PRE 2010 DOCSr
City of Fridley, Minn.. N? 8 515
BUILDING PERMIT
Date: OCTOBER 6, 1965
Owners DR. ROY R. INGEBRETSON Builder STUART CONSTRUCTION COMPANY
Address 5811 West Moore Lake Drive Address 109 Lowry Avenue N. E.
Fridley 21, Minnesota Minneapolis, Minnesota
LOCATION OF BUILDING
No. 5811 Street WEST MOORE LAKE DRIVE Part of Lot
Lot 10 Block Addition or Sub-Division_D.onnay_'s_Lakp:jd aw Manor
Corner Lot. Inside Lot Setback _ _ Sideyard
Sewer Elevation Foundation Mevation
DESCRIPTION OF BUILDING
To be Used as:
Remodeling & Addition Front 59 _ Depth 43.6 Height 20 Sq. FL 616 Cu. Ft. Jan0
Front 59 Depth 22 freight 10 Sq. Ft. 1,298 Cu. Ft. -12,,,.9AO
Type of Construction Est. Cost _=,..Q0jL00- .- To be Completed
VARIANCE APPROVED BY BOARD OF APPEALS - SEPTEMBER 12, 1962
VARIANCE APPROVED BY CITY COUNCIL - SEPTEMBER 17, 1962
(VARIANCE from 5' to 216" side yard
from 10' to 616" side yard)
In consideration of the issuance to me of a permit to c
the proposed work in accordance with the description above
ordinances of the city of Fridley.
operibed adfmlia with h provisions ree
In consideration of the payment of a fee of $ 26.00 permit is hereby granted to STUARV�
CONSTRUCTION CO, 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, ffi 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
within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
ALLEN G. JENSEN Building Inspector
NOTICE:
Ub permit does not emr the constrnstien, hoWle im for .wkinq, plumbing, ges boating, swnr or water. Be sure to we
the Building hupeator for sepwaN porn& for thea Hum,
APPLICATION FOR BUILDING PERMIT
LOCATION OF BUILDING '
N0,STREET P SOF LOT
LOTS BLOCK l ADDITION OR SUBDIVISI
CORNER LOT INSIDE LOTSETBACK �c SIDE -YARD
SEWER ELEVATION 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;
Type of Construe
To be completed
DESCRIPTION OF BUILDING
G
Front �;, `( Depth q 3. 6, Height g
Sq. Ft. P Cu. Ft. H 3 �
Front Depth �2— Height
Sq. Ft. �'-`� Cu. Ft.
176 16
Estimated Cost %'ave. i-%3
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 IV �� SIGNATURE
(Schedule of Fee Costs can be found on the Reverse Side) F
Ala
J:ri, . .,. "', /
SUBJECT
PE
City ®f Fridley
18 z
AT THE TOP OF THE TWINS
BUILDING PERMIT
i ,
RECEIPT
-------COMMUNITY DEVELOPMENT DIV.
i PROTECTIVE INSPECTION SEC.
``�Q
4J l
r I
t 1 �
CITY HALL FRIDLEY 55432
NUMBER
REV.
GATE
OF
APPROVED BY
,'j 612-571-3450
910-F15
5/25/93
FPAGE
/ /
JOB ADDRESS 5811 West Moore Lake Drive NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
10
1
Donnay t s Lakeview Manor SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Kay Ingebritson 5811 West Moore Lake Drive NE
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Gates Roofing 4640 Ximi.nes Ln N Plyraouth, MN 55442 5 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 O ADDITION ❑ ALTERATION REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof House (30. Squarest 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.
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
ANY TIME AFTER WORK IS COMMENCED.
NO. DWLG. UNITS
OFFSTREET PARKING
1 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
$1F6.20.
