PRE 2010 DOCSCufty of Fridley
au3dECT
Permit No. /020
AT THE TOP OF THE TWINS
aA/
IPLUMBING
PERMIT APPLICATIOid UY'-
rL-------, COMMUNITY DEVELOPME0 DIV,
i PROTECTIVi? re OeMOp MPT,
CITY HALL RRipLFV • ON=
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1 1
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Job Address
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Miner Address Phone
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v-�C�i.> �AY� .
Contractor Address Phone
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K'nd ofgilding
Use
Completion Dat4
EstimatedCost
Plumb in Fixture Rates; NO. RATE TOTAL
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Number Fixtures x $2.00/, .00
'I
Future Fixturesx $1,50
a9svDl
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New Fixture -Old Open. x $1.50
a
Catch Basin x $3.25
eeoI
Water Heater -99, 000 BTU �' x $3.00 3-.()0
•os, W
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Ground Run Old Bldg. x $3.25
'MN,Va
Elec. Water Heater x $2.00
o sN,sve
&~ MaLvol
#
W
_Gas Fitting Fees;
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OaOO-1.4
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1st 3 Fixtures X $2.00 a?.y O
jo.°�
Additional Fixtures x .75
[ %umozi
'U HNiaal
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Gas Range -199,000 BTU x $5.00
qAMsvM
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$
Repairs &Alterations
See
Description: Code
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State Surcharge .50
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TOTAL FEE $ a . d O
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The undersigned hereby makes application for a permit
sivN,anl
for the work herein specified, agreeing to do all work
sa3VM�
in strict accordance with the City Ordinances and ruling
'`�
i
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of the Department of Buildings, and hereby declare that
all the facts and representations stated in this
application are true and correct.
Si natur Date '
i
City of Fridley
S�dfiGY
Permit No.
AT TMS TAP OF TW@ TWINS
`;
HEATING
PERMIT
APPLICATION
-------HEATING pEvl[Loa oENT OIv:
i PROTECTIVE VdV'tCTION DEPT.
CITY NAIL FRIOIQY §M2
KAVZi m
Rev. pAre
OF
APPROVED BY
910-F17A
IPAOE
0 2/15/73
1 1
800
Job Address
wrier
ddress
Phone
Contractor r�
Address
Phone
Kind of Bing
u'e
Us
Comp etio a e
Estimatfad Cost
GRAVITY WARM AIR:
iIATZ
60 J -D
TOTAL
Heating/Power Plants
Furnace Shell & Duct Work ...............
..$10.00
$_
Steam Hot Wat r Warm Air
Replacement of Furnace ... ..... . .....
.. 6.00
$
Repairs & Alterations—up to $500.00
6,00
Trade Name
Repairs &Alterations each add. $500.003.0()—_-
--
Size No.
MEML W dl AM
Capacity ,4.1p. S Ft
Furnace Shell & Duct Pork to 120,000 RTU ...... .
..$10.00
$—
EDR BTU/w d�`T.on.
each add. 60,000 BTU ............... ....
.. 3.U0
Total Connected Load, fl
Replacement of Furnace
6.00
$
Repairs &Alterations—up to $500.00
6.00
$
Kind of Fuel
Repairs & Alterations each add. $ 500.00
3.00
$
Burner
STEAM or NOT MATER SY,TEM
Trade Name
Furnace Shell & Lines—to 400 sq. ft. F.DR Steam
510.00
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water
10.00
g „
Size No. i
Each add. 200 sq. ft. EDR Steam
Xon
$..__
Capacity Sq.Ft�
Each add. 320 sq. ft. EDR Hot Water
3,W
$
EDR BTU Ton.
OIL BURNER—to 3 gal. per hour
6,08
$
over 3 gal. per hour—See Fee Schedule
OAS EURMER (up to 1' 3,000 BTU)
5.00
$
l
over IS9,000 BTU see Fes Schadnle
Z
GAS FITTIPoG FEES:
NO RATE TOTAL
1st 3 Fixtures
x$ 200
$
Additional Fixtures
x .75
$
Gas Range to 199,t
RIR C0'N IYIONIVG
FAN HE.A.TI TLG SYSTE5-3
VENTILATING SYSTLIM
ALTE11ATIONS & RTPAURS
ROUGH
nNAL_ 4-17- 2 X
$$ 6.0D S
.50 State Surcharge
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So* Fco Sch e +
SUBURBAN AIR CONDITI®NINS AL
S ignatu...
1fNNEAPOLIS, MINNESOTA 55432
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SUBJECTP
RMLT`NO.
