PRE 2010 DOCSCity of Fridley, Minn.
BUILDING PERMIT
Address
N° 5088`
Builder —
Address ; _!—
_O TION OF BUILDING
No. a6 M Street — , rr _ -Part Lot
Lot Block Addition or Sub -Div;o
Corner Lot • Inside Lot .._._..- Setback _ a '~ __ _ _ Sideyard _ -0 aft
Sewer Elevation _____ Foundation Elevation
DESCRIPTION OF BUILDING
1 ,
",. _, _ 1�c01 Ft.
Front .. *� Depth �� Height Sq. Ft. ���i����"�
Front Depth Height � 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.
A
In consideration of the payment of a fee ofA 1 �.. , 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. _. s, A
Inspector
NOTICE:
Thb permit does not cover the constmcdon, InsfaReflon for wiring, plumbing, gas heating, sewer or wafer. Be sun to see
the Building Inspector for separate pen ha for then home.
APPLICATION FOR BUILDING PRO=
CITY OF FRIDIEY, MINNESOTA
Owner's Name B & M, INC. Builder
B & M, INC.
Address 322 40-b Ave. N.F. Address 322 40- Ave. N.E.
LOCATION OF BUILDING
No. 54o0 Street P Fifth Part of Lot 14
Lot 15 Block 11 Addition or Subdivision Hamiltons Addition
Corner Lot a Inside Lot Setback 35' Side -Yard 10
SEWER ELEVATION FOUNDATION ELEPATION
Applicant attach to this form Certificate of Survey of Lot and proposed building
location.
To be used as:
DESCRIPTION OF BUILDING
54 HeiLrht
Sq. Ft. Cu. Ft.,ir-��( --
Front Depth Height
Sq. Ft. Cu. Ft.
-�
Type of Construction Fes° Estimated Cost r!7,ln
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 Ordinances and ruling of
the Department of Buildings, and hereby declares that all the facts and represenntations
stated in this application are true and correct. f -
(A Schedule of Fee Costs can be found on the Reverse Side.)
App _41
Application for Power Plants and: Healing, Cooling, Ventilation, .Refrigeration and
Air Conditioning Systems and Devices 10
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 $
Furnace Shell & Dtuct Work to 120,000 BTU ............ 8.00 $
y
each add. 60,000 BTU ........................ 2.00 $
Replacement of Furnace §.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. 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 $
GAS FITTING FEES: NO RATE TOTAL
r: 1st 3 Fixtures ...................... x $1.50 $
Additional Fixtures ................. x .50 $
s Gas Range to 200,000 BTU ............ x 2.00 $
AIR CONDITIONING
FAN HEATING SYSTEM
VENTILATING SYSTEM
ALTERATIONS & REPAIRS
ROUGH
FINAL
See Fee Schedule
TOTAL FEE $ eO
Dept. of Bldgs. Phone SII. 4-7470
Location�.�®D
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 application are true and correct.
Owner
Kind of Building/tJzE/
Used as
To be completed about
v
Estimated Cost, $. 17 A O O 'er
Old New. uilding Permit No. Permit No.
DESCRIPTION OF WORK - 41-
HEATING or POWER PLANTS—Steam, Hot Water, Warm Air—No-
Trade Name d? ® ��' .�/�iCL���/��Size No to
2® 000 ' - -
apdcity ��� Sq. Ft. E.D.R BTU H.P.
Total Connected Load�T�, .� C) Kind of Fuel
BURNER — Trade Name Size No
Capacity Sq. Ft. E.D.R. BTU H.P.
(REMARKS -OVER$
Sign jplooL
By
az 71N 7-59 Business Phone No �R ���
I
a COEF.1 BTU
INFILTRATION
GLASS - �d
i
i EXP. WALL
NET EXP. WALL
CEILING
FLOOR
TOTAL BTU.
Fl. ROOM LENGTH WIDTH HEIGHT
WIND WS AND DOORS-CRACKAGE AND AREA
N0. WIDTH I HEIGHT NO OF, LINEAL FT. AREA
LIGHTS OF CRACK S0. FT.
DATE [ADDRESS
NAME 006A1 -/%-to/ JOB - y4O
FL. a_je;C,,,l ROOM LENGTH d WIDTH HEIGHTF
WINDOWS AND DOORS-CRACKAGE AND AREA
NO. WIDTH HEIGHT NO. OF LINEAL FT. AREA
LIGHTS OF CRACK I SQ. FT
1-4,4 1 A? I / //
COEF.
BTU,
NAME
CONTR .L ' OS 'u%�✓ �T
%�
GLASS
ADDRESS
FL
ROOM LENGTH WIDTH HEIGHT
WINbOWS A
DOORS-CRACKAGE AND AREA
NO. WIDTH
HEIGHT N0. OF LINEAL FT AREA
LI WITS OF CRACK SQ. FT
�®
CEILING
FLOOR -
a COEF.1 BTU
INFILTRATION
GLASS - �d
i
i EXP. WALL
NET EXP. WALL
CEILING
FLOOR
TOTAL BTU.
Fl. ROOM LENGTH WIDTH HEIGHT
WIND WS AND DOORS-CRACKAGE AND AREA
N0. WIDTH I HEIGHT NO OF, LINEAL FT. AREA
LIGHTS OF CRACK S0. FT.
DATE [ADDRESS
NAME 006A1 -/%-to/ JOB - y4O
FL. a_je;C,,,l ROOM LENGTH d WIDTH HEIGHTF
WINDOWS AND DOORS-CRACKAGE AND AREA
NO. WIDTH HEIGHT NO. OF LINEAL FT. AREA
LIGHTS OF CRACK I SQ. FT
1-4,4 1 A? I / //
COEF.
BTU,
INFILTRATION
40
,
GLASS
0
EXP. WALL
NET EXP. WALL
�®
CEILING
FLOOR -
® 49
EXP. WALL
TOTAL BTU.
/®
d o
FL.
ROOM
LENGTH WIDTH
HEIGHT
WINDOWS AND DOORS-CRACKAGE AND AREA
NO. WIDTH HEIGHT 10. OF LEAL FT. AREA
LIGHTS OFINCRACK SQ. FT.
A!� Ih --
��
COEF.
BTU.
I COEF.1
BTU.
INFILTRATION
0
INFILTRATION
GLASS
GLASS
EXP. WALL
® 49
EXP. WALL
NET EXP. WALL
/®
d o
NET EXP. WALL
CEILING
��
CEILINGAe�
n
d a E
FLOOR
FLOOR
94
TOTAL BTU.
41.0
TOTAL BTU.
®,g Q
FL.'lea
ROOM LENGTH �� WIDTH
®
HEIGHT
FL.
ROOM LENGTH WIDTH
HEIGHT
WINDO S AND DOORS-CRACKAGE AND AREA
N0. WIDTH HEIGHT N0. OF LINEAL FT. AREA
LIGHTS OF CRACK SQ. FT.
19.9 e�
C� Oc✓
'
WIN OWS AN
DOORS-CRACKAGE AND AREA
NO. WIDTH HEIGHT NO. OF LINEAL FT. AREA
LIGHTS OF CRACK SO.FT.
e O
J o
COEF,
BTU.
COEF.
BTU.
INFILTRATION
�®
INFILTRATION93
GLASS
®
GLASS
Q
EXP. WALL
EXP. WALL
NET EXP. WALL
NET EXP. WALL
CEILING
�o
e
CEILING 1,.36 le ,gQ o
FLOOR
FLOOR
TOTAL BTU.
o
TOTAL BTU.
r aa
TOTAL BTU. HEAT LOSS -,f_7_ l ��
HEAT I NG UN I T
TOTAL
E.D.R. STEAM
�y
/.W. -d-6
TOTAL SQ. //FT. H.W.
rAME
77✓ ,.Gl
41TG . CONTR . DDRESS
F ROOM LENGTH f WIDTH HEIGHT
WINDOWS AND DOORS-CRACKAGE AND AREA
N0. WIDTH HEIGHT No. OF LINEAL FT AREA
LIGHTS OF CRACK SQ. FT.
/Y I /
DATE [ADDRESS-2%V40
NAMEJOB O
FL. ROOM LENGTH WIDTH HEIGHT
WIN OWS AN6 DOORS-CRACKAGE AND AREA
NO. WIDTH HEIGHT NO. OFILINEAE-FT.1 AREA
LIGHTS OF CRACK I SO. FT
D z 1161
COEF.1 BTU 11 1 1 1 1 1 1 COEF.1 BTU
INFILTRATION
/
0
INFILTRATION
®
INFILTRATION
Q
GLASS
oV 0
GLASS
GLASS
NET EXP. WALL
i
GLASS
0
EXP. WALL
EXP. WALL
NET EXP. WALL
�D
EXP. WALL
NET EXP. WALL
E.D.R. STEAM
NET EXP. WALL
CEILING
/ �
`10
NET EXP. WALL
FLOOR ®
CEILING
D
FLOOR
CEILING
FLOOR
�0 ('
FLOOR
.4,11 7o
t7
(p O Q
FL.
�&f ,P, ROOM LENGTH WIDTH
HEIGHT f
FL.
ROOM
TOTAL BTU.
HEIGHT
WINDOWS AND DOORS-CRACKAGE AND AREA
NO. WIDTH HEIGHT I N0. OF LINEAL FT. AREA
, / n LIGHTS OF CRACK SO. FT.
.sA s !�' / x �A. " /4
TOTAL BTU.
WINDOWS AND
N0. WIDTH
DOORS-CRACKAGE AND AREA
HEIGHT N0. OF LINEAL FT. AREA
LIGHTS OF CRACK SQ.FT.
6 -0 -
FL -1 FL. ROOM LENGTH
WIDTH
HEIGHT
FL.
ROOM
LENGTH �/
WIDTH HEIGHT
WINDOWS AND DOORS-CRACKAGE AND AREA
WINDOWS AND
NO. WIDTH
DOORS-CRACKAGE AND AREA
HEIGHT N0. OF LINEAL FT.
LIGHTS OF CRACK
AREA
SO. FT.
NO. WIDTH HEIGHT NO. OF. LINEAL FT.1 AREA
LIGHTS OF CRACK SO. FT.
COEF.I BTU. 11 1 1 1 1 1 1COEF.1 BTU.
INFILTRATION
O
0
INFILTRATION
®
GLASS
Q
GLASS
EXP. WALL
Q
GLASS
NET EXP. WALL
�0
r EXP. WALL
B a
EXP. WALL
NET EXP. WALL
�D
4j ® Q
NET EXP. WALL
E.D.R. STEAM
CEILING
CEILING
FLOOR ®
D
FLOOR
TOTAL BTU.
.4,11 7o
TOTAL BTU.
FL.
�&f ,P, ROOM LENGTH WIDTH
HEIGHT f
FL.
ROOM
LENGTH. WIDTH
HEIGHT
WINDOWS AND DOORS-CRACKAGE AND AREA
NO. WIDTH HEIGHT I N0. OF LINEAL FT. AREA
, / n LIGHTS OF CRACK SO. FT.
.sA s !�' / x �A. " /4
WINDOWS AND
N0. WIDTH
DOORS-CRACKAGE AND AREA
HEIGHT N0. OF LINEAL FT. AREA
LIGHTS OF CRACK SQ.FT.
INFILTRATION
GLASS
EXP. WALL
NET EXP. WALL
CEILING
FLOOR
TOTAL BTU.
TOTAL BTU. HEAT LOSS
HEATING UNIT
BTU. 11 1 1 1 1 1 1 COEF.1 BTU. j
b
O
INFILTRATION
�O
®
GLASS
EXP. WALL
Q
O go
NET EXP. WALL
CEILING
B a
FLOOR
TOTAL BTU.
TOTAL
E.D.R. STEAM
TOTAL SQ. FT. H.W
QTY OF FRIDL, Mn*zSDMI
�
ADDRESS AND LEGAL DESCRIPTION. _
OWNER/CONTRACT PURCHASER: is,r
CONSTRUCTION DATE: /- q- 4�t, / ADDITIONS:
CERTIFICATE OF OCCUPANCY ISSUED: YES NO DATE
A. ZONING ACTION: ORDINANCE NO:
B. SPECIAL USE PERMIT(S): #
C. IDT SPLIT(S): #
D. VACATIONS) : # ORDII WE NO:
E. VARIANCES
APPEALS COMMISSION: APPROVED DISAPPROVID DATE NO.
CITY COUNCIL: APPROVED DISAPPROVEfl DATE NO,
F. EASEMENTS: REQ'D DEPT RDC'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 COMPLY
I. MISCELLANEOUS:
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432
572-3604 FAX: (763) 571-1287
ADDRESS : 5400 5 ST NE
PIN : 233024340017
LEGAL DESC : UNAVAILABLE
: LOT BLOCK
PERMIT TYPE : PLUMBING
PROPERTY TYPE : MULTI DWELL
CONSTRUCTION TYPE : ADDITION/ALTERATION
PERM NO.: 2004-01969
DATE ISSUED: 10/25/2004
VALUATION
NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. INSTALL GAS WATER
HEATER.
# BACK FLOW PREVENTERS 0 # CATCH BASINS 0
# ELEC WATER HEATERS
# GAS WATER HEATERS
# RAIN WATER LEADERS
APPLICANT
H P PIPEWORKS
3670 DODD RD STE 100
EAGAN, MN 55123-
(651) 365-1340
OWNER
ELLESTAD TODD T & STACEY A
1850 BLUE SPRUCE CT
GREEN BAY, WI 54311
0 # NEW FIXTURES (EXIST OPENINGS) 0
1 # OF NEW FIXTURES 0
0 VALUE (FOR MINIMUM CALL) 200
AGREEMENT AND SWORN STATEMENT
This permit becomes null and void if work or construction
authorized is not commenced witin 60 days or if construction
or work is suspended or abandoned for a period of 120 days
at any time after work is commenced.
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of work
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions any other state or local law
regulating constru.c ' nor the rform ce of construction.
Applicant Date -
Bldg Insp
PLBG FIXTURES (NEW OPENINGS)
0.00
PLBG FIXTURES (EXIST OPENINGS)
0.00
CATCH BASIN
0.00
RAIN WATER LEADER
0.00
WATER HEATER - ELEC
0.00
WATER HEATER - GAS
35.00
BACK FLOW PREVENTER
0.00
STATE SURCHARGE, PLBG FLAT
0.50
PLBG PERMIT MINIMUM FEE
0.00
TOTAL
35.50
PAID WITH CHECK # 10054
SEPARATE PERMITS REOUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
'1IT( OF FRIULEY INSPECTION DIV
431 University Ave NE
'ridley, MN 55432
ry 763) 572-3604, FAX (763) 571-1287
11
Effective April 1, 2004
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR p
Wash ' . fry> - Floor ':._ :Auto.
ILUMBING FIXTURE RATES;
N0,
RATE TOTAL
law Fixtures
;'--a•"i:!...?,,.
$10.00 _
)Id Opening, New Fixture
Gas
' 1> Water Heater
Stories
: .n Y^<ii;
;�,}><o
=i5<x?
Urinal
'i i;
:«,o>;
}};: Shower_°°'
...
Tra
10.1, v?.
ts.,w_� >M rain
►}R=`' D
>Xq>a>a::rarnX
%� Was
;=,>X
<!.!.-"'!>-:-+• .:
; o�� ti_xrn Ran a
•;-:i':••-.,�:'.
saa<1 Gas Elec
$10.00
.: -
'J]Y x«VX
XY`..'-ii$§A�%:
... ..
A4IiGukb:?o..
<O"�
Y<•?•.FS9:�%
at?i,
0:1 JC }V}.i40 �x
•. _•• C<f%R%cy?
yJjr."<'au. :. •.
•..u`i: •o;_,. -...
`,1za.x a..-:ofX�
:4YYC5C4)jY_tiy�-'�•�
.yti.. K+r.
Basem.>�
ent
.Y,.-.�T..-?MY-<O:!):
$35.00 �d b
t 3as Range*"
$10.00
jJ�Y•.TO.".,'t•U,.•�
�+iTft'A: ¢,f-::�!%<Lj
�Y�F'O_A�UO>4-R
)Yes () No
Y'J-.i\\r
S���-2Y�=_��?
Type
.j.!4.'%%. 4<C-;gyY:V_YiY�V.'C�
'y�Nb.CY�\�.<-O�f.i:ryro':'
y,i?.pD.�:.-{i.x: Y_7!..?.;X:_-\:\::�aJ"rti:�.-SwNQ'i['•.
w"_%xx?YX.:<4.G•r�'�,x!XjCU:tIyYCDSjY j/:.
•:Xi�:�
.ACiT>;:OUeYUuziC>%a:-�b'
K�4c2}aX%t%ti
Floor 1
->,:�. i_pv;.�
'G::.l
:%i't9}vtitCi-X.•
'-\.'V:i:.: :..
vn.Jf.<.........
:-i -.-.._.....
Ym':!:✓v.,.wY
-....-.:::..
%jjiQ0b:'�:Xt?
-><. ':q'
.•y::..; -
•X>q••:itf
jdj4 �:.: �.;j::..•..K
.-:.�J.V{t:�\?,!<yt3F.
_tiirY�DY3j�p:
OR
Floor2
U'-'.fX�A'J'xT.fSiV.W>SYCOYfi(
<�Sv�
J\j
4'J.i
W>}tr>!K:RV
.Yja'•vtl
G9.��RC d4:
l:_:fQjijXG
V'iY,.f r>:<C,
:
.Oi
�_.'_>..�]:.h1,c.
