PRE 2010 DOCSCI
is
City of Fridley, Minn.
BUILDING PERMIT
Date: APRIL 14, 1966
Owner: I Builder
CHESTER MACIASZEK
XO
Address Address 6380 Quincy St. N. E.
Fridley, Minnesota 55421
LOCATION OF BUILDING
No. 221 Street 79th Way N. E. Part of Lot
Lot 15 & 16 _ Block 3 Addition or Sub -Division SPRING BROOK PARR
Corner Lot _ Inside Lot — X Setback 35' Sideyard 12' & 22'
sewer Elevation ____ 849.45 JONDROM Elevation 852.45
TOP OF FOOTING
DESCRIPTION OF BUILDING
8769
To be Used as:
DWELLING Front 26 Depth 40 Height 20 S9. Ft. 1, 040 Cu. Ft. 20, 800
Front Depth freight Sq. Ft. — Cu. Ft.
Type of Construction WOOD �FRANE Est Coat __ $14, OQQL, 00 _ To be Completed —
WATER - 10' East of SENT Sewer
SEWER - 20' East of Manhole
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 and W cin �liance with 21 provisions of
ordinances of the city of Fridley. / / / „ // h
In consideration of the payment of a fee of $ 21s 00 , permit is hereby granted to CHESTER L.
MAC?,.ASZEK . 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
Fridleythe , Minnesota regarding putt may revoked at any upon violation ofrand moving any of the provisions of ea�d
ordi�nancces. city limits and this
ALLEN G. JENSEN Building Inspector
NOTICE:
'fhb p*m* don not offer the aomtruetlon, InneBftion for wMho, phnnhing, on heetine, ewer or wabr. Be on to as
the BelMkg her for apm to pormh for than keno.
1
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNER'S NAME_0&t-j- r���C/i41i2�/�C BUILDER
ADDRESS JL Njk- o ADDRESS
LOCATION OF BUILDING
Hai= Street �� �� A:�d 1/j/„F part of Lot
LOTJY t / 16 R 3 ADDITION OR SUBDIVISION 5'P
XJA,& &Z®®
Corner Lot__Inside LOTS Setback IJ- Side -Yard
SEWER ELEVATION FOUNDATION ELEVATION
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:
_j / N Fel K D J4j9 Al AfC— Front 2 (, , ^Dept4 I} 0 Height a? 0
Sq. Ft.__/ 0 Cu. Ft. Z
Front Depth �_Height
Sq. Ft. Cu. Ft.
Type of Construction (��/� ®� ��,�/V,c _ Estimated Cost /-/ *�
To be completed /.2 y 4A9/S
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.
DATB AA a , 4 SIGNATURE -o�Y
(Schedule of Fee Costs can be found on the Reverse Side).
JdOA . fj<
aciORC.94ofumd ���o�c ��GS� LANDSURVEYORS
10731 MISSISSIPPI BOULEVARD N.W COON RAPIDS, MINNESOTA Telephone
421-6340
Certificate of Survey:
'.hest :r "ac;aszek
ALLY/
79T" WAY N.E.
cr;
-S- �'''�►�.
A P -r. E L E) 6.
Ln'. ; 1'; ar ' IF . :,100 3
1b3"; 147-45
• `',nrir,n Froof Park,
AnOa County, Yinrlo.-,ota
1 HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT REPRESENTATION OF A SURVEY OF THE BOUNDARIES
OF THE ABOVE DESCRIBED LAND, AND THE LOCATION OF ALL BUILDINGS THEREON, AND AL,L VISIBLE EN-
CROACHMENTS, IF ANY FROM OR ON SAID LAND
AS SURVEYED BY ME THIS7ti. DAY OF A D 10 f16
N C HOIUM ANL A',',TF wC -ND SURVEYORS
Al
r
'
City of Fridley, Minn.
BUILDING PERMIT
Date: May 12. 1970
owner: - n- Mi -h 1 St:Lvp-xs Builder Sem
Address _ 231.-79t'h WAY N. -E - Address Same
LOCATION OF BUILDING
No. _221 _—Street -79th Way N . E - Part of Lot
Lot 15 & 16 Block - 3 Addition or Sub -Division UX g Brook Park Addition
Corner Lot _ Inside Lot Setback _____ Sideyard
Sewer Elevation --- Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
Garage Front 261 Depth 26_ Height �101_ Sq. Ft Cu. Ft. 676
Front Depth — Height Sq. Ft. Cu. Ft
Type of Construction — Frame Est Cost _.112 600.00 _ To be Completed 1 year
Provide Hardsurface 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 accordance with the description above set forth and in compliance with ail provisions of
ordinances of the city of Fridley. () '--
In consideration of the payment of a fee of 13.00 _ _., permit is hereby granted to D • S t iyer s
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.
CLARENCE BELISLE
NOTICE:
M permit dos not cover the construction, tnstaMon for whinng, phnnbhng, gas henfing, sewer or water. Be am to as
the Building Inspector for separate permits for these Items.
i 0
e
..
APLICATION FOR RESIDENTIAL, ALTERATION,
OR ADDITION BUILbING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWNER'S . NAME S 101ci-MI- 4 .57-1bVIER. BUILDER:
ADDRESS: Z'z WAY k, r, ADDRESS:
NO: STREET:
LOT.- 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:
(A R A C, F- Yront:_2� Depth: 26 Height: /C
Square Feet: Cubic Feet: 6
Front: —Depth: Height:
Square Feet; Cubic Feet:
Type of Construction:
To Be Completed:
Estimated Cost: $ Z /
-9 e7v
The undersigned hereby makes application for a permit for the work herein
6 pecitied', 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: SIGNATURE:
(See Reverse Side For Additional Information.)
r
1
i
�. C. c54oium acid uAggoetates, USC. LAND SURVEYORS
10130 HIGHWAY 65 NORTHEAST — MINNEAPOLIS, MINNESOTA 55433 Telephone
784-5480
Certificate of Survey: Iy l T i V E R S
I r 7.0 `
I ,
126.x7' 3.0
I 26.0
I
SCALE: 1=30"
2700- 147-78
0 D ENO--r.�B IRON
H o USE
2e9i I .
ru in
in
79T" Avr-. N.E.
1 HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT REPRESENTATION OF A SURVEY OF THE BOUNDARIES
OF THE ABOVE DESCRIBED LAND, AND THE LOCATION OF ALL BUILDINGS, THEREON, AND ALL VISIBLE EN.
CROACHMENTS, IF ANY, FROM OR ON SAID LAND.
AS SURVEYED BY ME THIS.' .V`I..... DAY OF ........... .....C:..A:?.. ............A.D. 19.7.0....
N. C. HOIUM AND ASSOCIATES, IN - LAND SURVEYORS
-............!.................................................«
•
SUBJECT
PER _.
City of Fridley
O 5 9 5
AT THE TOP OF THE TWINS
BUILDING PERMIT
K
�tECgIPT-NOr.--
COMMUNITY DEVELOPMENT DIV.
~ PROTECTIVE INSPECTION SEC.
/
CITY HALL FRIDLEY 55432
NUMBER
REVDATE
PAGE OF
APPROVED By
j 612-571-3450
910-F15
9/27/90
JOB ADDRESS 221 - 79th. Way N.E.
1 LEGALLOT
NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
15,16
3
Spring Brook. Park Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Bill Walus 221 - 79th Way N.E. 786-5620
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
D & D Home Improvement 7401 Central Avenue N.E, Fridley 784-7543
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
Reroof Dwelling (2nd layerl 15 Squares
9 CHANGE OF USE FROM TO
STIPULATIONS
Roofing can be 2nd layer but not 3rd, Install ridged galvanized valleys.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
ZONING
SO. FT.
CU. FT.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
NO. DWLG. UNITS
OFFSTREET PARKING
ANY TIME AFTER WORK IS COMMENCED.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1
STALLS GARAGES
VALUATION
SURTAX
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$7550
$,50
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PROVISIpk4S OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$21.00
STRUC O�®R THE PERF RMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTALFEE
re SC $,7
$22.25
S ATUREOFCONTRACTORORAUTHQRIZEDAGENT IOATEI
H R E�LID THIS IS YO�U,nAR PE/R\AMIT
-[/ V
BLIrG INSP GATE
SIGNATURE OF OWNER IIF OWNER BUILDER, ID— AT�A
NEW [ ] Effective 8/16/90
ADrN [ ] R-1 AND R-2
ALTER [ ] B Al-diing /Permit �A�p�p�l/i�catio/ai/�'
Construction Address:
Legal Description:
Owner Name & Address: Tel.
Contractor: C� ��d�di� Tel.
Address: :Z -Q
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
n TvrrrC�i of newma TP
MUNG AREA: length Width Height Sq. Ft.
GARAGE AREA: length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Grou:d Sq. Ft.
OTHER:
Corner Lot [ ] Inside Lot [ ] Ft. Yd Setback Side Yard Setbacks
Type of Construction: A5 .1" ZJ.VZQ. Estimated Cost:
Approx. C:campletion Date: AD&
Proposed Driveway Width If NewIs Desired: Ft. $ $
Width + 6' See Back Page
DA'L'E: �� APPLICANT: c Tel. #
Permit Fee
$ a/, on,
Fire Surcharge
$ ��
State Surcharge
SAC Charge
$
Driveway Escrow
$
Park Fee
$
Sewer Main Charge
$
TOM $ �a
CITY USE ONLY
Fee Schedule on Reverse Side
.001 x Permit Valuation (1/10th �)
$.50/$1,000 Valuation
$600 per SAC Unit
Alt. "A" or Alt. "B" Above
Fee Determined by Erigineering
Agreement Necessary [ ] Not Necessary [ ]
CITY OF FRIDLEY PERMIT =2004-00953
6431 UNIVERSITY AVENUE NE
FRIDLEY, MN 55432 DATE ISSUED: 06/21/2004
572-3604 FAX: (763) 571-1287
ADDRESS : 221 79TH WAY NE
PIN : 033024420003
LEGAL DESC : UNAVAILABLE
: LOT BLOCK
PERMIT TYPE : HEATING
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDITION/ALTERATION
VALUATION
NOTE: AIR CONDITIONERS CAN NOT BE PLACED IN A SIDE YARD WITHOUT WRITTEN PERMISSION FROM
ADJOINING PROPERTY OWNER. COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A.
INSTALL RANGE WITH FLEX CONNECTOR, SHUT-OFF VALVE, AND ANTI -TIP BRACKETS.
# A/C UNITS 0 VALUE OF APPL OR WORK 175
# FURNACES 0 # GAS DRYERS 0
# GAS RANGES 0
APPLICANT
CENTERPOINT ENERGY/MINNEGASCO
13562 CENTRAL AVE NE
ANOKA, MN 55304 -
OWNER
WALUS WILLIAM JOSEPH
221 79TH WAY NE
FRIDLEY, MN 55432
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 work
will be complied with whether specified herein or not. The
granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state or local law
regulaf g nstl tion or the performance of construction.
Applicant. II Date I
HEATING PERMIT MINIMUM FEE
15.00
FURNACE SHELL/DUCT WORK
0.00
GAS RANGE FEE
0.00
GAS DRYER FEE
0.00
AIR CONDITIONING FEE
0.00
HEATING REPAIRS/ALTERATIONS
0.00
STATE SURCHARGE, MECH FLAT
0.50
TOTAL
15.50
PAID WITH CHECK # 1011069
SEPARATE PERMITS REOUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
CITY OF FRIDLEY BUILDING INSPECTION
6431 University Ave NE
Fridley, MN 55432
763-572-3604 FAX 763-571-1287
RATE SCHEDULE
Residential
Furnace Shell and Duct Work, Burner &
also Replacement Furnace
Gas Piping (New Furnace, Fireplace, Insert)
Gas Range
Gas Dryer
Effective 4/1/2004
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION
REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS �) C Al
Fee Total
$35.00 $
$10.00 $
$10.00 $
$10.00 $
*Air Conditioning -All Sizes $25.00 $
All Other Repairs or Alterations (List on Back)
1% of Value of Appliance or Work $
Minimum Fee $15.00 for Residential or 5% of cost of
Improvement whichever is greater on work less than $300.00
Commercial/Industrial/Institutional
1.25% of Value of Appliance or Work (List on Back)
Minimum Fee $35.00 for Commercial/Industrial/Institutional
State Surcharge
TOTAL FEE
REINSPECTION FEE $50.00/HOUR
Owner
Building Used As�i�c�
6:
ESTIMATED COST /�� PERMIT NO ADD G - Co / f3
DESCRIPTION OF FURNACE AND BURNER
'# of Heating Units Circle One (Steam) (Hot Water) (Warm Air)
Trade Name Size No.
BTU HP EDR
Fuel Total Connected Load
Burner Trade Name
BTU
HP
Size No.
EDR
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes
$ and rulings of the Building Division, and hereby declares that all the facts
and representations stated in this application are true and correct.
$ HEATING
Signed
*Air Conditioners can not be placed in side yard without written approval
from adjoining property owner - copy to City
FILL OUT BACK SIDE FOR STACK VERIFICATION ON REPLACEMENT FURNACE
v
2
Tel �7'!5-7-44?
