AF - 47968SUBJECT
City of Fridley 20023
AT THE TOP OF THE TWINS g U I L D I N G P E R M I T
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� • COMMUNITY DEVELOPMENT DIV. � � � �
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1 ; �
i--_. A �/"',,J CITY HALL FRIDLEY SS432 NUMBER REV. DATE PAGE OF APPROVED BV
Z '� 612-571-3450 910-F15 7/27/89 � �
JOB ADDRESS 1642 KY'1S'tlIl C011Y"t N.E.
1 LEGAL �OT NO. BLOCK TRACT OR ADDITION SEE ATTACHEO
DESCR. 8 1 Heather �ICS SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Brickner Bui.lders 6240 Highway #65 N.E., #208, Fridley 55432 574-9871
3 CONTRACTOF MAIL ADDRESS Z�P PHONE LICENSE NO.
Sdme
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER "�3�TE PERMITS REQUIRED F� PHONE LICENSE NO.
8 USE OF BUILDING > > •
RES 1CZP.Iltl3�.
7 CLASS OF WORK
� NEW � ADDITION ❑ ALTERATION ❑ REPAIR � MOVE ❑-`�REMOVE
8 DESCRIBE WORK
Canstruct a 35` x 36� Dwelling and a 26' x 22� Gara�e �AR�,��
Be�ore digging calt local utilities
9 CHANGEOFUSEFROM TO
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STIPULATIONS
Provide a hard surfa,ce drivehraX, �XOVide sod in the front and side yards.
Provide City with copy of verifying survey�. Paid �ark.Fee of $1�50Q,'00. Paid
Storm 5ewer �'ee of $800.00 See nota.tion� on plaxi,
SEW.ER LQCAT�ON Q 160 � S' �f M3ri�101@. (S. Ii1V., 958. 83� �(�Y,`E ELEV: 859, 47
TOP OF FOOTING: 862.47 Minimum
WATER LOCATTONq Approx. 10� South of Sewer Ser�ice
May need driveway curb cut - Existing depression appears to bE in wxong location
��I� C17Y OF �FRfDLEY DOES NOT GUARANTEE TME
ACCURACY OF UTILITY LOCATIONS AND ELEVATIONS,
TFiIS DATA IS FOR INFORP!;ATION �U^�-�O:;ES ONLY,
AND PER�OfJS USING THi� INFORMA710N SHJULD
VERIFY IT 6N fiHE SITE,
TVPEOFCONST. OCCUPANCYGROUP OCCUPANCYLOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTII.ATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZpNING SO. FT. CU. FT.
AUTHOFIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOH A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PAPKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION �- STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WIIL BE COMPLIED $144 IOO �`%�Le3S
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT �
DOES NOT PRESU E TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERM1T FEE SAC CHARGE
PROVISIONS O NY OTHER STATE OR LOCAL LAW REGULATING CON- $7�7.00 $575.00
STRUCTI HE PERFORMA E F CONS UCTION.
PLAN CHECKFEE TOTALFEE
�� /�i � " 7✓ �.' � N/A $l, 44�4. 35 -k Pk' & SS
SIGNATUREOFCONiRACT RO THORI2EDAGENT �DaTEi - WHEN PROPERLY V IDATED THIS IS YOUR PERMIT
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SiGNATUREOFOWNER�IFOWNERBUILDERi �IDATE� �� BLDG INSP �lA E
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RONALD F. NIEYER
LAND SIIRVEYOR
v,NO suRVewiNO sueoiv�stoN Dea�ot�t
TeLGPMONff 771-4886
96� JR9DIR 8T. ST. PAUL. MINN. SS101
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I hereby certify that this survey was prepared by me and that I am a duly
Registered Land Surveyor under the laws of the State of Minnesota. •.
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�- Reg. No. 9051 Date: C�
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o Indicates iron monument
' Lot 8, Block 1� HEATHER OAKS� Anoka County� Minneaota.
Contain�s 9,160 aq. ft.. '
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ADDN � �
ALTIIt � �
1�1 AND R-2
Building P�ermit Application
Effective 5/1/88
construction Adclress: �� Y� K dZ I ST I YV C�'
� ���� �� � Sr � L o � k ( _ h�� �rtl� e �- C��k S
Owner Name & Add�s.s: _�%('� e�.. Tel. #
coritractor: � v �� c k h� v J(� c�, i ��� v� Z�el •# S7 Y- % Fr 7/
19daress: ��, y (� /}l�». G � �.� l� rl �r,.� � ,� �, _ /�'1 ih v� _ �:��.� �
I+I�iaK' ARE�:
t�iR�E AREA:
D�CK AREA:
O�[t:
Attach to thi.s application, a Certificate of Survey of the
lot, with the prc�osed oo�structia� drawn on it to scale.
�St3tIP1'I�T �F'
Tar�h Width Heic,�t Sq. F't.
I�.ngt]i Width Heic�t Sq. Ft.
Tp�h Width Hgt/Ground Sq. Ft.
Corner Lat [] InsidQ L�t [] Ft. Yd Setback Side Yard Setbac,ks
Zj�pe of C�struction: Estimated Cost: $ / � _
,�lpprox. C�letion Date: �c� � � 1� �
'1 �� �
Proposed Driveway Width If N�a Op�ning Is Desired:luV Ft. $ $
` �I '���e � Width + 6 � - See Back Fage
nP,z�: — /— �,IC�,xr: ti �-.� �. # S7 y-9r�1 /
Piermit Fee $��.�
state surcharge $ �� .��
SAC Ct�arge $ �'�R .��
Driveway Escraw $ �---
Park Fee $ %'�'�.�Q
e $ fi��f�cl
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$ � ,
CITY LJBE �Y
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Fee Sc�edule a�► Reverse Side
$.5o/$i,000 va�uati�
$575 per SAC Unit
Alt. "A" or Alt. �B" �bove
FEe D�2�ID1I'1ed by F�ri r�aPri m
Agr�eemer►t Neoessary [ ] Not Ne�s.szxy [ ]
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The Chief Bui�lding Official shall, before i C4,; m permits for the erection of a�
building or structure, or for arry additioa� to any existinq b�iildinq or structure, or
for ariy alteration or repair to any pYl �t7, ��� or structure, upon application
therefore, require the payment hy, the applicant for suc� peYmit of fees to the amoauit
h+erein below set forth and in the manner herein prwided ta�ait:
TOr!'AL VAIIJE
$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
�+�.
S15 iMiniaa� Fee is $15 plus surcharge)
$15 for first $500 plus $2 for each additional, $100 or
fractiori ti�of, to and including $2, 000
$45 for first $2,000 plus $9 for each additional $1,000
or fractio� thernof, to and including $25,000
$252 for fitst $25,000 plus $6.50 for each a�iitional $1,000
or fractian thereof, to and including $50,000
$414.50 for first $50,000 plus $4.50 for each additional
$1,000 or fraction ther+eof, to arid including $100,000
$639.50 for fisst $100,000 plus $3.50 for each additional
$1,000 or fraction ther�of, to and includirig $500,000
$500,001 to $1,000,000 $2039.50 for the first $500,000 plus $3 for each additional
$l, 000 or fraction the�+eof, t� arid including $1, 000, 000
$1,000,001 and up $3539.50 for the first $1,000,000 plus $2 for each additional
$1, 000 or frackion thereof
D�tIVE'�iY �I�T ffi�
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(Qoncrete Curb Streets OnlY)
Alternate oA�� ; R,emaval and replac�nent of curb and onl
9utter y- Driveway width plus
6 feet times $13.50.
Alternate ��g�� ; R+anoval and replaoesoent of cutb and gutter and install a 3 foot wide
aPP�� with 6 in� depth - Drivew�ay width plus 6 feet times $15.75.
�'/�+: �� �': N •;� •)' :,�`�i.n - u •i,
Permits for oonstruction will },�e ;��,� a t�r;,m,m of 24 houis frwa the tiaie of
a�lication to allvw for prc�er review of the Pr� structure and of the
�uction site.
A Certificate of S�vey of tiie lot, sha�aing ti� location of the foqu�dation orioe it has
it h�s been vo�nstructed will be required before prooeeding with the fiaming.
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� o►rchitecturo►i consultants inc.
� SOOB 3� ST, a. E. OSSEO, MN. 66368 P11. 1�1-K4_9TTQ �
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Plan'* �"' �°'...-- Date
Owner�
�Controctort �� z��' �-- ' ' '�'�'D �` _
Site Ad d ress:
i)TOTAL EXPO$ED WALL AREA �-PLO 2 � sq. fk x�U�ly� �
, 2) TOTAL EXPOSED ROOF�CEILING AREA. � 2� sq. ft. X'U��' �
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�IALL AREA CALCUI.ATlONS� _ �
SOTAL WINDOW AREA
_ GLAZED
TOTAL DOOR AREA
70TAL GLASS DOOR AREA
. , GLAZED
TOTAL fIREPLACE WALL .AREA
?OTAL WALL FRAMING AREA
NET INSULATED WALL AREA
TOTAL RIM JOIST AREA
TOTAL FOUNDATION AREA (EXPOSED)
TOTAL FOUNDATION WINOOW AREA
� Z-�' sQ.ft.x�U��L`�� _. �
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�" 2 sq.fLX�U��-��'.—Z -- ,1— � —�
��-�' sq.ft.x�U����— ��
z3d �q.ft.x�U��' �� = Zo, "1
1�3g- _
.. _. sq.ft.z�U�� � — �`j � ._..
28� sq.ft.x U�� l�`� =.�.1-' S
-1 1 �q.ft.X'u",J `� _. °( � i
---- sq.ft.x�U° � -
- 3) TOTAL z3� �
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1 f item 3 is the same as, oi less than liem
2 MCAR I.f6008 A and O.
Y
ROOF/CElLINO CALCULATIONS�
l, you have met fhe lntent of
_�OTAL SKYLIGHT AREA �q.tt��U�� ". -
JOTAL ROOF��ILING FRAMIN(i AREA ��� �4•ftx����'D�" �--
NET INSULATEO ROOF CEILING AREA . �� 5Z sq.tt.x�U����Zi-Z�'3
��'4) TOTAL _ Z �' �
—. If Item 4 ls the same as,or less fhan ltem 2, ycu have met 1he intent of :
; 2 MCAR l.16008 A and 0.
ALTERNATE BUILDING ENVELOPE �ES10N .
• To utilize fhe totaJ envelope system method, the sum of (tems i and 2 shall �. �
� be Qreater than the sum of Items 3 and 4. . _ _ _ - . -- - - % :
" � �� . �2�_= .
- :_. .___3) �-4) _ . --
�.. 1 hereby certlfy that the bufldtnp her� descr�6ed meets or exceeds the State of Minnesota
fnerpy Conservatlon Act. _ , � : •
. islgned �
�� �ONSTRUCTION
� � .... I ��.�-, 2�-l-��
FRAMIN(3 SECTION
� Interlor air film 0.68
2 -�..' S�-F�,PJ ✓�. .4s
� SZ lnches of sofl wood �,g�
4 L�I se ���+E L, o�
5 ��o�.-� , � I
� exterior oir film 0.17
. TOTAL R � � � °
- v = 1/R ` °`�
SECTION (INSULATED)
� lntertor air fllm 0.68
2 ~ �J' h�'�!� 1 TV�
3 Sl a i3�+ �.-+S. I°I � d
4�'I sL E+r�� �.I-L' 4�E �, 0 6
5 '��w�.,+5 .'� I
g �exterior ofr film 0.17
_ TOTA L R Z.� � �
u = vR �
)I ST SECT�ION �
� Pnterior air fllm 0.68
2 �� g �F t.-��. I`i , o
3 �'d � ��G�-...�+o �, o�l
q Ls �al Bv�vEFN-E Z,o.�
5 '��,� � ��y � S l
� exterl�r alr film 0.17
- � TOTAL R � � �
U = I/R o a
ATION SECTION
� lnferlor nlr film 0.66
Q �usl-rP.,� �..�7. �.o
3 ����.�. v��- I ,24�
,q exterPor air f11m
5 0.17
_ _ TOTAL R 1 � tS
. . U = 1/R�
.
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VENTED
+CONSTRUCTION � �,
___ �EILING__.SECTION �INSULATED)._. _ . _
� ( � �interlor oir film 0.61
(.2 �„[$ �►G�„ZoL� �slo _. _._.
_>_.__.__ �
, _ ( 3 �+...o,,.,,., l ,��.,` �� _
______ ( � exterior air film (still) 0.61
' ; . TOTAL R ��,� S
_ U = _ilfi , OZZ
{
__CEILING FRAMING SECTION __.. t. __ ..
�_� lnterJor air f11m � 0.61
_�2;��g Str�ra�c�c. � . Slo
- ( 3 � �-�� I Ms..iv �
�4 interior air film 0.61 _.
(� �zinches of soft wood Q��� �
� ' TOTAL R �?
_ 1.1 = _ I /R � �Z�D
�EILING SECTION i INSULATED).
_ ( � interfor air film 0,6t
- -t2
-- �3
_ (q exierior air f11m (still) 0.61
TOTAL R
, �1 = V R
_CEIUNG FRAMING SECTION -
_( �.interlor air film 0.61
_ - �e
�3
44 interlor oir film 0.61
_ (5 inches of soft wood
TOTAL _ R —_—____
„!1 _= _. .11R
EXPOSED BEAM CEILING SECTION
(� interior ofr �tilm 0.61
(2
(3 �
i4
(5 exterior air film 0.17
TOTAL R _-.-.--
— --- - _ �
L = __I/R� _ ..
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RONALD F. NIEYER
LAND SIIRVEYOR
LAND SURVEYING SUBOIVI9ION DE31GN
TELEPHONE 771-4886
98S JEBSIE ST
ST. PAUL, MINN. 55101
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I he�eby certify that this survey was prepared by me and that i am a duly
Registered Land Surveyor under the laws of the State of Minnesota.
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o Indicates iron monument
• Lot 8� Block 1� �T� OAKS, Anoka County, Minnesota.
Contains 9,160 sq, ft..
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CHIM��EY AND STACK VERIFICATION
The undersi.gned hereby veri.fies that the existing chimney or stack; �
1. 'Has .been_ careful ly examined � Yes (, )
2. Is free from�rust or deterioration Yes ()
3. Has no foreign objects lodged within Yes ()
4. Is securely supported Yes ()
5. Meets all current Code requirements for size and
total BTU connected �
6. Has To ta 1 hea ti ng BTU' s of
All other BTU's
TOTAL
Rema rk s
No ( )
No ( )
No ( )
No()
Ye s ( ) No ( )
Company
Signed By
Da te
�
_
CITYOF
FRIDLEY
FRIDLEY MUMCIPAL CEtiTER • fri;l liNIVERSITY AVE. N.E. FRIDLEY. Mti 55�3� • �613) .57]-3-350 • F�X i(�1 �i �71-1'�7
November 15, 1989
Brickner Builders
6240 Highway #65 N.E., #208
Fridley, MN 55432
Re: Final Inspection at 1642 Kristin Court N.E., Fridley
Dear Sirs:
A final inspection was conducted on November 15, 1989 of the above
address and there were no corrections/violations noted at this
time. The structure is approved for occupancy.
If you have any questions on this matter, please feel free to
contact me at 571-3450.
Sincerely,
�
DARR G. CLARK
Chief Building Official
DGC/mh
� DVO�CL� , '
c�ty of Fridley
AT THE TOP OF THE TWINS � � � L D I N G P E R M I T
�
i �
� �
� ; y ___._ COMMUNI7Y OE�ELOPMENT OIV.
f � � PR07ECTIVE INSPECTION SEC.
� � �
� �'�'1 � C�TY HALL FRIOLEr 'SSI$2 NUMQEN NEV O�TE P�GE Oi
�""'� � �'' 612-571-3460 gt0-F15 10/26/00 / /
JOB ADORESS 1642 Kristin Court NE
1 LEGAL �OT NO. BLOCK TiiACT OR ADOITION
oesca. g 1 fleather Oaks
2 PROPERTY OWNER MAIL ADDRES$ 21P
Jim Phillips 1642 Kristin Court NE
3 CONTFACTOR MAIL ADORESS Z�P
North Metro Construction 525 Tower Pond Ct, Anoka, MN 55303
4 ARCNITECT OR DESIGNER MAIL ADDpESS Z�P
5 ENGINEER
8 USE OF BUILDING
Residential
7 CLASS OF WOFiK
MAII ADDFiESS
3 i 526
� ��
ED Br
SEE ATTACMEO
SMEET
PMONE
827-3648
PHONE LICENSE NO
763-272-4231
PMONE LICENSE NO.
21P PHONE LICENSE NO
❑ NEW O ADDITION O ALTERATION � REPAIR O MOVE O REMOVE
8 DESCRIBE WOIiK
Reroof House & Garage (31
8 CHAN(iE OF USE FROM
Tear-off
TO
STIPULATIONS
Underlayment must comply with the State Building Code.
SEPARATE PERMI7S AiiE REOUIRED FOR ELECTf11CAL, PLUMBING, NEATING.
VENTILATING OR AIR CONOITIONING
TMIS PERMIT BECOMES NULI AND VOID IF WORK OR CONSTFiUCTION ZONING
AUTHORIZEO IS NOT COMMENCED V'IITHIN 80 DAYS. Oii IF CONSTpUCTION
OR WORK IS SUSPENDED OF ABANDONEO fOii A PERIOD Of 120 DAYS AT
ANV TIME AFTER WOpK IS COMMENCED NO DWLG. UNITS
I MEREBV CERTIFV TNAT I HAVE READ AND �XAMINED TNIS APPLICATION 1
AND KNOW TME SAME TO BE TRUE AND CORRECT. ALL PROVISIONS Of LAWS yALUATION
ANO OR�INANCES GOVERNING TMIS TYPE OF WORK WILL 8E COMP�IEO 3 17O
WITM WHETHER SPECIFIED MEREIN OR NOT. THE GRANTING OF A PERMIT ��
DOES NOT PRESUME TO GIVE AUTMORITY TO VIOIATE OR CANCEL THE pEqMITfEE
PROVISIONS OF ANY OTMER STATE OR LOCAL LAW REGUTATING CON• @97 � 2S
STRUCTION OR TNE PERFORMANCE OF CONSTRUCTION '�'
n PLAN CHECK
(�.u,;,, f�� 'd,�G�a� QO�a.(o_ � Lice e C
� SiGN4TUfiE OF CON'AACiOp Op OU�MOA�2ED eGENT IDATE�
M P�1
iiF OWNEii BURDERi �
SC. FT
S7AlLS
r
�YGROUP OCCUPANCVLOAO
CU FT
OFFSTREET PARKING
GARAGES
SUR7AX
� $1.59
ir, SC $3.17
a'AL FEE
$107.01
THIS IS Ae P' Y+ L/G./
d �
f�6TF
NEW
ADDN
ALTER
� � �� �-
[ I {� � �' Effective 1/1/2000
[ l CITY OF FRIDLEY r�d (763) 572-3604 Bldg Insp
[] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: _ 1lo�c'� K�i s-1-��n �'. (U,
Legal Description: 1� �v� �-� q o.r�q �
Owner Name & Address: _�i cv� �I�� I� i� Tel. #��l - 3(0 4 8
Contractor: __ N�d� ��°fYo C��+-�-rc.� c.� c� e� MN UCENSE # 01�8� g 3°I?
LNING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
�
^ � Te�. #C� ) a� � - �-( a31
�S-�o,�
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length Width Height Sq. Ft
Le�ng�h
Hgt/Ground Sq. Ft.
Construction Type: �.� - (�o °� Estimated Cost: $ ��� � �� %�
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x$ _�
DATE: I v- 0`�2 b� o�.� APPLICANT: ��,.,' �. �j, p � Tel. # C7(a3 ),�ia- �{ a-3 f
CITY USE ONLY - Call (763) 572-3604 for Pennit Fees ff mailing in application
Permit Fee $ �, ��� Fee Schedule on Reverse Side
Fire Surcharge $ �� 17 .001 of Permit Valuation (1/10th%)
State Surcharge $ /, � $.50/$1,000 Valuation
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
$ $1100 per SAC Unit
$ �. O b $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
Sewer Main Charge $ Agreement Necessary [] Not Necessary []
TOTAL
STIPULATIONS:
$ � /�� Di
�
BUII.DING PERNIIT FEE SCHEDULE
The Chief Building Official shall, before issuing pernuts 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 to-wit:
TOTAL VALUE
$1 to $500
$501 to $2,000
$2,Q01 to $25,000
$25,�1 to $50,000
$50,001 to $100,000
$100,001 to $500,000
$500,00� to $1,000,000
$1,0(}0,001 and up
FEES
$23.50
$23.50 for first $5(� plus $3.05 for each additional $lUU or
fraction thereof, to and including $2,000
$69.25 for first $2,OQ0 plus $14.00 for each addirional $1,�0
or fraction thereof, to and including $25,OOD
$391.25 for first $25,000 plus $10.10 for each additional $1,000
or fraction thereof, to and including $SO,Q00
$643.75 for first $SO,OOO plus $7.00 for each addidonal
$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 $500,000
$3,233.75 for the first $500,000 plus $4.75 for each additional
$1,000 or fracdon thereof, to and including $1,000,000
$5,608.75 for the first $1,000,� plus $3.15 for each additional
$1,000 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.
Alternate "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 Certificate of Survey 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
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COMMON VENT. VENT CONNECTOR AND COMBUSTION AiR VERIFICATION
When replacinq an existing furance, the undersigned hereby verifies that the
venting has been examined and is ftee 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 specfications. 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 current codes
and manufacturers specifications.
When required to install a new combustion air, it will be sized and installed
To meet the current codes and manufacturers specifications.
Yes ( ) No ( )
Yes ( ) No ( )
Yes ( ) No ( )
When installinct a new ventina svstem, the undersigned hereby verifles 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 ()
Appliance 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 Fan 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 Conne�tor Height ft Length ft Diameter in Type
ALTERATIONS: (Describel
HEATING CO:
Signed By: Date :
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COMMON VENT. VENT CONNEC�OR AND COMBUS'FION AIR VERIFICATION
When replacing an e�cisting 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 plastiGPVC 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 existing combustion air is sized and installed to meet the cuRent codes
and manufacturers specifications.
When required to install a new combustion air, it will be sized and instailed
to meet the current codes and manufacturer's specifications.
Yes ( ) No ( )
Yes()No()
Yes ( ) No ( )
When installina a new ventina svstem, the undersigned hereby verifies that
it is a listed assembly and meets the current 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 ()
Appliance Tvpe and Size/Commo� Vent and l�ent 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 Fan Assisfed or Nat
Total Appliances Total Btu Input
Common Vent Type
Vent Height Diameter inches
Appliarice #1 Veni Connector Neight ft Lengii� ii Giameter in '�yp� __
Appliance #2 Vent Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
ALTERATIONS: (Describe)
HEATING CO:
Signed By: Date :