HomeMy WebLinkAboutBuilding Permit 95-0436 (NBC Products)
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/ CITY OF PRIOR LAKE
/ lDepartment of _utllling In'pettion
r:1Final Permitted 0 Conditional C,Q, Expires
This Certificate issued pursuant to the requirements of Section 307 of the Uniform Building Code
certifying that at the time of issuance this structure was in compliance with the various ordinances of the
City of Prior lAke regulating building construction or use. For the following:
Office/Manufacture/Warehouse 95-436
Use Classificatioll
Bldg: Pennit No.
Legal Description
B FS 1 Type Construction II Fire Zo~ N / A
P/O LI, B2,Waterfront Passage Addition
Zoning District BP
Occupancy Type
O fBuild. NBC Products
wnero mg ~
Contractor's Name &: ~ FiJ Co.
Gary Staber I
Building
1601
SiteAddress 16873 Fi"hpoint Road SE
E. Highway 13, 1I~~04 Burnsv:i.lle, MN 55337
City Planner
D:Jn Rye
Date:
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PR/ '
O~ ' (' I CITY OF PRIOR LAKE
~ I, '>: SEP 2 0 ~ I I : ~UILDING PERMIT,
I"l : J ~l TEMPORARY q~rIFICATE OF ZONING COMPLIANCE
I AND UTIYITY CONNECTION PERMIT
Permit No. '1'5 - Ll3(,
;.~--,.~
DIRECTIONS
SPACES NUMBERED 1 THRU 17 MUST BE FILLED IN
BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom)
2. SITE ADDRESS
Fish oint Road
3. LEGAL DESCRIPTION
LOT fIt) 1
ADDITION Waterfront
4, OWNER (Name)
NBC Products
(Address)
21455 Hamburg Ave.,Lakeville,MN
(Address)
2324 Universit Ave
(Address)
5. ARCHITECT (Name)
Finn-Daniels
6. BUILDER (Name)
EFH CO. 1601 E i
7, TYPE OF WORK Fireplace 0
New Constructio~ Alterations 0
Chimney 0 Misc.
8, PROPERTY AREA OR ACRES
Sq, Ft. 80,464
1. DATE
9-18-95
1. White
2. Pink
3. Yellow
File
City
Applicant
BUILDING INFORMATION
11. SIZE OF STRUCTURE
(HeI9.i 145 (145
12, NO, OF STORIES
13. TYPE OF CONSTRUCTION
14. FLOOR AREA APPORTIONMENT USE
Office - 3 337 S.F.
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS 20
SEATS
16. ESTIMATED VALUE
725,000
17. COMPLETION DATE
November 30, 1995
(Tel. 'Ml2-890-6450
Septic 0
Addition 0
Heating 0 Plumbing 0
Finish Attic 0 Residing 0
Reroofing 0 Porch 0
Finish Basement 0
I hereby certify that I have furnish Information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for
the above men property a hat all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the
building officia rmit for lust . Furthermore, I hereby agree that the city official or a designee may enter upon the property to pertorm needed inspections,
X 9-18-95
License No, Date
9. PROPERTY DIMENSIONS
Width 125 Depth 361
10. CULVERT SIZE
Yes No
FOR ADMINISTRATIVE USE
SETBACKS: Required
Actual
Baek
Side
Front
PROPOSED GRADE FOUNDATION
IN RELATION TO CURB OR CROWN
OF STREET
USE OF BUILDING
OFF STREET PARKING
SPACES REO,
SPACES ON PLAN
Side
MATERIAL FILED WITH APPUCATION
SOIL TESTS 0 ENERGY DATA 0
PILING LOGS 0
PLANS & SPECS ~
SURVEY 0
City:
'l2S J ~ ,/")If)
PLOT PLAN
~
PERMIT VALUATION
o
TYPE OF CONSTRUCTION: 1@IIIIV V
Occupancy Group A cD E I H R M (t) t[)
DivlsionG)2 3 4
Permit Fee ................................,.. $ 3.8"13, 5'0
Plan Checking Fee ......................... $ ~, I.( qB . '2.f!>
3<0'2. ,~o
2i~~
U"'-:~
State Surcharge ............................. $
Penalty ....................................... $
Septic System ............................... $
Other ......................................... $
Subtotal..................,............ $ l.D IT( OY ? 2>
Check if
Deferred
By
Certificate of Occupancy
Issued
Amount Brought Forward .........~....... $
Park Support Fee ..7.~~'e'. ...... $
SAC ...............g:~.~... .... $
Collective Street Fee .::1~~~... ... $
Sewer Tap ................................... $
License Check Fee . ./t'..................... $
...J.,..../. "
Pressure Reducer ....... .k............ $
Meter Horn .....1..i...\T.................. $
Water Meter ..j;J.~....1\........... $
o Sewer & Water ~n~~~eel":......... $
o Water Tower Fee ?~~.~......... $
Water Tap ................................... $
Builder's Deposit .. ..t.dl?:s.............. $
Other ......................................... $
Total Due .............................. $ 2..2..
. 1- Recei t No. oL
PERCOLATION TESTS 0
SETS
COPIES
t. 'JD ~ .-?~
3, ()(:)o I C) ~
~~ 4~'") , ~C)
I I c.... o~, ~~
I <..~_ ~~
4~c.."tO
~;) ~o<:::l ,'b~
2." YM~ \ oc\
Paid
st in the above application and accompanying documents is in accordance wtth the City Zoning Ordinance and may proceed as equested. This document when
tttutes a temporary Certq~Zo~nce and allows construction to commence. Before occupancy, a Certificate of Occupancy must be issued.
anner Date Special Conditions ij any
24 Hour notice for all inspections 447.42309:00 a.m. '10:00 a.m.
qs -1/.3'
Quantity
CITY OF PRIOR LAKE
PLUMBING PERMIT
1. Blue
2. Gold
3. Yellow
File
City
Applicant
#~t/
Applicant: Dakota P1umbinq & Heatinq
A~dress:3650 Kenneb,e:{ Drl", Eaqan, Mn
Signature: T-i.",-.-,,~ \, l~ ~<-< '-.3~_
Legal Description: Lot Block Sub:
Site Address: NBC Products - Cottonwood Lane & Fishpoint Rd
Building Permit # qS--~ PID #025"-2'1/'- /J P:J- -j
NOTE: This permit will not be processed without complete information.
FIXTURE UNITS
Phone: 4S4-nn411
55122
Type of Fixture
Unit
Amount
Total
^ $ 6.00
$ 6.00
$ 6.00
\ $ 6.0
\ $ 6.0
\$ 6.( 0
$ 6.10
$\ 6 Do
$ , .00
Bath Tub with or without shower
Dishwasher
Floor Drain
Lavatory (bathroom sink)
Laundry Tray (1 or 2 compartment sink)
Shower Stall
Sinks:
Bar Sink
Water Closet (toilet)
Rough-ins
Water Heater
Water Softner
Stand Pipe (washing machine)
Sewage Ejector
Backflow Assembly (RPZ, Double Check, PVB)
Backflow Assembly Test
Lawn Sprinkler
Other
Minimum Fee
$ .~
$ B.~
$ 6.0~
l 6.00\
6.00 \
1$25.00 \
1 $10.00 \
I $25.00 \
I $ 6.00
I $25.00
SURCHARGE .50
Contract 21,000.00 - 210.00
GRANDTOTAL$?lO 1)0
This permit is granted upon the express condition that said
contractor, shall comply in all respects with the ordinances
of the State Plumbing Code and the amend~nts thereof.
RECE NO. /4/Jj) 'tIS DATE
TIESI
Call for all inspections 24 h rs in advan~rr
4629 Dakota St. S.E., Prior Lake, Minnesota 55372 / Ph. (612) 447-4230 I FAX (612) 447-4245
AN EQUAL OPPORTUNITY EMPLOYER
Th. C.nl.. of Ih. Lob Country
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT E 1=.'" ~'^C!.
APPLICATION RECEIVED 9 - "2.0 - q ~
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
F.'<a,^- P~Iw\. erJ...
Accepted
Accepted With Corrections
)t.
Denied
Reviewed By: fJ"...f~
Comments:
Date:
t:?_ 28- tt6
I.~~.t-Olt..h P"t-lMi~~ r-4'_~. (l,.. I.IVA~ I ~Ir. ilPlb~)' Au~ ~.'",\..tllr-)ek.
2. ~p"t' ,'0..\ I V\.'!> ~t,.crn"i> t-eb, -ro.. ",1\ loU.L\&s. '. loo\\s ) ~ \-c. .
3'. l"\e.~-1:, AtI\ ,'\A~ ;c;. ror l.V....r~\.-oU,.lt.. ....,....J.... stH o...~ cnJ ~ o.J.k.ar- (J~~ lMlIoj
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pI u.....~,........... CloJ.
b
"The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
any of the provisions of this code or of any other ordinance of the jurisdiction. Permits
presuming to give authority to violate or cancel the provisions of this code or other
ordinances of the jurisdiction shall not be valid,"
.".,
BRAUNSM
INTERTEC
DAILY OBSERVATION REPORT
Project #: '$C!,>X ~ ?f=Z7~
Location: ?R:rrk t.......Kf oMN,
,
Report #:
:1-
Date: IO-Z6-~5/
Personnel
Classification
Regular
Hours
Overtime
Hours
E IV f':r
Areas and work performed this day: p~ f? Ft.),;'" 1'\ I (b HA~JT:;; ,,4,)('10'-. ?l206E t!Jf1.:: ~ /1:': v'A--r:r...-,..J
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:12) e' ~t.. ~.>uDY
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Performed By: /./1 7"/;;/ ;J ,.,"
Submitted To: E r;l
Cr'.
F: DAILY 1
r
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DOR-01
/
Th. C.n... 01 lh. Lok. Coun.ry
White . Building
Canary . Engineering
Pink . Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT. 'At ~rvl It.- Jj; a..
APPLICATION RECEiVeD. 9/)..4/ iT
,t.
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
~"rnL 4./ / of-, ~ "J:=I nuL
~/O-IO'CH-
Accepted ~v.! Accepted With Corrections
Denied ~
J/~IU/J1
- .J!.pLl~I./ 4t~'; /J I )rb -1.a/
il
Reviewed By:
Date:
kH<~~~~~< ~ ~
~ 9'\'\- /0 - ~ - 'I? ~ ~ <V\.fL--
-.01<,- -5'PvJ
liThe issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
,,PRY of the provisions of this code or of any other ordinan9~ ~~jU;Sdiction. P~~'"
, presuming to give authority to violate or cancel the proV~ ,~thiS codel.r~ , I. r, .._
ordinances of the jurisdiction shall not be valid." .- j," If ,-,' ~~['):, /,.,'
Th. C.nl.. or lh. Lab Counlry
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
-, ,}
NAME OF ApPLICANT flit YJi&i:<&.1 J / L ) I/. t
I
APPLICATION RECEIVED q /)./)/1/3-
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
.;-
(I It:: r -,/ . Q' ~ . f' i A
(1',' "..htl'rL.,\ (I . j" +-- . I" I,) I" l' ,-I -" -- t {cd...-
y.!/j' 4 .:../ -{ 'l
/
.I
-/ J
,- /, -
/1 4. ..., J ,"
-
",,'It
,.,Accepted V
--
Accepted With Corrections
Denied
?,{411';~J...~
Reviewed By: fiZ-. MII'J-tA'Fl i FF.~ Date: 9/2.~/J993-
co~menls: I) k/ ~~~~ 4//.a~~
~Z //~~/'Ah~ ~ ~//jdA.#ift' .
~~ / /:'~ c
2.) ~.,;/.hY.A' ~ ~=-A/rJ ...d>7ZA?<- ~~./ d- ~
; ~ ~ /'
eJ~ ~.. ~ "
~.,... ...o././~P'/~ ~~ /j ~/~ ~ ./~~~/A/b;?;~
A /' ,,~ '" ...
