PRE 2010 DOCSCity of Fridley, Minn.
BUILDING PERMIT
Date:
r
r' d
Owner:' `f `" Builder
Address _. _ Address
,... PLO , TIO O,F 111LDING
No. -= Street `""_ Part of Lo _
Lot 06, Block _ _ __ _. Addition or Su ivision ... r"
11 46
--
Corner Lot ._�.. Inside Lot _._.._� --Setback _Sid and ._._�.._..... _. .._..._...._._.....
Sewer Elevation _ _ _ — Foundation Elevation
DESCRIPTION OF BUILDING
To Used r
"
{ Front r Depth Height Sq. Ft.Cu. Ft.
Front Depfih Height -�! Sq. Ft. Cu. Ft.
Type -of Construction Est. Cost __ 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 compliance with all provisions of
grdinanoes 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
Pe
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 buildi--
within. e
gwithin.the city limits and this permit may be revoked at any time upon violation of any of the provisions 7sRM
ordinances.
1
Building Inspector
NOTICE:
This permit does not cover the construction, installation for wiring `plumbing, gas heating, sewer or water. Be sure to we
the Building Inspector for separate permits for these Items.
4
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
e
Owners Name ilder
Address
OF BUILDING
No. Street T ° 2, �/ �, Bart of Lot
Lot Y� Block Addition or Sub.Div, AIA 611,41,
Corner LotInside Lot_2=::::�Set Back-��`-,�--- Side -Yard Z_
SEWER ELEVATION FOUNDATION ELEVATION __
Applicant attach to this form Certificate of Survey of.Lot and proposed building
location.
DESCRIPTION OF BUILDING
To be -used as:
Sq. Ft. I I V //5' Cu.
(2A il nvi
Front Deptk Height %CJ,r'
Sq. Ft.�7-__ ::z ..Cu. Ft.__��.,__,
Type of.Construction Estimated Cost_
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 Buildingp, and hereby declares that all the facts and representa-
tions stated in this application are true and correct.
� P
DATE / -C SIGNATURE
(A Schedule of Fee costs can be found on the Reverse Side.)
-- q- . . > Yr
City of Fridley
Application for Plumbing and Gas Fitting PertMt
Dept. of Bldgs. Phone SUII,44
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
qq
47
K
Y
pZ
O�
w
a 3
w
1
Z
•
F
•
N
R.
WATER HTR.
GAS
ELEC.
o0
g�
O
Base
1st
d
2nd
3rd
_
4th
• Future Connection Openings
Connected with
Sewer E]
New Fixture, Old Openings
Cesspool 0
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures ............... x $1.50 $
av
Future Fixture Opening ................ ---:I x 1.20 $ � 6B
New Fixture Old Opening .............. x 1.00 $
Catch Basin ............................ x 3.25 $
Water Heater (Up to 200,000 BTU) ...... x 2.00 $
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 1&L -
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 Building o
Used as
To be completed about
EstiDXe
Cost, $
Old Building Permit
ROUGH (A' > /10/
FINAL
a z 2M 7-59
By�:�
Business
Permit No
0
FINAL
(REMARKS -OVER)
®(
Application for Power Pho is and.. Heating.
Cooling, Ventilation, Reh igration tind
Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE
Dept. ofBldgs. P ae SU. 4-7470
GRAVITY WARM AIR: RATE
TOTAL .
Locaff
Furnace Shell & Duct Work ..........................
8.00
$
City of Fridley:
Replacement of Furnace .............................
5.00
$
The undersigned hereby makes application for a permit for the work herein
Repairs & Alterations—up to $500.00 ..................
5.00
$
specified, agreeing to do all work in strict accordance with the City Ordinances
Repairs &Alterations each add. $50Q.08 ..............
2.50
$
and ruling of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
NECK. WARM AIR
Fridley, Minn 194!_1
Furnace Shell & Duct Work to 120,000 BTU ............
8.00
$�
reach add. 60,000 BTU ...._�..................
2.00.
$ _
Owner %(•�/
r-
Replacement of Furnace .............................
ۤ.00
$
Kind of Building
Repairs & Alterations—up to $500.00 ................
5.00
$_
Used as
Repairs & Alterations each add. $500.00 ...............
2.50
$
STEAM or HOT WATER SYSTEM
-
To be completed about
Furnace Shell & Lines—to 400 sq. ft. EDR Steam ......
8.00
$
Estimated Cost, $
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ...
8.00
$
�!�%��
Old ew. Nuilding 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 WORK
OIL BURNER—to 3 gal. per hour ........................
