Loading...
PRE 2010 DOCSCity of Fridley, Minn. UILDING PERMIT Date:_ 4 Owner:-�'"c °' Builder Address _ _ _ _ _ Address--.---. ----- �3 L®CATI B[JIL®ING No. Street __ Part—t - - e — zr.r LotBlock ddition or Sub-Division01- Corner Lot Inside Lot Setback Sideyard Sewer Elevation _ _ _ _ _ _ __ _ _ _ Foundation Elevation DESCRIPTION OF BUILDING To Used ' r* Front Depth Height Sq. Ft./uWl Cu. Ft. ;Fron Depth _ Height Sq. Ft. Cu. Ft. Type of Construction _ Est: Cost = -_ To be Completed JIf 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 ordinances of the city of Fridley. 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 within the city limits and this permit may be revoked at any time uponviolativri any -of the provisions of said ordinances. Building Inspector NOTICE: This permit does not cover the construction, installation for wiring, plumbing, gat heatingt sewer or water. Be sure to we the Building Inspector for separate permits for these items. 4 AP -PLICATION FOR BUILDING PRU41T CITY OF FRIDIM, MINNESOTA Owner's Nam l� v<-42 G ori/ Builder cS� Address 3z©a -5.-o OF BUILDING No. 1.2-2- _ Street__ is 1 ,fcA— Part of Int Lot -2--" Block _- - --3 - - -- -_ - Addition or Subdivision f,-Ww '/,(-- —',) 0^o< Corner Lot Inside Lot�Setback Side -Yard SEWER. ELEVATION FOUNDATION ELEVATION l� Applicant attach to this form Certificate of Survey of Lot and proposed building location. To be used as: DESCRIPTION OF BUILDING /lI' a, / -s 3 Denth Xa r. Height Sq. Ft. 1,3S-& Cu. Ft. ? Sfi, ir.f'O Front Depth Height Sq. Ft. Cu. Ft. Type of Construction Estimated Cost fzz7 /� 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 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. DATE SIGNATURE _ �Z14 Ll,�z 6� (A Schedule of Fee Costs can be found on the Reverse Side.) City ofFridley Application for Plumbing and Gas Fitting Perntitt DESCRIPTION OF WORK Number, Kind and Location of Fixtures �aaj NO. RATE TOTAL x $1.50 $�`— 0 Future Fixture Opening ................ x 1.20 $ New Fixture Old Opening .............. x 1.00 $ Catch Basin ............................ Water Heater (Up to 200,000 BTL) a N $ o oo New Ground Run Old Bldg . ............ w Zp P N WATER HTR. GAS ELEG Additional Fixtures .................... x .50 $ Gas Range to 200,000 BTU .............. x 2.00 $ O Base 1st 2nd _ 3rd _ 4th • Future Connection Openings Connected with Sewer El New Fixture, Old Openings Cesspool PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: Number Fixtures ......................—� NO. RATE TOTAL x $1.50 $�`— 0 Future Fixture Opening ................ x 1.20 $ New Fixture Old Opening .............. x 1.00 $ Catch Basin ............................ Water Heater (Up to 200,000 BTL) x 3.25 ...... x 2.00 $ $ o oo New Ground Run Old Bldg . ............ x 3.25 $ GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .......................... x $1.50 �� $� Additional Fixtures .................... x .50 $ Gas Range to 200,000 BTU .............. x 2.00 $ REPAIRS & ALTERATIONS—Refer to Code Description................................................$ TOTAL FEE sl 7, 0 b DepL of Bldgs. Phone SII 4-7470 City of Fridley: 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. Fridley, Minn. -7 �19hz Owner ��tr2yya- Kind of Building r Used as To be completed about Estimated Cost, $ Old—(& Building Permit No. cz� permit No. Signed By Business Phone No ROUGH 0 FINAL 48 2M 7-59 Application for Power Plants andHeating. Cooling„ Ventilation, Refrigeration and Air Conditioning Systems and Devices PARTIAL RATE SCHEDULE GRAVITY WARM AIR: RATE TOTAL, a Furnace Shell & Duct Work .......................... 8.00 $ Replacement of Furnace ............................. 5.00 $ Repairs & Alterations—up to $500.00 .................. 5.00 $ Repairs & Alterations each add. $500.00 ............... 2.50 $ MECH. WARM AIR Furnace Shell & Duct Work to 120,000 BTU ............ &00 $ `® y• each add. 60,000 BTU .,3 .................. 2.00 $ Replacement of Furnace .............................. .§.00 $ Repairs & Alterations—up to $500.00 .... ............ 