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PRE 2010 DOCSCity of Fridley, Minn. BUILDING PERMIT No C409i Date: .,,Ka r Owner: Builder -— AddressAddress v N O LDING No. Street We__ _ Part of Lot Lot Block Addition or Sub-Divisi Corner Lot _' Inside Lot _ _M Setback—_ Sideyard - —_ Sewer Elevation Foundation Elevation DESCRIPTION OF BUILDING., To Use Front Depth = Height Sq. Ft ocu. Ft. Fret Depth Height Sq. Ft. Cu. Ft.Type of Construction Est. C'oai lr be Completed _ W In consideration of the issuance to me of a permlt; 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 building, or any part thereof, shall conform in all respects to the ordinances of Fridley, Minnesota reg location, construction, alteration,! maintenance, repair and moving of buildings within the city limits and permit may be revoked at any upon vtolatlorl any of the provisions of said ordinances. '17 NOTICE iids permit don not cover the construction, huhllation for vArlo& phmbino, gn heatk& orvier or water. Be sura to see the BuNdhre hmpater for nparatn pormtfs for thea hang. APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER ° S NAME,� � BUILDER ADDRESS -- -- ADDRESS � 4-5f LOCATION OF BUILDING No. 1 -2- Street Lot_`" 3 ® Block Addition or Part of -Lot Subdivision Corner Lot Inside Lot. Setback 3 Side Yard SEWER ELEVATION FOUNDATION ELEVATION Applicant attach to this form Two Certificates of Survey of Lot and proposed build- ing location drawn on these Certificates. DESCRIPTION OF BUILDING To be used as: Front( Depth Height Sq. Ft. Cu. Ft. Front Depth Height, Sq. Ft. .Cu. Ft. Type of Construction, Estimated Cost To be Completed V ,_.. / — g e - 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 (Schedule of Fee Costs can be found on the Reverse Side). U, Application for Power Plants and Healing, Coding, Ventilation, .Rehigeralion and Air Conditioning Systems and Devices 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 $ MECH. WARM AIR Furnace Shell & Duct Work to 120,000 BTU ............ 8.00 $ 8.00 each add. 80,000 BTU ....................... 2.00 $ Replacement of Furnace ............................. 5.0.0 $ 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 4q. ft. EDR 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 GABS BURNER (up to 400,000 BTU) ....................... 5.00 $ 5.00 GAO FITTING FEES: NO RATE TOTAL 1st 3 Fixtures ...................... x $1.50 $ 1 .%0 Additional Fixtures ................. x .50 $ Gas Range to 200,000 BTU ........... x 2.00 $ AIR CONDITIONING FAN HEATING SYSTEM VENTILATING SYSTEM ALTERATIONS & REPAIRS ROUGH— OUGH FINAL— FINAL $ See Fee Schedule TOTAL FEE $ 14.50 Dept. Dept. of Bldgs. Phone SII 4-7470 Location 1255 — 66th Ave. N. E. 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 2-11 1 19 El Owner HireCh Bros, Inc. Kind of Building z -• Used as Hes • To be completed about 3-11-63 Estimated Cost, $ 400.00 Old—New. Building Permit No. 1'--: Q Permit No. DESCRIPTION OF WORK ABATING or POWER PLANTS -Steam, Hot Water, Warm Air—No 1 Trade Name Westinghouse Size No 0 -75 Capacity Sq, FL E.D.R T5M BTU H.P. Total Connected Load 439965 Kind of Fuel Gas BURNER — Trade Name Size No Capacity Sq. Ft. E.D.R BTU H.P. (REMARKS—OVER) Signed FRE® Q9OGT &-CC HEATING i AIR CONDITIDMji Bye est Lake St. * WE, 9.6767 64-42 2M 7-59 Business Phoar'� i►Rpis Park,Minnesota ' sa 3 s S! W-- Id1h HrhtN.. or Lineai ft T- Noof pane of pane lights of crack ri 8- YVy Coef. Btu HEAT LDSS CALCUATIONS .j '76 -5 / 'IWK OF BUILDINGS IbI1NNEAPOL IS, MM. Weatherstrips _ Net exp. wall I®t. wall Construction No. Insulation Windows I Doors Deference jj'A-tui� out. WaQI Int. Wall Ceiling Roof Floor [find How Applied Net exp. wall, 19— - - --- Int. wall Flom Room9— Room Length /dam WidtV fe Height r . II ! Fl.I Room I Length Width 5; Heiaht.4 Windows and Doors--Crackage and Area 1 Width Height No. of Lineal ft. Area No. at ne of pane lights of crackca. ft. W-- Id1h HrhtN.. or Lineai ft T- Noof pane of pane lights of crack ri Coef. Btu Coef. Btu Infiltration Gass 6 F.ap. wall Net exp. walls 'r Net exp. wall I®t. wall Int. wau Ceiling Ceiling (� `L Floor - I atal situ. — Required sq. ft. E.D.R. or sq. ins. W.A. Leader area of Fl.UIt-)&, � Room I Length ff s( Width.,/ -1 Heiuht A-"> Windows andrackage and Area ee / Wldth Height No of Lineal ft. Area No. of pane of pane lights of tract[ N. ft. W-- Id1h HrhtN.. or Lineai ft T- Noof pane of pane lights of crack ri Coef. Btu Infiltration Infiltration _Glass )e. Glass Earp. wall • � � �- � Net exp. walls 'r Coef. Int. wau Infiltration Ceiling (� `L Ceiling ., F loor Exp. wall i 1 otal Btu. I • C - Required sq. ft. E.D.R. or sq. ins. W.A. Leader area FI.1 ength I Width 4!" Height " Windows and Doors-Crackage and Area -T ee / Width Height No. WC Lineal ft. Area No. of pane of pane lights of trach p. it. W-- Id1h HrhtN.. or Lineai ft T- Noof pane of pane lights of crack A,Pa eq It _ Coef. Btu Infiltration _Glass )e. ZI7 t _ Exp. wall Coef. Btu Infiltration Ceiling ., _ Exp. wall i !U Net exp. wall, - - --- Int. wall Flom - - t ---- _Total ---"--- Required sa. ft. ED R or sq. in,. W.A Leader area -- Windows and Doors --trackage and Area ee / Width Height No. WC Lineal ft. Area No. of pane of pane lights of trach p. it. s Windows and Doors-Crackage and Area _ Coef. Btu Infiltration _Glass )e. ZI7 t _ Exp. wall Net exp. wall d. Int. wall Ceiling ., 6 b F'looi - !U Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area ee / �FLI Room I Length Width/ Height Windows and Doors-Crackage and Area Widlh Height :J o. of Llneal ft. Area No. of pane of pane lights of crack ty- ft- - Infiltration Glass Exp. wallNet exp. wall --- ---- - - --- �� int wall Ceiling -- - ---- -- .�_t -- z'y------------- --- Fioor _ Total Btu. - -Required sq. ft, E-D.R.-or sq. ins. W.A. Leader area / Room I _Length_! Widtb,p- Height Window, and Doors---Ciackage and Area -- - R'14th IieishtII L'No. f l'i'eu] ft. Areti I Ni . of pane "1 n /,ae ghle I r C crack I • j I� -- i- -1 -- - -- - - ----i Coef. Btu Infiltration - _Glass-- ' -�- - - --Earp wall -- Net exp, w.pll Int. wall ctluig Total Rt,: - - --t-}---- t,r,;alrr,; arts HEAT LOSS CALCULATIONS ' " DEPARTMENT OF BUILDINGS MINNEAPOLIS, MINN. Weatherstrips A.S. ---- Insulation Guide Construction No. Windows I Doors Reference Out. Wall In¢. Wall Ceiling Roof Floor Kind How Applied Yes—No es—No 19— I Rnnm l enath ,,9. r Width i 4 Heittht ','v II F1.1 Room I Length Width Height Windows and Doors—Crackage and Area Coef. Btu --- Q - i 4,4 Width Height No. of Lineal ft. Area No. of pane of pane lights of crack sq. ft. Coef.1 Coef. Btu Infiltration -1 Glass Glass 5 0 !' Exp. wall Int. wall Net exp. wall Net exp. wall Int. wall Int. wall / _—__ tP 10 - Ceiling _ Floor Floor Total Btu. Total Btu. fr— Required sq. ft. E.D.R. or sq. ins. W.A. Leader area f 11 f RfbmL-� entrth Width Height Windows and Doors—Crackage and Area Coef. Btu --- Width Height No. of Lineal ft. Area No. of pane of pane lights of crack eq. ft. Area sq ft. Coef.1 Btu Infiltration _ Infiltration 1 Glass —, Fap. wall _—- Glass Exp. wall Int. wall Net exp. wall Int. wall _—__ --- Gelling _ Floor Total Btu. _----_-.--- Required sq. ft. E.D.R. or sq. ins. W.A. Leader area t ri I P—m I I onatk Width Heisht Windows and Doors—Crackage and Area Coef. Btu --- — A'IJth Height tN� of Linea: ft. of pane of Dane Itghta of crack Area sq ft. _ Infiltration 1 Glass —, Fap. wall _—- _ Net exp. wall Int. wall _----_-.--- Total Btu.--- Requirrd sq. ft. E.D.M. or sq. ins_ W.A t.eacit, .area i Windows and Doors—Crackage and Area Wldih HefRht No. of Lineal ft. T Area No. of pane of pane lights of crack sq ft. -- Coaf.j Btu Infiltration - - - - ---- Glass — --- ----- -- Exp. wall Net exp. wall_ Int. wall -- - Ceiling — Floor Total Btu. _ Required sq. ft. E.D.R. or sq. ins. W.A. Leader area FU Room I Length Width Windows and Doors--Craekage and Area—T WidthHeight No. of Lineal ft Area No of pane of pane tights of crack sq ft. Exp. wall ------- - -- l -- — — I Net exp. wall Int. wall- _ _-_ ---- --- - Cciling Floor Total Btu. Required sq. ft. E.D.R. or sq. ins. W.A. Leader area F1.1 _ — Room I Length -- Width Windows and Doors—Crackage and Area W kith Height .l u. of -Ltneai tt Area No. of pane of pane ilghts�I of crack sq. ft. Height Coef.l Btu i Infiltration Glass ---- -- �--- --- — V; ---- - �_�— - - -Exp. wallNet exo. wall �I Int. wall — — - -- ----- --- (Ceiling---- — --` — i t 1 1001 Total Btu. Required sq. ft. E 0 R cr sq Ins W,A Leader area City of Fridley Application for Plumbing and Gas F*Nng Permit DESCRIPTION OF WORK Number, Kind and Location of Fixtures qU' 0e1 � �Yd z c 8Z LLO < V �°1 �� Z 0p • R • N WATER HTR. GAS ELEG Base 1st '-X Y )( 2nd 3rd 4th • Future Connection Openings New Fixture, Old Openings Coaaeded with Sewer bd Cesspool PARTIAL RATE SCHEDULE PLUMBING FIXTURE RATES: 1NO. 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 BTU) ...... x 2,00 $ og 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 Dept. of Bldgs. Phone SII 4-7470 Location 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 '-2, — / q — , 19_ Owner Kind of Used as To be completed about ®' — 3 Estimated Cost, $—� Old—New. Building Permit No Permit No. (-:::Z 6 Signed to Business Phone No- 3 -0 ROUGH d g S 43 FINAL Description ................................................$ TOTAL FEE QM 4 2 7M City of Fridley, Minn.. BUILDING PERMIT Date: - September 21, 1970 Owner: Gregory M. Coffey Builder Address _125.5 -66th Amen .e N.E. Address No. 1255 Street Same Same LOCATION OF BUILDING 66th Avenue N.E. part of Lot Lot�-30 _—__ Block Corner Lot _ Inside Lot Addition or Sub-Divisior Setback Brookview Addition Sideyard Sewer Elevation __ _— — Foundation Elevation DESCRIPTION OF BUILDING S3 z' N° 10841 To be Used as: Garage Front 241Depth 24 ' Height 10' Sq. � 576' CU. � 5760' Front Depth Height ._ Sq. Ft. Cu. Ft. Type of Construction _. Erie Est. Cost _ $1 5 00.0 0 __ To be Completed 7/1/71 Provide Hardsurfaced Driveway In consideration of the issuance to me of a permit to construct the building described above, I agree to do the proposed work in accordancewith the description above set forth and in compliance with all provisions of ordinances of the city of Fridley. I • �p /.01.. In consideration of the payment of a fee of $-11- 00 _, permit is hereby granted to Ift • CO f fey 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 oanform in all respects to the ordinances of Fridley, Minnesota regardinng 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 safd ordinances Building Inspector HANK. MUNICH NOTICE: This permit don not eo mr the construction, InstaiHHon for whdng, plumbing, gas heating, sewer or water. Be sure to we the Building Inspector for npare:e porm6s for these items. • APLICATION FOR RESIDENTIAL, ALTERATION, OR ADDITION BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAME : e LDrr BUILDER: ✓), ADDRESS: !gs 5' - AV ADDRESS: NO:. I0-99- STREET: LOT: 30 BLOCK: ADDITION: 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: Front • / ;Z _ � Y Depth • � � � Height • �� Square Feet:. 529 Cubic Feet: S i Ki 8 Front: Depth: Height: Square Feet; Cubic Feet: Type of Construction: a', c: Estimated Cost:_ $ 1(X) To Be Completed: 7 -1 -?t The undersigned hereby makes application for a permit for the work herein specified, agreeing to do all work in sttict 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:' V- d/ - 7'a SIGNATURE :� (See Reverse Side For Additional Information.) LA a SUBJECT P MIT NO. City of Fridley 23433-,- AT THE TOP OF THE TWINS BUILDING PERMIT'' RECEIPT NO. Ir ' ' • COMMUNITY DEVELOPMENT DIV. ______ r PROTECTIVE INSPECTION SEC. NUMBER REV DATE PAGE OF APPROVED Br CITY HALL FRIDLEY 55432 612-571-3450 910-F15 6/5/95 JOB ADDRESS 1255 66 Avenue NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 30 (Par el 1460) Brookview Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Teresa Gibbons 1255 66 Avenue NE 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Greg Wills Exteriors 4246 Royce St NE, Columbia Heights, MN 55421 788-0529 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 8 DESCRIBE WORK Soffit/Fascia 9 CHANGE OF USE FROM TO STIPULATIONS 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 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 @@ $1,230 @ $.62 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 STATE OR LOCAL LAW REGULATING CON- STRUCTION OR THE PERFORMANCE OF C STRUCTION ` PLAN CHECK FEE TOTAL FEE License SC "City" $32.85 SI NATUR OFC -RACTORORAUTHORIZEDAGENT IDATEI WHEN PROP Y V L]DATED THIS IS YOUR PERMIT jhDG INSP OA E SIGNATURE OF OWNERIIF OWNER BUILDERI IDATEI NEW [) Effective 1/ 1/95 ADDN --C1-TY OF FRIDLEY : ALTER (], SINGLE FAMILY AND. DUPLEXES R=1 AND R-2 Building Application plication P Construction Address: Legal Description: Owner.Name,& Address: Contractor: /—r 7Z5 �2oS; MN LICENSE A-ddress94 �-f Gc= S r ,C/ r . Tel. # ��—tea. J 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/Grouftd Sq. Ft. OTHER: Corner Lot [ ] Inside Lot [ ] Ft. Yd Setback Side Yard Setbacks Type of Construction: Lk•;i Estimated Cost: Approx. Completion Date: L w L-( (cost on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x DATE: APPLICANT: Tel. # CITY USE ONLY Permit Fee $ L 00 Fee Schedule on Reverse Side Fire Surcharge $ 3 .001 of Permit Valuation (1 / 10th %) State Surcharge $ (ra $.50/$1,000 Valuation SAC Charge $ $850 per SAC Unit License Surcharge $ $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 $ 3� �.- STIPULATIONS: q-&-4, 7 6JA1�� HEATING HOUSE HEATING TEST RECORD AIR CONDITIONING AND ELECTRIC. INC. ADDRESS //3 SS rD b Ay 945' APT. FLOOR CITY Fv Jk c-/ SUBURB OCCUPANT v''I OWNER S a� HEAT LOSS DATE HTG. INET. 12 SOLD BY i B 1 INSTALLED BY ;9164e LNG �C` Electrical Work By a .ems Gas Lbw By a AP74 TYPE OF HEAT GA FAX STEAM_ SPACE HTR._ UNiT HTR. OTHER IV � GAS DESIGN MAKE Model LL C9 fro %%F/it Serial 171 2.1-3911 MAKE OF BURNER Modal Max BTU Rating INPUT MAKE OF FURNACE Model CONTROLS THERMOSTAT -rv Heat_Plug Valve Limn S a� Limit Setting 'Fan Setting Pilot Type Pilot Make Pilot Model CONVERSION Vent Sbe 4 KIND OF LINER - [IT SIZE � ar NONE Draft Hood inr 4a r, a d Regulator Filters Size & X L Number Chimney Location Inside 8l Outside Chimney Construction H -/J/ s. -r- Smoke Bomb Wiring v Pilot Timing 9090 -50 . Draft Tat Tag !/ L W. Cut Off Door Pressure Ligtding Inst.­,(,-- Pressure nst./sPressure -4.5- Percent CO, ®a Data Toatod Input CFH Percent O, ►Jo Company Testing e ! Pe Stack Temp. Percent CO <3 Q4 Name of Teeter Form 235 S;w t QF FRIDLEY INSPECTION DIV. 6431 University Ave NE 4 Fridley, MN 55432 572-3604 RATE SCHEDULE Residential APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING -SYSTEMS AND DEVICES Furnace Shell and Duct Work, Burner - Also Replacement Furnace (Side Vent - Fill Out Back) Gas Piping (Needed with new furnace) Gas Range Gas Dryer *Air Conditioning - All Sizes All Others/Repairs & Alterations (LIST ON BACK) 11% of Value of Appliance or Work Commercial/I ndustrial 1.25% of Value of Appliance or Work Rate TOTAL $30.00 $ �jD,f3Z� $10.00 $ $10.00 $ $10.00 $ . $ 25.00 State Surcharge TOTAL FEE $ 9 �% 00 Effective On January 1, 1997 JOB ADDRESS 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 Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. _ / 1997 OWNER. I 4W-6 BUILDING USED AS J ESTIMATED COST PERK' $ No. of Heating Ura ' Circle One (Steam) (Hot Water) Trade Name Size No. H $ .50 MINIMUM FEE FOR ANY HEAT] NG/COOUNGNENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00 PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $42.00/Hr *Air Conditioners can not be placed in a side yard without written permission from adjoining propgrty owner. BTU 'i C7 D -U 0 HP EDR - =-- Fuel(rOa - Total Connected Load Burner Trade Name Size No. BTU HP EDR BLAINE HM AIC ELECT.. INC. HEATING COM�PY � CLAVI—N.E. Signed Byo. '?e 2 --&7� Approved By Rough -In Date Final Date 1�-1041 FILL OUT BACK SIDE F R STACK VERIFICATION ON REPLACEMENT FURNACE I CRD4NEY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack. 1. . Has been carefully examined Yes ( No'( ) 2. Is fee from rust or, deterioration Yes No ( ) 3. Has no foreign objects lodged within 4. Is securely supported S. Meets all current Code requirements for size and total BTU's connected 6 Has total heating BTU's of LTU� All other BTU's 0,0 y C) TOTAL BTU's U 7. Has a liner been provided. for water heater 8. Has combustion air been provided for water heater Remarks: . Yes �) No ( ) Yes �) No (. ) YesoNo() Yes ( ) No Yes .00 No ( ) List ALTERATIONS Being Done:,�.,��" HEATING CO: Signed By: Date: BLAINE HTO. AIC ELECT:. INC. 13582 CEN1WAVE. N.E. q'g