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AF - 46569� /"'� City of Fridley, Minn. � �� ����.� BUILDING PERMIT N° . 6534 ��1 Date: � � �� � . Owner: guild� i°°�r�� � Adaresa Addrese �� �� LOCATIO F B�DING No. .�� str+eet -��/.�-�—z"— Part � � Lot '`� Slock Addil3on or Sub-Divisi�n _���� � ���� ° Coraer Lot — Inside Lot � Setback ��� ^"•� — Sideyard ��� � Sewer IIevation Foimdation IIevation DESCRIPTION OF BUILDING To Used �%�' Front �� DePth .�" Height �� Sq. F't. �-L���' Cu. Ft ��� Fro t Depth ITeight ___._�.�Scl. F� � C�. FL Type of Construction `'—�-�.� Fst-C'ost -,,���..��o be Completed In consideration of the isauance to me of a perinit to construct the building described above, I agree to do the P�P�a work in accordance with the d+escrlption above set forth and in com�ce n� all ptpviaions of orrlinances oP the dty of Fridley. /T.� � J � 1 /r In coasiderat[on of the payment of a fee of $��� P�t is hereby granted to to construct the building or addition aa described above. Thia �rmit is grant� aPon the express con�iition tlzat the person to whom it is granted and lvts agents, emPloyees and workmen, in all work 8one in, around and upon seid building, ur anYpart thereof, shall conform in all respects to the ordinances of Frldley, M9nnesota regerding la:ation, construction, alteration, maintenance, repair and moving of b�ifldings within the dty ]imits and this permit may be revoked at any time upon violation of aay of the P�vfsiona ot said ordiaances. /'i � � � Building Ins�ctor �"� NOTIC� 1'W permlt dea not eensr ths wedrualloe, lestall�oa hr wWe�. pMmbiee, �a 6�ating, sw�r er watsr. B� aun to � � Buildh� les�etoe for aparal� parmNs foe t6as h�. APPLYCATION F08 BUILDING PERMIT CITY OF FP.iDLEY, Mli'I�PIESQTA � r j � 1` , � � '�\. � f ',c�i . � : � . ► �• � � ��, ,' „ , .� � �� � � � �� f, " � •��� �- �'� o Loca�oN o� s*�unzNc No. Street Part of Lot Lo� �`�— �� Block Addition or Subdivision � Coxae� Loe Ins3de Lot Setback ��� Side Yard � f� G�-f� ��� B�WLR ELEVATION F�UI�DATION ELEQATION Applicant attach to thia foxm Two Certificates of Suzvep of �ot and proposed i�ui�d- ing location drac�n on these Certificatea. To be used �.s ; OF BUILDING �� Sq, Ft. � � . Cu. Ft. grcnt Depth Aeighr _ � � •Sq. Ft . Cu . Ft . . . Tnse of Construction �/l„G�/1'�'"� Eatimated Cos� ���� D� To be Completed __ The undexsigaed hereby �kes applicatioa for a permit for the work herein apecifipd, a�reeing to do all work in stsict accordaace with the City of Fri�ley Ordiaances end xulings of the Depastm�:nt of �uildings, and hereby dec�ares that all the facts aRd gepresenta�tione st�eted in this applicatioa are trus and correct. r� DATE ��1s1� J SIGNATURL ' . (Sclaedule of l�ee Costs can be fouad on th� .Reverse Side). � � , � � � f r � ~ �� - �f e BUILDING PERMIT FEE SCHEDULE Section 2. The Inspector of Suildings shall. before isauing anq permit f�r �he erection of aay building or structure, or fo�r any addition to any exiat- iag building or atructure, or for any alterations or repaira to any exia�ing �building or s�ructure, u�ca application therefor� require the payment by the applicant for auch p�rmit of fees te the amount herein below seC £orth and in the maaner herein provided to-wit: 2.1. For any such permit for the erection o# any fire-proof building, othes than a garages vrarehouse, factory or grain elevator, or for the erection of any fire-proof addition, for aim�.lar occupancy, to �ny enisting building Rhall be at the rate oi $i.40 fdr each one thousand cubic feet, or fraction L-hereof, it� such cubical coatents. 2.2. For any such permit ior Che erection of any fire-proof ��rage, warehause, _ f��tory or grain elevator, or for the erection o� any fire-proaf eddit3o�a, �'or sian3l�r occupanep, to any existing building shall be at Che r�te of $1.25 fo� each one Chousand cu61c ieet, claeaified as °1firep�obf" bq Section 502 of the Niinneapolis Build3ng Code.- POUSES 2.3. For aay such permit for the erectioa of any non-fireproof buildiag othes thaa a garage, warehouse, factory or ffiraia elevator, or aay aon-fireproof addiCion, for similar occupancy, to any existing buildin� - permit $1.00 fos eac� one thousand cubic feet. GABAGES 2.�5. For any such permit for the erection of anq aon-fireproof gasa�e, warehouse, factory or grafn elevator, oi for the erection of anq ao�-fire.�raa€ additioa, €or a3�nilar occupancy, to aay existing building or for �ach such �y�iding or addition - ainety cents ($0,90) for each one Chousand cubic feet or �fraction thereof, in the cubical contenta thereof w9.th a miaim�emn cf $la.�pa� For the purpose of camputiag fee� for building permits, the c�abical conteats of aay building or addition to a uniform height throu�hout by a�ltiplying the ground area covered fram a poine aix (6) iaches below the floor line of the basemeat.or cellar to the average he3ght of the upper-surface or to the average height of the roof surface of the main gable of a pattched roof. 2.5. For repaira or alCerations to aa existing etrvcture, the fee sha11 be �t the rate of $3.00 per each Fiv� Suadred Dollars ($500.00) or fraction thereof in the coat of all proposed work. 2.6. In, no case shall the f�� chargad fnr ans per�a;fi �s set forth in uectio�n 2 6e less than $4.(W. °� . >� ^ `, � �, � � . � _ �_ . .� �: � —� . �•� � `/ • �1���� �. �� ,�.e_ r-'-.., �.�r., � � _; . � . , . . . . Y r . . '� '4 9 g : '+�' _ fa^, : � . +�sx�'� � r ` �`. , ; � * �k� u��� �.�� c}�ss�Cc��?�, ��. ��.�� : ` �� � IAND SURYEYORS .. L�= Anoka, Minnesota � �° ` � CBRTIFICATE Of �UR VEY : � � , . �,; RALPH N� i.tINC 92S�13O�2�j. �: , , 1 :� � I � N ��° �'J1' : ' _ .,. _ . _ / r�. o � � W ��=: . �s. � �� �ENOT�� , �: � � I RoNS 1 - �'� _-'' ,•. . � � �, �;5 r . r � � ,� r'JQV � � 1� � .- - � � � / o , �`�� � �; , �, _. „� 1,c�-rr /, � �, � 3a �� � f ' . � 5 � �� �� � � �� � �� o � � I �► � � _ , - - .o�� �� . co - '� , - , � , CJv t . � z��: � � GJCJ � `� '' � `i ' � � �, o . 5 r " �--'" ��,�� - � �� . � LOTS �5 iIMD �j6, QLOCK 1# ` �°� :� ' . RIVERVIEW HEIGNTS " ,� .. s. ' ANOKA COUNTY� MtM�E8OT� ��� ; � �: 1 FlERE�Y GERXIFY TNAT TMIS kS A TRUE AND COMEfCT REPRESBiTAT10N 01� A SURYEY 0�- 7,� �dINM9A� tC�f !