AF - 35291c�ty of F�.a�.��, n�.�..
6431 Univeraity Ave. N. E., Mianeapolis, Minn. 55432
BUILDING PERMIT
Date: Julv �7, 1972
Owner: Thomas�ickner Bwilder Same
,Address �_._�$�A Tennison Drive Address
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LOCATIOiV OF B4JILDING
No. _ 6245 � S�t � Ben More Drive _ P� of ��
Lot .�_ 1...___ Block ? _._.__ Addition or Sub-Division ._._ ��ather Hills
Corner Lot ..��.._.._._._.. Inside Lot X Setback 36' Sideyard 10 �
Sewer IIevation ..�__._._....._ Foundation IIevation .._._._.
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DESCRIPTION OF BUILbING
To be Used as: 2Z .6
dwelling -- �,I,�t 53' �p� 32 Hei�ht �. �, 1622 � �
Att . Garage F•ront 25 � Depth 28 b` 22 Height 10' �. � 620 �� 6200
Type of Construction Fr ame ��� 25 , 9 7 0. 76 To be Completed 1-1- 73
Owner check insurance
Provide verification survey
Provide Hard surface drive
In consdderation of the issuance to me of a permit to consiruci the building described above I agree to do
'�hhe proposed work in accordance with the description above set forth and in compl3ance with a�l prov3sions oP
4rdinances of tT�e city of Fridley.
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— 12.AR St^tp Rttirr'h^rge
In consideration of the payment of a fee of $ !1.00 ���t is hereby granted to �homas Brickn�
to construct flie building or addition as described. above. TYus permit is granted upollt
the express condition that the person to whom it is granted and his agents, employees and worlu�nen, 9n all Work
done in, around and upon said building, or any part thereof, shall conform in all. respects •to the ort�in�ncxs of
1�'ridley, Minnesota. regarding location, construction, alteration, maintenance, repair and moving of btullding8
��ce� city limits and this permit ma.y be revoked at any time upon violation oY any of the provisions of said
�� �a�ruains Inapeetor
CLARENCE BEL�SLE
PIOTICE:
This permit does not eove� the coaalruetion, installation for wirins, plumbing, ges heaNng, sewer ot water. Be sura fo �
f6e Building Inspeeto� fo� separeta permits fo� theae hems,
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AP.PLICATION FOR �ESIDENTIAL, AL���qTI�N,
OR AllllITION BUILD�NG p����
CITY OF FRIALEY, MINN�SOTA
OWN�i,�S �TAMEs,/ �11�.lJ/%�� �/,.�'�%GJ�N'�� BUILDER: ��/�'/ �
ADDRESS s_ ��'�� ��/�%�l.��dt/ �/f' • ADDRE.SS :�� �
,
N0: �, � Z`fS� STREET: ��i2�4.1� °�-���,v
�'.0�' : / BLOCK • �" ADDITION t
/ �
CORNER LOT : INS IDE LOT :�S ETBACR :-�� S I DEX�tI? o/��� „�,,.,
�lpp].icaat attach to thia foYm T�o Certificatea of Survey of Lot and pzop,p�sd
buildia� location drawn on these Certificatea.
HESCRIPTION OF BUILDING
�o �e Used As:
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-%�� ' Front: Depth: Height:
�C� .
Square Feet :�� f= %`- Cubic Feet :
� ° ' Front. _ Depth: Height;
.
S uare Feet; � ��
Q Cubic Feet: f-- � ,
/� �
'.�►pe of Construction: ��/ Estimsted Coet: �
To �e Co�mpleted: �%/' %� _� �- `, '�-
i
The undersigaed herebq makes applicativa for a pes�nit for ti�,e .wc��1� '�����q
�pec�,f�,ed, agreeing to do all work in attict accordance with ti�e C��y g,�
F�r�d�.ey O�dinancee and ruliugs of the Department of Buildings, and �e�eby
d��laxes that all the facte and repreaentationa atated in thia app�.�,����,�
a�'@ t�'uA AnA rnnrren*
MF�+.+1 i
(Se� Aever+�e Side For Additioaal Information.)
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�UILDING PERMyT FEE SCHEDUL� ,
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SI�CT�ON 2. The Tnspector of Buildings shall, before issuing permi.t� foz �h�
exectioa of any buildia�g or structure, or for any adclition �o any existi,n� `
bui].diag, or structure, or for any alteration or repairs ta any e��.sti.ng '
building or structure, upon �.pplication therefore, require the paymet�� b� ��
app��.cant for such permit of fees to the amount herein below eet fo7r�ii �i�d :�.R
the manner herein pravided to-wit:
i,1NI�ORM BUILDING CODE: Type 1, 2& 4-$2.15 for each one 3h�u5and �ub��c���
���1�, o�c fraction thereof, in such cubical coatents. Typ -$
each one thousand cubic feet.
ADDITIONAL INFORMATION
Far the purpose of computing feea for building permits, the cubical contents
of any building or addition, ia determined by multiplying the grouad area
covered fsom a point six (6) inches below the floor line of the bascna�er►t �
or the cellar to the average heights of the upper surface or to the average-
height of the roof surface of the main gable of a pitched roof.
�or xepairs or alterations to an existing atructure, the fee shall be at the
rate of $3.00 per e�ch five hundred dollars ($500.00) or fractioa thereof in
the cost of all propoaed work.
T.�, ao ease shall the fee charged for any permit as set forth in Sec�iQt� � i��
less thaa $5.00.
VFRIFICATION OF FOUNDATION
'�p�; Permita for eonstruction will be issued a miai�um of 24 hauxs f�o�p �h�i
titae of application, to allow for proper review of the proposed structuxe atnd
a� the conetruction site.
,A Cextified Survey of the lot, shawing the location of the founda��At�� Q�S�� �.�
hap been constructed, will be required befo�e proceeding with the £�aa�,n�,
CERTIFICATE OF OCCUPANCY
Ap�lication for a Certificate.of Occupaacy ahall be made ten (10)�days ��ci��
�c� the use ar occupancy of any structure for which a building pexmi� k�a+� ���A
iseued; and said atructure ahall not be used or occup�ed until a Certifi�a,��
o� Occupancy has been issued.
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I hereby certify that this is a true and correct representation of
a survey of the boundaries of:
Lot 1, Block 2, Heather Hills
And of the location of all buildings, thereon, and all visible encroach-
ments, if anyR from or on said land. P,s surveyed by me thi�, 13th day
of July, 1972. r: ,J��
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Land �.Surve�r ; Min�J Reg . No . 9 0 6 6 �
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��;,� "`✓r��� Project No. /b b %
MINNEAVOLIS, antl MUTCFIINSON, MINNBSOTA•
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I hereby certify that this is a true and correct representation of
a survey of the boundaries of:
Lot 1, Block 2, Heather Hills
And of the location of all buildings, thereon, and all visible encroach-
ments, if any, from or on said land. 8s surveyed by�me thi�, 13th day
of July, 1�72. . � '�: �
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As bui/� 6ASe �e f. � ' � .
Land �.�urve�r, Minn..� Reg. No. 9066
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�:�. �.-� , McCOMBS-KNUTSON ASSOCIATES, INC.
p L ��.. _ 1 t,. �:- CONSULTING ENGIflEERS � LAND SURYEYORS � SITE PUtXNEflS �,I
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Weathcrstrips ��•H•V•£' Cottstruction N�
Guide
Window-� Doors Reference Out. �i/all Int. �/all C.eeDia�
Ye� I 1'es—IVo 19_
' F1.� �� Roam Length � i�/ideh �, Hei�hc �,,�
Wis►dows and Doors—Craekage and Area
�V1dth Height No. oL Llneal ft. Area S�
No. ot Dane ot Dane lighta of cractc ea. Yt.
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Glass
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lne. wall
Ceiling - ,� �� � �'" ' �
Floor -
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Required sq. ft. E.Ii.R. or sq. ins. �1.A. Leader area
F7.� ��• x���_� R�m � Length � Width ,� I-�ei�ht �� i
Windows and Duars--Cracka�e and Area
Wldth AeigAt No. oY Llneal Yt. Ares
No. of D�ne o[ pane tfgLte ot crack ep. tt.
Coef. Beu
In6lcrataaee °°" -�.,._� , / . , .
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Gl�as
Exp. wall ��,e .,
Net exp. wall �-'�. � � �,,._
In@. vvall
Ceiling �.j 3 �/ °� :�,r �
Floor
�'otal Btu. � d �,,,,
Required sq. ft. E.D.F$. oa aq. ins. W.A. L.eadet area /
° Fl• ,:-'�,�,'�" qo�a Len�tls s- Width`' �:, Height ,:%''��
- Windorws and Ddors—Cracka�e and Area
WIdYh Helght No. ot Llneal tt. Aree
No. ot psne o4 pane 4�hte ot crack eq. !t.
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��. .
Ine. �sil '
Ceilin� � i %` "� ;�
� _� ,�,
�loor
Total �tu. ' -� f„ ;�- �^..,
4Zequered sq. ft. E.D.R. or sq. ins. �l.A. Leader area �
Fi. '>� , Roo�a �Len�ch /� lRl;dth // Heighe z"�i-- I
Windows and Doors—�racka�e and Area
Width Hei�hY No, ot Llneal ft. Area ��
PIo. of pane o[ yanm �Itghts ot crack eq. ft.
� r-°`. • _ O'�' % �
a'--
1
Q
` Coef. Beu
I '
�, Infileratioe� ~� �_' ,:� r
Glass ��.� -
�°,�>.,
Exp. wall-�% � _ �,
: Net c$p. dval� �;; . �i �
� Int. wall
Ceiling --re% • � r � �
l�loor �,.�.
Total �tu. �`° � � �
1c�eq�ired sq. fi. E.D.E$. or sq. ie�s. �i/.A. Leader area
9� .�� � .) � . � -� �
��f 2-x..,.....s ��<r=^!`� t s'..€:; ,,��Lf.J
�„ �Lf
/-y���`.^,- � ,:? o-A `' r'° �^''_
L",� . ,n
■
�. Insulstion
Roof F7oor Kind " �los�+ Applied
�.� ��� l.en�th /..�..-�lideh � c�e�� �'�
�lindaws and Doors—Cracka�e �nd Are�
�7Vldth Hel�ht No. ot Ltaeal iQ Are�
No. ot pane ot Dana llghte of crack eq. tt.
�. � � �
coef. �e�
Infiltracion ;.�` � .
.�:
Glasa �° � .�"
Exp. wall . ,� �
x
Net ezp. wall �=;�
Int. � rsll
Ce�iing �� � � � C`�
Floor
?otal Btu. `�
�tequired sq. ft. E.D.K. or sq. ins. �/.A. I.CB�P RYCS /
F°l. � .- �: - �oam � Ltn�ch ,/ �/idch f,� en� t ' �
Windows amd Daor�--Cracka�e and Area
Wtdth Hefght No. oP Llneal ft. Area
No. ot pane of pane llghta ot c ack eQ. 4t.
s'� .,� _ ° .�'J 1 �.�. � � ,
Z �. c� �� G.� .,.� �
-
f. �tu
Ia�filcration �'' .�` 9
falass ,�" : �"
F.xp. wall �-a > ,�
Net exp. w�ll �° � ,� �
Int. wall
Ceiling � ,� �`" �
Floor � �. �
Total Btu.
Required sq. ft. E.D.ii. oa aq. ans. W.A. I.esder area
� Fl.� �- R�m I Len�th / �Jidth . I�ei�he � a
1{lindows and •Dooe�--Cracka� snd Are�
Width Helght No. ot Llneai tt. Aree
No. of pane ot pane Ilghte of crack eQ. tt.
1
�� � .a � / /
Coef. Btu
Inhltration ,• : ;,� �,
Glas$ � � �
�p. WB�� ° � _
Net ezp. wall ��r f �/ °
In.k. wall
Ceiling ! ` `
Floor � � � � �
Total Btu.
Required sq. fc. E.D.R. or sq. ins. �/A. Lead�r a�a
/�.� �% li � Etomm I Len�ch �' P' Width /_ Hei�ht d
� �dindows and Doors—�Cr�cka�e and Area
R'tdth Helght No. oL Lfaeal Lt. Area
No. of psne ot Da�e Ilghts of crack �p. tt.
