PRE 2010 DOCSCity of Fridley, NUn ..
Date:BUILDING PERMIT N? .7355
• Builder
n,..
Address Address
�
LOT
NOF BUILDIN
No. Street PeAa T-nf vvpp t
Lot Block Addition or Su -Division ' •--
Corner Lot _ Inside Lot &� Setback Sideyard -
Sewer Mevation JV22, I -L ��
ovation
��vf,''
o DESCRIPTION OF BUILDING
T U
Front Depth - �� eight fLfe Sq. Ft. cu. ra-�&e
Front Depth Leight Sq. Ft. Cu. Ft.
Type of ction �'t. .."moo be Completed
in consideration of the issuance to me of a permit to const thFT!;5P=v:h
I agree to do
the proposed work in accordance with the description above set fo provisions of
ordinances of the city of Fridley.
In consideration of the payment of a fee of $ gA. A_'�__�_, t is hereby granted to—
to
oto construct the building or additio 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
NOTICE:
This permit does not cover the cemtructioe, installation for vArhne, phnnhing, ens heating, sawer or water. Be sure to sae
the Building impostor tar separate permits for them items.
APPLICATION FOR .BUILDING PErMIT.
My OF FRIDLEY, MINNESOTA
OWNER'S NAME 1 I J\ L _-Z_ 'N (I --,c k'
ADDRESS
LOCATION OF BUILDING
No. Street
.—part. of Lot��_
Lot. Block Addition or .Subdivision e
Corner Lot Inside LotL—Setback ._� Side; Yard
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to.this form Two. Certificates of..Survey.of Lot and proposed build-
ing location.drawn.on these Certificates.
DESCRIPTION OF BUILDING
To be used as: V�c wrt\
Front U Depth 1 Height
Sq. Ft. Cu. Ft
Front Depth Height
Sq. Ft. Cu. Ft.
Type of Constructionstimated :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_horeby declares.that. all the facts and
representations stated in this application are true and.correct.
DATE_
_SIGNATURE.
jSchedule of Fee Costs can be found on the Reverse Side).
� i 'st � • .
SUBJECT
PER O.
City of Fridley
16 3.5 5
AT THE TOP OF THE TWINS
BUILDING PERMIT
r
REC
�
1 6 _�_..�' COMMUNITY DEVELOPMENT DIV.
L
/ jj
{�16
I , PROTECTIVE INSPECTION SEC.
"t CITY HALL FRIDLEY 55432
!
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
612-571-3450
910 -F15
8/24/81
JOB ADDRESS 184 River Edge Way
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
3
2
1 Rivers Edge Addition SHEET
2 PROPERTY OWNER MAILADDRESS ZIP PHONE
David Porath 184 River Ede Way, Fridley, MN 55432 571-4734
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
same as above
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 [X ALTERATION ❑ REPAIR ❑ MOVE C REMOVE
8 DESCRIBE WORK
remodel basement
9 CHANGE QF USE FROM TO
STIPULATIONS
Provide outside combustion air.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
frame
VENTILATING OR AIR CONDITIONING:
yk, -Is
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
�y
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 I 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
1,500
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$1.50
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-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTALFEE
$26.50
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)
P -i
WF, N PROPER ALD THIS IS YOUR P RMIT
-a
G IN! TATE
SIGNATURE OF OWNER IIF OWNER BUILDER) (DATE)
CITY OF FRIDLEY Effective Aug. 1, 1981
APPLICATION FOR RESIDENTIAL BUILDING PER111TS
(New, Alterations, Additions, or Repairs)
OW14ER: V A U e'® POe AT -t4 BUILDER:
ADDRESS: 1 R tV.F EDGE (-J4ADDRESS: �� [Vfa O�E CJ,4Lf,
TEL NO: `' 7 (— � -73 `i/ TEL NO:
Construction Location
STRITT NO: I STREET: 1� l V E 2 FP erE top�-_
LOT: BLOCK: 1.2 ADDITION:
Corner Lot: Inside Lot: Setback.: Sideyards:
Applicant attach to this form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
DESCRIPTION OF CONSTRUCTION
14-,, b'5101 Front: Depth: Height:
Square.Feet: Cubic Feet:
Front: Height:
Square - Feet: Cubic Feet:
Type of Construction: Fy—o tv�'_R_ Estimated Cost: $ 1.5-00
Zb $e Completed: � ® r,+ k,5
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $ $
SEE REVERSE SIDE OF SHEET
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: 91 r 2 i " 9( SIGNATURE:
Stipulations:
o
P_
-0-.- � 'i
G i s
SUBJECT
PE
City of Fridley
®- 16 814
AT THE TOP OF THE TWINS
BUILDING PERMIT
r
�
Ulu ______ COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
vEyCEI
1 �
i CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
j 612-571-3450
910-F15
10/12/82
10B ADDRESS 184 River Edge Way N.E.
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION SEE ATTACHED
DESCR.
3
2
River Edge Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Dave Porath 184 River Edge Way N.E.
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Pearson Masonry 741 Kennaston Drive N.E. 571-7224
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION CX ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Install masonry fireplace
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.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
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 DAYS AT
ANY TIME AFTER WORK IS COMMENCED.
NO. DWLG. UNITS
OFFSTREET PARKING
1
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
$20100
$1.05
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRE,{ E TO GIVE THORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS f�F /ANY OTHER/ST TE OR LOCAL LAW REGULATING CON-
$3550
TR CTIOVOR E PERFO MA CE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
/ti 16-1 1 Z ,r
$39.55
IG ATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)
WHEN PROP LY VALIDATED THIS IS YOUR PERMIT
BLDG )NSP DAT
SIGNATURE OF OWNER 0F OWNER BUILDER) IDATEI ��
CITY OF FRIDLEY Effective Aug. 1, 1981
APPLICATION FOR RESIDENTIAL BUILDING PERMITS
(New, Alterations, Additions, or Repairs)
OWNER: DAVE Pi
iUILiE&ERMIT
N
City of Fridley
31 1
AT THE TOP Of THE TWINS
BUILDING
PERMIT
RECEIPT NO.
1 _____ COMMUNITY DEVELOPMENT DIV.
e; PROTECTIVE INSPECTION SEC.
4t r
r
WWRER
REV
DATE
PAGE OF
APPROVED BY
f CITY HALL FRIDLEY 55432
612-571-3450
910415
7/17/00
JOB ADDRESS 184 River Edge Way NE
1 LEGALLOT
NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
3
2
River Edge
Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Terrence J. Mudge 184 River Edge Way NE
763-574-2009
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
O NEW OC ADDITION ❑ ALTERATION• O REPAIR O MOVE O REMOVE
B DESCRIBE WORK
Construct 201 x 10' wood frame xac shed
9 CHANGEOFUSEFROM
TO
STIPULATIONS
For stipulations, see attached plans.
WARN11V
Before digging call for
all `
SEPARATE PERMITS
45 Ovations
02
REQUIRE® FOR:
REQUIRED B Y LAS
WIRING, HEATING
PWNVIBING AND SIGNS
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
1 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
$1,127.00
$e56
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-
Fire SC $1.12
STRUCTI OR THE PERFORMANCE OF CONSTRUCTION
1 $41.80
PLAN CHECK FEE
TOT FEE
J- �11 / - - I
. /
I 43°48
SIG uQ OFCOy ACTOR iIAUTHORIZED AGENT DATE+
N OgALID THISOUR P� Mldr••�11
Vol
RI SP r+AtE
+GNA U E OF OWNEQ dF 0 NEA BUILDERi + ATE `'
NEW []
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R=2
BUILDING PERMIT APPLICATION
Construction Address: 1P t'ye� CWsr-- W'd
Legal Description:
Effective 1/1/2000
(763) 572-3604 Bldg IIn\sp
Owner Name &Address:: IQIA& e 5fUiG=or. 4bcW- Tel. #763- 2-L00az
,
Contractor: ttj 4iic cz--- 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 IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: LengthQ Width �i� Hgt/Ground Sq. Ft
OTHER:
Construction Type:12,ac1 F V/J Estimated Cost: $ �/2 �• Com%
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ --=$
DATE: - APPLICANT: Tel.
CITY USE ONLY -
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
sem:
Call (763) 572-3604 for Permit Fe m in application
$ �® Fee chedule on Reverse Side
$ B .001 of Permit Valuation (1/10th%)
$ $.50/$1,000 Valuation
$1100 per SAC Unit
$ $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ]
TOTAL
STIPULATIONS:
$ 3 , /y
-Wou,Co
phow,
Olt.5
f
Rout P. Caswen, Jr.
Registered Professional Engineer. and Land Surveyor
SM Weremm died. 1AAMpAUs 16, MMm
p sof >Y of Nl A R W 2 JO NES -
'38/o ckiver E` de Addi'lien
ds�«f as *)%W&.
}.
Anck4 CGunf , Mi17nes,0tq
30
Scolex 1 hKh 1 --- - - -het.
3.
RTH
! r�
e
f-Ut Oif vno!Dro:noye �,Ease�ner��_..:.
ry
4
ty f W
s"e 1764170 to s Iran Manu ,,:7 e of
1 aR1MiC n of LOCATION of WMem
c Chweby cwdfy that ort---.-- 19
1'w�1dA;�a survey of" locatift of fM blind se for serve
wird pm"rty aad dw fM location of said bvBdkg is
corned ly shown an the obeve plot.
Job No. 7�z 4'- Book
a L'
pons=_ --rl
r
P
4
f
1
l
� 1
f-Ut Oif vno!Dro:noye �,Ease�ner��_..:.
ry
4
ty f W
s"e 1764170 to s Iran Manu ,,:7 e of
1 aR1MiC n of LOCATION of WMem
c Chweby cwdfy that ort---.-- 19
1'w�1dA;�a survey of" locatift of fM blind se for serve
wird pm"rty aad dw fM location of said bvBdkg is
corned ly shown an the obeve plot.
I
SUBJECT
PERMIT NO.
City of Fridley
0=5
AT THE TOP OF THE TWINS
P,
BUILDING
PERMIT
r
:
RECEIPT NO.
CIV.
COMMUNITY DEVELOPMENINSPECTION
INSPECTION SEC.
572-
0 4
% E � PROTECTIVE
E ,
1 = 1 CITY HALL FRIDLEY 85432
NUMBER
REV
DATE
PAGE OF
APPROVED BY
612-571-3450
910415
8/1/01
JOB ADDRESS 184 River Edge Way
I LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DIE
3
2
River Edge Addition
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PH
NE
Terry Mudge, 184 River Edge Way, Fridley, MN 55432
76
-574-2009
3 CONTRACTOR MAIL ADDRESS
ZIP PH
NE LICENSE NO
Midwest Roofing, 7395 Mark ST, Greenfield, MN 55357
763-416
4804 20010277
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE
LICENSE NO.
5 ENGINEER MAILADDRESS
ZIP PHONE
LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK ❑ NEW O ADDITION ❑ ALTERATION C REPAIR ❑ MOVE
O REMOVE
8 DESCRIBE WORK
Re-roof (tear-off) H & G
9 CHANGEOFUSEFROM 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 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 12Q DAYS AT
ANY TIME AFTER WORK IS COMMENCED.
NO. DWLG. UNITS
OFFSTR
ET PARKING
I HEREBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS APPLICATION
ISTALLS
GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
VALUATION
SURTA
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$2,573.00
$1.2
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 CH
RGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF NSTRUCTION
PLAN CHECK FEE
TOTAL
EE
$87
11
Si ATUREOFC OR ORAUTMORiZEDAGENT iDATEi
W N PROPERLY
4 pLdG' N F
VALIDATED THIS
S YOUR PER IT
ATE
S-GNATURE OF OWNEROF OWNER BU4.D,ERt 10 ATE.
I
NEW I ] Effective 1/1/2001
ADDN [ ] " , CITY OF FRIDLEY (763) 572-3604 Bldg Insp
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address:
Legal Description:
Owner Name & Address:
Contractor W _4
Address:
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
�H R,VefectC,e VV
-Tr-r'' Aj\,&Ae Tel. #_
MN LICENSE #
&wiWd A4/U � Wj? Tel. #
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length Width Height Sq. Ft.
Length Width Hgt/Ground Sq. Ft.
Construction Type: Rlel� Estimated Cost: $
Driveway Curb Cut Width Needed: Ft + 6 Ft = Ft x $
DATE: I' I APPLICANT: ��s�I Tel.
CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application
sjy_
1)0 - W ( G---
TOTAL
STIPULATIONS:
0
0
Wa cPZ 5`73
M- I-1 i ,; - 144614
��-
Permit Fee
$ oZ �j
Fee Schedule on Reverse Side
Fire Surcharge
$ o?. 5'7 .001 of Permit Valuation (1/10th%)
State Surcharge
$ i , 9 $.50/$1,000 Valuation
SAC Charge
$
$1150 per SAC Unit
License Surcharge
$ -®—
$5.00 (State Licensed Residential Contract(
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
STIPULATIONS:
0
0
Wa cPZ 5`73
M- I-1 i ,; - 144614
8431 University Ave NE
Fridley, MN 55432
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT ev
(763) 572-3604
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
Wash Floor :Auto Gas 'Water Heater
Sto Urinal
ries ..... Shower
Tray Drain Washer......' Range c
Basement
Floor 1
Floor 2
Floor 3
Floor 4
PLUMBING FIXTURE RATES:
NO. RATE
TOTAL
JOB ADDRESS
New Fixtures
$7.00
The undersigned hereby makes application for a permit for the work herein
Old Opening, NexvFixtuna
$4.00
specified agreeing tmdoall work instrict accordance with the city codes
Beer Dispenser
$5.00
and rulings ofthe Building Division, and hereby declares that all the facts
Blow Off Basin
$7.00
and representations stated inthis application are true and correct.
Catch Basin
$7.00
Rain Water Leader
$7.00
206Z-
Sump/Receiving Tank
$7.00
�
le
Water Treating Appliance
u_ $10.00
Owner j/0UA-i_'
Water Heater -Electric
$ 7.00
Water Heater -Gom°°
$10.00
Building Used
CSmaRonge°°
Gas Dryer**
$10.00
$10.00
Estimated Cost! ' PERMIT NO.
Bock Flow Prmxentar Required 1Yoo
Type
( ) No
$15.00
PLUMBING COMPANY
Reinspection Fee$47.O0Hr
SIGNED BYQ_OL2::::�Z�__TELNO 7
1.5% of Value of Fixture or Appliance
State Surcharge
TOTALFBE
Approved By Rough'|nOah»
$_.5D MINIMUM FEE �011 ANY PLUMBINGI
$ PLUS THE $.60 STATE SURCHARGE
Final Dat&
COMBUSTION AIR SHALL BEPROVIDED PER UMC SECTION 5Q4(A)AND TABLE 8-A. COMMON VENT INFO {JNBACK SIDE
THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPUCA71ON WILL BE RETURNED
COMMON VENT, VENT C`ONNFC'TOR ANn C:OMMISTION AIR VFRIFIC.ATION
When reIn acing an _Yie ing 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 plasticlPVC 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 eYisting nnmNintinn air is sized and installed to meet the current codes
and manufacturer's specifications. Yes( ) No( )
When required to install a new cnmNin inn 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
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 #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 M
HEATING CO:
Signed By: Date:
Building PLUMBING Permit
No.:,
Inspections RESIDENTIAL APPLICATION Received
By:
763-572-3604
CYrY OF FRIDLEY Da
>c
DATE ' ® YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT IS: 0 OWNER CONTRACTOR
PROPERTY
NAME:
OWNER/
TENANT
ADDRESS:
ADDRESS: I B4 Zko ca riy ) 6
7(p3
STATl
-53q -Q0
CONTRACTOR
NAME:
SUBMIT A COPY OF
STATE LICENSE #� (� q EXP DATE
YOUR STATE
ADDRESS: CITY 3670 Dodd R
SST& z1P
LICENSE WITH
PHONE FAX agan, Mnl 55'23-13'1`
APPLICATION
PERMIT TYPE
I[SINGLE FAMILY 0 TWO FAMILY 0 TOWNHOUSE
TYPE OF WORK:
ONEW ,REPLACEMENT
DETAILED DESCRIPTION OF WORK Kpq
PER MS 1613.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever
is greater, forth
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect
only the cost of
r )
Labor cost under $300 = $15.00. Labor cost between $300 to $500 = cost of labor x.05 =
FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
S: (INDICATE TOTAL
NUMBER OF EACH BELOW)
_ BATH SINK/LAV DRAINS SHOWER
WATER PIPING
_FLOOR _
—BATHTUB _ GAS PIPING (xm) c n7zjcmm) SWIMMING POOL
WATER SOFTNE
($35)
_
_ CLOTHES WASHER _ KITCHEN SINK WATER CLOSET
BACKFLOW PRE . ($15)
—DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
FOR IRRIGATIO
_ WATER METER
OTHER
PERMIT FEE PROJECTS FOR UNDER $500PERMIT
FEE MR
PROJECTS
VER $500
Permit Fee $ Number of fixtures @ $10.00
x $10.00 =
Surcharge .50 Number of fixtures @ $15.00
x $15.00 =
TOTAL DUE $ 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 acc
ate; that time wo
will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction
; that I under
Mmd this is
not a permit but only an application for a permit and work is not to start without a permit; that the work vy
ill be in accorda,
Ce with the
approved plan in the case of all work w 'ch and approval of plans.
-7 l
cl
SIGNATURE OF APPLICANT{�. } ., RINTNAME
DATE
PLEASE NOTE: SEP , PERNIIT S ARE REQUHUD FOR BUILDING, E =FCC ICAL AM MEMANICAL
WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
'C AN'. 17412 Gnr1 An?^l
L-13 CPQ