AF - 47197`Cit of Fridle , Minn. �
Y Y
BIJILDING PERMIT �o
� �
Date: ......../ .................�......_�-.--... .......--�- �--....--�--....._............._.................
4383
Owner: ..... � ...................... � ........... - .....................---._..-----...................... ...... Builder .--. ����'.:....�-- /�_.......---.. .. ...._............._....---�--..._........
Address................ Address ......................_............ .........:....---..........................---........_......._......._......----•---..
� %�� fI � LOCATIO OF ILDING
No. -��-`'.�"'y.. Street ... -... .... ...... - .._...- ...���/ZZ��p ............. Part f Lot ................ - ��--�--�--�-�- ............. ...........--�------ ... _.
Lot -......../. �._ ... Block -......�..........._ ............._._. Addition or Sub-Division �%....��aUp..........��..�.'./.�'��.
.i / f )
Corner Lot ..._..._ .......................... Inside Lot ..._.Ji_......---- _... ...... Setback .�`.�� ---...........
`�<� .............. Sideyard .��_'.'.._a...- ....._.....- ..__.........
Sewer Elevation
To be Used as:
� �
. . .__. ....._.. -....
�.u.�� C���� -�...
Type of Construction
Foundation Elevation
DESCRIPTION OF BUILDING
,l" O � �O '� Hei ht ��—� S �Q'3-7 , p �j
Front -- -......-----_._! Depth ...._---_._...- g --....._._......._ Sq. Ft. .......--------°S Cu. Ft. .�.,r.....�_� e7
Front .�Q...`.~O�Depth •3.�_'�� Height _�� �D Sq. Ft. ..X.../..�_ Cu. Ft. ...Y9.66
_.........__.._.. _ ................__....... Est. Cost__.,/ �.../ lJ....�_:..."_'_" To be Completed .....................--......._..............._ -
In consideration of the issuance to me of a permit to construct the building described above, I agree to do
the proposed wark in accordance with the description above set fort � and in comp ce with all pro�visions of
ordinances of the city of Fridley. ��� �� ��^
In consideration of the payment of a fee of $_!�iJ......._........., permit is hereby granted to_ ..........................._........lL.._......._.......
....._..._ ......................................._...................... to construct the building or addition as described above. This pernut is granted upon
the express condition that the person to whom it is granted and his agents, employees and workmen, in ail work
done in, around and upon said building, or any part thereof, shall cox�form in all respects to the ordinances of
Fridley, Minnesota regarding location, canstruction, alteration, maintenance, repair and moving of buildings
within the city limits and this pexmit may be revoked at any time upon violation of any of the provisions of said
ordinances.
.��1!�� ..............�.........?2��---------� -... Building Inspector
NOTICE:
This permit does not cover fhe wnsfruetion, installafion for wiring, plumbing, gas heafing, sewer or water. Be sure to ses
the Building Inspector for separafe permits for fhese items.
4
Cifiy of Fridley
App�ic�rtian for P'h�mbing and Gas Fitting Perm�t
Dept. of Bldgs. Phone SU 4-7470 _
DESCRIPTION OF WORK � t�' � J i/�r��
Number, Kind and Location of Fixtures Locatioa _�
� � Z
W,� �= z � x} zz `a2 �� cT3Z Os j C� w
<� � <� � z �� �p � �� ~7 5�i �a `�Z< `2a
�i 7 O f� m VI 3 F- � LL N LL � S m � 3 C� � CJ 6' U� O
Base �� V � �� 1
lst ( �
2nd _
3rd
4th _ _
• Fuiure Conaectioa Openings�
* New Fixfure, Old Openfngs
PARTIAL RATE SCHEDULE
WATER HTR.
• M
R N GAS ELEC.
