PRE2010 DOCS CITY OF FRIDLEY BUILDING INSPECTION (9,C' 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 SYSTEMS AND DEVICES
JOB ADDRESS � ►-�y l )W R C!
RATE SCHEDULE Fgg Total --� --'
Residential Owner ��(�C\���(`n `�-
Furnace Shell and Duct Work, Burner&
also Replacement Furnace $35.00 $ �J _ Building Used As
Gas Piping(New Furnace, Fireplace, Insert) $10.00 $�`� ESTIMATED COST �� � •� �PERMIT NO
Gas Range $10.00 $ DESCRIPTION OF FURNACE AND BURNER
Gas Dryer $10.00 $ #of Heating Units Circle One (Steam) ( ot Water) . Warm Air)
Trade Name Cl C t YYl Size No. ' t>
*Air Conditioning-All Sizes $25.00 $ cBTU_ > '° HP EDR
Fuel ti Total Connected Load -)(_00Q�(::�>
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 0 \ ,�_J(
TOTAL FEE $ -'.r-c1 Signed Tel# I )l-� (-1 Mo
REINSPECTION FEE$50.00/HOUR FAX# Wo J) Date_
*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
Approved by Rough-in Date Final Date
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 O 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 mc-et 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 ( )
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 OFFRIDLEYINSPECTION DIV. Effective April 1. 2004
8431 University Ave NE
Fhd|sy, MN 55432 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
(783) 672-38O4. FAX(7O3) 571-1287
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
G S Water Heater
Wash Auto. 0
Shower '93i ash A`
Floor 2
^�
PLUMBING FIXTURE RATES: NO. RATE TOTAL JOB ADDRESS I
'
New Fixtures « $1O.00 The undersigned hereby mnakaaappUuaUonforapermit for the work herein
Old Opening, New Fixture $10.00 specified agreeing to do all work in strict accordance with the city codes
Beer Dispenser $10.00 and rulings ofthe 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 �1OOO
� � ��� �
Rain VVaherLeader $10.00 DATE: ��' "�^� c/-' 2O__________
Sump/RaoeivingTonk $10.00
Water Treating Appliance $35.00 OWNER
VVatarHeabar-Beobic $35.00
Water Heater-Gas** �35�OO ��^� ��-- BUILDING USED A
-_--_ -
Gas Range" $10.00
Gas Dryer** $10.00 ESTIMATED COST PERMIT NO.
Back Flow PreventerRequired ( )Yeo ( ) No
Type $15.00 PLUMBING COMPANY N
)
Reinspection Fee$5O.00/Hr S|GNED8Y TEL NO
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.3596ofValue ofFixture orAppliance
Approved By Rnugh'|nDahe Final Date
State Surcharge 50
. MINIMUM FEE FOR ANY PLUMBING/GAS 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 6-4. "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-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 Furnice
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.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd:
DATE 1 L - CDs YOUR E-MAIL ADDRESS
SITE ADDRESS 55 39 c, ~ St- A)/_
THIS APPLICANT IS: ❑OWNER XONTRACTO,,Rii
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE# ' ` rr\ EXP DATE
YOUR STATE ADDRESS: /ky -6 t YCz t,,, tUC,.i CITY I- (dose STATEMe\ ZIP 553011
LICENSE WITH PHONE '-Ila 3- 7'7 FAX '?b3 - 30-% -6 1-7 Co
APPLICATION
PERMIT TYPE ❑SINGLE FAMILY ❑TWO FAMILY TOWNHOUSE
TYPE OF WORK: XNEW ❑REPLACEMENT
DETAILED DESCRIPTION OF WORK T�S z.c� Va10'�
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 SINIULAV _FLOOR DRAINS _SHOWER _WATER PIPING
_BATHTUB _GAS PIPING(NEED cirrucFYsE) _SWIMMING POOL _WATER SOFTNER($35)
_CLOTHES WASHER _KITCHEN SINK _WATER CLOSET BACKFLOW PREY.($15)
_DISHWASHER _LAUNDRY TRAY _WATER HEATER($35) FOR IRRIGATION
WATER METER OTHER
PEItMtT FEE x'R( E ,T :F�2.CJ�fiD1It :5()U, " 'ET ) P11CTS OVE) "$QUO:?
Permit Fee $ 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 APPLICATION 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 which requires review and approval of plans.
SIGNATURE OF APPLICANT C1,s� �"¢"'=��PRINT NAME s t �/ —DATE—1
;'PTEA E N. WXBPMATE PER,MI S ARE;I oumEEJ)'$ L A 3 M1 CI ANG W RK r T"}
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977