PRE 2010 DOCS- -,9:� 2 3.,0
City ®f Fridley, ffinn.
LOCATION F 1 DING
No. StrBe Part o t
Lot _ _ __ _ Block Addition or Sub -Division . A
Corner Lot _ Inside Lot Setback _ _ SideyardE�
Sewer Elevation — Foundation Elevation
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 th all pro ons of
ordinances of the city of Fridley.
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 anal moving of buildings
within the city limits and this permit may be revoked at any time t4 �a on of any of the provisions of said
ordinances.
NOTICE
This perm don not cover the condrnction, iusft%dm for wiring, plumbing, gas heating, ager or water. Be sore to see
the Building Inspector for separate penaHs for these items.
APPLICATION .:FOR B{JILDING PERMIT
CITY .OF FRID%EYa IINNE$OTA
LOCATION OF.BUILDING
No
part of Lot
Lot Block Addition o Subdivision; A �
Corner lot� Inside' Lot-4—Sethack -I Side Yard �.
SEWER ELEVATION FOUNDATION ELEVATION
Applioant,ittach.to this fora Two Certificates of Survey of Lot.,and proposed build-
ing ..location'dia n on these Certificates.
DESCRIPTION OF BUILDING
To be used as:
Front F_ Depth Height
Sq. Ft,. Cu. Ft. ,.
-f+L.G
' Front Dmpth ,�`,� Height
Sq, Ft. Cu. Ft.
Type of Construction Estimated Cost
To be Completed
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City of Fridley Ordinances and
rulings of.the.Department of.Buildings, and hereby declares.that all the -facts and
representations stated in this appiication are true,and.correct.
at:l►1LS►
,,(Schedule of Fee Costs can be found on the Reverse Side).
A
BUILDING PERMIT FEE SCHEDULE
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 exist-
ing building or structure, or for any alterations or repairs to any existing
building or structure, upon application therefor, 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 fire -proof building, other
than .a garages 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-proofaddition,
for similar occupancy; to`any"existing building shall be at the rate of $1.25
for each one 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 1non-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 a 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 maim 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 Fridley
53-84-S915.51
Application for Plumbing and Cas Fitting Permit
Dept. of Bldgs. Phone 560-3450
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures Location 7!172 Stinson `old.
y
0l
�fnn
X $1.50
$
X $1.50
$
x $3.25
Y
X $3.00
yZ
Z
p[
W
a $2.00
W
�a
a
?
Z
�O
R
t
N
WATER HTR.
GAS
E
ELG
Base
3.00
1st
2nd
3rd
4th
• Future Connection Openings
New .fixture, Old Openings I
Connected with
Sewer
Cesspool
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures .....................
Future Fixture Opening ...............
New Fixture Old Opening .............
Catch Basin ...........................
Water Heater (Up to 99,000 BTU) .....
New Ground Run Old Bldg. ...........
Electric Water Heater
GAS FITTING FEES:
1st 3 Fixtures ...... ..................
Additional Fixtures ................... .
Gas Range to 199,000 BTU .............
install (1) gas grin
REPAIRS & ALTERATIONS—Refer to Code
x $2.00
$
X $1.50
$
X $1.50
$
x $3.25
$
X $3.00
$
x $3.25
$
a $2.00
$
NO. RATE TOTAL
x $2.00
$ 2.00
x$.75
$
X $5.00
$
3.00
City of Fridley:
The undersigned hereby .makes application for a permit for the work herei
specified, agreeing to do all work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the facl
and representations stated in this application are true and correct.
Fridley, Minn June 263 1970 , 19—
Owner John Collodora
Kind of Building frame
Used as residence
Tobe completed about June 30, l 9!70
Estimated Cost, $ 10.00
Old XNew. Building Permit it No.
v
By
VOJ L! 13 GAS
Business Phone No—
ROUGH ROUGH
FINAL--LL2 o C
Description ................................................$
TOTAL FEE $-5 .45P.42
CITY OF FRIDLEY
Effective Date May 1, 1988,
APPLICATION FOR POWER PLANTS
AND HEATING,
COOLING, VENTILATION, REFRIGERATION AND
AIR CONDITIONING SYSTEMS AND DEV CES
RATE SCHEDULE
/
RESIDENTIAL RATE
TOTAL
Job Address
Furnace Shell and Duct Work,
Burner (Also replacement furnace) $ 20.00
$ 422
Department of Buildings, 6431 University Ave. N.E., Fridley, MN 55432
City of Fridley
Gas Piping $ 10.00
$
Tel. #571-3450
(piping needed with new furnace)
Gas Range $ 10.00•
$
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
Gas Dryer $ 10.00
$
and rulings of the Department of Buildings, and hereby declares that all the
facts and representations stated in this application are true andcorrect.
