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AF - 46444. J ,�� t�ity a���ridley :�• ,�, aT TkE TOP O� TNE TWIN4 � i� r rL ------. COMMVNITY O�VQL.OPldFNT DIV, � . � � P��iCTIVQ m1�CTlqq @'iK, l i �._. � Cm Ma�� iR1066Y i�� i....�.1`.� �.J f�A' 660' �l�0 � eaaress �l-� v_ G o S!, ft!- � �u'9�EGT - Perm3.t No. PLUMB I �Jr, PERf1I T,qPPLI CATI=��d Lc�Y, r�IlN n vl�l , :�l�l< N�1� 3Zl . ��l�unbing Contractox A ..�EL F' . Kind of Building Use SlNlic� n'�/ELLIaIG P��/��rr� �o�l5j, Coma etion Date Gr ii � �� I � i I �I �' I W ( I � i � � — ' -- --I, W I I 1 i I . 3 tl I \� � I � ao��al I � ; i i I � � "1ddYl _I � I --� — ava I , � � ' � i •� "I �� I �I I ' i •saa� � ! •enwrval � � I � � I m — I., sa�erel I I i i � FI�1Y7I I I x �3 Q 6Nrvaal�l I I I I ' doo�a � ,��o, ;w ,0 � I saaw�a+Sl I f I I I io � 'I •iNnoa I� tl HNtaal ( I I I � to R .� O � O w .� a i£ � Q� N YMI �S�I I I. I Lt�i � BHNISI\ �' � I r'� z �� I � sNwval � � *ont{ I �uvo I �. ,rN�YA I I �aeo,� � Y�IYM �� !� — � i � � � I I •e � � � � �v� � �• i « d �h � � c� � � i � � i � ss E/UCv ST, ss 1 U,. 1 rnone ? � �1- ' ��l- 3 Phone Plumbin Fixture Rates: N0. RATE TOTAL Number Fi�ttures � x$2 .00 �' n B� Future Fixtures � _� x $1.50 � " � New Fi.xture-Old Open. x $1.50 Catch Bastn x $3.25 Water Heater-99,000 BTU _� x $3.00 ,��� � Ground Run Old Bldg. x$3.25 Elec. Water Heater x $2:00 Gas Fitting Faes; lst 3 Fixtures �,dditional Fixtures � X $2.�� � x $ .75 Gas Range-199,000 BTU x $5.00 Repairs �-Alterations See Description: Code IState Surcharge � .50 TOTAL FEE $ .5'l I ' !The undersigned hereby makes appl�ication for a permit for the work herein specified, agreeing to do all wor�C in strict accordance with the City Ordinances and rulinF of the Department of Buildinge, and hereby declare that all'the facts and repreeentationa stated in this application are true and correct. �� � /.S� � � . �bTA}'1fYP �Ilt1 a �� '°""' """"-�-° —"" LE R�Y H. VlIINNER 8� ASSOCIATES, INC. O p�n�n� Iwn �Ip �Q,�j,(� c�Khl1�� Regi�lsnd Under laws of Stat� o! Mlnn��ota 8398 Center Drive • Minneapolia, Minn. SS432 Phone 784-0210 CERTIFICATE OF SURVEY �3URYEY FOR: Kurt Skrandies cESCaisEO �s: Lots 46 � 49 ana 50 � Biock A� Riverview Heights. Anoka County. Minnesota. �2 i�1 I I 50 I 49 �/!y�y"�'7D 1 � i I - ,� s � �ar � � � �i ��6 I --- ra.w --�- � HUGO STREET ° JOd NO. .._74,�70 � 8K. ._A �... Pd. ..54...._ ��� �� � . �` I here�r artifY that !1� vwy. Olon �► r�er1 riaa pryond �► � a wtd�r m�r dlncf si+0�►dlibn and tMl I� o duh R��t�.�d l.a�d 9rrvhro► w�dN 1M lars of th• Stot� ol Mim�awf�. � fr:. ' , , OoN J'`� %"' �°�" Rp. No. 49d7 FI AIAL BUILDING LOCATION ADDED • 6/12 / 74 � L,D.R. 3- 30 - 24 sus�ecr PERMI City of Fridley 12530 AT THE TOP OF THE TWINS g U I L D I�l G P E R M I T • � � RE � � � ; L ____ COMMUNITY DEVELOPMENT DIV. �/����� r � PROTECTIVE INSPECTION SEC. i � 1 . � i-__- � �r���;,� CITY HALL FRIDLEV 55432 NUMBER REV. DATE PAGE OF APPROVED BY � J � 612-580-3450 910-F15 5 7 74 � � JOB ADDRESS 311 Hugo Stxeet N.E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 48� 50 A Riverview Iieights Addition SHEET 2 PROPERTYOWNER MAILADDRESS ZIP PHONE Kurt W. Skrandies 32I Hugo Street N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Same 4 ARCHiTECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO. 6 USE OF BUILDING Residential 7 CLASS OF WORK �7 NEW ❑ ADDITION ❑ ALTERATION � REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBEWORK Construct a 26' x 44' plus 12'6" x24' Dwelling and a 21'6" x 24' Gaxage 9 CHANGE OF USE FROM TO STIPULATIONS Provide a hard surface driveHray. Provide a verifying survey before cappi.ng. 3ubmit data sheet on truss. SEWER LOCATION (LOT 48� 153' E. of Manhole (840.62) Wye Elev: 841.14 Top of Footing: 844.14 Minimum. WATER SERVICE: 13' East of Sewer Seroice. SEWER LOCATION (LOT 40) 105' E. of Manhole (Inv. 840.62) Wye Elev: 840.98 Top of Footing: � 844.48 Minimum WATER LOCATION: 12.4' E. of Sewer 5ervice SEPERATE PERMITS REQt1lRED FOR �iIIRING, NEATIfVG, PLUAIIBkNG �fVD SlCNS. SEPAFATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD VENTILATING OR AIR CONDITIONING. �pOd Fr�le THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING S0. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION R�. 1144+300 ZS�88O 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 Ta AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMP�IED $30, 730 15.3% WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMITFEE SACCHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. ' yi`SS.00 300.00 � PLAN CHECK FEE TOTAL FEE � $373.37 ' SI�NATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATEI �A/H N PROPERLY VALIDA�D� T . IS YOUR PERMIT o� U ,r •. � � SIGNATURE OF OWNER IIF OWNER BUILDERI IDATEI BLDG INSP �ATE � r� -'i�j; , ��w►�s, ���• � nn JOd NQ..�= 74 ,70 LE ROY W. WINNER � ASSOCIATES, INC. t=z�6 'O D�nN�� i�e �1�� 1� c�K%!.!/P.6y021 . BK� A 30._ �, . 54 .... •. Repist�r�d Undn law� of Sfat� of Minnuela 8398 Center Drive • Minneapoli:, Minn. 5543Z -°'"'° 'SURYEY FOR: oEUaieEO �s: ' Phone 784-0210 CERTIFICATE OF SURVEY Kurt Skrandi.es Lots 48. 49 and 50� Block A, Rfverview Heights. Anoka County� Minnesota. � I � �: � .� �� � �' � �`�%' a� �� � � 'L� ��� � g �� r�' 1 e � ' !� , I , ��J �� �,( ' �V `•���`� � � - �� � �I MN ON ..�. ��� :I F'�_ . Jr I JI I � � 25 s . ,� �• � � ,. .f � _�,�� � � � I' ' I r � '�% J ��� -- �a.w —.�- ° HUGO STREET � ° 0 ,, .1 Asreey artHy that 1Aifi arvyr, Olon �► ►�o►t wos pr�por� �r �+a o� �d�r �t alnq s�rrt�bn ond tMl I�n► a duy Rpishr�d l.a�d 9wwy0� uiWn tM ia�r� 01 tA• 3tot� 01 Mlnn��7oN. � -�-t.. /���'��`0'2�..t--���' ooa 5� /-' 7' � Rp. No. �9�7 3-30-24 � ��� �'� �er�1c �e �� T �� ' f S� ' �', o�i��, ��yo,��� ��� �c�'' � �'y�. ��/ � � � � o � ,� �- — � `/ � /y ���ti,h,� � 1� �9 Tz. i2 � eR V� e� �G 7 �p � l � r �e � � ��t,v �r � � � J r c °� L°l.t� � r �� le. �/� `� ��y�.�� �s� s.z�� �� ���I� ��� � ��� � T � � �. �� �, a� ��/�, ��rvv. �yo.G2� �65 % b � �, � ��� �-- � �o, �I � i�3� �� �� � �, � 3 f � ° �� � � oT,��-- -� � ��y� ����,� ���� �� � ���2 � �- ��°�✓/C �C,' �� �� o � ��� �% ( �� d � � � � t� 4 a J � ��fVle`e- �_ � K - t ,� � , AP.pLICATION FOR RESIDENTIAL, ALTERATION, OR ADllITION BUILDING PERMIT CITY OF ERIDLE�', MINNESOTA I�'�� `1 N � �' OWNER' S NAME :� IJ � T �il, Sli ��) /�1 D I�S BUILDER : S,4 N� � ADDRESS: ,� Z/ �J UGv S%, /l/. �r ADDRESS : S�1 Ni'� NO :��_ S TREET :_ �/ U�i D S? a LOT:� —��' BZOCK: �} ADDITION: �2 i YE 2 Y/ G� ?-/ �(C'� N l�' CORNER LOT : INS ID� LOT :� S�TBACK : 3� SIDEYARD :%t Applicant attach to this form �ao Certificates of SurveY of Lot and proposed building location drawn on �hese Certifi.cates. 0 DESCRIPTION OF BUILDING To Be Used As: /jk/�"L Z 1 U C� Fr•ont : Z� � 2�6 �v Depth : �� Height : 2 c, x z �- �° 3 � - '� �n ,��-� '�,�-�-, � � C `"`j Square Feet: �' - Cubic Fee�:, a �s t �A �,� G � Front :� I - ��� Depth : Z¢ Height : / G I � Square Feet; + Cubic Feat: � ��- �-' �rpe of Construction: j�pv (7 �� a M7� Estimated Cost:�"_� ���� ' , To Be Completed; � Y,� The undexsigned hexeby makes app�.icatinx� for a permit for the work herein specified, agreeing to do all work in strict accordance with�the City of Fridley Ordinances and rulings of the Degartment of Buildings, and hereby declares tha� all the facts and representations stated in this application are true and correct. / i DATE : �/ �� �� S IGNAT[JRE : � ��, � , . �.,-. _�/�� , , (See Reverse Side For Additional Informa.tion. ) f � � � � � ��f f �' � . 1 � 1 .1 < ,s � � . • � � � � _ � � �� ,�,,, r � �, � _ � � . � - • � < �' y . ,'� � r � s � f ,rT � ry,¢. k � r. , � s. � •`-- a �% ' .! �` . / � �BUILDING PERMIT FEE SCHEDULE SECTION 2. The Inspector of Buildings shall, before issuing permits for the erection of any building or stxucture, or for anq addition to any existing building or structure, or for any alteration or repairs to any existing build�ng or structure,�upon application therefore, requi.re 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: UDTIFORM BUILDING CODE: Type 1, 2& 4-$2.15 for each one thousand cubic feet, or fraction thereof, in such cubical con�tents. Type 3& 5-$1.85 for each one thousand cubic feet. ADDITIONAL INFORb7ATI0N For the purpose of computing fees for building permits, the cubical contents of any building or addition, is determined by multiplying the ground area covered from a point six (6) inches below the floor line of the basement ox the cellar to the average heigh�s of the upper surface.ox�to the average.�- height of the roof surface of the ma.in gable of a pitched roof. For repairs or alterata.ons to an existing structure, the fee shall be at the rate of $3.00 per each f�.ve hundred dollars ($500.00) or fraction thereof in the cost of all prop•osed woxk. Tn no case shall the fee charged for any permit as set forth in Section 2 be less than $5.00. VERIFICATION OF FOUNDATION NOTE: Pexmits for construction will be issued a minimum of 24 hours from the tiane of application, to allow for proper review of the proposed structure and of the construction site. �. ' A Certified Survey of the lot, showing the location of the foundation, once it has been constructed, will be required before proceeding with the fxaming. CERTIFICATE OF OCCUPANCY Application for a Certificate of Occupancq shall be made ten (10) days prior to the use or occupancy of any structure for which a building permit has been issued; and said structure shall not be used or occupied until a Certificate of Occupancy has been issued. c, � �1 � . s � i � � 1 � � � � � P � � � w a p to O ' ` t" "� �' �"� � Myx�e x ��'�d x � x � � O NP � � M � � � x M � � � � m � � � o � � � m � 0 C:r � � � � � � � � y y �1 w a9. � w x a; o � �e � p � � M►�i� C c�o °�-' M th N '� " � K .v��1i eC°o 0 � F+ k �' � g f+ � � : <� � $ � : �� : : m� . . � � � � : . . . � . : : � �: � ' ' a : I I I m � � � � x . �'��° : g u�i � � � � � � � � (� '� L+ y C, cr � 00 � eb � � � � � O on�i � � O�y � � � c � , � � �' � � � �. d � a w � � � � � � � � � fD O � m 4°J O r o� � c° � �o w oa W w p4 ..� � �! � �' y o� �o �` M m . N A �. �: x � E � � ti � .� � 0 � o� � � � � x �°n 0 � � �� � x� � � w � � � ,aa. ,�a'. `° `° x � � O N o � c�o y O O � ! .�� ��� m .�* � � � � 7 � ��s�� ��oo� �. � � :� � � � M M ; � � . �i � : � � • • o � . . � : ' � � . . y . � w W o 0 � � °o o° � � � � O ( A bd � � � � 0 m � rt � o � � f�p O a � o � � � � w g � � ��,� �� w � � ���� � R° R� � � m � � � � � � � � O pf y y{ �"� � �i Q 0 � j � �� �� FA .� f� N � � O O �. � . � � �.�: � a � : ►- o . ' � p QV ; : O 0 4 .° : : : � � W�o�wo o° c� c� °o $ � � � � �� � � R. p, w a W �y bd � � '�p�s . ss$. � �� �'�d�'�S ��'��� � V�i• f�p � � R° R° � � Y � a � � � f`�D (�D O ~ � y �' R° � W � M ���� � � ,� � o —� � � : � � �� �. � a • � � : . � � � ° : : � Q � . . � S : : : m ; � O � �' � � 0 O � � d �� _ � � �� 3��, o � 0.� Ae � I�i� � �� 0 � �s � � � .i ii. . . � W Oi O� � °o °o °o g v, � ��� � p R.Q'� 'C ��-1 � � � O •d �, �p � ro A � � � p �� � � ���,� .. � d�� � �, �bo ��°� �� a���c ... �* � � �° o � ��',y�i m bd�'� �ro ��'� � �b ���.� p='�N � � �x �o �aOp V e�y+� �,y G y � � � � m � b � a�� � 0 ~�`'� � � � N ���� G(] � �7 M e� �. �+ lD �j �y' m � jn � �. � �. c� O � K 1 � _ m C m � M W °� x � m � � 0 _. � ��.��,7 ���i� � �:d./+����,? � �,� ,�et' ��aL� s=. ���itt� j� '� ^ , J' . t�i�i � ' � � � E�' � �,�'� ���"f��<�t.� ��� � HF�4 LOSS CALCULA7'IONS .DEPARTMENT OF INSPECTION MINNFAPOLIS. MINN. Weatherstrips A.S.H.V.E. Conatruction No. Insnladon � I Guide Windowa I Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kind How Applied Yes—No Yes—No 19_ F7.� r��°� Room Length �-,, Width HeiBht � Fl.� ¢;Q .g �,� s P: Room Length � Width ,��, Height.?- Windowa and Doora—Crackage aad Area Windowa and Doara—Crackage and Area �Vldth HeigAt No. o! Llnoal tt. Area WIdtA Helght No. ot Llneal fL Ares No. ot pane o! Dane Ilghte o[ crack eq. it. No. ol Dane ot Dane IIBb� ot crack eQ. tt _ ;=.��'� a�� Y � o._C �`n .` ¢�f �S� �T't! 6?�d.� � �� A� P.r� m a`�e Infiltration y �; ` s' ,� ,� � �� ,� Glaas �i � �; %,� � � � Eup. wall ' '- � �-�; '"�� � Net e:p. wall � o;`� :��'� �� �s' �f � lnt. wall Ceiling � � �� �'�i � A r;a 5� Floor : ;°�:� � 7�cal B�u. : �' . °� -� Required sq. ft. E.D.R. or aq. ina. W.A. Leadv area i F7•� d°��' ;� Room � Length Width �'� Height ��° Windows and Doors--Crackage and Area Wldth Helaht No. ot Ltnenl tt. Area No. ot pane ot pane Iisht� of eracic ea. tt. m:�i' ...�ij�t $,-+Y,c. �� _.�3i� / ��' I Coef. Bcu �Ilb�tiBilOn '''<3 'a,�!(' `�t�'� �di� �� _a� .;� cv' ' � �Sp. WB�� �? ,� � �- '�;E�?9 Net e=p. wall �g�t� (�. � Int. wall Ceiling :) �F�s' � - ,R� Floor Total Btu. .-r_°, �s1 Required aq. ft. E.D.R. or aq. ina. W.A. Leader area � Fl. � r Room � Length �°� Width � Height Windowa and Doors—Cracl�age and Area Wldth Helght No. ot Llneai tt. Ares No. ot pane ot Dana 116ht� ot craok �q. tt. ` 4s ,� -: �� f i± ° � � � �; Coef. Btu 1n61tration "�' �� °r'„ � B � J .,� Glass " �° '�` 3� � c� �.1 ��p r-:p. wa� 4° ,� � � �,/ '/ Net exp. wall ,:'; � ,�, ,rp`y:Y� �p Inc. wall Ceiling �- � l':� r°' '° ,� d �., �� Floor - �;_ � Total Btu. �': " -� ;:�;,� Required sq. ft. E.D.R. or eq. ins. W.A. L.eader arca � Coef. Bcu In6ltration � "r'e �, w: i`� r,,� Glasa '�,�� � ::; " ° �-�'; Eap. wall ,,:: t ,�� ,y� - ' ;r � Net eap. wall ` > � ,:;� Int. wall Ceiling � °�" "�'` � °'�� � J �� � Floor � � Total Btu. !y _,� �„ Required sq. ft. E.D.R. or aq. ins. WA. Leader ana _ FI.I P 9 l� wC•4��� Room I Length '?�� Width - Windows and Doora—Crackage and Area Wldth 8elgbt No. 01 Ltneal [t. Area No. o[ yeae of pane llghte o[ crack eQ. tt. ',r -�a� �:�:.� �� +.$;�� _.`�"�,.� In6ltration �86s �p. W8u ;�� � � Net e:p. wall Int. wall Ceiling Floor Tota) Btu. �_� -�� Required aq. ft. E.D.R. or sq. ina. W.A. Leader area Fl.) i'� �=; f� Room I Length ���;• VUidth �; Windows and Doors—Crackage and Ana Wtdth He1Qht No. ot Lineal [G Ares No. ot yane ot p4ne IlBhts ot erack w. tt �!r��_ ` ( Inhltratioa Glaaa F�cp. wall �.`� �`,� �,� Net eap. wall Int. well Ceiling Floor Total Btu. �- :t�` f a �'..- i �� � k� _� -�`_".,� , ..� � -g� � � : IRequired sq. k. E.D.R. or aq. ins. WA. Leader area Btu ., � __ 1� �,.i � ;� ; .. r c + � + p�� �S6 � . _ F HEAT LOSS CALCULA'fIONS .DEPARTMENT OF INSPECTION NDNNF.APOLIS. NIINN. Weatheratrips A'S•H'V•E' Conatruction No. Ineulatioa Guide Wiadowa Doora Reference Out. Waq Int. Wall CeJing Roof Floor Kind How Yee—No I Yes—No 19_ Fl.� �• r:>., � p•� Room Length �`' r�" Width =� Height �� Fl.� J�;` � Room � Leagth � p� Width � Windows an Doora—Crackage aad Area Windowa and Doorb--Crackage and Area �Vidth HelgAt No. ot Llneal it. Area Wldth Selaht No. ot Llneal tt Arns No. ot Dane ot Dane Ilghts ot erack ep. tt. No. ot paee ot Dane Ilghts � o! erack W [L _ - i --,�k�y p�,�� L -� a _.,�� -.�� a� -- d' .-- Y. � 4.+ - f � } R' .� . `� � - � � � ' Coef. Btu Iafiltration ,, ;.�' ,..,�r' r �' �R �,� In6ltration � , .�3 '- ;.�,.� G1aas �'r '. _� r �` ���;.:9 Glasa ;:� d �"e�ua fap. wall �:.° � � � ° Eap. wall �� -�° - `�1°'d Net e:p. wall ' - -° -^"' ' °�,� � � . d ,� - = Net e:p. wall � , ��� ��;� �, ; � � lnt. wall Int. wall , Ceiling w.� � ,-`s ; �4 � �` � °G' °�� CeilinB � Fioor + �: . ' +.� � ."�`' � Floor � 1 " � 7atal Bcu. ��', ' �' �. ' Total Btu, '` i; � � . � Required sq. ft. E.D.R. or sq. ina. W.A. Leader area Required aq. ft. E.D.R. or aq. ina. WA. l.eader area � Btu F7.� � r; r:: �� Room � Length �`' ; Width Height ,� F7.1 �,N' i, ". Room � Length ,'A Width:°� Windows aad Doora--Crackage and Area F� B�� Wiadows and Doora—Crackage and Area Wldth Helaht No. ot Lfneal [t. Are� Wldth Helght No. oL Llneal tt. Area No. ot pane ot pane Ilsht� o[ er�cic p. tt. No. o[ yrne of pane itghb ot crack ep. [t ' -„°� ';1F _'.f � �B_. . ��.�,� %_�_� _9 Coef. Btu In6ltration �� ,: '° _ � I<� �, �ais �,._" 6.�� �,s:�� Eup. WBII t,�� rq f. ,s Net e:p. wall �, ��� ��;� � tA�. weu Ceiling '' a�� " <A Floor � 1° � ' " >�; Tota) Bcu. ti "`I � :�. I Required aq. ft. E.D.R. or sq. ina. W.A. L.eader area Fl. p�: �' .;�9 Room � Length ":'�' Width Height ; Windowa and Doora—Crae{�age and Area Wldth Hal`Rt No. of Llneal tt. Ares No. ot pane ot Dsoe 116b�� o[ crack �a. tG - ��� S S,s �� � � ��.� .� ,da Coef. Btu In6ltration , � - � � �' `'� �� ;� Glau .�e � � � °";� :� Eup. waq ` :' $ �, `'° � �.� �:k Net e:p. wall � `, ;:1 �°;' � , ��''t ;P Int. wall Ceiling Floor ' = � �;� � ,qh. Total Btu. _ ` � i` Required sq. ft. E.D.R. or aq. in�. W.A. Leader area �iu�■����� ����� ����� ���—� , , _� �8s5 Fap. wall Net e:p. wal) io�. Wau Floor �� - Total Btu. Requued aq. k. ED.R. or aq. ina. WA. Leader area F7.� Room I I�agth Width Heigh R/indows and Doora—Crackage aad Ana Wldth He1sAt No. o! Llneal tt Are� No. ot p�ne ot D�ns 11`6t� o! cnck �Q. tt • Infiltratioa Glasa Eup. wall Nee exp. wall Iat. waU Ceiling Floor Total Btu. 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Qas Une By .�7L�/n!/� /�Tfo TYPE OF HEAT GA FA y,(,_ HW STEAM_ SPACE HTR._ UNR HTR.� OTHER ?� � GAS DESIGN CONVERSION MAKE ���G�fddN� MAKE OF BURNER Modei 3t� i'd?�0 :�to�D Modal Sectal � � � ���/ 2� -k}e�t �°FU Ratir�—_ — --- - - — INPUT ��, rJ�� INAKE OF FURNACE Model CANTROLS THERMOSTAT �!N T��D Heat Plug Va�ve fo!/�cl�T� /2l����5 Limk ��islc� Limit Setling ��a° Fan Sening ��?dL) Pilot Type ��GG� Pllot Meke e ��! Pilot Model �I % Pilot Timing � � �� L. W. Cut OB Pressure � �` � L° Percon! CO, C5r- �f o%b Input CFH • 4f' �1t3� Percent O� �- !O °�D Slack Temp. O Percant CO �°�� Form 235 Vart Siza KIND OF UNER ,�i/`_�e•c*�. g�g �� NONE DraB Hood .�� Regulator Flltera Sisa �r�'X.�6 af / Number � Chimney Locetlon Inelda � Outside Chlmney Conatruetlon �°���/'i ��1�� �2r�. - 6/�G�� Smoke Bomb Wiring Draft Te� Tag Door Pre�ura LighUng Inst. Data Teated � - � Company Testina /1/�- t�JS� Name of Tester �c-��� ���dd%+i