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HomeMy WebLinkAboutBuilding Permit 12.607 ��j'' , te ' ` r � .,... �( (iirfiftiafr of (Otnix rnx CITY OF PRIOR LAKE K ' . . - : Ptpurfturtif tif liattilbittg c ilttsjarrfivtt . , Final Permitted 0 Conditional C.O. Expires \ "::,\: This Certificate issued pursuant to the requirements of Section 110 of the ' Residential / E International Building Code certifying that at the time of issuance this structure was in compliance with the various X ordinances of the ( Try of Pri : Lake regulatig building cons � truction or use. For the following :' >' � Use Classification c.? i �� 4 � 4,._-) '�^^� -- �` fi n � ( P � " - -� G� Bldg. Permit No /2 " G 6 0 7 Occupancy Type Type Construction .1- Zoning Dis ' t Legal Descriptio L q ! � / �� 1 i` f `' k-)e -i:-+� G� ✓ 1 K Owner of Buildi Site Address � V3) ,% 1 �, ci � � �( K Contractor' 2 & Ad ss ! 1 7 ( c` P!� �� � • - / ) l - / City Planner �? Building Official Date: _ /, ... Dat POST IN CONSPICUOUS PLACE V V V V V _X V VV V _ V. 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O F rx t0 .40 CITY OF PRIOR LAKE BUILDING PERMIT, Date Reed TEMPORARY CERTIFICATE OF ZONING COMPLIANCE (L AND tiTILITY CONNECTION PERMIT . /1. / .� r I=A N LNES O See Main. File i. Pink City PERMIT NO . / 7 3 . Penk cpt pl f — / 0 3. Yellow Applicant �/ - (Please type or print and sign at bottom) ADDRESS 1 y •s (gyp Rv S 1 DE C o CZ--fi ZONING (office use) LEGAL DESCRIPTION (office use only) LOT U `) BLOCK l ADDITION J r=te C r w A ( PID Z j '1 -1 2) U 1 9 6 OWNER (Name) ;'l P. T rk t - e 4 4 U r' F_.S (Phone) (Address) `1 is I IN A S I-4- I 1-1 v i ta 1- A V' E S STE_ 2p t an t t■t -A H N SS 439 BUILDER (Company Name) 1 ' 14 rT A Y 4 +v t'"t ES (Phone) (Contact Name) S U 1= B (Phone) (Address) - 1' 2 -c) t w k S I--} It-4 c, i vl . S S 7 ( t �o t t i t � t—I t,.1 SSLl 35 TYPE OF WORK 0 New Construction SIDeck ['Porch ❑Re- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace ❑Addition ❑Alteration ❑titility Connection CODE: I.R.C. ❑I.B.C. ❑ Misc: Type of onstruction: I II III IV V A B Occupancy Group: A B E F H I M R S U PROJECT COST /VALUE $ l" i 600 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 .A.`--e F : C. =z- P A C - 2 t ) 3 ' 1 S3 1 E I ' — S i g n a t u r e Contractor's License No. Date Permit Valuation ( 5 1 DdQ- Park Support Fee # $ Permit Fee $ (35S . ; SAC # $ Z . Plan Check Fee $ 5 i q h Water Meter Size 1 ' ; 1 "; $¢[✓t " .� State Surcharge $ Pressure Reducer $ k Z © 15; ` „ � Penalty $ Sewer /Water Connection Fee # $ t S00. Plumbing Permit Fee $ (S.-4 .5 Water Tower Fee # $ 1 ! - Mechanical Permit Fee $ ( 5 j c , S o Builder's Deposit $ ( -- Sewer & Water Permit Fee $ 5 Y3 Other $ Gas Fireplace Permit Fee $ ar. TOTAL DUE 21 0 This A ' e . esYYour Buding Permit Wh . A r ed Paid P y, � � � il a PP '96 3 - Z r Rec t N (. � Z.� /� � 7 Date `7. -L,. / 4- By Buil.ing Of is .' D ate This is to ce , , at - , -quest in the above application and accompanying docu ents is ' accordance with the City Zoning Ordinance an y proceed as requested. This document when signed • 'i' C tanner constitutes a temporary Certificate of Zoning c plianc d allows construction to commence. Before occupancy, a Certificate of Occupancy must be issued. 