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PRE 2010 DOCSDate /•/Jf! Owner Address Village of h idley, Mina.. N° 2 5 .... . .... .. :Lf.�1.. .... Builder it.../� ................. .. . . .... - aw Address ......:.................................. LOCATION OF BUILDING!, No.Street ............... Part of Lot ....................... Lot ......4 ....... Block............. Addition or! Sub -Division ... I Corner Lot ....... .... Inside Lot ............ Setback jj,{* . Sideyard f� ............ DESCRIPTION OF BUILDIN To be Used as: rI, f ' .. .. ... Front .4 0 Depth .... Height ... I Sq. FL ...°..... Cu. Ft, ........ "., I .A'•1�" ...... �. Front Depth MY .... Height .... Sq. Ft......... Cu. Ft. of Constructi .. Est. Cost 4 D � y ... Type i��. • �/�.��Q...........:.. To be Completed �ri�%/�t7 In consideration the proposed work i ordinances of the A In consideration the express conditioi done in, around and Fridley, Minnesota x in the village limits ordinances. NOTICE: This permit '—sewer or water. y t of the issuance to me of a permit tol construct the building described above, I agree 'to do accordance with the description above set forth and in compliance with all provisions of age of Fridley. if the payment of a fee of$. permit is hereby granted t . to construct the building ad tion as described above. This permitgranted upon that the person to whom it is granted and his agents, employees and workmen, in all work mon said building, or any part thereof, shall conform in all respects to the ordinances of garding location, construction, alteration, maintenance, repair and moving of buildings with- nd this permit may be revoked at any time upon violation of any of the provisions of said .. .... Building Inspector s not cover the construction, installation or alteration for wiring, plumbing, gas heating, sure to see the Building Inspector for separate permits for these items. Application for Power Plants and Heating, Cooling, Ventilation, Refrigeration and Air Conditioning Systems and Devices GRAVITY WARM AIR: Location �j FurnaceShell & Duct Work............................................................$ ................................. Replacement of Furnace ................$ ................................. City of The undersigned hereby makes application for a permit for the work herein Repairs &Alterations —up to $500.00 .................................... $................................. specified, agreeing to do all work in strict accordance with the City Ordinances Repairs & Alterations each add. $500.00 .............................. $ ..... _.......................... and ruling of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. MECH. WARM AIR Furnace Shell & Duct Work to 120,000 BTU ..................$ ................................. Columbia Heights, Minn .................... _............... y.. ^. ........., 19.73........ each add. 60,000 BTU ................................................... $ ................................. Owner .........b.................................................................................................................................................. . Replacementof Furnace.....................................................................$ ................................. Repairs & Alterations—up to $500.00.................................$....._.............._.......... Kind of Building....._............................................................................................................................................ Repairs &Alterations each add. $500.00 $ ................................. Used as ..................... _................... STEAM or HOT WATER SYSTEM3 J 73 Tobe compeletd about ............ ........_�-•-•----................................._.............................................................. Furnace Shell & Lines—to 400 sq. ft. EDR Steam ......$ ...... _........................ Furnace Shell &Line—to 640 sq. ft. EDR Hot Water $__.. ._................... Estimated Cost, $.-...............`.�.......... _............ .............. ............................. _.�...�/�� Each add. 200 sq. ft. EDR Steam _ ............................................. $ ..... _.......................... Each add. 320 sq. ft. EDR Hot Water ....................... _........... $. .......... CUI�- Ce_—� DESCRIPTION OF WORK OIL BURNER—to 3 gal. per hour ....................... ...... _.......... .... $ ................. .... .......... HE or ER PL . (underline) Steam, Hot Water, Warm Air — over 3 gal. per hour—See Fee Schedule Trade Name �— Size No. GASBURNER................................................................._.......................BTU$....... _........................ GAS FITTING FEES: NO Capacity Sq. Ft. E D R BTU H.P. 1st 3 Fixtures ........... _........... $ ...... __....................... Total Connected Load Kind of Fuel Additional Fixtures ..... _____.$................................. �������� AIR CONDITIONING Gas Range to 200,000 BTU ........................$ ................................. VENTILATING SYSTEMS Trade Name Size No. Duct work etc. not to exceed 2,000 cfm ........................ _.... $..... _.............. _......... Electric Gas Each additional 1,000 cfm................. _............................... $...... _......................... �� AIR CONDITIONING / Signed................................................................... $....F -r ................ $..................... __------ 4......._...... ...... .. ALTERATIONS & REPAIRS 9-/4 - 7L4/"�- / $.....r .............. _.......... TOTAL FEE s..••.U...�.� Business Phone No ...... .r%_k`). -1 / & 7 .......................................... Business Address................ Ste' (remarks—over) MINNEGASCO 53-8b -S-915.51 Cily of Fridley ApplisaTicn for Plumbing c-ld- G= It Dept. of Bldg*. Phone 5W.3M DESCRIPTION OF V:011=6 516 N. E. 67th. Ave. Number, Kind and Loca9on of Fixtures I'ocati suture Connocti: n OpeningsI -•••• .,owes � New Fixture. Old Openings Ccsspool 0 PARTIAL RATE SCHEDULE ,VMBING 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 fUp to 99,000 BTU).. • • x $3.00 $ New Ground Run Old Bldg......... x 15,125 $ Electric Water Heater........... .. z $2.00 $ AS FITTING FEES: NO. RATE TOTAL Ist 3 Fixtures ............ • • • • • • x $2.00 ; Additional Fixtures .............. x $ .75 $ Gas Range to 199.000 BTU ........... 1 x 55.00 00 EPAIRS & ALTERATIONS—Refer to Code City of Fridley: The undersigned hereby makes application for a permit for the• work herei specified, a„ Being to do all work in strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that all the fact and representations stated in this application are true and correct Fridley, Minn L-3-75 19— Owner F. E. Samuelson Kind of Building Frame Used as Res. To be completed about 1-10-75 Estimated Cost, $ 10.00 Old—DinexBuilding Permit No. Permit No._ -:71 Signe By MINNEGASCO -- Business Mine No ROUGii rizin .50 State Surcharge .Description ........................................ TOTAL FEES 5.50 . Glass O'K' Surcharge .50¢ C CITY OF FRIDLEY 37�)!-9915051 -a--� APPLICATION FOR PLUMBING AND GAS FITTING PERMIT PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Nu--I-er Fixtures x $3.00 n Future Fixture Opening 4-i ar $2.00 $ Water x u $ Ap x $5.00 W c a y q $ 4 ro W p, W ( 0%Heater Water Softener x u $ .qi H N $ F •14 ro W $ H J •01 N 'N 11 W to N 0f p 4, 0 -Af $4 C " ' ro —1 7 Wo O A O .4 +ul roroo ro ro •� E c .G .0 o as lec w c`� U m a U 1st connect f irg_j ilace 2nd 13rd 4th (R) a Future Connection Opening Connected with Sewer (*) o New Fixture, Old Opening Water PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Nu--I-er Fixtures x $3.00 $ Future Fixture Opening ai $2.00 $ New Fixture, Old Opening x $2.00 $ Catch