PRE 2010 DOCSCity of Fridley, Minae
BUILDING PERMIT 0C487
AA
Date:
Owner: ...�`°. �>T� ._� :_��. _..! _ __._. Builder .............
A�eAddress ...�►��_"` ' Address
LO TION F BUILDING
]go. _..... Street _._ _.... �_.__.._ Part of Lot ._..
Lot ....---. ...-----....._...----- Block ....._....
.......................... Addition or Sub-Divisi;��-- .
Corner Lot .......................... _........ Inside Lot ..... .............. _. ,+
.............._�tback �' •-=...._ .. _.. � Sideyard ....._...---' ---......._..._-•----_...._...-•--------...---•---
Sewer Elevation ........... ........_.._..._...._.._._...._.....__...___....._._.._.__...._.:_.... Fo ation Elevation .................... ....... __............... ................ ......... ...........
_..._..
DESCRIPTION OF BUILDING
To be Us as:
-
-......._.._..._.. ®Front ._ : ;Depth __._...::_.. Height ----- .. Sq. Ft.. Cu. Ft
--.............. ......... .............
_..........
.... Fro t ... Depth ....................
4n..eight _ ..... _... ;............. Sq. Ft. ............. ......_.. CU. Ft.........................
Type of Construction .......... ...., .. Est. Cost ..s....._'. 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.
In consideration of the payment of a,fee of $. �q ._..__._._...., permit is hereby granted to. ... _...... .................. - ...........
_.._..._.
to construct the building or additionas 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 violatld f of any of the provisions of said
ordinances.
-.�+I..:! .,'�..� Building Inspector
NOTICE:
This permit does not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sure to ase
the Building Inspector for separate permits for these items. CAUTION ION
1101� ..dao...,, -, nrr AWQ&CC NNInT AUTHORIZE VIO
ION OF ANY Pl vA I L LAND COVENANTS AND
BUILDING RESTRICTIONS.
APPLICATION FOR. BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
Owners Name x�1;6-12 ilder. -
Address fe'7I' 3 uIO_ Address
LOCATION OF BUILDING
No. Street Part of Lot
Lot s Block. '2 Addition or Sub.Div. &0jrZ �XA,E
Corner Lot Inside Lot Set Back Side -Yard
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Certificate of Survey of Lot and proposed building
location,
DESCRIPTION OF BUILDING
To be used as:
Front �� Depto?� ____Height � / ,
._ .� h ..�....
et
Sq. Ft. Cu. Ft.
0
Sq. Ft. Cu. Ft.
t
Type of Construction (g Estimated Cost ,A �,.Q�_______
To be completed nQ -- 19e
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City Ordinances and ruling of
the Department of Buildings, and hereby declares that all the facts and representa-
tions stated in this application are true and corrppt. 1 ZI
DATE6.a V _ SIGNATURE
(A Schedule of Fee costs can be found on the Reverse Side/.)
•
cNS
rh
City of Fridley
Applicaflon for wd G n Fitting Pwmit
Dept. of Bldgs. Phone 960-34W
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
���yyy
NO. RATE TOTAL
Number Fixtures
r$�$
$
Future Fixture Opening
x $1.50
ti
New Fixture Old Opening
r
$
Catch Basin
x $3,25
W
00
•
t
•
N
WATER MTR,
GAS
EIEC
Base—
x $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures .. ..
1 x $200
$ 2.00
Additional Fixtures ... ..............
x $ .75
$
Gas Range to 199,000 BTU ..............
x $5.00
$
install (1) gas grill
3.00
REPAIRS & ALTERATIONS—Refer to Code
lst
Description .... ... ........................
...........$
2nd
3rd
4th
° Future Connection Openings Connected with — -- --
* Now Fixture, Old OpeningsSewer
I Cesspool
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO. RATE TOTAL
Number Fixtures
x $2.00
$
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
$
Electric Water Heater
x $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures .. ..
1 x $200
$ 2.00
Additional Fixtures ... ..............
x $ .75
$
Gas Range to 199,000 BTU ..............
x $5.00
$
install (1) gas grill
3.00
REPAIRS & ALTERATIONS—Refer to Code
Description .... ... ........................
...........$
TOTAL FEE $ 5.00
_ • -
City of Fridley:
53-84-3915.51
The undersigned hereby makes application for a permit for the work herei
specified, agreeing to do 411 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, Minn_ June 13, 1970 y 19—
Owner D. J. Bona
Kind of Building frame
Used as residence
To be completed about `rune 18, 1900
Estimated Cost, $ 10.00
X
Old—New. Building Permit No._ _ _ _Permit No.
By- -- -
Business Ph a No
INNEAPOLIS GAS CQ
ROUGH
FINAL
City of Fridley
AT THE TOP OF THE TWINS
FIRER -DEPARTMENT REQUEST
PUBLIC WORKS DIVISION
CRY HALL FRIDLEY .55432
612'560-3460 NUNBER '
No.. 1p
DATE OF BREAK %
�G�1F�) '
TIME
A.M. X P.M.
LOCATION OF BREAK
I'0 % ? _ 6
3
REPORTED
DAMAGE TO PAVING apd/or PRIVATE PROPERTY
REPAIRS MADE (Materials, Labor, Equipment)
REPAIR DIFFICULTIES (if any)
INSTALLING CONTRACTOR C
TYPE OF MAIN L��t�-tf SIZE / JOINT
COVER: S ft. in.
THICKNESS AT POINT OF FAILURE in.
NATURE OF BREAK: CIRCUMFERENTIAL ❑ LONGITUDINAL ❑ BOTH ❑ BLOWOUT ❑ JOINT ❑
SPLIT AT CORPORATION ❑ SLEEVE ❑ MISC ❑
APPARENT CAUSE OF BREAK: DEFECTIVE PIPE ❑ CORROSION ❑ DETERIORATION
MISCELLANEOUS (Describe) Q IMPROPER BEDDING ❑
STREET SURFACE: PAVED IaUNPAVED ❑ TRAFFIC: HEAVY ❑ MEDIUM ❑ LIGHT
TYPE OF S OIL / • *9t�
ELECTROLYSIS INDICATED: YES ❑ NOM" CORROSITN: OUTSIDE ❑ INSIDE ❑
CONDITIONS FOUND: ROCKS ❑ VOIDS ❑ PROXIMITY TO OTHER UTILITIES
DEPTH OF FROST in DEPTH OF SNOW in.
ESTIMATED WATER LOSS 9 G (hours) TOTAL WATER LOST / 5 7, 5 93,�Gal.
INITIAL INSTALLATION DATA:
TRENCH PREPARATION: NATIVE MATERIAL /Q -se- �' SAND BEDDING ❑
(describe type)
GRAVEL BEDDING ❑
BACKFILL: NATIVE MATERIAL DESCRIBE BANK RUN SAND & GRAVEL ❑
GRAVEL ❑ SAND ❑ CRUSHED ROCK F1 OTHER
SETTLEMENT: NATURAL ❑ WATER ❑ COMPACTORSVIBRATORS ❑ OTHER
(describe)
1
'REMARKS
SP
OtAEGTORATE
® OF
PUBLIC WORKS
C�L.LT OF MEMORANDUM
10,
Ralph VoU non, Public Wbrks Superintendent PW86-81
FR M: John G. Flora,f Public Works Director
SUB=T: Basement Flooding - 1072.63rd Avenue
DATE: April 8, 1986
C suncilman Sahnei der received a am plaint from the resident
at 1072 63rd Awxm (571-5114) regarding -basement flooding
as a result of work the City did on Pierre Street.
Request you review the records -to determine what work was
ac amplished cap Pierce and 63rd that may have a flooding
impact an this res3.denoe 0
r
Nlr j 1 IA"I
JGF/ts
iW
®
IF
DIRECTORATE
00
oeQ
PUBLIC WORKS
CITY
MEMORANDUM
�—
TO:
Nasim Qureshi, City Manager
Pw86-87
i
FROM:
John G. Flora, Public Works Diector
SUBJECT:
Basement Flooding - 1072 63rd
DATE: April 10, 1986
At the April 7, 1986 Council meeting, Councilman Schneider requested
information regarding a complaint from Mrs. Tims at 1072 - 63rd (571-5114)
regarding basement flooding.
Our history indicates that this residence has experienced basement flooding
for a number of years. This is primarily caused by the high water table in
this area.
Currently, we are aware of a possible water leak on Dellwood Drive in the
vicinity of Mrs. Tims residence. We are attempting to locate the problem.
It is anticipated that we will find it and correct it next week.
While we do have a water leak, it is quite small and is not endangering
Mrs. Tims residence, but it is not improving the situation as the ground
water table has continued to be fed.
I have talked to Mrs. Tims and will keep her appraised of what the City is
doing and will inform you of any information we develop during the water
leak repair process.
JGF/ts
W DIRECTORATE
o:.
� of Ro
PUBLIC WORKS
CIN(Y
MEMORANDUM�—
f UDL Y
TO: Nasim Qureshi, City Manager FW86-108
FROM: John G. Flora,ppublic Works Director
DATE: April 24, 1985
SUBJECT: Basement Flooding - 1072 -63rd Avenue
The water leak originally identified in the Dellwood/63rd Avenue area was
found to be the water services to 1072 - 63rd Avenue. A repair was made
this past week.
This should reduce the amount of ground water in the area and also reduce
the basement flooding of this residence.
JGF/ts
cc: Nasim Qureshi
rt v 1/21
�• o
4
CITY OF FRIDLEY
M E M O R A N D U M
TO: NASIM QURESHI, CITY MANAGER
JOHN FLORA, PUBLIC WORKS DIRECTOR
FROM: DENNIS SCHNEIDER, COUNCILMAN WARD 2
SUBJECT: CONTINUING DRAINAGE PROBLEMS
DATE: MAY 12, 1986
I have spoken to you on several occasions relative to some of the drainage
problems my constituents are having this year. In one case, I have discovered
that the drainage problems have related to two broken water mains which were
on each side of the constituents home. The case in question is the home of
Mrs. Timms at 107_ 63rd Avenue. John, as you may recall I spoke to you
about her problem about w"-ee�cs'`-ago. At that time, you had indicated that a
small water main leak was found, but that you didn't believe it could have
anything to do with Mrs. Timms flooding problems. Subsequently, approximately
a week later, I am told that another water main was broken at the pump house
directly between her home and Highway #65. Talking with some of the neighbors
in the area, they indicated that water was gushing out of a hole in the ground
behind the well house. Further, they indicated that when the crews came to
repair the pipes, whenever they stuck a rod in the ground water just bubbled
out.
Mrs. Timms contends, and I certainly have to agree with her, that the water
and subsequent damage she suffered was a result not of the heavy rains, but of
the two broken water mains which in effect surrounded her house.
Further more, Mrs. Bergstrom at 1086 63rd Avenue, also suffered water damage
from the second water break. She indicates that she called in on April 21st
to report that she was gettinwater in her basement and it appeared that
there was a broken water main begind the pump house. According to her, City
crews did not come out until 4 days later on April 25th. When she spoke to
them, I believe on a Thursday, water was beginning to seep in to her basement.
The City crews attempted to find the water break, but were unable to locate
it. She asked what she should do, and was told we will be back on Monday or
Tuesday.
Over the weekend, needless to say, her basement on the corner of her house
towards the water break became flooded. When she called to see if the water
would be shut off, she was told that the water could not be shut off because
the business directly behind her needed the water and they had priority over
her.
Finally, on Tuesday of the followingg week the water was turned off and the
break was located. She claims tfiat within 24 hours of the break being
repaired all the water in her basement subsided.
Clearly I believe.both Mrs. Timms and Mrs. Bergstrom have suffered damage as
a result of the water main breaks. Whether the City is liable for the breaks
I don't know. It does seem to me, that we were quite negligent in not taking
corrective action more quickly then the six to seven days that it took to
solve the problem.
Nasim, 'an you please tell me what we can do to help these folks who have
suffered considerable damage and inconvenience as a result of these breaks. T
have suggested to both of them that they make claims against the City through
their insurance, and if that fails that they take the City to court through
Conciliation Court. Is there something short of that process that I can
suggest?
In another unrelated situation, but also dealing with drainage, I am having
significant problems with three people in the area of 64th and Old Central.
Particularly, the Calderon's, Rau's, and the Nelson's. All three of the
K1
claim that this year their water problems have been exasperated by the
fillingg of the lot on Mississippi Street where the old abandoned house stood
that int
Fire Department burned down a couple of years aggo. Apparently this
lot has acted as an informal holdingg pond and now that it is being filled, the
water which had not affected the Rau's or the Nelson's before is now causing
them significant problems. We have cleaned the culvert out for Mr. Calderon
and that has helped somewhat, but there is still a significant problem in the
area.
Could you please tell me what engineering options exist, hopefully not major
progects, but in any event what can we do to solve the problem that these
folks now have?
I believe that Mr. Nelson will be present at the Council meeting on May 19th
to indicate his concern and make a statement in to the record at the open
forum.
I would appreciate your attention to both of these situations. I know water
problems are difficult, but I am looking to you as experts to at least
indicate what options there may be and what information I can give back to my
constituents. Thank you for your help, we are looking forward to your prompt
reply.
Sincerely,
Dennis Schneider
Councilman, Ward 2
� w
rAd WW DIRECTORATE
OF
PUBLIC WORKS
CITYOF MEMORANDUM
f WDLEY
TO:
FROM:
DATE:
SUBJECT:
Nasim Qureshi, City Manager
John G. Flora, Public Works Director
May 13, 1986
Continuing Drainage Problems
;11=01oo Ip - o
o
_Ti_ -q .
