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PRE 2010 DOCSCity of Frid1gy, Minn. BUILDING PERMIT® s 17 Date: .. /1 Owner: .. ��Builder ..... _.... _........... ..._ _.. _.__........ ....... Address ....__ ... .._. .. _ Address - , '` ?._. e_......._... _.._.. LION OF BUILDING No. ...:. Street ....._ } _. ._ . _... ----- Lot Lot .. ....... - .._ Block ........._........ Addition or Sub -Division .... _...._`f�....___..... CornerLot ........ ................--------- Inside Lot ..... .............. _................. Setback .............. ::......... ................ Sideyard..... ........ ...... _............................ .............. ............ Sewer Elevation....._............._............._......._...._..........................._....................._ Foundation Elevation DESCRIPTION OF BUILDING x `�Usea Front .., . :.. Depth ...._ Height . ._.. Sq. Ft. _ Cl �1 Cu. Ft. .......... ............. -............. .......... Front Depth Height Sq. Ft...................... Cu. Ft. ..... _................. Type of Construction Est. Cbst..... -. To be Completed .-- •----- ............._. THIS PERMIT DOE -,S, ,[\1C)h;'A',JTHORI?E VIOLAT- ION OF ANY PI :;',TELi!D COVENANTS AND BUILDING RESTRICTIONS. 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 $.,,�..._ :.....___..., 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 Amy be revoked at any time u olation;�f any of the ero sions of said ordinances. '; Inspector NOTICE: This permit does not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sure to see the Building Inspector for separate permits for these items. APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA Owners Name f, Builder �Address Address ,�, r) � , � �`"t��.�_ ,� � ����-�,s. � �. OF BUILDING No. �' Street ' Part of Lot Lot : Block er Addition or Sub.Div. / i�%' Corner Lot Inside Lot± ° o Set Back � �{� Side -Yard SEWER ELEVATION FOUNDATION ELEVATION Applicant attach to this form Certificate of Survey of Lot and proposed building location. DESCRIPTION OF BUILDING To beZ'C�A' 9_4# W used as: Front L40 D Sq. Ft. J '_/Ij Cu'. Ft. -1 e 4 �..—.-- Front Depth height Sq. Ft. Cu. Ft. Type of Construction �A_,4,. _ Tstimated Ca t�//,. To be 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 representW' tions stated in this application are true and correct DATE .2 SIGNATURE ' (A Schedule of Fee costs can be found on the Revere Side.) i � i I I h - i I ' I I I - I I i i _ I - I I I I I I - I AL I . I { II I �-- I� -y IIZI 1L -i-- I I fi 1 , I I I r ------ i I I I � ---- I I I SUBJECT City of Fridley r�? 14 i H AT THE TOP OF THE TWINS BUILDING P E R M I' f ECEIPT N Lu COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. / CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 612-560-3450 910-F15 10/18/77 JOB ADDRESS 5821 - 2�i Street N. E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 21 22 1 Hyde Park Addition SHEET 2 PROPERTY OWNER MAILADDRESS ZIP PHONE' Sandy Oven 5821 - 211 Street N.E. 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 ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE X 8 DESCRIBE WORK roof and reside front 9 CHANGE QF USE FROM TO STIPULATIONS Roof can be 2nd roof put on but can not be the 3rd. Install ridged galvanized valleys. l 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 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 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. $800 $ r,0 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 PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- 50 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTALFEE $8.00 GNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE) WHEN PROP RLY VALIDATED THIS IS YOUR PERMIT J® �q IUREO WNE 'F OWN UILDERI f (D E) r• BLDG INSFY DATE CITY OF FRIDLEY APPLICATION FOR RESIDENTIAL BUILDING PEWTS (NEW, ALTERATIONS, ADDITIONS, OR REPAIRS) OWNER: SNJ(i 0Aj BUILDER: Address; o-� Address: Tel. No. No.: / Street: LOT: BLOCK: ADDITION: _ CORNER LOT: INSIDE LOT: -=� SETBACK: SIDEYARDS: Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. DESCRIPTION OF BUILDING 1. To Be Used As: Front: Depth: Height: Square Feet: Cubic Feet: Front: Square Feet: Depth: Height: Cubic Feet: Type of Construction: StddA,�— Estimated Cost: $ 6600041!1` To Be Completed: Alt. A Alt. B Proposed Driveway Width If New Opening Is Desired $ $ (SEE REVERSE SIDE OF SHEET) 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. See reverse side Aor additional information. DATE: 10A 9J SIGNATURE: s r� - �. A , Stipulations: '-0 City of Fridley SUBJECT F""Zl AT THE TOP OF THE TWINS BUILDING P E R M I r ` CEIPT NO. COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. q 1 � i CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY j 612-560-3450 910-F15 7/20/78 JOB ADDRESS 5821 - 2h Street N.E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 21 22 1 Hyde Park SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Sandy Oven 5821 - 23 Street N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Miles. Garages 4500 Lyndale Avenue North 588-9750 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 ElREMOVE X 8 DESCRIBE WORK Construct a 16' x 22' Garage 9 CHANGE OF USE FROM TO STIPULATIONS Provide hard surface driveway within one year. Maintain, = 25 foot set back from alley and 3 feet from side lot lines. SEP qTE PERA41TS . . WARMING RE Ui HEATi REO � WIRMG nU. PLUM61t4G $atom -digging cool i0cat utilities %i=lE�1flNE AND SIGN - �LWRIC-- GAS Etc. REQUIRED BY LAW 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 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 I HAVE READ AND EXAMINED THIS APPLICATION 1 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. $21548 $1.27 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 PROVISIONS OF ANY OTHER STATE OR LOCA LAW REGULATING CON- $14.08 ST TION OR THE ORMANC F CON UCTION. Pur LANCHECK FEE TOTALFEE 7 ` A6 -Tv $15.35 _ IGNATUREOFCONTRACTORORAUTHORIZEDAGENT (DATE) H O le RLY VALIDATED THIS IS YOUR PERMIT BLDG. INSP DATE SIGNATURE OF OWNER (IF OWNER BUILDER) (DATE) OWNER: CITY OF FRIDLEY APPLICATION FOR RESIDENTIAL BUILDING PERMITS (NEW, ALTERATIONS, ADDITIONS, OR REPAIRS) S, o ve IV Address: S- 8 c- r No. S �'? ( LOT: a I /Ve Address :> G� ��/l.%fa� f0 Tel. No.: Street: �. % �— S 7— �= BLOCK: DLZZ ADDITION: CT jl'Q CORNER LOT: INSIDE LOT: — a-ZTBACK: SIDEYARDS: Applicant attach -to this form T<ao Certificates of survey of Lot and proposed building location drawn on these Certificates. DESCRIPTION OF BUILDING To Be Used As: e � e Front: Depth: Height: 1 r Square Feet: �� Cubic Feet: Front: Depth: Height: Square Feet: Cubic Feet: 7,ype of Construction:Estimated Cost: $ To Be Completed: � � � Alt. A Alt. B Proposed Driveway Width If New Opening Is Desired $ $ (SEE REVERSE SIDE OF SHEET) 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. See reverse side for additional info ion. DATE: 11 -%P SIGNATURE: Stipulations: •o /Le�� ��� 0 SUBJECT PERM+T N@ _< City of Fridley £"®2 2 6 7 6 AT THE TOP OF THE TWINS BUILDING PERMIT _ r � RECElPTNO.� COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. r � 1 "'1 CITY HALL FRIDLEY 55432 NUMBER REV GATE PAGE Of APPROVED BY it", 11'j 612-571-3450 910-F15 I I ..t 7 / 12 / 94 � JOB ADDRESS 5821 2 1/2 Street NE 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 21 22 Hyde Park SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Gordon Wax 5821 - 21 Street NE 789-2513 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. 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION ❑x REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof House (7 SQ 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 SO. 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 $525 $.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- $17.00 Fire SC $.53 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE $18.03 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI O 11 LY IDA 'S IS YOUR PERMIT 91 of &NAREOF (yW RiI OWNER BUILDER) IDATEI-Z ;.L DATE 0 NEW. (j Effective 1/1/94 ADDN (] CITY. OF FRIDLEY ALTER (j SINGLE FAMILY AND DUPLEXES R-1• AND R-2 Building Permit Application Construction Address:z1=_=/�� -- ----- — -- --_ Legal Description: _ Owner Name & Address: God jil/ax 61Z- Z2,hJAW 1f Asli MAJ Tel. # Z5-/ 3 Contractor: (y,%T� rh %/a� MN LICENSE # Address: tom/ JU SSY %d Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRiPTION•�bF. IMPRQ��FT. MEi�iT Width Height Sq: Ft** Width Height Sq. Ft. .. Width . HgUGroiind __ $q. Ft: LIVING* AREA: . GARAGE AREA: ..DECK AREA:' OTHER: Length Length Length Comer Lot [ ] Inside Lot [ ] Type of Construction: Approx. Completion Date: Ft. Yd Setback Side Yard Setbacks' Estimated Cost: $ t5-ds— (Cost on Back) Driveway Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: % % APPLICANT: Tel. # ` 0 Z�I� CITY USE ONLY Permit Fee $ 0 Fee Schedule on Reverse Side Fire Surcharge $ .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge $ $800 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 $ o6', 03 STIPULATIONS: City of Fridley AT THE TOP OF THE TWINS SUBJECT BUILDING PERMIT PERMIT NO. 