PRE 2010 DOCSCity of Fridley, Minn.
BUILDING PERMIT
Date: ,_,_October 23, 1968
Owner: Dalberg Blders . Builder
Address 1121 80th Ave. N. E Address
Same
Same
N9 999'7
LOCATION OF BUILDING
No. _ ��IZ _ _ Street ._.. McKinl eg S t . N. E . _ palt of Lot
Lot —14 --- Block 2 — Addition or Sub -Division ._._Dalberg Terrace
Corner Lot ---- Inside Lot _ _ x 7setback 35 — Sideyard 10 15
Sewer Elevation 895.39 898.39
Top of Footing
DESCRIPTION OF BUILDING
To be Used as:
RW 1� ling. Front 40' Depth 25 Height YO' Sq. Ft. 1000 Cu. Ft 20,000
Garage_ . Front 20' Depth 331 Height 10 Sq. Ft. — 660 Cu. Ft. 6600
Type of Construction Frame Est. Cost _$18,500____ To be Completed
SEWER LOCATION - 24.5' South of Manhole
WATER LOCATION - 13' South of Manhole
In consideration 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 set and in complian,�eQwith all provisions of
ordinances of the city of Fridley. �-, ( 1 ;. ;'
$100.00 Sewer Connection Charge /
In consideration of the payment of a fee of - _4 .90 , permit is hereby granted to Dalberg Blders .
to construct the building or addition as described above. This permit is granted upon
the express condition that thele to whom it is granted and his agents, employees and workmen, in all work
done in, around and upon said building, 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
within the city limits and this permit may be revoked at any time upon violation of the. provisions of said
ordinances.
r �
Clarence Belisle
NOTICE:
This permit does not cover the construction, Wdelledon for wiring, Plumbing, gas heating, sewer or water. Be sun to see
the Building Inspector for separate pormifs for than Items.
APPLICATION FOR BUILDING PERMIT
CITY OF •
ADDRESSOWNEEVS NAME BUILDER
3?�-I'eev�e
ADDRESS
NO. STREET
LOT_Z 4BLOCK
LOCATION OF BUILDING
0
COR -NM LOT INSIDE LOT
z
ADDITION OR SUBDIVISION
41IOSETBACK 3-5— SIDE -YARD
SEWER ELEVATION TOP OF FOOTING
Applicant attach to this form. T-zA7o Certificates of Survey of Lot and
proposed building location drawn on these Certificates.
DESCRIPTION OF BUILDING
To Be Used As:
� Front 6r Depth Height,'� �
Xoe
fiquare feet Cubic Feet
ito Front �` 2 Depth a Height
Square feet Cubic FeetV N9a
Type of Construction � Estimated Cost
To Be Completed
/i C
The undersigned aeby makes application for a permit for the work
herein specified, agreeing to do all work in strict accordance with the
City of Fridley Ordinances and rulings of the Department of Buildings,
and hereby declares that all the facts and representations stated in
this application axe true and correct
DATE � � �O
SIGNATURE
(Schedule of Fee Costs can be found on the Reverse Side.)
" I A
City of Fridley
Application for Plumbing and Gas Ruing Perm*
Dept. of Bldgs. Phone 560-3450
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
3
Number Fixtures ......................
Is 1
�
�TOT�AL
$–Z'ZOO
12
,id'�s
Y
New Fixture Old Opening ..............
Z
$
Catch Basin ...... .....................
x $3.25
w
?
go
•
F
•
Nrn
WATER HTR.
GAS
eLEG
Base
a $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................Z
x $2.00
Additional Fixtures ....................
x $ .75
$
Gas Range to 199,000 BTU ..............
x $5.00
$
1st
l
L
l
L
2nd
3rd
4th
• Future Connection Openings
* New Fixture, Old Openings
I
Connected With
Sewer
Cesspool �
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO. RATE
Number Fixtures ......................
� x $2.00
�TOT�AL
$–Z'ZOO
Future Fixture Opening ................
x $1.50
$
New Fixture Old Opening ..............
x $1.50
$
Catch Basin ...... .....................
x $3.25
$
Water Heater (Up to 99,000 BTU) ......
x $3.00
$ 3, Con
New Ground Run Old Bldg . ............
x $3.25
$
Electric Water Heater
a $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................Z
x $2.00
Additional Fixtures ....................
x $ .75
$
Gas Range to 199,000 BTU ..............
x $5.00
$
REPAIRS & ALTERATIONS—Refer to Code
Description .............. .................................$
TOTAL FEE 047
U
City of Fridley:
The undersigned hereby makes application for a permit for the work herei
specified, agreeing to do all work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the fact
and representations stated in this application are true and correct.
