PRE 2010 DOCSCity of Frid1gy, Minn.
BUILDING PERMIT® s 17
Date: .. /1
Owner: .. ��Builder ..... _.... _........... ..._ _.. _.__........ .......
Address ....__ ... .._. .. _ Address - , '` ?._. e_......._... _.._..
LION OF BUILDING
No. ...:. Street ....._ } _. ._ . _... ----- Lot
Lot .. ....... - .._ Block ........._........ Addition or Sub -Division .... _...._`f�....___.....
CornerLot ........ ................--------- Inside Lot ..... .............. _................. Setback .............. ::......... ................ Sideyard..... ........ ...... _............................ .............. ............
Sewer Elevation....._............._............._......._...._..........................._....................._ Foundation Elevation
DESCRIPTION OF BUILDING
x `�Usea
Front .., . :.. Depth ...._ Height . ._.. Sq. Ft. _ Cl �1 Cu. Ft.
.......... ............. -............. .......... Front Depth Height Sq. Ft...................... Cu. Ft. ..... _.................
Type of Construction Est. Cbst..... -. To be Completed .-- •----- ............._.
THIS PERMIT DOE -,S, ,[\1C)h;'A',JTHORI?E VIOLAT-
ION OF ANY PI :;',TELi!D COVENANTS AND
BUILDING RESTRICTIONS.
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.
_.'..__......._......
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 Amy be revoked at any time u olation;�f any of the ero sions of said
ordinances. ';
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
Owners Name f, Builder
�Address
Address ,�, r) � , � �`"t��.�_ ,� � ����-�,s. � �.
OF BUILDING
No. �' Street ' Part of Lot
Lot : Block er Addition or Sub.Div. / i�%'
Corner Lot Inside Lot± ° o 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 beZ'C�A' 9_4# W used as:
Front L40 D
Sq. Ft. J
'_/Ij Cu'. Ft. -1 e 4 �..—.--
Front Depth height
Sq. Ft. Cu. Ft.
Type of Construction �A_,4,. _ Tstimated Ca t�//,.
To be
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 representW'
tions stated in this application are true and correct
DATE .2 SIGNATURE '
(A Schedule of Fee costs can be found on the Revere Side.)
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SUBJECT
City of Fridley
r�?
14 i H
AT THE TOP OF THE TWINS
BUILDING P E R M I'
f
ECEIPT N
Lu COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
/
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
612-560-3450
910-F15
10/18/77
JOB ADDRESS
5821 - 2�i Street N. E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
21
22
1 Hyde Park Addition SHEET
2 PROPERTY OWNER MAILADDRESS ZIP PHONE'
Sandy Oven 5821 - 211 Street N.E.
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 ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X
8 DESCRIBE WORK
roof and reside front
9 CHANGE QF USE FROM TO
STIPULATIONS
Roof can be 2nd roof put on but can not be the 3rd. Install ridged
galvanized valleys.
l
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.
$800
$ r,0
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-
50
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTALFEE
$8.00
GNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)
WHEN PROP RLY VALIDATED THIS IS YOUR PERMIT
J®
�q
IUREO WNE 'F OWN UILDERI f (D E) r•
BLDG INSFY DATE
CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL BUILDING PEWTS
(NEW, ALTERATIONS, ADDITIONS, OR REPAIRS)
OWNER: SNJ(i 0Aj BUILDER:
Address; o-� Address:
Tel. No.
No.: / Street:
LOT: 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 these Certificates.
DESCRIPTION OF BUILDING
1.
To Be Used As:
Front: Depth: Height:
Square Feet: Cubic Feet:
Front:
Square Feet:
Depth: Height:
Cubic Feet:
Type of Construction: StddA,�— Estimated Cost: $ 6600041!1`
To Be Completed: Alt. A Alt. B
Proposed 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 Aor additional information.
DATE: 10A 9J SIGNATURE: s r� - �. A ,
Stipulations:
'-0
City of Fridley
SUBJECT
F""Zl
AT THE TOP OF THE TWINS
BUILDING
P E R M I
r
`
CEIPT NO.
COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
q
1 �
i CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
j 612-560-3450
910-F15
7/20/78
JOB ADDRESS 5821 - 2h Street N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
21
22
1 Hyde Park
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Sandy Oven 5821 - 23 Street N.E.
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
Miles. Garages 4500 Lyndale Avenue North
588-9750
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 ❑ REPAIR ❑ MOVE ElREMOVE
X
8 DESCRIBE WORK
Construct a 16' x 22' Garage
9 CHANGE OF USE FROM TO
STIPULATIONS Provide hard surface driveway within one year. Maintain, = 25 foot set
back from alley and 3 feet from side lot lines.
