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DATE TIME
.<IOR LAKE '{-1M
.,mON NOTICE SCHEDULED
AODRESS S.J' q !- P/A4I./
OWNER CONTR.
PHONE NO. PERMIT NO. :7 --/1.- J. 8:
o FOOTING o PLUMBING RI o EXIGRADIFILLING
o FOUNDATION o MECH RI o COMPLAINT
o FRAMING o WATER HOOKUP o FIREPLACE RI
o INSULATION o SEWER HOOKUP o FIREPLACE FINAL
o FINAL o PLUMBING FINAL o GAS LINE AIR TST
o SITE INSPECTION o MECH FINAL 0
COMMENTS: ~/rY1t1C-f..
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~K SATISFACTORY. PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WO~K.~L FOR REINSPECTION BEFORE COVERING
Inspector: r VI. q. (~"'~r/Contr:
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
INS1IOTI
HOUSE HEATING TEST RECORD
ADDRESS 53&''1 LEMLEY C-Ji? -S.I5.
OCCUPANT "'TI{o.-"1A~ 1>AY
HEAT LOSS . DATE HTG. I'NST. "l-/S..""'s
SOLD BY --;>Jlll-t:/vA/ ~~~. INSTALLED BY $~A/T'r.AL
Electrical Work By ~rF--A/ I':>ftt:5Ll::::- Gas Line By It
TYPE OF HEAT GA _FA ~HW _STEAM _SPACE HTR. _UNIT HTR. _OTHER
MAKE
Model
Serial
12 \.AU I> GAS DESIGN
U_G P:f-07EAv.EE. .'
:r~7>~{)~~{j<,nl'::;<' /
. 'J~ 4cO RTVt''] -
.- /
INPUT
THERMOS~~ "'1'-/00 CONTROLS
JPv...; Heat Plug
'~
J91!T~r
F1C, "F
, .l;AAeJ!.
'.flvJ
Va Iv.-'
Limit
Limit Setting
Fan Setting
Pilot Type
Pilot Make
Pilot Model
Pilot Timing
I<JE<::.'
L.W. Cut Off
5'{(
Pressur..' <. W* C. Percent CO ,%
-J<) 2
Input CFH ._ 0-&0. Percent 02~~
Stock Temp. ~D e r Percent CO Q
Form 235
APT. _FLOOR _CITY
OWNEP
SUBURB
CONVERSION
MAKE OF BURNER
Model
Max. BTU Roting
MAKE OF FURNACF
Mod.1
I I II /.L I' {.
Vont S;u J.+ CLA77 C
KIND OF L1NERrL.,A-Y; ,. f<;," SIZE t,.
Draft Hood RegulaTor
Fi Iter. fA:<:- Siu 7..ex-zS~ J Number /
Chimney Location Inside ~' A _
Chimney Construction / '"' (r-\
NONF
Outside
Smoke Bomb
Draft
Wiring
Test Tog
Lighting Inst.
""I-/c;-e93
P~~b/? A/"'7:J:3IIL.
c.f.t~5
Door Pressure
_ Date Tested
Company Testing
Name of Tester
/
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONINGIFIREPLACE PERMIT
Date Rec'd
;;;;;,~" ~:~ I PERMITNO'o2--p~16
3. Yellow Applicant !:/ '-'I
:ase tyPe or print and siJm at bottom)
\ _ .DDRESS
5'36'1 lk,.....,L-E,--(
ZONING (office use)
e,a r, r_
s.~
LEGAL DESCRIPTION (ollice use Duly)
LOT j BLOCK / ADDITION
1iP};2 ~If)~
PID,;25.... ()5S-r.JOI- 0
~ I
OWNER
(Name)
~
Irl,'I""'r-\s
'])<"1-'-
(phone)
qs z. 22f:.,-/,46{,
(Address)
;:'"J, {.,q
L (:, "^ I {-'-C
L ,RC.LC-
0. (,
APPLICANT ~
(Name) l' E:::..-S I~~--..-nf"lll.l
\..I,{-....,...~.r ... A ,a,
(Phone)
bI7-7z..lf-tRQq
l41 ~T 5,. ,e::", .-:-(- A Nl,~, ~,(-APClL.cS .i\>"l..... 6S'<<:ii~
(Address) '\ ~ (City) (Zip Code)
(Contact Person) A.~ 00'" \:::.. \ (Phone) ^ (7.724 -IRe, C,
APPLICANT SIGNATURE ~J--t( , _ DAlh
I
APPLICANT PLEASE COMPLETE BELOW
DNEW CONSTRUCTION . REPLACEMENT D AL TERA TIONS
rURNACE MAKE AND MODEL Juun U(::d]J'(,)7Ec~""'c'L. FUEL rJ"".
FLUE SIZE RETURN OPENINGS INPUT .:i1l.DO() OUTPUT
,
HEATINGORPO~RPLANT
I ~ 1"1
(:.
(Address)
G",'::;,
5f,. cn6
TYPE OF SYSTEM
OWann Air Plants
iGravity
Mechanical
Air Conditioning
OVent System
o Steam
o Hot Water
o Radiation
o Special Devices
o Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
Residential, Heating & Ale (New Construction)
Residential, Heating Only (New Construction)
FEE SCHEDULE
1 % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50
$64.50
$39.50
Industrial, Commercial & Multi-Family
Residential, Additions & Alterations
Residential. AC Only
$39.50
$39.50
Estimated Cost $ -':L t, q ?> - 00
Building Permit #
REA TING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$
$
?''i 50
.50
'-{(", . "0
(Office Use Ouly)
This Application Becomes Your Building Permit When Approved
Building Official
Date
I Paid L/O. ---
I Date 9~/b ~.3
R~.r~57
Bo--.-
v
24 hour notice for all Inspections (952) 447.9850, fax (952) 447-4245
16200 Eagle Creek Avenue, Prior Lake, MN 55372
1