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PRE 2010 DOCSSUBJECT Paley City of Fr 22235 AT THE TOP OF THE TWINS BUILDING PERMIT i? RECEIPT NO. COMMUNITY DEVELOPMENT DIV. 1 L i PROTECTIVE INSPECTION SEC. �'/®� r 1 � 1 . � CITY HALL FRIDLEY 55432 NUMBER REV. DATE PAGE OF APPROVED BY L J` 612-571-3450 910415 11/12/93 JOB ADDRESS _196' 711� Way NE 1 LEGALLOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR.. 2 1 1 SHEET 1 Gary 0br ckl Addition 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Brickner Builders Inc. 6240 Hwy 65 NE #201 Fridley 55432 574-9871 3440 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. 8 USE OF BUILDING Residential 7 CLASS OF WORK Ek NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Construct a 61' x 30 Dwelling and a 28' x 241 Garage REQUIRED FOR 9 CHANGE OF USE FROM WRING, HEATING, PLUMBING AND SIGNS. STIPULATIONS See notations on plan. Provide a hard surface driveway. Provide sod in the front and side yards, Provide City with copy of verifying survey before capping. Paid Park Fee of $1,500. Paid Assessment of $1,236.80. Paid Driveway Escrow of $297.00. Contact City Engineering Department for Water & Sewer Locations. IV Before digging call for all utility locations THE CITY OF FRIDLEY DOES NOT GUARANTEE THE ACCURACY OF UTILITY LOCATIONS AND ELEVATIONS. 454-0002 THIS DATA IS FOR INFO ":'.-'t' );'K-MPOSES REQUIRED BY ONLY LAW AND PERSONS US!ND_ THIS tNF,R;b;ATION SHOULD VERIFY IT ON THE SITE, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCYLOAD SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. ZONING S0. FT. CU. FT. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 80 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 ISTALLS GARAGES VALUATION SURTAX Fire SC AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED 000 $144,000 $ 72.00 144.00 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT PERMIT FEE SACCHARGE DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- $793.50 $750.00 STRUCT�ORTHERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTALFEE � License SC $5.00 $1,764.50 +PF,DW,A SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)j WHEN PERLY LIDATED THIS IS YOUR PERMIT 11-17-e_ LD 1 I DATE SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI NEW [ ] Effective 5/26/93 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND (DUPLEXES R-1 AND R -2t Building Permit Application i Construction Address: I O S 71 1�� W G.(./ Legal Description: L Q � e LCA C k I G CAV v O b v j4aA®® Owner Name & Address: s A-' c- Tel. # 97 y -cls-2 i Contractor: jb &I C 1c nJEd-L jS u I L n E2 S -'FaU !C, MN LICENSE # 000 3 y '16 Address: 6 a H D )4w y 6s-- �'a o Fx x i - E y Tel. # 577 y -9e 7 L Attach to this application, a Certificate of Survey of the lot, with the proposed co ArUCdon drawn on it to scale.r ;x,11 _ 107 (t J, 40 r 2A s) cz DESCRIPTION OF IMPROVEMENT �� --I -' LIVING AREA: Length Width Height Sq. FL GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length � Width tJ ;a Hgt/Ground Sq. Ft. OTHER: Corner Lot [ ] Inside Lot [ ] Type of Construction: Approx. Completion Date: Ft.,Yd Setback Side Yard Setbacks Estimated Cast: $ e (Cost on Back) Driveway Curb Cut Width Needed: !b Ft. + 6 Ft = Ft x $ 992-00 =$ DATE: (0'a APPLICANT:Z—1&��jTel. # '57 e,7 / Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th`) $.501$1,000 Valuation $750 per SAC Unit ?Vc�n 7 sdfa�' $5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above Conservation Plan Review $450.00 Park Fee $ Fee Determined by Engineering Sewer Main Charge Agreement Necessary { ] Not Necessary [ ] ✓y am /,a34o •80 TOTAL $ �STIPULATIONS: I J� 2422 Enterprise Drive Mendota Heights, MN 55120 * PIONEER LAND SURVEYORS • CIVIL ENGINEERS (612) 681-1914•FOx 681-9488 engineering LAND PLANNERS • LANDSCAPE ARCHITECTS 625 Highway 10 Northeast * Blaine, MN 55434 * * (612) 783-1880•Fox 783-1883 Certificate of Survey for: Brickn•er Builders, Inc. House Address: .711/2 Way, Fridle-Y MN CV N n in LO n� Z 10.00 864.3 86'5AI w \ �c 863.5 BGS Egsr R , R/VER • oz2848� Rp 19 ?2•� ao '0 0-4, S64V" \ J �$6Z.74 v Asp 86z 863 SSS y�992 IrO 9 F 3 � S 00.0 Z 4X? Aa 863 71 1 /2 WAY A NOTE-" CONTRACTOR, MUST VERIFY ALL DIMENSIONS AND DRIVEWAY DESIGN X 900.0 Denotes Existing Elevation PROPOSED 'HOUSE ELEVATION x<900.0 Denotes Proposed Elevation Lowest Floor Elevation: Bsy-z - - - Denotes Drainage & Utility Easement Top. of Biock Elevation: S6s, 3 --- Denotes Drainage Flow Direction --o•- Denotes Monument Garage Slab Elevation: 865 —a- Denotes Offset Hub Bearings shown are assumed LOT 2 BLOCK 1 GARY OBRYCKI ADD, ANOKA COUNTY. MINNESOTA I hereby certify that this survey, plan or report was prepared by me or under my direct supervision and that I am duly Registered Land Surveyor under the laws of the State of Minnesota. Dated thisZSNday of V C-{ ah ei A.D. 19 q). Scale: 1 inch = 3 0 (feetROBERRTT • B. SIKICH L.S. REG. NO. 14891 13-6-31 13293.00 T IS,, RNDERSON'S i architectureJ consultants 9008 303T. SA. OSSM. YN. DW9 /M_ (02)-424-9772 Plan -n Date 1— I z -_ Owned Contractor---- Site Address: op') PHONE I)TOTAL EXPOSED WALL AREA ' Q sq. ft ltoo U4--' L =1 16-7.7 2) TOTAL EXPOSED ROOF/tEILING AREA �� sq. ft. x'Uof rouO S2 ' WALL AREA CALCULATIONS: TOTAL WINDOW AREA GLAZED TOTAL DOOR AREA TOTAL GLASS DOOR AREA GLAZED TOTAL FIREPLACE WALL AREA TOTAL WALL FRAMING AREA NET INSULATED WALL AREA TOTAL RIM JOIST AREA TOTAL FOUNDATION AREA (EXPOSED) TOTAL FOUNDATION WINDOW AREA 1155 SQ. ft. X'u"' d -z-- 23cz`�P sq.ft.ztU01 -L21= Z ` I s q.f t. X" U " 6 �-� sq -ft. 11U#1 ' — — sq.it.x U "09= sq.ft.z-U,- I o — sq.ft. X UIt d 7 = p / sq. ft.x"U" sq.ft.x"U" 3) TOTAL If item 3 is the some as, or less than item 1, you have met the intent of 2 MCAR 1.16008 A and 0. ROOF/CEILING CALCULATIONS' - TOTAL SKYLIGHT AREA TOTAL ROOF/PEILING FRAMING AREA NET INSULATED ROOF CEILING AREA Aq.ft.x"U" —�Z—5q.ft.144U11 .0 = 4) TOTAL If item 4 Is the some as,or less than Item 2, you have met the intent of 2 MCAR 1.16008 A and 0. ALTERNATE BUILDING ENVELOPE DESIGN To utilize the total envelope system method, the sum of Items I and 2 shall be greater than the sutra of Items 3 and 4. 1) +2) 3) +4) a I hereby certify that the building here described meets or exceeds the a of Energy Conservation Act. (signed) a A t w1va i nuko I wiv RUING SECTION Interior oir film 0.68 Sol inches of soft wood L X31 exterioi air film 0.17 TOTAL R o `� U a I/R ' o') 'ECTION (INSULATED) interior air film 0.68 s„a,�� b exterior air film 0.17 TOTAL R L� • !'1 U = VR , `4_ )IST SECTION I interior air film 0.68 2 !'9. o 5 0-1 a s; 6 exterior air film 0.17 TOTAL R ! U = 1 /R ic,,ele ATION SECTION I interior air film 0.68 2 1 of �" 3 q exterior air film 5 0.17 TOTAL R 1,11 U a 1/R 1 11_ tr k VENTED CONSTRUCTION CEILING SECTION (INSULATED) (I (interior air film 0.61 ( 2 gza l eE�gtZ K I S[o (4 exterior air film (still) 0.61 TOTAL R 45. F5 U = I/R CEILING FRAMING SECTION ( I interior air film 0.61 (2'45y8 St;<T¢oc.ic. , Slo (3-E-Lo—s- I ►-sucd &Z, (4 interior air film 0.61 (5 S�zk inches of soft wood 4 �S TOTAL R U = I/R 10Z�-P CEILING SECTION ( INSULATED) ( I interior air film 0.61 (2 (3 (4 exterior air film (still) 0.61 TOTAL R U = I/R CEILING FRAMING SECTION ( (,interior air film 0.61 (2 (3 (4 interior air film 0.61 (5 inches of soft wood _TOTAL R U = I/R EXPOSED BEAM CEILING SECTION (,1 interior air film 0.61 (2 (3 (4 (5 exterior air film 0.17 TOTAL R J Print Key Output Page 1 5738SS1 V2R2M0 920925 FRIDLEY 11/16/93 11:53:58 Display Device . . . . . . DSP11 User . . . . . . . . . . . COLE CR400I04 City of Fridley 11/16/93 Payment Inquiry 11:53:36 Operator ID: COLE Date: 11/12/93 Number: 00 Receipt number: 0004008 Customer Location Amount Type Sry 1236.80 CP ...................................... G/L Credit account 10100003612000 Payment Description G/L Debit account Bank code . . . . . . View information, press Enter. Project number . . . . Description BRICKNER BUILDERS BP # 22235 FOR 105 71 1/2 WAY NE F12=Cancel F5=Comments F12=Cancel:....................................: CITY OF FRIDLEY INSPECTION DIV, Effective On January 1;1993 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, 572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES JOB ADDRESS RATE SCHEDULE The undersigned hereby makes application for a permit for the work herein Residential Rate TOTAL specified agreeing to do all work in strict accordance with the City Codes and Furnace Shell and Duct Work, Burner — �1 rulings of the Building Division, and hereby declares that all the facts and Also Replacement Furnace $ 20.00 $ oto - representations stated in this application are true and correct. Gas Piping (Needed with new furnace) Gas Range Gas Dryer *Air Conditioning — All Sizes All Othem/Repairs & Alterations (LIST ON BACK) 1% of Value of Appliance or Work Commercial/Industrial I% of Value of Appliance or Work $10.00 $ 6 ®d OWNER $ 10.00 $- BUILDIN $10.00 $10.00 $ ESTIMATED COST NO. $10,00 $ DES RIPTIQN QF FURNACE AND OR BURNER $ No, of Heating Wnits Circle One (Steam) (Hot Water)(Warm Air) Trade Name _ Size No. z> �-v BTUAq�4 D O _ HP EDR $ Fuel Total Connected Load State Surcharge $ ,50 TOTAL FEE ®, 50 MINIMUM FEE FOR ANY HEATING/COOLINGNENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS 115.00 PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $30.00 *Air Conditioners can not be placed in a side yard without written permission from adjoining property owner. Burner Trade Name Size No. BTU HP EDR HEATIN Signed Approved By Cr,,?f' Rough—In Date Final Date 1� FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE CHIMNEY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack: .1. Has been carefully examined Yes ( i No ( ) 2. Is free from rust or deterioration Yes ( ) No ( ) 3. Has no foreign objects lodged within Yes ( ) No ( ) 4. Is securely supported Yes (-) No ( ) S. Meets all current Code requirements for size -and total BTU's connected Yes ( ) No ( ) 6. Has total heating BTU's of All other BTU's TOTAL BTU's Remarks List Alterations Being Done: HEATING COMPANY Signed By Date 1 33-W FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY. MN 55432 • 16121 571-3450 • FAX (612) 571-1287 March 29, 1994 Brickner Builders 6240 Highway #65 NE, #201 Fridley, MN 55432 Re: Final Inspection at 103 71 1/2 Way NE, Fridley Dear Sirs: A final inspection was conducted on March 28, 1994 of the above address and the following items were noted which must be completed before the structure can be finaled: 1. Provide sod in the front and side yards by June 15, 1994. 2. Provide a hardsurface driveway by June 15, 1994. 3. Provide a front step or handicap ramp by May 1, 1994. We will expect these items to be completed by the scheduled dates and reinspections called for. If you have any questions on this matter, please feel free to contact me at 571-3450. Sincerely, GARY R. FO Building/Mechanical Inspector GRF/mh CITY OF FRIDLEY INSPECTION DIV. Effective On January 1, 1993 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT 572-3604 �4- t ) MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR Stories Urinal Shower o� $ 7.00 s . loo Tr*ay Drain $ 4:00 Auto. Washer as Range a ereater Gass Elec�� Basement Catch Basin Rain Water Leader $ 7.00 '• $ 7.00 Water Treating Appliance $10.00 Floor 1 $ 7.00 Water Heater — Gas $10.00 CZ now Me Gas Dryer ON Back Flow Preventer Required ( )Yes Floor 2 Type •$5.00 Reinspection Fee $30.00 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS Floor r 3 0 4 Floor Ag� —M PLUMBING FIXTURE RATES: NO. RATE TOTAL New Fixtures o� $ 7.00 Old Opening, New Fixture $ 4:00 Beer Dispenser $ 5.00 Blow Off Basin $ 7.00 Catch Basin 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 •$5.00 Reinspection Fee $30.00 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1 % of Value of Fixture or Appliance State Surcharge TOTAL FEE 9 JOB ADDRESS A) 3 7/ !a I J(, ij The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the city codes and rulings of the Building Division, and hereby declares that all the facts and representations stated in this application are true and correct. I _ S . IN 199$ Owner Building Used As Estimated Cost PERMIT NO. PLUMBING COMPANY Th �OI7 � OYI el UM rl A SIGNED BY TEL N0. q 9V1 G ?2 Approved By �I� Rough—In Date Final Date— .50 rJ MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 $.� PLUS THE $.50 STATE SURCHARGE SUBJECT PE City of Fridley 22303 AT THE TOP OF THE TWINS BUILDING PERMIT � • COMMUNITY DEVELOPMENT DIV. r � PROTECTIVE INSPECTION SEC. � CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY 612-571-3450 910-F15 2/16/94 / / JOB ADDRESS 103 711� Way NE 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 2 1 SHEET Gary Obrycki Addition 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Brickner Builders 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Fireside Corner 2700 N Fairview e s 633-2561 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 ❑ ADDITION CIX ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Install a built-in fireplace 9 CHANGE OF USE FROM TO STIPULATIONS stall per manufacturers specifications. TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED 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 80 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 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 $1� 100 $,55 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- $27.00 Fire SC $1.10 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE License SC $5.00 $33.65 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IDATEI HEN PROB7Y IS YOUR ;tI�TED %PERMIT -i / BL )NSP DATE SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI NEW [ ] Effective 1/1/94 ADDN [ ] CITY OF FRIDLEY ALTER [ J SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Building Permit Application �" T Construction Address: 101 :2Z %2 Lt� A OF Legal Description: Owner Name & Address:c k q_f (, �, ` s Tel. # Contractor: F tici rr MN LICENSE # Address:®O (�—R'� r� \ Tel. # 13 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/Ground Sq. Ft. OTHER: `��.�s�� l c` tA:N Corner Lot [ ] Inside Lot [ ] Ft. Yd Setback Side Yard Setbacks Type of Construction: Estimated Cost: $ /Q O p° Approx. Completion Date: Driveway Curb Cut Width Needed: _ DATE: APPLICANT: Permit Fee $ 7 Fire Surcharge $ / State Surcharge $ o mss' SAC Charge $ License Surcharge $ S� Driveway Escrow $ Erosion Control $ Park Fee $ Sewer Main Charge $ TOTAL $ 3 3. � S_ �dJ k STIPULATIONS: / C_ (Cost on Back) Ft. + 6 Ft = Ft x $ CITY USE ONLY Fee Schedule on Reverse Side M9 Tel. # .001 of Permit Valuation (1/10th%) $.50/$1,000 Valuation $800 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 [ J " CITY OF FRIDLEY INSPECTION DIV. Effective On January 1, 1997 6431 University Ave NE Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, 572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES JOB ADDRESS ° RATE