4 , Plan - 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 f .y5i4.41( p�0 Builders Deposit rx ArrN so�� City of Prior Lake A $1,500.00 Builders Deposit is included in the Building Permit fee. The Builders Deposit is issued as security to insure compliance for a Final Occupancy Permit. (It is not an escrow account.) All exterior items including but not limited to grading, sodding, landscaping, tree planting, driveways, siding and painting shall be completed 180 days after the date the building permit is issued. If the work is not complete within the 180 day time period, the City shall notify the applicant of the violation and the applicant shall have 10 days to comply or the $1,500.00 builders deposit will be forfeited and the applicant will be billed for clean up or corrective work to rectify the situation. A $500.00 Tree Deposit may also be required and will be refunded if specified trees are preserved for a period of one year. By signing -this I, the undersigned contractor, acknowledge that I am aware of the erosion control requirements of the City of Prior Lake as outlined in the Erosion Control Measures for Building Contractors handout. DATE: SITE ADDRESS: t ` (�° R � S` DE_ C6 `Z* PERMIT #tZ (67 REFUND TO BE MAILED TO: M'V t 4+o t-1 ES 120 t le.J t1/4'/E S SU t Zo 1 SS439 PLEASE REMEMBER 1. KEEP STREETS CLEAN DURING CONSTRUCTION 2. KEEP EROSION CONTROL IN PLACE 3. TEMPORARY OCCUPANCY PERMIT MUST NOT EXPIRE OR $500.00 WILL BE FORFEITED SIGNATURE: c " -- -- - C:\Documents and Settings\sbare1Local Settings\Temporary Internet Files \Content.Outlook1BD8OXI9A \BUILDERS DEPOSIT FORM.DOC SEP -07 -2012 06 :48 FIRESIDE - RSV 651 633 1749 P.003 DO • o4i 4>< CITY OF PRIOR € E Date Recd ',..:' k.. a , _ , ._, ...._ 40., HEA G/A. cOND1TIONINGI LREPLA,t PERMIT • et 1 = P a a r s I ruthirr NO. lie4(11 : R. WIWI Amami • LEGAL DESCRIPTION (officepeec b) _ LOT BLOCK ADDITION PM - OWNER c HERMITS-Rune TeciiNoloGies, inc. • A RLICAN .. 1 R - `.,. • $ . Warne) Lic, BCD512060 (P : _ 27+ ! FAIRVIEW AVENUE N (Ass) ROSEVILLE�MN SSii _. -. 6$346,13.2561 -- . t aiRcodd (contact Pewee) (Phone) q : APPLICA1 T STGNATEURE ' f 'i�.r'r ... . DATE 'Z " ... * '�,.! APPLLCANT PLEASE COMPLETE BELOW • W CONSTRUCTION fl RI:.PLAC r(F.N!` 0 At: fERAI IONS MANAGE MAKES AND MODEI, fl E' t% • PLUM SIZE ) _.�,,. RETURN OPENINGS _ __._.. -.. IN}v1' 1 "' o rrPur . TYP OP s YSTEM IIEAT G OR POWER PLANT • PLEASE .NOTE: Air Conditioner ( Wanu Air t'Iantc S'tc units sand Fireplace; Eincreaeb R oily Q tics weer into Required Side Yard Setbacks. G l6c trier+l' Radiation Fi p q witp Vox Additions or System Udder Devices - CAn levers to the Outside o Suildiuge : Require a Building Permit. ' FIREPLACE MAKE AND MOTWr.. / a27sas - �J s:rt. C J '. . v ' 1Y -. FEB SHEDUIT i �i ortehi Fsntdly i % of job cog Residential, Gen Replace : S44.50 $49.50 minimum Residential, &ad & ?A (New ) $14).50 Residential, ntial, A ions & A t lone $49.50 Residemti51, Heating Only (New Construction) uction) $64.50 Redd,ntial, AC Only $49.50 &tinseled Qint $ 1$(9L9, 00 Building Peas* # , The Mini:clamSia:u:e t116:4.t4x !MATING PERMIT FfiE S "`[ Rel:ARM.° : brrn chm:S,d Air am } cur atrtivc S T A T E SURCHARGE $ _ . .50 .filly t. 20 tU, nnin dune 111. 2VI I t. TOTAL PE)R,MJT VIE S„ Tor 0401011610 C/Irtiterarl4r s "Mee rer Wermit Mirky Vie to t% t:, beadigag Joie 1. 2010 nis " a pplication Seeming Your Building Pernik When Approved ! 1'3ul -.— . Receipt "ii . •. i Dot By SD F E,F eitivavii 24 hear sotto for NU logretiageg 052) 4474$54. 614952)447-4245 ;646 Dakota Street S.L. Prier rxice, Mitaswwts 55372 • O VRI Date Recd CITY OF PRIOR LAKE SEWER AND WATER PERMIT �jNNESD� . 1 . G reen FiCity l e PERMIT NO. 2 Y 3. Gold Applicant (Please type or print and sign at bottom) ADDRESS ZONING (office use) 1 P J co- LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID (Naa "p'+` (Phone) (Address) (Address) (City) (Zip Code) APPLICANT /1n (Name) D , £ 1 ' ► (Phone) 6 Si-ii so -13 FS (Address) -- "G Av 4. (- }-In /th'r` gro33 (Address) (City) (Zip Code) (Contact Person) M 1 ke At (Phone) l I?---q 1 9- L/3 Ye APPLICANT SIGNATURE DATE 7- "V / Z APPLICANT PLEASE COMPLETE BELOW Size of water service inches. Location of any couplings from structure feet. Type of sewer pipe. ❑ ABC ❑ PVC ❑ Cast Iron Estimated length of sewer line feet. Clean out (if required) located at feet from structure. FEE SCHEDULE Residential sewer and water line connection $51.50 Industrial, Com'l & Multi- family 1% of job cost with a $51.50 minimum Sewer connection only $25.50 Water connection only $25.50 Estimated Cost $ Building Permit # SEWER AND WATER PERMIT FEE $ STATE SURCHARGE $ NO TOTAL PERMIT FEE $ � ILON G � (Office Use Only) PEI', This Application Becomes Your Building Permit When Approved Paid Receipt No. Date By Building Official Date The Minnesota Statutes § 326B.148 our notice for all inspections (952) 447 -9850, fax (952) 447 -4245 "SURCHARGE" has been extended 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 until June 30, 2013, The minimum surcharge for a "fixed fee" permit is $5.00 � A v. V R1O Date Rec'd 1 " � ; 1 CITY OF PRIOR LAKE PLUMBING PERMIT f p71 N '''. '' fi 1 U 1. 117 F* PERMI NO. 1 —d40 xYe� Z 1 3. Yellow L (Please type or print and sign at bottom) ADDRESS H.35-- � Pd■A(K.Cd'e n i A/1/1 1 Z ONING (o05ce rue) L__ LEGAL DESCRIPTION tofricr use only) LOT BLOCK ADDITION PID OWNER (Name) (Phone) (Address) APPLICANT (Name) GENZ -RXAN h 952 - 767 -1847 + ( 2200 HIGHWAY 13 W , BURNSVILLE, MN 55337 (Address) (City) (Zip Code) (Contact Person) LISA HERNANDE Z {Phone) 952-767-1847 APPLICANT SIGNATURE i rJ i-ri DATE 7p0/(-L/ APPLICANT PLEASE C PLETE BELOW Quantity Type of Fixture Quantity Type of Fixture c 2. Bath Tub with or without shower Rough -ins 1 Dishwasher 1 Water Heater 1 _.. _ Floor Drain Water Softener __ Lavatory (Bathroom Sink) Stand Pipe (Washing Machine) I Laundry Tray (1 or 2 compartment sink Sewage Ejector t Shower Stall Backflow Assembly Sinks Backflow Assembly Test Dar Sinn Lawn Sprinkler '3 Water Closet (Toilet) Other FEE SCHEDULE Industrial, Commercial & Multi - family 1% of job cost with a 549.50 minimum Residential, New One & Two-Family 5149.50 Residential, Additions & Alterations 549.50 The Minnesota Statutes 32ti13.14l .1st $ L I _ Building Permit # "SURCHARGE" has been changed for one PAID W111-1 year efTective PLUMBING PERMIT FEE $ July t, 2010. until dune 30, 2011. STATE SURCHARGE $ .56 BUILDING PERMIT The minimum surcharge fora 'fixed fee" permit TOTAL PERMIT FEE $ is g, beginning July 1, 2010 This Application Becomes Your Building Permit When Approved Paid Receipt No. — ._ Date By nolldine Official Dote 24 hour notice for all inspections (952) 447-9850, fax (952) 447 -4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 F ?Rio CITY OF PRIOR LAKE Date Rec'd ° '` t; M1 {� HEATING /AIR CONDITIONING /FIREPLACE PERMIT 4 ' 1 4 , vEso t- � n °ttwi city "t Ft PERMIT NO. /4_ 0 411 7 (Please type or print anti sign it bottom) Mow ppacmt ADDRESS l � � 51 Dtu� r ti n , N t � � ZONING (office use) LEGAL DESCRIPTION (office use only) 11, ► 1r LOT BLOCK ADDITION PID OWNER (Name) (Phone) (Address) APPLICANT (Name) GENZ -RYAN (Phone) 952 -767 -1847 (Address) 2200 HIGHWAY 13 W, BURNSVILLE, MN 55337 (Address) (City) (Zip Code) (Contact Person) LISA HERNAN? EZ / (Phone) 9 52 7 6 7 -18 4 7 APPLICANT SIGNATURE 1il k„''/ �T �t DATE APPLICANT PLEASE C PLETE BELOW _ NEW CONSTRUCTION R ❑ ALTERATIONS AT t k FURNACE MAKE AND MODEL VI,, !t- �l .1. Cj 1 LT 311 (Rae ,�� �� FUEL �� FLUE SIZE RETUT V OPENINGS _ 0 INPUT 5c( CUD OUTPUT r qua TYPE OF SYSTEM HEATING OR POWER PLANT j ❑Warm Air Planes ❑Stearn PLEASE NOTE: Air Conditioner Units and Fireplaces Cannot Encroach ❑ Ma ❑ Hot Wafer into Required Side Yard Setbacks. ❑ Radiation Fire laces with Box Additions or i hmcal t Conditioning El Special Devices p Diem. System ❑ Other Devices Cantilevers to the Outside of Buildings Require a Building Permit. FIREPLACE MAKE AND MODEL FEE SCHEDULE Industrial, Commercial & Multi - Family l% of job cost Residential, Gas Fireplace $49.50 $49.50 minimum Residential, Healing & A/C (New Construction) $149.50 Residential, Additions & Alterations PAID • Residential, Heating Only (New Construction) $64.50 Residential, AC Only BUILDING PERMIT Estimated Cost $ . .t �. Building Permit ft 'Me Minnesota Statutes * 32613.14R "St ;Ra lARCiii" has hecn changed fur one HEATING PERMIT FEE $ year effective STATE SURCHARGE $ .50 .hOy 1. 2010. until June 30. 2011. TOTAL PERMIT FEE S The minimum surcharge fora "lisrd fee" permll (Office use Only) Is IS beginning Judy 1.2010 This Application Becomes Your Building Permit When Approved Paid Receipt No. Ba11dIne Official Date By Date 24 hour notice for all inspections (952) 447-9850, fax (952) 447 -4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 . 11 g CE i i 11. ri CITY OF PRIOR LAKE BUILDING PERMIT. Date eC tl TEMPORARY CERTIFICATE OF ZONING COMPLIA7stCE SEP 2 1 2012 AND UTILITY CONNECTION PERMIT 4 - .s7 ...„ E ,// By PERMIT NO. 04111,10 i i'l.e.ase ;live or print and siga at bottom) ADDRESS ZONING --/ --/ a ,....-„,-1 'n i CZK S iil LEGAL DESCRIPTION (office use LOT BLOCK ADDITION rip OWNER j (Name), itc'i_471.iiivi 4 (Phone) i - =--- '—' , , '. (Address) 72Zi ( iXt1( 4Ni ii' '_;; Cr i'l t ' 1 8ifiti3ER ,„`.. •Pilonel. F.Contact Name) ,....f's:: AL,Pt1,4.I.1- i Phone) t -LL t'--t-z'•- L.= TYPE OF WORK ,New Construction DD. 0-7,',h DRe-Roofing DRS.: g 1:::,0 Levei Funsh 0 Fireplace 0A6'....,..'ilion 0Aneration. CUirlin Co:meet:en CODE: "VLI,C. DLB.C. ,, 0 miv Type of Construction: 1 II 111 IV . (:V - ' A LIU ; Occupancy Group: A 8 E F II 1 "A ft) S L' COST/VALUE S ,,,, , 5 ,... PROJECT COST/VAL S ...°,‘,..;,,, r', i Division: 1 I / I 4 (exchniing land) i ey ,itl:fri trlAt 1 twe mrrosee,i mformamm On U17,,,17,7.. W; v... 1,:- Mc .., ,;,!.. my know!rJee mit ar01 .:7 ; ...1.. .177%!!. :"',.1: : Arn Ow 41 or r..ths.me.e4 AVIV :77 IT>e , , ,t, ,,,,, Ar.d that all chhattuallt.mt, w::: c...,h!i.trh tt. a:: tx.3r.eg SiATe ar..1 kk IAA'S ,me wi: x ;tuts : ,am 7 SWIATUIte t. t. 5 1 ; Peeniz Valuantin 1 ' Park Snpr;cri Fee ;;,.. ! S ! Perrrut Fee : $ , SAC r: S , Plan Check Fee $ Water Meter h:ze F. "S' Stare Surcharge i s 1 Pressure Reattter 5 PeraIr, : $ i Sewer, We Ce,r,r,e.-7],-.(7-, 1,--, ra $ 1 , Plumbing Perinn Fcc i 5 ; Water Tower Fee r: i 5 Nlcchann:al Permit Fee 5 ! Builder's Derr. PAW WITH Sewer & Water Perrtht Fee : $ - Other PH-IMIT Gas F:replae Perma Fee $ , TOTAL DUL BUILDIN , Ci XI' A ;',/, Beco es Your Building P it When Approved ; Pax! : Date Retpt No AP 9 26 .3,- m:31,41 , On'o.:13; 111111111F A'' ' rsa , tr, ceeta-„ te..,e, thc rcRlicit. In 'as( Abwoe App4,:x.mr a.nd 01-0'emem^ym4 „":"..wr,r1 3 - .3: 1 IV ;: ,;• ‘.:: .,87.:4 l'7 lx...: r71.4) prv ni r.t.Z •r,.t n.,.> , , shets u-i.med 1 the Ce'Y Minrcr ' a rerr1 , ..c .,777 ;i -- -re Z1.!. 3 L‘tr.p•t-A 17 7 , t and 430.s ,....mi:, !,,;- c,,,r, !„ , A Cot7f of 4a:, .°17.'...r. n.littAing DI= tor ,).4; ,,,...,4,311,i, 14 dour notior for All inspections (952i 4477-9& fax t i 4.1 4640 Dokota Street SY-, Prior Lake, Minnesota 0 * It I *4 '.1 • •*,3 Contractor's Material & Test Certificate for Aboveground Piping PROCEDURE Upon completion of work, inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall be corrected and system left in service before contractor's personnel finally leave the job. A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. It is understood the owner's representative'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 1 1-2g-12- PROPERTY ADDRESS: 14357 PARKSIDE COURT ACCEPTED BY APPROVING AUTHORITIES: CITY OF OCrailigIV e1pP LA) ADDRESS: PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS YES ONO EQUIPMENT USED IS APPROVED RYES ONO IF NO, EXPLAIN DEVIATIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS YES 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 OYES ONO 3. NFPA 25 YES ONO LOCATION ENTIRE BULDING YEAR OF TEMPERATURE MAKE MODEL MANUFACTURE SIZE QTY. RATING RELIABLE RES 49 2011 1/2 12 155 SPRINKLERS RELIABLE RES 44HSW 2011 1/2 15 155 RELIABLE F3QR 2011 1/2 1 155 PIPE AND Type of Pipe BLAZEMASTER FITTINGS Type of Fitting CPVC MAXIMUM TIME TO OPERATE ALARM DEVICE THROUGH TEST CONNECTION ALARM VALVE OR FLOW INDICATOR TYPE MAKE MODEL MIN SEC FLOW INDICATOR POTTER VSR - F 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 W/O Q.O.D. WITH Q.O.D. IF NO, EXPLAIN LOCATION MAKE & SETTING STATIC PRESSURE RESIDUAL PRESSURE FLOW RATE & FLOOR MODEL (FLOWING) 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 0 N CONTROL STATIONS DELUGE & IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT IF NO, EXPLAIN PREACTION FOR TESTING VALVES OYES ONO N/A DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO MAKF MC)r)FL St IPFRVISIflN 1 055 Al ARM OPFRATF VAI VF RFI FASF OPFRATF FFI 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 in excess 01150 psi (10.2 bars) for two hours. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All Aboveground piping leakage shall be stopped. TEST DESCRIPTION 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 pressure 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 ONO EQUIPMENT OPERATES PROPERLY ®Y ES 0 N 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? ■S YES J]NO DRAIN READING OF GAGE LOCATED NEAR WATER RESIDUAL PRESSURE WITH VALVE IN TEST CONNECTION TESTS TEST SUPPLY TEST CONNECTION / 7PSi CONNECTION OPEN WIDE It" 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 OYES ONO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDERGROUND SPRINKLER PIPING _AYES ONO IF POWDER DRIVEN FASTENERS ARE USED IN EWES ONO IF NO, EXPLAIN CONCRETE, HAS REPRESENTATIVE SAMPLE TESTING BEEN SATISFACTORILY COMPLETED? BLANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED GASKETS 0 WELDED PIPING OYES ONO IF YFS DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3? YES 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 -3 ONES 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? YES 0 N 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 YES ONO NAMEPLATE REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: f _z_s= - /Z NA O SPRINKLER CONTRACTOR: FIRE SUPPRESSION SERVICES, LLC. TEST WITNESSED BY /f� ' y.,, (SIGNED) �, TITLE r____ /� � SIGNATURES I j r— / OR SP R CONTRACTOR (SIGNED) TITLE DATE j noy-vt4,10,1&7 0 - -Ze' /Z ADDITIONAL EXPLANATION AND NOTES L9 PRI0R L DEPARTMENT OF BUILDING A 1NSP IO N e inn File INSPECTION RECORD SITE ADDRESS 14 35 1 latare.S i Cre c NATURE OF WORK N £ t -- r10 � L. L . Fr•! USE OF BUILDING - ' 4, PERMIT NO. 12 -1vc:1 DATE ISSUE CONTRACTOR i-1,C -'S PHONE `��Z ��vlz NOTE: THIS IS NOT A PERMIt FOR ANY OF THE INSPECTION B LOW .J� y� ,� HE IT PERM IS BY SEPAR TE DOCUMENT < , t flfrs _ I FOOTING 1 FOUNDATION (Prior to Backfill) PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ROUGH - INS SEWER / WATER / SEPTIC /3- 7 / / a /,i )vivi FRAMING I ro5s Dk toPe1 /7- 0 6,,, _ INSULATION M ' 0kk -. k , ., ELECTRICAL PLUMBING Vis 06 Pt ioi' i2 1c7 rz. HEATING (if required) d'OS ',al/a/ - FIREPLACE S LINE AIR TEST leADAN '' C NO WORK UNTIL ABOVE HAS BEEN SIGNED I t -r w P1 o// LA 1 1 Nil.. ., / £ /v /2 FINALS GRADING (Prior to Sodding) 3 BUILDING y= j nt j z ELECTRICAL PLUMBING HEATING 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 there no service cabinet is available, card shall be placed near main entrance. FOR ALL INSPECTIONS (952) 447 -9850