PRE 2010 DOCSCity of Fridley
SUBJECT
PE IT
13941
AT THE TOP OF THE TWINS
PERMIT
r
BUILDING
R CEIPT NO.
COMMUNITY DEVELOPMENT DIV.
r � PROTECTIVE INSPECTION SEC.
r
�
1 . i
CITY HALL FRIDLEY 55432
NUMBER _7_1
EV
DATE
PAGE OF
APPROVED BY
612-560-3450
910-F15
3/7/77
JOB ADDRESS 7565 McKinley Street N.E.
1 LEGAL
LOT NO,
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
4
1
Bayer's Lakeside 2nd Addn.
Ba Y'SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Cedar Bay Builders 1700 - 3rd Avenue N.W., New Brighton, Mn. 55112 633-8800
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
Same
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
Ek NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
IN
Construct a 26' x 38' Dwelling and a 22' x 22' Garage
EPtATE PERMITS REQUIRE?e FtR,.:WlRI�VC• TELEPHONE-ELECTRIC-
9 CHANGE OF USE FROM EATIM PLUMBING AND SIGNS.
f>
REQUIRED 8Y
STIPULATIONS provide a hard surface driveway. Provife sod in the front and side yards.
Provide a verifying survey before capping. Provide 2" x
8" rafters or trusses.
SEWER LOCATION: (Approx. 10,' Deep) No Existing Wye. 8" sewer line 25' west of
property line.
9-4MPORTANT-••,.
WATER LOCATION: MUST BE TAPPED. 6" watermain 10' west of se1.WE FRtDI.EY ENGR.
DIVISION REGARDING CARS
REMOVAL-AND REPLACEMENT
THE CUT OF "FXDW DMS NOT QUARAWK- " 7HE
30 DAMP"i 'R �Nt''EN
ACCURACY OF UTrtttY tOCArjM AND MVAj0j,
..
THIS DATA IS FOR INFORMATION PURPOSeS OPmLY AN,)
SIV. REQUIRED FOR CU
P» SOMS USING R 011CIULD Vl£RIFY THE INFORMARON
:6:AAOVAL AND REPLACEME
ON LME SITE
AT DRIVEWAY OPENINGS
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
WOOD FRAME
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
R-1
1118+484
13,416+4840
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
$33,295
$16.65
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-
ST TI N OR THE PERFORMANCE OF CONSTRUCTION.
$104.64
$375.00
I&
PLAN CHECK FEE
TOTALFEE
`� Q 6
$2 6
$522.45
IGNATUREOFCONTRACT ROS UT RIZEDAGENT IOAT
W N O
r
RLY VALIDATED THIS IS YK;_Az
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BLDG. INSP
ID E
'- SIGNATUREOF OWNERIIF OWNER BUILDERI (DATE)
dlities
AS Etc.
LAE
CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL BUILDING PERMITS
(NEW, ALTERATIONS, ADDITIONS, OR REPAIRS)
OttiTlJER: A
DD
Address:
AJF-uj
No.: 7 ,�,j Street:
LOT: '7 BLOCK:
BUILDER:
Address:
Tel. No. �yy
CORNER LOT: INSIDE IAT: _�_ SETBACK: SIDEYARDS: sU —
Applicant attach to this form Two Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
�A <
DESCRIPTION OF BUILDING 7�S
To Be Used As:
o)
4t
Front: �1p Depth: 3 Height:
Square Feet: 111,R Cubic Feet: 4a V//
C�
Front: tea' Depth: Height:
Square Feet: d%h'� Cubic Feet:
Type of Construction: Estimated Cost:
To Be Completed:
/Alt. A Alt. B
Proposed Driveway Width If few Opening Is Desired $ $
(SEE REVERSE SIDE OF SHEET)
The uiIderAigned 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. See reverse side for additional information.
DATE: SIGNATURE•
Stipulations:
C ,
>,� AFSS
00, 74965 5 S
ooh eV
®4�
/! , 6 "r
BUILDING PERMIT FEE SCHEDULE
SECTION 2. The Inspector of Buildings shall, -before issuing permits for the erection
of any building or structure, or for any addition to any existing building or structure,
or for any alteration or repairs to any existing building or structure, upon application
therefore, require the payment by the applicant for such permit of fees to the amount
herein below set forth and in the manner herein provided to -wit:
NEW CONSTRUCTION: Single Family Homes and Garages: $4.00/1,000 cubic feet.
PLAN CHECK: 25 percent of building permit fee.
DRIVEWAY DEPRESSION: (Concrete Curb Streets Only)
Alternate A: Removal and replacement of concrete curb and
gutter only; Driveway width plus 6 feet x $11.75
Alternate B: Removal and replacement of concrete curb and
gutter and install a 3 foot wide approach with
6 inch depth; Driveway width plus 6 feet x $15.75
1 1 • _ •' • \
For the purpose of computing fees for building permits, the cubical contents of any
building or addition, is determined by multiplying the ground area covered from a
point six (6) inches below the floor line of the basement or the cellar to the
average heights of the upper surface or to the average height of the roof surface
of the main gable of a pitched roof.
For repairs or alterations to an existing structure, the fee shall be at the rate
of $3.00 Per each five hundred dollars ($500.00) or fraction thereof in the cost
of all proposed work.
In -no case shall the fee charged for any permit as set forth in Section 2 be less
than $7.50 plus $.50 state surcharge.
VERI_FI_CATIO"F F(ZUNDATION
NOTE: Permits for construction will be issued a minimum of 24 hours from the time
of application to allow for proper review of the proposed structure and of the
construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it
has been constructed will be required before proceeding with the framing.
VWGj;W$X411jZ11
Application for a Certificate of Occupancy shall be made ten (10) days prior to the
use or occupancy of any structure for which a building permit has been issued; and
said structure shall not be used or occupied until a Certificate of Occupancy has
been issued.
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CITY OF FRIDLEY
APPLICATION FOR PLUMBING AND GAS FI'T'TING PERMIT
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO.
p,
M
TOTAL
Number Fixtures
p
o
$3.00
x
m
3
Water
$2.00
q
M
x
$2.00 0
N
r.}��
r. -11
M
Ll
$5.00
4
p,
kms,
b'
�
$5.00
Heater
100,000 BTU to 199,000 BTU
N
bb+
$10.00
$
Water Softener
E
�
0
354
4 0�
N
Q
$5.00
$
H
+1
11
01
A
GAS FITTING FEES:
YM
,,l�C�.
1st 3 fixtures
f
x
'$3,00
$ ;.CSU
Additional Fixtures
M
$1.00
$
Gas Range to 199,000 BTU
O
x
-S
$
R
N
r7 "�
O
O
i� M
0 till
M
M
M
each add. $100.00 or fraction
ai
U
D
P%
a1
y
3
A W
ai
W
U r�A
3
Cel
tro7
O
as
lec
1st
0
2nd
3rd
4th
(R) = Future Connection Opening
Connected with Sewer
(*) = New Fixture, Old Opening
Water
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO.
RATE
TOTAL
Number Fixtures
p
x
$3.00
$ aA/(1 U
Future Fixture Opening
3
x
$2.00
$ (?.
New Fixture, Old Opening
x
$2.00 0
$
Catch Basin
x
$5.00
$
Water Heater - to 99,000 BTU
/
x
$5.00
$ �•DO
100,000 BTU to 199,000 BTU
x
$10.00
$
Water Softener
x
$7.00
$
New Ground Run Old Building
x
$5.00
$
Electric Water Heater
x
$5.00
$
GAS FITTING FEES:
1st 3 fixtures
f
x
'$3,00
$ ;.CSU
Additional Fixtures
x
$1.00
$
Gas Range to 199,000 BTU
x
$10.00
$
REPAIRS $ ALTERATIONS
First $100.00
$5.00
$
each add. $100.00 or fraction
$2.00
$
State Surcharge
$ .50
TOTAL FEE
$ �O
REINSPECTION FEE
($10.00)
Job Address 7,' J G z'//Aa— a
Department of Buildings
City of Fridley
Tel. #571-3450
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 Department of Buildings, and hereby declares that all
the facts and representations stated in this application are true and correct
Fridley, Mn. C� '19 7
OWNER
KIND C
USED AS /a1
TO BE COMPLETED ABOUT
ES MATE ST
OLDNEW BUZ ING PERMIT NO. PERMIT NO.
Company
Signed By
Tel. No. Y C �'�� 0 2r
ROUGH INSP.
Date
FINALINSP. a /
Date
APPROVAL FOR PERMIT ,
MINIMUM FEE FOR ANY PLUMBING PERMIT IS $7.50 PLUS $.50 STATE SURCHARGE
CITY OF FRIDLEY
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND
.AIR CONDITIONING SYSTEMS AND DEVICES
PARTIAL RATE SCHERUIF
GRAVITY WARM AIR:
Furnace Shell & Duct Work
Replacement of Furnace
Repairs & Alterations -up to $500.00
Repairs & Alterations each add. $500.00
MECHANICAL WARM AIR:
Furnace Shell & Duct Work to 100,000 BTU
each add. 50,000 BTU
Replacement of Furnace
Repairs & Alterations -up to $500.00
Repairs & Alterations each add. $500.00
STEAM OR HOT WATER SYSTEM:
Boiler & Lines up to 100,000 BTU
each addn. 50,000 BTU
Boiler only up to 100,000 BTU
each addn. 50,000 BTU
OIL BURNER- to 3 gal. per hour
each add. 3 gal. per hour
GAS BURNER- from 100,000 BTU to 199,999 BTU
(over 199,999 BTU see Fee Schedule)
GAS FITTING FEES:
RATE
TOTAL
$12.00
$
7.00
$
4.00
$
$12.00
$ e ��
4.00
$
7.00
$
7.00
$
4.00
$
$12.00
$
4.00
$
7.00
$
6.00
$
$10.00
10.00
$10.00
1st 3 Fixtures x $ 3.00
Additional Fixtures x $ 1.00
Gas Range to 199,000 BTU x $10.00
AIR CONDITIONING
FAN HEATING SYSTEMS See Fee Schedule
VENTILATING SYSTEMS
ALTERATIONS $ REPAIRS
State Surcharge
TOTAL FEE
ROUGH INSP. REINSPECTION FEE
Date (,$10.00)
FINAL INSP. A -
Da e
in
APPROVAL FOR PERMIT
MOM
MINIMUM FEE FOR ANY HEATING PERMIT IS $7.50 PLUS $.50 STATE SURCHARGE
Job Address
Department of Buildings
City of Fridley
Tel. #571-3450
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Cddes.%
and rulings of the Department of Buildings, and hereby declares that all the
facts and representations stated in this application are true and correct.
Fridley, Minn.
OWNER
KIND OF BUILDING
USED AS1/�_' "
TO BE COMPLETED ABOUT
ESTIMATED COST
OLD -AM.AUILDING PERMIT NO.
PERMIT NO.
DESCRIPTION OF FURNACE/BURNER
HEATING or POWER PLANTS, Steam, Hot Water Warm Air- No.
Trade Name Size No.��Q
Capacity sq. Ft. EDR "eSTU HP
Total Connected Load �ti� Kind of Fuel 14
BURNER - Trade Name' &�nize No. A A
44
Capacity/A Ft. EDR® TU HP
RAY N. SMELTER HEATING CO.
Company
Signed By Minneapolis. bAinn solcl 55407
Tel. No. ,� E1!7
SuBjECT
N0.
City of Fridley
7ERNItT
n r,7
AT THE TOP OF THE TWINS
BUILDING PERMIT
Ir?
RECEIPT NO.
L _---_ COMMUNITY DEVELOPMENT DIV.
-7-7
r� � PROTECTIVE INSPECTION SEC.
:
NUMBER
REVDATE
PAGE OF
APPROVED BY
1 CITY HALL FRIDLEY 55432
1'J 612-571-3450
910-F15
1
J10/
31/94
JOB ADDRESS
7565 McKinley Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
4
1
Bayer's Lakeside 2nd Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP
PHONE
Larry Galdonik 7565 McKinley Street NE
786-1402
3 CONTRACTOR MAIL ADDRESS ZIP
PHONE LICENSE NO.
Gates Roofing 4640 Ximines Ln N Plymouth MN 55442
550-0043 6793
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 ❑ ALTERATION !M REPAIR
❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof House & Garage 24 S Tear-off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the 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 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
I STALLS
I 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
$.90
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$1,800
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-
Fire SC $1.80
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
$41.00
PLAN CHECK FEE
TOTALFEE
License SC $5.00
$48.70
SIGNATURE OF CONT RACTOR OR AUTHORIZED AGENT IDATEI
WHEN OPE Y VALIDATED THIS IS YOUR PERMIT
/V/
a DO INSP
T
S,GNATUREOFOWNER,IFOWNERSUILDERI IDATEI
NEW [ ]
ADDN [ ]
ALTER
ConstructionAddress:
Legal Description:
CITY OF FRIDLEY
SINGLE FAMILY AND DUPLEXES R-1 AND R -Z
Building Permit Application
?'-(o
Effective 1/1/94
Wyq- 77
Owner Name & Address: i Tel. # / �( 0
Contractor: MN LICENSE # 19, '3
Address: �� ��` = C_1/ .rj Tel. # . �vo 0
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: Length Width _ Hgtl ound .t.
OTHER: —��9 � 2 (5;; ';�
Corner Lot [ ] Inside Lot [ ] Ft. Yd Setback Side Yard Setbacks
Type of Construction: Estimated Cost: $ /Boo
_Approx. Completion Date:
(Cost on Back) =
Driveway Curb Cut idth Needed: 6 Ft ; Ft x 1$ — $
DATE: (9 -2- %APPLICANT: Tel. #
Permit Fee
$ 41100
Fee Schedule on Reverse Side
Fire Surcharge
$
.001 of Permit Valuation (1/10th%)
State Surcharge
$ C7
$.50/$1,000 Valuation
SAC Charge
$
$800 per SAC Unit
License Surcharge
$ . GCS
$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 [ ]
TOTAL $��
STIPULATIONS:
BUILDING PERMIT FEE SCHEDULE
The Chief Building Official shall, before issuing permits for the erection of any building or structure,
or for any addition to any existing building or structure, or for any alteration or repair to any existing
building or structure, upon application therefore, require the payment by the applicant for such permit
of fees to the amount herein below set forth and in the manner herein provided to -wit:
TOTAL VALUE FEES
$1 to $500 $15 (Minimum Fee is $15 plus surcharge)
$501 to $2,000 $15 for first $500 plus $2 for each additional $100 or
fraction thereof, to and including $2,000
$2,001 to $25,000 $45 for first $2,000 plus $9 for each additional $1;000
or fraction thereof, to and including $25,000
$25,001 to $50,000 $252 for first $25,000 plus $6.50 for each additional $1;000
or fraction thereof, to. and including $50,000
$50,001 to $100,000 $414.50 for first $50,000 plus $450 for each additional
$1,000 or fraction thereof, to .and including $100;000
$104,001 to $500,000 $639.50 for first '$100,000 plus - $3.50 for each additional -
$1,000 of fraction thereof, to and including $500,000
$500,001. to $1,000,000--., - $2039.50. for: the first $500,000 plus $3 for each`addrtional
$1,000 or fraction thereof, to and including $1,000,000
$1,000,001 and up $353950 for the first $1,000,000 plus $2 for each additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
(Concrete Curb Streets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times
$13.50 -
Alternate "B": Removal and replacement of curb and gutter and install a 3 foot wide
approach with 6 inch depth - Driveway width plus 6 feet times $15.75.
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of application to allow
for proper review of the proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has been
constructed will be required before proceeding with the framing.
CIiYOF
FRIDLEY
FRIDLEY MUNICIPAL CENTER - 6431 UNIVERSITY AVE. N.E. FRIDLEY. MN 55432 - (612) 571-3450 - FAX (612) 571-1287
November 26, 1996
L. M. Galdonik, Jr.
7565 McKinley Street N.E.
Fridley, MN 55432
RE: Home Occupations
Dear Property Owner:
In the zoning district where you live, home occupations are permitted as an accessory
use, provided that certain criteria are met. I have enclosed a copy of this City Code
section for your review.
Recently, we received information suggesting that you may be operating an automobile
repair garage out of your residence which is not in conformance with the restrictions. If
this is correct, please comply with the City Code by discontinuing this activity
immediately.
Feel free to call me at 572-3595 if you have questions or wish to discuss this further.
Thanks for your cooperation!
Sincerely,
Kurt Jensen -Schneider
Code Enforcement Officer
KJS:Is
CEM -96-488
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.
JOB ADDRESS 7,
OWN
Effective On January 1, 2000
TOTAL
6s� BUILDING USED AS
$
ESTIMATED COST j� ®� PERMIT NO.
$
il
DESCRIPTION OF FURNACE AND OR BURNER
ti
No. of Heating nits Circle One (Steam) (Hot Water) (Warm Air
Trade Name Size No.
BTU HP EDR
Fuel 2 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
MAINE HTt3. A/C & ELECT. lVC,
HEATIN C 13b62 CENTRAL AVE. N.E.
9
Signed TEL
Approved By Rough -In Date Final Date,/6 �
' COMMON VENT VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
d
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 firestcpped where required. Yes O 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 -LAMA 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 airit 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 r BTU Input Fan Assisted or at
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: _ LAINE HHG. ASC & ELECT. N' .
A�IC hi
AA10Kla N 55304 Date : —
Signed By: