PRE 2010 DOCSCity of Fridley, Minn.
f.
BUILDING PERMIT No 4 99 5
1 � r
Date:
Owner: Z.1=
_..=.1+I" Builder .�
E _.._
_.._ ..._..._......._...._.._........._..Address` � .� ;.,� Address
�j
LOCATION OF UJILDING
Street _ , �' -- .r_ /,r ,�_. Part Lot ....._..... ,_... .....
.
Lot ....._.. ..... ..............' Block ....._.....�..............--....... Addition or Sub�Iivisi n .. '�i,°�r-a •��-•—✓ r
.. �
Corner Lot ................_........ Inside Lot ..... _...............................
*back ..Z...."`�ideyard ... �.
SewerElevation .....-.._.........---_..._....__ --- _............................. __...__...._....._. Fo tion Elevation .... ._................. -----._._......_........-_--._----_---_...._._...._.-
DESCRIPTION OF BUILDING
To Used as:
�. '2..
i�.1
�_L Front . -. Depth .-. - .. Height . ./�. a-- Sq. Ft. �.�!_... Cu. Ft. _; -j_..•
_...... ` ........._....... -.... Front ..... ......... ....... Depth ,�!%ihfi r �. Sq. I+'t.....- ............ ... Cu. Ft. ..... _.....:...........
ro .............._.__� ! � .�........�.. 0
Type of Construction �.�t. �.0 ... Est Cost......... '�. �....a................ 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 all provisions of
ordinances of the city of Fridley.
.. Z........_.......__..__.._.._....._........_........_..._....._...._.. ....._...._..._..__.�__....
In consideration of the payment of a fee of $..7-i . ..... ....... , 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 violation of any of the provisions of said
ordinances.
'.-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.
4
•
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
Owner Is Name �: ®� S <b o6
s Builder
fl e
Address "?z;'/ 4 4�''/e% e l�L , Address 3 3 YL/
LOCATION OF BUILDING
No. / Street e! l 1' yW., e )-y-E Fart of Lot 6
Lot 902 Block 3 Addition or Subdivision �S—d" S® ee
Corner Lot _Inside Lot Setback Side -Yard _-Y
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Certificate of Survey of Lot and proposed building
location.
To be used as:
DESCRIPTION OF BUILDING
20
Sq. Ft. -) Re) Cu. Ft.
Front Depth Aeight
Sq. Ft. Cu. Ft.
Type of Construction �-z � >X -t P Estimated Cost
To be Completed /----1 /
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 representations
stated in this application are true and correct. o /� _ /`'_ "i'
O
(A Schedule of Fee Costs can be found on the Reverse Side.)
3200 FRANCE AVE. S0.
3rd. STREET
N.E.
ROMAN ROAD
ki
i
W
Z
W
t
h,
I hereby certify that the above to s survey of Late One (1) through Twenty (20). Block z
Three (i).,CAW.iONIS-SUNIIIT MANOR SOUTH ADDITION. Anoka County. Nlnneacte. showing the :<;r
location of the houses on said lots. a
As surveyed by me this 18th day of April 1955 A. D.
signeA
Nintweoea ReA ntretfon No. 2x94
CITY OF FRIDLEY
APPLICATION FOR
POWER PLANTS AND HEATING,
COOLING, VENTILATION, REFRIGERATION AND
.AIR
CONDITIONING SYSTEMS AND DEVICES
PARTIAL RATE SCHEDULE
Furnace Shell & Duct Work to 100,000 BTU
$12.00
$ "
each add. 50,000 BTU
GRAVITY WARM AIR:
RATE
TOTAL
Job AddressG:
7.00
Furnace Shell & Duct Work
$12.00
$
7.00
$
Replacement of Furnace
Repairs & Alterations -up to $500.00
7.00
7.00
$
$
Department of Buildings
Repairs & Alterations each add. $500.00
4.00
$
City of Fridley
Tel. #571-3450
MECHANICAL WARM AIR:
Furnace Shell & Duct Work to 100,000 BTU
$12.00
$ "
each add. 50,000 BTU
4.00
$
XReplacement of Furnace
7.00
$
Repairs & Alterations -up to $500.00
7.00
$
Repairs & Alterations each add. $500.00
4.00
$
STEAM OR HOT WATER SYSTEM:
Boiler & Lines up to 100,000 BTU
$12.00
$
each addn. 50,000 BTU
4.00
$
Boiler only up to 100,000 BTU
7.00
$
each addn. 50,000 BTU
6.00
$
OIL BURNER— to 3,gal. per hour
$10.00
$
each add. 3 gal. per hour
10.00
$
GAS BURNER- from 100,000 BTU to 199,999 BTU
$10.00
C4
$ j p°i
(over 199,999 BTU see Fee Schedule)
$
GAS FITTING FEES:
s
c�
'
— 1st 3 Fixtures x
$ 3.00
$
3
Additional Fixtures x
$ 1.00
$
Gas Range to 199,000 BTU x
$10.00 •
$
AIR CONDITIONING
FAN HEATING SYSTEMS
VENTILATING SYSTEMS
ALTERATIONS $ REPAIRS
ROUGH INSP.
Date
FINAL INSP.
Uare
APPROVAL FOR PERMIT
See Fee Schedule $
$
$
State Surcharge $ .50
TOTAL FEE
REINSPECTION FEE
($10.00)
MINIMUM FEE FOR ANY HEATING PERMIT IS $7.50 PLUS $.50 STATE SURCHARGE
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes
and rulings of the Department of Buildings, and hereby declares that all the
facts and representations stated in this application are true and correct.
s�
G% Fridley, Minn. 1g/"
OWNER
KIND OF BUILDING
USED AS
TO BE COMPLETED ABOUT /lam
ESTIMATED COST
�D - NEW BUILDING PERMIT NO. PERMIT NO,
DESCRIPTION OF FURNACE/BURNER
HEATING or POWER PLANTS, Steam, Hot Water, a1 Vii.- No.
i4�,.` �y
Trade Name Size No. f7. e
Capacity Sq. Ft. EEDDR^ BTU .� G � HP
Total Connected Load �i �J Kind of Fuel
BURNER - Trade Name
Capacity Sq. Ft. EDR
Size No.
BTU HP
Company NC.
Signed By 31ff CAJFORNIA STREET NORTH EAST
0AINNMA 1
Tel. No.
HEAT LOSS CALCULATIONS ! DEPARTMENT OF INSPEC NJ
Weatherstrips A.S.H.V.E. ` ` Construction No.
Guide
Windows I Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kind
Yea— o Yea—No 19
11
ft »_I (-'iil RnnmAfpneth q,7 W;dth i-isht a Ulf 7 o—J r --
Windows and Doors—Crackage and Area
11
Width Height No. of Lineal ft.
No. or pane of pane Ilghte of cracksq.
Area
ft. -
_
y
ato G.
iAcx
ba
Av .
Coef.1 Btu
020
2
Q4.F Btu
Infiltration
Coef. Btu
Infiltration
Exp. wall
Glass
996
Glass
y A
Net exp: wall
Int. wall
Exp. wall
Int. wall
Ceiling
3 of /
Net exp. wall
�.
Floor
Floor
Inc. wall
Ceiling
Floor
Iota[ Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area r
/ . Fl.1 • Roornitenath 1z Width -i L/ 14e;aht fe,"
Windows and Doors--Crackage and Area
Width Height No. of
No. of Dane of pane Ilghte
Lineal ft. Area
of crack sq. ft.
"� l9
oral.
-24 cM-//
.
Infiltration
Av .
Coef.1 Btu
Infiltration
Glass
Exp. wall
Q4.F Btu
Infiltration
6
Exp. wall
Glass
996
Exp.. wall
y A
Net exp: wall
Int. wall
Int. wall
Ceiling
3 of /
Ceiling
�.
Floor
Floor
I otal Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader. area
I F1.1 /% RoomA Unath ", -o Width --) 1/ iU.ht
Windows and Doors--Crackage and Area
Width Height No. ofLlneal ft.
No. of pane of pane light. of crack eq. fL
e6 Q I IL/.
`►
.
Cocf-1 Btu
Infiltration
Coef.1 Btu
Infiltration
Glass
Exp. wall
t f
6
Exp. wall
Ceiling
996
Net cup. wall
y A
Int. wall
Ceiling
3 of /
�.
Floor
Total Btu.
Required sq. ft. EA.R. or sq. ins. W.A. Leader area
Windows
NDMEAPOLIS. NIDVItI
Insulation
How
a
Width
and Area
neat t1
Ar-
. rL
CoeE Btu
Infiltration fib
GlassDoc(o `�
Exp. wall 9 TZ 1/a
Net exp. wall - f0
Int. wall
Ceiling 5 ---z 38'yZ 41
Floor
Tot tu. �p
equired sq. ft. E.D.R. or sq. ins. W.A. Leader area ,
F1 I &W Roonf ength U Width Height ZoK
Windows and Doors—Crackage and Area
Glass
Exp. wall
Net exp. wall y
Int. -wall
Ceiling '3 -),e /a iffy
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
FLS Room I Length Width Height
Windows and Doors—Crackage and Area
Width Height No. of Lineal fl. Area
No. of pane of pam lights of crack ep. M
Cocf-1 Btu
Infiltration
Glass
Exp. wall
Net exp. wall
Int. well
Ceiling
Floor
Iwo tstu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
SUBJECT
PE
City of Fridley16255'
AT THE TOP OF THE TWINS
BUILDING PERMIT
RECEIPT NO.
`v _ COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
3y Z�f
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
'o-_1 `j
L 612-571-3450
910-F15
6/23/81
JOB ADDRESS 201 - 49th Avenue N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
3
3
Carlson's Summit Manor South. Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Nick Schoens 201 - 49th Avenue N.E. 560-4597
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Viking Home Improvement Co. 4832 - 2h Street N.E. 572-1820
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
Reroof structure - install aluminum soffits: & gutters
9 CHANGE QF USE FROM TO
STIPULATIONS
Roof can be 2nd but not 3rd roof. Install ridged galvanized valleys.
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
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
$1,750
$.88
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMITFEE
SACCHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTALFEE
$12.88
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)
WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
BLDG INSP I 9FATE
SIGNATURE OF OWNER IIF OWNER BUILDERIi� iD TES
CITY OF FRIDLEY
APPLICATIOd FOR RESIDENTIAL BUILDING PERMITS
(New, Alterations, Additions, or Repairs)
OWNER:�/Ick/ BUILDER: � �
ADDRESS: ®/— 9 / -(e &EADDRESS:
TEL NO: 7TEL 110:
Construction Location
STRM- T NO: Q ( STREET: J/9 C�z ale k)
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 certificates to scale.
DESCRIPTION OF CONSTRUCTION
Aeoo F Front: Depth: Height:
Squane.Feet: Cubic Feet:
Front: Depth: Height:
Square- Feet: Cubic Feet:
xaw4lml'�'11111,tf 7Type of Construction: Cost: $ Z7!��
To Be Obxtpleted:
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $ $
SEE REVERSE SIDE OF SHEET
Mie undersigned hereby makes application for a permit for the %.nrk'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 coYre
DATE: (l/ � � SIGNATurE : G�
Stipulations:
A j")-00
c°30
SUBJECT
Pym-„' ,- •\
City of Fridley
27531
AT THE TOP OF THE TWINS
BUILDING
PERMIT
I ,
PT NO.
T �
COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
' j %®�
I i
NUMBER
REV
DATE
PAGE OF
APPROVED BY
= CITY HALL FRIOLEY 56432
612-571-3450
910415
9/3/98
JOB ADDRESS 20149th Avenue NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
3
3
lCarlson's Summit Manor South Addn. SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Forslund
572-1402
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Viking Home Im rovment Co. 4832 2 1/2 St NE Xpls MN 99421
572-1,920,
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 O MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and garage 17 SO Tear -off; Sidinp, and rewrap fascia
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
Call for building wrap inspection before covering.
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
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
7456
$3.72
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-
STRUC N OR THE PE FO MANCE OF. NSTRUCTIO
$137.25
Fire SC $7.45
PLAN CHECK FEE
TOTAL FEE
License SC $5.00
1$153.42
SiG TUREOF ACTOR OR AUTHORIZED AGENT (DATEi
WHEN PROPE RYRALIDATED THIS IS YOUR PERMIT
BL NSP
/�
DATE
SIGNATURE OF OWNERi IF OWN ERBUILDERI IOATEi
NEW . L ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION711 g Z� 6
ConstructionAddress: 1 42--- ZI V4�
Legal Description:
Owner Name & Address: L v,✓ Tel. # :5-72 - i q0 Z
Contractor: V�� MN LICENSE # !2 7 71 ----
Address: 4-lfl-? Z �% -L S-7`— Tel. # Z -,Irl Z.
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:
l 3 -°ikA j -pRe Lvn °p rkse `A e�'46VO-' / s
Construction Type: ,,� Estimated Cost: $�s�
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ = $
TOTAL $ /,S-3.-42
STIPULATIONS:
CITY USE ONLY
11 �)
Permit Fee
$ / "2s�Fee
Schedule on Reverse Side
Fire Surcharge
$ 5.001 of Permit Valuation (1/10th%)
State Surcharge
$ $.50/$1,000 Valuation
SAC Charge
$
$1000 per SAC Unit
License Surcharge
_
$ L
$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 $ /,S-3.-42
STIPULATIONS:
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
572-36U4 JFAX: (763) 571-1287
ADDRESS : 20149 AVE NE
PIN : 263024230052
LEGAL DESC : CARLSONS SUMMIT MAN SO ADD
LOT 3 BLOCK 3
PERMIT TYPE PLUMBING
PROPERTY TYPE RESIDENTIAL
CONSTRUCTION TYPE ADDITION/ALTERATION
PERMI NO.: 2004-01667
DATE ISSUED: 09/23/2004
VALUATION : $ 400.00
PLBG PERMIT MINIMUM FEE
PLBG FIXTURES (NEW OPENINGS)
0.00
0.00
NORBLOM PLUMBING CO
NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC CHAPTER 6 AND TABLE 6-A. INSTALL A
GAS WATER
HEATER.
MINNEAPOLIS, MN 55408-2173
WATER TREATMENT APPLIANCE
0.00
# ELEC WATER HEATERS
0
VALUE OF FIXTURE/APPLIANCE
0
# NEW FIXTURES (EXIST OPENINGS)
0
# GAS WATER HEATERS
1
# GAS DRYERS
0
# GAS RANGES
0
# OF NEW FIXTURES
0
VALUE (FOR MINIMUM CALC)
400
# WATER TRMT APPLIANCES
0
TOTAL
35.50
APPLICANT
PLBG PERMIT MINIMUM FEE
PLBG FIXTURES (NEW OPENINGS)
0.00
0.00
NORBLOM PLUMBING CO
2905 GARFIELD AVE S
PLBG FIXTURES (EXIST OPENINGS)
0.00
MINNEAPOLIS, MN 55408-2173
WATER TREATMENT APPLIANCE
0.00
(612) 8274033
WATER HEATER - ELEC
0.00
WATER HEATER - GAS
35.00
GAS RANGE FEE
GAS DRYER FEE
PLBG REPAIR/ALTERATIONS
0.00
0.00
0.00
OWNER
KAREN FORSLUND
201 49TH AVE NE
STATE SURCHARGE, PLBG FLAT
0.50
FRIDLEY, MN 55421
TOTAL
35.50
PAID WITH CHECK # 29120
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 work
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
re ting construction or the performance of construction.
Annlican �'' Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
'RITY 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 k4p5o7
MARK NUMBFR OF FI)M IRFR Tn RF IMAT01 I Fn nKi Peru ci nno
61�0 / Y'9
3LUMBING FIXTURE RATES: NO.
RATE
TOTAL
JOB ADDRESS 64nnn2 - a.S o'LJVa+ -
4ew 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
3eer Dispenser
$10.00
and rulings of the Building Division, and hereby declares that all the fads
Now Off Basin
$10.00
and re FORSLUND, KAREN true and correct.
..atch Basin
Water Leader
$10.00
$10.00
201 49TH AVENUE NORTHEAST I� r�
FRIDLEY, MN 55421
lain
2U V�
Sump/Receiving Tank
$10.00
(763) 572-1402
Nater Treating Appliance
$35.00
OWNEi
Nater Heater -Electric
$35.00
Nater Heater - Gas** �_
$35.00
� -
tt
BUILDING USED AS k.4&S1 d e nGe_
Sas Range**
$10.00
Jas Dryer'*
$10.00
ESTIMATED COST �6 of7 PERMIT NO. c2?0
3ack Flow Preventer Required ( )Yes () No
Type
$15.00
1 t
PLUMBING COMPANY O t(-�` OVA LLAAH tpi
Reinspection Fee $50.00/Hr
SIGNED BY A TEL N0. N12) $27-clo33
kLL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.25% of Value of Fixture or Appliance
b�
Approved By Rough -In Date Final Date
State Surcharge
$ •
�S
MINIMUM FEE F Y PLUMBING/GAS PERMIT IS $15.00 or SO/* OF COST
TOTAL FEE
$
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 reglacinra 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 Installinsa 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 ( ) No( )
Appliance Tvpe 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: