PRE 2010 DOCSBUILDING PERMIT
Village of Fridley, Minn. N° 2693
Date` ��.......�. 7 ......................
Owner ......��U.............Builder ...........................................
Address Y4S. .4fld `® r
o�
LOCATION OF BUILDING
No. 4A00........ Street-✓���!? ...... Part of Lot .......................
Lot ...... /le ...... Block ..... �F........ Addition or Sub-Divisio ��2 .. s .
Corner Lot ............ Inside Lot ............ Setback 30.7 Sideyard IJP. 1%cg ...............
DESCRIPTION OF BUILDING
To bb�e,rUsed as:
.1d%s!"l�" ..... ,
Front ��. Depth .2—..t.. Height Sq. Ft. IVA& Cu. Ft. ........
.................... Front ........ Depth ........ Height ......... Sq. Ft......... Cu. Ft.........
®® 10,9Type of Construction ...... .... Est. Cost .11# ............. To be Completed . ..
In consideration of the issuance to we 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 village of Fridley.
gQc hsideration of the payment of a fee of permit is hereby granted to .......... .
-V4,0k4 ............ 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 village limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances. 16-3 — -
V' �... 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 items.
Date: NOVEMBER 9s 1965
Owner:
Address
MYRON SJOSTROM
N?
Builder CARLSON - L6VI s INC.
!rT=
LOCATION OF BUILDING
No. 6240 Street Starlight Boulevard Part of Lot
Lot _ 12 _Block 4 . Addition or Sub -Division ___._. Sylvan Hills, Plat 3
Corner Lot ._ Inside Lot _.._.XSetback 35' -- Sideyard . 10'
Sewer Elevation _ _ _ — Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
8592
GAGE & Front 18 Depth 24 Height 20 Sq. Ft. 432 Cu, Ft 8,640
BEDROOMS Front Depth Height Sq. Ft. Cu. Ft.
Type of Construction Frame Est. Cost _$3, 000 _ 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 and in compliance with ;h Provisions of
ordinances of the city of Fridley. ;J L
In consideration of the payment of a fee of $--2 ®00 permit is hereby granted to CARLSON
LAVINE, INC, 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 &f—sJd
ordinances.
ALLEN G. JENSEN Building, or
NOTICE:
TMs permB does not aowr tho aondeoadon, huhgation for mop phnnhh+o, on hoxtb& sower or wdtor. Be vire to no
the BQIWInB htspeator for aspamb parmhs for those Bons.
Q
i
• I I fi ..L7 \ 7
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNER'S ► �� .�.' J ..' .. � .Ire 1 BUILDER
ADDRESS ADDRES
LOCATION
No. Street
LOT BLOCK ZADDITION
Corner Lot Inside LOT Setback _� Sidewyard
SEWER ELEVATION FOUNDATION ELEVATION„
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;
d.4 Front Depth /—Height
Sq. Ft. Cu. Ft.
Front Dept Height
Sq. Ft. Cu. Ft. er
Type of Construction.. Estimated Cost5,1—.14f&1
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.
DATEfT 5=�
(Schedule of Fee Costs can be found on the Reverse Side).
lop
RUMDING+:PERMIT FEE SCHFMME
SECTION 2. The Inspector of Buildings shall, before issuing any permit for the
erection of any building or structure, or for any addition to any existing build-
ing or structure, or for any alterations or repairs to any existing building or
structure, upon application -therefore, require the payment by the applicant for
such permit of fees to the amount herein below set forth""and in the manner herein -
provided to -wit;
2.1. For any such permit for the erection of any fireproof building,
other than a garage, warehouse* factory or grain elevator, or for the erection
of any fire -proof addition, for similar occupancy, to any existing building,
shall be at the rate of $1.40 for each one thousand cubic feet, or fraction
thereof, in such cubical contents.
'2.2. For any such permit for the erection of"any fire -proof garage,
Warehouse, factory or grain elevator, or for:the erection of any fire -proof
addition, for similar occupancy, to any existing building shall be at the rate
of $1.25 for each Pae thousand cubic feet, classified as "fireproof"_by
Section 502 of the Minneapolis Building Code.
HOUSES
2.3. For any such permit.for the erection of any non -fireproof building,
other than a garage, warehouse, factory or grain elevator, or any non -fireproof
addition, for similar occupancy, to any existing building - permit $1.00 for each
one thousand cubic feet.
GARAGES
2.4. For any such permit for the erection of any non -fireproof garage,
warehouse, factory or grain elevator, or for the erection of any non -fireproof
addition, for similar occupancy, to any existing building or for each such
building or addition - ninety cents ($0.90) for each one thousand cubic feet
or fraction thereof, in the cubical contents thereof with the minimum of $4.00.
For the purpose 'of computing fees for building permits, the cubical contents
of any building or addition to a uniform height throughout by multiplying the
ground area covered from a point six (6) inches below the floor line of the
basement or cellar to the average height of the upper surface or to the average
height of the roof surface of the main.gable of a pitched roof.
2.5. For repairs or alterations to an existing.,structure, the fee shall
be at the rate of $3.00 per each Five Hundred Dollars ($500.00) or fraction
thereof in the cost of all proposed work.
2.6. in no case shall the fee charged for any permit as set forth in
Section 2 be less than $4.00.
CITY OF FRIPLEY INSPECTION DIV.
6431 ltniversity Ave NE
Effective On January 1, 1991
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
Gas Piping (Needed with new furnace)
Gas Range
Gas Dryer
Rate TOTAL
$ 20.00 $ 20.00
$ 10.00 $Reconnect
$ 10.00 $
$ 10.00 $
"Air Conditioning - All Sizes $ 10.00 $
All Others/Repairs & Alterations (LIST ON BACK)
1 % of Value of Appliance or Work $
Commercial/Industrial
1 % of Value of Appliance or Work $
State Surcharge $ .50
TOTAL FEE $ 20.50
MINIMUM FEE FOR ANY HEATING/COOLINGNENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $15.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $30.00
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
JOB ADDRESS 6240 Starlight Blvd, Fridley, MN 55432
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 ruling of the Building Division, and hereby declares
that all the facts and representations stated in this application are
true and correct. September 19 ,1991
OWNER Myron & Mary Sjostrom
BUILDING USED AS Residence
ESTIMATED COST
$2934.00
PERMIT NO. /C'S)9/
DESCRIPTION OF FURNACE AND OR BURNER
No. of Heating Units_,L— Circle One (Steam) (Hot Water) (Warm Air)
Trade Name Comfortmaker Size No. 100,000 BTU
BTU 100,000 HP EDR
Fuel Nat. Gas Total Connected Load
Burner Trade Name Comfortmakeer Size No.
BTU 100,000 HP EDR
HEATING
inaoor air uuaiity
Rapids vd, Coon Rapids, MN 55433
No. 757-5040
Approved By Rough -In Date Final Date
FILL OUT BACK SIDE FOR STACK VERIFICATION ON
REPLACEMENT FURNACE
CHIMNEY AND STACK VERIFICATION
The undersigned hereby verifies that the existing chimney or stack:
1.
Has been carefully examined
Yes
( )
No ( )
2.
Is free from rust or deterioration
Yes
( )
No ( )
3.
Has no foreign objects lodged within
Yes
( )
No ( }
4.
Is securely supported
Yes
( )
No ( )
5.
Meets all current Code requirements for
size and total BTU's connected
Yes
( )
No ( )
6. Has total heating BTUrs of
All other BTU's
TOTAL BTU's
Remarks
List Alterations Being Done:
HEATING COMPANY
Signed By
Date
n
HOUSE HEATING TEST RECORD
ADORE Ss' Le APT. FLOOR4UdUR
CITYrf9
OCCUPANT j" OWNER
HEAT LOSS D � TG. INST.
SOLD BY INSTALLED BY -T�- b DL IP--
Electricol Work By ` Gas Lino By —'
TYPE OF HEAT GA FA Z: Hyf STEAM SPACE HTR. UNIT HTR. OTHER
r GAS ESIGN CONVERSION ".
�r
MAKE � �6y CILC& FAKE OF BURNER
Model ® Model
Serial Max. BTU Rating _
INPUT ���� ®®� MAKE OF FURNACI
Model
CONTROLS
/ Il
THERMOSTAT Erl_� Heat Plug
✓ Vont Sise
VolvoKIND
OF LINER
SIZE—NONE-
IZE NONELimit
Limit
Draft Hoed
Regulator
Limit Setting ®�rs®
Filters Sia•
r dumber G X Z4/ I//
Fon Setting 9 o
Chimney Location
Inside =L Outside
Pilot Typo
aimney Construction
Pilot Mo k.
Spillage
Pilot Model<� � � — i L/y
Smoke Bomb
Wiring
Pilot Timing
Draft
Test Tag
1 L.W. Cut Off
Door Pressure
Lighting Inst.
Pressure r -� - Parcont CO
Data Tested
.�
2
InputPereont 0
r�
a Company Testing
�p y�
Sack Temp. T,L® Portent C 7 0
.2 Name of Tester
Certificate
f Compentency_ # �"gLLtlZ.
CITY OF FRIDLEY INSPECTION DIVISION
Effective On January 1, 1998
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND
HEATING, COOLING, VENTILATION,
572-3604 REFRIGERATION AND AIR
CONDITIONING SYSTEMS AND DEVICESS
JOB ADDRESS 4':�'-) �/e
RATE SCHEDULE
The undersigned hereby makes application for a permit for the work herein
Residential Rate.
TOTAL
specified agreeing to do all work in strict accordance with the City Codes and
Furnace Shell and Duct Work, Burner —
rulings of the Building Division, and hereby declares that all the facts and
Also Replacement Furnace $ 30.00
$
representations stated in this application are true and correct.
(Side Vent — Fill Out Back)
—3— ?/,1996
Gas Piping (Needed with new furnace) $10.00
$
OWNER
Gas Range $10.00
$
e
BUILDING USED AS
Gas Dryer $10.00
$
_
ESTIMATED COST PERMIT NO.
___--!AkConditioning — All Sizes $ 25.00
$
DESCRIPTION OF FURNACE AND OR BURNER
All Others/Repairs & Alterations (LIST ON BACK)
1% of Value of Appliance or Work
$
No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Trade Name Size No.
Commercial/Industrial
BTU HP EDR
1.25% of Value of Appliance or Work
$
Fuel Total Connected Load
State Surcharge
$ .50
Burner Trade Name Size No.
TOTAL FEE
$ !�S
BTU P EDR
.w
Sharp
satin
HEATING CO and Air Conditioning
Y
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
Col u bia Heights. Nils! 55421
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
Signed By (612) 972-0459rel No.
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $42.00/Hr
Approved By Rough—In Date Final Date
*Air Conditioners can not be placed in a side yard without
FILL OUT BACK SIDE FOR STACK VERIFICATION ON
written permission from adjoining property owner.
REPLACEMENT FURNACE
CHEWNEY AND STACK VERIFICATION
The undersigned hereby verifies that the existing chimney or stack:
1. Has been carefully examined Yes () No ( )
2. Is free from rust or deterioration
3.
4.
5.
6
7.
A
Has no foreign objects lodged within
Is securely supported
Meets all current Code requirements for size
and total BTU's connected
Has total heating BTU's of
All other BTU's
TOTAL BTU's
Has a liner been provided for water heater,
Has combustion air been provided for water heater
Remarks:
List ALTERATIONS Being Done:
HEATING CO:
Signed By:
Date:
Yes
No
Yes
O No
( )
Yes ()
No
( )
Yes ()No()
Yes () No ( )
Yes () No ( )
Av
SUBJECT
-
M
City of Fridley
2 S 016
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
`v COMMUNITY DEVELOPMENT DIV.
w P
d PROTECTIVE INSPECTION SEC.
