PRE2010 DOCS CITY OF FRIDLEY BUILDING INSPECTION Effective 4/1/2004
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION
763-572-3604. FAX 763-571-1287 REFRIGERATION AND AIR CONDITIONING SY TEMS AND DEVICES
JOB ADDRESS
RATE SCHEDULE Fee Total
Residential Owner
Furnace Shell and Duct Work, Burner& --
also Replacement Furnace $35.00 $ Building Used As
Gas Piping(New Furnace, Fireplace, Insert) $10.00 $ ? r` ESTIMATED COST t ,C PERMIT NO
Gas Range $10.00 $ DESCRIPTION OF FURNACE AND BURNER
Gas Dryer $10.00 $ #of Heating Units_ Circle One (Steam) (Hot Water) Warm Air)
C-3 C`�� Trade Name Size No. `%%
*Air Conditioning-All Sizes $25.00 $3 BTU (OCI 000 HP EDR
Fuel A_2C - Total Connected Load i { , C C
All Other Repairs or Alterations(List on Back)
1%of Value of Appliance or Work $ Burner Trade Name Size No.
Minimum Fee$15.00 for Residential or 5%of cost of BTU HP EDR
Improvement whichever is greater
The undersigned hereby makes application for a permit for the work herein
Commercial/Industrial/Institutional specified agreeing to do all work in strict accordance with the City Codes
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 true and correct.
State Surcharge $ HEATING CO
7 - �C
TOTAL FEE $ �(.)• Sign, q,3 -56
Tel #�„
REINSPECTION FEE$50.00/HOUR FAX# Date J
*Air Conditioners can not be placed in side yard without written approval
from adjoining property owner-copy to City
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE l f '
Approved by Rough-in Date Final Date
6
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 ( ) 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 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 Fumace
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 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 :
CITY OF FR|DLEf INSPECTION DIV. Effective April 1. 2OO4
6431University Ave NE
Fhd|oy, MN 55432 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT '
(7G3) 572-3GO4. FAX (7G3) 571-1287 ~Z-0 ^^ '
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
Water Heater
Gas
t Wash 5h M
Range a
Washer A0
I ray
Drain
Floor 4
PLUMBING FIXTURE RATES: NO RATE TOTAL JOB ADDRESS
�
NovvFixtures _�La1O.O0 The undemignedhereby makes app|iooUonforapermit for the work herein
Old Opening, New Fixture $10.00 specified agreeing toduall work instrict accordance with the city codes
Beer Dispenser $10.00 and rulings of the Building Division, and hereby declares that all the facts
Blow Off Basin $10.00 and representations stated inthis application are true and correct.
Catch Basin --___ $10.00 _—_-----
Rain VVabarLeader $10.00 DATE: =~ "�� � . 2O_________
Sump/ReoeivingTonk $10.00
Water Treating Appliance $35.00 OWNER
Water Heater-Electric $35.00
Water Haatar'Gas'~ $35.00 BUILDING USED AS
Gas Range** $10.00
Gas Dryer** $1000 ESTIMATED COST PERMIT NO.
Back Flow PreventerRequired ( )Yea ( ) No
Type $15.00 PLUMBING COMPANY
Reinspection Fee $5O.00/Hr SIGNED BY / ' TELN0.�261
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.25% of Value of Fixture or Appliance
Approved By Rough'|nDate Final Date
State Surcharge 50
MINIMUM FEE FOR ANY PLUMBINGIGAS PERMIT IS $15.00 or 5% OF COST
TOTALFEE $_______ OF THE IMPROVEMENT WHICHEVER IS GREATER ON WORK LESS THAN $300
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. "PROVIDE COMMON VENT INFO ON BACK SIDE
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 ( 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-LAMA 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 Furn4ce
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 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
Building PLUMBING Permit No.: g
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd:
DATE 10 - ___), YOUR E-MAIL ADDRESS
SITE ADDRESS 5'5%3 C;Ft St: !UG
THIS APPLICANT IS: ❑OWNER XONTRACTOR
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: Lk S
SUBMIT A COPY OF
STATE LICENSE# ` rr. EXP DATE
YOUR STATE ADDRESS: CITY I�r�C(O-er- STATEMe\ ZIP-55-30
LICENSE WITH PHONE '-Ila 3-a� 5, 1-1 FAX L 3 C':�C ` '1-7 �
APPLICATION
PERMIT TYPE ❑SINGLE FAMILY ❑TWO FAMILY TOWNHOUSE
TYPE OF WORK: XNEW ❑REPLACEMENT
DETAILED DESCRIPTION OF WORK D(e�
PER MS 1613.665 the permit fee is a minimum of$15.00 or 5%of the total cost up to$500.00, whichever is greater,for the
improvement, installation or replacement of a residential fixture,excluding the fixtures. (This should reflect only the cost of labor)
Labor cost under$300=$15.00. Labor cost between$300 to$500=cost of labor x .05=
FOR PROJECTS WHERE LABOR EXCEEDS$500,FEES ARE BASED ON$10.00 PER FIXTURE,EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL
NUMBER OF EACH BELOW)
_BATH SINKILAV _FLOOR DRAINS _SHOWER _WATER PIPING
_BATHTUB _GAS PIPING(NEED cirrucENsE) _SWIMMING POOL _WATER SOFTNER($35)
—CLOTHES WASHER _KITCHEN SINK _WATER CLOSET BACKFLOW PREY.($15)
_DISHWASHER _LAUNDRY TRAY _WATER HEATER($35) FOR IRRIGATION
WATER METER OTHER
PERMIT FSE PRC)EC7S'FOR J3*IDEIZ` 500 ERIv[iT FEE P.O PRU3ECTS�VETt'$500'
Permit Fee $ L>. -) Number of fixtures @$10.00 x$10.00=$
Surcharge .50 Number of fixtures @$15.00 x$15.00=$
TOTAL DUE $ Number of fixtures @$35.00 x$35.00=$
State Surcharge=$ .50
Total=$
THIS 1S AN APPLICAT}ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit;that the work will be in accordance with the
approved plan in the case of all work wh*h requires review and approval of plans.
SIGNATURE OF APPLICANT�1ts�- PRINT NAME —DATE—/ a S
LEA'SE..x+ibT .SET?Al7A ;E PERMIT .ARE:REQUIREDTOTZ`$UI DING; T:ECT LiC�4I.A'NDUWHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, N N 55432
763-572-3604
FAX: 763-502-4977