�E 11� _ DESCW6EO LAND, AWD TME LOCA71pN Oi ALL llpLDwJGS, THEREON, AND ALL V151ltE ENCROACHMENii, If ANY. ���'' � �:; LAWD. . .�;, AS SURVEYED !Y ME TFYS 2 H T H..,. DAY �f ............ M A Y ........: :� ...............». ........ A.D: 19. ,�,�,,;! � � �C � ..... ...... . ``�n N. C. HOIUM I!1t�tD AS�QQ�k i '°" LA�ii� -�.�� ;� - '�-�z / � �a�, ` � � . . . �� � . � '. � E�i�� S �� rr � �"i��4 k �. � - � . .. .. .. . �� � . � • } � �U�`.� �� M1� �: � i .� . . . � ,�.� ���;n.y�' � 'i t�� x w . ., �' �:. � „�A�%,,,� 'k T fM� � `iri.5 � . .: _. . � . , M� ��i: .a.. .....��.:..., .. � �$ ���� � �,• �`� `� � � d� � � � � o '� p �. : N : x° : � m : m • M : o . a �'7 . � : � � tia �� � N � � � � y H � � � 4� � � � � O � a�o � � � o • � � : o . o . o . bd : : � : : � x � � � � � ►�+ � o q p � e� ts �» \ ,,,� � O `y � z � � � � � rt � � � nM y � � a O � � � � � a���� � m � C � � � i1 a b o � ¢' b 0 0 � � � � a N : � � : ra G1 °o : � : �� � � : : O ' : td : : : : : � : : : : ��x � � aC �C iC i4 k w �v eo r. �. � � en o c�n o 0 0 � tn t» tts tfl a» tn �'�,� H � �:�y v F'-' � � D � 1"' � � m �^ `I 2 �ii °c r m �. • �P W �N ►+ � � � �x w a, �' � 8 �' �� � � • � 0 a p� ,: � �� , � � � �. � � � 8 8 M 0 ° � o � � � � x � � � � ro � y M � � � � � � g � � � o iJ� � � � � �, �° \ "�� (�i � ;,� �, � � a �� � � `� i� 0 , i.� `A� � �, �' � � ,?;�� � �� o �� � 9 � �' , � c �C � � � � ° � P o� ^ .� i� WATER . CI.OSETS URINAIS EATH � B/511�6 SINILS W,� �' ranrs DRINK. FOUNT. sHwRS. FLOOR DRAINS u� BASINS �wro �/A$HER GAS APPL GAS RANGE G1S ' OPENINGS � • z e � i P � � � � � �' � ��� � � y � �a� � y � � ���+++ � � � � � �' � y ;e �x �r �D• �. ��o� � �, � �� ��o� � �� ��• � �' � G �a ^� � �° � � , � � ayw ��•� � �� � F � b � y � � � p � m o n � � � R, o p m a° � y m y ���g� a� ��. ���� ���y �.��� �. � � � �y�M � i�"'i �. fD �. � ro � (,, � 3 � �. C �' d r'C A � i"y � H aM Rx � h°n p � M � �n � a m � �i �i 0 .i � � • � � � � � � � � � � � � � » � M � � � . � b � o � � m A � a � �. � V O iy � e A � � � �. �I' �� d � �. 0 p o� � : � • �" ♦ �; F„ N � � � � � � � � � � � �' `� � � M � � � N • o • o • o : o . o . � ' : x 0 �4 �E yE N N � O Q O � �.�� � '� O � � � � qt� 3 �e � � � � '� z � e � � � � � n � � � � � � � a��� � �i " : o � � ro � O �° � � a a � � �_ � � N . � 6 . E�d o : � : � � . . � � . . . . � . . . . : bd : : : : : � : : : : 0 �4 N x k D4 k w N W t+ t+ N � C�i� p C�7f O O O t� tn ts� tn v� in � H yy C" 0 Q x �� �� � �� , w �� � `1 ' p 'a �� � � � �;� � "� , �;� A`° %ya� �� !� y � � r � � m N^ `I 2 m C r m O o I °. Z � � � a ° a � � b � � ��� � � g � � � � n p 'I M� �I � � i r g M � o '� ' � � � ...., _ ���1 � s ...� � ■■■, • • ■�■, ,: : ....1 ����� � ... a � a. � � � r�e y � � ci.osers URINALS e�rH � BASIH6 SINKS wast+ ra►rs DRINK. FOUNT. s►+wes. FLOOR DW11N5 BtiSINS Atrro WASNER GAS APPL GAS RANGE GAS OPENINGS a • Z. � � � � � aa� b ,� � � � � ���a °��� ��o� b . �� ��o � � � � � � � �a � �e � ���� 00 � b � �� � b o��� p � m o � � ¢ � p � � O q � � M ����w °aa��. � �� �`��►°� n� . ��A �MOo � � �+ A � .7 m hp fD � 3 `� � �+�� � h�A � ;a 9 G �� GC � � �y . ao � O & �n p � M � � � � � �; �i :i � n `� • O � �' � � C O. a m � � � M � � 1`�, b D �` � 'v � � � . : �o Q e � � � s � � < ° M � 0 E� td Y� � � r [ H x x tn W �� �' �M�xo � b � � � x y�'�'d �'��y '° � � � x n Z F"•] `� � W f��i � o � �Ra+ �C�• �til 0 C I W N � ., � N o � fA � "O2iM' � � � � ,d W p o 0 �m ra � �* � � � o oa " , � c j ° m °' � '0 � � o k � o � � � t� Q o � � � o�: g o� �� �, . . a� � o x �n H : � � � � o 0 � � � : : : � � : � . � . . . ; Fij ; y ; �—� . . . . � . . . � : : : : � : : : � I I I � � � � � � N -� � P� � a p � 0 � � y � � � � x : : : : . : � m �e �a x o : : _ : _ : � N � � � N��� 000�, o 0 0000 �� ��� � � � ���� 0 �� , I �� � � �J �d '�f � h1 �f �f S `� 'ty b 'p ! � � � � � � M � � ii �" � W fD � �• � � � � y � � � � a� p R° (Z° c� � u� R° R° � v� y � y p � y a x� I G � � `� � � � � � `+ G R° � ��' �° a R° m��' R° M ; � � � o � g � � � � l� 5d ��. �� °°� �.��o ;� �' � ��' � �: � � g � a � : � �' a v, : : � : .. ?� � . , � sn o : : � c�i� ° : : � $ o : : o o ° : : I � o . . . � � . . . � o : : � � � : : : � : : : : : : . : : � Z � � W (�I �r 2 h�ll n � YJ �I� ❑ m D � . Z � � 0 b � ° �a � � w � � w � � � � � � � � I n M � � z � � � � � �- - �- - - -�---- � � � � e�% � \ eb � Fl � �q x � O � '+J � � '� � � a � � �� K W � o � � o � 0 � � � b b � ��,�N� 00000 �� � O � o N O � t�a r�e � Q' m fD - o �' � ~ � � � � � � � � °° � m � g I`� � � �. � o � � � � � � � m W � - y __ �-����� �000 0000. � 0 � n�� n ���� r�s •, � a 7. ��m p �� � a w � y � J o����. � d� °� � �, �� � �� °� � �, � � a �-��e �. � �roy � .� 07 �'�' � `` ��ro��� � �.� dy�� � �,a�p �: � �, o M ���� � a� �� � � � � F � A M �.�n� ��� _— � 8 � � � x � � �. � �° � � ��� � D � � � �"' m � 2 m C m d 'd M � � � � b � 'O� �i 0 � � O � so o� �o o; � o' � �. � � �N- rt � �� 0 � �� v< p' �. � °�. 0 � 70 � � � � � 0. �� � � � � City of Fridley, inn BUILDING PERMIT �.: . . ..- • •.• Owaer; —Ron l�cZ T,� T,a.m�g}^t g�� �a.ma Address �52Q_Hu�o_ Stxeet N.E. Ad� Same ���o � N° 10476 LOCATION OF BUILDING No. �2� Street - A,�g� .'F.Y'PP'f �T.F. Part of Lot Lot � _ Block R Addition or Sub-Division R;ve�viPt,t_HP�htG Corner Lot _ Inaide Lot x Setback � Sideyard �� II�a�� _ Foundation IIeval3on DESCRIPTION OF BUILDING To i� vsea as: �•r e Front � Depth ;� c Height �.R! _ Sq. Fk ��_ C�. Ft _$�h(L Front Depth FTeight Sq. Ft Cu. F� Type of ConatrucLion F'� m- F.�t. Cost —�2 .00.�♦0� To be Completed �(?�+ahe,r �D-,– � 969 � Permit to include: l, North in.terior wall to be of �8 Type X Sheetrock. � 2. West interior wall to be of 5 8 Type X Sheetrock. 3. Ceiling of West area to be of 5l8 Type X Sheetrock., 4. North & West facia to be of 2'� thicknesa. 5. North & West soffit to be covered by asbestos board, �"� Provide ha.rdaurfaced dsiveway. In consideration oP the issuance to me of a permit to constivvet the building described above, I agnee to do the P�P�d work in accordance with the descripl3on above set forth and im compliance with all provis%ns of ortlinanc� of the dty oP FrYd1eY. � n .0 ,_ . In consfderat[on of the payment of a fee of $ �,4.rgg , permit is hereby graated to , to construct the buflding or addition as descrYbed above. Thia permft is gianted upon the express condition that the person to whom it fs granted and hia agents, employees and worlanen, in all work doae in, around and upon said buflding, or anypart thereof, shall conform in all respects to the ordinances of Fri�IIeY� Minnesota regarding location, construction, alteration, maintenance, repa3r and. moving of bufldiugs within the dty lfrnita and thia permit may be revoked at aqy tlme upon violation oP any oE the provisiona oP seid ordinan�. ,�Q� � �`l Bu9lding Ins�tor — AA ll,� 1VITTFfTCFf—Rnilr7in�r nffinial e NOTIC� iUis psemh does net eevsr t6s wa�rueHoe, teshllatlen }er whieg, plum6teg, ga he�tee, aw�� or water. B� sun fo aes t6a BoiW1e8 Inspsetoe for pparab parmtfs for tha� tt�ms. ,� Ct _ e c �.� y APPLIC�TION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWN�i'S NAME �p?�a,�.C�1 t� a�� t� BIIILDPR ��'y� '� �_____ ADDRTSS ��D ��� �g �� I Ya� � ADDRE.SS � �„6 � LOCATION OF BUILDING N0. D STREEI' /V Ai � � LOT ��_BLOCK � ADDITION OR SIIBDIVISION CORNER LOT INSIDE LOT SETBACK�_SIDEYARD`_ SE6JII3 ELEVATION TOP OF FOOTING Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on theae Certifiaates. DFoSCRIPTION OF BTJILDING To Be IIsed Ae: ���.� Front � Depth � � Height �' Square feet $ 9� Cubic Feet Front Depth Height Squa,xe feet Cubic Feet Type of Conetruction d�� Estima.ted Cost ���d �•r-� To Be Completed �� � C� -� / Cl �� The undereigned hereby makes application for a permit for the work herein epecified, agxeeing to do all work in strict accordance with the City of Fridley Ordinances and rulings of the Depaxtment of Buildinge, and hereby declaxea that all the facte and representations stated in thie application are true and correcta D�TE CO� �Q-� � �' SiGNATIIRE � �„ � (Schedule of Fee Costs can be fouxi.d on the Reverse Side.) �� � =� �� . �� �° .r ---��--.-=°'-°�.�.. � � �- �� � - �- � _- r ; t ;' � -- � ; f �-� �� ��, / .�� � p�� �,f�� �P F ,`�% � _ �1' �,..�- a �P 2° �'/ � � ��✓ � , � C' � ��° �U, ,��`��,�a� ���� �� �� of � / �vj / P Y� U-y �� L � � � � � °'� �^ � i/ �-y,� ������� �� i � � �f �� t . �'�,;� �� � f �PS � � �PQ �� 6,� a � , �1,��� �'���� �� �� o� ��� ��,��/-��s� o� �` ��, �'�°f��� �'a �aP CmV'�ye�i �y aS��7'�Cs � , �0� / �f BtTILDING PERMIT FEE SC�IILE SECTION 2. The Inapector of Buildinge eha,ll, before iasuing permite for the erection of any building or atructure, or for any addition to any existixig structure or buil�ding,.or for any alteration or repaire to any euisting building or structure, upon application therefore, require the payment by the applicant for such permit of fees to the amount herein below aet forth and in the ma.�ner herein provided to-wit: IIniform Buildin� Codes Type 1y 2, & 4-�1e75 for each one thoueand cubic feet, or fraction thereof, in auch cubical c.nn.tents. Type 3& 5- $1e50 for each one thousand cubic feete For the purpose of computirrg fees for building permits, the cubical contents of any 'builii.ix� �Y��addition to a uniform heig�rt �thraughout �y ' multiplyin� the ground axea covered from a point aix (6) inchea below the floor line of the baeement or the cellar to the average height.of the upper eurface or to the average hei�ht of the roof surface of the main �a.ble of a pitched roof. For repairs or alterations to an existin$ atructure, the fee ehall be at the rate of �3.00 per each five hundred dollare ($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 Sectioa 2 be leae than $5.00. NSSSD Connection Chax�ea based on location - Area 1 or 2. � Q- � V . � \� � � - • - . � � "� � • � � �� - s � (�• �j• c�ocur� ar�� �ssoe�ates� �C. LAND SURVEYORS � 10130 HIGHWAY 65 NORTHEAST — MINNEAPOLIS, MINNESOTA 55433 Telephone �sa-s�so Certificote of Surver: R C� N A L D L AN1PE RT R�ET Nv�'� ��� � 25 / ` �` 1 1W 1 `� W �� .�� �p � � �� \ , 3 � 1 � � �3 •� `. . . ` - � SCA�E: i��= 2O� 1�•Z5 8•g 2�11-13c�-79 — � w —� 5-F � o �DENOTES �R�W_- - O �- �� _:� -Q N��, � � �a 52 0 �-- E - ��� : ,. �. � � � : ; . - , . o .' .1 _ � � . , . . . �: � . 2 � � � . a � Gi!r,�,, �,� u. ,, s i�r ;'_� 7� 1 � V�. Ct Y �� � � ����� � l� . � �� � �' � . 1 `: " � �il��YlS/O�S, ,�j/ �'� • � 1 �P. � � � l�-3�-�� �� � � � , �� g� �g ) -` .- 3 I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT REPRESENTATION OF A SURVEY OF THE BOUNDARIES OF THE ABQVE DESCRIBED LAND, AND THE LOCATION OF ALL BUILDINGS, THEREON, AND ALL V151BLE EN- CROACHFIENTS, NF ANY, FROM OR ON SAID LAND. : J �� y� AS SURVEYEO BY ME TMIS...I�....'.......DAY OF............!:..'..'�.'..Ce :: k .............A.D. 19...,.��..... N. C. MOIUM AWD ASSOCIATE9, INC. — LAND SURVEYORS F.. ' � �' 1, ' �1 ' . ' . �,.."�. (.},, _.' . . ^ ......................1...............,......� ................. ................ ..._ . .� .. P � � 1 � �� �� ��i� �, �.€�t�:+� �� �� ��� ���� ��:e�, ��n�+�a�� ��� �: ��:;#�t� �� €� �� �i��ir � i� �_ ��� � ���� � � ��.t ���� �� � ��� �� �� �� � ���� �� ��� ��� � �� � �� �� �� �� � � ����� �������� � �� ��� �� � ������ � fi� �� � �� ��� �� ���� ���� �� � �� �� � �� ��� � ���� �� �e. ����, �� �� �z� +t� � _ +� +�� �� � �� � - ������ �� �� �� � . . . � � � � ��c� ��. ��� ����� �� �� � � �� �e `� � �� �;�► w�:�t;� � ��! #�' : � �� � ����� ��� �� ��. � � ���� � ����. �� � ��� ��t �� ,� � �' �t�;t+��`s ���+� �� � � e�a�� '� �� �'i#-�-��'. �������. rac�r M. � - � � ; �r • i + ��!�� �� �� �� ��� ������ ����� 560-3450 I�L�L O �!"dGL�� � � ANOKA COUNTY 6431 UNIVERSITY AVENUE NE AugUSt 31, 1973 FRIDLEY, MINNESOTA 55421 TO 6QHOM IT MAY CONCERN: The single family home located on Lots 55, 56 and 57, Block H, Riverview Heights Addition in Fridley, Minnesota, the same being 520 Hugo Street N.E. is in the proper zoning district, R-1, for single family dwellings and meets a7.1 the requirements of the zoning district. The City of Fridley does not have a housing maintenance code. DC/de cc: Ron Lampert 0 DARREL CLARK Community Development Adm. ._ " °- -- ---°- `=:'t�2ASHlitu� iRi2Ri2i2ilitY:Ri`.i2:2i7WliltitiYi`S:.iiiti:{2iliii2witit3:i>tLSkt:i2i:i2i:i2i � • �. a � � � n � o � � y� o N � o �, � � o � 3 � a~ o � 3 -p m � v a 0 � � � N �m �� 1 Q � � 0 � � � � r O C� � Z n --� � -n cs� �v zm ao c� � m � n � < m � � � � 0 Z O z � m z � � n � z � m m � w 0 0 0 a '� � < a a�o � 0 c � 3 0 � v � m � � v m W � \ � � � � � � � m a W . �. 1 ' `.. � _ � Z � c� 0 a z � �� u � � • O N � � � r � � m � � m � C� � � o c3 m � n m z � _ � � m z 0 m' � � ...► \ / ��0 °• m � �c m � �' c -a �a � 0 O � D ' j � � �o � o n o s o � L Q' m w � � °. £. m� a � i � R� Y �v N � � �� o � �`^, � � O ^ 1 c _ ��� --I �Z W t 3 �� Q o � o � � �o �. � m �, � m � m I m �6 = ' -� � C7 � w n � � m � � � � v� � � m m � °.po^ ap • s 0 CA1 � �m � � ` a, v Vn` V ' v � c� � � 0 z O � c � z n m z v 0 � ao C � z m � � � � m � � y � � � m � N � v � m z � m � a � � f L � � � a�� 0 3 a �� � � � � 0� � p 3 � � m � � -n v � � � o � � C � � I � � � � 0 0 0 o ap o° o° °o o � m � � � � � � � ! � � o � � -� D -a v n � � � � � -o m � � , =i z 0 \ \ \ � ov C v Z � c � m v � � 0 � � n 3 "� �L m �: '� � u m � � o > > 7o n.• m y a � � N � m � � � � � co c,� Q. m � � � � c � � a�m� -�omm � � :« � � � m o w � (b � W °. m O 7 � Q- � � � y � O � � v�� o.°u�,� � � � � � � o � � c�i m � � o � 1 � � � � '-N � �o�mo � � � � � � m �.�' m � � N � � � � � m n _ � � � � i N.Q�n �. I � J � 1 rn� c0 � � < Z y � �� v N � � zZ mN -o n --1 Z �o a ° < � � �a m� �z Z � D � vo a� �m c� �0 o� z vz �N o� z �v 2 � Z . � � � zp v� vz �< nm N Z -i 5 Z �` � �+ m O � m � c � � � cc J � �. d CSIMNEY AND BTACR VERIFICATION The undersigned hereby verifie� 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 Yes () No () 5. Meets all current Code requirements for size and total BTiJ's connected 6. Has total heating BTU's of All other BTU's TOTAL BTII's Remarks List Alterations Beiaq Done: Yes ( ) No ( ) HEATING COMPANY Signed By Date 6 ������ HEATING HOUSE HEATING TEST RECORD AIR COiVDIT10NING AND ELECTRIC. lNC. ADDRESS �1 �6� � V�� APT. FLOOR CITY ��� � SI�eUR� OCCUPANT �' � OWNER HEAT LOSS DATE HTG. INST. SOLD BY 4 II� � INSTALLED BY Electrlcal Work By Gas Line By TYPE OF HEAT GA FA HW STEAM SPACE HTR. UNR HTR. OTHER GAS DESIGN CONVERSION MAKE r�n� MAKE OF BURNER Model ���.�°���� ��.' Model Serial 4i b q 11 yrqQ Max. BTU Reting INPUT - �i�'��' - ---- - -- - �AICEQE�ILRNAGE .+� CONTROLS THERMOSTAT � / Heat Plug Valve W LimR �Q�f�ca Limft Setting 17� Fan Setting � e �`�'� L Pllot Type � AT � Vf 4E$ Pilot Make I�0 P P n Pilot Model � f Pllot Ttming Qo� �� L. W. Cut Off Pressure 3e Percent CO, � Input CFH r��� Percent O, '� � StackTemp. �� Percent CO A , Form 235 Model Verrt S(ze .� � KIND OF UNER � pq� � g�g NONE DraftHood SAc�vefd, Regulator Fiitere Stze ' �'���� � Number 4 Chimney Locatlon Inside Outslde Chimney Construction � 3moke Bomb � Wiring Draft `� Test Tag �� Door Pressure '�J Lighting Inst. °! Date Tested � � � ° �1' � Company Testing � e � t° Name of Tester