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AF - 47672BUILDING PERMIT Village of Fridley, Minn. N° 2 315 Date �� ............................. . Owner �/C��. . .4�y'l�:'T.►�.�. . . . . .��ld! . . . . . Builder .«�*'�� . . . . . . . . . . . . . . . . . . . . . . . . . . Address .��f:d.�%�-.°..�tijlll�.�,rr�...�� Address .............. , : LOCAT(ON OF BUILDING No. ..,�j�"'?'�j..... Street .�:��-i4-'�"x.y!..•��*�f'�.-:-�. Part of Lot ....................... Lot . . . .. .. .. .. . �p. . Block . . .�. .. . . . . . .�, Addition or Sub-Divisio .G%1Z'.��L, ,c�Gi , ,�'�'�, ;-d�,� . _ . . . . n ,,e'. Corner Lot . . . . . . . . . . . . Inside Lot . .. . . t.r!: . . . Setback . .�"'��,�y Sideyard . .,��%.�,!�'�'�!-r-�, , , , , , , , , , DES�CRIPTION OF BUfLD{NG To be Used as: ..,��+�i%�� . . Front . �.�.. Depth . �.,�. . Height �e+;��. .. Sq. Ft. ........ Cu. Ft. ........ �Q't,��y' /Q' • �. . �ti„� Front . .�,.L . . Depth . .,� 1. . . Height .�.+�t. . . Sq. Ft. . . . . . Cu. Ft. . . . . . . . . .��' Type of Construction ;;��,�,�,, Est. Cost . .��!+�rp;�'. . .�.�'.°�, . , , , , , , To be Completed . �+. !."7�'l. �°�,� In consideration of the issuance to me of a permit to construct the building described above, I agree to do the proposed work in accordance with the description above set forth and in compliance with all provisions of ordinances of the village of Fridley. +r!�' :................................................ Tn consideration of the payment of a fee of $.�lj� ��ermit is hereby granted to ... .... .. .. .. .... .. .. to construct the building or ad dition as described above. This permit is granted upon the.express condition that the person to whom it is granted and his agents, employees and worlunen, in all work done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of �'ridley, Minnesota.regarding loca,tion, construction, alteration, maintenance, repair and moving of buildings with- in the village limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. � NOTICE: ••... Building Inspector Thts permit does not cover the construction, installatlon or alteration for wirtng, plumbing, gas heattng, sewer or water. Be sure to see the Building Inspector for separate permits for these items. .�-�. � �. . � � ��-� � � City of Fridley, Minn. N° '7893 BUILDING PERMIT Da�. June 15, 1965 �: Wesley Tretsven ��park Region Development Corp. Ad�res� 6340 Jefferson St. N.E. Ad� 3242 Hwy 8 Mpls 18, Minn, LOCATION OF BUILDING No. 6340 S�t J�fferson � p� of Lot � 6 — �� ' Addition or Sub-Divisfon _��ristie Coraer Lot — Inaide Lot Setback Sideyard Sewer IIevation Fo�mdation IIevation DESCRIPTION OF BUILDING To be Used as: F�nt —.�. Depth Height Sq. I't Front Depth fT� t Sq. Ft 7.j►pe of Conslrucl3on F.st. Cost _ 14, 65 0 To be Completed W. Ft Gtt. Ft. Rebuild. Storm Damage 0 Ia conslderat4on o4 the iseuance to me of a permft to construct the � PaoPosed work in accrordance with the drescription above set f� orriinanc� oP the city oP F�idley. �� 10. 00 ' .