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City of Fridley, Minn.
WELDING PERMIT N® 3632
Date: ../ :... f ...... ...... .
Owner....................................... Builder ..................... ... ................
Address ...................................... Address .............................................
��� �� ION �OF BUILDING
... � street ... � '�
No. ... .. ..... ...... .0...4........... Part of Lot .................
....
Lot ....r.... Block .... ........... Addition or Sub -Division .460> ... .. ...... .... .
Corner Lot ............ Inside Lot Setback .. Sideyard ../Q .-.0 .? ...........
DESCRIPTION OF BUILDING
To Used .
..... ... Front .V� Depth � l.. Height / �:�. Sq. Ft. .�(�6. Ca Ft. /.d. �O
...... Front .......: • .Depth ..... .. Hei t ........ Sq. Ft ........ Cm Ft ........
............ . p
Type of Construction .. .... ... Mt. QZ41* R . l/. � Comp ...................
••• •.• ..'..�^. To be leted ......
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 fo and in co liance with allprovisions of
ordinances of the city of Fridley.
A.... . ............. ....... ... ............
In consideration of the payment of a fee of $. Al?,
•, Ppermit 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 with-
in the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
..,g/. Building Inspector
NOTICE:
This permit does not cover the construction, Installation or alteration for wiring, plumbing, gas heating,
sewer or water. Be sure to see the Building Inspector for separate permits for these items.
( City of Fridley
f
Appiication for Plumbing and Gas Fitting Permit
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures x $1.50 $
Future Fixture Opening ................ x 1.20 $
New Fixture Old Opening .............. x 1.00 $
Catch Basin ............................
qq
$
Water Heater (Up to 200,000 BTI) ......
4
x 2.00
New Ground Run Old Bldg . ............
x 3.25
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................
x $1.50
z €eJ
$
V'
F
N
WATER HTR.
x 2.00
$
REPAIRS & ALTERATIONS—Refer to Code
t �� d
Description ................................................
cvtd
TOTAL FEE
__
$ -�� " '° = -�
GAS
ELEC.
Base
1st
2nd
3rd
4th
• Future Coanw-don Openings
Connected with
New Fixture, Old Openings
Sewer E]
Cesspool ❑
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
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 BTI) ......
4
x 2.00
New Ground Run Old Bldg . ............
x 3.25
$
GAS FITTING FEES:
NO. RATE TOTAL
1st 3 Fixtures ..........................
x $1.50
z €eJ
$
Additional Fixtures ....................
x .50
$
Gas Range to 200,000 BTU ..............
x 2.00
$
REPAIRS & ALTERATIONS—Refer to Code
t �� d
Description ................................................
cvtd
TOTAL FEE
__
$ -�� " '° = -�
Dept. of Bldgs. Phone SU 4-7470
Location l� r�"�-S 7��. .
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.
Fridley, Minn � - � � , 19
Owner %� %� r� (e �i �/ y 19
Kind of Building , 19—
Used as
To be completed about
Estimated Cost, $
Old—New. Building Permit No.y%
Signer P G !
Business Phone No
Connection Permit No . .......................................................
o it ® eRa7z. Water
Sewer
11 1 M-8-58
Meter Deposit
City of Fridley
App9carlon for ming and Gas RM" ftimit
Dept. of Bldgs. Phone SW -3450
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO. RATE TOTAL
Number Fixtures ...... ......
x $2.00
N
Z
Future Fixture Opening .... ..
`
Y
New Fixture Old Opening
C �
N
Z
Catch Basin ... ... ... ......
x $3.25
$
Water Heater (Up to 99,000 BTU)
•
F
�
N
WATER NTR.
GAS
ELEC.
Base
x $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
lot 3 Fixtures ..........................
x $2.00
$
Additional Fixtures . .......... :.......
x $ .75
$
Gas Range to 199,000 BTU ..............
1 x $5.00
$ 3.00
lot
-
2nd
3rd
--
4th _ --
' Futurs+ Connection Openings Connected wifh
Now Fixture, Old OpeningsBower
I Cesspool ❑
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
NO. RATE TOTAL
Number Fixtures ...... ......
x $2.00
$
Future Fixture Opening .... ..
x $1.50
$
New Fixture Old Opening
x $1.50
$
Catch Basin ... ... ... ......
x $3.25
$
Water Heater (Up to 99,000 BTU)
x $5.00
$
New Ground Run Old Bldg. ... ...
x $3.25
$
Electric Water Heater
x $2.00
$
GAS FITTING FEES:
NO. RATE TOTAL
lot 3 Fixtures ..........................
x $2.00
$
Additional Fixtures . .......... :.......
x $ .75
$
Gas Range to 199,000 BTU ..............
1 x $5.00
$ 3.00
REPAIRS R ALTERATIONS—Refer to Coda
Description ...............................................$
TOTAL FEE $--3.00—
N)
-3.•0.0N
Localinn 5851 IV E 6th St
City of Fridley:
The undersigned hereby makes application for a permit for the work herei
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 9-18-69 .19,
_ Owner G Kirs chner
Kind of Building -----
Used as res
To be completed about _ —23-69
Estimated Cost, $ 10.00
Old—New. Building Permit o. p it iia
Signe
By M NEMLIS Co
Business Phone No
FINAL -22: /�o
City of Fridley
SUBJECT
PER 12632
AT THE TOP OF THE TWINS
BUILDING PERMIT
`
RE T N
• ______ COMMUNITY DEVELOPMENT DIV.
y
r PROTECTIVE INSPECTION SEC.
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
CITY HALL FRIDLEY 55432
IL I.J
L ----A 612-560-3450
910-F15
7/16/74
JOB ADDRESS 5851 6th Street N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
8
6
1 Bonny Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
C. Kirschmer 5851 6th Street N.E.
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Inter City Builders 2500 MurrayAvenue N.E.
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Attached garage
7 CLASS OF WORK
NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
22Z8 22 x 16 attached garage
9 CHANGE OF USE FROM TO
STIPULATIONS
Provide a hard surface x! driveway.
(see attached letter from adjacent property owner releasing
owner from having a survey) 7/15/74
�`�: f2AiE =EkMiT3 REQUIRED FOR WIRING,
-HEATING, PLUMBING AND SIGNS.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
TYPE OF CONST. OCCUPANCY GROUP
OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
wood frame
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
3,520
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
352
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
$1,865.60
.93
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SACCHARGE
PROVISIONSOF A Y OTHER STATE OR LOCAL LAW REGULATING CON.
STRUCTION OR T RFORMANCE OF CONSTRUCTION.
06.50
1dVx/"1q
PLAN CHECK FEE
TOTAL FEE
-
1 7.43
IGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)
WEN VALIDATED THIS ISYOUR/PERMIT
BLDG. )NSP DATE
SIGNATURE OF OWNER IIF OWNER BUILDER) (DATE)
J
APPLICATION FOR RESIDENTIAL, ALTERATION,
OR ADDITION BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
a
OWNER'S NAME: C.)t�S/' /1 y ae BUILDER: %Nne d ! < r f,3ell Ze S
ADDRESS: �� `' L S r � ADDRESS :.2Z py
r
NO:., /.. STREET: L 7T -
LOT: BLOCK: ADDITION: /5 )J
CORNER LOT: INSIDE LOT:_SETBACK: SIDEYARD:
Applicant attach to this form Two Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
DESCRIPTION OF BUILDING
To Be Used As:
POO_ Front: I � Depth: Height:
Square Feet: �_ Cubic Feet: ;z S_/%
Front: Depth:
Height:
Square Feet; Cubic Feet:
Type of Construction: 'e Estimated Cost:
To Be Completed: - ��- 7
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in stiict 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.
DATE: -?` l 7 7 tv
SIGNATURE:
(See Reverse Side For Additional Infon on.)
4. v
9
��3
1.
m
C/ �owner of the property located
have no objection to the City
allowing the construction of a&;( --I %li 1hd o%I����d�'�to be located at:
,ne � /'" 5th without the required certificate or
survey that the City ordinarily req u es for all new construct,/
0,6" de- -
i
ness
Address
Date
•
r,
a
1-7
FIRM STAMP
CONTRACTOR'S
JOB COST ESTIMATE FORM-NO.155
Name
Phone
Date
Street
City
State
Location
of Job
Sheet No.
Estimator
Checker
Estimate No.
Terms
Cost
Basis of Bid " Plus
Definite
Bid
Other
Job to be Commenced
To be Finished
Description
of Job
QUANTITY DESCRIPTION MATERIALS - EMPLOYMENT
UNIT LABOR
PRICE HOURS RATE
EXTENSIONS
TOTAL
s
TOTALS
FORM NO. 155 - THE BLACKBOURN SYSTEMS, INC.. ST. PAUL, MINN.
R
X. 231
suBdEcr
PE NO.
City of Fridley
1437
AT THE TOP OF THE TWINS
PERMIT
BUILDING
RECEIPT NO.
L'-_�--_ COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
�•-'-� • •�� 612-560-345020
910-F15
9120177
� �
JOB ADDRESS
5851 - 6th Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
8
6
1 Bonny Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE BUS. ,#
Mar ita H. Kirschner 5851 - 6th Street NE 55432 571-6492 786-220
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
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION J7 REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
9 CHANGE OF USE FROM TO
STIPULATIONS
1. Provide galvonized ridged valleys.
2. Roof must be stripped before the 3rd roofing.
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
ZON NG
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
ISTALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
VALUATIONIc
04
SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED.
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$11000.00
•50
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-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
$7.50
PLAN CHECK FEE
TOTAL FEE
$`8.00
EEeOF CONTRACTOR OORRR AUTHOOR�IZZEED AGENT IDATEI
SIGNATURE
O RLY LIDATED THIS IS YOUR 5FRMIT
I �Y/ .l G.a R. • 6 C&O'p22j,6:97
O� o 7
BLDG INSP DAT
SI NATUR OF OWNER IIF OWNER BUILDERI IDATEI
X. 231
CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL BUILDING PERMITS
(NEW, ALTERATIONS, ADDITIONS, OR•REPAIRS)
OWNER: BUILDER:
Address: 5®,_ 57 - 451'e 46e -t kj Address:
Tel. No.