* Air Conditioning Call sizes) $ 10.00
$ } _
Minn. 19_
All Others/Repairs and Alterations
OWNER _ S
1% of Value of Appliance or Work
$
r
KIND OFBUILD G
,
COMMERCIAL/INDUSTRIAL
USED AS
1% of Value of Appliance or Work
$
TO BE COMPLETED ABOUT
ESTIMATED COST
State Surcharge
$ —.
/�•
FEE
- NEW BUILDING PERMIT NO. PERMIT NO.
TOTAL
�SZ%
Reinspection Fee ($15.00)
$
DESCRIPTION OF FURNACE/BURNER
Rough Insp.
Warm Air- HEATING or POWER PLANTS, Steam, Hot Water o.
Date
�,�
Trade Name %l/%//-G/l/X , Size No. /
Final Insp.
Date
Capacity Sq. Ft. EDR BTU �P
Approval for Permits
Total Connected Load Kind of Fuel [ 7�
BURNER - Trade Name Size No.
Capacity Sq. Ft. EDR BTU HP
MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00
Company �:! AIR rmmnM®k'�'NG W.
PLUS $.50 STATE SURCHARGE
8419 CENTER DRIVE
Signed By
i „•92
gJdiY'
Tel. No.
*Air Conditioners can not be placed in side yard without
written permission from adjoining neighbor.
,
/ (!�
•
Fill out back side for stack verification on replacement furnaces,
CHIMNEY AND STACK VERIFICATION
The undersigned hereby verifies that the existing chimney or stack;
1. Has been carefully examined Yes ( )
2. Is free from rust or deterioration Yes ( )
3. Has no foreign objects lodged within Yes ( )
4. Is securely supported Yes ( )
5. Meets all current Code requirements for size and
total BTU connected Yes ( )
6. Has Total heating BTU's of
All other BTU's
TOTAL
Rema rk s
Company
Signed By
Da to
No ( )
No ( )
No ( )
No ( )
No ( )
SUBJECT
City of Fridley
19754
AT THE TOP OF THE TWINS
I I L D I� I i� P E D A N T
BUILDING
r
V 'v v �'" L"'v,
REC
COMMUNITY DEVELOPMENT DIV.
INSPECTION SEC.
4p Y1.4
r PROTECTIVE
P
1
`�
/1 CITY HALL FRIDLEY 55432
�•�
NUMBER
REV
DATE
PAGE OF
APPROVED BY
----A-If
612-571-3450
910-F15
11/15/88
JOB ADDRESS 7472 Stinson Boulevard N.E •
1 LEGAL
LOT NO.
BLOCKTRACT
OR ADDITION SEE ATTACHED
DESCR.
4
2
Dalberg Terrace SHEET
2 PROPERTY OWNER MAILADDRESS ZIP PHONE
Collodora 7472 Stinson Boulevard N.E. 784-2886
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
D & D Home Improvement Inc. 7401 Central Avenue N.E. 784-7543
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 Z REPAIR ❑ MOVE ❑ REMOVE
6 DESCRIBE WORK
Reroof Dwelling
9 CHANGE OF USE FROM TO
STIPULATIONS Roof can be. 2nd layer but not 3rd. Install ridged galvanized valleys.
On all new roofs
or tear -offs and replacement roofs,
State Code requires
that 2 layers of
mopped
15 lb. felt,
together, be installed to
a point 24 inches
UP from exterior wall line,
or the use of other
approved underlayment
membrane.
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
$990.00
$•50
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-
$25.00
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
$25.50
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT ;DATE)
, WHEN PROPERLY V DATED THIS IS YOURPERMIT
BLDG INSP GATE
SiGNATURE OF OWNER IIF OWNER BUILDERI IDATEI
NEW I ] City of Fridley Effective 5/L
ADDU [ ] R-1 AMID R-2
Construction Address
Building Permit Application
/7!-1 � V
LQ i y I
Legal Description: -
Owner Name & Address: 00 r W L 01 0 Tel. #
Contractor: �` '�I C' improvyw � 1
716 Tel. #
Address: Q l UffA- 'Vyi I Ve -- A/C
Attach to this application, a Certif icate of Survey of the
lot, with the pr coed construction drawn on it to scale.
EESCRIPTION OF IMPROVERMT
LIVING AREA: Length Width Height sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sg. Ft.
Corner Lot I ] Inside Lot 0 Ft. Yd Setback Side Yard Setbacks
Type of Construction: (�C%!20�� oje AA"Wg90 Iq "/Astimated Cost:
Approx. Completion Date:
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $ $
Width + 6' See Back Page
DATE:
APPLIC1M: Tel. # '7 75-Y3
CLTY USE ONLY
Permit Flee O U Flee Schedule on Reverse Side
State Surcharge S $.50/51,000 Valuation
SAC Cham 5 $550 per SAC Unit
Driveway Escrow 5 Alt. "A" or Alt. "B" Above
Park Fee 5 Fee Determined by Engineering
Sewer Main Charge 5 Agreement Necessary I ] Not Necessary I ]
TOTAL
LuiolvMi4 �.
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
r
$1 to $500 $15 (Minimum Fee is $15 plus surcharge)
$501 to $2,000 $15 for first $500 plus $2 for each additional $100 or fraction
thereof, to and including $2,000
$2,001 to $25,000 $45 for first $2,000 plus $9 for each additional $1,000 or
fraction thereof, to and including $25,000
$25,001 to $50,000 $252 for first $25,000 plus $6.50 for each additional $1,000 or
fraction thereof, to and including $50,000
$50,001 to $1001000 $414.50 for first $50,000 plus $4.50 for each additional $1,000
or fraction thereof, to and including $100,000
$100,001 to $5001000 $ 639.50 for first $100j,000 plus $3.50 for each additional $1r000
or fraction thereof, to and including $500,000
$500001 to $1,000,000 $2039.50 for the first $500,000 plus $3 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$1,000,001 and up $3539.50 for the first $1,000,000 plus $2 for each additional
$1,000 or fraction thereof
1) �VWA 'I we P Dl' t • M5�&; 0
(Concrete • Streets Cray)
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.
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.
SUBJE�T
P
City of Fria�ey
�0�
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
RECEIPT NO.
`v ------COMMUNITY DEVELOPMENT DIV.
SEC
r PROTECTIVE INSPECTION
�
V
k•� CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
A111PAOVED BY
L 612-571-3450
910415
5/8/00
JOB ADDRESS 7472 Stinson Blvd NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
4
2
Dalberg Terrace SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Tacheny Roofing & Siding Inc 49 S Owasso Blvd, Little Canada, MN 55117
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO.
484-1466 7596
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION ! REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof House & Garage (20 Sq) Tear -off
9 CHANGEOFUSEFROM
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
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
$.87
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$1,748
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-
$63.15 Fire SC $1.75
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
It
PLAN CHECK FE TOT L FEE
AlNA�.'CACTOQORAUTMOR11
Licens S $5.0 $70.77
GENT ATE
EN ROP L VALIDAT THIS IS YOUR P IT
/ 6TH
S-GNATURE OF OWNERoF OWNER BUILDER, ,DATES
BLD INS �AiE
FROM : Tacheny Roofing Inc PHONE NO. : 482 8377 May. 05 2000 02:10PM P1
NEW Effective 1/1/99
ADDN [ ] CITY OF FRIDLEY
XLTE,R (] SINGLE FAMILY AND DUPLEXES R-1 ASVD R-2
l o
BUILDING PERMIT APPLICATION
ConstructionAddress: '_� H
Legal Description:
Owner Name & Address: n®� �(1 �( Tel.
Contractor. no �7nC . MN LICENSE #
Address: ) Tel. # 144'M- jc4 to( a
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF Il%ZPROVEMENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width HgVGround Sq. Ft.
OTHER. �- j
Construction Type: Estimated Cost: S
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: APPLICANT:Or Tel. #(�
�e �s CITY USE ONLY
Permit Fee $ Fee Schedule on Reverse Side
Fire Surcharge $ L -7S, .001 of Permit Valuation anoth%)
State Surcharge $ 0 S.501$1,000 Valuation
SAC Charge $ $1050 per SAC Unit
License Surcharge $ S $5.00 (State Licensed Residential Contractors)
Driveway Escrow $ Alt. "A" or Alt. "B" Above
Erosion Control $ $450.00 Conservation Plan Review
Park Fee $ Fee Determined by Engineering '
Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ]
TOTAL
STIPULATIONS:pa
S7t--r
Q..,46
q* CITY OF FRIDLEY PERMIT NO.: 2005-00015
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432 DATE ISSUED: 01/05/2005
(763) 572-3604 FAX: (763) 571-1287
ADDRESS : 7472 STINSON BLVD NE
PIN : 123024140046
LEGAL DESC : DALBERG TERRACE
: LOT 4 BLOCK 2
PERMIT TYPE : HEATING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION
NOTE: AIR CONDITIONERS CAN NOT BE PLACED IN A SIDE YARD WITHOUT WRITTEN PERMISSION FROM
ADJOINING PROPERTY OWNER. COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A.
# A/C UNITS I
VALUE OF APPL OR WORK
0
# FURNACES I
# GAS DRYERS
0
# GAS RANGES 0
VALUE (FOR MINIMUM CALC)
300
APPLICANT
HEATING PERMIT MINIMUM FEE
FURNACE SHELL/DUCT WORK
0.00
35.00
DAVES HEATING & AIR INC
160137 AVE NE
GAS RANGE FEE
0.00
COLUMBIA HEIGHTS, MN 55421
GAS DRYER FEE
0.00
(763) 781-6901
AIR CONDITIONING FEE
25.00
HEATING REPAIRS/ALTERATIONS
0.00
STATE SURCHARGE, MECH FLAT
TOTAL
PAID WITH CHECK # 35799
0.50
60.50
OWNER
COLLODORA JOHN R & JUDITH
7472 STINSON BLVD NE
FRIDLEY, MN 55432
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of work
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
regulating construction or the serforma a of construction.
Applicant Date
Bldg Ins �4Dat �"j
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
CITY OF FRIDLEY BUILDING INSPECTION
6431 University Ave NE
Fridley, MN 55432
763-572-3604 FAX 763-571-1287
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner &
also Replacement Furnace
Gas Piping (New Furnace, Fireplace, Insert)
Gas Range
Gas Dryer
*Air Conditioning - All Sizes
All Other Repairs or Alterations (List on Back)
1% of Value of Appliance or Work
Minimum Fee $15.00 for Residential or 5% of cost of
Improvement whichever is greater
Effective 4/1/2004
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS �] H :1 D !�:) n e, -j n I V(' L
Fee Total
Owner,���, �)1_ L) l 17 n
$35.00 eG
$10.00 $
$10.00 $
$10.00 $
$25.00
l' v
Commercial/Industrial/Institutional
1.25% of Value of Appliance or Work (List on Back) $
Minimum Fee $35.00 for Commercial/Industrial/Institutional
State Surcharge $
TOTAL FEE
REINSPECTION FEE $50.00/HOUR
*Air Conditioners can not be placed in side yard without written approval
from adjoining property owner - copy to City
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
Building Used As
ESTIMATED COST
PERMIT NO 2('Y)5 — C
DESCRIPTION OF FURNACE AND BURNER
# of Heating Units_ Circle One (Steam) (Hot Water) (Wm Air)
Trade NameJL Size No.
BTU" �I�� i� S� HP EDR
Fuel Total Connected Load
Burner Trade Name
BTU
HP
Size No.
EDR
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes
and rulings of the Building Division, and hereby declares that all the facts
and representations stated in this application are true and correct.
Tel # "U! bj
Approved by Rough -in Date Final Date
FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacing an existina furnace, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes () No( )
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination. Yes () No( )
The undersigned also verges that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances. Yes () No ( )
The existing combustion air is sized and installed to meet the current codes
and manufacturer's specifications. Yes () No( )
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacturer's specifications. Yes () No ( )
When installina a new venting system, the undersigned hereby verifies that
it 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 ( )
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes () No( )
Appliance Type and Size/Common Vent and Vent Connector Information
'f -11
Appliance #1 Type BTU Input 6 Fan Assisted or Nat
Appliance #2 Type — A BTU Input 0 Fan Assisted or Nat �
Appliance #3 Type BTU Input 115 an Assisted or Nat
Total Appliances -7Total Btu Input
CommT Vent Type Vent Height ��_ Diameter inches
Appliance #1 Vent Connector Height ft Length_ —.':�—ft Diameter in Type
Appliance #2 Vent Connector Height ft Length -ts ft Diameter °' in Type )Eve—
Appliance
EvLAppliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS: (Describe) w C t -c V - 0'c J L- r kc
HEATING CO: I D cam• --��
Signed By:� Date : r-