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AF - 47447n � � � Date: ,�.•.� City of Fridley, Minn. BUILDING PERMIT July 8, 1968 Homedale Blders. g��. Same Adaress —._5.217�T��zata Blvd. _ Address SaTas— , �To 9817 LOCATION OP BUILDING No. .�.. 74�8 Street Jackson St. N. E. ____ p� of Lot Lot _.._ 2 _ Block 2 Addition or Sub-Divfsion —M�l�,y__Mannr �rd Coraer Lot — Inside Lot —. X Setback 35 ��._ Sideyard 10' / 5' Sewer Elevatian �._.._ 880.71 �� R$� 71 Top of Footing DESCRIPTION OF BUILDING To be Used as: Dwelling �t 46' �p� 2 28 xei�ht �' Sq. F't. _1]52. C�. Ft, Garage �nt 19' �P� 24' ���t 10 gq, � 456 �, �, 4560 Zj►pe of Construciaton _._. Frame F..st. Coat ......�-,�.QQ._......___ To be Completed - n_.s.r _ � T7 nHSt SLWER LOCATION - 1�' North of Manhole WATER LOCATION - 116' Nmrhh of Manhole In conaideration of the issuance to me of a permit to construct the building described above I agree to do the proposed work in accordance with the description above aet Porth and in compliance with a�l proviafona oP orrlinances oY the dty of Fridley. ,� �, � ,� 10(1!00 Sewer In consfderation of the payment of a fee oE $ �+3 . 00 ��t � h��, �� ,� I3omedale Blders . to oonstruct the building or addition as described above. Thisperm� t ia granted upon the express c�ndition that the peraon to whom ft ia granted and hia agents, employees an� worlmien, in a11 work dane in, around and u�n eaid building, or any part thereof, shall �n4orm in all respects tfl the ordinances of FridleY� Minnesota regar8ing location, constructfon, alteration, maintenance, repair and moving of bufl�ng� wlthin 'the dtY limi'ts and this Permit may be revoked at ar�y time upon violation of any oP the Provteiona of eald ordinaacea. � . �ufltiinBInspector Clarence Belisle NOTIC� ihb psrmh does eof eovsr ths eo�ueN�, le�tallatloe hr vrUteg, plumbine, �as 6eM►eg, saw�r er wtlsr. B� sun !o sss tha BuiWlee I�o� fee sspuate parmits Por thas Huns. � � � . APPLICAT:COPI FOR BUILD?NG PEI�MIT CIZ`Y OF FRSDLEY, 1�1II�1UZE50TA _ �' , . . . � �,�, - . - OWNER' S NAI+� $UILDER ADDi�c.SS .. � . . _�.,�T1D�S�.`���_%..�G��if'�' r��������'� +.�.�r ..i - - r � s �i� , � � _ ^f�i �.E��;' ' ::! � �i .:. , . L TION OF� �gU7G�.1}�Nd, . . � • �: :s:. -;� . � , . . .. .. N0.-J=�--,�I�-�--STxEET ' �.�+���- �.: �...:�. . .; . —._, � �. LOT BLQCR _� ADDITION OR SIISD�VIS�i��i��''�� �' � �--�--. . � . . . � ; .. -..�����.��� �� CORi3ER �OT • � �NSI�E. LOT� V� . < . : SETfl�CK ��!�� � ���4' ,,�D. • . . � �--� __�_____�___ .. -; ����..�..�..:- SEWER ELEVATION O g� •% I T�P OF FOOTiNG ���� ��� f��� � Ap��i��t aCtac��to i t b is�form 2�ro Certificates of Surveq oP Lot and pr�opoe�d buil iag �ocatioa drac�a on � tilrese CerC�ficates . . .; � ,�, , . •.,, , :.,a, , . S?��s�c%� � /D ��� ��%• �d�- �a2j. �! . . •. ' . -, . -t , . . � . ' • � . :.=r: �;,. , '• DES�RIPTION OF B�IT.I?�NG, • : . . � � • . . . . - � . . �. , , . _ . . . ��:: , � To Se Used Asa . . ' I������ ��� _ � e_ „___� �1 / .. _ _� �a� /,� �, _ . -. .. � ��' . , . . � � : . �� �. � � �. •_ - „�, , .� �; �• , • , ' �Square feet �, ,i . �,' - Eubic Feet . . , � • . Front��, Depth� $eight � � , ; ;..,.,.: . . � . Square feet' ��`r% Cubia Feet- � ' Tqpe of Coastructioa ,Esti�ated Cost�__ . ��`����' �-- _ r�!- To Be C�pleted The undersigned hereby makes app�ication for a permit for the work hereia speciiied, agreeing to d all work in etr3ct accordance with the Citq of Fridley Ord�tnances aad ru�in�s af the DepartmenC of Buildings, and herebq declaresfthat all the facts and representations stated in this appllcatloA are tru� and correct. DATE �'� ; � SIGNAT�7RE /� , �� � � (Schedule of Fee Coats caa be fvund on the Reverse Side). ��'�"'��� �- '� > , � a', - p - `� _ -_ - '-,� a l:� ^ /� I 1 � � S ` BUILDING pERMIT FEE SC�DULE� �.. � . SECTION 2�, The.InepecCoY of Buildinga.shal,�, �efore isauing perinits for ei erection of �ny_building �r structure, or for any addition Co any � e�tilsting s�r�c-ture' or"bt�ilding, or fer a.t�y altergtibn or repairs t`o �any existing building or ��'tt+cCure, upon application th�.refore, require the •• � t�e payment bq the' �app����nt fo� sueh �ermit � of i�eE to •the am�bunt 'herein belaw set forth and ia the. manner herin prov�.ded to-w�tt: .. -_ IIniform ?