PRE 2010 DOCSCity of Fridley, Minn.
BUILDING PERMIT N® 3745
Date: ....�. ..�.� ........................ . r ........��
Owner ............................. Builder ....................... ...............
Address ...................................... Address ............................................
LC>�CAT ON OF BUILDING
No. / Street of Lot ............... .............. .
Lot ../.Q...... Block ..;? ............. Addition or Sub -Division
Corner Lot ............ Inside Lot ............ Setback ............ Sideyard ...........................
DESCRIPTION OF BUILDING
To be ;Us!,�P a �o _f d,
Front .� Depth e 6 Height .� ®..� Sq. Ft. IZ.. Cu Ft./.�.
.................... Front ........ Depth ........ Height ........ Sq. Ft......... Cu. Ft..........
Type of Construction ................... Est. Cost.. A Y® e. .... To be Completed ....................
In consideration of the issuance to. me of a permit to construct the building desribed 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 with-
in the city limits and this permit may be revoked at any time u on violation of any of the provisions of said
ordinances. .) -- _
,r.......IA- Building Inspector
NOTICE:
This permit does not cover the construction, Installafion or alteration for wlring, plumbing, gas heating,
sewer or water. Be sure to see the Building Inspector for separate ikermits for these Items.
BUILDING PERMIT
!, MINNESOTA
6
Builder
lddress ✓� l'4-�.:ri l= �.a.��
'J
BUILDING' .:.
- ).rt of Lot
i or Sub':• 'Div.
! .. .� 'Set. Back411
•1� �� " ,:,
:.
�1 to of Survey of Let and proposed
UILDING
�h Height .,
B
Height
Type of 'CQnstruction `''�`� Estimated Cost-:..
To be completed
The undersigned hereby makes application for a permit for the work
herei-s- sper,ified, - a:gi-eeing 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
:::-U .Sahtedule 'of Fee Costs can be, found on the Reverse Side;)-
BUILDING PERMIT FEE SCHEDULE
Section 2, The Inspector of Buildings shall, before issuing any permit
for the erection of any building or structure, or for any addition to
any existing building or.structure, or for any alterations or repairs to
any existing building or structure, upon application therefor, 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:
2,1 For any such permit for the erection of any firepr6of building,
other than a garage, warehouse, factory or grain elevator, or'for the
erection of any fireproof addition, for similar occupancy, to any
existing building shall be at the rate 'of $1.40 for each one thousand
cubic feet,,or ,fra ction thereof, in such cubical contents.
2.2 For any such permit for the erection of any fireproof garage, ware- •':
house, factory or grain elevator, or for the -erection of any,.fireproof
addition, for similar occupancy, to any existing building shall be at the
rate of $1.25 for each one thousand cubic feet, classified as ."firep±oof"
by,Section:502_6f the Minneapolis Building Code.
HOUSES
2.3 For any such _permit ' for the erection... of any non -fireproof , blUlding
other than..a: garage, warehouse, factory or grain elevator, or any
non -fireproof -addition, for similar occupancy, to any existing building,
Permit $1,00 for each one thousand cubic feet.
4
GARAGES
2.4 For any such permit for the erection.of any non -fireproof garagep
warehouse, factory or grain elevator, or for the erection of any non
fireproof addition, for similar occupancy, to any existing building or
for each such building or addition. Ninety Ceiits for each one �..
thousand cubic feet wr fraction thereof, in the cubical contents thereof
with a minimut of $4.00.
For the purpose of computing fees 'for building permits the cubical
contents of any building or addition to a,uniform hei ht throughout by'
multiplying tlze,ground area covered from a point six 1.6) inwhes below
the floor line of the basement or cellar.to the average height of the
upper surface or to the average height of the roof,surface of the main
gable of a pitched roof..-
2.5
oof...
2.5 For repairs or alterations to an existing structure, the fee shall
be at the rate of $3,00 for each Five Hundred Dollars (6500.00), or
fraction thereof in the cost of all proposed work.
2.6 In no case shall the fee charged for any permit as set forth in
Soction 2 be less than $4.00.
a
Application for Power Plants and Healing. 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 AYR
6:00
$�%
Furnace Shell & Duct Work to 120,000 BTU ......p-....$10.00
$
each add. 60,000 BTU .....................
Replacement of Furnace .............................
3.00 $
6.00 , C)
Repairs & Alterations—up to $500.00 .................
6.00
$
Repairs & Alterations each add. $500.00 ..............
3.00
$
STEAM or HOT WATER SYSTEM
Furnace Shell & Lines—to 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
$
Dept. of Bldgs. Phone 560-3450
' fI
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.
1 Fridley, 34pn_ l 1.9
Owner =—
Kind of Building
Used as
To be completed about
Cost, $
wilding Permit No. I 0-� 0 i Permit No. 54,1&*
&*
OIL BURNER—to 3 gal, per hour ........................
6:00
$�%
over 3 gal, per hour—See Fee Schedule
HEATING or POWER PLANTS—Steam, Stea, Hot Water, Warm Air—No
-° 4!:� C- 53 7-4"y l"y
J GAS BURNER (up
f 6 6 0
Trade N amXM _19
�� CS 3=/�� Size No 4
to_199 000 BTU) .................
_ -
... b.00
$
over 199,000 BTU See Fee
Schedule
6-0 0
Capacity
Sq. Ft. E.D.R BTU H.P.
GAS FITTING FEES:
1st 3 Fixtures ..... ................
NO RATE TOTAL
x$ 2,00 $ ®�
Total Connected Load
Kind of Fuel -
Additional Fixtures ................
x .75
$
BURNER —Trade Name
Size No
Gas Range to 199,000 ...........
x$ 5,00
Capacity
Sq. Ft. E.D.R BTU
H.P.
AIR CONDITIONING
FAN HEATING SYSTEM
e
See V.
VENTILATING SYSTEM
1f14 ON1140
w�JYI1
ALTERATIONS & REPAIRS
TOTAL FEE
$
Signe q ra.
0q 0,
By --._ Ni+i11iF_i'i1TT�rn�
ROUGH
i
Business
°
C4611).42
Phone Nom'
FINAL
(REMARKS -OVER)
8431 U141VERSITY AVENUE N.E., FRIDLEY, MINNESOTA 5.5432
TELEPHONE .( 612)571-3450
m
0
OBSTRUCTION:
Lot Block Addition
Property Omier-,' ddress
RE -CORD OF C0K%UNIQkTI0N'5:
2.
J.
4.
G.
7.
SUBJECT
PER
City of Fridley
2:2178
AT THE TOP OF THE TWINS
BUILDING PERMIT
RECEIPT NO.
i
� • COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
36 -as
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
/---1 CITY HALL FRIDLEY 55432
512-571-3450
910-F15
10/13/93
JOB ADDRESS 7501 University Ave NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
17
2
Osborne Manor SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Ford 7501 University Ave NE 786-1185
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Twin City Storm Sash. Co 10825 Greenbrier Rd, Mtka 55305 546-8160 3090
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 ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Replace Sashes.
9 CHANGE OF USE FROM TO
STIPULATIONS Every sleeping room shall have at least
one window w: a. sill height of not more than 44" above the floor and shall provide
not less than 5.7 sq,ft, of openable area. Minimum width 22", minimum height 24".
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
ZONING
SQ. FT.
CU. FT.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
NO. DWLG. UNITS
OFFSTREET PARKING
ANY TIME AFTER WORK IS COMMENCED.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1
STALLS GARAGES
VALUATION
SURTAX
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$8Q0
$.50
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$21.00
Fare SC $.80.
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
License SC $5.0
$27.30
SIGNATURE OF CONT RACTOR OR AUTHORIZED AGENT tOATEt
WHEN E Y ]DATED THIS IS YOUR PERMIT
N �f
BLDG iNSP DATE
SIGNATURE OF OWNEROF OWNER BUILDER] iDATEi
Contracts
Address:
a a%.�. yr zndYKUVEMENT
Effective 1/ 1/93
R-2 J^7/-.5445�9
Tel. #
LICENSE #�a�'y
iTel. #
f the
scale.
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft. -
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER:,(���
Corner Lot [ ] Inside Lot ] Ft. Yd Setback Side Yard Setbacks
Type of Construction: Estimated Cost: $ .560
Approx. Completion Date:
(Cost on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: Q °� - 5�s APPLICANT: Tel. #
Permit Fee $
Fire Surcharge $ d55r 0
State Surcharge $
SAC Charge $
License Surcharge $
Driveway Escrow $
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
$750 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
W GJ
9�
NEW [ ]�
ADDN '
ALTER
Construe
y
"J'
Legal 1:
v
Owner ]
Contracts
Address:
a a%.�. yr zndYKUVEMENT
Effective 1/ 1/93
R-2 J^7/-.5445�9
Tel. #
LICENSE #�a�'y
iTel. #
f the
scale.
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft. -
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER:,(���
Corner Lot [ ] Inside Lot ] Ft. Yd Setback Side Yard Setbacks
Type of Construction: Estimated Cost: $ .560
Approx. Completion Date:
(Cost on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: Q °� - 5�s APPLICANT: Tel. #
Permit Fee $
Fire Surcharge $ d55r 0
State Surcharge $
SAC Charge $
License Surcharge $
Driveway Escrow $
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
$750 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
W GJ
V
CITY OF FRIDLEY INSPECTION DIV. Effective On January 1, 1997
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS PAID HEATING, COOLING, VENTILATION,
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)
Gas Range
Gas Dryer
*Air Conditioning – All Sizes
All Others/Repairs & Alterations (LIST ON BACK)
I% of Value of Appliance or Work
Commercial/Industrial
1.25% of Value of Appliance or Work
JOB ADDRESS—'7501 Un l 'var5lq Ave . N , E
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
$ 30.00 $ representations stated in this application are tru ,anVorrect.
$ 10.00 $ 11997
$10.00 $
OWNER MeX I F-CY-d
BUILDING USED AS I7e5 i der�H cj
$10.00 $
ESTIMATED COST( 50).00 PERMIT NO.
$ 25.00 $ 5.00
State Surcharge
TOTAL FEE
DESCRIPTION OF FURNACE AND OR BURNER
$ No. of Heating Units Circle One (Steam) (Hot Water) arm Air
Trade Name uLcd Size No._VP/+0-7
BTU 15,C00—HP EDR
$ Fuel IN Total Connected Load
$ .50 Burner Trade Name Size No.
BTU HP EDR
d.oxt. so
I- T�
HEATING COMFY r.icksnt �Pl lir Y11,1/l� lZic oc, l 110
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
k
I Signed By.
:5-45-45-
Rough–In
-45-45-
IN
REINSPECTION FEE $42.00/Hr
Approved By
Rough–In Date Final Date
*Air Conditioners can not be placed in a side yard without FILL OUT BACK SIDE qbR STACK VERIFICATION ON
written permission from adjoining property owner. REPLACEMENT FURNACE
Remarks: .
List ALTERATIONS Being Done:
HEATING CO:
Signed By:
Date:
CHIMNEY AND STACK VERIFICATION
The
undersigned hereby verifies that the existing chimney or
stack:
1.
Has been carefully examined
Yes
O
No
(
)
2.
Is free from rust or deterioration
Yes ()
No
(
)
-3.
Has no foreign objects lodged within
Yes ()
No
(
)
4.
Is securely supported
Yes
O
No
(
)
5.
Meets all current Code requirements for size
and total BTU's connected
Yes ()
No
(
)
6
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 Being Done:
HEATING CO:
Signed By:
Date:
SUBJECT
City of Fridley
5195
T
SA T® F HETWINS
BUILDINGPERMIT
'
` • ®COMMUNITY DEVELOPMENT DIV.
____
ti: -
PROTECTIVE INSPECTION SEC..
(0105r
NUMBER
REV
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
' 612-571-3450
910415
10/13/98
JOB ADDRESS
7501 Universitv Avenue
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DESCR.
17
2
Osborne Manor
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Ford
786-1185
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Eagleview Const. Inc. 2937 174 Ln NW Andover MN 55304
753-5469 20076
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 I0x REPAIR O MOVE O REMOVE
8 DESCRIBE WORK
Reroof house and garage (20 Sq) Tear-off
9 CHANGEOFUSEFROM 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
1 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
$1714
.86
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
$56.75
Fire SC $1.71
PLAN CHECK FEE
TOTAL FEE
p
License SC
5.00
64.32
NATURE e CON'RACTORORAUTHORIZED AGENT IOATEI
WHEN PROPERLYALIOATED THIS IS YOUR PERMIT
_4
s
BL G INST'
TATE
_
S-GNAYURE OF OWNEROF OWNER BUILDERS IDATEI
w
NEW [ 4 ] Effective 1/1/98
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: .A I`ve
Legal Description:
Owner Name & Address: / " Tel. #
Contractor: qe&AMNLICENSE#-
Address: % / 7 L Tel. #
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 Hgt/Ground Sq. Ft.
OTHER:
Construction Type: ltsy4s --e ,t Estimated Cost: $
4;;e' -5A (Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ = $
DATE: �% 3 i� APPLICANT: r Tel. #
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
$ S� ?S7
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 [ ]
r
CITY OF FRIDLEY INSPECTION
6431 Univ ive NE
Fridley, MN 55432
(763) 572-3604
RATE SCHEDULE
DIViSION •
. 4. �
Effective On January 1,'2002
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
(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 T ON BACK)
1% of Value of Appliance or Work
Commercial/Industrial
1.25% of Value of Appliance or Work
TOTAL
$ 30.0 $
$ 10.00 $
$ 10.00 $
$ 10.00 $
($2D5.00$-
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 XW/
OWNER
L % GL-21MZ_
BUILDING USED AS
ESTIMATED COST
PERMIT N0. /�3
DESCRIPTION OF FURNACE AND OR BURNER
(
No. of Heating Units
Circle One (Steam) (Hot Water) Warm Air
Trade Name
Size No. 70
BTU
HP EDR
Fuel
Total Connected Load
Burner Trade Name Size No._
BTU HP ED
$ 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
representations stated in this application are true and correct.
APR - 3 2003
DATE
GOLDEN VALLEY HEATING & AIR
HEATING CO dba RICH MO
Sign /-5182WEST BROADW�AA� #
F #*
Approved B
pp y Rough -In Date Final Date
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
COMMONVENI.MENICONNECTOR AND COMBUSTION AIR V RIFT ATION
When rain_acing an axis ing f ,r� anre, 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 axis ing comb ,c ion air is sized and installed to meet the current codes
and manufacturer's specifications.
Yes) No
When required to install a new nomhi iction air,itwill be sized and installed
to meet the current codes and manufacturer's specifications.
Yes ( No ( )
When installing a new ventingyyctem, 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 #1 Type WqM4)!,�k7_0� BTU Input .�®�O' an M-qk-lid e Nat
Appliance #2 Type � TU 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
t
-44 R " 1,
fir= MOD & SONS ELECTRIC
5182 ..!
i x_ i.
CRYSTAL, MN 5U29
HEATING CO:
ll
'�/ i9 ���
Signed By:- /�/.�/
HOUSE HEATING. TEST RECORD
ADDRESS ^ ! � . � ,� PT. FLOOR CITY SUBUR
OCCUPANT ri OWNER
HEAT LOSS DATE HTG. INST.
sbLD BY INSTALLED BY
Electrical Work By Gas Line By
TYPE OF HEAT GA FA HW STEAM SPACE HTR. UNIT HTR. OTHER
i
• l
W NAW,
THERMOS T T
VALVE 1A
LIMIT
LIMIT SETTING
FAN SETTING _
PILOT TYPE _
PILOT MAKE _
PILOT MODEL
PILOT TIMING.
L. 1 W. CUT OFF
CONTROLS
A HEAT PLUG
MW
C -
PRESSURE AJ -5
INPUT CFH i0
STACK TEMP.
FORM 235
PERCENT CO,2
PERCENT 02
PERCENT CO
CONVERSION
MAKE OF BURNER
MODEL
MAX. BTU RATING _
MAKE OF FURNACE
MODEL - -
VENT SIZE
KIND OF LINER SIZE NONE
DRAFT HOOD REGULATOR
FILTERS SIZE NUMBER
CHIMNEY LOCATION INST IDE
CHIMNEY CONSTRUCTION �t�v O�Uy U k,,�-e�
• - -•