SCHEDULE The undersigned hereby makes application for a permit for the work herein Residential Rate TOTAL specified agreeing to do all work in strict accordance with the City Codes and Furnace Shell and Duct Work, Burner — rulings of the Building Division, and hereby declares that all the facts and Also Replacement Furnace $ 30.00 $ representations stated in this application are true and correct. / % , � 1997 (Side Vent — Fill Out Back) —1 Gas Piping (Needed with new furnace) $10.00 $ OWNER�i(� %�� r�h�► Gas Range $10.00 $ q BUILDING USED AS Mp Dryer $10.00 $ Gas D er _ ESTIMATED COST PERMIT NO. *Air Conditioning —All Sizes $ 25.00 $ DESCRIPTION OF FURNACE AND OR BURNER All Others/Repairs & Alterations (LIST ON BACK) Work $ No. of Heating Units_ Circle One (Steam) (Hot Water) arm Ai 10% of Value of Applian a or 12 S f � Trade Name Size No. Commercial/Industrial I BTU HP EDR 1.25% of Value of Appliance or Work $ Fuel Total Connected Load State Surcharge $ .50 Burner Trade Name Size No. ' BTU HP EDR TOTAL FEE��_�� HEATING CO ANY MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION REFRIGERATION/AIR CONDITIONING PERMIT IS $25.00 Signed By el o. PLUS THE $.50 STATE SURCHARGE REINSPECTION FEE $42.00/Hr Approved By Rough—In Date Final Date *Air Conditioners can not be placed in a side yard without FILL OUT BACK SIDE F R STACK VERIFICATION ON written permission from adjoining property owner. REPLACEMENT FURNACE i CHD4 EY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack: 1. Has been careft ly examined Yes () No ( ) 2. Is free from rust or deterioration Yes () No ( ) 3. Has no foreign objects lodged within Yes ( ) No ( ) 4. Is securely supported . Yes ( ) No ( ) 5. Meets all current Code requirements for size and total BTU's connected Yes () No ( ) 6 Has total heating BTU's of All other BTU's TOTAL BTU's 7. Has a liner been provided for water heater Yes ( ) No ( ) 8. Has combustion air been provided for water heater Yes ( ) No ( ) Remarks: . List ALTERATIONS Being Done: HEATING CO: Signed By: Date: CITY OF FRIDLEY INSPECTION DIV. .6434 University Ave NE Fridley, MN 55432 572-3604 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO BE INSTALLED ON FACN F1 nnR 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 Blow Off Basin $ 7.00 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 Reinspection Fee $42.00/Hr ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.5% of Value of Fixture or Appliance 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. Owner Building U d AsA Estimated qst PLUMBIN OMPANY SIGNED I 1997 5 7/ -115;27 TNO. / , n� a TEL N0. Approved By Rough—In Date Final Date State Surcharge $ .50 - 6L,41& MINIMUM FEE FO ANY PLUMBING GAS P IT IS $20.00 TOTAL FEE $ �u PLUS THE $.50 STATE SURCHARGE **COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6—A. MINIMUM SIZE 9 SO INCHES. s v SUBJECT PERMIT.biOQ-.... _ City of Fridley 9 AT THE TOP OF THE TWINS BUILDING P E R M I T f � RECEIPT NO. `v -------COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC.®�' r 1 � i CITY HALL FRIDLEY 55432 NUMBER REV DATE PAGE OF APPROVED BY 612-571-3450 910415 11/18/97 JOB ADDRESS 103 71 1/2 Way NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR.2 1 Gary OBrycki Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Michael/Jean Mattson 103 71 1/2 Way NE 571-8828 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 Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION] ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Basement finish 9 CHANGE OF USE FROM TO STIPULATIONS See notations on plans. NPARATt PERMITS REQUIRED F'IR WIRING; HtATING, PLUMBING AND SIGn 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 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 GOVERNI G THIS TYPE OF WORK WILL BE COMPLIED $4.25 WITH WHETHER SPECIFIED REIN OR NOT. THE GRANTING OF A PERMIT8,500 DOES NOT PRESUME TOG E AUTHORITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE PROVISIONS OF ANY OTH STATE OR LOCAL LAW REGULATING CON- $149.75 Fire SC $8.50 ST UCTION OR THE PERFO MANCE OF CONSTRUCTION IFI PLAN CHECK FEE TOTA FEE 162.50 IGNAj�1RE NT ACTOR AUTHORIZED AGENT IDATEI EN RQ VALIDAT THIS IS YOIT EONE OFOWN ILDERI IDATEI Pa 01 OA TF s v NEW [ ] Effective 1/1/97 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION�� ConstructionAddress: l�� .3 t -�2 Legal Description: '-) Owner Name &Address: M;C]nro p c, \P� N �(�,, a-6,- A- # 7 Contractor: MN LICENSE # Address: Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF EWPROVEM ENT LIVING AREA: Length Width GARAGE AREA: Length Width DECK AREA: Leng9i Width OTHER: fiS ,) 7� l-9 ( 7)/s Construction Type: Driveway Curb Cut Width Needed: DATE: - APPLICANT: H e Height Sq. Ft. _ Height Sq. Ft. _ Hgt/Gr and Sq. Ft. _ Cost: $ chedule on Back) Permit Fee $ 14'? '7-!r Fee Schedule on Reverse Side Fire Surcharge $ .001 of Permit Valuation (1/10th%) State Surcharge $ $.50/$1,000 Valuation SAC Charge $ $950 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 $ % S� STIPULATIONS: I Z X O O K c 00 m 0 O O Z SUBJE& PERMIT NO. City of Fridley AT THE TOP OF THE TWINS BUILDING PERMIT 28860 Ir • `v __�___ COMMUNITY DEVELOPMENT DIV. f PROTECTIVE INSPECTION SEC. i I CITY HALL FRIDLEY 55432 NUMBER NEV DATE OF APPROVED BY --_-� ...... ".j L 612-571-3450 910415 1/21/99 F;GE / JOB ADDRESS 103 71 1/2 Wav NE 1 LEGAL BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. ILOTNO. 2 1 1 Gary Obr cki Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Michael Mattson 103 71 1/2 Way NE 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Jayson Lindsay Roofing; 2638 Clearview Ave Moundsview MN 55112 792-1857 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 20098263 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ ❑ NEW ❑ ADDITION ❑ ALTERATION X REPAIR X ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof House & Garage 33 S Tear -off; Partial Reside 9 CHANGEOFUSEFROM TO STIPULATIONS Underlayment must comply with the State Building Code. Call for building wrap inspection before covering. SEPARATE PERMITS ARE REOUIRED 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 1 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 SE COMPLIED $4.41 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $8,828 DOES NOT PRESUME TO GIVERUTH ITY TO VIOLATE OR CANCEL THE PERMIT FEE SAC CHARGE O LOCAL LAW REGULATING CON. PROVISIONS OF ANY OTffloifXa $149.75 STRUCTI OR THE PEROCONSTRUCTION Fir SC $8.82 PLAN CHECK FEE TOT EE License $5. 167.98 SIGNATURE FCON:RA,TORORAUTMORI G NT IDATEI EN7P;WOP&, DAT I$ I$ UR PERMIT BLDG So NATE S,GNATURE OF OWNER,1F OWNER BUILDERI IDATEI NEW [ ] Effective 1/ 1/99 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND. DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION Cob v2� ConstructionAddress: Legal Description: Owner Name & Address: Contractor: Address: LIVING. AREA: GARAGE AREA: DECK AREA: OTHER: Construction Type: Tel. # MN LICENSE # 2QL La63 Tel.# 24q /ST -7 Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF BOROVEMENT Length Width Length Width Driveway Curb Cut Width Needed: DATE: I,- a-/— 9 q Ft. + 6 Ft = Height Height Hgt/Ground Sq. Ft. Sq. Ft. Sq. Ft. Estimated Cost: $ r D (Fee Schedule on Back) Ft x $ = $ 88,;28 Tel. # �22 9 A % STIPULATIONS: CITY USE ONLY Permit Fee $ %L Fee Schedule on Reverse Side Fire Surcharge $ Sy° a .001 of Permit Valuation (1/10th%) State Surcharge $ y y/ $.50/$1,000 Valuation SAC Charge $ $1050 per SAC Unit License Surcharge $ �9- 6�/U $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 $ /0 STIPULATIONS: CITY OF FRIDLEY PERMIT �2001703 6431 UNIVERSITY AVENUE NE FRIDLEY, MN 55432 DATE ISSUED: 10/01/2004 A 572-3604 FAX: (763) 571-1287 ADDRESS 103 71 1/2 WAY NE PIN 103024410066 LEGAL DESC GARY OBRYCKI ADD LOT 2 BLOCK 1 PERMIT TYPE PLUMBING PROPERTY TYPE : RESIDENTIAL CONSTRUCTION TYPE : ADDITION/ALTERATION VALUATION : $ 200.00 NOTE: COMBUSTION AIR SHALL BE PROVIDED PER UMC CHAPTER 6 AND TABLE 6-A INSTALL A GAS WATER HEATER. # ELEC WATER HEATERS 0 # NEW FIXTURES (EXIST OPENINGS) 0 # GAS WATER HEATERS 1 # GAS DRYERS 0 # GAS RANGES 0 # OF NEW FIXTURES 0 VALUE (FOR MINIMUM CALC) 200 # WATER TRMT APPLIANCES 0 APPLICANT PLBG PERMIT MINIMUM FEE PLBG FIXTURES (NEW OPENINGS) 0.00 0.00 H P PIPEWORKS 3670 DODD RD STE 100 PLBG FIXTURES (EXIST OPENINGS) 0.00 EAGAN, MN 55123- WATER TREATMENT APPLIANCE 0.00 (651) 365-1340 WATER HEATER - ELEC 0.00 WATER HEATER - GAS 35.00 GAS RANGE FEE GAS DRYER FEE STATE SURCHARGE, PLBG FLAT 0.00 0.00 0.50 OWNER HYEJEEN & JAMES BARDON 103 711/2 WAY NE TOTAL 35.50 FRIDLEY, MN 55432 PAID WITH CHECK # 9835 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 wort will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancek the provisions of any other state or local law regulatiog cons ction or the performance of construction. Annlic Date I I Bldg Insd Date q t SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE. CITY OF FRIDLEY INSPECTION DIV. 431 University Ave NE "; Adley, MN 55432 ry 763) 572-3604, FAX (763) 571-1287 E.iteciive April 1, 2004 APPLICATION FOR PLUMBING AND GAS FJTTING PERMIT FAA1:2W All IKARRR nl 1:1YTI IPPR Tn RF IWgTA1 I Fr? ON FAM FI r`nR 'LUMBING FIXTURE RATES; NO, RATE TOTAL JOB AD law Fixtures $10.00 )Id Opening, New Fixture � Wash ;tCS...vc�. Floor u..>O.yYYwN.,= Auto. '•,>�1:%':+:O-1 S.Ji:i,%O:.-.,F..:$i;C.iwY.{w Gas .:y.X.m:tori water Heater )>. $10.00 a�i:Y»>r2iAi�YiYrY $10.00 _ :i_`"; >c•((- ;opQ•-:i: "S Drain .t3Xj..o.:. >C•.JJc_-.yu rYL,-. 2YTYW>:Ss'iJ.Y >(/:C Washer -Y Range :,aaa.6Gas Elec.Ses O Vater Heater -Gas** x^.j:C=<-"�%•trYlro:..�JC. Urinal Shwr Ta :f> $10.00 lack Flow Preventer Required (ffes No ' ."" Type "."yJv:<i_:>.=>Y :�.: VtiV:?jA..:CRD <ci..jC_tT;y Ua J:T�^'.a.':Sp_J .>jwtO..>°000.Yy2i. h>':, �a�>1M.n•'qcaC?.� , xa%>{<<ix,�¢dt>>�• yC:>tJ?iS<YC{:.f _ p. fS.�C'>:'ii �v<N:.:tctx.:.4:1i<%.:xyJ> G<WTBasement .h,Q C.O_X{N AS:-N ",;ii.%vX•l%� Jv . ?>X-Y:�SYL<_-:<X<•< Floor 1 �-{Y<<<YXX:XiO:--Vx.�b:!SO:oX' �,x d .XO .:r'�OOJ.?iMs:<>:_Or.:"<.<�i .0C:.,;. ~Ap<":K!<.Qc,\U?:1 . ., ,L: ....>.... Y?':.__iY:±Y vi. iY:tliY •}�R•Q.y: tt4qJ.>S Nk<.1kx. =<Xl� C A.- �rlyi'OgiY ]x..c -=MA:0).:O ' !<J titO X`,t6\Y Floor 'i::S:<xJ»Y-iCF"oa :�J'"��2A.->•�i_>{>t,. .C:�i9t:<OiC;iY_w ef;;'�=:::v3iwy_r.<,'t, ia>;cacx-.;vx>.}�;Jt •r.6ii.Y �iiis»:<}. kY.:,?i,.:.. :ar: N:�S•�2i.' 4i ;r.Jya�a. ':G:fi}>XJ:iJ -�s>>3J.> - ..,_Si: �?:mak :: a O %>1;:>:iG �':vrn,;!?�y�:,•.:. <�M<;):tOV:}ld f;0 .-ica;'y-v�?+)xp,� �k:�{J :2L�.1�% .'.'ei3:>koii:cii%;i8i: -.r.2i: ;C �Y.>.OS:t?�.LY,. 'ip?tilc_i�;ii tt0�<O)i)?O•"O,''-IJP Floor 3 XJ. ,>}Me •:::.. ., r. r»: :-�. :•:: :..:... ar.M�\,........ ..- n>r_a:-:u ::,.,.•.• x<Jf .>;�,.<o..an.?. ,2a.J>»*a.s._... Floor 4 :Y:j]TY:}i`>�Xti: v: :�:>>x,<P.-Q-J•CY�Yn•AT�.XJXCX( `>)lt}: A:y.;>: -'':.:J] >!Jiv.y%� .�O ^Q Y XJi Rt?:�>N.T:.'.jwL �_' .G%vC. %�a /vD'l. 'a:Xi:!Q>l%iG:%iY.jS y} l>' C\A> > "YX•'.O`%�.C.S'i_�C•:jii is r>Y �>:J;fjtUK �r:'d-ix,:a+iy>: t14X!C CTJ'l S4X3:v 'v >:YnK0..X :Ov'�.r}."•-0t\:"�%•. .: C Y tC 4 a = J 9 i� .MAE M' •'-x' RN".... 'LUMBING FIXTURE RATES; NO, RATE TOTAL JOB AD law Fixtures $10.00 )Id Opening, New Fixture $10.00 leer Dispenser $10.00 Ilow Off Basin $10.00 :atch Basin $10.00 >.lain Water Leader $10.00 A IumpfReceiving Tank $10.00 Vater Treating Appliance $35.00 LL Vater Heater -Electric $35.00 O Vater Heater -Gas** $35.00 ,�� t )as Range" $10.00 Sas Dryer** $10.00 lack Flow Preventer Required (ffes No Type $15.00 UO teinspection Fee $50.0011 -Ir m kLL OTHERS ANDIOR REPAIRS AND ALTERATIONS 1.25% of Value of Fixture or Appliance f 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. OWNER DATE: 204 A) BUILDING USED AS ¢¢�� }}�� j ESTIMATED COST oCC �l�C� PERMIT NO. c2664_,% `l_// -!6J PLUMBING COMPANY•r',I®1�8ladtRt LL 3410 mn-a/� V SIGNED BY d k u ULa 4LJ-) TEL NC/,,5/ -,Y,5 -)J40 v Approved By NState Surcharge MINIMUM FEE FOR N TOTAL FEE OF THE IMPROVEMI J ',OMBUSTION AIR SHALL. BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. a Rough -In Date Final Date "PROVIDE COMMON VENT INFO ON BACK SIDE °8,35,61 JUL-27-2004 10:50 CITY OF FRIDLEY P.03iO3 ' FILL IN COMPLETELY FOR REPLACEMENT FUEL BURNING APPLIANCE PERMITS COMMON VENT VENT CONNECTOR AND COMBUSTION AIR VERIFICATION When r6placing anexisting furnace, the undersigned hereby verifies that the vbnting 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 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 daes include AGA -LAMA 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 mahufacturer's specifications. Yes () No ( ) When required to install a new combustion air it Wil be sized and installed to meet the current codes and manufacturer's specifications. Yes {) No ( ) When ilinstaffina a new venting s stem, 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 Ventind 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 ° 0 *j 7" /fit' ._ 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 Tctal 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 #t Length ft Diameter in Type Applia6ce 93 Vent Connector Height ft Length ft Diameter in Type HEATING CO: Date:. / - / Signed By: TOTAL P.03 CITY OF FRIDLEY INSPECTION DIV. 6431 University Ave NE Fridley, MN 55432 (763) 572-3604, FAX (763) 571-1287 Effective April 1, 2004 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOOR PLUMBING FIXTURE RATES: NO. RATE TOTAL JOB ADDRESS Wj I I t[ A \IgaN tA New Fixtures �(5�� $10.00 The undersigned hereby makes application for a permit for the work herein Old Opening, New Fixture $10.00 specified agreeing to do all work in strict accordance with the city codes Beer Dispenser $10.00 and rulings of the Building Division, and hereby declares that all the facts Blow Off Basin $10.00 and representations stated in this application are true and correct. Catch Basin Water Leader $10.00 I —' o� Rain $10.00 DATE: 20 Sump/Receiving Tank $10.00 Water Treating Appliance $35.00 T OWNER Je�VI ( on Water Heater -Electric $35.00 Water Heater - Gas** $35.00 BUILDING USED As fes(dex) ctJ Gas Range*" $10.00 Gas Dryer"" $10.00 �1 i�� ESTIMATED COST �VtJ , Q o PERMIT NO. Back Flow Preventer Required ( )Yes () No Type $15.00 PLUMBING COMPANY 1 ID(k S Reinspection Fee $50.00/Hr SIGNED BY )U ®V[i TEL N0. 6'-" Vo ALL OTHERS AND/OR REPAIRS AND ALTERATIONS 1.25% of Value of Fixture or Appliance Approved By Rough -In Date Final Date State Surcharge $ •5® MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 or 5% OF COST TOTAL FEE $ OF THE IMPROVEMENT WHICHEVER IS GREATER PLUS THE SURCHARGE. �5 30 0 COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A. "*PROVIDE COMMON VENT INFO ON BACK SIDE FILL IN COMPLETELY FOR REPLACEMENT FUEL BU14NING APPLIANCE PERMITS COMMON VENT; VENT CONNECTOR AND COMBUSTIONAIR VERIFICATION When replacing an existing fOrnace, 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 O 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 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 :