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PRE 2010 DOCSCity, of Fridley, Minn. 12031 6431 University Ave. NE., Minneapolis, Minn. 55432 BU"MG PERMT Owner: ..Dennis P i kapen Builder Leif f H nr i s -n Address Address 495. Mississippi S rPet• N E No. _643q__ StreetRiverview Terrace N.E. pare of Lot Lot 4___ Block — l Addition or Sub -Division — V e i t s Addition .Corner. Lot *9v)vq' Sewer W Inside Lot Elevation Setback Sideyard TOP of Footing To be Used as: Dwelling _vY Front 36Depth 32' Height 20' Sq. FL _1152' Cu. Ft.2 040 Garage _ Front 24' Depth 22' Height, 10' Sq. Ft. 28' Cu. Ft. 5.28Q Type of Construction Wood Frame Est, Cost $33.313 To be CompletedJune. 1973 - Stipulations: Provide a hard surface driveway. Provide a verifying survey before rough -in inspection. $275.00 due for Sewer Availability Charge. In consideration of the issuance to me of a permit to construct. Vib buil ' g c%sc d abov agree tp do the proposed work in accordance with the description above set forth ante 'wi provisions of ordinances of the city of Fridley. -5-1 14)-P5 In consideration of the payment of a fee of *_Q. 00 , permit is hereby granted to Leif Henriksen 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 ordinamees of Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings within the city limits and this permit may be revoked a t any time upon violation of any of the provisions of saiti ordinances. r Building Inspector CLARENCE BELISLE NOTICE: This permit does not cover the construction, installation for wiring, plumbing, Bas heating, sewer or water. Be sure to aso the Building Inspector for separate permits for these hems. y APPLICATION FOR RESIDENTIAL, ALTERATION, OR ADDITION BUILDING PERMIT OWMIS N L. lr�iL BUIL t ADDRESS: ADM=3: r XO;. , 011 LT; —z ION 3 C.Qjm LOT: IMUE LOT; SNTBACICf SIDEYARD: AM jL4ant attach V* OU f+io Certificates of 3uxveX of Leat and proposed b"JAUS location d (m terse Certificates, VESURIETION OF BUILDING Be U04 Ats L L atl 3 NW . iBht square rest; //.5-.2--- cuffs% yeet-; .2.3, U Alo Front: Depth; '10 z Sei.- .,,,. e Square Feet; Cubic Feet: Tyfa of Coa:structiom �0�, rn Estimated Cost: $ "toted; N 19 � The %Md rsigned hereby sakes applicaaim for. a permit for the work herein #p jf#.ed„ Wee-JuS to do all Work in stt;tct accordance with the Qity of l 116Y 01 rd : 4U4 ;�f Oe Deftazt ment (?f Buildings, apd bereby a ref mat all the facts a representations stated la this app catia Me tme correct, rAT94 /lam SIONAA : (040 a de For Additional Inforwtti J 72 iC/% 4 City ®f Fridley 4T THE TOP OF TME TWINS i L-------- CONIrUNiTY DEVELOPIWENT CIV, ° 1 PR0TECT11/q t1lI�CTpp WT, CITY HALL FINOL4Y 111102 (Job Address - r�y30 -R� Contractor of Building di � J W i 3 0 �oOva I I_ I_ 'lddvl I I to PLUMBING PERMIT APPLICATION 1 one �— Plumbing Fixture Rates: NO. RATE TOTAL 60 INumber Fixtures_ x $2.00 �o Ij Future Fixtures x $1.50 I' New Fixture -Old Open. x $1.50 I Catch Bastn x $3.25 f ' Water Heater -99,000 BTU _� x $3.00 I Ground Run Old Bldg. x $3.25 1 Elec. Water Heater x $2.00 Gas Fitting Fees: I 1st 3 Fixtures �� x $2.00 d' 0 Additional Fixtures x $ .75 I Gas Range -199,000 BTU x $5.00 Repairs & Alterations See Description: Code State Surcharge .50 TOTAL FEE $ The undersigned hereby y snakes application for a permit for the work herein specified, agreeing to do all work . in strict accordance with the City Ordinances and rulin of the Department of Buildings, and hereby declare that all'the facts and representations stated in this application are true and correct. Signature Date , P 3 •xld I i '� i '7sIW •saa-II •�nNtva I I I I a. SNISVBI I I O iM H71V71 I!I II I ! 0 W loo sNWao I I � i� c aoo�dl •� O, I� U I Sa3M0H$I I I q '1Nnod PG NNING A V� SAvalH m— H A 891NISI I� I I >iN19vYl _­_1� I I j mvNlan� I I I ttaa M81v f* ol 31"al c6 PLUMBING PERMIT APPLICATION 1 one �— Plumbing Fixture Rates: NO. RATE TOTAL 60 INumber Fixtures_ x $2.00 �o Ij Future Fixtures x $1.50 I' New Fixture -Old Open. x $1.50 I Catch Bastn x $3.25 f ' Water Heater -99,000 BTU _� x $3.00 I Ground Run Old Bldg. x $3.25 1 Elec. Water Heater x $2.00 Gas Fitting Fees: I 1st 3 Fixtures �� x $2.00 d' 0 Additional Fixtures x $ .75 I Gas Range -199,000 BTU x $5.00 Repairs & Alterations See Description: Code State Surcharge .50 TOTAL FEE $ The undersigned hereby y snakes application for a permit for the work herein specified, agreeing to do all work . in strict accordance with the City Ordinances and rulin of the Department of Buildings, and hereby declare that all'the facts and representations stated in this application are true and correct. Signature Date , P 3 P7 arwql "co—ft C@AMS" MY, 37vava ag MATM WAR= MR: M -4§1"N 7MMM Shen a Dud 410.60 RvIaeement of -Ynmee . . .... 6.00 Repairs & Alterations—up to �SMXO 6.00 ROL-CMITO & Alt eraUens c—.ch a Turnace Shell & Lines—to 400 sq. ft EDR Steam $10.00 F�ffn&ce Sheb & Line—to 640 sq. ft. EDR Hot Water 10.00 Each add. NO aq. ft. MDR Steam &00 Math aM. 320 sq. ft. ZDR itot Water 3.00 J�A W v MA'O i (I 4,11NO (41 _T: ROMIM— FMAL 9-I- 7 41 — Llee scm&b ® $-- TOT" Me. .5,1) -7)L MY of Fdalar: The undersig-Aed hereby makes appHeaftn ft,2, El pm7nit fw �� woa-h hereb, specified, agreeing to do all work in stricta 'lame w .pDord e with Me aty CF@jkaMW-- amd ruling of the Department ®E Buildings, ahereby deck thn f2d �ze5 t zn tEje and representations stated in this application are tom,. rm aud cayg-act. le . Owner Kind of Buildtpfi— Used as - - Qeo-y'4407- Tobe completed about Pormit SUBURPA # L !"D' r"T"r3IT1101�ING f:Q MINNF,gppLIS, r- Badma Pb� HEAV TOSS CALCULATIONS DEPARTMENT OF BUILDINGS Weatherstrips A.S.H.V.E. Construction No. Insulation Guide Windows Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kind I How Applied Yes—No I Yes—No 19_ I Fl.l 1- D Room Length a9 /_/ Width , / Height II i Fl.l f > Ae ,,- Room I Length i-_-n_Width % / Height Windows and Doors—Crackage and Area i i Width Height No. of Lineal f . Area No. of pane of pane lights of crack sq. ft. Width Height No. of Lineal ft. Area No. of Dane of pane lights of crack sq. ft. a Coef. Btu Infiltration Glass _ e) Exp. wall Infiltration Net exp. wall 4 A Int. wall Glass Ceiling Floor Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area I F1.I r, __- , Room I Length - / Width J LA Height Wihdows and rs—Crackage and Area i i 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 Dane of pane lights of crack sq. ft. a Coef. Btu Infiltration Coef. Btu Infiltration , % 4 A Net exp. wall Glass r °� Ceiling 9 Exp. wall Net exp. wall Int. wall Floor Ceiling Floor Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area I a F1.1 I , V Room I Length --I / Width /,/.,-/Height if I Windows and Doors—Crackage and Area i i Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. a r Coef. Btu Infiltration �ra ;�'� Glass , Exp. wall Net exp. wall Int. wall _ Ceiling 9 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. fit.. G✓ Coef. Btu Infiltration �ra ;�'� Glass Exp. wan Net exp. wall Int. wall Ceiling Z Floor Total Btu. 6,6 Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Fl_I