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O � � � � � ..� � � � � z O � � ro � �� 1 tn tn �cn tn � � 'rU H � � d C O O y � ro q � N y I� O � � H H z O i � � O � M 0 0 H 1 �vs tn tn in C d d � � 00 a � H d H czi � � � � � � '�1 � �� M � 'U h' C �• r• w N N n � � � � m R� Q+ ID .'7' N � Y 7 a o rt rt O W 1~-� h N �� � N N'�)tn� h r*a o�q F'' N• rS 0 0 � o n :f ;7 w o rt y y fT O �o�mwo �� CX' xa a u�', � in o °o o ° °o O p� o ,.�. � �P�1Jd� N O O O O O O O O O O tn tn �tn tn tn a � G� � � � % �L7 �U � ti ~ ., w a o� : i ;,� n r• r• w N x" u�i 4i n � � r p (�'+ N � J' � y`; Y��t� � (D (D M ~ H y a a � �' � H � O O � f] •• :7 '..7 W ft a 'GO � r°t �o � W v�i 0 0 y tn o o° 0 0 � � r J� �1 J N O O O O �]y O O O O ���� H 0 r y O W N H t�-�r� � N C M � � O � w rr• � v,n,� w� a. a N�� n m a H' wY.ct t�t M N W O N M N F+� (D � %. � �w "' i� a d rr r�o �rop� ° m w � Pt O 'C N N m �p N � ��'S rt � S' N � O+ M k, b `�C � c w N . ,.. � �. fr r � F w °r'. �r r�r � N W w O RJ y rF � �w w o t+� � (� h{ ' o �w'm ��� �a9 a ,c � � K rt �� N N• M � a � n fD m x�r � N N (D a��s� o rwr �C �' � n a � x a ro r o m ,Lo, � NtLn �r m m , �.J � N �'. O CY a H m w N .� � � A -�—I � r � m N n � d C r rn � � �w a� `v "l7 r n a --i 0 Z O � 0 � m 7J A -O � D Z t") � O Cn %1 D �d .. o= m : y� COi N 2 V� G) -G � � � � �il O a O N � � � � � d � d � G � (7 M m � � -i O � � t� "�7 � � m � D --�! O Z n z G n -~-� =G C T T � d t"' m � 0 CITY OF FRIDLEY APPLICATION FOR HEATING REPLACEMENT CHIMNEY AfdO SYACK VERIFICATION THIS FORM MUST ACCOMPANY STANOARD APPLICATION FOR HEATING PERMIT FORM. LOCATION �� � DATE %o� � ��� - OWNER ADDRESS The u�dersigned hereby verifies that the existing chimney or stack: i. Has been carefully examined 2. Is free from rust or deterioration 3. No foreign obj ects are lodQed within 4�. That it is securely suppo�^ted 5. That it meets a11 current Cade requirements for size and total BTU connected 6. Total Heating BTU Ali Other BTU TOTAL / �, � ,� , , � ✓ � � � � REP7ARKS J • � SIGNEO �eQ� � � � Licensee by �/''��', � ' Addres s �/��^ �S �G� � Telephone �,f°'� �� -�� HEATING PERMIT # ' . Fridley City License � �7� o e l � � SuBJECT P City of Fridley I_ 15 7 81 � AT THE TOP OF THE TWINS g U I L D I N G P E R M r - � � RECEIPT NO. COMMUNITY DEVELOPMENT DIV. r ;.: ------, � � ��� � PROTECTIVE INSPECTION SEC. � � � (, -_-_ � �����,,� CITY HALL FRIDLE� 55432 NUMBER REV. DATE PAGE OF APPROVED BY i � � 612-571-3450 910-F15 6/13/80 � � JOB ADDRESS 627g gaker Avenue N.E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. ], 1 Moore Lake H].CJ�aI1t�S 4'til. SHEET 2 PROPERTYOWNER MAILADDRESS ZIP PHONE Rose Jasper 6279 Baker Avenue N.E. 571-1365 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Erickson Roofing 3930 Xerxes Avenue 588-6358 4 ARCHITECTORDESIGNER MAILADDRESS ZIP PHONE LICENSENO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO. 8 USE OF BUILDING RESICZC'ri't].3,�. 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE O REMOVE X 8 DESCRIBE WORK Reroof dwellin 9 CHANGE QF USE FROM TO i STI PU LATION S _ Roof can be 2nd but not 3rd roof. Install ri.dged galvanized valleys. S�PE�tAT� PERMITS R�QUtRED ��! MEATfIVG, PIUM��N� �4��fJ �1��. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT 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 WITH WHETHER SPECIFIED HEREIN OFi NOT. THE GRANTING OF A PERMIT ��-sOOO yti`.SO 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- STRUCTIO OR THE PERFORMANC ON�TRUCTION. �%. SO - PLAN CHECK FEE TOTAL FEE f'� $s.0a SIGNATUREOFCONTRACTO O-AUTHORI2EDAGENT (DAT WHEN PROPERLY ALIDATED THIS IS YOUR PERMIT SIGNATUREOPOWNERUFOWNERBUILDERi IDATE) BLDG INSP pA7 _ _ ;_- _. �� �...___ _.. .._....� ..v. __. _ �_.,_:.a_ _..:.:._._, _. , _ w _ _._...�_ �_. _.._...�. _ _...,., � CITY O}° �fiIDLCY � • Af'{'LIC/1TIOid FOR RESIDENTI/1L QUII_UIPaG PCRMTTS (Cdew, l�lter,ations, l�clditians, ar Jtepairs) . ., _ � ,. _,�. �...��_ OldfdER: �5� ��,�� QUILQER. ����C�Sf� �C.�?i�/�'�,-- ADDRESS: �,� �% � ����� ��•N�DDRCSS: � � J�� ��2���� TCL N0: — �.�%! -I J�n� TEL t��4: y��� .��� . Construction Location ST,RELT NO: ��'��� � STI2EET: - LO'�': • , I3LOCY.; ____�____ AbAITION: ���� ,.�.���L�3�`'3� `�i'�l� /��C� y�. Corner Lot: � Tnside.Lot: SefbacY.: Sidey�rds: Applicant attach to tliis form �.-wo Certificates of Survcy of lot and proposed building �.ocation drawn on certificates i:o scale. pESCRZPTTO�� OF CONSTRUCTION - � ���l�/QV�i-- E'rant: _ _ _ _ _ _ Depth: Heigh�: ��`S� Squa�e. Feet: GU.bic Feet: Froni� : Deptlz : H eight: Square� Feet: Cubi.c Feet: 0 7L`ype O� COIlStruc�ion: �, _� ��CC.I �stimated Cost: $ ��� � 7�U Be Cbmpleted: ! � ls Alt. A Al.t. B Propased Driveway Width Tf New Opening Is Desixedz $� $ , SEE REVERSE SIDE OF SAEET The undersigned her4by makes application ior a permit ior the work�herein specified, agreeing to do all work in strict accordance with the Cifi.y of �'ridley Ordiiiances and zulings o�' the Dej�arime�it. of Fuildings, and hereby dec�.ares that all the �'acts and represen�tions sta�ed in this application are true and correct. , A�TE: � - I� "��� SIGNATUF.E: � � Stipulatioizs : u �„�,- � • (/���'� . � � ���� � .�-� � � .� . �. - . . IIU)LllIiJG PERf�11'i rri SGfICDUt_G� • al,C'.�:tOt•� 2. 'Phe 7n�c��cctar.' of l3ui.lclir�<J:; s.ha).�., bGtor.r. i.:.: ,uinq 1�e�:�niL•� �'ox Lhe er.c:cLion o� �ny )�ui.�.d.i.nc3 or. :�Lruct:ure, or. for ai�y addi.L•i.on L•o a��y CY.1.::Li.n� builda.ny ox st�nicL-w:e, . a� ���' a�'ry �z].L-cr.aL•iori or. xep�,ir.�, L•o •a�,y cr.a.:.ting }�ui.ldir���3 or. :sLr.ucturc, uZ��n ap�,��.ic�xti.on 'L•hcr.efor.e, requizc U�c p�iy�ncnL• l�y tlic appl.i.c�zn� �or. :;ucl� pe�ynxt of. fces L'o, L•l�e amaunt� hezcin bcJ.ow seL forth �ind in i:hc manncn c�rcin �?�:�vic7��a Lo-w9.L-: ` J�};yl CON��TP,UC`J'iQN : Sing]_e l.'ami7.y liomCS and Gar.ages : $d . 00/�., 000 cuUic iec�. �>I,AtJ C1ihCY.: 25 },�cr.cenL- of bui.ld.i.ng r�ca.-�nit� fee. , , D1tIVJ���7nY UEl'I2L•'SS�OI1: (Conczci:q Cur_b �LrceLs Only) • n1L-crnat:e I�: R{�m�val and rep].acemenL- of concrete cuxk� and yuLter only; nriveway widtli plus 6 teei: x Y��.o7S . Alternate I3: itemova]. and rep].ac�ment a£ concreL-e curb and . , ' guttex and .]_IlSta].J. a 3 Loai: wide approach cvit.h • . G a.nch clepth; Driveway width p].us G feet �: $17.85 . � �' . �DnlTtot�n�. t r-or���n7-r0�- �'or the purpose oi computing fees foz building permits, the cubical. Coni:ents of any building or addi�ion, is dcLerm�_ned by rnultipJ.ying ihe ground ar.ea cavered i'rom a pai�lt six (6) inches below ih� floor line of the bas�ment or i:h� cellar Lo the avexage heiqhts af the upp�r surface or to the average heigiiL- o� ihe roof surface o� the :nain gabJ.e of a�iiched roo�. Fa�c xepairs or alterations to an existanq •struci�ure� tiic £ee shal�. be a� the rate o� $3.00 �er each iive hundred doJ.lars -($500.00) ar iractioai L-liereof i.n the cost o� all proposed work. . • In •no case shal.l the �ee charged for any pez:ma.t as uet �ortli �.n Secti.on 2 be less � than $7.50 pl.us $.50 state surcharge. � � � VFRIFICATI0�1 OF FOUNDATIOl� � ' NOTE: Permits for constx�uci�ion c�xl� be issued a nunimtun of 24 houzs fr.om the t9me o� application to allow far proper review of ihe proposed structure and oi the . construction site. A Certi��cate o� Survey of the 1at, siiocaing the �ocation of the toundation once it has been constnic�ed �,rill be xequired before prc�ceeding wi�h the �raming. Gi.RT I F I CAT� Q� OCCUPANCY _ llppla.cation ior a Certificate oi Occ�paricy shall be made ten (10) da�►s prior ta the use ar OCCLt�7321Cj� a� any st-ructuie �or WI11.Ci1 El' �U1.1C3111CJ �C'l:Tll].� IlEi� been �.ssued; 1I1C� SZ31C� S�1:l1Ct.UJC'G. SIlc3.�.�. IlOt: I�C USCC� Pl OCGL1j�lEC� t121�].l a. Cert�.�icate O{ ,OCCU�,��I1Cjr }lc'i5 ueell 1SSUCC�. n 0 � � � '�� !4._JR � � . � . • � • 0 <�M , �:. . v' ,�, , „ ,^, i MEMOF�NDUM TO: Nasim Qureshi, City Manager FROM: Jd'in G. F1ora,rPul�lic Works Director DATE: Ap3'i1 29r 198$ SUBJECT: Plsnting Baulevard/Chanticlear Pizza PW88-131 � r�� 7 � �� Chamiclear Pizza has ��eivec� fill material and placed it at the re�r of their �aperty adjoin�ng t�Q 40-f� planting strip. The fill has been spre�c7 and �d�d. Based �on yaur a�noer�, the City is remwing tree branch clippings and Placir�9 tlzeu in the H��.�r/Q��ira.ear tree rubbi€h pile for remo�al. In a�3itian, t�e City rArii3.� i� rel��ing s0me of the Civic Centea bu�hes ancl planting then ala�g the �:ster�� ec�e c� the ptar�ing strip in the vicinity of ttie JaspeF iu'o�rt�'• All of these above ac�ions s1ao�ld sat3sfy the c�ncerns expre�sed by Ms. Jasper. The City will oontinue to manitor th� drainage swale within the planting strip. JGF/ts cc: Jock Robertson .{ , , .. . -i . � ; ��,,� � ,. ;:� � C-- . .{, . " � � ;_ r.� , _ TO: FROM: DATE: Engineering Sewer ' Water Parks Streets Maintenance ����s� � �� � °� 7 ;� �l �,��,�:.� � i , MEMORANDUM Nas�m 4ureshi. City Marager Jahn Flora, Public Works Director Augtast 22. 1988 SUBJECT: �P Tree Qe�rir�g An188-279 Assflciated with �� under�rour�ding of the electrical distribution systen on Riee Cr�e1c Rct�d between Hi�aaay 65 affi Central Aver�ue is the installation of two additioral electrical phases to the service lir�es within the NSP easenent i�rallelirx,� HigY�ay 65 betvueen Higtaaay 65 and Baker Street. The NSP easanent extends five feet irito the p�vperties abutting the platted planting strip in Moore Lake Hi�larris 2rr1 Addition arrl the 10-foot easenent is entirely within theplanting strip in the 4th Addition. The distribution pol es are 1 oca ted on the property li ne. NSP i s currently cl e3 ri ng a rxi 3�b�a�� tria� distributi�n line in order to install the additional two service i�raes. Sane residents have raised the i�sue �f trespass and clearing within the planting strip. I hav�e been advised by NSP that they are working within their easenent ar�d upon oanpletion of the work will ranave all debris fram the site. Mrs. Jasper of 6279 Baker Street is aor�cerned h,ith ttle renoval of t�.e� d�bris azrl d��age to the lar�dscaping in the planting arm. NSP will ranwe all the tree debris. The bushes that the City planted adjacent to Mrs. Jaspers' property have mt been seriously damaged or destrq�ed. 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COMMUNITY DEVELOPMENT DIV. i VV ��.�� , ;� r � � PROTECTIVE INSPECTION SEC. — � S� e i i l.--_� ����� �'� CITY HALL FHIDLE� 55432 NUMBER HEV DATE PAGE Of APPROVEO BY � 612-571-3460 910-F15 6/12/98 � � JOB ADDRESS 6279 Baker Avenue NE 1 LEGAL LOT NO. BLOCK TRACT OR AODITION SEE ATTACHED DESCR. 1 1 Moore Lake Highlands 4th SHEET 2 PqOPERTY OWNER MAIL ADDRESS ZIP PHONE Rose Jasper 6279 Baker Avenue NE 571-1365 3 CONTRACTOR MAILADDRESS 21P PHONE LICENSENO. All American Roofin 4112 97 Lane NE Blaine MN 55014 786-6676 5160 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAII ADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ AODITION ❑ ALTERATION Q_ REPAIR O MOVE O REMOVE X 8 DESCRIBE WORK Reroof House & Gara e(23 S) Tear-off 9 CHANOE OF USE FROM TO STIPULATIONS Underlayment must comply with the State Building Code. SEPARATE PERMITS ARE fiEOUIREO FOR ELECTRICAL, PLUMBING, HEATINp, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOIp IF WORK OR CONSTRUCTION 20NING SO. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION OA WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WOfiK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFV THAT I HAVE READ AND EXAMINEO THIS APPLICATION 1 STALLS GARAGES AND KNOW THE SAME TO BE TRUE AND CORREC7. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED MEREIN OR NOT. THE GRANTING OF A PERMIT �1s918 �.96 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THF pEfiMIT FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORM NSTRUCTION �C)Z.ZS Fire SC �1.92 ° � PLAN CHECKFEE TOTALFEE License SC $5.00 $70.13 T EOF ONTRACTORORAUTMORIZEDAGENT �OATEI WHEN PFOPER VALIDATED THIS IS YOUR PERMIT - � "� " ��y , SiGNATURE OF pVyNER ili OWNER BUI�DER� �DATEi B G�NSP pqTE NEW ADDN ALTER [l [l [] ConstructionAddress: Legal Description: CITY OF FRIDLEY SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION 2�"l i � a l� � v� IA cJ Effective 1/1/98 � � G� � � � � � �� Owner Name & Address: � o s 2 �0.S p� r Tel. # �`� �- I 3 6 S Contractor: p �� IAwier «��y �2 v-of „� MN LICENSE # S�� a Address: _ u t t � �,'t �``' LN �j � Tel. # °7 �� �-� 67 � Atta.ch to this application, a Certificate of Survey of the lot, with the proposed construction dra.wn on it to scale. DESCRIPTION OF IlVIPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: n Wi th Hgt/Ground Sq. Ft. 01'HER: S � �a'�'�(� �.� .� , v Construction Type: `�P��'� oy`�' Estimated Cost: $ � l��n (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$ nATE: �O - c a - q � Permit Fee Fire Surcharge State 5urcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: � / APPLICANT: „c,� �✓`-� Tel. � � �c� --(� l� "1 � CITY USE ONLY $ �a. �.� $ � 9�2 $ � $ $ • �� $ $ $ $ � '10 . L.� Fee Schedule on Reverse Side .001 of Permit �aluation (1/10th %) $.50/$1,000 Valuation $1000 per 5AC Unit $5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above $450.00 Conservation Plan Review Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] �>. � BUII.DING PERMIT FEE SCHEDULE The Chief Bu�lding ��cial shall, before issuing permits for the erection of any building or structure, or for any addition to any existing building or structure, or for any alteration or repair to any existing building or structure, upon application therefore, require the payment by the applicant for such permit of fees to the amount herein below set forth and in the manner herein provided to-wit: TOTAL VALUE $1 to $500 $501 to $2,000 $2,001 to $25,000 $25,001 to $50,000 $50,001 to $100,00U $100,001 to $500,000 $500,001 to $1,000,000 FEES $21 (Minimum Fee is $21 plus surcharge) $21 for first $500 plus $2.75 for each additional $100 or fraction thereof, to and including $2,000 � $62.25 for first $2,000 plus $12.50 for each additional $1, 000 or fraction thereof, to and including $25,000 $349.75 for first $25,000 plus $9.00 for each additional $1,000 or fraction thereof, to and including $50,000 $574.75 for first $50,000 plus $6.25 for each additional $1,000 or fraction thereof, to and including $100,000 $887.25 for first $100,000 plus $5.00 for each additional $1,000 or fraction thereof, to and including $500,000 $2887.25 for the iust $500,000 plus $4.25 for each additional $1, 000 or fraction thereof, to and including $1, 000, 000 _ $1, 000, 001 and up $5012.25 for the first $1, 000, 000 plus $2 . 75 for each addit�nnal $1,000 or fraction there�f ,: DRIVEWAY DEPRESSION ESCROW (Concrete Curb� Streets Only) Alternate "A" : Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50. Alternate "B": Removal and replacement of curb and gutter and install a 3 foot wide approach with 6 inch depth - Driveway width plus 6 feet times $15.75. VERIFICATION OF FOUNDATION Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper review of the proposed structure and of the construction site. A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed will be required before proceeding with the framing. . . � � e� � _ GTYOF FRiDLEY FRIDLEY MUNICIPAL CENTER • 643 I UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(612) 57 I-3450 • FAX (612) 571- I 287 February 12, 1999 Rose Jasper 6279 Baker Avenue NE Fridley, MN 55432 Re: Final Inspection at 6279 Baker Avenue NE Contractor: River City Sheet Metal Dear Ms. Jasper: � ,1�� I � e , � �v � � �. �� / A mechanical permit was issued on January 29, 1998 for the property located at 6279 Baker Avenue NE for a furnace replacement installation. According to Section 305(a) of the 1991 Uniform Mechanical Code a final inspection sha11 be performed on the mechanical system. As of this date no inspection has been called for. You will be given thirty (30) days from receipt of this notice to respond. If we do not heaz from you, we will expire the permit and any inspections on this installation will require a new permit. Any questions can be addressed to myself at (612) 572-3603. Sincerely, �U � B Y CH Building Inspector : C �i_i � � rn 7 � � c� o -o � m � � ---1 . O N � Z. ..� 7 y �1 o � m m 3 � � S11 � N O (�p O �� _ cQ � � � Q. � � � `G y O � � � � �' a � � 0 c ... �� v �� n 0 � •v� m --� � `n � � m D °< �. -Z-� � � � � � � � v z 'Y' J, „ , n � rn � � n �° � °-:� 7C c ( (� (°�, < ��.. -m i -� �� � ( f ,,, 17 � , _� v � {`�-Di m � � �. o -� =� � Z � � � z � �° o !l,� -n . � , m �S ��I � ° � �^ ��, � �, � � \ �� �� � � (' � � � � _ m � Z � c7 Q � -o D Z . � .J � N � �, 3 � 3 o � � � tD a � C � � � � � m � 0 m 0 � O � O � --I � D � r � c m �- � cQ � D \ � 0 � j� N m c�o � o �, � y. � u� ai D A � m o ¢' � o �� N O � r � -� � Z D c� � t� � � � d � � c� m � a� Q m z � 3 N _ '� m 0 � � N fD z � . -n o� -� z � C Q p � � � � m � � � � �� �c � N 2 --i � n o � Q1 � n O o � � A 7 N n � � � Q- (n !1/ O N � Qoo--- � - 2 0 w �� � � 3 D � � �'? c� 0 3 Q 0 � � lfl I D � � m � � � � v A -. � � cNi� o o° o° r� � m � � � m � t� 6 � -� "O m � � -� Z o. � � ` c v Z � C � m v D � . � � � � � � tQ m L� DTt�p N y � N O � �. �^ �o � m zs- Q -cna � � cQ � pi � At Z <° m ro m �' r�r � a t � Q �.�'�v _ � c � � � � S C � < � ° � oa � o � o ?� C � W � _ 3 � m � � � � � � 0 0 0 � °o °o °o � � � � � � o . � � � ��-�m � � � � � � w � � � � �� y � � m a � N W�.� y = � Q � �� � � �. � ° fQ � � vo� < � � �' � N Q � � O c�D � � � y n' � � � � � � �- O � � � � �. � � n � A � � Q O ��u�,� � su � � � Q v @ m � � � � 3 o �' .: � � 5� . �� m ?'r.� � m � � � m �� �, �: z �� o y � �- su ° �- n. � - �. a, m �p L17 3 � � R � D � n m v C � O W � v v �7 rn � � �i � rn n N Q W � 1 � i �� � O � � � T Z m �p � �� � N c m � m z z �„ rn � Ili � � O Z Q C "il � �r rn n � � --Di O O � z -n Z 7� O � D O � � o� z -o v_� _' z zN z� � � v _ ma � � � Z �� � C� m p <r m� �� C m z � � _i � � � `. � �� � � m O _ � w a � m rn . � r`i^ �. , �. � ti� � \�, s CHIMNEY AND S�ACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack: 1. Has been carefiilly examined Yes � No () 2. Is free from rust or deterioration Yes �j No () 3. Has no foreign objects lodged within Yes () No (�j 4. Is securely supported Yes � No () 5. Meets all current Code requirements for size — - �d tc�tal BTU's conn�t�� _ _ -- - - Yes No ( ) 6 Has total heating BTU's of /����0 7�� All other BTLT's �3o�yU� �— TOTAL BTLJ's v J � � 7. Has a liner been provided for water hea.ter Yes (� No () 8. Has combustion air been provided for water heater Yes �(�j No () Remarks: List ALTERATIONS Being Done: HEATING CO: Signed By: Date: