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PRE 2010 DOCSVillage of Fridley, Mms. BUIOLDEW PFARM" N? 238 Office of INSPECTOR OF BUILDINGS Owner Architect Fridley, Minn., Builder LOCATION OF BUILDING No.!L----i Streetart Of Lot - Lot Block Addition or Sub-Divisionii it DESCRIPTION OF BUILDING 16- Front-yt-L— Depl h—Ly--- Height_Z7— Stories Manner of Construction TO be used asi To be completed Estimated Co f2 T III it )z' 9A Permit Is hereby granted t v the bulldinv— Ile, %scribed in the above statement. This permit is granted upon the express condition that the rson to whom It is granted, and his agents, employees and workmen, in all the work done in, around and upon aid building, or any part thereof, shall conform in all respects to the ordi- nances of Fridley, Blinn., 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. ctor of Buildings. UA AGREEMENT AND SWORN STATEMENT In consi&4'lon 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 and and say that the facts stated by me and contained in the above permit are true as therein sated. C t Subscribed an sworn to before me at Fridley, Minnesota this day of A.D. 19 -ti 0 0 0 Village of Fridley, Minn. BUILDING PERMIT N 699 Office of INSPECTOR OF BUILDINGS Fridley, Minn., e ~%j 1LOCATION ;OF BUILDING No. street E`- Part of Lot Lot Block u Addition or Sub -Division D ad�- DESCRIPTION OF Bun.DING Front—LL—'— Depth -' Height _ Stories Manner of Construction To be used as To be completed Estimated Cost Permit is hereby ranted to r } Y'� to the buiidin 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 an 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. 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 sttate& a°" � �� - �. �, i`M s ''�'y .�..�r'.•-LIZ.. sworn to before me at Fridley, Minnesota this .,. 4 Subscribed 'd y� � _ an ' n .. _. A_D. 19 day of - 0 4- City of Fridley, Minn. BUILDING PERMIT Date: __"4 !''_-.%_`_"w! -� Owner: _ac.t�, f'1 I' ._ _.. _ 3"' . Builder } Address ...._*1_.. - y_:_.. _.._ lAddress No (475=8 L TIS OF -BUILDING No....,F..... Street.. _ [_'�L�'aa'••...�,�.._..... Part ofLat Lot ........_: ...................... Block ....._...... ' .............. ...... ... Addition or Sub-Divisi n ....._..--•:.....:...._... _..t......--'--.._------ Corner Lot ........... #!!!! ............ Inside Lot ....._................................ Setback ...... _............. _._.... Sideyard - .. ..... .................................. -... Sewer Elevation ...... ........................ ............. __........ ..... ....... _.................. ,Foundation Elevation DESCRIPTION OF BUILDING j To be Used as i Front -/ ..... Depth .... .. Height �'.`'�.... Sq. Ft. ' Cu. � , _...... ........ ...................................... Front ....................... Depth .......... ..._ Height... Sq. Ft. ...... ................. Cu. Ft....................... Type of Construction ............ [Lr! ....... Est ............................................ --- To be Completed ........ -A UTI O N THIS PER1117IT DOES NOT AUTHORIZE VIOLAT- ION OF ANY PkI vATE EAND'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 buildit'lg, 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 urn viola ' f any of the provisions of said ordinances. d'.�:,►'i',l ,r � op r .''..-Building 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 C� Buil Owners Name Z/L ,�1 Jt� y1'l?�%r der Address 7/ 's5� /d F lv' P Address LOCATION OF BUILDING No. 7/ Street I? OC-- L Mt of Lot l Lot Block "I Addition or Sub.Div Corner Lot Inside Lot 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 a used as: 1='n�,7—Front Depth_ Height Sq. Ft. Cu. Ft., Front Depth Height Sq. Ft. CU Ft. Type of Construction Estimated Cost To be completed �� �„L 9,, (0- . ._. 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 representa- tions stAted in this application are true and corms. F�l��r7.�: I' ,/ � �' . Vii_ . �'_►� � � ..���c. Schedule of Fee costs can be found on the ReveVse Side.) ---,W -C' P � P VVI' 1 I 'TJ C-'= d '7 ) i"f, City of Fridley Application for Plumbing and Gas IFINIIng Pemdt Dept. of Bldgs. Phone SII 4-7470 � A� DESCRIPTION OF WORK Number, Kind and Location of Fixtures I'o�BOn uJ �ia z o� O (�o �Z S� < J �U' °1 t9 �U' C9 z �p F • N WATER HTR. GAS ELEG Base , 1st f 2nd _ 3rd _ 4th • Future Connection Openings New Fixture, Old Openings d Connectewith Sewer � Cesspool PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ...................... x $1.50 $moo Future Fixture Opening ................ x 1.20 $ New Fixture Old Opening .............. x 1.00 $ Catch Basin ............................ x 3.25 $ Water Heater (Up to 200,000 BTU) ...... x 2.00 $ New Ground Run Old Bldg. ............ x 3.25 $ GAS FITTING FEES: NO. RATE TOTAL 1st 3 Fixtures .......................... x $1.50 $ Additional Fixtures .................... x .50 $ Gas Range to 200,000 BTU .............. x 2.00 $ REPAIRS & ALTERATIONS—Refer to Code 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 elid--rr �� Owner ? 22-'&' IV yq d it", -T Kind of Building 1 �� Used as To be completed about�'� Estimated Cost, $ Old—New. Building Permit No Pe t No. /4-/d Signe By li Business Phone No. "� -2- ROUGH FINAL Description ................................................$ TOTAL FEE $ yi •3 qM10.42 2M 7-59 53-9-9915051 ally AppliccaHan for PIU &",3 C'M M Ff -cr�:�is • Dop . of Bldps. Phone W•3M ------------- DESCPIPTIOII 0: 470111: 571 53 Numb ?. M: d and Locr90M of F1'W ur•s t Now Pl-tura. Old a-rs^.ings PARTIAL RATE SCHEDULE so -war Q Cc:spool 0 City of FZ•4dley; The undersigned hereby rnikes app?icat:on for a permit for the- pork h, specified, aCr eeing to do all work in strict acco:Ca^.ce with tre Cit? O- diong and ruling of the Depar tme:It of Bull --'Ings. and hereby declares that 41 the • , and lrepresertauons stated in _':i: application are true and co. -red' Fridley. Minn 6-18-76 1' Owner GirgLowo,. framm Kind of Building Used as ros. To be completed about Estirr.3ted Cost. $ --- Old—$m Building Permit No. • P•r�it :r:a. P LLN. 3111C rIXTU?E RATES: N0. RATE TOTAL Si ' x52.x0. S -..-- Number Fixtures ......... WATf11 "Tit. 3 M;�� t 8 zju By MIM GASCO Busin�K..s Phare ffewFixture Old Oypninge o.o a a . a • •-----'-• x $1.50 5 ..-- — • Gas Mc. Al - Cateh ilasin .................... '' Nater lfesler'Up to 99.000 BTU)• • • •-------- x $3.00 S ROUGH E r I x ;3.25 S - $2.0 S • E!6ctew Wat.r FINAL+ iJLS FITTING TEES: NO. R:+TZ TOTAL x5200 $ . . 1st3Fixtures •••••••••••••••••' x S .75 $ Addiusaal Fixtures 0 0 0 0*064.6 . 6 6 6 6 -.--- ir sty. 1 1 •ri 1 050 State Surcha ge p.•e'? <:g3 k AL T ZAXTIONS—Rifer to Cods .De:.eri'yaon .,**ease 0 0 0 0 0 0 so I 0 0 6..0 6.6 04"'A" TOTAL F..F..5�. 5 s50 Kiss .,A„ Surcharhe .500 • 3rd t Now Pl-tura. Old a-rs^.ings PARTIAL RATE SCHEDULE so -war Q Cc:spool 0 City of FZ•4dley; The undersigned hereby rnikes app?icat:on for a permit for the- pork h, specified, aCr eeing to do all work in strict acco:Ca^.ce with tre Cit? O- diong and ruling of the Depar tme:It of Bull --'Ings. and hereby declares that 41 the • , and lrepresertauons stated in _':i: application are true and co. -red' Fridley. Minn 6-18-76 1' Owner GirgLowo,. framm Kind of Building Used as ros. To be completed about Estirr.3ted Cost. $ --- Old—$m Building Permit No. • P•r�it :r:a. P LLN. 3111C rIXTU?E RATES: N0. RATE TOTAL Si ' x52.x0. S -..-- Number Fixtures ......... fl:ture Fixture Opening 0 0 0 • • • • • • • • -- X $L50 S . _.— By MIM GASCO Busin�K..s Phare ffewFixture Old Oypninge o.o a a . a • •-----'-• x $1.50 5 ..-- — • x $3.25 $ - Cateh ilasin .................... '' Nater lfesler'Up to 99.000 BTU)• • • •-------- x $3.00 S ROUGH New Ground Run Old Bldr. 6 6 6 : 6 6.0 0 --- x ;3.25 S - $2.0 S ' ' • , E!6ctew Wat.r FINAL+ iJLS FITTING TEES: NO. R:+TZ TOTAL x5200 $ . . 1st3Fixtures •••••••••••••••••' x S .75 $ Addiusaal Fixtures 0 0 0 0*064.6 . 6 6 6 6 -.--- C:s Ft::ae to 10.000 BTU 6 6 •.0 0 0.6 6. ----•— x CO 5----- 050 State Surcha ge p.•e'? <:g3 k AL T ZAXTIONS—Rifer to Cods .De:.eri'yaon .,**ease 0 0 0 0 0 0 so I 0 0 6..0 6.6 04"'A" TOTAL F..F..5�. 5 s50 Kiss .,A„ Surcharhe .500 • I ©N CQ PrT E -K �-tail WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring WELL AND BORING SEALING RECORD �inesota Unique Well No. f� �+ H 2 6 County Name Minnesota Statutes, Chapter 1031 orWgNoANOKA � Township Name PRMLEY Township No. 30 Ra ge No. 24 " Section No. 26 Fraction (sm. -3- Ig.) SESE SE Date Sealed MAY 22, 2001 Date Well or Boring Constructed 195W S umencal SheS3LDet Address or Fire um rid Ciry of Well or Boring Location 5 JE t'IE Depth Before Sealing 1607 ft. Original Depth ft. location of Well o ng Sketch map of well or boring in section grid wn location, showing propertyinle lines, roads, and buildings. AOUIFER(S) Aquifer g q ❑ Mulfiaquiler STATIC WATER LEVEL Measured ❑Estimated CgMeasured ft (below ❑ above land surface WELUBORING [KWater Supply Well [IMonit. Well ❑ Env. Bore Hole ❑ Other NL I W E CASING TYPE(S) - �- -' - --F- --i-- Steel ❑ Plastic ❑ Tile ❑ Other j4rrtlk 4— e r mse� ao - CASING(S) Diameters, fl Depth 1, Set in oversize hole? Annular space Initially grouted? in. from to ft. ❑ Yes No ❑ Yes ❑ No ❑ Unknown in. hom to tt. ❑ Yes ❑ No E] Yes ❑ No ❑ Unknown in. from to h. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown PPERTY OWNER'S NAME 1 UNION ItWK OF DELAM Property owner's malung address if different 0* well location address indicated above. 411 DARLINGMN AVENVE S SCREEWOPEN HOLE TULSA, ox 74135Screen from 156 to 160 ft. Open Hole from to ft. OBSTRUCTIONS ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill [y No Obstruction Type of Obstructions (Describe) WELL OWNER'S NAME Wes owners maiing address if different than property owners address indicated above. Obstructions removed? ❑ Yes ❑ No Describe n PUMP I,1 Type Removed ❑ Not Present 0 Other GEOLOGICAL MATERIAL COLQA HARDNESS OF FROM TO FORMATION If not known, Udreete estimated fonnadon log nearby well or boring. - METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: Mlo Annular Space Exists Anmular space grouted with tremle pipe ❑ Casing Perfondion/Removal in. hom to ft. ❑ Perforated ❑ Removed in. hom ro ft. ❑ Perforated ❑ Removed Type of perforator stmd G ST.PE TER WHM 26 1130 $j y _ A go a Other JORDAN 1`I.1i GROUTING MATERIAMS) (One bag of cement - f# Ibs, one bag of bentonite = 50 Ors.) GroutIN Material PORTLAM from 16'to ft. yards 13 bags from toft. yards bags from to n. yards bags from to ft. yards bags REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS -RENLAMS: S: Other unsealed and unused well or boring on property? ❑ Yes YNo How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed In accordance with Minnesota Rules, Chapter 4725. The information contained in this report Is GEOLOGY FROM 6431 UNMRSf AVE, WATER LEVEL 1N ABO EI ELL- -M DATE WATER LEVEL TAKEN: 12/17/69 true to the beat of my knowledge. AMP CODE: E §1:E. LE M ER & SONS, INC. InO1s S� a License orRegistraeonft. According to MN State Regulations May 24, 2001 AufhorizedRep slgne<we Daft KEVIN HOPPE I KEVIN SCFMTMJ EM LOCAL COPY 18142 of Person Sealing Well or Boring ' SUBJECT City of Fridley 372176.42 AT THE TOP OF THE TWINS BUILDING PERMIT f � I. ______ COMMUNITY DEVELOPMENT DIV. r V PROTECTIVE INSPECTION SEC. 572-=04 NUMBER nEv DATE PAGE OF APPROVED By CITY HALL FRIDLEV 55432 ,o---% L J` 612-571-3450 910415 9/13/01 JOB ADDRESS 571 53 Avenue NE I LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 1 3 Oak Hill Addition SHEET 2 PROPERTY OWNER MAIL ADORES$ ZIP PHONE Tong Lee 3314 Girard Ave N, Mpls., MN 55412 612-588-0596 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Tong Lee Contractor 3314 Girard Ave N, Mpls., MN 55412 Same 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 8 USE OF BUILDING Residential Rental 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION £) REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Replace two windows within existing openings, install walls in basement 9 CHANGEOFUSEFROM TO STIPULATIONS See notations on plan. SEPARATE PERMITS REQUIRED FOR: WIRING HEATING PLWBINd AND SIGNS TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REOUIRED 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 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 $350 .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- $23.50 Fire SC $ STRUCTION OR THE PERFORMANCE OF CONSTRUCTION .35 PLAN CHECK FEE TOTAL FEE $24.35 SIGNATURE OF CONTRACTOROR AUTHORiZEDAGENT iDATE, WH PROPERLY VALIDATED THIS IS YOUA PERM S-GNATURE OF OWNERJF OWNER BUiLDERi IDA EiL iNSP AIf NEW [ ] Effective 1/1/2001 ADDN [ ] CITY OF FRIDLEY (763) 572-3604 Bldg Insp ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Construction Address: 5-�34 E , (U E Legal Description: Owner Name & Address: -CDN& LEE Tel. # C(o la)' S" 05q.6 Contractor: NIA MN LICENSE # Address: -5,31q &I911`12D AUE . N Tel. # ((o1a)-568'05'q,6 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: beNth Width Hgt/Ground Sq. Ft. OTHER:e� ,. J Q ,.tZ 6t-1)/AJ Construction Type: Estimated Cost: $ .3 5-1 — Driveway Curb Cut Width Needed: Ft + 6 Ft = Ft x $ = $ DATE: 0 f APPLICANT: Tel. # L i 2 . CITY USE ONLY - Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: Call (763) 572-3604 for Permit Fees if mailing in application $ Fee Schedule on Reverse Side $ .001 of Permit Valuation (1/10th%) $ S-0 $.50/$1,000 Valuation $ $1150 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 [ ] $ d > 676 AM 100 m 12 tell - A/71 CITY OF FRIDLEY INSPEC•1 iUN DIV. 6431 University Ave NE Fridley, MN 55432 763-572-3604 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT RAAOV w IRAMCD nc MYTI IRGc Tn RF INSTAI 1 Fn ON EACH FLOOR Effective On Jan 1, 2001 PLUMBING FIXTURE RATES: New Fixtures Old Opening, New Fixture Beer Dispenser Blow Off Basin Catch Basin NO. RATE TOTAL - JOB ADDRESS 17 t 5'� r"y Rain Water Leader Sump/Receiving Tank Water Treating Appliance Water Heater -Electric Water Heater - Gas" J Gas Range" Gas Dryer" Back Flow Preventer Required ( )Yes () No $ 7.00 The undersigned hereby makes application for a permit for the work herein $ 4.00 specified agreeing to do all work in strict accordance with the city codes $ 5.00 and rulings of the Building Division, and hereby declares that all the facts $ 7.00 and representations stated in this application are true and correct. $ 7.00 / $ 7.00 $ 7.00 $10.00 Owner $ 7.00 _ $10.00 Building Used As $10.00 3 $10.00 Estimated Cost J PERMIT NO.k'-P - r A"",b�" Type $15.00 Reinspection Fee $47.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance State Surcharge PLUMBING COMPANY SIGNED BY Com" — TEL N0. Approved B Y Rough -In Date Final t TOTAL FEE $ 2o?(d •.S0Z PLUS THE $.50 STATE SURCHARGE COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE . »:�:. ....4.: ::}f �•�: Wash >,?:::> Floor . ' Auto. .;<�} •S'::.+•�w^^..'':::.:% : Gas his::::::},..: ..-,: �?. Water Heater g• f .: ' •88.\•:{.: 1- ,$, :+µ4,.!i Tra<::<<:; tii;:::}: Drain B(<' Washer v.`•::.;fJ.:: ?.r Ran a ::L::?�'r.A}:: ;::>:> Gas Elec Stories °e Urinal Shower ... .< -' ;?: JN:}%t:.'•Y,Fi ::}:� �ivl i:<�:}.'ii�}8n,Y..? is}Yi.:::}i::fi::8}}+rn ::•il'r' "01 .::�Basement '::: :::: ^i::::::s. Floor 1 ::?.::::. jy...}� n.. Hs.:• ::t.}+, •; jr ..}}}:??ari}:•}' Floor 2 :bi'l•}+•�: +r::: : is -8:a48}:•}i: i :::�«;•::,': ::...:,;:.::.>;;: ?e:f i::: v -::e: Vii. Floor 4 00 :i�il:<: �L... �...... PLUMBING FIXTURE RATES: New Fixtures Old Opening, New Fixture Beer Dispenser Blow Off Basin Catch Basin NO. RATE TOTAL - JOB ADDRESS 17 t 5'� r"y Rain Water Leader Sump/Receiving Tank Water Treating Appliance Water Heater -Electric Water Heater - Gas" J Gas Range" Gas Dryer" Back Flow Preventer Required ( )Yes () No $ 7.00 The undersigned hereby makes application for a permit for the work herein $ 4.00 specified agreeing to do all work in strict accordance with the city codes $ 5.00 and rulings of the Building Division, and hereby declares that all the facts $ 7.00 and representations stated in this application are true and correct. $ 7.00 / $ 7.00 $ 7.00 $10.00 Owner $ 7.00 _ $10.00 Building Used As $10.00 3 $10.00 Estimated Cost J PERMIT NO.k'-P - r A"",b�" Type $15.00 Reinspection Fee $47.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance State Surcharge PLUMBING COMPANY SIGNED BY Com" — TEL N0. Approved B Y Rough -In Date Final t TOTAL FEE $ 2o?(d •.S0Z PLUS THE $.50 STATE SURCHARGE COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. COMMON VENT INFO ON BACK SIDE 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 manufacturers 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 #3 Vent Connector Height ft Length ft Diameter in Type ALTERATIONS: (Describe) HEATING CO: Signed By: Date :