PW86-132
The following information is submitted in response to Councilman
Schneider's May 12, 1986 memorandum subject as above:
1.) IQ72 61rd Avenue:
As indicated in a previous memorandum dated April 24, 1986, we were aware
of a water leak in the front of Mrs. Timms' residence. Attached please
find a memorandum from Ralph Volkman explaining when the water leak was
discovered and our repair procedures.
Our informal records indicate that this residence has experienced basement
flooding for a number of years in the past. This neighborhood has a
history of high water.
While the two water leaks contributed water to the ground, the ground has
been saturated as a result of this spring's snow melt and heavy rains.
Therefore, the amount of contribution to Mrs. Timms' problem appears to be
negligible.
If the history of this house is true, it would appear prudent that the
owner should take action to water -proof the exterior of the foundaton
and/or install a baseboard drii.nage system to deal with any seepage.
2.) 64th and Older Central:
Since the heavy rains of April 27, we have cleaned the asphalted Swale on
64th and the drainage ditch along Old Central to insure there is flow
without obstruction to the Harris Pond ditch. The original plat identifies
a depression at the boundaries of 6421 and 6401 Old Central and 1341 and
1357 64th Ave. The sideyards between 6421 and 6401 is depressed and
provided the outlet for not only the depression to the northeast, but also
the platted depressed area. While the depressions have been reduced in
area because of the site improvements, there still is a depression and the
water is overflowing and travelling on its original course. With the
extraordinary rains that we have received, the entire system is saturated
and flooding.
Page 2 - PW86-132
In an attempt to solve this problem, it appears that a drainage pipe can be
installed along the 6441 and 6421 property lines westward to Old Central
and then connected to the ditch system along Old Central which drains into
the Harris Pond ditch. This work can be accomplished via our storm water
utility fund and scheduled when the land dries out and necessary easements
are obtained.
JGF/MLB/ts
Attachment
�1
PUBLIC WORKS
MAINTENANCE
FRIDLFY
)ATE May 16 1986
MEMORANDUM
ROM Ralph Volkman Superintendent
TO
ACTION
INFO
UBJECT
Water Leaks at 1072 -63rd Avenue
Mark Burch, Assistant
Public Works Director
x
1st Leak:
On Monday, April 7th, a water leak was discovered in the water standpipe shutoff,
at 1072 -63rd Avenue, by the Sewer Department while they were making a routine
check of their sewer lift station. They then reported this leak to the Water
Department. In investigating the problem, they determined it was a small leak
in the water service to this home and not a watermain break. With our water
flushing in full swing, some of the men attending water schools, and the leak
causing no apparent problems, the repair was scheduled for the following week.
Because of the high.water table in the area, well points had to be used to dry
up the area so repairs could be made safely. Repair preparations began on
Monday, April 14th, and finished on Wednesday, April 16th. The problem was
a.small hole in the 1 inch water service, about 10 feet from the home's stand-
pipe shutoff.
2nd Leak:
On Monday, April 21st, Gerry Long, water maintenance man, turned on the water
for the lawn sprinkling system for the water pumping station and the Municipal
Liquor Store. This shutoff is directly behind the pumping station. When the
water was turned on, there was no indication of any water break. On Friday,
when Gerry Long returned to make his routine check of the area and the pumping
station, he discovered the ground around the water valve was very wet, indica-
ting a water leak of some kind, but of a minor nature. On Monday, April 28th,
the water foreman made attempts to locate the source of the leak. It was de-
termined that the leak had to be in the 1 inch water service. To repair this
leak, preparations had to be made, such as notifying the businesses affected
about the necessity of repairing this line, and scheduling the work at a time
that would least inconvenience them. There are two restaurants that were
affected by this. On Monday, May 5th, well points were installed for dewater-
ing and at 5:00 a.m. on Tuesday, 14ay 6th, the waterline was shut off and the
dewatering equipment was turned on. By 10:00 a.m. repairs were made and water
was restored to the businesses. A small 1/4 inch hole in the water shutoff
valve was causing the problem. This was not a watermain break, but a small
hole in a 1 inch valve. This type of leak can run for a long, long time
without being discovered, and almost never would cause problems to private
homes. This area has a history of a high water table, and with the above-
average rainfall it was hard to connect these leaks with water seepage to the
Memo To: Mark Burch
Water Leaks at 1072 -63rd
Page 2
basements.
It is our policy to attempt to correct immediately any water leak problems
that could cause property damage.
sueJEcr PERM)
City of Fridley
16.655
AT THE TOP OF THE TWINS
BUILDING PERMIT T" Z
� t
COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
�� 1
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
j 612-571-3450
910-F15
6/30/82
JOB ADDRESS 1072 - 63rd Avenue N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
6
2
1 Moore Take Highlands 3rd SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Alan D. Timm 1072 - 63rd Avenue N.E. 571-5114
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
8 DESCRIBE WORK
9 CHANGE OF USE FROM TO
STIPULATIONS
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
Asphalt
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
$1►000
$.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-
$17.50
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
$18.00
ORA HORI DA.GENT
PROPERLY VALIDATED THIS IS/jYOUR PERMIT
>,2S1GN&ATURE0FCON`TRAUDR /(DATE)WHEN
BLDG )NSP ATE
SIGNA URE OF OW RIIF OWNER BUILDER) DATE)
CITY OF FRIDLEY Effective Aug. 1, 1981
APPLICATIM FOR RESIDtNTIAL BUILDING PEIU41TS
(New, Alterations, Additions, or Repairs)
OWNER: PI M BUILDER: S
ADDRESS: 3 ADDRESS:
TEL NO: S-7/ TEL NO:
Construction Location
JD 7 1- Z
STRE T NO: STREET:
LOT: 0 BLOCK: ADDITION:
Corner Lot: Inside Lot: �_ Setback: Sideyards:�1J
Applicant attach to this form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
LR—C��LFront:
DESCRIPTION OF CONSTRUCTION
Depth:
Height:
Square -Feet: Cubic Feet:
Front: Depth: Height:
Square -Feet: Cubic Feet:
e—�
Type of Construction: Lr Estimated Cost: S /
RC Be Oompleted:
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $ $
SEE REVERSE SIDE OF SHEET
Mie undersigned hereby males 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: (% SIGNATURE:
0
Stipulations:
. s�
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
V
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner -
Also Replacement Furnace
(Side Vent - Fill Out Back)
Gas Piping (Needed with new furnace,
but not replacement)
Gas Range
Gas Dryer
*Air Conditioning - All Sizes
All Others/Repairs & Alterations (LIST ON BACK)
1% of Value of Appliance or Work
Commercial/Industrial
1.25% of Value'of Appliance or Work
Effective On January,1, 2002
0
JOB ADDRESS i o z_ (o-2,'-01 Av F _ _ PuE_
OWNER C+\A WF_ AQ12r-12'�bOkJ
Rate TOTAL
BUILDING USED AS
$ 30.00
ESTIMATED COST ?---I - R2 PERMIT NO.
$ 10.00 $
DESCRIPTION OF FURNACE AND OR BURNER
$ 10.00 $
No. of Heating Units_ Circle One (Steam) (Hot Water) ar
$ 10.00 $ Trade Name C*M-2i0L Size No: 60, .00
60(,000BTU Gc(HP EDR
$ 25.00 $ Fuel MAY. Total Connected Load 110.10,'10
State Surcharge
TOTAL FEE
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
Burner Trade Name Size No.
$ BTU HP EDR
$ The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes an
90 rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
$_39151a
DATE t7 n,
HEATING CO MA_X �A'E_L- {- A QI CAL_
Signed W,40 TEL #
FAX # 4 i
A
Approved ByAt P Fr_Rough-In Date Final Date 'l'0.3
(LIZ 30.SD
�TOJIE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
COMMON VFNT- VENT CONN TOR AND rnMRI ISTION AIR V RIFT ATION
When raIa _ing an swisfing furance, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes 0 No ( )
The venting system is plastictPVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination. Yes M 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 exmnn ramba,ction air is sized and installed to meet the current codes
and manufacturer's specifications.
Yes No( )
When required to inctaN a n,= cambiustinn airrit will be sized and installed
to meet the cwmt codes and Manufacturer's specifications.
Yes No ( )
Wheng a the undersigned hereby verifies that
it is a Isted asset and meets the current codes and manufacturer's
specWtations. This does include AGA GAMA Category I Central Furnace
Venting Talmo for fan assisted and natural draft appliances.
Yes No( )
Is the common gent and vent conrectors sized and installed correctly after
an appFence has leen removed from the common vent and vented
separatay as per cunwft codes.
AWflance T= and Size/f nmmen Vent and V nt ['nnn etar
Yes No( )
Infnrma inn
Appfiance #1 Type e,�,a-c r BTU Input Go. voo Fan Assisted or Nat
Appliance #2 Type WA -79;r KT2 BTU Input r,,V. oo o Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances 7, Total Btu Input ; 110 Ooo
Common Vent Type By h(7 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
HEATING CO: _)C Acuff-nllr
Signed By: _lit/,•(, Date: I_ 2-11-1 1lL