAME
TESTED � Z % �i
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OF TESTER
sue�ecr :' .�ERMIT NO�'
c�ty of Fr�a�ey r� � �, ;� , ,
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
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; � RECEIPT NO.
� • COMMUNITY DEVEIOPMENT OIV.
r � v � PROTECTIVE INSPECTION SEC. �� �
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1 �
, � �'��1 � CITV HALL FRIDLEY 55432 NUMBEA NEV DATE PAGE OF APPROVED 8�
�""'�'� �'' 612-571-3450 9�0-F�5 5/6/97 / /
JOB ADDRESS 6301 Jackson Street NE
1 LEGAL LOT NO. BLOCK TRAC? OH ADDITION SEE ATTACHED
DESCR. ZO,Pt 19& 1 5 Florence Park Addn to Fridley SNEET
2 PfiOPERTY OWNER MAIL ADDRESS ZIP PHONE
3 CONTRACTOR MAI� ADORESS Z�P PHONE LICENSE NO.
Steven Woods Construction 6830 Beard AVe N, Brookl n Center Mn 55429 6810
4 ARCHITECT OR DESIGNER MAIL ADDiiESS ZIP PHONE LICENSE NO.
537-2664
5 ENGINEER MAIL A�DRESS Z�P PHONE LICENSE NO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW O ADDITION ❑ ALTERATION � REPAIR O MOVE O REMOVE
8 DESCRIBE WORK
Reroof House & Garage (20 Sq) Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
TYPEOFCONST. OCCUPANCYGROUP OCCUPANCVLOAD
SEPARATE PERMITS ARE REQUIFED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAVS, OR IF CONSTRUCTION
OR WORK IS SUSPENOED OR ABANDONEO FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OfFSTREET PARKING
I HEREBY CERTIFV THAT I HAVE READ AND EXAMINED THIS APPL�CATION 1 STALLS GAFAGES
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 �1,650 �.H3
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING Of A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOIATE OR CANCEL THE pERMiT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING coN- �54.0� �.S�F.00IF Fire .SCi �1.65
STRUCTION OR THE RfORMANCE OF CONSTRUCTION.
.� �C,� �J � �� PLAN CHECK FEE OTAL FEE
� ut o� Licens C .00 $115.48
S�GNATU�7EOFCON'RACT0�70pP.UTH0�7�ZEDNGENT IDA EI E ERLY V LI ATED THIS IS VOUR PERMIT
� �.�f • �
S�GNATU�7E OF OWNEP iIF OWNER BUILDERi �DATEI DG INS� ���TE
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ADDN
ALTER
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ConstructionAddress:
Legal Description:
CII'Y OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
�� � �
�
Effective lll/97
���
Owner Name & Address: � Tel. #
Contractor: ���m � � � MN LICENSE # � � � �
Address: _� �3 � �� � �`� �• v'
!
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IlIZPROVEMENT •
LIVING AREA: Length Width
GARAGE AREA: Length
DECK AREA:
OTHER:
Construction Type:
Width
Tel. #
Height Sq. Ft.
Height Sq. Ft.
Driveway Curb Cut Width Needed:
(r'ee Schedule on BacJz)
F�+6Ft= Ftx $ _$
DATE: ��o APPLICANT: � L,�� �V O � CLS Tel. # s3 %� v� G�
�
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
�'Y. � U CITY USE ONLY
S�° $� �ee Schedule on Reverse Side
l� � $ .001 of Permit Valuation (1/lOth%)
� $ � $.50/$1,000 Valuation
$ $950 per SAC Unit
License Surcharge $ �� C� l� $5.00 (State Licensed Residential Contractors)
Driveway Escrow $ Alt. "A" or Alt. "B" Above
Erosion Control $ �$450.00 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement Necessary [) Not Necessary []
TOTAL
STIPULATIONS:
���i.
— ; ����
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.- •
CITY OF FRIDLEY PERMIT NO.: 2004-00���
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432 DATE ISSUED: 02/09/2004
(763) 572-3604 FAX: (763) 571-1287
ADDRESS : 6301 JACKSON ST NE
PIN : 143024410090
LEGAL DESC : UNAVAILABLE
: LOT BLOCK
PERMIT TYPE : PLUMBING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION .
NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A
INSTALL GAS WATER HEATER
# ELEC WATER HEATERS 0 VALUE OF FIXTURE/APPLIANCE 0
# NEW FIXTURES (EXIST OPENINGS) 0 # GAS WATER HEATERS 1
# GAS DRYERS 0 # GAS RANGES 0
# OF NEW FIXTURES 0 ENTER VALUATION 720
# WATER TRMT APPLIANCES 0
APPLICANT PLBG PERMIT 1LZINIMUM FEE 20.00
TIMS QUALITY PLUMBING 1NC PLBG FIXTURES (NEW OPENINGS) 0.00
523 CENTRAL AVE PLBG FIXTURES (EXIST OPENINGS) 0.00
OSSEO, MN 55369- WATER TREATMENT APPLIANCE 0.00
(763) 571-0454 WATER HEATER - ELEC 0.00
WATER HEATER - GAS 0.00
GAS RANGE FEE 0.00
OWNER GAS DRYER FEE 0.00
REES CHARLES M& LORRAINE C PLBG REPAIR/ALTERATIONS 0.00
6301 JACKSON ST NE STATE SURCHARGE, PLBG FLAT 0.50
FRIDLEY, MN 55432 TOTAL 20.50
PAID WITH CHECK # 8723
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 governing this type of work
will be complied with whether specified herein or not. T'he
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 rformance of construction.
Applicant Date
Bldg Ins � Dat� !�
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
Ci�"Y pF �RlDi.cY INSPECTION DIV.
6431 University Ave NE
Fridtey, MN 55432
(763} 572-3604, FAX (763) 571-1287
Stories
Fioor
Floor 4
PLUMBING FIXTURE RATES:
Urinal
APPLICA710N F4R PLUMBING AND GAS FITTING PERMI7
BER OF FIXTURES
�:f"��<: Wash
NO, RATE 70TAL
New Fixtures $ 7.00
Oid Opening, New Fixture $ 4.00
Beer Dispenser �m $ 5.00
Biow Off Basin $ 7.00
Catch Basin $ 7.00
Rain Water Leader � $ 7.00
Sump/Receiving Tank $ 7.00
Water Treating Appiiance $10.00
Water Heater -Electric $ 7.00
Water Heater - Gas•' � $10.00 �
Gas Range" _,,,, $10.00
Gas Dryer" ; $10.00
Back Ftow Preventer Required ()Yes () No
Type $15.00
Reinspection Fee $47.00/Hr
aLL OTHERS AND/OR REPAIRS AND ALTERATIONS .� �,� jJ
1.5'io of Vatue of Fixture or Appliance p�1=_
State Surcharge
TOTALFEE
�
•
�,,I
BE INSTALLED ON EACH FLOOR
{�{ ��f,�;;'�`� Fioor ���+� ��;; Auto.
,��'"' . �,z .�frf� {::
��'�.��,':� Drain ��f1'%;;: Washer
JOB
Ett�cuve Uri Jari �, ��u.:
G8s �{�$�, Water Heater
Range �Ixt;: .. „ ; Gas Elec
� ��
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the city codes
and rutings of the Buiiding Divislon, and hereby declares that all the facts
and representations stated in this application are true and correct.
1 ✓� , Zoc�`�
Owner
Building Used
�/ � occ.,�-t _ a r �: l � , ;
Estimated Cost "L�` PERMIT NO.� _
` ^ �PLUMBING COMPAN
SIGNED BY TEL NO.��,� �
J
�.:: , t_ d: ; �.. t. ;
Approved By � Rough-In Date Final Date � t' r
MIN�MUM FEE FOR ANY P1.UMBING/GAS PERMIT IS 520.00
PLUS THE 5,50 STATE SURCHARGE
COMBt�"STION AIR SHALL BE PR4VIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE
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