AF - 39484sue�ecr PERMI
City of Fridley ° 16 8 8 4
' ` AT THE TOP OF THE TWINS g U I L D I N G P E R M I T CEIP .
r
� 1 v_.__ COMMUNITY DEVELOPMENT DIV. 3 1
'"' J
r � � PROTECTIVE INSPECTION SEC. S a3
1 . �
� � /"'1 � CITY HALL FRIDLE� SS432 NUMBER REV. OATE PAGE OF APPROVED BY
�----� • •�� 612-571-3450 910-F15 12/22/82 � �
JOB ADDRESS 5415 East Brenner Pass N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. Ej 12 Innsbruck North Townhouse Plat G SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Darrel A. Faxr �velopment Corp. 4600 Lake Road, Robbinsc7ale 55422 536-9936
3 CONTRACTOR MAII ADDRESS Z�P PHONE LICENSE NO.
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK •
O NEW ❑ ADDITION 0 ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X
8 OESCRIBE WORK
Construct an 18' x 28' Townhouse Unit C"$")
9 CHANGE OF USE FROM TO
STI PU LATIONS
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING. WQOCI Fr�E
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT. CU. FT.
AUTHORI2ED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VAI.UATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED $33, 750 $�-E'•88
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- $2].]..00 $425.00
STRUC ON OR HE PERFORMANCE OF CONSTRUCTION.
e � PLAN CHECKFEE TOTALFEE
r'� �� -�� None $652.88
SIGNATUPEOfCONTRACTORORAUTHORIZEDAGENT IDATEI EN PRO E V LI TED THIS IS YOUR PERMIT
e e �� ''lT6O �
SIGNATUREOFOWNERIIFOWNERBUILDERI IDATEI BLOG INSP �ATE
CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL BUILDING PER��ITS
�NEW, ALTERATIONS, ADDITIONS, OR REPAIRS). _
OWf7ER: DARREL A. FARR DEVELOPMENT CORP . gUILDER:- S�
Address: 4600 LAKE ROAD' Address: �
R ,
- Tel. No.: 536-9936
1Jo.: 5415 Street: East Brenner Pass
LOT: 6 BIACK: 12 ADDITION:
6th
CORNER LOT: X INSIDE IAT: SLTBACKs SIDEYARDS:
Applicant attach to this form 7.tao Certificates of Survey of Lot and pro,�osed
building location drawn on these Certificates.
To Be Used As:
DESCRIPTION OF BUILDING
nBn .
HOUSE Front: 18 Depth: 28 Height: 28
� Square Feet: 1332 Cubic Feet:
. �, — -
Front:
Depth:
Height:
Square Feet: C�bic Feet:�
Zj►pe of Construction: WOOD FRAME Estimated Cost: $ 32,250
Zb Be Completed: June 1983
Proposed Driveway Width If New Opening Is Desired
Alt. A Alt. B
$ $ .
(SEE REVERSE SIDE OF SHEET) .
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City of
Fridley�Ordinances and rulings of the Department of Buildings, and hereby
declares that all the facts and representations stated in this application
are true and correct. See reverse side far additional information.
DATE: Z 0 SIGNATURE:
Stipulations: .
i-
�
sue�ECr PERMIT NO.
City of Fridley _ 1 3 9 8
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T �
�
� � RECEIPT NO.
� `y _____ COMMUNITY DEVELOPMENT DIV. �'��
r j � PROTECTIVE INSPECTION SEC.
1 . �
1
l--_- A �����,•� CITY HALL FRIDLE� 55432 NUMBER REV. DATE PAGE OF APPROVED BV
i �� 612-571-3450 9t 0-F15 1/17/84 / /
JOB ADDRESS 5415 East Brenner Pass N. E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED.
DESCR. S 12 Innsbruck North Townhouse Plat 6 SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
Daxrel A. Faxr Development Corp. 460.0 Lake Rd. Mpls. , NIl�t 55422 536-9936
3 CONTRACTOR MAILADDHESS ZIP PHONE LICENSENO.
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS Z�P PHONE LICENSENO.
6 USE OF BUILDING
Residential Townhouse Garage
7 CLASS OF WORK
O� NEW O ADDITION ❑ ALTERATION ❑ REPAIR � MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 1Q' x 22 �. Ga�;age
9 CHANGE QF USE FROM TO
STIPULATIONS
' ' TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
SEPARATE PERMITSARE FEQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING. �OOd FrdT�e
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOF A PERIOD OF 120 DAYS AT 22O ZZOO
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTFEET 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 $2 � 349. GO �`1. 1.%
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLV�TE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- 38.50
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. �
PLAN G-IECK FEE TOTAL FEE
'� � - � � / �T, �',� $39. 67
�
`SIGNATUI�EOFCONiRACTOROAAUTNORIZEDAGENT �DATEI WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
s e
SIGNATUREOF OWNER iIF OWNER BUILDERi IDATEI BLDG �NSP �A E
�
Effective r�ag, l� 1381
CI i t J1' �ItIDICY '
• �f'i'LICnTla� FO(t �'LSIDLilT1P.� I3UlLDl�:G PLf��1TS
(Nc�•�, nl terativns. �iddit��ns, or �crairs) .
�F�trER: Darrel A. Farr Development Corp. '�UILDkR: SAME
�DJi:ESS: 4600 Lake Rd. Mpls., MN 55422 �iDDiZCSS:
YEI�. �`�0: 536-9936 TEL IdO:
�onstruction Location
��.�� �p. • 5415 ���p;�; East Brenner Pass
�o� : 8 �a�oc�c: 12 �oni�io:i: 6th
Corncr I.ot: Y�siric S�t: A �etbaci:: Sideyards:
Ap, lae�lnt a�tach 4� this �orsm t�.�o Ceztificates of S1�rvcy of lot �nd
g�_oposed building locaticn dro:+n on ccrtificates to scdle.
DESCRIPTIO„ OF CO;:ST};UCTIOt�
Garage F�ont: 10 �epth: 22 Neight: 20
Squarc �'c�t: �bic Fcet:
Front: Depth: Heigl�t:
Square Fcnt: Ctibic 7'�et:
:��pe of Co.:structicn: Wood Frame Estimated Cost: S 1-8QQ`_
.,� �„ r,.,� �, „�0,�, January 1984
Alt. A A1 t. B
pro�s�d Dzive+�ay Tni�t� If �cna Ogening Is D�sf�ed: $ S �
, SLL PiVFFLL' SIDi OF S}IFST .
'ii¢� undcrsigncd hcreb.� :r��l:�� a��plic�ticr► foz a p�rrit fcr tt�e �ozk hcreSn sp�cificd,
�greein3 to c�o .all aork ir� strfct accozd.�rice yith �he Ci�y of I'ridle�• Ozdii�ances z�ici
zulin�� of tl�e Dei�.�rtsne��t of d3ui:din�s, and heseby �iecl�res that all tl�c tact� and
�epre�c�6.�itacns s�.a�c•d :n f.}�zs �ppbic`tion are. tru� z�nd corrcct.
D`T�: j,=17-gy SIC�1A°I1)T�: ��^�' � �/�
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-,-_-- �
sue�ecr PER _
City of Fridley 2 0 6 6 4
' , AT THE TOP OF THE TWINS g U I L D I N G P E R M I T pT N
r
� �
� • COMMUiJITY DEVELOPMENT DIV.
r � V � PROTECTIVE INSPECTION SEC. 3� y D�
1 ` �
� �'�'1 � CITY HALL FRIDLE� 55432 NUMBER REV. OATE PAGE OP APPROVED 8V
�'""'� � �'� 612-571-3450 9t0-F15 11/9/'90 / /
JOB ADDRESS 5415 East Brenner Pass
t LEGAL �OT NO. BLOCK TRACT OR ADOITION SEE ATTACHED
DESCR. 6 12 ]hnsbruck North_ Townfiouse Plat 6 SHEET
2 PfiOPERTYOWNER MAILADDRESS ZIP PHONE
Mark Schmidt 5415 East Brenner Pass 571-6439
3 CONTRACTOR MAIL ADORESS ZIP PHONE LICENSE NO.
Kimlinger Construction 695Q Bxooklyn $lvd., Brooklyn Center, MN 560-1823
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDFiESS Z�P PHONE LICENSENO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW � ADDITION [� ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Finish Basement family x'oom
9 CHANGEOFUSEfROM TO
STIPULATIONS pmvide smoke detectors on a11 le�els of house. Provide outside
comYaustipn air to existing �urnace.
SEPARATE P�R��I�S �������ED Fp�
WiRif�G, �-lEATiP1P(;, ���a"�j�liVG At41� SiG
NS.
TYPEOFCONST. OCCUPANCYf3ROUP OCCUPANCYLOAD
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATINO,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOIO IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED 1S NOT COMMENCED WITHIN 60 DAYS, OFi 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
1 HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION STAILS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PFiOVISIONS OF LAWS VALUATION SURTAX
AND OF;DINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIEO
WITH WHETHEFi SPECIFIED HEHEIN OR NOT. THE GRANTING OF A PERMIT $5,150 $2, S8
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION O THE PERFORMANCE OF CONSTRUCTION 58�.•OO
PLAN CHECKFEE TOTAIFEE
,��� .� I — ( � '� % � ire SC $5.15 $88. 73
SIGNATUREOFCONTRACIORORAUTNOii12ED GErvT IDATEi WHEN PROPERLY V IDATE THIS IS YOUR PERMIT
. �' = � l / ( �
SiGNATUREOFOWNER�iFOWNERBUI�DER1 IDATEI � BLOG �NSP IATE
� [ ] Effective 8/16/90
� [ ] I�1 AND i�2
AL'I�t [ ] Buildiu�g P�mit Applicatio�
�• � —i+t � • � :•:. ��
r�egal D�scrip�tion:
�T�� �
% �- , � , /.�2 . /N � �S
, / T7 V+ 1
a�r rr� & �,ar�: __ f'� �I�K S G�, ��,OT" �. # .S'�/— � 5�3�
c�ontractor: �,�/ � �� � °G1� �cC S772Pi r1�i(� Tel . # �� � --/��- J�
.
.r �..
AI
Attach to this ap�plicatioai, a C�rtificate of SuYVey of the
lat, with the propo�-.�ed o�ruCti� drawn on it to scale.
• � �,,ia;.•����.���±��
LIPaIG AREA: IPSigth Width Height Sq. Ft.
C�,RA�GE AREA: Lexigth Width Heic�t Sq. Ft.
D�ECK AREA: T p* �'h Width iigt/Grv�u�d Sq. Ft.
O�: I- i v� i�� �i4 Y�1 �� � D� .1_�1 �% ( �'�.�/ ����1�
Oorner Io�t [] Inside Iot [] F't. Yd Setback Si.de Yard SetbacJ�
�'pe of Construction: Estimated Cost: $ ��/�
Approx. CJa�pletion Date: pec, �T�90
Propose�a Driveway wiatn If rT�w � Is nesir�a: Ft. S S
Width + 6' See Back Page
n�: o V 6 — � �rc�,rrr: ' ` �. # �� o —I a-� �
Pexmit Fee $
Fire SuYrllarge r� e � �
State S�rchar9e $ �
SAC Charge $
Driveway Fscraw $
Park Fee $
Sewer Main Ct�arge $
� $ '�3
!�
��
CITY IISE C�,Y
Fee ��ie a�n Reverse Side �/'J� I,
.001 x P�mit Valuation (1/lOth %)
$.50/$1, 000 Valuation �� �'� �°��
$600 per SAC Unit ��j �
Alt. nAn oZ' Alt. ngn Abc3ye Q` �, i� �
Fee Det,e�r�mitled bI' �l��'�1 �
Agre�rent Ne�ssaty [ ] Nat Nec�essary [ ]
�. ��
� P � �. � �
� �'� �
��
:?�1� � ■�� i�•.+v�� ° r° _ �:i���
Zhe Chief Building Official shall, before iss�*+� permits for the exection of ariy
,; 7 ding or structure, or for any addition to ariy existirig building or stnicture, or
for ariy alt�.r-ation or repair to ariy existing building or structure, upon application
therefore, require the paym�nt by the applicant for such �*�++; t of fees to the a¢n�nt
herein below set forth arid in the manner herein prwided t�o-wit:
� TO►I'AL 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 (Mininnnn Fee is $15 plus surrhaYge)
$15 for first $500 plus $2 for each adciitional. $100 or
fraction thereof, to ar�ci iricluding $2, 000
$45 for first $2,000 plus $9 for each additional $1,000
or fraction thereof, to arid including $25,000
$252 for fiYSt $25,000 plus $6.50 for each a�ditior�al $1,000
or fraction thereof, to and includirig $50,000
$414.50 for fixst $50,000 plus $4.50 for each additional
$1,000 or fraction thereof, to and including $100,000
$639.50 for first $100,000 plus $3.50 for each ac'�ditional
$1,000 or fraction thereof, to arid including $500,000
$500,001 t.o $1,000,000 $2039.50 for the first $500,000 plus $3 for each additional
$1,000 or fraction thereof, to arid includirig $1,000,000
$1,000,001 and up $3539.50 for the first $1,000,000 plus $2 for each additional
$1,000 or fraction thereof
DRIVE�Y DEPRE.SSION ESCI�UW
(Concrete Gvxb Stre.ets On1Y)
Alternate "A": Removal and replacement of cutb and gutter only - Driveway width plus
6 feet times $13.50.
Alternate "B": Removal ar�d replac�nent of curb and gutter and install a 3 foot wide
a�roach wi.th 6 inch depth - Drive�ray width plus 6 feet times $15.75.
. � a. ����. ; M .��1
P�ermi.ts for oarLStruction will be issued a minim�un of 24 hwrs frcen the time of
a�lication to allow for proper review of the praposecl structure and of the
con�ruction site. �
A Certificate of S�YVey of the lot, sh�wing the location of the foundation once it has
it has been constructed will be required before procx�ing with the fYaming.
,
0
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C� � I OF
FRIDLEY
.
�
FRIDGEY MIJNICIPAL CENTER • 6431 UNNERSITYAVE. N.E. FRIDLEY, MN 55432 •(612) 571-3450 • FAX (612) 571-1287
June 1, 1999
Darlene Huisinger
5415 E. Brenner Pass
Fridley, MN 55432
Re: Final plumbing inspection at 5415 E. Brenner Pass
Contractor: Tschida Bros.
Dear Ms. Huisinger:
A plumbing permit vi►as issued on June 15, 1998 for the property located at 5415 E.
Brenner Pass for a new water heater. According to Section 30.5(a) of the 1991 Uniform
Plumbing Code a final inspection shall be perFormed on plumbing systems. As of this
date no inspection has been called for.
You will be given thirty (30) days from receipt of this notice to respond. If we do not
hear from you, we will expire the permit and any inspections on this installation will
require a new permit.
Any questions can be addressed to myself at (612) 572-3603.
Sincerely,
Barry Riesch
Buirding Inspector
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City of Fridley
AT THE TOP OF TME TWINS
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� �v ����� � COMMUNITY DEVELOPMENT OIV.
r � � PROTECTIVE INSPECTION SEC.
i � ;
� � �"'1 � CITY HALL FRIOIE� 55�32
�""� � ,�� 612-571-3450
SuBJEC�
BU ILDING PERMIT
NUMBEN f1EV OATE' VAGE Of
910-F15 6/27/00 / /
31090
., ..�.. . .....
��� �
APPROVED BY
J08 ADDRESS
5407 09 11 13 15 17 East Brenner Pass
t LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACNED
oescR. 1-6 12 Innsbruck North Toumhouse Plat 6 SMEET
2 PROPERTY OWNER MAIL ADOiiES$ 21P PMONE
Innsbruck Townhome Association �B�cStBg 651-224-5482
3 CONTRACTOR MAIL AOORESS ZIP PHONE LICENSE NO
Garlock-French Roofing Corp., 2301 E. 25th St., Mpls., NIlV 55406 612-722-7125 000014
� AIiCMITECT OR DESIGNER MAIL AODRESS ZIP PMONE LICENSE NO.
S EN(i1NEER
AODRESS
8 USE OF BUILDINa
Residential
7 CLASS OF WORK
O NEW O AODITION O ALTERATION
8 DESCRIBE WORK
Reroof Townhouse Building (Tear Of�
8 CNAN(3E OF USE FROM
STIPU�ATIONS
TO
ZIP PMONE LICENSE NO
O REPAIR O MOVE O REMOVE
Underlayment must comply with the State Bui�ding Code.
���it Inspection Cards
'�li�� �e R�ai��d
�� �i�n�eowner To Post
SEPARATE PERMITS ARE REOUIiiEO FOR ELECTii1CAL, PLUMBING. NEATING. �'r� ��
VENTIIATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOIO IF WOFK OR CONSTRUCTION 20NING
AUTHORQED IS NOT COMMENCED WITMIN BO OAYS. ON If CONSTRUCTION
OF WORK IS SUSPENDEO OR ABANDONEO FOR A PERIOD OF 120 OAYS AT
ANY TIME AFTER WOAK IS COMMENCED. NO. ON
S0. FT
1 NEREBY CERTIFY TMAT I HAVE READ ANO E%AMINEO TNIS ApPLICATION 6 STA�LS
AND KNOW TME SAME TO BE TRUE AND CORRECT. ALl PiiOVISIONS Of �AWS yp�UATION
ANO OROINANCES GOVERNING THIS TYPE OF WOpK WILL BE COMPLIEO . �22 OG%.4O
WI7M WME7NER SPECIfIEO MEREIN OR NOT. TNE GRANTING OF A PERMIT �
DOES NOT CFESUME TO GIVE AUTMORITY TO VIOLA7E Ofi CANCEL TNE pEqM17fEE
PROVISIONS OF ANY OTHER STATE OR �OCAL LAW REGULATING coN. �363. ZS
STRUC710N OR TME PERfORMANCE Of CONSTRUCTION
SiGN�TUAE O� CON'aACTOa Op AUTMOp�2E0 AGEN1
�O�TEi
OCCUPANCVLOAO
CU FT
OFFSTREET PARKING
IGARAGES
SURTAX
$i1.00
SAC CMARGE
Fire SC $22.00
TOTA�FEE
/�396.25
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THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
CnMMnN VFNT� VFNT C(�NNFCT(�R AND .nMF3 1STInl� AIR �/FRIFI ATlnl�
When _rQ la _ing an exictino f�ri ancP, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes () No ()
The venting system is plastic/PVC and meets all cuRent codes and manufacturer
specifications including sizing, length, number of elbows and termination.
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturers specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The Pxist�np come�,�tier, air is sized and installed to meet the current codes
and manufacturers specifications.
When required to in�tau a new �omb ��tien air�it will be sized and installed
to meet the current codes and manufacturer's specifications.
When inctallin8 a nPw v_ntin�,�y� m, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Fumace
Venting Tables for fan assisted and natural draft appliances.
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 ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
Yes � No ( )
Yes ( ) No ( )
Yes( )No( )
_.• .i .- .�• - •uu•� -� .�• -� .��- . � .r��. •�
Appliance #1 Type BTU Input Fan Assisted or Nat
Appliance #2 Type BTU Input Fan Assisted or Nat
Appliance #3 Type BTU Input Fan Assisted or Nat
Total Appliances Total Biu input
Common Vent Type Vent Height Diameter inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance #2 Vent Cannector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
�� /�-((N G /� � I� v`� '"�
�� ��,�� � c�/'�--
HEATING CO: �c� co ��,c/ �—�F�'
Signed By: Date : % �'/�'-�
� HOUSE HEATING TEST RECORD
�ADDRESS - /'� � � APT. FLOOR CITY SUBURB �' �e�G,
OCCUPANT ��51�e- ��5�� -�� OWNER
HEAT LOSS DATE HTG. INST.
SOLD BY �� � INSTALLED BY �v� �� �
ElKtrieal Wwk Bp ��� Gos Lin� Br
TYPE OF HEAT GA FA �HW STEAM SPACE HTR. UNlT HTR. OTHER
GAS DESIGN CONVERSION
MAKE �47✓'�O� MAKE OF BURNER
Mod•I s Sr /J L/� G 7!� /a /< �-- Model
S�ria l y a- °�� 3�`�°'' y Mox. BTU Rati np
INPUT �r''� ��a' MAKE OF FURNACE
Modsl
CONTROLS � ��
THERMOSTAT �� Heat Pluy �'L Vsnt Size
Valvs �/'�-� KIND OF LINER �lu��+-�ju-- SIZE.�NONF
Limit `l � Draft Hood Rsgulator
Limtt S�ftiny a Filt�rs Size �l�"�d � Nu�° r,�
Fon SsNiny � Chimn�r Loeation Inaids "' Outside
Pilot Trps � Chlm�r Construdion '�u-��
Pilot Maks �%y�
Pilot Modsl Smoke Bomb Wirinp �
Pllot Timinp ���- Draft �am� Test To0 `�
L.11Y. Cuf OFf Door Proasure Li9htiny Inst.�
Prossun 3- S P�rceM CO � QaM Tsstsd ��%Z
2
Irtput CFH 7� Pere�nt 0� �'� Company Teating
Stack T�mp. 3��- � Peresnt CO � Nams of Tsater
Form 23S