� park Re ion Paymeat oE a f� of $� , permit is hereby " ted to g Development Corp. to conatruct the building or addition as d�cribed above. Thiapermi t fs granted upon 'We express condition that the P�on to whom it is granted and his agenta, employees an� worl�en� in all work ��, ��a�nd uPon said� ding, or anY part thereof� shall conform in all respects to tlie ordinanc� of Fridley, tiont; conatruction, alteration, maintensace, r+epafr and moviag oE buildings wl�� dty ]imits�� may be r�voked at any time upon violation of any of the provisiona of said A11�n Jensen BuiIding Inapector NOTIC� iYs �! das � eersr ths eo�ln+eH�, �taqaHoe ior �rfrlao, plum6teg, ia b�9, +�nr or w�ter. B� sun fs a� dn Butldiee in�te� fer aparah P�rm� Por t6a� Nw. AP1'LICATION FOR BUILDING PERIKIT CITY OF FRIDLEY, MINNESOTA OWI�R i S NAML �✓i l �F �2' . S � ,t' BUiLDER %�� ( �� ' � � o� � � 4� , ADDRESS�G � �f o �al �-�,L��,,� J'L „� � ADDRESS �''Z. ;F Z. �%� r�� 1 � LOCATION OF BUILDING No. Street Part of LoC ,�° -- LOT `� gLQCK ADDITION OR SUBDIVISION (�� Corner Lot`_Inside LaT Setback Sicie-�Yard SEWER ELEVA�,'TON FOUNDATION �I,EVi4TI0N � Applicant attach to this form Two Cereificates of Survey of Lot and proposed building locatioa drawn on these Certificates. DESCRiPTION OF BOILDING To be used as; ..._..�� Front pepth _� geight Sq. Ft. Cu. Ft. Frcrat bePt �_Height Sq. FC. Cu. Ft. Type of Coastruction _�i� ��_� EetimaCed Coat � j� � To be completed The uaderaigned hereby makes application for a permit for the work herein apecified, agreeing to do all work in strict accordance with the City of Fridley �rdiaanc�s and rul.�tngs of the Department of Bu3ldings, and hereby declares that all the facts aad representiationa stated in this application are true and correct. DATE � '� / $ '� � i� SIGNATQRE �' � (Schedule of Fee Costs can be found on the Re erse Side). � G � �j c� � ( �'/ , 07 0 � � � 4° � �% ;� �° � ; �� , �= t- BIIILDING PER1�T I�E -&�E SECrION 2. The Inspeator of Buildings sha].1. before issuia� any permit for the erection of any buildin� or sCructure, os £or any addition to any esistin� build- ing or seructure, or for any alteratior►s or repaira to any esiating building or structure� upoa appiication thexefore, require the payment by the applicant for su�h pe�rmit af��feee to the emount herein below set foath�and ia the manuer i�erein_ pravided to•wit; . 2.1. For any such permit for the erection of any fire�proof buildin�, other than a garage, warehouse, factory or graia elevator, or for the erection of any fire•proof addition, fos aimilar occupancy, to any existing building, shall be at tbe rate of $1.40 for each oa� thou�aad cubic feet, or fraction thereof, in euch cubical contents. 2:2. . For any auch perimit ior t�ie e�ection-oi any fire-proof garage, Warehouse, factorq or.grain elevator, or for the erection of aaq fire-proAf addition, for similar occupancy, to any existing building shall�b`e at the rate of $1.25 for each oae thoueaad cubic feet, claseified as. "fireproof" by SecCion 502 of the Minneapalis Suilding Cade. , HOo USBS 2.3. For anq such permit for the erec�ion of any non•fireproof building, other than a garage, warehouse, factory or grain elevator, or any non-fireproof addition, for similar occupancy, to any exiating building - permit $1.OU fQr each one thousand cubic feet. GARAGES � " � .__.__._ 2 4_ . For any such permit far the�erection of any non-fireproof garage, warehouse, factorq or grain elevator, or for the erection of any non-fireproof -addition� foz similar occupancy, to any existing building or for each such buildiag or addition - niaety ceats ($0.90) for each one thousand cubic feet os fractioa eheaeof, in the cubical contenCs thereof with the minimum of $4.00. For the purpose of computing fees for building permits, the cubiaal contents of any building or addition to a uniform height throughaut by multiplying the graund area co�et�ed from a point siac (6) inchea below the�floar line of.the basement or cellar to the average height of the upper surface or to the average height of the roof eurface�of the main gable of a pitched .ro.of. 2 S+, For repairs or alterationa to an exiating structure, the fee ehall be at the rate of $3.00 per each Five Huadred Do118rs ($500.00) or fraction thereof in the cost of all proposed work. 2.b. In no case ehalZ.Che fee charged for.aay permit as eet forth in Secti n 2 be less than $4.00. � �-_� .� � '�' _. . i /5 " . : � � � � ,: �'$�i��18i '�i�� #� P$Y'1C �8$;i�, pE''4t�:lOpeSB �2G.2 �g'�s�e� No. 8 �t. Aa�honp Vili�ge M;ttesae�pol�ls. Mi�esotg L�e:ar 9ir�: Insgacticin, t'�3a d�te, �� r� �cb at 634� J��sa�e�n S�reee �tor�h�st, Fzid9.�y,� I�tinuee��c�, �,�ts%icstes etast ��e:�e �� Ive i�eans �rhlab hav$ nat t�raan xep�i.��c� ox �on��et�8 � Si�ce� �u �h+�ose t� ��qn� the ��' � requ�r�� nd do x�c�t raaii t�ii� d�p�cem�e�t w�ea �.�k� �o, this , is t� 3�n��'+��m �rs�u �hat unle�s� ��i�a �s ��n wi�t�3�.�� dap��, �bie matter wi�i ba tuaned`av�� a oug +�ity At� ��rn�y fo� �pc>ssibae l�get ��9.�m� A�e�e��3or� �n��+�e ia�s t��em p�see�„ et��a� d,�te, �et �� b �dd�e��. ��ie� c� �; i��pe��3+an Repo�t ��e oa £�1a �a.an th�� f��e� th� ��ar��s al�o �hc�w th�t q+t�� pplieati+�n f�r� ��n�r�l C��taee��r's �i��se is �u�cmagle��, bacsnso your Ger�l�f#.�ate� of I�t�rax�se h�tve never '�een �i�,ed wi�h �xe. Ogex�Cin� r�it-��e �n a�plea�r� �i.c�eaee ��avee g�� e�b�g+�C t� � Stog W6rk �Dx�ca+a�� d +� fine,� t� �re tru�ti�g ��,se t%�.s +�'.�l �eceiv� �c�r �.n�d3.�te �ct�n- ��$n. AGJ: 3.k Ver3► t�utiy yours, ALLEN t�. �JEi�Sf� Sc��idi�g IYtsp�c��t -,�-�-^ � �� l� � „ n ;, r2o�rx � — � � — � �'� DATE DAY CONTRACTOR CAL�TIl++� INSpECTION & ADDRESS TIN1E �Y� i'� 0 c-� � � � � �`' a % s � a �, �r �-- �� .� � � f -� �=U � ,�i� � � S � � � -� � S � � �� -�yT sue�ecT PE City of Fridley 2 918 � AT THE TOP OF TNE TWINS g � I L D i N G P E R M I T ;, .� . COMMUNITY DEVELOPM�NT OIV. f � v � PAOTECTIVE INSPECTION SEC. �� j , � /"'1 � CITY MALL FRIDLE� SS�3P NUMBER pEV DATB PAGE OF APPROVED BY �'""�" �'' 612-571-3450 9t0-F�5 4/13/99 / / JOB ADORESS 6340 Jefferson Street NE � t LEGAL �OT NO. 6LOCK TRACT OR AODITION SEE ATTACNEO DESCR. Fj 4 Chri�tie Addition SMEET 2 PROPERTY OWNER � MAIL AOpR�S$ ZIP PMONE Robert Strand 6340 Jefferson Street NE 3 CONTRACTOR MAILADDRES3 21P PNONE LICENSENO Advance Aluminum Su 1 Inc 7701 Main St NE Fridle MN 55432 571-3440 4 ARCh11TECT OF DESIGNER MAIL AOORESS ZIP PMONE LICENSE NO 7983 5 ENGINEER MAIL ADDRESS ZIP PNONE LICENSE NO 8 USE OF BUIl01NG Residential 7 CLASS OF WORK 0 NEW O ADDITION O ALTERATIpN � REPAIR O MOVE O REMOVE 8 DESCRIBE WOFiK Reroof House & Gara e(Z9 S) Tear-off 9 CHANGEOFUSEfROM TO STIPULATIONS ' Underlayment must comply with the State Building Code. CONSTRUCTION WORK HOURS: 7:00 am to 9:00 pm, Monday thru Friday; 9:00 am to 9:00 pm on Saturday; No work on Sunday. SEPARATE PEHMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY (3ROUP OCCUPANCV LOAD VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOIO If WORK OF CONSTRUCTtON 20NING SO. FT CU FT AUTHORIZED IS NOT COMMENCEO V�1ITMIN 60 DAYS. OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONEO FOR A PERIOD OF 120 DAYS A7 ANY TIME AF7ER WORK IS COMMENCED. NO DWLG. UNITS OFFSTpEET PARKING I HEFEBV CERTIFV THAT I HAVE READ ANO EXAMINEO TMIS APPLICA710N 1 S7ALLS GARAGES AND KNOW TNE SAME TO BE TRUEAND COFRECT. ALL PROVISIONS OF LAWg VALUATION SUpTAX � ANO ORDINANCES GOVERNING THIS TVPE OF WpqK WILL QE COMPUED WITM WME7MER SPECIFIED MEREIN Ofl NOT. TME GRANTING OF A PERMIT �2, 485 $ L. Z�F DOES N07 PpESUME 70 GIVE AU7HORITV TO VIOLA7E OR CAMCEL TNE pEqM1T FEE SAC CNARGE PROVISIONS OF ANY OTHER STATE OR I,OCAL LAW REGUTATING CON- TqUCTION OR ME PEHFORMANCE OF CONSTRUCTION �7�F.75 Fire .5�.' �Z.�FB eA/�n OIi, PLAN CMECK FEE TOT f EE , �5�� Lic SC $ .00 $83.4 iG 4TUAE O� CON'AACTO OA AUTM0�7iZE� 4GENi iOATE� MEN PRO VALI D THIS IS V U E iT i � S�GN4TUAEO�OWNEp��OWNEABUiLDEA� �D�rE� . ' B� G�NS� r„tE iNG DA1CF.; Permic Firej Su Stat� S SACI C Park: � Sewer � � �� [] a ei2 s�i Zase ADUANCE RLUMINUM C�1'Y OF FYtIDLEY SINGLE FAM.iLY AND DUPLE7�]S R•1 AND lt-2 BUILbING PFRMIT APPLICATION ��_�� 01 Elffective 1/1/98 �� l �� 0 �� G� . � l Description: :r Na�ne & Address: /.�,c,z. "~ 5T,� '1'el. � •actor: �q,0li,g,�.t,,� ,q�,�,.�,,,��,�,; � vP,oL y, ��L MN LICENSE ��98 3 -. :ss:! 7 yv I/L1� i� 5 T��i Tel. �' S�/�--3 YYD Attach to this applicacion, .a Certificate of Survey of the ~ lot, with the proposecl construction drawn on it to scale. G �REA: GEi AREA: A1i�EA: DESCRYPTION OF �.MPROVEMENT Length Width Height Sq. Ft.. �ng� : wid� Height Sq. Ft. �ng� �:, �id� Hgt/Ground Sq. Ft, 5 y�o n..r-��9tir A� G•� ctior� 1 jrpe:` ��.�.,.. ` _ R d 0�/NG ,� q� Estimated Cost: $. f�y� �`.� (Fee Schedule on Baek) ay Curb C�t Width Needed: Fc. + 6 1 c= Ft x$• —$ �, _, APPLICANT: Tcl. � ,S�'�' ,� y� CITY US� ONLY Surcharge y F.s�row Conorol Charge � �-�� Fee Schedule on Reverse Side � � � �� .001 of Pennit Valuation (1/lOth%) � > � $.SO/$1,000 Valuation $ $1000 per SAC Unit $ � ��-1„ $5.00 (Stace Licensed Kesidential Con�ractors) $ Alt. "A" or Alt. "B" Above � $450.00 Conservation Plan Review $ Fee Determined by Engineering � , Agreement Necessary [ j Not Necessary [] � � � �. �'I'I�NS: �M tia/`� ,c�.�c� r .ti�� t °" � - �. City of Fridley AT TNE TOP OF THE TWINS � i � � `L �_�� COMMUNITY OEVELOPMENT DIV. r � � PROTEGTIVE INSPECTION SEC. i = : `.--.�: �"'i.� CITY NALL FRIDLEV SSIJ2 L 612-571-34b0 �U ILDING PERMIT NUMBER REV OATE PAGE OF 91Q-F15 3/2/00 / / JOB ADDRESS 6340 Jefferson Street NE t LEGAI �OT N0. BLOCK TiiACT OR ADDITION DESCfi. ( 4 Christie Addition 2 PROPERTY OWNER MAIL AQORES$ Robert Strand 6340 Jefferson Street NE � CONTiiACTOR MAIL A�ORESS 21P Creative Iiomes 4616 5 Street NE, Columbia Heights, MN 55421 4 ARCHITECT Oq DESIGNER MAIL ADDRESS ZIP 5 ENGINEER MAIL 3069E RECEIPT NO. �� vnrtOVED Br SEE ATTACMEO SHEET 571-5612 PHONE LICENSE NO 572-1426 20205186 PMONE LICENSE NO. PMONE LICENSE NO 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION � ALTERATION �7 REPAIR p MOVE O REMOVE 8 DESCRIBE WORK Replace existing windows; replace front steps; replace portion of garage floor; insta so t& asc a 9 CHANOE Of USE FROM TO STIPULATIONS