, Ca �-J �� r�-^- ��
Coef. �eer
Infiltraeion ,1�," �^.. � ���
Glass r:,; ��
F�cp. wall � •
Net exp. wall . � � ;� o _ �
Int. wall
Ceiling �,. !: �.,
�� '`
Floor °.� �,,, � �
Total Btu. p
Required sq. ft. E.D.R. or sq. ins. W.A. Ldea�t arma
�
i' �— !' �1 �
L.OSS CAI.CULA'TIONS
Weatherstrips �•S• V• Conatruction AIo.
Guide
. Windo �s I,i Doors diefersnce Out. Wall Ynt. �all C.eilin� Roof Floor Kind
Yes—No Yes—No 19_
Fl•� �,^1 Room Len�th /'_ �idth �' Fiei�ht 4� .FI.� - Etoam 1
i�indow and Dooes—Crackage and Area l�lindows and Doora—Cri
�Yldth Helghc No. ot Lfneal ft. Area Wldth HelgAt Ato.
No. ot yane ot pane Ilghta o1 crack sq. tt. No. of pane ot Dane llgl
/ ;:::� �*•` r,'�i� � � �e.i �, � � �� /,:
f, , �• ,,8 ,, �, �.> , • �, ,,
.* ,a.•.�, �... �`:��- �.q � i
Coef. Btu
Inhttratioa a � � �.
" °`� Infiltraeion
Gla�s m� ,� � � � ' �; .�„� , Glsaa
Facp. wall ° �' �- E:xp. wall
Nec exp. wall `, � ' �`�`�_.`°° '
Ina wall
� � 1Vet eap, wadl
,� - � .?�..^—
�
lnsulation
I-ioa�
�
and Area
�eal it. Ates
drack ea. tt.
Gef. �to�
��' � C e�
Ceiling �� } Ynt. �rall
a
� 0 � ` eC,i1Rg -- — — -- --
Floor - -- - --
Floor °��°�' �. �' .S
Total �tu. � 7ota1 Btu.
Required sq. ft. E.D.fR. or sq. fns. W.A. L.eader area Eteqvired sq. ft. E.D.EZ. or sq. imms. i�/.A. Leader �rta
, . �.� - ✓� ; Ro�m � Length / � �lidth / D Height `�=�../ ,� �'1.1 �'�n o � Rooas I Len�th ;� �/idch �,�
�endows and �oaas—�racka�e and Area Windows and Dooas—�rackage aad �isea
Width Xel�ht No. of Lineai ft. Area
No. ot Dane ot pane li�hte of crack eg. ft. � Width HelBht No. of Lineal tt. Area
� �, � ti....z No. of Dane ot pane ll�hts of crack ea. %t.
�� B �
��J� �,fl_�. � r �
,.:
,e.
Coef. Btu
In6le�atioa � ..�, ? �^ � � Infiltration
Clasa c°°�
• F' -� � Claas
�p. wal! o' ° ;}�. it �.... _ _ �' � F.�cp. wall �~A `�' °' ,�C�
Iolet exp, wall �' `� � Net exp. �vall P,�
Int. wall s �; �..,a ��;' ,�� Int. `erall &'
Ceiling � � � �
Ceiling � -•
Floor •� � � � . Floor
Tota! Btu. � :��� Total Btu.
�2equir�d sq. $e. E.D.R. or aq. ins. �J,A. ].eader area / Required aq. ft. E.D.R. ot sq. ins. �/.A. I.eader atea -
Fl. �'.�� ftcme� L.en�th ._ Width p/� . Height � a,.- I ,
�indows and Doors—Cracka�e and Area �'� �� I I.en�th Width Hei�hc
w�acn xessne No. oe Llnaal tt. Area �/indows and'Doors—Crsck��e and Area
No. oY Dane o[ pano !lghtm ot craek eq. it. W/dth Hetght No. ot Lfeeal f� Aeea ,.j
No. of pane ot Dnne Ilghts ot creck op. Yt
? � -'��- � 2 ! : 3� � !� .
��
��
�0
Coef. Btu
Ir�hltr�taoa �- , � --
���
Cl�ss �,r �`' .�,,�
u � � ��^
�xp. wa o �-._:�-�_.,,-
x ,
Idec e�p. �val1 � ��.
Int. ta�all
Ceiling
1� loor °;�- �' u� . °� i�" c.�
T'otal Btu.
U
Requered sq. ft. E.D.R. or sq. iaaa. W.A ].eader area
' f`,�1• ; � ,;!�! �-, ,._ R�m � l.en�th ., .,,.. �/idth �� Hei�ht � i°
Windoivs and D�ozs—Ceacka�e and Area
Do
Rid[h Hei�ht No. of L(neal tt. Area •
P1o. ot yane o[ psne Ughte ot crack eq. tt.
; ttr � i r , . rw
�: � .
COt�. B�U
Infrltra¢ion • �- �. �
CJsaa - ? `�
� �� r, .
Ex�. w�ll " � -�:n_�,.. _ ....�...
��i tXp. WSI� 9�g k.'Ar r
Int. �mral!
Ceilin� �. �„
_ �,�,
I' IOOr � c� �.�
'Toeal �cu.
IZequired aq. ft. E.D.f$. or sq. ins. W,A, ].,eader area /
� ��
Coef. �tu ;;
Inhltration
Glass
E�ap. wall
4
Ide4 txp. wall
Int. w�ll
Ceiling ?
Floor
7ota1 �tu. �
Required sq. fe. E.D.R. oe sq. ins. �I,,�. (,eadxr are8
� Fl•� Ia�m I Len�th V Width -- He' ht �
. � �
Windows and Dooas—Cracka;e and Atea
Wldth Hetght No. ot Llneal tL Aren �'
No. ot yane of pane Ilghte ot ceacB ea. (t j;
Inhltration
Glass
Exp. wall
N@t CRp. W8��
Ynt. wa11
CC1�lIlg
Floor �
Total Btu.
Coef. �eu ;
ired sq. fc. E.D.R, or sq, ins. Q/.A, 1,eea�r gnea
M, ',
�_
�
'q
�._ r
�:
sueaecr PER .
City of Fridley . 1512�
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
r REC
� �
� `L ______ COMMUNITY DEVELOPMENT DIV.
r � � PROTECTIVE INSPECTION SEC. �� 2 1�
1 . , J J
1-_--� �"��1'J CITY HALL FRIDLE� 55432 NUMBER REV. DATE PAGE OF APPROVED BY
J � � , 612-560-3450
910-F15 4/16/79 � �
JOB ADDRESS 6245 Ben More Drive NoE,
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 1. 2 HP.d.'tYLEY HlI.I.S SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Gorski R��� 6245 Ben More Drive N.E., Fridley
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
A aland Pool Co ]'nc. 3400 Dakota Avenue South 920-8244
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
6 USE OF BUILDING
7 CLASS OF WORK
� NEW ;;: 0 ADDITION 0 ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK ' .
� n � n � POO�.
9 CHANGE OF USE FROM TO
STI PU LATIONS
See stipulations on letter dated 4/16/79 from Environmenta.l Officero
s�P�RAr� ���r�,Y� ����rR�� �a� ���� �I/�R�tN"G
N�AiIld+�, (�1.1�IW�IPV� ANi� �IG�VS.
Before di,�ir�g �1i ���a� �ts�;t�e�
.,. T�l.EPH�lVE - �L�C'f�i� a ��S ��c�
RE+C�dJiR�� ��' �4���
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 ZpNING SQ. FT. CU. FT.
AUTHORI2ED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK I5 SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEFEBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION ]. 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 OR NOT. THE GRANTING OF A PERMIT �`%� SOO y�+3. %S
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-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. 4S.00
� PLAN CHECK FEE TOTAL FEE
$48.75
SIGNATUREOFCONTRACTOROR/(UTHORIZ DAGENT 1DATE) WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
� .� `t�Q ��t�A �� � �o _'1�
SIGNATUREOFOWNERUFOWNERBUILDERI IDATEI SLDG.INSP - DATE
.
0
- i
�
. . .
�ITY or- �i�z,��cY ,
° �PPLIC/17IOtJ rOR RL-SIllC(JTI11L LU11_DING PERMITS .
' � ��VEW, (ILTCPIITIONS, �DDITIDIJv,' OR REPAIRS) �
. , ,� � .
�w�a�R: /�� /���C�d��� ��e���� . SUILDER: A�'��,C��.� ���' �� ��ac .
-�---
Address : �� �i� . ��%�'���.L �/�1 II�,� 11c3dress : � ��O ����� �i��e �. .
Tei. 2vo.: '���'� ���//�j.� •
No. . � � �� Str�e�: ��� l��i�� �aPA�.�
-.�
x..oT: / ��vcr.: � �nz�xor� : d���/��'�i� ����°
�?�AIF'R �t?T� INSID� LOT: SLTI3I�CI;: SIDL'YAFti'iS:
�ipplica'r.t atiach 'ta this farm 7.tao Cextit'icates of Survey of Zot and propns�d
bt�ilding locatian dra�m on these Gerta.ficates. . �
� �}ESCRI PT10Pd �F BUI LDI NG � '
To Be iJsed As: ��a/d���°�� ��� /� �" �� � /�`'����° ��� k���� .
� �xont• Depth: ' ' . �Iei�ht: -
Sc�uare Feet: ��� L�bic Feet:
Fronts � Depth: � �i�ight: .
� dquaxe Feet: Cubic Feet: ' •
�pe ai Const:ruction: ,�f,����O�Q� .z����. Esti.mated Cost: $ %�� �
so �e comp2etea: /�%��' ;��a �i ��'�Ol�'. - A3.t. A Alt. �
Prci�osed Driveiaay I�lidtlz Zf' New flpening is Desired $ $ •
� �SEE 3t�L�RSE S�D� D�'--,�YIEET)
�`he undersigned hereY�y ma3;es application for a perm2t for the work h�reisi
specified, agreeing to do atl work in s�rict accardance with the Ci�ty of
Fridley Ordinances and rulings of the Department of Buildings, and her�y
rlec].axes that.all the facts and representaticns sta�ed a.n this applicarion
are true and correct. Sse reverse side iar aclditional inf�xmation.
IDATE: � /�%� SIGNATUI2E:
S�3.pv3.ations : ,
���� �� �
�
�n.��r 7.s � G. = 4S•O° -
'rx
3 •7j
�� � s
� �
, ,
, L .
s
�
;: � ,� , . . . . . .. .
,._�.,,,�d.._._ . .......... .. .. . _..,._..... _.. .. __.. . .. .. ..... . - -
. . _ � _.
. BUILDTtJG PERP�1Ii FEt SC{�EDUL�
m
SECTION 2. The Ins�ector oi 13uildings shall, before'i.ssuing permits for �he erec�ion
of any building.or struc�ure, or for any additian to any existing building or structure,
. or for any alteration or repairs to any cxisting building or structure, upon apYlication
there£ore, require the payment by the applican� for such permit of fees to the amount
herein below set forth and in the manner herein provided to-wit: •
2dEW CONSTRUCTION: Single Fami].y iiomes and Garages: $4.00/1,00D cubic feet.
pLAN CHECK:. 25 percen� of building permit fee. .
DRSVEWAY DEPEtESSION: (Concrete Curb Streets Only)
� Altiernate A: Removal and replacement of concrete curb and
gutter only; Driveway width plus 6 feet x$15.75
Altemate B: RPrctova7. and replacemant of concrete curb arad
c�utter and install a 3 foot wide approach with
.� 6 inch depth; Driveway width plus 6 feet x$17.85
� � ° ia�3�iT�CN�,L ir�FO�;�at��
�'or tlae purpose of compu�ing fees for builciing permits , the cubical contents of any
building or addition, is determined by multiplying the ground area covered from a
point six (6) inches below the.floor line of the basement or the cellar to the
average heights of the upper surface or to the average height of the roof surface
of the main gable of a pi�ched roof .
For repairs or alterations to an existing structuse, the fee shall be at the rate
of $3.00 per each five hundred dollars-($500.00) or fraction thereof i.n the co'st
of all proposed work.
In •na case shaZl the fee charged for any pernlit as set forth i.n Secti.on 2 be less
tia�ri $%e50 plus $.50 state surcharqe.
�� i . � � � � � � � �
NOTE: Permi�s �or cons:truction will be issued a minimtun of 24 hours from tlie time
of application to allow for proper review of the proposed structure and af the
construction site. �
A Certii'icate of Surve}r o� �he lo�, shawing tne iocaLion or �Ehe founda�i.on once i..t
has been constructed will be required before proceeding with the framing.
_i ` � ':1
.
App7.ica�ion for a Certificate of Occupancy shall be made ten (10) days prior to the
use or occupancy of any structure for which a build�ng ,permit has been issued; and
sai.d structure sha11 not be used or occupied until a Certifi.cate of Occupancy has
been issued.
0
0
F. w ,
5' . ��l� v d'�1�. s
�. 4 `�y., �:5 � �+ { s�a^ � - .�^�.a.
6431 UNIVERSITY AVENUE N.E., FRIDLEY, MINNESOTA 58432
TELEPHOIVE (612)571-3450.
April 16, 1979
Aqualand Pool Co., Inc.
3400 Dakota Avenue South
Minneapolis, D�T 55416
Swiinming Pool Construction at 6245 Ben More Drive N.E.
Dear Sirs:
This lettes is to make clear this departments requirements for the swimming
pool construction at the above address.
1. As indicated, one (l� skiuuiaer approved by the National Sanitation
Founda.tion will be provided. �- Z �-
2. As indicated, two ( 2) inlets af approved design for fresh and/or
repurified water �aill be provided. ��
3. The f ilter and pump shall be approved by the N.S.F. and be of
sufficient capacity to provide a minimum turnover of at least twa (2)
titnes in 24 hours. This depar�ment reco�nends a turnover rate af
6-8 hours.
4. A deck of at least three (3) feet wide, measured fr�n the pool waters
edge, shall be provided which extends coaapletely around a1Z private
residentia.l pools. Above ground private residential pools may be
pro�ided with decking of a minimum size of 4 feet by 4 feet at pool
entry points and.provided that such decking has the approval of the
City.
5. Fencing or other effective means including but not limited to walls
or buildings, acceptable to the City, shall be provided to positively
control all access to public and private residential swi�¢uing paols.
Fencing shall meet the following criteria:
(a) The fencing shall prevent the entrance of children and be without
hand or toot holds that would enable a person to clitnb over it.
(b) The �encing shall be at least 6 feet high and entrances shal]. be
equipped with self-closing and self-latching gates capable of
being locked.
(c) 5elf-closing and self-latching deviGes shall be placed at the tx�p
of the gate or otherwise inaccessible to sma.11 children.
(d) 'I'he opening between the bottom of the fence and the ground ar
other surface shall be not more than four inches.
6. An automatic chlorinator should be provided with a suitable test kit.
7. A11 electrical and plumbing installations shall be i.nspected and .
approved by the City Inspectian Depar�.inent.
8. Al1 electrical lines mus� be greater than 15 feet away from the pool
surface. An alternative is to bury sai.d lines.
.. - sy F �r , � z . _Y., . - a �:,.� �a'��?-�",�`''r t� -. > .� "� . "'r
f�
� � �A.�..� �
.., } .... . . .
.,z Aqualand Pool Co., Inc.
April i6, 1979
Re: 6245 Ben More Drive N.E.
Page 2
9. The pool f ill spout must be air-gapped or protected by a vacuum breaker.
10. Suitab.le safety equipment to include but not liu�ited to a ri� buoy
and rope that is 1� times the pool diameter, and shepherds crook ,pole
must be provided and maintained with the pool at all times.
Furthermore, these and any other �equirPments must meet the provisions of
the Fridley City Code, Section 115, Swimmirig Pools. The building permit is
approved con�ingent on final inspections and approval by the City.
If any questions or problems arise from this letter, please feel free to
contac� me at 571-3450.
Sincerely,
.��5� �.� (� � .�..
STEVEN J. OLSON �
Environmental Officer
SJO/mh
CC: Mr. Michael Gorski
6245 Ben More Drive N.E.
t
Eas�-����� .�
�.-`�' ��
�. :,
, � � '� ,� �°
1 ," � � !� �r• i ar ± r' � � i�t ;i�,.:� �.'
a t �r. �r��.ti_
J;��'i; r� +kT ;�'�;. i ��ds � `'"�! � x ���k;s
: �, - r �.
1Y� i ?� � p_ k � ,j; � t: i t� r6 '1 ` �. � . � ,� -
y
A �
CUStOJDBY
Address
City
Phone
Submitt�
DATE /�"/�'�'c,''�'"� /�, �' � `'��' .
POOL DATA t ("�r�,�-�
Pool Size & Shape ����C.�'� `�'i%�'�, Tu�°nover Rate �s � Hours
Suriac� Ar�a �/.�C �' Sq e F`t o Rate of Flow �,�,�;L GP�i
Capa.city ���,��.°',e Gals, i'erimeter 9� �IN FT
PIPING DATAs�
SUCTI ON 0 �;l `''.�'%%�� �c�• � `�,� � ��'°,�
R�"I"t�tld� / /�'' .4,� ..� a� � � �' -
MANIF�LD /%.,��� �"Ido'�iC��C�;'
'�'���.s'-�",.��L° ���C� /�.���.
