PRE 2010 DOCSVillage of Fridley, Minn.
BUILDING PEBMIT
0
N . 7 74 Office of INSPECTOR OF BUMDINGS
Owners
Archite /
Builder
Fridley, Minn.
LOCATION F BUILDING
No.rk street f '^* x u Part of Lot
Lot Block Addition or sub -Division
DESCRIPTION OF BUILDING
Front_+ Depth ..'- °-Height-2 stories' ' saner of Construction
To be used as "" To be completed Estimated Coat
p"
Permit is hereby granted to_,,.
the building ' t. -" described in the above statement. This permit is granted
upon the express condition that the person to whom it is granted, and his agents, employees and workmen, in all
the work done in, around and upon said building, or any part thereof, shall conform in all respects to the ordi-
nances of Fridley, Minn., regarding the 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.
Inspector of Buildings.
AGREEMENT AND SWORN STATEMENT
In consideration of the issue and delivery to me by the Inspector of Buildings of Fridley of
the above permit,'' I hereby agree to do the proposed work in accordance with the description
above set forth and according to the provisions of the ordinances of Fridley, and, being first duly
sworn, I hereby state and say that the facts stated by me and contained in the above permit are
true as therein stated.
Subscribed and sworn to before me at Fridley,
day of ( �I 4&t, wa.s A .D. 19
0
Minnesota,,thi�a r ?
•
Date; ! `. ,✓ "�. j�ri► r
Omer Bufder ... 'rw`"r► .... ... ...
Address .. 'sr . r�. Address ......... .
'�
O TIQN OF 'BUILDING
X0..... . st reet ..... .................... ... .. Part of Lot .
Lot B k ..... Addition or Sub Division ..... ..........................
Corner . Lot Inside Lot Setback ` . Sideyard ..'� ..".... .. .. .
DESCRIPTION OF BUILDING
To be Used
'j Front Depth 0. .Y . freight° _ Sq. Ft. ....... Cu. Ft.. ....
dj#
Front Depth . , . Leight Sq. Ft. Ca. Ft. ........
Twpe or Construction I!: d,i + r ..; ..... Est. Cost .... . .. ...... To be Completed ... .
w
i
X ' '" ,►
00
ope
pi
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. villag of Fridley.'
...� .. ...LI
......
h'
.
In consideration of e, payment of a fee of $., 1 ..:. l,- permit is hereby gtanted to
,.to construct the b or addition as desmi , ', c
.............:....... . wilding bed above. �'iTh4a permit is granted upon.
the express condition t the person to whom it is granted and his agents, employees and workmen, in all work
done in, 'around and u said. building, or aril► part thereof,, shall conform in all respects to the .ordinances of
Fridley; Minnesota re9f g itxsrtiota, construction,_ alteratioir, maintenance, repair and movig of buildings with
--
construction,
the village limits ant this permit may be'revoked at any time upon violation of any of the provisions of said
ordinances.
..- Building inspector
{ NOTICE:
This permit does not coverthe construction, Installation or alteration for wirlrl'g, plumbing, gas heating,
t sewer or water. Be lure to Building Inspector tor, separate permits f ase ,items.
j.
SUBJECT
PERMIT NNe -._
City of Fridley
0 19326
AT THE TOP OF THE TWINS
BUILDING PERMIT
• COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
ry�/
1
r
/
}}
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
L , ` 612-571-3450
910-F15
2/19/88
JOB ADDRESS 5860 - 3rd Street N.E.
1 LEGAL
LOT NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DESCR.
1
22
Hyde Park
SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Roger Vanous 5860 - 3rd Street N.E. 571-5365
3 CONTRACTOR MAIL ADDRESS ZIP PHONE
LICENSE NO.
Anerican Remodeling 3700 Annapolis Lane, Mpls. 553-0020
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 Q. REPAIR ❑ MOVE ❑ REMOVE
6 DESCRIBE WORK
Reside. Dwelling
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
1 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 GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
,ORDINANCES
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$4,900
$2.45
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
ROVISIO ANY OTHERS TE OR LOCA AW REGULATING CON-
S R C N O THE P RFO A CE OF UCTION.
$50.50
PLAN CHECK FEE
TOTAL FEE
$52.95
IG TURE OF ONTRACTO AUTHORIZED AGENT (DATEI
WHEN PROPERLY VA TE THIS IIS
YOUR PE MIT
BLDG INSP
aTE ��
SVGNATURE OF OWNER OF OWNER BUILDERI IDATEI
NEW [ ] City of Fridley Effective 4/1/86
ADDN. t R-1 AND R-2
ALTER. [ ] Building Permit Application
Constructii
Legal Desc,
Owner Name
Contractor
IJ
Address: 3 701 AviL/�ed Ze& Gig•
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:
Corner Lot [ ] Inside Lot [
Type of Construction:
] Ft. Yd. Setback
Estimated
Side Yard
Cost: $
Setback
Approx. Completion Date:
Alt. A Alt B
Proposed Driveway Width If New Opening Is Desired: $ $
See Back Page for Explanation
DATE:
Permit Fee
Plan Check
State Surcharge
SAC Charge
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
APPLICANT: Tel. 0 C.'47 .1
CITY USE ONLY
Fee Schedule on Reverse Side
25% of Building Permit Fee
$.50/$1,000 Valuation
$ 525 per SAC Unit
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
G
SUBJECT
City of Fridley
? 4 1 89 :]
AT THE TOP OF THE TWINS
BUILDING
PERMIT
RECEIPT NO.
Ir?
�4
COMMUNITY DEVELOPMENT DIV
�� ------
r i � PROTECTIVE INSPECTION SEC
CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED By
612-571-3450
910-F15
5/17/96
JOB ADDRESS 5860 3 Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
1
22
1 Hyde Park
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP
PHONE
Roger Vanous 5860 3 Street NE
571-5365
3 CONTRACTOR MAIL ADDRESS
ZIP
PHONE LICENSE NO
Midwest Restoration 1628 Hwy 10 NE M
ls. MN 55432
784-2772 5267
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❑
B DESCRIBE WORK
Re lace soffit fascia
9 CHANGEOFUSEFROM
TO
STIPULATIONS
Ventilation to meet 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
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
$692
$.50
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SACCHARGE
PROVISIONS OF ANY OTHER STA E OR LOCAL LAW REGULATING CON-
$
$.69
STRUCTION OR HE AN STRUCTION
PLAN CHECK FEE
TOTALFEE
_
p
License SC $5.00
$32.69
SIGNATURE OF CONIR OR OR AUTHORIZED AGENT ATE)
WHEN PROPEPA VALIDATED THIS IS YOUR PERMIT
8 )NSP
r
BATE
SIGNATURE OF OWNER OF OWNER BUILDER) )DATE)
NEW [ ] Effective 3/1/96
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
Building Permit Application
ConstructionAddress:t>
Legal Description:
Owner Name & Address: v ��lp�� Tel. #%/
Contractor: ` ip��s•�' �� /rte—�� MN LICENSE # 5 ; 7
Address: / D Tel.00,
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: Le4gth Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER:'';8�.F� .4eLa=mfg-'
Comer Lot [ ] Inside Lot [ ]
Type of Construction:
Approx. Completion Date:
Ft. Yd Setback Side Yard Setbacks
Estimated Cost: $
(Cost on Back) dD
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x
DATE: 7 9 APPLICANT -
Tel.
CITY USE ONLY
Permit Fee Fee Schedule on Reverse Side
Fire Surcharge $ ,
State Surcharge $ • 150
SAC Charge $ _
License Surcharge $ '57 C
Driveway Escrow $
Erosion Control $
Park Fee $
Sewer Main Charge $
TOTAL $�
STIPULATIONS:
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$900 per SAC Unit
$5.00 (State Licensed Residential Contractors)
Alt. "A" or Alt. "B" Above
$450.00 Conservation Plan Review
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
01
SUBJECT
City of Fridley
=2�
AT THE TOP OF THE TWINS
BUILDING
PERMIT
r
RECEIPT NO.
COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
I
NUMBER
REV
DATEPAGE
OF
APPROVED By
=
1 '0 ... I CITY HALL FRIDLEY 35432
,''
612-571-3450
910415
4 /15/99
10B ADDRESS 5860 3 STREET NE
1 LEGALLOT
NO.
BLOCK
TRACTOR ADDITION
SEE ATTACHED
DESCR.
1
22
HYDE PARK
SHEET
2 PROPERTY OWNER MAIL ADORES$
ZIP PHONE
Roger Vanous 5860 3 Street NE
571-5365
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO
Midwest Restoration 6319 Hwy 65 NE, Fridley, MN 55432 502-1082 5267
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 j] REPAIR O MOVE ❑ REMOVE
B DESCRIBE WORK
Reroof House & Garage (12 Sq) Tear -off
9 CHANGE OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
CONSTRUCTION WORK HOURS: 7:00 am to 9:00 pm, Monday
thru Friday; 9:00 am to
9:00 pm on Saturday; No work on Sunday.
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
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 1 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 13E COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$1,028
$ •51
DOES NOT PRESUME TO GIVE AUTHORIT TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR OCAL LAW REGULATING CON-
$37.50
Fir"C $1.03
STRUCTION OR TH RFO UCTION
PLAN CHECK FEE
TOT FE
L e C
$5.
$4 .04
SIGNATURE OF CONTRACTOR AUTHORIZED AGENT IDATEI
ENR
A DAT 5 IS Y PE IT
.�
0
SIGNATURE OF OW NER ,If OWNER BUIIDER� IDATEI
9l INSP
BATE
01
NEW [ ] Effective 1/ 1/99
ADDN [ ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION 0A L
ConstructionAddress
Legal Description:
Owner Name & Address:
Contractor:
Address:
Tel. # ,.��%� ,�3G•/r'
MN LICENSE # S-0 G
Tel. #
1—�
Attach to this application, a Certi icate 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:
/ C�timated Cost:
Construction Type: .
hdleonPack)
Driveway Curb Cut Widt?- XT--A-A.
DATE:
(Fee Sc e u
(, Ft = Ft x $ = $
CITY USE ONLY
Tel.
Permit Fee
$ C>
Fee Schedule on Reverse Side
Fire Surcharge
$
.001 of Permit Valuation (1/ 10th%)
State Surcharge
$ m 2_L
$.501$1,000 Valuation
SAC Charge
$
$1050 per SAC Unit
License Surcharge
$ '� r t�l�
$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
$ � 9 I C4
STIPULATIONS:
e6 6,600+ 2" ft o`N CT-T� WRI-F-6Z
WELL OR BORING LOCATION
MINNESOTA DEPARTMENT OF HEALTH Minnesotai o Well and Bor)ng
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
H 1a C G 4 e A 2 7 5
County Name
Alwka
Minnesota Statutes, Chapter 1031 or W -series No.
t a mu a na awn)
Township Name
Township No.
Range No
Section No.
Fraction (sm. i Ig.)
Date Sealed
Date Well or Boring ConstructeedT
U
30
24
123
I
�i 2 ^
ld ®"
Numerical treat Adtlress or Fire Number and City of Well or Boring Location
�
SF- Cr of e
Depth Before Sealing 25h.
Original Depth 25 ft.
Show exact location of well or boring Sketch map of well or boring
AGUIFER(S)
STATIC WATER LEVEL
in section grid with 'X'.location, showing property
Nlines, roads, and buildings.
N
\
\�(�L...(�� `
Single Aquifer ❑ Mult aquifer
*easured ❑ Estimated
ft. [I below C3 above land surface
WELUBORING
i),4ater Supply Well [:1Monit. Well
E] Env. Bare Hole C3 Other
W - T- -T- -i- E�. k�^
CASING TYPE(S)
a
-i-- -i-- --i--
Aniffe
-- - -i-- - I-- --� %SAL
t mle �t, �`
r
Ixfeel ElPlastic ❑ Tile ❑ Other
CASING(S)
Diameter Depth YSet in oversize hole? Annular space initially grouted?
2 in. from 0 .to 22 ft. ❑ Yes 060 ❑ Yes o ❑ Unknown
7❑`
in. from - to ft. [:1Yes ❑ No ❑ Yes No ❑ Unknown
PROPERTY OWNER'S NAME
ritv ti
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
ProperFjowner's mailing address it different than welllocationaddress indicated above.
vmw NE
6431 vn1�N,f•�T
SCREEWOPEN HOLE
cAt
F111�1e�1, NI 55432
�f
Screen from 22 to `5 ft. Open Hole from to ft.
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill XNo Obstruction
Type of Obstructions (Describe)
WELL OWNER'S NAME
Santa
Well owners malting address if different than property owner's address indicated above.
Obstructions removed? ❑ Yes ❑ No Describe
PUMP
Type
❑ Removed E)Aot Present ❑ Other
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
if not known, Indicate estimated formation log from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINOS, OR CASINO AND BORE HOLE:
l�o Annular Space Exists
❑ Annular space grouted with trance pipe
9 & �
Gra
Gravel
1 22
Jmdan
Yellow
216
—
❑ Casing Perforation/Removal
In. from to ft. ❑ Perforated ❑ Removed
in. from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement = 941bs., one bag of bentonite = 60 gam)
1
Grouting Matarial Neat from - 0 to 25 ft yards �2 bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
OTHER WELLS AND BORINGS
`^
No How many? ��� A ko t` CLX
Other unseated and unused well or boring on property? ❑ Yes C]l..'I
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
Remarks:
VGVl From 6431 L AVC. MThis
well or boring was sealed In accordance with Minnesota Rules, Chapter 4726. The information contained in this report is
true to the best of my knowledge.
Water Level in Abm Well: 70 f.
Date Wader Lound Taken: 12/17/69
Code:Map
SALE D
EJL Renner & Sass, Inc. 71015
Contactor Business Name Uoartse or RegtbaWn No.
07I0M
Authorized Represents Signature Date
TMy S1iqLwXeVn Saheitei%ui
According to Mfg State Regulations
IM PLR ANT -FI WNTH PR PYERTY
H �+ 2 7
Name of Person Sealing Well or Boring
CITY OF FRIDLEY INSPECTION D1ViSION
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
763.572.3604 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,
but not replacement)
Gas Range
Gas Dryer
*Air Conditioning - All Sizes
All Others/Repairs & Alterations (LIST ON BACK)
1%, of Value of Appliance or Work
Commercial/ industrial
1.25% of Value of Appliance or Work
Effective On January 1, 2001
.SOB ADDRESS S&�e c)i rl
OWNER
Rate TOTAL
$ 30.00
BUILDING USED AS
$�
ESTIMATED COST PERMIT NO. 15 W
$ 10.00 $
DESCRIPTION OF FURNACE AND OR BURNER
$ 10.00 $
No. of Heating Units _ Circle One (Steam) (Hot Water)m Air)
$ 10.00 $ Trade Name 1.--emY1zE?
COMMON VENT, VENT CONNECTOR AND COMBUSTION AIR VERIFICATION
When replacing an existing furance, 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 (--f 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 verities 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 (-Y'*No { )
The existing combustion air is sized and installed to meet the current codes
and manufacturer's specifications. Yes (,--rNo ( )
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacturer's specifications. Yes (41"No { )
When installing a new venting system, the undersigned hereby verifies that
it 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( }
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 (-f No( )
Appliance Type and Size/Common Vent and Vent Connector Information
Appliance #1 Type I A A BTU lnput I=an Assisted or Nat
Appliance #2 Type BTU Input an 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 C(
Signed By: