PRE 2010 DOCSIn consideration oe issuance to me of .a permit to construct the building described above, I, agree to do
the proposed work in rdance with the description above set ,forth and in compliance with all provisions- of
ordinances of the villa of Fridley.
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO. RATE TOTAL
Number Fixtures
x $200
$
Future Fixture Opening
Y
$
New Fixture Old Opening
tt
d
$
Catch Basin
x $3.25
$
?
d
•
I
!
N
WATER HTR,
GAS
ELEG
Base
z $200
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..... .... ..... ..
x $2.00
$
Additional Fixtures ..... ..............
x $ .75
$
Gas Range to 195,000 BTU ..............
x $5.00
$
1st
--
-
--
-
2nd
-
3rd
4th f L I
° Putrue Connection Openings Connected with
* Now Fixture, Old Openings I Sewer
Cesspool❑
❑
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO. RATE TOTAL
Number Fixtures
x $200
$
Future Fixture Opening
x $1.50
$
New Fixture Old Opening
x $1.50
$
Catch Basin
x $3.25
$
Water Heater (Up to 99,000 BTU)
x $3.00
$
New Ground Run Old Bldg.
x $3.25
$ '•3 • °2-
Eiectric Wates Heater
z $200
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..... .... ..... ..
x $2.00
$
Additional Fixtures ..... ..............
x $ .75
$
Gas Range to 195,000 BTU ..............
x $5.00
$
REPAIRS & ALTERATIONS -Rages to Code
Description .... .... ....................... ...........
TOTAL FEE $ -
City of Fridley:
The undersigned hereby makes application for a permit for the work herei
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. c�
ey, Minn- ISO
Owner
Kind of Building
Used as
To be completed about �-
Estimated Cost, $ _(�7/.)
Old ewi Building Permit No._ _ _ _,Permit No. -S e -V 7
Signed
By - _
Business Phone Nom e 73 �%T el
ROUGH
FINAL ' 1 '
Origin Permit forPLUMBING AND GAS RTTING
N.B. When work covered by this permit is ready, the Plumbing Ordinance requires that request for
inspection shall be phoned in to the plumbing Inspector, 560-3450 giving number of this permit.,
Number. Sind and Location of Fixtures
d' y1 Q i S m x F m m S m d WATER HTR.
Stories O Z m m x N z O O Z ttt m Q rc ®_ p�p, m z
U m F m m 3 F O W IJi. p U m b 6A8 ELEC.
Basement
1st
2nd
3rd
4th
Connected with Sewer -Cesspool Gas Piping for Openings
Permission is hereby granted - to do the plumbing and
gas fitting in the building describA in the 9tatement attached, &n the express condition that
the person to whom this permit is granted, and his agents, employees and workmen, in the plumbing
or gas fitting of said building shall conform in all respects to ordinances of the City of Fridley, and
this permit may be revoked at any time upon the violation of any of the provisions of said ordinances.
By Order Of The Inspector Of Buildings
Roughing in Inspection Date
Inspector.
Final Inspection Date
N? 5007
[pr$*t
F5. —25—
City of Fridley V: ,19!9
Location '754 S'- 4L -.7a . �? 6 ,
Kind of Building
Used as
To be Completed , 191
Estimated Cost $ A6 -r.
Old -New. Building Permit No
Date
ft
Inspector. Inspector of Buildings.
4z �M-6-69-v
City of Fridley
SUBJECT
P IT NO.
® 13656
AT THE TOP OF THE TWINS
BUILDING PERMIT
•
i
CEIPT NO
' COMMUNITY DEVELOPMENT DIV.
r � PROTECTIVE INSPECTION SEC.
�
CITY HALL FRIDLEY 55432
L
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
612-560-3450
910-F15
17/20/76
JOB ADDRESS 7565 - 4th Street N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
19
1
Osborne Manor SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Harold Sorenson 7565 - 4th Street N.E.
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Sussel Company 1850 Como Avenue, St. Paul 55108
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
R NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK —IMPORTANT—
Construct a 20' x 22' Garage
DIVISION. REGMING CURB
ENT
9 CHANGE OF USE FROM TO
AT DRIVEWAY OPENINGS.
STIPULATIONS Provide a hard surface driveway. Maintain a minimum of 3 feet
between the eaves or provide a one hour separation.
Release signed by neighbor for building without survey.
Wnu
KRMiTS REQUIRED FOR WIRING) Before digging call local utiiitlrs
SEPERAYE TELEPHONE - ELECTRIC - GAS Etc.
NEAnt4G PLAJUBING AND SIGN& REQUIRED BY LAW
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
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
440
4400
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.
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$3,256-00
1.63
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-
STRUCT10y OR THE PERF RMAI)L�E OF CONSTRUCTION.
$17.60
�5�
PLAN CHECK FEE
TOTAL FEE
�+
,E,
1 $19.23 a.
- SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)
WHEN PR PERLY VALIDATED THIS IS YOUR PERMIT
BLDG INSP DATE n -
SIGNATURE OF OWNER OF OWNER BUILDER) (DATE)
W,
CITY OF FRIDLEY
PPLICATION FOR RESIDENTIAL ALTERATION,
ADDITION, OR REPAIR BUILDING PERMIT
ee a
NAME: eAzt, "Lzt: Z a 4_e?,z.>'BUILDER: 4-���C
0
ADDRESS : SL - %? ADDRESS: ,✓� _ c �%�'- L�e5'�G
NO • STREET:
LOT: 9 BLOCK: / 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.
To Be Used As:
DESCRIPTION OF BUILDING
Front: Depth: Height:
Square Feet: Cubic Feet:
Front: Depth:
Square Feet; Cubic Feet:
Height:
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.
A
DATE: �— d - ?� SIGNATURE : ," c � �
C-
(See Reverse Side For Additional Information.)
S`�;s
n i" f$ i
3 (f tip , " t� ✓ C -'r �ei_T..t�+ + ' C�_d
3j 2.5a
I
AGREEMENT
owner of the property
located at , have no objection to the
City allowing the construction of a Q"-C)rQa I'- to be
located at ���` ��.. GA without the required
certificate of survey that the City ordinarily requires for all new
construction.
r)
sigzUture.
Address
t r5776
Date
0. 14Witness
SUSSEL GARAGE SUSSELCOMPANV
Permit by J V _-ftj�
Legal Description
Lot
Blk
Add'n y
Value Z�
Type Const.
SLA
SUSSfL
M
WORK ORDER
HOME PHONE. 7gZi
NAME %-IA90 D X 5b f?-C-NSoAi BUS. PHONE:!7B/
JOB ADDRESS 7S6S' !,/ 7)1S7 -XC -C -r Ae- 5-51#32
BLDG CODE AREA `2/ DLC%
SALESM l o/h `+nlLi 1 CONTRACT DATEY/rh7 SIZE ` c, X 2_Z
FOR OFFICE USE ONLY r
CONTRACTOR AFAA)s T JOB #
y Owner Approx. - - - --
❑in _ DOOR SWING:
2-9� TIN GS POINTS ONLY LH
S.P.L. OUTSIDE INSIDE
S. S. P. L. R H
R.P.L.
Alley
tNp House
F. Street
Other
CaSquare With
B-Ra'ds-
(' Mesh
CgAod Rem. - By S v -■5G 1
B 5.0 g Mix
V6 -Bag Mix
•Camping
Tamping/o
.B.0-F(OXO
Grade Point
Conduit
By Owner ❑ By Sussel J
Bidl-vir"in 8' Total Wall CL
�
Height including Blocks vJ
aintain 8' Wall Height on
Top of Blocks
ja Other
VjQ.H. Or Offset j
Location
indows
❑ Att Gar Roof Tie-in
Drawn on attached pictures ,
Existing garage: No M
❑ Detached ❑ Attached Yes ❑
Size of existing: —x —
Existing garage will be:
❑ Left as is
❑ Converted to L.S. - By owner
❑ Removed By: Ovor
jJunk Must Be Removed By Owner;)
❑ Specify removals by Sussel
or owner - trees, bushes, etc.
❑ Show approx. dist. garage to
house and all prop. lines /
Stakes visible - ❑ Yes Impo
/Survey available - ❑ Yes 9No
L1G Special instructions from
IS"cr-1 N G S O
P-4
n
M
P1PL-
5
j
PURCHASER'S INITIALS:
ROOF: GABLE :REVER�SEGABLE HIP
EAVE OVERHANG: 4 ��
SUSSEL GARAGES SUSSEL COMPAD VISION OF NY
RAKE OVERHANG:
1" x 8" Ridgeboard 240# SEAL DOWN SHINGLES WITH PLYWOOD
= - - ROOF SHEATHING AND 15# FELT
?„ a,
�.
s''
-- Rafters Plywood Sheathing
240# Seal Down Shingles
2" x 6" 3/8" Plywood Trim
Cross Ties Gussets Fascia
2" x 4" Double
1" x 6" W -Bracing Top Plate 1'' x 4" Sub
when applicable
Fascia
per Minn. State Code
Soffit
NOTE: 3/4" Cove R
1) Trusses set 48" O.C. (Gusset - 3/8" Plywood). -
2) Intermediate rafters are 2" x 6" 's braced with 2" x 6" collar ties.
3) On 18' and narrower garages, eliminate the W -bracing and collar 2" x 4" Studs "
ties.
4) Roof approved by Minn. State Building Dept. as meeting Minn.
State Code Requirements of 30# snow load. Refer to State Siding f "
Building Code.Letter Number 35.
5) Hip roofs consist of 2" x 6" rafters, 2" x 6" cross ties 48" O.C.,
2" x 8" hip rafters and no plywood gussets are used.
RAFTERS: 2" x 6"; -16" O.C.
STUDS: 2" x 4 16" O.C. --24" O.C.
WALL SHEATHING:- Giroe
SIDING: cer4Dwoad S/Y14/C4"5*
OVERHEAD DOOR HEADER: Double 2"x 12" with vo not steel
,_....._. _ plate, plywood filler.
Slab on grade construction approved per Minnesota State Code. Refer
to State Building Code Letter Number 11. ,
/z x 7 Anchor Bolt
per U.B.C.
2" x 4" Bottom Plate
SLAB: 4" WITH MESH 6" x 6" #10 Gauge
\� Grade Line
450I All
n_
J
MIT NO.
SUBJECT
R
City of Fridley
�
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
RECEIPT NO.
COMMUNITY DEVELOPMENT DIV
%�
__
v PROTECTIVE INSPECTION SEC.
1
CITY HALL FRIDLEY 55432
/JLC'
NUMBER
REV
DATE
PAGE OF
APPROVED BY
612-571-3450
910-F15
I ]JOB
9/20/96
ADDRESS 7565 4 Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
19
1
Osborne Manor
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Harold Sorenson 7565 4 Street NE
784-7167
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Best SidingCo Inc 9153 Davenport St Blaine
-
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
Reside House & Garage; Install soffit fascia
9 CHANGE OF USE FROM TO
STIPULATIONS
Ventilation to be provided that meets 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 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
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
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$5,860
2.93
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVIS NS OF ANY OTHE TATE OR LOCAL LAW REGULATING CON-
STRU TI N OR T E ERFO M NCE OF CONSTRUCTION.
112.25
Fire SC 5.86
PLAN CHECK FEE
TOT FEE
I
Li s
5A
126.04
ROP
)NS'sIr,
VALI T THIS IS�G9�U� MIT��
GATE
SIGNATURE OF 6MTRACT( R R AUTHORIZED AGENT (DATEI
SIGNATURE OF OWNER, IF OWNER BUILDER) IDATEI
J
MIT NO.
NEW [ ] Effective 3/1/96
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application!` (�
T
ConstructionAddress:T
-7s � s �// - 5T. N.C .