5.00 $ Repairs &Alterations each add. $500.00 ............... 2.50 $ Dept. of Bldgs. Phone SU" 4-7470 ✓71 � City of Fridley. 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. Owner Kind of Used w STEAM or HOT WATER SYSTEM -ro oe compietea aoout co Furnace Shell &Lines—ta 400 sq. ft. EDR Steam....... 8.00 $ Estimated Cost, $ 7 y Furnace Shell & Line—to 640 sq. ft. EDR Hot Water'... 8.00 $/�� Old ew,, uilding Permit No. Permit No. Each add. 200 sq. ft. EDR Steam ...................... 2.50 $ Each add. 320 sq. ft. EDR Hot Water .................. 2.50 $ DESCRIPTION OF WORN OIL BURNER—to 3 gal. per hour ........................ 5.00 $ HEATING or�'E}R� : 33ot- Warm Air—No over 3 gal. per hour—See Fee Schedule ' Size No L GAS BURNER (up to 400,000 BTU) Fade Nam �1LE - � ���z� -�� ( 5.00 $ Capacity Sq. Ft. E D.R ��� BTU J H.P. GAS FITTING FEES: NO RATE TOTAL 1st 3 Fixtures x $1.50 $ �' " Total Connected Load Kind of Fuel Additional Fixtures ................. x .50 $ BURNER — Trade Name � , � " Size No �� �� Gas Range to 200,000 BTU ........... x 2.00 $ �� Capacity Sq. Ft. E.D. ®e''2�� "BTU A.P. AIR CONDITIONING $ > CEO. SED ICK FITC. & AIR -GOND. CO FAN HEATING SYSTEM See Fee Schedule �� . 1001 Xenia AV. S. VENTILATING SYSTEM �- $ Minneapolis 16, Minn. ALTERATIONS & REPAIRS TOTAL FFE $ 1 SBy% \ jy%�-c r ROUGH 4 Z tin 7-59 Business Pho e No FINAL (REMARKS—OVER) D-36 .0jJW79 HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS Weatherstrips A.S.H.V.E. Construction No. Guide W' lows I boors ference Out. Wall Int. Wall Ceiling Roof Floc e est-- , 19— �%D MINNEAPOLIS. MINN. Insulation Kind How Applied d' Fl_I J- , ., . � z - Room I Length Width z:!4- Height .� II / MI.- Room Length 4 Width / 'C Helght Windows and Doors—Crackage and Area �(?4 Y /� Width Height No. of Lineal f . Area No. of pane of pane lights of crack sq. ft. 44 - 7J ,f Infiltration Glass Coef. Btu Infiltration c 7 i � Net exp. wall L L Glass Int. wall d Exp. wall', Exp. wall Net exp. wall �, Exp. wall I L. Net exp. wall ///,L - Int. wall Required sq. Net exp. wall,_' Int. wall Ceiling Floor Ceiling ` Floor."+ A Ceiling Az Total Btu. f Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Fl.l /77 �,>t ''Room I Length Width // Height Windows and Doors—Crackage and Area �(?4 Y /� Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. xv 4 2r - 7J ,f Infiltration Glass Btu Coef. Btu Infiltration�- 7 i � Net exp. wall L L Glass Int. wall Glass Exp. wall', f Net exp. wall �, Exp. wall I L. ( ///,L - Int. wall Required sq. Net exp. wall,_' Ceiling Floor Int. wall ` Ceiling Az Es+� Floor Total Btu. " 161 Required sq. ft. E.D.R. or sq. ins. W.A. Leader area J FI M Rnnm I Length ,-j Width r-�;, Height s Windows a Doors—Crackage nd Area y // - j Width Height No. of Lineal ft. Area No. of pane of pane tights of crack sq. ft. Infiltration Glass Btu Coef. Btu Infiltration 7 i � Net exp. wall L L Glass Int. wall Exp. wall �` s Exp. wall', Net exp. wall Floor Net exp. will I L. ( ///,L - Int. wall Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Ceiling Floor Floor ` Total Btu. / Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Windows and Doors—Crackage and Area Width Height No. of Lineal ft. Area No. of pane of %pane lights of crack sq. ft. Y d ``j / Width Height No. oL Lineal ft. Area No. of pane of pane lights of crack eq. ft. Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. Coef. Btu Infiltration Glass Btu Infiltration Exp. wall Infiltration 7 i � Net exp. wall L L i Int. wall Exp. wall �` s Ceiling Net exp. wall Floor Py /7 I L. Total Btu. Net exp. wallLiz y ` Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Int. wall . A -r ,^ jj --- --- o -- --- - Windows and Doors—Crackage and Area Width Height No. oL Lineal ft. Area No. of pane of pane lights of crack eq. ft. Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. Coef. Btu Infiltration B.tu Infiltration 7 i � Glass iz i Exp. wall �` s Net exp. wall Int. wall Net exp. wallLiz Ceiling Int. wall Floor Total Btu.' Required sq. ft. E.D.R. or sq. his. W.A. Leader area /` FI -U -�*' Rnnm I Length 1,Y Width %ti," 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. B.tu Infiltration a,'� 5',;Glass Exp. wall Net exp. wallLiz Int. wall Ceiling Floor ® Az Es+� Total Btu. , ,/ A, Required sq. ft. E.D.R. or sq. ins. W.A. Leader area / A- D -Y6 7 9 HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS MINNEAPOLIS, 'MILAN. Weatherstrips A.S.H.V.E. Construction No. Insulation Guide Windows I Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kind How. Applied, eo es 19— F1.1 X :` —.,,Room I Length ,�— Width II Fl.i Room I Length //'�'. o Width H, Windows and Doors—Crackage and Area B d, Width Height No. of Lineal f . Arear�ll� No. of pane of pane lights of crack sq. ft.61 Width Height No. of Lineal ft. Area No. of pan of pane lights of crack sq. ft. J A Coef Btu Infiltration InfiltrationJ3 Infiltration A Glass�1 Glass,411 Glass J Exp. wall' Exp. wall ' f Exp. wall Net exp. wall Net exp. wall = .- Int, wall Int. wall Ceiling Ceiling Floor _''`sem Ceiling .. a Total Btu. a Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Fl.j� 7/) Room ( Length J-/' Width Height _%' Windows and Doors—Crackage and Area Width Helght No. of Lineal ft. Area No. of Bane of pane lights of crack sq. ft. Btu Infiltration Glass Exp. wall Net exp. wall Int. wall Ceiling Floor' jF j6_:.' Total Btu. C' Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Room I Length s- Width X Height Windows and Doors—Crackage and Area -� o J f Width Height No. of Lineal ft. Area No. of pan of pane lights of crack sq. ft. J A Coef. Btu InfiltrationJ3 Infiltration Glass,411 Glass J Exp. wall ' f Exp. wall rte' .A Net exp. wall = y Net exp. wall Int. wall ' Ceiling Floor Ceiling Total Btu., Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Windows and Doors—Crackage and Area -� o J f Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. J A Coef. '', Btu Infiltration Glass ' f Exp. wall rte' .A = 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 Windows and Doors—Crackage and Area Wldth Height No. of Lineal ft. Area No. of pane of pane lights of crack Q. ft. Infiltration Glass Exp. wall Net exp. wall Int. wall Ceiling Floor Total Btu. Required sq. ft. E.D.R. or sq. his. W.A. Leader area F1.1 Room I Length Width Windows and Doors—Crackage and Area Width Helght No. of Lineal ft. Area No. of pane of pane ltghts of crack eq. ft. 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 CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 572-3604 Effective On January 1, 1991 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR PLUMBING FIXTURE RATES: 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 Water Heater -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 $5.00 Reinspection Fee $30.00 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1 % of Value of Fixture or Appliance _ State Surcharge TOTAL FEE .50 $4- �n JOB ADDRESS l7 Z-4/ LGi I S 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 pp1�224�� PEGIS Cp�E� . rryyry FA n I ELI T, P M +7L Building Used As, H 574-M 18 H Estimated Cost -PERMIT NO. 16 C�&' PLUMBING I SIGNED BY TEL N0. Approved By Rough -In Date Final Date Cil MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 PLUS THE $.50 STATE SURCHARGE 1r:TraY .......:... ...........:::... Wash .. ...........:.:.....:::. or Drain Auto. ............... Washer .... .........Gas R n9 Wtt HeaterFI r "'Urinal .:..>.:..:::::. GasStories jElec Base men:>x> Floor FI 2 Floor '? FI r 00 3 Floo r4 . . PLUMBING FIXTURE RATES: 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 Water Heater -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 $5.00 Reinspection Fee $30.00 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1 % of Value of Fixture or Appliance _ State Surcharge TOTAL FEE .50 $4- �n JOB ADDRESS l7 Z-4/ LGi I S 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 pp1�224�� PEGIS Cp�E� . rryyry FA n I ELI T, P M +7L Building Used As, H 574-M 18 H Estimated Cost -PERMIT NO. 16 C�&' PLUMBING I SIGNED BY TEL N0. Approved By Rough -In Date Final Date Cil MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 PLUS THE $.50 STATE SURCHARGE SUBJECT PE City of Fridley 2964 AT THE TOP OF THE TWINS BUILDING PERMIT i ` O. 416 COMMUNITY DEVELOPMENT DIV. SEC. r PROTECTIVE INSPECTION 1 ; � ( A-0 �,; CITY HALL FRIDLEY 55432 NUMBER REY DATE PAGE OF APPROVED BY L 612-571-3450 910-F15 6/8/99 JOB ADDRESS 1224 Re is Terrace I LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 2 3 iParkviewOaks -First Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Eleanor He da 574-0018 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Sela Roofing & Rem. Inc - 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION X$ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof house and garage (18 Sq) Tear -off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with the State BuildingCode. a 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 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 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 $1573 $.79 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- STRUCTO THE PERF NCE OF CONSTRUCTION 57.05 Fir C 1.57 PLAN CHECK FEE TOT FEE Lic e 5 4.41 SIGNATURE OF CON'RACTORO TMORi2E0 AGENT [DATE, E P B G iNSF' IDA MI� IS Y R IT {//�/ DAtk SIGNATURE OF OWNERJF OWNER SURDERi - [DATES NEW [ ] Effective 1/1/99 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION IR. .ConstructionAddress:�t Legal Description:*- _ - Owner Name & Address: Tel. 1-j l ContractOnL®ROOFING & REMODELING, INC. MN LICENSE # lo60 Address•4100 EXCELSIOR BLVD. ST. r OTAS Rain --MN KK41 Tel. # a ID 11to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. ESCRI> PON QF, IWRQVEMENT - LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Lengt# Width _ Hgt/Ground Sq. Ft. OTHER: - r Construction Type: c -k Estimated Cost: $ (Fee Schedule 'on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: Co APPLICANT Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: Tel. # CITY USE ONLY $ S� Fee Schedule on Reverse Side $ S` ` 7 .001of'Perimut Valuation (1/10th%). $ J $.50/$1,000 Valuation $ $1050 per SAC Unit $ Q a $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 [ ] 1_ 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 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: TOTAL $ ILiTI OWN Effective On January 1, 2002 BUILDING USED AS aAlLbU J-1` ESTIMATED COST 9 Z • 0-0 PERMIT N0. 1536 DESCRIPTION OF FURNACE AND OR BURNER No. of Heatingits—L Circle One (Steam) (Hot Water) rm $ Trade Name Size No. E MTggo %6 BTU jl(), (1 HP EDR $ Fuel_ Total Connected Load Burner Trade Name Size No. $ BTU HP EDR $ The undersigned hereby makes apication for a permit for the work herein specified agreeing to do all work in trict accordance with the City Codes an $ .50 rulings of the Building Division, and hereby declares that all the facts and $3D,0 3D 0 representations stated in this application are true and correct. Center Point Energy MGCO ')ATE l %' b 13562 Central Ave NE . HEATING CO Anoka, MN 55304 Signe �- TEL # FAX Approved By Rough -In Date Final Date THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE APPLICATION WILL BE RETURNED COMMON V NT, VENT CONNECTOR ANn COMPIURTION AIR VIFRIFICATION When re lacing an existingfuranr_e, 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 plastictPVC 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( zn The pYisting rnmhustinn air is sized and installed to meet the current codes and manufacturer's specifications. Yes �A No ( ) When required to install a new rnmhi ,edam airy it will be sized and installed to meet the current codes and manufacturers specifications. Yes No ( ) When installing a new ventina s=tem, 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. Yesj-�No ( ) Appliance Tune and Size/Common V _n and Vent nnnector Information Appliance #1 Type Rth Y10 -U BTU Input Q 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 Le`hgth 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 Center Point Energy MGCO 13562 Central Ave NE HEATING CO: Anoka, MN 55304 Signed By: Date: f� r'Ll 0