Fridley, Minn_ 3 ® %F , 19AT
Owner
Kind of Building V, -
- A r
Used as �a
To be completed about
Estimated Cost, $
Olduilding Permit No 9� °17 Permit No.
Signe
By
Business Phone No
ROUGH
FINAL_ Z - 3 -
42
° 4864
Original Permitfor PIUMBING AND GAS FMING 4/l� 3,2-0
N.B. When work covered by tbis permit is ready, the Plumbing Ordinance requires that request for Permit
inspection shall be phoned in to the plumbing Inspector, 560-3450 giving number of this permit., I Fee
DFSCBIPTION OF WORK
Number, Kind and Location of Fixtures
City of Fridley ."� o ,19,E
Stories
a W
tW
<
Z
mry
.. �
m
m
Y
m
m 6
x F
Z
w
O
K m
S m
F m
Z a
U
q
m
WATER HTR.
GAS
ELEC.
O
Q J
t=
Q 0
m
Q
Z
Q C
0
E 0
o a
I
N
O Q
J K
a o
Q 4
m m
Q O
rc J
K
f 'a
m
Q LL
n Q
Z
Q Q
O rc
Basement
let
2nd
3rd
4th
Connected with Sewer -Cesspool Gas Piping for 3 Openings
Permission is hereby granted fl'to do the plumbing and
gas fitting in the building described i the statement h9reto attar d, upon the express condition that
the person to whom this permit is granted, and his agents, employees and workmen, in the plumbing
or gas fitting of said building shall conform in all respects to ordinances of the City of Fridley, and
this permit may be revoked at any time upon the violation of any of the provisions of said ordinances.
By Order Of The Inspector Of Buildings
Roughing in Inspection Date
Inspector.
Final Inspection Date
Inspector.
Owner
Location 7 q i 3
Find of Building 63��
Used as
To be Completed ,19_
Estimated Cost
Old -New. Building Permit No. ! L3!2 '%
Date
Inspector of Buildings.
Original •
PERMIT for Power Plants and ideating. Cool-
ing, Ventilation. Refrigeration and Air
Conditioning Systems and Devices
DESCRIPTION OF WORK
No. of / Heating Plants ` 2Z4W_) to be ' tape ltered—repaired
Make��, / ,Size �;a ;
Oil fired ; Coal fired—, Gas fired._; Gas Authorization No.
Remarks
Approved by.
Fm
Final Inspection Date , 19_
U_Aa_410L
Inspector
Permit N° 4424
Fee $ 17.6-6
Office of the Inspector of Buildings
City of Fridley
City of Fridley, Minna 19-.
Owner
Location
Kind of Building-
How
uildi How Occupied A�
Work to be Commenced �- - Q 'Iy ,19-4
To be Completed ,19—
Estimated Cost, $
Old -New, Building Permit No. 9992
Permission is hereby granted to be -Y . (-6 to install—erect—use the material and devices described in the
above statement. This permit is granted upon the express condition that the person to whom it is granted, and his agents, employees and workmen, in all the work
done and materials used under this permit, and in the operation of the devices herein mentioned shall conform in all respects to the ordinances of the City of Fridley
relating to or governing the work to be done and the operation of the devices herein named, and to the speci ations set forth in the approved application for this
permit on file in the office of the Inspector of Buildings.
Inspector of Buildings
.4123$042 2M11 -67V
Application for Power Plants and Healing. Cooling, Ventilation. Refrigeration and
Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR: RATE TOTAL
Furnace Shell & Duct Work ..........................$10.00 $
Replacement of Furnace ............................. 6.00 $
Repairs & Alterations—up to $500.00 .................. 6.00 $
Repairs & Alterations each add. $500.00 ............... 3.00 $
MECH. WARM AIR
Furnace Shell & Duct Work to 120,000 BTU ............ $10.00 $
each add. 60,000 BTU ....................... 3.00 $
Replacement of Furnace ............................. 6.00 $
Repairs & Alterations—up to $500.00 ................. 6.00 $
Repairs & Alterations each add. $500.00 .............. 3.00 $
STEAM or HOT WATER SYSTEM
Furnace Shell & Lines—to 400 sq. ft. EDR Steam ...... $10.00 $
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ... 10.00 $
Each add. 200 sq. ft. EDR Steam ...................... 3.00 $
Each add. 320 sq. ft. EDR Hot Water ................... 3.00 $
OIL BURNER—to 3 gal. per hour 6.00 $
over 3 gal. per hour—See Fee Schedule
GAS BURNER (up to 199,000 BTU) .......................
5.00
$
over 199,000 BTU See Fee Schedule
GAS FITTING FEES:
NO RATE TOTAL
1st 3 Fixtures ......................
x$ 2.00
$
Additional Fixtures .................
x .75
$
Gas Range to 199,000 ...........
x$ 5.00
$
AIR CONDITIONING
$
FAN HEATING SYSTEM See Fee Schedule
VENTILATING SYSTEM
$
ALTERATIONS & REPAIRS
TOTAL FEE
$
ROUGH
FINAL �� s
Dept. of Bldgs. Phone
e
City of Fridley:
The undersigned hereby makes application for a permit for the work hereiL
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.
Owner
Kind of
Used as
To be completed about
Cost, $__ X, ._69
s1
)Building Permit No. q 1 Permit No.
DESCRIPTION OF WORK
HEATING or POWER PLANTS -Steam, Hot Water, Warm Air—No—
Trade Name C Size No(X
Capacity Sq. Ft. E.D.R BTU H.P.
Total Connected Load Kind of Fu
BURNER —Trade Name Size No
Capacity. Sq. Ft. E.D.R BTU H.P.
(REMARKS—OVER)
SUBURBAN AIR CONDITIONING CO.
Signed B41-9 CEW DRIVE
By YINN_EWW8 MINNESOTA 55432
CQN�b42 Business Phone No
879.01
City of Fridley
Applicallon for N=Wng and Gas RMIng Pante
Dept. of Bldgs. Phone 990-3490
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures ..... .. . ......
x $2.00
$
Future Fixture Opening ... ... ......
x $1.50
$
New Fixture Old Opening
x $1.50
$
Catch Basin .. ... ... ......
x $3.25
$
Water Heater (Up to 99,000 BTU) ....
x $3.00
$
New Ground Run Old Bldg.
WATER HU.
GAS
Eur-
LEGBase
Base
$
GAS FITTING FEES:
NO. RATE TOTAL
tat
Ind
3
1
—
2nd
3rd
--
4th
Feature Coaaeelton Openings
New Fixture, Old OpeningsGsspo
Coaaected with
r
I ❑
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures ..... .. . ......
x $2.00
$
Future Fixture Opening ... ... ......
x $1.50
$
New Fixture Old Opening
x $1.50
$
Catch Basin .. ... ... ......
x $3.25
$
Water Heater (Up to 99,000 BTU) ....
x $3.00
$
New Ground Run Old Bldg.
x $3.25
$
Electric Water Heater
= $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures .......................... x $2.00 $
Additional Fixtures . .......... , ....... —x$.75 $
Gas Range to 199,000 BTU .............. I x $5.00 $ 3.00
REPAIRS & ALTERATIONS—Refer to Code
Description ................................................$
TOTAL FEE $--5- - 02
NE. McKinle
City of Fridley:
The undersigned hereby makes application for a permit for the work herei
specified, agreeing to do all work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the fact
and representations stated in this application are true and correct.
Fridley, Minn MAY 19 1969 19—
Owner Barton Sura
Kind of Building Frame
Used as Re si dente
To be completed about MAY 2 4 1969
Estimated Cost, $ 5.00
O1dZ,New. Building Permit No. Permit go. � S
MINNEAPOLIS S CO.
Sign
Business Phone
ROUGH
FINAL - _/2 - ZO
SUBJECT
City of Fridley
- 16 9 2
AT THE TOP OF THE TWINS
BUILDING PERMIT
PT NO
• COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
r i
1 I i
CITY HALL FRIDLEY 55432
,•�
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
""'" 612-571-3450
910-F15
2/25/83
JOB ADDRESS 7473 McKinley St. N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
14
2
1 Dalberq Terrace SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Darlene Westling 7473 McKinley St. N.E. Fric1lev 55432 784-8108
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Kreps Const. Co Inc631-8543
-Ray
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Residential
7 CLASSOFWORK
❑ NEW ❑ ADDITION ❑ ALTERATION V REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
9 CHANGE OF USE FROM TO
STIPULATIONS
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
Wond 'Frame
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SO. 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 EXAMINED THIS APPLICATION
STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
VALUATION
SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
pERMITFEE
SACCHA G
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
q
STRUC ON OR THE PERFORMA OF CONSTRUCTION.
PLAN CHECK FEE,
TOTAL FEE
•Z 5 hel
-SIG TURE OFCONTRACTOR ORAUTHORIZED AGENT (DATE)
WHEN ROPERLY VALIDATED THI S O R PERMIT
BLDG INSP DATE
SIGNATURE OF OWNER OF OWNER BUILDER) IDATEI
CITY OF FRIDLEY
Effective Aug. 1, 1981
APPLICATION FOR RESIDENTIAL BUILDVIG PERMITS
(News Alterations, Additions, or Repairs)
OWNER: ,�,,a
!�
�- :.
BUILDER:
Y 4f ens C e " s i , cam` .4- ��.
ADDRESS:
7% 3
/'7 CIt r�Ge y
ADDRESS:
/G' 7G e �A 7-4,9,mW AC 2 -
TEL
TEL 110:
1' 7 Sy_
/ c' S'
TEL NO:
613 i- -9-5-Y 3
Construction Location
• STR = NO s `2 y ? 3 /l dt�gTJtEET:
LOT: % L/ BLOCKs 2-- ADDITION: 0 fi 1- 4 e i�q i t rpt dt
Corner Lot: Insibe Lots Setback: Sideyards:
Applicant attach to this form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
DESCRIPTION OF WNSTRUCTION
e /► r>� Front: Depths Height:
G, 14 i0 C � � � � Square Feats Cubic Feet:
Front: Depth: Height:
Square Feet: Cubic Feet:
Type of Constructions Estimated Cost: S
Tb Be Cbripleted:
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: S S
SEE REVERSE SIDE OF SHEET
The undersigned hereby makes application for a permit for the vrork herein specified,
agreeing to do,all work In strict accordance with the City of Fridley Ordinances and
rulings of the Dejxirtment of Buildings, and hereby declares that all the facts and
representations stated in this applicati n are trueandcorrect.
DATES , 5 SIGNATUJE:
Stipulations:
t
/Q e
IaJ Y Y
SUBJECT
City of Fridley
27092
AT THE TOP OF THE TWINS
BUILDING
PERMIT
� �
NO.
i COMMUNITY DEVELOPMENT DIV.
_ _
Vy ---
r � � PROTECTIVE INSPECTION SEC.
I Ch1
E . i
NUMBER
REV
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
' 612-571-3450
910-F15
8/10/98
JOB ADDRESS
7473 McKinlev St NE
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DESCR.
14
2
Dalberg Terrace
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Joseph Ewest 7473 McKinley
785-1682
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Owner
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK
NEW O ADDITION O ALTERATION REPAIR O MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and garage 21 STear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with State Building
Code.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SO. 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 EXAMINED THIS APPLICATION
STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
VALUATION
SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL, BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$1751
.87
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING COW
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
$56.75Fire
SC $1.75
PLAN CHECK FEE
TOTAL E
.3
SI TUBE OF CONTR CTOR A i RIZED AGEN (DAT
/}I
Xw�.. �V '�' far(
N PE LIDAT IS IS Y PE�T��
ZfT
5 NA fURE OF OWNER OF OW B ILDER) IDATEI
BL INSP
PATE
NEW [ ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION-7-7�3
� P
ConstructionAddress: `f I , ` (� CSE
Legal Description: CC
Owner Name & Address:-7Tel. #
Contractor: MN LICENSE #
Address: Tel. #
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF RUPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft. II
OTHER: V P -u - `[ n r�.var,'r, � l sa Qa)1e S z l t;a. r o rip
Construction Type:
Estimated Cost: $ l ?S—/
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
FV
DATE:0
�(q q APPLICANT: A.,AAjr Tel. # 0
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
CITY USE ONLY
$
Fee Schedule on Reverse Side
$ i 7��
.001 of Permit Valuation (1/10th%)
$
$.50/$1,000 Valuation
$
$1000 per SAC Unit
$
$5.00 (State Licensed Residential Contractors)
$
Alt. "A" or Alt. "B" Above
$
$450.00 Conservation Plan Review
$
Fee Determined by Engineering
$
Agreement Necessary [ ] Not Necessary [ ]
NEW []
ADDN [ ] CITY OF FRIDLEY
ALTER SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address:
v\
Effective 1/1/2001
(763) 572-3604 Bldg Insp
oar�r� -631-Z�
Legal Description:
Owner Name & Address: S axpM s 6 -aro 6 E-2. -n4-- Tel. # 7& .3 - 717- �S�o
Contractor: MN LICENSE
Address: 7351 Kr kwydd hN N Ne.,01e ra"up dnd 55,56!2 !2 Tel. # '763- 710-a00
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER:
Construction Type: L<) %f)Y4 [gj.9-",&$S Estimated Cost: $ _ % 6. O[LD 01
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ —=$
DATE: 12,,11ZQr APPLICANT: ?(v 3 .-ZW ,ao o
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
��>i11�JI��[eli•F�i
Call (763) 572-3604 for Permit Fees if mailing in application
$ Fee Schedule on Reverse Side
$ /A 00 .001 of Permit Valuation (1/10th%)
$ 5 -,S -t) $.50/$1,000 Valuation
$ $1150 per SAC Unit.
$ UO $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [ ]
$ '21lo .
1-1
61-) Zilov 1
�6q V-0�;-
ca'q- 55 7F
K31 University Ave NE
"ddley, MN 55432
763) 572-3604, FAX (763) 571-1287
• �nca.urc�Nu , cVvs
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
8E
:�i.i;
:<},,
}s:<: Urinal€y::
1i?
2
FlooYi.{r}}'f:4•s:Svi^
3
4.
nwrcf% NUM
.:
Shower
R OF
Y>,in :
::•;
FIXTURES TO BE INSTALLED
Wash :
ts.
n• :::<:<.:.•::;.Y ::
,...{:.
Tra " •
,:.xa•:.FIoor
Floor
Drain
ON EACH FLOOR
?:r ::::
== Auto.
{fi;,:
: x._? Washer
<
..;
Ran a
► Water HeaterStories
{.:,!,::;.:
ir: Gas ElecBasement
$10.00
r-?•,:{�v:Y::•'':+✓:
leer Dispenser
$10.00
and rulings of the Building Division, and hereby declares that all the fads
Ilow Off Basin
iti i::>i:::::
::::.Floor
..:+•..
:,:,.n
[IlWateras
:§rn.
,atch Basin
:::,f+J.i; n•{:jvr$,r .•.r.SX:r,..:y:'•.+•}:i:' :YfI.:.,:r
'•'•°+'�"ii=l+i:.'Floor
i.'>i:;a:':; ::.r'•::: ::•;::•}•::+�;:';......n
.: {:.: {:i: •.,:.y}:S';•i
'LUMBING FIXTURE RATES: NO.
RATE
'TOTAL
JOB ADDRESS
Jew Fixtures
$10.00
The undersigned hereby makes application for a permit for the work herein
)Id Opening, New Fixture
$10.00
specified agreeing to do all work in strict accordance with the city c9des,
leer Dispenser
$10.00
and rulings of the Building Division, and hereby declares that all the fads
Ilow Off Basin
$1Q:00
and representations stated in this application are true and correct
,atch Basin
$10.00 ;
lain Water Leader
$10.00
DATE:y �3/ , 20�_
;ump/Receiving Tank
$10.00
Vater Treating Appliance
$35100
OWNER _Vila I�Q �t4
Vater Heater -Electric
$35:00
Vater Heater - Gas** �_
$35.00
St70
BUILDING USED AS 51 e.YlGe_
*as Range". _ `
$10.00
las Dryer**
$10.00
ESTIMATED COST q60 oo PERMIT NO.
;ack Flow Preventer Required ( )Yes ( ) No
Type
$15.00
PLUMBING CO PANY 0 i(` 0k 01w\. be
reinspection Fee $50.00/Hr
SIGNED BY TEL NO. AP 12) 927— elo33
,LL OTHERS AND/OR' REPAIRS AND ALTERATIONS
•
1.25% of Value of Fixture or Appliance
State Surcharge
$ ...�
Approved By Rough -In Date Final Date
TOTAL FEE
$ 3S. SD
MINIMUM FEE FO -ANY PLUMBING/GAS PERMIT IS $15 00 or b% OF COST
OF THE IMPROVEMENT WHICHEVER IS GREATER PLUS THE SURCHARGE.
:OMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. **PROVIDE COMMON VENT INFO ON BACK SIDE
FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When reolacina an existing furnace, the undersigned hereby verifies that the
BTU Input Fan Assisted or Nat
.venting has' been examined and is free from rust, deterioration, obstructions,
BTU Input Fan Assisted or Nat
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 ( )
The undersigned also verifies that the replacement unit is a listed assembly
and. meets the current codes and manufacturers specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances.
Yes ( ) No ( )
The existing combustion air is sized and Installed to meet the current codes
and manufacturer's specifications.
Yes ( ) No( )
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacturer's specifications.
Yes () No ( )
When Installing a new venting system, the undersigned hereby verifies that
itis a listed assembly 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.
Yes ( ) No( )
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes.
Yes ( ) No( )
Appliance Type and Size/Common Vent and Vent Connector Information
Appliance #1 Type
BTU Input Fan Assisted or Nat
Appliance #2 Type
BTU Input Fan Assisted or Nat
Appliance #3 Type
BTU Input Fan Assisted or Nat
Total Appliances
Total Btu Input
Common Vent Type
Vent Height Diameter inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance 42 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 :