PRE 2010 DOCSVillage of Fridley,, Mnm
BUILDING PER MT
N? 670 Office of INSPECTOR OF BUIMINGS
()wner,
Architect Fridley, Minn, 19
Builder
LOCATION OF BUILDING
No.Street Part of Lot
Lot Block Addition or Sub -Division
DESCRIPTION OF BUILDING
Front _!�'_'_'2 Depth L_'"" Height—::'_ Stories Manner of Construction
To be used asTo be completed ;V' - Estimated Cost__2._�
:Permit is hereby gmuted to
building described in the above statement. This permit Is granted
upon the express condition that the person to whom it is granted, and his agents, employees and workmen, In an
the work done In, around and upon said building, or any part thereof, shall conform in all respects to the ordi-
nances of Fridley, Minn, regarding the 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.
inspector of Buildings.
AGREEMENT AND SWORN STATEMENT
In consideration 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 and according to the provisions of the ordinances of Fridley, and, being first duly
sworn, I hereby state and say that the facts stated by me and contained in the above permit are
true as therein stated.
Subscribed and sworn to before me at Fridley,
day of 1W
Minnesota, this
•
11
City of Fridley, Minn. a? -O® %
BUILDING PERMIT N® 7151.
Date: 9— z
Owner: Builder
Address ____ Address —
O ION OF BUILDING
No. Street 142=____ Part of Lot
Lot ---- .._ – Block Addition or Sub -Division ._ _
Corner Lot W Inside Lot Setback I. `—/ —.._ Sideyard A
Sewer Elevation _ Foundation Elevation
DESCRIPTION OF BUILDING
Tyqas:
Front Depth Height /2 Sq. Fta'i_�Lg Cu. Ft. d1W
nt Depth eight _!�_ Sq. Ft. Cu. Ft.
Type of Constructio Est. Cost �y __ 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 compliance with all provisions, of
ordinances of the city of Fridley.
v
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
withino nthe city limits and this permit may be revoked at any time upon viol�iep of any of the provisions of said
NOTICE:
Thb permit don not cover the construction, hmftnWon for WhIoe, plumbing, gas boding, sews or water. Be erre to see
the Building Inspector for separate permit for these Ilona. - -
APPLICATION FOR BUILDING PERMIT ..
CITY OF FRIDLEY, MINNESOTA
OWNER'S NAME .� BUILDER
ADDRESS
LOCATION OF BUILDING
aLl
No./ (�. Street ,Fart, .of Lot
y
Lot,' Black ; Addition or Subdivision
Corner Lot, Inside Lot Setback Side -Yard:
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Two Certificates of Survey,of Lot .and.proposed.build-
ing location drawn on these,. Certificates . E ;
DESCRIPTION OF BUILDING
To be used as:
G� a Front a Depth_ , a Eeight .
Sq. Ft. Sa 8 Cup. Ft.
Front Depth Height
Sq. 'Ft. Cu....Ft.
Type of Constructions Estimated Cost
To be Completed
The undersigned hereby make's application for..a permit for the work herein.ppecified,
agreeing to do all work in strict accordance with the City of. Fridley Ordinances and
rulings of the.Department of Buildings, and hereby decj,ares that all:the facts and
representations stated in this application are true and correct..
DATE_ �-�C� / / SIGNATURE
(Schedule of Fee Costs can be found on the Reverse Side).
r �
U
City of Fridley, Minn..
- F/
BUILDING PERMIT N® 7399
Date:
Owner: - _ __ Builde
Address Address
ON BUILDING
No. Street �_r. - - Part of Lot
Lot ---- —_ Block Addition or Sub -Division .
Corner Lot Inside Lot _ . Setback --- Sideyard _
Sewer Mevation _. _ — Foundation Mevation
DESCRIPTION OF BUILDING
T Used
Depth . _ Height Sq. Ft Cu. Ft
t $epth. eight Sq. Ft Cu. Ft.
Of Constry �1 3�.L Est. __ "' � 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
permit is hereby granted to—
to construct the building or addition as described above. This permit is granted upon
the express condition that the pens�n 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 vid4t1 sof any of the provisions of said
ordinances. ^ O1 I 1�
• NOTICE:
fhb peroth daft not cover The condrucdoe, h►ahUaHoe for wiring, phimbing, gas hoding, awn or water. Be vera to see
tiro Beiidieg hmpector for apara» permhc for thus hon.
City of Fridley, Minn. 'J Z 33
6431 University Ave. N. E., Minneapolis, Minn. 55432
BUII.DiNG PERMIT
Date: January 3131.s 1973
Owner: — Gezald Waldorf Builder _Same_
Address __.._.16.1.0 66th Avenue N _ R _ Address Same
LOCATION OF BUILDING
No. -_1410._..._ Street _ 66 tb Avenna, 111 A. Part of Lot
Lot _ ___ Block Addition or Sub -Division Clarkta Addition
Corner Lot Inside Lot __ _ Setback Sideyard
Sewer Elevation __ Foundation Elevation __.....
DESCRIPTION OF BUILDING
To be Used as:
Fire Reuai er _ Front _ _ Depth Height Sq. Ft. Cu. Ft.
Front Depth Height Sq. Ft. Cu. Ft
Type of Construction Est. Cost $3,900.00--_ To be Completed q monj-_hs
In consideration of the issuance to me of a permit to construct the building described above, I agree t9 do
the proposed work in accordance with the description above set f nand in pli with7j1_
p ons of
Ordinances of the city of Fridley. \/ �_ % � ���
R o 1%i // r� A ra
1.60 State
In consideration of the payment of a fee of $ 21.00 , permit is hereby granted to G gra l d Waldorf
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
w� cee s. city limits and this permit may be revoked at any time upon violation of any of the provisions of said
Q uil InspeCtor
CLARENCE BELISLE
NOTICE:
This permit does not cover the construction, installation for wiring, plumbing, gas beating, sewer or water. Be sure to no
the Building Inspector for separate permits for these items.
APPLICATION FOR RESIDENTIAL, ALTERATION,
OR AUDITION BUILDING PERMIT
CITY OF PRIDLEYs MINNESOTA
OW +�. I S Nm:61 U !Q / LOA ,ddiGdfr t-LBiTYLDER i^�Rz ee7e e s e,.11 1,
ADDRESS: AD=S.
{�fTl 1 11 I 1 I!
$LOCK x AIMUIONi
CORNER LOT: maE LOT;,^ S="CK; SIDEY,ARD:
Antllvgmt attach to tbU fom-Vo Certificates of Survey of Lot and proposed
114Ug location dans on these Certificates,
VESCRIPTION OF BUILDING
"To Be i seA As:
Height:
Square Feet; -Cubic Poet;
—Fro". Depth; Height:
Square Feet; Cubic Feeti
Trfe
of Constructions ` Hstimated Cost: $� �
To Be t3c+s Ieted s
fte undersigned hereby ask" application for, a permit for the work herein
apsej9#.e44 agreeing to do all work in sttict accordance with the CAty of
Tv dley tOrdleuances and vmlits of the Department of Buildinsev mW bereby
deelaref t all the facts and representations stated in this application
axe true =4 correc tt
SIGNATURE:
(Rm Rowena Bide For Additional Inforagation.)
SUBJECT PP;ITN
City of Fridley
- 16 5 5 8
AT THE TOP OF THE TWINS
BUILDING PERMIT
rp
RECEIPT NO.
L'______ COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
-ICITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF APPROVED By
L 612-571-3450
910-F15
1
1 5/5/82
JOB ADDRESS Gerald Genosky 1610 - 66th Avenue N.E.
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION SEE ATTACHED
DESCR.
1
1
Clarks Addition SHEET
2 PROPERTY OWNER MAILADDRESS ZIP PHONE
Gerald Genosky 1610 - 66th Avenue N.E. 574-1237
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 ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof Dwelling
9 CHANGE OF USE FROM TO
STIPULATIONS
Roof can be the 2nd but not the 3rd roof. Install ridged
galvanized valleys.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
Asphalt
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SQ. 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 BE COMPLIED
$700
$.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-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FE
$15- 0
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATEI _
WHEN PROPERLY LIDATED THIS IS YOUR PERMIT
~
6
`t
BLDG INSP ov,
B DATE)
RE OF OER I 1. ERUILD
IGNATUWN
CITY OF FRIDLEY Effective Aug. 1, 1981
APPLICAT194 FOR RESIDENTIAL BUILDING PE•R19ITS
(New, Alterations, Additions, or Repairs)
OWNER: 6evo 5kz' e?A 1-0 BUILDER: am �
ADDRESS: 16 /® 'P (' � 0 '� VC ADDRESS:
TEL NO: 15 ? TEL NO:
Construction Location
• STREET NO: %/ iJ STREET: ( `�
LOT: BLOCK: ADDITION:
Corner Lot: f 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
Front: Depth: Height:
Square Feet: Cubic Feet:
Front: Depth: Height:
Square -Feet: Cubic Feet:
Type of Construction: o Estimated Cost: $ /6)0• ® G
7b Be Completed: TU P e -
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $ ' $
SEE REVERE SIDE OF SHEET .
The undersigned hereby makes application for a permit for the uork- herein specified,
agreeing to cb ,all work in strict accordance with the City of Fridley 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.
a -
DATE: �'I� ,� ��� Simmrx:
Stipulations:
CITY OF FRIDLEY
Effective Date May 1, 1988
APPLICATION FOR POWER PLANTS AND HEATING,
COOLING, VENTILATION, REFRIGERATION AND
AIR CONDITIONING SYSTEMS AND DEVICES
RATE SCHEDULE
Job Address
RESIDENTIAL RATE
TOTAL
Furnace Shell'and Duct Work,
Burner (Also replacement furnace) $ 20.00
$
Department of Buildings, 6431 University Ave. N.E., Fridley, NN 55432
City of Fridley
Gas Piping $ 10.00
$
Tel. #571-3450
(piping needed with new furnace)
Gas Range $ 10.00
$
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
Gas Dryer $•10.00
$
and rulings of the Department of Buildings, and hereby declares that all the
facts and representations stated in this applicatio are rue and correct.
• Air Conditioning (all sizes) $ 10.00
p®
$_L�
Fridley, Minn. b 19 vo
All Others/Repairs and Alterations
OWNER (r r &44
li of Value of Appliance or Work
$
KIND OF BUILDING %`"tom
COMMERCIAL/INDUSTRIAL
USED AS�O iC rl / N
li of Value of Appliance or Work
S
Ta BE COMPLETED ABOUT
ESTIMATED COST / V
State Surcharge
$ .50
TOTAL M
$ �
OLD -NEW BUILDING PERMIT NO. PERMIT NO.
Reinspection Fee ($15.00)
$
DESCRIPTION OF FURNACE/BURNER
Rough Insp.
HEATING or POWER PLANTS, Steam, Not water, Warm Air- No.
Date
JJ11
Final Insp. �.�(1
Trade Name Size No.
Date
Capacity Sq. Ft. EDR BTU HP
Approval for Permit
Total Connected Load Kind of Fuel
BURNER - Trade Name Size No.
Capacity Sq. Ft. EDR BTU 'L Y'' HP 2
MINIMUM FEE FOR ANY HEATING PERM IS
)Q4
$15.00-.
Company
PLUS $.50 STATE SUI(CI(ARGE
Signed By s UV
L �/
31P
Tel. No. 7 .5
*Air Conditioners can not be placed in side yard without
written permission from adjoining neighbor.
Fill out back side for stack verification on replacement furnaces
CHIMNEY AND STACK VERIFICATION
The undersigned hereby verifies that the existing chimney or stack;
1. 'Has .been. carefully examined Y
2. Is free from. rust or deterioration Y
3. Has no foreign objects lodged within Y
4. Is securely supported
5. Meets all current Code requirements for size and
total BTU connected
6. Has Total heating BTU's of
All other BTU's
TOTAL
Rema rk s
Company
Signed By
Da to
Y
0
SUBJECT
City of Fridley
-
28469
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
R O.
�
• -------COMMUNITY DEVELOPMENT DIV.
INSPECTION SEC.
r PROTECTIVE
I
CITY HALL FRIDLEY 55492
NUMBER
REV
OAT E
PAGE O:
APPROVED BY
612-571-3450
910415
10/29/98
JOB ADDRESS
1610 66th Avenue NE
1 LEGAL
LOT NO. BLOCK
TRACTOR ADDITION
SEE ATTACHED
OESCR.
1 1
Clark's
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Geri Genosk
574-1237
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
New Haven Const. Co. 4208 83rd Ave N Brooklyn Pk 55443
566-5225 20077950
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 REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and garage 24 Sq) Tear -off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
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
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 TRU NO ORR T. ALL PROVISIONS OF LAWS
VALUATION
SURTAX
AND ORDINANCES GOVERNING IS YPE F WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED H IN R NO .THE GRANTING OF A PERMIT
2056
$1.03
DOES PRESUME TO G AU GRIT TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROW I S OF ANY OT R ST E OR LOCAL LAW REGULATING CON-
STRUCTI OR THE PE 0 A CE O C STRUCTION
$74.75
Fire SC $2.06
PLAN CHECK FE
TOTA EE
Lice C
.84
SCGNATURE Of r'IIALTOA R UTHO 1ZEDA ENT 10ATE,
E P
rVA. IDAT r HIS IS YOUR PERMIT
BL G -NSP
i
(/ pAtE
SIGNATURE OF OWNERoF OWNER SUILDER1 IDATE�
0
NEW [ ]
ADDN [ ]
ALTER [
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R -Z
BUILDING PERMIT APPLICATION
ConstructionAddress: /(-, 1-6
Legal Description: _____
Owner Name & Address:
Contractor:
Address:D jar
erg
a,-
Attach
r
Effective 1/2/98
A j�
Tel. # S7
MN LICENSE # ac-D7'71� S'?
Tel # S& 6 - 5 � 2r sr
Attach to this application, a Certificate of Survey of the
lot, with the proposes construction drawn on it to scale.
DESCRIPTION OF WROVENZNT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width
Height_
Sq. Ft.
DECK AREA.
Length r width Hgt/Ground Sq. Ft.
DTHER.
'onstruction Type: �£�az - O /e6-)2 o U �
Estimated -Cost:. $
(Fee Schedule on Back)
nveway Curb Cut Width Needed_ Ft. + 6 Ft = Ft x $ _ $
ATE: 7,:5: � APPLICANT: Tel. #
TOTAL$. , °
PULA77ONS:
CITY USE O Y
emit Fee
$ L. S^
Fee Schedule on Reverse Side
re Surcharge
$ .2 0 (
.001 of Permit Valuation (1/10th%)
cte Surcharge
$ lam
$.501$1,000 Valuation
,C Charge
$
$1000 per SAC Unit
Sege
$ o
$5.00 (State Licensed Residential Contractors)
iveway Escrow
$
Alt. "A" or Alt. "B" Above
)Sion Control
$
$450.00 Conservation Plan Review
t Fee
$
Fee Determined by Engineering
ver Main Charge
$
Agreement Necessary [ ] Not Necessary I l
TOTAL$. , °
PULA77ONS:
New Fixtures
$ 7.00
The undersigned hereby makes application for a permit for the work herein
Old Opening, New Fixture
$ 4.00
specified agreeing to do all work in strict accordance with the city codes
Beer Dispenser
$ 5.00
and rulings of the Building Division, and hereby declares that all the facts
Blow Off Basin
$ 7.00
and representations stated in this application are true and correct.
Catch Basin
$ 7.00
_ (�
17
Rain Water Leader
$ 7.00
, 2001
Sump/Receiving Tank
$ 7.00
Water Treating Appliance
$10.00
Owner GENOSKY, GERALD
Water Heater -Electric
$ 7.00
1610 66TH AVENUE NORTHEASTFRIDLEY,
MN 55432
Water Heater - Gas** �_
$10.00 (
Building Used As (763) 574-1237
Gas Range**
$10.00
Gas Dryer**
$10.00
Estimated Cost PERMIT NO.
Back Flow Preventer Required ( )Yes () No
�i, _
®rQ l om PUI.� C1 V
Type
$15.00
PLUMBING COMPANY I � / 6yy�
t2'714 �3
Reinspection Fee $47.00/Hr
SIGNED BY TEL N0.
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture or Appliance
Approved By44i,Rough-In Date Final D to -46-01
State Surcharge
$ .50
�® ��
MINIMUM FEE F R ANY PLUMBINGIGAS PERMIT IS $20.0.Q
TOTAL FEE
$
PLUS THE $.50 STATE SURCHARGE
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE
COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacina an existing 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( 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 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 It 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
Cv,-73g4
CITY OF FRIDLEY BUILDING INSPECTION
v
9 3431 University Ave NE
9=ridley, MN 55432
L
763-5723604 FAX 763-571-1287
9
D
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner &
also Replacement Furnace
Gas Piping (New Furnace, Fireplace, Insert)
Effective 4/1/2004
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
Fee Total
$35.00 $ 35,06
$10.00 $
JOB ADDRESS k �O t (�.O—" �e -
Owner agr o.- i � Qoenos% i
Building Used As C� e 1"1C 110—
ESTIMATED COST -1 -a. -5000b . PERMIT NO
Gas Range $10.00
$
DESCRIPTION OF FURNACE AND BURNER
Gas Dryer $10.00
$
# of Heating Units_ Circle One (Steam) (Hot Wate (Warm Air)
Trade Name Size No.
*Air Conditioning -All Sizes $25.00
$
BTU O no 0 HP EDR
Fuel or ( c s Total Connected Load
All Other Repairs or Alterations (List on Back)
r 1% of Value of Appliance or Work
$
Burner Trade Name Size No.
A
Minimum Fee $15.00 for Residential or 5% of cast of
BTU HP EDR'
Y improvement whichever is greater on work less than $300.00
The undersigned hereby makes application for a permit for the work herein
:3 Commerciallindustrial/Institutional
specified agreeing to do all work in strict accordance with the City Codes
r 1.25% of Value of Appliance or Work (List on Back)
$
and rulings of the Building Division, and hereby declares that all the facts
Minimum Fee $35.00 for Commercial/industrial/institutional
and representations stated in this application are tnie and correct.
CENTERPOINT ENERGY
Y State Surcharge
$ .50
HEATING CO 13562 CENTRAL NE BLAINE, MN 55304
1
TOTAL FEE
$35.56
`AV`E
Signed Te!# 763-757-6202
v
v
t U ages
REINSPECTION FEE $50.00/HOUR
FAX #! 763-757-6701 Date
*Air Conditioners can not be placed in side yard without written approval
M
1\+ from adjoining property owner - copy to City
o-
ry .
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
cc
Approved by Rough -in Date Final Date
ze ' d '14101
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 (X) No( )
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination.
Yes (y) 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
No ( )
Venting Tables for fan assisted and natural draft appliances.
Yes (
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 ang Size/Common Vent and Vent Connector Information
Appliance #1 Type Al J i BTU Input igaw Fan Assisted or Nat /l- f
Appliance #2 Type BTU Input Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances �_ Total Btu Input 410,&D
Common Vent Type C°f Vent Height Diameter inches
Appliance #1 Vent Connector Height % ft Length 63 ft Diameter / in Type Cr
Appliance #2 Vent Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS: (Describe)./ 922 ao1,A
CENTERPOINT ENERGY
HEATING CO: 13562 CENTRAL AVE NE BLAINE, MN 55304 -
Signed By: Date
FA/Fn ' H T VV A. SL Ol JJ IG 1 NA A0 .1110 WON -1 (7.: T T 0002-L2-Nc4H