PRE 2010 DOCSCity of Fridley, Minn.
BUILDING PERMITN® s
--
Date:
Owner:_.�-.._..." ..'" ....... Builder
Address .. ... .....`._ . ' .:::.. �� r, , ' + :8?. ,?._...... Address
LOCA N OF BUILDING
No -,:., Street .�.: .,a ._ .,:'"#.- S- ....-•---..._....._..........._. Part of,. jot .. ti.
•r �#(--
44"
--
Lot . - -- ...... Block ...._... _ ...............................Addition or Sub -Div s on ....:. ,E' ...Corner Lot .....__ � ...._........ Inside Lot .- ............._ ............... Setback 4, ....._..------...._..---... �ideyard �: 44 .e
Sewer Elevation-------------------_.......-----_....----------.................................................. Foundation Elevation . .................................... ...
DESCRIPTION OF BUILDING
To be sx�41 Ft.. Front ... ..._..._.. Depth ,..... & .. Height r ..._4:. _.. Sq. Ft...... f .._� Cu.
14xot Depth .:..._:......... Height ... . Ft ....._............._.. Cu. Ft. ...._........_.:...
..--.......................�
Type of Construction � :� , _. i, °:.. '�:: .. Est. Cost .............. r .. 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. r
In consideration of the.payment of a fee.of........ ..................., 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 upgn violation of any of the provisions of said
ordinances.
Building Inspector
NOTICE:
This permit does not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sure to see
the Building Inspector for separate permits for these items.
4
Owners N
Address
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
LOCATION OF BUILDING
No. , ® Street Part. of Lot
Lot ,0`7`� Block Addition or Sub.Div.�
Corner Lot Inside LotSet Back Side -Yard
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Certificate of Survey of Lot and proposed building
location.
r DESCRIPTION OF BUILDING
To be used as:
Front ` Depth 6 Height
Cu. Ft.-----
Front-
Sq.
t.-Front-Sq. Ft. Cu. Ftp
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 Ordinances and ruling of
the Department of Buildings, and hereby declares that all t acts and representa-
tions stated i this application are true and corp'
DATE SIGNATURE
(A Schedule of Fee costs can be found on the Reverse Side.)
Original
No.
Make
PERMIT for Power elants and Ideating. Cool-
ing, Ventilation. Refrigeration and Air
Conditioning Systems and Devices
DESCRIPTION OF WORK
Plants to be installed--altered—repaired
Oil fired—,- Coal fired—, Gas fired ; Gas Authorization No.
Remarks
-T f
Approved
Final Inspection Date , 19_
Inspector
Pmt N°
Fee 4509
$ �� � • i
Office of the Inspector of Buildings
city 01
Owner
Locatic
City of Fridley
Kind of Building *��_
How Occupied
ALe'" I
or
Work to be Commenced—, 19—
To be Completed ,19_
Estimated Cost, $
Old -New, Building Permit
Permission is hereby granted to 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 specifications set forth in the approved application for this
permit on file in the office of the Inspector of Buildings. A
–Inspector of Buildings
42 2M11 -67v
Application for Power Plants and Ideating. 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 $
NECK. 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 $ e)
AIR CONDITIONING - -/ ,
FAN HEATING SYSTEM See Fee Schedule
VENTILATING SYSTEM $
ALTERATIONS & REPAIRS TOTAL FEE �J
ROUGH
FINAL
Dept. of Bldgs. Phone 560-3450
I
City of Fridley:
The undersigned hereby makes application for a permit for the work hereir
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 o:
Used as
To be completed about
ed Cost, $
0- --'
Old ,New. Building Permit No,
Permit N
DESCRIPTION OF WORK
HEATING or POWF.4 PLANTS --Steam, Hot Water, Warm Air—No
Trade Name Size No
Capacity Sq. Ft. E.D.R BTU ® H.P.
z '112
Total Connected Load Find of Fue
BURNER — Trade Name Size No
Capacity.
(REMARKS—OYER)
Sq. Ft. E.D.R BTU H.P.
SUBUUBAN/yR �NDITIONINU
8419 -u& DRIVE
Signea Pat to
By NAUOTA 554�-
Business Phone No
P
�11 _ . g n
Building
BUILDING
11'7 Q , q
Permit No.:
Inspections
RESIDENTIAL APPLICATION
Received By: " 't
763-572-3604
CITY OF FRIDLEY
O 3 ' (0)
Date Rec'd�
DATE 6-2&— 04b Y UDR" E-MAIL ADDRESS , , CRI S-rL
0 N z&.'Q its. 1v E T
SITE ADDRESS AA1 E
.0005 x Permit Valuation Minimum $.50
THIS APPLICANT IS: ,� ❑ OWNER CONTRACTOR
$
PROPERTY OWNER/
NAME: Al PAf 1.50 i
SAC Charge
ADDRESS: 61VO S, -Are e- A"S CITY
STATEA*IP SS X
TENANT
Curb Cut Escrow
PHONE: "7&3-- 639 6675
CONTRACTOR
NAME: A& Al Al -7- d&
$
STATE LICENSE #_ 2®'136'0 6 EXP DATE ^gr24.H 200-7
SUBMIT A COPY OF
YOUR STATE LICENSE
ADDRESS: /Y/YEr s;r ,,v&J r,4,7E F CITY
11rs-5 30
WITH APPLICATION
PHONE `%�a� — ry � 6 .. e � ?r FAX 74- — 79 6- <--
{STATFrM�IP
®lf�
PROPERTY
PROPERTY TYPE
❑ SINGLE FAMILYINEW CONSTRUCTION SIZE
Total Due
$
TWO FAMILY/NEW CONSTRUCTION STORIES
Make checks payable to: City of Fridley Attach Stipulations
PERMIT TYPE
ff ADDITION ❑ GARAGE/SHED ❑ W DOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK:
❑ NEW XNDDITION
❑ MAINTENANCE/REPAIR .fREMODELING
DESCRIBE WORK BEING DONE: A0&,v4 A Sgt,& -w@ s"v,,. :'o
SIZE OF IMPROVEMENT LENGTH SS °3 °® WIDTH e;2113"
HEIGHT S 6t. ( 70s
ROOFING HOUSE ONLY
NUMBER OF SQUARES 2 i5' HOUSE & GARAGE
BASEMENT REMODELING SUBMIT:
GARAGES ❑ ATTACHED GARAGE
1.
2.
Existing Floor Plan
Proposed floor plan
PROPOSED SIZE: !-1 /Q1 ❑DETACHED GARAGE
3.
List of structural members to be used
PROPOSED HEIGHT: "ia
_._
SIDING
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl Soffit
ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum I1 Trim
1.
Site Plan/Survey showing the existing structures
)9�,°,Other 1-1 A r— ®➢ Fascia
and proposed project.
WINDOWS
2.
Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
3.
Energy Calculations
OR FOR NEW OPENINGS -DESCRIBE SIZE OF 5265,OPENING
CHANGES &
TYPE OF WINDOW TO BE INSTALLED A1449 ^1 AQ/P NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
31 04 IQ (USING TH + .B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � -7 2 . ®® OCCUPANCY TYPE
Permit Fee
$
11'7 Q , q
See Back Page for Fee Schedule
Plan Review
$
65% of Building Permit Fee
Fire Surcharge
$
O 3 ' (0)
.001 times the total job valuation
Surcharge
$
61743
.0005 x Permit Valuation Minimum $.50
License Surcharge
$
15-06
$5.00 (State Licensed Residential Contractors)
SAC Charge
$
$1550 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow
$
ft + 6 ft = ft x $21 =$
Erosion Control
$
$450 Conservation Plan Review
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement necessary ( ) Non Necessary ( )
Total Due
$
"7
Make checks payable to: City of Fridley Attach Stipulations
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 work which requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME 11 1° .e C/a I�'%'°�. e.7 DATE C -Z 4-0
J
HARVEY A. CARTWRIGHT
ANOKA COUNTY SURVEYS
HENNEPIN COUNTY SURVEYS
MINNEAPOLIS SURVEYS
8410 PALM STREET N.W.
SUNSET 4.768$
OWNER
INDUSTRIAL — JUDICIAL
BUSINESS — TOPOGRAPHICAL
CITY LOTS + PLATTING
Clem Johnson & Son
= V T & OLSON
LAND -SURVEYORS
REGISTERED UNDER LAWS OF STATE OF MINNESOTA
LICENSKO SY ORDINANCE OF CITY OF MINNEAPOLIS
326 PLYMOUTH BUILDING FEDERAL 8-8721
HENNEPIN AT SIXTH • MINNEAPOLIS 3. MINNESOTA
*urbepor'o tertiftcate
COMBINING THE RECORDS OF
J. E. HILL, CIVIL ENGINEER
ESTABLISHED logo
C. F. SANDHOFF
CIVIL ENGINEER
ESTABLISHED ISIM
JAMES NELSON
SURVEYOR
ESTABLISHED 1922
METROPOLITAN LAND
SURVEYORS. ESTABLISHED 1901
Invoice 20590
696/20
% of;
1
q{ap\ 1
r i
-7-r,-ter• �
_f
'
r 661%?
0
I hereby certify that this is a true and correct representation of a survey of the
boundaries of:
That part of Lot 13, lying Northerly of a line drawn parallel with and
59 feet Northerly of, measured at right angles, to the South line of
Lot 13, and the sane extended; and, also, all of Lot 14, all in Block 1,
Sylvan Hills.
And of the location of all buildings, if any, thereon, and all visible encroach -
me nt s, if any, from or on said land. . 41
As surveyed by me this 21st day of SIGNEF!
May, 1959 • CA.R<T RIGHT AND OL90N -A
Permit Number
REScheck Compliance Certificate Checked By/Date
2OOO Mnnesota Energy Code
REScheck Software Version 3.6 Release 2
Data filename: C:\DOCUME—l\ADMM—I\MYDOCU—l\ARCHTr—l\IUGHPO—l\6140ST-1\6140_6-1.RCK
0I4�?-;/ <�,
PROJECT TITLE: 6140 / 6142 Star LN NE, Fridley 55432
COUNTY: Hennepin
STATE: Minnesota
ZONE: 2
CONSTRUCTION TYPE: Single Family
WINDOW / WALL RATIO: 0.17
DATE: 06/21/06
DATE OF PLANS: 6/9/06
PROJECT DESCRIPTION:
Second story addition
DESIGNER/CONTRACTOR:
Highpoint Builders
14148 Lincoln Street NE
Ham Lake MN
PROJECT NOTES:
The existing subject property are side to side one story
rambler style homes sharing a common wall.
COMPLIANCE: Passes
Maximum UA = 441
Your Home UA = 437
0.9% Better Than Code (UA)
Gross Glazing
Area or Cavity Cont. or Door
Perimeter R- ale R Value U -Factor UA
Ceiling: Raised or Energy Truss
1773 38.0 0.0
44
Second Floor. Wood Frame, 16" o.c.
1400 19.0 0.0
67
3856(2w): Above-Grade:Wood Frame:Double Pane with Low -E
30
0.310
9
2424: Above-Grade:Wood Frame:Double Pane with Low -E
4
0.310
1
2424(3h): Above-Grade:Wood Frame:Double Pane with Low -E
12
0.310
4
2424(3h): Above-Grade:Wood Frame:Double Pane with Low -E
12
0.310
4
2424: Above-Grade:Wood Frame:Double Pane with Low -E
4
0.310
1
3856(2): Above-Grade:Wood Frame:Double Pane with Low -E
30
0.310
9
2424(2w): Above-Grade:Wood Frame:Double Pane with Low -E
8
0.310
2
2424(3w): Above-Grade:Wood Frame:Double Pane with Low -E
3856(2w): Above-Grade:Wood Frame:Double Pane with Low -E
2424: Above-Grade:Wood Frame:Double Pane with Low -E
3856: Above-Grade:Wood Frame:Double Pane with Low -E
3856: Above-Grade:Wood Frame:Double Pane with Low -E
3856: Above-Grade:Wood Fra=Double Pane with Low -E
3856: Above-Grade:Wood Frame:Double Pane with Low -E
2424: Above-Grade:Wood Frame:Double Pane with Low -E
3856(2w): Above-Grade:Wood Frame:Double Pane with Low -E
2424(3w): Above -Grade -.Wood Frame:Double Pane with Low -E
2424(2w): Above-Grade:Wood Frame:Double Pane with Low -E
Existing first floor: Wood Frame, 16" o.c.
3856(2w): Above-Grade:Wood Frame:Double Pane with Low -E
3856(2w): Above-Grade:Wood Frame:Double Pane with Low -E
3856(2w): Above-Gra&Wood Frame:Double Pane with Low -E
3856(2w): Above-Grade:Wood Frame:Double Pane with Low -E
2656: Above-Grade:W ood Frame:Double Pane with Low -E
2656(2w): Above -Grade -Wood Frame:Double Pane with Low -E
3856: Above-Grade:Wood Frame:Double Pane with Low -E
3856: Above-Grade:Wood Frame:Double Pane with Low -E
3856: Above -Grade -.Wood Frame:Double Pane with Low -E
3856: Above-Grade:Wood Frame:Double Pane with Low -E
2656(2w): Above-Grade:Wood Frame:Double Pane with Low -E
2656: Above-Grade:Wood Frame:Double Pane with Low -E
Front entry: Solid
Front entry: Solid
Rear entry: Solid
Rear entry: Solid
Basement: Masonry Block with Empty Cells
Wall height: 8.0'
Depth below grade: 8.0'
Insulation depth: 8.0'
Basement window:
Basement <= 5.6 12:Wood Frame:Single Pane
Basement window:
Basement <= 5.6 12:Wood Frame:Single Pane
Basement window:
Basement <= 5.6 12:Wood Frame:Single Pane
Basement window:
Basement <= 5.6 12:Wood Frame:Single Pane
Furnace 1: Force Hot Air, 80 AFUE
Furnace 2: Forced Hot Air, 80 AFUE
Proposed and Maximum U Factor Averages
Above -Grade Windows and Glass Doors
Includes Foundation Windows > 5.6 12
Foundation Windows <= 5.612
12
0.310
4
30
0.310
9
4
0.310
1
15
0.310
5
15
0.310
5
15
0.310
5
15
0.310
5
4
0.310
1
30
0.310
9
12
0.310
4
8
0.310
2
1400 13.0
0.0
89
30
0.310
9
30
0.310
9
30
0.310
9
30
0.310
9
7
0.310
2
14
0.310
4
15
0.310
5
15
0.310
5
15
0.310
5
15
0.310
5
14
0.310
4
7
0.310
2
20
0.250
5
20
0.250
5
20
0.250
5
20
0.250
5
1400 15.0
0.0
65
2 0.510 1
2 0.510 1
2 0.510 1
2 0.510 1
Proposed
Average U -F actor
0.310
0.510
Maximum
Allowed U -Factor
0.370
0.510
REScheck Inspection Checklist
2000 Minnesota Energy Code
REScheck Software Version 3.6 Release 2
DATE: 06/21/06
PROJECT TITLE: 6140 / 6142 Star LN NE, Fridley 55432
PLAN REVIEW AND INSPECTION ISSUES
This list of items may be helpfitl for Plan Reviewers and Building Inspectors to use as a guide frr enforcing the Minnesota
Energy Code. The items apply to Group R, Division 3 Occupancies, one- and two-family residential dwellings. The
items marked with * apply only to detached one- and two-family residential dwellings.
PLAN REVIEW ISSUES
FOUNDATION INSPECTION
[ ] foundation wall insulation R-5 minimum
[ ] foundation insulation extends from top ofwall down to top of the footing
[ ] exterior foundation insulation is covered by a protective coating finish
CONCRETE SLAB OR UNDER -SLAB INSPECTION
[ ] slab on grade perimeter insulation R-5 minimum
[ ] slab insulation extends from top of slab to design frost line or top of footing
[ ] floors over unheated space R-30 minimum
WINDOWS / DOORS / SKYLIGHTS
[ ] average U -value is 0.37 maximum for windows and glass doors (excludes 1bundation windows)
[ ] window U -values consistent with building plan and REScheck Certificate
[ ] window and door areas consistent with building plan and REScheck Certificate
MECHANICAL VENTILATION ISSUES
[ ] residential mechanical ventilation system provides adequate ventilation per code requirements*
[ ] furnace efficiency is consistent with REScheck Certificate or building plan
[ ] protection against excessive depressurization is installed per code requirements*
ENVELOPE INSULATION FOR PLAN REVIEW
[ ] interior basement insulation R-5 minimum (ifno exterior insulation)
[ ] ceilings with attics R-38 minimum or consistent with building plan and REScheck Certificate
[ ] wall framing and insulation level is consistent with building design and REScheck Certificate
INSPECTION ISSUES
CONCEALED INSULATION
Framing and Sheathing
[ ] wind wash barrier installed at attic edge
[ ] exterior wall corners framed so that insulation can be installed after exterior sheathing is installed
[ ] intersections ofinterior partition walls and exterior walls framed so that insulation can be installed between the
partition and exterior sheathing after exterior sheathing is installed
[ ] gaps between framing less than one-halfinch are eliminated by securing framing together or are insulated at the time
of assembly *
,
[ ` ] all penetrations between conditioned and unconditioned spaces made prior to framing inspection are sealed
Interior Air Barrier
[ ] all fire stops are air sealed
[ ] pipes, ducts, wires, equipment and flues and chimneys through the interior air barrier are sealed
[ ] a sealed continuous interior air barrier is installed on the warm side of the building envelope at ceilings, walls, and
floor rim joist areas *
[ ] air barrier behind tub and shower is sealed and protected
[ ] recessed light fixtures are sealed
Envelope Insulation
[ ] basement insulation R-5 minimum
[ ] wind wash barrier on wall separating house and garage is sealed
[ ] loose fill insulation is prevented from entering the eaves
[ ] insulation on skylight shags and walls exposed in attics is supported on the unconditioned side
Attic Insulation
[ ] attic access panel insulated to R-38 for ceiling panel and R-19 for wall panel
[ ] attic card attached to framing near access opening
[ ] notification of attic R -value and date ofinstallation posted near building permit inspection card
This is a summary only. Other requirements may apply. See the Minnesota Energy Code. Questions? Call the
Department of Public Service Information Center at 651-296-5175 or 1-800-657-3710.
Jul -07-2006 02:57 PM TAMARACK MATERIALS INC 7637842963
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-dypsum musomm wool) cruos
Base layer W type X gypsum wallboard or gypsum veneer base applied at right angles to
each side of double raw of 2x4wood etude lwo.a onseparate pial 11 spartwith6d
coated nails, 171e long, 0.085" shank, Ile heads, 941 o.c. Face layer W type X gypsum
wallboard or gypsum veneer base applied at right angles to each side4ih ed coated
nails, 231V long, 0.1001 shank, W heads, 81 c.c.
Joints staggered 116r each IW and side. Sound tested with 31W glass fiber Insulation
stapled to studs In stud spaces on one side and with nails for base layer spaced S' o.c.
Horizontal bracing required at mid-halght (LOAD-BEARING)
L
Thlokness: low
Approx. Weight; 13 psf
Fire Test See WI' 4135
(FM WP -360, 9-27-74)
Sound Tog; NOG 3056, 4-7-70
GVPSULI WALUMARD, WOOD STUDS
ease layer ata' type X gypsum wallboard or gypsum veneer base applied at tight angles to
each side of 2 x 4 wood etude IS' o.c. staggered 8" o.c. on 2 x 8 wood Oates with Od
coated nags, 1171V long, 0.066" shank, Ile heaft 24" o.c. Face layer W type X gypsum
wallboard or gypsum veneer base applied at right angles to each side with ed coated
nails, 2910" long, 0.113" shank, D/W heads, V 0.0.
Vertical Joints staggered 18" each layer and side. Sound tested with nags for base layer
spaced 01 o.c. Horizontal bracing required st mid -height (LOAD -SEARING)
Thickness: all
Approx. Weight 13 psi
Fire Test: Sao WP 4135
(FM WP -360, 0-87-74)
Sound TM: NOC 2377. 6-19-70
This Space Left Blionk
66 GA -600-2003
2/3
N
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Building
Inspections
7.63-572-3604
E%
SITE ADDRESS (1 l ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
❑ OWNER 580NTR.ACTOR
Permit No.:
Received By:---,Zl
Date Rec'd:
NAME:
ADDRESS: CITY STATE ZIP
PHONE:
COMPANY NAME:i�'�$ �Z—C
CONTACT PERSON: ��W0" Vt
STATE LIC # EXP DATE
ADDRESS: 1 ® &MO ITY lst2 STATF_ZIP592`6
PHONE _-&-3 - ��- � C FAX -7
❑ SINGLE FAMILY fd0 FAMILY
❑ NEW 0fiPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
ERATION/REMODEL
PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor )
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. FIXTURES: (INDICATE TOTAL
NUMBER OF EACH BELOW)�n57 �--� SIZE/BTU �j®
Equipment Installed MFG: �J- MODEL:
MFG:
MODEL: P SIZE/BTU
MFG: MODEL: SIZF/BTU
%dC $25.00 _FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL .0.00
BOILER $35.00 FURNACE $35.00 _GAS HEATER $35.00
HTR $100.00
_CHIMNEY LINER $10.00 _GAS DRYER $10.00 _POOL E
_GAS PIPING $10.00 _VENTILATOR $1500
aL DUCT WORK $10.00
a
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 @ $25.00 l x $25.00 = $�
Number of fixtures @ $35.00 � x $35.00 = $ SSU
State Surcharge = $ .50
Total = $ 'ltd
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 work which requires /review and approval of plans.
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SIGNATURE OF APPLICANT PRINT NAME DATE
City of Fridley
Building Inspections Department .
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977