.3) ',,- d~./~ ~..A'~. ~.."J;./1/J" ~~rJ.b<- --bZ;~
'The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
any of the provisions of this code or of any other ordinance of the jurisdiction. Permits
presuming to give authority to violate or cancel the provisions of this code or other
ordinances of the jurisdiction shall not be valid."
MWCC 92C
Service Availability Charge (SAC) Commercial Detail
PROJECT TYPE :
~ew Building Only [] Alteration (change In use)
o Addition 0 Demolition with New Use
( Attach to Form MWCC 92A )
o Demolition Declaration Oriy
( Attach to Form MWCC 920 )
Date Issued
SAC UNITS
Quantity
Retail
OffICe ~ ~ l-
Warehouse Gl c::..i -z.....
~ _ - .J
Other C-^ ~~ 1'2--
sq.ft. @ 3000 sq.ft. Per SAC =
sq.ft. @ 2400 sq.ft. Per SAC =
sq.ft. @ 7000 sq.ft. Per SAC =
~ S 'Z... ~ I <......S: ~ =
-~~
.5.t::l\
4' \ ~
=
Determination Made by: {r-~"t s....~b~
=
Date: (~l-CJ ~ TOTAL CHARGES =
3.. ~ Co
Previous Occupant
(in units)
Site Address
Demolition Permit No.
Demolition Date
TOlal Square Footage
CAlCULATION OF SAC CREDITS:
Was previous use in existence prior to 1973? 0 yes 0 no
If no, Original Blilding Permit No. Date Issued
Actual SAC paid for space n-..olved: (choose one) 0 Entre Building
Additional SAC paid for space Involved: Bldg. Permit No(s)
SAC UNITS
If yes, Use
1973 Retail
1973 Office
1973 Warehouse
Other
Quantity
o Portion of Blildng =
Date(S) =
TOTAL CREDITS = (
(in units)
sq.ft. @ 3000 sq.ft. Per SAC =
sq.ft. @ 2400 sq.ft. Per SAC =
sq.ft. @ 7000 sq.ft. Per SAC =
=
=
Actual SAC paid after 1973: Bldg. Permit No(s)
Determination Made by : Date:
Date(s)
=
TOTAL CREDITS = (
)):F'ol'aoow.*tlOri $'stiOW.SOt:ifceofSACd8terrillnmtOriitt=ff,,:,:,tf,t::)
(in units)
N
If a determination for Ills location was made by MWCC,
please reference date of letter or atlach copy.
(0.5 roundl up to whole number In uniIa )
If NET SAC UNITS Is a CFEDrr BAlANCE, please
indicate how many will be reserved as...
Site-specifIC units of aedit (Form 92RCR)
or taken as...
City-wide units of aedit (Form 92A).
NOTE: Determinations based on phone
conversations are only estimates.
GREEN . FILE
YELLOW . APPLICANT
GOLD. CITY
CITY OF PRIOR LAKE NO. c;s -/ )..,f
SEWER AND WATER PERMIT
NOTE: Sewer and Water
contractors must
be registered
with the City.
APPLICANT: L1J't/fcd ~f 9- Sewer
ADDRESS: 1/ ~& W6..t-rafa !o,./ c.Jd -t!- ol.o ("
SIGNATURE:q~~
SITE ADDRESS: Cj toR 7:5 PJs'h. ~ j" -t R t\
FILL IN THE BLANKS
1. Estimated length of water service )~
PHONE: S'<.p.l - g J. ~ ~
DATE: /UOLJ - 'J. - ~S-
BLDG. PERMIT # 9 s - ~3 <P
PID# J ~ -c;)'l" -60 )...-/
feet.
2. Size of water service GoV
inch(es) .
3 .
Location of any couplings from structure feet.
Type of sewer pipe. ABS pvc~Pcast Iron
Estimated length of sewer line !:2r:;- feet.
Clean out (if required), located at ~OD/ feet
structure.
from
4 .
5.
6.
------------------------------------------------------------------
------------------------------------------------------------------
This application becomes your permit when approved.
BY JJn1,JJ...k./t ~. DATE: JJ/iJf(
====== =:======= =~===============================================
FEES: $ 35.00 Sewer and water line connection permit.
$ .50 Surcharge
$ 35.50 TOTAL
* Fee for either sewer or water individually is $20.00 plus
$ .50 surcharge.
* Sewer and water permits issued for new construction must be
recorded on the building permit card at the time of issuance
to insure that no duplicate sewer and water permits are
issued.
DATE PAIDlfg/9r
RECEIPT # J.. 7tJ6f
AMOUNT PAID \.3S.SV
REC'D BY ~~
16200 Eagle Creek Av. S.B., Prior Lake, Minnesota 55372 / Ph. (612) 447-4230/ FAX (612) 447-4245
An Equal Opportunity Employer
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FIRE ALARM INSPECTION
AND TEST REPORT '.
INSPECTION DATE ! -';;t~,-16
SALES (612) 895-8455 METRO ALARM, INC.
SERVICE (612) 894-0360 P.O. BOX 1776
FAX (612) 894-9960 BURNSVILLE, MN 55337
"WE PROTECT LIVES AND PROPERTY"
ACCT.NO /1 ;)nJ 1.../ I SERVICE CALL NO. STATE CERTIFICATE NO. -L -L
PAGE OF
CUSTOMER I'\J R C ~~~c) ,:') (A c.. T )' CONTACT PERSON
~-r;;liG' 7OL.\!STA i::> TITLE
ADDRESS J (",,8 -, 3 ;-:-1 :s- If /iJ N r i?r-.. PHONE -;; tJ.t.... ~ III c;. I OMTHLY OSEMI.AN! FI~
o OTRL Y 0 ANNUAL
CITY Pt'(,\O R.... LA K-e STATE}'_ J ZIP 5'5? 7,..,) TYPE
1A
CONTROL PANEL
MANUFACTURE I MODEL NO, LOCATION
I
TYPE OF SIGNALING POWER CIA. BRKA. LOCATION NO LOCKED CIA. BRKR DEDICATED CIA. I
o GENERAL ALARM 0 SELECTIVE SIGNALS 0 CODED 0 PRE.SIGNAL SOURCE OYON OYON
VOLT WITH CHARGER o NOTEt TROUBLE RESPONSE TO ZONE TROUBLE SIGNAL TROUBLE ACirP POWER LOSS EARTH GOUND
BA TTERIE S VOLT WITHOUT CHARGER NEW CONDITIONS o NORM 0 NOTE. o NORM 0 NOTE. 0 NORM 0 NOTE. 0 NORM 0 NOTE.
COMMUNICATOR
MANU~CTURE P I MOD!~~O.;::; ~R. LOCATION:r f\..,1 , L-J. ,
/""'1 :_ N Wjt~iJiU6. \-\o...A5. 6- (t:> ,~ tJ el€- I
.. VOLT WITH CHARGER ONOTE. JI~ TROUBLE RESPONSE TO ZONE TROUBLE SIGNAL TROUBLE .~ POWER LOS;~iH GOUND '
BATTERIES VOLT WITHOUT CHARGER NEW'/ CONDITIONS ~NORM 0 NOTE. l2f.NORM 0 NOTE. ORM 0 NOTE. ORM 0 NOTE.
I CENTRAL MONITORING RESPONSE TO ALARM TIME OF DAY cItY CITY RESPONSE TO ALARM OFFICIAL CONTACTED
i STATION ":ffiORM 0 NOTE. OUT OF SERV, IN SERV, CONNECTION o NORM 0 NOTE .
AUXILIARY FUNC IONS ,
MFG I MODEL LOCATION i
ANNUNCIATOR ITV \ "I-~ {.) c L:\,..r:.:,.- <.____-\ k [oA;) 1 L,) ,-; LL
TIME 0 INCAND 0 GRAPHIC 0 CRT I VOLTAGE NO, OF ZONES I UNUSED PTS, ELEVATOR RECALL TO PRIMARY FLOOR
'0 u:n 0 nRC'lP ~IR~ R~~AII - ,-_., n Nl'lTr::. n NIl.
AUX. 0 LAMP TEST 0 REMOTE RESET I ADDITIONAL NOTES: RECALL TO ALTERNATE FLOOR ELEVATOR RESTART
FUNCTIONS 0 DRILL SW 0 REMOTE ACK o NORM, o NOTE. ON/A FROM FIRE sue, AUTOMATICALLY OYON
COMMUNICATOR '''\1..:. - ( II ,3> COMMUNICATOR ~JI_~/III...{
PRIMARY # r1 0- .:.) SECONDARY #
PERIPHERAL FUNCTIO.N TEST .
DEVICE A~o/ / / / // }L// // / / / / /VOLTS MFG & MODEL # NOTE
#
Manual Stations
A of A Heat Detectors
Fixed Heat Detectors
Photo Smoke
Ion Smoke
Duct Smoke
Waterflow J -SIj-6rf:. '1""- .{~, ~tL
GVT bJ ;5't~'tQ~ 5e;,,):;<') ~...
\/' ;~..., "r
PIV
Horns I Ide \/ff:. t"J1'\f t.L0( ~h
Bells
Door Holders
Emergency. Lighting
Emer. Exit Sounder
HEATING TEST RECORD
~OORESSJ1i(13~~~t...I.\- ~'~PT_FLCOR_CITY rrz ~,III~.
OCCUPANT ~t+5 OWNER ~~
HEAT LOSS DATE HE~TING INST. ~~ tl~
~*-Q ~ I INSTALLED BY ~ me-
SOLD 8Y
ELECTRICAL WORK BY
GAS LINE BY
TYPE OF HEAT: GA_FA ~W_STEAM_SPACE HTR_UNIT HTR_OTHER ~rr
GAS DESIGN
CONVERSION
Ii'H= 1J T
~-
~rr.:re/)IJ?- S/; I
'/?7bG ZfJ 7~(
/ /'7?)t:J 0
,
MAKE OF 8URNER
MAKE
MODE:L
MODE:L
.:;:r--..,.. "L
..... .:.. r<. .l. i-!
:'1AX. 8 itj RA iING
MAKE Of FURNACE
MODEL
CONTROLS
THEFMCSTAT 1ft, HEAT PLUG
\lENT SIZE
LIMIT
~~~
nf;~
LIMIT SETTING L ZZO v '10
~J
-ti'~
~
KING OF LINER.
S---,
l.~=.
NONE
VALVES
OR:~FT HOOD
REGUL.Co TCR
ffZF3
FILTERS: SIZE 2b;XJ'Z~,.f--l-- NUMBER 7""
FAN SETTING
CHIMNEY LOCATION: INSIDE OUTSIDE:
PILOT TYPE
CHIMNEY CONSTRUCTION
PILOT MAKE
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DRAFT ~~r-
y'-
WIRING
TEST TAG .".,..--
LIGHTING INS:. V'
PILOT MODEL
;JILOT TIMING
L . '11I. CUT OFF
PRESSURE 1tJ'J
DOOR PRESSURE
PERCENT
C02 tj. 3 PC
/2, ~
oZ
DATE TESTED
NAME OF TESTER
~~
INPUT CFH PERCENT 02
STACK TEMP 1;30 PERCENT CO
COMPANY TESTING
HEATING TEST RECORD
HEAT LOSS
SOLD 8Y f1\a*-tz.. ~/
~I
DATE HEATING INST.
INSTALLED BY
GAS LINE BY _D~ ~~
TYPE OF HEAT: GA_FA ~W_STEAM_SPACE HTR_UNIT HTR_OTHER ~
CONVERSION
ELECTRICAL WORK 8Y
GAS DESIGN
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77"t?V'<<9
MAKE OF BURNER
MAKE
MODE:L
MODE:L
ScR.IAL
'1AX. 8TU RATING
MAKE OF FUR.NACE
MODEL
CONTROLS
TH EFMCST A T m
HEAT PLUG
VENT SIZE
KING OF LINER SI:E NCNE /'
DRAFT HOOD h4ce.--r"' RE:GUL~TCR $Z~:5
FILTERS: SIZE~".k"~ NUMBER .y
CHIMNEY LOCATION: INSIDE OUTSIDE
CHIMNEY CONSTRUCTION
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WIRING
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i=lILDT TIMING t:.f~ ..5r~ DRAFT
,
TEST TAG
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L . '~. CUT OFF
DOOR PRESSURE
LIGHTING INS7. t../'
PRESSURE J-t PERCENT C02 ,;,r'i DATE TESTED
INPUT CFH PERCENT 02 /~ 5' ~ COMPANY TESTING ~A/~
STACK TEMP JZ?PERCENT CO o'Z NAME OF TESTER ~tn~
HEATING TEST RECORD
ADDRESS IbPfl7fi4.~N.t~.~._FLDDR_Cm~~ ~f~'
DCCUPANT ~ ~lJtfS DWNER 'I ~rne....
HEAT LOSS DATE HEATING INST. ~, Vf~
SOLD 8Y ~~I"t.. P\u~ INSTALLED BY ~l"r\e---
ELECTRICAL WORK BY GAS LINE BY y~ r~7
TYPE OF HEAT: GA___FA___HW___STEAM___SPACE HTR___UNIT HTR~THER
GAS DESIGN
MAKE ~
-.L/ -? ~
MODEL z:.:L-v7
SER,IAL A'?lPfl k~2 ,/~r-
INPUT /2'72/00
CONVERSION
MAKE OF BURNER
MODEL
:'1AX. ETl) RATING
MAKE OF FURNACE
MODEL
CONTROLS
THEFMCSTAT 'lit HEAT PLUG
vALVES ~ ~
LIMIT / 0:r';^
LIMIT SETTING L 220
KING OF LINER.
7;'/
~~
~---
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NONE
'.lENT SI.cE
DRAFT HOOD
REGUL~TCR ~2S--~
FILTERS: SIZE
NUMBER ~,..............
PILOT
lf0e
TYPE ~7
MAKE ~J:,~~ ~~r
t/'
CHIMNEY LOCATION: INSIDE
DUTSIDE
FAN SETTING
CHIMNEY CONSTRUCTION
PILOT
PERCENT
C02 /f,f'l
02 12 ,
co () t
SMOKE BOMB WIRING /'
DRAFT TEST T;~G Y
DOOR PRESSURE LIGHTING INST. /
DATE TESTED t.,- I?-if}
COMPANY TESTING ,~~~
NAME OF TESTER ~,f ,
PILOT MODEL
PILOT TIMING
l.'N. CUT OFF
PRESSURE .5t
INPUT CFH PERCENT
STACK TEMP~5J PERCENT
HEATING TEST RECORD
ADDRESS 1~1~()i l'-I1=-IZ<>' ~...c.-APT. _FLOOR_C In ~l.ct~ ( Y4J'
OCCUPANT Net-~ut<t"> OWNER ,~~
HEAT LOSS DATE HEATING INST. ~ ' q~
SOLD 8Y ~ ~ INSTALLED BY :;tx.~
GAS LINE BY ~ ~
TYPE OF HEAT: GA_FA_HW_STEAM_SPACE HTR_UNIT HTR ~THER
ELECTRICAL WORK BY
GAS DESIGN CONVERSION
MAKE ~~~ MAKE OF BURNER
MODE' ;= /Z r MODEL
I
SC:RI~L ./l~:?/~6#"Z'1'/7t/ :'1AX. 8TU RATING
INPUT ~~~c/() MAKE OF FURNACE
MODEL
VENT
SI~E Y //
OF LINER ~ 5
....---
~l.~=.
NCNE
KING
DRAFT HOOD
REGUL.~TGR 5"'?S;-; '5
FILTERS: SIZE NUM8E~
CHIMNEY LOCATION: INSIDE OUTSIDE
CHIMNEY CONSTRUCTION
SMOKE 80MB
WIRING
~
~
PILOT TIMING
DRAFT
TEST TAG
L.IJ. CUT OFF
DOOR PRESSURE
LIGHTING
INS7.
NAME OF
Z-~ /9- 7~
::::::G ~~~
PRESSURE ~-t
PERCENT
C02 1.. S
/Lf. (,
o
DATE TESTED
INPUT CFH PERCENT 02
STACK TEMP~PERCENT CO
COMPANY
HEATING TEST RECORD
ADDRESS IWJ7f~INJ-'~' ~'APT. _FLOOR_ern ~~Dt2-- ~~ ( t\~ ·
OCCUPANT IJU ~litJ<; OWNER ~~
HEAT LOSS DATE HEATING INST. _t2t. q<
SOLD BY ~k\t, ~ ~, INSTALLED BY to-t'h.t-
ELECTRICAL WORK BY GAS LINE BY ~ ~~A7.I!;;:/
TYPE OF HEAT: GA___FA___HW___STEAM___SPACE HTR~~NIT HTR~OTHER
GAS DESIGN
MAKE 1;;.A1~
MODEL-~tPO
SER,IAL 44"~5/~AJ 2~/Y~
INPUT /t:?Of:?l?Oc)
CONVERSION
MAKE OF BURNER
MODEL
:'1AX. 8TU RATING
MAKE OF FURNACE
MODEL
'-lENT
SHE f"
OF LINER ;!., ,6
S---
..L..:.::.
NONE
KING
DRAFT HOOD
REGUL;'TCR
.:5c~5
FILTERS: SIZE
NUMBER
CHIMNEY LOCATION: INSIDE
'JUTS!D€:
CHIMNEY CONSTRUCTION
WIRING
~
SMOKE BOMB
PILOT TIMING
TEST TAG
V"'"
DRAFT
L.'N. CUT OFF
LIGHTING INSi.
y
DOOR PRESSURE
PRESSURE J t- PERCENT C02 '-/,! DATE TESTED L,y /r-/~
INPUT CFH PERCENT 02 Is',;;" COMPANY TESTING ~
STACK TEMP3t~PERCENT CO O~ NAME OF TESTER _____________-
HEATING TEST RECORD
"DDRESS~~h~tIJ}W' ~. APT. _FLODR_CITYt:tlfl.. kktl \'lw ·
OCCUPANT J,\e&- ~I.!cr:> OWNER ,'?t~
HEAT LOSS DATE HEATING INST. Pic l tl-s:
SOLD BY ~*h.--~~ INSTALLED BY ,~
ELECTRICAL WORK BY GAS LINE BY ~ ~S
TYPE OF HEAT: GA___FA___HW___STEAM___SPACE HTR___UNIT HTR___OTHER
GAS DESIGN
MAKE If'l~
MOD€L ~~~
SER,L~L4v6//e":~AJ 79q~
INPUT 27'000
CONVERSION
MAKE OF BURNER-
MOD€L
'1AX. 8TIJ RAIING
MAKE OF FURNACE
MODEL
CONTROLS
IHEFMCSTAT ff~ HEAl PLUG
VALVES ~Li-/~
LIMIT ~~~
LIMIT, SETTING!2I'~ .
FAN SETTING /~.
/, .:Irk ~
PILOT MAKE ~ / ~~
\lENT SI~E '5'/1'
KINe, OF LINER ~.6'
....---
~..L~=-
NONE
DRAFT HOOD
REGULP<TCR 52$7-$
FILTERS: SIZE NUMBER
CHIMNEY LOCATION: INSIDE QUTSID€
PILOT TYPE
CHIMNEY CONSTRUCTION
SMOKE 80MB WIRING p/'
DRAFT [./ TEST TAG t,/'"
DOOR PRESSURE LIGHTING INST. ~
DATE TESTED
COMPANY TESTING Ir~ ~Ud~
NAME OF TESTER
PILOT MODEL
PILOT TIMING
L.~. CUT OFF
PRESSURE 5i PERCENT C02 s:. ~
INPUT CFH PERCENT 02 /l,S-f
STACK TEMP~2~ERCENT CO 0 ~