�
LIIdER STYL� - �J�i��'! SER.# �
COPING STYLE' ,���,��''�-'. �/�?i �a��
BOTTOAi �ATFRIAL .�"i/�'s�,�,�.���" _<" ,�Z�
FILTER �..� ��'.i' � ��r,��:; i�' .�'��- ,�'
PUMP �c I�OTOR �f'% � .,�/ .2��vL' c� .�'.�
SKINASERS .� � ' ya/�.�' � c' �°' �''�`�!`,�.�� .9�/�'"' �'�,�._'
DIR. FLC3W INLEfiS �° ' l'.�',�9� MAIN DRAIN e C'e.�ar'✓�°'' .2�T/° °'�
CHLORiNATOR �'i�-�"'6` o,/' ��: DISCHARGE .�"'�'�i�"�,�"�C /.a�' G. ,
MANIFOLD ,C ip THERAPY FI'TTINGS �"' ,i � .�'
POOL HEATER yi�% /di�"i�"�",,� . - & F'1,0
POOL STEPS �i"�� � �' ° .�.,�.��-'�P,�� �D .�.%�
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ANCHOR CUPS �' ESCUTCHEONS � �/�
DNING BOARD � �S�z ,�L.°' �l.�' 'e�=,o �ar,�
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VACUUM KTT / ! >
AUmO POOL CLEAN�R /�/�'� WALL FIT'TING �/ S r�� S�r��:�'
P(30L COVER !/s� �'G� �,'.��°�'.�.
INFLATEABLE DOP+f� /,J �
�00� CHEMICALS `"C� i .�A9�%
�tF.�C K WORK �. S� � .�•' c:.' �F' ., . ✓s,%' �"',r�
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SUBJECT PER
City of Fridley o 15 2 6 0�
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T �
i�
, � R O.
� �� _.____ COMMUNITY DEVELOPMENT DIV.
r � � PROTECTIVE INSPECTION SEC. q� U� �
i� _ �
-__-� �����;,� CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BV
i 612-571-3450 910-F15
6-13-79 � �
JOB ADDRESS 6245 Ben Mare Dro
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. ]. 2 Heather Hills Add. SHEET
2 PROPERTYOWNER MAILADDRESS 21P PHONE
Mike Gorski 6245 Ben More Dr. Fridley 55432 571-2149
3 CONTRACTOR MAILADDRESS Z�P PHONE LICENSENO.
Natures Way, Inc. 3530 West Hwy 7 Excellsior 474-3501
4 ARCHITECTORDESIGNER MAILADDRESS ZIP PHONE LICENSENO.
5 ENGINEER MAIIADDRESS ZIP PHONE LICENSENO.
8 USE OF BUILDING
ReS1C1@Ii'tl.c'i�.
7 CLASS OF WORK
� NEW 0 ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Bui.ld a 15' X 15' deck in the rear arcT..
9 CHANGEpFUSEFROM TO
STI PU LATIONS
_ �REV� �R w►���.
,�, p�,1�11TS ��� � $tGNS�
s��� � +�,�,�''"� �` . w�p�
�11�A'C1 Bef�e djg�� cal �� .
tflEPN�r��_�iF�fr;��� t�it��s
� . . . , � f.',�1S Ef�„
� � � .
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING. HEAT�NG, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING. HTOOCI
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZpNING 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 R 1
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 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 OR NOT. THE GRANTING OF A PERMIT �.QOO. OO m SO
DOES NO PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISI N OF A Y OTHER ST E OR LOCAL LAW REGU TING CON-
TR CT O OR T PERF E OF . NSTRUCTION. ']� �jp
' . / � PLAN CHECK FEE TOTAL FEE
i"�
ATUREOFCONTRA�TORORAUTHORIZEDAGENT tDa i WHEN PROPERL VALIDATED THIS IS YOUR PERMIT
� ` �` 4' ' � ��--� � 13.
SIGNATUREOFOWNER�IFOWNERBUILDERI IDATEI BLDG iNSP qA E
CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL.BUILDING PERMITS
(New, Alterations, Additio�s, or Repairs)
� � � j
' ��' i� �i�� ��� � ��
TEL iVO:
BUILDER: `V 4C i V��`� ��`f ` N�, C'.
AUDRESS: ��� ���j� i��' �I -��
TEL N0: ��� ��I
� Construction Location
S'1"R�T NO : 1�J �� ✓ 5TREET: �r'/ l�► � � ,�����
LOT: BLOCK: ADDITION:
Corner Lot: Inside Lot: Setback: Sideyards:
Applicant attach to this form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
DESCRIPTIOtJ OF CONSTRUCTION r _
���/� f
�_ Front: �� Depth: � Height:
Squa�e.Feet:�� Cubic Feet:
Front: Depth: Height:
Square Feet: Cubic Feet:
Type of Gonstruction: Estimated Cost: $ � ��
7.b Be Completed: '` �c✓ �
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $ $
� SEE REVERSE SIDE OF SHEET
Z'he undersigned. hereby makes application tor a permit for the work herein specified,
agreeirig to do all work in strict accordance with the City af Fridley Ordinances and
rulings of the Departmerlt of Buildings, and hereby declares that all the facts and
representations stated in this application e true an corr t.
DATE: � � � � ( SIGNATIJRE : 4 �� •
Stipulations:
��(d, �, G �` I , �� �
a°'�� � � �
�1� �
#: _
BUILDI(JG PERt�1IT FEt SCE�IEDULE
SECTION 2. The Tnspector of �3uildiiigs shall, before issuing pe�nits for the erection
of any building or si:ructure, or for any additi.on to any existing building or structure,
ar for any alteration or repairs to�any existi.ng building or structure, upon application
therefore, require the payment by the applicant for such pexmit of fees to the amount
herein be�ow set iorth and in the manner herein provided to-wi�:
NEW CON5TRUCTION: Single I'ami].y Homes and,Garages: $4.00/1,000 cubic feet.
PLAN CHECK: 25 percent of building permit fee.
DRIVEWAY DEPRESSION: (Concrete Curb Streets Only) �
' Alternate A: Removal and replacement of concrete curb.and
gutter only; Driveway width plus 6 feet x��5.75
Alternate B: Removal and replacement of concrete curb and
gutter and install a 3 foot wide approach wi�h �
6 inch depth; Driveway width plus 6 feet x$17.85
_ ADDI T IONAL I NFOR�1i�T I ON
For the purpose of computing fees for building permits, the cubical contenis of any
building or addition, is determined by multiplying the ground area covered from a
poi.nt six (6) inches below thc f].00r line of the basement or th� cellar to the
average heights of the upper surface or to the average height of the roof suriace
of t.he main gable of a pitched roof.
For repairs or alterations to an existing structure, the tee shall be at the rate
of $3. d0 Zier eaeh five hundred dollars -� ($500.00) or fraction thereof in the co�t
af all pxaposed work.
In�no case shall the fee charged for any pezmit as set forth in 5ection 2 be less
than $7.50 plus $.50 state surcharge. '
� ' : � � �.►1� �
NOTE: Permits for construction will be issued a minimiun of 24 hours from the time
cif application to allow for proper rev,iew of the proposed structure and of the
construction site.
A Certi.ficate of SuYVey of the lot, showing the location of the foundation once it
has been constructed will be required before proceeding with the framing.
: : � ''►
Application for a Certificate of Occupancy shall be made ten (10) days prior to the
use or occupancy of any structure for which a building �nnit has been issued; and
said structure shall not be used or occupied until a Certificate of Occupancy has
been issued.
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ADDRE55
PIN
LEGAL DESC
PERMIT TYPE
PROPERTY TYPE
CON5TRUCTION TYPE
CITY OF FRIDLEY
6431 iJNIVERSITY AVENLTE NE
FRIDLEY, MN 55432
(763) 572-36U4 r'AX:
: 6245 BEN MORE DR NE
: 133024430019
: HEATI�R HII,LS
: LOT 1 BLOCK 2
: BUII.,DING
: RESIDENTIAL
: RESIDING
571-1LS"/
PERM ,T NO.: 2004-00488
� �
DATE ISSUED: 04/13/2004 ���
h�,,,
VALUATION : $ 12,301.00
NOTE: PER SECTION 1402, 1997 LTNIFORM BUII.DING CODE, REQUIRES THAT A WEATI�R RESISTIVE BARRIER BE
PLACED OVER EXTERIOR SHEATHING TO PROTECT TI� INTERIOR WALL COVERING. EXCEPTIONS FOR THIS
PROVISION WOULD BE IF SHEATHING IS AN APPROVED WEATI�RPROOF PANEL OR WHEN TI� SIDING IS AN
APPROVED WEATI�R BARRIER. VINYL SIDING I5 NOT A WEATI�RPROOF COVERING UNLESS TI�
MANUFACTURER STATES THIS IN TI�IR APPLICATION GUIDELINES. CALL FOR INSPECTION OF WRAP BEFORE
COVERING OR TAKE PICTURES.
STATE LICENSED CONTRACTOR 1
APPLICANT
RMA HOME SERVICES INC (20268257)
3200 COBB GALLERIA P
ATLANTA, GA 30339-
(952)345-6047
� ./� '
TRAHAN TI�ODORE C& RAMONA L
6245 BEN MORE DR NE
FRIDLEY, MN 55432
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or constnzction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and lmow the same to be true and correct. All
provisions of laws and ordinances governing this type of work
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
regulating construcrion or the performance of construction.
Applic Date
Bldg Ins , Date (3 ��
BUII.DING PERMIT FEE
FIItE SURCHARGE
STATE SURCHARGE, VALUE
LICENSE SURCHARGE
TOTAL
PAID WITH CHECK # 34534
�erm�� �r�spe�tion Cards
Will �e Mailed
To Homeown�r T� Post
�F.PARATF: PF.RMiTS REOiJIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
223.25
12.30
6.15
5.00
246.70
04/02/2004 FRI 13:21 FAg -�-�-� ELDER JONES
� ooiiooi
. . . •�•. : . .. ..
� � � � �1 ��_ � ,��,�, � _ - -� -- --
��4
NE1N [] CITY OF FRIDLEY Effective 4/1/2004
ADDN [] 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp
ALTER [] SINGL.E FAMILY AND DUPL�XE5 R-1 AND R-2 (763) 571-128� Pax
BU{LDlNG PERMIT APPLICATION
Construction Address: �O o� y � rr�Y�[! �� ��f ►1�, `(�. �- �
Legal Description_ •
Owner Name & Address:��.d �`c0.�nD. � �i ' Te[. # �� 3 °- 5 �- I ° I `o� ��
Cpn#raCtor. � RMA HOME SERVICES INC. MN LICENSE #
Home Depot Installed Sales
Addr�ss: 3200 Cobb Galleria Pkwy., Ste. #200 Tel. #
Atlanta, GA 30339 Certificate of Survey of the
763-542-8826
Bc-2o26s2s� vction drawn on it to scale.
n��c��rio� o€-i��a�ov��r- - -
LMNG AREA:
GARAGE AREA:
bECK AREA:
oTHER:
Length Wid� Height Sq. Ft.
Length Wdth Height Sq. Fi
Length �dth Hgt/Ground Sq. Ft.
�c �,-�;d-e. l�1or� ua � 13�.s � c.. t7i u�'c�n\a(J V i�1 S sct �(�oJ
0�Construction Type: Estimated Cost: $ � � ` � � � _
priveway Curb Cut Width N�ed�d; Ft� + 6 Ft = Ft x$ _$
DATE: l� `�CJ ( i 1"d �t APPLICANT: (���1.�`+2�2/`f��� Tel. # ��� ' �`l �' ��y�
Call (763) 572-3604 for Permit Fees if mailing in application. Fax t� 763-571•1287 if using credit card and we w"tll call
you fo� card numbe�.