X4>vY
-Y-jCi..! �:�:-:'•:
�_-=S•I=».�Gxrw.v?♦>;'. ?hC:-:�ri.:<.Y>:.:.:.+% .l'...
i:: {G:3•.N,t>;Y>;>
aJX:iL-ti;J>w::X>X>
¢'�:}0y%N.J:2�X^!>j:<%�o-.Y.n�i.
?i
p
xO:n:=a.Jh.•.'a.^J.>M..:r..:.r .Nl'..
Ot.Y%4i;1i%�SJ.V>.jV-..�.0
tiY�..O:N_jAa}:ry!Y_xmY�>..a;YN'.xYlt.:
�.<iiGoC:::!'>>i�C
Floor 3
.>�-Y \>Xy.;�>�_Y:vv;>tt;
.GYlilOS4. AdO.
Floor 4
t'Ti �-v»'.�,•K.Y•.•:
JyXJ.[x:iiJA_�.
<i,.
>� :d.?i.i:MI
C:-?T.aJ..%j�vvim:�
_'
..Sn1:•.>D},.Y.C}S;i:-_.:-
GO_.IYtiTJaY%w:'
?A-
U�
jI}<..arA
<.v.>•�
<._Y..CA'.-};:�
ii. YOY-xp �•
n-:X.YC%<JCW
Ywy/l•.>��
:i;O.�xLL.
.t: }Y. iY \<U:%
H.}h .
ILUMBING FIXTURE RATES;
N0,
RATE TOTAL
law Fixtures
$10.00 _
)Id Opening, New Fixture
$10.00
leer Dispenser
$10.00
Ilow Off Basin
$10.00
:atch Basin
$10.00
} ;ain Water Leader
$10.00
A ;Ump/Receiving Tank
$10.00
ry Vater Treating Appliance
$35.00
1 Vater Heater -Electric
$35.00
O Vater Neater -Gas"*
$35.00 �d b
t 3as Range*"
$10.00
" 3as Dryer"
$10.00
lack Flow Preventer Required (
)Yes () No
Type
$15.00
LO Zeinspection Fee $50.00/Hr
m %LL OTHERS AND/OR REPAIRS AND ALTERATIONS
`1 1.25% of Value of Fixture or Appliance
JOB ADDRESS '/'d e �th .&�. � . I!") n • 1
The undersigned hereby mattes application for a permit for the worts 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.
DATE: .2Q ell—
OWNER
BUILDING USED AS
16,
ESTIMATED COST �2" , y PERMIT NO.
PLUMBING COMPANY8Yi jjU..�AlZlt�d- � L6" 1271 15-6lA3
SIGNED BY TEL Nil / 3A5 -/13 X4
v Approved By Rough -In Date Final Date
NState Surcharge
rr MINIMUM FEE FOR ANY PLUMBINGIGAS PERMIT IS $15.00 or SO OF COST
J TOTAL FEE $ > J,� OF THE IMPROVEMENT WHICHEVER IS GREATER ON WORK LESS THAN $300
;ONIBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. "PROVIDE COMMON VENT INFO ON BACK SIDE
435,50
JUL-27-2004 10:50 CITY OF FRIDLEY
P.03iO3
FILL IN COMPLETELY FOR REPLACEMENT FUEL BUFkNING APPLIANCE PERMITS
COMMON VENT VENT CONNECTOR AND CONIEUSTION AIR VERIFICATION
When reolacing an existing furnace, the undersigned hereby verifies that the
v6nting 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
speclftc�tions including sizing, length, number of elbows and terminatidn. 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 -LAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances. Yes ()
No ( )
The exi sting combustion air is sized and installed to meet the current codes
and mahufacturer's specifications. Yes ()
No ( )
When required to install a new combustion air it will be sized and installed
to meet the current codes and manufacturer's specifications. Yes t
No( )
When installing a new venting system, the undersigned hereby verifies that
it is a lilted assembly and meets the current codes and manufacture.
specifications. This does include AGA -LAMA Category I Central Furnace
Yes
No ( )
Venting Tables for fan assisted and natural draft appliances. ()
Is the �ommon 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
AppiiarIice #1 Type - u r, _ 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 Connecter Height ft Length ft Diameter in Type
Appliance #2 Vent Connector Height ft Length �ft Diameter in Type
Aoolia6M #3 Vent Connector Height ft Length ft Diameter in Type
HEATING CO.
Signed By:1 Date: a/d
TOTAL P.03