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PRE 2010 DOCSCity of Fridley, Minn. N° 10015 BUILDING PERMIT owner: Robert D. DeGardrer Builder Same Address 2010 A-1— Ave North, els. Address s5ame LOCATION OF BUILDING No. x 94 _— Street — Part of Lot Lot _I & 2Block 12 Addition or Sub -Division _frig Brook Park Corner Lot _ X Inside Lot _ Setback 351 __ Sideyard 90r Sewer Elevation ._ Foundation Elevation DESCRIPTION OF BUILDING To be Used as: Dwellijig Front Depth 241 Height _ 902 Sq. Ft A 5n cu. Ft I!z ol0 Front Depth Height ._ _ Sq. Ft. Cti. Ft Type of Construction _ Frames Est Cost _ _..00Q__ To be Completed April 1. 1969 l,eA U_ k_ - ��% � � CD o j: API, —se, -)Ek ., OF: APP 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 66fj!�gd4 the city of Fridley. .ocest i 100.00 Sewer Connection Chi. In consideration of the payment of a fee of $__26_.QQ - permit is hereby granted to to construct the building or addition as described above. This permit is granted upon the express condition that the person to whom it is granted and his agents, employees and workmen, in all work done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of Fridley, Minnesota regarin location, construction, alteration, maintenance, repair and moving of buildings within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. NOTICE. fids psrmk don not cover the comtrutdon, iesfatlafioe for whine, phnnbing, gn heath& sewer or water. Be sura to tee the Building hupsctor for separate permhs for these its APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNEEc IS NAMEBUILDER j2/ Z- i % %% %JL- "Op%�N�� ADDRESS ADDRESS LOCATION OF BUILDING NO o / %Z STREET LOTS / 71 ;2, BLOCK Zg: ADDITION OR SUBDIVISION Sr`Zl,&� ,&y �'df& COR -NM LOT 1`� INSIDE LOT SETBACK 3S- / SIDEYARD --7U / SEWER. ELEVATION TOP OF FOCTING Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. DESCRIPTION OF BUILDING To Be Used As: Front Depth Height ,quare feet �.`� Q Cubic Feet Z U Front Depth Height Square feet Cubic Feet S Type of Construction ��:7rJ� Estimated Cost /(% 0`�CT To Be Completed The undersigned hereby makes application 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 Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. DATE SIGNATURE (Schedule of Fee Costs can be found on the Reverse Side.) BUILDING PERMIT FEE SCHEDULE SECTION 20 The Inspector of Buildings shall, before issuing permits for the erection of any building or structure, or for any addition to any existing structure or building, or for any alteration or repairs 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 toawit2 Uniform Building Codeo Type 1, 2, & 4 - $1.75 for each one thousand cubic feet, or fraction thereof, in such cubical contents. Type 3 & 5 $1050 for each one thousand cubic feet. For the purpose of computing fees for building permits, the cubical contents of any building or addition to a uniform height throughout by multiplying the ground area covered from a point six (6) inches below the floor line of the basement or the cellar to the average height of the upper surface or to the average height of the roof surface of the main 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 $50000 NSSSD Connection Charges based on location _ Area 1 or 20 ;� s CERTIFICATEI OF SURVEY MILNER W. CARL EY ,& ASSOCIATES CONSULTING CIVIL ENGINEERS.l LAND SURVEYORS 500 W. HWY. 96 314, AK ST. 18 4TH AYE. S.E. ST. PAUL 12, MINN. SAU CENTRE MINN. ST. CLOUD, MINN. 484.3301 352 664 251-7751 hereby certify that this survey, plan, or report was prepared by me or under my direct supervision and that I am a duly Registered Land Surveyor under the laws of the State of Minnesota. C Reg. No.. 7725 .Date Juno 18, 1968 OF so" L/��'TJ� Sr• '� Lots 1 and 2, Block 12 SPRING 131100K PARK ADDITION, Anoka County, Minn. =M /,I.:- 4D 6d 237 26's -S9 f9.3` �s tf N° 4818 Original Permit f®r PLUMBING AND GAS F11 fING N.B. When work covered by this permit is ready, the Plumbing Ordinance requires that request for I Ti Peg ermit $ o�� • � c9 inspection shall be phoned iu to the plumbing Inspector, 560-3450 giving number of this permit., DESCRIPTION OF WORK II Number, Kind and Location of Fixtures Stories w6 a o J �S U z ...— m 6 7 m F Z 0 d m m z U = 0 a s K 3 F Y~ z G O 0 LL w o S dJ K Z 0�_ J K LL 0 = 2 Q Q U m Q O J K a IL c y Q IL O Q W m z d Q t9 WATER HTR. GAS ELEC. Basement (t) rQ I l l 1st 2nd 3rd 4th Connected with Sewer -Cesspool Gas Piping for Openings Permission is hereby granted to do the plumbing and gas fitting in the building descr ed in the statem t hereto attached, upon the express condition that the person to whom this permit is granted, and his agents, employees and workmen, in the plumbing or gas fitting of said building shall conform in all respects to ordinances of the City of Fridley, and this permit may be revoked at any time upon the violation of any of the provisions of said ordinances. By Order Of The Inspector Of Buildings Roughing in Inspection Date Inspector. Final Inspection Inspector. 42 IM -6-6&V Location 1/7 Kind of Building Used as AZ't-e rs� To be Completed_ ____042'1-� Estimated Cost $ // S70 .A -a Old -New. Building Permit No. 70� O i S— Date Inspector of Buildings. No. Mak Original PERMIT for Power fonts and Pleating. Cool- ing, ventilation, Refrigeration and Air Conditioning Systems and Devices DESCRIPTION OF WORK be Oil fired—, Coal fired ; Gas fired ; Gas Authorization No4&. Remarks✓/-B'�'� 1`" k� Approved by Final Inspection 19_ V >0S Inspector Permit N ° 4378 Fee $ Office of the Inspector of Buildings City of Fridley City of Fridley, Min 9 , 19_1 Owner Location Kind of Building- Ir ;�� e— How Occupied Work to be Com19 SSV To be Completed i�h ,19� Estimated Cost, $ %6r -'e-0 • G� Old -New, Building Permit No. /o ",0/ Sr Permission is hereby granted to - _ to install—erect—use the material and devices described in the above statement. This permit is granted upon the press condition that theperson to whom it is granted, and his agents, employees and workmen, in all the work done and materials used under this permit, and in the operation of the devices herein mentioned shall conform in all respects to the ordinances of the City of Fridley relating to or governing the work to be done and the operation of the devices herein named, and to the specifics ' ns set forth in the approved application for this permit on file in the office of the Inspector of Buildings. Inspector of Buildings 42 2M 11-67 V Application for Power Plants and Heating. Cooling. Ventilation. ReFrigeration and Air Conditioning Systems and Devices PARTIAL RATE SCHEDULE GRAVITY WARM AIR: RATE TOTAL Furnace Shell & Duct Work .......................... $10.00 $ Replacement of Furnace ............................. 6.00 $ Repairs & Alterations—up to $500.00 .................. 6.00 $ Repairs & Alterations each add. $500.00 ............... 3.00 MECH. WARM AIR Furnace Shell & Duct Work to 120,000 BTU ............ $10.00 $ each add. 60,000 BTU ....................... 3.00 $ Replacement of Furnace ............................. 6.00 $ Repairs & Alterations—up to $500.00 ................. 6.00 $ Repairs & Alterations each add. $500.00 .............. 3.00 $ STEAM or HOT WATER SYSTEM Furnace Shell & Lines—to 400 sq. ft. EDR Steam ...... $10.00 $ Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ... 10.00 $ Each add. 200 sq. ft. EDR Steam ...................... 3.00 $ Each add. 320 sq. ft. EDR Hot Water . ...... ......... 3.00 $ OIL BURNER—to 3 gal. per hour ........................ 6.00 $ over 3 gal. per hour—See Fee Schedule GAS BURNER (up to 199,000 BTU) ....................... 5.00 $ over 199,000 BTU See Fee Schedule GAS FITTING FEES: NO RATE TOTAL 1st 3 Fixtures ...................... x$ 2.00 $ Additional Fixtures ........... '...... x .75 $ Gas Range to 199,000 ........... x$ 5.00 $ AIR CONDITIONING FAN HEATING SYSTEM VENTILATING SYSTEM ALTERATIONS & REPAIRS ROUGH FINAL See Fee Schedule TAL FEE Dept. of Bldge. Phone M-3450 7e W, City of Fridley: The undersigned hereby makes application for a permit for the work hereir. specified, agreeing to do all work in strict accordance with the City Ordinances and ruling of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. Owner Kind of Building�� Used as To be cc Estimated Cost, $ Old ew ' uilding Permit No. —4,0115 Permit No. ds -1.57t DESCRIPTION OF WORK HEATING or POyn3R �PLANZS--.Steam, Hot Water, arm�AiNo �/ Trade Name /- -J,�� Size No - Capacity Sq. Ft. E.D.R 4W BTU H.P. Total Connected Load_ 7 l � Kind of Fue//!��%/ A�� BURNER — Trade Nam s Size No.�s Capacity Sq. Ft. E.D.R BTU H.P. (REMARKS- sWY N. WELTER HEATING C- 4631 CHICAGO AVE.. By MINNEAPOLIS 70 ee Business Phone No { * � / � � m m , 2 } { \ k \ \ ; g , § f / / / < \ } \ Ci$y Of Fridley Application lay Plumbing clod GCM Fas-¢sig pem. it DESCRIPTION OF WORK Number. Kind and Locaticn of Fixtures PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ..................... 9 x 00 $ b $2".00 Future Fixture Opening ................ 3 x. 38gx $ $1.50 New Fixture Old Opening ....... x )bE& $ $1.50 Catch Basin ... ..................... — x 3.25 $ Water Heater (Up to ZBTU) ...... x XW $ 3' ° ° #3.00 New Ground Run Old Bldg . ............ x 3.25 $ Dept. of Bldga. Phone 560-3450 City of Fridley: The undersigned hereby makes application for a permit for the work herei specified, agreeing to do all work in strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that all the fact and representations stated in this application are true and correct Fridley, Minn / - -;? 3 __, 19jO Owner Kind of Building Used as To be completed about Estimated Cost, $ // Old—New. Building Permit No- / , 0 / 5— Permit No. "�Ig%ie ROUGH Electric Water Heater $2.00 FINAL d �76 GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .. ........... ........... x $1 $ -2- ° y $2.00 Additional Fixtures .................... Gas Range to 9r TU .............. REPAIRS & ALTERATIONS—Refer to Code X 3NX $ .75 x , $ $5.00 Description ...............................................$ TOTAL FEE $ 3 S 0 .43D042 L Signed ,� J/e By Business Phone No $ - v"3 ti I N C hWATER HTR. � on o o GAS ELEC. Base 1YF 1st 2nd 4 3rd 4th ' rufure Connection Openings Connected with I Sewer New Fixture, Old Openings Cesspool 0 PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ..................... 9 x 00 $ b $2".00 Future Fixture Opening ................ 3 x. 38gx $ $1.50 New Fixture Old Opening ....... x )bE& $ $1.50 Catch Basin ... ..................... — x 3.25 $ Water Heater (Up to ZBTU) ...... x XW $ 3' ° ° #3.00 New Ground Run Old Bldg . ............ x 3.25 $ Dept. of Bldga. Phone 560-3450 City of Fridley: The undersigned hereby makes application for a permit for the work herei specified, agreeing to do all work in strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that all the fact and representations stated in this application are true and correct Fridley, Minn / - -;? 3 __, 19jO Owner Kind of Building Used as To be completed about Estimated Cost, $ // Old—New. Building Permit No- / , 0 / 5— Permit No. "�Ig%ie ROUGH Electric Water Heater $2.00 FINAL d �76 GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .. ........... ........... x $1 $ -2- ° y $2.00 Additional Fixtures .................... Gas Range to 9r TU .............. REPAIRS & ALTERATIONS—Refer to Code X 3NX $ .75 x , $ $5.00 Description ...............................................$ TOTAL FEE $ 3 S 0 .43D042 L Signed ,� J/e By Business Phone No $ - v"3 City of Fridley, Minn. 6431 University Ave. N. E., Minneapolis, Minn. 55432 BUILDING PERMIT Dom: may 11, 1972 owner: _ Frank Niznick Jr. Builder Same Address _.._.__19J_ LibPrtY Street N.E. Address Same LOCATION OF BUILDING No. _ ._7.21.__._ Street — Liberty Street N E Part of Lot Lot __j,2 __ Block ____12Addition or Sub -Division Spring Brook Park Corner Lot_._ X__..._...._ Inside Lot Setback Sideyard Sewer Elevation If — Foundation Elevation DESCRIPTION OF BUILDING To be Used as: Garage ____ Front 20' Depth 20' Height 10' Sq, Ft, 400' CU. Ft. 4, 000' Front ._ _ Depth Height Sq. Ft. Cu. Ft. Type of Construction — 1nlnnd Frame _ Est. Cost $1,812.�_ To be Completed &y 1. 1973 Provide a hard surface = drive. 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 a111 provisions of ordinances of the city of Fridley. _ I I n A In consideration of the payment of a fee of $ 7.50 , permit is hereby granted to Frank Niznick to construct the building or addition as described above. This permit is granted upon the express condition that the person to whom it is granted and his agents, employees and workmen, in all work done in, around and upon said building, or any part thereof, shall conform in all respects -to the ordinances of Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings vlithin the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. /-V _ CLARENCE BELISLE NOTICE: This permit does not cover the construction, installation for wiring,, plumbing, gas heating, sewer or water. Be sure to we the Building Inspector for separate permits for these hems. e e .t r 11A� V � ;1 .ti .._ j .. _ __ ,. t��i. ... .5��` � 4. . �t . �, � p �. r APPLICATION FOR RESIDENTIAL, ALTERATION, OR ADDITION BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAME Q -V1. IV ,r2 aLQ & BUILDER: .S ADDRESS: % �a r f(,S' f /lr 1. ADDRESS NO:. % q / STREET: LOT: % 2 BLOCK: / ADDITION: _S' �„ , !nom®� /r D /� CORNER LOT: YC S INSIDE LOT: SETBACK: SIDEYARD: Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. To Be Used As: DESCRIPTION OF BUILDING Front:- G r Depth: b Height: Square Feet:Cubic Feet: (I ®l1 T Front: Depth: Height: Square Feet; Cubic Feet: Type of Construction: kVod __,Cl a o7, e Estimated Cost:_$ ' To Be Completed: 4 � T ' The undersigned hereby makes application for a permit for the work herein specified, agreeing to do all work in sttict 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 true and correct. DATE: ,j - // - SIGNATURE: (See Reverse Side For Additional Information.) �0 BUILDING PERMIT FEI SCHEDULE SECTION 2. The Inspector of Buildings 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 repairs 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: UNIFORM BUILDING CODE: Type 1, 2 & 4 - $2.15 for each one thousand cubic feet, or fraction thereof, in such cubical contents. Type 3 & 5 - $1.35 for each one thousand cubic feet. ADDITIONAL INFORMATION 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 or the cellar to the average heights of the upper surface or to the average height of the roof surface of the main 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 $5.00. VERIFICATION OF FOUNDATION NOTE: 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 Certified Survey of the lot, showing the location of the foundation, once it has been constructed, will be required before proceeding with the framing. CERTIFICATE OF OCCUPANCY Application for a Certificate of Occupancy 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. SUBJECT NO. City of Fridley 1443'7 AT THE TOP OF THE TWINS BUILDING PERMW r ECEIPT NO. •COMMUNITY DEVELOPMENT DIV. U. r PROTECTIVE INSPECTION SEC. 1 � ; CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 812-560-3450 910-F15 110/24/77 JOB ADDRESS 191 Libertv Street 'd 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 2 12 1 Spring SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. 466 - 83rd Avenue NE 786-5552 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING 7 CLASS OF WORK ❑ NEW ❑ ADDITION X1 ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Fireplace 9 CHANGE OF USE FROM TO STIPULATIONS OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. �YPE 1j'60IL& THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. FT. CU. FT. AUTHORIZED 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. UNITS OFFSTREET PARKING 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 WILL BE COMPLIED, WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $1,500.00 .75 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF AN THER STATE OR LOCAL LAW REGULATING CON- STRU ON OR TH P RFORMANCE OF CONSTRUCTION. $9.00 PLAN CHECK FEE TOTALFEE -%/ SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE) W ENP OP LY V LI TED THIS IS YOUR PERMIT La BLDG INSP DATE SIGNATURE OF OWNER (IF OWNER BUILDER) (DATE) OWNER: Address CITY OP FRIDLEY APPLICATION FOR RESIDENTIAL BUILDING PERMITS (NEW, ALTERATIONS,. ADDITIONS, OR -REPAIRS) No.: Street: l BUILDER: Address: yZ'z , Tel. No.: LOT: BLOCK: ADDITION: CORNER LOT: �NSIDE LOT: SETBACK: SIDEYARDS: Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. DESCRIPTION OF BUILDING To Be Used As: e Front: Depth: Height: ' Square Feet: Cubic Feet: Front: Depth: Height: Square Feet: Cubic Feet: Type of Construction:mated Cost: $z� (�% . To Be Completed:ary 4L Alt. A Alt. B Proposed Driveway Width If New Opening Is Desired $ $ (SEE REVERSE SIDE OF SHEET) The undersigned hereby makes application 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 Department of Buildings, and hereby declares that all the facts and representations statin this application are true and correct. See reverse side,k4' additio&Y information. DATE: '&-- 9-y—:22 SIGNATURE:°" 1^ Stipulations: BUILDING PERMIT FEE SCHEDULE SECTION_ 2. The Inspector of Buildings 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 repairs 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: NEW CONSTRUCTION: Single Family