PRE 2010 DOCSCity of Fridley, Minn. 15
6431 University Ave. N.E., Minneapolis, Minn. 55432
BUILDING PERMIT
Date: June 15,1972
Owner: Vern Donnay Realty, Inc. Builder SAM -9
Address _ 7300 -36th Avenue N. Address Same
533-2741
LOCATION OF BUILDING
No. _._], ...;L___. Street -i aadcal =A W1.11 . Part of Lot
Lot _.._2p._ Block
Addition or Sub -Division .—Mearlommocir Terrace
Corner Lot ____ _____ Inside Lot — X_ Setback 15 - 91 — Sideyard 10.5 t
Ny4fil Elevation ._._889 _1 1 _ �b iy q� ��j���y(3 feet abov _ waver table minimum
Wye Top of Footing (Water Table - 895.6 AFp-ox.)
DESCRIPTION OF BUILDING
To be Used as:
Dwelling Front 32' Depth Height 20' Sq. Ft 777.6 1. cu. Ft 15.s 5.52
Garage Front 14' Depth 22' Height 10' Sq. Ft 308_ Cu. Fi. 3080
Type of Construction Wood Frame Est cost $19,580 To be Completed Sept. 1072
WATER LOCATION: 10t E.of Sewer Service SEWER LOCATION: 49' W. of E. property line.
Stipulation: This permit issued subject to stipulations in 'Mutual Agreement" signed
by Vern Donnay Realty, Inc. and dated June 14, 1972.
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 an in comp ance with all provisions of
ordinances of the city of Fridley. /-,)."` n
In consideration of the payment of a fee of $ 34-00 , permit is hereby granted to Utmrn nonnav Realty Inc.
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 builtiffigB
within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
Building Inspector
NOTICE:
This permit does not cover the construction, installation for wiring, plumbing, gas heating, sower or water. Be sure to as
the Building inspector for separate permits for these items.
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WIN nmi�
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Land Plonnrny /� J 6B75 : if away 15 NE
Lad Surwe "'Y minnxv fvlis 31.
sa,ls kst&iq
ENGINEERING, INC. ��s,l°
cw/ o- Mimrupnl SU7Mt f-066
fn jiment y Engineers Sur veyors ---
certificate of surveY for
LOT 20
0
at i4
O N
0i Proposed l
NoU$N' {Gar N
137 7
h
M
/J
MEADOWMOGR DRIVE
NOR TH
oDENOTES /UPON — — DENOTES 071Z/TY e ORA//V.4G,E' ,FASEMENi
ZOT--a3t OCK —2 _/y,EA001+/MOOR 7,z' -RRA c,4c-
COUNTY OF AAVkA
/ bemhy, cerfi`y flet Nips rs a 6w a"d eAvrecl reareseata pan e�a survey q(7#x &wndw-;o qP* abaet d5uvkd /aid, avid
af'Nr /uwfinvi o/'ad durfdo ys , *mw, , and d/ rvsl&e dnrnvdirnenfs , rrdry, fan w w-wd lyd. As surveyed 6y im °by
fEB_ A.0 /9-4. SUBURBAN ENG/NEERING , INC.
_ Er�irrers Fr Sur Oyora
SCALE = SIO -- •
Su)�-P Z®c v
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�' , ®� . �� ��� �'��� vim �
fW
31
Cilfy of Fridley
AppficWm for PWmbbq and C"m R"big
apt. of Bldoa. Pham
DESCRIPTION OF WORK
Number. Kind and LoeaBan of Flxtosea � �•� % 3 % `% �rG i n
Y e a WATER urs.
Base I /
PARTIAL RATE SCHEDULE
City of Fridley:
The undersigned hereby makes application for a permit for the vrork hereic
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 7h 17 -r— ,l9.
Owner V c2�
Kind of Building
Bawer Q Used as
PLUMBING FIXTURE RATES.
NO. RATE TOTAL
Number Fixtures ................
x $2.00
S
Future Fixture Opening ............
x $1.50
i
New Fixture Oflat Opening ..........
x $1.50
=
Catch Basin ....................
x $3.25
$
Water Beater 'Up to 99.000 BTU) ....
x $3.00
t
New Ground Ruga Old Bldg.........
x $3.25
$
Electric Water I$ester..............
_ $2.00
$
GAS FITTING FEES-.
NO. RATE TOTAL
lat 3 Fixtures ...... • • • • • • ......
_Z3100
$
Additional F'ixturefsyv................
z $ 355
$
Gas Range to 199,000 BTU
x $5.00
$
State Surcharge
$ .50
REPAIRS A ALTERATIONS—Refer to Cada
_
Description ..........................
TOTALFEE EE
$
To be completed about �/0 I–X I07 -'r—
Estimated Cost. $�-
Old Ne Building Permit No. Permit No. JZ 13 q
Signed
By
Business Phone No A/
ROUGH
FINAL
Appkvflm for Power Phaft and HeatingE Cooling, Ventilation, Refnigeratio® and
Air Conditioning System and Devices
PARTIAL RATE SCHEDULE
GR.AVr TY WARM AIR:
RATIN 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 $
BCH. 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.OG $
over 3 gal. per hour—See Fee Schedule
GAS BURNER (up to 199,000 BTU) .......:...... '......... SAG $ _
over 199,000 BTU See Fee Schedule
GAS FILING FEES: NO RATE TOTAL
1st 3 Fixtures x$ X00 $ saw
Additional Fixtures ............... x .78 $
Gas Range to 199,000 ........... x$ Sim $
AIR COPDITIONING
FAN HEATING SYSTEM
VENTILATING. SYSTEM
ALTERATIONS do REPAIRS
$
See Fee Schedab
TOTAL FEE
Dept. of Bldgn. Phone 5W-3"30
City of Fridley:
4-19'19'1
Iv- If
U°
The undersigned hereby makes application for a permit for the work herein
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.
I
. 1 Kridley, inn I& ls!/
Owner
Kind of Building
Used as • A
To be completed about �_/y
Estimated Cost, $ "S*
Old New Building Permit No. Permit No.
DESCRIPTION OF WORK
STATING or POWER PLANTS—Steam, Hot Water, arld No t
Trade Name Size No. 11 1111-01
Capacity—Sq. Ft. E.D.R BTU H.P.
Total Connected Loa�i� (A Rind of Fue
BURNER — Trade Name Size No
Capacity Sq. Ft. ZDR BTU S.F.
RmLa signw
By
n"A Nn
G.
1.001 Xenia Av. S. - 545-1611
(REMARKS—OYER) AinMpolis, Minn. 55416
City of Fridley 53-84-S-915.51
Appliu*11onfor and "Pomb
Dept. of Bldgo. Phone NO -3450
DESCRIPTION OF WORK XIM 1377 N. E. Meadow Moore Drive
Number, Kind and Location of Fixtures
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures ................ x $2.00 $
Future Fixture Opening ............ x $1.60 $
New Fixture Old Opening .......... x $1.50 ;-
Catch Basin .................... x $3.26 $
Water Heater (Up to 99,000 BTU) .... x $3.00 $
New Ground Run Old Bldg......... x $3.25 $
Electric Water Heater .............. : $2.00 $
GAS FITTING FEES: NO. RATE TOTAL
1st 3 Fixtures x $2.00 ;
Additional Fixtures .................. x $ .75 ;
Gas Range to 199.000 BTU ............... 1 x $5.00 $ 5.00
REPAIRS & ALTERATIONS:—Rotor to Code
Description ..............................................;
TOTAL FFA ; 5.00
(SURCHARGE $_.50)
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 (11a 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, Wnn 10-16-72 „ 19,
Owner
germ Donnay Homes Inc.
Kind of Building
Frame
Used as Res.
10-23-72
To be completed about
Estimated Cost, $ 10.00
MML-New. Building Permit No. Permit No.
n
Signe .
By hfi1N1NPnAqrn
Business Phone No
ROUGH
FINAL
Class "A" Surcharge 'S.5Q
IYc
oj
Qj
x
�
•
•
WAM MTX.
GAS
REG
Base
1st
1
2nd
3rd
4th
' Future Connection Oponin"
+ Now Fixture, ON Openims
_
Conneetad with
Sawa
Cesspool ❑
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures ................ x $2.00 $
Future Fixture Opening ............ x $1.60 $
New Fixture Old Opening .......... x $1.50 ;-
Catch Basin .................... x $3.26 $
Water Heater (Up to 99,000 BTU) .... x $3.00 $
New Ground Run Old Bldg......... x $3.25 $
Electric Water Heater .............. : $2.00 $
GAS FITTING FEES: NO. RATE TOTAL
1st 3 Fixtures x $2.00 ;
Additional Fixtures .................. x $ .75 ;
Gas Range to 199.000 BTU ............... 1 x $5.00 $ 5.00
REPAIRS & ALTERATIONS:—Rotor to Code
Description ..............................................;
TOTAL FFA ; 5.00
(SURCHARGE $_.50)
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 (11a 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, Wnn 10-16-72 „ 19,
Owner
germ Donnay Homes Inc.
Kind of Building
Frame
Used as Res.
10-23-72
To be completed about
Estimated Cost, $ 10.00
MML-New. Building Permit No. Permit No.
n
Signe .
By hfi1N1NPnAqrn
Business Phone No
ROUGH
FINAL
Class "A" Surcharge 'S.5Q
SUBJECT
ER
7:::2::2:1:
City of Fridley
2 216-9
AT THE TOP OF THE TWINS
BUILDING PERMIT
RECEIPT NO.
_ COMMUNITY DEVELOPMENT DIV.
35729PROTECTIVE
INSPECTION SEC.
CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED By
�'� 612-571-3450
910-F15
10/12/93
JOB ADDRESS 1377 Meadowmoor Dr NE
1 LEGALLOT
NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
20
2
Meadowmoor Terrace SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
William Diane Sharp 1377 Meadowrmoor Drive NE 784-5300
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Exterior Design Service 6391 Monroe St NE Fridley 571-3220
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
Reside House (Steel/Aluminum)
9 CHANGE OF USE FROM TO
STIPULATIONS
Provide smoke detectors as per UBC 1210 adjacent to all sleeping areas
and in basement,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
ZONING
SO. FT.
CU. FT.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
NO. DWLG. UNITS
OFFSTREET PARKING
ANY TIME AFTER WORK IS COMMENCED.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1
STALLS GARAGES
VALUATION
SURTAX
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$4,42Q
$2.21
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTI OR T E PERF MANCE OF CONSTRUCTION.
$72.00
Fire SC $4.42
PLAN CHECK FEE
TOTAL FEE
License SC $5.00
$83.63
WHEN PROPER ALIDATED THIS IS YOUR PERMIT
SIGNATUREO CO TRAC RORAUTHORIZED AGENT IDATEI
2
GINS DATE
SIGNATUREOF OWNERIIF OWNER BUILDERI IDATEI
NEW 11
ADDN [ ]
ALTER [)
Construction
Legal Description:
Owner Name & Address:
r
Contractor: �Z!E�-
LIVING AREA: Length
GARAGE AREA: Length
DECK AREA: Length
OTHER:
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
Effective 5/26/93
-4357;7v
MN LICENSE #
Tel. #,J71- 3 >-2—'0
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
Corner Lot [ ] Inside Lot [ ]
Type of Construction:
Approx. Completion Date:
DESCRIPTION OF fl"ROVEMENT
Width Height Sq. Ft.
Width Height Sq. Ft.
Width Hgt/Ground Sq. Ft.
Ft. Yd Setback Side Yard Setbacks
Estimated Cost: $ 4/Z27V, e --a
(Cost on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: d C�y APPLICANT: Tel.
Permit Fee
$ 0
CITY USE ONLY
Fee Schedule on Reverse Side
Fire Surcharge
$ - 44
.001 of Permit Valuation (1/10th%)
State Surcharge
$ f
$.50/$1,000 Valuation
SAC Charge
$
$750 per SAC Unit
License Surcharge
$ CO
$5.00 (State Licensed Residential Contra)
Driveway Escrow
$
Alt. "A" or Alt. "B" Above
Erosion Control
$
Conservation Plan Review $450.00
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement Necessary [ ] Not Necessary [ ]
TOTAL
$
STIPULATIONS:
City Fridley
SUBJECT
PERMIT-NO. --
��
of
AT THE TOP OF THE TWINS
?
BUILDING P E RSM I T �-
/
,
RECEIPT NO.
COMMUNITY DEVELOPMENT DIV.
I fr PROTECTIVE INSPECTION SEC.
r
I ,
I"% CITY HALL FRIDLEY 55432
DATE
PAGE OF
APPROVED BY
612-571-3450
rUM96REV
0415
12/19/97
JOB ADDRESS 1377 Meadowmoor Drive NE
BLOCK
TRACT OR ADDITION SEE ATTACHED
1 LEGAL
DESCR.
ILOTNO.
20
2
Meadowmoor Terrace Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Diann Sharp 1377 Meadowmoor Drive NE
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO
Affordable Exteriors 11938 Utah Ave N, Champlin, MN 55316 323-9697
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 J3 REPAIR ❑ MOVE D REMOVE
8 DESCRIBE WORK
Reroof House (Tear-off) 14 Sq
9 CHANGE OF USE FROM TO
STIPULATIONS Underlayment must comply with the State Building Code.
Contractor left office with original application & building permit form.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING,
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
1
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
$1,170
.58
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
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-
$40.25
Fire SC $1.17
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
PLAN CHECK FEE
TOTAL FEE
$1,170
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE,
WHEN LIDATED THIS IS YOUR 17�pr
"PnsE/R,M
�P/R�OPERLY
!!'V , / "7./ !
LD INSP OA TE
SIGNATURE OF OWNEAOF OWNER BUILDERI IDATEI
NEW [ ]
ADDN [ J CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress:
T .eaal Descrintion:
Owner Name & Address: Tel. #
Contractor: MN LICENSE #
i
Address: Tel. # _
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
Construction Type:
this ,;application, a Certificate of Survey of the
he " osed construction drawn on it to scale.
OF IMPROVEMENT
Length Width Height
Length Width Height
Length Width Hgt/Ground
Driveway Curb Cut Width Needed:
DATE:
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
. STIPULATIONS:
APPLICANT:
Effective 1/1/98
Sq. Ft.
Sq. Ft.
Sq. Ft.
Estimated Cost: $
(Fee Schedule on Back)
Ft. + 6 Ft = Ft x $ = $
Tel. #
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1000 per SAC Unit
$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 [ ]
14
CITY OF FRIDLEY INSPECTION DIV.
���`�y ��I
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
5i2-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
JOBADDRESS 37-7 M ddoWMnQ(' N -NC -
Effective On August 1, 1995
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) J a _1 9' '199
Gas Piping (Needed with new furnace) $10.00 $
OWNER
Gas Range $10.00 $
BUILDING USED AS
Gas Dryer $10.00 $ v�
ESTIMATED COST ?)RL) — PERMIT NO.
*Air Conditioning —All Sizes $ 25.00 $
DESCRIPTION OF FURNACE AND OR BURNER
All Others/Repairs & Alterations (LIST ON BACK)
I% of Value of Appliance or Work $ No. of Heating Units Circle One (Steam) (Hot Water) EaD
Trade Name R 1a 1 a CI Size No.
Commercial/Industrial BTU —n .O0l HP EDR
1.25% of Value of Appliance or Work $ Fuel QH Total Connected Load
State Surcharge X50_ Burner Trade Name Size No.
BTU HP EDR
TOTAL FEE s 305D DEPENDABLE INDOOR AIR QUALITY. INC.
HEATING COMPA 2619 COON RAPIDS BO LEVARD
MINIMUM FEE FOR ANY HEATING/COOLINGNENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00 Signed N
PLUS THE $.50 STATE SURCHARGE ""�� Cl�lvt-t t�C4't
REINSPECTION FEE $42.00/Hr Approved By Rough—In Date Final Date
* t be laced in a side and without FILL OUT BACK SIDE F R STACK VERIFICATION ON v
Air Conditioners can no p y
written permission from adjoining property owner. REPLACEMENT FURNACE
6 Has total heating BTU's of (a ®oo
All other BTU's
TOTAL BTU's
7. Has a liner been provided for water heater Yes (Y) No ( )
8. Has combustion air been provided for water heater Yes No ( )
Remarks:
HEATING CO:
Signed By:
Date:
/4- ` / 8—fig
CHIMNEY AND STACK
VERIFICATION
The
undersigned hereby verifies that the existing chimney or stack:
1.
Has been carefully examined
Yes (X)
No
( )
2.
Is free from rust or deterioration
Yes (y)
No
( )
3.
Has no foreign objects lodged within
Yes (,()
No
( )
4.
Is securely supported
Yes ()G)
No
( )
5.
Meets all current Code requirements for size
and total BTU's connected
Yes ()()
No
( )
6 Has total heating BTU's of (a ®oo
All other BTU's
TOTAL BTU's
7. Has a liner been provided for water heater Yes (Y) No ( )
8. Has combustion air been provided for water heater Yes No ( )
Remarks:
HEATING CO:
Signed By:
Date:
/4- ` / 8—fig