PRE 2010 DOCSBUILDING PERMIT
I�
N° 2145
Wage of Fridley; Minn. ;
Date,A.
..............................
Owner
... I .. Builder
f
AddressallyAddress
.. .. .
i LOCATION OF BUILDING
No. .oas,..
Street , .. .... Part of Lot .. ... .
Lot . ............
...
Block .. • . e ......:.:. Addition or Sub -Division` .' •
Corner Lot .....
ir. Inside Lot ...... Setback _Sideyaard .149. ";fie";' .........
DESCRIPTION OF BUILDING
To be Used as:
' =u'
I,
Front ., " .. , Depth A.. ... Height Sq. Ft..... Cu. Ft........ ,
.............. .....jr
Type of Constructioi4
Front ........ Depth ........ Height ......... Sq. Ft........ • Cu. Ft . ........
=s `.. Est. Cost
.: ,a. .... .... .
......... To be Completed ip .. ...
l
In consideration;
of the issuance to we of a permit to construct the building described above, I agree to do
the proposed,, work i
a, accordance with the description above set, forth., and in compliance with all provisions of
ordinances of the village
of Fridley.
In consideration,l,of
ele xpr#nnditioi
done In, around an,d
Ar, 1W
the payment of a fee of $..:', permit. is hereby granted, to , .. . .
... to construct the building or ad dition as described above. This 'p • 't is granted upon
that the person to whom it is granted and his agents, employees and workmen, in all work
upon building,
Fridley, 1V innesota rlegarding
.said or any part thereof, shall conform in all yespects to the ordinances of
location, construction, alteration, maintenance, repairand moving of buildings with-
in the village limitsIpnd
ordinances.
this permit may be revoked at any time -upon olati any of the provisions of said
,,
". ,. ' ° Building Inspector
NOTICE:
This permit does
not cover the construction, instaIlatiotf or alteration for wiring* piwmbing,"gas heating,
sewer or water.
be sure to -see the Building Inspector .for separate permits for thew'items.
I
City of Fridley, Minn.
BUILDING PERMIT
Date: ....:_.._...... ... rte'_.....:....:s
j�
Owner: - .........
.a
Address .... :.. 'y . ...."
1
N® 4763i -
Builder.. ... _......... ........ ......:_... _._ _.'!....._
,Address ................ .................. ........ '_.......__._'_......_
C N OF BUILDING
No.... .. ..:.. treat ._. _ :_ ..v...._._......... ...... Part t ....._.. ._..._-----._............................_.....
p
Lot .. .._ Block -----.... .... ....... Addition or. yb-Di�;is I........._
Corner Lot ....................................Inside Lot ..... .. _. ac _',.: _.... eyard ......... :
_......... _..........
SewerElevation -------------------- ................... ----...... ._................. ...................... Fo ation Elevation..._.....-------------------------------------------------
DESCRIPTION OF BUILDING
T Us
Front .::. ..__.. Depth ._.. Height .. ........ Sq. Ft. Cu. Ft. .-
_....._._...::. _......._......:......: Front ....... Depth .......:. Height Sq. Ft....: Cu. Ft. ..... _.................
Type of Constructions—?;—. :.94'....... Est. Cos :.. v"--1.3�.....----•--.. To be Completed ................... ..........................
CAUTION
PHIS PE WAIT DOES NOT AUTHORIZE VIOLAT-
ION OF ANY PIM, i E LAND COVENANTS AND
@UILDIN IiL:-;-i RIlGTJONS.
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 city of Fridley.
:y, ............... ..._..._
of a fee of $yment
In consideration of the payment ,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 time upon violatio of any of the provisions of said
ordinances.
� 7W� .
Building Inspector
(NOTICE:
This permit does not cover the construction, installation for wiring, ,plumbing, gas heating, sewer or water. Be sure to see
the Building Inspector for separate permits for these items.
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
LOCATIONN OF BUILDING
No.
Street , Part of Lot
Last Block__Addition or Sub.Div.
Corner Lot Inside Lot <--- Set Back Side -Yard ~
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Certificate of Survey of Lot and.proposed building
location.
DESCRIPTION OF BUILDING
To b ed s:
Front Depth Height . �� ..
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 Ordinances and ruling of
the Department of Buildings, and hereby declares that all the facts and representa-
tions stated in this application are true and correct. d .
(A'Schedule of Fee costs can be found on the Reverse Side.)
,,& ...F W W- ft
City of Fridley
Application for Plumbing and Gas Fitting Pem*
Dept. of Bldgs. Phone SII 4-7470����
DESCRIPTION OF WORK ®� �° ® 4 ,�
Number, Kind and Location of Fixtures Luca o
q
City of Fridley:
The undersigned hereby .makes application for a permit for the work beret
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 fact
and representations stated in this application are tru°e and correct.
('\ ® _
Frid�Anon- nn. I � ru
® v , 19 -co d
Owner
Kind of
• Future Connection Openings I ��®csea wiaa
Sewer GK Used as
New .Fixture, Old Openings Cesspool El
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO. RATE
TOTAL
Number Fixtures ......................
�° x $1.50
$ �• 5)
Future Fixture Opening ................
Zz
$
z�z
<z
oz
Catch Basin ............................
x 3.25
(D
z
(�9O
•
F
s
N
WATER HTR.
GAS
ELEC
Base
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................
Z_ x $1.50
$—/-'
Additional Fixtures ....................
x .50
$
Gas Range to 200,000 BTU ..............
x 2.00
$
1st
j
2nd
3rd
4th
City of Fridley:
The undersigned hereby .makes application for a permit for the work beret
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 fact
and representations stated in this application are tru°e and correct.
('\ ® _
Frid�Anon- nn. I � ru
® v , 19 -co d
Owner
Kind of
• Future Connection Openings I ��®csea wiaa
Sewer GK Used as
New .Fixture, Old Openings Cesspool El
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO. RATE
TOTAL
Number Fixtures ......................
�° x $1.50
$ �• 5)
Future Fixture Opening ................
x 1.20
$
New Fixture Old Opening ..............
x 1.00
$
Catch Basin ............................
x 3.25
$
Water Heater (Up to 200,000 BTU) ......
x 2.00
$2 t u
New Ground Run Old Bldg. ............
x 3.25
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................
Z_ x $1.50
$—/-'
Additional Fixtures ....................
x .50
$
Gas Range to 200,000 BTU ..............
x 2.00
$
REPAIRS & ALTERATIONS—Refer to Code
Description ......... $
TOTAL FEE $
To be c
Estimated Cost, $
®�
Old` New. uilding Permit No-
sn/
ROUGH
FINAL
4z 2M
WYFi�
Business Phone No- 1�
01-A
Minnesota Well and Boring
it. Open Hole rom
jet
-
Ma ling Address if different than property address indicated
- -
WELL OR BORING LOCATION
MINNESOTA DEPARTMENT OF HEALTH
Sealing No.
H 72248
Set in oversize hole? Annular space initially grouted?
❑Yes t No 11 Yes ❑ No El Unknown
[I Yes EI No ❑Yes 11 No El Unknown
❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
WELL AND BORING SEALING RECORD Minnesota unique No.
County Name
Anoka
Minnesota Statutes. Chapter 1031
or W -series No.
TO
If not known, indicate estimated formation log from nearby well or boring.
(Leave blank it not known)
Township Name
Township No.
Range No,
Section No.
Fraction (sm. • Ig.)
Date Sealed
MEMO
Approximate Date Well
or Boring Constructed
Fr�idi~
30
9-
I
23
M414NU141411tt4
q q q�
10-18-95
MEESE
Numerical Street Address or Fire Number and City of Well or Boring Location
52
3�a
Depth Before Sealing
ft.
Original Depth ft.
Show exact location of well or boring
Sketch map of well or boring
Static Water Level & Accurate
in section grid with -X-.
location. showing property lines.
❑ Approximate
N
roads. and buildings.
-
W
® Single Aquifer ❑ Multiaquder ft. below above land surface
CASING TYPE
® Steel El Plastic El Tile El Other
'> tulle
62 f to ft
Screen from to
S
PROPERTY OWNER'S NAME
M� h
'
OBSTRUCTIONIDEBRISIFILL
{ Obstruction El Debris El Fill
q
Type of debris/obstruction F y 1 y tl d,p.
'
ObstructionlDebrislFill removed? IlYes ❑ No
it. Open Hole rom
jet
-
Ma ling Address if different than property address indicated
- -
above
PUMP
N Removed ❑ Not Present ❑ Other
CASING
Diameter Depth
in. from 5 to 5 ft.
in. from to ft.
in. from to ft.
Set in oversize hole? Annular space initially grouted?
❑Yes t No 11 Yes ❑ No El Unknown
[I Yes EI No ❑Yes 11 No El Unknown
❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
GEOLOGICAL MATERIAL
COLOR
HARDNESS OF
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
MEMO
METHOD USED TO SEAL ANNULAR SPACE BETWEEN
No Annular Space Exists
❑ Annular space grouted with tremie pipe
❑ Casing PerforationlRemoval
in. from to
in. from to
Type
MEESE
® Single Aquifer ❑ Multiaquder ft. below above land surface
CASING TYPE
® Steel El Plastic El Tile El Other
'> tulle
62 f to ft
Screen from to
S
PROPERTY OWNER'S NAME
M� h
'
OBSTRUCTIONIDEBRISIFILL
{ Obstruction El Debris El Fill
q
Type of debris/obstruction F y 1 y tl d,p.
'
ObstructionlDebrislFill removed? IlYes ❑ No
it. Open Hole rom
jet
-
Ma ling Address if different than property address indicated
- -
above
PUMP
N Removed ❑ Not Present ❑ Other
CASING
Diameter Depth
in. from 5 to 5 ft.
in. from to ft.
in. from to ft.
Set in oversize hole? Annular space initially grouted?
❑Yes t No 11 Yes ❑ No El Unknown
[I Yes EI No ❑Yes 11 No El Unknown
❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
GEOLOGICAL MATERIAL
COLOR
HARDNESS OF
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN
No Annular Space Exists
❑ Annular space grouted with tremie pipe
❑ Casing PerforationlRemoval
in. from to
in. from to
Type
2 CASINGS, OR CASING AND BORE HOLE:
-
ft. ❑ Perforated ❑ Removed
ft. ❑ Perforated ❑ Removed
-
-
of perforator
❑ Other
GROUTING MATERIAL
L Crat
Grouting material from
from
from
from
5 62 1
to ft. yards bags
to ft. yards bags
to ft. yards bags
to ft. yards bags
REMARKS, SOURCE OF DATA, DIFFICULTIES IN
r
SEALING
y
i�
I- !AJR
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes IN No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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.
Mork Well Co., Inc. � 02133
Contra ness Na License or Registration No.
"a")ii,iiiiiII 10-18-95
Authorized Representative � Signature
Greg 1e
ck
Date
d MMM
H
+w t
Name of Person Sealing Well or Boring
HE•01434.01
CITY OF FRIDLEY INSPECTION DIViSION Effective On January 1, 2000
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
572.3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS '01
RATE SCHEDULE
OWNER,--
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.
$ .50
BUILDING USED
eA�e
ESTIMATED COST ( C)O a® PERMIT NO.
DESCRIPTION OF FURNACE AND OR BURNER
No. of Heating Units Circle One (Steam) (Hot Water) (Warm At
Trade Name r k Size No. `�`aa�3� 0-t
BTU 'o 0 o o HP EDR
Fuel , -.4, Total Connected Load
Burner Trade Name Size No.
BTU HP 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 an
rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
H EATI N
Signed
DATE Ll- 3 - 00
BLAINE HTG. A/C & ELECT. INC.
13562 CENTRAL AVE. N.E.
C�
Approved By
M
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
i
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 K 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 manufacturers 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 K 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 9No
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 KNo ( )
Appliance Type and Size/Common Vent and Vent Connector Information
Appliance #1 Type (�7v VAc,'-e-r- BTU Input LoO100 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 An, Type
ALTERATIONS: (Describe)
OIAINEr, �
A�:lK 6 ELECT. !alt..
M02.0: _; ' AAVE. �.I�
by �
HEATING CO: MN 5WO4 1
Signed By: Date 3-00
SUBJECT
7RWf NO.
City of Fridley
3 2 2 6 8
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
COMMUNITY DEVELOPMENT DIV.
1 V
REEIPT NO.
Ig`��
r , PROTECTIVE INSPECTION SEC.57P.-SU"04
I "'1 CITY HALL FRIDLEY 55412
NUMBER
REV
DATEPAGE
OF
AOPROVED BY
612-571-3450
910-F15
10/22/01
JOB ADDRESS 6039 2 Street NE
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DESCR.
27 , 28
7
Hyde Park SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Dave/Kelly Lisk 6039 2 Street NE
763-571-8327
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Window Lite Home Improvements 8400 89 Ave N STE 460, Brooklyn Park, MN 55445
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO
763-391-8314 20039258
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW O ADDITION O ALTERATION 5P REPAIR O MOVE O REMOVE
8 DESCRIBE WORK
Replace one window within existing opening
9 CHANGEOFUSEFROM
TO
STIPULATIONS
Provide smoke detectors in all sleeping rooms and on all levels of the
dwelling per Section. 310.9.1.2 of the 1997 Uniform Building Code. Caulk
and flash all exterior openings.
Permit tns
tet 4 carq
s
o ® ,9t0
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL. PLUMBING. HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCYLOAD
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 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
$2.34
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$4,676
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-
Fre SC $4.68
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
$111.25
PLAN CHECK FEE
TAL FEE
101
Lice SC $ ,00
11123.27
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
H VA A E THIS IS YOUR PERMIT
ZRIY
1
SIGNATURE OF OWNER IIF OWNER BUILDER. IDATEI
DG INSP QA TE
NEW [ ] �TS 00q :0 495-5
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
C -t-T-1 H
Effective 1/1/99
/'IMA -l -0J
03.9,7
ConstructionAddress: bo3q am n S4 �) F
Legal Description:
Owner Name & Address: Dave IA, 44:0< Tel. 4 -11e3d 59 / k3 Q 7
Contractor: WINDOW LITE Home Improvements MN LICENSE # C2Q033d5
Address:
Crosstown North Business Ctr. # 4 Tel. #
G,,ite 460-84 99-891h Ave. N0111 I
efookkffiftrib MN Wfttion, a Certificate of Survey of the y
lot, with the proposed construction drawn on it to scale. fal
LIVDdG AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER:
. C0
Construction Type: ihv,-, /7(/ pXg
&arXY Estimated Cost: $
(Fee I Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: '119--
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
-7&)
APPLICANT:(- Tel. #
Park Fee $
Sewer Main Charge $
TOTAL
STIPULATIONS:
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1110th%)
$.501$1,000 Valuation
$1050 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 [ ]
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
572-3604 FAX: (763) 571-1287
ADDRESS
6039 2ND ST NE
PIN
233024220049
LEGAL DESC
UNAVAILABLE
WATER TREATMENT APPLIANCE
LOT BLOCK
PERMIT TYPE
PLUMBING
PROPERTY TYPE
RESIDENTIAL
CONSTRUCTION TYPE
ADDITION/ALTERATION
PERM No.:2004-00639 .,`'
DATE ISSUED: 05/04/2004
VALUATION : $ 400.00
NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC CHAPTER 6 AND TABLE 6-A. INSTALL A GAS WATER
HEATER.
# ELEC WATER HEATERS 0 # NEW FIXTURES (EXIST OPENINGS) 0
# GAS WATER HEATERS
# GAS RANGES
# WATER TRMT APPLIANCES
APPLICANT
NORBLOM PLUMBING CO
2905 GARFIELD AVE S
MINNEAPOLIS, MN 55408-2173
(612) 827-4033
LISK DALE & KELLY
6039 2ND ST NE
FRIDLEY, MN 55432
1 # GAS DRYERS 0
0 # OF NEW FIXTURES 0
0
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 worl
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 conction or the performance of construction.
ADD1icallt r Date i
Bldg
PLBG PERMIT MINIMUM FEE
0.00
PLBG FIXTURES (NEW OPENINGS)
0.00
PLBG FIXTURES (EXIST OPENINGS)
0.00
WATER TREATMENT APPLIANCE
0.00
WATER HEATER - ELEC
0.00
WATER HEATER - GAS
35.00
GAS RANGE FEE
0.00
GAS DRYER FEE
0.00
STATE SURCHARGE, PLBG FLAT
0.50
TOTAL
35.50
PAID WITH CHECK # 28211
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
,ITY OF FRIDLEY INSPECTION DIV. Effective April 1, 2004
431 University Ave NE
'ridley, MN 55432 APPLICATION FOR PLUMBING AND GAS FITTING PERMITa�j
763) 572-3604, FAX (763) 571-1287 _
MARK NUMBER OF FIXTURES TO BE INSTALLED ON FACH FI nnR
'LUMBING FIXTURE RATES: NO.
RATE TOTAL
Unnal
Shower r
Wash 1t :;:::::::>
_:::......
TraStones�•
Floor
Drain
C ::<:::<::. Auto.
:;
8:.:: �:•.:"::::::::Washer :•.::
Gas
Range��.::.::-:::.:
Water Heater
Gas Elec
Seer Dispenser
�
:........
Base
31ow Off Basin
$10.00
and representations stated in this application are true and correct.
',atch Basin
lain Water Leader
$10.00
$10.00
>ump/Receiving Tank
$10.00
Floor or 1
Nater Treating Appliance
$35.00
OWNER (763) 571-8327
Nater Heater -Electric
$35.00
Nater Heater - Gas''
$35.00
Floor 2
was Range**
$10.00
' I 6 0
�7 ��' l � ���
Sas Dryer**
$10.00
ESTIMATED COST PERMIT NO.
3ack Flow Preventer Required ( )Yes () No
$15.00
Floor 3
Type
COMPANY 7O1
Reinspection Fee $50.00/Hr
SIGNED BY a� TEL NO
%LL OTHERS AND/OR REPAIRS AND ALTERATIONS
Floor 4
Approved By Rough -In Date Final Date
Surcharge
$
State
'LUMBING FIXTURE RATES: NO.
RATE TOTAL
JOB ADDRESS txM k a.S 01A) UVtnr U—) % C;( )a
Jew Fixtures
$10.00
The undersigned hereby makes application for a permit for the work herein
)Id Opening, New Fixture
$10.00
specified agreeing to do all work in strict accordance with the city codes
Seer Dispenser
$10.00
and rulings of the Building Division, and hereby declares that all the facts
31ow Off Basin
$10.00
and representations stated in this application are true and correct.
',atch Basin
lain Water Leader
$10.00
$10.00
LISK, DALE
!A
6039 2ND STREET NORTHEAST .2 2
>ump/Receiving Tank
$10.00
FRIDLEY, MN 55432
Nater Treating Appliance
$35.00
OWNER (763) 571-8327
Nater Heater -Electric
$35.00
Nater Heater - Gas''
$35.00
11
BUILDING USED AS �St ca►e.�tc �
was Range**
$10.00
' I 6 0
�7 ��' l � ���
Sas Dryer**
$10.00
ESTIMATED COST PERMIT NO.
3ack Flow Preventer Required ( )Yes () No
$15.00
r- `-
PLUMBING O C O'VYi1
Type
COMPANY 7O1
Reinspection Fee $50.00/Hr
SIGNED BY a� TEL NO
%LL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.25% of Value of Fixture or Appliance
Approved By Rough -In Date Final Date
Surcharge
$
State
MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 or 5% OF COST
TOTAL FEE
$ -3
OF THE IMPROVEMENT WHICHEVER IS GREATER PLUS THE SURCHARGE.
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. "PROVIDE COMMON VENT INFO ON BACK SIDE
FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT. VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacing an existing 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 O 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 existina 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 O 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 O 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