Homes and Garages: $4.00/1,000 cubic feet... PLAN CHECK: 25 percent of building permit fee. DRIVEWAY DEPRESSION: (Concrete Curb Streets Only) Alternate A: Removal and replacement of concrete curb and gutter only; Driveway width plus6 feet x $11.75 Alternate B: Removal and replacement of concrete curb and gutter and install a 3 foot wide approach with 6 inch depth; Driveway width plus 6 feet x $15.40 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 or the cellar to the average heights of the upper surface or to the average height of the roof surface of the main 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. VERIFICATION OF FOUNDATION NOTE: 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 been constructed will be required before proceeding with the framing. Application for a Certificate of Occupancy 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. SUBJECT PERS City of Fridley 16330 AT THE TOP OF THE TWINS BUILDING P E R M I T _ . rp L RECEIPT • COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. i---1 CITY HALL FRIDLEY 55432 NUMBER REV, DATE PAGE OF APPROVED BY. 612-571-3450 910-F15 8/6J81 6 81 JOB ADDRESS 191 Liberty Street N.E. 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 1,2 12 Spring Brook Park SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Frank Niznick Jr. 191 Liberty Street N.E. 786-6302 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Same 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ADDITION El ALTERATION ❑ REPAIR El MOVE ❑ REMOVE X 8 DESCRIBE WORK Construct a 141 x 14' Gazebo witha, deck around it. 9 CHANGE OF USE FROM TO STIPULATIONS WARNING Beforl diggint.cill 10cal TFIPPNBNE - ELECTRIC - GV -1 sic. sEPERATE PERMITSREQUIRED FOR yW NIG. REQUIRED BY LAW HEATING, PLUMBIMG AIVQ SIG(, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED 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. UNITS OFFSTREET PARKING I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS I GARAGES AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $3,135 $1.57 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. $44.50 NONE PLAN CHECK FEE TOTAL FEE 11.13 1,S57.20 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI HEN PROJEF LI AT D THIS IS YOUR PERMIT BLDG INSP DATE SIGNATURE OF O E OWNER BUILDER) IDATEI I;. lq a} ' rl ��'�Sn i`r• a .... � - .. ... .... � __.... .. .. ... .. ._ .. a .. Al �� ut t.�••i �1'Y. ° "-i i� A -s$ 'f' R-.2,'�' _ .. n t ,.. .. .. Y ...a .. . e�,nR � 9 4 1 9 t e✓ .t i sf :.4., _ _ r IL,_.r r *.,,' .. '.,: '`•.. a,c .,,. Esc.; .,. -,.•_.. .,';s;r �r^, .. .wa. ._..... s if is x p � uu,t�.r '�`"+4+' " �7�J'��t►.dI3M�l � ._ -� r9 f I1y (/ y(�if]:e�:ayj r - - _ - F. b" # ? • yjr��[}�(j] j 'j e .F •. b. y�'yS �+�)`( bdl® •i'i". ••"''uhf ,F9'l•.A g. ' A. gfi i?^, '+ �{ mea-P+i, _ i f .`.�• ... d ... .. J � 1.4 1 .✓r.. � Ri-.,. 1 4 k'"Ra � ,1 =rr x•-� a, � x _ r„p.-. tv it t t �. .. t d f Ti—�zii -.s 1 } s� , n l Cy�'tFr CITY OF FRIDLEY APPLICATION FOR RESIDENTIAL BUILDING PEMITS (New, Alterations, Additions, or Repairs) OWNER: �� e� j 1:2 UUILDER.��' ADDRESS: ADDRESS: _ TEL NO: TEL 1-40: _ Construction Location STREET NO: STREET: y 3 �' 2�a i LOT: BLOCK: ADDITION: � Corner Lot: Inside Lot: Setback.: Sideyards: Applicant attach to this form two Certificates of Survey of lot and proposed building location drawn on certificates to scale. DESCRIPTION OF CONSTRUCTION Front: Depth: Height: Square. Feet: Cubic Feet: 62 aS'z b 10 Front: % /�/ � Depth. !z Y Height: Square - Feet: Cubic Feet: _ -too -111S 3 Type of Construction: Estimated Cost: $ To Be Oorapleted: �%Z — l Alt. A Alt. B Proposed Driveway Width if New Opening Is Desired: $ $ SEE RZVERSE SIDE OF SHEET The undersigned hereby makes application 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 Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. ,r A A DATE: �—,� �� SIGNATUM: Stipulations: �' -so) . DSUJLDIIIG PERMIT FEE SCHEDULE Sil-'CTION 2.- 'lilt! 7.n�:pector. of Building., ::hrtl.l, bcf-ore issuing permits for the erection of any buildingl or structure, or for any addition to any existing building or structure, 6r for any alteration or repair.: to -any existing bui.l_di.jig or structure, upon appli_c:atioii thert2fore, 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: • I.3E1.1 CONSTRUCTION: Single Family IJomes and Garages: 11:4.00/1,000 cubic feta:. PLAT@ CII}:CI;: 25 percent: of building permit- fee. DRIVEWAY DEPRESSIOI•I: (Cpncretc Curb Streets Only) Alternate A: Removal and replacement of concrete curb and gutter only; Driveway width plus 6 feet x $13.50 Alternate B: Removal and replacement of concrete curb and gutter and install a 3 foot wide approach with 6 inch depth; Driveway width plus 6 feet x $15.,75 ADDITIONAL INFORMATION nor the 1purpose 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 or the cellar to the average heights of the -upper surface or to the average height of the roof surface of the main gable of a pitched roof. For repairs or alterations to an existing structure, the fee shall be at the rate of $3.00 Iter 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. VERIFICATION! OF FOUNDATION NOTE: 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 been coia.itructed will be required before proceeding with the framing. SRTIFICATE OF OCCUPANCY Application `or a Certificate of Occupancy shall be made ten (10) days prior to the use or occupancy of any structure for which a building permit Inas been issued; and said structure shall not be used or occupied until a Certificate of Occupancy has been issued. MILNER W. CARLEY & ASSOCIATES CONSULTING CIVIL ENGINEERS LAND SURVEYORS 500 W. HWY. 96 314 OAK ST. 18 4TH AVE. S.E. ST. PAUL, MINN. 55f12 SAUK CENTRE, MINN. 56378 ST. CLOUD, MINN. 56301 484-3301 352-3664 251-7751 hereby certify that this survey, plan, or report was prepared by me or under my direct supervision and that t 1 ammaa.duly�stered land Surveyor under the laws of the State of Minnesota; �,�►��✓ Reg. No '51Date Apri 1 28, 1372 7F'/ �S /I�o iro/�s �o/dlto! J Lots 1 and 2, Lock 1.2 SPRiNU BROOK PARK ACDITIUN, Anoka County, Minn. 2s < 8,E R 7Y sT SUBJECT IT City of Fridley 1 9 3 AT THE TOP OF THE TWINS BUILDING PERMIT f R NO. � COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. o!@ r NUMBER REVDATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 612-571-3450 910-F15 6/18/97 JOB ADDRESS 191 Liberty Street NE 1 LEGALLOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 1,2 12 Spring Brook Park SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Frank Niznick 191 Liberty Street NE 786-6302 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Reveal Remodeling 13243 Jay St NW, Coon Rapids MN 55448 755-8652 7846 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK REplace windows and patio door 9 CHANGE OF USE FROM TO STIPULATIONS Replacement sleeping room windows must meet the State Egress Code. Install smoke detectors to meet the State Building Code. TYPE OF CONST. OCCUPANCY GROUP OCCUPANCYLOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT. AUTHORIZED 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. UNITS OFFSTREET PARKING 1 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 WILL BE COMPLIED $10, 000 $5.00 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SACCHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- $ 162.25 Fire SC $10.00 STRUCTION THE PERFORMANCE OF CON RUCTION PLAN CHECK FEE TO AL FEE ,s4C $182.25 SIGNATURE OF CONrRAC R OR AUTHORIZED AGENT (DATEI EN B G INSPOV VALIUVED THIS IS YOUR P RMIT 0 DATE SIGNATURE OF OWNER OF OWNER BUILDER) IDATEI NEW [ ] Effective 1/1/97 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION *100 ConstructionAddress: Legal Description: Owner Name & Address:�,� /r/ ��vrc Tel. Contractor:ys9� /r �i�p�.��/�� MN LICENSE Address: Tel. ff %.��"��`=�� Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: Construction Type: A-llwa o w S 7-/ o Estimated Cost: $/p , (0.0 O (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ DATE: APPLICANT: Tel. # X5,..5 CITY USE ONLY Permit Fee $ Fee Schedule on Reverse Side Fire Surcharge $ /C. LrC .001 of Permit Valuation (1/10th%) State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: $ CC $.50/$1,000 Valuation $ $950 per SAC Unit $ lT C1 $5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above $450.00 Conservation Plan Review Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] BUILDING PERMIT FEE SCHEDULF The Chief Building Official shall, before issuing permits for the erection of any building or structure, or fir any addiction, 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 t6 -wit: 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 $1,000,001 and up FEES $21 (Minimum Fee is $21 plus surcharge) $21 for first $500 plus $2.75 for each additional $100 or fraction thereof, to and including $2,000 $62.25 for first $2,000 plus $12.50 for each additional $1,000 or fraction thereof, to and including $25,000 $349.75 for first $25,000 plus $9.00 for each additional $1,000 or fraction thereof, to and including $50,000 $574.75 for first $50,000 plus $6.25 for each additional $1,000 or fraction thereof, to and including $100,000 $887.25 for first $100,000 plus $5.00 for each additional $1,000 or fraction thereof, _to and including $500,000 $2887.25 for the first $500,000 plus $4:25 for -each additional $1,000 or fraction thereof, to and including $1,000,000 $5012.25 for the first $1,000,000 plus $2.75 for each additional $1,000 or fraction thereof DRIVEWAY DEPRESSION ESCROW (Concrete Curb Streets Only) Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $13.50. 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 $15.75. VERIFICATION OF FOUNDATION 1'crmits 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 construc--_•,1 i;3 he. required hcfore proceedin<(, „pith the framing, CITY OF FRIDLEY INSPECTION DIViSION 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, 572.3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES RATE SCHEDULE Residential Furnace Shell.and Duct Work, Burner - Also Replacement Furnace (Side Vent - Fill Out Back) Gas Piping (Needed with new furnace, but not replacement) Gas Range Gas Dryer *Air Conditioning - All Sizes All Others/Repairs & Alterations (LIST ON BACK) 1% of Value of Appliance or Work Commercial/Industrial 1.25% of Value of Appliance or Work Rate $ 30.00 $ 10.00 $ 10.00 $ 10.00 $ 25.00 State Surcharge TOTAL FEE MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00 PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $47.00/Hr *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. Effective On May 10, 1999 JOB ADDRESS 111 QDPr S+. Y I E OWNER (AV\ � � i ZY) I C- 1K-, TOTAL BUILDING USED A$_ J P h -�,'a, ESTIMATED COST qo 0 PERMIT NO. 129 6 DESCRIPTION OF FURNACE AND OR BURNER No. of Heatin Units I Circle One (Steam) (Hot Water)arm Ai $ Trade Name_ OLSaV14 - Size No. BTU \10 ,o oa HP EDR $ Fuel f\a4-A A l Total Connected Load Burner Trade Name Size No. $ BTU HP EDR $ The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the City Codes an $ .50 rulings of the Building Division, and hereby declares that all the facts'and representations stated in this application are'true and correct. Remarks: List ALTERATIONS Being Done: HEATING CO: Signed By: Date: CHEWNEY AND STACK VERIFICATION 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 Yes () No ( ) 5. Meets all current Code requirements for size and total BTU's connected Yes () No { ) 6 Has total heating BTU's of All other BTU's TOTAL BTU's 7. Has a liner been provided for water heater Yes () No ( ) 8. Has combustion air been provided for water heater Yes () No ( ) Remarks: List ALTERATIONS Being Done: HEATING CO: Signed By: Date: CITY OF FRIDLEY INSPECTION DIVISION Effective On January 1, 1999 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, 572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES JOBADDRESS /?//U- RATE SCHEDULE The undersigned hereby makes application for a permit for the work herein Residential Rate TOTAL specified agreeing to do all work in strict accordance with the City Codes and Furnace Shell and Duct Work, Burner - rulings of the Building Division, and hereby declares that all the facts and Also Replacement Furnace $ 30.00 $ representations stated in this application are true and correct. (Side Vent - Fill Out Back) Gas Piping (Needed with new furnace, but not replacement) $10.00 $ OWNER Fran X),`z yj e Gas Range. $10.00 $ BUILDING USED AS Gas Dryer $10.00 $ ESTIMATED COST, c9® PERMIT NO. *Air Conditioning - All Sizes $ 25.00 $ DESCRIPTION OF FURNACE AND OR BURNER All Others/Repairs & Alterations (LIST ON BACK) 1 % of Value of Appliance or Work $ Commercial/Industrial 1.25% of Value of Appliance or Work State Surcharge $ .50 No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air) TradeName -� / : J_;�4jj vcASize No. BTU e� HP EDR Fuel Total Connected Load Burner Trade Name BTU TOTAL FEE $�� MINIMUM FEE FOR ANY HEATING/COOUNGIVENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00 PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $42.00/Hr *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. Size No. HP EDR HEATING COMPANY Signed By Tel No. d6-1- - ZsIC/ Approved By �� Rough -In Date Final Date FILL OUT BACKSIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE 1<44� 6 Has total heating BTU's of All other BTU's TOTAL BTU's 7. CHIlVMY AND STACK VERIFICATION Yes ( ) No The undersigned hereby verifies that the existing chimney or stack: Yes ( ) No 1. Has been carefully examined Yes () No ( ) 2. Is free from rust or deterioration Yes () No ( ) 3. Has no foreign objects lodged within Yes O No ( ) 4. Is securely supported Yes () No ( ) 5. Meets all current Code requirements for size and total BTU's connected Yes () No ( ) 6 Has total heating BTU's of All other BTU's TOTAL BTU's 7. Has a liner been provided for water heater Yes ( ) No ( ) 8. Has combustion air been provided for water heater Yes ( ) No ( ) Remarks: List ALTERATIONS Being Done: HEATING CO: Signed By: Date: U I Y Ut- rMIULtY 1Nbt tU I IUN UIV. 6431 University Ave NE Fridley, MN 55432 572-3604 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMRFR OF FI)M IRFC Tn RF WRT0.1 1 Fn nKi Genu M nno Effective On Jan 1, 2000 PLUMBING FIXTURE RATES: New Fixtures Old Opening, New Fixture Beer Dispenser Blow Off Basin Catch Basin NO. RATE Rain Water Leader Sump/Receiving Tank Water Treating Appliance Water Heater -Electric Water Heater - Gases'_ Gas Range" Gas Dryer"' Back Flow Preventer Required ( )Yes () No $ 7.00 $ 4.00 $ 5.00 $ 7.00 $ 7.00 $ 7.00 $ 7.00 $10.00 $ 7.00 $10.00 $10.00 $10.00 Type $15.00 Reinspection Fee $47.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance State Surcharge TOTAL FEE TOTAL JOB ADDRESS NNE- dts dW&315 e_ Y11 1_m��Tw The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the city codes and rulings of the wilding Division, and hereby declares that all the facts .and representations stated in this application are true and correct. NIZNICK, FRANK 191 LIBERTY STREET NORTHEAST 41122 , 20oZ FRIDLEY, MN 55432 Owner (763) 786-6302 Building Used As �;S6 I.Dc Y C z Estimated Cost PERMIT NO. 1� PLUMBING COMPANY � LUA1 Q SIGNED BY TEL NO.I Z -6Z7`4 Approved By Rough -In Date Final Dat .50 e`�4 $Za-550 PLUS THE 5.50 STATE SURCHARGE COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE 7 . ��R • • _•tom • ® p ® ffivn�sl PLUMBING FIXTURE RATES: New Fixtures Old Opening, New Fixture Beer Dispenser Blow Off Basin Catch Basin NO. RATE Rain Water Leader Sump/Receiving Tank Water Treating Appliance Water Heater -Electric Water Heater - Gases'_ Gas Range" Gas Dryer"' Back Flow Preventer Required ( )Yes () No $ 7.00 $ 4.00 $ 5.00 $ 7.00 $ 7.00 $ 7.00 $ 7.00 $10.00 $ 7.00 $10.00 $10.00 $10.00 Type $15.00 Reinspection Fee $47.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance State Surcharge TOTAL FEE TOTAL JOB ADDRESS NNE- dts dW&315 e_ Y11 1_m��Tw The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the city codes and rulings of the wilding Division, and hereby declares that all the facts .and representations stated in this application are true and correct. NIZNICK, FRANK 191 LIBERTY STREET NORTHEAST 41122 , 20oZ FRIDLEY, MN 55432 Owner (763) 786-6302 Building Used As �;S6 I.Dc Y C z Estimated Cost PERMIT NO. 1� PLUMBING COMPANY � LUA1 Q SIGNED BY TEL NO.I Z -6Z7`4 Approved By Rough -In Date Final Dat .50 e`�4 $Za-550 PLUS THE 5.50 STATE SURCHARGE COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE COMMON VENT VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When replacing an existing 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 O 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 manufacturer's specifications. This does include AGA-GAMA Category I Central Furnace Venting Tables for fan assisted and natural draft appliances. Yes () No ( ) The existina combustion air is sized and installed to meet the current codes and manufacturer's specifications. Yes () No 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( When installing a new venting system, 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 Furnace 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 Type and Size/Common Vent and Vent Connector Infonnation 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 Connector Height ft Length ft Diameter n Type ALTERATIONS: (Describe) HEATING CO: Signed By: Date