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CITY OF PRIOR LAKE
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❑ Final Permitted C] Conditional C.O. Expires
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M-..., CI El .. This Certificate issued pursuant to the requirements of Section 110 of the Residential / International ;;ill
Building Code certifying that at the time of issuance this structure was in compliance with the various
1 . mow' ordinances of the City of Prior Lake regulating building construction or use. For the following: )
. - Use Classification ' SINGLE F AMILY Bldg. Permit No. 12 -0928 ` I ` '_ !
ii -: R3 VN PUD 11. o
Occupancy Type Type Construction Zoning District
Legal Description
L37, Bl, JEFFERS WATERFRONT
ft-- , �
of : — : 14400 PARKSIDE COURT 1 ..:
Owner of Building Site Address
Contractor's Name & Address M A T T A M HOME S
ROBERT D. HUTCHINS r,)
�1 City Planner III
B lding Official
( . _ Date: /
B Date: . })
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�1l CONSPICUOUS PLACE ( ,)
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/ rx CITY OF PRIOR LAKE BUILDING PERMIT, l t °d
_� , TEMPORARY CERTIFICATE OF ZONING COMPLI_�NC
�' AND UTILITY CONNECTION PERMIT AUG 1 0 2012 ,;
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MinFile _ ..— _
i. White File �� �T7�
3 . Pink City PERMII` ►•- � /�l4I
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS 1 6 6 PAR-IL-SID e G U v OCT ZONI G (office use)
1 1
LEGAL DESCRIPTION (office use only)
LOT 3 1 BLOCK 1. ADDITION _A E..- -,,A-r 2 ge -t- PID 'zs `I `I P.O - 1 O
OWNER
(Name) 1' P."1 i A- M 1 -14 U M ES (Phone)
(Address) 12 1 W A S 14 it--1 6T t, A v' E S S"TE 2p l E.O t l-,1 1-1 N c5 S 4 3 9
BUILDER
(Company Name) M k-T 1 ''`t -1 y 4 + 0 ~ ES (Phone)
(Contact Name) S v (Phone)
(Address) - 1'L4_. t 1.....A S t-{ 11-.1 Z) J A, v1=. S s--r_ 7 e) t 1 -O 1 Nl .1! I-1 1 S SL-139
TYPE OF WORK 21 New Construction 1.Deck ['Porch ❑Re- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Utility Connection
CODE: J]I.R.C. ❑I.B.C. ❑ Misc:
Type of Construction: I 11 III P/ V A B
Occupancy Group: A B E F III M R S U PROJECT COST /VALUE $ 140, DO(-
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__ FCC, - 7--c ,2 - 1 532)b $ - 9 — t •2
Signature Contractor's License No. Date
Permit Valuation t 5 - s O4 - Park Support Fee # $
Permit Fee $ t 3 r A;.:5-0 SAC # $ 7....3 (05.., -
Plan Check Fee $ 0 cq Water Meter Size 08"; 1 "; $ 4 E56,_.,...
State Surcharge $ 1-i , S-0 Pressure Reducer $ t 2_0 t
Penalty $ Sewer /Water Connection Fee # $ k S40 _
Plumbing Permit Fee $ 15- Sp Water Tower Fee # $ ` O
,Mechanical Permit Fee $ (5 w Builder's Deposit $ t COO- -
Sewer & Water Permit Fee $ 5 , 5� Other i> Lou j 4 L� $ (4S . Gas Fireplace Permit Fee $ 54 � TOTAL DUE $ • 79
This pplic • n Becomes Your Building Permit Wh Ap oved Paid f 7 Re 1pt NO. f� Gj �j��, tz. ` Date 3. 0-- B /
uildine Date
This is to ' tha the request in the above application and accompanying documents ' in acco dance with the City Zoning Ordinance and may proceed as requested. This document
when sign'. by 1 ity Planner constitutes a temporary Certificate of Zoning compd. e and ows construction to commence. Before occupancy, a Certificate of Occupancy must be
issued.
