HomeMy WebLinkAboutRPZ Test 2/9/2009
CITY OF PRIOR LAKE PLUMBING PERMIT
Date Rec'd
3, zo, OJ
; ~~ ~:~ PERMIT NO. 0 c/, 0'1/' q
3. Yellow Applicant -, ' I '-'" I
(Please tvoe or \lrint and sign at bottom)
ADDRESS
lfle7lJ ParI<.. A//' L/)./I-c--1- kv-e. . Sf:
~=R fdt,yK.. AJ/ClJl lei ~dtc.J . (Phone)
(AddreSS):?I1po ~rk N/LP/k.II1W- ,51-. /Mi<; ~K
; I
' APPLICAJ'1I'_ n , h. . f) / ~ .h .L9
(Name)----L!!fJ.\.. /Jik vrtCtv ~L-V t 1/ (...; (phone) 7 U ~. "7 on ';/u ~ 6
(Address) j~ / LrCJI1~L7d t/re-k #531) 71/Jblt:,y ~ .I)?; -3 )tf
~AddreSS) (City)J (Zip Code)
(Contact Person) a hot ~ /) (phone) IltL3 U. ;)-U /"-3
APPLICANTSIGNATURP~~~'fl;t( Lf/~ DATE L3//lJki
APPL~ANT PLEA1SE COMPLETE BELOW
T e of Fixture Quanti
Bath Tub with or without shower
I Dishwasher
Floor Drain
Lavato Bathroom Sink
Laund Tra 1 or 2 com artment sink
Shower Stall
I Sinks
Bar Sink
I Water Closet (Toilet)
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
Quantity _
ZONING (office use)
PID
Type of Fixture
Rough-ins
Water Heater
Water Softener
Stand Pi Washing Machine)
Sewa e Eiector
Backflow Assembly
Backflow Assembly Test UZ
Lawn Sprinkler
I Other
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a $49.50 minimum Residential, New One & Two-Family $149,50
Residential, Additions & Alterations $49.50
Estimated Cost $
Jsv-
Building Permit #
(Office Use Only)
PLUMBING PERMIT FEE $
STATE SURCHARGE $
TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved
t.f~ .-
.50
'-fq. t.;l)
Paid 41, 50
Date? Z3 q
Date oJ . , 0
24 hour notice for all inspections (952) 447-9850, fax (952) 447-424~
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
BuUdinl!: Official
RecjPtNO'57281
IBy
C-
G R Mechanical, Inc.
12401 Ironwood Circle #500
Rogers, MN 55374
763-428-2663 Fax: 763-428-7656
Date:
Customer:
Site Address:
Contractor:
Address:
;UJ
19'[)
Annual RPZlBackflow Test
j...- 9--0 l}
ePJ.m.e- PI';O,r 1,"!.J{.fL,
t.ff.Lln l?&cl< A./,'U)(/e.:I- 4-re SE:- /w-J.;.r Lk-
,UL.L4.J
G R Mechanical, Inc. Master License" PM061337
12401 Ironwood Circle; Phone: 763-428-2663
Rogers, MN 55374 Fax: 763-428-7656
~:~~~O~e%':'Vice: Gpo ~~~-X
Make: .wJ.R:~ MOdel: 97!jxL-. Size:
3} \\
~
Test before
Repairs
Final Test
. Describe Repaires
Remarks:
Check
Valve #1
Leaked { }
Closed { }
Closed
Check
Valve #2
Leaked { }
Closed { }
~ Closed
if
:Cleaned only: {}
Replaced:
Rubber kit {}
CV Assembly { }
O-rings { }
Seat { }
Spring { }
Stem/Guide {}
Retainer { }
Lock nuts { }
Other { }
:Cleaned Only: {}
Replaced:
Rubber kit { }
CV Assembly { }
O-rings { }
Seat { }
Spring { }
Stem/Guide . { }
Retainer { }
Lock nuts' {}
other { }
Serial #:37 3:1.1J1,
Pres. Oif. Pres Oif
Across #1 When Relief
PSI -- PSI
Strainer
None {}
Clnd {}
PSI7.l
PSI~
~~JJ :J{)ao
I hereby certify that this date is accurate and reflects the proper operation and maintenance
of the assembJey.
Testers Name (Print)
Testers Signature:
iJ1 fJvtf- kri 1~ n
. (r)~A '
Certification #
Date:
D~hI9).f3f-
-:J-19JJ 9-
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