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PRE 2010 DOCSBUILDING PERMIT Village of Fridley, Minn. Date.,f ......................... . a R . Owner �r,►' .. 3$- '° d . Address Builder ....... 2404 Address......................................... L VLOCATION OF BUILDING No. �:to :...... I Street,.. n�,.. �. ............... Part of Lot ...... .. ................... Block Addition or Sub -Division, ......... Corner Lot ............ Inside Lot ....... Setback Sideyard �! DESCRIPTION OF BUILDING To be Used as: 'd ri w... Front�i Depth .f... Height's .. Sq. Ftw /6114T ..�. Cu. Ft......... Front . ... Depth ... Height ° Sq. Ft.... Cu. Ft........ . Type of Construction x .. Est Co r aAP ........ To be Completed .*'Fe . . 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 village of Fridley. In consideration of the payment of a fee of $.. .. , ..... . p permi isl hereby granted to.4w : . ........... .. to construct the buildinor addition as described above. Thist granted upon the e Bec* I 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. .. uilding 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. \j SUBJECT R O. City of Fridley 18807 AT THE TOP OF THE TWINS BUILDING PERMIT r RECEIPT NO. • COMMUNITY DEVELOPMENT DIV. 170 r PROTECTIVE INSPECTION SEC. 6 1 � � CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 612-571-3450 910-F15 3/2/87 JOB ADDRESS 5890 Stinson Blvd N.E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. S i 37 Aud. Sub. #92 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE MErylin Larson 5890 Stinson Blvd., Mpls. MN 55432 571-0615 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. AMRE 3700 Annapolis Lane ,.Plymouth, MN 55441 553-0020 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 j1 ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reside Dwelling 9 CHANGE OF USE FROM TO STIPULATIONS 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 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 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 $ 3,310 $1.66 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- $44.50 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTALFEE -) $46.16 SIGNATUREPF O RAC OR OR AUTHORIZED AGENT (DATE) - -Z,WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT BLDG WSP D TE SIGNATURE OF OWNER 0 OWNER BUILDERI IDATEI NEW [ ] City of Fridley Effective 4/1/86 ADDN. [ ] R-1 AND R-2 ALTER. VT Building Permit Application Construction Address: .5' 7 1) S.V,I LI'iO °� Legal Description: � Owner Name &Address : � � 3 Tel. Contractor: A rn Tel. # 5s Address: 3 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: Length _ Width Hgt/Ground Sq. Ft. OTHER: �--0-� °`� Corner Lot [ ] Inside Lot [ ] Ft. Yd. Setback Side Yard Setback Type of Construction: Estimated Cost: $ 3 Approx. Completion Date: — — Alt. A Alt B Proposed Driveway Width If New Opening Is Desired: $ $ See Back Page for Explanation DATE: APPLICANT: Tel. CITY USE ONLY Permit Fee $ All Fee Schedule on Reverse Side Plan Check $ 25% of Building Permit Fee State Surcharge $ f= $.50/$1,000 Valuation SAC Charge $ $525 per SAC Unit Park Fee $ Fee Determined by Engineering Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ] TOTAL $ STIPULATIONS: SUBJECT PERMIT N - City of Fridley 0 1941 AT THE TOP OF THE TWINS BUILDING PERMIT _ R E C E IPT-N13' COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. �� CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 612-571-3450 910-F15 4/25/88 JOB ADDRESS 5890 Stinson Blvd N. E. 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. Sli 37 Auditor ' s Subdivision *92 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Marilyn Larson 5890 Stinson Blvd N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Turin City Storm Sash Co. 10825 Greenbrier Road, Mtka, MN 55343 5468160 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 REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Install.siding/soffit/Facia/trim 9 CHANGE OF USE FROM TO STIPULATIONS 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 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 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 $4,30'0 $2.15 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- $50.50 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTALFEE $52.65 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATEI-----,WHEN PROPERLY VALI ATED THIS IS YOUR PERMIT f SIGNATURE OF OWNER IIF OWNER BUILDER) (DATE) BLDG INSP 1, e BATE ANEW [ ] City of Fridley Effective 4/1/86 ADDN. [ ] FR -1 AND R-2 j ALTER. [ ] Building Permit Application Construction Address: 5890 Stinson Boulevaid N.E. Legal Description: Slam of Lot 37 Auditor -'s Subdivision #92 Owner Name & Address: Marilyn Larson 5890 Stinson Blvd N.E. Tel. # Contractor: Twin City Storm Sash Co - Tel. # 546-8160 Address: 10825 Greenbrier Road, Minnetonka, MN 55343 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: Length Width Hgt/Ground Sq. Ft. OTHER: Siding - Soffit/Facia/Trim Corner Lot [ ] Inside Lot [ ] Ft. Yd. Setback Side Yard Setback Type of Construction: Approx. Completion Date: Estimated Cost: $ 4,300 Alt. A Alt B Proposed Driveway Width If New Opening Is Desired: __ $ $ See Back Page for Explanation DATE: 4/25/88 APPLICANT: By Mail Tel. # 546-8160 Permit Fee Plan Check State Surcharge SAC Charge Park Fee Sewer Main Charge TOTAL STIPULATIONS: A CITY USE ONLY $ 50.50 6� $ $ .2.15 $ $ $ 52.65 Fee Schedule on Reverse Side 25% of Building Permit Fee $.50/$1,000 Valuation $ 5.5Q per SAC Unit Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] �U 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 Valuation $1.00 to $500.00 $501.00 to $2,000.00 $2,001.00 to $25,000.00 $25,001.00 to $50,000.00 $50,001.00 to $100,000.00 $100,001.00 and up Fees $10.00 (Minimum Fee is $15.00) $10.00 for the first $500 plus $1.50 for each additional $100 or fraction thereof, to and including $2,000. $32.50 for the first $2,000 plus $6.00 for each additional $1,000 or fraction thereof, to and including $25,000. $170.50 for the first additional $1,000 or including $50,000. $283.00 for the first additional $1,000 or including $100,000. $25,000 plus $14.50 for each fraction thereof, to and $50,000 plus $3.00 for each fraction thereof, to and $433.00 for the first $100,000 plus $2.50 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 been constructed Will be required before proceeding with the framing. APPLICATION FOR BUILDING PERMIT •1MWI, JOB LOCATION TYPE OF. WORK COST�j® COMPANY'S NAME SUBJECT City of Fridley 2 �. 7 4 AT THE TOP OF THE TWINS I B U I`®I I� P E R M I T Ir RECEIPT NO. • COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. -f 31 F � 11L CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY j4., "'j 612-571-3450 910-F15 2/18/93 JOB ADDRESS 5890 Stins:ori Blvd NE I LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. pt 37 Allditor"s Sub. #92 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Marilyn Larson 5890 Stinson Blvd NE 571-0615 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Twin City Storm Sash Inc 10825 Greenbrier Rd, Mtka 55305 546-8160 309 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 ❑ REPAIR ❑ MOVE ❑ REMOVE X B DESCRIBE WORK Replace storms 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 SO. FT. CU. FT. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION 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 STALLS GARAGES VALUATION SURTAX AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED $982 $.50 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- $25.00 Fire SC $,98 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTALFEE License SC $5.00 $31.48 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE) WH P PERLY VAL ATED THIS IS YOUR PERMIT BLDG )NSP Lz DATE SiGNATURE OF OWNER IIF OWNER BUILDER) IDATEI W:. , :;[:;:�:: , :�7�`3�� .. ............................ ..........................._ Effective 311/92 .... - ADDN [ ] CITY OF FRIDLEYt� ALTER [ j SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Building Permit Application Construction Address: �� c L Legal Description: Owner Name & Address: C Tel. # - Contractor: MN LICENSE # Address: 10825 CREENCRI7, Tel. # L 61A J6othis application, a Certificate of Survey of the K 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: Length Width Hgt/Ground Sq. Ft. OTHER: Corner Lot [ ] Inside Lot [ ] Ft. Yd Setback _ Type of Construction: , Approx. Completion Date: Driveway. Curb Cut Width Needed: Ft. + 6 Ft = Side Yard Setbacks Estimated Cost: $ (Cost on Back) Ft x $ = $ DATE: N % - 9 APPLICANT: Tel. # Permit Fee $Ott Fire Surcharge $ , g State Surcharge $ 4 -Sl SAC Charge $ License Surcharge $ 4'00 Driveway Escrow $ Park Fee $ Sewer Main Charge $ TOTAL STIPULATIONS: $�, 4Y Y USE Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th l ) $.501$1,000 Valuation $700 per SAC Unit $5.00. (State Licensed Residential Contractors) Alt_ "A" or Alt. "B" Above Fee Determined by Engineering Agreement Necessary [ ] Not Necessary ( ] SUBJECT P I19;5� City of Fridley 00 AT THE TOP OF THE TWINS BUILDING AA T PER I 1,9) 1 . , RECEIPT NO. `V ...... COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. / 1 � = CITY HALL FRIDLEY 55432 NUMBER REV DATEPAGE OE APPROVED BY L J` 612-571-3450 910 -Ftp 5/19/00 JOB ADDRESS 5890 STINSON BLVD NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. Pt 37 Auditor's Subdivision #92 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Marilyn Larson 5890 Stinson Blvd NE 571-0615 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Grayhawk Builders 3020 Centerville Rd, Little Canada, MN 55117 651-486-9888 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 O ADDITION ❑ ALTERATION jp REPAIR O MOVE O REMOVE 8 DESCRIBE WORK Reroof House & Garage (22 Sq) Tear -off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with the State Building Code.. ferii insciari ill Be mailed Hameovineff To post 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 1 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 $1,923 $.96 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- $69.25 Fire SC $1.92 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION PLAN CHECK FEE OTAL FEE Lice e SC $5./0 $77.13 SIGNATURE OF CON'RACTORORAUTHORiZED AGENT tDATEi W R LY VALJOAfED THIS IS YOUR P RMIT l0G iNSP �1ATE SIGNATURE OF OWNER ,,F OWNER 8U4OERi iDATE� MAY -1a-2000 1 14:35 FROM CITY OF FR I DLEY TO NEW [ ADDN [ l CITY OF FRIDLEY ALTER [ 1 SINGLE FAMY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Legal Description: NMIr-0 M7t9 f L.�.La� QWAMW i L1 1 11 Attach to this application, a Certificate of Survey of the lot with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT 6514268632 P. 02/02 EffeCtIve 1/1/2000 (763) 572.3604 Sidg Inv LMNG AREA: Length --�_ VAft Height a„ Sq. Ft GARAGE AREA: Length Width -- .�--� ht_ Sq. Ft DECK AREA: Length Wkb Hgt/Ground Sq. Ft OTHER: Construction Type: Estimated Cost $ Driveway Curb Cut Width NeWed: Ft + e Ft , Ft x $ _ $ DATE: APPLICANT: Tel. CI%Y USE ONLY - Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Parte Fee Sewer Main Charge TOTAL STIPULATIONS. Call (763) 572.3644 far Permit Fe" If mailing in application Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th%) $.50/$1,000 Valuation $1100 per SAC Unit $ 0 $5.00 (State Licensed Residential Contractors) $ Alt "A" or Alt. "S" Above $ $450.00 Conservation Plan Review $ Fee Determined by Engineering $-----Agreement Necessary [ I Not Necessary L I $ 2,13 TOTAL P. 02 CITY OF FRIDLEY INSPECTION DIViSION 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, (763) 572.3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES JOE RATE SCHEDULE Residential Furnace Shell and Duct Work,- Burner. - Also Replacement Furnace (Side Vent : Fill Out Back) Gas Piping (Needed with new furnace, but not replacement) Gas Range' Gas Dryer *Air Conditioning.- All Sizes All Others/Repairs & Alterations (LIST ON BACK). 1% of Value of Appliance or Work Commercial/Industrial 1:25% of Value of Appliance or Work Rate $ 30.00 $ 10.00 $ 10.00 $ 10.00 $ 25.00 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. G $ .50 OW Effective On January 1, 2002 BUILDING USED AS_" ESTIMATED COST PERMIT NO.:: DESCRIPTION OF FURNACE AND OR BURNER No. of Heating Un' s Circle One (Steam) (Ho Water) arm it Trade Name SizNo. �l BTU / HP' �DR Fuel Total Connected Load Burner 4de Name Size No. BTU> HP _ EDR The undersigned hereby makes application fora permit for the work herein specified agreeing to do all work in strict accordance with the City Codes an rulings of the Building Division, and hereby declares that all the facts and representations stated in, this application are true and correct. HEATING CO FAX # Approved pp d By Rough -in Date DATE ZL—�,�� P Final Date 1 �� FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE APPLICATION WILL BE, RETURNED COMMON VFN I, MEW CQNK1FCTQIR AND COMRI IRTIQ I .ATIaNi When tiring a isflnnglurarice, the undersigned hereby verifies that the ?renting has :been examined_and-is free from lust, deterioratiori obstructions, and is securely supportedand firestopped where required. Yes O No c :. The venting system is plasticJPVC 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 Fumace Venting Tables for fan assisted and natural draft appliances. Yes (} No ( ) The existiing na mbustion air is sized and installed to meet the current codes and manufacturer's specifications. Yes() No() When required to install a n _;mj aambusMgn.air it will be sized and installed to meet the current codes and manufacturer's specifications. Yes O No ( ) When installing ane1. _ system, the undersigned hereby verifies that it is a listed assembly and meets the current codes and manufacturer's specifications. This does include AGA -LAMA Category I Central Fumace Venting Tables for fan assisted and natural draft appliances. Yes () No ( ) Is_the common. vent and vent connectors sized and installed correctiy.after an appliance has been removed from the common vent and vented separately as per current codes: Yes( )No( ) Appliance Tyne and qiWQoM mnn Vent and Vent Connector Info=a inn 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 IVent 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 HEATING CO: Signed By: Date: THE BEL MUST E FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE APPLICATION WILL BE RETURNED r`OMMQN VENT, VFNT GONNFCTQR ANn COMBI ISTI®N AIR V RIFICATICIN Whenre In aci�� an pxietine=f irate . _, 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 04 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 K No( ) The gaxi i_ng noMhusfinn air is sized and installed to meet the current codes and manufacturer's specifications. Yes( ) No e� When required to install a new nombuistean air,itwill be sized and installed to meet the current codes and manufacturers specifications. Yes 64 No( ) When installing a new venting Sy_qtem, 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 .k) 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 V) No( ) Appliance T#pe and Si'p/C`_ommen Vent and Ygnt ronnPetar Information Appliance #1 Type BTU Input 4o/,i—by Fa As fisted r N Appliance #2 Type _ r,, rn�C-p— BTUInput vG a Assiste or at Appliance #3 Type BTU Input Fan Assisted or Nat Total Appliances Total Stu Input Common Vent Type `� �-�` G`�Qr Vent Height 15 ` Diameter inches ,r Appliance #1 Vent Connector Height ft Length ft Diameter �_in Type (U Appliance #2 Vent Connector Height ft Length ft Diameter in Type Appliance #3 Vent Connector Height ft Length ft Diameter in Type HEATING CO: Signed By: Date SEDGWICK HEATING & AIR CONDITIONING CO. HEATING JOB �,b 29 8910 WENTWORTH AVENUE SOUTH • MINNEAPOLIS, MN 55420 • (952) 881-9000 TEST RECORD ADDRESS ;� X ` P sTLl;l Ise, 1L) lV�✓! �" � OCCUPANT SOLD BY MAKE �10 40 j SERIAL NO. !�mn - �— THERMOSTAT e I VALVE W6"4 /f CCi F 0 LIMIT 1- A-1 LIMIT SETTING FAN SETTING PILOTTYPE- IGNITION MODEL �e PILOT TIMING ��47"I- PRESSURE 3- AJC INPUT CFH 0 STACK TEMP. FORM 2355 (REV. 11189) PERCENT CO2 PERCENT 02 PERCENT CO CITY ' OWNER V / (oGl /r -It 11— INSTALLED BY MODEL (. !6 I 11119.76j6 - 676 INPUT s1 /o VENT SIZE 2- TYPE OF LINER® LINER SIZE 4 FILTERS: SIZE ci�. 6 6 / NUMBER WIRINGeLOdG��r°i��' TEST TAG LIGHTING INST. DATE TESTED COMPANY TESTINGS G NAME OF TESTE FORM DISTRIBUTION: WHITE COPY - JOB FILE YELLOW COPY - CITY Building BUILDING Permit No.: ' Inspections RESIDENTIAL APPLICATION Received By: 763-572-3604CITY OF FIZII)I.EY mate Rec'd: ®` DATE V " tj —0 YOUR E-MAIL ADDRESS SITE ADDRESS > L' ^ IV i THIS APPLICANT IS: ❑ OWNER CONTRACTOR PROPERTY OWNER/ NAME: Y i ADDRESS: CITY STATE ZIP TENANT PHONE: t 22 -- SSI1-- UP 1 S CONTRACTOR NA STATE LICENSE # U` g i EXP DATE w� — > I "' C! / + � SUBMIT A COPY OF YOUR STATE LICENSE ADDRESSA714 _AT b It, �i xx� CITY�'�D �STATIINL �� WITH APPLICATION PHONE FAX -" PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE ❑ TWO FAMILY/NEW CONSTRUCTION STORIES PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED/INDOWS ❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE ❑ DECK ❑ SIDING ❑ OTHER ❑ SWIN0IING POOL TYPE OF WORK: ❑ NEW ❑ ADDITION MAINTENANCE/REPAIR ❑ REMODELING DESCRIBE WORK BEING DONE: SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT Sq. Ft. ROOFING ❑ HOUSE ONLY i NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT: ❑ ATTACHED GARAGE 1. Existing Floor Plan - .GARAGES PROPOSED SIZE: ❑ DETACHED GARAGE 2. Proposed floor plan PROPOSED HEIGHT: 3. List of structural members to be used SIDING FOR NEW CONSTRUCTION INCLUDING DECKS, ❑ Vinyl 0Soffit ADDITIONS. & PORCHES SUBMIT: El Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures ❑ Other ❑ Fascia and proposed project. WINDOWS j 2. Two sets of construction plans IN EXISTING OPENINGS14(es ❑No LOCATION OF WINDOWS 3. Energy Calculations OR FOR NEW OPENINGS -DESCRIBE SIZE OF QI n i.1 V WA CSO QIM OPENING CHANGES & i) TYPE OF WINDOW TO BE INSTALLED AvJW -%A i)-%ANUMBER OF WINDOWS HLL S1GE7 HR1. iwxar.L %J N vAJUUA11U1N, 11N1;1,UJJ11NU Inh UUNI UN LABUIRA1ND MA1'1+K ALS: ' (USING THE 1997 U.B.0 FEE SCHEDULE) TOTAL JOB VALUATION $ $ OCCUPANCY TYPE Permit Fee $ See Back Page for Fee Schedule • Plan Review $ 65% of Building Permit Fee Fire Surcharge $ .001 times the total job valuation Surcharge $ .0005 x Permit Valuation Minimum $.50 License Surcharge $ ��', 6 ® $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 $ Make checable to: C!q 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 NAMEDATE BuildingPermit �ITILI)II�G (USING1997 U.B.0 FEE SCHEDULE) No. • i -00�3� Inspections $ RESIDENTIAL APPLICATION Plan Review Received By: TSZ 763-572-3604 Fire Surcharge CITY OF FRIDLEY .001 times the total job valuation •, Date Recd: : , DATE_ - 1 ? d Y, DRESS License Surcharge SITE ADDRESS ��L1UTl./ SAC Charge $ $1550 per SAC Unit (Plans to MWCC for determination) Curb Cut Escrow THIS APPLICANT IS: ❑ OWNER ONTRACTOR Erosion Control PROPERTY OWNER/ NAME: Park Fee p Q ADDRESS: orp 7 O -04 STVTT ZIP TENANT $ PHONE: I 10 3 T1 l -' d b Total Due CONTRACTOR NAME' STATE LICEN1SE # EXP DATE 3 , — O Z 7 r .. _ h y SUBMIT A COPY OF YOUR STATE LICENSE ADDRESS: �[ CTTY_g ATE WITH APPLICATION PHONE 4 5 " �J— 1 J& LtA FAX (o S 1 " � � 3-1057b PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE ❑ TWO FAMILY/NEW CONSTRUCTION STORIES PERMIT TYPE ❑ ADDITION ❑ GARAGEISHED INDOWS ❑ BASEMENT FINISH El DRAIN TILE ❑ DECK ❑ SIDING ❑ O R ❑ SWIMMING POOL TYPE OF WORK: ❑ NEW ❑ ADDITION ❑ MAINTENANCEIREPAIR ❑ REMODELING . DESCRIBE WORK BEING DONE: Ra JAt& &t -• SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT Sq. Ft. ROOFING ❑ HOUSE ONLY NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT: GARAGEGARAGEf ❑ ATTACHED GARAGE 1. Existing Floor Plan P120POSED SIZE: ❑ DETACHED GARAGE 2. Proposed floor plan PROPOSED HEIGHT: 3. List of structural members to be used SIDING FOR NEW CONSTRUCTION INCLUDING DECKS, ❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT: ❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures ❑ Other ❑ Fascia and proposed project. WINDOWS 2. Two sets of construction plans NEXISTING OPENINGS ❑Yes ❑No Lqq TION OFA WIND n _(� , -_ _ 3• Energy Calculations _ _ _ OR FOR-NF.W OPENINGS -DESCRIBE SIZE OF .,f/(J( ti �P./'i� (,(9 6/ OPENING CHANGES & TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: (USING1997 U.B.0 FEE SCHEDULE) THE TOTAL JOB VALUATION $ ID 1) OCCUPANCY TYPE Permit Fee $ (� .:See Back Page for Fee Schedule Plan Review $ 6.5%0 of Building Permit Fee Fire Surcharge $ .001 times the total job valuation •, Surcharge harge $ .0005 x Permit Valuation Minimum $.50 License Surcharge $ fl . 0 0 $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 $ ., Make checks payable to: City of Fridley Attach 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 workjhick req ' es re iew an approval of plans. �% % x SIGNATURE OF APPLICANT PRINT NAMI06 `� � f � R "a ATE O" ~ ✓ _ 0 7 N ENEE NONE ONES NONE I Mile Steel [:] Plastic F-1 Tile [:]Other C WELLHEAD COMPLETION Outside: [I Well House L] At Grade 1h Mile ti r-1 Pftless Adapter/Unft Ej Buried Well Pit Ej Other 1VjLCLLjLjLYL1 1--cuou.0 only owner's mailing address If different than well location address indicated above 5890 Stinson Blvd Fridley, MN 55432 =,R'S NAME/COMPANY NAME owners mailing address N different than property owner's address Indicated above Inside: 99-ement Offset U Well Pft El Buried El Other Diameter Depth Set in oversige hole? Annular spatinitially grouted? 1 3 in. from 0 to 148 ft. 0 Yes *1 0 El Yes 1111110000 No F1 Unknown In. from to ft. [3 Yes E] No El Yes No El Unknown In. from to ft. r] Yes El No El Yes El No El Unknown SCREEN/OPEN HOLE Screen from 148 to 151 ft. Open Hole from tcL-tL Ir ods/Drop Pipe E] Check Valve(s) El Debris ❑ Fill El No Obstruction Type of Obstructions (Describe)— Pipe and Jet GEOLOGICAL MATERIAL I COLOR I HARDNESS OR I FROM To Obstructions removed? [:]Yes E] No Descri FORMAMON If not known, indicate estimated formation log from nearby well or boring. UMP r%qV I rnum 0 ')A Tma Clay Prairie du Jordan Sa OF DATA, El Removed of Present E] Other Brown 24 1.80 MEWHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: Cray 180 205 f, o Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe El Casing Perforaton/Removal Tan R05 331 In. from to ft. El Perforated E] Removed in. from to ft. El Perforated El Removed 335 34HO Geology From: Well close by Water Level in Above Well: 118' - Date Water Level Taken: 07/22/1988 Gamma Logged 1988 Unique 447900 Certified Representative Signature Cerfffed Rep. No. Date Kevin Scheiterlein 289753 Name of Person Sealing Well or Boring 9/09R Type of Perforator ❑ Other -.MINNFs6TA DEPARTMENT OF HEALTH Minnesota Well and Boring Se No. H 8, 29753 WELL OR BORING LOCATION 6 WELL AND BORING SEALINGAECORD aling County Name yardsbags Minnesota Unique Well No. yards_ bags Anoka OTHER WELLS AND BORINGS Minnesota Statutes, Chapter 1031 or W -series No. (L— blank ff W kl—) Other unsealed and unused well or boring on property?. F1 Yes AD How many? Township Name No. Range No. Section No. Fraction (sm. — Ig.) Date Sealed Date Well or Boring constructed Fridley ITownship 30 24 24 � N/ NEX 10/11/10 License or Registration No. Unknown 10/25/10 151 151 GPS Latitude �_ degrees. — minutes_ seconds Depth Before Sealing ft. Original Depth —ft LOCATION: Longitude— degireesL_ minutes— seconds STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or . Boring Location Single Aquifer Ej Multiaquffer [NO easured E] Estimated Date Measured 10/11/10 5890 Stinson Blvd, Fridlqy 55432 Water-SupplyL/BoWell El Monft. Well Show exact location, of well or boring In section grid with 1X' Sketch map of well c , boring on, showin pr c oerty -4 location, roads, and lings. [I Env. Bore Hole El Other--, 130ft. slow above land surface E] N CASING TYPE(S) N ENEE NONE ONES NONE I Mile Steel [:] Plastic F-1 Tile [:]Other C WELLHEAD COMPLETION Outside: [I Well House L] At Grade 1h Mile ti r-1 Pftless Adapter/Unft Ej Buried Well Pit Ej Other 1VjLCLLjLjLYL1 1--cuou.0 only owner's mailing address If different than well location address indicated above 5890 Stinson Blvd Fridley, MN 55432 =,R'S NAME/COMPANY NAME owners mailing address N different than property owner's address Indicated above Inside: 99-ement Offset U Well Pft El Buried El Other Diameter Depth Set in oversige hole? Annular spatinitially grouted? 1 3 in. from 0 to 148 ft. 0 Yes *1 0 El Yes 1111110000 No F1 Unknown In. from to ft. [3 Yes E] No El Yes No El Unknown In. from to ft. r] Yes El No El Yes El No El Unknown SCREEN/OPEN HOLE Screen from 148 to 151 ft. Open Hole from tcL-tL Ir ods/Drop Pipe E] Check Valve(s) El Debris ❑ Fill El No Obstruction Type of Obstructions (Describe)— Pipe and Jet GEOLOGICAL MATERIAL I COLOR I HARDNESS OR I FROM To Obstructions removed? [:]Yes E] No Descri FORMAMON If not known, indicate estimated formation log from nearby well or boring. UMP r%qV I rnum 0 ')A Tma Clay Prairie du Jordan Sa OF DATA, El Removed of Present E] Other Brown 24 1.80 MEWHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: Cray 180 205 f, o Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe El Casing Perforaton/Removal Tan R05 331 In. from to ft. El Perforated E] Removed in. from to ft. El Perforated El Removed 335 34HO Geology From: Well close by Water Level in Above Well: 118' - Date Water Level Taken: 07/22/1988 Gamma Logged 1988 Unique 447900 Certified Representative Signature Cerfffed Rep. No. Date Kevin Scheiterlein 289753 Name of Person Sealing Well or Boring 9/09R LOCAL COPY HE -01434-12 lC# 140-0423 Type of Perforator ❑ Other GROUTING MATERIAL(S) (One bag of cement = 94 Ibs., one bag of = 50 Ibs.) Neat Grout 0 '(bentonite l5kyards 6 Grouting Material from to L bags from to ft._ yardsbags from to ft._ yards_ bags OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property?. F1 Yes AD How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION 'L 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. E.H. Renner & Sons, Inc. 1431 Licensee Bus#w7 License or Registration No. 10/25/10 LOCAL COPY HE -01434-12 lC# 140-0423