PRE2010 DOCSCity of Fridley
Application for Plumbing and C%n Fitting Permit
Dept. of Bldgs. Phone 560-3450
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
'�
— x $2.00
$
— x $1.50
4_
�
� i� � �z aaZ ox 1
�
0
i
•
s
N
WATER HTR.
GAS
ELEG
m
NO. RATE TOTAL
— x $2.00
$-
- x $ .75
—x$.75
$
— x $5.00
$
Base
1st
2nd
3rd
4th
• Future Connection Openings
_
Connected with
* New Fixture, Old Openings
Sewer
I Cesspool
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
Number Fixtures ......................
Future Fixture Opening ................
New Fixture Old Opening ..............
Catch Basin ............................
Water Heater (Up to 99,000 BTU) ......
New Ground Run Old Bldg . ............
Electric Water Heater
GAS FITTING FEES:
1st 3 Fixtures ..........................
Additional Fixtures ....................
Gas Range to 199,000 BTU ..............
NO. RATE TOTAL
— x $2.00
$
— x $1.50
$
— x $1.50
$
— x $3.25
$
— x $3.00
$
— x $3.25
$
— x $2.00
$
NO. RATE TOTAL
— x $2.00
$-
- x $ .75
—x$.75
$
— x $5.00
$
REPAIRS & ALTERATIONS—Refer to Code
Description ................................................$
TOTAL FEE $
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 applicaU*M are true and correct.
Fridl�y, Minn 1
Owner
Kind of
Used as
To be a
Estimate
Old—Ne
ROUGH
FINAL
42
Business Phone
City of Fridley, Minn. N° 10359
BUILDING PERMIT
.,.
owner: Robert u. Olsen Bider Gorco Construction Company
Address 730 Marigold Address 55884 Rr�ni,ml nw Ay'armP S -F._ Paul
LOCATION OF BUILDING
No.7310 — Street ri oldTrer-race . _ .._.... Part of Lot
Lot e _ Block 4 Addition or Sub -Division . DonuayI s Lakeview Kknor
Comer Lot _ Inside Lot X Setback — Sideyard
Sewer Elevation
Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
��_ Front 201 Depth 22' Height 101 Sq. pL 440' Ca. Ft 44001
Front Depth Height Sq. Fin Cu. Ft.
Type of Construction - Frame Est. Cost $2,5100.00 .____ To be Completed A-uglig. t;= 969
Hard surfaced driveway
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 forth and in complian with all provisions of
ordinances of the city of Fridley. (4�
In consideration of the payment of a fee of - 8. QQ —, permit is hereby granted to GOrco Construction
to construct the building or addition as described above. This permit is granted upon
the express condition that the person 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 any of the provisions of said
ordinances.
Inspector
CI(CLARENCE BELISLE
NOTICE:
This permit does not cover the construction, InstellaMon for whimg, plumbing, ges heating, sewer or water. Be acre to see
the Building Inspector for separate permits for these Items.
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNEC IS NAME2�/T� BUILDER
ADDRESS .7Q ADDRESS
LOCATION OF BUILDING
NO. � D STREET M,01 %D Ll) / E 104 MC`' 6 -
LOT BLOCK ADDITION OR SUBDIVISION ®l161 -4 Lc- L4j�F.dj F—LJ
CORNER LOT INSIDE LOTSETBACK SIDEYARD
SEWER ELEVATION TOP OF FOOTING
Applicant attach to this form Two Certificates of Survey of Lot and
proposed building location drawn on these Certificates,
DESCRIPTION OF BUILDING
To Be Used As:
Front of Depth Height
Square feet Cubic Feet
Front Depth
Height
Square feet Cubic Feet
Type of Construction gfe� 9:4 Estimated Cost "rod,
To Be Completed
The undersigned hereby 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 are true and correct. A
DATE (� C tol / SIGNATURE
.(Schedule of Fee Costs can be found on the Reverse Side.)