aaRonm I Lenlzth —1A Width 'moi, Height Windows and rs—Crackage and Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack I sq. ft. Coef. Btu Infiltration Glass / Exp. wall 17,74, Net exp. wall Int. wall Ceiling Floor Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area I F1.I Room I Length Width Height Windows and Doors—Crackage and Area Width Height No. of I -Lineal ft. Area No. of pane of pane lights of crack sq. ft. Coef. Btu Infiltration Glass Exp. wall Net exp. wall Int. wall Ceiling Floor Btu. Required sq. t. E.D.R. or sq. ins. W.A. Leader area BROOKLYN PRINTING & ADV. CO. , HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS Weatherstrips A.S.H.V. . Construction No. Insulation Guide Windows I Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kind How Applied Yes—No Yes—No I9— Y. Fl.lo_ Room'I Length 9.1 Width ',,Height II_%/Rnom I Lenath '5" Width /GA Height Windows and D rs—Crackage and Area Doors—Crackage ana Area Width Height No. of Lineal f . Area No. of pane of pane lights of crack sq, ft. v v WldtHeight No. of Lineal ft. Area No. of pane of pane lights ofeq• ft. perack ICoef.1 Btu ' Infiltration / Glass Btu Exp. wall JAL Net exp. wall , Int. wall Ceiling G Floor Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area ,_ �' I. d r,_ A Room I Length "a Width / 14 Heiaht Windows and Doors—Crackage and Area Doors—Crackage ana Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. rte!✓ o J WldtHeight No. of Lineal ft. Area No. of pane of pane lights ofeq• ft. perack Coef.1 Btu Infiltration Glass / Exp. wall Btu Net exp. wall 12all JAL Int. wall Ceiling Floor G Total Btu. IQ Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Fl.l Room I Length Width Height Windows and Doors—Crackage and Area Doors—Crackage ana Area Width Height No. of Lineal ft. Area Noe of pane of pane lights of crack sq. ft. WldtHeight No. of Lineal ft. Area No. of pane of pane lights ofeq• ft. perack Coef.1 Btu Infiltration / Glass Btu Exp. wall Net exp. wall Int. wall Ceiling G Floor Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Windows and Doors---Crackage and Area Doors—Crackage ana Area Width Height No. of Lineal ft. Area No. of pane of,ppans lights of crack sq. ft. WldtHeight No. of Lineal ft. Area No. of pane of pane lights ofeq• ft. perack Coef. Btu Infiltration V, / Glass Btu Exp. wall Net exp. wall Int. wall Ceiling Floor G Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Fl.l Room I Lenath IAI Width Height Windows a Doors—Crackage ana Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. WldtHeight No. of Lineal ft. Area No. of pane of pane lights ofeq• ft. perack Coef. Btu Infiltration Coef. Btu Infiltration ®` Glass Exp. wall Ceiling Net exp. wall Int. wall Ceiling Floor Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area FI -1 Ranm I Lrnath Width 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. Btu Infiltration Glass Exp. wall Net exp. wall ° Int. wall Ceiling Floor Total. Mu. Required sq. ft. E.D.R. or sq. ins. WA. Leader area BROOKLYN PRINTING & ADV. CO. BURNER - Trade Name _ Size No. Capacity Sq. Ft. EDR BTU HP MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00 j�Company PLUS $.50 STATE SURCHARGE X13 ►` s Signed BY odd-` 0 Tel. No. 1 *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. Fill out back side for stack verification on replacement furnaces CITY OF FRIDLEY Effective Date May :, 19aa APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES . RATE SCHEDULE RESIDENTIAL RATE TOTAL t° Job Address t2 T 3 Q V e V- `J G P -W Furnace Shell and Duct Work, Burner (Also replacement furnace) $ 20.00 $ Department of Buildings, 6431 University Ave. N.E., Fridley, MH 55432 City of Fridley Gas Piping $ 10.00 $ Tel. #571-3450 (piping needed with new furnace) Gas Range $ 10.00 $ The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the City Codea Gas Dryer $ 10.00 $ and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. 9� • Air Conditioning (all sizes) $ 10.00 S d 1�`�,�� Fr/i�dhey, Minn. . 19 All Others/Repairs and Alterations OWNER Q1 6 and _ �' �'d&a Ie4 It of Value of Appliance or Work $ ao� KIND OF BUILDING - rei m e COMMERCIAL/INDUSTRIAL USED AS It of Value of Appliance or Work $ TO BE COMPLETED ABOUT ESTIMATED COST / U� State Surcharge $ .50 TOTAL !EE $ iss OLD - NEW BUILDING PERMIT NO. PERMIT NO. Reinspection Fee ($15.00) $ DESCRIPTION OF FURNACE/BURNER Rough Insp. HEATING or POWER PLANTS, Steam, Hot hater, harm Air- No. Q Date a Trade Name Size No. , Final Insp. �/ < Date Capacity Sq. Ft. EDR BTU HP Approval for PermitTotal Connected toad Kind of Fuel BURNER - Trade Name _ Size No. Capacity Sq. Ft. EDR BTU HP MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00 j�Company PLUS $.50 STATE SURCHARGE X13 ►` s Signed BY odd-` 0 Tel. No. 1 *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. Fill out back side for stack verification on replacement furnaces CITY OF FRIDLEY INSPECTION DIV. Effective On January 1, 1993 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, 572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES liuxovlt Residential Furnace Shell and Duct Work, Burner — Also Replacement Furnace Gas Piping (Needed with new furnace) Gas Range Gas Dryer *Air Conditioning — Ali Sizes All Others/Repairs & Alterations (LIST ON BACK) 1% of Value of Appliance or Work Commercial/industrial 1 % of Value of Appliance or Work JOB ADDRESS b l"3 ® � h) e4-0 %W The undersigned hereby makes application for a permit for the work herein Rate TOTAL 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 $ 20.00 $ representations stated in this application are true and correct. ,1993 $10.00 $ OWNER I l $ 10.00 $ i BUILDING USED AS $ $ 10.00 $ Q ESTIMATED COST ISO PERMIT NO. Z $ 10.00 $ DESCRIPTION OF FURNACE -AND OR BURNER $ No, of Heating Units Circle One (Steam) (Hot Water) (Warm Air) Trade Name Size No. BTU HP EDR $ Fuel Total Connected Load State Surcharge $ .50 TOTAL FEE $ 4 • P '�SLS- a4 iJ� MINIMUM FEE FOR ANY HEATING/COOLINGNENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS $15.00 PLUS THE x.50 STATE SURCHARGE REINSPECTION FEE $30.00 *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. Burner Trade Name. BTU Size No. HP EDR BLAINE HTG, A/C & ELECT. INC. 13562 CENTRAL AVE. N.E. HEATING COMPANY ANOKA, MN 55304 Signed By C 1A Tel No. Approved By Rough—in Date Final Date FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE 4 SUBJECT - City of Fridley T�;572® THE TWINS BUILDING PERMIT(4 RECEIPT NO. �____COMMUNIYY QEVELOPMENT DIV.�� m— PROTECTIVE INSPECTION SEC.�'1 NUMBERDATE PAGE OF APPROVED BY IL CITY HALL FRIDLEY 55432 ----A,612-571-3450 910-F15 11/20/98 JOB ADDRESS6430 Riverview Terrace NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED oescR. 41 Veits AdditionSHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Albin M sla'ek 5 1-9765 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Ideal Roofin 1680 McAndre sRd W - 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 O ADDITION ❑ ALTERATION � REPAIR ❑ MOVE ❑ REMOVE B DESCRIBE WORK Reroof house and arae (21 S Tear -off 9 CHANGE OF USE FROM TO STIPULATIONS e Underlayment must comply with the State Building Code. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,VENTILATING TYPE OF CONST. OCCUPANCY GROUP OCCUPANCYLOAD 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 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 1799 .90 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SACCHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-STRUCTION OR THE PERFORMA CE O CONSTRUCTION Fire S 1.80 PLAN CHECK FEE TOTAL FELfEOFCON' TOR ORAUTHORiZE NT 1DATE,HE PROP L ALIDATED T SIS YOUR PERMIT 8 G NSP nArE S,GNATURE OF OWNERoF OWNER BUiLOERI�OATE� 4 NES/ Effective 1/1/98 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 # BUILDING PERMIT APPLICATION .2 Owner Name & Address: ;k\it a ni b �!a e- K Tel. # Contractor: 6np' Oct MN LICENSE # 9,;? Address: A� �n�s cdus R�- �]�I�d1SV �e )J, Tel. # 5-30fo r Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: W'dth Hgt/Ground Sq. Ft. OTHER: L 1 g `C' Construction Type: F Rap\p,.�.� Estimated Cost: $ (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ = $ DATE: qk APPLICAN JI Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control $ 1.60 $ 943 $ '5. 6c) Park Fee $ Sewer Main Charge $ TOTAL STIPULATIONS: 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 [ ] '_ 0� iCITY OF FRIDLEY BUILDING INSPECTION � / f:,(,o Effective 4/1/2004 6431 University Ave NEi Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION 763-572-3604 FAX 763-571-1287 RATE SCHEDULE Residential Furnace Shell and Duct Work, Burner & also Replacement Furnace Gas Piping (New Furnace, Fireplace, Insert) Fireplace insert Gas Range Gas Dryer *Air Conditioning - All Sizes REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES Fee Total $35.00 $ $10.00 $ $15.00 $ $10.00 $ $10.00 $ $25.00 $ �xJ All Other Repairs or Alterations (List on Back) 1% of Value of Appliance or Work Minimum Fee $15.00 for Residential or 5% of cost of Improvement whichever is greater on work less than $500.00 Commercial/Industrial/Institutional 1.25% of Value of Appliance or Work (List on Back) 'Winimum Fee $35.00 for Commercial/Industrial/Institutional JOB ADDRESS &'00 Aivc-z t1i- W 7X Owner "Al Z! A d 62.901 Building Used As ESTIMATED COST PERMIT NO DESCRIPTION OF FURNACE AND BURNER # of Heating Units_ Circle One (Steam) ( of �No Trade Name BTU 74'oe0 HP EDR Fuel ! A r Total Connected Load Burner Trade Name BTU HP Size No. 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 $ and rulings of the Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. State Surcharge - $ 0.50 (if permit fee is over $1,000 multiply by .0005) TOTAL FEE $ �® *Air Conditioners can not be placed in side yard without written approval from adjoining property owner - copy to City FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE HEATING FAX # `763 -0 %s **Fo -73(/% d c _,35 /a7oa �_\ q Approved by Rough -in Date I Tel #_ C ed- -Of0 X10 Final Date FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When replacing an existing furnace, 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 Of 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 OR 1 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 Fa eAAe-F BTU Input 7A, eyo Fan Assisted or Nat Appliance #2 Type zg BTU Inputt Fan Assisted or Nat ,�/4� Appliance #3 Type BTU Input Fan Assisted or Nat Total Appliances _Q- Total Btu Input Irv, &vim Common Vent Type Class �9 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: my—®$ v®S'