Basin x $5.00 $ Water Heater - to 99,000 BTU x $5.00 $ 100;000 BTU to 199,000 BTU x $10.00 $ Water Softener x $7.00 $ New Ground Run Old Building x $5.00 $ Electric Water Heater - x $5.00 $ GAS FITTING FEES: 1st 3 fixtures x $3.00 $ Additional Fixtures x $1.00 $ .Gas Range to 199,000 BTU x $10.00 $ REPAIRS $ ALTERATIONS First $100.00 $5.00 $ each add. $100.00 or fraction $2.00 $ State Surcharge $ .50 TOTAL FEE $ '8.00 REINSPECTION FEE ($30.00) Job Address 51667 AVE. NE ? Department of Buildings City of Fridley Tel. #571-3450 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 correc Fridley, Mn. 12-3-76 19 OWNER FILMORE SAMUELSON KIND OF BUILDING frame. USED AS res. TO BE COMPLETED ABOUT 12-10-76 ESTIMATED COST lO�OO OLD - NEW BUILDING PERMIT NO. PERMIT NO. Company —/T : Signed By MINNFrAgrn Tel. No. ROUGH INSP. Date FINAL INSP. & n Date APPROVAL FOR PERMIT 'O's MINIMUM FEE FOR ANY PLUMBING PERMIT IS $7.50 SUBJECT City of Fridley ""--17205 2 0 5 41 AT THE TOP OF THE TWINS BUILDING PERMIT r COMMUNITY DEVELOPMENT DIV. r I L PROTECTIVE INSPECTION SEC. 37617 CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY 612-571-3450 910-F15 8/28/90 JOB ADDRESS 516 - 67th Avenue N.E. 1 LEGALLOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 9 7 Rice Creek Terrace Plat 4 SHEET 2 PROPERTY OWNER 516 MAIL ADDRESS ZIP PHONE Mark Babcock $9X - 67th. Avenue N.E, 571-9205 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. D & D Home Improvement Inc. 740.1 Central Avenue N.E. 784-7543 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 Cj REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof Dwelling (_18 Squarest 9 CHANGE OF USE FROM TO STIPULATIONS Roof can be 2nd layer but not 3rd. 2nsta1l ridged galvanized valleys. On all now mis OT teaT-Offs and Te 1W"1lted 1' ft State Code requires that 2 layers of 15 Ib. felt, mopped together, be installed to a point 24 inches up from exterior wall line, or the use of other approved underlayment membrane. TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING, ZONING SO. FT. CU. FT. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT NO. DWLG. UNITS OFFSTREET PARKING ANY TIME AFTER WORK IS COMMENCED. I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES VALUATION SURTAX AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED $90a $,50 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT PERMIT FEE SAC CHARGE DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- $23,Q0 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE 23,50 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI WHEN PJPERLY V I T HIS IS YOUR PERMIT BLDG INSP DATE SIGNATURE OF OWNER IIF OWNER BUILDERI (DATE) NEW [ ] Effective 1/1/90 ADDN [ ] R-1 AND R-2 ALTER [ ] Buildii7m ngPermit Application Construction Address: 5/ 7 ��� Legal Description: Owner Name & Address: Contractor: Tel. # -O®.� Tel. Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. OF UVIM AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DBCR AREA: Length Width Hgt/Ground Sq. Ft. OR'iER: Corner Int [ ] Inside lcq;[ ] Ft. Yd Setback Side Yard Setbacks Type of Construction: ,QBE , -Zt tel. Estimated Cost: $ Approx. Completion Date: _�}�- /s 18 7,0glzm-1 Proposed Driveway Width If New s Desired: Ft. $ $ Wath 6' See Back Page DATE: 9 ed Q8 APPLICANT: Tel. # Permit Fee $ 2,T, �® State Surcharge $ �® SAC Charge $ Driveway Escrow $ Park Fee $ Sewer Main Charge $ STIPULATIONS: CITY USE ONLY Fee Schedule on Reverse Side $.50/$1,000 Valuation $600 per SAC Unit Alt. "A" or Alt. "B" Above Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] 0 SUBJECT AFERAMIT NO. City of Fridley 29647 AT THE TOP OF THE TWINS BUILDING PERMIT r RECEIPT NO. COMMUNITY DEVELOPMENT DIV. y � r PROTECTIVE INSPECTION SEC. 10 CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY 612-571-3450 910415 16/8/99 JOB ADDRESS 516 67th Avenue NE 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DescR. g 7 Rice Creek Terrace Plat 4 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Theresa VanLith 55432 572-3830 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Owner 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 O ADDITION O ALTERATION M( REPAIR O MOVE O REMOVE B DESCRIBE WORK Reroof house and garage (24 S 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 OCCUPANCYLOAD 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 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 $2098 $1.05 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 TOT FEE $ .40 SIG ATUREOFCON�RAC OAORAUTMO ZEDAGENT iDATE. E R VALIDAT THIS IS R P Mz IT ' r z SiGN4TUAE OF OWNER.IF OWNER BU4 DERi IOAf- BL G NSP pAtE 0 or NEW[ ] Effective 5/10/99 ADDN [ ] CITY OF FRIDLEY 4�22P ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Y BUILDING PERMIT APPLICATION Construction Address: J to (� % fh�/Q 1�� ;Cf `j l�'t t1 ��3 Legal Description: Owner Name & Address: Contractor: S� l � Address: MN LICENSE # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF E14PROVEMENT Tel. # LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width am HHgt/Ground Sq. Ft. OTHER: pp d2.n' // 7 . e) % .-,/ D %�. CO3 Construction Type: Estimated Cost: $ Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ DATE: 6/'Y q � APPLICANT: Tel. # TOTAL STIPULATIONS: CITY USE ONLY Permit Fee $ , Z� Fee Schedule on Reverse Side Fire Surcharge $ .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge $ $1050 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 STIPULATIONS: -CITY OF FRIDLEY INSPECTION DIVISION 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING,, VENTILATION, 572.3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES 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) lata of Value of Appliance or Work Commercial/Industrial 1.25% of Value of Appliance or Work Rate $ 30.00 $ 10.00 $ 10.00 $ 10.00 $ 25.00 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. Effective On May 10, 1999 JOB ADDRESS a160 — Ave, ME OWNER :[JeReSA 1/A A.) TOTAL ` BUILDING USED AS `0 LTJ -2 LL i nl G ESTIMATED COST 1 ADD , DO PERMIT N0. DESCRIPTION OF FURNACE AND OR BURNER No. of Heating Units / Circle One (Steam) (Hot Water) arm Air $ Trade Name Liuwu D Size No. LIG P14 0 1 EA G BTU .' .0 06 HP EDR $ Fuel Total Connected Load Burner Trade Name Size No._ $ BTU HP ED $ 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 $ .50 rulings of the Building Division, and hereby declares that all the facts and representations stated RI@S CWGftetaMftP ..correct. $ Sv 9925 Bluebird St. N.W Coon Rapids, MN 55433 HEATING CO •.x;(612) 754-2199 Fax (612) 754-2909 Signedl4 DATE Approved By /�—k Rough -In Date Final CHEWNEY 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 3. Has no foreign objects lodged within 4. Is securely supported 5. 0 Meets all current Code requirements for size and total BTU's connected Has total heating BTU's of All other BTU's Yes () No ( ) Yes O No ( ) Yes () No ( ) Yes ( ) No ( ) TOTAL BTU's 7. Has a liner been provided for water heater Yes ( ) No ( ) 8. Has combustion air been provided for water heater Yes ( ) No ( ) Remarks: List ALTERATIONS Being Done: HEATING CO: Signed By: Date: CIIYOF FRIDLEY FRIDLEY MUNICIPAL CENTER - 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 - (763) 571-3450 - FAX (763) 571-1287 October 17, 2001 Theresa Vanlith 516 67 Avenue NE Fridley, MN 55432 Re: Final Inspection at 516 67 Avenue NE Contractor: River City Sheet Metal Inc. Dear Ms. Vanlith: A mechanical permit was issued on October 7, 1999 to install a furnace at your address. According to section 305 (a) of the 1991 Uniform Mechanical Code, a final inspection shall be conducted on the mechanical work authorized by this permit. As of this date, no inspection has been called for. The permit fee that was paid covers the inspections to make sure the work was completed according to the Mechanical Code. We will keep your permit open for another 30 days and if we do not hear from you within this time to set up the inspection, we will expire the permit and no further action will be taken. To set up the inspection or to have any questions answered, please contact the Building Inspection Division at (763) 572-3604. DAVE JENSEN Building Inspect( DJ/mh ;,ITY OF FRIDLEY INSPECTION DIV. 3431 University Ave NE Fridley, MN 55432 572-3604 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO BF INSTALLED ON FACH FI nnR Effective On Jan 1, 2000 In In $ 7.00 The undersigned hereby makes application for a permit for the work herein MOSS $ 4.00 IN ME $ 5.00 and rulings of the wilding Division, and hereby declares that all the facts Blow Off Basin $ 7.00 .and represe-`- — -`-` and correct. Catch Basin $ 7.00 PEISSIG, PAM Rain Water Leader $ 7.00 516 67TH AVENUE NORTHEAST D 2003 FRIDLEY, MN 55432 — Sump/Receiving Tank $ 7.00 (763) 571-9696 Water Treating Appliance $10.00 Owner Water Heater -Electric $ 7.00 Water Heater - Gas** -j— $10.00 Building Used AsE`�t�%� c.. Gas Range** Gas Dryer** $10.00 $10.00 Estimated Cost PERMIT NO. Back Flow Preventer Required ( )Yes () No Type $15.00 PLUMBING COMPANY Reinspection Fee $47.00/Hr SIGNED BY TEL N0. 1Z -8Z7-40 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance Approved By Rough -In Date Final Date State Surcharge $ .50 TOTAL FEE $�� MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $20.00 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 PLUMBING FIXTURE RATES: NO. RATE TOTAL JOB ADDRESS 54NE i -e, 6WO1-5l'r— 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 wilding Division, and hereby declares that all the facts Blow Off Basin $ 7.00 .and represe-`- — -`-` and correct. Catch Basin $ 7.00 PEISSIG, PAM Rain Water Leader $ 7.00 516 67TH AVENUE NORTHEAST D 2003 FRIDLEY, MN 55432 — Sump/Receiving Tank $ 7.00 (763) 571-9696 Water Treating Appliance $10.00 Owner Water Heater -Electric $ 7.00 Water Heater - Gas** -j— $10.00 Building Used AsE`�t�%� c.. Gas Range** Gas Dryer** $10.00 $10.00 Estimated Cost PERMIT NO. Back Flow Preventer Required ( )Yes () No Type $15.00 PLUMBING COMPANY Reinspection Fee $47.00/Hr SIGNED BY TEL N0. 1Z -8Z7-40 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance Approved By Rough -In Date Final Date State Surcharge $ .50 TOTAL FEE $�� MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $20.00 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 replacing 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 O No ( ) The undersigned also verifies that the replacement unit is a listed assembly and meets the current codes and manufacturer's specifications. This does include AGA-GAMA Category I Central Furnace Venting Tables for fan assisted and natural draft appliances. Yes () No ( ) The existing combustion air is sized and installed to meet the current codes and manufacturer's specifications. Yes ( ) No ( ) When required to Install a new combustion air, it will be sized and installed To meet the current codes and manufacturer's specifications. Yes ( ) No ( ) When installing a new venting system, the undersigned hereby verifies that it is a listed assembly and meets the current codes and manufacturer's specifications. This does include AGA-GAMA Category I Central Furnace Venting Tables for fan assisted and natural draft appliances. Yes () No ( ) Is the common vent and vent connectors sized and installed correctly after an appliance has been -removed from the common vent and vented. separately as°:per current codes. Yes( ) No ( ) Appllance Type and Size/Common Vent and Vent Connector Information Appliance #1 Type Appliance#2 Type Appliance #3 Type Total Appliances _ BTU Input _ BTU Input _ BTU Input Total Btu Input Fan Assisted or Nat' Fan Assisted or Nat Fan Assisted or Nat 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 :