PRE 2010 DOCSCity of Fridley, Minn.
BUHMING PERMIT N® 3782
Date: ... z5' 7
...... .. ...........
Owner ....................................... Builder-", fe;K ..........
Address ...................................... Address .............................................
LOCATION OF BUILDING
No. 67.3.9f... Street �??:s►% !.. :.!� ..... Part of bot .................... ..
—Lot ... ...... Block .... PZ .......... Addition or Sub -Division .
Corner Lot ............ Inside Lot . A ........ Setback : '. + SIcKeyard 167b ..................
DESCRIPTION OF BUILDING C�
//63
.......... Front r Depth °?i�.'Height /. �.—� Sq. Cu. F't.
..... ......... Front ........ Depth ........ Height ........ Sq. Ft. ........ Cu. Ft. ........
... ... l
Type of Construction ................ Est. Cost./ . .M.. To be Completed ...................
In consideration of the Issuance to me of a permit to construct the building desribed 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 city of Fridley.
X.,
...............................................
In consideration of the payment of a fee of $`�..®... 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 regarding location, construction, alteration, maintenance, repair and moving of buildings with-
in the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
• ® f®�gcyf. <9eo.�.e ..... 7. Building Inspector
NOTICE:
This permit does not cover the construction, Installation or alteration for wiring, plumbing, gas heating,
sewer or water. Be sure to see the Building Inspector for separate permits for these items.
r
t
97-84-879001 CITY OF FRIDLEY
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
PARTIAL RATE
SCHEDULE
PLUMBING FIXTURE RATES:
NO.
RATE
TOTAL
Number Fixtures
x
$3.00
$ '
Future Fixture Opening
x
0
$ _^
Water
as
0
m
u
m
A
�
m
$5.00
w
H
C•a
a m
m
A
$
.oi
V
w
r•.
$
Water Softener
Heater
$7.00
$
New Ground Run Old Building
x
$5.00
$
Electric Water Heater
x
ab
!J
x c
(d d�
'lec
O
41
u 0
M
L
N
r-
•.01 0
O
N•m
0
8
$
V N
imp
' N
rom
y��1
U)
u
w
P
q
U
N
9
9
w
M
a 9
6
;as
1st
irr
ir
2nd
3rd
4th
(R) o Future Connection Opening
Connected with Sewer
(') o New Fixture, Old Opening
Water
PARTIAL RATE
SCHEDULE
PLUMBING FIXTURE RATES:
NO.
RATE
TOTAL
Number Fixtures
x
$3.00
$ '
Future Fixture Opening
x
$2.00
$ _^
New Fixture, Old Opening
x
$2.00
$
Catch Basin
x
$5.00
$
Water Heater - to 99,000 BTU
x
$5.00
$
100,000 BTU to 199,000 BTU
x
$10.00
$
Water Softener
x
$7.00
$
New Ground Run Old Building
x
$5.00
$
Electric Water Heater
x
$5.00
$
GAS FITTING FEES:
1st 3 fixtures x $3.00 $
Additional Fixtures x $1.00 $
Gas Range to 199,000 BTU x $10.00 $
REPAIRS $ ALTERATIONS
First $100.00 $5.00 $
each add. $100.00 or fraction $2.00 $
State Surcharge. S .50
TOTAL FEE $ 8 00
REINSPECTION FEE
sa1n nn%
Job Address 5371 IE Madison
Department of. Buildings _
City of Fridley
Tel. #571-3450
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 Department of Buildings, and hereby declares that all
the facto and reprosentations stated in this application are true and correct
Fridley, Mn. 6-28-79 , 19
OWNER Ng,TGHTON
KIND OF BUILDING ' fr me
USED AS
TO BE COMPLETED ABOUT 7-5-79
ESTIMATED COST ho .00
OLD - NEW BUILDING PERMIT NO. PER14IT NO.
;e.
Signed By
Tel. No.
ROUGH INSP.
Date
FINAL INSP.
Date
APPROVAL FOR PERMIT
MWNEGASCO
MINIMUM FEE FOR ANY PLUMBING PERMIT IS $7.50 PLUS $.50 STATE SURCHARGE
7 A Wtseq.3 ,tom �p c AetT' r -70
D-36 93
HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS FRIDLEY, MINN.
Weatherstrips A.S.H.V.E. Guide Construction No. Insulation
Wows ors Reference. Out. Wall Int. Wall Ceiling Roof Floor Kind How Applied
e No I. es No 19—
I -_ • Y/ R....... I 1 annth JT r NIRAPh 14-;..t -OV 1 nnafh 17 Width % CA Raiaht M /
Windows and Doors—Crackage and Area
Doors-Crackage and Area
WidthHeight No. of
No. of Dane or pane llg�h_te
Width Height No. of Lineal f . Area
No. of pane of pane lights of crack sq. it.
�/ s!P
� 1
r i p 0
J
w
/.
Glass
Exp. wall
Coef.
Btu
Infiltration
Infiltration
Glass`(]
Exp. wall
Infiltration
7
j
f
Glass
Exp. wall
&
Exp. wall
/
Int. wall
67 .o
Ceiling
Net exp. wall
Floor
p
Int. wall
Ceiling
Floor
Total Btu.
Required s4. ft. E.D.R. or sq. ins. W.A. Leader area
I Fl.l oM /7t/ Room I Lenath 1-2 Width 16 Height
Windows a d Doors-Crackage and Area
Doors-Crackage and Area
WidthHeight No. of
No. of Dane or pane llg�h_te
Lineal ft. Area
of)craa`ck sq. ft.
�/ s!P
of pane lights of crack sq. ft.
Width Height No. of Lineal ft.
No. of pane of pane, lights of crack
J
w
/.
Glass
Exp. wall
t�
Net eap. wall
Int. wall
Coef.1 Btu
Infiltration
Glass`(]
Exp. wall
Infiltration
j
Net exp. wall
Exp. wall
Int. wall
Net exp. wall
3
Ceiling
Floor
Int. wall
rvzj
67 .o
Total Btu.'
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
J F1.I Ds et • / Ai . Room I Length J Width J f Heiaht .
Windows aril
Doors-Crackage and Area
Width Height No. of Lineal 1t. Area
No. of panne of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
No. of pane
of pane lights of crack sq. ft.
Width Height No. of Lineal ft.
No. of pane of pane, lights of crack
J
w
Glass
Exp. wall
t�
Net eap. wall
Int. wall
Coef. Btu
Infiltration
j
Glass
Exp. wall
fp
Net exp. wall
3
10 1430
Int. wall
rvzj
67 .o
Ceiling
Floor
Tbtal Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area I AP 3 1'
illFBIL __w— -____ ___
Windows and Doors--Crackage and Area
-
Width Height No. of Lineal 1t. Area
No. of panne of pane lights of crack sq. ft.
Pa
Windows and Doom—Crackage and Area
Width Height No. of Lineal ft.
No. of pane of pane, lights of crack
Coef. Btu
Infiltration
Glass
Exp. wall
t�
Net eap. wall
Int. wall
Ceiling
Floor
s
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
F1 I Roo (Length W1 'delgth t H ' ht
r
m
Windows and Doom—Crackage and Area
Width Height No. of Lineal ft.
No. of pane of pane, lights of crack
Area
sq. ft.
Q'
Coef. Btu
Infiltration
Glass
1D
Exp. wall
72 -
Net exp. wall
Int. wall
rvzj
67 .o
Ceiling
Floor Lf
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
F1.1 Room I Length Width Height
Windows' and Doors—Crackage and Area
Width Height No. of Lineal tt. Ares
No. O! pane ofpane tights of crack
Coef. Btu
Infiltration
Glass •-
Exp. wall ""-Y
Net exp. wall
Int. wall
Ceiling
Floor
Total Btu. '
Required sq. ft. E.D.R. or sq. ins. WA. Leader area
DS6 9.6
HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS FRIDLEY, MINN.
Weatherstrips A.S.H.V.E. Construction No. Insulation
Guide
WindowsI Doos Reference Out. Wall Int. Wall Ceiling Roof Floor Kind How Applied
Yes—No Yes—No 19—
/ Fl.1 &A . Room Length x".21 Width Heistht .,A) II FI.I Room I Length Width Height
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
_221—
Ar y
Coef. Btu
Infiltration
Coef.
Btu
Infiltration
,�
Exp. wall,,
Glass44e
Ceiling
Net exp. wall
Exp. wall
Int. wall
Net exp. wall
Ceiling
Floor
170
/0
f!
Int. wall
Ceiling
Floor
Total 13tu. I Z)
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
1 F1.1 RRoom I Lenath .1. Width Height
Windows and Doors—Crackage and Ana
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq., ft.
Ar y
Coef. Btu
Infiltration
Coef.
Btu
Infiltration
Glass
Net exp. wall
Exp. wall,,
Ceiling
Net exp. wall
,d
Int. wall
Ceiling
Floor
Total Btu. ,�P+
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
F1.1 Room I Length Width Heiaht
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Coef. Btu
Infiltration
Glass
Exp. wall
Net exp. wall
Int. wall
Ceiling
Floor
Tbtal Btu.
Required sq. ft. E.D.R. or sq. ins. WA. Leader area
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane light,, of crack sq. ft.
Coef. Btu
Infiltration
Glass
Exp. wall
Net exp. wall
Int. wall
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
F1.I Room I Length Width Height
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Coef. Btu
Infiltration
Glass
Exp. wall
Net exp. wall
Int. wall
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
F1.1 Room I Length Width Height
Windows and Doors—Crackage and Ana
Width Height No. of Lineal ft. Area
No. of pane of -pane lights of crack sq. ft.
Coef. Btu
Infiltration
Glass
Exp. wall
Net exp. wall
Int. wall
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. WA. Leader area
97-8h-879001
._ .-,. i, -.i � •';u! :J f•,lili UiiS ,"I I i'lu •.IL',I r
Ll I 3 L.,�4
b in
-I -'-
! t.,t.te ...r.ne..tlac G1..:nlrJ �' :.etCc3 w:•—
th Sewer
Nater
Job Audcrsy 5371 NE Madison
Dr-parLrPr:nC c1;
City of t•ridll:y
Tel, b5li-3.150
9'ha tit,dorylgn.:d I;ar;:Cy , .;kea appllc_cl.:- i -r a �r:c:t („ "
®pe"fled 1 C1
a. re,:i1).
3 La dc' al., work ir. SLr:-' -Ga�ar.:o Witt. v,ClC,,dcs
and rulings of 010 M!"ArUrCnL of 8.:al,iir. ;
010 facCu at:ona Stat.03 1r - rocr 'Glare: ttat at:
C,J0 and
9-22-80 ty---
OWNER NAUGHTIN _
KIND OF IIUI LZol u7 ; frame
USED AS res. —
TO BE C01111•LE:ED UL;ur 9-29-80
9 ESTINATI D CUSP 50.00
OLD - HCN UUILCN,; PL1,1•111 t2. FL(�
`-"'I'any
51,p :.t Ey
ROUGH INSP,
Data
FINILL I116P. -= )
Dass
hl•PItUVAL VOR FEIoll'f fq3
M111IMU11 11:L• I,:q I-II' 1•LUrulHu Prhilr IS 0.50 PLUS 6.50 :1).Tt 6URC31A1uGg
I Jltl: Kn i [r
RAT E
TOTAI.
tut,,tr. CaIa C+6;rnIr1
X
$2.00
$
-1Le, Old ul,e:.l: ,
tt
S:. CO
$
Ua411,
$5.00
$
1.1 L
1 uJ, J00 blU to 1S »:.0 BTI,
x
510. 00
$
lftr� �..ttenar
x
57.00
$
lew :.:L.II d It)n OW BJtl.11r.,
x
55.00
5
:leLL,t, Nater tleatar
x
$5.00
$
5 I' I I f ING FtES;
1st t ttaturaa
,
x
$].00
$
tt.ittt„oai El.tura®
��—
x
$1.00
$
'•sa 1s9,0uiu blu
x
$10.00
$
r.><I rt1 4 ALTHL;TIONS
1t:.t )lau.uu
$s.00
$
ts�n o.ta. $IJO.du ..c lracuan
$2.00
5
5
So
TOrr.L i LL
�W
Job Audcrsy 5371 NE Madison
Dr-parLrPr:nC c1;
City of t•ridll:y
Tel, b5li-3.150
9'ha tit,dorylgn.:d I;ar;:Cy , .;kea appllc_cl.:- i -r a �r:c:t („ "
®pe"fled 1 C1
a. re,:i1).
3 La dc' al., work ir. SLr:-' -Ga�ar.:o Witt. v,ClC,,dcs
and rulings of 010 M!"ArUrCnL of 8.:al,iir. ;
010 facCu at:ona Stat.03 1r - rocr 'Glare: ttat at:
C,J0 and
9-22-80 ty---
OWNER NAUGHTIN _
KIND OF IIUI LZol u7 ; frame
USED AS res. —
TO BE C01111•LE:ED UL;ur 9-29-80
9 ESTINATI D CUSP 50.00
OLD - HCN UUILCN,; PL1,1•111 t2. FL(�
`-"'I'any
51,p :.t Ey
ROUGH INSP,
Data
FINILL I116P. -= )
Dass
hl•PItUVAL VOR FEIoll'f fq3
M111IMU11 11:L• I,:q I-II' 1•LUrulHu Prhilr IS 0.50 PLUS 6.50 :1).Tt 6URC31A1uGg
01
SUBJECT
City of Fridley
25829
AT THE TOP OF THE TWINS
BUILDING P E R M I T
RECEIPT NO.
• _____ COMMUNITY DEVELOPMENT DIV.
-
PROTECTIVE INSPECTION SEC.
Y65
r
CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED BY
L 612-571-3450
910-F15
3/3/98
JOB ADDRESS 5371 Madison Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
2
2
1 Temple Terrace 2nd
SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP
PHONE
William Dokken 5371 Madison Street NE
571-9206
3 CONTRACTOR MAIL ADDRESS ZIP
PHONE LICENSE NO.
Seal Guard Systems Inc 11464 Robinson Dr NW M ls. MN 55433
757-0097 20093688
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 Cj REPAIR
❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof House (Tear -off), Residing, Soffit & Fascia
9 CHANGE OF USE FROM TO
STIPULATIONS Underlayment on roofing must meet the State Building Code. Install
building wrap under the siding and have inspection of same. Install ventilation in
soffits to meet the State Building Code.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCYLOAD
VENTILATING OR AIR CONDITIONING.
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
ISTALLS
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
$16,850
$8.43
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.
$249.75
F e SC $16.85
PLAN CHECK FEEAL
T FEE
Lic S $5.
$280.03
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
VAEN
THIS IS YOUR PERMIT
MP�ALID
BLDG ASP
GATE
SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI
01
NEW [ ]
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress:
Legal Description:
Owner Name & Address:
Contractor:
Address:
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
mlk�W�
Effective 1/1/97
Tel. # ( - GaC)Cp
M�CE�NSE t�c� �
# �g8
Tel. # -75'7-0W-7
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF Il"ROVEMENT
Length Width Height Sq. Ft.
Length Width Height Sq. Ft.
Length Width Hgt/Ground Sq. Ft.
Construction Type: I 51 imated Cost: $
ry" fa_ Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ — $
DATE: 2 iw APPLICANT. Tel, #
STIPULATIONS:
CITY USE ONLY
Permit Fee
$�49 - -1 5
Fee Schedule on Reverse Side
Fire Surcharge
$ , to. SS
.001 of Permit Valuation (1/10th%)
State Surcharge
$ • �j
$.501$1,000 Valuation
SAC Charge
$
$950 per SAC Unit
License Surcharge
$j, ®�
$5.00 (State Licensed Residential Contractors)
Driveway Escrow
$
Alt. "A" or Alt. "B" Above
Erosion Control
$
-$450.00 Conservation Plan Review
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement Necessary { ] Not Necessary [ ]
TOTAL
$
STIPULATIONS:
4--) -)4 Effective January 1, 2003
CITY OF FRIDLEY INSPECTION DIViSION
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
(763) 572.3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
FAX (763) 571-1287
RATE SCHEDULE
Residential Rate TOTAL
Furnace Shell and Duct Work, Burner -
Also Replacement Furnace $ 30.00 $
(Side Vent - Fill Out Back)
Gas Piping (Needed with new furnace, $ 10.00 $
but not replacement)
Gas Range $ 10.00 $
Gas Dryer $ 10.00 $
*Air Conditioning - All Sizes $ 25.00 $_21S .CSC)
(2o- r r , -e -r- -3'T `TVC IS I5
All Others/Repairs & Alterations (LIST ON BACK)
1% of Value of Appliance or Work $
Commercial/Industrial
1.25% of Value of Appliance or Work $ aS._CD 0
State Surcharge $ .50-
TOTAL
50
TOTAL FEE $ S I
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.
JOB ADDRESS
OWNER Crc`n ��r1g i ,euX
BUILDING USED AS �������f 1L'C.
ESTIMATED COST a \ C0. 0® PERMIT N0.
DESCRIPTION OF FURNACE AND OR BURNER
No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Trade Name Size No.
BTU HP EDR
Fuel 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
rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
DATE '�Z - I —�
CenterPoint Energy Miunegasco
HEATING CO13562 Central Ave NE, Anoka, MN 55304
Signed 763-757=6202
"A4ZW-9�_
FAX # 763-757-6701"0
_'L�
Approved By _ Rough -In Date' Final Date _�3
THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
When t�enla,:inr7 "'n existinn furanre, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
Yes (x) No ( )
and is securely supported and firestopped where required.
The venting system is plastic/PVC and meets all current codes and manufacturer
Yes (X) No ( )
specifications including sizing, length, number of elbows and termination.
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
Yes (x) No ( )
assisted and natural draft appliances.
The is sized and installed to meet the current codes
Yes No ( )
and manufacturers specifications.
When required to 3n�u a now cembustien air_ it will be sized and installed
Yes No
�) ( )
to meet the current codes and manufacturer's specifications.
When Inatalling a new yonting system, the undersigned hereby verifies that
it is a listed assembly and meets current codes and ees
Furnace
AGA-GAMA Category I Centhe
tral
specifications. This does
Yes f) No( }
Venting Tables for fan assisted and natural draft appliances.
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
Yes (X) No ( )
separately as per current codes.
Tyne Si7e/C n men Vent anti Vent Cannnater
Infennatien
pl*anc-o and
Appliance #1 TypeBTU Input Fan Assisted or Nat
BTU Input Fan Assisted or Nat
__
Appliance #2 Type
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
Appliance #2 Vent Connector Height ft Length ft Diameter
Type
in Type
Type
Appliance #3 Vent Connector Height ft Length ft Diameter
in M
HEATING CO:CenterPoint Fnergy Him" e$asee 13562 Central Ave NE, Anoka, MN 55304
Date:
Signed By: