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rn�O, CITY OF PRIOR LAKE BUILDING PERMIT, g C P - c •
TEMPORARY CERTIFICATE OF ZONING COMPLIANC
g AND UTILITY CONNECTION PERMIT JUL 19 2011 I
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2. Pink City PERM L' MI . l a
3, Yellow Applicant 1 1_ / _ / J
(Please type or print and sign at bottom)
ADDRESS t L{ 2 310 P'-,121e- S I 0 E C pLJt.L T ZONING (office use)
►U
LEGAL DESCRIPTION (office use only)
LOT 12 -BLOCK I ADDITION J ak" F-t2_ S 1 'I t1/4 F P t.) - r PID 2 -S q -1 2,0 1
OWNER
(Name) 1' A 'T I M `t' -1-4 o N- > s (Phone)
(Address) - 12.42A W R S I - 1 - II-1 t , u -1 A vie S S - T - e_ 2 i a.0 1 1 --R H N S S 4 3 9
BUILDER
(Company Name) r' N' t 4 i v r't ES (Phone)
(Contact Name) S' E Bt"R- (Phone)
(Address) - l2C..) t I.., tk S l-} 11-.4 ( t., ti_ S STS ? f) t 1=O t N A P-11,1 SSc135
TYPE OF WORK New Construction SDeck ❑Porch ❑Re- Roofing ❑Re- Siding ['Lower Level Finish ❑ Fireplace
DAddition DAlteration ❑Utility Connection
CODE: K]I.R.C. I.B.C. ❑ Misc:
Type of Construction: I II III IV V A B
Occupancy Group: A B E F H I M R S U PROJECT COST /VALUE $ l 4 0 0 00
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have furnished 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 - mentioned property and that 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
official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X ,µ1 -- B6.- 2./= 538 b 1 t1 9, 1(
Signature Contractor's License No. Date
Permit Valuation «(i ®atz Park Support Fee # $
Permit Fee $ l ," 91- S-o SAC # $ Z Z p
Plan Check Fee $ S8 GS Water Meter Size r'; 1' ; $ ;
State Surcharge $ -I S co Pressure Reducer $ 010 _
Penalty $ Sewer /Water Connection Fee # $ 1 S
Plumbing Permit Fee $ 154 Water Tower Fee # $ ( CeD
Mechanical Permit Fee $ ( Builder's Deposit $ 1 5 be) ,
Sewer & Water Permit Fee $ Jc Co Other P( s5 $ { 54 So
Gas Fireplace Permit Fee $ S TOTAL DUE $ i$L■S•
This Application Becomes Your Building Permit When Approved Paid 9 U ?,,3,, / b/ Rec t No. 6,3 81 /
Date e -( /, fir' By .
Building Official Date
This is to certify that „e request in the above application and accompanying document is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed • the Planner constitutes a temporary Certificate of Zoning com ce and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
. lan , m - to Special Conditions, if any
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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F P CITY OF PRIOR LAKE Date Rec'd
oa ? - 4 4 .
A,.,„.,-,,, . 4.t-k HEATING /AIR CONDITIONING /FIREPLACE PERMIT
41INNESO•(P 2. 1. rin Gree k r ty PERMIT NO.
n C
J. Yellow Applicant 1 $
Please ty . e or . 'nt and si _ n at bottom
ADDRESS ZONING (office use)
N330 Part/ de CO--
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER p n
(Name) ----- 1 L M* A , A 4' _A, (Phone)
(Address)
APPLICANT , - i ( Phone ) , _ 1 6`O
' t() ( � ` n , r j"� VU
(Address) /��� T _ . a v k, ,L� 9 . '
is • ddress) (City) (Zip Code)
(Contact Person) y
° ti _ 4 (P on "1�� P • 0
APPLICANT SIGNATU' ._L!�►� �. (' 1� a' DATE b, ?)-61 1
IV
APPLICANT PLEASE COMPLETE BELOW
NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL QJ X 53 1 UJ 'R2.._ FUEL 13a.t.
FLUE SIZE RETURN OPENINGS INPUT ) MD OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water
' Si Mechanical ❑Radiation into Required Side Yard Setbacks.
I V Air Conditioning ❑ Special Devices Fireplaces with Box Additions or
l nt. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi- Family I% of job cost Residential, Gas Fireplace $49.50
$49.50 minimum
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50
Estimated Cost $ 58_0 Building Permit #
LP( r l ,� year Minnesota Statutes § 32613.145
HEATING PERMIT FEE $ 1 L - ' SIiRCI IARCie has been chanced for one
car effcctivc
STATE SURCHARGE $.0\ - 51T — duly i, 2010, until June 30. 2011.
TOTAL PERMIT FEE $ )5 rS The minimum surcharge for a "fixed fee" permit
(Office Use Only is ti , beginning duly 1.2010
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date B WITH
Baildin Official Date 8J
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
f
tie
pRI Date Rec'd
°`' CITY OF PRIOR LAKE PLUMBING PERMIT
�'� ex
4 ' NNESO
2 1. Blue File Cit PERMIT NO. 1' / i�
. Gold
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 D Pik - ■.C9..e_ COM
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER �(�/; i \,,
(Name) €5- _ 1" �WJII}.� \ \ (Phone)
(Address)
APPLICANT Q ']
(Name) 1. L� * (Phone) qat.lifirl-kiu00
(Address) ILAI1 I 1 ? (��.J 6 �`� "� S `
(Addres •1 (City) (Zip Code)
(Contact Person) 1 4r4 (Phone)
APPLICANT SIGNATURE �'�� �� 1 ` ` P FE J--)1
i
APPLI COMPLETE BELOW
Quantity Type of Fixture • uantity Type of Fixture
Q Bath Tub with or without shower Rough -ins
Dishwasher 1 Water Heater
Floor Drain Water Softener
3 Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) 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
The Minnesota Statutes § 326B.I48 At $ (09-1 Building Permit # _
"SURCHARGE" has been changed for one 1
year effective PLUMBING PERMIT FEE $ F - 1 1
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5 ,M)
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $
is 51 beginning July 1, 2010 �� ' S
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date B WITH
Building Official Date BUILDING PFPMIT \
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
t
t :::41)44 •
?Rib. n M V Fl Ti 1' r
CITY OF PRIOR LAKE BUILDENG PERMIT, ate Rec gil i
TEMPORARY CERTIFICATE OF ZONING COMPLIAN OCT 1 7 2011 ))
AND UTILFIN CONNECTION PERMIT
4 )-146.0ek 0
PER ..
rrlitale type ot print and sign at bottom)
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ADDRESS it 1 I ZONING
I 4 ; -,-' c
LEGAL DESCRIPTION office 4.5=e inliy ..-
LOT BLOCK ADDITION PIT-)
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OWNER -
WNER LA ,
Name) I t 4 11 tk M HC 3 (Pin e' C 15 .4 = ? * - -
(Addressi 72,-,-,,, i (.4) (4 t Ki t„,„ T c ,r,:, Av i',....::::. S , ,
BUILDER
(COMparly Nanle) H.C.--r. IT., tr- i 4,..": e '....;„cf :it 0,:t f rhene) (a t)) -"' E'4.... 0. q i7
(Contazt Name) _IA A.t t. ikt IC ,----- ( Phone
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L li 8 si
TYPE OF WORK ANeva Constrwawa Gr.)e OP-o;,:h ORe-Roofing OR 4 1:7,1,L,Wei: 1.0 FiniSh 0 rim-place
0 Addatort aloteratian OUt.1411 ConnectIon .
CODE: ZLR.C: DIALC. , 0 Mr.:
Tyre of 1 TT ID !V , A 61,) 7 ,-,t,.--
Occupancy Group: A 8 E F H I MAL'S 4J PROJECT COST/VALUE S 3 ' 1 - - """ ' - '-
Division: I 2 iq' 4 5 (excluding land)
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;hat t •! tril,r5,;za, . .§„T.,,'i..: * !,1 !,? Of rrt7 know't ,3gc , r.:e X: ti141 1 , Itit it', ownet m
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°S1: , :di , .J.t. or , ae7,1,7 ^r:,:i. t. .,:,, '..::, r - T ,,,,,. , s rr7f ret4c.e, ,11:Frrri,.6rts
C''' ' C 7+
StgriattiT
to
iltinintut V aluatn ;
1 41 00;4,44 0 0 e 1 Pali S;;;ntintit
, .
Plan Check Fee 7 s /h.% : i.vermel,„ SY..,:c
„ 4
State Sun:harge t ;;44 ; Presgtte Rduce; 1 $
2490 , t
' Penalty .) i
Seel /Water 4Connt;;tnnitn. Fee # t $
PmbIng Pernut Fee ; $
1 Water towel Fee # I $
: 'Mechanical Pennn Fee : S t Ilut•I‘lertt Dtf
,
Szwer & Water Permit F th
Fe i S , t Othe )
G...ts. Ft.r.,.ia.:c Permit Pee S ! TOTAL DUE. PAID WITI—I
,..._ _ ....._, ,....._
......._ •
n "leo. . es y. . :. Wng permit When Artrnin%eti i Pald BUIPING PERM FT
i
4#1.4 I Date ! rz
! .-"..
/ 111,1111., II 8 if ..
VallAirtrgr tIK17- f";,--
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11'M tN T. XIX! tht: the requeet th the dee., s vph, , Ah.,.., 4,,, ,,,,, 6.),,unsee,h, .•.,=. in u.o:uslAnc, w,,r, :.r„.e :::.;-,. ,L ,'.' .:#30 May rracetei is, rr.Tate d "ihm. doc .
, ..het. ■upe. 17, t C'TV Numr: coratmat* ';' Ce - Z ,,,nwiNtr,:::' 4 ,„i .Celr....fiwe ;.,i ktce-a
ol...•.r
4.),;
24 boar notret for ali innatarons 0524 44"-9g54), fax C452 s 44'4245
4646 Dakota Street S.L. Prior Lake, Minftraofa 553 -
-----------.
•. J4
6
Contractor's Material & Test Certificate for Aboveground Piping
PROCEDURE
Upon completion of work. nspcct on and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall
be corrected and system eft in service before contractors personnel finally leave the job.
A certificate shall •e f" >ed out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. It is
understood the oAtmer's *epresentative's signature in no way prejudices any claim against contractor for faulty material, poor workmanship, or failure to
comply with approving authority's requirements or local ordinances.
PROPERTY NAME: JEFFERS POND DATE 2_8..11
PROPERTY ADDRESS: 14330 PARKSIDE COURT
ACCEPTED BY APPROVING AUTHORITIES: CITY OF WOODBURY
ADDRESS:
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS [OYES ONO
EQUIPMENT USED IS APPROVED YES ONO
IF NO. EXPLAIN DEVIATIONS
. HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS OYES ONO
TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANCE
OF THIS NEW EQUIPMENT?
iF NO. EXPLAIN
INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: OYES ONO
1. SYSTEM COMPONENTS INSTRUCTIONS YES ONO
2. CARE AND MAINTENANCE INSTRUCTIONS YES ONO
3. NFPA 25 OYES ONO
LOCATION ENTIRE BULDING
YEAR OF TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QTY. RATING
RELIABLE RES49 2011 1/2 12 155
SPRINKLERS RELIABLE RES 44HSW 2011 1/2 12 155
RELIABLE F3QR 2011 1/2 1 155
PIPE AND Type of Pipe BLAZEMASTER
FITTINGS Type o} Fitting CPVC
MAXIMUM TIME TO OPERATE
ALARM DEVICE THROUGH TEST CONNECTION
ALARM VALVE OP
FLOW INDICATOR TYPE MAKE MODEL MIN SEC
FLOW INDICATOR POTTER VSR - F Z) 54
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
DRY PIPE TIME TO TRIP TIME WATER ALARM
OPERATING TEST THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED
CONNNECTION' PRESSURE PRESSURE AIR PRESSURE TEST OUTLET' PROPERLY
MIN SEC PSI PSI PSI MIN SEC YES NO
'a '0
0.0.0
WITH
0.0.D.
IF NO. EXPLAIN
LOCATION MAKE & SETTING STATIC PRESSURE RESIDUAL PRESSURE FLOW RATE
& FLOOR MODEL (FLOW_ ING)
PRESSURE
REDUCING INLET (PSI) OUTLET (PSI) INLET (PSI) OUTLET (PSI) FLOW (GPM)
VALVE TEST
N/A
OPERATION: ❑PNEUMATIC ❑ELECTRIC ❑HYDRAULIC
PIPING SUPERVISED OYES ONO DETACHING MEDIA SUPERVISED OYES ONO
DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE OYES ONO
CONTROL STATIONS
DELUGE & IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT IF NO, EXPLAIN
PREACTICN FOR TESTING
VALVES OYES ONO
N/A
DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO
MAKF LIMP! SIIPFRVISI(ON 1 CISS AI ARM OPFRATF VA VF RFI FASF OPFRATF Fl FASF
YES NO YES NO MIN SEC
HYDROSTATIC: Hydrostatic test shall be made at not less than 200 psi (13.6 bars) for two hours of 50 psi (3.4 bars) above static pressure
,^ excess of 150 psi (10.2 bars) for two hours. Dillerential dry-pipe valve clappers shall be left open during test to prevent damage. All
Aboveground piping leakage shall be stopped.
TEST
DESCRIPTIC! , PNEUMATIC: Establish 40 psi (2.7 bars) air pressure and measure drop, which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours. Test
N tanks at normal water level and air pressure and measure air pressure drop, which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT 200 PSI FOR 2 HRS IF NO, STATE REASON
DRY PIPING PNEUMATICALLY TESTED OYES ®NO
EQUIPMENT OPERATES PROPERLY YES ONO N/A
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM
SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR
TESTING SYSTEMS OR STOPPING LEAKS?
DYES NO
DRAIN READING OF GAGE LOCATED AR WATER RESIDUAL PRESSURE WITH VALVE IN TEST CONNECTION
TESTS TEST SUPPLY TEST CONNECTION lQ. PSI CONNECTION OPEN WIDE �� PSI
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO
SPRINKLER PIPING.
VERIFIED BY COPY OF THE U FORM NO. 85B !DYES ONO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDERGROUND 11 1
SPRINKLER PIPING OYES ONO
IF POWDER DRIVEN FASTENERS ARE USED IN OYES ONO IF NO, EXPLAIN
CONCRETE, HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED?
BLANK TLSTFNG NUMBER USED LOCATIONS NUMBER REMOVED
GASKETS 0
WELDED PIPING OYES ONO
IF YFS
00 YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES
COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3? OYES ONO
WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN
COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR - YES ONO
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED
QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISC ARE RETRIEVED, THAT
OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE
REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED? OYES ONO
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
CUTOUTS (DISCS) ARE RETRIEVED? OYES ONO
HYDRAULIC NAMEPLATE PROVIDED IF NO, EXPLAIN
DATA -AYES ONO
NAMEPLATE
REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: 12-3-It
NAME OF SPRINKLER CONTRACTOR: METRO FIRE PROTECTION
TEST WITNESSED BY
Fr, - - r • ; = -ei,. R (SIGNED) T TL DATE
SIGNATURES , /2 / /
OR S • R IK -.: Ce L, RACTOR SIGNED) TI DATE
'►
ADDITIONAL EXPLANATION AND NOTES d\ 9
PRIOR LAKE BUILDING AND IN SPECTION
INSPECTION RE a ` 7 File
SITE ADDRESS (4{--g f 5 ip Gr.
NATURE OF WORK 5101.t. - rtuitLy A frac, -k. II t wz fir, IA
USE OF BUILDING S+PA
PERMIT NO. ll - `72_(O i DATE ISSUED 8#
CONTRACTOR Fl -A (4 t PHONE asz- Wig- e-(26
NOTE: THIS IS NOT A PER FOR ANY OF THE INSPECTI NS BELOW
THE PERMIT IS BY WARATE20 rs A 1---6,146c
1/,, - .elks ( y A " INSPECTOR DATE
I FOOTING 1 1
1 FOUNDATION (Prior to Backfill) 1 1
PLACE NO C (MICR E UN 1 ABOVE HAS BEEN AZ`tvki O - IW
SEWER /WATER /SEPTIC ,,,'L,1 f -- - ;:',.50 -le, lit -i* f . r-.I, 11 � y1"
! '
FRAMING L /24 /0/
INSULATION Pa' 'cizs�/
ELECTRICAL
PLUMBING 0.69.7 eA /cs,� (�
HEATING (if required)
FIREPLACE
t
GAS LINE AIR TEST M� r/1 Ahz__
OW P N co .N tc�
rs
COVER NO WORK UNTIL ABOV HA i L SIGNED
I 14i.f-A I I 1
PRvJKt, - 1.+ AY3 1 FINALS Rt /
GRADING (Prior to Sodding)
BUILDING PP I ) d
ELECTRICAL �r�,
PLUMBING (j is fgiy
HEATING ( 0 i lei Il
DO NOT OCCUPY UNTIL ABOVE HAS BEEN SIGNED
NOTICE
This card must be posted near an electrical service cabinet prior to rough -in inspections
and maintained until all inspections have been approved. On buildings and additions
where no service cabinet is available, card shall be placed near main entrance.
FOR ALL INSPECTIONS (952) 447 -9850