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PRE 2010 DOCSPermit is hereby�anted . the building° described in the above statement. This permit is granted upon the expresscondition that the person to whom it is granted, and his agents, employees and workmen, in all the work done i around and upon said building, or any part thereof, shall conform in all respects to the ordi- nances of 1s ridiei Minn., regarding the construction, alteration, maintenance, repair and moving of buildings within the city ts, and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. yr "_ Inspector of Buildings. i�. AGREEMENT' AND SWORN STATEMENT In consideli tion of the issue and delivery to me by the Inspector of Buildings of Fridley of the above ,pe t, I hereby agree to do the proposed 'work in accordance with the description above set fo and according to the provisions of the ordinances of Fridley, and, being first duly sworn, I here 'state and 'say that the facts stated by nae=and .contained in the above permit are true as therein�i stated. Aj 1I Subscribed And sworn to before me at Fridley, Minnesotan day off. � �. � F�� i' K li City ®f Fridley, Mnm ')cj '--) - 0 Le F BUILDING No. Part o t Lot _ Block ____ Addition or Sub- on . - 0 Corner Lot _ Inside Lot Otback _Side Sewer Elevation _ F dation Elevation DESCRIPTION OF BUILDING T U /Front �r �' Depth Height � SCI. Ft. � Cu. Ftp, o Depth Height _ SqCu. Ft. . Ft. ____ Type of =��Oe Est.�� To be Completed In consideration of the issuance to me of a permit to construct the building described above, I agree to do the proposed work in accordance with the description above set forte and in compliance with all provisions of ordinances of the city of Fridley. ,� / z- ,—) i /% In consideration of the payment of a fee of $.— , permit is hereby granted to to construct the building or addition as described above. This permit is granted upon the express condition that the person to whom it is granted and his agents, employees and workmen, in all work done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings within the city limits and this permit may be revoked at any upon violatian,of any of the provisions of said ordinances. / �) Building Inspector NOTICE: 11ds permit does not corer the construction, instaQattoo for whbg, ph►mhtng, on heatte®, cower or water. Be core to we the suildlag Inspector for separate permit for these hems. APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA Oti E! R ° S NAME , j6 6 Q/ BUILDER ADDRESS 6�fj* A -dr .S f ADDRESS LOCATION OF BUILDING No. /Y Street Part of Lot Lot 3 qi- Block Addition or Subdivision P/y 0 t Corner Lot Inside Lot__X _Setback Side Yard SEWER ELEVATION FOUNDATION ELEVATION Applicant attach to this form Two Certificates of Survey of Lot and proposed build- ing location drawn on these Certificates. DESCRIPTION OF BUILDING To be used as: nfaeI,. C✓ Front /� Depth- _Height /0 Sq..Ft. Cu. Ft. Front Depth 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 application are true and correct. SIGNATURE (Schedule of Fee Costs can be found on the Reverse Side). SUBJECT PER O. City of Fridley 15060 AT THE TOP OF THE TWINS BUILDING PERMIT REC `L _ COMMUNITY DEVELOPMENT DIV. r � � PROTECTIVE INSPECTION SEC. 1 . ( CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 612-560-3450 910-F15 1/19/79 JOB ADDRESS 4868 _ 2nd Street N. E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 3,4 4 Plymouth Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Corrine Kaluza 4868 - 2nd Street N.E. 3 CONTRACTOR MAILADDRESS ZIP PHONE LICENSE NO. Viking Home Improvment Co. 4832 - 221 Street N.E. 560-3794 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 C. ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 6 DESCRIBE WORK Inside alterations; change windows and add paneling 9 CHANGE OF USE FROM TO STIPULATIONS SEPERATE PERMITS REQUIRED FOR WIRING, HEATING, PLUMBING AND SIGNS, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD, SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. Wood Frame 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 R-1 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. $2,000 $1.00 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- $12.00 STRUCTION OR THE P RFORM NCE OF CO TRUCTION. PLAN CHECK FEE TO TALFEE - $13.00 IGN URE OFCONTRACTORORAUTHORIZE AGENT (DATY) - WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT -t9 .^ BLDG. INSP DATE SIGNATURE OF OWNER (IF OWNER BUILDER) - (DATE) CITY OF FRIDLEY • APPL.ICATION FOR RESI1 ENTIAL BUILDING PE1214ITS (NEW, ALTERATIONS, AUDITIONS, OR REPAIRS) B A Address: G°Z�fU4 BUILD13,11: (� d���.� it /1✓j r7 s� /1� 1y� v, i t� Address: Tel. No. No. Street: r�� - -- —• LOT: � BLOCY.: � ADDITION: p 4,1 e� CORNER LOT: INSIDE IAT: S13TBACK: SIDL'YARDS: . Applicant attach 'to this form'lWo Certificates of Survey of Lot and proposed building location drawn on these Certificates. DESCRIPTION OF BUILDING To Be Used As: - -front: Depth: Height: square Feet: Cubic Feet: Front: - Depth: Height: • Square Feet: Cubic Feet: Type of Construction: Estimated Cost: To Be Completed: �� —�� Alt. A Alt. B Prdposed Driveway Width If New Opening Is Desired $ $ (SEE REVERSE SIDE OF SHEET) 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. See reverse side for additional information. J DATE: � � l SIGNATURE: Stipulations: e ,a 00 ' • 1-3 j�. City of Fridley AT THE TOP OF THE TWINS SUBJECT BUILDING PERMIT F11' r � COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. t . , ­_i CITY HALL FRIDLEY 55432 L 612-571-3450 R 9® NUMBER 910-F15 REV. DATE 4/12/83 PAGE OF APPROVED BY JOB ADDRESS 4868 - 2nd Street N.E. 1 LEGAL DESCR. LOT NO. 3,4 BLOCK 4 TRACT OR ADDITION SEE ATTACHED Plymouth Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Corinne Kaluza 4868 - 2nd Street N.E. 572-8960 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Same 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 C] ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE X 6 DESCRIBE WORK Construct a 10' x 16' Storage Shed 9 CHANGE QF 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 AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION ZONING SO. FT. CU. FT. 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 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- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. $15.00 PLAN CHECK FEE TOTAL FEE $15.50 'N TURE OF C(RNTRACTOR OR AUTHPFJ&ED AGENT (DATE) WHEN PROPERL VALIDATED THIS IS YOUR PERMIT p�iyq E OF OWONE JIIF R BOLDER) IDATE) BLDG WSP D E CITY OF FRIDLEY Effective Aug. 1, 1981 APPLICATION FOR RESIDENTIAL BUILDVIG PEMITS (NEW, Alterations, Additions, or Repairs) OWNER: ��` � A/ • ADDP.ESS. TEL 90: BUILDER: ADDRESS: TEL NO: Construction location • STRICT NO: STJU T: 2 VZ - IAT: BLOCK: ADDITION: Corner Lot: ` Inside Lot: Setback: Sideyards: Applicant attach to this form two Certificates of Survey of lot and proposed building location drawn on certificates to scale. DESCRIPTIOR OF CONSTRUCTION sran 4 Front: 10 Depth: %6 Height: Square Feet:—) cubic Feet: Front: Depth: Height: Square Feet: Cubic Feet: Type of Constructions Estimated Costa S Rb Be Completed: Alt. A Alt. 13 ]Proposed Drivm,Tay 'Width If New Opening Is Desired: $ SEE PEVERSE SIDE OF SHEET Zile undersigned hereby makes application for a permit for the work herein specified, agreeing to d4_all Work Ln strict accordance with the City of Fridley Ordinances and rulings of the Delkartment of Buildings, and hereby declares that all the facts and representations stated in this applicatio"re true and correct. DATE: q q °LSIGNATURE: \eI `o Stipulations: 9A4._'_� T'9 Rough Insp. Date Q Final Insp. '`� —v 4 Date a Approval for Permit` s - MINIMUM FEE FOR ANY HEATING PERMIT IS $10.00 PLUS $.50 STATE SURCHARGE Attach stack verification fors with replacement furnace permits *Air Conditioners can net lns placed in sid,• yard without written, persission from adjoining neiqhbor. HEATING or POWER PLANTS, Steam, Hot Mater, Warm Air- No. Trade Name Site No. 3 /G ! Hh uj® 3( Capacity Sq. Ft. EDR BTU f� HP Total Connected Load Kind of Fuel BURNER - Trade Name Size No. Capacity Sq. Ft. EDR STU j HP Company 4 4- Signed By Tel. No. C �/ Effective Aug. 1. 1981 ' CITY OF FRIDLEY 0 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES RATE SCHEDULE RESIDZNTIAL RATE TOTAL Job Address Furnace Shell and Duct Work, (Also replacement furnace) $ 20.00 $ Department of Buildings. 6431 University Ave. N.E., Fridley, MN 55432 Burner City of Fridley Gas Piping $ 10.00 $ Tel. 11571-3450 (piping needed with new furnace) $ 10.00 $ The undersiqned hereby makell application for a permit for the work herein Gas Range specified agreeing to do all work in strict accordance with the City Codes Gas Dryer $ 10.00 $ and rulinqs of the Department of Buildings, and hereby declares that all the facts and representations stated in this applications are true and correct. / 19 • Air Conditioning (all sizes) $ 10.00 $ t Fridley, Minn. , LAL210��;& All Others/Repairs and Alterations OWNER It of Value of Appliance or Work S - KIND OF BUILDING COMMERCIAL/INDUSTRIAL USED AS 1% of Value of Appliance or Work $ 70 BE COMPLETED ABOUT p /� ESTIMATED COST _ / 7-ao— io State Surcharge $ .50 !EE $•� OLD - NEW BUILDING PERMIT N0. PERMIT NO. TOTAL Reinspection Fee ($15.00) $ DESCRIPTION OF FURNACE/BURNER Rough Insp. Date Q Final Insp. '`� —v 4 Date a Approval for Permit` s - MINIMUM FEE FOR ANY HEATING PERMIT IS $10.00 PLUS $.50 STATE SURCHARGE Attach stack verification fors with replacement furnace permits *Air Conditioners can net lns placed in sid,• yard without written, persission from adjoining neiqhbor. HEATING or POWER PLANTS, Steam, Hot Mater, Warm Air- No. Trade Name Site No. 3 /G ! Hh uj® 3( Capacity Sq. Ft. EDR BTU f� HP Total Connected Load Kind of Fuel BURNER - Trade Name Size No. Capacity Sq. Ft. EDR STU j HP Company 4 4- Signed By Tel. No. C �/ i • CITY OF FRIDLEY APPLICATION FOR HEATING REPLACEMENT CHIMNEY AND STACK VERIFICATION THIS FORM MUST ACCOMPANY STANDARD APPLICATION FOR HEATING PERMIT FORM. LOCATION t `',a E DATE 9_(®'84 OWNER ADDRESS The undersigned hereby verifies that the existing chimney or stack: 1. Has been carefully examined 2. Is free from rust or deterioration 3. No foreign objects are lodged within 4. That it is securely supported S. That it meets all current Code requirements for size and total BTU connected 6. Total Heating BTU All Other BTU TOTAL REMARKS HEATING PERMIT # R SIGNED Licensee by AddressC- Telephone 757—!®�� Fridley City License CITY OF FRIDLEY APPLICATION FOR PWMBING AND GAS FITTING PERMIT RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL New Fixtures $ 5.00 $ Future Fixtures $ >, m Old Opening, New Fixture $ 1.50 u Beer Dispenser x N S Water 61 5.00 $ Catch Basin $ 5.00 ea c r.4)14 fd $ 5.00 M 4 14 a w $ Sump or Receiving Tank Heater 4 $ .y�gq, $ a W x 4J 3 w .ci x 10.00 u Gas Dryer m 10.00 $ ALL OTHERS AND/OR REPAIRS AND ALTERATIONS la of Value of Fixture or Appliance $10 oo State Surcharge $ .50 Reinspection Fee $ 10.50 ($15.00) TOTAL FEE o v�i D aea v'ii S o w 0w u lec 1 1st 2nd 3rd 4th (R)-= Future Connection Opening Connected with Sewer (*) a New Fixture, Old Opening Water RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL New Fixtures $ 5.00 $ Future Fixtures $ 3.50 $ Old Opening, New Fixture $ 1.50 $ Beer Dispenser S 4.00 S Blow Off Basin $ 5.00 $ Catch Basin $ 5.00 $ Rain Water Leader $ 5.00 $ Hydraulic Valve $ 5.00 $ Sump or Receiving Tank $ 5.00 $ Water Treating Appliance $ 7.00 $ Hot Water Heater f $ 5.00 $ Gas Range $ 10.00 $ Gas Dryer $ 10.00 $ ALL OTHERS AND/OR REPAIRS AND ALTERATIONS la of Value of Fixture or Appliance $10 oo State Surcharge $ .50 Reinspection Fee $ 10.50 ($15.00) TOTAL FEE $ LtteCtWe Aug. 1, 19bl Job Address 4868 - 2rd Street N.E. Department of Buildings 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, Mn. _9 6 1 19-84— OWNER Corinne Kaluza KIND OF BUILDING USED AS Residence TO BE COMPLETED ABOUT 9-84 ESTIMATED COST $00.00 OLD - NEW BUILDING PERMIT NO. PERMIT NO.