SEP qTE PERA41TS .
.
WARMING
RE Ui
HEATi REO � WIRMG
nU. PLUM61t4G
$atom -digging cool i0cat utilities
%i=lE�1flNE
AND SIGN
- �LWRIC-- GAS Etc.
REQUIRED BY LAW
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
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.
$21548
$1.27
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 LOCA LAW REGULATING CON-
$14.08
ST TION OR THE ORMANC F CON UCTION.
Pur
LANCHECK FEE
TOTALFEE
7 ` A6 -Tv
$15.35
_ IGNATUREOFCONTRACTORORAUTHORIZEDAGENT (DATE)
H O
le RLY VALIDATED THIS IS YOUR PERMIT
BLDG. INSP
DATE
SIGNATURE OF OWNER (IF OWNER BUILDER) (DATE)
OWNER:
CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL BUILDING PERMITS
(NEW, ALTERATIONS, ADDITIONS, OR REPAIRS)
S, o ve IV
Address: S- 8 c- r
No. S �'? (
LOT: a I
/Ve Address :> G� ��/l.%fa� f0
Tel. No.:
Street: �. % �— S 7— �=
BLOCK: DLZZ ADDITION: CT jl'Q
CORNER LOT: INSIDE LOT: — a-ZTBACK: SIDEYARDS:
Applicant attach -to this form T<ao Certificates of survey of Lot and proposed
building location drawn on these Certificates.
DESCRIPTION OF BUILDING
To Be Used As:
e �
e
Front: Depth: Height: 1
r
Square Feet: �� Cubic Feet:
Front: Depth: Height:
Square Feet: Cubic Feet:
7,ype of Construction:Estimated Cost: $
To Be Completed: � � �
Alt. A Alt. B
Proposed 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 info ion.
DATE: 11 -%P SIGNATURE:
Stipulations:
•o
/Le�� ���
0
SUBJECT
PERM+T N@ _<
City of Fridley
£"®2 2 6 7 6
AT THE TOP OF THE TWINS
BUILDING
PERMIT
_
r �
RECElPTNO.�
COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
r �
1
"'1 CITY HALL FRIDLEY 55432
NUMBER
REV
GATE
PAGE Of
APPROVED BY
it", 11'j 612-571-3450
910-F15
I
I ..t
7 / 12 / 94
�
JOB ADDRESS 5821 2 1/2 Street NE
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DESCR.
21
22
Hyde Park
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP
PHONE
Gordon Wax 5821 - 21 Street NE
789-2513
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.
8 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION ❑x REPAIR
❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof House (7 SQ Tear -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.
ZONING
SO. FT.
CU. FT.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
NO. DWLG. UNITS
OFFSTREET PARKING
ANY TIME AFTER WORK IS COMMENCED.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1
STALLS
GARAGES
VALUATION
SURTAX
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$525
$.50
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$17.00
Fire SC $.53
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
$18.03
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
O
11 LY
IDA 'S IS YOUR PERMIT
91 of
&NAREOF (yW RiI OWNER BUILDER) IDATEI-Z
;.L
DATE
0
NEW. (j Effective 1/1/94
ADDN (] CITY. OF FRIDLEY
ALTER (j SINGLE FAMILY AND DUPLEXES R-1• AND R-2
Building Permit Application
Construction Address:z1=_=/�� -- ----- — -- --_
Legal Description: _
Owner Name & Address: God jil/ax 61Z- Z2,hJAW 1f Asli MAJ Tel. # Z5-/ 3
Contractor: (y,%T� rh %/a� MN LICENSE #
Address: tom/ JU SSY %d Tel. #
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRiPTION•�bF. IMPRQ��FT.
MEi�iT
Width Height Sq: Ft**
Width Height Sq. Ft.
.. Width . HgUGroiind __ $q. Ft:
LIVING* AREA: .
GARAGE AREA:
..DECK AREA:'
OTHER:
Length
Length
Length
Comer Lot [ ] Inside Lot [ ]
Type of Construction:
Approx. Completion Date:
Ft. Yd Setback Side Yard Setbacks'
Estimated Cost: $ t5-ds—
(Cost on Back)
Driveway Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: % % APPLICANT: Tel. # ` 0 Z�I�
CITY USE ONLY
Permit Fee
$
0
Fee Schedule on Reverse Side
Fire Surcharge
$
.001 of Permit Valuation (1/10th%)
State Surcharge
$
$.50/$1,000 Valuation
SAC Charge
$
$800 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
$
o6', 03
STIPULATIONS:
City of Fridley
AT THE TOP OF THE TWINS
SUBJECT
BUILDING
PERMIT
PERMIT NO.
'f'
L.
rr _---. COMMUNITY DEVELOPMENT DIV-
� PROTECTIVE INSPECTION SEC.
r � ,
CITY HALL FRIDLEY 55432
J 612-571-3450
REC
NUMBER
910-F15
REV
DATE
8/21/95
PAGE OF
APPROVED By
JOB ADDRESS 5821 2 1/2 Street NE
1 LEGAL
DESCR.
LOT NO.
21
BLOCK
22
TRACT OR ADDITION
Hyde Park
SEE ATTACHED
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Gordon Wax 612 22 Avenue NE, Mpls.,
MN 55418
789-2513
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 Rental Property
7 CLASS OF WORK n
El NEW ADDITION C1 ALTERATION % REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Replace siding on front of house
9 CHANGE OF 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
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
]
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 NOT. THE GRANTING OF A PERMIT
$348
$.50
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SACCHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
$21.00
FireSC .34
PLAN CHECK FEE
TOTAL FEE
21.84
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
PR
%.LDG
ERLY VALIDATED THIS IS YOUR PE MIT
S)GNATURE OF OWNERI IF OWNER BUILDER) IDATEI
P
f MATE
.�:�'�C�.`�ifi"�`�"+;R,^.��:c.:.k`ktitt :K:.2:^n:; at�:nra:-;:;.:;:�::.:::�:ra , , , . ,a�;�atn o,•.wn�; : ; :., .. ,... ,........ . ... ..... .. ......
NEW [ ]
ADDN [ ]
ALTER [ ] SIN(
Construction Address:�-
Legal Description:
Owner Name & Address:
Contractor: 0 wmr
Address:
Attach
lot, wit
` - LIVING AREA: Left9d
GARAGE AREA: Lengtl
DECK AREA: Length
OTHER:
Corner Lot [ ] Inside Lot [ ] Ft
Type of Construction: ir 5
Approx. Completion Date:
lir
Effective 8/1/95
-;-6c�7
Driveway Curb Cut Width Needed:
.. %P A IL — _ - L •• .P
Z
APPLICANT: Tel. #
CITY USE ONLY
Permit Fee
$''
Fee Schedule on Reverse Side
Fire Surcharge
$
.001 of Permit Valuation (1/10th%)
State Surcharge
Ft.
$.50/$1,000 Valuation
Ft.
$
Driveway Curb Cut Width Needed:
.. %P A IL — _ - L •• .P
DATE: Z J
APPLICANT: Tel. #
CITY USE ONLY
Permit Fee
$''
Fee Schedule on Reverse Side
Fire Surcharge
$
.001 of Permit Valuation (1/10th%)
State Surcharge
$
$.50/$1,000 Valuation
SAC Charge
$
$850 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 [
_) /, L
TOTAL
$
STIPULATIONS:
CITY OF FRIDLEY BUILDING INSPECTION
6431 University Ave NE
Fridley, MN 55432
763-572-3604 FAX 763-5711287
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% 4 Value of Appliance or Work
Minimum Fee $15.00 for Residential or 5% of cost of
Improvement whichever is greater
boos - OZ) 73 9
Effective 4/1/2004
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
Fee Total
$35.00 $
$10.100 $
$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/Industriai/Institutional
State Surcharge
TOTAL FEE
REINSPECTION FEE $50.00/HOUR
JOB ADDRESS 6-6 D I I 5l=EMN 5s 32.
Owners E.51 - R -G E- N sl 54 M ^
Building Used As f -k'. 1 -
ESTIMATED COST PERMIT NO
DESCRIPTION OF FURNACE AND BURNER
$ # of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Trade Name Size No.
BTU HP EDR
Fuel Total Connected Load
$ Burner Trade,Name Size No.
BTU HPEDR
rV1�he 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 -' Heating & AC Inc
Sign 763-572-0459
FAX# 763-572-0164 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
City of Fridley MN
FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT, VENT CONNEC4TOR AND. COMBUSTION AIR VERIFICATION
When replacing an existing fwrn_a_ce, the undersigned hereby vermes that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and frrestopped where required. Yes 06 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
BTU Input
and meets the current codes and manufacturer's specifications. This does
Appliance #2 Type
include AGA-GAMA Category I Central Furnace Venting Tables for fan
Fan Assisted or Nat
assisted and natural draft appliances.
Yes No( )
The existing combustion air is sized and installed to meet the current codes
Total Appliances
and manufacturer's specifications.
Yes Q() No( )
When required to install a new combustion air, it will be sized and installed
manufacturer's
Vent Height
to meet the current codes and 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 13 Vent Connector. Height
e ft Length
ft Diameter in Type
HEATING CO:
Signed By.