5.00
$
HEATING or POWER PLANTS—Steam, Hot Water, Warm Air—No
over 3 gal. per hour—See Fee Schedule
"–'^�'^
No
A 'lam- Size "?
GAS BURNER (up to 400,000 BTU)
5.00
$ �i'�
Trade Name ,mac 09
.......................
Capacity Sq. Ft. E.D.R"BTU H.P.
GAS FITTING FEES:NO
!
1st 3 Fixtures x
RATE TOTAL
$1.50 $
Total Connected LoadOa�Sb �fii1 4nd of Fue
,
Additional Fixtures ................. x
.50
$
BURNER — Trade Name „- 1 --=Size No
Gas Range to 200,000 BTU ........... x
2.00
$
Capacity Sq. Ft. EM.R BTU H.P.
AIR CONDITIONING
$
FAN HEATING SYSTEM See Fee Schedule
VENTILATING SYSTEM 5
`
$.
,
Sign 1 v
ALTERATIONS & REPAIRS TOTAL
FFE
$
�
By
ROUGH
42 2M 7-59 Business Phone No
FINAL
(REMARKS -OVER)
Windows an& Doors—Crackage and Area
T
No.
Width Height No., of Lineal ft. Area
of pane of pane fights of crack sq. ft.
HEAT LOSS CALCULATIONS
cpm`
7
BURMAN COMPANY
Weatherstrips
A.S.H.V. :
Guide
Exp. wall
Construction No.
Coef. Btu
Infiltration Z-
Insulation
Windows(
Doors
Reference
't. Wall
Int. Wall Ceiling
Roof Floor
land
How Applied
Yes—No
Yes—No
19_
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
Room i Length Width
Height II
Fl.l . Room I Length
Width Height
Windows an& Doors—Crackage and Area
T
No.
Width Height No., of Lineal ft. Area
of pane of pane fights of crack sq. ft.
Coef.1 Btu
Infiltration
Glass
46
Exp. wall
Coef. Btu
Infiltration Z-
Floor
Glass 1
Ceil.
Exp. waR
Int. wall
Net exp. wall
Int. wall
- (�
Floor
Ceil.
Ceil.
Total Btu.
Required sq. ft. E. .R. or sq. ins. WA. Leader area
F1.1J Room I Length Width Height
Windows and Doors—Crackage and Area
T
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack eq, ft.
Coef.1 Btu
Infiltration
Glass
46
Exp. wall
Net exp. wall
Int. wall
J_b
Floor
Net exp, wall
Ceil.
o
Total Btu. 1�
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area I/'
Fl.LAg--W_ Ft Room I Length Width Height
Windows and Doors—Crackage: and Area
T
Width Helght No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Coef.
Btu
Infiltration
`)
Glass
Exp, wall
J_b
Net exp. wall
Net exp, wall
1
Int. wall
Ceil.
Floor
Ceil.
!v
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
Win ows and Doors—Crackage and Area
T
Width Height . No. of Lineal ft. Area
No. of pane of pane lights of crack ea: ft.
Coe, f. Btu
Infiltration I !r -z-
f ca 4.2-20
Glass
.Exp. wall
Net exp. wall
Int. wall
Floor
Ceil.
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
FI.1 Room I Length Width Height
Windows and Doors—Crackage and Area
Total
T
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. will
Int. will
Floor
Ceil.-
eil.
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-Craekage and Area
Width I - Height No. of Lineal ft. Area .
No. of pane of=. lights of crack sq. ft.
Infiltration
Glass
.Exp. wall
Net exp. wall
Int. wall
Floor
Ceil:
Total Btu.
Required sq. ft. E.D.R., or sq. ins. W.A. Leader area
HEAT LOSS CALCULATIONS 4: � (,r URMAN COMPANY
,tom, a: N
Weatherstrips A.S.II.Y.E: Construction No. ulation
Guide
Windows� Doors Reference ' Out. Wall Int. Wall Ceiling Roof Roar Kind How Applied
Yes—No Yes—No 19—
F1.1 V.,a - Room r Length Width Height II FU,/ _ J Room I Length Width Height
Windows and Doors—Crackage and Area
T
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.
Coef. Btu
Infiltration
401® 0
Glass
Exp. wall
Net exp. wall 12 (V
lid
Int. wall
Glass —12
Flonr
Exp. wall
Ceil.
E4 L�
'Dotal Btu.
Required sq. ft. E.D.R. or sq. ins. WA. Leader area
FUR Room I Length Width Height
Windows and Doors--Crackage and Area
T
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.
Coef. Btu
Coef.1
Btu
Infiltration
Glass
Floor
Ced.
Exp. wall
a a
Glass —12
Net exp. wall
Exp. wall
Int. wall
V
Int. wall
Floor
Floor 1
36 yv
Ceil.
% t�
Total Btu. 16
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
F1.1 ` �. Room I L.enath Width Height
Windows and Doors—Crackage and Area
T
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
of pane of pane lights of crack sq. ft.
Coef. Btu
Infiltration
Glass
Exp. wall
Btu
Net exp. wall
Int. wall
Floor
Ced.
Infiltration
Total Btu.
ft. E.D.R. or sq. ins. W.A. Leader area
Windows and Doors—Crackage and Area
T
No.
Width Height No. of Lineal ft. Area
of pane of pane lights of crack sq. ft.
Coef.
Btu
Infiltration
Coef. Btu
Infiltration
a a
Glass —12
Exp. wall
Exp. wall
Net exp. wall -
V
Int. wall
Int. will
Floor 1
36 yv
Ceil.
Total: Btu I I
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
FI -1 Room I Length . WidthHeight
Windows and Doors--Crackage and Area
T
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 -z-
I to
/3 2,b
Int. will
Floor
% t�
Ceil.
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
F1.1 1p
I Length Width Height
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane ofdmae I lights I of crack an.
ft.
Coef.1 Btu
Infiltration
Glass 6M
Exp. wail
Net exp. wall r
Int. wall
Floor
Ceil:
Total Btu.
Required sq. ft. E.D.R.,or sq. ins. W.A. Leader area
City of Fridley
Application for Plumbing and Gas Fitting Permit
Dept. of Bldgs. Phone SII 4-1
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures Location -
Number,
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO.
RATE
TOTAL
Number Fixtures ...................
Future Fixture Opening ................
x $1.50
x 1.20
$
�8Z
o�
�U'
0
�U'
0
z
�U'
•
F
•
N
WATER HTR.
GAS
EIEC.
x
2.00
$
New Ground Run Old Bldg. ............
x
3.25
$
u.0
az
U
<
NO.
ga
O
1st 3 Fixtures ..........................
x
$1.50
$
Additional Fixtures ....................
x
.50
$
Gas Range to 200,000 BTU ..............
x
2.00
$
Base
1st
2nd
_
3rd
_
4th
° Future Connection Openings
Connected with
Sewer El
New Fixture, -Old Openings
Cesspool
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO.
RATE
TOTAL
Number Fixtures ...................
Future Fixture Opening ................
x $1.50
x 1.20
$
New Fixture Old Opening ..............
x
1.00
$
Catch Basin ............................
x
3.25
$
Water Heater (Up to 200,000 BTU) ......
x
2.00
$
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 $ L
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 as
To be completed about —
Estimated Cost, $
*do New. Building Permit
BY -10442
Business Phone
ROUGH
FINAL
Permit
SUBJECT
MIT NO.
City of Fridley
8135
AT TH = s
BUILDING
PERMIT
� •
NO.
• COMMUNITY DEVELOPMENT DIV. .
V ve---e
INSPECTION SEC.
r ; PROTECTIVE
�
1 . ,
NUMBER
REV
DATE
PAGE OF
APPROVED BY
� CITY HALL FRIDLEY 55432
L J` 612-571-3450
910-Fll
JOB ADDRESS
35 Rice Creek Wa
1 LEGAL
LOT NO.BLOCK
I
TRACTOR ADDITION
SEE ATTACHED
DESCR.
6A, 6B
1
Edgewater Gardens
SHEET
2 PROPERTY OWNER MAIL ADDRESS
zip PHONE
Phyllis Heutmaker
574-7444
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Milton Johnson Co. 525 Lowry Ave NE Xpls HN 55418-2868-
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
O NEW O ADDITION O ALTERATION jk REPAIR O MOVE O REMOVE
8 DESCRIBE WORK
Reroof house (42 S Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
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
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 4E COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$1.80
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
L F E '
TOTA-------
*121' V;
QQ/
9
SIGNATURE OF CON'RACTO OR AUT.ORIZED AGENT IDATEI
N RO E LIDATE IS IS YOUR PERMIT /VJ
S,GNATURE OF OWNER SIF OWNER BUILDERI (DATE,
BL -NSP
�1ATE
NEW - 1X1 Effective 1/1/97
ADDN [ ) 'CITY OF FRIDLEY
ALTER ) ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILD[N�Q PERMIT APPLICATION
ConstructionAddress: 35 Rice Creek Way a 1p�
Legal Description:
Owner Name & Address: Phyllis Heutmaker (same) Tel. # 574-7444
Contractor: Milton Johnson Co. MN LICENSE # 2 0 8 3
Address: 525 Lowry Ave. N.E., Mpls. 55418
Tel. # 781-9548
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTHER:
DESCRIPTION OF IMPROVEMENT
Length Width Height Sq. Ft.
Length Width Height Sq. Ft.
Length Width Hgt/Ground Sq. Ft.
Construction Type: Tear off and re -roof houseEstimitedCost: $ -3,-)99
(Fee Schedule on Back)
Driveway Curb Cut .Width Needed: Ft. + 6 Ft = Ft x $
DATE: APPLICANT:
el. # 781-9548'
Permit Fee
7 -ire Surcharge
State Surcharge
SAC Charge
License Surcharge'
3riveway Escrow
rosion Control
F
'ark Fee $
ewer Main Charge $
TOTAL
"CIPULATIONS:
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.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 [ J Not Necessary [ ]
CITY OF FRIDLEY INSPECT iON DIV.
6431 University Ave NE
Fridley, MN 55432
763-572-3604
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
UADV w uuCMD na =1YT110 =c Tn RP wgTAI 1 Fn ON FACH FLOOR
Effective On Jan 1, 2001
>:<<�
$ 7.00
::«+:•
Old Opening, New Fixture
•r .: �v
....
Wash
�'.Floor
»Auto.
�a!`�>>�>.:
:.-. ,..
Gas<:?.::::. Gas
"sem;::::::::. :Water
Heater
;i{:vs::.}:.v.
. ::..
Stones : If
Urinal
.: }..e•.:gt;:�+t;r
?r
Shower
i 1,'.,r>',OzG•=:5
: ;::
Tra
' ,..ix}:.
<
it€`:>?<.
•.•`':•7p}•i:`:;:i:t:
Drain 1B1'=:::::: Washer
>: ?N:
`:;?}}`}:'-.: yx.. Ran a
' :5:: •}xa}••:•
:{:<.
Gas El
$10.00
Owner Pt* !�e ry-) g €�
------------
$ 7.00
i
?.}:
Water Heater- Gas'” _�
$10.00
Building Used
Gas Range"
$10.00
_ VIy
Estimated Cost a ®• PERMIT NO.
r�
$10.00
•:}A:i:: Y/::
r: •}.tr
Back Flow Preventer Required ( )Yes () No
Yi:11: r.•.N.1:<:
}!:
�/� -.1 S� 'O
� A. )4 r4 s,+
•: :xr}:ii}iii::}:
}::
vvi:'i:,':•:•::j:::::: �i:•
':.
Vii•::>:•}:•::??:}:
{
Y::::::::::
Basement ... R W:•..rr.:�,
Reinspection Fee $47.00/Hr
.v:.v.. v
SIGNED Ba TEL N0. A 63- S.1 3
r•:.{:.:
�+:..•.:+.•::i r .:.::::::::::
:::.•:
..:..........::.:.
:>....:.:::::.::,.
I 1
Floor
State Surcharge
::1•.
1 -
I r2
F o0
.ti{i4
:...
''„?':: n.: Y.:::v
? •:.:tii:i::}::::::ii
Floor 3
Floor 4
PLUMBING FIXTURE RATES: NO. RATE TOTAL JOB
;' ?e—c, V_
New Fixtures
$ 7.00
The undersigned hereby makes application for a permit for the work herein
Old Opening, New Fixture
$ 4.00
specified agreeing to do all work in strict accordance with the city codes
Beer Dispenser
$ 5.00
and rulings of the Building Division, and hereby declares that all the facts
Blow Off Basin
$ 7.00
and representations stated in this application are true and correct.
Catch Basin
$ 7.00
Rain Water Leader
$ 7.00
��- / . 20® z-
Sump/Receiving Tank
$ 7.00
Water Treating Appliance
$10.00
Owner Pt* !�e ry-) g €�
Water Heater -Electric
$ 7.00
i
_
Ash
Water Heater- Gas'” _�
$10.00
Building Used
Gas Range"
$10.00
_ VIy
Estimated Cost a ®• PERMIT NO.
Gas Dryer"
$10.00
Back Flow Preventer Required ( )Yes () No
�/� -.1 S� 'O
� A. )4 r4 s,+
Type
$15.00
PLUMBING COMP NY . /J
'7 (� 3
Reinspection Fee $47.00/Hr
SIGNED Ba TEL N0. A 63- S.1 3
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture or Appliance
Approved By Rough -In Date Final Date
State Surcharge
S •50
1 -
TOTAL FEE $ ,�L®.5d PLUS THE S.50 STATE SURCHARGE
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE
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 manufacturers 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 manufacturers 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 :