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�, ' Metro Region �+lai�ers, 1200 Warner Road, St. Paul� Minnesota 5510�6
Steve Geis
Real Estate 10, Inc.
I635 Coon Rapids Blvd.
Mpls., Minnesota 55433
RE: LOTS.63, 64, 65, B14ck A, Riverva.ew Heights
OcCober 27, 1978
- �� • �
� Dear Mr. Geis: � .. . �
We have reviewed the survey plan for the above referenced lots in Fridley.
�. Based on the scaled drawing showino the Iocation of the proposed house,
we have determined no D�iR permi.t is required. .
�
There are certain conditions, however, which rsust be adhered to in order
for the construction to proceed. . �
First, no alteration of the watercourse may occur as gart of the develop-
ment of the property.
Second, the�.watercourse shall be considered to be that part of the chaxuiel
which lies wi.thin the banks of the channele In otherwords, the top of
the banks of the channel, define the limi.ts of D:3R jurisdiction.
Third, the contractor shaZl ensure that no grading, filling or erosion.
occurs below the top of �he banks of the channel_ This includes an}r
sediments that may wash into the channel by overland flow. We sugges�
any excess material be re�oved from the site or stockpiled away from the
channel and stabilized with�raulch and hay bales.
If you have any other questions regarding this r,latter�. please contact
Mike Muellex.
. � ; � Yo�rr truly, . ��
. � � �.
� � , ,,
1 ��, �i
R nald D. a�r.�cic
Regional Hydrolooist
RDHoMLM:sb
�c:� City of Fridley, Re Sobiech ✓
Rice Creek TJatershed District
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ADMINISiRATIVE SERVICES • WATERS, SOiLS, AtdU MINERAI� • LAfdDS AND FORESTRY
GAFAE ANU FISH • PARKS AND RECI2EATION • EFIF02CE!'AENT AND FItLD SEBVICE
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MEMO T0: File: 350 Ironton St. (Lot l, Blk. 1, Chouinard Terr.)
355 Hugo St. (Lots 63-65, B1k.A, Riverview Hts.)
MEMO FROM: /�om Colbert, Assistant City Engineer
`
DATE: 12/3/76
SUBJECT: Stipulations of Lot Devel�pment
Springbrook Creek (Anoka County Ditch #17) traverses through
both of the above referenced properties. Through past requests,
it is apparent that some relocation of the creek would be re-
quired before development can occur.
In order to physically relocate the creek bed of Springbrook
Creek, a permit is required from the Department of Natural
Resources. Anoka County will accept whatever stipulations are
set by Fridley.
Before any building permit is issued where a relocation of the
ereek is required, the permit from DNR must be obtained and plan
reviewal of the relocation must be approved by the Engineering
Division.
TAC/jm
cc: Darrel C1ark�Community Dev. Adm.
SUBJECT P �R . �
City of Fridley 15 4 3 3-
' ` AT THE TOP OF THE TWINS g U I L D I N G P E R M I T ECEIPT N
r
� ; L ____� COMMUNITY DEVELOPMENT DIV.
r � � PROTECTIVE INSPECTION SEC. y
� _ � �' /
� ����1 � CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY
�'"'"� � ,�J 612-571-3450 910-F15 9/5/79 / /
JOB ADDRESS 355 Hugo Street NeE.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. F'j3-65 A Rinerview Heights SHEET
2 PROPERTYOWNER MAILADDRESS ZIP PHONE
E. D. J. Develo ent Inc. 6305 East lb.ver Road N.E. 571-4212
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
S. J. Construction 6 OS East r d
4 ARCHITECTORDESIGNER MAILADDRESS ZIP PHONE LICENSENO.
5 ENGINEER MAILADDRESS ZIP SENO.
B USE OF BUILDING
TEIEPH�NE • EIECTRiC • GAS Etc,
7 CLASS OF WORK
❑ NEW ❑ ADDITION � ALTERATION ❑ REPAI R
8 DESCRIBE WORK
t �. � �
9 CHANGE OF USE FROM TO
STIPULATIONS p�vide a hard surface driveway. Provide sod in the front and side
yards. Provide City wit,h copy of verifyingg`� survey before capping.
F�nt yard variance setback to 26.5' approved on 8/14/79.
SEWER I�OCATION ;(Approx. 10' Deep In Street) 23' E. of M.Ho (Inv. 839.93)
WYE ELE`iT: 839.99
TOP OF FOOTING: 842.99 MinimtIIn
WATER LOCATION: Must Be Tapped - 6° QP wates�ai.n 10' 5. of Centerline fQ��
Hugo. � ,�! � �+►
DRIVEWAY DEPRESSION ESCROW: 12' + 6' = 18' x$15.75 =$283.50 �d � O��
_ �� �o��-
S E P E R A T E P E R M I fi S R F Q U i R E O � 0 R 1� Y� R' 1� �' ti�� �`
NEaTIMG� P�LUMB�N6� A�1�! StG� ��`°��
SEPARATE PERMITS ARE RE�UIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. O�U OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING. WOOCI Fl"d�@ d�
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING . F�� , CU. FT.
AUTHORI2ED 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. � �� OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION ], �`� A GARAGES
AND KNOW THE SAME TO BE TRUE AND COflRECT. ALL PROVISIONS OF LAWS VALUATION
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED � O�► SURTAX
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $32 350 yS`B�X�� y�`�.G. I.S
DOES NOT PRESUME TO GIV HORITY TO VIOLATE OR CANCEL THE pERM1T EE SACCHARGE
PROVISIONS OF NV OT AT OR LOC LAW REGULATING CON-
ST ON O HE P F M CE OF CO FUCTION. �$�� $%. SO 425. OO
� PLAN CHECKFEE TOTALFEE
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. 21 88 550 56
SiGNnTUREO Co RACTORORAU R12ED . E� WHEN PROPER�' _VALID�HIS IS YOUR PERMIT
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3fl0 BRUNSWICIC AVE S.
GOLbEN VALLEY. MINN.
MINN. REG. �10. 4741
LOT SllRVEYS C�MPAI�IY
LAND SUIiVEYORS
BE�BTEBED IIL�IDER LAWB OF 8TA'PE OF MIIrTNE�OTA
• 7801 - 73rd Ave. No. 580-3093
INOUSTRIAt — JUDICIAL Minneapalis, Minnasota 55428
COMMERCIAL — TOPOGRAPHICAL ����pr$ v�.p�r��*�
GITY LOTS — PLATTING t�1, I iar
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6917 IDAHO AVE. N.
BROOKLYN P/�RK, MINN.
MINN. REG. NO. 6743
INVOICE NO. $ P
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For Excavation Orily
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We h�reby carlify thet 4hia ie a trua ertd coned ropresentetion �s''`� '
oi e suewy of ths bounderies ct the nbove deacribed brtd and `
t!►� locatlan of ell bufldings ertd visihl� encroeehmertts, if eay. ;�� J�'
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Swvsyed by ua this 22day of. Au�ust �v 79 , �. LQ��i' $UR +`YS CQ�MP
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6875 H�yhway No. 65 N.E.
Mmneapolis, M�nnesota 55432
II Sou�h Otlice 890 6510
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; A���A� C�;�°�NT�Y
1 herebr cerfiiy tho► fhis is o frue and correet rspr�seMatfon o} a s �rver oi the boundaries of th• abov�
d�scribsd land� and of ths locofion o} al� buildieqs� th�r�ee, and all v�iibl� eneroachmsnts, ff any, from � ow
said lond. As surveyed by me this ` doy ef � C-/.� � A.D. 1��v �`
L 376 susuRS�N,i�N¢�NEERIN� INC.
Enqin��yi ; �'� _,Sdrv�ror•
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Not rubusnea: Au•rtignts rteservea
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CITY OF FRIDLE�Y •
ARPLICATIOP� FOR RESIDENTIAL BUILDIPJG PE{ZMITS
(t�ew, Alterations, Additions, or Repairs)
0
� OWf�ER: � � � ��'��'LoPr���� BUILDER: ,�. .�: �n�.S����io.►%_/��_
ADDRESS: ��� ���" �, �� ADDRESS: _f ������T�� �
iEL NO : �% % � � �- / � TEL N0: .� % 0 —' � � r "�
Consiruction Location •
STRI�T NO : � � J� STREET: � � � � '
LOT: � �� �� BLOCK : — � •— ADDITION : % �a e!'�2 ii�/ ��✓' f� � � �'�a° T,�
P � �
Corner Lot: Insicle Lot: Setback: �"�'�r' 5ideyards: �C'� ��
Applicant attach to this form two Certificates of Survey of lot and
pro,posed building location drawn on certificates to scale.
DESCRIPTIOtJ OF CONSTRUCTION � �
� � �: � � � Height: /� � 4
.�'�� � Front: !�f P
Squa�e Feet: % Cubic Feet: ,>' -
Front: �pth: Height:
Square• Feet: Cubic . Feet:
Type of Construction : �j��-i°. ��' Estimated Cost: $
Zb Be Cbmpleted; �o� °- � ' `��
Alt. A Alt. B '
i ^
Pro,posed Driveway Width If New Opening Is Desired: � $ Of $
• .� �` SEE RE`IERSE SIDE OF SHEET ,
• ��
The undersigned hereby makes application for a Permit for the work herein specified, �
agreeing to c� all work in strict accordance 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 �rue and��� � �'�
DAT�, :� � o�� ��. �_ S IGNATU RE :
Stipulations : � �-
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. BUJLDIt�G PERt�IIT F�r SCHEDULE� ,. ` � �
S�CTION 2. 7.'he znspecL•oz ot 13uilclinc�s shal]., before i�suing renniL-s for the erec�ion
ot any building or st.ruciure, or ior any addiL9.on to any existing building or structure,
. or for any alteration or rel�air, to •any existing builcling or structure, upon ap�,�lication
�thcrefor.c, require L-he paymenL• by the applicant for sucli permiL- of fces to, L•tie amount
hcrein below set Lorth and in the manncr herein provided to-r�iL•: •
NL'4I CONSTRUCTION: Single �ami].y.lIomes and Garages: $4.00/1,000 cubic feet.
I'LAN C1iL•'CY.: 25 percent of building permit fee. ,
DRIV�{rJAY D�PRESSrON: (Concrete, Curb Streets Only) �
• AlternaL-e A: Removal and replacement of concrete curb and
gutter only; Driveway width plus 6 feet x�],�,75
. Alternate B: Removal and replacement of concrete curb and
.' gutter and install a 3 foot wide approach with �'
' - . 6 anch depL-h; Driveway width plus 6 feet x$17.85 �
:11 1 : . ► �' ' �1
I'or 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 (G) inches below t.he floor line of the basement or th� cellar to the
average heights of the upper surface or to the average height of the roof sur�ace
of the nain gable of a pitched roof. �
For repairs or alterations to an existing structure, the fee shall be at the rate
of $3.00 Per 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 Section 2 be less�
than $7.50 plus $.50 state surcharge. �
Y�RIFIGATIO� OF FOUNDATIO�J
NOTE: Permits for construction will be issued a minimum of 24 hours from the time
ai application to allow for proper review of the propc�sed structure and of the
construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it
has been coi�structed w9.11 be required before proceedi.ng with the framing.
�ERTIFTCATE OF �GCUPANCY
Appli.cation for a Certifa.cate of Oceupancy shall be made ten (10) days pri�r to the �
use or occupancy of any structure for which a buildiiig pern�it has be�n issued; and
said structure shall not be used or occupied until a Certificate of Occupancy has
been issued. `'�
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s0 � UB4 RB' N � � 6875 Hyhwey Yu 65 N.E.
N 11� ERINO I Mmnea�w��s, td�nnewta 5543I
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SouthOff�ce 8906510
�:: � 1'u�d 14 tifarur�pnl Eng�nrvnng ► vW/ Tvenng � f.und .1'wrey�nR � Land Plananp 1101 Cldt Roe�f
Burn9vii�g. Minnego►e 553�7
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Certificate of Survey for RL A L C. S TA TC= 1 �./
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5��1 je •t fo e. x,, �rr, en fs o�'r� -�r d � i�'��r Y.
, ANo�� ��y�NrY
1 hereby cerfify thaf lhis is o true and correcf rspr�ssntotion oi a s�rvey of fhe boundoriss of fh• obow
d�scribad land� and oi the locatiort of oll buildinas� th�r�on� and o!I vjsibl• sncroochmsnts� if any� lrom o► o�
�oid lond. As su►vsysd br me this '� doy oi �._=/! � A.D. 19J`:' �!"
L 3%F SUSUR�6A�N;�EN NEERINC�' INC. �
� Engin�*�►i , � --.S�fivsyors
� 3 �, s bY l_ --�:. �y .�.-.
Ntrt Published: A11 Rights Reserved
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��,� ... `�` � � � i, .,a t � ', �'r*� �, f �
�� 4 � 1 � �� , ��"� �1 � '�' � •
�t' �' s ,4,� C� -- r1 �
"�>�'! �` �,?(i�� �' Y."� � � , �
R � ���.,..� � �,_,_._ ��1C� f� t�, �d�a r,
' �r�� � � �" � �' �
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ti �
� . �. . ..� '. . ...�'� dt ; y���� T �' �� . . . :�t. . .. � . •,� . . . ..� •
, -:..., .. ..
� Determin ' worki�g s uar�,� ��, ° .
- , _ , 4 f"t�t�agc Uf e�rc�i �
l. Total exposed wall area...... ,
' -.�.�2._,� s� , f t . :c 1 i = �
=-.____
� 2• T��1 roof/c�i1 n -----_.�..
� 9.a�ea ..,... ,
, . � s�. ft �c .�.w.. �' � �, f9 �
M�,� r �y�
°.,� �!�+�,�:f.3lr"$Q(Y Wc1�1, $Y28 $j70V � ' _ i t { ,
' �� . 4r .A .. � � �1d�1� 1� � � ,�� �
� � - . � . .. . , � .. �i '�*.r.+�+� ' '� 4 , 'ei r_�;1�
. a. To�I wa��, ���ca�r ��a. + ' '
i�• �'a6ra.a�1 �fOC� � .......s�,.lR••�.,•.r•••s...��'a a.��w�Gr� �) , • „ ,
'i�i � �';. �i �(�. i � ��� �. � � � � � �irF Ir..� . .
. � �. � ����1 ... . ....��..ti�•.� •'.�i�-r . . � • � ����Y� . ' �g� } � ,' �� ._t�ll-'/"�r CJ.:' , -
si�:a�.��r 9iass a�o ..., f .
�. � x. a�e$ . . . . _r
��o � . . ' • •.a�..� r �i • • .
firrpS��c� wail ored ..... . , .
' $o��otal wal� ta�� �� - - '
..
� . I A ' �� .i.
• • � • • ♦ • � • • ! -#' � • 111r_-'_�
_ . -� ��g-.. ar�a - ta�v�ra - � "'" - ,� - - - .
-- - " tal ' � ge IO$7"
. f. To rim joist' area . . . . . . . . . ": . . . . . . �. . . .; . .. L..! I ,it,�� .
,rq• . � � .r•�.'��.•s..•.•�•.••.�.��. � .. .
� wal$�aren abo�e £loor.. • �
h . wall arca above f loor • . . . , . . . . . . . . . . . . . . . . _ �J_.�.�.,d''3
i. ........ ....... . �
wall area above floor.. •... ....
� ..
i• wall area above floor,.• �...........,,,
l4. �0....
Z'otal exposed foundation area =`lp t�. q � 4„ ,
k. �otal foundation window �i
l. Total area ............... ..... �. �o 0
net foundation area above �� ����
qrade........., -r..
....... Z
� Determine "U" value of each wall _ se�_�mer�t 4q 3�& Z"
ie•q. window, door, each separate wall sectinn)
a• !1�, �4 x �,�„ �55 = � , �.
• , b. I JC "U" ��_ �` S� �
. �c• �f��—_. pa _ � pVp I 5� r� � 0 � .
�
Y. � pRp
Y �
_v_�.C., _:=_.__e_.. ��.___..r_,-._ _ __._. _` _.,__ . . . . . _ � -�-
-: `_"'�'.'_ ' '-. _ . _ ___. _ __" _ . .
e• �/�-- � � — X pUf1. .. 1 1�9 �'_� -__'_
..�.,,� �i : .
f . � /a / }� �ji° • t� ST a -T I �D
� g• `�' � �� X Nv"� .O S$i = �'I �
�! ., X nUu
s
� e � pVn . '
�
. �va�,q x �g .
p� nUn �.? y _ a � �
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A• Yr � �.. �� Y q/}II
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' �c� � � ��� � �
1. �.- �� X '�(Jn s� �� c Z g'
a
• ra
3o e............
................ Total v�°-s ���
T- '
...: -`___ .- - -.-_ _ . _' ^' . _ _'-�_... _-�., ..<'__'�.._-.-: _ �-:._�.__,.-_�'
If item #3 is tne same a
or less than it�em fF1, y�,
have met ttie intent oE •
SBC 6006 (c) 2.
��
��y : ic�� �nvelc►� � .A�'eraqe ��U", C�mP�tat�on
�,��„ F�:' �
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�- , gotal ex�sed roof/ceilinq area m
�
�. �bta�I skyTight area .................... .......
4 n. Total roof/aeiling framing area (average.l0$)..�.
o. Total net insulated roof/ceiling area........... Q 4-re , 9
Determine "U" value for each roof/ceiling segment ^
m. ' X "U" _
� n. � x��v„ . �04- _ '� , 7 b e
:
�� c�-(o , Q x „v., , 0 3 S = � D,�-a
o. _
. 4... ........................ Total =
If total of #4 is the same as, or less than #2, you have met the intent of
SSG 6C3�}6 (e } l . - _ __ _ _ � _ _ � ----
• Alternate Building Envelope D�sign
To utilize the total ei►velope sy::tem method, the values established by the sum of
items #3 and #4 shall not be greater than the sum of items #1 and #2•
i. �oz,o1 + a. � S � 3 4q , 06
3. `L �$��g7 + 4. �� 1b � Z S�,p3
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� ��:.. ni.nt�. anr`i �
w����
Zi}� �t �ac� wa11' area for
u9 c�llst�ct��i
834� iC
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t` '' `� u•
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b�•• �� + •
FRAtiE 1?2�LL
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► _ ,� �_ j �� � , �c� � ^ .
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`Construction � � R-Value
l. Interior air fiLn � 0.68
.1p8 2. �/Z 5 EF� cT 2g. � e4`�
Q���$ 3• ��L STv�uUla�L 4� 3b�
Z: O(0 4• ��3 "�- F3 � c r 2 � r-� . z. .0 (o
.(01 s. t�L.f�so,..� ��-E a b 7
o( 6. Exter.i�r air f ilm 0.17
. r%� q�'�= • ti'� fo Total _$-) 4-1
� _ .i�q
�(cg 1. Inter�or air film 0.68
� • — 2. � z��St�E ��-Ro c,l� �4S
��+ +�03 . 3�[' ,-L " I N S v�- a�r� o w� , I 3, � c� o
2t,� 4• 25 I'��.. t� 1�-T R i�c E 2, 0%
�%7 s. M ASon1 �T E mb7
��+�► . �� 6. bcterior air film 0.17
�� v= , abo Total IT,O3
• v � .0 5�
- �----'�.___'� ' �
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1. Interior air film 0.68
��Z• 3�Z I,.isv � A-r�o.►J l��oo
.�,`'�3 . i y2 �� ah r� Q.\ S T ��$$
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4• Z5�3a SK�A-�+���C; 2.O
= s. ►v�RSn� �TF ob'�
6. Exterior air film 0.17
U=. O 54 Total 1�, 4 fo
1. Interior air film 0.68
2.
3.
- - _.
9.
5. �
6. Exterior air film 0.17
Zbtal
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fleat flow
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FIG. 4,5 �
,�l��� �N�".-�,a�•��... • _�►�/.(��,r�naC.l^�-.Lil�t��
. t"� __ --.":��' � - ='-= - =-�
- __._____��..�._._ -- __ _;--__�_.__�.
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}:c��� flr�c� up . , ; �vented
. .FI�. �i6 . �. � ' .
- • _� ---- -- �r .- :) '
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, �, •.�_ �,.c�,�.�`. • .•`.-�e!.!':'''--1`1' � -�.•'r • � .�/�
-- � Jj' J ~ '.=_��l.,. • / � , %�i .
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1 � 2 � �, i
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Page 4 of 4
, `
Con:.truction R-Value
1. �Interior air film O.t61
2.
3.
4. bcterior ai� film (still) 0.61
Total '
1. Interior air film 0.61
2• _J8 SH �'ETROC�,; •�(�
3. I'z" 1r�1s��A-no�. � a��oo
4. Exterior sir film (still) 0.61
Total ��. 7�j
� �=.o3s�
1. Insi<3e air fiLn 0.61
2. 'S�S I'fEETF20Gi= • 'SrD
3. ' __ 4. 38
3i%. ' T� �155
4.�Yz.'. 1 n� , v ��4 ri o,•� �8', '?'o
5. Outside air film 0.17
Total � � � 4' Z-
� v�.o4
Note: Use additional sh�aets if•�re space is
needed for detsils and calculations
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N° - - 5 7
� CITY OF FRIDLEY `° ��a �
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PUBLIC WORKS DEPARTMENT
TAPPING APPLICATION AND PERIVIIT
FOR INSTALLATION OF WATER & SEWER SERVICE
I) This form to be completed before a tap is made to any e8isting water or
sewer line. _ _ _ ,
Address � / � � • `
Owner � �. ,
.
Plumber
CHARGES TO BE PAID BEFORE TAP IS MADE — WHERE
ASSESSMENT HAS NOT BEEN LEVIID AGAINST PROPERTY
II) Wafer & sewer connection permit must be registered before this Tapping
Permit can be issued.
City supplies all material and labor for 1" or under water tap. Con-
tractor supplies all material and labor for water tap over 1", and all
sewer taps.
WATER TAP: Materials Used: $ ���� �
Street Patch: �: $/ D 11 � D�
• � . i.
SEVqER TAP: Street Patch: x :$
III) If this property has not paid a full Lateral Charge for its share of the
water and sewer system, additional charges will be placed against it.
This will be in addition to the normal connection and tapping permits,
meter deposits, etc.
�l�n Water
� ASSESSMII�ITS TO BE LEVIED: Lateral: $
Sewer Lateral: $
TOTAL ASSESSMENT: $ �— O i
Clerks Signature
Supt. of Public Works '
M/P 3/76 White P.W. Canary Finance Pink Prop. Owner Goldenrod Plumber
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6431 UIVIVERSITY A'l�NUE N.E., FRIDLEY, MIPIPIESOTA 6b432
10, 1980
; .�", ,' Mr. John Doyle
I ' S. J. Construction
��. 6305 East River Road 21.E.
Fridley, Mtd 55432
Re: Final Inspection at 355 Hugo Stxeet N.E.
Dear Mr. Doyle:
TElEPHOPdE ( 812)571-3450
A final inspection was mad.e on December 9, 1980 of the above address and
the following items were noted which must be completed before the structure
can be finaled out;
l. Provide City with a copy of the verifying survey by February 1, 1981.
2. Post the address on the structure by Februazy 1, 19�1.
3. Complete the firewall in the garage by E'ebruary l, 1981.
4. Provide a vapor barrier in the basement by February 1, 1981.
5. Provide sod in the front and side yards by June 15, 1981.
We will expect the above i.tems to be completed by the reinspection dates.
noted above. If you Iiave any questi�ns on these i.tems, please contact me
at 571-3450.
Sincerely,
. CLARK
Chief Building Official
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CHTMr�EY IIN� STACK VERIF�CATION
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 lodged within Yes () No ()
4. Is securely supported
5. Meets all current Coc�p requirem�nts for size and
total BTU connected -
6. Has Total heating BTU's of
All other BTU's
TOTAL
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8a1te 222
Com pa ny plymont6, MN b�7
Signed By � �.
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CgIMNEy AND STACK VSRIFICATION
The undersigned hereby verifies that the existing chimney or stack:
1. Has been carefully examined Yes (✓j No ( j
2. Is free from rust or deterioration Yes (� No ()
3. Has no foreign objects lodged within Yes (�j No () ,
4. Is securely supported Yes (�/j No ()
5. Afeets-all current Codc r�r�=��ments for Yes ((/j No ()
size and total BTU's connected
6. Has total heating BTU' s of �, e Q�-�7
All other BTU's
TOTAL BTiJ' s
Remarks
List Alterations Beina Done:
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' 2619 COON �:nF'i:.. . �?�:;U�_t�'f.nR[i };
HEATING COMPANY n �`'r,' `u �_ '' -�, .� ' '
Signed By
Date -� ����
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