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Cll)' OF PRIOR LAKE
INSPECTION NOTICE
DATE
TIME
. ''i
(-(,
SCHEDULED
ADDRESS
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CONTR.
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
COMMENTS:
PERMIT NO.
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o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
~ MECH FINAL
FUyv1Ql.-<-- I7fJ
lC/
o EX/GRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR 1ST
o
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~ WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINsPECTION BEFORE COVERING
Inspector: ~ 1-(,. D:> Owner/Contr:
CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH &: SAFETYl
lNSNOTl
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HOUSE
/ 1U' cf./ ~~
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ADDRESS ~ h 1
OCCUPANT
HEAT LOSS DATE HTG. INST.
SOLO BY H'1JJ lit J'" I! "'c.C-4
. .. /
Electrical Work By ,
.;r.YPE OF HEAT GA FA - HW
Ii r , GAS DESIGN
...:. ,f.tAK E -re h1i); .)1_J r-
"" Model Vrl-f./DO (;(tJJ
'" \ 'Serial --'.:. q'13Jj/~ /11 (/
. "INPUT /OOdll"...e
,
CONTROLS
THERMOSTAT -U Heat Plug
~n Ved..,e 111/ J
r; Limit rl u",/
'! Limit Sening j l~,cr~
. Fan Setting ') <:5' I.J./) <[) ~.
Pilot Type 6 (~ -
Pilot Make ,J J t J ~
Pilot Model S.) llr).fl d tfrJ} "
~ ~~t Timing :5e ,-<,J s.r<..
......., J,;IW. Cut Off ,-
....
,Pressure ~, {,; 1,1, I c....
,Input CFH.J,/J 0 .
. Stack Temp. "%:' ~ Ur
Form 235
l
Percent CO A
2 ---<.-
Percent 0 ~'I
Percent CO 2 ~
....
HEATING TEST
7/,,,,) 5{;T.
,OWNER
RECORD
C1TI L" SUBURB
FLOOR
INSTALLED BY 2".:.. ,,J,,. "J..J, /'/
Gas Line By
SPACE HTR.
STEAM
,MAKE OF BURNER
Model
, Max. BTU Rating
. MAKE OF FURNACE
Model
<"'11 {
Vent Size
KINO OF LINER
Draft Hood
Filters Size
Chimney Location
Chimney Construction
Smoke Bomb
, Draft
~~Uf"
, ,4teTtsted
t..... Q,mpony Testing
{ Name of Tester
c.,.
///w'rill....
'7
UNIT HTR.
OTHER
CONVERSION
^ .-.
\./ /
A /
/' '~
r
Lo ~'(15
. SIZE
NONF
Regulator
:i..,)~,;, y I Number
Inside Outside
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.Wiring
Test Tog.
Lighting Inst.
CITY OF PRIOR LAKE MC
16200 Eagle Creek Av. S.E. Permit No. qq..../ 2.1 Z-
Prior Lake, MN 55372
HEATING APPLICATION I PERMIT
/o/4-./QCf PID# 2.5-D70 - 6/4-{)
Site Address ---sC,3f,c1 C.A~O<.( LovE.. '\ v...fld.. S -L.
Lot 9 Block 2- Addition L-A/CcS/06 /i-Jr1/1/0/2.. 2ti:2 ',e./$
Owner's Name :tf, c W \ <. ~
Address 51> bq CAN v'1
Heating Contractor ~E::b\.'O G-...S\\......l
'T
Address \ g \ 6 E.. - 4 \ So ~ '" S u \, ~ ~
Telephone # 6 \J - ""1/_ l-\-l8q~
Furnace Make & Model ~€:..~ ~ S ~ (L
Date
L.u\f(. \e.A \L- s,<~.
").f.(- A.'T\ ,..." \ G o\r A ,-R-:
Model Size
NTL(f"oo
TYPE OF SYSTEM
Warm Air Plants
Gravity
Mechanical )(
Air Conditioning
Vent. System
Conn. Load.
Fuel N...n. G^SFlue Size
Supply Openings
HEATING OR POWER PLANT
Steam
Hot Water
Radiation
Special Devices
Return Openings
Input} DO I o<=> 0 Output.
Edr.
Cfm.
Other Devices
Alterations
TYPE OF WORK
')(.
New Construction
. Replacement
Repair Est. Comp. Date
b6 ..00
Est. Cost $ _/~ 3 Building Permit #
HEATING PERMIT FEE $ ~. - ~ ,-.... 3j$ 0
STATE SURCHARGE $ .50
~~~~
TOTAL PERMIT FEES ~ . Receipt # .
~L/tJ.oO
9tp- /2/2-
3fpz8Q
I
I. Pink
2. Green
3, Yellow
File I ./
Cityf...,/
Contractor
TYPE OF STRUCTURE
Single Family
Commercial
)C
Two-Family
Multi-Family
Other
Industrial
Public
Fee Schedule
Industrial, Commercial & Multi-Family
Residential, Heating & AC
Residential, Heating Only
Residential, Gas Fireplace
Residential, Additions & Alterations
Residential, AC Only
1% of job cost ($39.50 minimum)
$99.50
$64.50
$39.50
$39.50
$39.50
Remember to add the State Surcharge on the bottom of this application.
The price of your heating permit includes one rough-in and one final inspection.
Additional inspections will be billed at $35.00 each.
House Heating Test Record must be submitted with buildinQ permit numbe~ before build-
ing certificate of occupancy will be issued.
HEAT CALCULATIONS REQUIRED with number of supply and return openings listed per
room with CFM's per opening. New structures or additions send floor plan with supply
and return locations shown. HEAT LOSS CALCULATIONS, PAYMENT AND
APPLICATIONS MAY BE MAILED TO THE CITY OF PRIOR LAKE, 16200 EAGLE
CREEK AVE. S.E. PRIOR LAKE, MN 55372.
City Hall business hours are 8 a.m. - 4:30 p.m.
ALL WORK MUST BE INSPECTED (ROUGH-IN AND FINAL) - CALL CITY HALL
447-9B50
I hereby apply for a mechanical systems permit and I acknowledge that the
information above is complete and accurate; that the work will be in conformance
with the ordinances and codes of the city and with the state building/mechanical
codes; thatKt.h. is fo rm. does no ecome a permit until signed by the BUILDING
OFFICIAL; that the work wi! b in accordance with the approved plan in the
case of all ork which e re review and approval of plans.
. A ti~ ~. q- 2:,~(
ji, A'J5PIiC~. ..n)'~.; Signature f Date .
P':. L yll i ~ . /(1 /S Jqq
I ~ri9 OUK:a~'$.Signature}d'" I Date . I