AF - 37006Date:
Owaer
Caty of Fridley, Minn.
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Address Address
,,� LOCATI � I 1 G
No. .���.��� Stceet Part o! Lot °
Lot ._._�_S.% Block Addition or Sub-Divisi �._.L�'� �° ��.`�-
Coraer Lot _ Inside Lot �� Setback ���� Sideyard
Sewer IIevatfan — — Foundation IIevatian
DESCRIPTION OF BUILDING
T be d as: � �'j
' Front .�:�.�.� Depth .��p�� Height � Sq• Ft.q'� Cu. F��./'
� Depth t Sq. Ft Cu. Ft
Type �! Conatructi�a ���-� Fst Co ..._. �–�o be Com�leted
In coneideration of the issuance to me of a permft to construct the building described above, I agree to do
the proposed work in accordance with the description above set Porth and in compliance with all provlaions of
ordinancea oP the dty of Frldley.
�
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In coasfderation of the payment of a fee of $� �C' , permit is hereby granted to
to construct the buflding or addition as descrlbed above. This permit is granted upon
the express condition that the person to whom it ia granted and hia agents, employees and worl�en, in all work
done in, around and upon said building, or any �art thereof, shall conform in all reapects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenaace� repair and moving of bwtldings
within the dty ]imits and this permit anay be revoked at any�ipon violatio�.e�any of the P��� of said
ordinancea �
Inspector
NOTICE:
'tids psrmM das eot eover t6s eoe�troeNoe, InsnUalloe fer �r1�t.y, �tum6tna �as 6..Nn�, sww� er rrmr. B� wre ro as
�in Bnildin8 Imp�eror for ap�rab p�rmih h� th� (iwa.
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� APPLICATION FOR BUILDING PERMIT
� CITY OF FRIDLEY, MZNNESOTA
pwaer'a Nam Builde � t
Address Address
LOC ON OF BUILD
�
No ��� �+ Street Part of Lot __
Lot Block Additioa or Subdivisioa
� � a
Corner Lot Inaide Lot �etback ,��j Side-Yard �
�
�E[�dBR ELEVA�ION FOU�TDATION ELEVATION �
Applicant attach to this form Two Certificatea of Surveq of Lot and proposed
building location drawa on thes� Certificatea.
DESCRIPTION OF BUILDING
To b as•
� Front�� � Depth ��- fleight � �
Sq. Ft, �. � � Cu. Ft. � � �
Front Depth Height
Sq. Ft. Cu. Ft.
Type of Conatructi Estimated Coat
To be Completed
The under�igaed hereby
specified, agreeiug to
Fridley Ordinances and
declares that all the
are true aad correct.
DATh %"� � / �
makes application for a permit for the work hesein
do a11 work ia strict accordance with the Citq of
rultags of the Departmeat�-of Buildings, and hereby
facts and representatio ata ed in this application
(Schedule of Fee Coets can be found on the Reverse Side).
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BUII�DING PERMdT FBE SCSEBULE
Section 2. The Tnspector of Buildings ehall, before is�uing any permit for
the erect3oa,of any building or structure, or,for any addition to aaq exist-
ing bu�.ldin� or structure, or for �siy alteratioas, or repaira to a�y euisting
building'or structure, upoa applicat3.ort th�refor, require the paymen� by �he
appl3cant for such peruiit of fees to the amount herein below set forth and
�n the maaner herein provided eo-wiC:
2.1. For any such permit for �he erection of �nq fire-proof building,, other
thaa a garaffie�, warehouse, factory or grain elevator, or for the erectioa of
aay fire-proof adc�it�.oa, for sim�.lar occupaacy, to any egisting building
sha11 be at the rate of $�.40��or each oae thousand cubic fee�, or fract3on
�hereof, in auch cubical.contents.
2.2. Bor aay..auch permit fos �he erection of any fire-proof �erage, warehouse,
fac�cory or grain elevator, or for tt�e erectioa of any fire-proo£ additioa,
for s3mil�r occupancy, to any exist3ag building shall be at the rat� of $1.25
for each oae thousand cubic feet, ciassified as °1fireproof°1 bq Section 502 of
the T�Iinneapolie Building Code.
iiOUSES
2.3. For any auch permit for the erection oi any non-fireproo� building other
thaa a garage, warehouse, factory or grain elevator, or any noa-fireproof
additioa, for similar occupancy, to any existing build3ng - permit $1.00 for
each one thousand cubic feet. `
GARAGF.S
2.4. For aay �uch permit for the erectioa of anq non-fireproof garage,
warehouse, factory or grain elevator, or for the ereceion of any non-fireproof
addltion, for satmilar occupancy, to any exi�tin� building or for each such
building or addiC3on - ninety cent� ($0.90) for-e�ch.one thousand cu'�ic feet
-'��o� fraction.thereof, in the cubical conteats thereof c,�ith a minimum of $4.00.
For the purpose of computing feea for building permita, the cubical contenta
of any building or addieion to a uniform he3ght throughout by multiplying the
ground area covered fram a point six (6) iaches below the floor line of the
basemeat or cellar to the average heigh� of the upner surface or to the
average height of the roof surface of the main gable of a pitched roof.
2.5. For repaisa or alterat3ons to an exis�ing seructure, the fee sha11 be
at the rate of $3.00 per each Five flundred Dollass ($500.00) or fraction
thereo£ ia the cost of a].l propoeed work.
2.6. In no:case shall the fee charged for anq permit as set forth in
Section 2 be less than $4.00..
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°� OUSE HEATING TEST RECORD
ADDRESS ! �S�
APT. FLOOR e
OCCUPANT C�'�'Y SUBURB.���°�!���
HEAT LOSS OWNER
------- D E H TG. INST.
SOLD BY
Electrieal Work By INSTALLED BY
TYPE OF HEAT GA pq t'� Gaa Line By
HM� STEAM SPACE HTR. UNIT HTR. OTHER
� G S DESIGN
MAKE. � � CONVERSION
Model � � � �MAKE OF BURNER
Model
Serial_ ��� �7� Max. BTU Rating
INPUT- R'L� �/�
� MAKE OF FURNACE
Model
� CONTROLS f�
THERAAOSTAT �, " e Heat p�u9 f� Ven4 Size �
Valve �����
KIND OF LINER SIZE�NONE��
Limit `
Draft Hood
Limit SeMing �-� � ��X� � Regulator
Filters Size ��umber �
F�� ��i�9 � C�imney Location I � ide
Pilot Type Outaide
Chimney Construetion .�
Pilot Make
Pilot Model Smoke Bomb �
Pilot Timing Wj��^9
Droft Test Tag c�
L.W. Cut Off
,a. Door Prossura
Prossure � s Pereent CO2 �� ��,� �9hting Inst. ��
Date Testsd• �
Input CFH Pereent 0
Stack Tem 2 COmPa�y Testing ` --.
P• ��—�.__Percent CO Name of Tastar �
Form 235
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L$ZI-IZS-Zi9 ��31
J�3��� I2l� �0 J�l I �
sue�ecr ERMIT NO.
City of Fridley � � �� � 2
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
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� • COMMUNITY DEVELOPMENT DIV
' � �: — Z �
r � � PROTECTIVE INSPECTION SEC. �
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� � /'�'1 � CITY NALL FRIDLE� SS432 NUMBER REV OATE VAGE O: APaqOVED Bv
�""� � �'' 612-571-3450 910-F15 3/26/96 / /
JOB ADDRESS
6735 CHANNEL RD NE
t LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
oESCa. Lot 4J Second Revised Aud. Sub. ��21 SHEET
2 PROPEi;TY OWNER MAIL ADDRESS ZIP PHONE
Judith Jones 6735 Channel Road NE 571-3897
3 CONTRACTOR MAIL ADDRESS Z�P PHONE LICENSE NO
Twin Cit Exteriors Co 906 Zac r o 3 253
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
425-4737
5 ENGINEER MAILADDRESS Z�P PHONE LICENSENO.
6 USE OF BUILDING
Residential
7 CLASS OF WOHK
❑ NEW ❑ ADDITION O ALTERATION g REPAIR � MOVE ❑ REMOVE
8 DESCRIBE WOHK
Reside Dwell
9 CHANGE OF USE FROM TO
STIPULATIONS
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCV LOAD
SEPARATE PERMITS ARE REOUIRED FOR EIECTRICAL, PLUMBING. HEATING.
VENTILATING OR AIF CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT CU. FT.
AUTHORI2ED IS NOT COMMENCED WITHIN 60 DAVS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. OWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINEO THIS APPLICATION 1 STALLS GAHAGES
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. TME GRANTING OF A PERMIT �4'f6OO �Z.3O
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pEqMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- @
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. �p99.7.5 Fire SCi �4.6�
PLAN CHECKFEE TOTALFEE
License SC $5.00 $111.65
SIGNATU�7E OF CON'RACTOA OP AUTMOAIZED AGENT IDATE� WHEN PFiOPER VALIDATED THIS IS VOUR PERMIT
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SiGNATUAE OF OWNE�+i�F OWNER BUILDEAI �DATE� BL G�NSP ��FTE
NEW
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ConstructionAddress:
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
,, Building Permit Application � :. .
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Effective 3/1/96
%�C�
Legal Description: : �
Owner Name & Address: �jj -d�7—� ��-,��5 Tel. # sr.JJ—��3g JT
Contractor: ��� � p S�a MN LICENSE # o�.,S�3 �"�
Address:_ 5TC /� � �13�?J �/�H��,�A��� 6,�J ,,,�� - - Tel. # yo��= %�%
LIVING AREA:
GARAGE AREA:
DECK AREA:
01'HER:
' � �.736
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
Length
Length
Length
DESCRIPTION OF IlVIPROVEIOZENT
Width Height Sq. Ft.
w�a�n ' Height Sq. Ft.
Width Hgt/Ground Sq. Ft.
' -�'/�
Corner Lot [] Inside Lot [] Ft. Yd Setback Side Yazd Setbacks
Type of Construction. . , ' E�timated Cost: '$ �T� --
Approx. Completion Date: 3 _ �,�— �'j�o � ' ' '
,(Cost on Back)
,,,.rga;:�, �: � . , , , �
Driveway Curb Cut Width Needecl: Ft. � 6.Ft =, Ft x_$ � _$
DATE: � 3 �I G}'' `�� APPLICANT: Tel. #�, 5- �% �
;,: ,. , . . . .
CITY USE ONLY' ' `
Permit Fee
Fire Surcharge
State Surcharge,
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park � Fee ' � �' �
Sewer Main Charge
TOTAL
7�
$ � Fee Schedule on Reverse Side� ��
,v ,.;. . .. . � :� �
$ � �{ .001 of Permit Valuation (1/lOth%) .
$. ; � `3� $.5%$1,(?UO Valuation , , , ,' ��,,
$ � ' � $900 per SAC Unit � �, , � � .
$ ,S � $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 [ ]
� �
$ �
STIPULATIONS: _ _ { a
BUILDING PERMIT FEE SCHEDULE
YE
The Chief Building Official 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 per�ni�-o��€es t�
herein below set forth and in th� manner herein provided to-wit: � r�,� ,• a��-� ' �
� � LL',�,�,� �;��"��� �
} .` �
TOTAL VALUE FEES � ; � , � ��
e : J /, ,sr . > 1�<� .!.`�L' � a �
$1 t0 �5�
$SO1. t0 $2,000
$2,001 to $25,000
$25,001 to $50,000
$50,001 to $100,000
$100,001 to $500,000
�5��,��1 t0 �1,��0,���
$1,000,001 and up
$21 (Minimum Fee is $21 plus surcharge)
,$21 for •first $500 plus $2.75 for each, addidonal�
, fraction, thereof, to , and includ'ing $2,000 ;
,. ::. ;s�• s _:;�
" r.- _l�' ,.:��,,�'N F!B � .
or
.$62.25 for first $2,000 plus $12.50 for each additional $1,(�0
or fraction thereof, to and including $25,000 _
- �`� .:
$349.75 for first $25,000 plus $9.� for each additional $1,0� �, ,,;� `A�� ; �
� or. fraction thereof, to and including $50,000 ,, :�, ,; o
� ;�:�-:_ . 4 .
$574.75 for first $50,000 plus $6.25 for each addidonal � 9 � ` `' �t ° �
$1,000 or fraction thereof, to and including $100,000
$887.25 for. first $100,OQ0 plus $5.00 for each additional
$1,�0 or fracdon thereof, to and including $500,000
$2887.25 for the first $500,000 plus $4.25 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$5012.25 for the first $1,000,000 plus $2.75 for each additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
_ (Concrete G�rb Streets Only)
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a
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Altemate "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. ,. ;�: `Y .. �;
. . ;�'i�`:I� � ��.:� �'�� �`e'
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SuBJECT pC�i16H'T=N�, '">
City of Fridley ' 2 7 5 0 4 ''
BU ILDING PERMIT - ��
AT THE TOP Of THE TWINS _
�
� �
� �
� `y �_�___ COMMUNITY DEVEIOPMENT DIV.
r � � PROTECTIVE INSPECTtON SEC.
1 . ,
i--__� ��"' �'� CITY HALL FRIDIEV 55432 NUMBER
t 612-571-3460 910-F15
JOB ADDRESS 6735 Channel Road NE
t LEGAL LOT NO. BLOCK TRACT OR ADDITION
oesca. 4-J (1000 Second Rev.
2 PROPERTV OWNER MAIL ADDFiESS
Judy Jones
3 CONTRACTOR MAIL ADDRESS
Town & Countr� Roofing & Sidin� 9403 Minne
4 ARCHITECT OR DESIGNER MAIL ADDRESS
5 ENGINEER MAIL ADDRESS
6 USE OF BUILDING
Residential
7 CLASS OF WORK
RECEIPT NO.
�� � �
REV DATE PAGE OF APPROVED 8Y
a/i /aQ � �
SEE ATTACNED
SHEET
21P PHONE
21P F49NE-.�UCENSE NO.
282
ZIP PHONE LICENSE NO.
ZIP PMONE LICENSE NO.
❑ NEW � ADDITION O ALTERATION � REPAIR O MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof house and gara�e (22 Sq) Tear-off
9 CHANGEOFUSEFROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
TYPE OF CON
SEPARATE PERMITS ARE RE�UIRED FOR ELECTRICAL. PLUMBING, HEATING.
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WOFK OR CONSTRUCTION 20NING
AUTHORI2ED IS NOT COMMENCED WITHIN BO 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.
I HEREBY CERTIFV THAT I HAVE READ AND EXAMINED THIS APPLICATION
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT 1885
DOES NOT PRESUME TO GIYE AUTHORITY TO VIOLATE OR CANCEL TH� pEqMIT FEE
PROVISIONS OF ANY OT R STATE OR CAL LAW fiEGULATING CON-
STRUCTION OR THE PE ORMANCE OF NSTRUCT r,. 59. SO
�PLAN CNECK
� Licens
ATUfiE NTRAC O A T RI D AG IO TEI
SiGNATURE OF OWNER qF OWNER BUILDER� �OATEI A�
S�.
UNITS
STALIS
CU. FT.
GANAGES
i IS I ��—^—
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OaTE
� , ri
`�y�� RUG-13-1998
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ADDN I l
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CoasauctionAddress:
Legal Description:
08�42 FROM CITY OF FRIDLEY TO 8589320 P.01i02
rrir�:uves ti iiya
CITY OF �'RIDLEY
SINGLE FAMII,Y AND DUpLEXES Yt 1 ANp R-2 +�
BUYI.DII�iG PERNIIT ApPLICA?ION � �- °� �
Owner Name & Address: � ,.,,� o n... � �QCv��� p �1?��,'' (� �Q�,TeI. �l _ `� � � � ���
Con�actor: � NIN LICENSE �t o��D �� 2g �
Address: `i�� I ,.�►n �..� T�l. # ��'Z �
LIVING AREA:
GARAGE AREA:
DECK AREA:
OT'SER:
Attach to this applicateon, a Certificate of Survey of the
lot, with the proposed consavaioa drawn on it to scale.
r1ESC�TYON OF IDRPROVEMENT
Length ,_ Width Height � $q. Ft. _
�� � Width _ Height Sq. Ft.
�$� Width �_ HgVGround Sq. Ft.
.� �"°2 v no �t
Const�uc�ion TYPe' �—� % ti�� Fscia�tc.� C�st: S� J��_
(Fee Schedule on Back)
Driveway Curb Cuc Widtb Needed; Ft. + 6 Ft a Ft x$ —$
DATE: '- � APPLICANT: Tel. � 5��-/�='C/c�.3 3
Peimit Fee
Fire Surcharge
State Seucharge
SAC Charge
Liunu Surcharge
Driveway F�serow
Frosion Controt
Park Fee
Sewer Main Charge
roTai.
• STIPULATIONS:
$� S'o
$ /• ��
$ •g�
$
$ S''c� v
$
$
$
$
$ �' 7 2
y M.1! � � U. .
Fee Schedule on Reverse Side
.001 of Permit Valuation (1ll�h�)
$.s0!$1,�0 valuacion
$1000 per SAC Unit
$5.00 (Stata Licensod Rcsidential Conaacwrs)
A1G 'A" or Al� "B" Above
$450.00 Conservauon Plan Review
Fee Aetermined by Engineesing
Agreement Necessary [ ] Not Ne�yessary [ ]
�
Building BUILDING Permit No.: �
Inspections RESIDENTIAL APPLICATION Received By• -
763-572-3604 CITY OF FRIDLEY D���'� � P 2007
DATE / �v� (' YOUR E-MAIL ADDRESS - ' " � , ��
SITE ADDRESS (/�� �rie� � �7�
THIS APPLICAN'1' IS: ❑ OWNER �'CONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS: CITY STATE�IP�=��-�l.C�
PHONE: �IQ3' S�l I '��
CONTRACTOR NAME: '�
STATE LICENSE # E DATE J�'� I�O
SUBMIT A COPY OF '"� �
YOUR STATE LICENSE ADDRESS:�(Gl� ��1,1� O%� CTTY �STATq],�j�IP °:t9
WITH APPLICATION pHONE '�� °�l' � FAX i(GS - - TOJ'%
PROPERTY 1'YPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCT[ON STORIES
PERMI'1' TYPE � ADDITION ❑ GARAGE/SHED ❑ W(NF�WS
❑ BASEMENT FINISH ❑ ROOF ❑ RAIN TILE
❑ DECK ❑ SIDING �THER
❑ SWIMMING POOL
7'YPE OF WORK: � NEW ❑ ADDITION
❑ MAINTENANCG/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ��{�� � - `Q�P,����,��- �� �� ��„ �� �
_T'_
SIZE OF IlVIPROVEIV�NT LENGTH WIDTH HEIGHT S. Ft
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
GARAGES ❑ ATTACHED GARAGE 1. Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE Z• Proposed floor plan
PROPOSED HEIGHT: 3. List of structural members to be used
� FOR NEW CONSTRUCI'[ON INCLUDING DECKS,
� V�nY1 ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXIS7'ING OPENINGS ❑Yes ONo LOCA710N OF WINDOWS 3. Energy Calculations
OR FOR NEW OPEIVINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
aLL r �:�a ax�;; sa��:u Uiv vALUA'I'IUN, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN ��TH,�E ,1�997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ L��— OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
T��
$
$ i:
$
$ , �'f�i
$
$
$
$
$
$ � �/
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$1675 per SAC Unit (Plans to NIWCC for determination)
ft+6ft= ftx$21=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 a.nd 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 work is not to start without a permit; that the work will be in accordance with the approved
plan in the case of all wo c'i req� " ,view a proval of plans.
SIGNATURE OF APPLICA PRINT NAME �����DATE�� ��J
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COM ON Ni NT CQNNECTOR AND COd{!lI�UaT'ION A&R VERIFlCATION
ilVhen �eAlacins� an euist�n�g fu,�aa�ee, thie undersigne� �ereby vp�ifes �at ihe
ven�ng has been examined and is f�e� �rorat ra��t, detetiora�on. obslnKtions,
and is secureiy st�pported and fcrestopped where required. y� �Na �
�The venting sysfern is plas�e;/P11�C and meefs a�l current codes �n� manufac�ur�r
speoffications induding sizir�g, i�pngth, number of elbows and iecmination. Yes (�No (
The undersign� atso verifles th�t the �eptacemen4 unit is a listed assembiy
and rrteets the cuRent oodes and manuiac�ture�'s specifications, Thjs does
inctude A�A-CAMA Catego►y 1 Central Futreace VenNng Tabtes for fan
asaisted �nd natural draft appliance�.
T'he e ls ' o bu tio air is sized ae�d �r�stalled to meet the current �des
and manuFacturer's specific�tions.
When required to instatl a nevr comb�astion aip it will be si�ed and ins4aited
To meet the wrreni codes and ;reanufacturers sp�ci�r,a�on�.
Yes (1�No {
Yes (c,.YNa ( )
Yes �No ( )
Whe� nstallinc� a new ventino� system, the undQrsig�ed hereby vetif�es that
Et is a listed assembEy and meets the currer�t codes and manufac�u�ers
specific�tio�s. This does indude AC�O-GAN4A Category i C�ttrr�� Fumac,.�
Vettting Tables for fan �ssisted and natural draft applianc�s. Yes (Q,y�o ()
Is tiie common vent and verdt connedors sized artd instatled correctly after
an appliance has been� removed from Qh� evmmon vent atad v�nted
separatefy as per current c.�aies. Y�e �a ��
A�aliara Tvo� aatd Size/Catnnton Vent and 1/ent Corotteator Informatlon
Appliance #1 Type��� g�� (�p�t Fan Assisted or Nat
�pbance #2 Type „� �Tt1 �npu� - Fan Assistesi or Nat,_,�
Appliance #3 Type _ �TU Input �an Asslsted or Nat
T'otal Ap�lances v, 'Totat Bt�a tnput
Common Ver� Type
V�nt Helgh4 Diamete� _______ inches
Applfance #1 Vent Connec�or Neight __ � Length i� �tameter in Type
AppEiance #z 1/ent ConnecQor H�igh� ft Length it D€ameter in Type �
Appliance #3 Vent Connector H�ight f� �ength � Diameter in Type
Ai1'�RATIONS• (DescNbel
•�A � l� - � �
. -. ! il,��''� ��`►:��� ._ -
�.. - _ _ �
Z0/Z0 ' d S0�68L Cll J.3�Q I 21� .�0 J�l. I � WQZI� $S ; Zt 000Z-ZZ-f10N
e
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CfiYOE
FRtDLEY
FRIDLEY MUNICIPAL CEN'TER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287
August 23, 2002
Ms. Judy Jone
6735 Channel Road NE
Fridley, MN 55432
Re: Final Inspection at 6735 Channel Road NE
Contractor: Daves Appliance Heating & Air Cond
Dear Ms. Jone:
A mechanical permit was issued on October 5, 2001 to install a furnace at your address.
The final inspection conducted on October 11, 2001 noted the following conection:
Size vent connector per GAMA tables.
We need to reiaspect to verify the correction was completed. To set up the reinspection or
to have any questions answered, please contact the Building Inspection Division at (763)
572-3604.
DJ/mh