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PRE 2010 DOCS'W5,"6 Y� City ®f Fridley, Mmm N° 8 619 BURDING PERMIT Date: NOVEMBER 30, 1965 Owner: _ Builder CHARLES E. JOHANSON Address Address 160 Hartman Cirole N. E. Fridley, Minnesota 55432 LOCATION OF BUILDING No. 560 Street RICE CREEK BOULEVARD Part of Lot Lot _ _. _A __ Block Addition or Sub -Division N v Tjj.17 d Corner Lot Inside Lot --- Setback _ _ Sideyard Sewer Elevation 7, 4 5- — g tion 4C' 4 � To ? �'�L-� �G n U r` d" DESCRIPTION OF BUILDING To be Used as: DWELLIN G Front 48 Depth 28 Height 20 Sq. FL 1344 CtL Ft, 26,880 ATTACHED GARAGE Front 20 Depth 22 Height 10 Sq. Ft. 440 Cu. Ft. 4...a400 Type of Construction Frame Est. Cost r 202 000___ To be Completed In consideration of the issuance to me of a permit to construct O/ �uD above I agree to do the proposed work in accordance with the description above set in pan with ail provisions of ordinances of the city of Fridley. 7 In consideration of the payment of a fee of $ 31.00 , permit is her granted to CHARLES E. JOHANSON to construct the building or addition as described above. This permit is granted Zka 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 reg location, construction, alteration, maintenance, repair and moving of buildings within the city limits andel this permit may be revoked at any time upon violation of any of the provisions of said ordinances. ALLEN G. JENSEN Building Inspector NOTICE 1Ms pormh don not Cover the Construction, huhlis ion for whhm plumbing, gn heaNae, ewer or water. Be Cure to as the Bulhliog Inspecror for aparate ponnib for Nun Berra. APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA mak- ,� OWNER'S HAMS � � _ �'�s i .� BUILDER tea' ADDRESSe,�� - DRESS LOCATION OF BUILDING Mn-,___ Street JA CV Part of Lot LOT 41 aI.00K ADDITION OR SUBDIVISION Corner Lot -inside LOTSetback Side -Yard SEWER ELEVATION 11 FOUNDATION_ ELEVATION. 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 Depth,_ ol-Height Sq. Ft..,i b`L �. Cu. Ft. =�J�top Front® Depth Height Sq. Ft.__�/ �/ o Cu. Ft. � Type of Construction, Estimated Cost /'s Co 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 " el -f6 �;--- Z I (Schedule of Fee Costs can be found on the Reverse Side).1 Psl� -'W" - � &� I � . 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 $ 1C, 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—ta 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$ 200 $ ® f 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 $ TOTAL FEE Dept. of Bldgs. Phone 560-3480 0 �! 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 1 q � � 19 �I Owner Kind of Building J -�/� �^�^e-� Used as-�.�.�1 To be completed about _'e ® o Estimated Cost, $ _ ✓ o Gkl--New. Building Permit No. PermitNo. DESCRIPTION OF WORK HEATING or POWER PLANTS -steam, Hot Water, Warm Air—No Trade Name 0 Size1-11 No��✓� ` /� Capacity Sq. Ft. E.D.R BTU H.P. Total Connected Loader Lf) ® Find of Fuel�� BURNER — Trade Name^��® Size No .0, ®� Capacity Sq. Ft. E.D.R BTU H.P. (REMARKS -OVER) Signed By « Business Phone No— rAW GNOF FRIDLEY FRIDLEY MUNICIPAL CENTER - 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 - (612) 571-3450 - FAX (612) 571-1287 LICENSE AGREEMENT The undersigned John Vye and Gloria Vye , being the fee owners of certain property located in Fridley, Minnesota, at 560 Rice Creek Boulevard , and legally described as: 14-30-24-21-0004 hereby grant to the City of Fridley, Minnesota, and that the City's employees, a license for the purpose of gaining access across the above-described property to a retaining wall and other structures adjacent to Rice Creek. This license is only for the purpose of allowing the aforementioned persons access for maintenance purposes. This license is intended to last ten (10) years from the date of its execution, and is not transferable or useable by any persons other than those designated herein. By accepting and using this license, licensee hereby agrees to repair any and all damage caused by the City or its employees while using this license on the above-described parcel. Subscribed and sworn to before me this 3 0 day of C4 , 1998. o ary Public - �LLYJO SVYBVDSE�1 .:• epT�lr>n�lraaNr�sou ANNAMW Vyy Commission Expires Jan. 31.2000 City of Fridley SUBJECT =2-50 3 AT THE TOP OF THE TWINS BUILDING PERMIT f RECEIPT NO. � _ r COMMUNITY DEVELOPMENT DIV. 1 � PROTECTIVE INSPECTION SEC, 19 3o -"S CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BV 1.j 612-571-3450 910-F15 4/28/97 JOB ADDRESS 560 Rice Creek Blvd NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 4 1 Holiday Hills SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Jack Vye 560 Rice Creek Blvd NE 784-4830 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Dahl Builders & Remodelers 451 Maple Street NE 784-4830 20050777 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 0 ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Construct an 18' x 12' Three Season Porch Addition 9 CHANGE OF USE FROM TO STIPULATIONS See notations on plan. Before digging 011 'or all utility locations SEPARATE PERMITS REQUIRED FOR 454-0002 BY LAIN WIRING, I-i(:.ATING, PLUMBING AND SIGNS. REQUIRBJ) 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 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 $5,578 $2.79 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- $112.25 Fire SC $5.58 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. / PLAN CHECK FEE JOTAL FEE Licens -SC $ .00 $125.62 SIGNATURE OFC NTRACTOR OR AUTHORIZED AGENT IOATEI P LY VALI ATED THIS IS Y�O`U PERMIT A.G- GATE + SIGNATURE OF OWNER of OWNER BUILDERI IDATEI ►�' NEW [ ] ADDN ALTER [ ] ConstructionAddre; Legal Description: .Owner Name & Address: 1-7711�'le s>" �/.,C Tel. # IRK- Contractor dw- gall. .:5��%�� /''�� MN LICENSE # �-7 Address: !f r / `��1e--�- A/ Tel. # Effective 1/1/97 CITY OF FRIDLEY SINGLE FAMILY AND DUPLEXES II -1 AND R-2 ` BUILDING PERMIT APPLICATION LIVING AREA: GARAGE AREA: DECK AREA: OTHER: Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF DWROVEMENT Length j Width AI Length Width Length Width Height Sq. Ft. Height Sq. Ft. Hgt/Ground Sq. Ft. Nie 1 a >e fA Construction Type:rrid2�� �2 Estimated Cost: $ (Fee Schedule on Back) Driveway Curb Cut Width Needed: .Ft. + 6 Ft Ft x $ = $ DATE: W'17-.4' APPLICANT: Tel. # Permit Fee Fire Surcharge State Surcharge SAC Charge License- Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: $ Ze •-9.5- $ 5:.5? $ .7.7 '? $ ,L-5: (; CITY USE ONLY Fee Schedule on Reverse Side .001 of Permit Valuation (1110th%) $.50/$1,000 Valuation $950 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 [ ] 0 SUBJECT MIT NO. , City of Fridley 28528 AT THE TOP OF THE TWINS BUILDING P E R SII I � x• M 572®360 LAITY DEVELOPMENT DIV. RECEIPT NO. PROTECTIVE INSPECTION SEC. �� q r I 1 NUMBER REV DATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 612-571-3450 910-F15 11/5/98 JOB ADDRESS 560 Rice Creek Blvd 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 4 1 Holida Hills SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE John Vye 574-9564 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Dahl Builders & Remodelers 451 Maple St NE Spring Lk Pk 55432 784-4930 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO B USE OF BUILDING Residential 7 CLASS OF WORK O NEW O ADDITION O ALTERATION Rx REPAIR ❑ MOVE O REMOVE 8 DESCRIBE WORK Reroof house and garage (29 Sq) Tear -off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with the State Building Code. SEPARATE PERMITS ARE REQUIRED 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 SQ. 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 r WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $2485 $1.24 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIO OF ANY OTHER STATE OR LOCAL LAW REGULATING CON. STRUCTI R THE PE ORMANCE OF CONSTRUCTION $74.75 Fir SC $2.48 Jp�jVy/ hIL'(�yl�Y PLAN CHECK FEE TO L FEE /'' —T Licen S 5.0/1 3.47 SIG RE OF CONTRACTOR OR AUTHORIZED AGENf)AU IDATEI EN R P L A I THIS IS Y-OLPR PER MI S-GNATURE OF OWNEROF OWNER BUILDER, ,DATE, - - BlD ,NSP NEVA R [ ] Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION �7 rJ ConstructionAddress: l� �',('� C Z t 4 91Uot Legal Description: Owner Name & Address: 1 Jam Ua Tel. # Contractor: L ��f dept 5 MN LICENSE # )0550-777 Address: L/J Dk 5 `- Tel. Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. LIVING AREA: Length GARAGE AREA: Length DECK AREA: Length OTHER: DESCRIPTION OF IMPROVEMENT Width Height Sq. Ft. Width Height Sq. Ft. Width - Hgt/Ground Sq. Ft. q�4 Y Construction Type: Ac Estimated Cost: $� (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + b Ft = Ft x $ = $ DATE: //s V-1 APPLICANT: /dyes Tel. # 79A0>C-) TOTAL STIPULATIONS: CITY USE ONLY Permit Fee $ Fee Schedule on Reverse Side Fire Surcharge $ S .001 of Permit Valuation (1/10th%) State Surcharge $ f , $.50/$1,000 Valuation SAC Charge $ $1000 per SAC Unit License Surcharge $ S r 4 D $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 [ J TOTAL STIPULATIONS: 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 - Aiso 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 -;?5%Q of Value of Appliance or Work Effective On May 10, 1999 JOB ADDRESSr-J�on_R� OWNER 1b)r k u Rate TOTAL $ 30.00 $ 10.00 $ 10.00 $ 10.00 $ 25.00 State Surcharge TOTAL FEE MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATI9N REFRIGERATION/AIR CONDITIONING2ERMI1-IS $25.00 PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $47.00/Hr L'Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. BUILDING USED AS $ ESTIMATED COST PERMIT N0. 1 16$6 DESCRIPTION OF FURNACE AND OR BURNER $ No. of Heating Units 1 Circle One (Steam) (Hot Water) diariiD $ Trade Name 'Aly c Size No. BTU aL-) t! 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 hereii specified agreeing to do all work in strict accordance with the City Codes .50 rulings of the Building Division, and hereby declares that all the facts and representations stated in this application are•true and correct. $ Signeq���- DATE \1\1-100 A+ Approved t'• �, D Remarks: List ALTERATIONS~Bei pig 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 (/f No { ) 2. Is free from rust or deterioration Yes No ( ) 3. Has no foreign objects lodged within Yes No ( ) 4. Is securely supported Yes (✓f No ( ) 5. Meets all current Code. requirements for size and total BTU's connected Yes (.^' No ( ) b 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~Bei pig Done: HEATING CO: Signed By: Date: CIIYOF FRIDLEY FRIDLEY MUNICIPAL CENTER - 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 - (612) 571-3450 - FAX (612) 571-1287 August 9, 2000 Gloria Vye 560 Rice Creek Blvd NE Fridley, MN 55432 Re: Final Inspection at 560 Rice Creek Blvd. NE Contractor: on Appliance Heating and Air Inc. Dear Ms. Vye: A mechanical permit was issued on May 4, 2000 for the property located at 560 Rice Creek Blvd. NE for a furnace and an air conditioning unit. According to Section 305(a) of the 1991 Uniform Mechanical Code a final inspection shall be performed on the mechanical system. As of this date no inspection has been called for. You will be given thirty (30) days from receipt of this notice to respond. If we do not hear from you, we will expire the permit and any inspections on this installation will require a new permit. Any questions can be addressed to myself at (763) 572-3603. Sincerely, tlby,/41. •- • CITY OF FRIDLEY INSPECTION 6431 University Ave NE Fridley, MN 55432 " (763) 572.3604 RATE SCHEDULE DIViSION APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, . REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES Residential Furnace Shell and Duct Work, Burner - Also Replacement Furnace 5 (Side Vent - Fill Out Back) Gas Piping (Needed with new furnace, but not replacement) Gas Range Gas Dryer 6� ei<4-- *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 Effective On January 1, 2002 JOB ADDRESS -5—� OWNER C� `�'��✓� Rate TOTAL BUILDING USED AS�°�.` $ 30.00 $ � ESTIMATED COST �'• PERMIT NO.� $ 10.00 $ , DESCRIPTION OF FURNACE AND OR BURNER $ 10.00 $ No. of Heating Units Circle One (Steam) (Hot Water) (Warm Air) $ 10.00 $ Trade Name Size No. BTU 3:z HP EDR $ 25.00 $ Fuel N1`ld'_ Total Connected Load Burner Trade Name Size No. $ BTU HP EDR 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 $ .50 *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. ® r 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 HEATING CO Signed 7 TEL # FAX # Approved By Rough -In Date Final Date ` D_� 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 Effective On January 1, 2002 JOB ADDRESS 5(0-0 (Zl� m OWNER Rate TOTAL d !ry BUILDING USED AS $ 30.00 $ ESTIMATED COST WI ���" PERMIT N0. $ 10.00 $ DESCRIPTION OF FURNACE AND OR BURNER $ 10.00 $ '.11I- No. 11 " No. of Heatin nits Circle One (Steam) (Hot Water Warm Air $ 10.00 $ Trade Name Size No.3o)Dd0V0 BTU_i G 16 J HP EDR $ 25.00 $ Fuel N%J-M- Total Connected Load Burner Trade Name Size No. $ BTU HP EDR 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. $ 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 S� representations stated in this application are true and correct. DATE ) /` � �. HEATING CO HEATING & CWUNG T1111® INC 18550 County Rd. C1 Signed Maple Grave, MN 55 -PEP -#Z31 FAX #7 ) 428-3677 Approved By Rough -In Date Final Date o'- iO o FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE APPLICATION WILL BE RETURNED COMMON VENT, VENT C'ONNFCTOR ANn C-OMRIISTION AIR VFRIFI ATION When rela .ing an axisting 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 (4 No ( ) The axicting cnmb cation air is sized and installed to meet the current codes and manufacturers specifications. Yesj. No ( ) When required to install a new r-nmhi istinn air�it will be sized and installed to meet the current codes and manufacturers specifications. Yes W No( ) When installing a new venting, the undersigned hereby verges that it 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. Yeses 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 f,�No ( ) Appliance Type and Size/Common Vent and Vent .nnn _ctnr Informa ion Appliance #1 Type BTU Input *7-bk, or Nat Appliance #2 TypeBTU Input t� o Lan &ed or Nat Appliance #3 Type BTU Input anor Nat Total Appliances Total Btu Input — Common Vent Type Vent Hei ht / 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 HEATING CO: Signed By: Date: