PRE 2010 DOCSCity of Fridley, Minn.
'BUILDING E I N� a
Date:
i
Owner:4 Builder
Address _ .._ Address
W11CA F BUILDING
icv
No. !�. Street ___�_ Part of pt
Lot Block ___ Addition or Sub -Division + `
Corner Lot Inside Lot Setback �- _ _ ____ Sideyard
Sewer Elevation
Foundation Elevation
DESCRIPTION. OF BUILDING
Front Depth Height Sq.
-- -_ t Depth eight _ Sq. Ft. __ _. Cu. Ft. _
Type of Construction _ Est. ""'.✓To be Completed _
In consideration of the issuance to me of a permit to construct the building ,described 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 $ s , 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
within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances. 14 ..1
NOTICE:
This permit does not cover the construction, installation for whh% plumbing, gas heating, sower or water. Be sure to see
the Building Inspector for separate permits for these Rens.
4
APPIIMM SUBJECT TO COx FOR -MLI CE
TO AFPLICADLE CODES MID 0FDr__,rULTCLS -
BU 2LDRTG COil
CITY OF F EY,f±F@Mf0N FOR BUILDING PERMIT
CITY OF FRIDLEY# MnmsOTA
G%�/�`il 9�
Owner's Name /�.,�_ Pilder
Addres
®v V r/"/-
.- LOCATION QF BUILDING
� 7y
No* Streefi� �� Fart of Lot
$ ... �+.
..Block °r7 Addition or Subdivision�zA
.�.
Corner Lot�&' Inside Eot Setback L Side Yard
SLrVMR ELEVATION FOUNDATION ELE� T:101q
Applicant attach to this form Certificate of survey of Lot and
proposed building location.
DESCRIPTION OF BUILDING
To be used ass
Front,Depth .Z Heights
sq. S t . LCU. Ft,�-
Front_______ Depth Height
sq. Ft. Cue Vt.
Type of Construction _Estimated Cast
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 ruling of the Department of Build-
ings, and hereby declares that all the facts and representations
stated in this application are true and correct
(Schedule of Fee Cots can be found on the Reverse side).
City of Fridley
Application for Plwnbing and Gas Fitting Permit
Dep:. of Bldgs. Phone SII 4-7470
DESCRIPTION OF WORK % ®�
Number, Kind and Location of Fixtures Location
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: O. RATE / TOTAL
Number Fixtures x $1.50 e ® (-)
Future Fixture Opening ................ x
New Fixture Old Opening .............. x
Catch Basin ............................ x
Water Heater (Up to 200,000 BTU) ...... __�" x
New Ground Run Old Bldg . ............ x
1.20
$
1.00
$
3.25
$
2.00
$ ;23 � d
3.25
$
w
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Y
Z rz
Z
pp
tT3 Z
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Z
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.
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t
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b
N
WATER HTR.
GAS
ELEC-
U' O
Base
.2
1st
2nd
3rd
4th
' Future Connection Openings
Connected with
Sewer
New Fixture, Old Openings I
JJ
Cesspool El
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: O. RATE / TOTAL
Number Fixtures x $1.50 e ® (-)
Future Fixture Opening ................ x
New Fixture Old Opening .............. x
Catch Basin ............................ x
Water Heater (Up to 200,000 BTU) ...... __�" x
New Ground Run Old Bldg . ............ x
1.20
$
1.00
$
3.25
$
2.00
$ ;23 � d
3.25
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................
x $1.50
$
Additional Fixtures ....................
Gas Range to 200,000 BTU
x .50
x 2.00
$
$
..............
REPAIRS & ALTERATIONS --Refer to Code
Description ................................................. $�
TOTAL
i
City of Fridley:
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 a true and correct.
Fridley, Minn lJ� 19ce-.
., r 10% 1 It
Owner
j
Kind of Building
Used as�.�
To be completed about
Estimated Cost, $ aa eze",
Old New. uilding Permit No Permit No.
Signe
By
Business Phone No
ROUGH ' S �-
FINAL
Application for Power Plants and Heating. Cooling, Ventilation. Refrigeration and
Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE Dept. of Bldgs. Phone SU 4-7470
GRAVITY WARM AIR: RATE TOTAL Location G O
Furnace Shell & Duct Work ........................... 8.00 $
Replacement of Furnace ............................. 5.00 $ City of Fridley:
The undersigned hereby makes application for a permit for the work herein
Repairs & Alterations—up to $500.00 .................. 5.00 $ specified, agreeing to do all work in strict accordance with the City Ordinances
Repairs & Alterations each add. $500.00" '" " " " " ' 2.50 $ and ruling of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
MECH. WARM AIR
Furnace Shell & Duct Work to 120,000 BTU ............ 8.00 $
each add. 60,000 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
Xurnace Shell & Lines—to 400 sq. ft. EDR Steam ..... 8.00 $
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ... 8.00 $
Each add. 200 sq. ft. EDR 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 $ S" G O
GAS FITTING FEES: NO RATE TOTAL
1st 3 Fixtures ...................... $1.50 $
Additional Fixtures . ............... x .50 $
Gas Range to 200,000 BTU ........... x 2.00 $
AIR CONDITIONING $
FAN HEATING SYSTEM See Fee Schedule
VENTILATING SYSTEM $
ALTERATIONS & REPAIRS TOTAL FEE $ I Ste'
ROUGH
FINAL
Owner
Kind o:
Used as !7'
To be completed about R --'36 'Ire Z_
a-c3�
Estimated Cost, $ :;!00
New. Building Permit No. tf 141 Permit No. !:>C
DESCRIPTION OF WORK
HEATING or POWER PLANTS -Steam, Hot Water, Warm Air—No 1
Trade NamPa2z-"4��- Size No-
Capacity
o Capacity Sq. Ft. E.D.RTi7 0 BTU A.P.
Total Connected Load -7 34 72 r L7 Kind of Fuel
BURNER — Trade Name Size No
Capacity Sq. Ft. E.D.R BTU H.P.
ADVANCED
HEATING i AIR CONDITIONING, INC.
4709 & E. RAIN STREET
Mil. °APOUS 21, MINS..
Signed 7$G. C,57a
sy
(REMARKS -OVER)
gy42 2M Business Phone No.
D•56 a z
HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS FRIDLEY, MINN.
Weatherstrips A.S.H.V.E. Construction No. Insulation
Guide
Windows I
Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kind How Applied
Yes—No Yes—No 19._
iz Fl.l/_ ° /ter,` Room Lensth�/" rt Width) ev '/Height lw of II r Fl_I I . I. _ f�..o Room l Length � �� "Width .,er!.a
Windows and Doors—Crackage and Atea
v
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
G� Vacl 3
2— 7— 33
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. it.
Z- aP
Coef. Btu
Coef.
JCoef.l Btu
Infiltration
Btu
p
5, Lo
qo 1,060
Glass
�^^®
Exp. wall
Net exp. wall
a
Exp. wall
Net exp. wall
Int. wall
Ceiling
Exp. wall
Net exp. wall
Ceiling
g p
Ceiling
Int. wall
/g J
/d
'900
/0
Ceiling
y
Floor
Ceiling
v
1 otal Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
A FI.I/V J /?',o,(Room I Lengthy; '., # Width/ z_'-I.?Height R -A �r
Windows and Doors—Crackage and Area
v
Width Height No. of Lineal ft. I Area
No. of pane of pane lights of crack sq. ft.
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
2— 7— 33
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. it.
Z- aP
Coef. Btu
Coef.
Btu
Infiltration
Btu
o
5, Lo
Glass
Exp. wall
�^^®
Exp. wall
Net exp. wall
a
16 44-t7
Net exp. wall
Int. wall
Ceiling
Exp. wall
Int. wall
Ceiling
g p
Ceiling
Floor
/g J
/d
'900
1 otal Btu. Z�
Required sq. ft. E.D.R. or sq. ins. WJL Leader area
J Room 1 Lengthy s °P, Midth 9 4,, 7 Height Sri .0 A er
Windows and Doors—Crackage and Area
v
Width Height No. of Lineal ft. I Area
No. of pane of pane lights of crack sq. ft.
f 4dth Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
2— 7— 33
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. it.
Z- aP
Coef. Btu
Coef.1 Btu
Infiltration
T,
Btu
Vol
Glass
Exp. wall'
5-01d
Exp. wall
Glass
p
Int. wall
Net exp. wall
Ceiling
Exp. wall
Int. wall
Floor
g p
Ceiling
Net exp. wall
/d
Floor
/0
,� Z
y
1 btal btu.
nequtrea sq. it. nai.m. or sq. ins. W.A. Leader area 1
:.gyp/I
Windows and Doors—Crackage and Area
v
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
f 4dth Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
2— 7— 33
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. it.
Z- aP
Coef. Btu
Infiltration
Coef.
Btu
Infiltration
S-0 9 Q
Exp. wall'
YC'
2
Glass
p
Int. wall
Net exp. wall
Ceiling
Exp. wall
Int. wall
Floor
g p
Ceiling n
Net exp. wall
/d
2
/0
,� Z
Int. wall
Ceiling
p
Floor
Total
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
1, Ell /Voll c % ra _
Windows and Doors--Crackage and Area
v
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
2—
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. it.
Z- aP
Coef. Btu
Infiltration
yo T
Glass
7
S-0 9 Q
Exp. wall'
® �
v
Net exp. wall
p
Int. wall
Net exp. wall
Ceiling
f g
Int. wall
Floor
Total
rs:
1 otal lata .L 4
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
... I .......e..
�.e... P --v
Windows and Doors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. it.
Z- aP
Coef. Btu
Infiltration
Glass
® �
v
Exp. wall,
Net exp. wall
io
lla
Int. wall
Ceiling n
/d
Floor
1 otal lata .L 4
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
Ddb 1 a z
HEAT LOSS CALCULATIONS DEPARTMENT OF BUILDINGS
Weatherstrips A.S.H.V.E. Construction No.
Guide
Windows( Doors Reference Out. Wall Int. Wall Ceiling Roof Floor
Yes—No Yes—No 19_
.11 FO r. r ,....,Room l Lenstth/i ,'Widths? t. ,n "f f Height ji ' q 'r'lI R.l
Windows and oors—Crackage and Area
Width Height No. of Lineal ft. Area
No. of pane of pane light,, of crack sq. ft.
1 It P rr I �d �L
1 LQ
Coef.1 Btu
Infiltration ®
&'-,v
Glass
Exp. wall
Btu
Net exp. wall
Int. wall
�y
Ceiling
Glass
Floor
2
1 otal Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
J1JF1.1 ,Q- rl-n 1/Room I Length.*,.'-A'rWidth x-',, It Height
Windows andboors--Crackage and Area
Width Height No. of Lineal ft. Area
No. of Dane of pane lights of crack sq. Lt.
Width Height No. of Lineal ft. Area
of pane of pane lights of crack sq. It,
VX.o.
' 7 I 0
Coef. Btu
Infiltration
Coef.1
Btu
Infiltration
Net exp. wall
�y
0
Glass
Ceiling
2
2-
a O
Exp. wall
Net exp. wall
Int. wall
1,03
0
Ceiling
94
/®
Floor
1 otal titu.
Required sq. ft. E.D.R. or sq. ins. 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 Dane of pane lights of crack sq. Lt.
Coef. Btu
Infiltration
Glass
Exp. wall
Net exp. wall
Int, wall
Ceiling
Floor
1 btal titu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
Kind
Room
Windows and Doors—Cracl
Width Height No. of
No. of pane of pane lights
FRIDLEY, MINN.
Insulation
How Applied
Width Height
and Area
meal ft.Area
'crack sq. ft.
.--
Coef. Btu
Infiltration % —
Glass 2 p
Exp. wall
Net exp. wall
Int. wall
Ceiling
Floor
Total Btu.
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
Width Height No. of Lineal ft. Area
No. of pane of pane lights of crack sq. ft.
Coef. Btu
Infiltration
Glass
Exp. waU
Net exp. wall
Int. wall
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. WA. Leader area
Fl.l Room I Length 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
1 otal titu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
H. STIPULATIONS (List): DATE REQUIRED DATE COMPLETED
I. MISCELLANEWS:
BAY Summm S M
QTY OF FRIDLEY, HINNESDukoZ
jf�e1
ADDRESS AM LWAL DESCRIPTION.
'
OwNEWCONTRACT
OOKSTRUCTION DATE: ADDITIONS:
CERTIFICATE OF OCCUPANCY ISSUED: YES NO DATE
A.
ZONING ACTION: ORDINANCE NO:
B.
SPECIAL USE PERMIT(S):
C.
IDT SPLIT (S) :
D.
VACATION (S) '"24 (� ! ORDINANCE NO:
E.
VARIANCES
APPEALS COMMISSION: APPROVED DISAPPROVED • DATE
NO.
CITY COUNCIL: APPROVED DISAPPROVED DATE
ND.
F.
EASEMENT'S: REQ'D DEPT
RBC'D
Bikeway/walkway
Street right-of-way
Utility
Drainage
Alley
Other (Specify)
G.
LICENSE(S) (List): Date of Renewal:
H. STIPULATIONS (List): DATE REQUIRED DATE COMPLETED
I. MISCELLANEWS:
SUBJECT
PER JJT_N.O._
City of Fridley
y
27545
AT THE TOP OF THE TWINS
BUILDING
PERM I T
-Rs PT-N-
_ COMMUNITY DEVELOPMENT DIV.
v PROTECTIVE INSPECTION SEC.
NUMBER
REV
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
612-571-3450
910-F15
19/2/98
JOB ADDRESS
6061 2nd Street
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
29 30
7
d
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Herb Aaker
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
Tachenv Roofing Inc. 49 Owasso Bl494-1466
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 jj REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK four- lex
Reroof lsmxsiEx= 23 SO 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
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
1971
.98
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STAT -OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFO CE OF CONSTRUCTION.
62,25
$1.9,7
PLAN CHECK FEE
TOT FEE
.20
SIGNATURE OFON CTORORAUTHORIZEDAGE T MATEI
HENMPFJLID
THIS ISjr'QIJIRSIGNATURE
-
OF OWNER IIF OWNER BUILDER, (DATE,
BL N
MATE
Prepaid Plan Check $
Estimated Cost $
Receipt #
Effective 1/1/98
CITY OF FRIDLEY
R-3, COMMERCIAL & INDUSTRIAL a�
BUILDING PERMIT APPLICATION
Construction Address (Po (jZomig
Legal
Owner & Address
CONTRACITOR & ADDRESS
Architect
Tel#.
j2ookmciTNS j Oyu,. 31 c) Lf -:"Pele'aq 14(
Reg.# Engineer Reg.#
BUILDING CONSTRUCTION
TYPE OF WORK [] New [] Addition [] Alteration-pescribe
_Q��...
OFC. AREA: Length
Width
W[M AREA: Length
Width
OTHER AREA: Length
Width
Height
Sq. Ft.
Height
Sq. Ft.
Height
Sq. Ft.
APPLICANT Tel # '04-14fo Date
Sq. Ft. x $
Sq. Ft. x $
Sq. Ft. x $
Building Use
Air Conditioning [] Yes [] N
Performance Bond Amount $
Pezmit Fee
Plan Check
Fire Surcharge
State Surcharge
SAC Charge $
Erosion Control $
Park Fee 1 $
Spec. Assessments $
VALUATION
Cost/Sq.
Ft. =
Valuation
$ )
Cost/Sq.
Ft. =
Valuation
$ )
Cost/Sq.
Ft. =
Valuation
$ )
Construction Type C+� Occupancy Group
o Fire Protection govided [] Yes []No
Driveway Escrow $
T07MLAL $ �. •�
VALUE
See Reverse for Schedule Received []Yes []No
See Fee Schedule on Reverse Side
In Excess of Prepaid Amount - See Reverse Side
.001 x Permit Valuation (1/10th a)
$.50/$1,000 Valuation (See Sched. for > $1 Million)
$1000 per SAC Unit (Plans to MCC for determination)
$450.00 Conservation Plan Review
Fee Determined By Engineering
Agreement Necessary [] Not Necessary []
feet x $13.50/foot
ATTACH STIPULATIONS
6431 University Ave NE
Fridley, MN 55432
(763) 572-3604
�v IQN UIV. utective un Jan 1, zuuz
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT QA
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR
PLUMBING FIXTURE RATES:
New Fixtures
Old Opening, New Fixture
Beer Dispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Water Heater -Electric
Water Heater - Gas**
Gas Range**
NO. RATE
Gas Dryer**
Back Flow Preventer Required ( )Yes () No
Type
Reinspection Fee $47.00/Hr
$ 7.00
$ 4.00
$ 5.00
$ 7.00
$ 7.00
$ 7.00
$ 7.00
$10.00
$ 7.00
$10.00
$10.00
$10.00
$15.00
TOTAL JOB ADDRESS S11-
NE
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.
200
Owner JoWh �
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture or Appliance
State Surcharge .50
Building Used As W 15LILU V
Estimated Cost D _ PERMIT NO. / y
PLUMBING COMPANY, MCGUIRE & SONS
ns, MN 55343 -q �' -� ��
SIGNED BY ff TEL N0.
FAX I� ���
Approved By Rough -In Date Final Date
TOTAL FEE $ PLUS THE $.50 STATE SURCHARGE
COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE
THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLIANCES OR THE
APPLICATION WILL BE RETURNED
(`SIL MON VFNT, VENT QNNFGTOR AND r.01VIRURTION AIR VFRIFIM110N �5
When re la g an avis ingfi rancum, 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 plastictPVC 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 manufacturer's specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances. Yes () No ( )
The exicti nmis,stinn air is sized and installed to meet the current codes
and manufacturer's specifications. Yes () No ( )
When required to install a new _nmh intron air, it will be sized and installed
to meet the current codes and manufacturer's specifications. Yes( ) No( )
When jpgtajlonn a new y _nting 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 #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
HEATING CO:
Signed By: Date: