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PRE 2010 DOCS. BUILDING PERMIT Village of Fridley, Minn. N? 2 9 7 9 Pip Date .. �' .. �! . .... ............ . P Builder ` ................... ... ... ... ....... ...... ........... Owner ..... / Address ��!. ®.+. �/....... .i . ............ Address (., ja�� .�. �. ....� .. .. .. LOCATION OF BUILDING No. ..®.. Street ... ,Z!....:v"— .......... Part of Lot ................. .. . Lot .: .......... Block .... ., 7 ....... Addition or Sub -Division . A01-4o�{., e. ".. � Corner Lot ............ Inside Lot ............ Setback d?. s.i..�.... Sideyard DESCRIPTION OF BUILDING To be Used as: r/ k"j.... Front ��/ Depth 2%11 4– . Height ,x' ¢ Sq. Ft. j� 49. Cu. Ft. ........ .................... Front ........ Depth ........ Height ......... Sq. Ft......... Cu. Ft......... Type of Construction Est. Cost ... D ...... 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 village of Fridley. In consideration of the payment of a fee of $.... .. ermit 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 with- in the village limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. n m,m Inspector NOTICE: This permit does not cover the construction, Installation or alteration for wiring,mbing, gas heating, sewer or water. Be sure to see the Building Inspector for separate permits for th 611ptems. c,2 City of Fridley, Minn.. N° 7832 • BUILDING PERMIT Date: June 10, 1965 Owner; IMMMEM Richard Cameron Budder Dailey Homes Inc. Address 2$0 67th Ave. N, E. A $510 Central Ave. N. E. LOCATION OF BUILDING No. 28 Street 67th Avenue N. E. Part of Lot Lot - 3 _ Block 5L Addition or Sub -Division Rice Creek Xgmigm Plaza, So. Add* Corner Lot _ Inside Lot Setback Sideyard Sewer Elevation _ Foundation Elevation DESCRIPTION OF BUILDING To be Used as: Front Depth Height Sq. Ft. Cu. Ft. Front Depth Height Sq. Ft. Cu. Ft. Type of Construction Est. Cost x,,$5.0 _ To be Completed is Stozm Damage repair • 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 se forth and compliance with ajl provisions of ordinances of the city of Fridley. In canaideration of the payment of a fee of • 00 • , permit is hereby granted 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 rdjn anc done in, ara�md and upon said building, or any part thereof, shall conform in aII respects to the ordinances of Fridley, Minnesota regarding location, construction, alteration, maintenance, repair anti moving of buildings wio dty limits and this permit may be revoked at any time upon violation of any of the Provisions of said Allen Jensen Building Inspector NOTICE fhb permit dose not corer the construction, leshlladon for whlng, plumbing, gn boating, sewer or water. Be are to sse the BulMing Inspector tar separate parmks for thea keno. 4 APPLICATION FOR< ING PERMIT CITY OF FRIDLEYi NNESOTA '4 OWNER'S NAME Richard Cameron BUILDER Dailey liothes Inc. ADDRESS 280-67t;h Ave. , N i'., ADDRESS 8510 Central Avenue N. E# LOCATION OF 40 BUILDING Part of Lot, Lot Block Additioar or Subdlvis Corner Lot Inside Lot etk Side -Yard SEWER ELEVATION FOUNDATION ELEVA°iTION Applicantattach to this form, Two Certificates of, Survey of Lot and proposed build--- ing location drAwn on these Certificates. Tia be used as: DESCRIPTION OF BUILDING d Front Depth Height ,- Sq. Ft. Cu. Ft. _,,;,FrontDepth Height u ;Std. Ft. Cu. Ft. Type of Construction Tornado Damage re air Estimated Cost $486.00 The undersigned hereby makes application for a permit for the work herein specified,, agreeing to coo all work ift 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. tSchedvl,e.of Fee Costs can be found on the Reverse Side). J 0 • • 0 City of Fridley, Minn.. BUILDING PERMIT N? 6719 Date: 2-0,9 " ( 3 Q Owner: �!�i-����� Builder Address Address O ION BUILDING No. uldoo Street Lot _ Block Addition or Sub- on Corner Lot — Inside Lot ._._.. � Setbac=dation Sideyard Sewer Elevation — ...._ Fon DESCRIPTION OF BUILDING To/BeU sa: Front _r� "� Depth lA _ Height Sq. Ft. Cu. Ft. 44-460 Front- DepthHeight _ Sq. Ft. Cu. Ft. Type of Constructio Est. Coat//, �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 Korth and I co,}npliance with all provisions of ordinances of the city of Fridley. �/ // In consideration of the payment of a fee of permit is hereby granted to to construct the building or addition as described above. This permit is granted upon the express condition that the person to whom it is granted and his agents, employees and workmen, in all work done in, around and upon said building, or any paw 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. _ o, /I Building Inspector NOTICE: This permh does not cover the construction, boanwon for wiring, plumbing, gas heating, waver or water. Be sues to we the Building Inspector for separate permits for thew honor o4NE- R ° S =49 APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA LOCATION OF BUILDING No. Street] G ��� Part of Lot B *t Lot Block Addition or Subdivision�� Corner Lot Inside Lot -4—., -Setback FfC4'rd 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. DESCRIPTION OF BUILDING To be used as: Front c2 Depth P-0 Height 7 Sq. Ft. V Cu. Ft. 3 0 6 b Front Depth Height Sq. Ft. Cu. Ft. Type of Construction 4yi. Estimated Cost M 0.0 To be Completed _6 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. DATE �3 SZGNATtYRE (Sebedule of Fee Costs can be found on the Reverse Side). s SUBJECT PERMI City of Fridley - - 7 6 AT THE TOP OF THE TWINS I T BUILDING PER77PAGE r � ECEIPT NO. • COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. :1LCITY HALL FRIDLEY 55432 NUMBER REV. DATE OF APPROVED BY �'"'"" ��� 612-571-3450 910-F15 62079 / JOB ADDRESS 280 - 67t1i Avenue N. E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 3 5 Rice Creek Plaza South Addn. SHEET 2 PROPERTY OWNER MAILADDRESS ZIP PHONE Edward Polanski 280 - 67th Avenue N.E. 571-6849 3 CONTRACTOR MAILADDRESS 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 Construct a 16' x 12' Addition to House 9 CHANGE OF USE FROM TO STIPULATIONS Existing Garage will need a fire wall installed from NW comer to doors on N and W walls. WARMG edm fling all lali utilith TELEPHONE • ELECTRIC • GAS Et SEPERATE PERMITS REQUIRED FOR REQUIRED BY LA VjIRf HEATING, PLUMBING AND SIGNS. � TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED $5,850 $2.93 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- $36.00 NONE STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE $ 9.00 $47.93 IG RE OFCONTRAC OR EDAGENT (DATE) WHEN PROPERLY VALIDATED THIS IS Y U/R PERMIT BLDG INSP D E IIf SIGNATURE OF OWNERIIF OWNER BUILDER) (DATE) s CITY OF FRIDLEY APPLICATION FOR RESIDENTIAL BUILDING PERMITS (New, Alterations, Additions, or Repairs) OWNER: ������ BUILDER: ADDRESS: 2' • ADDRESS: I_A4� TEL NO: _f z/—,� � TEL NO: Construction Location STREET NO: STREET: LOT: go 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 �. Front: Depth: Height: Square. Feet: Cubic Feet: Lill1L t� Front: _ Depth: Height: Square Feet: Cubic Feet: 'Th—wt.- 38`0 Type of Construction: Estimated Cost: $ To Be Completed: Ada-.- /I Z Alt. A Alt. B Proposed Driveway Width If New Opening Is Desired: $ �^ $ SEE REVERSE SIDE OF SHEET The undersigned hereby makes application for a permit for the work herein specified, agreeing to do all work in strict accordance with the City of Fridley Ordinances and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. DATE: 7-0 SIGNATURE: ,: a Stipulations: i I L_ x 6.0ra - R 1)l. s^2 I9sXx' • ;04. 8 r P: a CO. o0 4 0 ^, 58TY �� . Fs�.owt N• w Ccw►..a�• T� Dod�.S' � �'{w�.s 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 RESIDENTIAL RATE Furnace Shell and Duct Work, Burner (Also replacement furnace) $ 20.00 Gas Piping $ 10.00 (piping needed with new furnace) Gas Range $ 10.00 Gas Dryer $ 10.0c * Air Conditioning (all sizes) $ 10.00 All Others/Repairs and Alterations 1% of Value of Appliance or Work COMMERCIAL/INDUSTRIAL 1% of Value of Appliance or Work State Surcharge TOTAL FEE Reinspection Fee ($15.00) TOTAL $ 20.00 $ 10.00 $ $ .50 $ 30.50 Rough Insp. **Also installing one (1) Date Carrier 38EN024/24 2 ton Final Insp. 7 ^ g 9 -f air conditoner Date Approval for Permit A�9— MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00, PLUS $.50 STATE SURCHARGE Attach stack verification form with.replacement furnace permits *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. Job Address 280 67th lAve. NE Department of Buildings, 6431 1 niversity Ave. N.E., Fridley, MN 55432 City of Fridley Tel. #571-3450 The undersigned hereby makes application for a permit for the work herein specified agreeing to do all wirk in strict accordance with the City Codes and rulings of the Department of Buildings, and hereby declares that all the facts and representations stab,d in this application are true and correct. Fridley, Minn. July 18 , 19 88 OWNER Ed Polanski KIND OF BUILDING Frame USED AS Residential TO BE COMPLETED ABOUT ESTIMATED COST $2900.00 OLD - NEW BUILDING PERMIT NO. - PERMIT NO. �J DESCRIPTION OF FURNACE/BURNER HEATING or POWER PLANTS, Steam, Hot Water, Warm Air- No. one Trade Name Carrier size No. 58SS060 Capacity Sq. Ft. EDR BTU 60, 000 HP Total Connected Load Kind of Fuel nat. gas BURNER - Trade Name Size No. Capacity Sq. Ft. EDR BTU HP Company , Dependable Heating and A/C Signed By 4 ,,L- a" ,La . A ay 1 Tel. No. 757-5040 ,� ?bCX-(,sKC C.��,,4 C;,� , cu`9-a CHIM14EY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack; 1. Has been carefully examined Yes (� No ( ) 2. Is free from rust or deterioration Yes (.%f No ( ) 3. Has no foreign objects lodged within Yes (� No ( ) 4. Is securely supported Yes (vr No ( ) 5. Meets all current Code requirements for size and total BTU connected Yes No ( ) 6. Has Total heating BTU's of 60,600 V F()(:) C All other BTU's TOTAL1 C0 , C5 (1-110 Rema rk s Com .. ny no. E1 a U I OjtQ1 i Signed By QLbCh]C�Cj,,3 1. SUBJECT .- City of Fridley 26750 AT THE TOP OF THE TWINS BUILDING PERMIT r R O. COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. 44 10 r 1 i NUMBER REV DATE PAGE Of APPROVED BY i CITY HALL FRIDLEV 55432 ' 612-571-3450 910415 7/22/98 JOB ADDRESS 280 67th Ave NE 1 LEGALLOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 3 5 Rice Creek Plaza South SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Ed Polanski 571-6849 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Bo's Construction 2218 22nd Ave S M is MN 55404 709-5037 20100656 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 Reroof 20s Tear -off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with StateBuilding 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 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 1668 .83 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- STRUCTI N OR THE PERFORMANCE OF CONSTRUCTION. $54.00 Fire SC $1.67 PLAN CHECK FEE TOTAL FEE 61.50 �y �� ,/ sr NATURE CON'RACTORORAUTNORIIEDAGENT DATE) AI WHEN PROPEraATED THIS IS YOUR PERMIT V v BL G iNSP 11 ® f DATE SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI NEW [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Allp\Z)BUILDING PERMIT APPLICATION r a ConstructionAddress: ��jU (�-% +1n AUC IV f r";y (-,:z MAJ 52y 3d Legal Description: Owner Name & Address: Ej Po f cam, s ��U (oWh A -e VE �� ''el. # Contractor: �S cc �s`�V�c� �` MN LICENSE # �j 60 6 56 Address: XL (8- Tel. # -7b9-_S� 37 Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF EM PROVEMENT LIVING AREA: Length Width Height Sq. Ft. QK&W9 GARAGE -AREA: - Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: b I i z- 0 r� Construction Type: nU R2 �o.01- Estimated Cost: $ a (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: �_a `�� APPLICANT: )co �os c, C /� �/ Tel. # CITY USE ONLY Permit Fee $ 06 Fee Schedule on Reverse Side Fire Surcharge $ l .001 of Permit Valuation (1/10th%) State Surcharge $ c $.50/$1,000 Valuation SAC Charge $ $1000 per SAC Unit License Surcharge $ $5.00 (State Licensed Residential Contractors) Driveway Escrow $ Alt. "A" or Alt. "B" Above Erosion Control $ $450.00 Conservation Plan Review Park Fee $ Fee Determined by Engineering Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ] TOTAL $ l STIPULATIONS: CITY OF FRIDLEY PERMIT NO.: 2004-01021 6431 UNIVERSITY AVENUE NE FRIDLEY, MN 55432 DATE ISSUED: 07/01/2004 572-3604 FAX: (763)571-1287 ADDRESS 280 67 AVE NE PIN 143024230067 LEGAL DESC RICE CREEK PLAZA SOUTH ADD LOT 3 BLOCK 5 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. INSTALL AN AIR CONDITIONER. # A/C UNITS I VALUE OF APPL OR WORK 0 # FURNACES 1 # GAS DRYERS 0 # GAS RANGES 0 VALUE (FOR MINIMUM CALC) 1800 APPLICANT RIVER CITY SHEET METAL 9928 BLUEBIRD ST NW COON RAPIDS, MN 55433- (763) 754-2199 OWNER POLANSKI EDWARD & LUCY MARY 280 67TH AVE 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 regulating construction or the performance of construction. Applicant Date Bldg Insp Date HEATING PERMIT MINIMUM FEE 25.00 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 25.50 PAID WITH CHECK # 13385 SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE. CITY OF FRIDLEY INSPECTION DIViSION Effective January 1, 2003 643f University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, / (763) 572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES (p FAX (763) 571-1287 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 jo of Value of Appliance or Work 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 $ .50 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 rulings of the Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. H DATE G7 FAX # TEL # 743 -75 a19 q *Air Conditioners can not be placed in a side yard without Approved By Rough -In Date Final Date written permission from adjoining property owner. FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE JOB ADDRESS 2 ET O 14 ✓ e— Al E OWNER L74 C66 Vl,., Rate TOTAL BUILDING USED AS $ 30.00 $ ESTIMATED COST /SOD. 1 OD PERMIT NO. $ 10.00 $ DESCRIPTION OF FURNACE AND OR BURNER $ 10.00 $ No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air) $ 10.00 $ Trade Name Size No. BTU HP EDR $ 25.00 $�.��, oa Fuel Total Connected Load 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 $ .50 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 rulings of the Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. H DATE G7 FAX # TEL # 743 -75 a19 q *Air Conditioners can not be placed in a side yard without Approved By Rough -In Date Final Date written permission from adjoining property owner. FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE '1Fi IE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE APPLICATION WILL BE RETURNED WhenIn acing an axic+in0 Mrance, 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 away nme mfinn air is sized and installed to meet the current codes and manufacturer's specifications. Yes( ) No( ) When required to install a new enmhiistinn air. it will be sized and installed to meet the current codes and manufacturer's specifications. Yes( ) No( ) When in-ciallinn a new yanking cye _m, 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 #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 HEATING CO: Signed By: Date 0 CITY OF FRIDLEY PERMIT NO.: 2004-01094 3 6431 UNIVERSITY AVENUE NE FRIDLEY, MN 55432 DATE ISSUED: 07/13/2004 572-3604 YAX: (763) 571-1257 ADDRESS : 280 67 AVE NE PIN : 143024230067 LEGAL DESC : RICE CREEK PLAZA SOUTH ADD : LOT 3 BLOCK 5 PERMIT TYPE : ELECTRICAL PROPERTY TYPE : RESIDENTIAL CONSTRUCTION TYPE : ADDITION/ALTERATION VALUATION NOTE: ELECTRICAL PERMIT BECOMES VOID 12 MONTHS AFTER PERMIT ISSUE DATE. INSTALL AIR CONDITIONER. # INSPECTIONS 1 APPLICANT DEPENDABLE ELECTRIC INC 2619 COON RAPIDS BLVD NW COON RAPIDS, MN 55433 OWNER POLANSKI EDWARD & LUCY MARY 280 67TH AVE 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 wort 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 regulating construction or the performance of construction. Applicant Date Bldg Insp ELEC PERMIT FEE - MIN (RESI) 20.00 STATE SURCHARGE, ELEC FLAT 0.50 TOTAL 20.50 PAID WITH CHECK # 28593 SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.