No.: Jam/
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
To Be Used As:
I?el-
j2oC haae Front: Depth: Height:
Square Feet: Cubic Feet:
Front: Depth: Height:
Square Feet: Cubic Feet: Ar
kill -
Type of Construction: _5..��Gf� Estimated Cost: $ �l�T®� C7-0
T
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 information.
DATE: SIGNATURE:
Stipulations:
SUBJECT
PERMIT NO.
City of Fridley
o 5 7 2
AT THE TOP OF THE TWINS
BUILDING PERMIT
r
--
_ COMMUNITY DEVELOPMENT DIY.
>r PROTECTIVE INSPECTION SEC.
CITY HALL FRIDLEY 55432
NUMBERDATE
PAGE OF
APPROVED BY
612-571-3450
910-F1577
9./14/90
JOB ADDRESS 5851 - 6th Street N.E,
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
8
6
Sonny Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Gabriele Kirschner 5851 - 6th. Street N.E. 571-6492
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Daniel Andrs Const. & Remodeling 17512 Evener inlay, Eden Prairie 55346 934-3074
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 C;k ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
B DESCRIBE WORK
Install bow window (131° extension).
9 CHANGEOFUSEFROM TO
STIPULATIONS
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REOUIRED 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
$3,000
$1.50.
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-
$54.00
TRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTALFEE
/y 0
Fixe SC $3,00
$58,50
SIGNATURE OFICONTRA0OR OR AUTHORIZED AGENT IDATEI
WHEN VALIDATED THIS IS YOUR PERMIT
gPROPERLY
//
• ' // 0 �C l J
BLDG INSP /QATE
SIGNATURE OF OWNER OF OWNER BUILDERI IDATEI
NEW [ ] Effective 8/16/90
ADEN [ ] R-1 AND R-2
ALTER [ ] Building Permit Application
Legal Description:
Owner Name & Address: as !o � ►` � �P ,;e,;sZ s G Tel. # --z-
Contractor: ez- „/ " e- Tel. # 3 -V` 30'7</
Address: t / -7S'i ja 2—�✓ r- AJ ea i � �� �� �.� �. °� ; `� d`7ii% 5�� 3
Attach to this application, a Certificate of Survey of the
lot, with the prcposed construction drawn on it to scale.
LIVIM AREA: length Width Height Sq. Ft.
QNRAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTR: Pq2lacL ,J ' o
�-'i1 O L �. cc �►/ q `o e �r ; S 7�. � ✓� d. �cc d� �,,C. I �i �iv % ��� ✓b�
Cornea Lot [ ] Inside lot [ ] Ft. Yd Setback Side Yard Setbacks
Type of Construction: �p,ae7r e Estimated Cost: $ -3 ®00
Approx. Coppletion Date: Gj�q O
Proposed Driveway Width If New Opening Is Desired: Ft. $ $
Width + 6' See Back Page
DATE: g 0 APprzcmu: Allo e4z, 5 Tel. # 3 y - 3 0 `7y
Permit Fee $ '5V on
Fire Surcharge $ S 0 d
State Surcharge
SAC Charge $
Driveway Escraw $
Park Fee $
Sewer Main Charge $
CITY = my
Fee Schedule on Reverse Side
.001 x Permit Valuation (1/10th �)
$.50/$1,000 Valuation
$600 per SAC Unit
Alt. "A" or Alt. "B" Above
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary.[ ]
sTiPvrMCM :
�' .sa
CITY OF FRIDLEY INSPECTION DIVISION
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
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
Rate
$ 30.00
$ 10.00
$ 10.00
$ 10.00
$ 25.00
State Surcharge
TOTAL FEE
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $47.00/Hr
Effective On January 1, 2000
JOB ADDRESS s: ,F �-q Sc-- P.
OWNER
TOTAL
BUILDING USED AS ZU iffZf—i &/C
ESTIMATED COST 7 ?00 PERMIT NO. 7 /�
DESCRIPTION OF FURNACE AND OR BURNER
No. of Heating Units 1 Circle One (Steam) (Hot Water) Warm Air)
$ Trade Name GA�2a�2 Size No. Gc; A-V 0 7,6
BTU & 0 HP EDR
$ Fuel tiA-'V— —Total Connected Load
Burner Trade Name Size No.
$ BTU HP EDR
$ 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 an
$ .50 rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct.
&;UPERIOR COMTFtACTO FIT1=
6121 42nd Avenue l:
Crystal Mn 505422HEATING 0
Signed TEL #
*Air Conditioners can not be placed in a side yard without Approved By Rough -In Date Final Date JV'ffo
written permission from adjoining property owner.
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 () 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
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 existing combustion air is sized and installed to meet the current codes
and manufacturer'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 () 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 L-J4yy-2o BTU Input 66,gooe 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
rL
SUPERIOR OOMTRAOTORS INN
6121 42nd Avenue No.
HEATING CO: CrystP-I, Gln F 22
Signed By: Date :