Permit Fee
Plan Revievv
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Curb Cut Escrow
Erosion Contro)
Park Fee
Sewer Main Charge
T07AL
CIiY USE ONLY -
$��� .� 5 Fee Schedu{E on Reverse Side
� 65% of Permit Fee
$ I�. �� .001 of Permit Valuation (1/10th%) �
� f�. l S ._ $.50/$1,000 Valuation �
S $1350 per SAC Unit
S �� OC� __$5.00 (Sta�ie Licensed Residenti�l Contractors)
$ AI�. "A" or Alt. "B" Above
$ $450.00 Cvnservation Plan Review
$ Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [ ]
$ C�Li �D � T`° STIPULATIpN�:
From: 7637834566 Page: 7/7 Date: 10/8J201011:29:34 AM
1V�ECHA1'�TICAL ��t rro.:
►e�ti.o�us RE►SIDE� APPL�XCA.TION �,e��i�� sy: �
s�2-��aa �ITY OF F��.EY '
SQ2-4977 FAX � �-� zazo
1QI7J20 xov7�k-naa.II.ADDRESS ��rickson�ihearteri.cksQn.com
��� 63 �n More Dr 1�E
,pPLC �';, I9:�p � ' � C7 UWNF:It I�."px+1'CItP,.CI'C�Zt
ROPEI�TY N,a�; Musta�a Karamano lu
0�� ,�p�ss: 6345 Ben More Dr NE �x FridleY Sxa,�� z�r 55432
TENANT
�exor�: --
;ONTRAG°TOTt cot��t�a.�: Er�.Gkson PHC
1BMIT A COI'X 0'�
CONTACIPfiItSON: Zach Lzi�kson
XOCFR STA1E S�,A.'tE LTCENSE # ��'A'� jd� 55�49
LICBIVSE WIl'� ppp�s: 1471 92rid LB.ne NE q�ySlaine s�'a.� Zar
'�'���TT� rxor� 763-783-4545 x,p,� 763-.783-4545
�'�RMIT TYi'E ��GLE F,A�.X ❑ TWO FAMII.X
'Yp'E C1� WQRK: Q N�w E�RgPLACEN�+TT
BTAILED DESCR�T'z4N 0� WORK
�a rowrrxovs�
O AE.TERAT°ION1�,k3MOIlEG
.�,� �ns��►+�r� sxo.00 �.a z�nc�u�, Exc�rr wr�a� �vo�n. r�,xrus�s: t�vuac.n.� �o r,�. �Fat oz� �ca� s�z.ow�
7D� �EA.'A' LaSS CALC'S PER 1ViA�TU J 2�6 As'�'�A� YiANDBOOxf.
�,�„►,�, �c: ' Lennox Mone�.: c�� 5?B �. o anz o� sr�a�v a. o o, a a a
A+IFG: MODEL: � SIZFJB'R3
� �C,., MdDEL: SfZFJB7U
C S2S.00 k'�tEPLACE (G.AS) $15.00 _GA.S.�t.P�NGFJOVaI SIQ.00
R TO AIREXCEIANCs�XL $�S P1RkP�.oA.C� (WO�D) $35,00 �g �1�' �'�`K $ 0.00�
)I4ER $35.00 ?�Ft}�AG73 $35.00
iIMNIEY LIIHEK �10.00 GAS DRXk�t $�0•08 POOL HEATk�.535.00
_. __--__ _"_ __ rr.wiTif lT/�DQif(111
"T�g IS .A.N �AkPT.rCanOx �OR A PBR�IT NoT vALID uN'f�. �.o��ssEo
b,ereby apply for a huildip,g p�oaut and I ackaowled,ge daat We iunformafion above xs complete and acourate; kb«at t}a� work will be in
onfo�natance w�itb, thc ordinauces and codes o� the City of Fridley and wl,t}a tk►e Miamesota ConsEructxon� Codcs; that i undea�sta;�,d tl�ds is
ot a permit but only an a��c9 '.£ar a p �d aad work is mok to start without a�ermit; that ibe wo�c wi�ll be in accordmlee vcdtlx tb�e
��rove�i paam iuu t}ae case o �^ wIuch �c �d s�rova� o� ans- P��
[G�iP,.'�U�t.E OF APPLFCANT q�qE � G�.�'�"� DATE w� �
,PPROVAL 1NSPRGTURS SIGNATURE AATE ` � � �
'=�
' `� City +af Frid�ey .
Stu7 ' g Xmspections Uepa�rtment
6431 iTniver5xty .E�,ve�p,ue NE, �'ridley, It�f�T 55432
763-572-36(�4 FAX: 753-502-497'l
HOUSE HEATING TEST RECORD
' FLOOR � -CITY �—SUBUR6.—�^ �
- A : ,� APT. =;,- � -�`, �
ADDRESS '� °__ `� ' " OWNER F
���`� � . ,� r ` � -�� � . ��,, .��. � � i
OCCUPANT < GAS C0. METER BADGE # � � ��r �, ;, � ,g�"�=�=
HEATr L055.-----''-DA'TrE HTG INST
�. . �. �, �!` ;� ,� � �'' INSTALLED BY � ' �; �' � � ,
SOLDI BY �' ` � � �, * �� �r Gas Line By
Electricol Work By UNIT HTR. OTHER
FA ��� HW STEAM SPACE HTR. -
TYP4 OF HEAT GA CONYERSION
.�CAS DES�GN
, �w,,�,,��, �, � � � �j;. �''" MAKE OF BURNER
�� � ��' �'`
MAKE �v� , ar '. � i � %-t �0 5� �;a, Model ,r�,n
Mcdel , �: ' Max. BTU Rating
' Seriall �;� � s� � �. µAKE OF FURNAGE _ °' �
INP � �' � ��,
4T . ` � '¢ �4 Model . _
CONTROLS ---_ T___ _ -�� .-
-,A— --
��' ��"`� _ �.{eat Plug - - Vent Size q ��" ;-� ,�. __`'� r" " SIZ ..E�NO��E_._--
1'�iERN105T,AT .�.- �; -�- KIND OF LINER `"° m _
� �. . ; Re ularor �.�' "',, , j �
Valve �� �' Draft Hood °�' p`'�� 9
Limit � �A� Filters Size � Numbar
p= � ��:, �,�` Outside ',m'
Limit Setting a�m�ey Location Inside--Y----s-
> -"'>' P��,,�_,. °��
Fan Setting `��'� ,.ti `s �
.�.-,�� G?►imney Construetion
Pilbt Type � "�� �
� $,�a�'� Wiring �� � � � �
Pilot Make Smoke Bomb _ i:,. �., _
Pilot Model "'"�" praft F'� Test Tag p��..
,; µ� .�,; � ��"� Lighting Inst
Pilot Timin9 '' ` . Dopr Pressure ��,
�. fi'" �� p
L.W. Cut Off -�^ Date Tssted �r' `'� °" ° "
`�.� _ �� Pereent CO �''� "'d. `°�' "� & `�'�`b� ,
Prbssure �-� f��;�. � 2 -� � Compuny Testing
� .� �r Pereent 0 _ �¢ ;
Input CFH 2 �'=•m Nome of Tcster
Stoek Temp. `'��� �� w per�nt CO
Fa�m 235