Sewer �
Ceaspool n
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number F`ixtures . . . . . . . . . . . . .. . . . . .. . . � x $1.50 $ 0 D
Future Fixture Opening . . . . . . . . . . . . . . . . � x 1.20 $ �. � o
New Fixture Old Opening . . . . . . . . . . . . . . x 1.00 $
Catch Basin ...... ..................... x 3.25 $
Water Heater (Up to 200,000 BTU� ......�� x 2.00 $ � � Q
New Ground Run Old Bldg. . . . . . . . . . . . . x 3.25 $
GAS F'ITTING FEE3: . NO. RATE TOTAL
lst 3 Fixtures .. ....... x $1.50 $
, ................
Additional Fixtures . . . . . . . . . . . . . . . . . . . . x .50 $
Gas Bange to 200,000 BTU . .. . . . ... .. . .. x 2.00 �
REPAIR3 & ALTERATIONS—Refer to Code
Description ....... .....................$
. . . . . . . . . . . . . . . . . . . . TOTAL FEE $ � � �
L
City of Fridley:
�a +�
�
�
The undersigned hereby makes application for a permit for the work herein ,
specified, agreeing to do all work in strict accordance with the City Ordinances
and ruling of the Department of Buildings, and hereby declares that all the facts '
and representations stated in this application are true and correct.
Fridley, 1Vlinn � � , 19 � c' ` . ;
Owner � � ��`�
Kind of Building � –1-- � �
Used as
To be completed about
Estimated Cost,
�el--New. Building Permit No '7` '~3 � Permit
''��1 : �
Signe
l..G
By cw�x
Business Phone
ROUC3H �PR 2 '� 1960 �. � .
FINAL
a z 2M 7-89
s` ��
y�,�LJ
./y
AppRcation I�or'owtr !'1a�1� and H�rtisg. Cooli�. Yentila�ioe� Rftrig�rafion a�d
Air Condi�OniAg SYstwns and D�vic�s
PARTIAL RATE SCHEDULE
filIAVTTT WARM AIR: !l11TE TOTAL
lh�rnace 3he11 d� Duct Work . . . . . . . . . . . . . . . . . . =10.00 �
Replacement oi P1�rnsce . . . . . . . . . . . . . . . . . 6.00 �
Repairs d� Alterations—vp to =500.00 6.pp s -- --_—
Repairs d� Alterations each add. :500.00 . 3.W �__._
MZCH. WAlq�f AIA
1�lunsce Shell dc D�ct Woric to 1l0,000 HT[T . . . . . . . . . . 510.00 �_
each �d. Q0,000 BTU ............. ....... .. 3.W i
�PLcement of 1+1�rnace . . . . . . . . . . . . . 6.00 �
Repairs dt Alterations--up to ;500.00 .... 6.00 �
Repairs dt Alterations each add. :500.00 .. S.pp :
STEJ►D� or HOT WATEA SY3TEM
FLrnace She�l dc Lines—to 400 sq, tt. l:DR Steem �10.00 a.
�trnace Shell & Lin�-to 640 sq, ft. EDR Flot Watrr 20.00 :_
Each add. 200 sq. ft. EDR Steam S.(1(► ____ .__--
Each add. 320 sq. it. EDR Hot Water g,pp ;_
OIL BIIRIQER—to 3 gal, per hour g,pp = _
over 3 gal. per hour�ee Fee 3chedule
GAS BIIRIfEA (up to 199,000 BTU) . . . . . . . . . . . . 6.00 =
ove! 199.000 BT[I SK FN seMdul�
G118 FITTING FEEB: 110 RATE TOTAL
lst 3 FSxtures . .. .. xi 200 S
Additional li�rttuea .. ; ,� _
Gas Rangie to 199.00Q .. � b 0� �
�►rn co�arriosnta —�G��a L� � fD � °��
Pl1l� HHA7il�G 3TS?EM � !» fc�WoM
v�►rua s�rsraM �
ALTEAATiOIts t AEPJLIAi 1'OT>L �ii �
ROiJOH . • • s�
�. � 8�.- rj►�. aeo.�so
� / / / // o
�� �
��
,,
�
CitY o� F�idley: v
The undersigaed hereby mahes appHcation for a permit !or the worlE :hereir
specified, agreein� to do a11 work in strict accordance with the City Ordinance:
and ruling of the Department ot Buildin�s, and hereby declares that aIl the lacts
and representations stated in this application are true and oorrect.
Owner
Kind of Building ._ I,L.Q„/_7�J
Used as _ _--- - ___ � . _
__�,�%_J
To be completed about __._ __��=..1 � ' ! �
Estimat Cost, a-_--.----. _-_ ��� . DQ
!�d -New. Building Permit No. — P�rmit No._ �J /�
I
I
Trade Nam - g� lde_T`� lo e2. ' d�
s
�Y �4-� BTU y3 Hp
Total Connected Lwd �� pt � �.
�w �%D'�_� /� 5�
/ '
(�tMI�RKf�OYER)
-, _ .l / // ��� � ���� � �
-_ I , /� � _� . i �
r . , �
� � / /
sue�ecr P N
City of Fridley 15 7 0 8
ATTHETOPOFTHETWINS gUILDING PERMIT �
r
; � RECEIPT N .
' COMMUNITY DEVELOPMENT DIV. +�
' j y__—.�_— l rt�
r � � PROTECTIVE INSPECTION SEC.
1 � ,
� � �
� /�'�L CITY HALL FRIDIEY 55432 NUMBER REV. DATE PAGE OF APPROVED 8V
�'----� • •�� 612-571-3450 910-F15 / /
5/ 7/80
JOB ADDRESS 6967 Hi.ckory Circle N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. ].9 1 Ostman's 3rd Acldition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Charles Swanson 6967 Hickory Circle N.E. 571-8933
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Professi.ona.l Roofing Service 7257 Yucca Lane 425-8233
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE UCENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE IICENSE NO.
6 USE OF BUILDING
Residnetial
7 CLASS OF WORK
❑ NEW ❑ ADDITION [� ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
X
8 DESCRIBE WORK
Reroof Dwellin
9 CHANGE OF USE FROM TO
STIPULATIONS g�g can be 2nd but not 3rd roof. Insta.11. ri.dged galvanized valleys.
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCV LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING Ofi AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID If WORK OR CONS7FiUCTION ZONING SO. FT. CU. FT.
AUTHORI2ED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONS7RUCTION
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 fiEAO AND EXAMINED THIS APPLICATION �- STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VAIUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $li 2OO $. E)O
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 TH PERF MANCE OF CONS RUCTION. �9.00
PLAN CHECK FEE TOTAL FEE
�` $9. 60
I NATUREOFC N'RA TO RAUTHOR DAGENT IDATE� WHEN PROPERLY L///I���DATED T IS IS YOUR PEF±MIT
t . . �" \�y^�V l9�� � �� V
-_SiGNATUREOFO�NNERIIFOWNERBU�lDER1 IDATEI � BLDG iNSP � �ATE
CITY OF FRIDLEY
ARPLIC/1TION FOR RESIDENTII�L [3UILDIP,
� (fdew, Alter�i:ions, Additions, or
�,
OWfdER: �� Q� l,c al `LZ�...dv,�-- BUI LDER :
ADDRESS: i `� ` ' AQDRESS:
TEL N0: � 7/ -��3 TEL M0:
Construction Location
• STRF'�T NO :`�Q��,�� STREET: � r Ci � r
. ' i- /
1 G'
BLOCK: l ADDITION: � •
LOT: � g -.
Corner Lot: Inside Lot: Setback: Sideyards:
Applican� attach to this form two Certificates of Survey of lo t and
proposed building location drawn on certificates to scale.
DESCRIP7I0f� OF CONSTRUCTION �
Front: Depth: Height:
Squa�e. Feet: Cxibic Feet:
Front: Depth: Height:
Square• Feet: Cubic Feet:
�P 00
Type of Construction : j� �- jr'O-t� Estimated Cost: $����—
7.b Be �mpleted: �_g�`
� Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $� $
' , SEE REVERSE SIDE OF SHEET .
7.�e undersigned hereby makes application for a permit for the work herein specified,
agreeing to dp all work in strict.accordance with the City of Fridley Ordiiiances and
rulinqs of the Department of Buildings, and hereby declares that all the facts and
representations stated in this application are true an d correct.
� �
DATE: ''2-a � SIGNATUitE: � • •
Stipulations:
. � �o�
< <o�
_9�
� �
. �
. -�
-
sue�ecT N .
City of Fridley 25892
AT THE TOP OF TME TWINS g � I L D I N G P E R M I T
� ` RECEIPT NO.
� � COMMUNITY DEVELOPMENT DIV.
r � � � PROTECTIVE INSPECTION SEC. j
� � l���
i � �
, t /"'1 � CITY HALL FRIDLE� 55432 NUMBER REV OATE PAGE OF APPROVEO BY
�.__.1`: '•� 612-571-3450 910-F15 4/2/98 � /
JOB ADDRESS 6967 Hickory Circle NE
t LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 19 1 Ostman's 3rd Addition SHEET
2 PROPERTY OWNEFi MAIL ADDRESS IIP PNONE
Chuck Swanson 6967 Hickory Circle NE 571-8933
3 CONTRACTOR MAIL ADDRESS ZIP PMONE UCENSE NO.
Up Top 2737 111 Ave NW, Coon Rapids, MN 55433 422-8785 7712
4 ARCHITECT OR DESIGNER MAIL ADDFiESS IIP PHONE LICENSE NO.
5 ENGINEER MAII AODRESS ZIP PHOP1f LICENSE NO.
6 USE OF BUILDING
Residential
7 CIASS OF WOqK
O NEW ❑ ADDITION ❑ ALTERATION C� REPAIR O MOVE O REMOVE
8 DESCRIBE WORK
Reroof House (24 Sq) Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
TYPE OF CONST. OCCUPANCV GROUP OCCUPANCV LOAD
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIQNING.
THIS PEfiM1T BECOMES NULI AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 OAYS, OR IF CONSTRUC�ION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCEO. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CENTIFV THAT 1 HAVE REAO AND EXAMINEO THIS APPLICATION 1 STA��S GARAGES
AND KNOW THE SAME TO BE TRUE AND CORpECT. ALL PROVISIONS OF LAWS VAIUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK Wl�l, BE COMPLfED
WITH WHETHER SPECIfIED HEREIN OR NOT. THE GRANTING OF A PERMIT �2sOO1 �I.00
DOES N E T GIVE AUTHORITV TO YIOIATE OR CANCEL TH£ pERMIT FEE SAC CNARGE
PROVI ONS F AN T R STATE OR LOCAL LAW REGULATING CON-
STR TIO R T PE C OF CONSTRUCTION. �%�F.%S Fire SC �L.00
PLAN CHECK FEE TO L FEE
f �% c��,�'� Lice C$5. $82. 75
S� AT O CON'RACTOAO AUTHOAIZEDAGENi IOATFt� E Q VAU T THIS IS Y UR PERMI
• �� r
SiGNATUFlE OF OWNER UF OWNEA BUILDEAi iOATE� DG �HS� - ���TE
NEW
ADDN
ALTER
�l
�]
[l
ConstructionAddress:
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Effective 1 / 1 /98
`�� y ��
�` / �
...�--. ' ' ' �
Legal Description: /� ���
Owner Name & Address: ��v�K Si�.��So�✓ _ Tel. �t �7/— �9��
Contractor: �//' � MN LICENSE # 7 % / �
Address: _ � �7 � �7 /// !�'� ��' ^ �.,., , �%�.,, �-� Tel. # �aa ���s
LIVING AREA:
GARAGE AREA:
DECK AREA:
OT�iER:
Attach to this application, a Certi�cate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height
Length Width Height
Length Width Hgt/Ground
.��5�. ��-��
Sq. Ft.
Sq. Ft.
Sq. Ft.
Construction Type: � ao Estimated Cost: $ ��
° �Oc� /
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = F $ _$
DATE: •o�� APPLICANT: Tel. � �aa -�7.P f"
CITY USE ONLY
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
$ , ��
$ o�. 0 6
� 1.��
$
$ S. ov
$
$
$
$
$ . '�f�
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth%)
$.50/$1,000 Valuation
$1000 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 [ J
..� . .
�
CITY OF FRIDLEY 1NSPECTION DIV.
6431 University Ave NE
Fridiey, MN 55432
572-3604
Stories
Basement
Floor 1
Floor 2
Fioor 3
Floor 4
PLUMBING FIXTURE RATES:
� Effective On Jan 1, 2000
APPLICATION FORPLUMBING AND GAS FITTING PERMIT
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
a,:::: :>::::::>;:::«:::«< :.::;,;;:�.;:>:<:.:>::»:<: ; ��;.;: ::;: :.::»�:»:: : :: �::;.:::::>::::>:<:>::>
:�<r�:;:<:::_>;:;: Wash �t�c:::::;::=>:=>:: Floor �#�f>::�::>:: Auto. -
:.:;-: .
�;;>;;:::;;:::: Gas ��::::>:::>::::: Water Heater
h
:> S ow
er r
Ta
�:���:::<:> -�� Drain
::� Wash
:.�: :.::::.� ::::::.::::.:. :::.,.::::.�:::.. -: _
.................. :�:::::.-:.�>:::.;::.:
.>:<.: ..::.::::..:.. ---- --� :..:.::::::
...,:._: . .. .......
:....:: :.. . ...... ...
:;::..: >;> � �:,;;;;.: _ �: :
....... .. .....
..... . ::::; ::.::...........
�..< ....:... ��:::��:>::::::<:- -��r�:,;:.::.: er ��,«::,;::><. Range �'�ct::>::`:::::>::>:: Gas Elec
NO. RATE
New Fixtures
Old Opening, New Fixture :
Beer Dispenser
Blow Off Basin �
Catch Basin
Rain Water Leader
SumplReceiving. Tank
Water Treating Appliance
Water Heater -Electric
Wate� Heater - Gas*' �_
Gas Range"'
Gas Dryer*'
Back Ftow Preventer Required ()Yes () No
Type
$ 7.00
$ 4.00
$ 5.00
$ 7.00
$ 7.00
$ 7.00
$ 7.00
$10.00
$ 7.00
$10.00
$10.00
$10.00
$15.00
Reinspection Fee $47.00/Hr
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture orAppliance
State Surcharge
TOTAL FEE
l�al�'1 � �4 t�o �r,�;�,�,
TOTAL JOB ADDRESS `.�IK� �"s Qu3���
0
$ —��- _'�'�
The undersigned hereby makes app{ication for a permit for the work he�ein
specified agreeing to do atl work in strict accordance with the city codes
and rulings of the Q,uilding Divisi�n, and hereby declares that all the facts
and representations stated in this application are true and correct.
Owner
�/ � � /�� , 20
�
Building Used As �'E�\�%N C�
—�-�- --- �.� �-�C� �
Estimated Cost PERMIT NO.
PLUMBING COMPANY �I�C�L�I� �LU/✓jCal/l�(, ( �}
SIGNED BY TEL NO.��Z"S�I'�O ��
, Approved By _� Rough-In Date Final Dat �i \
v ���-
�_ MINIMUM FEE FOR ANY PLUMBINC��eS vFaiuir �S S20 00
PLUS THE 5.50 STATE SURCHARCF
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE
^ITY OF �RIDLEY BUILDING 1NSPECTION
v
9 5431 University Ave fdE
9 =ridley, MN 55432
L
763-572-3604 FAX 763-575-1287
9 ��lol�
D
n RATE SCHEDULE
Residential
Furnace Shell and Duct Work, eurner &
also Replacement Furnace
Gas Piping (New Furnace, Fireplace, Insert)
� Gas Range
Gas Dryer
...� � , �lX'j��C�/��'�
�•��- Effective 4/1/2004
APPLICATlON FOR POWER PLANTS AND HEATING, COOUNG, VENTILATfON
REFRfGERATIOi� A�1D AIR CQNDITIONI�S� SYSSEMS AND DEVICES
�
$35.00 $,
$10.00 $.
$10.00 $
$10.00 $
*Air Cflnditioning-All Siz�s $25.00
�1 � �� v'P�mC - C� a� a"�
All ather Repairs ar Afterations (List on Back)
} 1% of Value of Appliance or Work
a Minimum Fee $15.00 for Residential or 5% of cost of
Y Improvement whichever is greater on work less than $300.00
i
� CQmmercial�lndustria�/Institutional
?" 1.2596 of Value of Appliance or Work (List on Back)
� Minimum Fee $35.00 for Commerciaijindusiriaijictisiitutiona�
�
Y
�
State Surcharge
TOTAI.FEE
10BADDRESS � e�i �n� �i0 �Co,r n � c . �i� ,
�' ��r�e
Owner 5 ��f'IcSC��I
$�� C�O
$
�
$ •50 ,
� $ o25,SC�
v
� REINSPECTION FEE $50.00/NOUR
@*Air Conditioners can not be placed in side yard w(thout �vritten approval
N from adjoining property owner - o�py to City
N
N
'� FILL 4UT BACK SIDE FOR STACK VERIFICATION ON REPIACEMENT F'URNACE
¢
Building Used Its � ES i� E n e
ESTfMAT�O COST � oZ l06 •�O PERMIT (30
�ESCRIPTION OF FURNACE AND BURNER
R of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Trade Name Size No.
BTU HP EDR
Fuel Totat Connected Load
Bumer Trade Name Size No.
BTU - HP - --- EDR
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in stri�t aocordance with the City Codes
and rulings of the Bw'iding Division, and hereby declares that all the facts
ar!c! repr8sentations srated in this application are tn�e and correct.
CENTERPOINT ENERGY
HEATING GO 13562 C�NTRAL AVE NE BLAINE, MN 55304
Signe� �,�� �" �"\ \� 7el # 763-757-6202
FAX �l 763-757-6701 Date �" at�"��
Approved by Rough-in Date Final Date
C@ " d �C101
FILL IN COMPLETELY FOR REPLACEMENT FUEL BURN(NG APPLIANGE PERMITS
COMM�N VENT VENT CONNECTOR AND COMBUSTI�N AIR VERIFICATION
When replacin� an existinq furnace, the undersigned hereby verifies tl�at the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. Yes (� No O
The venting system is plasticJPVC and meets afl 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 specifcations. This do�s
include AGA-GAMA Category I Central �urnace Venting Tables for fan
assisted and natural draft appliances.
The existinq combustion air is sized and instalied to meet the current r.odes
and manufacturefs specifications.
When required to install a new combustion air it will be sized and installed
to meet the current codes and manufacturer's spec�cations.
Yes ( �l No ( )
Yes ( �
Yes � )
When installina a new veniina svstem, the undersigr+ed hereby veri��:s that
it is a listed assembly and me.ets the current codes and manufacturer's
speci�cations. This does include AGA-GAMA Category I Central Furnace
Venting Tables for fan assisted and natural draft appliances. Yes (�
Is the common vent and vent connector� sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes �)
Appliance Tvpe and Size/Common Vent and Vent Cunnector Information
Appliance #1 Type BTU Input Fan Assisted or Nat
Appliance #2 Type BTU Input Fan flssisted or Nat
Appliance #3 Type BTU lnput Fan fissisted or Nat
Toial Appliances Tatal Btu tnput
Common Vent Type Vent Height Diarneter 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
ALTERATIDNS• (Describe)
Na ( )
No ( )
No ( )
No ( )
CENTERPOINT ENERGY
HEATING CO: 13562 CENTRAL AVE NE BLAINE, MN 55304 _
Signed By: �� �'°� - �-�, Date
�Gi/�Gi' �I TAJ,9J.SL Ol J.3"1Q 1�I� �0 1,11 � WO?1-1 S� :'[ Z b�JOZ-L�-�1dH -