�!�*•,:. Date 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
4 t4i f
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I • • #
Residential Building Permit Checklist
New Cons ruction for Single or Two - family Dwellings in '4 or R -2 Districts
Reviewed by: ' ' i Date: g zZ ( z
IP
Building Permit # 'ID: - Zoning:
Address: tv_e9 v I ' I "4 0 4 (ik 4 oc, t r rdr- C6k-it-r
Legal: L , B Subdivision:
Existing Structure? YES /1 . Existing Nonconforming Structure? YES / NO
CONFORMS TO ZONING ?f1j) NO
ORDINANCE
Yard Setbacks: NA I FAILS/ CO Standard Proposed
• Front Yard (can be 20' if avg. w/in 150') 4 --2,4-
• Side Yards
25' if a as c - /- r4¢ ( O
vim ,,• b 0 1 Pi iVO A.P84;
• Sidewall exceeding 60' requires additional side 2" 10' setback +
setback for every 1' over 60' in length. Not required 271' over 60'
if building wall is 10' -0" or greater of being parallel to
a ea lot line. f) v Q .2 i .q7--
• Rear Yard
• 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 1 FAILS 1 COMP I .30 Maximum 1 r I .
1
Yard Encroachments: NA I FAILS /COOLIES 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. ll�
I Tree Preservation'
�N 1 FAILS 1 COMPLIES I Standard I Proposed
• Total caliper inc es
• Permit 35% Removal
• Caliper Inches Rerr,'oved
• " Calip i1rrches P,rherved
• Replacementl 1/2:1
L: \TEM PLkTB\BLD GLI S T.D O C
/
Driveway: NA / FAILS / COMPLIES Standard
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% 43,
• All parking areas to be paved including R -V or
spaces adjacent to the garage _
• Location to match subdivision grading plan •
I Building Height: NA / FAILS / C PIES I 35' Maximum
Shoreland District: NA / FAILS / COMPL IE:S . Standard
Minimum lot area (square feet) Proposed
_ 7,500 Rip, 7,999 Non rip
Minimum lot width 50' Rip, 57.3' Non -rip
Shoreland alterations
Impervious surface 30% Maximum
S "� i ►fit
Bluff in Shoreland: NA/ FAILS / COMPLIES Standard
Setback from top bluff Proposed
• op of 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 / 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 0 C
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White - Building
M, �P Canary - Engineering
LANES° Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT / i rri /v! V t/01 6 LS
APPLICATION RECEIVED 0 - l 0.. ! m)
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/14 / 44 o ( IMPS /61i 0E -- ' (JAW -
Accepted A Accepted With Corrections
Denied
Reviewed By: /2'14 Date: ?
Comments: See Reverse Side for Additional Information!
See A t., i u - I • ..... • 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
6 Surface storm water drainage flowing to the perimeter of this lot to
and from adjoining p - operties 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.
E The builder is respcnsible for maintaining the erosion control
measures until the turf is established.
The rock construction entrance must be installed a fi the t of
Abackf of the foundation.
•
•
•
6; \Admin \dept info \ADDITIONAL COMMENTS FOR BUIUDING PERMIT APPLICATIONS.doc
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White - Building
Canary - Engineering
MINNEsoc' Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT "' FM my /16 Es
APPLICATION RECEIVED /
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/1--4/7) f 4-4-c Pii- IticS (o ( 4 - UN/ %3
Accepted � Accepted With Corrections
Denied A/ / 1 9 .4,
Reviewed By: Date:
e ZZ l z
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Comments: �``'- --
�c_.. 6n--c-)S /off 4 '� „ cF:r�/ r-(2-
AT
"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 ccde 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
Canary - Engineering
J , NEsoc - 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 Ac :e ted With Corrections
p p
Denied /19
22 IZ
Reviewed By: _.. Date:
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."
pRz0 Date Rec'd
° ` }.'�= = CITY OF PRIOR LAKE PLUMBING PERMIT
� f •ma
) 'fir
t, aim F;„ I PERMIT NO.
•
Y"M App 1
7. Yellow Applicmi f
3 .
(Please type or print and sign at bottom)
use
o p - k's i \\I V ZONING (office l
� `J
LEGAL DESCRIPTION (office use only) ( .
LOT27BLOCK 1 ADDITION t T -( LS P��j PID
R a } � _ n ,�, �i
(N `1�( 1 C)Z- S yak 1v,�ti - Ly u CC (Phone)
(Address)
APPLICAN
(Name) �j -P�k 7 --∎ l (Phone)
(Address) L� \i \ Y v B i 1 r? - - - -- 5G33 - 7
(Add s) / (City) (Zip Code)
(Contact Person) c964-- � L ( O Sv re (Phone) (2) - 7(Q - 7- ( e S(Q
APPLICANT SIGNATURE 9—---Q'— DATE \ 2
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
2 Bath Tub with or without shower 3 Rough -ins
( Dishwasher , Water Heater
A Floor Drain Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
` Laundry Tray (1 or 2 compartment sink Sewage Ejector
I Shower Stall Backflow Assembly
1 Sinks Backflow Assembly Test
Bar Sink 1 Lawn Sprinkler
_ 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
_
//�� r� Residential, Additions & Alterations $49.50
The Minnesota Statutes 32613.1411 32613.1411 —'1st $ • 0 `-' Building Permit #
"SURCHARGE" has been changed for one � ` *'
year effective PLUMB 0" r'�` ING PERMIT FEE $ r 1 l.r T
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50 p O' 'k$. p'
The minimum siirebarge for "fixed ree" permit TOTAL PERMIT FEE $ J301_
is Is beginning duly 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
4 '4,
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o � r CITY OF PRIOR LAKE Date Reed H IN
EATING /AIR CONDITIONG /F I EPLACE PERMIT
A
oi i. >ti o.� r c k m PERMIT NO. I � � 0
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3. Yellow AppUnot r ,
(Please type or print and sign at bottom)
AD4k � y, 1 `' "" ` --
IV`
LEGAL DESCRIPTION (office use only)
LOTg7 BLOCK 1 ADDITION 3e `te--r S Rd-y-.(.\ PID
OWNER N& `^ �, /�
(Name) n i s cS1\ 1 v 1 U (Phone)
(Address)
APPLICANT
(Name) L7� \"T � � (Phone) `
(Address) 2-2.O0 W 9 . y V V l ! e SG � ' 33
(A ` V �1 Tess) (City) (Zip Code)
(Contact Person) Cap t .____OS
"0 C'e ( Phone) 0 52) (1, — SC
APPLICANT SIGNATURE •_,.Ar DATE Z
APPLICANT PLEASE COMPLETE BELOW
`AN CONSTRUCTION ❑ c REPLACEMENT ❑ ALTERATIONS l
FURNACE MAKE AND MODEL l i t L A . 1 2 J I A � O I S ( FUEL 1 • Cl aS
FLUE SIZE RETURN OPENINGS 8 INPUT Sa 000 OUTPUT 5 3 1 3 (o 0
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Mr Conditioner
,Wann Air Plants ❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity ❑ Hot Water into Required Side Yard Setbacks.
❑ Mechanical ❑ Radiation
it Conditioning ❑ Special Devices Fireplaces with Box Additions or
QVent. System ❑Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL 1
FEE SCHEDULE
Industrial, Commercial & Multi - Family I% of job cost Residential, Gas Fireplace 549.50
$49.50 minimum
Residential, Heating & A/C (New Construction) S149.50 Residential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) $64.500 Residential, AC Only $49.50
Estimated Cost $ 5 5'12 • C Building Permit #
I The Minnesma Stnlutes fi 32611.148
"St'RCHAR(ii ?" has been changed for one
HEATING PERMIT FEE $ year effective
STATE SURCHARGE $ .50 Jai) 1.3n1 uni June 30, 2011.
TOTAL PERMIT FEE $ The minimum surcharge for a "fixed fee" permit
(Office Use Only) is g beginning July 1.2010
This Application Becomes Your Building Permit When Approved Paid Receipt No. ` I
Date By ? Pow - 6a � �f
Building Official Date _
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 e
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
PR t
CITY OF PRIOR LAKE BUILDING PERMIT, Date Recd
,
.1.. e
a.... I TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
;., ".r• AND UTILITY CONNECTION PERMIT
41 7 11 611 1 PK.': 7 2
kk.. L..): fel- /2-
,
: Ptak Cay PERMIT NO. /2, .
... op,. •
3 y.a
(Please pe or print and sign at bottom)
1 ADDRESS ZONLNG (off= Easel 1
e ..... 1- .
I44 00 1 K5 - 1 - .)e.
