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CITY OF PRIOR LAKE 4
:::.--,-,5,-.-0_- Prparfittruf of 1,Builbin 4Thsprtfiutt _„,,,,,,
(! ❑ Final Permitted ❑ Conditional C.O. Expires
0., This Certificate issued pursuant to the requirements of Section 110 of the El Residential / El International it
Building Code certifying that at the time of issuance this structure was in compliance with the various
(� ' ordinances of the City of r t• g uildin construction or use. For the following:
I f1 g f ig 1017
�,
Use Classification Bldg. Permit No.
0:::t ,--11 VN PUD __ _
i
Occupancy Type R 3 Type Construction Zoning District ,
Ara.:,
Legal Description L19, B1, JEFFERS WATERFRONT ` '
Oft ' 14362 PARKSIDE COURT
O wner of Building Site Address
(II Contractor's Name & Address MATTAMY HOMES
ROBERT D. HUTCHINS
(J City Planner
1 Building Official'
06 ;'-1 Date: J 1. _ Date:
($ ,, POST IN CONSPICUOUS PLACE
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�� r tcl0� AN C\ CITY OF PRIOR LAKE BtiILDING PERMIT, Date Recd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE g 30, f 2,
I
C21 AND UTILITY CONNECTION PERMIT
4"f NN E S (ST. G Main File 1. White File PERMIT 2. Pink City NO./2_ , / a /7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS 1 , 4 x_(02 p1s,p- -, t D E c O V OT ZON NG (office use)
PU D
LEGAL DESCRIPTION (office use only)
LOT 1 9 BLOCK l ADDITION t= F - .R-S "A -- F tZ-- IZOr i PID 2-S Li '1 $O t 9 U
OWNER
(Name) ;1 R T P. 1"1't' -1 U I` ES (Phone)
(Address) l v./ASH-It-1 6 — , v *-3. A te E S STE 2.4D i t=0 t hl 4 \ H t1 S S 4 3 9
BUILDER
(Company Name) MS i\-1-1 i 4 +U (`"t E S (Phone) 2— S 9 - `2-1 D C)
(Contact Name) S U E- R (Phone) 9 G' - e) 8- 6 12$
(Address) - 12L 1 1e..1t S 1 4 lit (, J A, vE. S S Th_ r) t 1=Q t N t, t-11......1 SSc-I ''D9
TYPE OF WORK 0 New Construction ElDeck DPorch ❑Re- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace
DAddition ❑Alteration ❑Utility Connection
CODE: E.R.C. TI ❑I.B.C. ❑ Misc:
Type of Construction: I II III IV V A B
Occupancy Group: A B E F III M R S U PROJECT COST /VALUE $ 1 40, 000
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�,_..`_, 1 BC.- - 2.-C) - 1 532) b - 2-9 - 12
Signature Contractor's License No. Date
Permit Valuation (So OCO, -- Park Support Fee # $
Permit Fee $ ( -3 5 - 3 92) SAC # $ ;; te r—_ —
Plan Check Fee $ Sl 1 ,18 Water Meter Size ;8 "; 1 "; $ ,i 6
T �
State Surcharge $ _ Pressure Reducer $ _
Penalty $ Sewer /Water Connection Fee # $
Plumbing Permit Fee $ (C4 9) Water Tower Fee # $ ( O W r
Mechanical Permit Fee $ ( 5-4.5) Builder's Deposit $ It 5-da '"
Sewer & Water Permit Fee $ s Other �� $ l
�5
Gas Fireplace Permit Fee $ TOTAL UE $ 7
j�
This , ■ "ca , o I B , co ..'es Your Building Permit When pprov d Paid q e 7. 1 J ceipt No. ( 1 /C.' / 7 ,,. / 5 -
A q / / 1 1 tip a∎ _- l I / Z-- Dat L�. I 1 - ti
B • . mg Official Date
s
This is to - ' th• th r que in the1/4jove application and accompanying d cuments in accordance with the City Zoning Ordinance and may proceed as requested. This document
when si: by th /Ci. , er constitutes a - m.orary Certificate of Zonin compli e and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
� ��r 1 ( f z---
Date 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
tieltv. - Aa45
• g
' a
Residential Building Permit Checklist
New Cons r ction for Single or Two - family Dwellings in ' -4 or R -2 Districts
Reviewed by: It j Date: 9 k 4 / .
Building Permit # - ii • - Zoning:
�V i
Address: t �3 1 - 6C, ?A0-t&C(oc a:
Legal: L , B Subdivision:
Existing Structure? YES 1 4,1 . Existing Nonconforming Structure? YES / NO
CONFORMS TO ZONING JP NO
ORDINANCE
I Yard Setbacks: NA / FAILS/ CO S Standard Proposed
• Front Yard (can be 20' if avg. /in 150') 25' z-6—
S
• Side Yards 10'/
25' if abutting a street
• 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 Tine.
• Rear Yard ..2 , z \ -1Z
• 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'
I Floor Area Ratio: NA /FAILS /CODES 1 .30 Maximum 1 Fro 1 2 --/(os` 1 .
Yard Encroachments: 6 FAILS /COMPLIES 1 Standard Proposed I
Eaves and Gutters no more than 2 feet in width and no
closer than 5 feet to a lot line (Easements).
A/C and other equipment cannot encroach on interior
side yards.
Tree Preservation/ FAILS /COMPLIES 1 Standard 1 Proposed I
• Total caliper inches
• Permit 35% Removal
• Caliper Inches Rerr?oved
• Caliper Irlches Pjserved
• Replacementf '2 :1
L: \TEML'L- iTE\BLDGLIST.DOC
/
Driveway: NA / FAILS / COMPLIES Standard I Proposed
• Maximum width at property line 24'
• Required setback 5' from side lot line or
_ 30' from r -o -w on corner lots
• Maximum slope _ 10% - Z _
• All parking areas to be paved including R -V or
spaces adjacent to the garage _
• Location to match subdivision grading
Building Height: NA 1 FAILS / COMPLIES 1 35' Maximum (2_4)
Shoreland District: NA I FAILS / COMPLIES . Standard I Proposed
Minimum lot area (square feet) 7,500 Rip, 7,999 Non -rip
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 top 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 impact zone _ No importing /exporting
Floodplain: NA / FAILS 1 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 1 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 stricture
L: \TEMPLATE\BLDGLIST.DOC
c C m P RIP
■ White - Building
M, � P Canary - Engineering
LA NES° Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT n ffi
APPLICATION RECEIVED ` `� ` i
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/436 2 - — 6't; F i ‘--C/ 0 ( Cl ' .
Accepted )( Accepted With Corrections
Denied
Reviewed By: 4 Date: 9` / /'/z
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."
ADDITIONAL COMMENTS FOR BUILDING 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 construction entrance must be installed at the time of
ibackfilling of the foundation.
6: \Admin \dept info \ADDITIONAL COMMENTS FOR BUI >DIN6 PERMIT APPLICATIONS,doc
1 PRIp
4
U m
White - Building
"'•NNESO'cP Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT v g /T
APPLICATION RECEIVED " a '
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/4-362 z 66 /0b ( . .
Accepted Accepted With Corrections
Denied
4 1) Reviewed By: — -- Date: �� f 4 Z�
Comments: ' ' _
' s c r ‘ .. /714 - , .r,,/
5? Ar— J (
"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."
K PRIp� �Y
U tx
White - Building
1roNESO�A Canary - Engineering
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:
Accepted Accepted With Corrections
Denied / a
Reviewed By: I'�■�iir Date: / � Z''
Comments:
i
"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."
BLILDING PERMIT#
P.LD.#
CITY OF PRIOR LAKE
SINGLE FAMILY WORKSHEET
NAME OF GENERAL CONTRACTOR: IA is.. ) 1401 -
ADDRESS OF PROPOSED PROJECT: - L2- `Pp.2 -ILSI D F COO t2-
SQUARE FOOT FLOOR AREA
FIRST FLOOR (INCLUDE 4- SEASON PORCH AREA) o
SECOND FLOOR \ ' t 2-
BASEMENT FINISHED
BASEMENT UNFINISHED ev S
GARAGE LI LI4
DECK So
3- SEASON PORCH
SCREEN PORCH
NUMBER OF FULL BATHROOMS 7--
NUMBER OF HALF BATHROOMS 1
SEWER AND WATER CONTRACTOR: OS M E-) 411 t-1 1s l - q �jp 1355
NAME PHONE #
NUMBER OF GAS FIREPLACES:
INSTALLER: F. l 12 [O t .) �4 oME SI - L,3`p - 333 9
NAME PHONE #
NUMBER OF WOOD BURNING FIREPLACES:
INSTALLER:
NAME PHONE #
MECHANICAL CONTRACTOR: C.- 1= 4 2 - C i, 9 S 2 -1 6 - I O O°
NAME PHONE#
FURNACE: CHECK ONE: ® YES ❑ NO
AIR CONDITIONER: CHECK ONE: ® YES ❑ NO
AIR TO AIR EXCHANGER: CHECK ONE: ❑ YES IK NO
PLUIVIBING CONTRACTOR: (E NI 2 - CZ`[ �c�l S 2 - - 1 671- L 06D
NAME PHONE #
WATER METER SIZE: CHECK ONE: ❑ 5/8" (STANDARD)
❑ 1"
11 1 %2"
❑ 2"
❑ THE CONTRACTOR HAS VISUALLY INSPECTED THE SIDEWALK AND CURB AND THERE ARE NO CRACKS.
❑ THE CONTRACTOR HAS VISUALLY INSPECTED THE SIDEWALK AND CURB AND THERE ARE CRACKS IN THE
❑ SIDEWALK ❑ CURB
ATTENTION APPLICANT: YOUR BUILDING PERMIT APPLICATION WILL NOT BE ACCEPTED UNTIL ALL REQUIRED INFORMATION IS
COMPLETE.
C:\Documents and Settings \sbare\Local Settings \Temporary Internet Files \Content.Outlook\BD8OXI9A \Single Family Worksheet.doc
PRTq Date Rec'd
i
4.,,, ' CITY OF PRIOR LAKE PLUMBING PERMIT
2 1. PI Fi Cd y PERMIT NO.12
Oald
3. Yellow Applicr"t ...,,,,..
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 6 2_. Ta-1,-- N(.___C7,...
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PLO
OWNER.
(Name) 1 ` F' t 1 b (Phone)
(Address)
APPLICANTS
(Name), -0 !7, C .•K\ (Phone)
1 (Address) 2- 0 ' t "�J 1 ` ��? .--�I ?. 0 f 1l�� k ( Ire SG33 7
(Address) (City) (9 �^ (Zip Code)
(Contact Person) (ct4 7 ! l '� LOS ' (Phone) (l 2) 76 1 ' ( eD E
...
APPLICANT SIGNATURE „tl r - L DATE ` Z� 2
yr APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
T Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain V/ I ` Water Softener
11 Lavatory (Bathroom Sink) 1 Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 conxpartment sink Sewage Ejector
i Shower Stall Backflow Assembly
I Sinks Backflow Assembly Test
Bar Sink ( Lawn Sprinkler
Lk. 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 § 32613.148 — 1st $ ! �7 , 6 IS 0 0 Building Permit #
"SURCHARGE” has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2019, until June 30, 2011. STATE SURCHARGE $ .50
The minimum sarchnrge for "ffaed fee" permit TOTAL PERMIT FEE $
is IS, beginning July I, 2010
This Application Becomes Your Building Permit When Approved Paid Receipt Noppap 1
Date By euAD ti. 3
Building Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447 -4245
4646 Dakota Street 3.E., Prior Lake, Minnesota 55372
■
4 TRIO CITY OF PRIOR LAKE Date Rec'd .
° IfEATING /AIR CONDITIONING/FIREPLACE PERMIT
I.-, c.)''' `. , hi
4/' /AWE
` l r "` PERMIT NO. i 1 Yellen A P Pl kent .' a
(Please type or print and sign at bottom)
ADD
ik SS ZONING (Office use)
- 2 0 CH- ■N)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) OWNER N\ 6.0—r1 1 --e c• (i i n (Phone)
(Address) •
APPLIC
(Name).__________________ (Phone)
(Address) 2 J1 • t\ \1\) it liryS _ - ` 5G 33 /
(A . dress) (City) (Zip Code)
(Contaetl?erson) 1 r? (» c
O — (Phone) (9 52 ) -7L ( P /' 1 8S
APPLICANT SIGNATURE irjj a � �_I♦__� DATE t a
APPLICANT PLEASE COMPLETE BELOW ,
❑ REPLACEMENT [ ALTERATIONS
ill EW CONSTRUCTION
FURNACE MAKE AND MODEL '(Z G—I 2 H 2 O(1 OS FUEL ' V c • C
FLUE SIZE RETURN OPENINGS 1 0 INPUT G$ OUTPUT 6 ) 3(0 0
TYPE OF SYSTEM HEATING OR POWER. PLANT
arm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
AOGravity ❑ Hot Water into Required Side Yard Setbacks.
fi echanical 0 Radiation Fireplaces with Box Additions or
Air Conditioning ❑ Special Devices
❑ em. 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
549.50 minimum
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) $64.500 Residential, AC Only $49.50
Estimated Cost $ 5, 69S
. DO Building Permit #
The Minnesota Statutes §32611.1
HEATING PERMIT FEE $ "SURCHARGE" bus been changed ft r one
year effective
STATE SURCHARGE $ .50 July 1.20111. until Jane 30, 2111 I.
TOTAL PERMIT FEE $ The minimum snreharae far a "fixed fee" permit
(Office Use Only) is S�',�, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Tti
Balldlne Official Date Date By PA `s EF j
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 W
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
.. pp i
.0 ..1) CITY OF PRIOR LAKE BUII_DINC, PERMIT. Date Ree'd
L...
.... '-,- TENIPORARY CERTIFICATE OF ZONING COMPLIANCE
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.AND UTILITY CONNECTION PERMIT
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PERMIT NO.11 • 1 Di/
■ Please t■ pe or print .and sign at bottom)
ADDRESS ZONINC:
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4- ' c I' 11'N KS t DE. ---- N4 '-'--
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LEGAL DESCRIPTION (offick:
LOT BLOCK ADDITION PI)
OWNER
(Narne), F I I A t-kk ‘A Ofrt&S (Phone) 154: -
(Addre -- 72o k \-A..\f 11--)U1 -..:._ ") . /.'")i T‘'l I
;‘Atkj S. 5431
i IMIIIIVIeR C....,' 0.4:-.1
(Company Name)
F1R,C -- 3k,)p c :i:z...--,--, t (-v.:, 4:-..‹ (Lie..,-----) 1 L-LL'_.. (Phone)
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(Lontact Name) f" rxi".•1 te-:'. ektsiC-‘ -CZ: (Phone)
(Address) l 1 ) 1 1 () :11,-.)0k,.).`1-V-1.6-Ni.._ (--...c.-Li.- t" `..SL.. erC
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TYPE OF WORK New Construmon DL?- E.Fordi ORe-Roofmg Sr OLower Level Finish 0 FL:I-place
DAddstion OAlrerat:on Ey" L:tiltry Connection
CODE: 1.FL.C. 1:11.B.C. 0 mis:
Type a Cmstruction: 1 IT III I% eV A CB- -2 Z _, -'" , _--- _
Occupancy Group: A R E F 11 1 M 01,:: S 0 PROJECT COST/N'ALLTE S --i' . CY--:'
Division: I 2 C3:: 4 5 (excluding land)
1 hentr? orrofy that i have fornohe.: miorot.r.on or 111:3 1.7.7......2.■: wrx:ze 5 so fee hr-st of ea knowledge rcri API - - t Us,: errhfy rhaf I am ttle ownv in itefta,e,red agent for the
ah,..we•ersentorsd perverts ar...: tat all oo1!u1 unt will confarre to a.! entstang state &mill tawa setel vall proceed tn ac:ordance Mitt sutsmined ;gam I am awarf that the huld' Ing
thn permit f o r lust rise F O fe, I here .t.rf ::■"...1.' ft..e cry eftlnal or a cfes,,pee mar eTer: ore,- - .et ,eowerry ro petorn neetle‘i rtarecrons
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X L i alert -)1,.e•1/-rt.,i C.- - 14 G //- Z7- 12
signatrure Contractor's License No
Pc:TrIlt VItiatron Park Support Fcc :: 5
Pertn:r Fre ; S SAC r-.- S
Plan Check Fe: i s Water Meter Size 5 5 I
State Surcharge S Pressure Reducer 1 S
Pewi) S
Sewer 'Water Connection Fcc
Plumbing Perrn:t Fee S : Water Tower Fee .....: $
1
Mechanical Perna Fee , $ , ,
Butlder 5 Der-ova I S
Sewer 84 Water Permit Fee i S Other S
, Gas Fireplace Perrrn Fee ' $ TOTAL DUE $
Ai a VW
This ppl' s . tcolcs Your Building Pcrmi Vinc . pproned
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Date ._
R fliati s r „ i c cktgc
rho r, te •.,rmr-r que lthr ree•ece. al the ;457:,-..affon and ao.n.Intsanyreg d...k..urneurs Is :n a,:cord.uus wstn ass Con Zortatg Or•iffuncr arui ITt. PICKV241 .17 ro4oe• ..
.-5 5--1-•-••••- 1-5. !he Ceel. Planer: con:amines a tenfrerran Cernfuare on ?onus* kompliar,:e .ussi allows constructors to covarr.enet PetOre mcupanc, a Ccr7ticAte Cf . ..}....:.:^Jr-N mow be
Kte.rng Dleciol D474. ,ipeCz2.1c.an4/1I(T..,
24 hour notiee f.sr all inspections (951) 4.4 fan ; 44
4646 (.1‘'t 2 weft S.F...., Prior I Ake, Minnesota 59'2
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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 contractors representative and witnessed by an owner's representative. All defects shall
be corrected and system left in service before contractors 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.
PROPERTY NAME: JEFFERS POND DATE ,2— j f -j
PROPERTY ADDRESS: 14362 PARKSIDE COURT
ACCEPTED BY APPROVING AUTHORITIES: CITY OF WOODBURY
ADDRESS:
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS El YES ONO
EQUIPMENT USED IS APPROVED RYES 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: [DYES ONO
1. SYSTEM COMPONENTS INSTRUCTIONS OYES ONO
2. CARE AND MAINTENANCE INSTRUCTIONS YES 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 0 ,5J
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: ❑ PNEEUMATIC ['ELECTRIC ['HYDRAULIC
PIPING SUPERVISED OYES ONO DETACHING MEDIA SUPERVISED OYES ONO
DOES VALVE OPERATE =ROM 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
MAKE MODFI SIJel= RVISInN 1 n5S Al ARM OPFRATF VAI VF RFI FASF OPFRATF FFI FASF
YEES NO YES NO MIN SEC
HYDROSTATIC: Hydrostat c lest 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) far two hours. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All
Aboveground piping leakage stall 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 EYES 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?
EYES ONO _
DRAIN READING OF GAGE LOCATED WATER RESIDUAL PRESSURE WITH yA1VE IN TEST CONNECTION
TESTS TEST SUPPLY TEST CONNECTION �_ PSI CONNECTION OPEN WIDE K PSI
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO
SPRINKLER PIPING.
VERIFIED BY COPY OF 1 HE U FORM NO. 85B EYES ONO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDERGROUND
SPRINKLER PIPING EYES 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 1
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? EYES 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 AFIE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE
REMOVED, AND THAT T-IE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED? EYES 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:
NAME OF SPRINKLER CONTRACTOR: FIRE SUPPRESSION SERVICES LLC.
TEST WITNESSED BY
FOR PROPERTY OWNER (SIGNED) TITLE DATE
SIGNATURES
FOR SP IPtIE E CONTRACTOR (SIGNED) TITLE DATE
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._-- ---- -- -- -_-- oi NIINV
ADDITIONAL EXPLANATION AND NOT 4)19
•
c- ac-- 2/15
° `� a Builders Deposit
U . trt-
A,. Kt, 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 1, 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: -1-9 - 12 SITE ADDRESS: t t-1 3 G _ 1 c ) R9-- 1 . 1 -s tom Cr PERMIT # 12 •I0I
REFUND TO BE MAILED TO: 1- 1 - rTh 1 -moo t'1 F S
1 20 1 wAS1-1- 11-,1GTh Act/ E._ S Su Zo 1
1 t-t .tom / t-Thl SS 1 -43 9
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
AUTHO ZATION TO RELEASE
SIGNATURE: \. 11 iiiiS Od
Lynda . • . (n Cu ig Services Amount
Acct. 801.20204
Date
C:1Documents and Settingslsbare\Local Settings \Temporary Internet Files\ Content .Outlook \BD8OXI9A \BUILDERS DEPOSIT
FORM.DOC
PRIOR LAKE BUILDING AND INSPECTION
k 4. n
INSPECTION RE
SITE ADDRESS /'�.3lIZ PfP J/D Fi C r•
NATURE OF WORK
USE OF BUILDING -
PERMIT NO. /Z . /0 DATE ISSUED 9/
CONTRACTOR /yI S PHONE :.11; i
NOTE: THIS IS NOT A PERMI FOR ANY OF THE INSPECTI • NS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
Install erosion control a maintain clean streetss,i oall times. DATE k 4'
FOOTING ,, of- ,r PtS 1 `j ZS iv
FOUNDATION (Prior to Backfill) Pe %s 'z.
4/0/, PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
adon system under concrete slab afrOrurGH - INS
SEWER / WATER / SEPTIC V 12 - 017
FRAMING P LA FCC R. (, t
INSULATION up �� TI . 'z // /7
G
ELECTRICAL
PLUMBING i z•P- I�(..
HEATING (if required)
FIREPLACE
GAS LINE AIR TEST o4-1,W, p. )_ ba t 2/0
r adon piping COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
ystem, I
Housewrap
-
Fire Sprinkler Pik' -2./4,,b2-2./4,,b2_, FINALS 1
GRADING (Prior to Sodding)
BUILDING ( by l `b {i;
ELECTRICAL
PLUMBING Pig
HEATING (2 I-,
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