HomeMy WebLinkAboutBuilding Permit 04-0019
CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT f..) - J.. 9 - 0 J
Main File
;~;~:o ~:~ I PERMIT NO. itA .00/0
3. Yellow Applicant v~"1
(Please type or print and siJm at bottom)
ADDRESS
5lCB ~tCb.k'Pal'rttD('I'1 >e..
ZONING (office use)
jC.I
LEGAL DESCRIPTION (office use only)
LOT 1 BLOCK~ ADDITIoillc2Q./"'h'eJd ICY
PID Z~. 4-01.02-7.0
OWNER
(Name)
(Phone)
(Address)
~~;;;)~. ~ I t--krLtrm"JDL'--. (Phontfj'6d..ft8S -7 fXf6
(Contact N ame)f}l ,'.1f _ 'y.JM 'routJ.<)Cl.-- (Phone) t1SZ - Zu,,-l/7 "'L.
(Addressb?CA{d)~~,Ci. ):st;?-{OO; ~.I); /~'i mil! 5F..ol/!
TYPE OF WORK
~N ew Construction
DLower Level Finish
DDeck
DPorch
ORe-Roofing
DRe.Siding
o Fireplace
DAddition
DAlteration
DUtility Connection
o Misc.
PROJECTCOST/VALUE (excluding land) $ /59, /83
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 y.vy...n) 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
;~~~';\\d:d;::::S ~CX'i>JSCaS, Jd.<3,~-o:~
. 1-. - ( \ Signature Contractor's License No. Date
Permit Valuation '1f;SCfooo.ao I Park Support Fee # $ FSc, 00
Permit Fee $ J~07. Sol SAC # $ ;'3'50,0'fJ
I Water Meter CSi~I";
Plan Check Fee $ ql4:,~ $ ZSO, {JO
I State Surcharge $ 79. '5"0 I Pressure Reducer $ '-1'5.0 0
I Penalty $ I City SAC and WAC # $ ;ZOo,O~ I
I Plumbing Permit Fee $ 100.00 I Water Tower Fee # $ 70eJ, D cl I
I Mechanical Permit Fee $ 100, 00 I I Builder's Deposit $ lS-ao,Oo I
I Sewer & Water Permit Fee $ ~'5.'!5"'O I I Other $ I
I Gas Fireplace Permit Fee $ Lja. 00 I I TOTAL DUE $857Z.3BJ
,- ) )
This Application Becomes Your Building Permit When Approved Paid 8'JS'12..14 I Receipt~. H2--IJ I
~:OffiC~ --UI3jv Date J If / i t!J;.- I Bv .....
.....
G
This is to certify that the request in the above application and accompanying documents is ill accordance with the City Zoning Ordinance and may proceed as requested. This document
~d:~:lanner con,titutes ~I'mpor"l' Certificate of Zoning compliance and allows construction 10 commeuce. Before occupancy, a Certificate of Occupaucy must b,
Pian:ing Dir~t:.J .f/3~e 'I ~ ~nditions, if""y
24 hour notice for all inspections (952) 447-9850, tax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372
&~;
Main File
White - Building
( cal}lU-ll - t:nqineerinv
Pink - Pla'nnlng
Tht Crnltr of Ihr I.lbCountry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
[) F," !-I{;/c!..TO / j
/2 2-0.0,3
The Building, Engineering, and Planning Departments have reviewed the building permit
application lor construction activity which is proposed at:
,5 (e, e ;--1,;-; Or) /(: F ,J! 1'./ T DIC-
Accepted
Denied
X
\.
Accepted With Corrections
Reviewed By:
1YI9f5
Date:
/-q=f)~
Comments: See Reverse Side for Additional Information!
41c.,'" h'l(
See Attachment~. 1) nrading..EI"n, 7) Hr(l~ion rontml MeasllTe~
"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."
s~~
Main :File
White - Building
Canary - Enginepring
s:lT'K - Planninij:::)
Thl' ("pnler of lhl' L.kf ('ountr)'
BUILDING PERMIT APPLlCATIION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
L. /~~ ! !f. I .' f I /
I . '/ , ( '/
~ "-- I ~
The Building, Engineering, and Planning DElpartments have reviewed the building permit
application for construction activity which is proposed at:
;--.1 ?
t; /:, ,~ .~. '/ /, ,.. i !"_
I' ( / /'" -;- .I fiG-
Accepted
Accepted With Corrections ~
Denied
....
Reviewed By:
Comments:
~ ~~ Date: J J,~h, if
~ ~ ~'/.,~~~,
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."
~
~~
Main File
C~i:' - Buil!l~
an I y E:Ag1nAerlng
Pink - Planning
Th~ C~nlu of lh. L.kf ("ounlry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
D. J<. /-fOte.::17J N
/2-. z,q,a.3
The Building, Engineering, and Planning DElpartments have reviewed the building permit
application for construction activity which is proposed at:
5/ () f7 e,4..fT Ofl/C., P ~ 1 tJ T DIL.
Accepted
Accepted With Corrections
~
Denied
Reviewed By:
~
K'~.t
r-
~.--9A Date: //;3'~if
f
a.,LfJ ~~,
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."
Janl3. 2004 10 55AM
GENZ RVAN PLUMBING AND HEATING
No 3182 P 2.8
~~2J~~~
'. -'11'.'.'.,-.,
" \ . -.\,'."" v "'...~
';~\:;~~~:(:~\~;@~, "IN E:l) 0 1: to>
\t',".-:J~""')'""
Date Rec'd
CITY OF PRIOR LAKE
SEWER AND WATER PERMIT
; ~=-~.;. I PERlVllT NO. 11_ ( q
J Gold ,~"'tlt
(Fl~~ type: Qr pu:nt and sjp;;nat hottom)
ADDRESS
DS /0 ~ fCls ~ 00.. k Pil {Vl.T C!Q Sf:
ZONING (ofW:,>,,,u)
LEGAL DESCRIPTION (ollice u", only)
LOT I BLOCK ~ ADDITION tee I2fldot
I~I
PID
OWNER
(Name) ..J)lLli--~-- ""~~~Ill Il---'
(Address) 2.<:.)&,,0 Kev1IOK\bL-€.. Cr $-rPIf'f"\
(Addro.)
(phone) _
La.kl.\Jille..-
(CitY)
ct52..q85-IX~V'"
&'J'?:;;CoWU
(ZipC:odr.) .
APPLICANT
(Name) Genz-Ryan Plumbing & Heatinz
(phone)
651-423-1144
(Address) 14745 So Robert Trail
(.~ddre,,)
(Cont.1ctPetSon). Q)'lK:CS,f1 G=(r (.~
'ICANT SIGNATURE r V 1 1~ --:fd...e~
Roaemount, MN
(City)
(Phone)
DATE
55068
(Zip Cod<)
651-423-1144
1- /qoL{
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure
Type of sewer pipe. 0 ABC [J PVC
Estimated length of sewer line feet
Clean out (if required) located at j)~et from structure.
feet.
o Cast Iron
Re<ldential sewer and water Ime (;Qnnectlon
Sewer connection o.nly
FEE SCHEDULE
$35.50 Industrial, Corn'! & Multi-famlly 1% of job cost WIth a $39.50 DlJD.JJnUlll
$17.50 Water connection only $17.50
Estimated Cost $
BUIlding Pennit #
SEViER AND WATER PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$
$
.50
8 PJlID
U/L.D/ft, "Writ
'vG 1'/2,
'Fi/l,frr
(Office U!lt OI)IYJ
I TMs Appllcatiol1lkcomes Your Building Permit When Approved
Building 01l1cild
D:u~
I Paid
I Dete JAN 2 1 2003
Receipt No.
By
~-
24 hour nOlic, for .11 ,"'pections (952) 447-9350, fax (951.) 447--4245
Wffi~ PRIO~".,
... \'
... "
- "
u \ '"
\,.+,Jv ......
,~~~~~&{{g #IrSO
Jani9. 2004 10 55AM
GENZ RVAN PLUMBING AND HEATING
No, 8 i 82 P 3
Date Rec'd
CITY OF PRIOR LAKE PLU1\rIBING PERMIT
~ ~~ ~~~ I PERMIT NO. I J,-- /1
1. YelkIw Appliew l/f
(please type OT'PODrand Slm. at bottom)
ADDRESS
"t)'IOt f)~+ [(;{(c... Rii nt-/YIZ- S't;-
ZONING (offi..",,)
, LEGAL DESCRIPTION (office >= only)
LOT'! BLOCK;Z ADDITION luuz..:h e(d I fA~1A...
PID
OWNER
(Name) DR Horton Custom Homes (phone)
(Address)
%2-Q'}."i -i'6DCl
2-CCSG 0 :Len B~ l P&::. Co S,e I bD
uduvillG t'\AN E6ci-lW
APPLICANT
(Name).r;~__-"y"- "'''-?-;i.-: e u._"_'_::;
(Address) 14745 So Robert: Trail
(Coptact Person)
(phone) ,<; 1_[. ?<_ 11 t./.
Rosemount
55068
(Zip Code)
MN
C'~1(kT~fl fit f I ~ ~
rllA~)~(A/1
(City)
(Phone)
651-423-1144
{- (t11J4
APPLICANT SIGNATURE
I
I
I
I.
I
I
I
,
I
Quantity
b'-..
I
I
4-
I
.-?l.
I
:{
DATE
APPLICANT PLEASE COMl'LETE BELOW
I Type of Fixture Quantity I
Bath Tub with or without shower I Rough-ins
I Disbwasher I Water Heater
Floor Drain l2.-.:t:: Water Softner
] Lavatory (Bathroom Sink) I Stand Pipe (Washing Machine)
I Laundry Tray (l or 2 compartment sink I Sewage Ejector
Sbower Stall Backflow Assembly
Sinks I Backflow Assembly Test
Bar Sink Lawn Sprinkler
I Water Closet (Toilet) I Other
Type of Fixture
I
I
I
I
I
I
I
I
I
I
FEE SCHEDULE
!ndusmal. CommercIal & MuJu.famtly 1 % ofjob cost with a $3950 minimulIl Resldennal, New One & nl'o~Famtly S9950
Residential. Addition. & Alteration, $3950
Estimated Cost $
, P,q/O
:()/tv,G~
:)p~ '
,'f:1Ai!/r- .1
BU:lldJng PermIt #
PLUMBING PERMIT FEE $
STATE SURCHARGE $
TOTALP~~nTFEE $
50
10m" u.. Only)
Til;, Apl'lication Becomes Your Building Permit Wilen Approved
Paid
I Receipt No
I By
JAN 2 I 7nh1
Date
Building Offil:i2J
Due
24 hou.r notIce for r.i1 in5pectioll5 (952) 44'1-9850, fa~ (952.) -447-424S
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
q>lease!VPt:. ororint and sign at bottom)
I ADDRESS
,90?C O~ ~/~ u-
LEGAL DESCRIPTION (office use only)
LOT 7 BLOCKc:::9 ADDITION
OWNER DR HORTON
(Name) - 20860 KENBRlDGE CT
(Address) LAKEVILLE, MN 55044
APPLICANT ./10 ~
(Name) /-//.~~ //7-'/"../~4/'r-/
(AddreSS)~ ~~~~~ 4
~AddreS
(Contact Person) A ~ . 6-
APPLICANT SIGNATURE .. ~ ~
Date Rec'd
~?ux;,
I. Pink
2. Green
3_ Yellow
~:~ I PERMIT NO~ ~O
AppllC8n1 r;,r-~
. ZONING(ufficeuse)
~...c-
(7L-
PID
(phone)
(phone) ~5../.. 45""'?~ ..?/;7~
~---e~ ~.5::-? '?
- (Clll1If (Zip Code)
(Phone) ~ - c;/~ -."t 77,s:,
DATE
, APPLICANT PLEASE COMPLETE BELOW
~NEW CO~TRUCTION 0 REPLACEMENT 0 ALTERATIONS ,
FURNACEMAKEANDMOD~/r-.J~ .:?/~~.y'07~ FUEL -LI h." .,4,:"-~
FLUE SIZE~~h~ RETURN OPENINGS INPUT ~ ~ OUTPUT a_ ~
TYPE OF SYSTEM HEATING OR POWER PLANT
FEE SCHEDULE
1 % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential, Additions & Alterations
$64.50 Residential, AC Only
OWarm Air Plants
OGravity
o Mechanical
~ir Conditioning
~ent. System
o Steam
o Hot Water
o Radiation
o Special Devices
o Other Devices
FIREPLACE MAKE AND MODEL
Industrial, Commercial & Multi~Family
Residential, Heating & NC (New Construction)
Residential, Heating Only (New Construction)
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
$39.50
$39.50
$39.50
Estimated Cost $ . ~Q:)BuildingPermit #
REA TING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
(Office Use Only)
This Application Becomes Yonr Building Permit When Approved
Building Official
Date
24 hour notiee for all inspections (952) 44~-98SlI, fax (952) 447-4245
$~..// ..&......./~.DAID WITH
~ (7' ,50 'B01C.OING PERMIT
I Paid
I D'lIAN 2 6 2003
Receipt Np
By '1-
()
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
Date Rec'd
i: ~:~~~ ~l~icant I PERMIT NO. OLf-1 Cj I
(Please type or print and siRll at bottom)
ADDRESS
ZONING (office use)
5108 E. OAK POINT DRIVE S.E.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION
PID
OWNER
(Name DR HORTON
(Phone)
(Address)
APPLICANT
(Name) AT J .TED FTRFSTDR DRA FTRFSTDR HEARTH & HOME
(Phone)
/\51-/\33-25/\ 1
(Address)
?700 NORTH FAIRVIEW AVENUE
(Address)
ROSEVILLE
(City)
'\5113
(Zip Code)
(Contact Person)
BRENDA HUSTON
(Phone) _651-633-2561
APPLICANT SIGNATURE
BRENDA HUSTON
DATE
3/23/04
APPLICANT PLEASE COMPLETE BELOW
xD NEW CONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE
RETURN OPENINGS
TYPE OF SYSTEM
INPUT
m,ATING OR POWER PLANT
OUTPUT
DWarm Air Plants
DGravity
o Mechanical
DAir Conditioning
OVent. System
o Steam
D Hot Water
D Radiation
D Special Devices
o Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
HEATN OLO SL-750TR-C X 2
Industrial, Commercial & Multi~Family
FEE SCHEDULE
1% of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential, Additions & Alterations
$64.50 Residential, AC Only
$39.50
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Building Permit #
$
$
$
.so
$39.50
~. $39.50
."I<'JA"~
' """,:, ~;J1
--.;'\1,
,.~'" .
.!"'~
'<';'/fl(~
~&~'Ir
Residential, Heating & NC (New Construction)
Residential, Heating Only (New Construction)
(Office Use Only)
Buildine: Official
iOC"Paid"-
i
. Date
I
Date ' , MAR ~ Ii 20QA
uu .
24 hour notice for all inspections (952) 447 9850, fax (952) 447-4245
By__,.
I Receipt No.
]
J
This Application Becomes Your Building Permit When Approved
IBy
o
PRIOR LAKE
INSPECTION RECORD
, '
SITE ADDRESS .s/d? EAS; ~~ ~/Alr- ])ltllle
NATURE OF WORK ~W ~~~~/ON
USE OF BUILDING SeF:14.
PERMIT NO. 04-. OO/C/ DATE ISSUED l.LL.3..k #
CONTRACTOR 1), fl.. HotUtJ,J . J i.Jc:. , PHONE~ "Zl' - 't2Jl-
,
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
DEPARTMENT OF Main File
BUILDING AND INSPECTION
I FOOTING I ;J;.~r:rOR I ~/II i;Eq
I FOUNDATION (Prior to Backfill) ~'I jj-l',~/J,j61 /1/W"1 . ;;t-/~-ot1
PLACE N:> CONCRETE' UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS ~
rj/r~/>
f/L{ / -,
ill/V /
SEWER I WATE,~ I SEPTIC
FRAMING 5h{q1Jr...... K> 1~'tIt1
INSULATION
ELECTRICAL
PLUMBING V, (y. w( 'll~'o~ (YY: 'J... J '~oll
HEATING (if required) rvr'l L..-!-{.()t1
FIREPLACE iltr , 11 ~C- otJ
GAS LINE AIR TEST 611/ /..,{'-(,-o"l
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
I I
FIN.ALS
Ale
3- 2-0<.1
i-/_ (. - Ol/
l_+ r -0'-1
GRADING (Prior to Sodding)
BUILDING 14.{) IJ'il.~\ 7,-/1J1-/
ELECTRICAL { \
PLUMBING
HEATING
DO NOT OCCUpy
Ius. d f:-
/#'4/
tj~
t! v .
UNTIL ABOVE HAS BEEN
NOTICE
/..2-fi'6/ ~
,~-~~
(\-),-7-<1'-(
SIGNED
This caro 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
aIrdifirab of @rrnpant'll
CITY OF PRIOR LAKE
~qntrftuent of '!Jiuil~ing c1lnspedion
~Final Permitted D Conditional C.O. Expires
This Certificate issued pursuant to the requirements of Section 110 of the D Residential I D International
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/allowing:
Use Classification
SINGLE FAMILY
_ Bldg. Penni' No. 04-0019
Occupancy Type
R3
Type Construction_
VN
_ Zoning District
Rl
Legal Description
L7. B2. DEERFIELD 10TH
Owner of Building
Site Addre" SlOB EAST OAK POINT DRIVE
KENBRIDGE COURT. SUITE 100. LAKEVILLE
Contractor's Name & Address D. R. HORTON. 20860
ROBERT D.-HUTCHIN~
Date b ~6,.B~~cial -
City Planner
DON RYE
Date:
I
I
L
OATE
bNfiJl"
.
b^/ ~~ ~/ ,4
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHIOOULEO
ADDRESS ,j7~ ~
OWNER
CON'fR.
PHONE NO.
PERMIT NO.
o FOOTING
o FOUNDATION
o FRAMING
~SULATION
INAL
o SITE INSPECTION
o PLUMBINC; RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBINI; FINAL
o MECH FINAL
CO~~ENJS: _ ..1
~&--/"b<e I hk / ,1~n~.
~<<''-t!I'v~ J' ~i..z;:;",,'4#"'-
(~ &~/ft' r;.;
(1) ,\r.~/
- 3;~ul~-
-
(O;;,...S'<, a,
,
~ ?;-~ 1". C 04,..-
4'#.4""''''4/
> ",
TIME
~-/9
o EXIGRADIFILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
. ~
t;// ~:/
&,-~
~_6
#'
r; .
-h;...,.../
--
7..e_~ ~
,
di-l rr~L~
k
o WORK SATISFACTORY, PROCEED
~ORRECT ACTION AND PROCEED
;J!f!CORRECT WOR~, CALL FOR REINSPEGTlON BEFORE COVERING
Inspector: ~ Owner/Contr:
- ~
CALL 447-9850 FOR THE NEXT INSI'ECTION 24 HOURS IN ADVANCE.
INSNfrrl
CODE REQUIREMENTS ARE FOR YOUR. PERSONAL HEALTH'" SAFETY!
DATE TillE
CITY OF PRIOR LAKE
INSPECTION NOTICE
OWNER
11-1'>-oY
SloJl E.,,f O~)~ II D"
D L f-kJlh.-
SC~IEDULED
ADDRESS
CONTR.
PHONE NO.
PERMIT NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
:&:::FINAL
- 0 mE INSPECTION
o PlUMBlIlG RI
o MECH Rl
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
-gI~lLlNG
"'D'eo LAINT
o FIREPLACE Rl
o FIREPLACE FINAL
o GASLlNE AIR TST
o
COMMENTS:
1+/1 mV
.-
r)( WORK SATISFACTORY, PROCEED
v'O ~RRECT ACTION AND PROCEED
o CORRECT WORK, CAll FOR REINSPE,CTION BEFORE COVERING
In$pector:d~ Owner/Conlr:
.r
CAll 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANC~
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY/
IM'NOT1
s:).(.;-c,y
e u'ti!L f?r I2d
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
ADDRESS
.:.,7011
OWNER
CONTR.
PHONE NO.
PEFIMIT NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH Rl
o WATER I~OOKUP
o SEWER IHOOKUP
J1f PLUMBING FINAL
o MECH FINAL
COMMENTS:
(7) P6:JA'vfJIrl
r; /fI?C'~
'-'
DATE TIME
t-( - iXN I{
o EXlGRADfFlLLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
o ~K SATISFACTORY, PROCEED
~ORRECT ACTION AND PROCEED
o CORRECT ~~L FOR RElNSPECTION BEFORE COVERING
Inspector: 'II! o-vner/Contr:
CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE..
CODE REQUIREMENTS ARE FOR fOUR PERSONAL HEALTH .l SAFETY!
IN.r/WTJ
.
APPLIANCE
PERFORMANCE TEST
Attach to gas line adjacent to regulator
Heating Contractor JIt.A--t,J? JM<!ZcK
~iS
s-;/ WtH
Name ot Tester
Date
Percent 02
Q1JtSE.PA~ be,
AJLA-oJ'"T M"""U
ffidJu $
~~
~
, q::,---..J
7, 0 '7D
9..s'gF
Job Address
Healing Contractor
Name of Tester
Date
Percent CO
Percent C02
Stack Temp
Combustion air is adequately supplied per
UMC Sec. 606 I/I?.s
,
input 90 M)