'f' L. rr _---. COMMUNITY DEVELOPMENT DIV- � PROTECTIVE INSPECTION SEC. r � , CITY HALL FRIDLEY 55432 J 612-571-3450 REC NUMBER 910-F15 REV DATE 8/21/95 PAGE OF APPROVED By JOB ADDRESS 5821 2 1/2 Street NE 1 LEGAL DESCR. LOT NO. 21 BLOCK 22 TRACT OR ADDITION Hyde Park SEE ATTACHED SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Gordon Wax 612 22 Avenue NE, Mpls., MN 55418 789-2513 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 Rental Property 7 CLASS OF WORK n El NEW ADDITION C1 ALTERATION % REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Replace siding on front of house 9 CHANGE OF USE FROM TO STIPULATIONS 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 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 $348 $.50 DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SACCHARGE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION $21.00 FireSC .34 PLAN CHECK FEE TOTAL FEE 21.84 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI PR %.LDG ERLY VALIDATED THIS IS YOUR PE MIT S)GNATURE OF OWNERI IF OWNER BUILDER) IDATEI P f MATE .�:�'�C�.`�ifi"�`�"+;R,^.��:c.:.k`ktitt :K:.2:^n:; at�:nra:-;:;.:;:�::.:::�:ra , , , . ,a�;�atn o,•.wn�; : ; :., .. ,... ,........ . ... ..... .. ...... NEW [ ] ADDN [ ] ALTER [ ] SIN( Construction Address:�- Legal Description: Owner Name & Address: Contractor: 0 wmr Address: Attach lot, wit ` - LIVING AREA: Left9d GARAGE AREA: Lengtl DECK AREA: Length OTHER: Corner Lot [ ] Inside Lot [ ] Ft Type of Construction: ir 5 Approx. Completion Date: lir Effective 8/1/95 -;-6c�7 Driveway Curb Cut Width Needed: .. %P A IL — _ - L •• .P Z APPLICANT: Tel. # CITY USE ONLY Permit Fee $'' Fee Schedule on Reverse Side Fire Surcharge $ .001 of Permit Valuation (1/10th%) State Surcharge Ft. $.50/$1,000 Valuation Ft. $ Driveway Curb Cut Width Needed: .. %P A IL — _ - L •• .P DATE: Z J APPLICANT: Tel. # CITY USE ONLY 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 [ _) /, L TOTAL $ STIPULATIONS: CITY OF FRIDLEY BUILDING INSPECTION 6431 University Ave NE Fridley, MN 55432 763-572-3604 FAX 763-5711287 RATE SCHEDULE Residential Furnace Shell and Duct Work, -Burner & also Replacement Furnace Gas Piping (New Furnace, Fireplace, Insert) Gas Range Gas Dryer *Air Conditioning - All Sizes All Other Repairs or Alterations (List on Back) 1% 4 Value of Appliance or Work Minimum Fee $15.00 for Residential or 5% of cost of Improvement whichever is greater boos - OZ) 73 9 Effective 4/1/2004 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES Fee Total $35.00 $ $10.100 $ $10.00 $ $10.00 $25.00 Commercial/industrial/institutional 1.25% of Value of Appliance or Work (List on Back) Minimum Fee $35.00 for Commercial/Industriai/Institutional State Surcharge TOTAL FEE REINSPECTION FEE $50.00/HOUR JOB ADDRESS 6-6 D I I 5l=EMN 5s 32. Owners E.51 - R -G E- N sl 54 M ^ Building Used As f -k'. 1 - ESTIMATED COST PERMIT NO DESCRIPTION OF FURNACE AND BURNER $ # of Heating Units Circle One (Steam) (Hot Water) (Warm Air) Trade Name Size No. BTU HP EDR Fuel Total Connected Load $ Burner Trade,Name Size No. BTU HPEDR rV1�he 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 HEATING CO -' Heating & AC Inc Sign 763-572-0459 FAX# 763-572-0164 Date *Air Conditioners can not be placed in side yard without written approval from adjoining property owner - copy to City FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE Approved by Rough -in Date Final Date City of Fridley MN FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS COMMON VENT, VENT CONNEC4TOR AND. COMBUSTION AIR VERIFICATION When replacing an existing fwrn_a_ce, the undersigned hereby vermes that the venting has been examined and is free from rust, deterioration, obstructions, and is securely supported and frrestopped where required. Yes 06 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 BTU Input and meets the current codes and manufacturer's specifications. This does Appliance #2 Type include AGA-GAMA Category I Central Furnace Venting Tables for fan Fan Assisted or Nat assisted and natural draft appliances. Yes No( ) The existing combustion air is sized and installed to meet the current codes Total Appliances and manufacturer's specifications. Yes Q() No( ) When required to install a new combustion air, it will be sized and installed manufacturer's Vent Height to meet the current codes and 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 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 13 Vent Connector. Height e ft Length ft Diameter in Type HEATING CO: Signed By.