�uildia� Code: Type •1, �2, ���=� $1:75� for each one ��iousani� cubic feet, or f�cactiac� thereof, in such cubical contents. Type 3� 5- $1.50 for � _ each one theuaand cubi��feet. �' . - •- � � �• �� � - F�� the �aur-�ose ef`ccmputing fees for buiidi�g permits, the cubical'��� contents �f any buildittg or additiort t• a yadiform h�ight throughaut by � multiplyin� the groun8 area co�vere�l frvm �a �o�nt eis '�6) iach�e be�.o�i the f1oo� tiae af tke basement or the cellar te the'a�i�rage�heiight of the upper eurface or to the average he�tght of.the roof,su�face.,of ehe main gable of a pitched roof . � . . • . .. . . For_repair.s o� s�terations to aa �xistiag struceur�; 'ttie fe�� s1�a�.Y be at the rate qE $3.00 pez each five hundred do118rs ($500,00) or fraction thereof . . . in the co�t •f a11 proposed wark, . ... .. ,.. . . . . ... ... In na case sha1Z the. fee chaxged �oi �nq permit as sez�� forth' ix% Sectfon 2 be less thata; $S.AO. . - . , NSSSD Can�ecti�n Chargea basad on locatiess- A�cea 1 or 2. i��1 � � -P--f - s . :��� � � , :. . .. . , . , . . ���. . ..' .. ��> �� t, .. ,. . . , . �? .. . � . � . "� >� i"� • ,, i_ I � l� Pl�rnrrn3 c�.S�ey,�y Sorts Test�,y t'�w,l �- ,N�ir�pa> E�,���� � L" � .a+ / &873 N,�h� �GS y�. M.��1�s32, ENGiNE�i�ING, INC. ���,� . SUn�f 4�0�6 — En�ineers � � Surve�/or� -�--- cests�ic�te o� s�s�r�e �o: T � i �m oEVgt�Q�m�n� � a��� � w .� � � � - � O � Y v a � 1 � � � � DENOTES IRONip�,NOT�g .OQAtr�e►GE an�D �T�1.�TY EASEMf.1�1T LOT Z�_BLOCk ��,MEl.00Y MANO�t 3RC ADCiT1AN Awox� c TY / Rr1t�6rc� e�i�y fhof llu� �s o trt�e aru/ mrreef re�ese�o��n o�'4 srr�ef �� �s � aGeir c(�;6ed la�f. c�nd' a`'liSc �acot,ian c�('oU �d�rlear�s , Ikna►� , e�d�d/ ris,6de ��rrnochmtnff ,,j'a,y. �ran av� r�t�1 �mrd. as su►we�ed ty m�e /Jos --� � �!_T� A,D. �9.�. StlBUldBAN EIYGlNEERING . 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Z. � � > A m � � O.p.� `� � �� b � � �''° � � �o�� � €'t � fD �. ���� � o� �' � � � ���� � .� � �. � ���� � b �� �� p � €Z m o �p'oe� fD e�o a� M ~ ���w � p. ¢ �. � � �. �B�►°� �m�� m : �o � � � � ►s � 3�� C �� �A �� O. u'� � � & �°n i� � M o �. � � � � �; �i 0 � $ � . � � � �7 � � � � � � ;+ �r�i, � �� D x� 0 m � � � � � � d � � � � � p � : � : 7i :Y ' M • M : o � a . m � : � . �� • O N � � "� � '� a�� p� � w�� z x � � W z � 8 � � � � � c� �p � (�i � � Wi fD �-7 �°�'�������� � s' � � � � � ~ : � � � � � � : � � b ¢ � � � �. : � ": �`°: � a ° � � . Pn n Q �: : � � � � . . . � � . � . . . . . OC . . . : : : : � � : : : N 0 0 x �e x�°' x �a k k�s k� � &J 6'3 &! W W '� F�+ i,-�+ N S� S��� �� g o g� 9: �A � Efl t!3 t!! {fl Ef! Hi • y � � � � 1 � � � Q x D � r � � m � � _ m C r m � � � i �' ~ � a � w � � � 8 �• � � �� p � � I � �� ��a� $ M O v�i � � � � � Ary � � � y 8 a � t� � o � � � � � �� � w � g � � � � ° ��� � `�o N ' a . WATER � URINALS �� � ewsin�s SINKS W�, rw�vs DRINK. FOUNT. s►+was. FLOOR DRAINS GTCH BASINS �uro w�sr�e GAS APPL �� RANGE GAS OPENINGS a • z w � � � A n � ��� � a � � �� � � �a� � p ,,o� Q4 a � �a � � ���� � ���,� �� � � � ���� � �°��.� � � ���� � b 0 y � m p � m a ��+ p, o p id � .y o � ���� ro 0o p'� �� ����: ���ti �� W� �� � w �'�o �aoa' ►• � � ]' I m�� � t.. C �' d r`C n � ro w� Rx & �°n p � M� �� � � � 0 � � I � � N �J-1 • �il F-' 'b � �i 0 a � � � � � � .�' � '9 O_ � � � ». � � � � b� 0 m � � � � ��� - SUBJECT R . City of Fridley o 1618 8� ' ` AT THE TOP OF THE TWINS g U I L D I N G P E R M I T R IPT NO r � `v _.�_� COMMUNITY DEVELOPMENT DIV. r j � PROTECTIVE INSPECTION SEC. � a � � _ � l---.� �����,,� CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BV L 612-571-3450 910-F15 5/14/81 � � 'oe ^°l�� Jackson Street N. E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 2 2 Mel ody Manor 3rd Addi ti on SHEET 2 PROPERTYOWNER MAILADDHESS ZIP PHONE Ronald E. Nekola 7478 Jackson Street N.E. 786-3716 3 CONTRACTOA MAILADDRESS ZIP PHONE LICENSENO. 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO. 8 USE OF BUILDING garage residential 7 CLASS OF WORK ❑ NEW �J ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE O REMOVE 8 DESCRIBE WORK 18' by 20' Addition to an existing garage 9 CHANGE qF USE FROM TO STIPULATIONS 1. No windows on the north side of the addition �ATE PERMITS REQUIRED FOR ��G� � aCPE �� �� ��.�e�'� �� I�EA�ING, PI.UMBING AND SIC�NS. ��►� ca��to c.��� ce 8���`� �`��'��\ � �� ge�° pC1F." � ����,Q� �`��O 4 SEPARATE PERMITS ARE RE�UIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING. WOOCI 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 ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINEO THIS APPLICATION STAL�S 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 3�q,O2 �.7O 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- p STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. �"r.4O PLAN CHECKFEE TOTALFEE 16.10 III�ATU'�� TOROR UTH, RIZEDAGENT �re� _ EN�Y��TE�S S Y RM� �- �i / � ' ,� SIGNATUREOFOWNER�IFOWNERBUILDEii� �DATEI BLDG INSP �pTE c�YV ar �«io�cY . � Af'PLIC11TI0'� FOft RE:SI[)EhITIIti_ (3U1LDItJG PGRi�lI7S � � � (Wc�•r, Al �er��i:ians, Additions, or Repairs) � OtJt1ER: �o�%�� �r .�.c���� . [3UILpER: • - • ADD�:ESS: 7�/�� �.�'��%�So:� S�, �e.�, 11pDRCSS: - TEL �►0: ��f - � ?� TEl ��d0: ' ' Const-ruction Location ' . . sT�T rio : '� `7 � STREET: ��� ��i`�'a,�em' S �'`� �r � , ��it�.�,� i �.i�/P i.o�: ;� si.oac: �_ �nniTZO�: ,���t-.0 �� 7� .�'�'�.���' ��',��f�''J� Corner Lot: inside Lot: Setback: Sideyards: Applicant attach to tliis form tcao Certificates o£ S�rvey of lot and proposed building location drawn on certificates to scale. . � DESCRIPTIOiv OF C�fdSTRUCTIOPd - . � � �C�e�Front: !�� Depth: v'�—� Height: Squane. Feet: � � � Qtbic Fcet: � �'ront: Depth: Height: . Square• Feet: � Glabic I'eet: . Y Type of Consrruc�ion: Estiunated Cost: $� �d Zb Be Oo��pleted: ' . _ Alt. A Alt. B Froposed Drive��ay Width If New Opening Is Desired: $� $ . . S�� R�VERSE SIDE OF SHEET . The unaersigned hereby ma}:es applic�ticn for a permit for the �:�ork'herein specified, agreeing to c?o .all work in strict accordance �•�ith the City of I'ridley Ordinances �id xulings of tlie Departmen� of Bilildings, and hereby declares that all tl�e iacts and represen�Ztions stated :s� this application are true and correct. D.iT�: ��'�� �� SIGNATUF�: � ,� 1/����� • � S�i��ula L- ions : � �� �v � �, �U _ � � ( d . f .� � . , . Bu�i_n�r�c �c�r�rir�t�r r-c:�_ sc�ir_nut_c� � . . - . � ;1::C'rx01�� 2. �'1'l�Z� 7n�c��ecLar. of llai.lc?in�J ::ch��l.7., ?�ctor:c: i.:�.a.i�icJ pr:»nit� Tor i:lic cracL•i.on c�t ���►y l�u�.].�l.ir�!� t�x :�i::.-uct:urc:, or. £��: uny adcli.Ci.r�n +.:o any cr,i;;L-3.nq Ltiilding nr ::tzuc�:ur.�� cir. l:��� r>>iy aa.t.c:r��L•irni or. r.el,<<ir.:� L•o •any e;:i.::L•in�� hc�i.).di.�r.J oz sL•��ucture, UJ)C�11 ax���li.c:ata.on thcr.�:Lor.e, r.cqu.i.�:c U�c �,caymc��t� ?�y U�c ax�p].i.�ant: tnz- :;ucli ��er.m9.t• of fee, to tl�e �nount hcxuii� be1.U�•� seC Lor.th �uid i�i tlic �nannel: hcrcin ��roviclecl t•o-�::it: . 11;:1•J COI1:�:`!7'cUCTIO2J; Si�igJ.c L•'amil.y Iloiacs and G�r.aqcs: y�l.00/7.,000 cu1.�i.c tea�. • P7,A?d CIt1:C1:: 25 i�erce�,t: of hu3.1c1incJ J�e�-mii: ic:e. URIVEI;111' llL•'I'P.c:SSIOI•I: (Cpncretc, Gt�rb �LZCets Only? �' ' Al.ternat:e A: lte�noval and re��laccment of concrete cuzb and gutter only; uriveway �•ridth plus 6 feet x$13. �0 AltcrnaL•e II: Removal and replacement of concrete curb and • � guttcr and inst�ll a 3 fooL- � wide approac:h ceith '' ' ,� 6 inch depth; Drivew�y �•�ic:th �plus G ieet x$15., 75 • . �DDI i I ON/1L I Ni=OR'�f/1T I ON I'or the �uri�se of co�npui.ing i'ees for building permits,. L-he cubical. contents of any build�.nc� or addition, is deter.mi.ned by rnuli:iplyir►g the ground area covered iro:n a poxnt sir. (6) inches belof� ihe i'loor ]_a.ne oi tlze basement or th� cellar to tiie average iieights of the •up�er sur.face or i:o the average height of the roof surf:ace oi the raain gable of a pitched rooi. • � Fox reFaixs or a].terations to ar► existing stL-�icture, the fee shall be at the xate . of $3 .00 Pex cach fivc hundred dollars -($500.00) or fraction tlierc:af in the cost oi' all proposed wor.k. . , - In •no c.ase shal.l the fee charged fc�r any pPxmit as set iorth a.n Secti�n 2 be less - than $?.50 plus $.5Q state surcharge. � � - � , . V�RI F I CATIO�! OF F(1U��IDA1 I Of� NOTE: I'ermits �or construction ��ill be issued a minimtun oi 29 hours £rom the time of ap�lication to a].low for proper re�rie�,r of the pro�osed sfxucture and of ihe , construction site. � . A Certificate � of Survey of the lot, shoc,*inq the l.ocation ot tiie foundation once it has been cons�ructed �aall be required before proceeding with the iraming. �F,RTIFICATE OF ��CUPAh�CY � ' ?►PPlicatic�n ior a Certificate oi Occlipancy shall k�e mad�� ten (10) days priar to the u; e or occur3nCy oi any structure for ��hich a Liuil�iing permit 12as been issued; and said struct.ure shall not be used oz� occupied L,.�iL-il a Cezi.i.ficate ot OccuP�ncy h�s been xssued. � � �, • � t • . • . , • , . "°�,� n(o: : a ,;.� -� , -, .,. � . :.. - z — =� ' R�� ai' � "X.�r _ 4�x =,.F`„ t . � �� �a `t-f. pP � �.�.�. s }. .; � .. �`:' a �d � -a . �� °�*,ti �s 9� x, .� .o.-s .., f ,'�,., ,�,� � d 'r ��`.• � °:mr � �i�= �oi�{V'..r �YAi1i ro - f "s .s.. � � `F �SCAGE."� IYCH�EET� �i` �'��'°�f6029ELBYAVENUE.'737".PAULlIHf04 � � TELEPHONLG�6468BSB �r�� lvia'�: 4 . l ;, � � ' ' - -) .. � y�}, �. '�� R. ; AA;.._E,,,�. -_..,�, " � � . a � . S, z _ ^� . � W 4rY °t� .7�i _� +..� sl� .� �-Sr_ A � $ �6"��y`.." � � ,R � _���� �'��1 :� :'�• ��� { -� � �~ -t' � j.� ��'r8„i�+ � �'' T� 'rG�Yf•'�'i'�". ! �3: t � -`L �.i.lt�" i''n � y - - � _tt r. ' - � � .< �:i S"' ..C, t '8 '�%S ��z- �. � �:.s'��..� . �. :' .� � ��::.: . . .,_� � ..ab. :. . , ::�� . � __ � I .r- 4. , y _ � �a _ F ' T. �_ i : 3S : w-d�`� � f. a C'' � o- e. . *a , �'_ � S rO�F PRQPERTY: OF �Rbnalc% E.= Ple3�ola' � m � . � - . ~� - •,,;, y�,°-L� _� � - -� ,,�.�,5 :,N g , x. '� �,. � ��: � �g., ,�„g ,*�y-. ..,a-'$tua � . -' ::':'. .. � _,,,- +�..... .v .� . �.,. . . t ,�' �..-. r x�- .,4c � ,+ r- -.. y R" �.S °' '� �a,�. "` L T[O `�� J�K:a�Cil 5�i�'i a 1'� i Ti' • ^r � 1.�i�6g -.> n, . _ ° ', L *�„'°�' s•c ; -� ,� - ` y s" s �3Z1990t.$ r ' � °.�;. �� 4 � a�..�. +� � . ??_ s ' `=+ { . : _,:�:;,: �t � -2 �': Block =�2 � -- Meloc�y I�arsor-'3rd '.�ddi.tior� ' �� `3nok8 . V � y _ •� r �-. 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FRIDLEY, MINNESOTA 55432 • PHONE (612) 571-3450 June 8, 1990 Bruce Plumbing Co. 4747 Twin Lake Avenue Brooklyn Center, MN 55429 Re: 7478 Jackson Street N.E., Fridley Dear Sirs: As per our telephone conversation on May 5, 1990, a vacuum breaker must be installed on the hose threaded faucet your company installed at the above address. Please complete this item as soon as possible and call for a reinspection. If you have any questions on this matter, please call me at 572-3603. Sincerely, i .' , , -- ; , � � ' `'L-C l'i:, ( � C '/' �.� t�C' CLYD WILEY / Bldg/Mech Inspector cw/mh sue�ecT • PERMIT N�-- --. c�ty of Fridley 2�. s o� AT THE TOP OF THE TWINS g U I L D I N G P E R M I T r ; � O. � `y _ COMMUNITY DEVELOPMENT DIV. �� �� r � � PROTECTIVE INSPECTION SEC. i� j � ----� �r'��;•, CITY HALL FRIDLEY 85432 NUMBER REV DATE PAGE OF APPROVED 8Y i 612-571-3450 810-F15 10/13/92 / / JOB ADDRESS 7478 Jackson Street NE LOT NO. BLOCK TRACT OR ADDITION t LEGAL SEEATTACHED OESCR. 2 2 Melody Manor 3rd SHEET 2 PROPERTYOWNER MAILADDRES$ 21P PHONE Ron Nekola 7478 Jacks.on Street NE 786-3716 3 CONTRACTOR MAIL ADDRESS Z�P PHONE LICENSE NO. Patio Enclosures Inc. 5120 Cedar Lake Rd, Mpls 55416 525^1494 1676 4 ARCHITECT OR DESIGNEH MAIL ADDRESS 21P PHONE LICENSE NO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO. 8 USE OF BUILDIN(3 Residential 7 CLASS OF WORK O NEW � ADDiTION O ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Construct a 12' x 18 �'I'hree Seascan �orch and a 12' x 8' Deck 8 CHAN(iE OF USE FROM TO STIPULATIONS See nntations, on plan. Z�dd smoke detectors in dwelli.ng unless they are already installed� ��������� Befere digging call for aBl utility locations EPARATE PERMIi'S REQUiREi3 FOR ��•0002 lg�R6f�G, HEf�Ti�VG, PLi��4��JiVG A�D SIGNS. REQUIREID �Y LA►� SEPARATE PERMITS ARE REQUIpED FOR ELECTRICAL, PLUMBING, HEATtNG, �PE OF CONST, OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OH CONSTfiUCTION ZONING SQ. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED Ofi ABANDONED FOH A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. OWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFV THAT I HAVE READ ANO EXAMINED THIS APPLICATION �- STALLS GAHAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS ypLUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OP WORK WILL BE COMPLIED $5 r �Z 3 $2 e 86 WITH WHETHER SPECIFIED HEREIN OR NOT. TFIE aRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- $81. 00. Fire SC $S. %2 STRUCT OR THE PERFORMANC F CONSTRUCTION. � PLAN CHECK FEE TOTAI FEE i�, ,� � �,3 �i License SC $5.00 $94. 58 SIGNATURE TRACTORORAUTHOR12EDAGENT IDATEI WHEN RO RlY VA ID '�D THIS IS YOUR PERMIT � � � /O-�� � SiGNATUREOFOWNERUFOWNERBUILDERi - IDATE� "'�BLOG �N " �FTE NEW [ ] ADUN,� ALTER [ ] CITY OF FRIDI.EY SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Building Permit Application Eff� 3/1/92 Constcvction Address: �� �� �/� � fi �f�/r� �`� ��-�. Legal Description: - Owner Name & Address: }�' � � � �' /� p L � Tel. # 78(a - � 7/ f� Contractor: �i�jT/!3 �/ld��D.Sfl��� .�/1/� < MN LICENSE � ��� ���� Address: � l .2 � � � �/Q/� �I`i � ���%� �1✓� ,�,,��/�Tel. # J �� ��9� = Attach to this appli�tion, a C�rtificate of Survey of the lot, with e propased COns�trucdon drawn on it to scale. � � � „ ON OF IIIRPRUVEMENT LIVING AREA: Le�ttgth �� Width � Hei,ght � Sq. Ft. �.I � GARAGE AREA: Length Wi�h Height Sq. Ft. DECK AREA: Length l�, Width �� Hgt/Ground � Sq. Ft. � OTHER: ��� s �� v�� Corne,r Lot (] Inside Lot j) A Ft. Yd ��back Side Yard Setbacks Type of Construction: �i�� /��/�7`� Estimated C�t: $ Apprax. Completion Date: 1� .5. /�'. � ��' Z3 � (Cost on Backj Driveway Curb Cut Width Ne�ed: Ft. + b Ft = Ft x$ _$ DATE: �o ��9 Z' APPLICANT: ` TeI. # J�-Z S-�y / CITY USE ONL� Permit Fee $ � 1 Q o� F� Schedule on Reverse Side Fire Surcharge $ ._S � 7Z .�1 of Permit Valuation (1/lOth%) State Surchatge S � , � � $.50/$1,0� Valuation SAC Charge $ � $7� per SAC Unit License Surcharge $ � D� $5.00 (State Licens� Re.sidential Contractors) Driveway Escrow $ - " Alt. "A" or Alt. "B" Above Park Fee $ �� Fee Determined by Engin�ring Sewer Main Charge $ Agreement Necessary [] Not Necessary [] TOTAL $ I � 3TIPULATIONS: C���� � BUII.DING PERMIT FEE SCHEDULE The Chief Building Official shall, before issuing permits for the erection of any building or st�ucture, 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 �rmit of fees to die amount herein below set forth and in the manner herein provid�- to-wit TOTAL VALUE $1 ' to $500 $501 to $2,000 $2,�1 to $25,� $25,001 to $50,000 $50,�1 to $1�,0� $10U,001 to $500,� $5�,001 to $1,000,(�0 $1,(H10,001 and up FEFS $15 (Minimum F� is $15 plus surcharge) $15 for first $500 plus $2 for each additional $lt� or fraction ther�f, to and including $2,000 $45 for fitst $2,000 plus $9 for each additional $1,�0 or fa�a�ti.an thereof, to and including $25,U00 $252 for fust $25,OOD plus �.50 for each additional $1,0� or fraction thereof, to and includ'wg $50,000 $414.50 for first $50,0� plus $4.50 for each additional $1,(I00 or fraction thereof, to and including $1(�,000 ' $639.50 for first $100,0(�1 plus $3.50 for e,ach additional .. _$1,�0 or fraction thereof, ta and including $500,000 $2039.50 for the first $S(�,� plus $3 for each additional $1,�0 or fraction thereof, to and iacluding $1,�0,000 $3539.50 for the first $1,�,OOD plus $2 for each additional $1,()00 or fraction �thereof DRIVEWAY DEPRESSION ESCROW (Concrete �urb Streets Only) Altemate "A" : Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50. Alterna,te "B" : Removal and replacement of curb and gutter and install a 3 f�t 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 propos� structure and of the construction site. A Certificate of Survey of the lot, showing the location of the foundation once it has it has b�n constructed will be required before proce�ding with the framing. � ; c's: - �:iCItL[:�•��`�-1 .:.j y... , ��. e��l :'" '.°�3'-.�. , � �,�.. �.;; .. :;.•:OF',P 'r � ._�-i s:Y-n � *• _:.- ti_ �.:.�:�;� NCH�E� �� �!�a-:iv:�i: . y L; . .. ���� x�' 7+. : t. ,r.� �'i' ���=�e¢' r:�,��+��� :'I�d � � y�'�r�,,�`il,w'.�'«i t .' • i� "y: � � � � '��.. :^✓+ �.as�•w�y.�� PERTY' OF � Konald . E; . :. 1' � ~•,` s � � ^�.• i1��� •' ' � ^! 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' �'�A... �.• -.'� ���.'• ..���!'?�!, ;T'�� 'i• ;;CERTIFiCATE •OF LOCATION OF �BUILDING' .. - •.- •�` °'• , �CEBTIr"iGATE OF SIIBVEY .: '; �}' � ~. �.�•. ;. � .• . . � =; .:; .;. _-:' '•::= �' : ._ . �.• � � •• _:' •.; r'• -''+ • - • • ' :AUQl29Y� �ST 7�1� •` E'. •.-:. • - . �...� . ..i4;.• '•'��- -�-� �' - .� 'I'6sreby eer�ty tbst o� � -�.w:; ► _': I bereby eertffy that �,�, . . :_ �_•�. :� � •. =• , 19_,=.- �t- �• '' _:�� frac',s a sur+ey of the locetion of !he Dnildin�(s) �on the '•ti �-; bnrveyed tbe•pro,perty descn'bed above snd that tbe sbo�e :- �� ,� =abo�-e'described property and that t1►e locst;on of said..,;�-:�latia • eorrect repr�entsHoa oi said�scrvey.., .•.:.:• .-ti' �- .'' ;b�Sl g(c) ia conectly �po�vn on the �bo�e pla�: � - ::� . • . . . . - _ ,�-'. ';- .,� _ `' � . _ ,/ . .. . .�. - . • ''� . • % -•-• � � =-. � • - ' _ _-. - -• .. _ : . . •-'-�•'- _- . n � ' 9 -. i�i�...� ..��'-' ' . ..' •.t�. • � '" " ':i��. . , . . _ � _t�:�..� _� �pvn�� prr�r-►arn s�lr\/CY{�P_�^t., ��rc .• - . ... - ... SuBJECT - 'j'��.--_v c�ty of F'ridley 2758 0 AT THE TOP OF TNE TWINS g � I L D I N G P E R M I T r ; � IPT . ' � `v ______ COMMUNITY DEVELOPMENT DIV. ` r � � PROTECTIVE INSPECTION SEC. -rj �� � � , ✓ 1 . � � _ �'�'1 � CITY HALL FRIDLEV S5A32 NUbIBER REV DATE PAGE OF APPROVEO BY �----� • •'� 612-571-3450 910-F15 9/4/98 / / JOB ADDRESS �478 Jackson St 1 LEGAL �OT NO. BLOCK TRACT OFi ADDITION SEE ATTACHED DESCR. 2 2 Melod Manor 3rd SHEET 2 PROPERTY OWNER MAIL ADDRES$ ZIP PNONE Don Cham ion 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Ea leview Const Inc 2937 1 th I: a ARCHITECT OR DESIGNER MAIL ADORESS 21P PMONE LICENSE NO. 5 ENGINEER MAIL ADOiiESS ZIP PHONE LICENS6 NO 6 USE OF BUILDING Residential . 7 CLASS OF WORK ❑ NEW O ADDITION ❑ ALTERATION � REPAIR p MOVE ❑ REMOVE B �ESCRIBE WOF;K Reroof house and ara e 31 S Tear-off 8 CHANOE OF USE FROM TO STIPULATIONS Underlayment must comply with the State Building Code. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCV LOAD VENTII.ATING OF AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTIiUCTION ZONING SO. FT. CU. fT. AUTHORI2ED IS NOT COMMENCED WITHIN 80 OAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERI00 OF 120 OAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. OWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION STALLS GAqAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS ypLUATION SURTAX AN� ORDINANCES GOVERNING THIS TYPE OF WORK WILI BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT 2656 1 33 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL TFiE pERMIT fEE SAC CHARGE PROVISIONS OF ANV OTHER STATE OH LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. ]/{.]S Fire SC. Z.66 /� �� �� I„ PLAN CHECK FEE TOTAL FEE � n � o�l��\ �' Licen e S SIGNATUREOFCONii7ACTORORAUTHORIZEDAGENT �oarE� WHEN PROPEFILY Y I ATEAD�ATNIS IS YOU/R PERMtT/y S�GNATUAE OF OWNEA Uf OWNER BURDERI IDATE� • � �/�;/!d G A � �if BLOG SP riFiE . � �,. �-' NEW [ ] ADDN [ ] �,�R [ l CITY OF FRIDLEY SINGLE FAMII.Y AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Effective 1/1/98 ��� �1 �.���1 ConstructionAddress: � � 7 � �� � � S e �, s � � Legal Description: Owner Name & Address: ��� ��,-,� � �� Tel. # ��° S °� �� � �( Contractor: ��� 1.�� L w C�, �, S�' MN LICENSE #���7� f1'�.3 Address: �-� � � ) %`I �" /�.�w�c �i G✓ f�n�o��c� � v� �S� ��I Tel. �t 75.�'s`!� � Atta.ch to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. LIVING AREA: GARAGE AREA: DECK AREA: OTHER: DESCRIP'TION OF IlVIPROVEMENT Length Width Height Length Width Height Length Width Hgt/Ground Sq. Ft. Sq. Ft. Sq. Ft. /� �..� �.._�.� ��� � Construction Type: C� 1��� � ��r ea�� Estunated Cost: $ a�.���� (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$ ��h � .� DATE: I'� �� � APPLICANT: �� �- �Q��J� Tel. # ���— SY�� Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: CITY USE ONLY $ ��` .L � �Fee Schedule on Reverse Side $ �. �c (� .001 of Permit Valuation (1/lOth%) $ /, .�,� $.50/$1,000 Valuation $ $1000 per 5AC Unit $ -� �� $SAO (State Licensed Residential Contractors) $ Alt. "A" or Alt. "B" Above $ $450.00 Conservation Plan Review $ Fee Determined by Engineering $ Agreement Necessary [ ] Not Necessary [ ] $ �-J�' �> < � � ._, BUII.DING 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 $2,000 $2,001 to $25,Q00 $25,001 to $50,000 $50,001 to $100,000 $100,001 to $500,000 $500,001 to $1,000,000 $1,000,001 and up FEES $21 (Minimum Fee is $21 plus surcharge) $21 for first $500 plus $2.75 for each additional $100 or fraction thereof, to and including $2,000 $62.25 for first $2,000 plus $12.50 for each additional $1,000 or fraction thereof, to and including $25,000 $349.75 for first $25,000 plus $9.00 for each additional $1,000 or fraction thereof, to and including $50,000 $574.75 for first $50,000 plus $6.25 for each additional $1,000 or fraction thereof, to and including $100,000 $887.25 for first $100,(}00 plus $5.00 for each additional $1,000 or fraction thereof, to and including $500,000 $2887.25 for the first $500,000 plus $4.25 for each additional $1,000 or fraction thereof, to and including $1,000,�0 $5012.25 for the first $1,000,000 plus $2.75 for each additional $1,000 or fraction thereof DRIVEWAY DEPRESSION ESCROW (Concrete Curb Streets Only) Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50. 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 $15.75. VERIFICATION OF FOUNDATION Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper review of the proposed structure and of the construction site. A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed will be required before proceeding with the framing. .� ,� SuB��cT . c;ty of Fridley ; , �������,E�„NS �UILDIN� PERnIIIT ,� � ; v _�__� COMMUNITV DEVELOPM�NT DIV. r � � PROTECTIVE INSPECTION SEC. � . , � _ �"'1 � CITY HALL FRIDLE� SS�32 NUMB@R aEV OATE �.---�: �•� 612-571-3460 9/0-F/5 lOB AOORESS 7478 Jackson Street NE t LEGAL ��T NO. BLOCK TRACT OR ADOITION DESCR. 2 2 Melody Manor 3rd 2 PROPERTY OWNEp MAIL AOORQS$ Don Campion 3 CONTRACTOR MAIL ADDRESS Grand Exteriors 9601 W 16th St St Louis Park MN 5542 4 ARCMITECT OR OESIGNER MAIL ADORESS � � 28179 RECEIPT NO. � � IT APPROVEO B� SEE ATTACMEO SHEET 785-6014 ZIP PMONE IICENSE NO �19-5091 ZIP PHONE LICENSE NO. 5 ENGINEER MIAIL ADOpESS ZIP PMONE LICENSE NO 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATIQN � REPAIR ❑ MOVE � O REMOVE B DESCRIBE WORK Reside house and 9 CHANaE Of USE FROM STIPULATIONS e Call for building wrap inspection before covering. TYPF OF CON57 SEPARATE PERMITS AqE REDUIREO fOR ELECTFiICAL, PLUMBING, MEATING. VENTILATING OR AIR CONDITIONING THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION yONING AUTMORIZED IS NOT COMMENCED V�1ITMIN 80 OAYS. OR If CONSTRUCTION OR WORK IS SUSPENOED OR ABANQONED FOR A PER100 OF 1Z0 DAYS A7 " ANY TIME AFTER WORK IS COMMENCED ' NO DWLG. UN 1 MEREBV CERTIFY 7MAT I MAVE READ ANO EXAMIN�O THIS APPLICATION AND KNOW TME SAME TO BE TRUE AND COQRECT. A�L PROVISIpN$ bf LAW$ yp�UATION AND ORDINANCES GOVERNING THIS TVPE OF WORK WILL BE COMP�IED WITM WME7HER SPECIFIE� MEREIN OR NOT. TME GRANTING OF A PERMIT $4300 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OF GAMCEL TME pE�MITfEE PROVISIONS OF ANY OTMER STATE OR LOCAL LAW REGULA7ING CON- STRUCTI OR THE PERFORMANCE OF CONSTRUCTION $99, ],rj PLAN CMECK FE � �U � £ L�� . S�GNATUA F C "QACTpA Oii vUTNOAl2E0 eGENT IOATEi EN S�GNUTUAE O� OwHEp ��� OWNEp BU�lOE�1i �OAiE� ' 9 G �N� SO. FT STA��S OCCUPANCVLOAD CU FT. OFFSTREET PARKING IGAiiAGES $2.15 SAC CMARGE Fire C $4.30 TOTAL EE R�� � r�`tE NEW [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ J SINGLE FAMII.Y AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: �� � � � ��/,�„ �i, ,{/� Legal Description: Owner Name & Address: � ���, �� � � Tel. #_ � �J �to b f� Contractor: C�r��,�� (��� J)" � MN LICENSE # Address: /o f� / loi� ° �7'� �� - � �� f/� ,:� , Tel. #{ �% / �-�S� � � LIVING AREA: GARAGE AREA: DECK AREA: OTHER: Attach to this application, a Certi.ficate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT Length Width Height Sq. Ft. Length Width Height Sq. Ft. Length Width HgtlGround Sq. Ft. Construction Type: %`z��/�� �i ,� Estimated Cost: $ �� ��-! �-l� . (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$ DATE: APPLICANT: Tel. # � CITY USE ONLY Permit Fee $ .�S Fee Schedule on Reverse Side Fire Surcharge $ .�.001 of Permit Valuation (1/lOth%) State Surcharge $ �, /�r' $.50/$1,000 Valuation SAC Charge $ $1000 per SAC Unit License Surcharge $ �_(�� $5.00 (State Licensed Residential Contractors) Driveway Escrow $ Alt. "A" or Alt. "B" Above Erosion Control $ Park Fee Sewer Main Charge TOTAL STIPULATIONS: $450.00 Conservation Plan Review $ Fee Detemuned by Engineering $ Agreement Necessary [ ] Not Necessary [ ] $ l�� �� „ . .. BUII.,DING PERNIIT 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 $2,000 $2,001 to $25,000 $25,001 to $50,000 $50,001 to $100,000 $100,001 to $500,000 $500,001 to $1,000,000 $1;000,001 and up FEES $21 (Minimum Fee is $21 plus surcharge) $21 for first $500 plus $2.75 for each additional $100 or fraction thereof, to and including $2,000 $62.25 for first $2,000 plus $12.50 for each additional $1,000 or fraction thereof, to and including $25,000 $349.75 for first $25,0(}0 plus $9.00 for each additional $1,000 or fraction thereof, to and including $50,000 $574.75 for first $50,000 plus $6.25 for each additional $1,000 or fraction thereof, to and including $100,000 $887.25 for first $100,000 plus $5.00 for each additional $1,000 or fraction thereof, to and including $500,000 $2887.25 for the f�rst $500,000 plus $4.25 for each additional $1,000 or fraction thereof, to and including $1,000,000 $5012.25 for the first $1,000,000 plus $2.75 for each additional $1,000 or fraction thereof DRIVEWAY DEPRESSION ESCROW (Concrete Curb Streets Only) Altemate "A”: Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50. 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 $15.75. VERIFICATION OF FOUNDATION Permits for construction will be issued a minunum 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 constructed will be required before proceeding with the framing. -o a 0 m a � � 0 c � �� 0 � N � � v v °: m r 0 ti � N 0 0 � � 00 � O � m � � 7 m ci O � O c' � � � m Z � � m � O Z -� m m � � 0 � \ :L O C � O � m � � � � c m 3, N � � � � � ' �� o . �• '� � b'�� � � � � � � � �9 � � ��-s' � Z � � � 0 C� . �. �� w � � � 1 ` � � � j N � a c o � -� � � rn � cD � � D O� o ni 1 ' � � � o � � A � N � \ 1=' � � a � � � m � \ v 7 ryi � C �. 0 � � � . .� �, � a a � � N c �i �° � a � m � o � � �: s o � � =�o � � a a m � d o. °`� _ . v F � <: o '� o � N = �' N N � � �, ��,. �• a � rt � n -, � a o � `� a `° � _ c p�—� � � , � � � � a�,., o °�' m � � n ��� fD o -^ a � N � I-� D � • � — 0 n O C � S m � m � � m � � o � ��D�. F-ti A U1'� O � -, . < �O�j D � o � ° . � � � O 0 � N,�� m � x- � � r'• ,-N+ � � O O � -,, o� � � � � o ,. � � N N � O ' � � � o ' 0 b o - �F D b � a � 0 � 7 � D � N � � N N v m � G) N � � � � m � N N v v � oa z � T c � v � fD T fD v N n N 7 N m � m -n � � j N � � a � �p N � � � � � d � � — 7 ,�+ a � v c � � � o� � A � Q � � C � fD � a -i 'm^ VI C') 2 m O r � o o a c�'''i� '� b o $ °o °o I� 0 0 � � � � b �� „�-�� �� �-cao m _ � _ � Z � � d °: n� - a � � fD c z 3 � � ,� c� � _ � fD � �= o o� � 7 � � c�i r' .. � m � a � r N a = � � o � 0 m � ���°��' o ' n� �3 e D � 1 � � � � � � o � � � � � � m v 0 � � b' 'D m � � -� z O a �� oa c � m a � �� ` `o W D v v � � � � rn � � n W a � � � � F� ►� 3 ? O W z � '�1 O cn N. '�l �A � � � � N � v � r z � m v � � W C CJt � r F� v F� N Z � � N 'D m � O Z � D m � � r � D m ,� � -ni z z° o D � Z -v v o a� � � m n � Z � v � _-I � O � Z Z z v c� _ � y '""'� Z m � � � z °o 0 � v z � G m m � � � O Z � v �� � � � 1 � m � � � � N � 0 � FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS , COMMON VENT VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When replacina 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 meets all current codes and manufacturer specifications including sizing, length, number of elbows and termination. Yes �,}, No () I The undersigned also verifies that the replacement unit is a listed �ssembly 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 manufacturers 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 code� 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 () I 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 cuRent codes. � � Yes No () Appliance Tvpe and Size/Common Vent and Vent Connector Information Appliance #1 Type BTU Input �� �� Fan Assisted or Nat ' A liance #2 T e � BTU Input �� Fan Assisted or Nat -��n �— PP YP Appliance #3 Type BTU Input Fan Assisted or Nat � Total Appliances ,�_ Tdal Btu Input ,['�l?�1 . ,f .� Common Vent Type Vent Height _,�� Diameter l inches f � �� �� ��� Appliance #1 Vent Connector Height � ft Length ft Diameter p in ype Appliance #2 Vent Connector Height �ft Length �ft Diameter �in Type � Appliance #3 Vent Connector Height ft Length �_ft Diameter in �pe � HEATING CO: Signed By: 4' ��G � ��� Date fa_ % ��