PRE 2010 DOCSCity of Fridley, Minn.
BUILDING PERMIT N® 3230
Date: ....... ..............................
Owner....................................... Builder.................
Address ...................................... Address .............................................
LOCATION OF BUILDING
Street ... . `. .::: .. .................. Part of Lot ...... .. ... .. .
.. Block .................. Addition or Sub -Division :�:'..:.... �.. C , .r .5 r
Lot... ' ..
Corner Lot ............ Inside Lot .
. � ......... Setback Sideyard /�) :�.�� ..........
41 o
DESCRIPTION OF BUILDING
To be Used as:
9
v..::+.....c ....... Front ....'....
Depth Height ........ Sq. Ft. ........ Cu. FL :.......
.................... Front ........ Depth ........ Height .., .... Sq. Ft......... all Ft. .....
" - r
7!yp ...:... To be Completed
e of Est. Cost.': ..�....... .....-:'. �:....
cL- 5
In consideration of the issuance to me of a permit to construct the building desribed above, I agree to do
the proposed work in accordance with the description above set forth and in compliance with all provisions of
ordinances of the city of Fridley. ��,,���
... ...................:��.� 4z. ........
.
U
payment $. . .. .., . Permit is hereby granted to ". .... .:..'..:.::.
In consideration of the a ent of a fee of ....
......................... 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 with-
in the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
.................. building Inspector
NOTICE:
This permit does not cover the construction, Installation or alteration for wiring, plumbing, gas heating,
sewer or water. Be sure to see the Building Inspector for separate permits for these itemm
THOMAS S. SILVIS DESIGN • DEVELOP • BUILD
2100 INDIANA AVE. NORTH • MINNEAPOLIS 22, MINN.
-6
Application for Power Planus and Heating, Cooling, Ventilation, Refrigeration and
Air Conditioning S stenand Devices
Systens
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR: RATE TOTAL
Furnace Shell & Duct Work .......................... 8.00 $ RE 0 Q
Replacement of Furnace ............................. 5.00 $
Repairs & Alterations—up to $500.00 .................. 5.00 $
Repairs & Alterations each add. $500.00 ............... 2.50 $
MECH- WARM AIR
Furnace Shell & Duct Work to 120,000 BTU ............ 8.00 $
each add. 60,000 BTU ....................... 2.00 $
Replacement of Furnace ............................. 5.00 $
Repairs & Alterations—up to $500.00 ................. 5.00 $
Repairs & Alterations each add. $500.00 .............. 2.50 $
STEAM or HOT WATER SYSTEM
Furnace Shell & Lines—to 400 sq. ft. IDR Steam ......
800
$
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ...
8.00
$—
Each add. 200 sq. ft. IDR Steam ......................
2.50
$
Each add. 320 sq. ft. EDR Hot Water ..................
2.50
$
OIL BURNER to 3 gal. per hour ........................
5.00
$
over 3 gal. per hour—See Fee Schedule
GAS BURNER (up to 400,000 BTU) .......................
5.00
$ S Oy
GAS PIPING (Up to 3 Fixtures) ..........................
1.50
$ / S o
(Add 50c each over 3)
AIR CONDITIONING
$ S- —g-)
FAN HEATING SYSTEM See Fee Schedule
VENTILATING SYSTEM
$
ALTERATIONS & REPAIRS TOTAL
FEE
Dept. of Bldgs. Phone SII 4-7470
City of Fridley:
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City Ordinances
and ruling of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
Fridley, Minn S" Z ( , 195
Owner " 195—
Kind of Building 195—
Used as
To be completed about
Estimated Cost, $
Old—Neve. Building Permit No.�
DESCRIPTION OF WOR$
HEATING or POWER PLANTS --Ste m, Hot Water, Warm Air—No
Trade Nam Size No
Capacity Sq. Ft. E.D.RBTU Q S 0-7-72 H.P.
Total Connected Load��� Kind of Fue
BURNER — Trade Name Size No—
Cap city
o
Capacity Sq. Ft. E.D.R BTU H.P.
Saga
Sy
11 POST 1 M-8-58 Business Phone No
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City of Fridley, Minn.
BUILDING PERMIT N�
51'74
Date:
Owner: f y .P �n , Builder
Address Address
LOCATION OF DING
No. Street Murt of Lot
Lot--_-LL__Block
—Addition or Sub-Divisio �oe
Corner Lot _ Inside Lot Setback deyard —
Sewer Elevation
Foundation Elevation
DESCRIPTION OF BUILDING
To
• "� Front Depth- 1 Heig Sq. Ft. Cu. Ft.
Front — Depth . eight _ Sq. Ft. __. _ _ __ Cu. Ft. _
Type of Construction __ _°'A ~' Fit. t ..r"To be Completed
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• forth and in compliance with all provisions of
ordinances of the city of Fridley.
In consideration of the payment of a fee of $;Z , permit is hereby granted to
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 viRQip�Vjany of the provisions of said
ordinances.
Building Inspector
NOTICE
Sle permit does not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sure to we
the Building Inspector for separate permits for these Mems.
Owner's
Address
APPLICATION FOR BUILDING PRO=
CITY OF FRIDLEY, MINNESOTA
LOCATION OF BUILDING
Street r 12 �� Part of Lot
Lot Block Addition or Subdivision
Corner Lot Inside Lot Setback Side -Yard
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Certificate of Survey of Lot and proposed building
location.
To be us d Ate_
A
s
DESCRIPTION OF BUILDING
0
Sq. Ft. � Cu. Ft. _a 4 6 6
Front Depth Height
®% Sq. Ft. Cu. Ft.
Type of Construction 4 - Estimated Cost
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 Ordinances and ruling of
the Department of Buildings, and hereby declares that all the fq,*s and representations
stated in this application are true and correct.
(A Schedule of Fee Costs can be found on the Reverse Side.)
SUBJECT
PER T NO.
City of Fridley
G 1977
AT THE TOP OF THE TWINS
BUILDING
P E R
_
M I T
rp
�
RECE
COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
// 7®
1
i CITY HALL FRIDLEY 55432
NUMBERREV.
DATE
PAGE OF
APPROVED BY
612-571-3450
910-F15
1/10/89
JOB ADDRESS 6366 Pierce Street N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
11
Moore Lake Highlands 1St
SHEET
2 PROPERTY OWNER MAILADDRESS
ZIP
PHONE
Nelson 6366 Pierce Street N.E,
574--0151
3 CONTRACTOR MAIL ADDRESS
ZIP
PHONE LICENSE NO.
Addition & Rmodeling Specialists 10800 Xavis Street
NWf Coon Rapids 427-7330
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP
PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS
ZIP
PHONE LICENSE NO.
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION] REPAIR
❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof Dwelling
9 CHANGEOFUSEFROM TO
STIPULATIONS
Roof can be 2nd layer but not 3rd, Ihs:tall ridged
galvanized valleys,
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SQ. 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
1
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
$700
$.50
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-
$19.00
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
$19.50
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATEI
- WHEN PROPERLY V IDATED THIS IS YOUR PERR,MIT
BLDG )NSP
V
f1AT
SIGNATURE OF OWNER I IF OWNER BUILDER) (DATE)
NEM I ] City of Fridley EEfective 5/1/88
AMN I ] R-1 AND R-2
ALTER I ] Building Permit Application
Construction Address: do 3� 6ec-c .J�- JV F
Legal Description:
Owner Nene & Address: tnr- J mc, Ale ISoc\ Tel. #
Oontractor: )qdd t h�� , �� ;� c Sy e c «/«'!-c Tel. #
Address:
n
Attach to this application, a Certif icate of Survey of the
lot, with the proposoed construction drawn on it to scale.
DESCRIPPION OF IMPROVEMMT
LIVING AREA: Length Width Height Sg. Ft.
GARAGE AREA: Length Width Height Sg. Ft.
DECK AREA: length
)I Width Hgt/Ground(` Sg. Ft.
comeS h h 1 0 �a� env /� Pkv, u�y/� J k&s S
Gbrner Lot [ ] Inside Lot [ ] Ft. Yd Setback
Type of Construction: _
Approx. Completion Date:
Side Yard Setbacks
Estimated Cost: $ 940 C)
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $
Width + 6' See Back Page
DATE : 1 Jfc) hL APPLIaw : Tel.
crry USE OIC,?
Permit Flee 5 - 6�0 Flee Schedule on Reverse Side
State Surcharge 5 SZZ $.50/51,000 Valuation
SAC Charge 5 59.-6556 per SAC Unit
Driveway Escrow 5 Alt. "A" or Alt. "B" Above
Park Flee 5 Fee Determined by Engineering
Sewer Main Charge 5 Agreement Necessary [ l Not Necessary I l
TOTAL 5 M, �
STIPUIMIO11S: ��'
�1m mo (0-(.5-13 Minnesota Well and Boring
WELL OR BORING LO TION t'M , MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 43758:::
County Name ELL AND BORING SEALING RECORD Minnesota Unique No.
y R�si Minnesota Statutes, Chapter 1031 or W -series No.
,yyyt��l�A � (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction (sm. - (g.) Date Sealed Approximate Date Well
FPTDLEY 0300 24 Si I S4 {p} r orBorngConstructed
1 ry'� v �:et a F{K� 4S Y � 6., � ce 4'A �
Numerical Street Address or Fire Number and City of Well or Boring Location
6366 PIERCE STREET NE Depth Before Sealing i ft. Original Depth
Show exact location of well or boring Sketch map of well or boring Static Water Level[,� Accurate
in section grid with "X-. location. showing property lines,
roads, and buildings. ❑ Approximate
N
S — t
I� r r^rre so_ y
i
Screen from to ---- 174&-
ft. Upen dote from
to n.
OBSTRUCTION/DEBRIS/FILL
❑ Obstruction ❑ Debris ❑ Fill
Type of debris/obstruction
ObstructionMebds/Fill removed? ❑ Yes ❑ No
PROPERTY_ OWNER'S NAME
NELS, 1LATHLEEN OR LAWRENCE
Mailing Address if different than property address indicated above.
NEL.S�--)N, KATHLEEN OR LAWRENCE
6366 FIERCE STREET NE
FRIDLEY • ASN 5543"12
PUMP
PRIOR REMOVED SW JET
11 Removed R3 Not Present ❑ Other
PUMP."...
CASING
Diameter Depth
`3 t in. from _( to 6 ft.
in. from to ft.
in. from to ft.
s i
Single Aquifer ❑ Multiaquifer
ft. below above land surface
-f-
- -
- a _
-�
CASING TYPE
W
1
f i1
g 4 A
NI D rTc
El
1
METHOD USED TO SEAL ANNULAR SPACE BETWEEN
No Annular Space Exists
❑ Annular space grouted with tremie pipe
❑ Casing PerforationtRemoval
in. from to
in. from to
Type
2 CASINGS, OR CASING AND BORE HOLE:
ft: ❑ Perforated ❑ Removed
ft. ❑ Perforated ❑ Removed
smile - --�-- !
4
� Steel ❑ Plastic 11 Tile Other
1
i
i
1
--
-
-4-
S — t
I� r r^rre so_ y
i
Screen from to ---- 174&-
ft. Upen dote from
to n.
OBSTRUCTION/DEBRIS/FILL
❑ Obstruction ❑ Debris ❑ Fill
Type of debris/obstruction
ObstructionMebds/Fill removed? ❑ Yes ❑ No
PROPERTY_ OWNER'S NAME
NELS, 1LATHLEEN OR LAWRENCE
Mailing Address if different than property address indicated above.
NEL.S�--)N, KATHLEEN OR LAWRENCE
6366 FIERCE STREET NE
FRIDLEY • ASN 5543"12
PUMP
PRIOR REMOVED SW JET
11 Removed R3 Not Present ❑ Other
PUMP."...
CASING
Diameter Depth
`3 t in. from _( to 6 ft.
in. from to ft.
in. from to ft.
Set iA oversize hole?
❑ Yes No
❑ Yes ❑ No
❑ Yes ❑ No
Annular space initially grouted?
11 Yes ❑ No ❑Unknown
❑ Yes ❑ No ❑ Unknown
❑ Yes ❑ No ❑ Unknown
GEOLOGICAL MATERIAL
COLOR
HARDNESS OF
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN
No Annular Space Exists
❑ Annular space grouted with tremie pipe
❑ Casing PerforationtRemoval
in. from to
in. from to
Type
2 CASINGS, OR CASING AND BORE HOLE:
ft: ❑ Perforated ❑ Removed
ft. ❑ Perforated ❑ Removed
of perforator
❑ Other
GROUTING MATERIAL
ENVIROPLUG
Grouting material from
from
from
from
16
to
„ to
to
to
, qo--t
ft. yards bags
ft. yards bags
ft. yards bags
n. yards bags
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
LC)CATED IN W CORNER, OF DSHT..
MEASURED FROM GRADE LEVEL...
PIT?* 13-030-24-3I 0046
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report is
true to the best of my knowledge.
Contractor Business Nameiic a or Registratron No.
d Mvrori Hal.enke t < _ {1r�;. � � I0�r
Authorized Representative Signature
JESSE NALENKE JASON KELLY
Date
LOCAL COPY
p
H 3��
of Person Sealing Well or Boring
HE -01434-01
SUBJECT
P N
City of Fridley
AT THE TOP OF THE TWINS
BUILDING PERMIT
30001'
`v _ COMMUNITY DEVELOPMENT DIV.
r � PROTECTIVE INSPECTION SEC.
1 � �
CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED BY
L 612-571-3450
910-Fl5
8/4/99
JOB ADDRESS 6366 Pierce Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
11
Moore Lake Highlands 1st
SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP
PHONE
Kathy Garman
574-0151
3 CONTRACTOR MAIL ADDRESS ZIP
PHONE LICENSE NO
Murphy Bros. Bldg & Remodeling Co. A1613 93rd Ln NE Blaine 55449 780-3262 3416
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
O NEW O ADDITION O ALTERATION x® REPAIR
O MOVE O REMOVE
B DESCRIBE WORK
Reroof house and garage 29 S Tear -off; Reside house and garage
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
Call for building wrap inspection before covering.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
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
I
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
$4835
$2.42
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-
$111.25
Fire
S RUCTION R THE PERFORMANCE F CONSTRUCTION
SC $4.84
PLAN CHECK FEE
TOTE
Licens $5.0
$03.51
SIGNATURE OF CO " CT AUTHo z- _ iDATE,
EN ROP ALIDA THIS IS YQ.UB PER
BLOt INS
HATE
S.GNATURE OF OWNER IF ER BUILDER, iDATE,
Agg-04-99 11:06 P_02
` NEW [) Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ) SINGLE FAMILY AND DUPLEXES R-1 AND R -Z
BUILDING PERMIT APPLICATION
ConstructionAddress: V iOrG4?, '�'r rV1
Legal Description:
Owner Name & Address: Tel. # 67*410 j
Contractor;' M INS II -ftJ J. �Jt�U1/M4'� r M L' ' MN LICENSE # / (P
Address: �P� � %�`� LAW /Vii I<44 Vw-, Tel. # &12-7E70 - 37-b2�-
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVING AREA: Length
GARAGE AREA: Length
DECK AREA: Length
OTHER:
DESCRIPTION OF IMPROVEMENT
Width
Width Height Sq. Ft.
Width Height _ Sq. Ft.
Width Hgt/Ground ^_ Sq. Ft.
Construction Type: `��'/G Estimated Cost: $y U
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $
DATE: APPLICANT: 1G[ Tel. # &1,9-700-377 p 2—
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
$
Erosion Control
$
Park Fee
$
Sewer Main Charge
$
TOTAL
STIPULATIONS:
S
CITY USE ONLY
Fee Schedule on Reverse Side
.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 [ ]
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
572-36U4 JFAX: (763) 571-1287
ADDRESS : 6366 PIERCE ST NE
PIN : 133024310046
LEGAL DESC : MOORE LAKE HIGHLANDS 1 ST
: LOT 11 BLOCK
PERMIT TYPE : PLUMBING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
PERMIT NO.: 2004-02149
DATE ISSUED: 11/22/2004
VALUATION : $ 0.00
NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC CHAPTER 6 AND TABLE 6-A
# ELEC WATER HEATERS 0 VALUE OF FIXTURE/APPLIANCE
# NEW FIXTURES (EXIST OPENINGS) 0 # GAS WATER HEATERS
# GAS DRYERS 0 # GAS RANGES
# OF NEW FIXTURES 0 VALUE (FOR MINIMUM CALL)
# WATER TRMT APPLIANCES 1
APPLICANT
SHILOAH WATER CO
7319 166 AVE NW
RAMSEY, MN 55303-
(763)753-9244
OWNER
GARMAN KATHLEEN R
6366 PIERCE ST NE
FRIDLEY, MN 55432
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of worl
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 provisions of any other state or local law
regulating construction or the performance of construction.
