PRE 2010 DOCSVillage of Fridley, MUWuu .
BUILDING PERM"
No 684 Offiice of INSPECTOR OF BURMINGS
Owner'
Architect Fridley, Minn., �'19
t
Builder
LOCATION OF BUILDING
Nod - Street' `' x 4 r Part of Lot
Lot Block Addition or Sub -Division
� P
DESCRIPTION OF BUILDING
Front(Manner ` Height L Stories ` ti Manner of Construction "~
To be used as 6, To be completed: ., ` + '" Estimated Cost
Permit is hereby granted to ¢' r + to ff'
x
the building_ 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 in, around and upon said building, or any part thereof, shall conform in all respects to the ordi-
nances of Fridley, Minn., regarding the 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.
AGREEMENT AND SWORN STATEMENT
In consideration of the issue and delivery to me by the Inspector of Buildings of Fridley of
the above permit, I hereby agree to do the proposed work in accordance with the description
above set forth and according to the provisions of the ordinances of Fridley, and, being first duly
sworn, I hereby state and say that the facts stated by me and contained in the above permit are
true as therein stated.
Subscribed and sworn to before me at Fridley,
k
day
Minnesota, this
r`
City ®f Fridley, a 0 N 9194
BUILDING PERMIT
Date: April 21, 1967
Geo. J. Zachau Peter Dukinfield Co.
Owner:
Builder
Address 6250 Rainbow Dr. N. E. Address
No. 6250 Street
Lot 2 -- Block
4725 Excelsior Blvd.
LOCATION OF BUILDING
Rainbow Dr. __ _____ part of Lot
4 Addition or Sub -Division Sylvan Hills, Plat 4
Corner Lot --- Inside Lot
Sewer Elevation
x Setback
Sideyard
Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
Addn. - Family Rm. Front 141 Depth 20' Height 91 Sq. Ft. 280 Cu. Ft. 2,520
Front Depth Height -- Sq. Ft. Cu. Ft.
Type of Construction _ _Faame Fst. Cost $3 000.00 __ To be Completed 5/15/67
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 orth and in plian�th provisions of
ordinances of the city of Fridley.
In consideration of the payment of a fee of $--- 5.00 , permit is hereby granted to Peter
Dukinfield Co. 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 previsions of said
ordinances.
CLARENCE BELISLE Building mor
NOTICE:
This permit does not cover the construction, installation for whing, plumbing, gas heating, sewer or water. Be rare to as
the Building inspector for separate permits for these items:
�NA
S
APPLICATION FOR 14. IN. PERMIT
CITY OF-PRIDLEYo NNESOTA
OWNER'S NAMEGeo. J. Zach4u BUILDER Peter Dakinfield -Co.
ADDRESS 4725 Excelsior Blvd.
,ss 6250 Rainbow trive
ADDRESS
Fridley, Min -r.!55421 Mpls, Minn. 55416
LOCATION OF B&DYNG
No, 6250 Street Rainbow Drive —Part of Let.
Lot Block Additioir Subdi+irikion
Corner Lot Inside Lot x
etbatk Side-tard
SEWER WiATIOW Foumnw EL9VATzoq
Applb-44at attach to thit form, Two Certificates of Survey of Lot and proposed build—
ing loca tion diAva on these CA-iltificates.
DESCRIPTION OF BUILDING
y. be used as:
Addition to existing dwg. 141 201 91
Pront —Depth Height
Sq. Ft. 280 Cu. Ft.— 2x520
Depth Height
Sq. Ft. Cu. Ft.
Type of Construction frame Estimated cost 3,000.00
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work ift strict accordance with the City of Fridley Ordinances and
rulings Of the Department'-ok Buildings, and hereby declares that all. the facts and
representations stated in this application are and correct.
DATrk 4/20/67 SIGNATURE _e
..edule-.of Fee Costs can be found on the Reverse side).
Application for Power Plants and Hearing. Cooling. Ventilation. Refrigeration and
Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR: RATE TOTAL
Furnace Shell & Duct Work .......................... 8.00 $
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. EDR Steam ......
8.00 $
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ..
8.00 $
Each add. 200 sq. ft. EDR 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 $ Q
GAS FITTING FEES:
NO RATE TOTAL
1st 3 Fixtures ......................
x $1.50
$ �•J U
Additional Fixtures .................
x .50
$
Gas Range to 200,000 BTU ...........
x 2.00
$
AIR CONDITIONING
$
FAN HEATING SYSTEM
See Fee Schedule
VENTILATING SYSTEM
$
ALTERATIONS & REPAIRS
TOTAL FEE
$ [_ . J U
ROUGH
FINAL
Dept. of Bldgs. Phone 560-3450
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 /� y 19 7` -
Owner
Kind of Building _- eY
Used as
To be completed about
Estimated Cost, $_ � L L
Old New. Building Permit No. / DT Permit No.���
DESCRIPTION OF WORK
HEATING or POWER PLANTS—Steam, Hot Water, Warm Air—No
Trade Name Size No
Capacity Sq. Ft. E.D.R BTU H.P.
Total Connected Load Kind of rue
BURNER — Trade Nam f Size No...��®
`
Capacity J 120 6 Sq. Ft. E.D.R BTU Hp.
(REMARKS -OVER)
City of Fridley, Minn. N9 10306
BUILDING PERMIT
Date: June 24, 1969
Owner: George Zachau Builder M. L. Johnson Rooding Co.
Address 6850 Rainbow Drive Address 2513 Central Ave. N. E.
LOCATION OF BUILDING
No. 6250 Street _._. Rainbow Drive N. E. _ part of Lot
Lot ___ Block Addition or Sub -Division
Corner Lot — Inside Lot . _ Setback -- Sideyard
Sewer Elevation ___ _ Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
Aluminum Trim Front Depth Height — Sq. Ft. Cu. Ft
Front Depth Height Sq. Ft Cu. Ft
Type of Construction Est Cost $1400.00 _ 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 i�`�mpliance with all provisions of
ordinances of the city of Fridley. U. _ _ ,-, 1 1 A /
In consideration of the payment of a fee of $� 9.00 , permit is hereby granted to M. L . Johnson
Roofing Co. 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.
Clarence Belisle Building
NOTICE:
This permit doss not ewer the construction, inshlla4ton for wiring, plumbing, gas heating, sewer or wa%r. Be sere to see
the Building Mveftr for separate permits for tbam hems.
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNER'S NAME BUILDER .
ADDRESS z 5-6 ADDRESSi��,o�
LOCATION OF BUILDING
NO. STREET
LOT BLOCK ADDITION OR SUBDIVISION
CORNER LOT INSIDE LOT SETBACK 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 Depth Height
Square feet
Cubic Feet
Front Depth Height
Square feet Cubic Feet
Type of Construction 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 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.
DATE Q? � " (t SIGNATURE
(Schedule of Fee Costs can be found on the Reverse Side
I �
SUBJECT
P
City of Fridley
_
AT THE TOP OF THE TWINS
BUILDING
PERMIT
0
r
RECEIP .
I _e_�� �; COMMUNITY DEVELOPMENT DIV.
L PROTECTIVE INSPECTION SEC.
7�
r
!
CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED BY
�;`�
L 612-571-3450
910-F15
4/8/94
JOB ADDRESS 6250 Rainbow Drive NE
t LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
2
4
Sylvan Hills
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Scott Popovitz
571-5350
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
553-0020 2406
American Re o
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
Reside
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.
ZONING
SQ. FT.
CU. FT.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
NO. DWLG. UNITS
OFFSTREET PARKING
ANY TIME AFTER WORK IS COMMENCED.
1 HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
STALLS GARAGES
VALU TION
SURTAX
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$9,538
$4'77
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$117.00
Fire SC $9.54
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
License SC
$5.00
$136.31
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
WHENPROPERLY VALIDATED THIS IS YOUR PERMIT
SIGNATURE OF OWNER OF 0WNER BUILDERI IDATEI
BLDG I
nATE
NEW [ ] Effective 1/1/93
ADDN [ j CITY OF FRIDLEY
ALTER[ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2a��
Building Permit Application
d
Construction Address:
Legal Description:
Owner Name & Address: _ �, ��® U., Tel. #`571--r-x5-®
Contractor: )qM gR s cu �r��n 6d , 7 MN LICENSE # G�� °r°�6.
Address: 3 7m Tel. # X593 - ®Cb2®
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. T
DECD AREA: Length Width Hgt/Ground Sq. Ft.
OTHER:
Comer Lot [ ] Inside Lot [ ]. Ft. Yd Setback Side Yard Setbacks
Estimated Cost:
Type of Construction: iJ ���.-.� .
Approx. Completion Date:
(cost on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: - APPLICANT: %%�� Tel.
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge $
Driveway Escrow $
Park Fee $
Sewer Main Charge $
TOTAL
STIPULATIONS:
$-L&2.1 3/
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$750 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ j
SUBJECT ..
Ij
City of Fridley
2 X246
AT THE TOP OF THE TWINS
BUILDING
PERMIT
�4 672®3 �
UNITY DEVELOPMENT DIV.
INSPECTION SEC.
f PROTECTIVE
CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED BY
j 612-571-3450
9t0-Ft5
10/14/98
JOB ADDRESS
6250 Rainbow Drive NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
OESCR.2
4
$ lyan Hills
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Scott Po owitz
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
New Haven Const. 4208 83rd
-
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 ❑ ADDITION ❑ ALTERATION SPIC REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and garage 29 S Tear-off
9 CHANGE 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
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
ISTALLS 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
2485
$1.24
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-
CON-
STRUCTOR THE P RFO ANCE OF CONSTRUCTION
STRuC>Tr
$74.75
Fire SC 2.48
PLAN CHECK FEE
TOTA
Lice
5.0/$837
SIGNATURE OF O .RA OR R AU7HOA1ZEO AGENT iDATEt
N ROP
LIGATE S IS YOUR PERMIT
BL G NSP
® •a O
pAtt
S-GNATURE OF OWNERJF OWNER BU4DERt iDATE1
NEW [ ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION A
ConstructionAddress:
Legal Description:
Owner Name & Address: <S CIO 7_4-/ P,2- 00 c.J /'-/Z- Tel. # S
Contractor: A�e w -2,� S v MN LICENSE # Z.d d 777,S-0
Address: ' Iz O k g3ild 4GAZf241(/(pith' Tel. # 66& -,!;-g dLS;—
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
GARAGE AREA:
Length
Width
DECK AREA:
Length
Width
Height Sq. Ft.
Height Sq. Ft.
Hgt/Ground Sq. Ft.
OTHER:
Construction Type: �I r2 D F, r-: /0E /? V b F7 Estimated Cost: $ oa7S
(F'ee .schedule on Zack)
Driveway Curb Cut Width Needed: Ft. + b Ft = Ft x $ _ $
r
DATE: O APPLICANT: Tel. #
STIPULATIONS:
r
5 -2,, 1 �-r2-z-�
CITY USE ONLY
Permit Fee
$
Fee Schedule on Reverse Side
Fire Surcharge
$
.001 of Permit Valuation (1/10th%)
State Surcharge
$ /,
$.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
$
$450.00 Conservation Plan Review
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement Necessary [ ] Not Necessary [ ]
TOTAL
$ J- y
STIPULATIONS:
r
5 -2,, 1 �-r2-z-�
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 -
eplacement Fu=a�k)
veer
Gas Piping (Needed with new furnace,
but not replacement)
Gas Range
Gas Dryer
*Air Conditioning •All Size
All Others/Repairs & Alterations
1°Jo of Value of Appliance or W/
Commercial/Industrial
�Q,1, .25% of Value of Applianc or Work
/Tie_ L gll-7c
5-r-, "X !A-6?6
Rate
$ 30.00
$ 10.00
$ 10.00
$ 10.00
$ 25.00
ON BACK)
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.
Effective On January 1, 2000
JOB ADDRESS l�o�-S O '1�I/%�D�J► `��r
OWNER 4if7f �' DIy� jpjODU�ilZ
TOTAL
BUILDING USED AS
ESTIMATED COST ED OG PERMIT NO.
DESCRIPTION OF FURNACE AND OR BURNER
No. of Heating Upits Circle One (Steam) (Hot Water) arm Air
$ Trade Name,;*M/67K Size No.
BTU 11D, A, -Vo HP EDR
Fuer Total Connected Load
Burner Trade Name Size No.
$ BTU HP EDR
$ 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
$ .50 rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
DATE
HEATING CO
SignedTEL # 9q
Approved By Rough -In Date Final Date
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 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 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 manufacturers
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 #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: yqwm ll
Signed By: Date
Building
MECHANICAL
Permit No.: '
Inspections
RESIDENTIAL APPLICATION
Received By:
763-572-3604
CITY OF FRIDLEY
Date Rec'd: ?
DATE� •7 YOUR E-MAIL ADDRESS
SITE ADDRESS 4S vS SO
THIS APPLICANT IS: ❑ OWNER )<ONTRACTOR
PROPERTY
OWNER/
�--
NAME;
CITY �O�/DG L�� STATEI!'
TENANT
ADDRESS:
CONTRACTOR
COMPANY NAME:
SUBMIT A COPY OF
CONTACT PERSON: G G
STATE LICENSE # 5� 2 ?Z EXP DATE
YOUR STATE
LICENSE WITH
�1�
ADDRESS; CITY ��� 1 STATI�GIP�
APPLICATION
PHONE FAX
PER UT TYPE
?SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
❑ REPLACEMENT 2<TERATION/REMODEL
TYPE OF WORK:
❑ NEW
DETAILED DESCRIPTION OF WORK S ��
i G i �J Tio
PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whicheve2only e
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect onlylabor
between $300 to $500 — cost of labo� x .05 —!FOR
Labor cost under $300 = $15.00. Labor cost
PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.ATE TOTAL
NUMBER OF EACH BELOW) SIZEBTU
Equipment Installed MFG: MODEL:
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00_FIREPLACE (GAS) $15.00 _GAS RANGEIOVEN $10.00
AIR TO AIR EXCHANGEER $15 (WOOD) $35.00 NEW GAS GRILL $10.00
_FIREPLACE
BOILER $35.00 _FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00_GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $1000 GAS PIPING $1000 DTII -ATO $
R
b �
0077117.11=1111511�1 57";
Permit Fee $ .19a> Number of fixtures @ $10.00 x $10.00 = $
Surcharge $ .50 Number of fixtures @ $15.00 x $15.00 = $
TOTAL DUE $! Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ .50
Total = $
THIS IS AN APPLICATION FOR A PERMIT NOT VALID UNTIL PROCESSED
I hereby apply for a building 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; that the work will be in accordance with the
approved plan in the case of all w rk whrnuires re�vand pproval of plans.
SIGNATURE OF APPLICOIATE
u
city of f ridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
B
V