Provide smoke detectors in all sleeping rooms and on all levels of the dwelling per Section 310.9.1.2 of the 1997 Uniform Building Code. Front step to meet size, rise and run requirements of the State Building Code. Provide soffit ventilation to meet the State Building Code. SEPARATE PERMITS ARE REQUIRED FOH ELECTRICAL, P�UMBINCa, NEATING, TYPE OF CONST. VENTILATING OR AIH CONOITIONING THIS PEFMIT BECOMES NULL AND VOID IF WOfiK OR CONSTRUCTION 10NING AUTHORIZED IS NOT COMMENCED V�IITMIN 80 DAYS, Oii IF CONSTRUCTION OH WORK IS SUSPENDED OR ABANOONED fOR A PERIOO OF 120 DAYS AT ANY TIME AFTER WORK IS COMMENCED. NO DWLG. UNI I HEREBY CER7IFY 7HAT I MAVE READ AND EXAMINEO TNIS APPLICATION 1 AND KNOW THE SAME TO 8E TRUE AND CORRECT. ALL PROVISIONS OF �AWS yqLUATION AND ORDINANCES GOVERNING THIS TYPE OF WORK WILI BE COMPLIEO �iS�OOO WITM WHETMER SPECIFIEO MEREIN OR NOT. TNE GRANTING Of A PERMIT OOES NOT PRESUME TO GIVE AUTMORI7V TO VIOLATE OR CANCEL TME pEFMITfEE PROVISIONS OF ANY OTNER STATE OR LOCAI LAW qEGULATING CON- RU TION OR TME PERfOiiMANCE OF CONSTRUC710N �251 . ZS r" PLAN CNECK f EI � �- License i S�GN4TUAE CON'RACTpqO •urHOaiLEOaGENi IOATE� E F i � �D�tE� SEPARATE PERN�t'� � REQUIRED FO�: WIRING, yEq�� PLUM��N� �� ,� vGGUPANC�GROUP OCCUPANCYLOAD SO. fT CU FT OFFSTREET PARKING STALI$ GARAGES SURTAX � $7.50 Fire SC $15.00 T ALfEE $5.0 $278.75 � VA A D TMIS I�O�PEIi� � � � � � �' N� � � Effective 1/1/2000 ADDN [ ] CITY OF FRIDLEY ALTER [] SINGLE FAMILY AND DUPLEXES R-1 AND R-� (763) 572-3604 Bldg Insp BUILDING PERMITAPPUCATION ��W (,� � �� Construction Address: y Q C'�2 S� � S-� f� .�,�, � Legal Description: Owner Name 8� Address: �� Cl,P.2-r Tei. # -S�i j � $��/� Contraetor: — � � �(� �I1�ICENSE # � O � o L� ) � G, Address: °`/ I (o S'�'� S -{- 2, ,�j ( "' �� Tel. # _ S7a -1 �l a Attach to this application, a Cert�cate of Survey of the lot, with the proposed construction drawn on it to scale. LMNG AREA: GARAGE AREA: DESCRIPTION OF IMPROVEMENT Length Width Height Sq. Ft Length Width Height Sq. Ft DECK AREA: Length Width Hgt/Ground Sq. Ft OTHER: ��.�(,�� x��T�� , 7AO �S, �e�l�ce T-�Zon�� STea°S �PCReg �p2T�aN O�F (�jR2AGQ F'Lo02t TIJS1'oQ�L Al.tiarv�. Ss��-l-"i-r�FFAS�i,�. Construction Type: Estimated Cost: $$ �S 0 O o Driveway Curb Cut Wdth Needed: Ft. + 6 Ft = Ft x$ _� DATE: �^ O a— O O APPLICANT: �> �� Tel. #_ S i 2—�{ e� �,o CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application Permit Fee $��/,,��'Fee Schedule on Reverse Side Fire Surcharge $_ /,� �� .001 of Permit Valuation (1/10th%) State Surcharge $ %, .'�Q $.50/$1,000 Valuation SAC Charge $ $1100 per SAC Unit License Surcharge $ �� C� C7 $5.00 (State Licensed Residential Contractors) Driveway Escrow $ Alt. "A" or Alt. "B" Above Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: � $450.00 Conservation Plan Review $ Fee Determined by Engineering � Agreement Necessary [ ] Not Necessary [ ] $ � % � 7� BUII..DING PERMIT FEE SCHEDULE 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 alteration 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 tawit: TOTAL VALUE $1 to $500 $501 to $2,000 $2,001 to $25,000 $25,001 to $50,000 $50,001 to $100,000 $100,001 to $500,000 $500,001 to $1,000,000 $1,(�10,001 and up FEES $23.50 $23.50 for first $5� plus $3.05 for each additional $100 or fraction thereof, to and including $2,Q00 $69.25 for first $2,000 plus $14.00 for each additional$1,000 or fraction thereof, to and including $25,000 $391.25 for first $25,000 plus $10.10 for each additional $1,(�l0 or fraction thereof, to and including $50,000 $643.75 for first $50,0� plus $7.00 for each additional $1,000 or fraction thereof, to and including $100,000 $993.75 for first $100,000 plus $5.60 for each additional $1,000 or fraction thereof, to and including $SOO,Oi� $3,233.75 for the first $500,000 plus $4.75 for each additional $1,(}00 or fraction thereof, to and including $1,Q00,000 $5,608.75 for the first $1,000,000 plus $3.15 for each additional $1,Q00 or fraction thereof DRIVEWAY DEPRESSION ESCROW (Concrete C�rb Streets Only) Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $15.50. Alterna.te "B" : Removal and replacement of curb and gutter and install a 3 foot wide approach with 6 inch depth - Driveway width plus 6 feet times $23.25. 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 Certificaxe of S�rvey of the lot, showing the location of the foundation once it has it has been constructed will be required before proceeding with the framing. New Houses Onlv �. , � � � m � c � s D '° r � '� m m � � � c� O � z � m z --I z O O z 00 n � � v m D v v < a W � � � � � 7 v w � D � � � rn � o �� ,2p N � � C � � O Z m T � EA �OV c � o o m = � D ' D _ v � v � �v D � m � O z � � � Z m v �� a, u°1, m c^"u m c o�i, cni �� W m m d � � ci ° °' � 'O T � � -� � � � C � O � ,0 'Tl � � N � fD N � � ,�.► pWj �i t/i � .�. � � � � p � � �' �� d � � � � -+ '� � °� 7 �� i tn, N� Ul � � � (G � � � (� Z m co � N � � � � i � T � � A � � c � m � m c. .� rn N v Z 0 I ( I � I( I I I I I I I � � � � � � � � � � � � � CT1 O O q V p V�I V�I t71 A V 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 � C � � Z � C� O � 'O D � -- •� � 7 O1 Z � O �: � � � 1 Q� .�. N m �: m a n 0 � � D G � � m � 3 -a � � _a � m � C � a w S � � � 0 �g % a m s A � � 2 � C � � co Q- m i N fp N i O� � tG '. s �. f�D . � � Q ? �° g m . Q a Q . � � ,a : o = � < o m . y � y � O d ? � a � u, a •a� �i ��'d o ' �D � � `�a� a o� d � � � � � N � cJ.► � O •°1-► (�D � m c, cu � � o m � �- -h a�p y N N � � r C � W Z 1'I � C � m � m � .—. ^. � � m � O D r � O W ►❑ . COMMON VENT. VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When realacinp an existina furance, 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 venting system is plastic/PVC 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 existina combustion air is sized and installed to meet the cuRent codes and manufacturer's specfications. When required to install a new combustion air, it will be sized and installed To meet the current codes and manufacturer's specifications. Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) When installina a new venting system, the undersigned hereby verifies that it is a listed assembly and meets the cuRent codes and manufacturer's 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 () Aapliance Tvpe and Size/Common Vent and Vent Connector Information Appliance #1 Type BTU Input Fan Assisted or Nat Appliance #2 Type BTU Input Fan Assisted or Nat Appliance #3 Type BTU Input Fa� 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 ALTERATIONS• (Describel HEATING CO: Signed By: Date :