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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= -91Q NU rvf t 1 R9v. p4YE FADE Oar AF�PROV 0 BY QI:4-Sao- 3400 -F 0 2 15 3 1 1 800 -IBA Job Address D d h �-1��2 Miner Address Phone �� �y v-�C�i.> �AY� . Contractor Address Phone d K'nd ofgilding Use Completion Dat4 EstimatedCost Plumb in Fixture Rates; NO. RATE TOTAL L; I I- I I = w I Number Fixtures x $2.00/, .00 'I Future Fixturesx $1,50 a9svDl •� 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 I I I I i Ground Run Old Bldg. x $3.25 'MN,Va Elec. Water Heater x $2.00 o sN,sve &~ MaLvol # W _Gas Fitting Fees; y\I `smva OaOO-1.4 I I I hD ,� 1st 3 Fixtures X $2.00 a?.y O jo.°� Additional Fixtures x .75 [ %umozi 'U HNiaal ( ( I I Gas Range -199,000 BTU x $5.00 qAMsvM I I $ Repairs &Alterations See Description: Code w SNISVeI State Surcharge .50 I ( I I •S TOTAL FEE $ a . d O I �{I Mtvel j I I 1 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 I U 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 � 1 So* Fco Sch e + SUBURBAN AIR CONDITI®NINS AL S ignatu... 1fNNEAPOLIS, MINNESOTA 55432 -, r " 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. d U 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 14 tr3�nvao�g - ,L r> ,, " .• .:�.� .� 'ted;--s.��.L e Ila t ! A it .�.. V { t'h?` I JL 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• �� �/Y S9a fiaiayG�ifl_S1.89 ! r ) / r CJlUIlP fd FUC 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 0 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 5zi 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 0 N: 3 Z a .g upas Tounaafeori 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„ a� LIN 0 N: 3 Z a .g upas Tounaafeori 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