� Company Blaine Iumbing & He ti Signed By 4- LAI Tel. No. 757-6200 ROUGH INSP. Date Q� FINAL INSP. i Date APPROVAL FOR PERMIT MINIMUM FEE FOR ANY PLUMBING PERMIT IS $10.00 PLUS THE $.50 STATE SURCHARGE City of Fridley SUBJECTIr? , r29438') AT THE TOP OF THE TWINS BUILDING PERMIT RE IPT NO. I `� COMMUNITY DEVELOPMENT DIV. 1 PROTECTIVE INSPECTION SEC � V 1 � v 000 = CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY 612-571-3450 910415 5/10/99 JOB ADDRESS 4868 2 Street NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 3,4 4 Plymouth Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Walt Slatowski 4868 2 Street NE 572-8960 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Four 3MXXX Seasons Roofing & Remodeling 7930 University Ave NE, Fridley, MN 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO 795-9410 20138780 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION REPAIR ❑ MOVE ❑ REMOVE B DESCRIBE WORK XEI<3Fb= Reroof House & Garage (19 Sq) Tear -off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with the State Building Code. 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 $1,628 $.81 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION $60.10 Fir,4 SC $1.63 ar PLAN CHECK FEE Lic C $5.0 TOT L FEE $67.54 SIGNATURE OF CON: RACTOR OR AUTrIORIZE AGENT IDATEI It PROP --, ULAAN6 VA IDA HIS IS Y.O`UR PERMIT `r/ DACE S,GNATURE OF OWNEROF OWNER BUILOERI IDATEI NEW[ ] Effective 5/10/99 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMELY AND DUPLEXES R-1 AND R-2 , r'�� BUILDING PERMIT APPLICATION N 0 U0 p Construction Address: n. s'i- d _ '� �,LAY Legal Description: Owner Name & Address: %O/-L.T S L � 1 o ,,-; 5X 1 IM6;3 ZNo 54. AiTel. # 3-7a-- Y R G Contractor: U- S�& &4® ,.) MN LICENSE # , Address: r2-1 ®7 Y -z- Lj , ca �:e Qc1-11 Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF EWROVEMENT LIVING AREA: Length Width Height' Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: 40 3 Q - Q -E 1 '� \ .0. Construction Type: Estimated Cost: $ /61:283 Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: /® ��j APPLICANT: �'��eOl..q_lTel. # CITY USE ONLY Permit Fee $ 6®,10 Fee Schedule on Reverse Side Fire Surcharge $ 1.,63 .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge $ $1050 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 $ 42 .a 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 BE INSTALLED ON EACH FLOOR Effective On Jan 1, 2000 PLUMBING FIXTURE RATES: NO. RATE TOTAL JOB ADDRESS JAPE & Qi~ to&E New Fixtures $ 7.00 The undersigned hereby makes application for a permit for the work herein Old Opening, New Fixture $ 4.00 specified agreeing to do all work in strict accordance with the city codes Beer Dispenser $ 5.00 and rulings of the Building Division, and hereby declares that all the facts Blow Off Basin $ 7.00 and representations stated in this application are true and correct. Catch Basin $ 7.00 Rain Water Leader $ 7.00 ? , 20 0-b Sump/Receiving Tank $ 7.00 SLATOSKI, WALT 4868 2ND STREET NORTHEAST Water Treating Appliance $10.00 Owner . FRIDLEY, MN 55421 Water Heater -Electric $ 7.00 (612) 572-8960 Water Heater - Gas** _j_ $10.00 Building Used As Gas Range** $10.00 Gas Dryer** $10.00 Estimated Cost PERMIT NO. _2 c Back Flow Preventer Required ( )Yes () No j���� ) Type $15.00 PLUMBING C ANY i�Urb ��77') Reinspection Fee $47.00/Hr SIGNED BY TEL N0. 192-7-q033. ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance It Approved By Rough -in Date Final Date ;�Vuo) State Surcharge .50 TOTAL FEE $ Z! •-50 PLUS,THE S.50 STATE SURCHARGE COMBUSTION AIR SHALL. BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION 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 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 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 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 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 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 ALTERATIONS: (Describe) HEATING CO: Signed By: Date :