Applicant _ / _ Date
Bldg
COD ADA
TC DCD11 diT[+ nr. �i.rn r•.. rte..
PLBG PERMIT MINIMUM FEE
PLBG FIXTURES (NEW OPENINGS)
PLBG FIXTURES (EXIST OPENINGS)
WATER HEATER - ELEC
WATER HEATER - GAS
GAS RANGE FEE
GAS DRYER FEE
PLBG REPAIR/ALTERATIONS
STATE SURCHARGE, PLBG FLAT
WATER TREATMENT APPLIANCE
TOTAL
PAID WITH CHECK # 10209
----- • ---• .......,..., aW� V 11WL 1- vim n %-,- -1—ax 1 nt%114 Ljrla%.1V or U i1ISU V C..
0
0
0
300
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.50
35.00
35.50
CITY OF FRIDLEY INSPECTION DIV. Effective April 1, 2004
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
(763) 572-3604, FAX (763) 571-1287
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
;:.: ::: •: n}'ri::i::i --:....::;}:{: +•. v: F.: iiiii:-iiii: i'. '.;'p'w..:.:i::ii::i: : . �':': •:'{i::iiiti:i::i � :'•:ri::i-
:.:::::: Wash :::: Floor ::::<:: Au
::>:.... :��:::...... to. :..�'�.::::>:::::::: Gas �� .>:::: Water Heater
Stories ::.:::<::.>:» Urinal ::::>:`< Shower Tray I"`'i''i> Drain
....lid........ :..13I_:._...� - ...�'�...�1<< Y i�l#I:ik:.�...�..>'�' Washer < Range :�::. ��<_�;::��:: Gas Elec
Floor 1
Floor 2
Floor 3
Floor 4
PLUMBING FIXTURE RATES:
New Fixtures
Old Opening, New Fixture
Beer Dispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Water Heater -Electric
Water Heater - Gas**
NO. RATE
Gas Range**
Gas Dryer**
Back Flow Preventer Required ( )Yes () No
Type
$10.00
$10.00
$10.00
$10.00
$10.00
$10.00
$10.00
$35.00
$35.00
$35.00
$10.00
$10.00
$15.00
TOTAL JOB ADDRESS G6N%0` Re?(''C;�
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 all the facts
and representations stated in this application are true and correct.
DATE: — —,2
OWNER
BUILDING USED AS RC,5j`2Q4e rJCP—
t�U
ESTIMATED COST a PERMIT NO.
Reinspection Fee $50.00/Hr
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.25% of Value of Fixture or Appliance
State Surcharge $ .50
TOTAL FEE $ �
PLUMBING COMPANY 5Q±6I `0,
SIGNED BYDTEL N0. Ci
Approved By
Rough -In Date Final Date
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AN'Q TABLE 6-A. **PROVIDE COMMON VENT INFOiON BACK SIDE
;e
FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacing an existing furnace, the undersigned hereby verifies that the
BTU Input
venting has been examined and is free from rust, deterioration, obstructions,
Appliance #2 Type
and is securely supported and firestopped where required.
Yes ( ) No( )
The venting system is plastic/PVC and meets all current codes and manufacturer
BTU Input
specifications including sizing, length, number of elbows and terminatidn.
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
Vent Height
include AGA-GAMA Category I Central Furnace Venting Tables for fan
Appliance #1 Vent Connector Height
assisted and natural draft appliances.
Yes ( ) No( )
The existing combustion air is sized and installed to meet the current codes
ft Length
and manufacturer's specifications.
Yes ( ) No( )
When required to install a new combustion air, it will be sized and installed
ft Diameter in Type
to meet the current codes and manufacturer's 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 Furnice
V6nting Tables for fan assisted and natural draft appliances. Yes () No ( )
19 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 #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