AF - 46428,�
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City of Fridley, Minn.
BUILDING PERMIT
��: June 15, 1965
Ernest Burkette �.L� Mi11er Co.
Ovvaer: Builder
7 W t St. Mp s.
Adcir�ess Addr�ss
�� ����
N° '7899
5168
No.
� 15
Coraer Lot _
Sewer IIevation
Hughes
8lseet
. Block �
Inside Lot
LOCATION OF BUILDING
Part of Lot
Summit Manor So.
Addition or Sub-Divieion
Setback Sideyard
Fo�mda,tion IIevation
DESCRIPTION OF BUILDING
To be vaed as:
Front �. Depth Height Sq. Ft Cu. Ft
Front Depth i� 3, 000 �. Ft Cu. Ft
Type of Conatruction F�t. Coat —. To be Completed
In canstderatton oP the �tssuancae to me of a permit to construct the building descril�d above I agree to do
th� proposed work fn accorrlance wlth the d�scrlption above �prth end in {� with afl provistona of
ordinanc�es of the dty of FridleY• l���' l/ ��. k p� �_
�
10.00 G.L.Mi1ler�o.
In cro�aideraiion oP the payment of a Pee of $ , permit ie hereby granied to
to construct the building or addil3on es described above. This permit 3s granted u�n
the expr2ss conditia�s that the person to whom it is granted and his agents, employ�s and worl�en, in all work
done iq araund and tipon eatd building, or anypart thereo� shall coffiorm in aII reapecta to the orrliaanceg of
FricIIey, M3nnesota regardin loc�tlon, construction, alteration, maintenaac:e� repair and moving of bufldings
wi� dty limfts aad � permft may be revoked at any tirne upon violation of aay of the provia�tona oP eaid
Allen 3ensen
Building Ins�ctor
�I NOTICEs
TW � doa am emru ths eoestrueH�, � 1er trddns. P��+�e. e�+ 6:a�9, sswu or rrmr. B� wn fo as
tla euqdi� I�tor ter aparata p�rmhs Por f6a� �
� . > .�
APPLICATION FOR BUILD7NG PERMIT
CI1R OF FRIDLEY; MINNESOTA
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OWi�R' S NAME��'�1 e s 7- /� �' f,�� �� LU�LD�:R �,� _/�% 1�s� d �,.
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�nna�ss ���,��,� �nn�ss_ ����=�y� S�� ���� .
LOCATION OF BUILDING
No. 5treet_ Part of Lot �
� /�, �°
LOT / S BL�R�_____��_ADDITION OR SUBDIVISYON � � � '��z �c� ,
Corner Lot Ins3de LOT Setback Side-tYard
�_
S�WER ELEVATION FOUNDATIOR`ELEV�TTON
ApplicanC attach to this form Two Certificates of Survey of Lot and propceed
building location drawn on these Certificatea.
DESCRIPTION OF BtJILDIIVG
To be used as:
�i� 1_a�. � � ^ Front Depth����fleight
Sq. Ft. �2.� Cu. Ft.
Front Dept _� fleigAt
Sq. Ft. � Cu. Ft.
�r�� � � � �
Type of Coastruction � ���� - �� , �� E�timaCed CosC � � � i
To be compleCed _� � ,�,��y �
The undereigned hereby makee application for a permit for the work herein specified,
agreein$ Co do all work in strict accordaace wi.th the City of Fridley Or•diaences
and rulin$B of the Department of Buildiags,�and herebq declares that all the facta
and represeneation$ stated in this application are true and' correct,
DATE � ' �,.�°� �� �
(Sch�ule of Ree Coats can be found on the Beeerse Side).
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. - - � 80iLDING PER1�T FEL SCi�,B �
SECTION 2. The Iaspeator of Buildings ehall, before issuing ang permit for ehe
-,�, erecCion of any building or structure, or for aay addition to any existing build-
ing or etructure, or for any alterations a�r repaire to anq exiatiag building ar
structure, u�on application therefore, recluire the payment.by tUe �pplicant for
sucb peioniti of feea to the amaunt herein below set forth aad in ttle°maaser herein,_
pravided to-wit; , . ,
2.1. For any such permit for the erection of any fire�proaf building,
other than a garage, warehouse, factory or grain �levator, or for the erection
of aay fire-proof addition, for aimilar occupancy, to any existing building,
shall be,aC the,�xate of $1.40 for each one .thoueand cubic feet, or fractiou •
thereof, in such cubical contenta. ' � "" �
2^.��'� --" Fo"r any such permit for Che erection of�any fire-proof gargge,
Warehouae, factory,o� gr$ia elevator, or for the erecti� of anq fire-prauf, ;
, ,,
` additi"ou;-for similar occupsncy, td enjt existing building sball be at the rate
of $1.25 for each •qx►�, thousand cubic� feet, claseif�.ed aa "fireproof" by. �,, a
� SecCi°on" �02 of"-�he Mianeapolis Buildirig Code. � ' ° � �
p }� m " . . . , . • " . , , . .7:4,
AOYSGS , .
2.3. For aay such permit ior�,�h,e;erect�on of any non-fireproof buildiag,
other than a garage, warehouee, factory or grain elevator, er any non-fireproof
additioa, for similar occupancy, to any existing build3ng - permit $1,00 far eacb
one thousaad cubic feet.
GARAGES - _�, . . - . - - - _ -... � _ . __ _ -
`_
2 4_ � " For any such permit for"�he erection of any nvn-fireproof �arege,
warehouse, factorq or grain .elepator, or for the erection of enq non•fireproof
addi��fon,�"'�or si.milar occupancy, to any exieting building or for each auc°h �
building or additiou - ainety cente ($0.90):for each one thoueand cubic feet
or fra�tio�n theiceof, in the cubical cbnten"ts t&ereof with the minimum of $4.00.
� .
�For Cf►e�purpose of camputing fees for bu3lding permits; the cubical contenCs L
of any building or additioa to a uniform height throughout by multiplying.the
ground asea cove"r"ed frrnn a point six (6) inches below the floor ifne of the
basement or cellar to Che average height of the upper surface or to the avezage
.l�eight of the roof..�urface of the main.gable o�-a �itched roof. . ,
2.`5.. For �cepaire or alterat3ons. to aa existin� structure, t1�e f�e4 sha3,�.�
be ae the rate�of $3.00 per�each Five;Huu�red Doller� ($SOO.QO) or fractioa
thereof in the coet of all proposed woric. �
2;6. In no case ahall the fee charge.d for_any permit as set forth in
�eCtioa � 2 `b� Iess tliaa $4.00. . _ . _ -
, . ,
^ `" � �
�-�--.��:y+4. �
SUBJECT
City of Fridley ' 1435
AT THE TOP OF THE TWINS g U I L D I N G P E R M •
�
� � � RECEIPT NO.
� ; y ____ COMMUNITY DEVELOPMENT DIV.
r � � PROTECTIVE INSPECTION SEC.
' i '
1� �"'1 � CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED 8Y
""� � �'� 612-580-3450
910-F15 9/14/77 � �
JOB ADDRESS 5168 Hughes Avenue N. E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR, lcJ 7 �r],gOA � S Stunmit Manor SOIl'�l ACZCIIl. SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
Warren Hansen 5168 Hughes Avenue N.E.
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Fire lace Construction Co. 7301 Iza.ak Walton Road 944-2922
4 ARCHITECTORDESIGNER MAILADDHESS ZIP PHONE LICENSENO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
8 USE OF BUILDING
7 CLASS OF WORK
❑ NEW ❑ ADDITION O ALTERATION ❑ REPAIR � MOVE ❑ REMOVE
X
8 DESCRIBE WORK
Install Fixe laoe
9 CHANOE OF USE FROM TO
STIPULATIONS
ERA�ITS REQI��R� �FO�R �� . s' ��I��i�7
SEPERA'i'E P a� �n� ceil loc�l utiiitie�.
�E�4T1fWG, PLl1htBl1NG �� ��� Before d+� ����R1C - C�S �'�•
. � . ZELEPNON��E� �� ��
R����
TYPE OF CONST. OCCUPANCY GHOUP OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING. MdSOI1�7
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS APPLICATION STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS yALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED.
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $3 �OOO �,� �`�.. SO
DOES NOT P SUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISI S O ANY OTHER STATE OR LOCAL LAW HEGULATING CON-
STRU ION O THE P FO NCE OF CONSTRUCTION. � $�-8.00
PLAN CHECK FEE TOTAL FEE
L $19.50
SIGNATU� OFCON7 ACTORORAUTH IZEOAGEN7 a7E1 WHEN PR PERLY VALIDAT D THIS IS YOUR PERMIT
� ��Y —
SIGNATUREOFOWNERIIFOWNERB ILDERI �� BIOG INSP qATE
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• � � CITY OF FRIDLEY
0
APPLICATIOfJ FOR RESIDENTIAL BUILDING PER��IITS
�NEW, ALTERATIONS, ADDITIONS;.OR REPAIRS)
orn�arR: .,,�/��"��c'°:�' ����sC�'� sozLn�R: �,e�'�'LA��' �G..�s � ��
Addres s : S �� � /f �JC, � Ct'S �►O�; .�C`� Address : � � D % ��AAA _ C,_%A� /� �/� ��.
Tel . No . : `� / ��� /.�o� .
No. �� �a� �treet: „�;.�,..+��+��.��=- �`�^� .�'`'� � d
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LOT : � �
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BLOCY.: � ADDITION: � � �����:'���:"� ^.`
CORNER LOT: INSIDE LOT: SLTBI�CK: SIDEYARDS:
Applicant attach 'to this form Z�ao Certificates of Survey of Lot and proposed
building locati�n drawn on these Certificates.
DESCRIPTION OF BUILDING
To Be Used As:
-�.^���, ?C.��w�:�*� Front: Depth: ' Height:
� ��� ,
• Square Feet: Cubic Feet:
Front:
Depth:
Height:
. � Square Feet: Ctabic Feet:
Type of Construction: ��SEs�r6l�''° �/����9C'F'i�timated cost: $�r.�0�
7.b Be Completed: Alt. A Alt. B
Proposed Drive�vay Width If New Opening Is Desired $ $
(5EE REVERSE SIDE OF SHEET)
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict acc�rdance with the City of
Fridley Ordinances and rulings of the Department of Buildings, and hereby
declares that all the facts and representations stated in this application
are true and correct. See reverse side for additional information.
DATE: SIGNATURE:
Stipulations:
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BUILDIt�G PER��IIT FEt SCN�DULE
SECTION 2. The Inspector of Buildirigs shall, before i_ssuing permits for the erection
of any building or structurc, or for any additian to any exist�ing bua.lding or �tructura,
or for any alteration or repairs to any existing building or structure, upan application
therefore, require the payment by t•he ap�licant for such permit of fees to the amount
herein below set forth and in the manner herein providefl to-wit:
NEW CONSTRUCTION: Single I'amily Homes and Garages: $4.00/1,000 cubic fee�..
PLAN CHECY.: 25 percent of building permi.t fee.
DRIV�WAY DEPRESSION: (Concrete Curb Streets Only)
AlternaL-e A: Removal and replacement of concrete curb and
gutter on1y; Driveway width plus 6 feet x$11.75
Alternate B: Removal and replacement of concrete curh and
gutter and install a 3 foot wide approach with
� 6 inch depth; Driveway width plus 6 feet x$15.40
ADAITIONAL INFOR�IPTION
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 sir. (6) inches below the floor line of the basement or th� cellar to the
average heights of the upper surface or to the average height of the roof surface
of. the main gable of a pitched roof.
For repairs or alterations to an existing structure, the Pee shall be at the rate
of $3.00 �er 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 5ection 2 be less
than $7.50 plus $.50 state surcharge.
VER� FICATIO� OF FOUNDATIO(d
NOTE: Permits �or construction will be issued a minimum of 24 hours from the time
of applicai:ion to allow for proper review of the proposed structure and of tY:e
construci.ion site. •
A Certificate of 5urvey of the lot, showing the location of the foundation once it
has been constructed will be required before proceeding with the framing.
CtRTIFICATE OF OCCUPANCY
Application for a Certificate of Occupancy shall be made ten (1G) days prior to the
use or occupancy of any structure for which a building permit has bee�n issued; and
said structure shall not be used or occupied until a Certificate of Occupancy has
been issued.
�
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�/�8 ��-c� ��=s ���
' a ND�3�D �: Jock Robertson. C,u�nuzitY De�el°�t Administrator
r�ND F'�M: Darrel Clark, Qzief Building Official
I�ND DATE: August 4, 1988
12�Ai�Il�: Foundation Froblens in Carlson's Siarmit Mamr North Addn.
please be advised that sir�e July 21, 1988, I have received calls from six
hameowr�ers wY�o aan Y�res in the vacinity of the 5300 block of Horizon Drive,
requesting that I inspect their house foundations because of apparent
differencial settlenents. Prior to these calls we had inspected 5 other
fourr3ations durirx,� 1987 ar�d 1976 that were in this ger�eral are3..
There appears to be a pattern of things that probably have caused these -
settler.ents to occur or are present at each location:
1. They have all occured durirx� long diy spells (1976, 1987 & 1988) .
2. All have had mature trees growing in the general vacinity of the failure.
3. Yard arrl street settlenent has also occured in front of those Y�nes that had
mature trees in the front yard near the failure.
4. All those that have had soil tests done have had a layer of moisture
receptive ar active soil at or belav the footir�g elevation.
5. All haneaaners have been advised to contact a soils engineer to test and
report their firriir,gs ar,d to suggest the ntiethod of correction.
6. Al l of the i�ees were buil t in the mid 195 0' s.
The cost of repair will deper�d upon the exterit of the failures. We estimate the
cost of such repair to range between a minim�n of $500. �0 to a maximum of
$20,000.00 or possibly higher. One hoane repaired in June, 1987 paid an
estimated $3,000.00 to a oontractor to replace the back wall l32 feet) of their
basanent. That repair oonsisted of the follaving: temporarily supporting the
structure on post ar�d timbers; r��ving the �iack foundation wall and footing;
diggir,g dawn throni�i approximately six feet of clay or silt to granular gravel
at t,�zree locations (each hole was about 4'x 2' )= pouring each hole full of
concrete; pouring a reir�orced concrete grade beam over the top of the new gads
to fonn a r�.w footing= laying up a r�a block wall ; and setting the house back
daan.
A ca�osit map is being maintair�ed t��at shows the reported dates ar�i addresses
of all riePorted pxcablens.
If anyone wants rwre inforn�tion on this subject, please contact our department
arrl we will be happ� to reviav air files. We do have imlividual recorc�s on mch
reported prablem.
Its possible that there o�uld be nx�re failures that have riot been called in for
our review.
DGC/mh
ATI'AQi: Map
CC: Mr. John Flora, Public Works Dir�ctor
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SuBJECT .
City of Fridley 2 5 9� 9
AT THE TOP OF TNE TWINS g U I L D I N G P E R M I T
r
; � RECEIP7 NO.
� • COMMUNITY DEVEIOPMENT DIV.
� `v- ���o
r � � � PROTECTIVE INSPECTION SEC.
1 = �
� /"'1 � CITV HALL FRIDLEr 85432 NUMBER REV DATE PAGE Oi AGPROVED BY
�----� • •'' 612-571-3450 910-F15 4/27/98 � �
�oe nooRess 5168 Hughes Avenue
1 LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACNED
DESCR. 15 7 Carlson's Summit Manor S SNEET
2 PROPERTY OWNER MAIL AODRES$ ZIP PFIONE
Ricic Zdarsky, 5168 Hughes Avenue, Fridley 55421 572-0796
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Milton Johnson Co., 525 Lowry Ave NE, Minneapolis 55418-0000 � 781-9548 2083
d ARCHITECT OR DESIGNER MAIL ADORESS 21P PhIONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
B USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION O ALTERATION g] REPAIR ❑ MOVE O REMOVE
8 DESCRIBE WORK
Roofing, siding
9 CHANaE qF USE FROM TO '
STIPULATIONS
Underlayment must comply with State Building Code.
Building wrap.
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCV LOAD
SEPARATE PERMITS ARE REOUIRED FOR ELECTR�CAL, PIUMBING, MEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID If WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHOF;IZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
Ofl WORK IS SUSPENOED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFfSTREET PARKING
I HEREBY CERTIFV THAT I HAVE READ AND EXAMINED THIS APPLICATION STALIS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALl PROVISIONS OF �AWS yqLUATION SUFTAX
AND OROINANCES GOVEFiNING THIS TVPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. TFiE GRANTING OF A PERMIT � 14 s OOO.00 �7 .00
DOES NOT PRESUME TO GIVE AUTHOFiITV TO VIOLATE OR CANCEI THE pERMIT FEE SAC CHAFGE
PROVtSIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- @
STRUCTION OR THE PERFORMANC�` OF CONSTRUCTION. W212.25 ire aS�.' �14.0�
, � � � /^ PLAN CHECK FEE TOTAI FEE
� � �r� �� 5�`� 7 � � License $5.00 238. 25
�' SIGNATUfiEOFCONTRACTQFORAUTNORI2EDAGENT iDATEi WHEN PROPEitLY UDATED THIS IS YOUR PERMIT
° / /i 6/
SiGNATUAE OF OWNEA I�F OWNER BUILDERI IOATE� BL� INSP f1FTE
NL=��V
ADDN
ALTEf:
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' C[TY OF F1E2IDLEY '
S[NGLE FAM[LY AND DUPLE7IES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: 516 8
Legal Descriptivn:
hes Avenue NE
��
Effective l/l/97
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Owner Name & Address: _ Riek Zdar�sky - 5168 Hughes Ave 1�E Tel. # 57�rQ796
Contractor: ��; �.�on ohnson Co MN LICENSE# 2083
Address:
, �.���� Tel. � 7 81� 9 5 4 8
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
DESCRIPTION OF IMPROVEME\'T
Length � Width Height
�ng� Width Height
�n� Wid� Hgt/Ground
Sq. Ft.
Sq. Ft.
Sq. Ft.
Construction Type: Roof.�n p� Sid��;g ��ated Cost: $ 1 • QQ �
{Fee Schedule on Back)
Driveway Curb G�t . Width Needed: Ft + 6 Ft = Ft x$ � —$ �
DATE: �� ? -y � A►PPLICANT_: r�� " � !t � 2c� ��-..— Tel. # "��° - i � "� �
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Permit Fee
��ire Surcharge
State Surcharge
SAC Charge
License Surcharge
�riveway Escrow
:cosion Control
'ark f=ee
Sewer Main Charge
TO"I'AL
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CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/lOth%) ������ ��
$.50/$1,000 Vaivation
$950 per SAC Unit
$5.00 (State Licensed Residentiai Contractors)
Alt. "A" or Alt. "B" Above
$ � $450.00 Conservation Plan Review
$ Fee Determined by Engineering
$ � Agreement Necessary [ ) Not Necessary [ ]
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«��c,i��,�cr t•fi �t�rrr rcr sct���c.��.t�:
"1'lic Cl�ief Building Ofticiat sllall, bcfore is,suing pern�ics for the erectio�� c>i' any building ar �tructure, or f<�r
aiiy addition to any existing building or stntcture, or for any alteration c�r repair to any cxisting buildin� or
stnicture, 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 �rovided to-wit:
TOTAL VALUE
$1 to $500
$501 to $2,000
�?,OUI to $2s,000
$25,001 to $50,000
$�0,001 to $100,000
�lOQ,001 to $500,000
6500,(}Ol to $1,000,000 -
�1,000,001 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,�00 .
562.25 for first 52,000 plus $12.50 for each additional �i,000
er fraction thereof, to and including �25,000
$349.75 for first $25,(�l0 plus.$9.00 for each additional �1,000
or fraction thereof, to and including ��0,000
�574_75 for first $50,000 plus $6.25 Cor each additional
�1,i�0 or fraction thereof, to and including $1(}0,(�i0
.$887.25 for fir� $100,000 plus $5.00. for each addition�l
$i,(�0 or fradion tliereof, _to and �including $SOD,000
$2887.25 for -the first �$SOO,OOO pius $4:25� for each :additional
$1,�0 or fraction thereof, to and including $1,�0,000 '
$5012.25 for the first $1,OQO,WO plus $2.75 for each additional
$I,OUO or fraction thereof � � '
DRI +'WAY DEPRESSION ESCROW }
(Concrete (�rb Streets Only) - - • � '
�Iternate "A": Removal and replacemeut of curb and�gutter only - Drive�vay width plus 6 feet,times $13:50_
.tternate "B": Removal and replacement of curb and gutter and iastall a 3 foot wide '
approach with b inch depth - Driveway width pius 6 feet times $15:75_
VERIF[CATION OF FOUNDATION
�rmits tor construction wi�l be issued a minimum of 24 hours from the� time of application to allow �or prop�r
:c�ie��� oti the proposcd stiticture and of the construction sit�_
�:�ei-titicate ot Sun�e�� c�f� th� lot, siiowinr the location ofthe foundatio�i �mce it has it has he�n c:�nstr-uct�c'
E!� ' f�C�Uli-t:cl h�li,re r�i�u�:�:�•din�_� «•iti� th� fr.�mii��.
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C�iIlVIlVEY AND STACS VERIFICATION
The undersigned hereby verifies that the existing chimney or stack:
1 e . Has been carefully examined Yes (�) No ()
2e Is free from nist or deteriordtion �� Yes ()� No {)
�3. Has no foreign objecLc lodged within Yes () No ()
4. Is securely supported Yes () No ()
S e 1Vleets all current Code requirements for size
and total BTU's connected
6 �Ias total heating BTiJ's of
All other BTU's
TOTAL BTU's
7. Has a liner been provided for water heater .
8. Has combustion air been providecl for water heater
Yes{)No()
Yes ( ) No ( ).
Yes.()No()
Remarks: . - .
List ALTER.ATIONS Bein� Done: �
HEATING CO:
Signed Bye
Date:
Ri71IKr �7��lyC �G�-sV � q �C.
C�ENifl�l. AVE. N.E.
ANOKA� MN 553
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