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AF - 37978� � City of Fridley, Min.n.. BUILDING DB�; August 7, 1968 PERMIT — — �� i�1T� 98�? Owner; Allam Anderson g��. Clemron, Inc . Address Ad�,�e 4411 Central Ave. N. E. LOCATION OF BUILDING No. 7401 S�t Concerto Curve ._,_, p� of Lot �13 __ gl� 3 Addition or Sub-Division .� Melody Manor 3rd CO��' I'Ot — x �� t — Setback 35 �.__ Sideyard 10 �/ 20 � Sewer IIevation ____� 872.60 _ n 87& 60 Ton of Footin� �' DESCRIPTION OF BUILDING To be Used as: -�? ? i n� Front _.._ 40' Depth 26 � Height ._.._ 20 � Sq. Ft, 1320 �� 26400 Ca.rage Front 20 � Depth 21 � fteight 1�� Sq. FL � 420 �� 4200 Type of Conatruction ..� Fra.me Faa� Cost �. $ 26 , 5 00^.. To be Compieted Sewer Location - 25' N. E. of Manhole Water Location - 37' N. E. of Man.hole In consideration oP the �tsaueace to me of a permit to c the building describe I agree to do the proposed work in accorriance with the description abo aet rth and in co li e � provTafons oP ortlinances of the dty oP Fridley. $100.00 Sewer Connec n C arge In conaYderation of the paqment of a fee of $ 46 .00 ��t ��by �� S$ Clemron, Inc . to construct the building or addition as described above. This permit ia granted up� 'the exAress condition that theperaon to whom it ia granted and hia agents, employees and worl�en, in aU work done in, around and upon said building, or anY part thereof, ahall conform in all reapects to the ordinau �� FridleY� M3nnesota regarding location, conatruction, alteration, maintenance, repair and moving of buil within the dty limits and this permit may be revoked at any tirne upon violation of an,y of the P�visiona of said ordinanc;�. I ; r, � Official Buil�ins ^ NOTIC� 'flds psm�h does eo1 eovsr �6s eoestrndioe, lestallatian hr wtrla9. P��9. 6+s be+�8. ssw�r ee w�hr. B� wn to � tha BniW[u0 letpsetor fo� �parats parmhs foe t6as tnms. - _ a M ' ' ! g r a APP`LICATION FOR BUILDING PERI�T `CITY OF FR�DLLY, MII�ESOTA � � • � � � i: ��>�� /.�' �%,, . ! : � r � �� ✓ � .J ; ��; . i� ` . � � . , � � . /��✓- � � ' � � � .% �%f�l�' �. �� LOCATIOAI OF BUII, ING N0. �� S�TREET � PART OF LOT LOT O BLOCR �� ADDITION OR SD � � f CORNER LOT !� INSIDE LOT SETBACK .� 'C SEWER iLEVATION ��Z • 6 0 FOUNDATION ELEVATIOft ��•� 6 J ��$-�'�. . o-d �- � pplicant attach to this form Two Certfficaees of Survey of Lot and propoaed � building location drawa on thes Certificates. ��i — 3�'Jl�.��i-� ... . s DESCRIPTION OF BV�DING s-- : � To be used as ; , � � 3� ��!�� .�� v � �� Front Q �' Depth��Height ; � � - Sq. Ft. a ��-,, � /�,.,.� � Cu. Ft. �"�� - ,a . _� ' -'- �� Front Depth�Aeight � . . Sq. Ft. �� Cu• Ft• �� P�'' ��' .� �� . Tqpe of Construction �j�/�� Eatimated Coat �" To be completed_ � ��F�� The undersigned hereby makes appl.ication for a permit for the work herein specified, agreeing to do all work in strict accordance with the City of Fridl.ey Ordinances and ruliags of the Department of Bu3ldings, and herebq declares that a11 the facts and r�presentations stated in this app].ication are true and correct. DATE_ , � �� (Schedule of Fee Costs can be found on the Reverse Side). ,.� _� r = _ _ �.�,_ , , -- l ,l�L (� ✓ ��Lc�`� ��' �rZ s s �� F � � '1�'I..o `�a..�ae..L.�. St � ° n ` ,� ,;: . �BUILDING PERMIT FEE SG�DULE SECTTOft 2. The Inspector of Buildings shall, before isauing any permit for the e�recti'on of any building or atructure, or for any addition to any.existing building or �tructure, or for any alterationa o� repairs to any existing building or atructure, upon application therefore, require the payment.by the applicant.for auch permiti of fees to the amouat herein below set forth �nd in the mauner herein provided to-wit: 2�1. For any euch permit,for the erection of any fire•proof building, othei than a garage, warehouae, fact�ory or grain elevator, or for the erection of aay fire-proof addition, for similar occupancy, to any.egisting building, sha11 be at the rate of $1.40 for each_one thousand cubic feet, or fraction thereo£, in such cubical.contenCa„ 2_2 For any such permit for the erection of any fire-proof garage, warehouse, factory or grain elevatflr, or for the erection of any fire»proof addition, for similar vccupancy, to any e$iating building ehall be at the raCe of $1.�5 for eaeh one thousand cubic feot, clasaified as "fireproof11 by Section 502. of the Minneapolia $uilding Code. flOIISES 2_3_ For any such permit for the erection of any noa-fireproof building, other than a garage, warehouso, facCory or grain elevator, or any noa-fireproof addition, for.s�imilar occupancy, to any exiating build.iag - permit $1.00 for each oae thousaad cubic feet. GARAGES � � 2.4. For any such permit,for the erection of aay non-fireproof garage, warehouse, factory or grain elevator, �r-for the eraction of any nou-fire-proof'° addition, for aimilar occupancy, t.o aay esisting buildiag or for each such building or addition - ninety cents ($0.90) for each one thousand cubic feet or fraction thereof, in the cubical contents thereof with the minimum of $4.00. For the purpose of computing feea for building permits, the cubical contents of any building or addition to a uniform height throughout by muZtiplying t1�e ground area coverad from a point si:x (6) inchea below the floor line of the basement or cellar to the average hgfght of the upper aurface or to the average height of the roof surface of the main gable of a pitched roof. 2,5. For repairs or alterations to aa exiating atructure, the fee sha:ll be at the rate of $3.00 per each Five Hundred Dollars ($500.00) or fr$ctivn thereof in the cost of all proposed work. . 2.6. . Tn no case shall the fee charged for any permit as aeC forth in Section 2 be less than $4.00. STORM REPAIR DAMAGE FEESt ResfdenCial; Eatimated Coat of work up to $500.�� - S5e�� Estimated Cost of work over $5�::.�:•"� .� ;;;.:;-, �p Commercial; Estimated Cost of work t►- �. _=`- .: „ `� F'-�- � � Estimated C�t of wo7:, u-,��;:r ;,..�i;�,u�' -;:::�� • '� . � -' 1 - ; Lmrd Pleavrrn�n� laad St�r'rx� �„� rtsr� t�mr � �r�yo� E�� 'S -ffir�h� K5 �!E. Mi,�mv�t.�rs �1, ENG 1 I�IE�RI NG, � NC. �'��°'° � � SUns�t 4-rPOio� -- En9i,�eers � S'ur v��ors ---� cesrti�ic�te �� rve �o: � � 111 �EV�.�Pm�,�1'i � T �.--- �� . c,`�� / / NOi�i'`M�1 o Q�wo7ES IR4M"�p�,NdTES �RAINAGE AND uT1LITY EASEMENT �.c,T t� �ac��,M�.ocY MANO� 3RD �►001T►ON AN01tA G TY /�dr� esrl�i�y, t� ll�is �s o hr� a►�d corracf npresenEafioc� o�'a su�y �'!�t b�w�da�s � adn,�r a(�f�d /aad,ond �Ic�4f'�n a�'aU d�kl,�s ,lhraan ,�d� ns'�1�ddt �a°o�rrrexrfs ,�,�°a�j►, �am ar � said /and. As sur-rt�rd fnJ me !� �' af�/ �'`''�# ��° �`' Su8 uRBAN ENGrNEEl��NG , lac, L�n�rrs Fr SurXcyora SCC1Ee%/ 1�r�dl} ly � � � a<-_-- �,�+� - . � � . �� '`� �� - �� .�-_:- �...-.. _.� — --- -._. � 1 . � _ � - ... -!� a ,-w--��-� --�- --- . _.. - _- _ _- --'_ - � --- -- ---- - - -- -- � - _ . - _ �, . _ � . — - -- ,� ^� � - - n � e n kX p o� � . � • iA I ID N � � � � 10 r e � �p 3 � � � a � � p� � � � � z x � ea x � 8 � �, � � � G] �p � �: � � � � � � �� m �� o � � �+ °' + � fD � �+ � . x 'ad : O � � � : � � b � O � y �. : �: � : . . � a o � � t� � ' ' GJ c� : �' �q ' � : : a Q : o° : . . . O4 $ . . . : : : : � : : : : : : : : � : : : : 0 0 94 id �4 ' M i� �4 5C k # 74 • �p � � �+��+�JJ �p W pW � N N Np �J O C�i O � O� G c7� O O O � 69 �l � ifl i� fA :i! H! {A ♦ O y Q • � O� p Cr. 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O � . . QO . . P . . . . � � �° W � � a � 0 0 o v �n O � a.a� � n �� ro b ,:. �, � � y � V w "'� � � � p � �,� .. y � � er �b O O+ ,� p y � p' p �� °��. �, � � �� b �5'w 07 �M� w (n f] f7 ' p� �� w ��op ra �+ � �,, y �� a� � o ~'��* ��f�DH � � ;a- n �� G�o � �. x .� �D � p' �. °�� D � D r � � T � 2 m C m d � M m � x O m � '�� ', � O � y► � o � D 0 �. ii" o= �• � � �� 0 � 0.� A 'r �• � � �'. ', � 0. � � �� HOUSE HEATING TEST RECORD ADDRE55 �� '�=��P` � APT. R CI SUBURB OCCUPANT OWNE�-�'�-- �%�� HEAT LOSS DATE HTG. INST. GAS C0. METER BAD� SOLD BY INSTALLED BY ,— � e!� Electrical Work By Gaa Line By TYPE OF HEAT GA FA HW STEAM SPACE HTR. UNIT HTR. OTHER � GAS DF�'GN �� CONVERSION MAKE � �-• �'� l° �'� -�' MAKE OF BURNER Model �_/� L//-?��y� Model Serial �� ' �� Max. BTU Rating - INPUT �� MAKE OF FURNACE Model CONTROLS y THERMOSTAT ��Heat Plug Vent Size � Valve �� KIND OF LINER Z c� NONE Limit �� 3��L�� Drok Hood Regularor Limit SsfTing �-� Fi Iters Size Number Fan Setting �� `'- Chfmney Location Inside Q� Outaide Pilot Type Chlmrrey ConstrueTion Pilot Make � � Pilot Model Smoke Bomb Wiring Pilot Timing --�;��6,- Draft � Test Tap �� L.W. Cut 0# � � Dqor Pressure— Lighting Inst. �� < ° _G Pressure �� P°�, e �2 ate Tested -� "' �� Input CFH f� F�}c n�Q � `' �" mpany Testing Staek Temp. •-�!� Pereent CO ��' �' Nams of Tester Form 235 . . � � � r �. ' � m .. A 'r .. �� •�'1 y / f� J '� 7: � . G � � � � � � � � � � � � W y, ,. L� � :. f c i. w 'T � � � "� n � , A c1 -� � ?: • ► C� .� r �vt f O fc '"� �C O n M " J� ✓• G tt ^, -' i'9 ; L' .. C K ' s � {� � a n � � F x .s . „ '" ° �+? a '+ �► �y '" O � M . �- x • =� c c: ' y � N y � �' . Z � v' • « R � ' p � "� � . �s M • � 0 0 ' ' a. ; N .� � • � ' �+► 7 t�f • ` ia , • � . . W W : K °; � ; i'__ . � . . • a, Q ' , . . . ti . . � � � �. 2i ; : . . , ?� � � � � .. . '. . . � , -. , . . � . . . •' . • � � • • � • � � � � � � • • � - � • ' '• .. � . . . . . . . . • ' . . . � : . . . . . • •• �• • • • •• • . • • � � • .. • • . . . . : • � i rn v . � � m ' M K x K x x x • x. x K f/� �,'� N � �� . v 41 �,J �.N.� . ✓ W "� �.. � � ,��' �' N S � ° � � -�+ �� M � � I {� M fA' M M N N M " � �. H • � ! � ►�l r • � r - I . . ' �r O � � O . x' � � y.i " � � • � . . '_ • � �. i I I 7. G � tl ' t� �� A � M � �o P M ti� }� N Q ~ .°. O � � p � �� O . 'I � . � . �,a � � 1 � � �o 0 N � � �� i�t �� o - -J . 6,� � . �� . _ �� - .... � - . � � . . - . � � 0 N o .0 7C � � z�� A , e� �• �� P. .. r,°'+ y ,s L1. G. w � � v ,�3 i� . ( c a a. �„ � � o r •s � �� '., " �i� . � .o " _d � "' �+ � . � � . - �� n ,° E �° �c'' � °' � . ... • .. „ � -.�. � " N � �: � •• .�".. =. ;� `.`� : � a ~ ' f9 °a v � � '6 t�.� o' oa °� • p�j N (Y � N� 0� r" y �' - �� O O � 'Q C • .Rs �f-` p, x � !'� �Y R ►� '� .L O � � � 1 ."� � ' a " t3 � :.. • � •� �aG� p` " "i �y ta =` " ` � p' ,� � V1 . "i o roo c� . • •� o � � i ,.��x ►Wf' � p0 n F� � p C'J � �. " v � Q, i', o j ai p ti�. p� O 7 ' O•"' � U] t= IL �: V '� o � v � �`�"� � ' � w � �. t= � . , � � . � � ro •- w � M � � O 0+ Y ; � . � a a' o � � e� �r � c, • o . ��,'' ' - � � � s � . ro � � n . a � � a�i. � � � . • . ': f n N 7 w d � � � � ' .T• O � ?�ns ,�- _ .. q � . , . �, � : , . . . �..-_. ��°. r i�ir - . City of Fridley S�B�E�T o 20033 AT THE TOP OF THE TWINS g U I L D I N G P E R M I T � � � RECEIPT NO. COMMUNITY DEVELOPMENT DIV. � � � L � PRO7ECTIVE INSPECTION SEC. r , , � � , � /'�'1 � CITY HALL FRIOLE� 55432 NUMBER iiEV. DATE PAGE OF APPROVED BV �'""'� � �� 612-571-3450 9t 0-Ft 5 8/1/89 / / , JOB ADDRESS �401 Concerto Curve N.E. , 1 LEGAL �OT NO. BLOCK TRACT OR ADOITION SEE ATTACHED DESCR. �-3 3 Melody Manor 3rd Additian SHEET 2 PROPERTY OWMER MAIL ADDRESS ZIP PHONE Renae. La.rson 7401 Concerto Gti�.rve N. E. 786-5222 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. D&D Home Imp.rovement 7401 Central Avenue N.Ea 784-7543 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO. 8 USE OF BUILDING ' Residential 7 CLASS OF WORK O NEW O ADDITION ❑ ALTERATION C� REPAIR � MOVE ❑ REMOVE 8 DESCRIBE WOHK Reroof Dwelli:ng 9 CHANOE OF USE FROM TO STIPULATIONS Roof can be 2nd layer b.ut not 3rc1� II�.stall ridged galvani.zed valleys. fln ali new roofs or te�r-offs and replacement roofs, St��te Code requires that 2 layers of 15 1b. feli, � mopped to�ether, be installed to .a point 24 inches up from exter;or wall line, or the use of other approved underia�ment membrane. SEPARATE PERMITS ARE REOUIRED FOR ELECTflICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT. CU. FT. AUTHORI2ED 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 APPLICATtON 1 STALLS GARAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PRQVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TVPE .OF WORK. WILL BE;COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT: THE G8AIV71NG.OF �A 'PERMIT $�- r �-SO S• 58 ' DOES NOT PRESUME `TO GIVE AUTHORITY•TO VIOLATE OR CANCEL tHE pERMITFEE SACCHARGE PROVISIONS OF ANY OTHER STATE QR LOCAL LAW HEGULATING CON- 29.00 S7RUCT O OR THE PERFORMANCE OF CONSTRUCTION. $ %,� PLAN CHECK FEE TOTAL FEE i�` $29. 58 S GNATURE OF CON i RACTOR OR AUTHOiiIZED A ENT IDATEI WHEN PROPERLY LIDATED THIS IS YOUR PERMIT SiGNATURE OF OWNER IIF OWNER BUILDERI IDATEI BL�G �NSP ! � qAT � [ ] Effective 5/1/88 �� [ ] R-1 AND R-2 �� [ ] Building Pn.�mit Application . . � .�. - � .�'��' ,° � ,� � .�� , Legal D�.scription: OWt1er Name & �a.a, �: �,/�/ � ��'.�if� Te1. # � � Contractor: • .. - �*' �f��'! � " , �, �v LNIIJG ARE�1: C,PiRAGE AREA: n� �,�,: o�: Te1. # ��5�/�' Attach to this application, a Certificate of Survey of the lot, with the proposed c;onstruction drawn on it to seale. DFS�RIPi'I@T c3iF Il�'lmVE�TP Iength width Height Sq. Ft. Length Width Height Sq. Ft. r�n wiatn �t/cr�uza sq. Ft. Cornex Lot [] Inside IAt [] Ft. Yd'Setback Side Yanl Setbacks 'Ij�pe of Construction• �- /,► p� Est�mated Cost: $ -�- r/S� Approx. Ccmq�letion Date: �/,S �/ � ��'/Z � � �.g,�� T , �° ' ' .S Proposed Driveway Width If New Opening Is Desired: Ft. $ $ Wid + 6' See Back Page n�: g- —�' �c�r: Tei. # '�,��f 7s9�� Permit Fee $ o� y' D O State SurcY�arge $ �� SAC Charge $ Driveway Escrow $ Park Fee $ Se�aer Ma.in C�arge $ : v� S'I'IP[TLATIONS : $ o�� CITY IISE �II,Y Fee Schedule on Rever�.�e Side $.50/$l,00o valuation $575Fper SAC Unit Alt.�"A" or Alt. "B" Abave � Fee Detezmined bY �'��'�1 Agree�ner►t Neces.saiy [ ] Not Ne�essary [ ] � I:?1�■ � ��. a�;�v�4 y:1i � s+:lyl�:l) The C�ief Building Official shall, before issuing permits for the erection of ariy building or structure, or for any -addition to arry existing building or structure, or for any alteration or repair to any existing building or structure, upon application therefore, require the payment by the agplicant for such �*�++;t of fee.s to the amo�nt herein belc�w set forth and in the manner herein prwided to-wit: TO�rAL �IAIIJE $1 to $500 $501 to $2,000 $2,001 to $25,000 $25,001 to $50,000 $50,001 to $100,000 $100,001 to $500,000 i � �. $15 (1Kinirm�aa Fee is $15 plus surcharge) $15 for first $500 plus $2 for each additional $100 or fraction thereof, 't� and including $2,000 $45 for first $2,000 plus $9 for each additional $1,000 or fraction thereof, to and including $25,000 $252 for first $25,000 plus $6.50 for each additional $1,000 or fractio� thereof, to ar�d including $50,000 $414.50 for first $50,000 plus $4.50 for each additional $1,000 or fraction thereof, to ar� including $100,000 $639.50 for first $100,000 plus $3.50 for each additional $1,000 or fraction thereof, to a�l including $500,000 � $500,001 to $1,000,000 $2039.50 for the first $500,000 plus.$3 for each additional � $1,000 or fraction thereof, to ar�l includirig $1,OOU,000 $1,000,001 ar�ci up $3539.50 for the first $1,000,000 plus $2 for each additional $1,000 or fraction thereof Alterria'te ��A�� s Al�ernate ngn : :�•� � _ �� . �r• •,� - .� � .,•.. n . � - - � . -- • R�maval arid replac�nt of curb arid gutter only - Driveway width plus 6 feet times $13.50. Remc,�a1 ar�d repla�t of curb ar�d gutter arid in.stall a 3 foot wide approach.�wit� f inch.,dep�th - Driveway width plus 6 feet t� $15.75. . . . VER�'IQ�iT,IOI�i OF �!OUDIDATI�T P�mits for c�nstniction wili be issued a m� n�mm+ of 24 hours from the time of application to alldw for propex review of the prop� structure and of the c�nstruction site. A Cextificate of S�nvey of the lot, shawirig the Iocation of the faundation or�e it has it has been constructed will be required before proceeding with the framing. ,., • , ;, - -�,:,. ; ,, . . .., , � . . f .;;, .. . �i . .�.. _ � _ ,� sua�ecr P O. City of Fridley 20047 AT THE TOP OF THE TWINS g U I L D I N G P E R M I T r � � O. i 1 V � COMMUNITY DEVELOPMENT DIV. � � ��r r � � PROTECTIVE INSPECTION SEC. �� i � ' /"'1 � CITY HALL FRIDLEY 55432 NUMBER FiEV. OATE PAGE OF APPROVED BY �"'"� � ,�� 612-571-3450 910-F15 8/9/89 / / JOB ADDRESS 7401 Concerto Curve N. E. 1 LEGAI LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. �-3 3 Melody Ma.nor 3rd Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Ranae Laxson 74Q1 Concerto Curve N.E. 786-5222 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICE SE NO. Jack �i�ley Sweeps Inc. 4179 - 14�th Avenue N.H1'., Andover 55304 422-048� 4 ARCHITECT OR DESIGNEH MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO. 8 USE OF BUILOING ' RES 1 C�P•Ilt].��. 7 CLASS OF WORK O NEW ❑ ADDITION ❑ ALTERATION � REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reline �'i:�epla,ce chi:mne�r 9 CHANGEOFUSEFROM TO STIPULATIONS � SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, �PE OP CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTIIATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 80 OAYS, 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 PAqKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION STALIS 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 COMPLIEO $1,432 $•%2 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT 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 PEfiFORMANCE OF CONSTRUCTION. S3S.00 PLAN CHECK FEE TO7AL FEE $35.72 SIGNATURE OF CON i RACTOR OR AUTMORIZED AGENT IDATEI WHEN PROPERIY V IDATED THIS IS YOUR PERMIT � „ - � U � SiGNaTURE OF OWNER iiF OWNER BURDERi �DATE� �BLDG iNSP ' � � qAT � [ ] , Effective 5/1/88 � [ l I�1 AND I�2 �T� [ ] Building Permit Application cao��.� �• -- "� � � 1 �� . e�-+-� C�v�- Isgal Descriptia�n: [ �7- r Owrier Name & Address: �� ,,. as.� �o,.ar'.f � 1e� Z�e1. # �� '.�oZ .2 2 c:ontractor: _ _ J �ss �i,cl f�v�S %ti c T�1. # �}.Z 2 —0 �'� I � . Addres.s: LI�TII�G AREA: Q�iR�GE ARE'�i: DECR AREA: ORR�R: Attach to thi.s application, a Certificate of SuLVey of the lot, wi.th the pro�o�ed oonstruction drawn on it to scale. Ler�th Ie.tx�i Ieng�i .;:�_ «. �:�� ,, �1_ width Width Width Height Heic�t �/� Sq. Ft. Sq. F't. �• �- Corner Iot [] Inside Iot [] Ft. Yd Setbaalc . Side YaYdd�etbacJss Z'YI� of ��Ctian: �� .e. -F rj�,,� Estinrated Cost: $ �f Approx. ck�npletion Date: ,�.G . c�'� � �'7�0?. Proposed Driveway Width If New Qp�xiit�g Is Desired: Ft. $ $ , Width + 6' See ffic3c Page n�: . S� �R �r�c�r: l Te1. # �fi2z —o � �'l/ C.LTY DSE �II,Y Piermit Fee $ �S . G� O State Surci�arcJe $ , '� � SAC Chazge . $ Driveway Escrvw $ Park Fee $ Sewer Main Q�zrge $ •w ��: $ �� Fee Sc�iedul.e an Rever�.,e Side $. 50/$1, 000 Valuatioai $575 per SAC Unit Alt. °A" or Alt. "B" 1�bove Fee De�termined bY II�git�eesir�g Ag�+e�ent NeoessarY L] Nort Nec��ssar'Y [] �� ; ► 1, � �� i:�� ,_ �:�;.��y ;��+- :��:i�+�_�1 The Chief Huzldit�g Official shall, before issuing ��;ts for the erec.�tion of ar�y building or stnicture, or for any addition to arYy existing building or structure, or for any alteration or repair to any existir�g building or sttucture, upon application therefore, requ,ire the payment by the applicant for suc�i ��++i t of fee.s to the amaunt herein below set forth and in the mannPS herein provided to wit: Z�OTAL VALUE $1 to $500 $501 to $2,000 $2,001 to $25,000 $25,001 to $50,000 $50,001 to $100,000 $100,001 to $500,000 �+�. $15 (Miri�aa Fee is $15 plus surcharge) $15 for fixst $500 plus $2 for each additional $100 or frdCtiaai thereof, to at�d inCluding $2, 000 $45 for first $2,000 plus $9 for each additional $1,000 or fraction thereof, to ar�d including $25, 000 $252 for fiYSt $25,000 plus $6.50 for each additional $1,000 or fractiaaz thereof, to and inclwding $50,000 $414.50 for first $50,000 plus $4.50 for each additional $1,000 ox'frdcti� theraof, to and including $100,000 $639.50 for first $100,000 plus $3.50 for each additional $1, 000 or fraction thereof, to arid includitig $500, 000 $500,001 to $1,000,000 $2039.50 for the first $500,000 plus $3 for each additional $1, 000 or fraction thereof, tfl arid inclucling $1, 000, 000 $1,000,001 arid up $3539.50 for the fitst $1,000,000 plus $2 for each additional $1,000 or fraction thereof D[tIVE'i�lY �P�SI�T ffiCE�OW (Ooncrete Curb Streets On1Y) L Alternate ��A�� ; Remaval and replaomoent of curb ar�d gutter only - Driveti,ray width plus 6 feet times $13.50. Alterr�ate "B" : R+emaval and replaoe�aent of cxirb ar�d gutter arid install a 3 foot wide approach with 6 inch depth - Driveway width plus 6 feet times $15.75. � :�• .� � .; .�- �.�� .. .� P�ermits for wnstruction will be issued a m�*+��m+ of 24 haus froaa the tiaie of application to allaw for prc�er review of the praposed structure and of the oonstnickion site. A Certificate of S�rvey of the lot, showirig the location of the fatuxiation orioe it has it has been van.stYUCtsd will be required before prooeeding with the framing. 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Z m m a w a � 7 f C � � � DTI�c 0 3 a � � � m N �� m m � � a � v m � � O � W c � m � � � � � o � o o �o w °o °o o °o m � � � � � � @ Q D � o� r �,, m � � � m v n 0 � � � N 0 0 0 0 � m � � Z � a' � � � ao v z � c � m v �n � � � d C') N � � N � '*=o �� c �, ,� m s m .. � m � � � > > a -» � y a ^ � y � � b � � =+� t% � � a m � � � C. � a o, io m c��u m °, m• c. 'C ..► � �G y � O � � � a � .o W� a � N � y � i '�a � � � � < a ° H � � .� �, � � � O y ? �j � '��mO� o�. a °. .:. N F1 � � O �� A � ? N� p� � m :+ m mn ? O � � � cc co � � m n _m C iil � OOD a v v v � 0 � c� O n m n r+ 0 C'� � N z � � � n V �. N p, W � � � �� C � � Z � � N � �,� v r m N � � Z z. m� '0 n� --I Z � � � C �p r �' a m � aZ Z � � � z � vo v_� �m �� o� vZ � N O� Z Z �v � -Ni Z �� D Z v� C � n< mZ �� Z � m m 0 � � c � � j �D t0 j � c CHIMNEY AND BTACR VERIFICATION The undersigned hereby verifies that the existing chimney or stack: l. Has been carefully examined Yes �c) No () 2. Is free from rust or deterioration Yes ('� No () 3. Has no foreign objects lodged within Yes (x) No () 4. Is securely supported Yes ( x) No () 5. 2ieets all current Cos3e �ec�:irements for size and total BTU's connected Yes (� ) No () 6. Has total he�ting BTU' s of $0, 000 All other BTU's TOTAL BTU' s 80, 000 Remarks ___ List Alterations Beinq Done: HEATING COMPANY Signed By Date � t� ��is �_I�., n�. � ,� Cicn V�I�:�!p ti��i,. . t1�� ;� - '� �','2St i�fU�!,�!'.'?1' ,,� r. �,.;��-�J(li�. sua�ecr NO. City of Fridley 3 3 3 01 AT TFIE TOP OF THE TWINS g U i L D I N G P E R M I T � ; � REC�EIPT NO. � ; v __��_ COMMUNITY DEVELOPMENT OIV. r � � PROTECTIVE INSPECTION SEC � � . � i---.� ��'�' �'� CITY MALL FRIOLEY y�132 NUMBER pEV OATE PAGE Oi AVpR /EO Br L 763-571-3450 9t0-F15 12/19/02 / / JOB ADORESS 7401 Concerto Curve NE 1 LEGAL ��7 NO. BLOCK TFiACT OR ADDITION SEE ATTACNED oesca. 13 3 Melody Manor 3rd SNEET p PFOPERTY OWNEq MAIL ADDRES$ ZIP PMONE David Cluelow 7401 Concerto Curve NE 763-785-7931 3 CONTRACTOR MAIL AODRESS ZIP PHONE LICENSE NO Twin City Exteriors 9060 Zachar Lane N Ma le Grove mN 55369 763-425-47 7 a ARCHITECT OR DESIGNER MAII ADORESS tIP PMONE LICENSE NO 2535 5 ENGINEER MAIL AODqESS tIP PMONE LICENSE NO 8 USE Of BUILDING Residential 7 CIASS OF WOIiK O NEW ❑ ADOITION O ALTERATION _p REPAIR ❑ MOVE O REMOVE X 8 DESCRIBE WCRK Reside House & Garage 9 CHAN(iE OF USE FROM TO STIPULATIONS Per Section 1402, 1997 Uniform Building Code, requfres that a weather resistive barrier be placed over exterior sheathing to protect the interior wall covering. Exceptions for this provision wou�.d be if sheathing is an approved weatherproof panel or when the siding is an approved weather barrier. Vinyl siding is not a weatherproaf coeering uniess the manufacturer states �his in their application guide'�ines. CalZ.for inspection of wrap before covering. Caulk a.r.d ��.ash alI exterior openings. SEPARATE PERMITS ARE fiEQUIREO FOR ELECTRICAL. PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCV LOAO VENTI�A7ING OR AIR CONOITIONING THIS PERMIT BECOMES NULL AND VOID IF WORK OF CONSTRUCTION 20NING S�. FT CU FT AUTHOR12E0 IS NOT COMMENCED WITHIN 80 OAYS. OR IF CONSTRUCTION OF1 WORK IS SUSPENDED OR ABANDONED FOR A PERIOO OP 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO DWLG. UNITS OFFSTREET PARKING 1 MEREBY CERTIFV THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES AND KNOW TNE SAME TO BE TiiUE AND CORRECT. ALl PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TVPE OF WORK WILL BE COMPLIED WITM WME7MER SPECIFIEO MERE�N Ofi NOT. TME GRANTING OF A VERMIT �$s4OO ��F.ZO DOES NOT PRESUME TO GIVE AUTHORITY TO VIOIATE OR CANCEI TME pEf1MIT fEE SAC CMARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING coN• �167.ZS Fire SC y�8.4O STRUCTION OR TNE PERFORMAN f CONSTFUCTION PLAN CNECK f TOTAL FEE . Lice e $ 0 $184.85 S� TUAE 0� LON'RACTOp Op �2E0 GENT IDAT i NE Pp � LV V ATED T►+iS IS �� / L S�GNATUAE O� OWNEp�� OWNEpBWIDEpi �DATE� 6 OG � �� . �� N� [ l ADDN [] ALTER [ ] Construction Address: Effec6ve 1i1/2000 CITY OF FRIDLEY (763) 572-3604 Bldg Insp SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Legal Description: �Lte� �c6c.� Owner Name 8� Address: �A.,�%1!� �� )� L�G� j�iyl� � Tel. # r%�3'%g •'%93� Contractor: TWIN CITY EXTERIORS MN LICENSE# 2535 Address: 9060 ZACHARY LANE N, MAPLE GROVE, MN 55369 Tel.#763-425-4737 LNING AREA: GARAGE AREA: DECK AREA: Attach to this application, a Certificate of Survey of the Iot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT Length Width Height Sq. Ft Length Length Width Height Sq. Ft. Width Hgt/Ground Sq. Ft. OTHER: OD ...._ Construction Type: �" $/�� Estimated Cost: $ Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$ DATE: �� / APPLICANT: T/�i ��,�� S Tel. #,_,Z� •9e�5 �ji%3 % CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application Permit Fee $��5 Fee Schedule on Reverse Side Fire Surcharge $ g, _Q_ .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee $ $1100 per SAC Unit $ $5.00 (State Licensed Residential Contractors) $ Alt. "A" or Alt. "B" Above $ $450.00 Conservation Plan Review $ Fee Determined by Engineering Sewer Main Charge $ Agreement Necessary [] Not Necessary [] TOTAL STIPULATIONS: ✓ • . • BUILDING PERMIT F�E SCHEDULE The Chief Building Official shall, before issuing permits for the erection of any building or structure, or for an� 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 hereic below set forth and in the manner herein provided ta-wit: TOTAL VALUE $1 to $500 $501 to $2,000 $2,001 to $25,000 $25,001 to $50,000 $50,001 to $100,000 $100,001 to $500,000 $500,001 to $1,000,000 $1,000,001 and up FEES $23.50 $23.50 for first $500 plus $3.05 for each additional $100 or fraction thereof, to and including $2,000 $69.25 for first $2,000 plus $14.00 for each additional $1,Q00 or fraction thereof, to and including $25,000 $391.25 for first $25,000 plus $10.10 for each additional $1,000 or fraction thereof, to and including $50,000 $643.75 for first $50,000 plus $7.00 for each additional $1,000 or fraction thereof, to and including $100,000 $993.75 for first $100,000 plus $5.60 for each additional $1,000 or fraction thereof, to and including $500,000 $3,233.75 for the first $500,000 plus $4.75 for each additional $1,000 or fraction thereof, to and including $1,000,000 $5,608.75 for the first $1,000,000 plus $3.15 for each additional $1,000 or fraction thereof DRIVEWAY DEPRESSION ESCROW (Concrete Curb Streets Only). Alternate "A": Removal and. replacement of curb and gutter only - Driveway width plus 6 feet times $15.50. 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 $23.25. V�RIFICATION 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 constraction 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. New Houses Onlv SUBJECT City of Fridley AT THE TOP OF TNE TWINS g U I L D I N G P E R M I T � � � � � � • COMMUNITY DEVELOPMENT DIV. � � �: - --- r � � � PROTECTIVE INSPECTION SEC. � j �"'1 � CITY HALL FRIDLEV SS�J2 NUMBEF AEV OATE �'""� � �'' 763-571-3450 910-Ft5 10/6/03 lOB AODRESS 7401 Concerto Curve NE A TI N v�GE os / / 3943 � ;EIPT NO. APPROVEO BY 1 LEGAL LOT NO. BLOCK TRACT OR DDI O SEE ATTACNED oesca. 13 3 Melody Manor 3rd Addition SHEET 2 PROPERTY OWNEH MAIL ADDRESS 21P PMONE David Cluelow 7401 Concerto Curve NE 612-865-`6898 3 CONTRACTOIi MAIL ADORESS ZIP PHONE LICENSE NO Roof Design Partners 4026 7 St NE, Columbia Heights, MN 55421 763-789-6566 4 ARCNITECT OR OESIGNER MAIL ADDRESS ZIP PMONE �ICENSE NO 20004817 5 ENGINEER MAIL AODqESS ZIP PMONE LICENSE NO 8 USE OF BUILDING Residen�ial 7 CLASS OF WORK O NEW � ADDITION ❑ ALTERATION �7 REPAIR O MOVE O REMOVE 8 DESCRIBE WORK Reroof House & Garage,(25 Sq), Tear-off 9 CHAN(iE OF USE FROM STIPULATIONS TO Underlayment must comply wi�h the State Building Code. TYPE OF CONST. SEPARATE PERMITS ARE REOUIRED fOR ELECTRICAL. PLUMBING. HEATING, VENTI�ATING OR AIR CONDITIONING THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION 20NING AUTNORIZEO IS N07 COMMENCED WITHIN 80 DAYS. OR li CONSTpUCTION OR WORK IS SUSPENDED OR ABANOONEO FOF A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO DWLG. UNI I MEfiEBY C TIFV 7HAT I MAVE READ AND E%AMINED TMIS APPLICATION 1 AND KNO TM SAME TO BE TiiUE AND CORRECT. ALl PROVISIONS Of LAWS ypLUATION ANp OR NAN ES GOVER G THIS TVPE OF WORK WILI BE COMPLIEO 2 g94 W�TH W E7ME SPECIFIE REIN OF NOT. TME GRANTING OF A PERMIT �� DOES N 7 P ESUME TO GI AUTMORITY TO VIOLATE Ofi CANCEL THE pEqMIT FEE PROVISI NS F ANY O M S7ATE Op LOCAL lAW REGULATING CON- @ STRU ON� F TNE PE O ANCE OF CONSTRUCTION 'P83.2S OFCON'AACTOAOM4UTNORiZEDsGENi IOATE� �OA�E� SO. STA�LS Licen e SC $5.00 EN PROPERLY Vi B G �hSo _ z' OCCUPANCV CU fT )FFSTREET PARKING IGARAGES SURTAX $1.45 SAC CMARGE Fire SC $2.89 �OTALFEE $92.59 ) 7M15 IS VOUR PERM17 NEVIN [ ] ADDN [ ] ALTER [ ] CITY OF FRIDLEY Effedive 1/1/2003 6431 University Ave NE, Fridley, MN 55432 (763) 572-3604 Bldg Insp SINGLE FAMILY AND DUPLEXES R-1 AND R-2 (763) 571-1287 Fax BUILDING PERMIT APPLICATION Construction Address: �`�fl� �.v�t�� .r�� Legal Description: Owner Name & Address: ��1� � fu�/oc.� Tel. # fof��'f�- �,��' Contractor. �t �c��.�� MN UCENSE # �� i Address: ��, � � � /�. Tel. # 7�3-7�R- (o�o� LIVING AREA: GARAGE AREA: DECK AREA: OTHER: Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT Length Width Height Sq. Ft. Length Length Width Height Sq. Ft. 8 und Sq. Ft. Constnaction Type: �►.� Estimated Cost: $ . ° oS O�'y Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$ DATE: I � ° �° �� APPLICANT: �� = �� Tel. # ��'`'J` ' �`�' (051� Call (763) 572-3604 for PeRnit Fees if mailing in application. Fax to 763-571-1287 if using credit card and we will call you for card number. Permit Fee Fire Surcharqe State Surcharge SAC Charge License Surcharge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge TOTAL_ $ ��5�' $ �.ga�i° $ � �S �. $ $ �. O6 $ $ $ $ $ o?, S CITY USE ONLY - Fee Schedule on Reverse Side .001 of Permi� Valuation (1/10th%) $.50/$1,000 �'aluation $1275 per SAC 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 [ ] ��Il�l��[�7��i : illil�l�( ' �: ulYli�l�lx.�y:l�1 1 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 applicaxion 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,�0 $2,001 to $25,000 $25,001 to $SO,OOQ $50,001 to $100,000 $100,001 to $500,000 $500,001 to $1,000,000 FEES $23.50 $23.50 for first $500 plus $3.05 for each additional $100 or fraction thereof, to and including $2,Q00 $69.25 for first $2,0� plus $1�.00 for each additional $1,000 or fraction thereof, to and including $25,0� $391.25 for first $25,000 plus $10.10 for each additional $1,000 or fraction thereof, to and including $50,000 $643.75 for first $50,(m0 plus $7.Q0 for each additional $1,000 or fraction thereof, to and including $100,000 $993.75 for first $1�,000 plus $5.60 for each additional $1,000 or fraction thereof, to and including $500,000 $3,233.75 for the first $SOO,U00 plus $4.75 for each additional $1, 000 or fraction thereof, to and including $1,000,000 $1,QQ0,001 and up $5,608.75 for the first $1,000,000 plus $3.15 for each additional $1,000 or fraction thereof cuxs=c�rr Escxow (Concret� Curb Streets Only) Removal and replacement of curb and gutter only - driveway width plus 6 feet times $17.�. 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. VERIFICATION OF FOUNDATION A Certificate of Survey of the lot, showing the locaxion of the existing founda.tion will be required before proceeding with the framing. New Houses Onlv CITY OF FRIDLEY 6431 iJNIVERSITY AVENUE NE FRIDLEY, MN 55432 57"L-36U4 1+'AX: (7631571-1287 � __--__ � ' � e� PERM T NO.: 2004-00956 � , DATE ISSUED: 06/21/2004 ' ADDRESS : 7401 CONCERTO CRV NE PIN : 113024130085 LEGAL DESC : MELODY MANOR 3RD ADD : LOT 13 BLOCK 3 PERMIT TYPE : PLUMBING PROPERTY TYPE : RESIDENTIAL CONSTRUCTION TYPE : ADDITION/ALTERATION VALUATION : $ 400.00 NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC CHAPTER 6 AND TABLE 6-A. INSTALL A GAS WATER HEAT'ER. # ELEC WATER HEATERS 0 VALUE OF FIXTURE/APPLIANCE 0 # NEW FIXTURES (EXIST OPEI�TINGS) 0 # GAS WATER HEATERS 1 # GAS DRYERS 0 # GAS RANGES 0 # OF NEW FIXTURES 0 # WATER TRMT APPLIANCES 0 APPLICANT NORBLOM PLUMBING CO 2905 GARFIELD AVE S MINNEAPOLIS, MN 55408-2173 (612) 827-4033 OWNER CLUELOW DAVID M& JEAN E 7401 CONCERTO CRV NE FRIDLEY, MN 55432 AGREEMENT AND SWORN STATEMENT This permit becomes null and void if work or construction 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 applicarion and l�ow the same to be true and correct. All provisions of laws and ordinances governing this type of wor� 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 co u ion or the performance of construction. Applicant �� Date a Bldg � PLBG PERNIIT 1�4INIMiJM FEE PLBG FIXTURES (NEW OPENII�TGS) PLBG FIXTURES (EXIST OPENII�TGS) WATER TREATMENT APPLIANCE WATER HEATER - ELEC WATER HEATER - GAS GAS RANGE FEE GAS DRYER FEE PLBG REPAIlt/ALTERATIONS STATE SURCHARGE, PLBG FLAT TOTAL PAID WITH CHECK # 28495 0.00 0.00 0.00 0.00 0.00 35.00 0.00 0.00 0.00 0.50 35.50 c� � � C � O Z D � D r r � m -o � � � m 0 -� m � c n � m � O z cn 0 .p .-. D Z v D � r m rn ,D � i � � �.1LUi � �nl � � � a: rn � c n � n� cc fD � � D v � < m n � � O _ � s � 0 °.' N � w v n� � .� � m r� N 0 o =� °,m= ni c�n � � � z m o v �, �Oo �. � o c�u m0 = o � � -a � v � � v r --I m � 0 Z � `�G a m a y n y � v � m � � m m � m � c, m n � m N .-. Z I0 ni Z y rt m � � _ � � c� � • � � � �� c d ci o m Q m` (��D (�rtD � � � � '�' Q � � p Q -v � �. � �D � �i rn � W '�a � �� z• r. � N N co N m� `� c��u' � � `Z° � � d � � � � �' � �; � � � m I—I � �� w w w � � � � � � � c�, o o� w cn o 0 0 0 0 0 0 o ;o 0 0 0 0 0 0 o c c o 0 rs •c o 0 0 0 0 0 0 0'0 0 0 � � � r Z C m � v °D W Z � � � m -_�i � m v n 0 � � a � �U � m � � =i z O � � ��n i � �� i � � '.. W C 0 z � c � m v � Z Q- � n N m m 2 �► � � I� � N� � m m N. o -, � v -n V C� '" � � �o�c m �' a. r m � s Y'�Z� W � � o�� Q a � wzm0 �' 0 `G -' � %� D �G N �W"oo o � � N � y. O �p . �- N m > > '°�v z m y �°– � a � �i i ? u o �rt � A�7 � � � O O a ni � � � � °1 � � — —� N � � Q- o o � � � � � a� c, m � � � `� o o i� �Q �• Q �. - N y � O � � � r= C � � Z G� � � C � m � m � Z O � m O D r L � W � o FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS COMMON VENT. VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When replacina an existinct 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 O The venting system is plastic/PVC and meets ail current codes and manufa�turer 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 Fumace Venting Tables for fan assisted and natural draft appliances. The existin�a combustion air is sized and installed to meet the current codes and manufacturer's specifications. 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 ( ) Yes ( ) NQ ( ) Yes ( ) No ( ) When installina a new ventina svstem, the undersigned hereby verifies that it is a listed assembly and meets the current codes and manufacture�'s specifications: This does include AGA-GAMA Category I Central Fumace 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 O No O Aqpliance Tvpe and Size/Common Vent and Vent Connector Information Appliance #1 Type BTU Input Fan Assisted or Nat Appfiance #2 Type BTU Input Fan Assisted or Nat App�iance #3 Type BTU Input Fan Assisted or Nat �otal ApP4iarac�s - — T�tal Btu Inou# _ - _ 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 :