SUBJECT
City of Fridley
27222
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
RECEIP
01. DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
� � I
NUMBER
REV
GATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
L J\ 612-571-3450
910415
/17/98
JOB ADDRESS
730 Mari old Terrace NE
1 LEGAL
LOT NO. BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
8 4
1 Donna 's Lakeview Manor
SHEET
2 PROPERTYOWNER MAIL ADDRESS
ZIP PHONE
Robert Olson
571-6753
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Four Seasons Roofing & Remodeling LLC 7930 Univ.Ave.NE Fridley 795-9410
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO
B USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION iL REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and garage (20 Sq) Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the 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 80 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 EIN OR NOT. THE GRANTING OF A PERMIT
1668
.83
DOES NOT P SUME T GIVE A THORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS F ANY O HERS TE OR LOCAL LAW REGULATING CON-
STRUCTIO OR THE P NCE OF CONSTRUCTION
$54.00
Fire SC $1.67
PLAN CHECK FEE
TOTAL FEE
L cense SC 5.00
$61,c50
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
Af:E PROP
OG )NSF
L ALIDATED IS IS YOUR PiAIT
S,GNATURE OF OWNER )IF OWNER BUILDER) IDATEI
_,_: iructionAddress:
Description:
Naine & Address:
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
30
Effective 1/1/98
Tel.
actor: �� r 5�s_I,a��� •cl �,,, LCC: MN LICENSE #_
Tel. #
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
AkEA:
Length 'Width
Height
Sq. Ft.
a_ f-;uL MtEA:
Length Width
Height
Sq. Ft.
-'K AREA:
Le th idth
Hgt/Ground
Sq. Ft.
Charge
$
$1000 per.SAC Unit
License Surcharge
Type Estimated Cost: $ (o(oD
(Fee Schedule on Back).
Curb Cut Width Needed: Ft. + 6 F _ $
—� APPLICANT: ' � Tel. # 7 t5 � l�
1,'i i'CJLATIONS:
CITY USE ONLY
60
Fee Schedule on Reverse Side
`.,rcharge
1 of Permit Valuation (1/10th%)
Surcharge
$ 83
$:507$1,000 Valuation
Charge
$
$1000 per.SAC Unit
License Surcharge
$ 5
$5.00 (State Licensed Residential Contractors)
.:. , c',%,ay Escrow
$
Alt. "A" or Alt. "B" Above
rL; iul: Control
$
.$450.00 Conservation Plan Review
Fee Determined by Engineering
tvlain Charge
$
Agreement Necessary [ ] Not Necessary [ ]
S
TOTAL
$
1,'i i'CJLATIONS:
�C
C17YoF
FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 • (763) 571-3450 • FAX (763) 571-1287
November 9, 2001
Mr. Robert Olson
730 Marigold Ter NE
Fridley, MN 55432
Re: Final Inspection at 730 Marigold Ter NE
Contractor: Home Energy Center
Dear Mr. Olson:
A mechanical permit was issued on July 12, 2001 to install a furnace and an air conditioner at
your address. According to section 305 (a) of the 1991 Uniform Mechanical Code, a final
inspection shall be conducted on the mechanical work authorized by this permit. As of this date,
no inspection has been called for.
The permit fee that was paid covers the inspection to make sure the work was completed
according to the Mechanical Code. We will keep your permit open for another 30 days and if we
do not hear from you within this time to set up the inspection, we will expire the permit and no
further action will be taken.
To set up the inspection or to have any questions answered, please contact the Building
Inspection Division at (763) 572-3604.
Sincerely,
Inspector
DJ/mh
or 1
0h
r�
l ,1
CITY OF FRIDLEY INSPECTION DIViSION
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner -
Also Replacement Furnace
(Side Vent - Fill Out Back)
Gas Piping (Needed with new furnace,
but not replacement)
Gas Range
Gas Dryer
*Air Conditioning - All Sizes
All Others/Repairs & Alterations (LIST ON BACK)
1% of Value of Appliance or Work
Commercial/Industrial
1.25% of Value of Appliance or Work
Effective On January 1, 2000
State Surcharge
TOTAL FEE
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
$ .50
$ '55"5D
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 an
rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
NOMEMM(3yCENTER
21TNAVE N. #128
PLYMOUTH, MN 55447
HEATING CO
Signed ox&"M
Approved By Rough -In Date
DATE -7,, Cil
TEL # 7& 3. 47 9 IR O
ei (.-I I(
Final Date 11-.2_0 -o /
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
JOB ADDRESS130 MAP.I (y 0i_
-rE 2ACC-
OWNER?Dbt1_r0L-5QPJ
Rate
TOTAL
BUILDING USED AS HOMG
$ 30.00
$ .3O • °O
ESTIMATED COST
PERMIT N0. 11-16
$ 10.00
$
DESCRIPTION OF FURNACE AND OR BURNER
$ 10.00
$
No. of Heating Units 1 Circle Qne
(Steam) (Hot Water) ( rm i
$ 10.00
$
Trade Name JAN iTZOL &KN
l,g
L) Size No. too, cob
$ 25.00
$
�5 DD
BTU D b01- HP EDR
Fuel S Total Connected Load 3 3'7
Burner Trade Name
Size No.
$
BTU HP
EDR
State Surcharge
TOTAL FEE
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
$ .50
$ '55"5D
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 an
rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
NOMEMM(3yCENTER
21TNAVE N. #128
PLYMOUTH, MN 55447
HEATING CO
Signed ox&"M
Approved By Rough -In Date
DATE -7,, Cil
TEL # 7& 3. 47 9 IR O
ei (.-I I(
Final Date 11-.2_0 -o /
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacing an existing furance, 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 ( )
The undersigned also verifies that the replacement unit is 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( )
The existing combustion air is sized and installed to meet the current codes
and manufacturers specifications.
Yes No ( )
When required to install a new combustion air, it will be sized and installed
To meet the current codes and manufacturers specifications.
Yes (/) No ( )
When installing a new venting system, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central 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 l"uKNACF
Appliance #2 Type
Appliance #3 Type
Total Appliances Tot
Common Vent Type
BTU Input 00,000 Fan Agigted or Nat r
BTU Input Fan AS or Nat
BTU Input Fan Adst'd
d or Nat
al Btu Input 'r
Vent Height Diameter` inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance #2 Vent Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS: (Describe)
HEATING CO:
Signed By: Date :
Notes:
Aknom` t
.
40"esinormaion,�.,.
Weather: Minneapolis -St. Paul, MN, US
Winter Design Conditions Summer Design Conditions
Outside db -22 OF Outside db 91 OF
Inside db 70 OF Inside db 75 OF
Design TD 92 OF Design TD 16 OF
Daily range M
Relative humidity 50 %
Moisture difference 29 gr/Ib
Heating Summary
Building heat loss 33793 Btuh
Ventilation air 0 cfm
Ventilation air loss 0 Btuh
Design heat load 33793 Btuh
Infiltration
Method Simplified
Construction quality Average
Fireplaces 0
Heating Cooling
Area (ft2)
864
864
Volume (ft')
6912
6912
Air changes/hour
1.2
0.5
Equiv. AVF (cfm)
139
58
Heating Equipment Summary
0.96
Make
Total sens. equip. load
14708
Trade
Btuh
Actual heating fan
Sensible Cooling Equipment Load Sizing
Structure
15321
Btuh
Ventilation
0
Btuh
Design temperature swing
3.0
OF
Use mfg. data
n
Btuh
Rate/swing multiplier
0.96
Heating temp rise
Total sens. equip. load
14708
Btuh
Latent Cooling Equipment Load Sizing
Internal gains
1380
Btuh
Ventilation
0
Btuh
Infiltration
1126
Btuh
Total latent equip. load
2506
Btuh
Total equipment load 17214 Btuh
Make
Trade
Cooling Equipment Summary
Efficiency
80.0 AFUE
Efficiency 0.0 EER
Heating input
0 Btuh
Sensible cooling
0
Btuh
Heating output
0 Btuh
Latent cooling
0
Btuh
Heating temp rise
0 OF
Total cooling
0
Btuh
Actual heating fan
819 cfm
Actual cooling fan
819
cfm
Heating air flow factor
0.024 cfm/Btuh
Cooling air flow factor
0.053
cfm/Btuh
Space thermostat
Load sensible heat ratio
86
%
Printout
certified by ACCA to meet all requirements of Manual J 7th Ed.
wng ht50ft
Right -suite ResidentlalTM 5.0.28 RSR20001
2001 -Jul -0316:59:01
C:\My Documents%Wrightsoft HVACt2001 WAABASICLOAD.rsr
Page 1
RIGHT -J WORKSHEET
0 Entire House
Home Energy Center
15200 25th Avenue North, Plymouth, MN 55447 Phone: 763.476.1990 Fax: 763.476.1143
Printout certified by ACCP, to meet all requirements of Manual J 7th Ed.
Wr�ght50Ft Right-SutteResidential T" 5.0.28RSR20001 2001 -Jul -0316:59:01
i Z� C:\MyDocuments\WdghtsoftHVAC\2001\AAABASICLOAD.rsr Page 1
MANUAL J: 7th Ed.
1
Name of room
Entire House
Olson
2
Length of exposed wall
120.0 ft
120.0 ft
3
Room dimensions
36.0 x 24.0 ft
4
Ceiings Condit Opfion
8.0 ftj d
8.0 ft heaUcool
TYPE OF
CST
HTM
Area
Load (Btuh)
Area
Load (Btuh)
Area
Area
EXPOSURE
NO.
Htg Clg
(ft2)
Htg Clg
(ft)
Htg I Clg
Htg Clg
Htg Clg
5
Gross
a 12C
8.3
1.8
960
""
""'
960
Exposed
b
0.0
0.0
0
""
""
0
walls and
c
0.0
0.0
0
0
partitions
d
0.0
0.0
0
* "
""*
0
6
Windows and
a 2A
43.7
"
136
5943
""'
136
5943
glass doors
b
0.0
0
0
""
0
0
Heating
c
0.0
0
0
"*"
0
0
d
0.0
0
0
"`"
0
0
e
0.0
**
0
0
""
0
0
f
0.0
0
0
`"**
0
0
7
Windows and
North
27.8
60
""
1668
60
""
1668
glass doors
NE/NW
0.0
0
"*"
0
0
**"
0
Cooling
EIW
85.8
38
""
3260
38
""
3260
SEISW
0.0
0
""
0
0
"'`
0
South
44.8
38
"*"
1702
38
* ""`
1702
Horz
0.0
0
"'"
0
O
'*'"
0
8
Other doors
a
1017
29.4
6.3
42
1236
263
421236
263
b
0.0
0.0
0
0
0
0
0
0
c
0.0
0.0
01
0
0
0
0
0
9
Net
a
12C
8.3
1.8
782
6475
1379
782
6475
1379
exposed
b
0.0
0.0
0
0
0
0
0
0
walls and
c
0.0
0.0
0
0
0
0
0
0
partitions
d
0.0
0.0
0
0
0
0
0
0
e
0.0
0.0
0
0
0
0
0
0
f
0.0
0.0
0
0
0
0
0
0
10
Ceilings
a
16D
4.9
2.1
864
4213
1832
864
4213
1832
b
0.0
0.0
0
0
0
0
0
0
c
0.0
0.0
0
0
0
0
0
0
d
0.0
0.0
0
0
0
0
0
0
e
0.0
0.0
0
0
0
0
0
0
f
0.0
0.0
0
0
0
0
0
0
11
Floors
a
21A
2.2
0.0
864
1908
0
864
1908
0
(Note: room
b
0.0
0.0
0
0
0
0
0
0
perimeter
c
0.0
0.0
0
0
0
0
0
0
is displ.
d
0.0
0.0
0
0
0
0
0
0
for slab
a
0.0
0.0
0
0
0
0
0
0
floors)
f
0.0
0.0
0
0
0
0
0
0
12
Infiltration at
8.8
5.7
178
14018
1018
178
14018
1016
13
Subtotal loss=6+8. +11+12
""
33793
-
-
33793
Less external heating
"''
0
""
""
0
Less transfer
' "
0
'""'
""
0
14
Duct loss
0%
0
`""
0°/
0
""
°/
"""
o/
..:.
15
Total loss =13+14
""
33793
33793
16
Int. gains: People @ 300
6
""
1800
6
""
1800
Appl. @ 1200
2
""
2400
2
-
2400
17
Subtot RSH gain=7+8..+12+16
"'
" "'
15321
""
""
15321
Less external cooling
'**'
0
""*'
*""
0
Less transfer
"'""
0
'*"
*""'
0
18
Duct gain
0%
""
0
0%
""
0
o/
*""
o/
19
Total RSH gain=(17+18)'PLF
1.00
""
15321
1.00
""
15321
20
Air required (cfm)
819
819
""'
819
819
Printout certified by ACCP, to meet all requirements of Manual J 7th Ed.
Wr�ght50Ft Right-SutteResidential T" 5.0.28RSR20001 2001 -Jul -0316:59:01
i Z� C:\MyDocuments\WdghtsoftHVAC\2001\AAABASICLOAD.rsr Page 1
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Gra,hawk Builders
3020 Centerville Road, MN 55117
To: City of Fridley
6431 University Ave NE
Fridley, MN 55432
Attn: License & Inspections
Re: 730 Marigold Ter. NE.
Cancellation of permit
03/03/05
wD J-^ OV aq C.)
Phone (651) 486-9888
(763) 425-0421
The homeowner at this address has decided not to do the improvements on his
property, attached you will find a copy of a permit for which Grayhawk Builders has
applied. This letter is a Request for a Refund. We will be not be doing the work at
_730 Marigold Ter. NE
If you would please attend to this matter and send a refund check as soon as
possible, it would be greatly appreciated.
Thank you for taking care of this matter. RE: Permit
$154.75
Sincerely,
j OLM. � _X-�A_
Jamie Thompson
Production Manager/Grayhawk Builders �t
CLQ'
Siding • Roofing - Windows - Porches - Additions
Free Estimates
JEW (1
Effective 1/1/2001
eDDN j j
CITY OF FRIDLEY (763) 572-3604 Bldg Imps
kLTER (j
SINGLE (FAMILY AND DUPLEXES R-1 AND W2
BUILDING PERMIT APPLICATION
'.onstruction Address: a3b
AA
1--Irlwah�6 :2�wla
.egal Description:
?caner Name & Address:
��MrA Tel. # jP
,ontractor:
MN LICENSE #
>ddress:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT iE
LIVING AREA:
Length
Width Height Sq. Ft.
GARAGE AREA:
Length
Width Height Sq_ FL
DECK AREA:
Length
Width Hgt/Ground Sq. Ft-
LOTHER:
OTHER:
,onstructien Tyre:
�jj Cy- fft Of*Estimated Cost: $ d _.
,,..eway Curb Cut Width Needed: Ft + 6 Ft = Ft x $ _ $
)ATE: (.� "� Y� APPLICANT: Tel. #
.ITY USE ONLY - Call (763) 572-3504 for Permit Fees if mailing in application
T�
Permit Fee$ Fee Schedule on Reverse Side
Fire Surcharge by .001 of Permit Valuation (1/10th%)
State Surcharge $_ $_50/$'1,000 VaIdation
SAC Charge $$1'150 per SAC Unit
License Surcharge $+ $5.00 (State Licensed Residential Contractors)
Driveway Escrow $ Alt "A" or Alt. T" Above
Erosion Control $__________.,$450.00 Conservation Plan Review
Park Fee $ Fee Determined by Engineering r
Sewer Main Charge $ Agreement Necessary Not Necessary j
TOTAL $
F— iLATIONS:
Building
PLUMBING
Permit NOltq �'
Inspections
RESIDENTIAL APPLICATION
Received By:
763-572-3604
CITY OF FRIDLEY
Da°dlUN 2 0
763-502-/4�97�g7 FAX
EFFECTIVE 2-19-09
DATE (0(-('V 1 YOUR E-MAIL ADDRESS
y
SITE ADDRESS _ �'/tJi (�jG� �T�i{/ l� C�
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPERTY
NAME:
OWNER/
ADDRESS: 1 C CITY STATEA11VGIP 32
TENANT
PHONE: (0 - IO
CONTRACTOR
NAME: I
SUBMIT A COPY OF
YOUR STATE
STATE LICENSE # EXP DATE
LICENSE, BOND AND
STATE BOND # EXP DATE
CERTIFICATE OF
1-
ADDRESS: I GP J I CITY STATE, V�ZIP 7vr �Z
INSURANCE
PHONE 14FAX
PERMIT TYPE
ASINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK:
❑ NEW REPLA CEMENT
DETAILED DESCRIPTION OF WORK : ft - i Q � Y.,1j9 jjC M
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER•OF EACH BELOW). MINIMUM FEE
$35.50.
_ BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
_ _
BATHTUB _ GAS PIPING (NEED CITY LIC) _SWIMMING POOL -WATER SOFTNER($
_ CLOTHES WASHER _ KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. $1
DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER -OTHER
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THIS IS AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT �� PRINT DATE U / p�
NAME
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977