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PRE 2010 DOCSCity of Fridley, Ainn. BUIIDING PERMIT N? 6161 Date: 00110id I —'Builder/. 0q_4Ar7jWW1W a 4 r Address LO TION OFAU NG NO. street P of Lot at Lot Block Addition or Sub Lot --Inside Lot comer Setbackf Sideyard Sewer Elevation Foundation Elevation DESCRIPTION OF BUILDING Used & Front Depth % Height sq. Ft.Depth Cu. Height S _A_zzj� . q. Ftff",� Cu. Type of etion Est. Co 'To be Cc In consideration of the Issuance to me of a work in accordance with the description above to construct the building described above I a to do the proposed the city of Fridley. p above set forth and In compliance with ;h agree to Of ordinances of In consideration of the payment of a fee of -2 -'i 7-1 mP_0'., permit Is hereby granted to._._. toconstruct 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 an work done In, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of Fridley, Minnesota re n alteration, repair and moving of buildings construction, It y r u within the city limits art1ffs1�rr1?tn`m'ao be revoked at any upon violation of any of the provisions of said ordinances. ---"A . A — gzae� Building Inspector NOTICE: Ibb pem* don not cover the condrueflon, huft"on for whim phnabbe, on heafts, sower or Water. Be sure to no His Buildino Wqmftr for separate permits for thus home. Owner's Name APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA Address LOCATION OF BUILDING` v � � No. Street.2G�'-i- Pr..�` " Part of Lot �. Lot Block�Addition or Subdivision Corner Lot Inside Lot` Setback ` �� Side -Yard I -IK 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: DESCRIPTION OF BUILDING Front Depth ,Height Sq. Ft. Cu• Ft. .._._. Front Depth Height Sq. Ft. 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 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 aAH correct. (Schedule of Fee Costs can be found on the Reverse Side). M Application for Power Plants and Heating, Cooling, Ventilation, Refrigeration and Air Conditioning Systems and Devices PARTIAL RATE SCHEDULE GRAVITY WARM AIR: RATE TOTAL Furnace Shell & Duct Work .......................... 8.00 $ Replacement of Furnace ............................. 5.00 $ Repairs & Alterations—up to $500.00 .................. 5.00 $ Repairs & Alterations each add. $500.00 ............... 2.50 $ MECIL WARM AIR Furnace Shell & Duct Work to 120,000 BTU ............ 8.00 $ each add. 80,000 BTU ....................... 2.00 $ Replacement of Furnace ............................. 5.00 $ Repairs & Alterations—up to $500.00 ................. 5.00 $ Repairs & Alterations each add. $500.00 .............. 2.50 $ STEAM or HOT WATER SYSTEM Furnace Shell & Lines—to 400 sq. ft. IDR Steam ..... 8.00 $ Furnace Shell & Line—to 640 sq. ft. IDR Hot Water ... 8.00 $ Each add. 200 sq. ft. IDR Steam ...................... 2.50 $ Each add. 320 sq. ft. EDR Hot Water .................. 2.50 $ OIL BURNER—to 3 gal. per hour ........................ 5.00 $ over 3 gal. per hour—See Fee Schedule GAS BURNER (up to 400,000 BTU) ....................... 5.00 $� 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 $ ,rAIR CONDITIONING $ '-FAN HEATING SYSTEM See Fee Schedule ,VENTILATING SYSTEM, $ ALTERATIONS & REPAIRS TOTAL FEE $� ROUGH FIN Dept. of Bldgs. Phone SII 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 applicationtt an d t. . Fridley, Minn 1 19 Owner Kind of Used as ' JAN 8 To be completed about Estimated Cost, $ . ew. wilding Permit No. Permit No. DESCRIPTION OF WORK HEATING fir, Warm Air—No- Trade Name—.A �' o'e� Size No—,/,A Capacity Sq. Ft. E.D.R ® BTU H.P. Total Connected Loa Kind of Fuel BURNER — Trade Name Size No G�9 de �s Capacity Sq. Ft. E.D. 1� s-`�y. TU H.P. G�mO. �2�WICK HTG. & AIR -CONN. CO 1001 Xenia Av. S. Minneapolis id, Minn. Signe By �? yg 42 2M Business Phone (REMARKS—OVER) D-56 . y % / 1) CT -4(9 VV HEAT LOSS CALCULATIONS DEPA1tTMENT OF BUILDINGS ' MINNEAPOLIS, MINK. Weatherstrips A•S.H.V.E, Construction No. Insulation Guide Windows I Doors Reference Out. Wall Int. Wall Ceiling Roof 1+1oor Kind How. Applied Yes—No Yes— 0 19` F1.1 Et4 TRY Room I Length (a fe Width Height Windows and Doors—Crackage and Area Width Height No. of Lineal Y . Area No. of pane of pane lights of crack sq. ft. Coef.I Btu Infiltration I Iff 1 3RI '791, Glass 90 kol i0ou Exp. wall K U Net exp, wall 3 .2 Int. wall Ceiling Floor Z ,1072 Total Btu. �, Required sq. ft. E.D.R. or sq. ins. W.A. Leader area 1 Fla JJ6 Room! Length to Width y Height " Windows and Doors—Crackage and Area ac�rack 9 a - WidthHeight No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. 24 4 9 52 14 % Q Width Height No. of Lineal ft. Area No. of pane of pane I lights of crack sq. ft. 4-3 ICoef.1 Btu Infiltration 1 5q 9.. Glass 4 1 Exp. wall '!3 q qv219 Infiltration, Net exp. wall 9 Int. wall Glass Ceiling . '® Floor -*' 13 Exp. wall 2-5 yc 1Z . Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area F1.1 n 1 L P 5 h N f Room I Length i HWidth 43 Heiaht a Windows and Doors--Crackage and Area Height Width Height No. of Lineal ft. Area No. of pane of pane lights of sq. ft. ac�rack 9 a - Width Height I No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. 10 % Q Width Height No. of Lineal ft. Area No. of pane of pane I lights of crack sq. ft. 4-3 JCoef.j Btu Infiltration �� Glass 4 q 1 Glass Infiltration, 13 39 Exp. wall 9 Glass Ceiling '® Net exp. wall Exp. wall 2-5 yc 1Z . 1,;-o Int. wall Net exp. wall 17c 91 Ceiling Int. wall Floor v Ceiling Total Btu. ft. E.D.R. or so. ins. W.A. Leader area F1.1 IC - tj) blRoom I Length 17 k' Width Height Windows and Doors—Crackage and Area Height Width Height I No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. 10 % Q Width Height No. of Lineal ft. Area No. of pane of pane I lights of crack sq. ft. 4-3 Coef. Btu Infiltration Glass 4 q <70g q 5,0 Exp. wall i ie Infiltration, Net exp. wall 39 Int. wall Glass Ceiling '® Floor J `� ie Exp. wall 2-5 yc 1Z . Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area I 11 F1.1 IF 1 15 ED Room I Length ''r Total Width ley Height Windows and Doors—Crackage and Area Width Height No. of Lineal ft. Area No. of pane of pane I lights of crack sq. ft. 4-3 �j q q j { q I Coef. Btu Infiltration, 39 l Glass 3 '® 1700 Exp. wall 2-5 yc 1Z . 1,;-o Net exp. wall 17c 91 1 r3 0 Int. wall Ceiling Floor ( 2-S113– -S`13– Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area FI.I 3 V & J(Room I Length 61 Width 41 Windows and Doors—Crackage and .Area Width Height No. of Lineal ft. Area No. of pane ofpane lights of crack Q. ft. i iC 4 1 � � Height Btu Infiltration 1 13 1 494 Glass /0 Exp. wall Z Net exp. wall Int. wall Ceiling Floor 9c ,f Total Btu. PAE Required sq. ft. E.D.R. or sq. ins. W.A. Leader area Ddb 7 s +y e HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS MINNEAPOLIS, MINN. Weatherstrips A.S.H.V.E. Construction No. Insulation Guide Windows Doors Reference Out. Wall Int. Wall Ceiling Roof Floor . Kind How. Applied Yes—No I Yes—Vo 19— rl.1 room I Lengtn wtaar v rnelgnt Windows and Doors—Crackage and Area sacaLr aaa Width Height No. of Lineal f . Area No. of pane of pane llghts of crack sq. ft. Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. I/ j4q 19 Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. u 1q 1 33 Coef. Btu Infiltration Coef. Btu Glass Coef. Exp. wall Infiltration I Ll I Net exp. wall I Ssl Int. wall Glass Ceiling Net exp. wall Floor qy(1, 1 Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area i _a . o %ff _,. - .. `l f r . , _ A`L aaa 1 ar ts.aa r t v—.. G. u{ — sacaLr aaa Windows and Doors—Crackage and Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. I/ j4q 19 Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. u 1q 1 33 Glass Coef. Btu Infiltration Coef. Btu Infiltration I Ll I x I Ssl 1 S !g= ,g Glass Floor Net exp. wall f (r„'so Exp: wall Int, wall Net exp. wall (o ` t S"O Int. wall Ceiling Floor jq9 ig 10? 153 1. lk Total Btu. 110 Required sq. ft. E.D.R. or sq. ins. W.A. Leader area P 1.1 04' 3 L3 ED Koom ILength 1%7 Width 40 f Height Windows and Doors—Crackage and Area Windows and Doors--Crackage and Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. I/ j4q 19 Width Height I No. of Lineal ft. Area No. of pane of pane lights of sq. ft. ss��crackk d " 4 a Glass Coef. Btu Infiltration Coef. 3 Glass x so 1 t o o Exp. wall & y, Floor Net exp. wall c Exp. wall t Z le Int, wall Ceiling Floor f i 1 * ILI 16 Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area F1.1 % ED Room I Length 12-1 Width (C)7 Width Height No. of Lineal ft. Area No, of pane of pan. lights of crack sq. ft. Height Windows and Doors--Crackage and Area Width Height I No. of Lineal ft. Area No. of pane of pane lights of sq. ft. ss��crackk d " 4 a Glass Exp. wall Coef. Btu Infiltration Int. wall 38 10(04 Glass Floor c Exp. wall t Z le Net exp. wall Int. wall Ceiling Floor Z Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area F1.1 Room ( Length Width Height Windows and Doors—Crackage and Area Width Height No. of Lineal ft. Area No. of pane of pane lights of crack I sq. ft. Infiltration Glass Exp. wall Net exp. wall Int. wall Ceiling Floor Total Btu. Required sq. ft. E.D.R. or sq. itis. W.A. Leader area F1.1 Room I Length Width Height Windows and Doors—Crackage and Area Width Height No. of Lineal ft. Area No, of pane of pan. lights of crack sq. ft. Coef. Btu Infiltration Glass Exp. wall Net exp. wall Int. wall Ceiling Floor Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area City of Fridley Application for Plumbing and C�x Ming Perndt Dept. of Bldgs. Phone SII 4-7470 DESCRIPTION OF WORK �! -1/ n/� m oNumber, Kind and Location of Fixtures I'��"" `/" PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TTO�AL® Number Fixtures ...................... x $1.50 $ / Future Fixture Opening ................ ,7Z�� � f[ O New Fixture Old Opening .............. 1�2 =Z U <3 O�- OSn OO P •TR. N WA -M H• GAS ELEG Base 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 $ 0 lot 2nd 3rd 4th • jr, Connection Openings a New Fixture, Old Openings I Conceded with Sewer E] Cesspool E] PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TTO�AL® Number Fixtures ...................... x $1.50 $ / Future Fixture Opening ................ 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 C) City of Ffidley: The undersigned hereby .makes application for a permit for the work herel. specified, agreeing to do all work in strict accordance with the City Ordinance and ruling of the Department of Buildings, and hereby declares that all the fact and representations stated in this application are true and correct. Fridley, Minn ® a 19AU Owner Kind of Building Used as To be completed about Estimated Cost, $ Old—New. Building Permit No 'e Permit No. Signe By Business PhoZe Noe- 4--- ROUGH—j6– X S� FINAL 42 $N1 City of Fridley AT THE TOP OF THE TWINS SUBJECT BUILDING PERMIT P I �---- 2 3 8 Ir COMMUNITY DEVELOPMENT DIV. r I L PROTECTIVE INSPECTION SEC /'--ICITY HALL FRIDLEY 55432 �.; 612-571-3450 RECEIPT NO. �/ 30 1 ' / NUMBER 910-F15 REV DATE 8/7/95 PAGE OF APPROVED BY JOB ADDRESS 1445 Windemere Drive NE I LEGAL DESCR. LOT NO. ] BLOCK 1 TRACT OR ADDITION Innsbruck 2nd Addition SEE ATTACHED SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Bud/Phyliss Erickson 1445 Windemere Drive NE 571-1193 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Deck & Door Co Inc 11632 Akron Ave E, Inver Grove Hgts 55077 451-3192 5457 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 ❑ NEW7 ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Construct a 12' x 11'6" Deck (Remove existing deck) 9 CHANGE OF USE FROM TO STIPULATIONS See notations on plan. 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 AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION ZONING SQ. FT. CU. FT. 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 ] ISTALLS 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 $1,385 @@ $.69 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- STRUCTIO R THE PERFO MANCE OF CONSTRUCTION 33.00 Fire SC $1.39 i PLAN CHECK FEE TOTAL FEE 35.08 SIGNATURE OF CONT RACTOR OR RIZEDAGENT (DATE) WHEN PROPER Z BL ot IN SP VALIDATED THIS IS YO R PERMIT w (5A'TE _ SIGNATURE OF OWNER OF OWNER BUILDER] IDATEI NEW j j Effective 8/l/95 ADDN CITY OF FRIDLEY ALTER f j SINGLE FAMILY AND DUPLEXES R-1 AND R-2 4-3017 Building Permit Application Construction Address: 124 61 - Legal Description: — Owner Name & Address: a;y Jl r z IZS �i Tel. # - 7! - �2 Contractor: d�dz42 d =cam Do �a �� C� /iv e _ MN LICENSE # 5 �S, # Address:-//(. l�i 3 )- e<tZ0,tW Au. r' iy�� c ��e��m,� �e�ris .+� Tel. J'�5 �- LIVING AREA: GARAGE AREA: DECK AREA: OTHER: Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT Length Length Length_ Width. Height - Width Height Width ZZ ' 4`Hgt/Ground c3' Sq. Ft. Sq. Ft. Sq. Ft. f yc sr.ri�> i3ss. S Comer Lot [ ] Inside Lot [4 Ft. Yd Setback Side Yard Setbacks Type of Construction: 146141+iii = Estimated Cost: $ � v — Approx. Completion Date: ciz 1 /'7 oz�v a (Cost on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ DATE: — APPLICANT: CITY USE ONLY Tel. # Permit Fee $ , ®� Fee Schedule on Reverse Side Fire Surcharge $ .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge $ $850 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 $ STIPULATIONS: GEORGE E. HOPKINS o Registered Land Surveyor and Civil Engineer Phone SO. 1-8856 1'0701 Nicollet Avenue South Minneapolis 20, Minn. PLAT. OF SURVEY t Scale 1 inch — 4 0 feet PROPERTY of Gl /1fy %/�i ��ti'! G'. YI O O!1 -- •� G f 4 ff i�F /(l,,—'i Described as Lot 1 Block 1, Innsbruck 2nd Addition �l DR1VE i •to ' 01 'ode'no}es aron nlonumen� a ;J J35^'} T'' 5 ! a,C y `+,^ x T,y�. A • .k„ .+•9, T� S r �a�la-`' �"S K� f''N ». a 4r v v ' t :;xhe r .This *' Vay. bac made ,and certifi�hte dra for tbs rposse� of ysholiting bourid&Aiii 'of the lot . widthe' eaeement` ol, rimeme There are` no'Fencraachmenta." z a tr a"r:: Buiii� $ weie Plot Set b3f ze j�a r C :r r n { s 4�+f ..x � �' : ` CERTIFICATS�'�OtF SURVEY,:" , ;. ��,�.:ff�t , �c �`''�fdis&�; °,'t �'� •�ghdA' � �,.��';x, � 2 7 ,,,, , . + , I herby .eettif�'°"tha on • : r 395 � 9ad tete r , ; 9'-1 1°� DECK TO FIT S❑ THAT POSTS COVER EXSISTING HOLES IN SIDING DECKING TO BE 5/4 CEDAR STAMPED HEARTWOOD LAID DIAGONALLY ALL RAILS MEET UBC REQUIREMENTS FOR 1995 4" DC PICKETS JOISTS ARE 2X10 TREATED 16" ❑ C 40 RET BEAMS ARE 2-2X10 TREATED NAILED LEDGER IS FLASHED AND LAG BOLTED AT HOUSE POSTS ARE 6X6 TREATED CGA 60 RET JOIST HANGERS AS REQUIRED T FLAG BOLT 3/8" X 4" 16 ❑,C, DE .STAIRS MEET 1995 UBC REQUIRMENTS 8" MAX RISE os FROST FOOTING A=12 B=12 C=12 D=12 E=12 F=12 DEEP >E AS REQUIRED POST JCRETE BASE I L AMEi Cl\ACRD\DRAWINGS\ERICKSON,DWG DATE+ JUL 10, 1995 TIME: 2.50 AM I - - - - ' I 14,'+D vvilvutmtmt UK 11 RAIL HEIGHT 36`` SPACING ON PICKETS IS LESS THAN 4" ALL PARTS ARE MADE FROM CEDAR TOP CAP IS A 2 X 6 STANDARD RAIL DESIGN 7fi7tj CITY OF FRIDLEY INSPECTION DIV, 6431 University Ave NE Fridley, MN 55432 572-3604 '�— -2C3�W (. Effective On August 1, 1995 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES Residential mace 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_,Z/ 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 true and correct. ,1995 $10.00 $ OWNER $ 10.00 $ $ 10.00 $ $ 25.00 $� $ State Surcharge TOTAL FEE e MINIMUM FEE FOR ANY HEATING/COOLINGNENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00 PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $42.00/Hr *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. BUILDING USED AS���`'� ESTIMATED COST PERMIT NO. No. of Heating ttnhs_ Circle One (Steam) (Hot Water) (Warm Air) Trade Name C . .. ��i v� Size No. BTU > HP EDR Fuel~ Total Connected Load Burner Trade Name Size No. BTU HP Sharp EDR Heating and A ditloning 4854. Central Ave. NE Columbia Heights, ISN 55421 HEATING COM ANY (6,2: 57 2 - QA s4 Signed Tel No. t E t h—In Date Final Date Approved B, Rough g I FILL OUT BACKSIDE F STACK VERIFICATION. ON REPLACEMENT FURNA, E CHIMNEY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack: 1. Has been carefully examined Yes (} No ( ) 2. Is free from rust or deterioration Yes () No ( ) 3. Has no foreign objects lodged within Yes O 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 8. Has combustion air been provided for water heater Remarks: List ALTERATIONS Being Done: HEATING CO: Signed By: Date: Yes () No ( ) Yes () No ( )