FAX # Date�il'
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 existina 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 () No( )
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances. Yes () No ( )
The existing combustion air is sized and installed to meet the current codes
and manufacturer's specifications. Yes () No( )
When required to install a new combustion air, it will be sized and installed
to meet the current codes and manufacturer's specifications. Yes () No ( )
When installing a new venting system, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Furnace
Venting Tables for fan assisted and natural draft appliances. Yes () No( )
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes O No ( )
Appliance Type and Size/Common Vent and Vent Connector Information
Appliance #1 Type_
Appliance #2 Type _
Appliance #3 Type _
Total Appliances
_ BTU Input
_ BTU Input
_ BTU Input
Total Btu Input
Common Vent Type Vent Height
Fan Assisted or Nat
Fan Assisted or Nat
Fan Assisted or Nat
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 :
'#ITY OF FRIDLEY INSPECTION DIV.
;431 University Ave NE
'ridley, MN 55432
763) 572-3604, FAX (763) 571-1287
Effective April 1, 2004
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT20DS'Oa996
MAKE% NUMtitK OF HA I UKES TO BE INSTALLED
ON EACH FLOOR
The undersigned hereby makes application for a permit for the work herein
)Id Opening, New Fixture
$10.00
Urinal
- ShowIF
:.:€t.::.:..
Tray
lt:::::>:::::
.::�::.:::s?>>�
�:
Floor
Drain
:;<;:;: Au o
vdt::..... t`a::-
....:.::::.:.:......:..'`::�
:: Washer
z::
�:. �::�_
Gas�::::<::
Range
;1... . Water Heater
S o 'es
to
"=>
>= Gas Elec
Base
'ump/Receiving Tank
$10.00
'Vater Treating Appliance
$35.00
OWNER 2 21 79T WILLIAM
221 79TH WAY NORTHEAST _
Vater Heater -Electric
$35.00FRIDLEY,
MN 55432
Vater Heater - Gas** r
Floor
BUILDING USED AS k.GSI O►11 e.1G1e__ (763) 786-5620
Sas Range**
$10.00
Sas Dryer**
$10.00
ESTIMATED COST '7 6 (9 PERMIT NO.
lack Flow Preventer Required ( )Yes () No
Type
$15.00
r
PLUMBING COMPANY O (_ 0k 0'VA t 1 LLAA l IDin4gj
Floor 2
Floor 3
00
Floor 4
)LUMBING FIXTURE RATES: NO. RATE TOTAL
JOB ADDRESS_ 6lvv% 0- - 0"S 01-J NI'v-
Jew Fixtures
$10.00
The undersigned hereby makes application for a permit for the work herein
)Id Opening, New Fixture
$10.00
specified agreeing to do all work in strict accordance with the city codes
Seer Dispenser
$10.00
and rulings of the Building Division, and hereby declares that all the facts
llow Off Basin
$10.00
and representations stated in this application are true and correct.
;atch Basin
$10.00
"0 11505
Iain Water Leader
$10.00
PATE: 20 _
'ump/Receiving Tank
$10.00
'Vater Treating Appliance
$35.00
OWNER 2 21 79T WILLIAM
221 79TH WAY NORTHEAST _
Vater Heater -Electric
$35.00FRIDLEY,
MN 55432
Vater Heater - Gas** r
$35.00
BUILDING USED AS k.GSI O►11 e.1G1e__ (763) 786-5620
Sas Range**
$10.00
Sas Dryer**
$10.00
ESTIMATED COST '7 6 (9 PERMIT NO.
lack Flow Preventer Required ( )Yes () No
Type
$15.00
r
PLUMBING COMPANY O (_ 0k 0'VA t 1 LLAA l IDin4gj
teinspection Fee $50.00/Hr
kLL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.25% of Value of Fixture or Appliance
SIGNED BY
TEL N0. (G12) 8Z%- 51033
Approved By Rough -In Date Final Date
State Surcharge $
TOTAL FEE
MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $15.00 or 5% OF COST
$ !S•SD OF THE IMPROVEMENT WHICHEVER IS GREATER PLUS THE SURCHARGE
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 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 () No( )
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances. Yes () No( )
The existing combustion air is sized and installed to meet the current codes
and manufacturer's specifications. Yes () No( )
When required to Install a new combustion air, it will be sized and installed
to meet the current codes and manufacturer's specifications. Yes () No ( )
When installing a new venting system, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Furnace
Venting Tables for fan assisted and natural draft appliances. Yes ( ) No ( )
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes. Yes ( ) No( )
Appliance Type and Size/Common Vent and Vent Connector Information
Appliance #1 Type 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 :