HomeMy WebLinkAboutBuilding Permit 03-0020
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
Id-d-~
(flease !VDe or orint and sUm at bottom)
ADDRESS
j 4.PIJ~ {; HJ I ~~: I ~ f'I, p.J J
}Ly)
; ;;~~ ~::y I PERMIT NO. fl? ~007 hi
3. Yellow Applicant ~'1 ~
I I ZONING(officeuse) I
LEGAL DESCRIPTION (office use only)
LOT 1(" BLOCK I ADDITION SiodJ.l :~, AJJ,' f,' () ""-
(;I
PID d !{'
OWNER ^ ) n ~
(Name) Ih ~ / U.'h II I "C!>.-c-I.
(Phone)
(Address)
BUlLDEll_ /J ~ ~
(Name) fYlt (/';'J T.
(Contact Name) c) .... ""'."t ..~/J e~r'
(Address) 1)(;,01 II..(~ "1-.- ,C'r- c...I-.J . A,AQlo(.'/.Jb
(Phone) tJ:2-4t3~ -?'~I
(Phone)~.J'Al-/c>~
c,t'2- "''1ek ~Ll <.(
TYPE OF WORK
~ew Constnlction
~ower Level Finish
~eck
~orch
ORe-Roofing
ORe-Siding
o Misc.
cI( Fireplace OAddition OAlreration ~ Connection
PROJECTCOSTIVALUE (excluding land) $ 30(J. 000_
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 up n r.....r.;..~.J to perform needed inspections.
x i? t.._ ;'("1 L. /a,.p.~oIJ-
. .-
Signature Contractor's License No. Date
I Permit Valuation I :3t90.~ge I I Park Support Fee # $ fjt0~ I
I Permit Fee $ ;Z. Hg.761 I SAC # $ l~-- I
I Plan Check Fee $ t 3 73'~o{ I I Water Meter Size 5/S"tp; $ 3(QC" I
I State Surcharge $ I 5""D.IJe I I Pressure Reducer $ '701/1I. I
I Penalty $ I I City SAC and WAC # $ I. ~~ I
I Plumbing Permit Fee 1$ IL;!:CJ ,QO I I Water Tower Fee # $ 7 cge .... I
I Mechanical Permit Fee 1$ l/f;$. - I Builder's Deposit $ I ,,")i90~ I
[Sewer & 'Water Permit Fee $ - .;&,5V I Other $ I
I Gas Fireplace Permit Fee 'J-- $ Mo'le I TOTALDUE~ I-~ . 0 ~ $9JJ/L~- IqJ
I ~~eiPt~~5JJ~1) .
. -
This Application Becomes Your Building Pennit When Approved I Paid 'i iug", tVI
IUI3!01- I Date i- /D-n;:..~'
~"'-...~
Building cia! Dare
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
Wh~: by the r. Plann", constitutes a temporary Certificate of Zonm. compliance and allows conmuclion to commence. Before occupancy, a Certificate of Occupancy mnst be
Wu~ ~~ ~/?/~3 ~ '~f~~V9IM.-
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
\. / 16200 Eagle Creek Avenue Prior Lake, MN 55372
\/ I.
,~~
Tht'('.,nlunflh..I,.k..<.'ounlry
White . Building
Canary . Engineering
Pink - Planning
NAME OF APPLICANT
BUILDING peRMIT APPLICATION DEPARTMENT C~CKLlSI
7JltlhtUc(J a~
APPLICATION RECEIVED Ie? - d - ~
The Building, Engineering, and Planning Departments have reviewed the building permit
application for constructi~n activi~y which ~r9posed at: Lt:J r~ r ~ /. _. ~ fir!..1
1t{~S ~~ PLIv--~r'~
V
Accepted
Accepted With Corrections
Denied
Date:
t ~/V3 tL:J2._
Reviewed By:
Comments:
v
~
/e4~u~veA
II
~ &L.lr~ked. L~~
~LTIovtS. .,
d-~~
"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."
White . Building
Canary . Engineering
Pink - Planning
Th.. ('lI'nlll'r or rhll' I..kll' (:ounlry
BUILDING PERMIT APPLICATION DEPARTMI;1IlT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
/
_.':~;]~}~.\.~~':.,i:~2._,__/
------"
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is pr9posed at: :) l"" (- r- .
,<~.. ,( . /.~ ./ ........i--.,L~~.
i-' f 1') " ('J ,/ d .... '""__
. _1._'C,";;.........;~"...;_.,':..".. -c'_:..- L~'"
Accepted
x
Accepted With Corrections
Denied
Reviewed By:
fh:7rs
Date:
/ '-b-c?3
Comments: See Revpr~p ~idF! for Additional Information!
~f>P, A tt~chmf>nt~. 1) ('TT~ding Plan. 2) Erosion COIitrol Measures
"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,"
White - Building
Canary - Engineering
Pink - Planning
Thr('rntuoflhrl.abCounlry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
71l~ I CJ'n1l"drV
/;;;7. - d- - d=-,.
,
J ,'-",
\,: '---'L-<
The Building, Engineering, and Planning Departments have reviewed' building permit
ap~~~~: '::- OO"~#~oh~ad al :t (I ~ ~
-
\
Accepted
v
Accepted With Corrections
Denied
.~
c;;?~~~ Date: 1.f4ftW/6~
Comments: rce.ot~ ....-:::l. 0 -J-rJ~U::1'
fYvy-, T - 'J 1-")' ()'lZVY) ~c... 6tJ c..tJJIQ
~- l3'
Cl.1..fh.- - I() \ f.l.e..p~ ~ ~,. 0 ~S'
Reviewed By:
.
"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."
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
Date Rec'd
~ E:w ~~;~, I PERMIT NO.fl3' -002-01
(Please tv'De or 1JIint and sian at bottom)
ADDRESS
ZONING (office use)
14965 HILLSIDE CIRCLE
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID
OWNER
(Name)
MCDONALD CONSTRUCTION
(Phone)
(Address)
APPLICANT
(Name)---p- T.T ,TFn 'FTRESTDE DRllTRRSTDR HEA R'T'H & HOMP.
(Phone)
1i51-1i33-251i 1
(Address)
2700NORTHFAIRVIEW AVENUE
(Address)
(Contact Person)
BRENDA HUSTON
ROSEVJT T P
(City)
(Phone) _651-633-2561
55113_
(Zip Code)
APPLICANT SIGNATURE
BRENDA I-IUSTON
DATE
2/10/03
APPLICANT PLEASE COMPLETE BELOW
xD NEW CONSTRUCTION D REPLACEMENT D AL TERA TI0NS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
OWarm Air Plants
OGravity
o Mechanical
OAir Conditioning
OVen!. System
HEATING OR POWER PLANT
o Steam
o Hot Water
D Radiation
o Special Devices
o Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
TYPE OF SYSTEM
FIREPLACE MAKE AND MODEL
HEAT N GLO 6000TR-OAK X 2
Industrial, Commercial & Multi-Family
FEE SCHEDULE
I % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50
$64.50
$39.50
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Residential, Additions & Alterations $39.50
Residential, AC Onl~ ~l~O
PAID WIl1-1.
BUil~ing Permit # IJ :r-""~DING
$ .50
$
]:I .t.KM11'
~ ~ G-W-~ ~ Receipt No.
iFfiEB 1 0 2003 ~ By
Residential, Heating & AlC (New Construction)
Residential, Heating Only (New Construction)
(Office Use Only)
This Application Becomes Your Building Permit When Approved
Buildinl! Official
Date
24 hour notice for all inspections (952) 447.111~50_ fox 19521447-4245
FROM
(TeE) 02 II 03 OiU6, :JT 03 34 NO.3~618~ I ~20 P I I
CITY OF PRIOR LAKE'riUMB~G PERMIT
:......."fF..
",. ., ,.":',, ....
. .., ~
. .:Dt:tt ".
... '.'-..-,~_lI"~~
. 1?fc~ ~,6~ mnt ~d rm" 'U bc!tDrR)
. ADDRESS
OWNER.
(Nam<:J'
(Addros)
I
I
I
r
I
I
I'
i.
I
Qrn:l1ti~
~
J
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. J.,.......
:, ' ": " ," .'. ;,.~~.~{.1:i.~
,. 11_: 'r", ", '":.','".11 __.i!"
i.. COld c; t PERMIT NO..<:.. .., r, . I '.
J y,~ lloJP'ioon ,. .<:...-"'O'-~~
. j ;,. . . f..,....~,
'. ZONING rolllco.,j,>
., ", '. ~71..l.~~""'~
..
.' .,'
/49&. ~ 1!1I...t..'SJ /J~
e. '..iJUJ
14. ..
:'"f~........_.......
,
~ , I '; ---;/';..J...wJ
(Phone) 1:,5"/- -452.~/~S-' .',
'~tPA.AJ. ftf}..).... ::5SIZr~~~""'"
I (City) , , '" (Zip COlk) "'Y" :",- .......c
.' . '.:';'l:~~~
(Phone)
DATE
zIJ, /0:3
.,.~;,.-;i~:'~:F
LEGAL DESCRIPTION (ol!l<z "'" only}
LOTi BLOCK I WOmaN 5-r~I2.Ul<JtO~~rrw PID,,;~'.!(.
~""':':I'..m1l&A.-1Ii
m~n~1J1k.O (!O~. . CPhcmc) '1S-Z'.4~2."7t.::LJ;._
7C:oI /ffj7"jI ~r ~I _ j)pPLi;;' llALLE:1 }}fA)' r
,
~~~ANT lJ EJJZ€f..- frJ6C-J./ AN I(:JJL:-
(Mdicr:.s) -12LO AU:=-)::ANOf:;.R P.Q
(Ad.dx=) J
(C~nt.aPer.:on) fYJ,lLE:-. / ~c..H . '.
AFPI1CANTSIGNATURE jJ(ai)~c...~"
.. .
;. ''iIIII
r .
C
APPLICANT PLEASE COMPLETE BELOW
..... .
.t.
TYJt<!clCFlXtu,..
Qu.utlty
..
~~;ns
.Warer Heater
,WI4ef Softner '.
:Sllllll1 Pj~(Wasbiri!tMllcllloe)
S"';"'aae EiectDr .
. . Baclffiow.A~mblY
S.cldloW Asmnllly test', ,'.
.uwn $prinl<!er . .' ,
otl1er
-'
Tyll" "rFI~re
, Bath Tub with or withOUT shower
Distro-ashcr
floor Unin
J.,avlltllry (Bath= Sinl<)
. Laundry TAY (I or 2 ~mPl!!'OlteJlt sh,Jt
Shower Stall
Sinks
Bar Slnk
W;ue,- ciosc:t (TolJel)
./
f
1
I
I
I. .,'
, 'I'
. .'.WE'dII
..,....J:s ..
R.eoldcrrtl~l. ~e" One .t. T_F..",ily' 'm.W . ""."
~;d""tf... AdOitiOn. fL Atr......iD... . 'm'.5d' '1-, . .
.e>: '. '. ., '1'ltciJ!!l:'lJll'l
EStlmsrcdC,,>t $ It.. ~()'() - .l3ttir~p=ii._o3- OC'lO " . . _ "..-..>
I?LUM~lNG PERMiT FEE s .. 'fl. ~O (lJf ~~/~Ei{)~!ii~
STATE SURCHAROE S .50 ' .,---.
'T'OTALI'ERMIIFEE ::/~ ~:- -i" ..,~:,:J7i:c:t'".."~-~
.10000"u,oO.ty/ -r~~ lB I~U lJJ~n~i1l';:::"t':~,~~,~;;:~::
TlIiJ Application B<<om", Yo"r g..,i1dmr.l'r",,1L WlTen ),J)prQYeI 'd Pnid, II Rc:eipt l'Io,', >~~
L~' ~P1 '~?nrn, ' . . ' ::z'" III
. ' 'I 0.\1:: L"I ay.. }'".. .. ...._'" !',b
, ..adl.. Officlol Do".1 .: f' '. ......
fiE SCHDJ'l'lLE
rnd""cri.l. Camm",clo' '" Mul,;-f",,"y l'r. or i'* oo=< ,.j,jr. ~~.so mirrlmum. '
, ,~\::. '0,1 ." .:
:a.,i~Or "'~':i~ r~1" I"!I in.ptCBa"' V,..u.-, ~,:..,..q-:::N,....... V..J., ....,.,_.."'.J
.~.~I.i; .~:~....._
..'.
j~ .
_ ---; _ ___0 ___ -----:-~ ~.' CI\.J.Ulf, L.o\KB
I4i 001
CITY OF PRIOR LAKE
HEATING/AlR CONDITIONINGIFIREPLACE PERMIT
Date Rec'd
t'Plase ~ or mior Uld Wrn at bottom)
ADDRESS
P/9c'~ dlh/[)p .f:-~
~~:. ~~..;.I PERMIT NO. /') 3 ",}..i)
-I I ZON1NG(o_~ I
LEGAL DESClUPTlON (ollioe os. Duly)
LOT BLOCK
~jJJ.nON
PIn
OWNER
(Name)~r.{;)"'~
(Address)
~I.
(.phone) ~S'OJ.-7t;O /
=~n~kD ~
(AddTcss) ,.9/,;J/O ~ r7AJ-/!
(Addrm,
(.phone)
-10D-~~ .'
5'~~ ..y
(Zl, Code)
7ai;:;:... t?7.v.
U ' (city)
(Contact Person)
~ ft~~
(Phone)
DATE
..-rJ - /,.0 - ('"j -<.
APPLICANT SIONATURE
/' APPLICANT PLEASE COMl'LETE BELOW
~ CONSTRUCTION . 0 REPLACEMENT 0 ALTERATIONS
FU~ACEMAKEANDMODEL ~-...~ rq""}));)/l"J<">d/...y FUEL j 1#.1- .
FLUE SIZE ~""PVC- RETUllN 0 OS . ~ INPUT //V') .t'loCl . OtrrPu,. 9,;l.MO
TYPE OF "J..:JJ."...,{ HEATlNGORPOWERPLAN'r .
OWum Air Plants OS~
gg.:.vil)' 0 Hot War.r
k::flooloohaolal .' 0 ll,.di.UQn
~ir Coodffioning 0 Special Devle..
J2l'I'ent. System 0 Other Devi...
PLEASE NOTE:
Air Ccnditionet Units
Cannot Encroach into
l\aqutrod Sid. Y.rd
Setl:i..ck.o
FIREPLACE MAKE AND MODEL
Industrial. Comnieroial 8< Ml1lti-Family
Ros1dcntlal. tloatlng '" Ale (Now ConStrUction,
Residential, aeating Onl)' (New COUlructioo)
n:E S,-.......uVL:E
1 ~ of job cott Itesidl;:nti.l. Ou Firepl~e!
539.50 minimum
S99.50 Resldeatial. Additions &. Altcra.ticms
$64.50 1l...ldentia(AC Only
$39.50
S39.50
S39.50
HEAnNO PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
s
s
.50
r
b"'1~4!D [.,.
~1'-4J/NG /1(',
'. Pt..;..,
Estimated Cost S
Bullding Permit #
Buildlnl omci.,
Dire
rnll.u~ ~I. . .
I . Pale! . n _~ ~ III ~ lleceiptNa_
~ -m ~ 0 lUUJ !.'VI By (, I
~"') ""7~145 J ~
(Orner: UIC Onty)
Tb13 Ap_pileatlo!1 Bccom~ Your l3uildi~g Permit When Approved
14 hOtl,r natic::e ror &11, inJptettbn~ (9SZ) IW~1.
TOOIli
lilY O!fTl0lLLNO:J
9LZ909tTS9 XVd 8t:CT OHM COOZ/Z1/ZO
PRIOR LAKE DEPARTMENT OF
BUILDING AND INSPECTION
INSPECTION RECORD
SITE ADDRESS /49(;5" fl/u--.J'/Oe C/.eu.6 Nw'
NATURE OF WORK .5rO
USE OF BUILDING<,FO
PERMIT NO. a3 - 0020 DATE ISSUED / - 8 -03
CONTRACTOR jI-1"",OOA/AL.O t!.-0N'STJe. _ PHONE (,/2. 70/.8'-44-
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
INSPECTOR f. ~ I
.t
I FOUNDATION (Prior to Backfill) I I
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
IYD
fin
~ Jlw
I FOOTING
.
,
SEWER I WATER I SEPTIC
FRAMING
INSULATION ~~
ELECTRICAL
PLUMBING
HEATING (If required)
FIREPLACE
GAS LINE AIR TEST F. ~ tI- JY...... /,/,0
"J:-ID
.
z - '2..<5""-
I 04re
I/ho/C)':?
Pc. 2 -; l:J
#fib 2\~ 3--J")
jJ
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
, l-Affi ~~P'i~.:n~6-.l I //P '1~ 1ft?
. ,
FINALS
GRADING (Prior to SOddln~) if I _ /VI<{
BUILDING -('vD.u~v fllj~. It
ELECTRICAL ,.
PLUMBING W { t- A1--
HEATING tv~
DO NOT OCCUpy
//./Z,04-
8 - ZY.c';
H {1-~ tC1'3
t;/fb(~
,
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
'-..
@edifiraf:e of Q1}rrupaurll
CITY OF PRIOR LAKE
~epatfnt1mf of ~uilMng J1nspedion
~Final Permitted
D Conditional C.O. Expires _
This Certificate issued pursuant to the requirements of Sec,ion 307 of the Uniform Building Code certifying
that at the time of issuance this structure was in compliance with the various ordinances afthe City of Prior
Lake regulating building construction or use. For the following:
Occupancy Type
R3
Fire Zone
Bldg. Permit No,
N / A _ Zoning District
03-0020
Use Classification
SINGLE FAMILY
Type Construction
VN
R1
Legal Description L8, B1, STERLING ADDITION
Owner of Building Site Address 14965 HILLSIDE CIRCLE N.W.
Contractor's Name & Address MCDONALD ~P)'SlR., 7601 145TH ST. W.. APPLE VALLEY 55014
ROBERT D. HUTCHINS Irr-. _ City Planner_ DON RYE
Building Official V
Date: R. '/</ "(l ~, Date:
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
DATE TIllE
ILl;) -t:Jlf
ADDRESS l!:L7?) tiJI9~-L-1 /-
OWNER CONTR. /'i1, /b"e,/./
PHONE NO. PERMIT NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
1"liil'INAL
.....0 SiTe INSPECTION
COMMENTS:
~JI &}I
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
~ILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
'If' WORK SATISFACTORY, PROCEED
/ ~RRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspeclor:~ Owner/Conlr.
CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE_
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH'" SAFETYI
IIifIIOfJ
CITY OF PRIOR LAKE _tnJ
""E_ """'E 7' ~
ADDRESS /# ;;,<;' 05/45
TIME
II: 3:l
, -
OWNER
CONTR.
PHONE NO.
61>3- t-o
PERMIT NO.
D FOOTING
D FOUNDATION
D FRAMING
D INSULATION
-og{ FINAL
", D "1lITE INSPECTION
D EXlGRADIFILLING
D COMPLAINT
D FIREPLACE RI
D FIREPLACE FINAL
D GASLlNE AIR TST
D
D PLUIIIBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
~LUMBING FI~
ECH FlNALW
COMMENTS: f. 5~! r~<;
L 6Ab ~rav-- (i"'"> I;"1!=-
~;-/f~ gj13
T-c:....O.
, ,
~RK SATISFACTORY, PROCEED
b CORRECT ACTION AND PROCEED
o CORRECT WO~CALL FOR REINSPECTION BEFORE COVERING
Inspector: P., Owner/Contc
,
CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE_
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEAL77l & s..tFETYI
INSNOn
----
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
lf/~/;J3
ADDRESS
t4l1{,Ll4tU1-~
OWNER
PHONE NO.
CONTR.
PERMIT NO.
3' -b 2D
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
~LUMBING FINAL
o MECH FINAL
o EXIGRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
COMMENTS:
{" r~_ rJ(~ JAj~ "f7,
~'I -
~ t-/L/AoI"CtL..7r
-;. y ~MA-'T2.>J'
I/le'~ (~
(YA;Ak ~,k }-t~..
o WORK SATISFACTORY, PROCEED
~CORRECT ACTION AND PROCEED
o CORRECT W~ FOR REINSPECTION BEFORE COVERING
Inspector: Owner/Contr:
CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH'" SAFETY!
INSNVTI
-
--~--
-
i~
Job Address /</?I>s- J../; II~~
Heating Contractor Controlled Air
Name of Tester ---tZ..1i
Date </~ :J,-:-_ o. 'f
Percent O2 ~ I
Percent CO2 7-_ {'
Percent co 0
Stack Temp. J Jo 'IC
. .
----