Legal Description:
Owner Name &Address: SC) dr-„% S ®�7 Tel. # "7 -714 7
Contractor: j3 C—S -j e . MN LICENSE #` �- 6
Address: /S-3 AVe�!/ipa�'Z`f S f n!•b l� t-A-IWL Tel. # 7k61
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: R65
074117 Neu
Comer Lot [ ] Inside Lot [ ] Ft. Yd
Setback Side Yard Setbacks
Type of Construction: V l ;,i L
Estimated Cost: $ ��
Approx. Completion Date:
(Cost on Back)
Driveway Curb Cut Width Needed:
Ft. + 6 Ft = Ft x $ _ $
DATE:'G f ( 2D APPLICANT:
4-0'� 2.7' ) . �� IZ&-- 56 A Tel. # z/ -71 &- 7
CITY USE ONLY
Permit Fee $/�. ���
Fee Schedule on Reverse Side
Fire Surcharge $ c?(c
.001 of Permit Valuation (1/10th%)
State Surcharge $
$.50/$1,000 Valuation
SAC Charge $
$990 per SAC Unit
License Surcharge $ G®
$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:
CITY OF FRIDLEY INSPECTION DIVISION
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
(763) 572.3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
A&
Residential
Furnac=Shell an Du ,t Work, Burner -
Also ment Furnace
(Side Vent: • ut 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 TOTAL
$ 30.00 $. 6V
$ 10.00 $
$ 10.00 $
$10.00 $
$ 25.00 $
State Surcharge
TOTAL FEE
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
JOB ADDRESS '7565— 4M S Nt
OWNER_ Did, SO hen5Oh
BUILDING USED AS—__ReSiWAAv� k.,L
ESTIMATED COST LL'PERMIT NO.,���
•.. • :rte X • 01
No. of Heating Units Circle One (Steam) (Hot Water)arm Ai
Trade Name &Anuk–&- Size No.
BTU '70�AIM HP EDR _
Fuel AkAiHJ 6"_Total Connected Load a no
v e-,,
Burner Trade Name _--�l . Size No.
BTU HP EDR
The undersigned hereby makes application for a permit for the work here
specified agreeing to do all work in strict accordance with the City Codes
rulings of the Building division, and hereby declares that all the facts anc
representations stated in this application are true and correct.
HEATING CO
Signed
TEL #
Approved By Rough -In Date Final Date
THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
When re lacing an fixosffn6 Mranro, 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�j No ( )
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination.
Yes () NW
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturers specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances. _
Yeso No ( )
The a iia enmhi isfiran arms is sized and installed to meet the current codes
and manufacturer's specifications.
Yes( ) No
When required to install a now cnmb istien air, It will be sized and installed
to meet the current codes and manufacturers specifications.
YesX No( )
When installing -a new yantinn SIM12M the undersigned hereby verifies that
it is a fisted assembly and meets the current codes and manufacturers
specifications. This does include AGA-GAMA Category I Central Furnace
Venting Tables for fan assisted and natural draft appliances.
Yes kpf 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 #1 Type BTU Input Fan Assisted or Nat /
Appliance #2 Type _AA jkIr L • BTU Input IleA oez�j Fan Assisted. or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances _ Total Btu Input
Common Vent Typ5—e yP Vent Height Diameter inches
Appliance #1 Vent Connector Height ft Length-1—ft Diameter in Type C
Appliance #2 Vent Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter Type
' a
HEATING CO:
Sighed By Date:
CITY OF FRIDLEY PERMIT NO.: 2004-02181
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432 DATE ISSUED: 11/29/2004
(763) 572-3604 NAX: (763) 571-1287
ADDRESS : 7565 4 ST NE R 6
PIN : 113024210027 I�
LEGAL DESC : OSBORNE MANOR
: LOT 19 BLOCK 1
PERMIT TYPE : HEATING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
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.
# A/C UNITS 0 VALUE OF APPL OR WORK 0
# FURNACES 0 # GAS DRYERS 0
# GAS RANGES 0 VALUE (FOR MINIMUM CALC) 150
APPLICANT
CENTERPOINT ENERGY/MINNEGASCO
13562 CENTRAL AVE NE
ANOKA, MN 55304 -
OWNER
SORENSON HAROLD I
7565 4TH STREET NE
FRIDLEY, MN 55432
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
regul ns ction or the performance of construction.
An licant Date 1
HEATING PERMIT MINIMUM FEE
15.00
FURNACE SHELL/DUCT WORK
0.00
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
15.50
PAID WITH CHECK # 1023514
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
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
3
Effective 4/1/2004
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS 5L4:96 -/, Al�
Fee Total
Owner I /_/ /Q/d����
$35.00 $ Building Used As
$10.00 $ ESTIMATED COST ZL171a PERMIT NO
$10.00
$
DESCRIPTION OF FURNACE AND BURNER
$10.00
$
# of Heating Units
Circle One (Steam) (Hot Water) (Warm Air)
Trade Name
Size No.
$25.00
$
BTU
HP EDR
Fuel
Total Connected Load
$
Burner Trade Name
Size No.
BTU
HP EDR
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
REINSPECTION FEE $50.00/HOUR
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.
$ /S -N6
*Air Conditioners can not be placed in side yard without written approval
from adjoining property owner - copy to City
Tel # i!W;`3�/ 30/b
FAX # 012- 3�+ �� � Date &--& ��%L'i
,-T46Wa' 01 alb �, 1, ,,Z�IW .
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
Permit Fee
BUILDING
See Back Page for Fee Schedule
Permit
Inspections
65% of Building Permit Fee
RESIDENTIAL APPLICATION
$
Received By:
763-572-3604
$
CITY OF FRIDLEY
License Surcharge
DatRN&J U N lfm
(0/11124X71
I
$
DATE
YOUR E-MAIL ADDRESS
.®lrl
SITEADDRES 79(1'-'!�
��
$
THIS APPLICANT IS:
°OWNER ❑CONTRACTOR
$
PROPERTY OWNER/
NAME: Iya M 18,Y.
$
TENANT
ADDRESS: CITYS lave
Fe>ete STA
. o7/J Make checks payable to: City of Fridley Attach Stinulatioas
PHONE: JT4.�
CONTRACTOR
NAME:
STATE LICENSE # EXP DATE
SUBMIT A COPY OF
YOUR STATE LICENSE
ADDRESS: CITY
STATE ZIP
WITH APPLICATION
p ONE FAX
PROPERTY TYPE
SINGLE FAMILY/NEW CONSTRUCTION SIZE
O FAMILYINEW CONSTRUCTION STORIES
PERMIT TYPE
❑ ADDITION ❑ GARAGE/SHEDWINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK:
❑NEW ❑ DIIION
❑ MAINTENANCE/REPAIR REMODELING
DESCRIBE WORK BEING DONE: m & 140
1600r -
SIZE OF IMPROVEMENT LENGTH WIDTH'HEIGHT
Sq. Ft.
ROOFING
❑ HOUSE ONLY
NUMBER OF SQUARES
❑ HOUSE & GARAGE
BASEMENT REMODELING SUBMIT:
GARAGES
❑ ATTACHED GARAGE
I.
Existing Floor Plan
PROPOSED SIZE:
❑ DETACHED GARAGE
2.
Proposed floor plan
PROPOSEDHEIGHT:
3.
List of structural members to be used
SIDING
FOR NEW CONSTRUCTION INCLUDING DECKS,
0 Vinyl
❑Soffit
ADDITIONS. & PORCHES SUBMIT:
p Aluminum
❑ Trim
1.
Site Plan/Survey showing the existing structures
❑ Other
❑ Fascia
and proposed project
WINDOWS
2.
Two sets of construction plans
IN EXISTING OPENINGSes ❑No LOCATION OF WINDOWS
3.
Energy Calculations
OR FOR NEW OPENINGS-
CRIBE SIZE OF
O
, Mt.10.0m. 2 "-'
TYPE WINDOW TO BE INSTALLED DOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(U ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION 5 CUPANCY TYPE
Permit Fee
$
See Back Page for Fee Schedule
Plan Review
$
65% of Building Permit Fee
Fire Surcharge
$
'3 .()-b .001 times the total job valuation
Surcharge
$
/ , 6TD .0005 x Permit Valuation Minimum $.50
License Surcharge
$
$5.00 (State Licensed Residential Contractors)
SAC Charge '
$
$1675 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow
$
ft + 6 ft = ft x $21 = $
Erosion Control
$
$450 Conservation Plan Review
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement necessary ( ) Non Necessary ( )
Total Due
$
. o7/J Make checks payable to: City of Fridley Attach Stinulatioas
THIS IS AN APPLICATION FOR A PERMIT NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge 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 ew anoval of plans, J
SIGNATURE OF APPLICANT _ PRINT NAME d 0 SOCCOM PDATE (ol,11-077