$181
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT PRESU E TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROW SgTOTHER ST OR LOCAL LAW REGULATING CON-
$39,00
Fire CC $1,62
T PERFO NCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
License SC $5,00
$46,43
SIGNAT ONTRACTORORAUTHORIZEDAGENT (DATEI
HEN R�f:E%±lY VA �A D THIS IS YOUR PERMIT
BLDG INS; Daip
SIGNATURE OF OWNER OF OWNER BUILDER) IDATEI
NEW f l
ADDN [ ]
ALTER[]
Construction Address:
Legal Description:
Owner Name & i
Effective 1/1/93
CITY OF FRIDLEY_
SINGLE FAMILY AND DUPLEXES R-1 AND R-2 -71�7-6�16
Building Permit Application -
Contractor: a Z� MN LICENSE # ( `7 l 3
Address: ® 4 -e s G-.✓ av Tel. # 52-z7502-005/3
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
GARAGE AREA: Length Width Height
DECK AREA: gth W. th Hgt/Ground
OTHER:
Corner Lot [ j Inside Lot [ j Ft. Yd Setback
Type of Construction:
Approx. Completion Date: S' Z
Sq. Ft.
Sq. Ft. T
Sq. Ft. T
Side Yard Setbacks
Estimated Cost: $ l (,o?Q
(Cost on Back)
Driveway Curb Cut Width Needed:Ft = Ft x $ _ $
DATE: - Z - 3 APPLICANT. Tel. #
CITY USE ONLY
Permit Fee
$
06
Fee Schedule on Reverse Side
Fire Surcharge
$ /, (off
.001 of Permit Valuation (1/10th`)
State Surcharge
$
i
$.50/$1,000 Valuation
SAC Charge
$
$750 per SAC Unit
License Surcharge
$
4-z5-, c --d
$5.00 (State Licensed Residential Contractors)
Driveway Escrow
$
Alt. "A" or Alt. "B" Above
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement Necessary [ ] Not. Necessary [ ]
TOTAL
STIPULATIONS:
k
SUBJECT
�
City of Fridley
28510-11-1
AT THE TOP OF THE TWINS
BUILDING
P E R M
P ,
i &57203_ " NITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC
1 ; e
NUMBER
AEv
DATE
PAGE OF
APPROVED BY
1l 1 1 CITY HALL FRIDLEY 55432
'-, 612-571-3450
910-F15
11/4/98
JOB ADDRESS West
5811 Moore L
I LEGAL
LOT NO. BLOCK
TRACT OR ADDITION
SEE ATTACHED
OESCR.
10
I D. L. Manor
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Kay In ebritson
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Gates Roofing 4640 Ximines Ln P1990-0043
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
O NEIN O ADDITION O ALTERATION :0 REPAIR O MOVE O REMOVE
B DESCRIBE WORK
Reroof house and garage (27 SO Tear -off
9 CHANGEOFUSEFROM 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 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 BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
2313
$1.16
DOES NOT PRESUMET GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY O HER STATE OR LOCAL LAW REGULATING CON.
STF14tTI-09 OR THE PE FORMANCE OF CONSTRUCTION
174.75
Fir -AC
PLAN CHECK FEE
TO FEE
GNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI
ENFI
8 G If; -SP J
LI THIS IS Vfjl PE 11M7
-9�
FeAeE
SIGNATURE OF OWNER,iF OWNER BUILDER) IDATEI
NEW [ ] -- Effective 1/1/98
ADDN (] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
ConstructionAddress: -5-9 H m �,k /t -->y,--
Legal Description:
Owner Name & Address:: �- �� ,.� Tel. #
MN LICENSE # & 7i 3
Contractor:
Address: �_�® ,� (—nA ,')-I'fs Z—e-'f '-'j Tel. # 5-5-V
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 e f round Sq. Ft.
OTHER:
Construction Type:
-------------------------------
Estimated Cost: $
(Fee Schedule on Back)
Driveway Curb Cut Width Needed:
Ft. + 6 Ft = Ft x $ _ $
DATE:
APPLICANT:
Tel. #
CITY USE ONLY
Permit Fee
$ ,�
Fee Schedule on Reverse Side
Fire Surcharge
$ -3 /
.001 of Permit Valuation (1/10th%)
State Surcharge
$ % /(
$.50/$1,000 Valuation
SAC Charge
$
$1000 per SAC Unit
License Surcharge
$ �r• �0
$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
$ c05S�v�
STIPULATIONS:
CITY OF FRIDLEY INSPECTION DMSION � I p' r—.-. ... ' .
' 6431 Unh mlly Ave NE Effective On,1
January 1, sss
Fridley, NIN 55432 APPLICATION FOR P0111IER PLANTSAND HEATJING, OOOUNG, VENTILATION
® 572-SM4 REFRIGERATION AND AIR CONDITION NG SYSTEMS AND DEVICES a: -
RATE LCHEDULE JOBADDI
v Aesidential The undsrslgned hereby makes application for a permft for the wait herein
Funke Shell and Duct ft*, gamer
Rate TOTAL spec iffed agreeing to do all work lA strict accordance wEth the City Codes and
--
ft*V Of the
Dhftfc
Also Replacement Furrface $30:00 $- � Q ° , repr�entatlor� sfi� in this �app�li�on�are �e amend � � the facts and
(Side Vent -Fill Out eack) mart.
Gas P4*9 (Neededwith new furnace) $1000 $ - J g C�
O1�UNER
Gas Range $10.OD �_
44-1
Gas Dryer BUILDING USED AS
*AirCorditioni ESTIMATED COST � � 5 _ PERMITNO. �
ng - AA Sizes $ 25.00 $
Ali 01hers5lepairs Afteratlons (LIST ON l9" DESCRIPTION OF FURNACE AND OR BURNER
A1%0f Value of Applianoe or Work
$ No. of Heating Urft i Name
Clyde One (StearrE� dict uvate�} AW
., Trade N� arni
u Commercia�lndustrial � .1 c l �� Size No. 1�
1.25% of Value of Apprrance or Work BTU 80,rx 3 3e� mss ' ` EDR
O $ Fuel Tata) Co
Gam. O ected Load
U State Surcharge
L—.50 Burner Trade Name Size No.
TOTAL FEE �0
BTU
HP EOR
m
MINIMYM FEE FOR ANY HEATINGICOOLING CATION HEATING COMPANY b
REFRIGERATIONIAIR CONDITIONING PERMIT IS $95.00��
CD PLUS THE .5Q STATE SUJ�CFrAD Tel No. _ tea
m REINSPECTION FEE $42.00lHrte
Approved 13yRough-In Date Final Oat-.
Z *AirCondkioners can not be placed In a side yard without'
FILL OUT BACK SIDEIFOR K VERIFlCATION ON � e1
wrkten percussion from adlOink�g property owner. REPLACEMENT FURNACE
Printout certified by RCCA to mr;zt all requimments of Manual J Form
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Printout certified by RCCA to mr;zt all requimments of Manual J Form
SUBJECT
PER
City of Fridley
10686
AT THE TOP OF THE TWINS
BUILDING PERMIT
COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
1/tea
1 . �
CITY HALL FRIDLEY 55432
NUMBER
REv
DATE
PAGE OF
APPROVED BY
612-571-3450
910-F15
2/25/00
JOB ADDRESS 5811 West Moore Lake Drive NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
10
1
Donnay's Lakeview Manor
SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP
PHONE
K. Ingebritson 5811 West Moore Lake Drive NE
571-3326
3 CONTRACTOR MAIL ADDRESS ZIP
PHONE LICENSE NO
Harmony Homes Inc 3158 Viking Blvd NE, Wyoming, MN 55092
413-1100
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP
PHONE LICENSE NO
5 ENGINEER MAIL ADDRESS ZIP
PHONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
0 NEW 0 ADDITION 0 ALTERATION REPAIR
0 MOVE 0 REMOVE
8 DESCRIBE WORK
Replace windows & door
9 CHANGEOFUSEFROM TO
STIPULATIONS
Provide smoke detectors in all sleeping rooms and on all levels of the
dwelling per Section 310.9.1.2 of the 1997 Uniform Building Code.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCYLOAD
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
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
$10,219
r
$5.11
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
UROOF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$195.25
Fire SC $10.22
S CTION OR THE PERFORMANCE OF CONSTRUCTION
PLAN CHECK FEE
TOT FEE
zj0r==-
License $5.00•
215.58
SIG ATUREOFC6N-RACTORORAUTHORIZEDAGENT IOATEI
HEN ROPE VALIDATE THIS IS YOUR PERMIT
SIGNATURE OF OWNER pF OWNER BUILDERi IDATEI
..BLD INSP
FIATE
NEW [ ] Effective 1/1/2000
ADDN [ ] CITY OF FRIDLEY (763) 572-3604 Bldg Insp
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
Construction Address: t�/eaS-�- Mt�y l'� � k� PC
Legal Description:
Owner Name & Address: Tel. # ( .2 -57 L'@ 37,-Z
Contractor: L11- JA MN LICENSE#_c20(;3aj,
Address:Z4, � /WIG v,c .,ll�/L/ ,�.,;,,� /ly11 5'��� 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:
.Sa �e- 9.0 �-
Construction Type:�A "64&- rlQlnj,I g Estimated Cost: $
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: APPLICANT: �.� Tel. #_610-Yi3'/Gt)
CITY USE ONLY - Call (763) 572-3604 for Permit Fees if mailing in application
Permit Fee $ 7,� Fee Schedule on Reverse Side
Fire Surcharge $ /0,-2.2 .001 of Permit Valuation (1/10th%)
State Surcharge $ $.50/$1,000 Valuation
SAC Charge $_$1 100 per SAC Unit
License Surcharge $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 $ 41s-' S
STIPULATIONS:
0 - .1.
6431 University Ave NE
Fridley, MN 55432
(763) 572-3604, FAX (763) 571-1287
LIICI•LIVC /'1F.1111 1, /-V
APPLICATION
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
MARK NUMBER OF FIXTURES TO BE INSTALLED
ON EACH
FLOOR
New Fixtures
$10.00
The undersigned hereby makes application for a permit for the work herein
Urinal
U nal
� _`����� Shower
''�'•........
............
..:..............
"••
.�f:::::
.
Was h
Tra �• � � •>:::::::::::
.::#�:
Floor
Drain
.....:.:.:...........:
.:..::.:::
:fa�::.::<�
' : •::::::
Auto.
Washer
•: • • ��:»<::<:
1....::•
Gas
Ran a
Catch Basin
Water ater
Sto ' s
ne
•>�: ::
Imo....
:.. ••;•::::::::::::
:�;::�:���:
Gas Elec
B e e
$10.00
/ _
Water Treating Appliance
$35.00
OWNER �" �0__C
@�
Water Heater -Electric
�
$35.00
M �
Water Heater - Gas**
$35.00
BUILDING USED AS
Floor 1
$10.00
Gas Dryer**
$10.00
ESTIMATED COST PERMIT NO.
Back Flow Preventer Required ( )Yes ( ) No
Type
$15.00
PLUMBING COMPANY ((, 10- L C S �C�
Floor 2
5
F loot 3
Floor 4
PLUMBING FIXTURE RATES: NO.
RATE TOTAL
JOB ADDRESS_
New Fixtures
$10.00
The undersigned hereby makes application for a permit for the work herein
Old Opening, New Fixture
$10.00
specified agreeing to do all work in strict accordance with the city codes
Beer Dispenser
$10.00
and rulings of the Building Division, and hereby declares that all the facts
Blow Off Basin
$10.00
and representations stated in this application are true and correct.
Catch Basin
$10.00
Rain Water Leader
$10.00
DATE: , 20 r'�°
Sump/Receiving Tank
$10.00
/ _
Water Treating Appliance
$35.00
OWNER �" �0__C
@�
Water Heater -Electric
�
$35.00
M �
Water Heater - Gas**
$35.00
BUILDING USED AS
Gas Range**
$10.00
Gas Dryer**
$10.00
ESTIMATED COST PERMIT NO.
Back Flow Preventer Required ( )Yes ( ) No
Type
$15.00
PLUMBING COMPANY ((, 10- L C S �C�
Reinspection Fee $50.00/Hr
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.25% of Value of Fixture or Appliance
SIGNED BY L� � � -(Ct
_ TEL NO. �� "2e-
Approved By_
State Surcharge $
MINIMUM F
TOTAL FEE OF THE IMP
Rough -In Date
Final Date
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. **PROVIDE COMMON VENT INFO ON BACK SIDE
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 No( )
The venting system is plastic/PVC and meets all current codes and manufacturer
BTU Input Fan Assisted or Nat
specifications including sizing, length, number of elbows and termination.
Yes (I No( )
r
The undersigned also verifies that the replacement unit is a listed assembly
BTU Input Fan Assisted or Nat
and meets the current codes and manufacturer's specifications. This does
Total Btu Input
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 airit will be sized and installed
to meet the current codes and manufacturer's specifications.
Yes No( )
When installina 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 :