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Final Permitted ❑ Conditional C.O. Expires '''
{ This Certificate issued pursuant to the requirements of Section 110 of the ❑ Residential / ❑ International 70
Building Code certifying that at the time of issuance this structure was in compliance with the various i1
(;1 ' ordinances of the City of Prior Lake � regulating building construction or use For the following:
(1r 1*-..rr, / . ' / / • - 7 1 % ,t
Use Classification Bldg. Permit No.
01,[: :
:7
Occupancy Type Type Construction Zoning District
/ l ,..I7 g 1 t it, ?&./Z– Legal Description F _ 1
Owner of Building Site Address /`T3 G o 1f ( ,K -.r7 v � j
Contractor's Name & Address / T7 / HO/ v it ,)
k.0 C) ) L T / / u(fl /i.i J City Planner .
( �1. �` Building Official _ r
ii Date: Date: .,
VI ,
PI UOUS PLACE
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TEMPO I ARY CERTI ICAATE OF BUILDING ZONING COMP LIANC
i. ,- AND UTILITY CONNECTION PERMIT 2011
Q 1, q JUN 1 3 rn
"NNE SO 'S
M AI N I, white File PERMI O „ FILE 2. Pink City r i •
3 Yellow Applicant i LZ�1JA
(Please type or print and sign at bottom)
ADDRESS (L1 3 00 P p(Y-.S (O P C C V 2` r- ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT l BLOCK l ADDITION JE-t C= -5 1...'1\ - t 1 =- l 2 - - . - t 2 . OF 1 - t • PID ZS - 1 -1. - 1 2, -co t - o
OWNER
(Name) t'1 L,T'T t--1' 44 C) 1--t - S (Phone) `x ry 9 0 - 2( ob
(Address) 21 DO 1.-.1 c_ i 1217 42 ZpURniS ✓t I L. (-1 N SS 331
BUILDER
(Company Name) 1N- TTA t-t`e 0c---L S (Phone) 9G2 - ‘9g - 2.10
(Contact Name) 5"E_ s.,..(ZI= (Phone), y S2- - 2 9 S - 6 12 -8
(Address) 2 t b a U) GT 1t] U 2 12D U 17-_t.1S V t L_L-g i•-t N SS -3
TYPE OF WORK ( New Construction EiPeck DPorch ❑Re- Roofing DRe-Siding DLower Level Finish ❑ Fireplace
Addition DAlteration OUtility Connection
CODE: , I.R.C. ❑I.B.C. D Misc.
Type of onstruction: 1 II III IV V AB ,..
Occupancy Group: A B E F H I M R S U PROJECT COST /VALUE $ t4t ems.
Division: 1 2 3 4 5 (excluding land)
I hereby certify that nave furnished information on this application which is to the best of my knowledge tree and correct. 1 also certify that I am the owner or authorized agent for the
above- mentioned property and that ail construction will conform to all existing state and focal taws and will proceed in accordance with submitted plans. 1 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 fit. _ bi✓20 -— , S3s.6 WIl
Signature Contractor's License No. Date
Permit Valuation ( d e- Park Support Fee # $
Permit Fee $ i 341 5-4" SAC # $ — 2-7,o -
Plan Check Fee $ g•-Z I -‘1,0 Water Meter Size 6); ; 1 "; $
State Surcharge $ 1 e Pressure Reducer S 'co,
Penalty $ Sewer /Water Connection Fee # $ l ,,
Plumbing Permit Fee $ Water Tower Fee # $
t54.Sc) 1 ,
Mechanical Permit Fee $ (am 4 c d Builder's Deposit S
Sewer & Water Permit Fee $ '� � Otkcr 1°if Z t $ l 5 e)
Gas Fireplace Permit Fee $ TOTAL DUE $9737 fil
This A.. • cation : • om our Building Permit Wile Appr,ved Paid - 1 - � e ,..,t'\-- Receipt No. b f 1
- Date - 1 - t t By 4-�Q 6
ur 'mg O1' � Date O
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
G/- G/( Zigerid s .S.t f- to nets iwosx,
' Planning D' ctor Date Special Conditions, if any
24 !tour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street Prior Lake, MN 55372
" "
Cr PRIp
Li
\ White - Building
\ �' �P Canary - Engineering
\ ^'NES° Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT H KirA my
APPLICATION RECEIVED t7 • 1 .) I I
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
k - - .J O i ► 1,)_,K5 11 > (' I . .
Accepted ,Y Accepted With Corrections
Denied
Reviewed By: Date: /-�� /l/
Comments: See Attachments: 1) Grading Plan, 2) Erosion Ga.trol Measures
4.
See Reverse Side for Additional Information!
"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."
O� PR /oie
0 x
U rn
White - Building
�� NP Canary - Engineering
nNEso Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED i i
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
Accepted / ` Accepted With Corrections
Denied
Reviewed By: Date: 6- — /(
Comments: 1 e 1 6 u re nz -eij z•,X; Iii ui /vl pzl'v1(iris
So-r6-ee, 1 me.±. / IL no/ l r eki„..4.. 4 ..("
11/". re, Le_ aiweip - ;Alf el.,/ Ippts sat-C6L re eket-
'7Ci More eleeit 4,
"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."
o� 1'11.1°
m White - Building
Canary - Engineering
�'`^NES ° Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT H POTA P
APPLICATION RECEIVED G • 13,
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
(+30 0 P I D C.71 .
Accepted ij Accepted With Corrections
Denied
Reviewed By: 10%•---L___Th Datee: �Z tl
Comments: 1 rc i r Fbv - (%ON+ ■ry,, kh R_sriAt. lies Pat-rt .
,. K - S i ..3-1/2.4.4(.9 Ar rplifek (At, ("5 I -n ov . .
3 Il - CcAraAcAvas o Pj - ?Pe Flos d4
r
.aG
4. Tadv, M 1 z mks. AN.1 op 4 )V, .-turo oF-45
r
S. NIo Si=te n. WA -z�+�- � - c19w v, + O.) rt L C ti-i
PAss‹ -s �C S',zr �► L- f.r( .
& 4-s - ut�,- Gc A,,.. Pupa "RL„J[! B- -c
N C.-se - t - t c.-Q (1.-1(.0,
"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."
(.--..- P RI3i 5 4 7
1...t 0 k I�-/ 3 a 2 1 1— 5 6 g y �7/ White - Building
Canary - Engineering ,,_,.,
""^NESO�P ` (j — �j 7,2 Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
r r` 1) ` , ^ ..' , t r" � � / - a 7
Accepted tY Accepted With Corrections
Denied
Reviewed By: Date: �� - /`/
Comments: _ See Attachments: 1) Grading Plan, 2) Erosion E iitrol Measures
See Reverse Side for Additional Information!
"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."
7 *,7 1 IFIRTIWWWINF' 1.• v• . 71111MT.7,7% 71,1,171f7r7 • . . ---
,
c i .
CITY OF PRIOR LAKE BUILDING PERMIT,
'&R' CER -.. - • ZONING COMPLIANCE
.
AND UTILITY CONNE . !N PERNIIT eg i. 1 • / I
4 r7 1 111111/04ek T
raa
51LS vi 441 •56 Cm/ PERMIT NO. ' i __, Cl
- . 4.91..... , s.'
i_1ca.tv-pe or prin, .. II.. at bortor
i ADDRESS LI 0 il" .- rN 1 Cr: 1 I ZONING (efface usc
t4 C-', 1 1
PA is c __4
LEGAL DESCRIPTION (office use oral' l
LOT BLOCK ADDITION PIT-)
OWNER
' 1 1-‘ A TTA 6-&-? 4-ko isA e- (Phone)
(Address) - 7L:' t oitrthek ■ t.i&Tc..-. sl Ne... .... .
BUILDER e_c
(Company Name)_ f'-'kC.11 t7, c? ) QE_ FF. c,TEL L N/ . t Phone) ( D t -1A4 - Oel ( 1
(Contact Name) -.1 (- Kt-TE-.1-' (Phone) (4.:; ( - 155
(Address) iip 7 - _v W ' . Ht.) i".5 0 VI.
TYPE OF WORK N g New Comm:mon 0Deck C3Porch ORe-Roofing ORe..Sg °Lowe: Level Finish G F,:replace
DA■idition DAlteratIon OUtthry Connecmon
CODE: RI.R.C. 01.B.C. 0 Mx
Type of Construction: I II III IV C A a)
Occupancy Group: A B E F 11 1 M p S II PROJECT COST/VALUE $
3 2 -"t
Division: 1 2 C.1 4 (excluding land)
1 helcFry creed*, that I have furnshed lamina:Ion on th■s applr:aom whIch Ls to the t of my knowledp true and coma 1 sIso ,..crufty Ma: I am the owner or au0 agent for the 1
above-mentoord m‘memy and that all construmon will conform to all rictstrig state and local a and uMt proceed m accordance wnb submmed pl.ms I arr. awn the the taaddiag
off.zta; carcw..14 thu pt.rm:: rot • . cause Furthenrme : hereby agree that the c.r., offh or a clesl ma met upon the sryopero to perform needed msT■ections
X _ 4244-1 4/111.44 — 074 "7- lc/ - i 1 ,
SIgnature Contractor s er.st Ne; Vatc
Pernut Valuation i —4- Park Support Fee # ! 5
000 0 CO ! i ,
Permit Fee 5 0 .00 SAC ,. a
Plan Check Fee 194.1D Water Meter S:zc 5 . 8". I - 1 5 _
_
1111==1111111111111111 5 Zoe> ' Pressure Reducer ; S
Penalty 1 5 Sewer W ater Connecnon Fee # c
Plumb:ng Perrna Fee I $ i
-- 1 Water Tower Fee # _-1-
1 5
1 i
Mechanical Peri= Fee 1 5 Budder's Depocit 5
—
Sewer & Water Permit Fee t $ Other S
Gas Ftreplace Pcmit Fee $
i TOTAL DUE PAID WITH
•
emfic 'on Rem ,i es 'lour Building Permit When Appru ed ..
Paid etzWer?it\P-PERMiT
,
1 Date ov
ff. J.' - ft aleili _ . ...._
I' Date
Tht.i Li w Mente that the request tn the #boye arrl.carion and acccunpanymg da., Is or; accordance with the Cay Zmung Ordnance may proceed as requenret Th:s u'ocumest
when ngntod try the Ca? Flanne! constmov a ter Cemkate of Innzn; cornrIanc( and alIosal Cnnft.:11:::' u." ‘ornmence Fieforr , N. ^..n Cert.riza•.e If 0,: .- t•e ,
. 1
trzurd i
a a A locollou.5._ 1
Inamung Diatetot D.r.e e . I any
Z. hour notice for all inspections 4951 44% fax 1,952) 44
4h46 Dakota Street S.F... Prior Lake Minnesota 55372
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Jul 05 2011 1:36PM DSM EXCFIVFITIHG 6514801385 p.2
•
01 ?R10� i Date Rec'd
t
CITY OF PRIOR LAKE
( � 7 . `i M SEWER AND WATER PERMIT
1 2: ,°;1 *, PERMIT NO. 1 1 .,,g I
•
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3. void Applicant
(Please type or Fiat Bad start of brlttom) 0
ADDRESS ZONING wee..
•
r q 3 oo -/ V3M 4 a e Sto -e 4 CI 4/-
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
lif
0
OWNER
(Name) rr) At ,nt I N0M P (Phone) 955- PPP 'gig '" '
(Address) a / LJJ ea ttnf. 4ej. QD r-1 e tkeKiSihlt . 4 ,orgAi 653.2 4
{Address) (City) (Zip Code) , ze
APPLICANT
(Na d Sffl 449A 9 fin," /0 ,i ( Phone ) 6J/- Y8o -/.1
(Name }._
(Address) 9/ Z !u tee i p a.;$ Av.,. 4,46f/ut9. 5 I Ai<r i' SS e--5' . r 3
(Address) (City) (Zip Code)
(Contact Person) , 11'l + ii l ' .44 f (Phone) , 6 S / - 91 9 - V? v d
APPLICANT SIGNATURE 4 Cu /i �_ DATE 7- S - -/I
APPLICANT PLEASE COMPLETE BELOW
Size :lofwater 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'I & Multi - family I% 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 $
s STATE SURCHARGE $ , -50
TOTAI. PERMIT FEE $ PAID WITH
BUILDING PERMIT
T
(office use only}
This Application Ileeome Your Building Permit When Approved Paid Receipt No.
Date By
Bulldlae Official Date
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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(.(1)Ric Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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7
41 In'NES 0
'. Blue File PERMIT NO . 6-(S7 2. Gold City I I
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
n no Pcr , N U
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER �
(Name) Ma 4A W' `
.e/ (Phone)
(Address)
APPLICANT � � n W) , ` L 1, (Name) i' '., ∎ tiW I (Phone) v j 1 y (J V
(Address) ,___9 fi, Y Vr l b (d , r 7i' add- ) 1 `t" �' ' /
(Addrr�s (City) (Zip Code)
(Contact Person) Q e . a e, tr Va (Phone) ` I `, ' I L . 1
APPLICANT SIGNATURE i:�!��i. �I 0 _.. L I J. _ 4 DATE O9 1
APPLICANT PLEASE COMPLETE BELOW 111
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough - ins
Dishwasher Water Heater
1 Floor Drain Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
ci Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink I Lawn Sprinkler
3 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.148 )st $ q1, Building Permit #
"SURCHARGE" has been changed for one f
year effective PLUMBING PERMIT FEE $ 1 L 4 C I' S
July 1, 2010, until June 30, 2011. STATE SURCHARGE $
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 15 1 .I l l 0
is S5, beginning July 1, 2010
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
P CITY OF PRIOR LAKE Date Rec'd
(-.--Rj� e. 7 l,
HEATING /AIR CONDITIONING /FIREPLACE PERMIT
1 Pink een File „,t.::.
Q,„...,,,w>t,1
1I NINTESO � z. Gr City PERMIT NO. I 1 ■ go
3. Yellow Applicant 1
(Please type or print and sign at bottom) �
ADDRESS . ZONING (office use)
L\o D PaystAt.. C-i” N
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER SP �n ' tA L �NAL � (Phone)
( Name) (� UV � 1 h ��
(Address)
APPLICANT 6e, , Q 5*Q ( O(3 (Phone)
'
Address 1b �� 1 evroarvt.to fUJ 55��J
( ) 1" 1 ddress) ) ( (Zip Code)
1 (Contact Person) 1 14e. Q,,, l��' q� -. nu
(Phone) �•�,
APPLICANT SIGNATU' . i`! .' • 11111_____.A � - "- • , (�r'1 11411
APPLI ' NT PLEASE COMPLETE BELOW
``EW CO TRUCTION ❑ REPLACEMENT ❑ ALTERATIONS
FURNACE MAKE AND MODEL T r t a-O to p FUEL A"
FLUE SIZE RETURN OPENINGS INPUT (.0 0 ' L 1 1J U OUTPUT 55 attp
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
['Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
Gravity CI Hot Water into Required Side Yard Setbacks.
Mechanical ❑Radiation Fireplaces with Box Additions or
it Conditioning El Special Devices
Went. System ❑ Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
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 $ Jj 'i() Building Permit #
The Minnesota Statutes § 326B.148 r--�
"SURCHARGE" has been changed for one EATING PERMIT FEE $ "1 C l• � O
year effective
CATE SURCHARGE $ S.-(�
July 1, 2010, until til June 30, 2011.
The minimum surcharge for a "fixed fee" permit DTAL PERMIT FEE $ ' ` r
is $5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Buildine Official Date
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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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 De
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 understoo I 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: )(4-ft rz *V■147kbe -p - DATE 3i2
PROPERTY ADDRESS: Vi i,'; UG Pe‘Y C. t
ACCEPTED BY APPROVING AUTHORITIES:
ADDRESS:
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS OYES ONO
EQUIPMENT USED IS APPROVED (OYES ONO
IF NO. EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS EYES 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 OYES ONO
2. CARE AND MAINTENANCE INSTRUCTIONS [OYES ONO
3. NFPA 25 EYES ONO
LOCATION ENTIRE BULDING
YEAR OF TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QTY. RATING
RLLiN{3LI 12E5 49 20I0 Ya" i Z i
SPRINKLERS R Li1s R 4 2o■O 55
R t.ita (3 LE r3cc2 2o op.
ya" J 106 ►E
RE t. In-e F• t N2
ZO Y� • Z 2l`C>
PIPE AND Type of Pipe
FITTINGS Type of Fitting
MAXIMUM TIME TO OPERATE
ALARM DEVICE THROUGH TEST CONNECTION
ALARM VALVE OR
FLOW INDICATOR TYPE MAKE MODEL MIN SEC
C tx� ' S 0 s 0
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 FRCM THE MANUAL TRIP AND /OR REMOTE OYES ONO
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 MOnF( S(IPL IVISION l OSS 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 of 150 psi (10.2 bars) "ior 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 presvre
tanks at normal water leve 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 PNEUMATICA_LY TESTED (DYES NO N/A
EQUIPMENT OPERATES PROPERLY [DYES ONO
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?
¢3YES QNO _
DRAIN READING OF GAGE LOCATED EAR WATER RESIDUAL PRESSURE WITH VALVE IN TEST CONNECTION
TESTS TEST SUPPLY TEST CONNECTION / PSI CONNECTION OPEN WIDE 30 PSI
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO
SPRINKLER PIPING.
VERIFIED BY COPY OF THE 'iJ FORM NO. 85B EYES ONO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDERGROUND
SPRINKLER PIPING YES ONO
IF POWDER DRIVEN FASTENERS ARE USED IN EYES ONO IF NO, EXPLAIN
CONCRETE. HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED?
BLANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED
GASKETS 0
WELDED PIPING OYES NO
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? (DYES ONO
WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN
COMPLIANCE WITH THE FEOUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3 !EYES 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? El YES ONO
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
CUTOUTS (DISCS) ARE RETRIEVED? YES ONO
HYDRAULIC NAMEPLATE PROVIDED IF NO. EXPLAIN
DATA EYES ONO
NAMEPLATE _
REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: slut
NAM • I'RINKLER CONTRACTOR: METRO FIRE PROTECTION
f TEST WITNESSED BY p
'o. • RjdER� . •WN-• 1SJGNEDj ,/ T D`� `/'
SIGNATURES
FOR SPRINKLER !ONTRAC OR (SIGNED) ITLE DATE
�L.r.4 G,, („ v, 42.9111
ADDITIONAL EXPLANATION AND NOTES =26\3
4 .�` T i � ®' r 4
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� Builders Deposit
X
I N , ES O 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. J
DATE: SITE ADDRESS: P F � O0 t -1 - Coo 1 PERMIT# //, 6
REFUND TO BE MAILED TO: M -I'M 1-1`C - N - 0 =
2 I") cTY' 1 -0 4 2--
Is v p_t,] S Vt Lt= VI ts-1 SS 3 ' ' -D
AUTHORIZATION TO RELEASE
PLEASE REMEMBER lQ/J '4500.00
ynda S len, Building Services Amount
1. KEEP STREETS CLEAN DURING CONSTRUCTION 9.30. 13 Acct.801.20204
2. KEEP EROSION CONTROL IN PLACE Date
3. TEMPORARY OCCUPANCY PERMIT MUST NOT EXPIRE OR $500.00 WILL BE FORFEITED
SIGNATURE
C:\Documents and Settings\sbarelLocal Settings\Temporary Internet Files\Content.Outlook1BD8OXI9A \BUILDERS DEPOSIT
FORM.DOC
PRIOR LAKE BU L DEPARTMENT
ING AND INSPECTIpN
Mani joile
INSPECTION RECORD
SITE ADDRESS t 4300 FAIZAA4 tc
NATURE OF WORK &LeFA t - ti LI - A- rt-/�c.i4 7 f lit . o&c-‘ 1.6 0444 do. rig. LL.
USE OF BUILDING
PERMIT NO. 1 t r 5(07 i DATE ISSUED (e-7/77 it
CONTRACTOR iA i Me> PHONE cicz - g98 , -C /2L
NOTE: THIS IS NOT A PER FOR ANY OF THE INSPECTIONS BELOW
THE
c-,t� , K PERMIT IS E T / � BY SEPA T DO CUMEN
( �1 ` u L ��9'� I4 /V�7' " � �a l SPECTO i 5 1 l DATE
FOOTING t r � I -� tbAp I ��i 77/n
1 FOUNDATION (Prior to Backfill) 11
PLACE N CONCRETE TIL /WOVE HAS BEEN SIGNED
Sci4f .° ti 'x`zq" L v CALD'' ,`�
R - O U G1
SEWER /WATER /SEPTIC PA - 7
FRAMING P6 8i 4'
INSULATION
ELECTRICAL
PLUMBING r, }4. S if ip
HEATING (if required) Qt3 8 /5/ �l
stagraoiee-
GAS LINE AIR TEST
- ' c P COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
I o u F -Sl'c to LA1 I i15 biti
PC B e-t� 4 zt; FINALS Sk l
GRADING (Prior to Sodding) (e �
BUILDING 1111
ELECTRICAL
PLUMBING rvl M rc 0- 6 „
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
where no service cabinet is available, card shall be placed near main entrance.
FOR ALL INSPECTIONS (952) 447 -9850