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PRE 2010 DOCS'1.— �G � City ®f Fridley, Minn. LQCAT ONO UI ®I G No. Street Part of t �- Lot _ Block _ 2 Addition or Sub -Division Corner Lot _ Inside Lot e0� Setback Si yard ._L Sewer Elevation — — Foundation Elevation DESCRIPTION OF BUILDING Tojoe, j4tas: Front Depth Height -1, Sq. Ft Cu. Ft DepthHeight Sq. Ft. Cu. Ft Type of Constructio Est. I � �'To be Completed 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 conx9iance with all provisions of ordinances of the city of Fridley. �3 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 pert thereof, shall conform in all respects ngs to the ordinances of Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildi within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinance. �a Building Inspector NOTICE: Me permit doss not cover the construction, installation for whing, phnnhing, ow heatimg, sewer or water. Be wre to we the Building Inspector far separate permits for these hum _ es City of Fridley ApplicaHm for Dept. of Bldgs. Phone 9®0-3490 DESCRIPTION OF WORK Number. Kind and Location of Fixtures PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ................ x $2.00 $ Future Fixture Opening ............ x $1.50 $ New Fixture Old Opening .......... x $1.50 $ Catch Basin .................... x $3.25 $ Water Heater :Up to 99,000 BTU) . • • • x $3.00 $ New Ground Run Old Bldg......... x $3.25 $ Electric Water Heater .............. a $2.00 $ GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures 2 x $2.00 $ 2.00 Additional Fixtures .................. x $ .?5 $ Gas Range to 199,000 BTU.. . x $5.00 $ install (1) gas grill & (1) lite 6.00 REPAIRS & ALTERATIONS—Refer to Code Description...............................................4 TOTALFEE $ 8-00 City of Fridley: 5384-5915.51 The .undersigned hereby makes application for a permit for the work herei specified, agreeing to do 411 work in strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that aR the fact and representations stated in this application are true and correct Fridley, Minn Max 19, 1972 , 19— ner Eugene Johnson Kind of Buildingframe Used as residence To be completed about Flay 19, 1972 Estimated Cost, $ 20.00 011 --New. Building Permit No. Permit P.S -Jr Signed. e rL v By miNNEGASCO Business Phone No ROUGH �cuaP, " Surcharge .5C`1 N 8 P WATER NTR. N GAS ELEC. ® 3 < (9 g (9 C7 Base 1st 2nd rd 4th ° Future Conamcdon Openings Connected with + Neat Fixture. Old Openings ._ Sever ❑ Cesspool ❑ PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ................ x $2.00 $ Future Fixture Opening ............ x $1.50 $ New Fixture Old Opening .......... x $1.50 $ Catch Basin .................... x $3.25 $ Water Heater :Up to 99,000 BTU) . • • • x $3.00 $ New Ground Run Old Bldg......... x $3.25 $ Electric Water Heater .............. a $2.00 $ GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures 2 x $2.00 $ 2.00 Additional Fixtures .................. x $ .?5 $ Gas Range to 199,000 BTU.. . x $5.00 $ install (1) gas grill & (1) lite 6.00 REPAIRS & ALTERATIONS—Refer to Code Description...............................................4 TOTALFEE $ 8-00 City of Fridley: 5384-5915.51 The .undersigned hereby makes application for a permit for the work herei specified, agreeing to do 411 work in strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that aR the fact and representations stated in this application are true and correct Fridley, Minn Max 19, 1972 , 19— ner Eugene Johnson Kind of Buildingframe Used as residence To be completed about Flay 19, 1972 Estimated Cost, $ 20.00 011 --New. Building Permit No. Permit P.S -Jr Signed. e rL v By miNNEGASCO Business Phone No ROUGH �cuaP, " Surcharge .5C`1 CITY OF FRIDLEY Effective Date May 1, 1988 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES RATE SCHEDULE' RESIDENTIAL Job SCJ [ 9 / k' RATE TOTAL Address ( Furnace Shell and Duct Work, ® Burner (Also replacement furnace) $ 20.00 $ 2 Department of Buildings, 6431 University Ave. N.E.e Fridley, MN 55432 City of Fridley Gas Piping $ 10.00 $ Tei. 0571-3450 (piping needed with new furnace) Gas Range $_l 0 -.0 0 $ The undersigned hereby makes application for a permit for the work herein Gas Dryer $ 10.00 $ 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 facts and representations stated in this application are true and correct. Air Conditioning (all sizes)$ 10.00 $_ Fridley, Minn. 6 3> All Others/Repairs and Alterations (AMER n It of Value of Appliance or Work $ KIND OF BUILDING e S , COMMERCIAL/INDUSTRIAL USED AS It of Value of Appliance or Work $ TO BE COMPLETED ABOUT ESTIMATED , State Surcharge $ .50 COST 'elo / OLD - NEW BUILDING PERMIT NO. PERMIT NO. TOTAL lLrE $ Reinspection Fee ($15.00) $% Rough Insp. Date Final Insp. ate Approval for Permit MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00 PLUS $.50 STATE SURCHARGE *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. DESCRIPTION OF FURNACE/ HEATING or R PLANTS, Steam, Not Water, r4 A - No. Trade Name VG�,1 �l_ Size No. Capacity Sq. Ft. EDR BTU M Hp Total Connected Load Kind of Fuel BURNER - ty / r F i l l ou bay Name Size No. Sq. Ft. EDR BTU Bp � Company P Signed By ^ o� Tel. No. Z?ZL�;�J side for stack verification on replacement furnaces CHIMNEY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack; 1. 'Has .been. carefully. examined. Yes f,,-A\i 2. Is free from rust or deterioration Yes 6() 3. Has no foreign objects lodged within Yes 4. Is securely supported Yes (7� 5. Meets all current Code requirements for size and total BTU connected Yes (i<) 6. Has Total heating BTU's of All other BTU's TOTAL Rema rk s Company Signed 8 Da to No ( ) No ( ) No ( ) No No ( ) �pF FiQ�_PUBLIMORKS MEMORANDUM TO: John Flora, Director of Public Works FROM: Paul Lawrence, Superintendent of Public Works DATE: October 23, 1995 SUBJECT: Walkway - Rainbow Drive to Sunrise Drive Eugene Johnson, 6191 Rainbow Drive, has requested that the city install a chain link fence between the walkway an his proper . I visited the site and found that some of the abutting properties have installed board fences, but the area is mostly open. I talked with Mr. Johnson by telephone on 6-23-95 and advised him that the city's current policy is not to make this type of installation, but he could install a fence at his expense. He asked the location of the property line and I told him that the city could assist in establishing a location for the fence if he decided to install a fence. He also requested that the city install a security light approximately mid -way along the walkway. I advised him that the city does not install security lights but NSP would install one (if there was a pole available) at his expense and he could discuss a cost sharing plan with the other property owners abutting the light. Curt Dahlberg said that the city does not provide any service (such as mowing) along the walkway and he does not recall any other type of maintenance request. 917V L—AISIV&DO 1AS 61 3NVI NVAI).S ST iA Pri L—AISIV&DO 1AS 61 3NVI NVAI).S N3NdIQ.� by Ll Pri Ll 1 9- SUBJECT PE City ®f Fridley26716 AT THE TOP OF THE TWINS BUILDING EMIT r IPT NO. COMMUNITY DEVELOPMENT DIV. i v �_____ r PROTECTIVE INSPECTION SEC. ���� NUMBERREV DATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 612-571-3450 910415 7/21/98 JOB ADDRESS 6191 Rainbow Drive 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 8 2 1 Sylvan Hills SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Eugene Johnson 571-1495 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. New Haven Const. 420883rd Ave N Brooklyn Park MN 55443 566-5225 20077950 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION O ALTERATION CX REPAIR O MOVE O REMOVE 8 DESCRIBE WORK Reroof 19 S tear -off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with State Building Code. 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 SO. FT. CU. FT. AUTHORIZED IS NOT COMMENCED WITHIN 80 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 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 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT 1584 $.79 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE Inv Fee SAC CHARGE PROVISIONS OF ANY OTHER STAT OR OCAL LAW REGULATING CON- $59.50 Fire SC $1.58 STRU ON OR THE P FORMANIF O NSTRUCTION. C k 59.50 PLAN CHECK FEE TOTAL FEE Q ,License SC $5.00 giza $126.37 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IRATE) WHEN PROPERLY VATED THIS IS YOUR. PERMIT SIGNATURE OF OWNER IIF OWNER BUILDER) (DATE) LD )NSP QATE 9- �e�-��ri Gans �cj 2cp775Us �y V-X/fes 10-? L. 3? IV. � v 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 TOTAL $ 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 lv E� Effective On January 1, 2000 JOB ADDRESS / 9?/��'Acs� r OWNER Eu�&,A--0Jc BUILDING USED ESTIMATED COST -2-rte- -lc--j PERMIT NO. 1�, DESCRIPTION OF FURNACE AND OR BURNER No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air) Trade Name h�O-G/v'_S14-2SSd7.�Size No. BTU _?0,HP EDR Fuel /LA,,,. ( 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 lB""-40e) HEATING CO Signed TEL # Approved By Rough -In Date Final Date %a I3'00 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 () 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 existing 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 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 Connector Height ft Length ft Diameter in Type ALTERATIONS: (Describe) HEATING CO: Signed By: Date: SUBJECT PERMIT Q� City of Fridley r 316 24 AT THE TOP OF THE TWINS BUILDING PERMIT i t COMMUNITY DEVELOPMENT DIV. >r ------ r PROTECTIVE INSPECTION SEC. o2f/ E o•j CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY L J\ 612-571-3450 910-F15 1/19/01 JOB ADDRESS 6191 Rainbow Drive NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 8 2 Sylvan Dills SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Eugene/Nancy Johnson 6191 Rainbow Drive NE 571-1495 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Window Lite Home Imp. 8400 89 Ave N, Brooklyn Park, MN 55445 763-425-2227 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 20039258 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 9 windows within existing openings 9 CHANGE OF USE FROM TO STIPULATIONS Provide smoke detectors in all sleeping rooms and on all levels of the dwelling per Section 310.9.1.2 of the 1997 Uniform Building Code. T= Permit l rg.a. Car Will Be ma-le'd 0 HOMONYM 703 posp SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING. HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD 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 1 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 $4.44 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $8,894 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 PLAN CHECK FEE TOTA FEE Licens $5.0,9/185.58 SIGNATURE OF CON'RACTOR OR AUTHORIZED AGENT 16ATEi N ROPE LIDA D HIS is YOUR P RMIT _ S-GNATURE OF OWNERdF OWNER BWLDERI IDATEj BLDG NSP PATE NEW"tel S� ffective ADDN [ ] - -��� CM OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R- BUILDING PERMIT APPLICATION ConstructionAddress : Legal Description: Owner Name & Address: Contractor: c� ` Address: Tel. # MN LICENSE #�D/� +'t — Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF BIPROVEMENT 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: stimated Cost: $ Driveway Curb Cut Width Needed: DATE: lbiqL Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL Ft. + 6 Ft = (Fee Schedule on Back) Ft x $ = $ s CITY USE ONLY Tel. # ��3 0f �?/- f m4 $fir/, Fee Schedule on Reverse Side $ .001 of Permit Valuation (1/10th%) $ > $.50/$1,000 Valuation $ $1050 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 [ ] s 185:.58 STIPULATIONS: � �10� �/�10e-&6 �lD�� /''� i!7�LL //✓�- /�M�-tl �•c/t� dv LG. ,,C �j�G r 6.Ae 7" 40 CITY OF FRIDLEY 6431 UNIVERSITY AVENUE NE FRIDLEY, MN 55432 572-36U4 YAA: ( 763) 5 71-128 7 ADDRESS 6191 RAINBOW DR NE PIN 143024330023 LEGAL DESC SYLVAN HILLS LOT 8 BLOCK 2 PERMITN0.- 2004-00072 DATE ISSUED: 01/21/2004 , p PERMIT TYPE PLUMBING PROPERTY TYPE RESIDENTIAL CONSTRUCTION TYPE ADDITION/ALTERATION VALUATION NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A INSTALL AN ELECTRIC WATER HEATER # ELEC WATER HEATERS # NEW FIXTURES (EXIST OPENINGS) # GAS RANGES # WATER TRMT APPLIANCES APPLICANT GAVIC & SONS PLUMBING 12725 NIGHTINGALE ST COON RAPIDS, MN 55448- (763) 755-6468 JOHNSON EUGENE L & NANCY L 6191 RAINBOW DR NE FRIDLEY, MN 55432 1 VALUE OF FIXTURE/APPLIANCE 0 0 # GAS DRYERS 0 0 # OF NEW FIXTURES 0 0 AGREEMENT AND SWORN STATEMENT This permit becomes null and void if work or construction authorized is not commenced witin 60 days or if construction or work is suspended or abandoned for a period of 120 days at any time after work is commenced. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of wort will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or local law regulating construction or the performance of construction. ADDlicant_ Date PLBG PERMIT MINIMUM FEE 20.00 PLBG FIXTURES (NEW OPENINGS) 0.00 PLBG FIXTURES (EXIST OPENINGS) 0.00 WATER TREATMENT APPLIANCE 0.00 GAS RANGE FEE 0.00 GAS DRYER FEE 0.00 PLBG REPAIR/ALTERATIONS 0.00 STATE SURCHARGE, PLBG FLAT 0.50 WATER HEATER - ELEC 7.00 TOTAL 20.50 PAID WITH CHECK # 10243 LIVDAD ATL' DL'U1IATTQ 13Vr%TTT13r77l UrND AlTr%DTI f►TLTL'D TTIAAT T1V42r'DT'n1Qn AT2(1 M OF 1=:ti.:.�t'� 'NSF'& . a �- DIV. a 6431 University Ave NE Fridley, MN 55432 (763) 572-M04, FAX (763) 571-1287 Stories Basement Floor 1 Floor 2 Floor 3 Floor 4 PLUMBING FIXTURE RATES: Urinal APPLICATION FOR PLUMBING AND GAS FITTING PERMIT v— ar rl -r^ MC IAIQTA) 1 Cr% nAI r:ArN FI r IR - s Wash p �i iQ..I> Floor chnwur Inl€' <`: Tr9V t l [lt : »:;'> Drain NO. RATE TOTAL New Fixtures Old Opening, New Fixture Beer Dispenser. Blow Off Basin Catch Basin Rain Water Leader Sump/Receiving Tank Water Treating Appliance WaterHeater-Electric Water Heater - Gas" Gas Range" Gas Dryer" Back Flow Preventer Required ( )Yes () No Type $ 7.00 $ 4.00 $ 5.00 $ 7.00 $ 7.00 $ 7.00 $ 7.00 $10.00 $ 7.00 $10.00 $10.00 $10.00 $15.00 -JOB ADDRESS L'I" "!Vl7 Vll jall 'I, _'-'UUJJ Water Heater Gas lElec 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 Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. Owner Building Used As Estimated Cost '�X7C) • PERMIT NO. PLUMBING COMPANYJL%�aV I G 1-10 ,2oN it Reinspection Fee $47.00/Hr SIGNED BY l.rANY TEL NO. -1(03 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance Approved By Date Final Date State Surcharge $ •50 MINIMUM FEE UMBINGIGAS PERMIT IS $20.00 TOTAL FEE $ R0.5D PLUS THE $ 50 STATE SURCHARGE COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE APPLICATION WILL BE RETURNED rOmmm VFNT- VENT CONNECTOR AND COMBI ISTION AIR V RIFICATUN When rpnlacina an existing ft iranrg, the undersigned hereby verifies that the . venting has been examined and is free from rust, deterioration, obstructions, �.". and is securely supported and firestopped where required. Yes () No ( ) The venting system is plastic/PVC and meets all current codes and manufacturer specifications including sizing, length, number of elbows and termination. Yes() No() The undersigned also verifies that the replacement unit is a listed assembly and meets the current codes and manufacturers specifications. This does include AGA-GAMA Category I Central Furnace Venting Tables for fan assisted and natural draft appliances. Yes( ) No( ) The 6 ix sting r-nmht ishan air is sized and installed to meet the current codes and manufacturer's specification's. Yes () No ( ) When required to Install a new .ombustion air; it will be sized and installed to meet the current codes and manufacturer's specifications. Yes () No ( ) When inasrinp a new venting cystam, 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 #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 t inches Appliance #1 Vent Connector Height ft Length ft Diameter in Type Appliance #2 Vent Connector Height ft Length ft Diameter in Type Appliance #3 Vent Connector Height ft Length ft Diameter in Type HEATING CO: Signed By: Date :