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City of Fridley, Minn.. BUILDING PE N® 3276 / Date: ... . �.�.. ............. . Owner .. ... F... Builder fg.. X� ........ ..bt-00.18 .... Address ...................................... Address LOCATION OIFBUILDING No. � /..1/1.. Street:. 34 0". .. .. ®.. Part of t ................. ........ �.... r1 - PO .... 1.7.. Block .... f • ............ Addition or Sub -Division .. ....... ..... `1.. ........... C� Corner Lot ............ Inside Lot ............ Setback ..... Sideyard .......�. ......,�... v DESCRIPTION OF BUILDING T Used as: alto .. ........ ...... Front .. I. .. / Depth � •-� • Height ...t. Sq. Ft.3. A Cu. Ftp ,:�. . ............ o . ....... on�..°t.'=.��. .... sit. cost... ,..Qr. i .. �.. To be Completed . . C%a. Ft........ . Type of Construction �,�� .......:...... In consideration of the issuance to me of a permit to construct the building desribed 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. .... ........... .. .. .......... 0 C2 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 with- in the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. Building ctor t NOTICE: This permit does not cover the construction, Installation or alteration for wiring, mbing, gas heating, �� sewer or water. Be sure to see the Building Inspector for separate permits for these Items. � 7 7? City of Fridley, Minn. N° 10278 BUILDING PERMIT Date: .lune 11 1969 Owner: Jean Kacheroski Bider Ciertsen Co Address 5741 West Moore Lake Drive Address 3501 Xenwood Ave. LOCATION OF BUILDING No. 5741 street West Moore Lake Drive — part of Lot Lot 17 Block 1 Addition or Sub -Division _ Donnay 1 s Addn . Corner Lot _ Inside Lot _ _ Setback __ Sideyard Sewer Elevation Foundation Elevation DESCRIPTION OF BUILDING To be Used as: Repairs after Fire Front Depth Height Sq. Ft. Cu. Ft. Front Depth Height Sq. Ft. C'.u. Ft. Type of Construction Est. Cost 5 00, 0 00 __.. To be completed According to recommendations of Building inspector. 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 a'll provisions of ordinances of the city of Fridley. In consideration of the payment of a fee of $___34.0.0_ _., permit is hereby granted to V� arts n .n _ 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 andmoving of buildings within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. NOTICE: We perndt don not cover the construction, hutaEWon for whdng, phnnhing, gas heating, sower or wafer. Be u to we the Boildh* Inspector for separate permits for them itemm I APPLICATION FOR BUILDING PERMIT CITY OF ; iMINNESOTA 'OWNER IS ` "_&Xa1=-t3-1A BUILDERL,,rj, ()I' LOCATION OF BUILDING NO . STREET le 9�n.�� LOT /7 BLOCK ADDITION OR SUBDIVISION_ cJ P CORNER LOT INSIDE LOT SETBACK SIDETARD_ SEWER ELEVATION TOP OF FOOTING Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. To Be Used As: DESCRIPTION OF BUILDING Front Depth Height Square feet Cubic Feet Front Depth Height Square feet Cubic Feet Type of Construction ,1441,1& � _ Estimated Cost��o o a h 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. DATE lz S3GNATURE a (Schedule of Fee Costs can be found on the Reverse Side.) I In—ne- 6„ 1969 Americau Family 1us'�t� u ' 1745 U verelty Avenin St. pa . -bumexota Attend on: Ur. MorganAN Tam ruacherooki 1• 3741 W. MaorelaM Drive. W a have carefially to ; tcd tho dwolUna located at the w I' 4Vo 9# , wbtch was: damaged by fire, and vubmit the Wawt:Mestimate: . ' rlo S ... 1. Fant Elevatlow 56x9 Paw plywood overs 13811,70 Pmt yanel able 2 Soy. �gy �o� g 4 w12 roof & stain abakes 56 SoYs Paint trbn 40 BO Y 41 Point o"thead door 14 soy. Pmt plywood erh 7 SOY* Patat panel SeMe 30x4 14 6 T Paint roof and gable tvim 4 Y: State 0hes S4 So'y. Paint tritu 8 Soy* 3.11 Rear ev : UxI6 Overhang bloddmg S—U4x3 n. M. Over ood 32 So r. r fact& la to 12 a. tI. . Overhang nalun,3 strip 1X321 & S So :-Ovorhamg bed molcUso 1-314°o GO 13 IN. I`. Elecitric service vatrmce BValtrite.vall sheathing 64 S.3". p � I 96 S. Ir. 13 & Y. 12 S. Y. 56 & Y. so Sly. 40 S. Y. 24 S. Y1 6 soy* a S. Y. 912.. 180 S. Y. mZ'6 . 61Z 5. F. 280 S. P. 67 U ire 170 S. F 40 S. Y. 26 S. Y. 170 S. r. p4ge 2 3. Rear Elevation:cpc�nftued Wall *bakes & �.er Alumimm combination st . wU- dow Faint plywood overhang Paint root trim stain shakes Paw Concrete foundation Faimt`trim Removes react & Paint shatters 2 ,pr. 4_. Worth'Movatiow MA4 Ge plywood Batten iiw� `strips Gable trim IrAzIS Cham® naubla strip 1X3XIS S D*U. Combinaticn athrm sash ` OvAnt ISAble plywood Pain gable trim Stain aides Paint cozerete faunfttion Paint trim Interiors Roof mars 2:38 Roof raftere 9. 144 B. M. Roof bau-de IxO 186 D. M. Ram shingles 3 sqe. C*ili ins Matic a Ceiling ),ofat 3-2X64 6 48 D. M. spray out &Me space 6. Northeast Corner De 3 131641nS & Sheetrock N's and ding Exterior wall in tis Base :ash, frame and trbn 3211x2011 Dow* frame and trim Hardwood aocr % sheatrock Spray tc;.°rc calling Cotton fabrics Edi one wall 3 SO R. Paint 3 walls; Finish* trim Sznd, owl & L"Inish floor Window shades(blackouts) 96 S. Ir. 13 & Y. 12 S. Y. 56 & Y. so Sly. 40 S. Y. 24 S. Y1 6 soy* a S. Y. 912.. 180 S. Y. mZ'6 . 61Z 5. F. 280 S. P. 67 U ire 170 S. F 40 S. Y. 26 S. Y. 170 S. r. 20 &To ito SOY* 99 & YG 14 soy* 1'o * zo S• Y•. is SOY* Page 3 i• Closets 216Z416=3* ' Sheezvock wane a=4 Cenin$• 1� f Shelf and %kstp Vis" oUdins downs frame and tam Baas 14 L. F9 Wrdwwd floor+ Tape isb tr 126 S* I'* P ,t z and caUina FWsh tt4m ftads D ' :& I.IrAab floor. 12 .s* '• • Noort weet Comer BegLooms 91644 Doors . a and t ra ROMOVO 03Mdt&9 two W918 and stse spray tele 001ung 11Q $o r* P s sewus tato vand SO R, L ... dash trim UiA4GW O ** Mad is Ga Cala nsish trim _.CINMi•'-0 ' ro frame and trim a qhs frame and tvim Pai vChumve - and rea es {RA��)ey� p�o{�ve dry rWa Shower g-08 gx x�[ s Agg�rp�p fig" ��'.y[Paddne ca blua T eg sea Tape 014 a . ro �e�trpcgg qqy9 ��yy ,Q,� �y pyy �j ��pg _161 _ inyl para on F+e:J3 ing &` umer W Ci 6 tom• A. oh trim Ted bares P,,)ev holder etc* �VW4�9' rrA ti o 4-bacuodt wane and Coag 170 S• Fe base zo-U- . Tape s."rvtvack 170S.94 Spray toxture edling1;1 • • . .P haus o r 20 &To ito SOY* 99 & YG 14 soy* 1'o * zo S• Y•. is SOY* rzl CITY OF FRI®LEY 6431 UNIVERSITY AVE. N.E. FRIDLEY, MINNESOTA 55421 PHONE: 560-3450 SUBJECT: �� - �" �� DATE: FOLD - DATE SIGNED SEND WHITE AND PINK COPIES WITH CARBON INTACT PINK COPY IS RETURNED WITH REPLY. 97-811-8 9001 =L't 'U) 1i111vi, hND bit - i- r--,_- r✓_________, _ Jc dr 57111 We Lk Dr U Ad es5 _ Sfi Onr® DL13arLmGnt Gi u y I L1 3 i-� I� .'IG tI J 1 J " C1 Ly Gt PridIGy Tel.. h571-3.1 __ 4 i_+ __.—,____1 I —i--1 T'ho undr,rxlgnLd h.;Ldty 1"ALi a .lic_t:r — PF ._r e ;:rt1L C r t:.., wrirx t.erctr, �� apeei[ied a9rtLinj L3 da a1; wcrk Sr. s - Lr: br .I a e•iti. L ., Clto --' r—tiiand ruliAgs of the Ge•::rtlrCnL ®C Bal:dir j, _-' ;rctl .:e litre; ttat at ! tho EacLir Rod rcl-r,,c.,reaLtOna etaLoJ t^ ti.ati• y .cats,,, ae, t,�o and 9-15-80 CIiNER I — !► 1••� ,ie [..reriL. tI�G Gt. nt{ C. : CGLcd HILhSetrLr KIND OF UUlLGIt:J frame '•-. t tnt,.tta, G13 Ul.rn:l Hitter I USED AS res. _— TO BE CONPLCTLO 1.LCU 1' 9-22-80 1i ESTIMTL:D CUSP 90,00 _. RATE TOTAL. j " OLD - ttL'N UUlLGIa:: l'4hPill t7:.. rL -- fut.,,r. t':At.�ao Gj.cr:r.3 x $2.00 $ � I,ea ! 