City of Fridley
1235
AT THE TOP OF THE TWINS
BUILDING PERMIT
r
�
COMMUNITY DEVELOPMENT DIV.
�CEIPT NQ:
y
L ____ '--
r PROTECTIVE INSPECTION SEC.
� I �
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
612-560-3450
910-F15
10/11/73
JOB ADDRESS 1010 - 68th Avenue N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
2
1
1 Michael Servetus Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Adel Marcus
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Amber Construction 6070 Stinson Boulevard 636-7880
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
C$ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK Construct a 40' x 26' Dwelling and a 24' x 28' Garage
9 CHANGE OF USE FROM TO
STIPULATIONS Provide a hard surface driveway. Provide a verifying survey before
capping.
SEWER LOCATION: 12" Sewermain on 68th Avenue is available but service
is not extended to property line.
WATER LOCATION: 6" Watermain located 5'-south of Sewermain on 68th Avenue
MUST BE TAPPED
SEPERATE PERMITS REQUIRED FOR WIRING,
HEATING, PLUMBING AND SIGNS.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
Wood Frame
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SQ. FT.1040+72+
CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, ORIF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
R-1
1112 -I- 600
27,500 Total
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
$21,478
10.74
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. -
$51.00
$275.00
STRUCTIO R THE PERFORMANCE OF CONST CTIO14
PLAN CHECK FEE
TOTAL FEE
$336.74
S16NATUREOFCONTRACTOR ORAUTHO ZED GENT 1 EI
W EN PR E V IDA D THIS I OUR PERMIT
I� !
DG INSP
SIGNATURE OF OWNER IIF OWNER BUILDER) (DATE)
Su. "'Du rban Envinecrino, Inc.
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6875 SfigAway To. 65 X e ,
1%finneapots, %nnesofa 55432
784-6066
'1ZoLeat �`JSIi+,�1el, .lieq. E'nyt.
e�instR �eg. F.ny►.
Dyson .9 Sreva R -g. engt.
e eA (-Oud) Rathbun, -'Reg. Sa wy01
Cvil & %Iunicipal Enginatky
SAnJ Susveyots
Sand Manning
Soil 9esting
Januarf 24, 1967
Devon Inc.
1%'r. Richard Ernst
Lowry Realty
2427 West Broadway
Minneapolis, Minnesota 55411
P •
Re: Soil Tests Lot 8, Second .
Revision Auditor's Subdivision
No. 21, Fridley.
Gentlemen:
On January 4 we drilled 8 test holes on the subject -property by
r.eans of a 6 inch power auger. Holes, were drilled at locations Indicated
on the attached sketch. Elevations were taken at the time of drilling
using the street centerline elevation at the northeast corner of the
property as a benchmark. Elevation of this point was taken from pre—
vious survey as 867.3.
The soil is predominantly sand with some peat at or near the surface
in all holes except numbers 4, 6 and 7. These holes were all sandy or
clay soil with no peat in evidence.
The water table was checked immediately after drilling and tray not
have stabilized in all holes. It should be assumed that it was still
rising in holes numbered 4 and 7.
41:'J : rnlz
Encs•
Very truly yours,
SWURBAN ENGINEERING, INC..
William E. Jensen P.E.
�. �.��. ��o�-,��.• g . moo-, . z
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tr3�nvao�g -
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r> ,, " .• .:�.� .� 'ted;--s.��.L e
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t ! A
it .�.. V
{ t'h?` I
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gicnGAJ17.',,
9QD.�pl��fiS !
fill,
D�OSJUU/�� e fi i.1 � � 4t 1l � ��� .� � a '3 � �Y emA r • L'UI�S:�(SflOs
•Z�S�oCID�JU/�y r '�` //
LYll�a 1.k7s• ��
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SOIL SURVEY REk1OXZ
Devon Inc. X Dick'Ernst, Lowry Realty
on: Lot 8 Second Revision Auditor's Subdivision No. 21, Fridley, Minnesota
January 4 1967
Test Hole No. 1
ev. 867.0
0.0-4.0' Black peat
4.0-14.0' Bcown sand
3.5' Water elevation
Test Hole No. 2
Elev.. 867,4 .
0.0-0.5' Brown peat
0.5-2.0' Black peat
2.0-14.0' -Brown fine-sand--
4.21
ine•sand4.2' Water table
Test Haile No. •3
0.0-2.0' Black peat
2.0-10.0' Brown sand
1.0.0-12.0' Grey clay
12.0-14.01 Brown sand
4.0' Dater tabla
Test Hole No. ,4'
•Eley. $690®• ' `' .
0.0-2.0' Brown loamy sand•
2.0-9.0' Brown sand
9.0-11.0' Gray clay '
11.0-3.4.0' Grey sand
9.0? Water table
Test Hole No. 5
Elev. 864.5
0.0-0.5' Dark brown sandy loam
'0.5-4.0' Brown loamy sand'
4.0-9.0' -Brown peat
.9.0-14.0° Brown sand
4.0' Water table
Test dole No. •6 t
Elev. 863.9
0.0-2.0' Dark brown loany sand
•2.0-11.0' Brown sand;,
r•
11.0-14.0' Grey sand
.4..4.0 ° . Water table
Test Hole No. 7
Elev. $67.8
0.0-0.52 ' Brown loamy -sand
0.5-1.01 Dark brown loamy clay
1.0-2.0' Dark brgwn loaty sand
2.0-7.0a_ Brown sand
'7.0-11.0' Grey sand
11.0-12.0' 'Grey clay
12.0-14.0' Grey sand '
9.0° Water tabl4
r
2 Soil Survey Report
„voa Inc.
r
Test Hole No.8
Elev. 866.1
0.0-5.0' Dark brown peat
5.0-11.0' Grey sand
11.0-14.0' Grey clay
3.9' Water table
Suburban Engineering, Inc.
6875 Highway #65 N.E.
Minneapolis, Minnesota 55432
.William E. J ns n Reg.No. 5830 .
ate: January 23, 1967
• I
I
City of Fridley
sua►E°T M
Permit No.
AT THE TOP OF THE TwtN>Z
BUILDING PERMIT APPLICATION
Receipt No.
�td-------- COMMUNITY DEVELOPMENT DIV.
I I PROTECTIVE INSPECTION DEPT.
I---� ; CITY HALL FRIDLEY 88432
/a1M BER
REV.DATE
PAGE OF
APPROVED 6Y
--.-. � IQ 012-880-3480
•
910-F14
0
1/15/73
1
Job Address:
Legal
Lot No.
Block"-
Tract or Addition See Attached
Descr.
12-
f
C HIE 4 ,2 v Z -Z L S Sheet
Propery Owner Address Zip Phone
ontractor Address Zip Phone License NZI
/eo.
/,070 S -r 1� Dew 910 Alk � �S
rc tect or Des gner Address Zip PhoneLicense No.
Eng neer Address Zip Phone License No.
Use of Building
Class of,WorkRemove
(D'® ❑ Q ®Move
New Addition Alteration Repair
Describe Work
Change of Use
From To
SPECIAL ASSESSMENTS:
If lateral assessments have not been placed on this property, an agreement urzst be
signed, agreeing to assume such lateral assessments before a permit will be issued
Agreement Necessary:
Agreement Unnecessary: Finance Director
J
OUTSIDE UTILITIES:
z
Sewer Elevation: Water Elevation:
®
Stub Location: Stub Location:
w
0
BUILDING INSPECTION
}
{—
Plumbing H.V.A.C. Electrical Fire Insp.
tj
Signature & _ --
Date Approved
i°
Registered Engn. Stamp. Legal Description Check
Exterior Devel. Check Performance Bond Check
Easements, R/W, Special Agreements
Final Approval Date
Certificate of Occupancy
Date
FOR CI SEONLY
DIMENS IONS • �i�
r
Length:_ 0 Height: Cu. Ft.
, 2, _
Width: Sq. Ft.
Accessory Buildings:.
Length: Height: �CU. Ft.
Width: ^r Sq. Ft.
VALUATION:
Sq. Ft. X Cost = Valuation )
TotAl
Valuation
Basement X Cost = Valuation )
PERMIT FEE: Residential
Total Valuation
Fee m
$1.00 to $500.00
$5.00
$501.00 to $2,000.00
$5.00 for the first $500.00 plus $1.00 for
each additional $100.00 or fraction thereof,
to and including $2,000.00.
'$2,001.00 to $25,000.00
$20.00 for the first $2,000.00 plus $3.00
for each additional thousand or fraction
thereof, to and including $25,000.00.
$25,001.00 to $50,000.00
$89.00 for the first $25,000.00 plus $2.50
'
for each additional thousand or fraction
,'thereof, to and including $50,000.00.
$50,001.00 to $100,000.00
$151.50 for the first $50,000.00 plus $1.50
for each additional thousand or fraction
thereof, to and including $100,000.00.
