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PRE 2010 DOCSS915-51 City of Fridley Application for Plumbing and Gas Fitting Permit Dept. of Bldgs. Phone 560-3450 DESCRIPTION OF WORK Number, Kind and Location of Fixtures 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 Z �O • F • N WATER HTR. GAS ELEG Base New Ground Run Old Bldg. ............ x $3.25 $ Electric Water Heater a $2.00 $ GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .......................... 1 x $2.00 $ 2.00 Additional Fixtures .................... 1st $ Gas Range to 199,000 BTU .............. x $5.00 $ Insi -al:Yd Lite and G 1 2nd 3rd i—F4 4th I I • Future Conaection Openings New Fixture, Old Openings Connected with I Sewer 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 $3.00 $ New Ground Run Old Bldg. ............ x $3.25 $ Electric Water Heater a $2.00 $ GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .......................... 1 x $2.00 $ 2.00 Additional Fixtures .................... x $ .75 $ Gas Range to 199,000 BTU .............. x $5.00 $ 2 x 3.00 6.00 REPAIRS & ALTERATIONS—Refer to Code Description ...............................................$ TOTAL FEE $�0 Location 211 NE. 45 Avenue 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 facl and representations stated in this application are true and correct. Fridley, Minn JUN 11 1908 19_ Owner Lloyd Blashell Kind of Building Frame Used as Residence e To be completed about JUN 18 1968 Estimated Cost, $ 10.00 Old `New. Building Permit No Permit No. Signe MINNEAPOLIS Business Phone No ROUGH FINAL 0 City of Fridley, Minn. BUILDING PERMIT Date: — August 12,. 1968 N9 9881 pvnjtloyd Blashill Builder _ Sussel Co. Address 211 45th Ave. N. E. Address 1850 Como Ave. St. Paul, Minnesota LOCATION OF BUILDING No. 211 Street — 45 th Ave. N. _ E. �_. Part of Lot Lot — 8 — Block 2 — Addition or Sub -Division . Rearrangement of Plvmouth Addn. Corner Lot __ Inside Lot Sewer Elevation Setback Sideyard Foundation Elevation DESCRIPTION OF BUILDING To be Used as: Detached Garage Front 24' Depth Z4' Height 10' Sq, Ft. 576 CtL Ft. 5760 Front Depth __ _ Height _ Sq. Ft. — Cu. Ft. Type of Construction Frame Fst, Cost 2190.00 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 se forth and in compliance with all provisions of ordinances of the city of Fridley. In consideration of the payment of a fee of $ 9.00 permit is hereby granted to_ Sussel Co._ 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. Official Building RRHOW . NOTICE: This permit does not cover the construction, installaMon for wiring, plumbing, gas heating, sewer or water. Be sun to see the Building Inspector for separate permits for them items. , 1 i APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNE& IS NAME lO g a BUILDER ADDRESS - 2// — 1,;1--e ADDRESS /s SO 0-orr, e 1 e S� pu Q LOCATION OF BUILDING NO o op t ( STREET Al OF • ij —0, LOT BLOCK ADDITION OR SUBDIVISIO.N COR1'M LOT SEWER EIHTATIOPn INSIDE LOT SETBACK SIDEYARD TOP OF FOCTING Applicant attach to this form. Tv.7o r'ertifioatoo of Survey of Lot and proposed building locatiox- drawn on thes:: Certificates DESCRI.T T:%ON OF BUILDING To Be Used As: 4 d d- c'" Front Depth `F Height --79quare feet 16-9(l Cubic Feet ' o Front Depth Height Square feet Cubic Feet Type of Construction /tea.'" e Estimated Cost ` n�v fn cxa To Be Completed 2O W, 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. DATE I /a — 6 (' SIGNATURE __L�� (Schedule of Fee Costs can be found on the Reverse Side.) I iso -&71`7 LOT NAME SIZE 4 1-1 I.,a Z q x 2� BLOCK ADDRESS ,eatVALUE /� 7— 1 # ' A -ni ` (+� 1J t<' . N t,� . / :2d ADD'N. AREA1o!! TYPE R f- f 01— w �a �` a i4 {--4 �g a COt�1Dyt� m�� '�,/ � 2 t .� t�.t `�,, tom► +P ►� tZcv OdtJ Nr= 7 'F"(> tZ e Ursa V Ft= NjC. _ e1 'Me c-f�.S°sAm-e. a)sQf.;Xae wl-r 1 Aovs - F9_om T' o F- fz,&►2 Ata E Ta _s77w r Z l 1 FX a M X120 N T �"i� �= 4= T Q.F. A �► � 1� 4a !