AF - 47562_
_
CITY OF
FRIDLEY
FRIDLEY MUN[C(PAL CENTER • 643( UNIVERS[TY AVE. N.E. FRIDLEY, MN 55432 •(612) 571-3450 • FAX (612) 571-1287
August 8, 1995
Judy Schommer
543 Janesville St. NE
Fridley, MN 55432
Dear Judy:
I am sending you a copy of the report our contractor filed with
the State Department of Health for the well capped on your
property. Please retain this with your property records as proof
that the well was properly abandoned and sealed. I will also put
a copy in the City's address file for both your property and 533
Janesville St.
If you have any questions, please feel free to call me at 572-
3591.
' cerely
Grant Fernelius
Housing Coordinator
Enclosure
Mmnesota Weil and Bonng �+ A
WELL OR B�R�NG IOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No H h� fa 6�
Counly Name WELL AND BORING SEALING RECORD ^^���esola ���Q�e "o. �-'�
--�^"- mnes a St lutes. Chapter 1031 or W-series No
�� '� ���_ � � � ILPave b�a�k �1 nol Mnow�)
Township No Ranye No. Sedron No. F�adwn (sm. • g.l Date Sealed App�oz�maie Dale Well
��� 30 2 4 3 S �S,i�t �;iW �„ JULY 31 , 19 9� or Bonng Consiructed 19 50' s
Numencal Slreet Address or fue Number and C�ty ol Weli or Borxig locatron
533 JAMESVILI,E STREET
snow eKaa aca�a� a Wen w� Skelch map oi well or bwing
m sectw� gnd with `X�-. �T locatan. showing Woperty Imes.
lV'^�1� •,°Ac ana M..1.1:.,.,..
N �['� 1 � \ � .
�����_�1��
����
���� �
����
Depth Betore SeaNfg � � S n. � Ongmal Depth � h.
Stat�c Water Levei � Accurale �
w� Smg1e AQuBer ❑ MultiaquNer
CASING TVPE �
p� $1ee1 ❑ PWSi�c ❑ Tde ❑ O�
1 Screen (rom 112 � 115
OBSTRUCTIOWDEBRIS/FlLL .
❑ Obslruclron � ❑ Debns ❑ FiU
❑ Approxanate
�- n. � beaoW . aewe ia�a
h. Open Hde Irom � �o
Type ot debrisldnhuctan
Ma�Xng Address d ditferent than propeny address mdicaled above. - � � �
431. ,.tINIVERSITY AVENUE o�5v�a�oen�ai,��ea� ❑ v� ❑ Na r
�
IDLSY, MN 55432 p"'"P �`
�.� ��ed O Na ere�i O a��
.r-�-°.�..-
; . :, _ . _ :,
cns��
HARDNESS OF
GEOLOGICAL MATERIAL � COLOR FORMA110N FROM TO •
Diameter Oepth Set in oversize hole? MnuWr space inqiaMy grouled? - _
II��M known. mdicate estimated fortnatan bg from nearby well or boring.
C�y
�[ �Ci�
—
�_
� .2 4 in. from O t� I 2 ft. ❑ Yes � No ❑ Ves ❑ No ❑ Unkrwwn ';
� 2.. $ in. from lo fl. ❑ Yes ❑ No . ❑ Yes ❑ No O Unknown .,i�;
�
Q�i 8 1 5 '^ ��" �o Q. ❑ ves � No O res ❑ Plo ❑ unwwwn fi
METHOD USED TO SEAt ANNULAR SPACE BETYVEEN 2 CASINGS, OA CASIMG AND BORE HOLE:
�� 1 � 1 $ � No Armular Space Ezists . .. �
r.
�iN r 11 ` 1 7.: ❑ n��a. sv�� 9�«nea War, u� v� °, 3
«
� ❑ Casing PeAoratarVHemoval �
i4 2 O
2 5 2 3 ��. t�om ta h. O Pertorated ❑ Renwree
in. from �o � h.
Type d peAorator
�
❑ PeAorated ❑ Rertioved .
❑ ane�
GROUTiNG MATERIAL �
.,
���.� �1e�� POItTI.AND �.a,r, 115 �SURF n.
ra�, 9
from to fl, yards bags
REMARNS, SOUACE OF OATA, OIFFlCUlT1ES IN SEAUNG
EOI,OGY FRt.11�I: FRIDLEY SR HS r.«� �o n. ve� o�
ATER LEVEL IN ABOVE i�iSLL : 70'
TE NATER, LEtTEI. . TAKEN: 4/18/72 h«� � e. r� �
UNSEALED WELLS ANO BORINGS
- � � � Olher unsealed weN or baing on prapeAy? ❑ Yes �No � � . . . . .. . . . . � . . . . .
. . . . . . � . . '- � r I` ' , , ` '' ; > UCENSED OR REGISTERED CONTAACTOR CERTIF1CA710N '.:± �,.; -� ' � s
. 'x -�, r::.
.����� � , This wetl a boring �ras sasled in axwdance vritl� Minnesota Rules. Chap�e� 4725 The MqortnaUOn coMa�ed n tlws Tepat ic .
�n,e w n�e oesc a my awwkage. ..
. _. ..�����l�'T_'__� �..�- sH� �. i�iinl�LiA'..� W11S�. ii\V�`��. � 71�15 ...�. . ' . .
. � .. � License or Regisfratan 11b.. � ..
8/2/95
: � .
._ .. _. , _.
� a�n,�zea �we s�a�� , , osre ,
: � JE�ttn� HoP� .. _� . � . . :.. : . . .. - . . . : . . ,
IMPQRTANT-FILEMIITH ' , - ° -•
. _ ,_ H - _ -
P/tPERS-WEtt OWMER COPY Name a Peison Sas�ing weN a8orng .. >.•r, �.� �, '
. ,.ps
►�c.me�e-m , ,- , - : , . :_� . . -:: _ __..
sue�ecr PER
City of Fridley ,� e� ��, 7
AT THE TOP OF THE TWINS g � I L D I N G P E R M I T �
f
' ' RE
� �
� ` ___� COMMUNITY DEVELOPMENT DIV. ���
r � L � PROTECTIVE INSPECTION SEC.
i �
� �
, ' /'��1 � CITY HALL FRIDLE� 55032 NUMBER REV DATE PAGE OF APPROVED 8♦
�'""'�" ,�' 612-571-3450 910-Ft5 1/22/96 � �
JOB ADDRESS
533 Janesville Street NE
1 LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
oESCa. 15-17 E Riverview Hei hts SHEET
2 PROPERTV OWNER MAIL ADORESS 21P PHONE
Four Diamond Bldrs I0738 Hanson Blvd NW Coon Ra ids MN -8668
3 CONTRACTOR MAI�ADORESS Z�P PHONE UCENSENO
Same 2007411
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGiNEER MAIL ApDHESS ZIP PHONE UCENSE NO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW ❑ ADDITION O ALTERATION ❑ REPAIR p MOVE O REMOVE
X
B DESCRIBE WORK
Construct a 22' x ' e r r
9 CHANGE OF USE FROM TO
STIPULATIONS
See notations on plan. Provide with copy of verifying survey before �
capping. Provide sod in the front and side s}x yards. Provide a hard surface
driveway.
Sewer & Water Locations: See City-Engineering Dept.
��� ���
Before digging caii for
all utility locations SEPARATE PERMtTS REQUlR.F_D FOR
454-0002 Wl�ING, HEATING, PLUMB1i�G �+��i7 SfGNS.
REQUIRED BY LAW
TYPEOfCONST. OCCUPANCYGROUP OCCUPANCVIOAD
SEPARATE PERMITS ARE REOUIqED FOR ELECTNICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL ANO VOID IF WORK OR CONSTRUCTION ZpNING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR If CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 OAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. OWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINEO THIS APPIICATION 1 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WOqK WILL BE COMPLIEO
WITH WHETHEF: SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT �lO�F�S1H �SL.�FL
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pEqM1T FEE SAC CHARGE $8SO.00
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
S7 ON R THE PERF RMANCE OF CONSTRUC710N �HS� �9�.2.25 Fire SC �L��F.82
P�AN CHECK FEE TOTAL FEE
�' �� c' �`'��t�` License SC $5.00 $ l, 924.48
SiGNATUREOFCON�NAC.T0�70HAUiH0�7�ZEDAGENT IDATEi WHEN PAOPERLY LIDATED THIS !S YOUR PERMIT
, - l�Z?��.—
SiGNATUF7EOFOWNEFliIFOWNEABUILDERI IDATEI°' Bl �NSP �1FTE
NEW
ADDN
ALTER
[1
��
�. �
Construction Address:
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
.
3� .��-►�sv,(��
Cffective 8/1/95
�` �
Legal Descripdon: � D"+�' %s _ f? %� f C� L,�/, � _
Owner Name & Address: �"c��� DrftlV�-�-Y��"drs� �73a �1�`^`�"� '��TeL # 7�v 7 g��$
Contractor: �'�� �(��r��� MN LICENSE # ��' `T���
Address: ta 3�h �,1�h1S� ra �� �� COOt�[ i2� �° � 5 ��-�'i3� Tel. #�d� ' O�%'�_
LIVING AREA:
GARAGE AREA:
DECK AREA:
4THER:
Attach to this appGcation, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
- y�32, 9� x �s G�= �� 3�iG, y9
DESCRIPTION OF IMPROVEMENT �= 5�8; .�3tC 57• 8d'= .328�y 9N
� a qs`D � 9�9� �7 Yr7.�� = s7 �x�.3�'
Length a '�--
Length .� a
Length
�
Width � Height Sq. Ft.
Width � c� Height Sq. Ft. X 1�,72 = 779G• &�
Width Hg#/t'xround Sq. Ft- �_1� �/�'. �j
Corner Lot [ j Inside Lot [] Ft. Yd Setback Side Yard SUbacks
Type of Construction: 1�Cabb1 ��' �� Esti�►ated Cc�st: $ O 5�� � ��� 9/
Approx. Completion Date: �� 3�' �� S-
(Cost on Back)
Driveway Curb C�t Width Needed: Ft. + Ft = Ft x$ _$
DATE:1 �- �3 ```r � APPLICANT: �t�t �-v� Tel. �� 1 b� 7
Permit Fee
Fire Surcharge
State Surcharge
�AC Charge
License surcharge
Driveway Escrow
Frosion Control
Park Fee
Sewer Main Charge
T4TAL
STIPULATIONS:
$ Z. ZS
� /aY. SZ
$ 32� `��
$ d�0, �
� �, �
�
$
$
$
$ '.�,
$ ' �` �
� �I
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth�)
$.50/$1,U00 Valuation
$850 pe� SAC Unit
$S.(l0 (S1�te Licensecl R�side�tial Contractors)
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Fe� D�ermined by F� ��
Agreement N�y i l Not Necessary,;P$,
��
� ��
._ - �
1� /. � -
�� �r�'
— - - - - - - -' �. F• r•,
�rf����������w ���, ������
i����l��� �C" �"�� +'�%V�� � l ���� ���r
� � � WaGO Sfreet
�'���`�� � � ��` ��� Rarr� - �Ennesota 55303
�c�,- �:-� �,���3 � �� : ;��r.���`Y€�R = �'
�._-- -- --- �_..�_ _
~��:
� �.s � �� �'T F�.�. C�:�`�� � �/��"J�/y Gl�l � �JL-�/��5" J
�y _ � �:,..,�� ��.�� ��t o�7 �ti� lJ.�
8` � � � "1(e`7 $fc�� �a �t"�`-�"
`'� �"`� `� 5 t� '� _.< <`�f+
:�_
w�
�.
i
M1
�' ;J
_�: �
_.�
��.
, }_ �:
.��.
, - r .• ; � �_
, � . �� I l f`
..-��•
4 � S; •� `;> --�-��. �r
� s__.�$L i? ... � �—.�� t f i 4� 1 Ll�
Y--: i — 1
f�^'-="° �4 _ �$-Eo
f' :s ,y �
3 �
"' Jf'�0 r'6?� L� c:�
� L`'� � f —
�..,� �� �!-f �� . C O
-c} � � N
r. L`T -3�
:4;i
rc, rr, e
�'- - �(�8b5�� 1� .y 2 z � x eib-5...
r�,:��-1� �x �L� �� an5� ' � �s,a '
( �-, ,L�'
�bi 6 � ���a`7' � J � � i
� ' � �
er
��
V
��
_�
�
. ,r
��
}, tn
�
'= ,. f ' i � �1
C�` i ' ' rj,
7 4 .� �{ ! �,
� 7.� j �
� �h
F. E�1
TEI.�PHONE
�612) A27-1020
i Det�otes lron Manuments Found
J t�er�ote� lrar� Manuments S�t
Scaie t Inch equais�° �#eet
�ook '���_ a����__i^_�__-�
II1VDiC6 ND. __ __ 4 4 z4
T "�
,� �, f
1��� ���
/p,�� ��
4.� �
�
�
�
i
�------ ---_ .-_ -_�.�__�T .�.
a
� � ;� �14%\l��'`/lLL �'T- r° �
���� iV
�' � � � ¢ � ��z .� J�,l �',
x 'o' x
r,.':in.,r,r,� r--!.
- .?',J:' ,� _ Y_ t '.1 �i i. � .i
_i �i'- 4'�,{f��..._�t;.Ylw'=��•� .. �;�3. � C�E?•��-?E� E�'•,I�TIP.0 �L��`.'��7I�N �:9;�'�,�^
_- - } � ., t_ � t _t .� E -= t� � "� 5 . � Ci C N tl �f � `, ;-"� ,.� �� � S k' � �; F7 ,e G1 c' S � .a' 1 _f , . �) '
i.. s.. - . { L=: � ; �-- �:5£s . �i C'lE�•#.)i;-� =�_i4z�ACE: �!?t� I N��:�� - . ....v- >
:° c=: �``__ ���±±fy ti�<at rr�s-i5 is r3 fi;!a� a,�d <-rrert �5*r'�?=;���tzit ��?t� :�f
= :t;Y. t :'� ���ir �1t,�J.'lC��t.�E:�; Of:
_ : �i i ' ' � 4 i r� c�. k: � , , _ � '�/ E �' �f' � t:1�.r I-� fi i �ti f 1 T � � , .. r, :7 r: ri � () li f '� r j' ,
!��: . : � "l .. _ - � ... . -
� t i � � -: � �,.: i.i ' ,.,:_i G ( � ± r ':._; � `y !j }•J t �tl �; i �� �t�� � �(! �.C-' [�l i � �=r t- t: i'� r�. Y �_� c'1 `, f �� f �. ��. v i'� C �� , �-� �
.. �- . ':_; i� � � V � ti t1' � il l � h t�.: y � � .: `� � ;� d y Eti f �I !7 � ? �() .i f'. r � � � �� '7 .
. f } ;'y �
' �;� r'"'-•(� /,. { Z. --l�i = �"� � ��s'�SC-'b ��'SE �.c�t.
�:���'3t��-F' �1'� ���;,�}-2�tt}-�r�
I�
`+ {, t � � _. t` - i_`r� t �j � t_{ .- Y' £' }+' i i'� C� = i !" r: .
�
=-_r, _±� �. ,',���:tssG:r;, t?ew,_:t�� �.:-! L� .:. ':�:rrvsyc�r, t,�N. i.ic��lse No: 13297
� �
I c� r
x�� z
O O� f
�
Q�� � �
a�� �
u� �t••.
aN� �
v? a u�e
4 U1 W
�z� �
► ° -' }
�NW m
w
�.e � Fs- t[1 {Ou
HWQ I�d
t3a W lq$
W �O e�W
� 4
2w yCd
q .+
Q� C7d
fA> W►+
r� �W
~w a
r o t�
<
I
i �OW :i
�wv �
w}a c�
� �
m� �
t�! ¢ t- �
i�� . �'�► �
. �,aa .ao �
hp��� ,
P T !'� y
� u p�
tM
N� 9 �
�a
w �
� �
'�- �oo �
_ �� ry
V �
m �d6 �
6 �N� �
VI
w
0
W
N
�
C
�
i n,
0
O
�
N
N
��
h1 M
W N
I ►�
�
s
3
c �
h �
�O N
�
n � �.
� "�
�� � �
� � �
. � v"
C 1-
1
_ � �
� � �
� �
. '�.
4 �
ti R � r;
� `�' ►` '�
� 'u1 3 L�
� +Q 4!
� �� �
v � �'
Q `` 4 w
� Z � '�
� � � �
a
� m �
�""� �3�}
00
��� .JWl�N�•yf
i1nY'� �pg�ONN
� ��
_�� WmY'IOu�
� � ao ►�..o
w�N ��3�
}
<V�I+a•Q.p�
y �Y�+f�q
;�� � �� ,
i, a�°y., uNi ��.° �mNrnw
I s�ti�e � �u �'�eb�.,o
� R �
W4.M.W �mmm
aada .i4����
VO00 �� ��i'�r.-
�w�.�d,,,�N vslf�
e" ^r i�u�RW�
ti W �y
�O RP � �41� Q
•4
�ic���G � ° _
��
J J �/ �./
O[r'�nt+-
�'� ° 1r N cs m r-- �- ��
1� ..I J
,�pSZ M �LLIk .�Wm�nNQ
� � �/ �o dSS��o
� � �J � � � ^,"''�
dxL^��O n�iNt�Y am!'YMd'N
flFm�� fmi `�R�{M�S
��
/ � ����
��S �oN �33 ��
r
ICl
1
�3
N
K
1
�r
,
�
�
ti
�
U W
.r �
� � _
> U.�G�
, � �— �.
u1
� "
�
� N
� r'
�
Im
i
m
i
1C�
�
�y �
01
4
a
�
�
i
�,
I
in
m
I
Q1
�
�
N
.i
� �
�
�
- :--' ' �
i i
ui �; "'
� � �
�
�n
an
nw
R� >
4 �
m � O
N 1C! M
1 �
r� W �
QjLL
�l1
•+
Z��9 SSZ � ti 9 F Q0��1 H� I�13WW3 L� ' b0 y- 96i9Zi�0
CITY OF FRiDLEY INSPEC710N DIV.
6431 Univers'rty Ave NE
Fridiey, MN 55432
572-3544
Stories C1os+e� Urinal
Basement 4
Floor i
Floor 2
Floor 3
F)oor 4
PLUMBING FIXTURE RATES: N�.
Effeciive On August 1, 1995
APPUCATION FOR PLUMBlNG AND GAS FiTT{NG PERMIT
MARK NUMBER OF FIXTURES TO BE {NSTALIED ON EACH �IOOR
�' Wash ��;, �;; FIOOf fi,�h Auto. ��� Gas
Shower '�inEt , TraY �t��t, . Drain B�,sirt ' Washer Aa�t. Ran,
New Flxtures � �'
Old Opening, Mew Fi�cture
Beer Dispenser
Blow Oif Basin
Catch Sasin
Rain Water Leader �
Sump/Rece+ving Tank
Water Treating Appliance , '
Water Heater —El�ctric }.
Water Heater — Gas** �_
Gas Range**
Gas Dryer**
Back Flow Prevenier Required ( jYes (} No
Type
RATE TOTAL
(�, ov
$ �.00 ��
$ 4.00
$ 5.00
� 7.00
$ 7.00
$ 7.04
$ 7.00
$10.00
$ 7.00
$i0;00 /C�•U(�
$10.00
$i0.00
$15.00
�oB
.S� 3 � --
Water Heatefi
Gas Eiec
/
The undersigned hereby makes apptication for a pemtit for the work herein
specified agreeing to do aN wark in strict accordance with the city codes
and rulings of the Building Division, and hereby declares that ail the facts
and representations stated in this application are true and correct.
�-�3 ,,�
owner il �/ �'-�%��—�
B�ilding Used As f�
Estimated Cost 3 J�� ✓ P�RMiT NO, ll5 ��
PLUMBING COMPANY
�
Reinspection Pee $42.00Mr SIGNED 6Y�%� � TEL NQ. �-5-� '�-/� �
ALL OTHERS ANDJOR REPAIRS AND ALTERATIONS Q/; �',���-gr ���5 �(
1.5% of Value af Fixture or Appiiance w'q/� �
Approved By Rough—In Date _���_�''Final Date 31��� ���-
State Surcharge .50
M NtMUM FEE FOR ANY PLUMBING/GAS PERMIT tS �20.00
TQTAL FEE $�� PLUS THE S 50 STATE SURCHAAGE
%�. S'U
**COM$USTI�N AiR SHALL BE PROVIDED PER UMC SECTtON 504(A) AND TABLE 6—A. MiNiMUM SfZE 9 SQ INCHES.
.:a
r
' CITY OF FRIDLEY INSPECTION DIV.
6431 University Ave NE
Fr'rdtey, MN 55432
572 - 3604 .
RAT,�SCHEnULE
Residentiat
APPLICATIQN FOR POWER PLANTS AND HEATING, COOLING, VEN7ILATIOId,
REFRIGERATION AND AIR CONDITIONING SYSTEBUS AND DEVICES
Furnace Shell and Duct Work, Burner -
Also Replacement Furnace
(Side Vent - Fiil Out Sack)
Gas Piping (Needed with new furnace}
Gas Range
Gas Dryer
*Air Canditioning - All Sizes
All Others/Repairs & Alterations (LIST ON BACI�
1% of Value of Appliance or Work
Commercial/Industrial
1.25% of Value of Appliance or Work
Rate TOTAL
�, �
$ 30.00 $ � o
�
$ 10.00 $ /O '`
$10.00 $
$10.00 $%4 O�
$ 25.00 $
State Surcharge
TOTAL FEE
Effective On August 1, 1995
JOB ADDRESS .5.3 3 �
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
rulings of the Building Division, and hereby declares that al! the facts and
representations stated in this application are true and correct. :
�� .. � ,199��
OWNER 5� �,c..�.-,-r-+-°�-1' ���^�-Q
BUILDING USED AS �,�`�--�-�-�.-�--�
ESTIMATED C�ST a�/>d� °—�° PERMIT N0. %��l �G1
�� �•� • :�t � �: .�_
$ No. of Heating Units ! Circle One (Steam) (Hot Water) arm Air
Trade Name ��-- Size No.
BTU 75 � o o HP EDR
$
��,___,50
��. '�,.�
MINIMUM FEE FOR ANY HEATING/COOLINGNENTILATION
REFRtCERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $42.00/Hr
Fuel-,e%� -1�- Total Connected Load
8urner Trade Name Size Nn.
BTU HP EDR
HEATlNG COMPANY � �
�--� , � - �
Signed
Approved IBy
Tel No. ��3 -: %G "= -
Rough-In Date 2 ��nal Date �'���!��
*Air Conditioners can not be placed in a side yard without FILL OUT BACK SIDp'FOR STACK VERIFICATION ON
written permission from adjoining property owrrer. REPIACEMEN7 FURNACE
.
.
HOUSE HEATING TEST RECORD
(Orsatt Test)
Address -� -� 3� + � Apt. Floor City Suburb
Occupant Owner ��� � � ��-�-�-�"'O
Heat Loss Date Heating tnstatled �- ��
Sold By �-�-t - -- �� � �� Installed By � ' �` � -
Electrical Work By G%`'�`'�--�-'"' Gas Line By `" . • .` �
Type of Heat GA FA �,� HW 'Steam Space Htr. Unit Htr. Other
GAS DESIGN OONVER.SION
Make �---�� Make of Burner
�llodel s> � � �d Model
. � p
Serial L� G d% �� a' �/ Max. 67U Rating
( c� GfL�c�
Input � ,� Make of Furnace
Model
CONTAOLS
� /i
Thermostat Heai Plug Vent Size
Vaive Kind of Liner Size None
Limit Draft Hood �� Regulator
Limit Setting Filters: Size Number
Fan Setting Chimney Location Inside �_ Outside
Pilot Type ��-+�� Chimney Construction � �
Pilot Make
Pilot Model Smoke Bomb Wiring
Piloi Timing Draft Test Tag
L.W, Cut Off Door Pressure Lighting Inst.
Pressure �� Percent CO2 = �� Date Tested
Input CFH � Percent 02 ��-� Company Testing � �
o �
Stack Temp. �a Percent CO . C1-3 Name of Tester
CITY OF FRIDLEY INSPECTION DIV.
6431 University Ave NE
Fridley, MN 55432
572-3604 .
[7� . _
APP�ICATION FOR POWER PIANTS AND HEATING, COOLING� VENTILATION,
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
Residentiat
Furnace Shell and Duct Work, Bumer —
Also Replacement Furnace
(Side Vent — Fill Out Back)
Gas Piping (Needed with new furnace)
Gas Range
Gas Dryer
*Air Conditioning — Ail Sizes
All Others/Repairs & Alterations (LIST ON BACi�
1% of Yalue ot Appliance or Work
Commercial/Industrial
1.25% ot Value of Appliance or Work
Rate
$ 30.00 $,
$ 10.00 $
Effective On March 1, 1996
JOB ADDRESS 5 �J?J �QI� �sV l � � � �� / v�
The undersigned hereby makes application for a pormit for the work herein
TOTAL specified agreaing to do all work in strict accordance with the City Codes and
rulings of the Buiiding Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
3' o� 9 ,1996
OWNER / ) II,iJ�� JU I �h"1/'Yl �
$10.00 $
$10.00 $
$ 25.00 $ 5 •��
$
$
State Surcharge
TOTAL FEE
��
,��
�,
�
MINIMUM FEE FOR ANY H ATING/COOLINGNENTILATION
REFRIG�RATION/AIR CONDITIONING PERMIT IS�,$25.00
PI.US THE 5.50 STATE SURCHARGE
REINSPECTION FEE.$42.00/Hr
•Air Cond'Rioners can not be placed in a side yard without
written permisston from adjoining p�operty owner.
BUILDING USED AS G1 �,(��III nQ
ESTIMATED COST � I J�OO� PERMIT NO. ���� ��'
� : �► � i �►� •: :� :
No. of Heating Units Circle Ono {Steam) (Hot Water) (Warm Air}
Trade Name Size No.
BTU HP EDR
Fuel Total Connected load
Burner 7rade Name Size No,
BTU HP EDR
HEATING
S
Buvr� Hrc�. �vc a �r. u�c.
��a c� .e� �_
Tei No. �� l lU�(d�
Approved By Rough—In Date Final Date ��
FILL OUT BACK SIDE OR STACK VERIFICATION ON �-��%�/
REPLACEMENT FURNACE
�
CITY OF
FR! I�LEY
FRfDLEY MI�NiCIPAL CENTER • 6431 UNIVERSITY AVE. ;�.E. f=RIDLEY, MN 5543? •(612) 571-3450 • FAX (612) 571-1287
March 29, 1996
Mr. Faul Emmerich
Four Diamond Builders
�.0738 Hanson Blvd NW
Coon Rapids, MN 55433
Re: Final Tnspection at 533 Janesville Street NE, Fridley
Dear Mr. Emmerich:
A final inspection was conducted on March 29, 1996 of the above
address and the following items were noted which mus� be completed
before the building can be finaled;
1. Complete the final grading and install sod in the front
and side yards.
2. Provide a hard surface driveway.
we will expect these items to be completed on or before June 15,
1996, and a reinspection called for. Occupancy of the structure is
appraved.
If you have any questions on this matter, please feel free to
contact me at 571-3450.
Sincerely,
� -
B R W. RIESCH
Building Inspector
BWR/mh