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CITY OF :;�\,
PRIOR LAKE, _
,,..L.! �, utU bits nsprrftiii - . ;7
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' L l fi nal Pe rmitted "O
� � ❑Conditional C.O. Expires :a
Y This Certificate issued pursuant to the requirements of Section 110 of the ❑ Residential /
�N)
Building Code certifying that at the time of issuance this structure was in compliance ❑ith the var ���
ordinances of the City of Prior Lake regulating building construction or use. For the ollowin �
t -1T1'7
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Use Classification 1 (i F F Q !� T �Y Bldg. Permit No. 01 ��
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Occupancy Type VN PUS D
Type Construction Zon • D U
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Legal Description e
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Owner of Building
Site Address 17053 KENNETT CURVE SW 1 i , I
Contractor's Name & Address
ROBERT D. HUTCHINS � � ;. y Planner
▪ i
Bu' , in: Official
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Date: 0 + A
�' Date:
` -1] POST IN CONSPICUOUS PLACE
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(ov PR CITY 01? PRIOR LAKE BUILDING PERMIT, Date Reed
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
S : i AND UTILITY CONNECTION PERMIT 1 , W • i 3
4Ir tV OA ti ed 3 -A I wlrita Fife
3 fief: pp
PERMIT NO. /3 / ( ,--7 4/
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 7o5 3 McN,N'- . t!a Vim^
LEGAL DESCRIPTION (office use only)
LOT 32-BLOCK / ADDITION ih Cl S/ S�t� - s Z' 4- 1) PID
OWNER /
(Name) (Phone)
(Address)
BUILDER
(Company Name) D.R.HORTON, INC (Phone) 952 - 985 -7272
(Contact Name) Brooke Nereid bmhareid @drhorton.com (Phone) 952- 985 -7806
(Address) 20860 Kenbridge Court, Lakeville, MN 55044
TYPE OF WORK ifi New Construction ['Deck DPorch DRe•R rofing DRe- Siding DLower Level Finish D Fireplace
DAddition DAtteration DUtility Connection
CODE: T.R.C. DI.B.C. 0 Misc. _.
Type of Construction: I II III IV V A 13
Occupancy Group: A I3 E F HI MR S U PROJECT COST /VALUE $ Z 3 b . 38
Division: 1 2 3 4 5 (excluding land)
l hereby certify that I have fumished Information on this applieauon which is to the best of my knowledge true and correct. 1 also certify that 1 am the owner 01 authonzcd agent for the
ahovc.menttoned probity and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. 1 am aware that the building
official can revoke this pemin or just cause Furthermore, t hereby agree that theory official or a designee may enter upon the property to perform needed inspections:
BC605657 2/26 Lam_
Sign ire Contractors License No. Da
Permit Valuation Z03, Oe- ' Park Support Fee # - $
Permit Fee $ t (p1 t . c4) SAC # $ Zet 3
S
Plan Check Fee $ 1 0 bfv 5 Water Meter Size 5�Z 1 $ iI Q j
State Surcharge $ Pressure Reducer $
Penalty $ Sewer /Water Connection Fee # $ (509 .
Plumbing Permit Fee 154'5° Water Tower Fee # $ t 0%50.
Mechanical Permit Fee $ t > � Builder's Deposit $ 25� ' '- Seaver & Water Permit Fee $ 5 Other $
Gas Fireplace Permit Fee $ 54 TOTAL DUE $ 1 v
•
t � J e
'C 45
This App an t - imes Your Building Permit WI it App ved Paid , ecei t No.
,, , 11 • Date 3 2C. ( (. / +y
glif r, 3 /! z t3
Building Official Date
i
This Is to cery that the r s; cst in he above application a nd accompanying documents is in accordance with the City Zoning Ordinance and may pr eed as requested. This document
when signed the ity P a ( er statues a temporary Certificate of Zoning c ptian• and allows construction to commence, Before occupancy, , Certificate of Occupancy must be
issued
Planni'g Director . s ate Special Conditions, if any
24 hour notice for all inspections (9521447 -9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372
•
•
0
40, •
• C :1 • t t
3
•
/ i r Rl°' Date Rec'd
4,:
CITY OF PRIOR LAKE
SEWER AND WATER PERMIT
a_ /6 (()
1. Green File PERMIT NO . / / ,
2. Yellow City ! LC/ i
3. Gold Applicant
rint and sign at bottom)
DRESJ ZONING (office use)
^I 0 5 1-53 )< -Z C /(.4A. #k (
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
=NT 0 . S .el• _dr. - (Phone) G,S / — 188---J ass
(Address) (City) (Zip Code)
ontact Persona' YVt i k- P 1,-i— (Phone)
. • • ANT SIGNATURE I A. / 6""U .. 6 -/3^'13
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ ABC ❑ PVC E 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 # mi. } EWER AND WATER PERMIT FEE $ I/
STATE SURCHARGE $ .50 '' j98yL
TOTAL PERMIT FEE $ V
15 U
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
r i Plti CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
'' TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT /3-
. -t:
M ..... OAP I. White File pERMIT NO.
2 Pink City
3 Yellow Applicant
(Please type or print and sign at bottom) �`
ADDRESS IS i (, 13 ' 1 G G . 3 -1(y 7 13 W / G �" ZONING (office use)
j7'-l 1 /7c7 ) (7c � (7Q K S5 o � r -(_,L v e___
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (C- 4) 5th (Phone)
(Address)
BUILDER ,,--
(Company Name) Al . �� (Phone)
(Contact Name) 1 Z[, Si17; J Y
(Phone) � 5 — Z g 8
S/ / " C)
(Address) 7s / /, 'i 1 G 4 a kg "Le_ (.t/ — 1, 10t..0 ( Ast / s-/ n3
TYPE OF WORK E New Construction ❑Deck ❑Porch ❑Re- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace
Addition ❑Alteration ❑Utility Connection _
CODE: DI.R.C. ❑LB.C. ❑ Misc. �'l le-- ,SPr /C/
. -.
Type of Construction: I II III IV V A B PROJECT COST /VALUE $ / Z s d
Occupancy Group: A B E F H I M S U i
Division: 1 ®3 4 (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 pro.erty and that all constru tion 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 rcLPerrnllforc.. ok ause irthermore I hereby agree that the city official or a designee may enter upon the property to perform needed inspections. )
- mature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 5/8 "; 1 "; $
State Surcharge $ Pressure Reducer $
Penalty $ Sewer /Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $ g
Sewer & Water Permit Fee $ Other ppS�y�� PERMIT ' l{
Gas Fireplace Permit Fee $ TOTAL DUE �1 D V4
This Applicatio . Becomes Your Building Permit When Approved Paid Receipt N
Date By
1 0 ie,.._
671/
Bu !ding ' tticial Date
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
16200 Eagle Creek Avenue Prior Lake, MN 55372
F v RI CITY OF PRIOR LAKE Date Rec'd
!ti0p HEATING /AIR CONDITIONING/FIREPLACE PERMIT 6 , / 9 / 3
Q t. I `1rt
41/ ESO''t. I. Pink Fite PERMIT NO. ��jj
2. City //7 -0/67
1 J. Yellow w Applicant ✓✓
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
[70 Gum 54/ ,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PIED •
OWNER n p
(Name) /J# , C - / ,. (Phone) L � 72 72-- -1
(Address)
ZD g40 6 4 oo I u`l •
APPLICANT HEARTH & HOB TFCHNOI OGIES
dba FIRESIDE HEARTH & HOME
(Name)_ Lic 662656 (Phone) •
(Address) 2700 FAIRVIEW AVENUE N •
(Address) ROSEVILLE, I` 1N 5 5113
65$ 633 2561 (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNA'I "{l RE % , .. i _ DATE 6- (2_,-/ 3_
APPLICANT PLEASE COMPLETE BELOW
Sr EW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT .
PLEASE NOTE: Air Conditioner
['Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
['Air Conditioning ❑Special Devices Fireplaces with Box Additions or
[Went. System ❑ Other Devices Cantilevers to the Outside of Buildings
_ Require a Building Permit.
FIREPLACE MAKE AND MODEL ' t 75� T A 'L & 30a1P*
FEE SCHEDULE .
Industrial, Commercial & Multi - Family 1% 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 $ / Ot L - t:�v ,�,,) Building Permit #
The M innesota Statutes § 326B.148 .
HEATING PERMIT FEE $
"SC RCI IARGE" has been changed for one
year effective
STATE SURCHARGE $ .50 July 1, 2010, until .dune 30, 2011.
TOTAL PERMIT FEE $ The minimum surcharge for a "Fixed tee" permit
(Office Use Only) is Ste, beginning July 1.2010 .
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date - P
Building Official Date BUILDING PERMIT
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
' . � 1 :D ate Kee 'd
CT "5' �J P Q►R LAS L ' ' ' L P 'liT'
v
vx .'" .c. ..,:. J . : , .: .:..-;:,:.: .‘,...!-:, .N , : _,...„:„...7.77.::::.. :„....,,........:: , , , , , :,
r ;a, r.I [PERMIT NO App � ,� •. . .
E (Please ay e o print a n d 'sign at bottom) _ _
AI)URESS ZONING (ofl. use)
LEf,1'.AG DESCRIP (off u onl —
LOT I3LOOI� A JDI CI T I'ID —
;OWNER — --
'.'. (Naive). • - _ _ - ( Ph o n e) _ - - --
r '
{ h dirt �)
AP PLIC AN'! 1
r n t -7'I �!
s . : {Name) a t -.._ - . { Ph o e) :.
(Address) )� 1 f ) _ l � .. -- _ . . — � Y ` 7
. ;, L . Code)
:; . {Address) { rV) ;
; 3'7..rson) J k \ trt • v� _ ._ ._ : ,_. _,� - _._._ = - - (Phone _ _ ` ' 5 -
' ` ' ' ... CAN SIGI lTL3RE . G� '1f(c' . , ,. 4 1 ?A'i' : � - s` !� !
Ql�aistt ? _ peo P�xtaxe (uan Type of F xtu�re _ •
Bath ` I'ub wi th ox ....,, aout shower Roug ii�s •
i .....1315---.- asher Water He tc1 — •
. Floor:Drain: :.:..,.:, W ater S.ofteli •
La v at oiry!Ba t hroom Srnkj`: Sta nd Pipe (W abb1n Maehtne ___.____ __ • _ Lau ndry T r I,I or cor artn t sink Sewage �e to x:"
Show r St _ Ba A Asse z x tbl y
Sl . .. B k4a f low .....77... s s e mbly T e s t _ _ , I •
Bar Si Lawla S
Watu C'Ios (' O(he
EE E ; C] EDULF • Indusirr G oral bi Muki fajn ly J %oi,iob ost w tlr a 9 i I2 ---- N on $r Iwo 1 df U 914 50
. ,: Ize s zc �e ingat, A dditio n s `& Alterat $49 5t)
T? Cost l3u .�
P LUMBING PER PE R J0 WITH
ST S URCHARGE $ 5 ' .
r TOT A L. PERMI[T FE L
° ( orr �e Mi a��y)
f
Phis Applica l Y II ttl>n Y'errmlt Wh A pproved : 'Paid V ltecetpt No
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. notice fu 11 �lts tiit 9 )447 91354?, f a# ( 9 2)r 44 t-4; 4S
4646 •Da kota Stieet E Prior lake M 5
3::
CONTRACTORS MATERIAL & TEST CERTIFICATE FOR ABOVEGROUND PIPING
PROCEDURE:
Upon completion or work, inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall
be 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 owners representative's signature in no way prejudices any claim for faulty material, poor workmanship, or failure to comply with approving authority's
requirements or local ordinances.
PROPERTY NAME: Hickory Shores IDATE: 08 -08 -13
PROPERTY ADDRESS: 7 053
ACCEPTED BY APPROVING AUTHORITIES ( NAMES)
City of Prior Lake
PLANS ADDRESS:
INSTALLATION CONFORMS TO ACCEPTED PLANS YES ❑ NO
EQUIPMENT USED IS APPROVED YES ❑ NO
IF NO, EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION
OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT YES ❑ NO
IF NO, EXPLAIN
INSTRUCTIONS
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: YES ❑ NO
1. SYSTEM COMPONENTS INSTRUCTIONS YES ❑ NO
2. CARE AND MAINTENANCE INSTRUCTIONS 18 YES ❑ NO
3. NFPA 25 YES 0 NO
LOCATION OF SUPPLIES BUILDINGS
SYSTEM ENTIRE BUILDING
DESCRIPTION MODEL YEAR ORIFICE SIZE TEMPERATURE QUANTITY
Reliable F1 44 2012 1/2" 155° 44
Reliable F1 49 2012 1/2" 155° 29
Reliable Dry F3QR 2012 1/2" 155° 3
SPRINKLERS
Blazemaster CPVC w/ CPVC Slip Fittings
PIPE & FITTINGS 1" Allied XL w/ 3001b Class Threaded Fittings
ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST
ALARM VALVE
GONNEU I ION
OR FLOW TYPE MAKE MODEL MINUTES SECONDS
INDICATOR Vane Potter VFS -R d a 9
DRY VALVE Q.0.D. 9
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
TIME TO TRIP * WATER AIR TRIP POINT TIME WATER REACHED ALARM OPERATED
THROUGH TEST CONNECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET * PROPERLY
MINUTES SECONDS PSI PSI PSI MINUTES SECONDS YES NO
DRY PIPE WITHOUT
OPERATING Q.O.D.
TEST WITH
Q.O.D.
IF NO, EXPLAIN
MEASURED FROM THE TIME THE INSPECTORS TEST CONNECTION IS OPENED.
OPERATION
0 PNEUMATIC 0 ELECTRIC 0 HYDRAULIC
PIPING SUPERVISED El YES NO DETECTING MEDIA SUPERVISED 0 YES NO
DELUGE
& PREATION DOES VALVE OPERATE FROM THE MANUAL TRIP AND /OR REMOTE CONTROL STATIONS Q YES Q NO
VALVES IS THERE AN ACCESSIBLE FACILITY IN EACH CURCUIT FOR TESTING IF NO EXPLAIN
[] YES 0 NO
MAKE MODEL DOES EACH CURCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO OPERATE
SUPERVISION LOSS ALARM OPERATE VALVE RELEASE RELEASE
YES NO YES NO MINUTES SECONDS
HYDROSTATIC: HYDROSTATIC TEST SHALL BE MADE AT NOT LESS THAN 200 PSI (13.6 BAR) FOR TWO HOURS OR 50 PSI (3.4 BAR) ABOVE
STATIC PRESSURE IN EXCESS OF 150 PSI (10.2 BAR) FOR TWO HOURS. DIFFERENTIAL DRY -PIPE VALVE CLAPPERS SHALL BE LEFT OPEN DURING TEST TO
TEST PREVENT DAMAGE. All ABOVEGROUND PIPING LEAKAGE SHALL BE STOPPED.
DESCRIPTION PNEUMATIC: ESTABLISH 40 PSI (2.7BAR) AIR PRESSURE AND MEASURE DROP WHICH SHALL NOT EXCEED 1 -1/2 PSI (0.1 BAR) 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 BAR)
IN 24 HOURS.
ALL PIPING HYDROSTATICALLY TESTED AT E- PSI FOR 2-' HRS. IF NO, STATE REASON
DRY PIPING PNEUMATICALLY TESTED YES 0 NO
EQUIPMENT OPERATES PROPERLY 0 YES 0 NO
TESTS DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OR
SODIUM SILICATES, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
YES 0 NO
DRAIN TEST READING OF GAUGE LOCATED NEAR WATER SUPPLY TEST PIPE: RESIDUAL PRESSURE WITH VALVE IN TEST PIPE OPEN WIDE
STATIC PRESSURE: 1 7 PSI 74‘ PSI
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFOR CONNECTION MADE TO SPRINKLER PIPING.
VERIFIED BY COPY OF THE U FORM NO. 85B YES 0 NO OTHER EXPLAIN:
FLUSHED BY INSTALLATER OF UNDERGROUND 0 YES Q NO
SPRINKLER PIPING
BLANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED
GASKETS
WELDED PIPING 0 YES Q NO
IF YES........
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY 0 YES I= NO
WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3
WELDING
DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED Q YES Q NO
IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A 0 YES Q NO
DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS 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.
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL CUTOUTS YES Q NO
(DISKS) (DISKS) ARE RETRIEVED
HYDRAULIC NAMEPLATE PROVIDED IF NO, EXPLAIN
DATA
NAMEPLATES YES Q NO
REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
�r j2 Zo t 3
NAME OF SPRINKLER CONTRACTOR: ) ;~ P`- tOTECT -
.,r m. �_.. :;. � � �,� 1 �. � < wsr , ,
SIGNATURES
FO PE ; /•W,�' TEST TITLE DATE
,, ` ' r .�vLS /fir 49/2 (tom
summa "�
FOR SPRIN ER V •NTRACTOR ( SIGNED) TITLE DATE:
�� b / 2 -7-0 1
PRj
Builders Deposit
V �y
N se. City of Prior Lake
A $2,500.00 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 $2,500.00
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: Ft // - SITE ADDRESS: /7 53 / N'ETT t PERMIT # / /
REFUND TO BE MAILED TO: £- f--
20560 16bAJEr/o& (,i-, _Co TE 100
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
AUTHORIZATION TO RELEASE
SIGNATURE:
i 50 0 . CO
Lynda S. len, Building Services Amount
/0 , ¢- /3 Acct. 801.20204
Date
J:IFORMSIBUILDERS DEPOSIT FORM.DOC
pRio CITY OF PRIOR LAKE Date Reed , �;.� r iy , HEATING /ATIR CONDITIONING/EMPLACE PERMIT T
71 s „ 1, Pink 1 ik PERMIT NO. //J s
2. Ye:en city 1 1 Vi" 1
]. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS, m 1 O 3 , e/tCvw {i(, �� 1/� / •� a Y Lc7k,e. 1.71/5 B (utece v5el
( J � V
LEGAL DESCRIPTION (office use only) I
LOT 1 ADDITION ge kcAt/ oh at-,5 2 l' 2b/ b/ PID0? - 9g2-o32-e-)
(Name) D Z 11 d 1� ri I-1 ov 'e (Phone) C /5Z - 96 5
•
(Address) . 2 0 b0 0 I ' el + "-'I dle, C - 1 - - . . 4 0 f ate 61 le 04 S il � k(
•
APPLICANT 7,,-,,,,, � ?. T e � /10(Name) e ( Phone) (O SLc I •
(Address) 2 Fey j v V l e (,'u 11-vc, ki go Jt 0 lie- f w 5 1 1
�y . k i (Address) (City) / (Zip Code)
(Contact Person) Le. Y 1 L e vie ev' (Phone) f O3I - 1o3 bi- 331
APPLICANT SIGNATURE k. ,.. . 4 .LOA DATE ._.,, 5 � / ._.. _._
APPLICANT PLEASE COMPLETE BELOW 1
ANEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS •
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Mr Conditioner
❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
['Gravity ❑ Hot Water
❑ Mechanical ❑Radiation into Required Side Yard Setbacks.
DAir Conditioning ❑ Special Devices Fireplaces with Box Additions or
QVent. System El Other Devices Cantilevers to the Outside of Buildings
_ _ _ r Require a Building Permit.
FIREPLACE MAIZE AND MODEL HL l 1j D — 2 — ( P I
FEE SCHEDULE
Industrial, Commercial & Multi- Family I% of job cost Residential, Gas Fireplace $49.50
$49,50 minimum
Residential, Heating & AJC (New Construction) $149.50 Residential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) $64,50 Residential, AC Only 849.50
Estimated Cost $ Building Permit #
The Ivlinncsota Statutes fi 326R.10
HEATING PERMIT FEB $ "St.JRCHARCiFi" has been changed for one
year effective
STATE SURCHARGE $ .50 July- 1, 2010, until June. 30. 2011.
TOTAL PERMIT FEE $ III minimum sarchiir far a "fixed fee" permit
(Office Use Only) Is.'�',r beginning July 1.211111
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By AID WITH
13uildhia Official Date
BLIILDIAK5 PERMIT
24 hour notice for all inspections (952) 447 - 9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
PRIOR LAKE DEPARTMENT OF
BUILDING AND INSPECTION
INSPECTION RECORD
SITE ADDRESS /7 7T &. ek
NATURE OF WORK - J
USE OF BUILDING s'
PERMIT NO. /Z _ D /Coi DATE ISSUED
CONTRACTOR D. IL. /1 ,c'a/C/ PHONE 911 5 _ 12.'7L
INSTALL EROSION CONRTOL AND MAINTAIN CLEAN STREETS AT ALL TIMES
INSPECTOR DATE
FOOTING
FOUNDATION (Prior To Backfill)
RADON RETARDER et .
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
SEWER/WATER/SEPTIC
FRAMING /4)
INSULATION a (,)(
ELECTRICAL
PLUMBING v,S t i c ,41, p r! 6,-72
HEATING G -
FIREPLACE - -
GAS LINE AIR TEST
RADON RZIWRDZR P1 p1 q Y 6 ,
COVE, . NO WORKCUNTI THE ABOVE HAS BEEN SIGNED
HOUSEWRAP LATH �.
Arm, T Ili l'`
5t: / ni
GRADING PRIOR TO ftIODDING)
BUILDING '�"''l? `'
Cat` C t i G ' fko /4 Y'70/'3
ELECTRICAL
PLUMBING F
HEATING /?
DO NOT OCCUPY UNTIL ABO «s 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