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PRE 2010 DOCSl �I j VMage of Fridley, Minn. j; BUILDING PERMIT 0 N • 7 100 ofce of INSPECTOR of BUILDINGS ,S^ y�: �1;'ss t � � Fridley, Minn., k ' 18 LOCATION OF BUILDING 140. � � Street o �✓ � Part of Lot Lot Block rw Addition or Sub -Division DESCRIPTION OF BUILDING Y� � 4� Front` Depth Height Stories Manner of Construction—Y, - To be used as ``:'" ;:r " ' To be completed""> Estimated Cost �' Y y h 3,F II Permit is hereby granIli ted to�'to a the buil described in the above statement. This permit is granted upon the express c," 'dition that the person to whom it is granted, and his agents, employees and workmen, in all the work done in, llaxound and upon said building, or any part thereof, shall conform in all respects to the ordi- nances of Fridley, !'i Minn., regarding the construction, alteration, maintenance, repair and moving of buildings within the city limAts, and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. P vt>inspector of Buildings. gs• AGREEMENT AND SWORN STATEMENT In consider tion of the issue and delivery to me by the Inspector of Buildings of Fridley of the above permit, I hereby agree to do the proposed work in accordance with the description above set forth Wand according to the provisions of the ordinances of Fridley, and, being first duly sworn, I herebystate and say that the facts stated by me and contained in the above permit are true as therein Mated. Subscribed an � sworn to before me at Fridley, Minnesota, this 4 ,i �4Sx".,�.3 ., R,. �.,,<...:. -+ day of �I,�I, A. D. 19 L�ry Date: AUGUST 24, 1965 EDMOND CASEY Builder Address 4720 .. 22 Street N. E. Address Fridley 21, Minnesota LOCATION OF BUILDING ca— 363 5 N° 8404 WESTERN CONSTRUCTION COMPANY 3117 ]'°Tyndale Avenue South Minneapolis, Minnesota No. 4720 Street 2,L,, Street N. E. part of Lot Lot .11 & K.20'Biock of Lot _12, 6 Addition or Sub -Division Plymouth Addition Corner Lot _ Inside Lot .__ Setback __ _ Sideyard Sewer Elevation ____ _. Foundation Elevation DESCRIPTION OF BUILDING To be Used as: D. Garai Front 20 Depth 22 height 10 Sq. Ft. 440 Cu. Ft.4,400 Front Depth Height Sq. Ft. Cu. Ft. Type of Construction Est. Cost _ _, 1 000.00 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 forth and in compliance with 21 provisions of ordinances of the city of Fridley. adm� ax'c"'/ a, �� 14�1 In consideration of the payment of a fee of $--A-- —00 , permit is hereby granted to WESTERN CONSTRUCTION COMPANY to construct the building or addition as described above. This permit is granted upon the express oondition that the person to whom it is granted and his agents, employees and workmen, is 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 locai3on, construction, alteration, maintenance, repair, and moving of buildings within the dty limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinanc�a. ALLEN G. JENSEN Building motor NOTICE: ihh permh does rot cover the construcdon, hutalldhn for VArhm phnrbing, an heetirg, sewer or wafer. Be core to we the Building hupector for Separate penrhs for than hero. 4 APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAME e4mo9zd BUILDER ADDRESS ADDRESS. LOCATION OF BUILDING NO. STREET PART OF LOT LOT _ZZ _BLOC R �%JL�ADDVION OR SUBDIVISION 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 building location drawn on these Certificates. DESCRIPTION OF BUILDING To be used as; d -ed Front2 d Depth__,.l a Height 7 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. DATEaL,4416.S— SIGNATURE (Schedule hof Fee Costs can be found on the Reverse Side). SUBJECT P .. City of Fridley ® 12672 AT THE TOP OF THE TWINS BUILDING PERMIT r RECEIPT NO. • COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. r � � i CITY HALL FRIDLEY 55432 -t-REV. NUMBER DATE -T PAGE OF APPROVED BY �'•-- ,�J 612-560-3450 910-F15 8/13/74 JOB ADDRESS 4720. 231 Street N.E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 11,12 6 Plymouth Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Ed Casey 4720 2k Street N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Martensen Construction' 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 CX ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 6' DESCRIBE WORK Construct a 151611 x 81 Addition ontoback of Dwelling 9 CHANGE OF USE FROM TO STIPULATIONS SEPE* ATE 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 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 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 $5,000 2.50 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- $30.00 STRUCTI N OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE $32.50 NATURE OF CONTRACTOR RAUTHORIZEDAGENT (D)EI WHEN PROPERLY VALIDATED IS YOUR PERMIT• THIS SIGNATURE OF OWNER (IF OWNER BUILDER) (DATE) BLDG. )NSP - DATVE APPLICATION FOR RESIDENTIAL, ALTERATION, OR ADDITION BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAM: �� !' 145e7 i! BUILDER:Y� 2i.C10 ,s,e�u o� J ADDRESS: oZ0 a: �, ADDRESS:, NO • . 4 7a -C) STREET • LOT: 11 4- / L- BLOCK: (p ADDITION : .�. CORNER LOT: INSIDE LOT: SETBACK: SIDEYARD: Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. DESCRIPTION OF BUILDING To Be Used As: 4 I Ont • % ��' �, �� Depth: / Height • % Square Feet: Cubic Feet Front: Depth: Height: Square Feet; Cubic Feet: Type of Construction: two . S'1?�VV\1e- Estimated Cost: $ j 0 0 2X 0® To Be Completed:`J� ® 1 97 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 :�� 12 2 j SIGNATURE: Gtsvv+-ego (See Reverse Side For Additional Information.) -5,50x( 0 a� owner of the property located at / have no objection to the City allowing the construction of al-) `' to be located at' . �- without the required certificate of survey that the City ordinarily requires for all neer construction: 71 epi Sz me Address Date W' Hess City ®f Fridl®y Applicel".fw MwAbq and G= rIMS Panmlt " Dept. of Bidgm. Phone M-3450 DESCRIPTION OF WORK Loeallm ��a� e � � � � 2�� /v r Number, Kind and Location of Fixtures ' O < •� S 2 < ;� ci i $ z 7 / p WATER HTR. GAS EIEC. Base 1st 2nd 3rd 41 4th -- • Future Coaaoetion Openings I `A"i`�=� `r'� &war 0 + New Fixture, Old Openings Cesspool [:] City of Fridley: The .undersigned hereby makes application for a permit for the work here! 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 true and correct • Fridley, hUnn IS ism ' 19 _2,1 Owner Kind of Building2 - Used as 4 1 t --t1 -C- L L, &16, , To be completed about PARTIAL RATE SCHEDULE Estimated cost, $ Old New. Building Permit No. Permit No. PLUMBING FIXTURE RATES: NO. RATE TOTAL ��Log �J f TC% �LLz/Y)/.��ib'l/G Number Fixtures ................. x $200 �® Signed $� Future Fixture Opening ............ x $1.50 $ _--- By New Fixture Old Opening .....:.... . x $1.50 $ Business Phone Catch Basin .................... x $3.25 $ Water Heater ;Up to 99,000 BTU) .... x $3.00 $ New Ground Run Old Bldg...... x $3.25 $ ROUGH Electric Water Heater........... x $2.00 SAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .. ........ • • • • x $2.00 a Additional Fixtures .................. x $ .75 Gas Range to 199.000 BTU .:. ,........... x $5.00 4 REPAIRS & ALTERATIONS—Refer to Code .50 State Surcharge Description ............................................. TOTAL FEE . 2 s?) City ®f Fridley SUBJECT - 2.7 5 4 3 PAT THE TOP OF THE TWINS BUILDING PERMIT "' P RECEIPT NO. �• _____ COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. r � � 1 � � NUMBER REV DATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 612-571-3450 910-F15 9/2/98 JOB ADDRESS 4720 2 1/2 Street NE 1 LEGAL LOT NO.BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 11, Pt. 12 6 1 Plymouth SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Matt Jansen 502-0602 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. AAAmerica's Best Inc. 2400 Interlachen Dr707-0100 201397( 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. B USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION REPAIR O MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof house and garage 13 SO Tar -off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with the State.Building Code. 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 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 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 1110 .56 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 HE PERF MANCE OF CONSTRUCTION. $40.25 Fire SC $1.11 V__,,� PLAN CHECK FEE TOTAL FEE -A - Liclanse SC .00 1$46.92 SIGN URE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI WHEN PROPERLYft&LIDA7D THIS IS Y VR PERMIT BLDgr INSP ryATE SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI NEW [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: qr4;'n Legal Description: Owner Name & Address: yyjQ-J-� :S�5 Tel. # _S?J� - ()(OC) 2 Contractor: MN LICENSE # 210 (3g `) p _S Address: ,;2qD() '�-kwjo- -ke,Vn )v- baa a Tel. # Y-� 01"1-O(co Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF EVIPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: P'e:'-Cs� _ Construction Type: � Estimated Cost: $ (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: APPLICANT: Tel. #,-)0'"i —0(C)n Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: $ 14 &, 9c� CITY USE ONLY Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th%) $.50/$1,000 Valuation $1000 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 [ J CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 572-3604 APPUCATION FOR PLU MARK NLI UR= ng MY I lacer Ma FITTING PERMIT . Effective On January 1, 1997 Water RATE TOTAL New Fixtures $ 7,00 Wash :-': Drtn ` :,: Auto. `fig:.,.,.;, Gas .., :,M;� Water Heater ::<:::�?x Stories Closet;: Urinal Tib " Showa ;Stitt` Tray '�" 1=U'.... . �„•,•-: •:.5;: i{t• ''• .�'h••w• '�':��.�:�:•;:s•. a Pp:~ ' ' Ran a g ,=.�:;;: ':.?.r.. Gas Elec Basemen $10.00 . $10.00 Back Flow Preventer Required ( )Yes () No Type $15.00 Floor 1 v:::[;:•:•:.:.:: ::�:Ct;-?��•?; :E':;c;:•:•'i%::'v:•: :?}`i •S,K,:i:?`r:;• Y' ... S,}?.?Y �,V,L•'y:':?iy ��,.'•�{;iS?:'.ti:Y,::: y{''�:p:5: eti;{yr';v?: Floor 2 .x,.. •�Y' <>.:::. u. v>�::�;,r�:::<: :s'-:,.x<:�::: Floor Floor 4 PLUMBING FU(TURE RATES: NO. RATE TOTAL New Fixtures $ 7,00 Old Opening. New Fbxture $ 4,00 Bea Dispenser $ 5,00 Blow Off Basin $ 7.Q0 Catch Basin $ 7.00 Rain Water Leader $ 7.00 Sump/Rece'NIng Tank 37.00 Water Treating Appliance $10.00 Water Heater -Electric $ 7.00 Water Heater - Gas** $10.00 ,Gas Range" $10.00 Gas Dryer** $10.00 Back Flow Preventer Required ( )Yes () No Type $15.00 Reinspection Fee $42.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance State Surcharge TOTAL FEE $ .50 A�o JOB ADD �a�� 4/ The and ereby makes application for a permit for the work herein specifi to do all work In strict accordance with the city codes and rutin Building Division, and hereby declares that all the fads and•rep stated in this application are true and correct. OwnZ. , J, ANI -1'11- PLU SI PERMIT LfVY TEL NO.- • r ��! Rough -!n Date Final Date / "COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) 6-A. MINIMUM SIZE 9 SO INCHES. 0 SuB�EtT - O. City of Fridley(_30431 AT THE TOP OF THE TWINS BUILDING PERMIT r � RECEIPT NO. COMMUNITY DEVELOPMENT DIV. >r __��_ r I PROTECTIVE INSPECTION SEC- NUMBER REV DATE PAGE OF AP ,•% CITY HALL FRIDLEY 55432 L J` 612-571-3450 910-F15 10/21/99 JOB ADDRESS 4720 2 1/2 Street NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 11,1t.12 6 Plymouth SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Matt Jansen 502-0602 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Owner 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION IDK REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Replace siding on house and garage (3 sides) 9 CHANGEOFUSEFROM TO STIPULATIONS Call for building wrap inspection before covering. SEPARATE PERMITS ARE REOUIRED 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 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 $600 $ .50 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL TME PERMIT FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION $26.55 $.60 PLAN CHECK FEE OTA E JIDAJIL $ .65 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDAtE, HEN RO I$ I$ YOU PER 7 SIGNATURE OF OWNERIIF OWNER BWLDERI IDATEI Bl INSo r,ATE 0 NEW[ ] ADDN [ l ALTER [ ] Construction Address: Legal Description: Effective 5/10/99 CITY OF FRIDLEY SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION 7�e d % 5/ lt� �16170V /Q/ Owner Name & Address: %��/ �GG�S�� S�vn aT Tel. #� ^ �� -ao� Contractor: �� MN LICENSE # Address: Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT Tel. # 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: e )ao e - ( i Oh�Qus� timated Cost: $ 6767 Driveway Curb Cut Width Needed: Ft. + 6 Ft = DATE: APPLICANT: Ft x $ =It Tel. # TOTAL STIPULATIONS: $ o .6-5 CITY USE ONLY Permit Fee $• S `i Fee Schedule on Reverse Side Fire Surcharge $ s ca .001 of Permit Valuation (1/10th%) State Surcharge $ .5-6 $.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 STIPULATIONS: $ o .6-5 M SUBJECT P City ®f Fridley 3082 4 AT THE TOP OF THE TWINS C BUILDING PERMIT • _____ COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. / r 1 1 a = CITY HALL FRIDLEY 55432 NUMBER REv DATE PAGE OF APPROVED By 612-571-3450 910-F15 4/13/00 JOB ADDRESS 4720 2 1/2 Street NE I LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 11, Pt. 12 6 1 Plymouth SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Matt Jansen 4720 2 1/2 Street NE 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Erik Johnson Concrete, Masonry & Waterproofing 3011 Pierce St NE, Mpls., MN 55418 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO 781-5822 City 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 Replace cement front step 9 CHANGE OF USE FROM TO STIPULATIONS Install to comply with State Building Code requirements for rise, run and platform minimums. 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 MOT 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. OWLG. 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 $ WITH WHETHER.SPECIFIED HEREIN OR PtqT. THE GRANTING OF A PERMIT $400 .50 DOES NOT P ESUME TO GIVE AUTH RI Y TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISION OF Ng OTHER STAT O LOCAL LAW REGULATING CON• $23.50 Fire SC $ STR CTI R E ERFOR F CONSTRUCTION .40 PLAN CHECK FEE TOTAL FEE it License $24.40 A UR CO T RAUTMORIZEDAGENT ID91t. E PROPERLY VALIDATED THIS IS YOUR YERMIT ..: /—/, SIGNATURE OF OV^EAoF OWNER BUILDER, iDATEi -h$P - M NEW I I Effective 1/1/2000 ADDN [ ] CITY OF FRIDLEY (763) 572-3604 Bldg,lnsp ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 tib BUILDING PERMIT APPLICATION Construction Address: "1 7 2C) /Z- -5T ' /9:�g %�%� , r1 j �J �1 Legal Description: IA-zi Owner Name & Address: Tel. # Contractor: �� MN LICENSE # Address:_ J r`�C`c' .� j , dL�. M5,/t1/0 Tel. # TOTAL $ C;2 / 7 ® l STIPULATIONS: -- — X2 del-DX&y(w-)�F ��5 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: ,�7--557 O Construction Type: X Estimated Cost: $ Driveway Curb Cut Width Needed: Ft. + 6 Ft = F x $ = $ DATE: % t D APPLICANT: L", -- Tel.I -k— ----- 'j�r CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application Permit Fee $ S Fee Schedule on Reverse Side Fire Surcharge $ .001 of Permit Valuation (1/10th%) State Surcharge $ $.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;2 / 7 ® l STIPULATIONS: -- — X2 del-DX&y(w-)�F ��5 C/ 01 SUBJECT City of Fridley TI,993 AT THE TOP OF THE TWINS BUILDING PERMIT r COMMUNITY DEVELOPMENT DIV. R CE PT NO. V _____ PROTECTIVE INSPECTION SEC. �1// ��®� CITY HALL FRIDLEV 55432 NUMBER REV DATE PAGE OF APPROV 0 BY 612-571-3450 910-F15 7/13/01 JOB ADDRESS 4720 2 1/2 Street NE 1 LEGAL LOT NO, BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 11, pt 12 6 Plymouth Addition SHEET 2 PROPERTY OWNER MAIL ADORES$ ZIP PHONE Matthew/Mary Jansen 4720 2 1/2 Street NE 763-502-0602 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Sears Home Improvements 8823 Zealand ave N, Brooklyn Park, MN 55442 763-315-4517 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 20090017 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 8 USE OF BUILDING Residential 7 CLASS OF WORK O NEW O ADDITION O ALTERATION G2 REPAIR ❑ MOVE - O REMOVE 8 DESCRIBE WORK Replacement windows within existing openings 9 CHANGE OF USE FROM 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. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE. OF CO ST. 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 BF COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $6,325 $3.16 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- Fire $6.32 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION $139.25 SC PLAN CHECK FEE TOTAL FEE Licen C $5 $153.73 St ATUREOF TRACTO AU ORiZEDAGENT iD E� HE PRO VALI ED THIS IS YOUR PERMIT S-GNATURE OF OWNEROF OWNER SU40.ER7 tDATEt 01 NEW [ ] Effective 1/1/2001 ADDN [ ] CITY OF FRIDLEY (763) 572-3604 Bldg Insp ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Construction Address: !�j, iii oz Z2- Legal 2 Legal Description: Owner Name & Address: rne�kh c �+t'�'I er- .. ��p� Tel. #3- 5OZ-�7C�7� Contractor:MN LICENSE # Address: Tel. # gSJ-f 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 HgVGround Sq. Ft OTHER: Construction Type: ?eft M e K� Estimated Cost: $ C® Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft z $ _ $ DATE: 3 APP ANT* Tel. #p.�-3/� CITY USE ONLY - Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: Call (763) 572-3604 for Permit Fees if mailing in application $ 139. �� Fee Schedule on Reverse Side $ .001 of Permit Valuation (1/10th%) $ $.50/$1,000 Valuation $ $1150 per SAC Unit $_ a. 60 $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 k'AX: (763)571-1287 ADDRESS : 4720 2 1/2 ST NE PIN : 263024320081 LEGAL DESC : UNAVAILABLE : LOT 0 BLOCK 0 PERMIT TYPE : HEATING PROPERTY TYPE : RESIDENTIAL CONSTRUCTION TYPE : ADDITION/ALTERATION PERMITO.: :2004-01:92:1'k) DATE ISSUED: 10/19/2004 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. INSTALL A FURNACE (WARM AIR, RUUD, 60000 BTUS) # A/C UNITS 0 VALUE OF APPL OR WORK 0 # FURNACES 1 # GAS DRYERS 0 # GAS RANGES 0 VALUE (FOR MINIMUM CALL) 0 APPLICANT SHARP HEATING & AC INC 7221 UNIVERSITY AVE FRIDLEY, MN 55432- (763) 572-0459 1'Xl ' SUVAD KARIC 4720 2 1/2 ST NE FRIDLEY, MN 55421 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 construction or the performance of construction. Bldg InsM Datelb(19 1'6',_ HEATING PERMIT MINIMUM FEE 0.00 FURNACE SHELL/DUCT WORK 35.00 GAS RANGE FEE 0.00 GAS DRYER FEE 0.00 AIR CONDITIONING FEE 0.00 HEATING REPAIRS/ALTERATIONS 0.00 STATE SURCHARGE, MECH FLAT 0.50 TOTAL 35.50 PAID WITH CHECK # 14897 SF.PARATF PF.RMTTC RF.nTTTRF.T) FnR WCIRK nTHFR THAN T)F.SCRTRF.T) ARnVE. CITY OF FRIDLEY BUILDING INSPECTION 6431 University Ave NE F Fridley, MN 55432 763-572-3604 FAX 763-571-1287 RATE SCHEDULE Residential Furnace Shell and Duct Work, Bumer & also Replacement Furnace R5538 Effective 4/1/2004 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES Fee . Total $35.00 $1 Gas Piping (New Furnace; Fireplace, Insert) $10.00 $ JOB ADDRESS H-1 Q � 19- Ist Owner ) U. u oa I`l, a v-) G Building Used As( - ESTIMATED COST PERMIT NO "C_ Gas Range $10.00 $ DESCRIPTION OF FURNACE AND BURNER Gas Dryer $10.00 $ # of Heating Units,_ Circle One (Steam) (Hot Water) ( arm Ar Trade Name IZI) Size No. n o *Air Conditioning - All Sizes $25.00 $ BTU HP EDR Fuel Total Connected Load All Other Repairs or Alterations (List on Back) 1% of Value of Appliance or Work Minimum Fee $15.O0 for Residential or 5% of cost of Improvement whichever is greater Commercial/industrial/Institutional 1.251/6 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 Burner Trade Name BTU I� Size 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. $ 50 HEATING CO Sharp Heating & AC Inc $! Signed,sS:A r Id,j 4N -Tel # 763-572-0459 FAX # 763-572-014- Date Io � is-[6�( *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 Approved Rough -in Date Final Date `' City of Fridley MN 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 fzrestopped 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 Length �ft and meets the current codes and manufacturer's specifications. This does Type include AGA -GALA Category I Central Furnace Venting Tables for fan Length ft assisted and natural draft appliances. Yes ( No( ) The existiinp combustion air is sized and installed to meet the current codes Length ft 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 verges 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 Yom` No( ) Appliance Tvpe and Size/Common Vent and Vent Connector Information Appliance #1 Type (at) (ee e�� 1t BTU Input COD Fan Assisted or Nat Appliance #2 Type BTU Input Fan Assisted or Nat Appliance #3 Type BTU Input Fan Assisted or Nat Total AppliancesTotal I3tu Input �0 6 a i Common Vent Type Vent Height- Diameter L{ inches Appliance #1 Vent Connector Height __,3�_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:Sharp Heating & AC Inc Signed By: Date: 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 Fee Total $35.00 $ $10.00 $ $10.00 $ $10.00 $ $25.00 $ 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 JOB ADDRESS Owner Building Used As��i�' ESTIMATED COST � & ` 1Z PERMIT NO DESCRIPTION OF FURNACE AND BURNER # of Heating Units Circle One (Steam) (Hot Water) Trade Name Size N BTU HP EDR _ Fuel Total Connected Load Burner Trade Name BTU HP Size No. EDR (Warm Air) 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. $ HEATING CO,�: : wy ZZ-'Za Tel # ��✓��?� REINSPECTION FEE $50.00/HOUR5�`A//�G✓FAX # (,�%�✓✓�� Date *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 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 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 () 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 : Building Inspections 763-572-3604 SIz THIS APPLICANT 1S: PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE WITH APPLICATION PROPERTY TYPE PERMIT TYPE TYPE OF WORK: DESCRIBE WORK BEING BUILDING RESIDENTIAL APPLICATION CITY OF FRIDLEY Vruwivr-x NAME: STATE LICENSE # ADDRESS: CITY STATE ZIP, CITY EXP DATE 0 Permit NO. Received By: Date Rec'd: STATEMA)ZIP M 2 J PHONE gSINGLE FAMILY/NE ❑ TWO FAMILY/NEW ❑ ADDITION ❑ BASEMENT FINISH ❑ DECK SIZE OF IMPROVEMENT_ ROOFING NUMBER OF SQUARES GARAGES PROPOSED SIZE: PROPOSED HEIGHT: SIDING ❑ Vinyl ❑ Aluminum ❑ Other PROOF ❑ SIDING ❑ SWIMMINC ❑ ADDITION PAIR ❑ REMODEL] LENGTH ❑ HOUSE ONLY ❑ HOUSE & GARAGE ❑ ATTACHED GARAGE ❑ DETACHED GARAGE ❑Soffit ❑ Trim ❑ Fascia WINDOWS IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS OR FOR NEW OPENINGS -DESCRIBE SIZE OF OPENING CHANGES & SIZE STORIES [ED ❑ WINDOWS ❑ DRAIN TILE ❑ OTHER POOL VG WIDTH HEIGHT Ft. BASEMENT REMODELING SUBMIT: 1. Existing Floor Plan 2. Proposed floor plan 3. List of structural members to be used FOR NEW CONSTRUCTION INCLUDING DECKS, ADDITIONS & PORCHES SUBMIT: 1. Site Plan/Survey showing the existing structures and proposed project. 2. Two sets of construction plans 3. Energy Calculations TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS 1 ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS. (USING THE 1997 U.B.0 FEE SCHEDULE) / 00 TOTAL JOB VALUATION $' 0'jP3:2�_e111-CUPANCY TYPE Permit Fee Plan Review $ Fire Surcharge $ Surcharge $ License Surcharge $ SAC Charge $ Curb Cut Escrow $ Erosion Control $ Park Fee $ Sewer Main Charge $1,11, Total Due A$r2,. 2n See Back Page for Fee Schedule 65% of Building Permit Fee .001 times the total job valuation .0005 x Permit Valuation Minimum $.50 $5.00 (State Licensed Residential Contractors) $1550 per SAC Unit (Plans to MWCC for determination) -ft +6 ft= ftx$20=$ $450 Conservation Plan Review Fee Determined by Engineering i��,�. Agreement necessary ( ) Non Necessary Make checks payable to: City of Fridley Attach Stipdlations FOR A PERMIT -NOT VALID UNTIL PROCESSED I hereby apply for a building pe'' - owledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of all work whic requires review and approval of plans. SIGNATURE OF APPLICANT -.,-"41 / ! r PRINT NAMEg � I Z J .CC CDATE 2 � � CITY OF FRIDLEY INSPECTION DIV. ;431 University Ave NE :ridley, MN 55432 763) 572-3604, FAX (763) 571-1287 Effective April 1, 2004 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT nr AKK NUMBIzIl Ut- I -IA I URES To BE INSTALLED ON EACH FLOOR '' 11t:> Urina :::-:: �� Shower '�� Wash Y �:3.tu::::::>::;: iC:�><> Floori DrainWasher Auto. �::==:::: ::.. ;(.: G8S Range :z<:::: Wa er Heat�:.�Tt er � Gas Elec e t Basem n <<>< r Floo 1 Floor FI 2 Floor 3 Floor FI 4 'LUMBING FIXTURE RATES: Iew Fixtures )Id Opening, New Fixture leer Dispenser flow Off Basin :atch Basin ;ain Water Leader pump/Receiving Tank Vater Treating Appliance Vater Heater -Electric NO. RATE TOTAL Vater Heater - Gas** � ;as Range** ;as Dryer** ;ack Flow Preventer Required ( )Yes () No Type $10.00 $10.00 $10.00 $10:00 $10.00 $10.00 $10.00 $35.00 $35.00 $35.00 $10.00 $10.00 $15.00 reinspection Fee $50.00/Hr .LL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.25% of Value of Fixture or Appliance 4.00 JOB ADDRESS_ "Sr - , a.S ow Nu -4- 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 fads and representations stated in this application are true and correct. DATE: /0 // 7 , 20 196 OWNER BUILDING USED AS k4'SI d e lic--e-- Suvad Karic 4720 2 1/2 Street Ne — Fridley, MN 55421 ESTIMATED COST q6 c) oo PERMIT NO. PLUMBING COM'PA4 NO O t- U OVA SIGNED TEL N0. ((y 12) 527- clo 3.3 Approved By 1—U Rough -In Date Final Date State Surcharge MINIMUM FEE FO ANY PLUMBING/GAS PERMIT IS $15.00 or 5% OF COST TOTAL FEE OF THE IMPROVEMENT WHICHEVER IS GREATER PLUS THE SURCHARGE :OMBUSTION 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 replacina 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 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 installina a new ventina 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 It Length ft Diameter in Type ALTERATIONS:_ (Describe) HEATING CO: Signed By: Date