PRE2010 DOCS CITY OF FRIDLEY \NSPECT []N DIV. Effective April 1. 2004
O431University Ave NE
Fhd|ey, MN 55432 APPLICATION FOR PLUMBING AND GAS FITTING PERMI�
(783) 572-3604. FAX(763) 571-1287 -
MARK NUMBER OFFIXTURES TOBEINSTALLED ONEACH FLOOR
...Water Heater
Wash
.Doc: Floor Auto. Gas
Floor 2
Floor 4
'�
^�~� � -� ���_
PLUK�B|NGFIXTURE RATES: NO. RATE TOTAL JOB ADDRESS �� �� -� �
.
NavvFixtures �� $1D.DO The undersigned hereby makes app|icaUonforapermit for the work herein
Old Opening, New Fixture $10.00 specified agreeing todoall 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 in this application are true and correct.
Catch Basin �10�OO '^~-
--_--_ -------__ ��
Rain VVaterLeader $10.00 DATE: .2U__________
Sunnp/ReceivingTank $10.00
'Water Treating Appliance $35.00 OWNER -
VVabarHeater-E|ectrio $35.00
VVaterHeobar-Gao°° �35�OO BUILDING USED A
Gas Range" $10.00
Gas Dryer** $10.00 ESTIMATED COST PERMIT NO.
Back Flow PreventarRequined ( )Yee ( ) No
Type $15.00 PLUMB|NGCOWYP/\N
Reinspection Fee$5U.O0/Hr SIGNED BY TELNO;;12:"S'��~�`/Y`���
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.2596ofValue ofFixture orAppliance
Approved By Rough'|nDote Final Date
State Surcharge 5O
MINIMUM FEE FOR ANY PILUMBING/GAS PERMIT IS $15.00 or 6% OF COST
TOTALFEE $ OF THE IMPROVEMENT WHICHEVER IS GREATER ON WORK LESS THAN $300
COMBUSTION AIR SHALL BEPROVIDED PER UMC SECTION 5O4(A) AND TABLE 8-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 ( )
• f
The venting system is plastic/PVC and meets all current codes and manufacturer No ( )
specifications including sizing, length, number of elbows and termination. Yes ( )
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 Yes ( ) No ( )
assisted and natural draft appliances.
The existing combustion air is sized and installed to meet the current codes Yes ( ) No ( )
and manufacturer's specifications.
When required to install a new combustionair, 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 ( )
15 the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented Yes ( ) No ( )
separately as per current codes.
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 (li YOUR E-MAIL ADDRESS
SITE ADDRESS 55 3-7 ~ 5t NG
THIS APPLICANT IS: ❑OWNER XONTRACTOR
PROPERTY NAME: e; S
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: Lt S pi,, v-, .
SUBMIT A COPY OF STATE LICENSE# ` yr EXP DATE
YOUR STATE ADDRESS: lily g i YCe CITY 171I-46-9.t STATEM+\ ZIP SS30y
LICENSE WITH PHONE ala .3-)-6`d -to T-? Cm FAX 1,3 �^`d ` `�-2
APPLICATION
PERMIT TYPE ❑SINGLE FAMILY ❑TWO FAMILY TOWNHOUSE
TYPE OF WORK: XNEW ❑REPLACEMENT
DETAILED DESCRIPTION OF WORK r\� (� Cy (� �1'Q L-�� e.✓ r -r ` n 1 /�
PER MS 16B.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 SINK/LAV _FLOOR DRAINS _SHOWER _WATER PIPING
—BATHTUB _GAS PIPING rivEEo ctrrcrcFssE) _SWIMMING POOL _WATER SOFTNER($35)
_CLOTHES WASHER _KITCHEN SINK _WATER CLOSET BACKFLOW PREV.($15)
DISHWASHER _LAUNDRY TRAY _WATER HEATER($35) FOR IRRIGATION
WATER METER OTHER
]PERMITFEE: R( IE TS, ,OR I7NIDEI2$500 ' �4 � �'ERMIT
'FEFFO OVER$St10
,�
Permit Fee $ Q_ 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 IS 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 �I�s�- �'��"c _PRINT NAME 6 C,:-* 5` 0r!�y DATE
.PLEA E:NCtT SEPA LATE PERMIT ARE REQUIRED'FOR J LI TN ,.ELEC` C�3I,A TI?t,1VIECI i ICAL W+C)Rl �_�._.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977