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AF - 45703SUBJECT . City of Fridley 17 4 4 3 AT THE TOP OF THE TWINS g U I L D I N G P E R M I T r � � RECEIPT NO. � `y _ COMMUNITY DEVELOPMENT DIV. r j � PROTECTIVE INSPECTION SEC. /�y�� . , � � �"�'1 � CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY �"""�� ,�� 612-571-3450 910-F15 4/5/84 / / JOB ADDRESS 6926 Hickory Drive N. E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. ].3 4 �S.�d,n 1 S rl,h].Y•a SHEET 2 PROPERTYOWNER MAILADDRESS ZIP PHONE Pf lug 6926 Hickory Drive N. E. 574-1836 3 CONTqACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Bergstrom Remodelin 4600 F.�nerson Avenue North 4 ARCHITECTORDESIGNER MAILADDRESS ZIP PHONE LICENSENO. 5 ENGINEER MAILADORESS ZIP PHONE LICENSENO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW O ADDITION ❑ ALTERATION ❑ REPAIR O MOVE ❑ REMOVE 8 DESCRIBE WOflK Reroof Dwellin 9 CHANGE OP USE FROM TO STI'pULATI�NS Rs�of can be Znd layer �Iylgt but not 3rd. Install ridged galvanized valley� whexe necessary.. SEPARATE PERMITS ARE HE�UIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTHUCTION ZONING SO. FT. CU. FT. AUTHORIZED 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 ], 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 $1,350 $.6$ WITH WHETHER SPECIFIED HEFEIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHOHITY TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE ROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- $23. �J,O RUCTI N OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECKFEE TOTALFEE - �. �^ S P�"� $2�.1.8 SIGNATU OFCONTRACT Ro �rH DAGENT IDATEI WHEN PROPERL ALIDATED THIS IS YOUR PERMIT � SiGNATUAEOFOWNERiIFOWNEABUILDERI IDATEI BLDG INSP �A E NEW [ ] ADDN. [ ] pLTER. [�f Construction Address: Legal Description City of Fridley R-1 AAD R-2 Building Permit Application � Effeetive �/1/8� Propertq Owner/Address: //%- t�� /�� G�. _ Tel .# S 7y / 83 6 Contraetor: /3er�Sfr�.,, /7e�,hG�/i�� Tel. # s�/-a9� E� Address: �l�cJ �s�e.-�v7 �� ,, /J'1�/�. /''/-�- S s"�1i 2 _ Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTIOA OF IMPaOYEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: �@ �°00% o✓er exis�+rig_�ns/Pr Corner Lot [] Inside Lot [] Ft. Yd. Setbaek Side Yard Setbaek Type of Construction:, '' � ' �''�=� Estimated Cost : $ l3 S� � `� Approx. Completion Date: 5'- /�- g`� Alt. A Alt B Proposed Driveway Width If New Openin� Is Desired: $ $ See Back Page for Explanation DATE: �� APPLICA . �9�"�� Tel. � �°� /-°a % % 8" CITY QSE ONLY Permit Fee $ � 3.5� Fee Schedule on Reverse Side Plan Cheek $ 25$ of Building Permit Fee State Surcharge $ • � � $.50/$1,000 Valuation SAC Charge $ $425 per SAC Unit Park Fee $ Fee Determined by Engineering Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ] TOTAI. $ � . I STIPULATIONS: . ., BIIILDING PERMIT FEE SCHfiDUL$ 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 applicant for such permit of fees to tbe amount herein below set forth and in the manner herein provided to-Wit: Total Valuation �1.00 to a500.00 $501.00 to $2,000.00 $2�001.00 to $25,000.00 $25,001.00 to $50,000.00 $50,001.OQ to $100,000.00 $100,001.00 and up Fees $10.00 (Minimum Fee is �15.00) $10.00 for the first $500 plus $1.50 for each additional �100 or fraction thereof, to and including $2,000. $32•50 for the first �2,000 plus $6.00 for each additional $1,000 or fraction thereof, to and ineluding $25,000. $170.50 for the first $25,000 plus $4.50 for eaeh additional �1,000 or fraetion thereof, to and including $50,000. $283.00 for the first $50,000 plus $3.00 for eaeh additional �1,000 or fraction thereof, to and including �100,000. �433.00 for the first $100,000 plus $2.50 for each additional $1,000 or Praction thereof. DRIVEHAY DEPRESSION ESCROii (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 curb and gutter and install a 3 foot wide approach With 6 ineh depth - DriveWay width plus 6 feet times $15.75 VERIFICATIOp OF FOUNDATION Permits for constructioa Will be issued a minimum of 2u hours from the time of application to allow for proper review of the proposed strueture and of the construetion site. A Certificate of Survey of the lot, showing the location of the foundation onee it haa been constructed will be required before proceeding with the framing. �. _ ..� � [p a~o r w r• � n e� r�n x .3 h7 � � � ro o � y N m E F� � � � n � < � o \ � � M Q Y � � z � �n ee � � 0 o � y, '� m � n � � 0 � � . ,p d • m �0 �b c* � r m W w H m rr w t�! m � -- � I m m H �- o n o � ]' vzi o r a K tn '. '�] W t� m t� v� `" 0 0 tA fp i/l N 0 � ro� cz N � �3 � in rh � O "=J H� �� mro x� �� C9 ro � � H H � � � O O G� L� �C � m iC x1 n W W O '] z w w o a a�e w w r m� p� �+ �+ r+ r* 9 a w cr o m a r► E m b n� o E K p �°+ a a k o c�� o d ro � r �� rt«3 rt r a oo rn r� m x N W N fi W rt W M fA � �+7 rt n m►s �e �o � w w ro w w a W fD M W W fD O C6 �'1 m w m� a r� m m`.Q rr �p a � w N m w m M m ,r w C C a � K x m �o w to a m m " ro w rmi � � W k w � rt � x a � rt � � 'o r c � z c� '17 rr H C � � � � �--�I rn N f'� S z �c o m tn +n tn �n tn v� �n v� ( m {n t� m in � r r 9 O o tn �t ln Vt ln u+ tn �P F-� w tn �„j 0 0 0 0 0 0 0 0 0 o v� u, o � 0 0 0 0 0 0 0 0 0 0 0 0 0 iA tA iA L/ iA iA f/) iA iA N iA tA i/l y 0 H ta-' � z � < �� 'y M �~ N o ro ?d � � � y �f�D N t lnl .� 0 c � � ro H tn N � � o w �e . py � a a � � Stories � � n n a e z Closets E �,� Urinals 7C � � � B&�'1 Tllb3 � � Basins 0 a ] sinks � '� Wash Trays a �. Drinking ,q Fountains Showers � Floor Drai O � Catch 1D Basins 0 aAutomatic E Washer F" Gas Appl. � Misc. Fixt g y Gas Range a m c* E �° K Other .�' w m� a r m r�t n � � y � � z � � M � � O � � O �g � m rrh1 C C O � � � y d � 4�] � ro r�° eH � � ,, y � o ( � �V C � � � N H �. ^ o � - V � � � � � �a� � �,�rop� a W CM� ae O M ?� � r w � u+ �-n � � �� aa ��a� m �a f0w � �ao `° „ M � � O � t�n � M N� �G a F� � �ro�"� a �' ��} o k e W 6 W 9 o � �, � � r � E w �Mk'� � � w � w . K �p, n � y W K A ^ � rr w w o F�'� � f1 � ban� � O W � � wro a -o v r c� D � 0 z 'n 0 � � E �' 3 - W -G 6'1 O T D Z C7 � � � a d N rm T -G � Z G) -v m � � � � W � � � � y. � m W M � k F'� N � �� - �� w a�rtKx' I1\-\ 8 � a n � � � rt m -n � n � < fD w° 3 � � m SUBJECT c�ty of Fridley -� AT THE TOP OF TME TWINS g U I L D I N G P E R M I T ��' f i� � COMMUNITY DEVELOPMENT DW ��NO. Ly �� r � � PROTECTIVE INSPECTION SEC. ' � ��ti � CITY HALL FRIDLE� 55432 NUMBER pEV DAiE PAGE Of APPROVED BV �'""� � �'' 612-571-3450 910-F15 4/3/95 / / JOB ADDRESS 6926 Hickory Drive NE t LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 13 4 Ostman's Third SHEET 2 PROPEiiTY OWNER MAIL ADDRESS 2�P PHONE Brad McDonald 6926 Hickory Drive NE 574-1458 3 CONTRACTOR MAIL ADDRESS Z�P PHONE IICENSE NO Panelcraft of Minn Inc 3118 Snellin Ave S, M ls., MN 55406 721-6628 2179 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGtNEER MAIL ADDRESS Z�P PHONE LICENSE NO 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW � ADDITION ❑ ALTEFIATION � REPAIR ❑ MOVE O REMOVE 8 DESCRIBE WOHK Install gutters & downs outs 9 CHANGE OF USE FROM TO STIPULATIONS TVPEOFCONST. OCCUPANCYGROUP OCCUPANCYLOAD SEPARATE PERMITS ARE REOUIRED FOfi ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 OAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING I HEREBY CERTIFV THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES AND KNOW THE SAME TO BE TRUE AND CORREC7. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $2,133 $1.00) DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pEfiM1T FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- @ STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. �S�F.00 Fire SC �pL.13 PLAN CHECK FEE TOTAL FEE License SC $5.00 $62.19 SIGNATUAEOFCON'RACTOAOAAUTMOA�ZEDAGENT iDnTEi WHEN PqOPERLY LIDATED THIS IS VO R PERMIT C � 7�� SiGNATURE OF OWNEHUi OWNER BUILDER� �DATE� L- �NSP ��F � � Effective 1/1/93 a� � � NER� [ ] � ADDN [ ] CITY OF FRIDLEY �'� �Cci ALTER� SINGLE FAMILY AND DUPLEXES R-1 AND R-2 �!! �� Building Permit Applica.tion , Cons�ruction Address: �� -�� $�'� �� ! ��. � � _ .. , , r. ° Legal Description: Owner Name Address: ` � ( ��,�'fy1Q�''�� ___ Te1. #��1� —l`-(� Contractor: vrU1Z � MN LICENSE #(1oc� a! 79 Address: %� � � 5� a 6 Tel. # 7� �-� 6 a 8 A ch to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT LIVING AREA: Length Width Height GARAGE AREA: Length ' Width Height DECK �REA: Length � Width . Hgt/Ground OTHER: sq. rt. Sq. Ft. � Sq. Ft. � � Corner Lot [] Inside Lot [] Ft. Yd Setback Side Yard Setbacks Type of Construction: (� ' d—� � Estimated Cost: $ 2 �� =�j Approx. Completion Date. t--� �� (Cost on Backj Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$, DATE: '�� APPLICANT: �� ,c� /�(�p� � Tel. # 7a/ � 6 �.�' Permit Fee $ �:��' Fire Surcharge $ �- ,� State Surcharge $ /. � � SAC Charge $ License Surcharge $ �, L`�C� Driveway Escraw $ Park Fee $ Sewer Main Charge $ TOTAL $ Cla� � � / STIPULATIONS: CITY USE ONI.Y Fee Schedule on Reverse Side .001 of Permit Valuation (1/lOth%) $.50/$1,000 Valuation $750 per SAC Unit $5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above , Fee Determineti by Engineering Agreement Necessary [ ] Not Necessary [ ] SUBJECT City of Fridley AT TFIE TOP OF THE TWINS g U I L D I N G P E R M I T i � � � � • COMMUNITY DEVELOPMENT DIV. � V y ��'��'� r � � PROTECTIVE INSPECTION SEC. L--__� ��"' �,� CITY HALL FRIDLEV 55432 Nu�uBER i 612-571-3450 910-F15 JOB ADDRESS 6926 Hickory Dr .�.g� t LEGAL LOT NO. BLOCK TRACT OFi ADDITION DESCR. 13 4 Ostman's Th 2 PROPERTY OWNER MAIL ADDRES$ Brad McDonald 6926 Hickory Dr NE 3 CONTRACTOR MAIL ADDRESS �X� Owner 4 ARCMITECT OR DESIGNER MAIL ADDRESS 5 ENGtNEER MAIL ADDRESS 8 USE OF BUILDING Residential 7 CLASS OF WORK REV I DATE 8/5/98 ZIP � 26996 �l�o� OF APPROVED BY � SEE ATTACHED SHEET PNONE i74-1458 PHONE LICENSE NO. PMONE LICENSE NO. PMONE LICENSE NO. O NEW 0 ADDITION O ALTERATION C� REPAIR ❑ MOVE � REMOVE 8 DESCRIBE WORK 9 CHANGE OF USE FROM STIPULATIONS TO Underlayment must comply with State Building Code. TYPE OF CONST. SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBIN(i, FIEATIN(i, VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OF CONSTRUCTION 20NING AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION ON WORK IS SUSPENDED OR ABANDONEO fOR A PERIOD OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS I HEREBY CERTIFV THAT I NAVE READ AND EXAMINED THIS APPL�CATION AND KNOW THE SAME TO BE TRUE AND CORREC7. ALL PROVISIONS OF LAWS VALUATION AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHEF SPECIFIED NEREIN OR NOT. THE GRANTING OF A PERMIT 2 DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pEfiMITfEE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. �7/1_75 OCCUPANCY GROUP OCCUPANCVLOAD STALLS CU.FT OFFSTREET PARKING IGARAGES ATURE OF CON7RACTOR fCA�TMORI2ED AGENT IDATEI EN FO IDA THIS I�Y.QUR PEF � i c�i �•r , C" �� f -,J^ �� > / s% �rS� 1�/ c.,� c� �� E OF OWNER i OWNER BUILDER� iOATEi I oi .�tieo � ne. NEW ADDN ALTER �l [l [l ConstructionAddress: I.egal Description: CI1'Y OF FRIDLEY SINGLE FAMII.Y AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION 0 � Effective 1/1/98 �a� Da �� R Owner Name & Address: ��f/ /r)%,_ �/�„-��,/�° (ol�l, g�/c,�o��r//L Tel. # ,� 'J�,/ -/y,� � Contractor: �� v �. �j � ,6P„s MN LICENSE # Address: �,p,� . Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. LIVING AREA: GARAGE AREA: DECB AREA: OTHER: Length Length DESCRIPTION OF IlVIPROVEMENT Width Height Width Height Width Hgt/Ground � Sq. Ft. Sq. Ft. Sq. Ft. v .�- Construction Type: Estimated Cost: $ �(�� -� � (Fee Schedule on Back) Driveway G�rb C�t Width Needed: Ft. + 6 Ft = Ft x$ _$• DATE: $ - �'- � APPLICANT: Tel. # �� / -/!� �3 Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL . STIPULATIONS: $ $ $, $ $ $ $ � �, � CITY USE ONLY � � Fee Schedule on Reverse Side .001 of Permit Valuation (1/lOth%) . �.50/$1,000 Valuation _ $1(�0 per SAC Unit _ $5.00 (Sta.te Licensed Residential Contractors) Alt. "A" or Alt. "B" Above $450.� Conservation Plan Review _ Fee Determined by Engineering _ Agreement Necessary [ ] Not Necessary [ ] $ � .� �UII.DING PERMIT FEE SCHEDULE The Chief Building Official shall, before issuing permits for the erection of any building or structure, oP for any addition to any existing building or structure, or for any alteration or repair to any existing building or structure, upon application therefore, require the payment by the applicant for such 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 $2,000 $2,001 to $25,�0 $25,001 to $50,000 $50,001 to $100,Q00 $100,�1 to $5(�,U00 $500,001 to $1,000,000 $1,0(�,001 and up FEES $21 (Minimum Fee is $21 plus surcharge) $21 for first $500 plus $2.75 for each additional $100 or fraction thereof, to and including $2,000 $62.25 for first $2, 000 plus $12.50 for each additional $1, 000 or fraction thereof, to and including $25,000 $349.75 for first $25,000 plus $9.Q0 for each additional $1,000 or fraction thereof, to and including $50,000 $574.75 for first $50,000 plus $6.25 for each additional $1,000 or fraction thereof, to and including $100,000 $887.25 for first $100,000 plus $5.00 for each additional $1, 000 or fraction thereof, to and including $500,000 $2887.25 for the first $500,000 plus $4.25 for each additional $1,000 or fraction thereof, to and including $1,Otm,O� $5012.25 for the first $1,000,000 plus $2.75 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 $13,50. Alternate "B" : Removal and replacement of curb and gutter and install a 3 foot wide approach with 6 inch depth - Driveway width plus 6 feet times $15.75. VERIFICATION OF FOUNDATION Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper review of the proposed structure and of the construction site. A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed will be required before proceeding with the framing. ��. �.Q, g D � o � � co Q: yfD . 't O H � A 1 � o � � � O a� 0 �� • n� ° � ma � � ?. � d � � `� Q- o � � � � ,��° Q. � � 0 c .�. D '� v � O < cfl a W � m Z � � m Ci '_i O z �'I m rn ? V 0 0 \ 2 � C� _ a � Z � � c� � � - Z ' o c 00 3 � n�i � D '--I m T � a o� II1 ^ , � �� \ � \ � � � � � �\ s � s � �� C!� O• � D � r � 'n c m � m �. a► � � � � � � , � �o d � n 0 �3 � � O� A � \ � c, �. N a� � �= -� n fD 0 � O � � � � y � � 3• c��u cD c�'o � cfl � .�+ -��. �' C�D � fl1 rt a1 O cSD�ODU � N W �. CD rt _. � Q fl: o' -r � � ��go� ,y, _<' a► 3 ? N � � N � O cD � � � � � �..0 n�C:`y'� � � rt n � m rt � � � � � lD Q. n -'` � A � O ��°' l�D � 'Q � N (�p � o- -� 3 � d �. �: O �-► � .-w � � rt O — ? •�► h � � � �D Ci CD �� o u! O T � � � p� . N c�D > > � O °. � < � N H � m �. � D � N � � �� D m � O �*; �o � O y � r � � O Z � a n � � C W � c� � �� oQ � 0 � 2 ' � � "Y) � N c� z O m' � z D G7 � N o � � � ' 1 � a N N � N � � � � O O � � D-ne�p d a� N � H d � � '� n � � -p_ �n c� � .. � � � d � d c Z� � m ^' � rt � a� � Q . � � �a�'�o _ � cD � � C � r: � o�i 'ny' � ?�� o � � � � .�r«, � � ao 7 � 61 j � �fD � • � � � � 0 0 ov � O O O .� n` cD � � �, i � V � O u, � � ��-�Z �c�° � o cfl ,..,, �Z 2 m � �3 � � J � 1 = T� � � O �j `C� oi "' c� O � � � > > m CD w^ a. '* � � r N Qmz3 � � O � 2 0 � � .-► tD v � n v � W C � c D � � z m � � C � � � ;-� D r �N � d � � m � � -i z O �..V �\ t,� KJ � n � "'� t�1 N t'� i m � C r m cn��n NQ.(W'� W cD ►-� � o� C O A��•� Z c�D � � `� m N < -C co Z Z N m� m c� -i O z � � D � � z � r �� 5'! a rn ,� �O � � O� Z� Z� � � aD � oN Z D g� �v o= � zm � Z -Di D � Z c° �� N n m � mo° �r aZ Z � �`�. G < � v� <_ ig�, m D N � � ? n � � � �. \ � c� <' � 0 7 � r O r-� � co � CAII�i INEY ANi) STACS VERIFICATION The undersi�ned herebq verifies that the existing chimney or stack: 1. Has been carefully examined Yes () No () 2. Is free from rust or dsterioration _ 3. Has no foreign objects lod�ed within 4. Is securely supported 5. Meets all current Code requirements for size and total BTU's conaected 6 Has total heating BTU's of All other BTU's . TOTAL BTU's 7. Has a liner been provided for water fieater 8. Has combustion air been providzd for water heater kemarks: List ALTERATIONS Bein�_ Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes()No() 3�es ( ) No ( ) Yes()No() HEATING CO: Signed By: Date: