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si: CITY OF PRIOR LAKE = t no
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❑ Final Permitted ❑ Conditional C.O. Expires .'
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This Certificate issued pursuant to the re uirements of Section 110 of the El Residential 1 El International ' A - A '
);WV- Building Code certifying that at the time of issuance this structure was in compliance with the various 4
40.1 ordinances of the City of Prior Lake regulating ng construction or use. For the following: i '
' � Use Classification S 1 N G I E FA r'4 T I Y Bldg. Permit No. 12-1423 -E-441H ;
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' ?� Occupancy TYPe R Type Construction Zoning District P U�
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Legal Description 'Jr'
` 14380 PARKSIDE COURT "" Owner of Building . - ��
(11 Site Address = =_ 1
5•, -t•+ 11i
MATTAMY HOMES
Contractor's Name &Address ., <
> ROBERT D. HUTCHINS
City Planner �N
. '= ilding Official i i _a- __.'
he 4 • ° Date: A_ 0414 _ 1, /C/.."/' 4 / .._s Date: E_ :$
1 1 , J POST IN CONSPICUOUS PLACE .'+ •
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CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
7 TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
c.; AND UTILITY CONNECTION PERMIT
r ,/- Main Fil
,y E S 0
I. White File PERMIT NO. /
2. Pink City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS l LI 3 `)6 .1-, 2_e- t ID E C_-r NI t ZONING (office use)
LEGAL DESCRIPTION (office use only) ` � I NIA.--1—E---12-12-0
LOT 2 J 1 BLOCK l ADDITION E- S a � � ' J— ' PID 2- 41 v p 2.-' 0
OWNER
(Name) 1'1 A T T 1, NI -1 0 N1 ES (Phone)
(Address)1 ? A 1 1N A S 1-E i tai 6 i ca +,l A, v E S S TE_ 2p i .O I t- J -►\ H N S S 4 3 9
BUILDER
(Company Name) MS 1 : -t i 4 +0 frl ES (Phone)
(Contact Name) S u E BARE (Phone)
(Address) 12o l 1... k S 14 it,/ (oTt) J Pc vE S STh- ? e l _.O t NJ to H 1�■ SC
TYPE OF WORK 0 New Construction (Deck ❑Porch ❑Re- Roofing DRe-Siding ❑Lower Level Finish ❑ Fireplace
DAddition DAlteration ❑Utilit Connection
CODE: QDI.R.C. ❑I.B.C. ❑ Misc:
Type of Construction: I II III IV V A B
Occupancy Group: A B E F HI M R S U PROJECT COST /VALUE $ 1 t-i-U 0 06 • 0 0
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 _ =—e_ Be-- X31 532)b Alto t1
Signature Contractor's License No. Date
Permit Valuation
155
✓5 s 00 0_ - Park Support Fee # $
Permit Fee $ 13 ; S0 SAC # $ 2-3e5-, ,
Plan Check Fee $ S. q a Water Meter Size 54 1 "; $ ,E�
-1
State Surcharge $ 1 0 Pressure Reducer $ 120 -
Penalty $ Sewer /Water Connection Fee # $
1 00 _
Plumbing Permit Fee $ l 5 j. 52 Water Tower Fee # $ ( Ord
Mechanical Permit Fee $ 154, .- , Builder's Deposit $ 1 �00
Sewer & Water Permit Fee $ 56 ` 5° Other k:'_ e......- ' ` ? ? e 'd $ s _,,
Gas Fireplace Permit Fee $ 5 50 • TOTAL DUE $ 1.
• This App . lion Bec . es Your Building Permit Wh Ap�roved - Paid q g qq 7, Receipt No. 7 ,(/�D
�/ Date 2-114// 2— By i ,,.c''
,.w� ► z r 2% �
Building O )ciallill ate
This is to certify t . e uest in the above application and accompanying documents . in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by /r e ty ' `iv • constitutes a temporary Certificate of Zoning co pli and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued. / )
>� II"— 1 /L
Plannin D - etoT P ate Special Conditions, if any
24 hour notice for all inspections (952) 447 -9850, fax (952) 4474245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT /1i9 7771,14 `
`�—�
APPLICATION RECEIVED /1. 0 . 1?
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/` 00 /� ay() /4 /t �/l ( (1.4/ -.. .
Accepted X Accepted With Corrections 62 0,4)/ FS
Denied / /1
Reviewed By: /� ,4 0 Date: /24 — /2
Comments: See Reverse Side for Additional Information!
See Attachments: 1) Grading Plan, 2) Erosion Control Standards
"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."
•
AbbITIONAL COMMENTS FOR BUILbIN& PERMIT APPLICATIONS.
Surface storm water drainage flowing to the perimeter of this lot to
and from adjoining properties must be conveyed to the roadway
and /or to the rear of the lot in drainage swales within the drainage
easement.
•
All- bare soil areas must be protected from eroding into neighboring
properties through the properly installed and maintained silt fence or
bales. . .
•
• The•silt fence required by the - erosion control plan must be installed
prior to any earthwork being started.
• The builder is responsible for maintaining the erosion.. control
measures until the turf is established.
•
•
„ The rock construct* entrance must be installed at the time of
- ibackfilling of the foundation.
:ion. -.
•
•
•
G; \AdmirAdept info \ADDITIONAL COMMENTS FOR BUILDING PERMIT APPLICATIONS.doc
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White - Building
Canary - Engineering
"
^'NNESO'P Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT n/9
APPLICATION RECEIVED 1/. 3 . /2—
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/43 00- /4- i97 / 1 & .
0,07
S
Accepted Accepted With Corrections
Denied
Reviewed By: Date: t L tTi
Comments: / /VA, rifl -( C-
"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."
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White - Building
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vES° Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT i / o Li/
APPLICATION RECEIVED i e
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
1 • 1 f <- / /\ / .. f
•
(...,: ciim --- ; ---c ,
Accepted Accepted With Corrections
Denied
/
/ /
Reviewed By: • Date: ` 2.- ' 11,
Comments:
"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."
Residential Building Permit Checklist
New Construction for Single or Two - family Dwellings in R -1 or R -2 Districts
Reviewed by: A ylei Date: t z f z
Building Permit # PID: Zoning: nv r-)
Address: \ 4-20 1. �f --ws er
Legal: L , B Subdivision:
Existing Structure? YES / NO . Existing Nonconforming Structure? YES 1 NO
CONFORMS TO ZONING YES NO
ORDINANCE
Yard Setbacks: NA FAILS/ COMPLIES Standard \ Proposed
• Front Yard (can be 20' if avg. wlin 150') ze9
• Side Yards 10'1 r+bo
25' ifabutting a street ?� 4
- rQ —o ' map -
• Sidewall exceeding 60' requires additional side 2" 10' setback +
setback for every 1' over 60' in length. Not required 2 "/1' over 60'
if building wall is 10' -0" or greater of being parallel to
a side lot line. �` � � � �
• Rear Yard ,25' e+E
• Patio Door: provide for minimum 10' deck or sign 10' side/
statement indicating no deck will be built in the future 25' rear
• From 100 year flood elevation of wetland /NURP 30'
pond.
• Refer in- ground pools to the Planning Department
• From OHW (Prior or Spring Lake) 75' or setback average of
adjacent structures, but no
less than 50'
Floor Area Ratio: NA / FAILS /COMPLIES .30 Maximum 1 r'
Yard Encroachments: NA/ FAILS /COMPLIES 1 Standard ' Proposed
Eaves and Gutters no more than 2 feet in width and no
closer than 5 feet to a lot line (Easements).
NC and other equipment cannot encroach on interior
side yards.
Tree Preservation: NA 1 FAILS / COMPLIES Standard Proposed
• Total caliper inches
• Permit 35% Removal
• Caliper Inches Rer ?oved
• • Caliper Inches P,r6served
• Replacement/ Y2 :1
L : \TBMEkATE\BLD GLIST.D 0 C
Driveway: NA / FAILS 1 COMPLIES Standard Proposed
a .
• Maximum width at property line 24' ,-)D
• Required setback 5' from side lot line or
30' from r -o -w on corner lots ` r
• Maximum slope • 10% ° C-
• All parking areas to be paved including R -V or
spaces adjacent to the garage
• Location to match subdivision grading plan [ nJc2
Building Height: NA / FAILS / COMPLIES 1 35' Maximum f? {>
Shoreland District: NA / FAILS / COMPLIES Standard Proposed
Minimum lot area square feet 7,500 Rio, 7,999 Non -ri,
•
Minimum lot width 50' Rip, 57.3' Non -rip
Shoreland alterations
Impervious surface 30% Maximum
Bluff in Shoreland: NA / FAILS 1 COMPLIES Standard Proposed
• Setback from tap of bluff By planning dept,
• Bluff impact zone 20' From Top of Bluff
• Engineering certification submitted /approved By City Engineer
• Grading in bluff or bluff im 'act zone No importing /exporting
Floodplain: NAI FAILS / COMPLIES Standard Proposed
• 100 year flood elevation 908.9' Prior Lake
914.4' Spring Lake
• Lowest floor elevation 909.9' Prior Lake /
915.4' Spring Lake
•
• Proposed lowest floor elevation Must be 1' above flood
elevation for new and existing
•
structures. If existing
structure was constructed
9/19/90 - 11/22/97 then
additional foot is not required.
• Elevations 15 feet from structure Must be flood elevation or
higher
• Road access must be no more than 2 feet below 907.9' for Prior Lake
Regulatory Flood Protection Elevation 913.4' for Spring Lake
Accessory Structure: NA/ FAILS / COMPLIES Standard Proposed
• Size 1000 sq,ft. or 30% rear yard
• Not located in front yard (Materials)
• Side yard and rear yard setbacks 10'
• Maximum height 15'
• Materials compatible with principle structure
L: \TEMPLATE\BLD GLIST.D O C
O4 vR10 Date Rec'd
� CITY OF PRIOR LAKE
` M SEWER AND WATER PERMIT
�P a..44/Z31 /L— /'�Z —ii /2--/442,r �
�NESD /.L — / , /�� /L /421 4- a-- - /'L6 �
1. Green Fle
2. Yellow C PERMIT NO.
3. Gold Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I L I :SC7 — ILI38a ~1438(0-11-13$6-1 4388- !y3 cio jet =je-P CO
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) �1„. t (Phone)
(Address)
(Address) (City) (Zip Code)
APPLICANT � - , ! I
(Name) I) • S A- �-£1/�' (Phone)
(Address) .- ti ' O' SSC 33
(Address) ^ (City) (Zip Code)
^�
(Contact Person) �I►'� 1 11-e A- - Y't (Phone)
APPLICANT SIGNATURE 12.FM DATE 1 7
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'I & 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 $ PAID WITH
STATE SURCHARGE $ BUILDING PERMIT
TOTAL PERMIT FEE $
(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
TrigiTN
!Rio, CITY OF PRIOR LAKE BUILDING
DING PERMIT, ate Rec
c TEN1PORARY CERTIFICATE OF ZONING COMPLIANCE APR 1 1 2013
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4,41.. C)
AIN S
\\N„....,....... AND UTILITY CONNECTION PERNIIT UL
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PERMIT NO. (2 1 .4
'Please type or print and sign at bottom) _____.
ADDRESS ; ZONING office use)
:
i 1.4-3000 Pik (ZS i PE- Ci I■iw 11 t k Lt...c..c.)Zgar.4. ‘‘
; I
.
1 i LEGAL DESCRIPTION (office use only)
i LOT BLOCK ADDITION PID
i OWNER
i (Name) 141-1 001ACS (Phone) ct; - 2.1 7 - 2 Joe
(Address) U.ASH it.,S( AQC . .61,.,A, NAN ,5c, 4 Sci
1
41441:0ER. ex tarer44. .,_
(Company Name) ft VE j VI'"? ErL4.1n ta Cr—R.V kt..4.:S I t...4-X— . (Phone) 7 ti, -17 7 - E5 C 1 (c0
(Contact Name) Mn g_q Ka-- iz {Phone)
(Address) 1 i 1 1 0 1 SitZ i AL. atecLe 1\ t;i Svi 'IE. 0 f g i VC Z I i 55S 3b '
TYPE OF WORK 1.44New Construction °Deck °Font ORe-Rooftng ERe-S:j:r.). :=',.c Level Finish 0 Fireplace
0iliddition °Alteration OL:talltv Connection
CODE: XI.R.C. 01.B.C. 0 Mu
Type of Construction: I II ID IV V A B
Occupancy Group: A B E F II 1 M t S U PROJECT COST/VALUE $ *.; .00
Division: 1 2 a) 4 5 (excluding land)
I hereby certify Out I have furnished information or. Ju a.ppliation whIc.h , s :,,, thr best of rn knowledge true an _ )orrct : 4:Ve Zertfy Mat I am the owner or gusto-Lied agent for the
aboseineritioned property and that all cons:Toccoa will conform to al: eiGsting StAtt And loca: , assi an..! .....!: ;troche,: h azcoriarice wtrh submitted plans 1 am aware that the budding
offiaal c revoke thu permit or lust cause Furthermore I hereby agree that the ory official or a . 1 , AN e't tt i "e prt to perform needed :rape:nem
X -. 041i
( 42
CI 1 4 I t — g ...' l
Signature Contractor's L:cense No Date
,--
Permit Valuation 1. I Park Support Fee
1 . SAC # ! $
Permit Fee 1 S # : s
Plan Check Fee 1 S .1—
i Water Meter Size 5/8" 1 I S
— F---
State Surcharge 1 S Prtfssure Reducer 5
Penalty ! 1 c
J 1 Water Canter Fce ri 5 .
1-- i
Plumbing Permit Fee S Water Tower Fee 1 S
Mechanical Permit Fee 1 S .....
Builder's Deposit S
Sewer & Water Permit Fee 1 $ Other
Gas FLreplace Permit Fee 1 S . TOTAL DUE -
to rPa c ili k ALT
---
This .. cac f .Ekcorri. Your Building Permit When Approved , Paid
• ifli
A 3,
41
A Afth... V / ?//—
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, .
:1,14. .c=fri,13,1 DaTc
nu/ si to certify that the requcsi us the above application and acrompanying documents is in accordance woh the Ctrs Zoning °rimer:cc and mar proceed as requested This document
when signed by the Coy Pl4nnet cowman a •Annporan Ceenfizate of Zoom ,..•conpilance and allows CertiMit:1104 • canymence Bef ,,,-,-- a c o f o ccu p anc ,„ mug b
issued
Platoung Director Date tspec ill conditions, if Any
:4 hour notice for all inspections (952144%9m, fax i452) 44742.45
4646 Dakota Street S.V., Prior Lake, ssionesosa 55r.;
Ir „
0 4 r Rro CITY OF PRIOR LAKE Date Rec'd
f � " -, HEATING /AIR CONDITIONING/FIREPLACE PERMIT
Z3 l .,. ` � r
�' i Pink Pik PERMIT NO. + /f
3. Yellow Applicant / W 3
(Please type or print and sign at bottom)
ADDRESS ZONING (office uso)
N PCB 1C-adt C uvl k)vU Pv5O
LEGAL DESCRIPTION (office use only) fi �; f /� j
LOT 'BLOCK / ADDITION `.✓ ert-C-�'. 'r7' .7.— vUYt C 4 AN/ / PM "35' ci 7 si' 0r O
((N me) tie UU (C)1 �� r, � . � (M (Phone)
(Address) WOO I
APLIC N1n 9sD—)( �/ (Name AN TG_c e t Y't u ad U' I (Phone) — 0, J
f∎ ,1.{ f ✓ y ig/i i e " D
(Address) � �� 11 I l � !.� _ _. _�____. ��/ �' rd�- 1("� - - -_ ��.� - - - --
_ (Addy s) (City) (Zip Code
(Contact Person) # r1 a I ' (Phone) 9 5 ) 17 •
APPLICANT SIGNATURE ' t /1� 6v / i r
� DATE /
•
APPLICANT PLEASE COMPLETE BELOW
CONSTRUCTION El REPLACEMENT E ALTERATIONS
FURNACE MAKE AND MODEL F :_, A ' q at L 1 1. FUEL
FLUE SIZE RETU' OPENINGS " INPUT ,) Zo OUTPUT � 0
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
r Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
chanical El Radiation
Fireplaces with Box Additions or
onditioning ❑ Special Devices
❑Vent. System I=1 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) $149.5D Iesidential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) ($ r '� Residential, AC Only $49.50
he Minnesota Statutes § 326B.148 Cost $ � "J Building Permit #
"SURCHARGE" has been extended 1 ` ��} ■ �7
until June 30, 2013, HEATIN - .PERMIT FEE $ ilv
The minimum surcharge far a STATE SURCHARGE $ ' CC
"fixed fee" permit is $5.00 TOTAL PERMIT FEE S 1 L , 0
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Bulldin¢ Official Date /�
24 hour notice for all inspections (952) 447 -9950, fax (952) 447 -4245 PA WITH
Y V ITH
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 BUILDING PER 4IT
, VRI0 Date Rec'd
0
Al
CITY OF PRIOR LAKE PLUMBING PERMIT
i
M scii>, is Bloc cry PERMIT NO. J�
3. Yellow Applicant /,, - / /v�
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
L-13 c Pai f)t C U4 P b
LEGAL DESCRIPTION (office use only) ��
LOTf BLOCK / ADDITION 7e e Ks G24444 4/ilmr ED ,25 L /TS "1
(Name) k yr W C (Phone)
(Address)
APPLIC �♦
{Name) ANT �� 1/} �� � � , -
i d All � II� / I (Phone) SD ---)(07-17r\59
(Address) a-aCD U • l 1 J ( - - - - 1. J3 - - - - -__ 1 n U le 3s 33 -)
(Address) (City) (Zip Code)
(Contact Person) I 1( ( d f C : cu o (Phone) �S - 74 7 1 bS f
APPLICANT SIGNATURE I ? . 4 ! 1 L All 4 DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
(D, Bath Tub with or without shower 3 Rough -ins
I 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
I Sinks Backflow Assembly Test
Bar Sink 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 5149.50
Residential, Additions & Alterations $49.50
1C�x
The Minnesota Statutes § 3268.148 'st $ -- Building Permit #
"SURCHARGE" has been extended tended
2
until June 30, 2013 PLUMBING PERMIT FEE $ ) (4 45 1
The minimum surcharge fora STATE SURCHARGE $
"fixed fee" perrnit is $5.00 TOTAL PERMIT FEE $ ( . SC) -
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Bulldlne Ofiklal Date ,
24 hour notice for ail inspections (952) 447 -9850, fax (952) 447 -4245 PAID WITH
p,
ITH
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 BUILDING PERMIT
Contractor's Material & Test Certificate for Aboveground Piping
PROCEDURE
Upon completion of work, inspection and tests shall be made by the contractors 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 owners 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. n
PROPERTY NAME: JEFFERSPOND 14380 �arkS - DATE 6 - -S -t3
PROPERTY ADDRESS: 14380 PARKSIDE COURT
ACCEPTED BY APPROVING AUTHORITIES: CITY OF PRIOR LAKE
ADDRESS:
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS YES ONO
EQUIPMENT USED IS APPROVED OYES 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: ®YES ONO
1. SYSTEM COMPONENTS INSTRUCTIONS YES ONO
2. CARE AND MAINTENANCE INSTRUCTIONS OYES ONO
3. NFPA25 YES ONO
LOCATION ENTIRE BULDING
YEAR OF TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QTY. RATING
RELIABLE RES 49 2012 1/2 11 155
SPRINKLERS RELIABLE RES 44HSW 2012 1/2 15 155
RELIABLE F3QR 2012 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 4!/
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 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
ua• u•■ • : 4111, • - -.,i • - ••
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) 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 NO
EQUIPMENT OPERATES PROPERLY OYES 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 NEAR WATER RESIDUAL PRESSURE WITHjA.LVE IN TEST CONNECTION
TESTS TEST SUPPLY TEST CONNECTION 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 OYES ONO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDERGROUND
SPRINKLER PIPING YES ONO
IF POWDER DRIVEN FASTENERS ARE USED IN RYES ONO IF NO, EXPLAIN
CONCRETE, HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED?
BLANK TESTING NUMBER USED I LOCATIONS I 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? 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 OYES 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 ONO
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
CUTOUTS (DISCS) ARE RETRIEVED? (DYES ONO
HYDRAULIC NAMEPLATE PROVIDED IF NO, EXPLAIN
DATA ®YES ONO
NAMEPLATE
REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: 6-s-1 3
NAME OF SPRINKLER CONTRACTOR: FIRE SUPPRESSION SERVICES, LLC.
TEST WITNESSED BY
Y• 1 ROP � Y o / R (� , fE DAT
SIGNATURES � � � �
• • SPRI , ONT' • TOR (SIGNED) TI E DATE
ADDITIONAL EXPLANATION AND NOTES "*2-60
0 PRj -
�,
Builders Deposit
4',NN sOSP 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: 1 L{ 7) o P4D V s' D G Cr NI 1,-,i 4
PERMIT # 17' � -
REFUND TO BE MAILED TO: 11 M t -1'T 1- I- 0t -1ES
12- O t W A 51-1- t IJ ( N V F S S V 1 i E= Z o 1
l tl .1s, 1 SS 43 9 AUTHORIZATION TO RELEASE
PLEASE REMEMBER it f . U 0
Lynda S. Allen, Building Services Amount
1. KEEP STREETS CLEAN DURING CONSTRUCTION PA d3 Acct. 801.20204
Date
2. KEEP EROSION CONTROL IN PLACE
3. TEMPORARY OCCUPANCY PERMIT MUST NOT EXPIRE OR $500.00 WILL BE FORFEITED
SIGNATURE: --�—
THE PACE OF THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER AND ORIGINAL DOCUMENT SECURITY ON BACK WITH PADLOCK SECURITY ICON.
Mattamy Minneapolis Partnership 1 876
7201 Washington Ave S., Ste 201
Edina, MN 55439
DATE 1 t 9, 12
PAY TO THE GI or Pt_- -, 012_ v--~ o
ORDER OF
1 Sgi 402 .
t C--1 el 6l-4T 11-40 US'.P.ND UtZ- to Um1OTU�1 mom/0 / D() - n Security features
DOLLARS o =Lb.,
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C :\Documents and Settingslsbare\Local Settings\Temporary Internet Files\ Content .Outlook1BD80XI9A1BUILDERS DEPOSIT
FORM.DOC
PRIOR LA K E DEPARTMENT OF
BUILDING AND INSPECTION
INSPECTION RECORD
SITE ADDRESS D AggieS70 E ET
NATURE OF WORK i• �_ �II� j /,; ��"�'.�%
USE OF BUILDING '�
PERMIT NO. /Z. /# DATE ISSUED
CONTRACTOR I/ : ILi LAT r►L : rr AAP' PHONE ;:111111M4:.
NOTE: THIS IS NOT A PERMI FOR ANY OF THE INSPECTI • NS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
Install erosion control & maintain clean streeti, TO 11 times. DATE
I FOOTING 1/18 /13
1 FOUNDATION (Prior to Backfill)
PLACE NO CONCRETE UNTIL ABOVE BEEN SIGNED
Radon system under concrete slab irG H - I N S
SEWER / WATER /SEPTIC t .)/1,' , 7 �
FRAMING
INSULATION ( IC z1 /L(. ) ?�
ELECTRICAL
PLUMBING //r ()Cr, .
HEATING (if required) ,Pb / 0.1/0
FIREPLACE
GAS LINE AIR TEST
adon piping ' C0 ER NO WORK UNTIL ABOVE HAS BEEN SIGNED
system, i - I
Housewrap
Fire Sprinkler AL iiizeit FINALS / y
GRADING (Prior to Sodding
I`
BUILDING
� I C� it l i l l?, ���� 6 Z' 111
ELECTRICAL
PL IJMBING
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