1,t.,Le, 31 Gpe:.1: cy .;rllrny . � � a..tiQ C.a i u a o t 1, $ 55.00 s i gn e.1 By MINNEGASCO 5 'lea Lc: Ilaatrr — L® 9�,C33 b;`J $5. OC 1 U0, 030 bl'u to 1S »:.0 9T61 :el. U0. x 510.00 $ _ fslatic s..Cten®r x 51 0® � 5 . I4cw -tu„110 FLen Old boll.lir.7 • ®x 55.0O ROUGH IttSP. i:lc L, Nater Ile®tsr x 515.00 5 Da to �S 1 t I f 91;G P•kES; . lar t tt4LureS x 51.00 j Da u A1•t�Lluaal tlatucd8 x $1,00 g 't•s' L,,..,o w 159,OOu 62U x $10.00 1%H'RUVAL 1'1:11 PLiou'r - :P,ollt, 4 AL EKATIONS t't:,t )I0u.vt) 55-.00 • S s: t, o.S.l, }1J�d:u0 :.c 1cscLtan $2.00 5 19IttZ19U#I t'L C l �;tt d11i' i LUt:ullta: Ft te;IT YS S7, SJ Stale Sl�rcharg` PLUS. ;.So d11.TP BUPOtAKE 5 , 50 TGir.L t t 1' ; 18.00' 01 SUBJECT P NO. City of FridleyNO- - 965 AT THE TOP OF THE TWINS BUILDING PERMIT r IPT � ' COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 612-571-3450 910-F15 4/5/83 JOB ADDRESS 5741 West Moore Lake Drive N.E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 17 1 Dpnnay's Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE 572-0873 Rev. Frances Decker 5741 West Moore Lake Drive N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Master Home Repair, Inc. 11116 Vera Cruz, Champlin 424-6616 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION .7 ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Repair Roof 9 CHANGE OF USE FROM TO STIPULATIONS TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING 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 $3'000 $1.50 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOESNOT RESUME TO GI UTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVI ION OF ANY OT R TATE OR LOCAL LAW REGULATING CON- $38.50 TRU 10 OR THE PER 0 NCE OF CONSTRUCTION. PLAN CHECK FEE TOTALFEE $40.00 C/ -F-93 SI &ATUREOFCONTR TOR 6R AUTHORIZED AGENT )DATE) WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT BLDG )NSR 6TE SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI 01 CITY OF FRIDLEY Effective Aug. 1, 1981 APPLICATION FO1( RESIDENTIAL BUILDING PERMITS (Rew. Alterations, Additions, or Repairs) OWNER: rAV, ' Y�J— -Ga`S��— ADDRESS: -!1-7 V1 A,), TEL M0: -Lf7 Z - 0873 BUILDER:dig ADDRESS:f �I/C // vg C'a(z TEL 110: LI^67 EL Construction Location • STRICT NO: 7 6 STREET: /ll % ©® ,cc- 4KC-- vI IAT: t `� BLODCz _ ` ADDITION: uN ik-svS At Corner Lot: Inslao Lot: Setback: Sideyards: Applicant attach to this form two Certificates of Survey of lot and proposed building location: drawn on certificates to scale. DESCRIPTION OF CONSTRUCTION Front: Depth: Height: Square Feets Cubic Feet: Front: Depth: Height: Square Feet: Cubic Feet: ®; Type of Constructions Estimated Cost: $dam To Be Cbripleted: ZS� AGI o i Alt. A Alt. 8 Proposed Driveway Width If New Opening Is Desired: $ ' $ SEE PZVERSE SIDE OF SHEET Mie undersigned hereby makes application for a permit for the work herein specified, agreeing to do,all work Lis strict accordance with the City of Fridley Ordinances and rulings of. the Delxirtmcnt of Buildings, and ereby declares that all the facts and representations stated in this applicatione true and cjerrect. DATE: SIGNATUiiE Stipulations: t SATE OF MINNESOTA DEPARTMENT OF HUMAN SERVICES 444 LAFAYETTE ROAD 1_ — 8 1 ST. PAUL. MINNESOTA 55101 Date City of Fridley Zoning Authority 6431 University AVe. N.E. Street Address Fridley, MN 55432 City State Zip Code RE: ZONING NOTIFICATION OF APPLICATION FOR LICENSURE Subject:PC\Z Name of 04y Care me Applicant Street Address F M�. City <ZJ State Zip Code r� i DHS -2722 (9-85) PZ -02722-02 Type of License: Family Day Care Group Family Day Care Licensed Capacity Phone No. t — Ci j This is to inform you that we are in receipt of an application for licensure under Minnesota Rules, parts 9502.0300 to 9502.0445 (formerly Rule 2), Family Day Care and Group Family Day Care Standards. Issuance of this license is subject to compliance with the provisions of Minnesota Statutes, Sections 245.781 to 245.812 and 252.28, subdivision 2, known as the Public Welfare Licensing Act and the rules of the Department of Human Services. You should note that under Minnesota Statutes, Section 245.812, Subvision 3, a licensed day care facility serving 12 or fewer persons shall be considered a permitted single family residential use of property for the purposes of zoning. Subdivision 4 of the same section indicates that a licensed day care facility serving from 13 through 16 persons shall be considered a permitted multi -family residential use of property for purposes of zoning. If we do not hear will consider the your local zoning Sincerely, from you within above-mentioned code. Kathy Speggen/pf Licensing Worker Street Address 30 days after receipt of this letter, we day care home to be in compliance with COMMUNITY HEALTH & SOCIAL SERVICES DEPARTMENT COUNTY OF ANOKA COURTHOUSE, FOURTH FLOOR Name o A ency Organization City State Zip Code AN EQUAL OPPORTUNITY EMPLOYER RESIDENTIAL CITY OF FRIDLEY Effective Date May 1, 1988 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES RATE SCHEDULE ` RATE Furnace Shell and Duct Work, Burner (Also replacement furnace) $ 20.00 TOTAL $ N6, oo Gas Piping $ 10.00 $ (piping needed with new furnace) Gas Range $ 10.00 $ Gas Dryer $ 10.00 $ * Air Conditioning (all sizes) $ 10.00 $ t6• ©® All Others/Repairs and Alterations 1% of Value of Appliance or Work $ COMMERCIAL/INDUSTRIAL 1% of Value of Appliance or Work $ State Surcharge $ .50 TOTAL FEE $ Reinspection Fee ($15.00) $ Rough Insp. Date Final Insp. Date Approval for Permit d MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00' PLUS $.50 STATE SURCHARGE *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. Job Address n LA I e.V Q�S+- 9 ' C�6�-oi\KQ Department of Buildings, 6431 University Ave. N.E., Fridley, MN 55432 City of Fridley Tel. #571-3450 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 Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and.correct.' Fridley, Minn. U-'alo OWNER FC -A ('\.` % KIND OF BUILDING USED AS TO BE COMPLETED ABOUT '010 ESTIMATED COST J 0C) OLD - NEW BUILDING PERMIT NO. PERMIT NO. DESCRIPTION OF FURNACE/BURNER HEATING or POWER PLANTS, Steam, Hot Water, Warm Air- No. Trade Name C;acc-�Qc- Size No. Capacity Sq. Ft. EDR BTU( Q HP Total Connected Load Kind of Fuel BURNER - Trade Name Size No. Capacity Sq. Ft. EDR BTU HP Company k Sign d B Tel. No. 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 ( ) 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 fur Size and total BTU connected Yes ( ) No 6. Has Total heating BTU's of All other BTU's TOTAL Rema rk s Company _ Signed By Date CITY OF FRIDLEY Effective Date May 1, 1988 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES RATE SCHEDULE RESIDENTIAL Furnace Shell and Duct Work, Burner (Also replacement furnace) Gas Piping (piping needed with new furnace) Gas Range Gas Dryer * Air Conditioning (all sizes) All Others/Repairs and Alterations 11 of Value of Appliance or Work COMMERCIAL/INDUSTRIAL 1% of Value of Appliance or Work RATE TOTAL Job Address f 6&eA $ 20.00 $ Department of Building* 6431 University Ave. N.E., Fridley, MH 55432 City of Fridley $ 10.00 Tel. #571-3450 $ 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 $ 10.00 $ and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. $ 10.00 $ Fridley, Minn. IT�i 19�� OWNER KIND OF BUILDING�p�� USED AS f��C/14 It - State Surcharge TOTAL FEE keinspection Fee ($15.00) Rough Insp. Date Final Insp. Date Approval for Permit MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00 PLUS $.50 STATE SURCHARGE *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. $ TO BE COMPLETED ABOUT "�/ QLc� e, ESTIMATED COST $ .50 OLD - NEW BUILDING PERMIT NO. PERMIT NO. S;V DESCRIPTION OF FURNACE/BURNER HEATING or POWER PLANTS, Steam, Hot Water, Warm Air- No. SY!2 Trade Name -',,P_ Size No. Capacity Sq. Ft. EDR BTU' ��� HP Total Connected Load Kind of Fuel BURNER - Trade Name Size No. Capacity Sq. Ft. EDR BTU HP Company Signed By Tel. No.� Fill out back side for stack verification on replacement furnaces CHIM14EY 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 connected Yes ( ) No 6. Has Total heating BTU's of All other BTU's TOTAL Rema rk s Company _ Signed By Da to 0 CITY OF FRIDLEY Effective Date May 1, 1988 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES RATE SCHEDULE RESIDENTIAL ` RATE TOTAL Furnace Shell and Duct Work, Burner (Also replacement furnace) Gas Piping (piping needed with new furnace) Gas Range Gas Dryer * Air Conditioning (all sizes) All Others/Repairs and Alterations 11 of Value of Appliance or Work COMMERCIAL/INDUSTRIAL 1% of Value of Appliance or Work $ 20.00 S $ 10.00 $eolto $ 10.00 $ $ 10.00 $ $ 10.00 $ State Surcharge TOTAL M Heinspection Fee ($15.00) Rough Insp. Date Final Insp. Date Approval for Permit 641 MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00 PLUS $.50 STATE SURCHARGE *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. $ .50 Department of Building% 6431 University Ave. N.E., Fridley, MN 55432 City of Fridley Tel. #571-3450 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 Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. Fridley, Minn. D" , 19 20 OWNER KIND OF BUILDING 1 USED AS /✓ L P A- 171 J L„ TO BE COMPLETED ABOUT -Da c— t, [ (� ESTIMATED COST t® OLD - NEW BUILDING PERMIT NO. PERMIT NO. l�. i0� DESCRIPTION OF FURNACE/BURNER HEATING or POWER PLANTS, Steam, Hot Water, Warm Air- No. Trade Name Size No. Capacity Sq. Ft. EDR STU HP Total Connected Load Kind of Fuel BURNER - Trade Name Size No. Capacity Sq. Ft. EDR BTU HP Company 72,5o uj Signed By Tel. No. 'q�/+ �7 "- 9 f e.- o Fill out back side for stack verification on replacement furnaces CHIM14EY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack; I. 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 connected Yes ( ) No ( ) 6. Has Total heating BTU's of All other BTU's TOTAL Remarks I Company _ Signed By Da to 01 SUBJECT O. City of Fridley , 2 0 2 3 3 AT THE TOP OF THE TWINS BUILDING PERMIT r RECEIPT NO. t • COMMUNITY DEVELOPMENT DIV. 1 �y-------� r � � PROTECTIVE INSPECTION SEC. -3 J � � t ----I CITY HALL FRIDLEY 55432 ,.j NUMBER REV. DATEPAGE OF APPROVED BY 612-571-3450 910-F15 1/30/9.0 JOB ADDRESS 5741 West Moore Lake Drive N.E. 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 17 l Donnay I's SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Frances Decker 5741 West Moore Lake Drive N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. John Beissel Inc. 153 East Thompson Avenue, West St. Paul 55118 451-6835 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 12 REPAIR ❑ MOVE ❑ REMOVE B DESCRIBE WORK Reside House 9 CHANGEOFUSEFROM TO STIPULATIONS TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING 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 $7,000 $3.50 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- $90.00 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE $93.50 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (OATE1 WW PROPER Y TE HIS IS YOUR PERMIT G WSP / xj'90 GATE SIGNATURE OF OWNER( IF OWNER BUILDER] (DATE) 01 NEW [ J Effective 1/1/90 ADEN [ ] R-1 AND R-2 ALTER V] iY� s��✓�rc� Building Permit Application Constructions Address Legal. Description: Owner Name & Address: f%e-1 ` Tel. # Contractor: Tel.3,5 Address: e Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. LIVIM AREA: Length Width Height Sq. Ft. GRRAGE AREA: length Width Height Sq. Ft. DBCR AREA: Length Width MUM: Hgt/Gra—d Sq. Ft. Corner lot [ ] Inside Lot [ ] Ft. Yd Setback Side Yard Setbacks Type of Construction: A&:,� S��/�� Estimated Cost: Approx. Completion Date: Proposed Driveway Width If New opening Is Desired: Ft. $ $ Wi + 6' See Back Page DATE: APPLICANT: Tel. # CITY USE ONLY Permit Fee $ ��• �� State Surcharge SAC Charge $ Driveway Escrow $ Park Fee $ Sewer Main Charge $ $ '79-5,6- Fee 9-,6 STIPULATIONS: Fee Schedule on Reverse Side $.50/$1,000 Valuation $600 per SAC Unit Alt. "A" or Alt. "B" Above Fee Detemined by Engineering Agreement Necessary [ ] Not Necessary [ ] SUBJECT PERMIT NO. City of Fridley 25026 AT THE TOP OF THE TWINS BUILDING PERMIT �f NO. COMMUNITY DEVELOPMENT DIV. L •O/J r ; PROTECTIVE INSPECTION SEC. CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE Of APPROVED BV 612-571-3450 910-F15 5/2/97 JOB ADDRESS 5741 West Moore Lake Dr NE 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 17 1 Donnay's Lakeview Manor SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Fran Becker 5741 West Moore Lake Dr NE 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Jansick Inc 6480 Squire Dr NE, Fridley MN 55432 574-9679 8618 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 O REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Construct a 12' x 8' Porch Addition; a 13' x 12' Deck 9 CHANGE OF USE FROM TO STIPULATIONS See notations on plan. Before digging Galt for 811 utility locati ¢54-0002 tons SEPARATE PERNSFTS REQUIRE® FOR WIRING, HEATING, REQC�rRLU By LA PLUIIABING AND SIG» � TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 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 $3,862 $1.93 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PR SUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIO O ANY OTHER STATE OR LOCAL LAW REGULATING CON- $87.25 Fire SC $3.86 STRUCTI THE PERFORMAI�C OF CONSTRUCTION PLAN CHECK FEE TOT FEE License $5. $98.04 U E RACTOR OR AUTHORIZED AGENT iDATEI N OP VALID T THIS ISP IT r/SIG BLD INSP �' �iaTe Si ATURE OF OWNER, IF OWNER BUILDERI IDATEf NEW [ ] Effective 1/1/97 ADDN I ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: ,6- 7 z-1 % 60. 1166 k c Legal Description: Owner Name & Address: kAti ,ASC Tel. # Contractor: /��� S/�� �� e : MN LICENSE # g e,1 1E Address: �l�D (,� C r �/� , Tel. # 57/-/ - 96 7 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: '1eA*K Length / 2- Width Height Sq. Ft.1' T' t Z GARAGE AREA: Length Width Height Sq. Ft. = % V, 72 DECK AREA: Length / ? Width l Z----Hgt/Ground Sq. Ft. /3 1 �1/7 OTHER: Construction Type: - Se5A-56i1-) � c> Estimated Cost: $ /96�)Q' 0' Z- (Fee (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: / APPLICANT: Tel. #� Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: CITY USE ONLY Fee Schedule on Reverse Side 001 of Permit Valuation (1/10th%) $.50/$1,000 Valuation $950 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 [ ] $ .y SUBJECT P City of Fridley 9 3 4 7 AT THE TOP OF THE TWINS BUILDING PERMIT r RECEIPT NO. • __ __ COMMUNITY DEVELOPMENT DIV. INSPECTION SEC. r PROTECTIVE 1 ".-11 CITY HALL FRIDLEY 55432 '•� NUMBER REV DATE PAGE OF APPROVED By .' 612-571-3450 910-F15 4/29/99 JOB ADDRESS 5741 West Moore Lake Drive NE 1 LEGAL LOT N0. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 17 1 Donnay's Lakeview Manor SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Fran Decker 5741 West Moore Lake Drive NE 572-0873 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Twin Lake Construction 3071 Colbert Ave NW Buffalo MN 55313 682-4246 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO 20132834 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 6 USE OF BUILDING Residential 7 CLASS OF WORK 0 NEW 0 ADDITION ❑ ALTERATION 0 REPAIR X 0 MOVE 0 REMOVE 8 DESCRIBE WORK Construct stairway over existing concrete stairs 9 CHANGEOFUSEFROM TO STIPULATIONS See notations on plan CONSTRUCTION WORK HOURS: 7:00 am to 9:00 pm, Monday thru Friday; 9:00 am to 9:00 pm on Saturday; No work on Sunday. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT CU FT AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS. OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 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 500 @ $ .50 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- /00STRUCTION OR THE PERFORMANCE OF CONSTRUCTION $21.00 Fire SC , PLAN CHECK FEE TOTA EE Z 11'9 j Licens-a-O None 2.10 SIGNATURE OF CON TRACTOR OR AUTHORIZED AGENT IDA EI HEN PMOPEYLIDAT THIS IS IT INSp F IATE 411 SGNATURE OF OWNER nF OWNER BUILDERI IDA TE -I NEW [ ] Effective 1/1/99 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION 1s%� �(p ConstructionAddress: -5-7q/ s ox -e 44-ke- Legal Description: Owner Name & Address: rli6V AeG1Q-V-- Tel. # -� 7w'f-'o Contractor: —! "';� ��- z ,� s�v,v �e� Q� e '3M411W MN LICENSE# Z®/ 3`/ Address: 3:) )) ii:� AJ. W-,AWfA-lrj /W-" 55-3'3 Tel. # &/?- - - Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: s4ta Construction Type: .Driveway Curb Cut Width Needed: Ft. + 6 Ft = DATE: 2S 9 i Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Estimated Cost: $ e� (Fee Schedule on Back) Ft x $ APPLICANT: Tel. CITY USE ONLY Fee Sched everse Side of Permit Valuation (1 / 10th %) < DJ $.50/$1,000 Valuation $ per $ $5.00 (State Licensed Residential Contractors) $ Alt. "A" or Alt. "B" Above $ $450.00 Conservation Plan Review Park Fee $ Fee Determined by Engineering Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ] TOTAL STIPULATIONS: t .� pp ' � '✓ k 'i' �. t'e y E� t r f TW S+s` �.. `` � Y..�' t r- "'•J d 1rr r ` pn++r y r t Y t .y ,ie. -el i R't'. *H't °t .+"°�r'd �'vs4 ��i'r -- f�� ti �,j�.+"yr�i 'Fit. A +z ,Yi, ' �f +c�;,� £�„4�a;'a�. a�� a_ ��� ° $ - '�� W � s AL ��,. + �5'°A����. � y.n'�'"' •• � y(�� ' N` " e., °i t s `' � e , '+I} �I" �4 � a ii.{ 1 ✓a4'• �F S ' r,`Nq� N ( -. ,, y �i d r r Pp �J �(rtAt �t e� .7.' $�>� �����/ T� '�J 1. ( a n�+�".1�",A.f �A � ���+• '�Y 'i Y 3���Q ` Y�°Jy64 91+ r:. FX" +< y ' roy f �`-"' 1 b ,� jf�yF"� t �r a r'µ1+.}`yYtr'�'•a�.yG .'++ti� �'r`.��,�. • b +t'�;�'.�r' �' '°}'.W i ,,;, k g r .4 .fk.: jr,"�''S° ^i. f: . � T r •r ,. � y. a. � �f t < F R hr y . ,. r } r �1 r d .tM�' ns a ', .z + ,-0 ,t''• t� �. is ; I r ` t t ' +' ! � iC � rd SYS ir� t 1 �K s•t r i ,}a, � .a 'r y tP�..+ Jy .°A `Y A a $ hl ♦ .t r.. r ?. �y,ya �a�; t,y r, ��,., '� ` •; t" 4< .i,^. � r ,,� ..j'� a ° { ria}.�, � r #�: 1d sv L.. SUBJECT 6-1®36®43 City of Fridley 2 2 0 9 AT THE TOP OF THE TWINS BUILDING PERMIT RECEIPT NO. _ _ COMMUNITY DEVELOPMENT DIV. �; �------ PROTECTIVE INSPECTION SEC. s- ,SSI E NUMBERREV DATE PAGE OF APPROVED BY i CITY HALL FRIDLEY 55432 612-571-3450 910415 10/ 1101 /01 JOB ADDRESS 5741 West Moore Lake Dr NE I LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DEscR. 17 1 Donnay's Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Fran Decker 5741 West Moore Lake Drive NE 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Richard Hastings Contr. 6331 Riverview Ter NE, Fridley, MN 55432 574-9966 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO 4051 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 8 USE OF BUILDING Residential 7 CLASS OF WORK O NEW O ADDITION O ALTERATION REPAIR O MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof House (19 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 SQ. 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 1 ISTALLS GARAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED $Z,O37 $1.02 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- $83.25 Fire SC $2.04 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION PLAN CHECK FEE TOTAL FEE Licen S $5.00 1.31 SIGNATURE OF CONTRACTOR OR AU ORi EN E LIDATE IS IS/YOUR PERMIT /jR�; re S-GNATURE OF OWNEROF OWNER BUILDER, (DATE) I3LQ6 INSP OA E L.. NEW I ] Effective 1/1/2000 ADDN [ ] CITY OF FRIDLEY (763) 572-3604 Bldg Insp ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Construction Address: 7 0,pR_p 4k ' 'D /a. Legal Description: Owner Name & Address: RAV Nk Tel. # Contractor: p3:fl c, 4 A?- 0 i tic -5 MN LICENSE # YDS Address:— 6,13 11 Ro-V,6z- 0 , L') q -E F Tel. # S'7 V - TOTAL $ C?/. '3 1 STIPULATIONS: 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: Construction Type:1&4Z Estimated Cost: $ 0� 1®3 7 Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE:10419 D APPLICANT: Tel. # CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application Permit Fee $__ r�d Fee Schedule on Reverse Side Fire Surcharge .001 of Permit Valuation (1/10th%) State Surcharge $ /, 0,2 $.50/$1,000 Valuation SAC Charge $ $1100 per SAC Unit License Surcharge $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 $ C?/. '3 1 STIPULATIONS: CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 572-3604 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO RF INSTAI_I Fn nN FAr.H FI nnR Effective On Jan 1, 2000 . � a..9 ER • � Q' � � .. � _•ate . r � a �F n_ _- -_ - ri�YF'i� �C� R • , _0=Mimi PLUMBING FIXTURE RATES: NO. RATE New Fixtures Old Opening, New Fixture - Beer Dispenser Blow Off Basin Catch Basin Rain Water Leader Sump/Receiving Tank Water Treating Appliance Nater Heater -Electric Water Heater - Gas's' � Gar Range'' Gas Dryer" Back Flow Preventer Required ( )Yes () No Type $ 7.00 $ 4.00 $ 5.00 $ 7.00 $ 7.00 $ 7.00 $ 7.00 $10.00 a 7.00 $1().00 m 10:00 $10.00 $15.00 Reinspection Fee $47.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance State Surcharge TOTAL FEE TOTAL $20.5-50 JOB ADDRESSfM&97,t-- 61AOIE 12— The The undersigned hereby makes application for a permit for the.work herein specified agreeing to do allwork in strict accordance with the city codes and rulings of the Puilding Division, and hereby declares that.ali the facts .and representations stated in this application are true and correct. DECKER, FRANCES 10 /31 5741 MOORE LAKE DRIVE 1 20 03 FRIDLEY, MN 55432 Owner (763)572-0873 _ - Building Used As�61DQ C r d Estimated Go&i 00PERMITNO. 139 PLUMBING COMPANY SIGNED BY L NO.II�"CSf.1�Bj Approved By ``- Rough -In Date Final Date 1 1 li r% COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A COMMON VENT INFO ON BACK SIDE When replacing an existing furance, the undersigned hereby verifies that the venting has been examined and is free from rust, deterioration, obstructions, and is securely supported and firestopped where required. Yes () No ( ) The venting.system is. plastic/PVC and meets all current codes and irenufacturer specifications.including sizing, length, number of elbows and termination. Yes( )=s:No (, The undersigned also verifies that the replacement unit is a listed asserrabiy 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 Installing a new venting system, the undersigned hereby verifies that it is a listed assembly and meets the current codes and manufacturer's u, 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.( ) Apcliance Type and Size/Common Vent and VentnConnector Information Appliance #1 Type BTU Input Fan Assisted or Nat Appliance #2 Type BTU Input Fan Assisted or Nat Appliance #3 Type BTU Input Fan Assisted or Nat Total Appliances Total Btu Input Common Vent Type Vent Height Diarfieter 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 ALTERATIONS: (Describe) HEATING CO: Signed By: Date: