AF - 45719SUBJECT P
City of Fridley 16 6 8 3
AT THE TOP OF THE TWINS B U I L D I N G P E R M I T �
�
� � RE .
� `v ______ COMMUNITY DEVELOPMENT DIV.
r j � PROTECTIVE INSPECTION SEC. %j �� T1
' ( Ld
1 . �
� � /�"1 � CITY HALL FRIDLE� 55432 NUMBER REV. DATE PAGE OF APPROVED BY
�----� • •�� 612-571-3450 910-F15 7/16/82 / /
JOB ADDRESS 6941 Hickory Drive N.E.
t LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
OESCR. 2( ], �3'�dSl� S Third Additi.on SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
Roger Wilson 6941 Hickory Drive N.E. 571-0151
3 CONTRACTOR MAILADDRESS ZIP PHONE LICENSENO.
same
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
6 USE OF BUILDING
RL Sl �rit7.3�.
7 CLASS OF WORK
❑ NEW X ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
S DESCRIBE WORK
Construct a 12' x 24' Addition to Dwellin (Three 5eason Porch with Ba.sement)
9 CHANGE pF USE FROM TO
ST�ULATIONS
�♦�Il��
Before di�in� ca� lec�i t�N�
ElEPH9N� • fLECi�lC • GAS �f�
��QU1R�� BY LAW SEP�RAfiE PE�MI�s ��Qu�r�o �oR v��
HEaTrMG. P�.t1�8tw�. ANA S�t�.
SEPARATE PERMITS ARE RE�UIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTII.ATING OR AIR CONDITIONING. WOOCI Fl"�2
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 DAYS AT ZHS
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 PFOVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GQVERNING THIS TVPE OF WORK WILI BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $6,850 y�3.43
DOES NOT PRESUME TO GIVE AUTHOFITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. SGZ.SO NONE
PLAN CHECK FEE TOTAL FEE
$15.63 $81.56
SiG A REOFCONTRf TORORA THOFIZ DAGENT tDarE� WHEN PROPERLY VALIDATED THIS IS YOUR PERMIT
� �1- �� q ��� �
SIGNATURE OF WNE iIF OWNER BUILDERI DATEI BLDG INSP � TE
G
CITY OF FRTDLCY Effective Aug. 1, �9s1
APPLIGIITI�'� FO�� RCSIDCiJTIIIi_ QUILQIf�G PCftf�iITS
(Ne►r, Alterations, Additions, or Repairs)
O�JI�ER: __��c.4�.�� ��--
ADDP.ESS : � _����T d R . �,
TEL IVO: ��%�— D f�5 �
. �
9
I3UI LDER : (� C,�J �?�/ ��_
AODRCSS:
TEL f�0:
Construction Location
•� STJiI�T NO : � / , STItEET: � � (/
LOT: HLOQC: ADAITION:
Corner Lot: Insiiie Lot: Setback: Sideyards:
Ap�licant attach to this orm two Certificates of Swrvey of lot and
proposed building locati drawn on certificates to scale.
3�"�''^- C1�� �, DESCRIPTIOiJ OF CUP�STP.UCTIO�J
�� �a � T��� ��bnt��� �epth: Aeight: !
�5quare. b'cet: , Gtibic Feet:
_ �ront: ID�:y�th: He3glat:
Square� FePt: Cvbic Feet:
2�5� 23•�S =G$�8.
Type of Cor,struction : � O �
Zb Be Onr.�pleted: ��/� � 1-- f Q��
.r��_�.
� . G $S� �,
Estimated Cost: �
Alt, A Alt. B
Broposed Drivc��ay Width If New Openinq Ys Desired: $� $
� , , SE� REVERSE SIDE OF SHEET ,
Ziie undersigned hereby make� application for a permit for the �:ork� herein specified,
agreeing to co ,all work ir, strict accordanec ��ith the City of I'ridley Ordinances �nd
rulings of the DeZk�rtmc�nt of Buildinqs, and hereby declares that all the facts and
represr�tations stated in this �pplication are true and correct.
DATE: lp / � — � � SSGNATUI2E :
Stipulations:
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BiJILDING PERMIT FEE SCHEDULE
The Inspector of buildinqs shall, before issuing permits for the
erection of any building or structure, or for any addition to any
bxistinq building or structure, or �or any alteration or repairs
to any existinq buildinq or structure, upon application therefore,
require the payment by the applican� f or such permit of fees to the
amount berein below set forth and iai the manner herein pronided to-wit:
TOTAL VALUATION
$1.00 bo S500.00
$501 to S2,000
52.001 tc $25,000
$25,001 to $50,000
$50,001 to $100,000
$100,001 and up
FEES
$10.00 Minimum Fee $15.00 plus surcharge
$10.00 for the first 5500 plus $1.50 for each
additianal $100 or fraction thereof, to and
including $2,000 �
$32.50 for the first $2,000 plus 56.00 for each
additional $�,000 or fraction th ereof, to and
includia�g $25, 000
$170.50 for the first $25,000 plus $4.50 for
each additional $1,000 or fraction thereof, to
and incauding $50,000
$263.00 for the first $50, 000 plus $3. 00 for
each additional $1,000 or fraction thereof, to
and inc.�uding $100, 000
S443.OQ for the first $100,000 plus $2.50 for
each ad�3itional $1, 000 or fraction th�reof
PLAN CHECK: 2� pere�e:n� of bu�ldi:ng g��it fee
DRIVk�VAY DEPRES�ION ESCROW: Concrete Q1rb Streets Only
Alternate "A": Removeal and replaceinent of curb and gutter only
Driveway width plus 6 feet x$13.50
Alternate "B": Renoval and replacement of curb and gutter and install a 3 foot
wide approach with 6 inch depth
Driveway width plus 6 f eet x S15. 75
VERIFICATION OF FOUNDATION
Pern�its for construction will be issued a minianinn 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 Suzvey of the lot, shcwing the location of the foundation once it
has been constructed will be required before proceeding with the framing.
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sue�ecr PERMIT NO.
City of Fridley � � �
AT THE TOP OF THE TWINS g U I l D I N G P E R M I T ��� �+�
i�
� �
� ; L __��� COMMUNITY DEVELOPMENT DIV
r � � PROTECTIVE INSPECTION SEC �
� �
� , /'��\ � CITY HALL FRIDLE� SS432 NUMBER REV OATE oAGE OF PROVEO BV
�'""� � ��' 612-571-3450 9�0-F15 / /
JOB ADDRESS 6941 HICKORY DR NE
1 LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 26 1 OSTMANS TIiIRD ADDITION SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PNONE
RODGER WILSON 6941 HICKORY DR
3 CONTRACTOR MAIL ADDRESS Z�P PHONE UCENSE NO
WANDREI CONSTRUCTION 95 SUZANNE AV COLUMBIA HIEGHTS MN 55127 483-6766
4 ARCHITECT OR DESIGNEFi MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO
6 USE OF BUILDING
RESIDENTIAL
7 CLASS OF WORK
❑ NEW � ADDITION O ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
3 SEASON PORCH ADDITION
9 CHANGE OF USE FROM TO
STIPULATIONS
SEE STIPULATIONS ON PLANS
SEPARATE PERMI7S ARE RE�UIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GHOUP OCCUPANCV LOAD
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION CU. FT.
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAVS AT
ANY TIME AFTER WOHK IS COMMENCED.
NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFV THAT I HAVE READ ANO EXAMINED THIS APPLICATION STALLS
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS GARAGES
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED VALUATION SUHTAX
WITH WHETHEFi SPECIFIED HEREIN OR NOT. THE GRANTING OF A pEFiM1T 3• 77
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- SAC CHARGE
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION 99.00 IRE SC %.S�F
P � PLAN CHECK FEE TOTAL FEE
ca"'"� _' L -�.(.�� ' /$' " 115 . 31
SIGNATUREOFCON�HACTOA AUTNOR12EDAGENT IDATEI
- E R � ALIDA7ED THIS IS YpUR PERMIT
S�GNnTURE Oa pWNEa �ic OWNER BWLDEPo iDATE�
' ���'"'&��
BLO �NSP
ri�7E
� i , '
NEW [ ]
� � :��DDN ��� ` �
ALTER [J
:: . ... . , .. . . . - •C�TY �OF FRI�LE'Y � . .:. . ..:.
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
ConslructionAddress: (o��- ( �)1C�1�' ��„ 1�1 �
Lega1 De�cription:.
Owner Name & Address:
o_ Inn r,
Effective 1 / l l95
Address:
� � - � � Attach to this app�icatiot�; a Ce�ificate oi SuFV.ey of the . � � � . � � �
1ot, with the proposed construction drawn oa .it to scale.
DESCRIPTION OF IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft. _
GARAGE AREA: Leagth � Width Height Sq. Ft. , 3y
DECg AREA: Length /� � Width /� � HgtJGround Sq. Ft. �' % �' 7,
OTHER: °� SF��� �r�fZ� ,1k� �t `rfC7l� IG `� � ���C lS'�.� _ /,3��; 7'�
„
-�- /. � `�r l� �' ,�-j, 3/ s.f..�.�y'
�
Comer Lot [] Inside Lot [�, Ft. Yd Setback �D Side. Yard Setbacks I� � ".�7r�r ��
T� of construction: �..� �i s1�� e1. Ca b,�. Estimated cost: $ 3�,�a�0 ���3`�, ��z
YPe ��C� , P�-
Approx: Completion Date:� (��p- ` � �'� � � � � � � .
(Cost on Backj �
Driveway Curb Cut Width Needed: Ft. + b Ft = Ft x$ _$ Z-84ro`�
DATE: � APPLICANT: 9 Tel. #��.. �� Z.�o
- I" ��, ��..._
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
$ �'
$ �, �N
$ 3, ��
$
$ � ��:/C)
$
$
$
$
Fee Schedule on Reverse Side
.�1 of Permit Valuation (1/lOth%)
$.501$1,� valuation
$850 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt °A" or Alt. "B" Above
$450.OQ Conservation Plan Review
Fee Determin� by Engineering
Agreemeut Necessary [ ] Not Necessary [ ]
s ll�,.� w_-
13U11_UIN(: PERMI"[' FGL' SCt[EDULE
�17ie (;hi�f I3uilding Ot�ticial sfi�all, tx;fore issuing permits for [fie erection of any building or struclure,
ur ti>r any aciciiticm tu nny cxisting building c�r structurc, or for any aileration or rcpair to any cxistin�;
t�uiliiing <�r structurc, u�n application ihereCore, require t#te payment by the applicant for such �ermil
�>1� tee;s tc� the amount hcrcin t�clow ��ct torth and in the manner herein �rovidul to-�vil:
"1'O"1'AL VAI_Ill?
� 1 to $500
�501 to �2,0(}0
$2,001 to $25,000
$25;001 to �50,000 -
$50,001 to 5100,000
$100,001 to �500,000
$SOO,OOi to $1,000,000� -
I=ri:S
$t5 (Minimum Fce is $15 plus surcharge)
$15 for Cust $S00 ptus $2 for each addiaonal $100 or
fraction thereof, to and including $2,000 �
$45 for fust $2,000 plus $9 for each additionai $1;000
or fraction thereof, to and including $25,000 • _
$252 �for fust $25,00p pt�s $6_50 for each additionaI $1;000
or fraction thereof, to. and inclading $50,000 �
$414_SO for first $50,000 plus $4S0 for each add.itional
$1,000 or fraction thereof, to and including $100,000
$63950 for fYrsi �$100,000 plus �$3_SO for each additional �
$1,000 or fraction ttrereof, to and includiug $SOO,OQO
$2039_SO for die fust $x10,00p pins $3 for each additional
$1,000 or fraction tl�ereof, to and including $1,000,(}00
$I,000,001 and up $353950 for the fizst $1,000,000 plus $2 for each additional
� $1,000 or firaction thereof -
DRIVEWAY DEPRESStOM ESCROW
(Concrete Curt� Streets Only)
Aiternate "A": Removai and replacement of curb and gutiter only - Driveway width plus 6 feet times
513_50_
Alternate "B": Kemoval and replacement of curb and gutter and install a 3 foot �vide
approach with 6 inch depth - Driveway width ptus 6 feet times $15_75_
VCRtF[CA"CION OF FOUNDAT[O[V
1'ermiLS for corutniction will be issued a minimum of 24 hours firom the time of application to allow
for proper revicw of tt�e pro�se;d �tnicture and of the coiutruction site_
A Ceriitic;;itc oC Sucvey of t�ie lot, showing [he location of die founciation once it hat it has bccn
constructe�i �vill be rc;yuire�cl betore proceeding with lhe framing.
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� �-� 14-17'y�+ t_7'�: 1�HI'1 rft'�_II'1 KUYHL l_.1 Ify:=���:1i-i I IlN.'Y � U �� 11��'r' F'. Q1
. _ _ • , .
14 August 1995
Gity ofFridley
7nspection Ditv�ts�ta�
6431 Univer�ity ,A.ve �
Fridley, N�T 55432
11�lir �a�xy Riesch:
�uSt�ri"i
Enviranm►e�ts
Tvis is the n�f�x;t�,at�on ycru reqvested �oar th� reside�tial a,pp�i�tion at 694I H`xckdry I3r NE.
Pa�e 3 a£A�awing:
The engine�xed parall�l chard ttusses are siz�ed and ac�co�no��y this Fax
1'he �eered b� is 3 1/2" x I.2° cca Ivl
Page S of Dxaawi�atg
'Ihe e�agia.ee�red woad beam is 3 112" � 12" cca lvl
I a�.so hsve mcluded the en�,eer�ug providad by t�te pxuduct m�ufactu�cex
�'he pra�t wi`!1 be co�st�uc�ed under the sup�iivision ofMattso�acDonatd, st�uctwra� engiaee�s
at � 5�� Vt� Lake St, N�pl,s 827 �'825.
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Custom Environments, Inc.
2229 Frie�ad,ship iaxte • BW�rtSVilie MN 55337 •(h12) 9443�73 • 1-�00-$92�225
�7N. Siatc Conlractc+r =00�Z86R
L1�-1-11-1'�'��� ta r�._�Hf9 rf�i �f9 t;'UYHL �.��JlV���f:�b�Hl Uk'"i' T�=1 �711c�7 F. F�1
, � • •.a�•rc - Drand fax tt8nsrn�r ` <
tb R'1@r)'fo i�/1 N of pag� s
� QC ieScrl F.�o�,+
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NS P ��
S+�rtember 10, 1995 �x �
Z, Fax �s
�llStazxar �- t 3 cy�
EriVi�'O�e1"�tS
1VV�rr Barry Riesch
City o£Fxidley
I)e,pt dfIn.s��ections
�
r�; 694i I�'ickory Urive NE
..r-
P� accept iu�tta tb�e plans aad ��cificatians far tb�e pxoj�t listed above, the followiuRg
�d.dendum:
�. xop beariug cord trusses require a 3 x 8�edgex '�te ledger will be bohed mto �� btoru.ce rim
and �t on top of a 3116 x 3" aug�ed steel l�g bolted into the block
2. The cord #russes lay aa top of t�e �edge�c a�td do nat require hangers.
3. The � ofthe roofrai�ers is 2 x 6
'�a�k yau for you inquir�, please let us lmaw when tLe pe�xait i�s avai�able.
Siaoer ,
� �
J��oaes Hewitt
CuStUZ�t Ertvironraents, Inc.
2229 Friendship �t�,e • Burnsvillc MN SS� i7 •(6�z) 944r3873 � 1-fiUo-$92-4225
�IN. $lale Coniraetor �2R(x¢
TOTFIL P. �1
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-1�-1'�'?� �y� 2=�Af1 FRCiM �OYAL C:QNSERVATO�Y TC�
. L,��I+'�r-"'.EI �_:fJhJS'+'F,���TInhJ C_CR''�'HhJ`r ��i�i��J� 'J�� • 4��� b76t•
5711G�r ` F.�4�
i?u9.13 15G5 8:10PM P01
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• . QWOtC tt4�e : OTI�
RUa'� WAPV�DRE) CdNST. CoalsEt : Andy BohnQlder
�0�: 1'AAC Sman : DMG
.iob ID : �Loaft mE�asE8
YARP: ��er
• • r ? :a' - �v�'.� -. ., � � � »_ >:.<;. �:` . ;� ; �' ,�,... f •R: i 1 j w �� ,
„ti c . i, ,d�t;. ; soo: a . .'i..""".�.'«•s D• loa • . r..;�. :r °i;: �i?4;w
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��� i '•��� � ' � , � .'i::.ns.�
�`S clnp : i- 7- 3 LevPl Raturn � rop �i.ive : 4�►.op �p .
a.uo ; sso � Ta� a�a : �a.00
R�►�r,t ae�pth : Boaom fl�ad : s.ao
cY!�art,eRtFR�wa,w�rr� „nr��,�, ._ .
�
Nataa : VER/FY TRtlSS DEAi1�d �4" 8/0.
. 8�btofal: 51.116.50
� Dlscopnt : 59.23
��I�a Tax �
Twhl ! 1t.�dd, 47
T�TAL P.B4
wi�h: a cor�q���rav�.e �aai•r�:� .,,. o:�."., .... -- ---- -
leng''ths invoived. There sr.ould �ii�ewiee�be �Sttle proble�
W�'til tft� �78tT8.11$1 t`JOY °iC�:OI�•
Page � 1
20th December 7.994
(ReT. W Smart T4�
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k?�-1�'+-1'��!� �'� • l��t-11'I t'f<UI'I 1';Li 1 HL ��UIY�CKVH I UK T I U � i 11GC� � r.✓Jt
A�'ON C�NS�J�LTAI'�'Y'S
�����
�,�, H8�17�r.
1�1. (0�276) 8�18I
DAVID wddD C. Eag. M. I, Mech. �.
Me��haai.cal En�neering 5tt's►i�es
?he enclosed �,rai�'AS.s for a� Be.y Victoriian with 3
egtra intermedi�te raf�ers assu�;�s a bas�c ground ��ow load
of �3�N/Dd`2, This B��rFroxamatEg �CO 4t� ;.831FT"2 it� Zmperisl
units� The wind velacity �s a2 �.4ctres/seo {115 M.P.H. } w}�i�h
is anly �eacl�ed in the L'.K• arour�3 narthern Scotiand.
In t�}8 �g��, �he xu3.l wiad pre,ssure and stao�e
Ica,ding $re �tot additi�e due to �he higk� negative primary
pressure coe£tiaierit�. Ths w�rs'� rase �e d�piCted, is due
mainiy ta the anow 1o�d�r�� comk�ined with a� �m�ll pOSi�tive
wind coefSi�ient ciuP to $ domxnast opening.
�� �ip member c�ef ? e�t ion and stre�s� 8�re bath iow,
wi�ih: a�or�Q�derable mar�5::� o� a�.fety due to the short
ieng'ths invoived. Th�re srouid �iite�riee be �Sttle problem
v�+ith the pe�rasll�l r�fli °ec�.=o�•
Page � 1
�Oth December ].994
tRef. - Smar� 747
,'.
��12 892 1305
14-1'��5 �9�13AM
FROM ROYAL CONSERVATQRY
TO
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57112B7 P.03
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GLAZE➢ Rr�t}F DESIG?v aVALYSXS F�RE�.SpZ�TERSECT�Nf33A�'�APEXCCR�WNN
WiTH EXTRA 3 I�3TEFtbiEUl?sTE RAF'�
USiNG SOLYD PLASTiC GLAZI?3G �����L�dW � ��D�LECTIONG $�S
ASSUMING � EDGE S�PPJR'f
& 2 EAGE C{�NDITICN FOR GLAZING C��vPPORTED SPAN.
P�O�AAD� N0.58S6pi�D, '0�12-94 15z07
r�ra�a���r���������rr��r.�w��r���
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MOMENT OF iI3ER7iA �'OR HI� �AFT�R�(�bSM�*i�1��4)
SEC�' I ON MODULUS �pR i� I P F.AF?E� . �
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XOiJNGS MODUL%5 FOR HI1' RA� Tr.p
�VEIGFiT OF HI�` RAF'F`ER S�CTI�� (�/�}
bIdINTENANCE DEgD LOAD (`%
Tg,ANSYERSE GLAZ iNG S�PAR�iT zON (���
HI P AAFTER APEX ANGLE I I� PI.3N ( DFGREES )
TppQGRAPIiICAL WIND °PEEU FACfiOR
�XPflSURE � �iE1t��T WIND FACTOR
,� , 3TA�'ISTICAL �III�D SPEED FAC'�OA
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$ASIC WIND SPE�D (M/S�C�
DYNAMICEWTND�PP�ESSUR���(pA�C)
pLASTIC GLAZIN� THICKNESS (u���
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COMBYNED P1�ES"��3R� CCt��FIGI EhTS {CFi & CP2 )
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CHIMNEY AND STACK VERIFICATION
The undersigned hereby verifies that the existing chimney or stack:
1. Has been carefully examined Yes () No ()
2. Is free from rust or deterioration Yes () No ()
3. Has no foreign objects ladged within . Yes () No ()
4. Is securelY �PP�� � ' Yes ( )� No ( )
S. Meets all cuirent Code requirements for size
and total BTU's connected ye.s () Na �)
�6 Has total heating BTU's of
- All other BTU's
TOTAL BTU's
7. Has a liaer � provided for water heater
8. Has cambus�ion air been provided for water heater
Remarks:
Y _� ' �,_ :• �� 11i'
, HEATING CO:
Signed By:
Date:
Yes()No()
Yes ( ) No ( )
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
� � R
� �
� • COMMUNITY DEVELOPMENT DIV.
� � ---�-�-�
r � v � PROTECTIVE INSPECTION SEC. ��
i �
� � /"'1 � CITY HALL FRIDLE� SS432 NUMBER pEV DATE pAGE OF APPROVEO Bv
�""� � �'' 612-571-3450 910-Ft5 10/8/96 � �
JOB ADDRESS 6941 Hickory Drive
t LEGAL LOT NO. BLOCK TFACT OH ADDITION SEE ATTACHED
DESCR. 2O 1 Ostmans Third Addition SHEET
2 PfiOPEi;TY OWNER MAIL ADDRESS ZIP PHONE
Roger Wilson, 6941 Hickory Drive, Fridley, MN 55432 572-8967
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO
Roger Wilson (same as above)
d ARCHITECT OR DESIGNER MAIL ADORESS ZIP PHONE LICENSE NO.
5 ENGINEER MA�L AODRESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Residence
7 CLASS OF WORK
❑ NEW � ADDITION O ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a deck.
9 CHANGE OF USE FROM TO
STIPULATIONS
����������
Be�ore digging call for
ail utility locations
454-0002
REQUIRED �Y LAUV
TYPEOFCONST. OCCUPANCYGROUP OCCUPANCYLOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION 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. OWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFV THAT I HAVE READ AND EXAMINED THIS APPLICATION STAILS GARAGES
AND KNOW THE SAME TO BE TRUE ANO CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WOHK WILL BE COMPLIED � 1 � 22Fj .00 State SC �. 61
WITH WHETHEF SPECIFIED HEREIN OH NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pEFiM1T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING cow- $43.00 Fire SC � 1. ZL
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECKFEE TOTALFEE
$44.83
N'RACT pOAAUTNOAi2EDAGENT IDATE� EN P ERLY V LI EO THI YOUR PERMIT
d • %% 8 "�'�
S�GNnTUAE OF O•NEA � F OWNEA DERi �DATEi B�D P �iFTE
�
e _
NEW
ADDN
ALTER
�l
[l
[l
Constructio n Ad d re s s:
Legal Description:
Owner Name & Address:
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
P
/__���
�� �� �
� ����, - S'���
Effective 3/1/96
C��
,�'� �
��
-�"�'� �,
� Te�. # b/��-s�7�,/°� �° ,�
Contractor: S� � � � MN LICENSE #
Address: s �- �.� Tel. #
Attach to tius application, a Certificate of Survey of the
lot, with the proposed construction dra.wn on it to scale.
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
DESCRIPTION OF IlVIPROVEMENT
Length Width � Height Sq. Ft.
Length Width Height Sq. Ft.
Length �� Width � Hgt/Ground 3�/�'�5q. Ft. 1��
Comer Lot j] Inside Lot . Ft. Yd Setback Side Yard Setbacks
Tyge of Construction: _ ,P �C Estima.ted Cost: $ la��
Approx. Completion Date: � � �
(Cost on Back) �
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: AP�'LICANT: Tel. #
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
� 3. Ov
� / � �—
$ . ��
$
$
�
�
�
�
� •8-3
� CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth%)
$.50/$1,� Valuation
$900 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Fee Detennined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
�
i%/�
s�� y � ��
�
� b�� B G PERMIT FEE SCHEDULE
��� �
� �
e _ �
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 altetation 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 $25,000
$25,Q01 to $50,000
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, OQO plus $12. 50 for each additional $1, 000
or fraction thereof, to and including $25,0(?0
$349.75 for first $25,000 plus $9.00 for each additional $1,000
or fracfion thereof, to and including $50,�0
$SO,QQ1 to $100,000 $574.75 for first $50,()00 plus $f.25 for each additional
' _ $1,OD0 or fraction thereof, to and including $100,000
$100,001 to $SOO,OOQ
$SOO,�Y to $1,OOO,QQO
$1,OOO,p01 and up
�887.25 for first $1(m,(�0 plus $5.00 for ea.ch �additianal
$1,000 or fraction thereof, _to aad including $500,� '
$2887.25 for the first $500,000 plus $4.25 for each additional
$1,0� or fraction.thereof, to and including $1,000,000
$501�.25 for the first $1,000,(�?0 plus $2.'75 for ea.ch additional
$1,�0 or fra.ction 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 instali a 3 foot wide
approach with 6 inch depth - Driveway width pius 6 feet times $15.75.
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper
review of the proposed structure and of the consttuction site_
A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed
will be required before proceeding with the framing. �
z
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SUBJECT
City of Fridley 2 6 0 7 9
AT THE TOP OF TME TWINS g � I L D I N G P E R I
r
; � RECEIPT .
� `� � COMMUNITY DEVELOPMENT DIV. � ���
r � � PROTECTIVE INSPECTION SEC.
1 ` �
� /'�'1 � CITY HALL FRIOLEr 85432 NUMBER REV DATE PAGE OF APPROVED BY
�""'� � �'' 612-571-34b0 9t0-F15 5/22/98 / /
JOB ADDRESS 6941 Hickory Drive NE
i LEGAL LOT NO. BLOCK TRACT OF ADDITION SEE ATTAGHED
oesca. 26 1 Ostman's Third Addition SMEET
2 PROPERTY OWNER MAIL ADORES$ IIP PMONE
Roger Wilson 6941 Hickory Drive NE
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
New Haven Construction Co 4208 83 Ave N, Brooklyn Park MN 55443 566-5225
4 ARCHITECT OR DESIGNER MAII ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADORESS Z�P PNONE LICENSE NO
6 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION C� REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Partial House Reroof (23 Sq) Tear-off
9 CHANdE Of USE FROM TO
STIPUCATIONS
Underlayment must comply with the State Building Code.
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL. PLUMBING. FIEATIN(i.
VENTILATING OR AIR CONDITIONING.
TFIIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION 20NING S�. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 8D DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOF A PERIOD OF 120 DAYS AT
ANV TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION � STALIS GAFAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TVPE OF WOfiK WILL 6E COMPLIEO
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT �1�915 �.96
DOES NOT PRESUME TO GIVE AUTHORITV TO VIOLATE OR CANCEL THE pEqM1T FEE SAC CHAiiGE
PROVISIONS OF ANY OTHER STATE OR OCAL LAW REGULATING CON-
STRUCT OR THE PERFORMAN E OF ONSTRUCTION. �E)L.LS Fire SC �I..9L
AN CHECK FEE TO L FEE
S �t � Licens C $5. $70.13
SIGNATURE Oi CONTRACTOR OR AUTMORIZED AGENT 1 TEt EN ROP L VALIOAT � HIS IS VOUR PERMIT �/�
� �-/ / � / V
S�GNATUAE OF OWNEA UF OWNEA BU�LDEAI �DATE� BLO N O � pATE
NEW
ADDN
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ConstructionAddress:
CTI'Y OF FRIDLEY
SINGLE FAMII.Y AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Effective 1/1/98
��
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Ixgal Description: . '
Owner Name & Address: ��� �r% S� Tel. �
Contractor• �C „✓ �/�. b,�,.� � _��r. �.� /z► ��__ � :___MN LICENSE #
Address• ��Ci � � ���� ��
�/� Te�. � �G�`� -��"a-� �
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IlVIPROVEMENT
LIVING AREA: Length _ Width Height Sq. Ft.
GARAGE AREA• Length � Width Height� Sq. Ft.
DECB AREA: . Length Width Hgt/Ground Sq. Ft.
,. � �
01'HER:
�
a
� �� '� Estimated Cost: $ �- �— f ��v
Construction Type: � -�-�-- -�
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _$
DATE: � �1 �l APPLICANT: ` Tel. # ✓���^ ����
Permit Fee
�ire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
$ • ��
$ - 9�
$ �
$
$ �,�
$
$
$
$
$ � �
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth%)
$.50/$1,000 Valuation
$10� 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 [ ]
�
BUII.DING PERMIT FEE SCHEDULE
The Cluef Building Official shall, before issuing permits for the erection of any building or structure, or for
any addition to any existing building or stcucture, or for any alteration or repair to..any .existiag building or
structure, upon application therefore, require the payment by the appiicant 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,Q01 to $50,000
$50,�1 to $100,(�0 •
$100,001 to $500,0�
$500,001 to $1,000,000
$1,004,001 and up
FEES
$21 (Minimum Fee is $21 plus surcharge)
$21 for first $500 plus $2.75 for each addirional $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 $9.00 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,�0 plus $5.00 for each additional
$1,000 or fraction th�reof, 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 $1,000,000
$5012.25 for the first $1,000,000 plus $2.75 for each additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
(Concrete Curb 3treets Only)
Alternate "A" : Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50.
Altemate "B": Removal and replacement of curb and gutter and install a 3 foot wide
. approach with 6 inch depth - Driveway vvidth plus 6 feet times $15.75.
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper
review of the proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed
will be required before proceeding with the framing.
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FR[DLE.Y
FRIDLEY MiJNICIPAL CENTER • 6431 UTTIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287
February 1, 2002
Mr. Roger Wilson
6941 Hickory Dr NE
Fridley, MN 55432
Re: Final Inspection at 6941 Hickory Dr NE
Contractor: R A Johnson & Son
Dear Mr. Wilson:
A plumbing permit was issued on March 31, 2000 to install a water heater at your
address. According to Section 4715.28� of the Sta.te Plumbing Code, a final
inspecrion shall be conducted on the work authorized by this permit. As of tYus date,
no final inspection has been called for.
The permit fee thax was paid covers the inspection to make sure the work was
completed according to the Code. We will keep your permit open for another 30
days and if we do not hear from you within this time to set up the inspection, we will
mark the permit "no inspection called for" and take no further action.
To set up the inspection or to have any questions answered, please contact the
Building Inspection Division at (763) 572-3604.
Sincerely,
DJ/mh
SuB�ECT
City of Fridley 3 3 6 8 5
AT THE TOP OF TME TWINS g U I L D I N G P E R M I T
r
; � RECEIPT NO.
� ; v _.���_ COMMUNITY DEVELOPMENT DIV. � �� �
r � � PROTEC7IVE INSPECTION SEC.
1 . �
� � /"'1 � CITY MALL FRIOLEV S$IJP NUMBEp pEV OATE PAGE OF APOppVEO BY
�'""'�� ��' 763-571-3450 9�o-F15 7/10/03 / /
lOB ADDRESS 6941 Hickory Drive NE
1 LEGAL LOT NO. BLOCK TiiACT OR AODITION SEE ATTACNED
oescA. 26 1 Ostmans Third Addi�ion SNEET
2 PROPERTY OWNER MAIL AODRESS 21P PMONE
Donna WiZson 6941 Hickory Dr�ve NE 763-571-0151
3 CONTRACTOR MAIL ADORESS 21P PNONE IICENSE NO
Crysta�. Kitchen Ce�tez� 668 N Hwy 169, Golde� Valle•, MN 55427 763-544-5950
4 ARCNITECT OR DESIGNER MAIL ADDRESS ZIP PMONE LICENSE NO.
�20�
S ENGINEER MAIL ADORESS 21P PMONE LICENSE NO
8 USE OF BUIIDING
Re s ider, t izl
7 CLASS OF WORK
O NEW ❑ ADDITION � ALTERATION ❑ REPAIR p MOVE O REMOVE
8 DESCRIBE WORK
Kitchen Remodey
8 CHANOE OF USE FROM TO
STIPULATIONS
See notations or� plan.
SEPARATE PERf�r%
REQUIRED FOR:
PLUM��I�GG �NQ��OGN�
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, MEATING, T�PE OF CONST. OCCUPANCV GROUP OCCUPANCY LOAD
VEN7ILATING OR AIq CONDITIONING
TMIS PERMIT BECOMES NULI ANO VOID IF WORK OF CONSTRUCTION ZONING SO. FT CU FT.
AUTMOqIZED IS NOT COMMENCED WITHIN 80 DAYS. OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOp A PER100 OF 1T0 DAYS AT
ANV 71ME AFTER WORK IS COMMENCED. NO. OWLG. UNITS OFFSTpEET PARKING
I NEfiEBY CEATIfY THAT I HAVE READ AND EXAMINEO THIS APPLICA710N I STALLS GARAGES
ANO KNOW THE SAME TO BE TRUE AND CORREC7. ALL PROVISIONS OF L,AWS yp�UATION SURTAX
AND ORDINANCES GOVERNING THIS TVPE OF WORK WILL BE COMPLIED @
WITH WMETMEA SPECIFIEO MEREIN OR NOT. TME GRANTING OF A PERMIT y�9�SOO ��F.7S
DOES NOT PRESUME TO GIVE AU7HORI7Y TO VIOLATE OR CANCEL THE pEqMIT FEE SAC CMARGE
PqOVISIONS OF ANY OTMER STATE OF LOCAL lAW REGULATING CON-
STRUCTION OA THE PE OR ANCE OF CONSTRUCTION �Z81.ZS FIYe SC �9.SO
P�AN CMECK fEE TOiAL FEE
ic nse SC $5.G0 �z00.50
� N4T aE CON' n DA Op oUTMOA�ZED AGENT �O�TEi WHEN PROPERLY VALIDATE� TMIS �IS �V UA PE IT
i � , ' \/ ¢�
i {..7
S�GaniUaEO�OwHEA�� OWNEQBwIDEA� iD�TE� LDG �hSO O�if
e
JUN-19-2003 09�20 FROM CITY OF FRIDLEY TO
NEW [ � cmr oF FRID�Y
ADDN ( j_ 6431 University Ave NE, Fridley, MN 55432
AL7ER �� SIINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUIIDING PERMIT APPLICATION
Construction Address: ���I'
Legal Description�
Owner Name � Address:
�
LIVING AREA:
GARAGE AREA:
7635932513 P.02iO3
�ffseetive 1/1/2003
(763) 572�3604 Bldg insp
, _ ,, �
(763) 571-128T Fax � � �� �� �'�
. �' .,
�'� �a. � )
��,� ����
,,� �
Tel. #7�2 a- �// �
ENSE # �
Tel. ���i"� °����
Attach to this applicalion, a Ce�tificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length _ Width Height ,,,_ Sq. Ft.
Length Width Height Sq. Ft.
O�CK AREA: length
, � i--r
OTHER:
NgVGround Sq. Ft. __
�
Construction Type: Estimated Cosr $ �� a� � T�
Driveway Curb Cut Width Needed: _,TFt. � 6 Ft = Ft x$. . _ ffi
DATE: ` f� �(� APPLICANT• Tel. # ��� ����
Call (763) 572-3604 for Permit Fees if ,' mg in applicatio ax to 763�571-7287 if using credit ca�d and we will
call you for card number.
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License SurchargE
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
CITY USE ONLY -
$��.�s Fee Schedule on Reverse Side
S .�� .001 of Permit Valuation (1/10th%)
$ , �5 $.50/$1,000 Valuation
$ $1275 per SAC Unit
$ � � � $5.00 (State Licensed Residential ConVact�rs)
$ Alt. "A" or Alt. "B" Above �
$ $450.00 Conservation Plan Review
$ � Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [ ]
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THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
(`�IL"6".�I� t�l`T� ����T C�I�iI CTC)R AI`� G(]MBl1STIC�N AIR VFRIFICATInN
�en � �Ra _in n Yic in0 f�rance, 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 ven6ng system is plastiGPVC 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 manufacturers specifications. This does
include AGA-GAMA Category I Central Fumace Venting Tables for fan
assisted and natural draft appliances.
The e�� S�n7 �eme�snen air is sized and installed to meet the current codes
and manufacturer's specifications.
When required to ���+-�� e n_��� _em6�ctien air� it will be sized and installed
to meet the current codes and manufacturers specifications.
Yes ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
�e� ; �Ihnae ne�•� ���ntin�iys�,m_, the undersigned hereby verifies that
it 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. 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 () No ()
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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 Btu Input
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
ni r�oe�nnic• �pP�� CZ ��'7�. � Y��� /
HEATING CO: � L � ��� �% : %t� �-��: h
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THE BELOW MUST BE FILLED IN WHEN REPWCING FUEL BURNING APPLIANCES OR THE
APPUCATION WILL BE RETURNED
(��6�IL�p1� <�I�T t�l��'r' CC�RI�FGTOR AI1!D G�I6"BI ISTIC�II Q►IR VFRIFICATI�N
When �epla�inp a�_ eY�.�np ��^ _�, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obsbvctions, �
and is securely supported and firestopped where required. Yes ( 1 No ()
'fhe venting system is plasticJPVC�and meets all current codes and manufacturer
speafications 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 manufacturers specifications. This does
include AGA-GAMA Category I Central Fumacs Venting Tables for fan
assisted and natural draft appliances.
The �Yo�s�e _ome��on s�r is sized and installed to meet the current codes
and manufa�turers specfications.
When required to �n�u a n_�y _eme ��+en a�ri it will be si�ed and installed
to meet the current codes and manufacturers specifications.
Yes ( ) No ( )
Yes ( ) No ( )
Yes( ) No( )
�en �� new ver�tinQy�, the undersigned hereby verifies that
it is a listed assembly and meets the cument codes and manufacturer's
speafications. This does include AGA-GAMA Category I Central Fumace
Ven�ng 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 () No ()
�.. .� �_.�. - .����.� -� .�. -� .��- . � .���.�.�
Applian�e #1 Type BTU Input e Fan Assisted or Nat �
Apppan¢:e #2 Type BTU Input Fan Assisted or Nat _
Appliance #3 Type BTU Input e Fan Assisted or Nat,_
To�l Appliances _,_, Total Btu Input
Common Vent Type Vent Height Diameter inches
Appliaance #1 Verit 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 N
ALTERATI�NS• (�@�ph@�
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U "�, n %'i� � `� " "`'� � � —
HEATING CO: `vT ( l �1 7����'l � ���e�
Signed By. �
Date : �" ���