PERMIT FEE: Commercial and Industrial
--
Total Cu. Ft. X $2.15/1,000
Permit Fee
sq. ft.
X
_
PLAN CHECK:
Take one half of permit fee =
STATE SURCHARGE:
Valuation X $.50/$1,000.00
x $.50/$1,000.00
PERFORMANCE BOND VALUATION
Blacktop
Curbing
Sod
Fencing
Bushes and Trees
1.50/sq. yd.
2.00 lin. ft.
0.40 sq. yd.
2.00 lin. ft.
5.00 - 30.00
TOTAL FEE
TOTAL BOND VALUE
r
Lend Planning (4a&"*t4L W75 gonvy NJ ME,
Lad SLrwylny mmmav/`Sl?
J0115 kshily ENGINEERING, INC. -
CIVI/ b- Alompal S!/me{ d-6066"
Engineers e Sur vectors
I
certificate of surve
7 few /vN
11016
(�S�-AVF- N.E. . ,
-- 745.00
Ian
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V%
N-,JV,',A COI-)ATY
75-00
hvv&j ceAjy Ow Ns is a #W mrdearred repmsmtehm #f*sLrvcq #0&&vidatipf q("*,o6epv AscivArdlard, mad
/me &a Ora# , etidk &ivw, wdoll m' 5 We wmabineflIs , ifamj, FWn or' w smid laid. As surveyed naet yed 6y fl
SUBURB" ENGINEERING , INC.
.
veers
C7 A)
Fpm erT-`/'
Lo4r-�7-Ao 61 JO 0 7/4 0
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SUBJECT
PERULT NO.
City of Fridley
2 0 6 0
AT THE TOP OF THE TWINS
BUILDING PERMIT
r
_ COMMUNITY DEVELOPMENT DIV.
�' SEC.
PROTECTIVE INSPECTION
l "1 CITY HALL FRIDLEY 55432
NUMBER
REV
DATEPAGE
OF
APPROVED BY
L.__.�' '•� 612-571-3450
910-F15
9/27/90
JOB ADDRESS 1010 - 68th. Avenue N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
2
1
Michael Servetus Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Del Marcus 1010 - 68th Avenue N.E. 571-5223
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
�7 NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 12� x 14' Shed in Rear Yard
9 CHANGE OF USE FROM TO
STIPULATIONS
Shed to be.no higher than 14 feet. Shed must be Securely anchored to
ground by either a Foundation or corner ties. Stied to be. placed 7 feet from rear
property line and 4 feet from side. property line.
WARNING
Before digging call for
all utility locations
454-0002
SEPARATE PERMITS REQUIRED FOR �EQU f REQ BY LAW
WIRING, HEATING, PLUMBING AND SIGNS.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCYLOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
ZONING
SQ. FT.
CU. FT.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 80 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
$80(1
$.550
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-
$21.00.
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
.0 $.80
Iq $22.30.
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE) _;:WH
N PROPERL V(WIS IS YOUR PERMIT
SIGNATURE OF OWNER IIF OWNER BUILDERI IDATEI
I BLDG INSP ryaTE
NEW [ ] Effective 8/16/90
ADON [ J R-1 AND R-2
ALTER [ ] Building Permit Application
Construction Address: 10/o A 7 e IV
Legal Description: - e ' �c `r �� - �v� *S Aw-W oAv
Owner Name & Address: //e / u-5,- -- /O /a 6 Al i Tel. # ! °'? / - Sz Z 3
Contractor:
Tel. #
Attach to this application, a Certificate of Survey of the ;
lot, with the proposed construction drawn on it to scale.
DESCRIP OK OF II�VE[�tt'
LT71M AREA: length Width Height Sq. Ft.
GAME AREA: Length Width Height Sq. Ft.
DBCR AREA: length Width Hgt/Ground Sq. Ft.
Clorner Int [ ] Inside Int [ ] Ft. Yd Setback Side Yard Setbacks
Type Of Construction: Estimated Cost: $ 00
Approx. Completion Date:
Proposed Driveway Width If New Opening Is Desired: Ft. $ $
Width + 6' See Back Page
DATE: ` � 2 -/`�� APPIZaWr: d�e Tel. # 5' 76 —5r- 2-
Permit Fee $'/.00
Fire Surcharge $ .6p
State Surcharge
$ _0
SAC Charge
$
Driveway Escrow
$
Park Fee
$
Sewer Main Charge
$
STIPUTATIONS:
CITY
CITY USE ONLY
Fee Schedule on Reverse Side
.001 x Permit Valuation (1/10th �)
$.50/$1,000 Valuation
$600 per SAC Unit
Alt. "A" or Alt. "B" Above
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
lona planning sir'drf � w"m
LandSurveyingnit • � p"' J 1► 1 'T.•s
Seib Testing 1
Civil Engineering
Municipal Engineering Engineers & Surveyors
Mortgage Loan Survey for Amscw
GSsAVE. N.F-
75.00
LIN
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54 oL
75.00
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&SYS Niginway 00.65 Al.f.
twintsropalis,
PAjeln. 55t312'
Telephone 11141-6066
Area Code 612
&v & ic - r qucrlav
This is a true and correct representation of a survey of the boundaries of the load above destribad and of the
loratfoa of all buildings, it any, lheraoin, a" all visible oncroactments, if any, from or on said land, this sDrvgq is
mode only in swrnostion with a mortgage lean now being placed an the ,property and no liability, it assumed
oacept to the hotter Of suck mortgage or any other iater*0 crequir" by the reosan of such enorlgoga, ft is
understood and all- p monuny�ts leave been placed for the purpose of estabfisbing lot lines or 6rowiJary
car"*". Oared th{s day of s + A. O. 11.880,
SUBURBAN INCiiN112I G, INC.
0 v"ors
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a�
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N:
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54 oL
75.00
•0PZ
&SYS Niginway 00.65 Al.f.
twintsropalis,
PAjeln. 55t312'
Telephone 11141-6066
Area Code 612
&v & ic - r qucrlav
This is a true and correct representation of a survey of the boundaries of the load above destribad and of the
loratfoa of all buildings, it any, lheraoin, a" all visible oncroactments, if any, from or on said land, this sDrvgq is
mode only in swrnostion with a mortgage lean now being placed an the ,property and no liability, it assumed
oacept to the hotter Of suck mortgage or any other iater*0 crequir" by the reosan of such enorlgoga, ft is
understood and all- p monuny�ts leave been placed for the purpose of estabfisbing lot lines or 6rowiJary
car"*". Oared th{s day of s + A. O. 11.880,
SUBURBAN INCiiN112I G, INC.
0 v"ors
- t„
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
FAX (763) 571-1287
JOB ADDRESS—/ 1 v
RATE SCHEDULE 5-- /
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 January 1, 2003
0''
OWNER I _—� r 1 OZ Z l
Rate TOTAL
� BUILDING USED AS [�S
$ 30.00 $ 3 -(/ V `--� 1�--�,�
ESTIMATED COST S_-(�,�[ PERMIT NO. !�
$ 10.00 $
DESCRIPTION OF FURNACE AND OR BURNER
10.00 $
No. of Heating Units Circle One (Steam) (Hot Water)7' ar Air)
$ 10.00 $ Trade Name Size No.
BTU HP EDR
$ 25.00 $ S'B� Fuel nct !4zvrs,aSTotal Connected Load
Burner Trade Name Size No.
$ BTU HP EDR
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.
$ 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 in this application are true and correct.
DATE f) 1
HEATIbaGO STANDARD HEATING & AIR CONDITIONING CO.
410 WEST LAKE STREET
lj MINNEAPOLIS,408-2998
# 612-824 2656
Approved By Rough -In Date Final Date
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
When raIn 9cinp an axirtinp fitramp,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.(' -'r No
The venting system is plastictPVC and meets all current codes and manufacturer /
specifications including sizing, length, number of elbows and termination. Yes (c-( 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 (�o ( )
The exhatlr�p rnmhi mrtinn air is sized and installed to meet the current codes
and manufacturer's specifications. Yes () No ( )
When required to install a new enmhnstien air. it will be sized and installed 1.
to meet the current codes and manufacturer's specifications. Yes (-�'No ( )
When inata�llinn 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 (11"'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 ( )
App- Upp and S'7e1Common Vent and Vent Connectnr Infmnatannn
Appliance #1 Type r Q BTU Input 0 0 0 () Fan Assisted or Nat 10
Appliance #2 Type 01 7ri- BTU Input D Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances Total Btu Input, O
Common Vent Type : Vent Height cP- O Diameter inches
Appliance #1 Vent Connector Height ft Length ft Diameter in TypeWC---"
C---"
Appliance #2 Vent Connector Height =ft Length=ft Diameter A_in Type d
Appliance #3 Vent Connector Height ft Length ft Diameter in Type M
HEATING CO:
Signed By: ,1 Date : l a- / 11 ^ 0-3