� .4) I mss= %��e�. �;1:�. 7-a �rA_f7r J.11,AF- AS aS14oWNI, p j o sag GW �t�teM VEIZ tl� 4 � o--ATIQ�n 4j H r -ml *, c0ml0LiI-r., _ . EE -r p2opmvL r`'d L -114G SUBJECT City of Fridley ®14253 AT THE TOP OF THE TWINS PERMI!f"'�? BUILDING RECEIPT NO COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION r SEC. 1 . � "1 CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY 612-560-3450 910-F15 7/29/77 JOB ADDRESS 211 - 45th. Avenue N.E. 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 8 2 1 Arrang. of Blocks 13,14,15, Plymouth Addn SHEET 2 PROPERTYOWNER MAIL ADDRESS ZIP PHONE L. Blashell 211 - 45th Avenue N.E. 3 CONTRACTOR MAILADDRESS ZIP PHONE LICENSE NO. Western Remodelers 2529 Nicollet Avenue ls. 823-6172 -7-ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 6 USEOFBUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE X 8 DESCRIBE WORK Steel siding and aluminum trim. 9 CHANGEOFUSEFROM TO STIPULATIONS SEPERATE PERMITS REQUW-D FOR WIRING, HEATING. PLUMBING AND SIGNS, 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 ] 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. $4,500 $2.25 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- $27.00 STRUCTION T PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE $29.25 IGNA EOF CONTRACTOR OR AUTHORIZED AGENT (DAA) HEN PROP RLY VALIDATED THIS IS YOUR PERMIT s� -77 BLDG 'NSP DATE SIGNATURE OF OWNER IIF OWNER BUILDER) (DATE) L1 I Y UI I QJJLLY APPLICATION FOR RESIDENTIAL BUILDING PERMITS (NEW, ALTERATIONS, ADDITIONS, OR REPAIRS) OWIMR: L a'aLiw BUILDER: �C.� 4 Address: )41 (f �� 409J. I� Address: 27 Z-cr /—,' C,6 L(/Zr- Tel. No.: - No.: �% Street: 7 �� CSS '0-j- /? LOT: " j BLOCK: ADDITION: �t�filuaN��v D F �• 43-/Z-, CORNET. LOT: INSIDE LOT: SETBACK: SIDEYARDS: / Applicant attach to this form Two Certificates of Survey of Lot and proposed building location drawn on these Certificates. To Be Used As: DESCRIPTION OF BUILDING Front: Depth: Height: Square Feet: Cubic Feet: Front: Depth: Height: Square Feet: Cubic Feet: Type of Construction: Estimated Cost: $ V'1-6 Z� , To Be Completed: Alt. A Alt. 5 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: i SIGNATURE: /,. Stipulations: CITY OF FRIDLEY INSPECTION DIV. 643f University Ave NE Fridley, MN 56432 572-3604 Stories �,Ciose ..I Urinal Floor 1 Floor 2 Floor 3 Floor 4 Effective On January 1, •1997 PLUMBING FIXTURE RATES: NO. RATE TOTAL New Fixtures $ 7.00 Old Opening, New Fixture $4.00 Beer Dispenser $ 5.00 Bicvv Off Basin $ 7.00 Catch Basin $7.00 _ Rain Water Leader S 7 -DO Sump/Receiving Tank _ $ 7.00 Water Treating Appliance $10.00 — Water Heater -Electric ~ $7.00 Water Heater - Gas** $10.00 Gas Range"* $10.00 Gas Dryer** $10.00 Back Flow Preventer Required ( )Yes (} No Type— $15.40 JOB ADDRESS S I �KhX P E Water Heater Gas I Elec 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 Bui'din.g Division, and hereby declares that all the facts and representations stated In this application are true and correct. —otc` � '1997 Owner Ouar-a P ' $ Building Used As Estimated Cost(3n6D PERMIT NO. PLUMBINGPOMPANY�I(Gtd(re (L-3 Reinspection Fee $42.00/Hr ALL OTHERS ANDIOR REPAIRS AND ALTERATIONS SIGNED B umv-- TEL NO 1.5°•a of Value of Fixture or Appliance U. (YD Approved By4FR Rough-In Date ('14141 ,-Final Date It 1Utq? State Surcharge $ .50 MINIMUM FANY PLUMBING GAS PERMIT IS $20.40 TOTAL FEE $ ZU. S'U PLUS THE $.50 STATE SURCHARGE "*COMBUSTION AIR SHALL SE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. MINIMUM SIZE 9 SO INCHES. tr M r'. I G� I r Lr, cr, cr, r 4.n r r0 a• T CITY OF FRIDLEY INSPECTION DIV. 643f University Ave NE Fridley, MN 55432 572-3604 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT _ MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR b1+aeter i:Bath Wash t?rrnk Floor Gatch Auto. Stories Closet _. Urinal:Tub Shower Smc `: Tray For�rit Drarn Bann Washer Basement' Floor 1 PLUMBING FIXTORE RATES; NO. RATE TOTAL New Fixtures $ 7.00 Old Opening, New Fixture $4.00 Beer Dispenser $5.00 oiovv Off Basin S7.00 Catch Basin $7.00 _ Rain Water Leader $7-00 Sump/Receiving Tank $ 7.00 Water Treating Appliance — $10.00 Water Heater -Electric _ $ 7.00 Water Heater - Gas** ✓ $10.00 Gas Range** $10.00 Gas Dryer** $10.00 Back Flow Preventer Required }Yes (} No _ Type— $15.00 JOBADDRESS`V( 49+1A �m N-&. Effective On January 1, 19,9? q 313°1 ► Gas iVltsc, Water Heater Range lt,__]Gas Elec 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 Bu tdin.g Division, and hereby declares that all the facts and representations stated In this application are true and correct. Owner Odom J e 7/ D � Building Used As ft -Ski tu(p- Estimated Cost 360 -IN PERMIT NO. PLUMBING COMPANY AAUAft. ISUva Reinspection Fee $42.00IHr II ALL OTHERS AND{OR REPAIRS AND ALTERATIONS SIGNED B 6 TEL NO 13 0676 1.5°;b of Value of Fixture or Appliance Z� -t►0 Approved By Rough -In Date9 �a� Final Date State Surcharge $ .50 - - TOTAL FEE $ 20.E MINIMUM FEE OR ANY J}L11NtB1NG GAS PERMIIT IS $20.00 - 6 ` �� i'�Ui7_ Ti IJ_ $.5 STATE SURCHARGE **COMBUSTION AIR SHALL BE PROVIDED PER UMC SEC71 ON 504(.0) AND TABLE 6-A. MINIMUM SIZE 9 SO INCHES. t� VOft- WO ene..Ututti§ d(j ft(Lit �1T8 tui Nay`r{i' ()till X1,12 c�la{ew �4 e (rnS 11�U $ 2 Ju CAJ +0 &Z -;e e fwe 9 Uit-!1� d o v� IaUL CT . me6u h. $- f Nu -n 0 9 Wk SUBJECT City of Fridley 29000 AT THE TOP Of THE TWINS BUILDING PERMIT RECEIPT NO. COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. r �/�� 1 = � CITY HALL FRIDLEY 55432 NUMBER REV DATEOF PAGE APPROVED BY 612-571-3450 910-F15 3/12/99 JOB ADDRESS 211 45 Avenue NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 8 2 Rearrangement of Bl 13,14,15 Plymouth SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Blashill/Fiers 211 45 Avenue NE 572-2981 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Viking Home Improvement Co 4832 2 1/2 St NE, Mpls., MN 55421 572-1820 4772 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 O ADDITION O ALTERATION j7 REPAIR O MOVE O REMOVE 8 DESCRIBE WORK Reroof House & Garage (24 Sq); Fascia; aluminum window wrap 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with the State Building Code. 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 SO. FT CU FT. AUTHORIZED IS NOT COMMENCED WITHIN 80 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 WITH WHETHER SPECIFIED HEREIN OR NOT, THE GRANTING OF A PERMIT $2,756 $1.38 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 PLAN CHECK F T AL FEE Lic se SC 5 0 $83.89 SIGNATURE OF CONCRACTOR AUTHORIZED AGENT (DATE, _ HEy P B OG I Y A - THIS YOUR PER GATE S-GNATUREOFOWNERIIFOWNER BUILDERI IDATEI 9 Wk NEW [ ] Effective 1/1/99 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: 0t y-s-Tff�f ssYa 1 Legal Description: Owner Name & Address: &Ws ff_tc c / F A6A 5 Tel. # S"7A — 2 t9) Contractor: r/2K Ca G Ala ... r T,k D co _ MN LICENSE # L% 7 72 - Address: ��,;,2 d %z .5 r, .y • F Tel. # s72- -i.fzo Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF E%IPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: Construction Type: A e A0o /r12 11"3c zy �,g�, w oow Estimated Cost: $ %'0'00. (Fee Schedule on c �7 Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ E99 DATE: Q3 -/2- 9 cj APPLICANT: Tel. #.572 Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: CITY USE ONLY $ 7.A/ �Fee Schedule on Reverse Side $ .001 of Permit Valuation (1/10th%) $ $.50/$1,000 Valuation $ $1050 per SAC Unit $ 6_ d o $5.00 (State Licensed Residential Contractors) $ Alt. "A" or Alt. "B" Above $ $450.00 Conservation Plan Review $ Fee Determined by Engineering $ 8.3 CS) 9 Agreement Necessary [ ] Not Necessary [ ] TY OFTRIDLEY INSPECTION DIV. •31 University Ave NE �$ idley, MN 55432 63j 572 '29P" a: LO u+ v Effective On Jan 1, 2002 APPLICATIGAf FOR PLUMBING AND GAS FITTING PERMIT %% I _LiMBING FIXTURE RATES: NO. RATE TOTAL JOB ADDRESl S �>' - �� _t✓!rc JY%� *i'd 1le- 4-1 0 ew FbMwes Id Opening, New Fixture aer Dispenser bw Off Basin etch Basin w ain Water Leader A umplReceiving Tank LL later Treating Appliance LL Mater Hestar -Electric I later Heater - Gas' u " age.. § as Drier" LL ack Flow PrL-venter Required ( )Yes (} No Type I $ 7.00 The undersigned hereby makes application for a permit for the work herein $ 4.00 specified agreeing to do all work in strict a000rdance with the city codes $ 5.00 and rulings of fie BUR*g Division, and hereby declares that all the facts $ 7.00 and vepresentatbns stated in this appUcalion are true and correct. $ 7.00 $ 7.00 $10.00 Ovear $ 7.00 $10.00 Buit ing Used As rP�I�P_L1 $11100 C� $113.00 Est ated Cost PERMT KO. $15.00 Cm *inspec bon Fee $47.OUIHr LL OTHERS AND/OR REPAIRS AND ALTERATIONS N 1.5% of Value of Fixture or Appliance State Surcharge $ .50 � TOTAL FEE $422,52-,) SIGNED BY TEL N0. /AV=0--4S/ i PLUS THE S.i511 STATE SURCHARGE ':OMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6,A. COMMON VENT INFO ON BACK SIDE v CITY OF ERIDLEY BUILDING INSPECTION00'' 0� J Effective 4/1/2004 9 3431 University Ave NE 9=ridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION L 7635723604 FAX 763-571-1287 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES 9 D 10B ADDRESS \�V 1y� n RATE SCHEDULE E ee Tota Residential Owner�C� Furnace Shell and Duct Work, Burner & 3 S,Q0 Used As �`�S k � P r1C also Replacement Furnace $35.00 (261 $ Building 1�pvoce r., 'J $ C 0ST_t3 R W C:PERMIT NO Gas Piping (New Furnace, Fireplace, Insert) $10.00 ESTIMATED - _0 Gas Range $10.00 $ DESCRIPTION OF FURNACE AND BURNER Gas Dryer $10.00 $ N of Heating Units_ Circle One (Steam) (Hot Water (Warm Air Trade Name o -r rt er Size No. *Air Conditioning -All Sizes $25.00 $ BTU O O HP EDR Fuels e r Total Connected Load All Other Repairs or Alterations (List on Back) r 1% of Value of Appliance or Work $ Burner Trade Name Size No. a Minimum Fee $15.00 for Residential or 5% of cost of BTU HP EOR Y Improvement whichever is greater on work less than $300.00 l The undersigned hereby makes application for a permit for the work herein Commereiallindustria!/Institutional specified agreeing to do all work in strict accordance with the City Codes } 1.25% of Value of Appliance or Work (List on Back) $ and rulings of the Building Division, and hereby declares that all the facts i Minimum Fee $35.00 for CommerciaVindustriai/institutional and representations stated in this application are true and correct. CENTERPOINT ENERGY r State Surcharge .50 BEATING CO 13562 CENTRAL AVE NE BLAINE, MN 55304 1�z TOTAL FEE $� Signed Tel # 763-757-6202 v REINSPECTION FEE $50.00/HOUR FAX # 763-757-6701 Date y '9 *Air Conditioners can not be placed in side yard without written approval rm from adjoining property owner - copy to City o- N FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE EL a: Approved by Rough -in Date Final Date FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS COMMON VENT VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When replacing an existing furnace, 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 (]6 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 (i1' 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 BTU Input Coy.60",Assi 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 C,, Vent Height f Diameter inches Common Vent Type 9 1__—_ 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 LengthftDiameter in Type ALTERATIONS: (Describe) }� l� <% l�� -°' w� ✓ C P_ e �OL_ /! ms`s �"7'✓� � r CENTERPOINT ENERGY HEATING CO: 13562 CENTRAL AVE NE . BLAINE, MN 55304 _ Signed By: Date: -7 -OL. FO/FA I A TA)AJ.SL 01 A91G I NA d0 Aim WON -4 <7.: T T b00Z-LZ-NCH