1 i
1 LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER . /
(Name) F-1A r -. ko N'ke-3 (P 9 S Z - 1
• (Address) 720 I WASH It..11-,;(14,,i tvoc. S ET- Di klit-1 , M
f
SUNDER C.,OrriZIACT
(Company Name) 'V r?..0 :':-;:_,)1,.; 0,-L k C iv e:,,ctz ,e,,..c.t; I_L-C, . (Phone) /Le - Z1 7
(Contact Name) F-kAg,+-/ KAP-A•C: R, (Phone)
(Address) 1 t 1 t 0 1.-4\ji; 1 e.t A (.... ,-1. ar " 0 „,. ' .1 P i t 0 '' 6-2- C- 5 ' C
Is
-
TYPE OF WORK . / .1:.+ew Construcuon (:)Da OForch Dile-Rooting 0 Re-Siding OLower Loc, Foush 0 Fireplace
' Addition 0Alteration OL:tatry Connection
CODE: 4 iiI.R.C. 01.B.C. 0 mix
Type of CoristTuction: I EI III iv A e.t
Occupancy Group: A B E F H 1 M (lits S I.: PROJECT COST/VALL'E $ 3 ,.... 'I L- , CO
Division: 1 2 (1) 4 5 (excluding land)
1 htTeVp M.ti daat I :we harnuhed ndurrnanon on elIS arfricatum can:,:c 0 :0 me hest di my knoraledge :rat and ceerm 1 4.10 a that I am lc owner. or .E.r.t4 agent FOC the •
abovemenoried prey and !tat all construchon uti:: =form re ei existing sate and local iaws and wiI n accordance with v,ibrearted plans 1 an aware the the budding
o pen eft: - - r ,c4's dia nir cu
for ;ust ase Furthermore, I ticrer,:i wet that the cry official .:it' a deal:nee nu) erne: upon rhc pnapernr :c. pencrm needed mapece.rma
41 : „. ;„5i
> 40 4 , 14, 4
X ‘"16.4•11i. C - 14 5 ‚o- Zz. - i Z
Signaiute
Contractors License No Date
Permit ‘'a:usr. 4 ooc> Park Support Fe
• ct>0
1
Permit Fee $ SAC .,.: $
Plan Check Fet S GC. , i< 1 Water Meter Stze 5/8", I". $
State Sure:large $ — • 00 I Pressure Reducer S
i
Penalty $ 1 Sewer/Water Connection Fe:: r.r. S
I
Plurn5ing Permit Fee S
Water Tower Fee 1 S
PA trtft-'71711R .
Mechar.ical Permit Fee $ I Builder's Deposit S
1
1
Sewer & Water Permit Fee 1 $ Other 2
1
Gas Ftreplace Fenn:: Fce f, S
TOTAL DUE MIT allii_Di yG
Anti , crn Bt..' n Your Building Permit When Approved Pdld 1 Receipt No.
y
ilb■.,. 0 SO 7-, — Date 1 By I
eu.,_ IF iti; Da I
Thu u :.; or.....raty Mu the rearing ...1 the alive annlxamsr. atrd a..,-,-aer panymg arxtancrds is LI azinaldante wan me Crev Zonal; Ord-mance and mist prurcerd al requeued This document
when saipx,1 toy 12:4 Cr, Plan.ter atructutes a scrnporat Cr-incite crf Zosong ,onani.anze and stows cm:rent/mon to coransence Before occupancy, a CrT:5cate of Om:pence mu= be
sser..ed
Planning DIrectoe Live Spec url Candannta, if an.
24 hour pollee for ail inspections (952) 447-9859, fax (952) 447 - 1245
4446 Dakota Street 5.F., Prior Like, Minnesota 55372
Contractor's Material & Test Certificate for Aboveground Piping
PROCEDURE
Upon completion of work, inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall
be corrected and system left in service before contractor's personnel finally leave the job.
A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. It is
understood the owner's representative's signature in no way prejudices any claim against contractor for faulty material, poor workmanship, or failure to
comply with approving authority's requirements or local ordinances.
PROPERTY NAME: JEFFERS POND DATE / „-,P, /L
PROPERTY ADDRESS: 14404 PARKSIDE COURT
ACCEPTED BY APPROVING AUTHORITIES: CITY OF PRIOR LAKE
ADDRESS:
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS OYES ❑ NO
EQUIPMENT USED IS APPROVED YES ❑ NO
IF NO, EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS ® YES ONO
TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANCE
OF THIS NEW EQUIPMENT?
IF NO, EXPLAIN
INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: OYES ONO
1 . SYSTEM COMPONENTS INSTRUCTIONS OYES ONO
2. CARE AND MAINTENANCE INSTRUCTIONS OYES ONO
3. NFPA 25 YES ONO
LOCATION ENTIRE BULDING
YEAR OF TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QTY. RATING
RELIABLE RES 49 2011 1/2 10 155
SPRINKLERS RELIABLE RES 44HSW 2011 1/2 12 155
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 C '(
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
MAKE MODFI SIIPFRVISIC)N 1 OSS Al ARM C)PFRATF VAl VF RFI FASF C)PFRATF FFI EASE
YE;S NO _ YES NO MIN SEC
HYDROSTATIC: Hydrostatic test shall be made at not less than 200 psi (13.6 bars) for two hours o150 psi (3.4 bars) above static pressure
in excess of 150 psi (10.2 bars) foe two hours. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All
Aboveground piping leakage shall be stopped.
TEST
DESCRIPTION PNEUMATIC: Establish 40 psi (2.7 bars) air pressure and measure drop, which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours. Test
pressure tanks at normal water level and air pressure and measure air pressure drop, which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT 200 PSI FOR 2 HRS IF NO, STATE REASON
DRY PIPING PNEUMATICALLY TESTED OYES ONO
EQUIPMENT OPERATES PROPERLY 1:3 YES 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 WITH VALVE IN TEST CONNECTION
TESTS TEST SUPPLY TEST CONNECTION / OS PSI CONNECTION OPEN WIDE 70 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 'EYES ONO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDERGROUND
SPRINKLER PIPING OYES ONO
IF POWDER DRIVEN FASTENERS ARE USED IN OYES ONO IF NO, EXPLAIN
CONCRETE, HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED?
BLANK TESTING NUMBER USED I 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? 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 YES 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? YES ONO
HYDRAULIC NAMEPLATE PROVIDED IF NO, EXPLAIN
DATA YES ONO
NAMEPLATE
REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
NAME F SPRINKLER CONTFACTOR: FIRE SUPPRESSION SERVICES. LLC.
TEST WITNESSED BY
F R %� l Y ._ E - .iNED) TITLE DAT
SIGNATURES ��� /
P IN ONTR 3R (SIGNED) TITLE DATE
ism -= 0 C S( /r tTil /2--7<f--12_
ADDITIONAL EXPLANATION AND NOTES 0
o rruo
Builders Deposit
U ;x
41iw,NEse. 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: N t YI\V- -V-StD Coota__ 1 PERMIT #12 " e��/+�/
REFUND TO BE MAILED TO: M'� 1 ' k+o F S
12c 1�i AS t 1--1 N\/E S SV t � = Za 1
t til t� F-t r i SS �3 9 AUTHORIZATION TO RELEASE
Building Servi
PLEASE REMEMBER ! • I o . 0
nda S. Al n ces
A
1. KEEP STREETS CLEAN DURING CONSTRUCTION D U I A cct. 8 01.20204
ate 2. KEEP EROSION CONTROL IN PLACE
3 tFnnRO.R,ARY O-CC-UP.AN.0 =Y - !? 1 MtT- MUST -•.NO • -o or . ..11110 _ _- . _
SIGNATURE:
G�___-
C:1Documents and SettingslsbarelLocal Settings \Temporary Internet Files\ Content .Outlook\BD8OXI9A1BUILDERS DEPOSIT
FORM.DOC
PRIOR LAKE DEPARTMENT OF
BUILDING AND INSPECTION
C ON
INSPECTION
RECO
SITE ADDRESS 144.079 P AIC-sio6" COO /LI
NATURE OF WORK SF4 it (1- i c, k- roec -K 02 f = /& , ). L
USE OF BUILDING ' Sir.. t__& FAert I LI 4. - i 4
PERMIT NO. 1 Z 1 Z-P> . DATE ISSUED 87zz-
CONTRACTOR KA r -/t-rl u (` PHONE ct S —89e, -0
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
p� � THE PE MIT IS By DDOCUM T ��e 'poi
I f�+�JtiT'r -� �- K i.��Cc�e,��.+'l k �j cJt_. d _ _" /� 6 • / S PE / rl
DATE
1 FOOTING 4 u I �>"�� , ��
< 1
1 FOUNDATION (Prior to Backfill) (/ I i ti‘i q(, li 1 1
PLACE NO C'QNC ETE UNTIL ABOVE HAS BEEN SIGNED
r(I io (L
�. 401 V6-0 •�k- ROUGH - INS
SEWER /WATER /SEPTIC , 1 u ,,;:\ -- . Q? 8 f
FRAMING 4- FARTTI WALL G1 (3(j v, " /S/Z
INSULATION P I ( /'/
ELECTRICAL 16/ PLUMBING., ,b I y4., KAI /)j/ ' HEATING (if required) l
FIREPLACE
GAS LINE )11.13 TEST r , > ' iz&
s P
le 1 P,
4,,,,,IceL-0(14„<v) I CO V UNTIL ABOVE HAS BEEN SIGNED
1 t g/b/A/z LA } 1 I
SPCL1NK' L, -R FINALS Pii .�� i z
GRADING (Pri • to Soddi g,
BUILDING A. il, 4b &. JD 171 (::7 c : 3
ELECTRICAL
PLUMBING a (2/4 , .
HEATING W y 13
f,
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