AF - 41584,�
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Caty of Fridley, Mi.n,n.
BUILDING PERMIT
Date: 4/3/67
3�i�i
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Owner. __Jerry Moytl Fern.dale Builders
• Builder ._._...�
Addn�s Addr�s 1323 S�ood Lane �
LOCATION OF BUILDING E. 5' of Z, s7
No. 516 s�t Ely ._._._ Part of Lot W. 15' of L.40
38 & 39 K Riverview Heights
Lot � __ Block Addition or Sub-Division _._.___._.
Coraer Lot _ Inside Lot _.. X Setback 35 f t.^�_ Sideyard _ 10 f t.
Sewer IIevat3on 846 .96 849 .96
� Top of Footing
To be Usea as:
Dwelling
Zj�e of Construction
�t 40
Front ._._..
Frame
Sewer Location-
Water Location-
DESCRIPTION OF BUILDING
Depth 26 �
Depth �_
____ Est Cost
. Height 8
I�eight —.._
$16,000.00
In consideration of the issuaace to me of a permit to construct the
the proposed work fn acc�rdattce with the description above set forth a
orclinances oP the city of Fridley. ,�
�����
ioo.
Sq. Ft. 1040 Cu. Ft
�. � � 7%1%67
To be Completed ._..
iing descrlbed above, I agree to do
� compliance th all provTafona of
�� � ��
21.00 Ferndale
In consfderation of the payment of a fee of $ , permit is hereby granted to—
Builders to construct the buflding or addition as described above. This permit is granted upon
the expr�s crondition that the person to whom it is granted and his agettts, employees and worl�en, in all work
done in, around and u�n satd building, or any part thereof, sixall conform in all respecta tfl the ordinances of
FrYdley, D2innesota reg location, conatruction, alteration, maiatenaace, repair and moving of buflain�s
within the dty ]imits and�s p�rm�tt may be revoked at aqy time upon violation of any of the proviaions of sa�d
ordinanc�s.
Clarence Belisle B�� �
NOTICE:
Thb penett d� no� cover t6s coestrncH�, InshllaHon for wtrta9. Plambing, ea heating, sswe� or wNsr. 8� son 10 ms
the Buitdieg laspsetoe foe aparata parmNs Po� thsss thea.
AE'li.IC�TiO� F�� BUIY,DiNQ PERMIT
CI3Y OF FRYDLEY, MINY�SaT�
OW19E8' S
,FE�'� m�1 �. E ,/} � � ��E�'?�
,
�DDRESS ADDRE35 �') a'° j' �'�c�'° ��� Q �v�/6e,
�.���.. ---------- �.�.�....�
LOCATION OF BUiLDING
�a���' s�';� �a�'
N0. �� STREET ����_ P�iAT OF L� �'��`����"�
�� �
L�T �`� � BL�� /%� ADDITIOAT OR SUSDNISION �� ����o �� /� ,7'P,�
�_.__
CORNER LOT� INSiDE LQT�SETBACR ��' • STDE-YARD so �
SEWLR BLEVATION , �� gpUNDATIOR �LEdATION
Applicant ettach ta this form Two Certificatea of Survey of Lot and propased
buiiding lacation drawn oa these Certificates.
DESCRIFTIaN pF BUILDIATG.
To Be Used A�: .
��'�0�� ,�� roat � � Depth � � � fleight` � ,�
Sq. Ft. �d �°� Cu. Ft.
,��� Frant Depth Height
. Sq. Ft. ..Cu. Ft.
Tppe of Constructica_ �.���°'� �i`iEsCimated Cost ���°°0 �Oe
Tc He Comp�eted - �'� � y ;� .. �:y �'�
� • ��...ur�r�r�+.�.�� ���r�..���ri�e ��r�.
The undersi'gned hereby makes�applicatioa for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City of Fridley Ordinaaces
and rulings of the,Depart�meat of Buildings,.and herehy declares that a11 the �acts
aad representationa atated:#n this applicatioa are trus and correct.
DA .__.��.r....� .._�
(Schedule of Fee Costs caa be found 4A the Reverse Sidej.
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BUILD3CfiIG PE c��C[[T ` FEE SCHEDViE
SECTIOR 2. The Inspector of Buildinge shall, before iesuing pesbtits for the
erection of any building or structure, or fosc aay addieioa to anq ex3sting
building or structure, or for any alterationa or rep��irs to any existing.building
or s,tructur�, upaa app�,.���t�on `therefQre, require the p$ymeat�bq the applicant
for such permit of fees to the amount berein below set forth and in the manner
herein provi.ded to-wie;.. ..... _. ;� � � .
2�,.1. For any such permit f�r the, erect�.on pf auy fire-proof buildin�,
oeher than a�arage, warehouse� factorq or grain eZevator, or for the erection
of anq fire-proof additiqn,, for similar occupancq, to aaq, eni'st�.ng .buildi�,g,
sha11 be.at.the=rate of $1�.40 for each ane thousand cubic feet, or fraatian
Chereo€, ia such cubical conteats. �`" •�
2_s, .u.�For aay auch permit for the erection of any fire-p�k'oof� garAger• '
warehause, factory or grain elevatflr,�or for the erectio�► of any fire-proof „
additian, for aimilar occupancy, to any existing building ahal�..b�...at:the rat'e
af $1.25•�or.each ane thousand cubic feet, cla��ified as "fireproof" by Section
502 of the Minneapolis Huilding Ccde.., . , � •�
80QSES
2a,3. For any auch permit far thr� erection of;anq non-fireproof building,
other than a gara�e, warehouse, factorq or grain elevator, or anq non-fireproof
addition, for similar occugaacy, to any existing building permit fee'$1.00 for'
each aae Chousand cubic feet. . , ... . . _ . .. . . . . .
, , . .. .
GARA. GES � ... � • � . ' � . ,
' 2,_��:' ` For �any such permit far the erection of an,y., aon-fireproof garage, .. _
warehouse, -�fa�ctor.p_ .or .grain elevatoY, rnc ��for the erection of� aay nou-firepraof _ ,
additiou; for si.milar occupancy, Co any existing building or for each such
buildi,ng or_addiCion - ainety ceats ($0.90� for eaah arie thousand cubic feee
or fracti� thereof, ia the cubieal contents thereof with the minimum of $4.00:
. . , �� _ _ _ ,
For the purgose of computiug fees for bu3lding pesmits, the cubical contents of`
� any building .or add3tion _to .e�_ uni#orm .height throughac��t" by multiplying the g�ounc�
area covered fram a point sin (6) iaches below the floor line of the basemenC or
cellar to the average height of the upper surface or to the aver�age height o€ the
roof surface of .the m�in �able of �a �pita�ed roof. � �
� . . . .
2� � Fcir: repair� -or� alteraC�ons `to aa eui�ting atructu=e, : the fee' shal�l
be at the rate of $3.00 per �ach Five �undred Dollare ($500.00) or firactiata
thereof in the cost of all proposed werk.
�__ 2,� 6. __ xn. na c�se.: shall. eh�,.fee ,�harger� for any permit_as. set f�orth ia
Section 2 be�leas than $4.00. , � ' '
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��111���� 4�d. �ARfl.�Y �'� �.5���1�'�7ES
COi+JSULT1ivG ClV�I E�dG(NEEFS---LANQ SURVEYGitS
500 1�V. HWY. 96 . • 18 FOURi�H AVE. S.E.
57. PAUL 12, M.[PIN. ST. CLOUD, MINNES07�
484-330 i Bt 1-7751
t hereby c�r#if;r ti�►at t�iis survey, pl�an, or feport wus pre�ured by me or un�er my direct supervision
and that i Ct�"a duly Re�isteredlland�veyc�r uncler fif�e lGws of fi�e State of A�1i7nesota.
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',,f � � ..- _..,, __,�.--- Reg. P;o.���----Date -�`_=-=z_ :;'�_..
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HEAT LOSS CAL�1'IQNS DEPARTMENT OF INSPECTION (yII]�(�pp�� �,
Weatherstrips A.S.H.V.E. Construction No.
Guide
Windows Doora Refereace Oat. Wall Iat. Wall Ceiling Roof F1oor Kind
Yes—No Yes—No 19._
Fl. ` Room � Length Width Height �.� �m j,eag�
Windows an Daors—Crackage an Area Windows and Doors—Crackage aa�
tVldth Hetght No, ot Llneal f. AreQ Wldth Haight No. of Linea.
No. _ o[ pane ot pane Iighta ot crack nq. ft. No. ot p ne ot Dane lighte � ot cre
�% 7-� '1/ ( �
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3 - __-,_—__ _ :
� - --- --=- - -
oef. Btu . _ _ _ _
In6ltration Infiltration
Glass �
Glass
Eap. wall �C.. � F.Sp. wall f>x
Net exp. wal� � / Net esp. wall
Int. wall
Ceiling -L
Floor y
Total Btu.
Required q. ft. E.D.R. or sq. ins. W.A. Leader grea
F1 Room � Length Width �
Windows and Doors—Crackage and Area
Wldth Height , ot Lineal ft. Area
No. ot Dane of pane g a of crack eq. tt. -
?.� � l /
/ � Y� 'L I i /
` Coef. Btu
In6ltration Q
Glaaa �
Exp. wall
Net exp. wall � 'Z �
Int. wall
Ceiling �� -L �
Floor `� � —�
Total Btu. �
Require q. ft. E.R. or sq. ins. W.A. Leader area
F1• oom � Length Width Height
Windows and Doors—Craekage a d Area
Width Helght No. oL Ltneal tt. Area
B�IO. of Dane of pane Ifghte ot crack ea. it
Int. wall
Ceiling
Floor
Total Btu.
Insulation
How
� Width
Area
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
oom ( Length Width ��en
W' dows and Doors—Crackage and Area
Wtdth Height No. of Lineal ft. Area
No. ot pan ot a e llghte of crack eq. t
(
�
Infiltratioa
Glass
�p. Wau
Net eap. wall
Int. wall
Ceiling
Floor
,$tu – �
nequue s. r�. c.v.ic. or sq. ms. w.�►. uaaer area
F7•� m I Length idth Height
Windowa and D�ra—Crackage and Area
Wldth Height No. 01 Lineal tt. Area
No. ot yaqe o! pane Ilghte ot crack ea. 1t
Coe£ Btu
dnhltration (� Infiltration
Glaas (�-�p Glass
F.ucp. wall X Exp. wall
IVet e�cp. wall Net exp. wall
dnt. wall Int. wall
Ceilin � �p (j� Ceiling
�loo� Floor
�'c$al �tu. Total Btu.
Require� sq. ft. E.D.R. or aq. ias. W.A. I.eader area Required sq. ft. E.D.R. or sq, ins. WA. Leader area
- , �
Btu I
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Ca.ty of Fridley, Minn. �f �0989
BUILDING PERMIT
Da�; A�ril 23. 1971
p�r; Gerald Motv$ g��r Same
Add�s 526 E1_y Street N.E. Addrea� Same
LOCATION OP BUILDING
1� o--��.3�. St�eet --- E1v Street
...� Part of Lot
I,ot�9 &40' __ gl� R Addition or Sub-Dividan _ R3,verview Heig.hts
Corne�' Lot — Inside Lot `. x Setback _.._ Sideyard
Sewer IIevation `. ..._ Foundation IIeval3on
DESCRIPTION OF BUILDING
To be Used as:
�
Gaxage Front 2�+ Depth 26 Height __�._..� .._ Sq. Ft. �.� Cu. Ft 6, 240
Front Depth I�eight � Sq. F't. Cu. Fk
Type of Construction Frame ��, �� 1 300 _ _ To be Completed - 4/23f 72
Provide hard surface drive.
In cons3deration of the fssuaace to me of a pexzn�tt to construct the building described above I agree to do
'the ProPesed work in accordance with the dpscriptaon above set forth and in compliance with a�l prov3sions of
ordinances of the dty oP Frfdley.
` `� = �� ��
�
In consfderation of the payment oP a fee of $12 . 00 � F�t � g��, �� to Gerald Motv1
to conatruct the buflding or addition as descrlbed above. Thi� �rmit fs granted u�n
the express conditfon that the person to whom ft fs granted and hia agents, employees an�� wor in all work
done fn, arouttd and u�n said building, ur anS' part thereo� shall conform fn all reapects to th�e�orainaace� of
Frld1eY� Minnesota reg location, constraction, alteration, maiatena,nce, se�pa3r an[l moviag of bwildings
wlthin the dtY ]im�tts and�s permft may be revoked at any time upon violation of any of the provis�lona oP sa�d
ordinancea
�
��
CLARENCE BELISLE
NOTICE:
'flds psne� das not eover t6s coettweHon, leslallaHoe �e� wlrYn6. plumble8. 6� b*+�8. �vsr er wafer. B� suro to tee
fhe Buildiq ie�pseto� }or �parate p�rmits for fhess It�ms,
,� '
.
APLICATION FOR RESIDENTIAL, ALTERATION,
OR AllllITiON $UILDING PERMIT
CITY OF FRIDL�Y, MINNESOTA
� � �"° � -:: ` ' � �
„ � ,� � �` °�a
OWNER`S BUILDER: �� ��
. �
ADDRE�uS: � ADDRESS:�
�_
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�ND�r ' STREET: (
r' <,
LOT:_��� �� 9 BLOCK:_ � ADDITION: �� .r' �,�, � � r? �'� °
! � �,� �
, .�J
CORNER LOT: INSIDE LOT:� SETBACK: SIDEYARD;
AppliGant attach to this form Zt,ao Certificates of Survev of Lot and proposed
building location drawn on these Certificates.
HESCRIPTION OF BUILDING
To Be Used As; 1
�- ;
- Frout : �_ � ;' Depth : �- �'� = Height : �� °- '
' Square Feet : � ' �- ,/_ Cubic Feet : �., f
_, Front: I�pth: Height•
Square Feet; Cubic Feet:
Type of Constructioa; �f "�'��� ' ���=--, =--��� Estimated Cost: � �` �
To Be Completed: �
The uadersigned hereby makea applicatinn for a permit for the work herein
specified, agxeeing to do all work in stiict accordance with the City of
Fridley Ordinaaces and rulings of the Department of Buildings, and hereby
declares that all the facts aad representations stated in this application
are true aad correct.
L1ATE : ' S IGNATIIRE •
(See Reverae Side For Additiona.l Information.)
.
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BUILDING PERMIT FEE SCHEDULE
SECTION 2. The Znspector of Buildings shall, before issuing pennits for the
erection of any building or structure, or for any addition to any existing
building or structure, or for any alteration or repairs to any exiating
building or structure, upon application therefore, require the payment by the
applicant for such permit of fees to the amount herein belaw set forth and in
the manner, herein proviaied to-wit : ,
UNIFORM BUILDING CODE: �pe 1, 2& 4-$2.15 for each one thousand cubic
feet, or fraction thereof, in such cubical contents. Type 3& 5-$1.85 for
each one thousa.n.d cubic feet.
ADDI'TIONAL INFORMATION
For the purpose of computing fees for building 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 aurface of the ma.in gable of a pitched roof.
For repa�.rs or alterations to an existing structure, the fee shall be at the
rate of $3.00 per each five hundred dollars ($500.00) or fraction thereof in
the cost of all proposed work.
In no case shall the fee charged for any permit as set forth in Section 2 be
les� than $5.00.
VERIFICATION OF FOUNDATION
NOTE: Permits for construction will be issued a minimuna of 24 hours fram the
time of application, to allow for proper review of the proposed structure and
of the construction site.
A Certified Survey of the lot, ahowing the lacation of the foundation, once it
has been constructed, will be required before proceedin� with the framing.
CERTIFICATE OF OCCUPANCY
Application for a Certificate of Occupaacy shall be made ten (10) days prior
to the use or occupancy qf any structure for which a building permit has been
issued; and said structure shall not be uaed or occup�ed until a Certificate
of Occupancy has been issued. •
a
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-------__._.—__._._____ __� -- ----------_ _ _- ---- -___.._._._--_ •----
� `THE JOHRi J. RYAPd CO. � g46-6858
`� 1602 SELBY AVEfVUE, ST. PAUL 55104 - 7ELEPHONES�� 333•6476
,SCALC 1 INCH�------ FEET . 742 BU►LDERS EXCHANGE BLDG.. MINNEAPOLIS 55402 �
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� -- i�i� y 13 •- 67 ---- ----
I lieret>y certif�� th:�t oii. _ 19__ .-- I here'.?y crrtiiy that on___ -19---
i_ I°r��de a stu�vev of thr location of the building(s) on the i sw•��cyed the pr�perty described al;ove �ird'th�.t the abo�e
;�hor,: describe:f pTOl�ert}� and t�utt thc loc<ition of snid ��lat is u coriect t��•presentation of saicl sttr�'ey.
't�uildi �g(s) i5 coa�•ectly;18}101Zll on the abo��e plat. . �
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SELBY AVENUE ST PAUL 55104 7ELEPHONES-� 333•6476
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y 5�/1LE: 1 INCH--�---- FEET 742 BUILDERS EXCHANGE BLDG.. MINNEAPOLIS 5SA02
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Gerald. L�, :�:ot��l �
OF PROPERTY OF_ _ - --" � - -"- " --- — � �
5z5 �1y Str�et I�orthea��, rri,�ley, r:inn.--- ---------
LOCATION- - -- . _ -�----- --- ---- ---- —�--._-_._--- � � �
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�' feet of Lot _�] ,. Lot 3�, _Lo� _��,_'_n_' _the ��`�st_1J_ �'eet ----
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CERTii''ICATE OF LOCATION OI' BT�II.DING
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J TP<�ie :� sui•vcv of thc location of the buildin;(s) on th�
';i�uc, de.cribe�� Z�ropc•rt}� and t��at the location of said
buildi ig{s) is cor�•ectly�sho�rn on the ahove plat.
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2VEYC?R, Nc. 448�
SUBJECT
City of Fridley
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
r
� �
; �L _ COMMUNITY DEVELOPMENT DIV.
r j � PROTECTIVE INSPECTION SEC.
l---_����"' ��� CITY HALL FRIDLEY 55432 NUMBER
i 612-571-3450
910-F15
IOB ADDRESS 526 Ely Street N. E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION
oesca. 38,39 K Rivervi� Fiei
2 PROPERTYOWNER MAILADDRESS
Gexald Mot-�rl 526 EIy Street N. E.
3 CONTRACTOR MAILADORESS
Same
4 ARCHITECT OR DESIGNER MAIL ADDRESS
5 ENGINEER MAILADDRESS
8 USE OF BUILDINCi
Resident%a,l
7 CLASS OF WORK
REV. I DATE
3/10/87
ts
ZIP
ZIP
PAGE OF
� �
1881
���� �
APPqOVED BY
SEE ATTACHED
SHEET
PHONE
786-5393
PHONE LICENSE NO.
PHONE LICENSE NO.
PHONE LICENSE NO.
� NEW ❑ ADDITION � ALTERATION ❑ REPAIR � MOVE ❑ REMOVE
8 DESCRIBE WORK
Insta.11 ma,son�� fireplsce
9 CHANGE QF USE FROM
STIPULATIONS
TO
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, �PE OF CONST.
VENTI�ATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING
AUTHORI2ED IS NOT COMMENCED WITHIN BO DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PEFiIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS
I HEFiEBY CERTIFY THAT I HAVE READ AND EXAMINE� 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 �2 i OOO. OO
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERM1T FEE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION, $32. SO
OF CONTRACTOR OR AUTHORI2ED AGENT_ �, 1DATEI
IIF pNVNEF BU�
OCCUPANCY(3ROUP OCCUPANCYLOAD
SO.FT. CU FT
STALLS
OFFSTREET PARKING
IGARAGES
SURTAX
$1. 0�
SAC CHARGE
TOTALFEE
$33.50
D T�,IIS IS YOUR PERMIT
NEW [] City of Fridley Effective 4/1/86
ADDN. [ ] �R-1 AHD R-2
ALTER. [ ] Building Permit Applieation
Construction Address: `�°2� �l � � � �l12-►�G� 1 �H m � �5�� �
Legal Description: -
Owner Name & Address : � e iZ2 �U` ►�1a �' �1 � Tel .# 7�6 - S3 9 3
Contraetor: �W �l � ►2 Tel . #
Address• �'�ri�
Attaeh to this application, a Certifieate oP Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPR09EMENT
LIYING AREA: Length Width Aeight Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER: �l�e���Ce_ VY��ss�v�'��`'�
—�—
Corner Lot [] Inside Lot [)C1 Ft. Yd. Setbaek Side Yard Setbaek
Type of Construetion: i�'1�So✓���"� Estimated Cost: $ �� ��� 0�
Approx. Gompletioa Date: � - � � — � �
Alt. A Alt B
Proposed Driveway Width If New Opening Is Desired: $ $
See Baek Page for Explanation
DATE: � - /o - � � APPLICANT: ���� ` Tel . � 7SS - % > > �/
CITY IISE ONLY
Permit Fee
Plan Check
State Surcharge
SAC Charge
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
� ��
� �J
$ ��.
$ l�c��
$
$
�
� 33,�u
Fee Schedule on Reverse Side
25� of Building Permit Fee
$•50/$1,000 Valuation
$ 525 Aer SAC Unit
Fee Determined by Engineering
Agreement Necessary L] Not Necessary []
_�_.�
BIIII.DING PERMIT FEE SCHEDIILS
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 applicatio n
therefore, require the payment by the applioant for sueh permit of fees to the amount
herein belo� set forth and in the manner herein provided to-wit:.
Total Yaluation
$1.00 to $500.00
Fees
$10.00 (Minimum Fee is $15.00)
$501.00 to $2,000.00 $10.00 for the first $500 plus $1.50 for eaeh
additional $100 or fraetion thereof, to and ineluding
$2,000.
$2,001.00 to $25,000.00 $32•50 for the first $2, 000 plus $6 .00 for each
additional $1,000 or fraction thereof, to and
including $25,000.
$25,001.00 to $50,000.00 $170.50 for the first $25,000 plus $4.50 for eaeh
additional $1,000 or fraetion thereof, to and
ineluding $50,000.
$50,001.00 to $100,000.00 $283.00 for the first $50,000 plus $3.00 for each
additional $1,000 or fraction thereof, to and
including $100,000.
�100,001.00 and up
$�33•00 for the first $100,000 plus $2.50 for each
additional $1,000 or fraction thereof.
DRIYEWAY DEPRESSION ESCROW
(Concrete Curb Streets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus
6 feet times $13.50
Alternate °B": Removal and replacement of eurb and gutter and install a 3 foot wide
approaeh with 6 inch depth - Driveway width plus 6 feet times $15.75
9ERIFICATION OF FOIINDATIOA
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 onee it
has been constructed will be required before proceeding with the framing.
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FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS
COMMON VENT VENT CONNECTOR AND COMBUST�ON AIR VERIFICATION
When replacins� an existinct furnace, the undersigned hereby verifies that the
venting has l�en examined and is free from nast, deterioration, obstructions,
and is securely supported and firestopped where required. Yes () No ()
The venting system is plastic/PVC and meets all current codes and manufacturer
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 spec�cations. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The existins� combustion air is sized and installed to meet the current cades
and manufacturer's spec�cations.
When required to install a new combustion air, it will be sized and installed
to meet tfie curreni codes and m�nufacturer's spec�cations.
V�r� ir��i� ��vv v��tm sv�, tl� under�igned 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 ( )
Ye� ( ) N� ( )
Yes ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
Appliance Tvpe and Size/Common Vent and Vent Connector Information
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 Tdal Btu Input
Common Venf 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: (Describel
HEATING CO:
Signed By: Date :