G%f/C�
76
• ,
NUMBER
REV
DATE
PAGE Of
APPROVED By
CITY HALL FRIDLEY 55432
•j
L J` 612-571-3450
910415
-9122128
JOB ADDRESS 6240 Starlite Blvd
I LEGALLOT
NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
12
4
1 Sylvan Hills Plat #3
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Myron & Mary Sjostrom571-2044
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
8 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW O ADDITION O ALTERATION IRx REPAIR O MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and garage (21 Sq) 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 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
1 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 HEREIN OR NOT. THE GRANTING OF A PERMIT
1799
$.90
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
$56.75
Fire SC
PLAN CHECK FEE
TOTAL FEE
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
1199-45
WHEN PROPER ALIDAT O THIS IS YOUR PERMIT
��
l
'
SIGNATURE FOWNER ERBWLDERI [DATE.
BLD INSo
BATE
NEW [ ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION �b �A
ConstructionAddress: (;, `jo StAAA 17'"x= R iy o
Legal Description: S y jj a vj 'PIA t f l a - A' -®e-/-- y
Owner Name & Address: Tel. # -5' 7l - W o �ey
Contractor: �J MN LICENSE #
Address: _� a ® t/t Tel. # 5 7l - ;Z o
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
DATE: `�j - �� APPLICANT: /V1 r otl -A M&p o �_I D5'7'AdM Tel. # -5 7!- 2 6rf 5�e'
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
n,. - W hD0 F
Driveway Escrow
$
LIVING AREA:
Length Width
Height
Sq. Ft.
GARAGE AREA:
Length Width
Height
Sq. Ft.
DECK AREA:
Length Width
Hgt/Ground
Sq. Ft.
OTHER:
tc-_ too A0 uS_ 4 Q"6��
e.
-e-0-Y, a �%-
Construction Type:
Estimated Cost: $
1 �;9 2
(Fee Schedule on Back)
Driveway Curb Cut Width
Needed: Ft. + 6 Ft =
Ft x $
= $
DATE: `�j - �� APPLICANT: /V1 r otl -A M&p o �_I D5'7'AdM Tel. # -5 7!- 2 6rf 5�e'
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
$
Driveway Escrow
$
Erosion Control
$
Park Fee
$
Sewer Main Charge $
TOTAL
STIPULATIONS:
$ 39,
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 [ ]
BUILDING PERMIT FEE SCHEDULE
The Chief Building Official shall, before issuing permits for the erection of any building or structure, or for
any addition to any existing building or structure, or for any alteration or repair to any existing building or
structure, upon application therefore, require the payment by the applicant for such permit of fees to the amount
herein below set forth and in the manner herein provided to -wit:
TOTAL VALUE FEES
$1 to $500 $21 (Minimum Fee is $21 plus surcharge)
$501 to $2,000 $21 for first $500 plus $2.75 for each additional $100 or
fraction thereof, to and including $2,000
$2,001 to $25,000 $62.25 for first $2,000 plus $12.50 for each additional $1,000
or fraction thereof, to and including $25,000
$25,001 to $50,000 $349.75 for first $25,000 plus $9.00 for each additional $1,000
or fraction thereof, to and including $50,000
$50,001 to $100,000 $574.75 for first $50,000 plus $6.25 for each additional
$1,000 or fraction thereof, to and including $100,000
$100,001 to $500,000 $887.25 for first $100,000 plus $5.00 for each additional
$1,000 or fraction thereof, to and including $500,000
$500,001 to $1,000,000 $2887.25 for the first $500,000 plus $4.25 for each additional
$1,000 or fraction thereof, to and including .$1, 000, 000
$1,000,001 and up $5012.25 for the first $1,000,000 plus $2.75 for each additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
(Concrete Curb Streets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50.
Alternate "B": Removal and replacement of curb and gutter and install a 3 foot wide
approach with 6 inch depth - Driveway width plus 6 feet times $15.75.
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper
review of the proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed
will be required before proceeding with the framing.
CITY OF FRIDLEY INSPECTION DIV.
6431 Universq Ave NE
Fridley, MN 5532
572-3604
RATE SCHEDULE
APPUCA110M FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
Residential
Furnace Shell and Duct Work, Burner -
Also Replacement Furnace
(Side Vent - Fill Out Back)
Gas Piping (Needed with new furnace)
Gas Range
Gas Dryer
*Air Conditioning -- All Sizes
AN 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 x,1997
JOB ADDRESS �2 a4o
undersigned hereby maf<es application for a permit for the work herein
Rate TOTAL 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
$ 30.00 $ 1 representations stated in this application are true and correct.
$10.00 $
OWNER r cam, L,n, /Mau, _ �, � .���
$10.00 $ f
BUILDING USED
$10.40 $ /
ESTIMATED COST SCOPERMIT NO. � �5
$ 25.00 $ '
DESCRIPTION OF FURNACE AND OR BURNER
No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Trade Name �Zn j N r.L - .moi'- -2—
BTU -�9,®(X) HP EDR
$ Fuel j C®c8 c Total Connected Load
State Surcharge 1 5U
TOTAL FEE
MINIMUM FEE FOR ANY HEATINGICOOLINGIVENTILATION
REFRIGERATIC"k.1 IR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $42-OD/Hr
'Air Conditioners can not be placed in a side yard without
written perri-Ission from adjoining property owner.
Burner Trade Name Size No.
BTU HP EOR
A1ged Fireside
Ljcsnse #20090911
HEATING COMPANY 27DO N. Fairview Ave.
Roseville, MN bOl 10
Signed By 651/63'11 X561
Approved ByRough-in Date
FILL OUT BACK SIJFSTACK VERIFICATION ON
REPLACEMENT FURNACE
Final Date ._ J
Z We:p:n A
Building
Inspections
7.63-572-3604
DATE / 0 -1
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERNIIT TYPE
TYPE OF WORK:
AUCHANICAL
11
CITY OF X1;1
YOUR E-MAIL ADDRESS
❑ OWNER CONTRACTOR
Permit No.:
Received By:
D °6C
ADDRESS:'a`l6 S (�c (Alupkr:CITY rka.al >& STATE,�t—jZIP 5I
PHONE: -J 63 - 5'71 - *141T 6,7
COMPANY NAME:_
CONTACT PERSON:
STATE LICENSE #_
PHONEIV-IA51-7-1J2
�rSINGLE FAMILY ❑ TWO FAMILY
0 NEW >rREPLACEIAENT
EXP DATE
FAX 16' -15� - ? 12f
0 TOWNHOUSE
O ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK T ,4-e.l ( Q �t � L &.. R - y► Ae k --
ATE A4N ZIP � � ;l -
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 $5DD, FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: MMICATE TOTAL
NUMBER OF EACH BELOW) MFG: I� v s� MODEL: o�f�e216-®� M#1~i SIZE/BTU - A. ®sb— 4
Equipment Installed SIMTU MODEL:
MFG:
MFG: MODEL: SnM/BTU
A/C $25.00 _FIREPLACE (GAS) $15.00. GAS RANGEIOVEN $10.00
_AIR TO AIR EjCCHANGEER $IS FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
FURNACE $35.00 GAS UNIT HTR $10.00
B YS.00 I1gER $10.00 -GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00 _
.rr ems.. �.."`TiF:a'�rTliiiryrea�!'Y a•�ni
Permit Fee $ ,3.5. of Number of fixtures @ $10.00 x $10.00 = $
Surcharge Number of fixtures @ $15.00 x $15.00 = $
TOTAL DUE $ S S . 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 work which requires review and approval of plans. .
SIGNATURE OF APPLICANT l �Ia��„ n n . PRINT NAME I of � DATE L®- --6
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
REQUIRED INFORMATION NEEDED TO PROCESS PERMIT
RESIDENTIAL PERMIT APPLICATION HVAC
❑ NEW HOMES/ADDITIONS EXISTING HOME ❑ MAKE-UP AIR
REQUIRED FOR NEWIEXISTING HOMES
1. Combustion Air (See note below)
a. Oil or solid fue11MC Chapter 7 with MN Amendments
b. Natural Gas or PropaneUGC Chapter 3 with MN Amendments
2. Make-up Air (See note below)
a. IMC Chapter 5 with MN Amendments
3. Venting
a. Gas appliances ]FGC Chapter 5 with MN Amendments
b. Fuel other than gas ]MC Chapter 8 with MN Amendments
REQUIRED FOR NEW HOMES
4. Heat loss & cooling load per room
a. Required on new constnxtion RMC 1346.0312
5. Ventilation
a. Per MN Energy Code 7670 or 7672
6. Duct Design Per IMC 1346:0603.2
a_ ACCA Manual D
NOTE: Centerpoint Energy Mechanical Code Guidelines software may be used for
combustion and make up air calculations
Building
PLUMBING
Permit No.:. -'N
Inspections
APPLICATION
Received By:
763-572-3604
CITY OF FRIDLEY
Da ffi%'(AFR 0.
763-502-4977 FAX
EFFECTIVE 1-1-08
DATE 13'v S YOUR E-MAIL ADDRESS
SITE ADDRESS V 0
TENANT SUITE NO.
PROPERTY
NAME: P P_ G C, 0 S 6 A L
ADDRESS: 6 3 '10 ' 7_412 ° k ✓� � ° e� CITY rIP- ° ` Y STATE*` ZIP
OWNER/
TENANT
PHONE:
NAME:
CONTRACTOR
# (a ®� Y S' Terry Overacker Plumbing, Inc
SUBMIT A COPY OF
STATE LICENSE 1p -
S 502 E Main St
YOUR STATE
PLUMBING BOND #
Anoka, MN 55303 ZIP
LICENSE AND BOND
ADDRESS: TE
PHONE
PERMIT TYPE
❑ INSTITUTIONAL ❑ MULTI -FAMILY ❑ SWIMMING POOL
❑ TOWNHOUSE ❑ COMMERCIAL/INDUSTRIAL ❑ OTHER
❑ NEW REPLACEMENT ❑ ALTERATION/REMODEL
TYPE OF WORK:
DETAILED DESCRIPTION OF WORK
_ CLOTHES WASHER _ FLOOR DRAINS _ RPZ VALVE _ URINAL
_ DISHWASHER _ GAS PIPING (CITY LIC REQ'D BACKFLOW PREY. 0 WATER HEATER
_ DRINKING FOUNTAIN _ GREASE TRAP _ ROOF DRAINS _ WATER METER
—FAUCET _ KITCHEN SINK _ SHOWER —WATER PIPING
_ FLAMMABLE WASTE TANK _ LAUNDRY TRAY _ SLOP SINK _ WATER SOFTENER
LAVATORY SWIMMING POOL _ WATER CLOSET
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Total Job $ All fees are based on valuation, including the cost of labor and materials.
Valuation
Permit Fee $ (1.25% of Job Valuation/ Minimum fee: $35)
Surcharge $ Valuation X.0005 ($.50 Minimum)
Total Due $ Minimum $35.50 Make Checks Payable to: City of Fridley
THIS I5 AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED
I hereby apply for a mechanical 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 PRINT NAME JAC/c,F_ eL,,e_o JL DATE
_ICA
APPROVED BY DATE
��� � �E ������.�r ��� FaI� �����l�,.Ezl✓���.Ic�. AND., �c�.�, � W��;�..
�?��� ..
amity of Fridley Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977