HomeMy WebLinkAboutBuilding Permit 13.1000 r_ „'��S' w.�,"",','�., ,.....^W 9.`»So :Y ",+�"S7'b`c',' '< v° .,- _. _mt'.✓<.,', �'n..: .x.. .w... r.... ?°w'.,++,9.
�/ i u � — � �/ � u � �i �/ u �/ U �/ �/ a �/ � U �/ �/ U u � � � �- �✓�
/ i, t ' , ` ► C Iii" , A + +� 't i"' t \c, A :?c . ;` 1
CZirftfi zfr of ®r pants
CITY OF PRIOR LAKE
Prparfturnf of ePuittrittg calttsprrfinit
) 'iinal Permitted ❑ Conditional C.O. Expires
This Certificate issued pursuant to the requirements of Section 110 of the❑Residential/❑International
Building Code certifying that at the time of issuance this structure was in compliance with the various
' ordinances of the City of Prior Lake regulating building construction or use. For the following:
Ki Use Classification SINGLE FAMILY Bldg.Permit No, 13-1000
PUSD
Occupancy Type Type Construction Zoning District
Legal Description L5, B1, HICKORY SHORES SECOND ADDITION
3827 TURNER DRIVE
Owner of Building Site Address
Contractor's Name&Address D.R. HORTON I INC. (
ROBERT D. HUTCHINS:-
City Planner
Building Official
KDate: if— 4p - / Date: ,.
POST IN CONSPICUOUS PLACE
I 0 0
2 0 0 0 000000 0 » 2n
n n a 000 O ■� - � � � & ■q
k rt
k 2 xx E gxceso z k �o
% t . q q a m � � §k2 ��
? _� K > � -I m o -, z-
73 -1 » n z o o
t 0 > > ° m k
_1 R 0 3 m
L.-
71
% z z 0 0vi
m m m m OQOCOO
o _f z 0 0 mIIV)■ E11
2» m )
$ f ■ . mxm -a n F CO
a -^ �■ ■ ■
112 ° - 0 > 000 �0 m k ) 0
■ 0 § rz \2 cp
t i§§ ) &
/ II
<
...._
■ c000 W
.4%
% » & o � � n r o
��k$
. -\ n mss tiq m 22�t
qua
...
r
■� z §
-1r o
J 0O 0 CIO 000 "0 0 > g
n n 0 ■ §'ioo 0 § k CC
n n . E 2 rco m in' no
to r ,it RI N x m 2� § Eoz A co k-0
en
E
n n ® 2 0 > o cm k § § w § z z § 7,
S 0 \ !11 m
m
n 4'1(3
b x § f ,� - )
I
0 0 oOOOCO
m mm ^o kE § rn73 X_ � m 00
0
§ E i Ill x
Q m 0 r m 0 0 73 - g ' 0
q - 3 § CC m
Pi z # m . r P o
/ r0 1
mt..,
0
n () kvl
\ 0 000000
.2 73 g.) 2.1 N re
E
� mm � § Q ®
R. 0 o r -o -o -oxi O
< ■
\ z 111 0 „ &011 §�
® � �� �
� §
B k.
\ .
3 0 0 0 000000 -4 0 a g
n q a § § § . g §2$ �2� $ § § H
cz m r § § u) rn $ � E§$ 2 0 XI 0/ `�� T. § .4 m o �- � Z§
§ --.�
• z q z Ft!'
n > 0 03 m '
% r § 7
m ill
% / o 73 XXl
Z 73 R R 000000
Ill
■ mm ■ 13 ■ gE ■ 1,
0 -1 Z 0 0 rnE ), rnE
| § fni q § 2� ¢§ m 0 0 y .
\ 0 k El
0 > °z ■ § m
r $§§ M = . 0
§ z 71
-nrII -a P m
a 2
z
_� M
m O'QOOQ
z :LI :P. I . .
a. / . 2%§� ® •
q z . m �S § cl
7fri » mm � � O
I=
cn / � z m
-1r o
I
5 0 0 0 r C) 000000 'o 0 > zC)
73 X " 3 r 3Z� m 72 y n"
tri r 0 0 y , to Z SzDz O N O�
-a -, > - Z 03' 0 z �
IQ
-1 > y a ..♦ m z O z O •
C n1 m co -1 z , .`
kO x o z WA 03 m m
-- F v �
4. m z z z 1� "�
z n 0000 ❑ ❑
':i x m m m 1 �cN � ;c
N v G m ->1 0
z 13 X mmx3 v C) Cl)
Q CA M xi We'
00 m m c) zzzz z m 0 z
ni m 7 0 r -nue) 73 z p C
Po z z m O m
A x
I m •
0) m000000 v.) �
7 \
41 Z ri g O
n > mmz �
to 5-Im m
-yi r Q
F PRt CITY OF PRIOR LADE BUILDING PERMIT, DateRecd
,� ° TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
E �: AND TTLIT NECTI I'i` ,�. /1{, /J�
,, ft, See m.am vile
'S'I tP t.ttttwte Fik //
tvtasa A 3 v Applicant PERMIT Nei/3. /4�
z r Fri:, )p
(Please type or print and Signet bottom)
ADDRESS ZONING(tttrrce use)
3827 Tv 4 . .Di l✓&"" h)5La
LEGAL DESCRIPTION(office use only) �f
LOT 5BLOCK / ADDITION r /a� ,Sffp 2-A--2-e-
� PID ' /.� - ,5"'
(Name)t 0 i &A-nni
(Mame} � , (Phone)
(Address)
BUILDER D R NORTON, INC 952-985-7272
(Company Name), , i<P1: c .
(comet Num)) Brooke Hareid bmhareid@drhorton.com (p'1 952-985-7806
(Address) 20860 Kenbridge Court, Lakeville, MN 55044
TYPE OP WORK ViNew-COnStMetiell CIDeck ( Porch CilteRooting ORe iing ElLittwerlovei Finish El Fireplace
0Addition CiAlteratiOn polity Connection
CODE: OLR.C. O1.$,C. 0 hese.
Type of Ccolatumtlon t I It fa
Occupancy Group: A B^ .E F H I M R S U PROJECT COST/VALUE $ .:2-77, 3 5)
Division:- 1 2 3 4 5
(excluding idttd?
i-herd certify that I have itnmished':tnfloniation tin thisimplication wilkh is to the best orrny knowledge true and Coma- f also certify that.In am the owner or auttwstzed-agmt for the
above-menttortetk MAW and that i-constmetioon will confocal►to all existing state and toed laws Patti will protect in accordance wilts submitted Plans. t:unaware that the building
official canrevolcc this permit:torn Cause- fkutiterniore.t, agree Mat the city official era deg ee martureeu :thesprOpe ty 10 portion netakeutsprtunns.
BC605657 a/2/5
Signature ContractorsL se No: Date_
Permit Valuation 7 000 Park 'Fee it
$
Permit Fee $ f _ SAC
ti
Plan Check Fee $ /3 7,-Off. Water Meter Size 5/8" � 5770. 00State Surcharge $ Pressure Reducer (J $
Penalty $ Sewer/Water Cor)tnection Fee # $
Plumbing Permit Fee $ /Pi'
Cd
Water Tower Pee # $ /'d®.
Mechanical Permit Fee $ _ ,SC, Builderr's:Deposit $ Q o-zie, o()
/5
Sewer&Water Permit Fee ffi Other rj rc.s _ $
Gas Fireplace Permit Fee . $ a-- TOTAL DUE. C
This Ap; ca n Beeontes)'our Building Permit Wire e Appr. ed• Paid /2.�7,tSd.54 Rec: t No. 700
: ' r Date P 2-t /3 By
tttildtnp Oitieial--oft 0al1
Tins is to certify at teinest in the above application and accompanying document in a,..rdancc with the City Zoning Ordinance and may proceed as requested. This document
when signed b f, ' Diann.:constitutes a temporary Certificate of Zoning compi" ice an. .flows construction to commence. Before occupancy.a Certificate of Occupancy must be
issued
Al �Il►i of `
'tanning Director ------ s Special t editionsi if any
24 hour notice for all inspections(952)447-9850,fax(952)447.4245
4646 Dakota Street Prior Lake,MN 55372
aBuilders Deposit
•
• „ , .
. it,x4virr‘s4c- - . .
, . . etty of Prior Lk -
A...$1.,§00.011rt� Buttde .i,: �pitttid 4n axe
[NOP*P tritt tn. lh.n f ikter�y'Oe.15( t iy:. ;01.,. d tw-WW Y r•: war it8 r�y�a
Fl 0oppntka • WiR' Y rfTf!R..gtp.44o 'ci tt„0All r(Was-int41449`W. ^` rt°t mni tV ' "•. E.i f.a rttej ��t 301: tY ®
p�tant ���c1 €ticf pattlt g Stint he of rapist n yrs-attar they to 1tin matting:Regi� f s. tt'tf t: i tk s.t ca�mt l . .
within the dais Thin>pit cteit ' itit`tinfir tt pO t�taf t violation :incl Ma 40 sfpit :I0 • cool V car the
$toms 't t tt-tie 4wtt1.41 i e4/ : ftWatSPf twit #�,r ilinr< toart+gyp orcara� tt rs ihretttify ration. -
A4Nitimo0Tre.g Einpns onywbot tro -attd Witt-t 'reltrinleit'ifsocitteti unto AM pr's crzrntinl It PefiOd nititte mit
/ .
Slit A O ..
38L7 . _ biz 1�� PERMIT* _ AIO.O 6
•
D.R. Horton, IncAttn: )AI , r r < I 1I�: , , , , ', �'
Rozuwir.0.60 twat Tv,. m
20860 Kenbridge Court Suite 100 2i w d 6
Lkeville, MNA 65644'
Lynda S. len,Build' Services ,mount
.....,.._...... ._,_._ 1 1 Acct 80]..20204
Date
elf I I(1'� I - \ � I I _
i. K ` 'fi` ? • :l .itt ° .. Lar oppler, City Engineer
2 KEEP ER0EN N. 0 (Qt=:IN PLAG
TEMPORARY Ø •. . A O°REI 1fi M 4T N.1 Ag .t . i:tt ' .n r
ED IN RED AND BLUE INK O THE FACE ON CHEMICAL AND BLEACH REACTIVE PAPER*TR INVISIBLE FLUORESCENT FIBERS ANp\ASK\TV�EA�E'0'040(„
THIS CHECK IS PRIN4 \ \\ \� \�. \ ` rat \
; o • Cheek 'du � Q6
7�� . :Ciptr d Dis ,fae rat\\. \. \� \ \\\�:\ \ k.
;f64,,-.443),A40: • 'hank of Alnbnc• a, A' 64 1278 Date �' �moun�t; •-
\ �dN
DRH Inc.South Dish Account Atlanta,Dekalb County Georgia\ \ 6�1 -Ga.\\ 09/18/13 S****36 7SQ fW \\
301 Commerce Street,Suite 8,0 \\ \ \\\ \ \\ k
\�` \ �� (i3,-‘��� �' Void after 6 months from date ot,�3�s� � \
Fort Worth,TX 76102 \ \. \, \\ N\\ \ \ ��\" ,.. ' \
l
/100
\ a THIRTY SIX THOUSAND SEVEN HUNDRED FIFTY 94
\
To the — � \ \o I � \\',
�RIOR LAKE(PERMITS) " � �v �SS -,N,\
••
Order Of: CITY OF ��;` i �` �
4646 DAKOTA STREET SE
PRIOR LAXI/MN 55372 /4-,e R<ito
11'0055909611' 1:06LL127881: 329 903 676611'
dsarvtim : f, E 11P- VT i RM
oF PRIo CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
i.
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
'' AND UTILITY CONNECTION PERMIT
vkx s �
Q. I. White File 1000 4/NNEso� s. pink city PERMIT NOI3
3 Yellow Applicant or(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
q ? 7 `rvr4 O(we k...)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER , (Phone)
(Name) l C.- •,
(Address)
BUILDERC'Q
(Company Name) I
_e► (Phone) 6 s7 � / '
(Contact Name) 5 v rh‘4.0' j—ire Ao)-er+r c ry (Phone)
S75 I4 nne&41a Ave k
(Address) c i, ietc,, �, yvl:t..i Ski 03
TYPE OF WORK ❑New Construction ['Deck ['Porch ❑Re-Roofing ❑Re-Siding ['Lower Level Finish ❑Fireplace
['Addition ❑Alteration ['Utility Connection
CODE: DLR.C. ❑I.B.C. ❑Misc. 2 c.,C
Type of Construction: I II III IV V p B PROJECT COST/VALUE $ 3 3 00 —
Occupancy Group: ABE F HI M SU (excluding land)
Division: 1 2 3 4
I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the
above-mentioned pro. ay 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 permit for just`use. Furthermor- hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X % ./� (7,0 75 od- a 7- 3
,� —Signature Contractors License No. Date
•
Permit Valuation 7 rvV .00 Park Support Fee # $
Permit Fee $ /oj.ao SAC # $
Plan Check Fee $ 4069.95' Water Meter .Size 5/8"; 1"; $
State Surcharge $ ZOO Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer&Water Permit Fee $ Other $
Gas Firepla e Permit Fee $ TOTAL DUE P4ID yy'T f7
This :pp!' ati• come I our BuBBing Permit When A.proved PaidReceipt o.Air Date By
BuiTng rciai Dat
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 Occupa,-icy must be
issued.
Planning Director Date Special Conditions,if any
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
Ot 1'Rio Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
4finrEso*
oaw aloe FcrY ae I
PERMIT NO. /3l �9
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS 1 ZONING(office,use)
3 Z1 1 knr u' '3\fJ
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
(Nam;' rSahVt, Pl\ g °4- l (Phone)1 EO) 416- 7-2-61
j
(Address) ►' 5 � + P�=f�1l V ri5
(Ad ) (City) (Zip Code)
(Contact Person) )CUA.A (Phone) 1(i 6'Zc3-l-1-7 t t
APPLICANT SIGNATURE QI\LtIAJA 1'A DATE C1"ZJ'2 O L3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavatory(Bathroom Sink) Stand Pipe(Washing Machine)
Laundry Tray(1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink 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
Residential,Additions&Alterations $49.50
The Minnesota Statutes¢32611.148 est $ • Building Permit# •
"SURCHARGE"has been changed for one PAID WITH
year effective PLUMBING PERMIT FEE $ (8411-DING PERMIT
July 1,2010,until June 30,2011, STATE SURCHARGE $
The minialua surcharge for a'7ixed fee"permit TOTAL PERMIT FEE $
beginning July 1,2010
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Building O f dal Date
24 hour notice for all inspections(952)447.9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
C Rx0� CITY OF PRIOR LAKE ]date Recd
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
4
Esoo ,.Pink File
2.Green city PERMIT NO./3-/,b O a
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS _ NWL
ZONING(office use)
3%2 i itArM r 1nJ
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
(Name)
APPLICANT--
& 'L 10\lt9OJ N- )4A'g
(Phone) ��D�"
416- 2.2-V1
(Address) 1C `iM �4�
Q1uy) t t 14 I 55441
(Address) (C (Zip Code)
(Contact Person) (Phone) 1 IO�-7-53- '7 re
APPLICANT SIGNATURE LLDATE -23,2-0 1..i
APPLICANT PLEASE COMPLETE BELOW
['NEW CONSTRUCTION ❑REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑warm Air Plants 0 Steam PLEASE NOTE: Air Conditioner
Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water
❑Mechanical El Radiation into Required Side Yard Setbacks.
DAir Conditioning El Special Devices Fireplaces with Box Additions or
❑Vent.System 0 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 $49150
$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 $49.50
Estimated Cost$ Building Permit # PAID WITH
HEATING PERMIT FEE $ it
BUILDING PERMIT
STATE SURCHARGE $ .50
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
PRIG Date Rec'd
s �y CITY OF PRIOR LAKE /V $ , /3
3 4 SEWER AND WATER PERMIT
4'jMvEso`�A 4/,3. 9V /3- 991
Green File PERMIT NO. J
. Gol /3' /O
3. Goldd ty Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
3gir- 2/. 27A • - 122tyt_. vSZ
LEGAL DESCRIPTION(oifisy use' do ig e�2ND/ 2,5' 1492- 003-0
L f+` /f // f-25-, 25- 912- 49061—
LOT / BLOCK / ADDITION Pi D 75' n e
/t '` affil
OWNER Dr2 v i1e .,/
(Name) 77 /Y (Phone)
(Address)
(Address) (City) (Zip Code)
APPLICANT / �1, Jil( . S/ Y0 /<3Sir
(Name) �Sr/�. � Y (Phone) G
(Address) 9:.4 e tae 1145774/.46 csz?3
(Address) (City) (Zip Code)
(Contact Person) _____Iii&-- 4-0.0 / Nd, / (Phone)
/2- 9/9 5''34 '
APPLICANT SIGNATURE 11 ii L`aa DATE /6-1-/3
APPLICANT PLEASE COMPLETE BELOW
Size of water service 1 inches.
Location of any couplings from struc feet.
Type of sewer pipe. ❑ ABC PVC ❑ Cast Iron
Estimated length of sewer line eet.
Clean out(if required) located at feet from structure.
FEE SCHEDULE
Residential sewer and water line connection $51.50 Industrial,Com'l&Multi-family 1%of job cost with a$51.50 minimum
Sewer connection only $25.50 Water connection only $25.50
Estimated Cost $ Building Permit#
SEWER AND WATER PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date
Buildine Official Date PAID WITH
24 hour notice for all inspections(952)447-9850,fax(9S1 VU G PERMIT
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
01 PBTp Date.Rec'd
, ��` CITY OF PRIOR LAKE PLUMBING PERMIT /® (- /3
lNNLse
t.Blue filo
Y.Gold City PERMIT NO. /3 moo
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(0 ilce we)
LEGAL DESCRIPTION office use only) •
•
LOT 5 BLOCK 1... ADDITION 010W ''L ``j k) P -lig, -110;.-a
OWNER D R. Ifoi - 'ON t
..
(Name) (Phone) 95 2" (16 6 0727
(Address)ZOEi . -O N8l iPtd-E Coto-r i JWO 64-iectititkopAIN 55(44-
APPLICANT
% 44-APPLICANT-
(Name) 31CL,CP_ y'" af3t, T 11T6- L LC (Phone) ( /-alt ' 42t C
(Address) .3) 3 5 -.1L742.,-1 1i AL t?i t1 =/ J iit rc zoo.t t r -t7.4 1 :col 5 s)22 Ji
(Address) (City) (Zip Code)
•
(Contact Person) , tie o//` 4 (Phone) 6'}l' 3/9- 4-Z
APPLICANT SIGNATURE V,` . �- DATE t L�l
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
1 Bath Tub with or without shower Rough-ins
I Dishwasher I Water Heater
I Floor Drain Water Softener
Lavatory(Bathroom Sink) I 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
..- Water Closet(Toilet) Other
FEE SCHEDULE •
Industrial,Commercial&Multi-family 1%ofjob cost with a$49.50 minimum Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
Estimated Cost $ Building Permit#
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Buntline Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447- i't�® WITH
4646 Dakota Street&E.,Prior Lake,Minnesota 55372 � 1iLD N G PPRf 4IT.
CONTRACTORS MATERIAL &TEST CERTIFICATE FOR AiiicwEGRomABOVEGROUND PIPING
PROCEDURE:
Upon completion or work,inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall
be left in service before contractor's personnel finally leave the job.
A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities,owners,and contractor. It is understood
the owner's representative's signature in no way prejudices any claim for faulty material,poor workmanship,or failure to comply with approving authority's
requirements or local ordinances.
PROPERTY NAME: Hickory ShoreDATE: 12-30-13
PROPERTY ADDRESS: 2'7 " (J✓,nt"ceec�{
ACCEPTED BY APPROVING AUTHORITIES(NAMES)
PLANS ADDRESS:
INSTALLATION CONFORMS TO ACCEPTED PLANS EfES ] NO
EQUIPMENT USED IS APPROVED • YES [] NO
IF NO,EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION
OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT • YES [] NO
IF NO,EXPLAIN
INSTRUCTIONS
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: YES 1 NO
1.SYSTEM COMPONENTS INSTRUCTIONS • YES [] NO
2.CARE AND MAINTENANCE INSTRUCTIONS MI YES [] NO
3.NFPA 25 U YES C] NO
LOCATION OF SUPPLIES BUILDINGS
SYSTEM ENTIRE BUILDING
DESCRIPTION MODEL YEAR ORIFICE SIZE TEMPERATURE QUANTITY
Reliable Fl 58 2013 1/2" 155° 13
Reliable Dry F3QR 2013 1/2' 155° 1
SPRINKLERS
CPVC with CPVC Slip fittings
PIPE&FITTINGS
ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST
ALARM VALVE CONNECTION
OR FLOW TYPE MAKE MODEL MINUTES SECONDS
INDICATOR Vane Potter VFS-R
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
TIME TO TRIP* WATER AIR TRIP POINT TIME WATER REACHED ALARM OPERATED
THROUGH TEST CONNECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET" PROPERLY
MINUTES SECONDS PSI PSI PSI MINUTES SECONDS YES NO
DRY PIPE WITHOUT
OPERATING Q.O.D.
TEST WITH
Q.O.D.
IF NO,EXPLAIN
"MEASURED FROM THE TIME THE INSPECTOR'S TEST CONNECTION IS OPENED.
OPERATION
0 PNEUMATIC 0 ELECTRIC 0 HYDRAULIC
-.--..... . .
•
PIPING SUPERVISED 0 YES 0 NO DETECTING MEDIA SUPERVISED 0 YES 0 NC
DELUGE •
&PREATION DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS 0 YES 0 NC
VALVES IS THERE AN ACCESSIBLE FACILITY IN EACH CURCUIT FOR TESTING IF NO EXPLAIN
0 YES Q NO
MAKE MODEL DOES EACH CURCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO OPERATE
SUPERVISION LOSS ALARM OPERATE VALVE RELEASE RELEASE
YES NO YES NO MINUTES SECONDS
HYDROSTATIC: HYDROSTATIC TEST SHALL BE MADE AT NOT LESS THAN 200 PSI(13.6 BAR)FOR TWO HOURS OR 50 PSI(3.4 BAR)ABOVE
STATIC PRESSURE IN EXCESS OF 150 PSI(10.2 BAR)FOR TWO HOURS. DIFFERENTIAL DRY-PIPE VALVE CLAPPERS SHALL BE LEFT OPEN DURING TEST TO
TEST PREVENT DAMAGE. All ABOVEGROUND PIPING LEAKAGE SHALL BE STOPPED.
DESCRIPTION PNEUMATIC: ESTABLISH 40 PSI(2.7BAR)AIR PRESSURE AND MEASURE DROP WHICH SHALL NOT EXCEED 1-1/2 PSI(0.1 BAR)IN 24 HCURS.
TEST PRESSURE TANKS AT NORMAL WATER LEVEL AND AIR PRESSURE AND MEASURE AIR PRESSURE DROP WHICH SHALL NOT EXCEED 1-1/2 PSI(0.1 BAR)
IN 24 HOURS.
ALL PIPING HYDROSTATICALLY TESTED AT -......k PSI FOR 2,4e.8, FIRS. IF NO,STATE REASON
DRY PIPING PNEUMATICALLY TESTED 0 YES Q NO
EQUIPMENT OPERATES PROPERLY Q YES 0 NO
TESTS DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS,SODIUM SILICATE OR DERIVATIVES OR
SODIUM SILICATES,BRINE,OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
0 YES 0 NO
DRAIN TEST READING OF GAUGE LOCATED NEAR WATER SUPPLY TEST PIPE: RESIDUAL PRESSURE WITH VALVE IN TEST PIPE C PEN WIDE
STATIC PRESSURE:/ PSI . ` PSI
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFOR CONNECTION MADE TO SPRINKLER PIPING.
VERIFIED BY COPY OF THE U FORM NO.85B 0 YES 0 NO OTHER EXPLAIN:
FLUSHED BY INSTALLATER OF UNDERGROUND 0 YES 0 NO
SPRINKLER PIPING
BLANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED
GASKETS
WELDED PIPING 0 YES 0 NO
IF YES........
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY 0 YES 0 NO
WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3
WELDING
DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED 0 YES 0 NO
IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A 0 YES 0 NO
DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE
RETRIEVED,THAT OPENINGS IN PIPING ARE SMOOTH,THAT SLAG AND OTHER
WELDING RESIDUE ARE REMOVED,AND THAT THE INTERNAL DIAMETERS OF
PIPING ARE NOT PENETRATED.
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL CUTOUTS 0 YES 0 NO
(DISKS) (DISKS)ARE RETRIEVED
HYDRAULIC NAMEPLATE PROVIDED IF NO,EXPLAIN
DATA
NAMEPLATES 0 YES 0 NO
REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
2 -1/_ 1 °/y
NAME OF SPRINKLER CONTRACTOR: SUMMIT FIRE PROTECTION
SIGNATURES
TEST WITNESSED BY
Fri' a•ERTY • SIGNED) TITLE DATE: /7
ir
SWAMI
FIRE PROT£GTIOh
FOR SPRINKLE CONTRACTOR(SIGNED) TITLE DATE:
-)/ 6:0,-,- a -/f- Zai
1/3
s
PRIOR LAKE DEPARTMENT OF
BUILDINA AN D PECTION
Nee ain. Ede
INSPECTION RECORD
SITE ADDRESS rdl?7 inmwesiale %b4 . Aio iivr..4
NATURE OF WORK_SF 0 Wf u Fig►? Z&�
USE OF BUILDING6 , ,444,..., % / ,r /,d
, ,
CONTRACTOR %A'P.M%, PHONE - °IMF, '
INSTALL EROSION CONRTOL AND MAINTAIN CLEAN STREETS AT ALL TIMES
INSPECTOR DATE
FOOTINGi,-," 09,0f
FOUNDATION (Prior To Backfill)
RADON RETARDER/, j,, /d, ,
PLACE NO CONCRETE UNTIL A VE HAS BEEN SIGNE
ROUGH - INS
SEWER/WATER/SEPTIC
FRAMING Me / .7. )4.
INSULATION ,dell
ELECTRICAL
PLUMBING r'�� �,�� s•�i►�lo� e 0.4, Rel/y.,,
HEATING tor .R4 0 P
FIREPLACE , ' ./A:1)/
GAS LINE AIR TEST
RADON matimpow Q(Ppi(a �5 T,v„..„
�iR�- 5(.„ i 9 19 C U_I/I-XTHE ABOV (f E IGNED
HOUSEWRAP LA H D
ALS
GRADING ( PRIOR DOING) .L.
BUILDING 5
Li
f LECTRICAL
PLUMBING t�-+ ill cS 13 )
DO NOT OCCUPY UNTIL ABOVE AS E N 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