HomeMy WebLinkAboutBuilding Permit 04-0057
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Main File
Date Rec'd
1/5".04-
; ~i~:' ~::, fPi1<MIT NO.O ". 00.' ~ -11
3_ Yellow Applicant I - - q' U II
(Please!vpe or print and sign at bottom)
ADDRESS
5144 kJ C"ttkl1:)Lnt Dr,\x. 2E
, LEGAL DESCRIPTION (oflice use only)
LOTlI BLOC~ ADDITIO~Ce-ld IO--t\,..
OWNER
(Name)
(Address)
I ZON~?fficeuse) I
PID z..'5: 401. 03/. 0
(Phone)
BUILDE~ <n ,1 '-:L -r_
(Name)----.1.). 1<-1 Mcl..,l..D""r-\ -J...J. Ie....
(ContactNam~l4 l yJchrP~
~68UP ~br,~~. ~u"Q<IOO
(Addressr'La..kwil'b.-1 rntJl 't::/&jlfl.{
TYPE OF WORK
o Mise,
~ew Construction
DLower Level Finish
ODeck
o Fireplace
(PhOne~'f3S-/f$JB
(Phonel~d,(; -L/7,32-
-"
OPorch
OAddition
ORe.Roofing
DAlteration
ORe-Siding
Dutility Connection
PROJECTCOSTIVALUE (excluding land) $ IS '1)l53
$
$
$
$
$
$
$
$
/S~. ~tlaCJdl
ILln 7. ~o I
9/'{,88 I
79.5'a I
I
I
I
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
'~y~':!:::r~fu~~ctions dOOD5~'51 1-/ZJ::(j~
X I T ~ Signature Contractor's License No. Date
I Permit Valuation
I Permit Fee
I Plan Check Fee
I State Surcharge
I Penalty
I Plumbing Permit Fee
I Mechanical Permit Fee
I Sewer & Water Permit Fee
I Gas Fireplace Permit Fee
10d.OtJ
fa",oo
35', S-O
~tI, tJ 0
This Application Becomes Your Building Permit When Approved
~ ~ //PI/OY
Building Official/Date
$ 850,60
$ 13StJ,Od
$ .-J ~cJ , 0'0
$ ~S; 00
$ I UO, 00
$ 7aor 00
$ 15o{),00
$
$P,57z.35I
, ;
I ';;'(f "'-7,0 ,
IlPark Support Fee
I SAC
I Water Meter ~/8"JI";
I Pressure Reducer
I City SAC and WAC
'Water Tower Fee
Builder's Deposit
I Other
I TOTAL DUE
#
#
#
#
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 .~"'1'~'''''') Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
~nin~ ~/1:,t /~ ~ditions'if#'Y /"
24 bour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372
/
Paid ((, ~7 z.. ,~ y
Date 2-. z,,-r. Q t----
Main ]~ile
~j~e ..- ~uildiliq)
Canary - Engineering
Pink - Planning
. -
lh~ CrnlPr nr thr ),akr ('ounln'
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
D. /C.~. Ho,e. 7[),.J
;. /5". o~
APPLICATION RECEIVED
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
6/4~
eJtJT OfrK- 1'7:
DIL.
Accepted
Accepted With Corrections
/
Denied
Reviewed By:
~0~ Date: ~/dl/ot..j
h/~ LLL/ ~C/L~"
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."
~~
Main FUe
White - Building
Canary - Enqineering
J>;, .1< - Plannln!J)
lh~ ("~nrH or lh.l..k. COUnlr)
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
./
,/'
.I .-
'...-'
I
( ~J.-.. --
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
-. !,', II . ";-
. / 4 4- ,I' ( i j Ie I /.
/- /~ .
Accepted
Accepted With Corrections
~
Denied
~
Reviewed By: ~ ~ . 17..0 Date: jc2I/o L(
. - .#. --..' '\
Comments: '11/l~, ~,..)ld2<-j 4',.a1l--1~.
4-;~, ~ ~'~~..A."~"~
.,!7
,~~ , ~ Al-<..fl t!..,. 0.:> d2 5'.
l/
"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,"
'~
\e~
White - Building
C ~narv - t:nqu-1et=!III'1:l>
Pmk - Planning
Thf (-."It. of lht L.kt Counln'
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLlS"(
NAME OF APP~ICANT
APPLICATION RECEIVED
!/). /.:"
,
J,' ,.--....,... "
./,./ ,A:.: _ I (/ /'-... '
.I /:- (.9---
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
c:; / 44- Eli J -;--- (, Jt1/C
/
, .
L '/."
_."./ '--.
Accepted
x
Accepted With Corrections
Denied
Reviewed By:
/YJ4-13
Date:
~-S.Of
Comments: ~"'''' Rever!':", ~ide for Additionallnfnrm~tinnl
11'7":,,, h'lf
See Attachments' I) Gr;:Jcling Plan, 2) Fro~inn rnntrol Mp';:Jsllrp.~
"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."
J A N 28 2004 1: 21 PM
GENZ RYAN SERVICE,
NO, 392
p, 8
Date Rec'd
CITY,OF PRIOR LAKE
SEWER AND WATER PERMIT
(PI,,,,,..\VI!' or .rint Uld .i.... 'at bottOm)
AD5J 4 L(
..-
-t.-
.
i:~::' ~t~, I PERMITNO/1U ,)~ I
J.GoIdAp,lil.Jllt ~
Oa /( fiJiflr by S-E ZONING (officeu,,)
/Jeerte/rt /1Jtf?
PID
LEGAL DESCRIPTION (olliee use only)
LOT // BLOCK. A ADDmON
OWNER
(Name) ~~. 'U~..t^~, C'llltQ1R HOlt.:"
(Address)
20&00 ~rol<..\DCe Or sn. ,1M
(Addre..)
(Phone) _ qs2.-qgS-,8M
La~vill€l._ &jf::0..JU
(CiIY\ (Zio Code\
APPLICANT
(Name,) Genz-Rvan PlumbiM & Heating
(Phone) 651-423-1144
(Address) 14745 So Robert Tr~,{l ~,f1,~emo",nt. M)I ~5068
(Ad~tw) ,(city) . .. . (Zip Code)
(cont,.atperson). J a/Y}-e{/Z{, "J.",'J ( (Pl'~hone) 651-423-1144
"-T,ICANTSIGNATURE f;;t?~/r ~'DATE /c5??--o1../'.
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure
Type of sewer pipe. 0 ABC 0 PVC
Estimated length of sewer line feet.
Clean out (if required) located at __ feet from structure.
feet.
o Cast Iron
FEE SCHlmULE
Residential sewer and water line connection $35.50 Industrial, Com'J & Multi-family 1 % of job cost with a $39.50 minimum
Sewer connection only $17.50 Water connection only $17.50
Estimated Cost $
Building Pennit #
SEWER AND WATER PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
S
$
$
eAl0 WITH
AI IlI-EftNG PERMIT
(omco v.. Only)
I Thl, Application Becom.. Your BuUlIlng Permit When Approy,:d
Paid
I Reoelpt No.
I By
L_
Building om,;..
DAte
~ il 6 2003
24 hour notke tor .lIln.poolion. (9~:Z) 447-9850, tox (952) 4474145
_._----~----------------
...,....._.._..... ._...~_,,__~,.___.._..~ _ _~...m.._...._ _____.____..._._._... ..__.....__.__,
JAN,2820041.21PM
;%-PR/Olt .
€~~
\..~+,.. ,,~
..-NDSC
. f?1eI1!C.!\',PC OJ' 'Drint and den at bottom)
ADD5J LflJ-' E f)a J< fr);'n -j- bv S[
lotR
GENZ RYAN SERVICE,
NO, 392
P 7
Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
I. BIlle 'lie
1. 00[. CilY
J. Yello..... ~pllUAI
LPERMIT NO.
ZONING (offic, ule)
LEGAL DESCRIPTION (offioe u,e only) /I
LOT// BLOCK~ ADDITION ueerheld
PID
, OWNER
(Name) DR Horton Custom Homes
(Address)' 2O'S~D KtV1l?'~l1':lGe.. CT 5re IDO
(Phone) ~2-q')fi -ilSM
IA~.l.II; IIG l-I.A N .scc4 L/
APPUCANT
(Name)..c",~':'_tl?'-:l~ l)'m'l'l1;d"'~ 1.. l-1""'I;I"'-f..,~,
(phone) ~,' _/,? ~_11 AI.
(Address) 14745 So Robert l'rail
Rosemount
MN
55068
(Zip Code)
~dress) (City)
(Contact Person) / CLrn.-e4rt1 .' f\:lhone) 651-423-1144
APPLICANT SIGNATURE 0A./nt..1JJ 7J1.aI ~:r$E /.- b? Ir-{) t../
Quantity
-8
J
I Of
I I.t
1/
I , /
I 1./-'
I
I 3
APPLICANT PLEASE COMPLETE BELOW
I Type of Fixture Quantity I
Bath TUb with or without shower Rough-ins
I Dishwasher /. I Water Heater
I Floor Drain K/J.. I Water Sofiner
j Lavatory (Bathroom Sink) . i I Stand Pipe (Washing Machine)
Laundry Tray (lor 2 compsTOnent sink Sewage Ejector
I Shower Stall Backflow Assembly
Sinks BackfJow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) Other
I
I
I
I
I
I
j
I
Type oC Fixture
FEE Scm:DULE
Industriel. Commerei.1 &: Multi.family 1% of job cosl with. 539.50 minimum Re.idenli.~ New One &: Two-Family $99.S0
Rcsidenti.~ Additions &: Allerations $39.50
(Office IJ.. Only)
This Application Become. Your Building Permit When Approved
Eatimetecl Cost $
Building Pennit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $
TOTAL PERMIT FEE $
PAID WITH
11l.6JJt.OING PERMIT
}
BuUdln~ om ell'
Dtr~
I Paid
IPEfJ 0 6 2003
I Receipt No.
IBy
I
J
24 hour notice for aUlnlpocllonl (95;1) 441-9850, fAX (952) 447.4245
CITY OF PRlORLAKE f~lPj,~
HEATING/AIR CONDITIONINGIFIREPLACE PERMIT
I. Pink
2. Green
3. Yellow
~:~ I PERMIT NO,-vL (J1IIfriftJ
Apphcant ~... ..,..., II
(Please type or orint and shoo. at bottom)
(~/4~ [asi fJakff.'Ir.
LbGAL DESCRIPTION (oflice use only)
LOT
BLOCK
ADDITION
OWNER
(Name)
/), Q. rl---hr'f.rWl
'--
(phone)
(Address)
Date Rec'd
, ZONING(ofliceuse)
PID
APPLICANT fJj ~ ' 1 11/1 I ~
(Name) -, (alii. Pc n. :J.;/1c.
(Address) l1(I~()/{:..nne 6e(' , /)f'. ,c~A. au n
~ss) ..J
(Contact Person) Aaron 't"lli.rh -----. /7
APPLICANTSIG~ATURE /'.L~( ~.IL,*
APPLICANT PLEASE COMPLETE BELOW
tl'!l%WCONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL --p,e..yA.JJ....._ ~'->~ C>?-.~ FUEL.N A...,..-.
FLUESIZE '2." PVc... RETURN OPENINGS {-, INPUT 9)0.~ OUTPUT
(phone) (,p cJ 1-1/5J - c1'115
/YW 0'5/~a-
(City)
(Phone) U 51-/15:2 - ,;1'715
DATE cfl/q~4
TYPE OF SYSTEM
iarm Air Plants
ravity
echanical .
;A.ir Conditioning
. cnt. System
HEATING OR POWER PLANT
[] Sleam
[] Hot Water
CI Radiation
[] Special Devices
CI Other Devices
FIREPLACE MAKE AND MODEL
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
Residential, Heating & NC (New Construction)
Residential, Heating Only (New Construction)
Estimated Cost $
Building Permit #
(Zip Code)
X,;JI.,L
GA..,
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
$39,50
$39.50
$39.50
REA TING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
!=Nm
PAID WITH
a~LDJNG PERMrr
(Office Use Only)
This Application Becomes Your Building Permit When Approved
I Paid
I Da~EB 1 0 2004---
Building Official
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
Receipt NOp
" it
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
Date Rec'd
(Please type or 1JIint and silUl at bottom)
ADDRESS
; ~::," ~::, I PERMIT NO. ll_ c.~ /'1
J. Yellow Applicant ~ ~ ~
.
ZONING (offi" u,,)
5144 E, OAK POINT DRIVE SE
LEGAL DESCRIPTION (oflice use only)
LOT BLOCK ADDITION
PID
OWNER
(Name D II. HORTON
(Phone)
(Address)
APPLICANT
(Name) ALLIEI' ml?"R,~nyp. DBA 'HTRFSTDP' Hp,A RTH &. 'H'OMF.
(Phone)
651.633.2561
(Address)
2700 NORTH F AIRVIEW AVENUE
(Address)
ROSEVTT T P
(City)
';5113_
(Zip Code)
(Contact Person)
BRENDA HUSTON
(Phone) _651-633.2561
APPLICANT SIGNATURE
BRENDA HUSTON
DATE
4/1/04
APPLICANT PLEASE COMPLETE BELOW
xD NEW CONSTRUCTION D REPLACEMENT D AL TERA TlONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM
mlATING OR POWER PLANT
OWarm Air Plants
OGravity
o Mechanical
DAir Conditioning
OVent. System
o Steam
o Hot Water
o Radiation
o Special Devices
o Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
HEAT N GLO SL.750TR.C
Residential, Heating & NC (New Construction)
Residential. Heating Only (New Construction)
FEE SCHEDULE
1% of job cost Residential, Gas Fireplace
$39.50 minimum
$99,50
$64,50
$39,50
Industrial, Commercial & Multi-Family
Residential, Additions & Alterations
Residential, AC Only
$39,50
$39,50
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Building Pennit #
$
$
$
.50
(Office Use Only)
Buildine: Official
Date
I Paid
I Date
l1P~
o 6..21lD.4
I~C:iPtNO,
!I ,ay .'. (,/
[."' 1
This Application Becomes Your Building Permit When Approved
"I,
24 hour notice for all inspections (952) 447.91 50','fax (952) 447.4245
;..3y __._
PRIOR LAKE
INSPECTION RECORD
SITE ADDRESS 571-/ L/ EAS, 014 It:.. 1'~ IN"- ])IJ ~
NATURE OF WORK NEI1J ~a.u<:n'O^,
USE OF BUILDING cg,s:: A...
PERMIT NO. 04-. 0057 DATE ISSUED ..,
CONTRACTOR 'I). R,.. ~~,...tW~. PH N - .. 2..
NOTE: THIS IS NOT A PERMIT FOR .~NY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
DEPARTMENT OF
BUILDING AND INSPECTION
INSPECTOR ~ DATE
I FOOTING ,IVY'/ ')- J.,G-O'-1,
I FOUNDATION (prior to Backfill) I f/~ I 3 -.2 .---CAt
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
t~(1);p
Vlf' '-/. 1,0'1 ~/
u1 AI"
f!1flOf
lit! ~
/1/1;/-./
,
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
I I
FINALS
Nt?
SEWER I WATER I SEPTIC
FRAMING Stw.,1k...,
INSULATION
ELECTRICAL
PLUMBING V\~. yVf
HEATING (if required)
FIREPLACE
GAS LINE AIR TEST
1-1- (,0'<\
GRADING (Prior to Soddil'!g)
BUILDlNG'7ii"tt? .P";' /~1 ~
ELECTRICAL '
PLUMBING
HEATING
DO NOT OCCUpy
1/. /.)../)4- .
/#?-
I/~
'~r
s-/J'-Oll
Ll;)./ -'cJ(1
LI-J:l:l-o"T
L1-lb'O( I
1.-(; t-J-(!G}
1.1- l-/-()il '
0-1)-()ti\
/...z.p&/~
~/ICJ/t4
(,- /lvd VI
7/7~f
UNTIL ABOVE HAS BEEN SIGNED
NOTICE
This card must be posted near an electric:al 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 INSPl:""""'ONS (952) 447-9850
QItrfifirab of (IDrmpaury
CITY OF PRIOR LAKE
;!E}rpatfmrnf of ~nilMng Jlnsprdion
~inal Permitted 0 Conditional C.O. Expires
I
This Certificate issued pursuant to the requirements of Section 307 of the Uniform 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:
Use Classification
STNr.T.E ~\fTT.Y
Bldg,PennitNo, 04 00';7
Occupancy Type R1
Type Construction VN
Fire Zone J.i1lA
Zoning District
.,
Legal Description U 1. B2. nF,ERFTE1,n 10TH
Owner of Building
Site Address
C:;144 F_A~'l' ()AK prHN'T' nRTUli' S.E.
Contractor's Name & AddresD. R. HORTON. /"::-5,,;/ 70860 KF.NRRTnr.li' r.nTfR'l'r
ROBERT \l. 1111Tr.\I.l.ll~~ City Planner n[>M .Vl1
Date: /:.2 //}~.::/Cial Date
/ / ,/
SllT'T'F lno,
DATE
?~~(
SlL/r &5,1 ~)' // (),,-
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
~INAL
o SITE INSPECTION
SCHEDULED
CONTR.
PERMIT NO.
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEVIIER HOOKUP
o PLUMBING FINAL
~MECH FINAL
COM!IIENJS:
~c-h~~/
~cL /;:'9 /;'
.Rec~' '....~d a,.r~
~ A
/7#",,/ ~......
-4cS r/
TIME
o~-s-7
o EXIGRADIFILLING
o COMPLAINT
o FIREPLACE RI
~IREPLACE FINAL
o GASLlNE AIR TST
o
G//t!) ~-:/
/ / '
_/
C/C
~ _/ / . / ~ rJ /
0) d''t''ed _(:)ad l' /rc.es Qrr'C"r-
h/l../ d;e.dc ~/,0t/4 r
~
'7~;?tp.
,
.....-?/"
C U*,
{/4 -t/
X"///~I
'" '
~WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
:'::O:ECT W~R REINS::::::::FORE COVERING
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FO,R YOUR PERSONAL HEALTH & SAFETY!
UUNOn
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
ADDRESS
,t.;I'I'1 I::d. 0", t
OWNER
CONTR.
PHONE NO.
PERMIT NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
C)l(.E!NAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
COMMENTS:
(,,;b I3tP/ 'ai!.~.
DATE TIME
/1-/5-0'(
fJl D/-
D t Nnlra",
01/ - )" 7
)l(El1GRAD/F.JlLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
r1I! WORK SATISFACTORY, PROCEED
11'0 "tORRECT ACTION AND PROCEED
o CORRECT WORK. CALL 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!
CITY OF PRIOR LAKE
INSPECTION NOTICE
TIME:
DATI!
VIIf#
., - '
~/ d,/ /f/ d-
SCHEDULED
ADDRESS
S/Yr' ~5/~11
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
CONTR.
PERMIT NO.
o PLUMBING RI
o MECH RI
o WA l'ER HOOKUP
~EWER HOOKUP
PLUMBING FINAL
o MECH FINAL
190-$"7 f Sf(
o EXIGRADIFILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
0,
COMMENTS:/') /" / r-- /"
/~./~6/-.? ~~~/S
, ..--
1I\SbA/(
IpH k
Mq-f/
V,.,,/k
I_
~,j ft-..
o WORK SATISFACTORY, PROCEEC'
~RRECT ACTION AND PROCEED
:S:~:ECT ;tALL FOR REINS::::::::FORE COVERING
CALL 447-9850 FOR THE NEX1'INSPECTION 24 HOURS IN ADVANCE.
CODE REQUlREMENTSARE FOR YOUR PERSONAL HEALTH & SAFETY!
HUNO"
~
~
..
APPLIANCE
PERFORMANCE TEST
Attach to gas line adjacent to regulator
Date
j}J1,'r.'4-f /#.pJ
aMI... 5
Jib/I') f/
,
Heating Contractor
Name oITester
Stack Temp
~/tJt/
/111:6.Ml+ JlfNl
l:~W1L... 5"
7-(, Ad
qt/
--1!Y%
Illb
Job Address
Heating Contractor
Name at Tester
Date
Percent 0,
Percent CO
Percent CO,
Combustion air is adequatelY,slpplied per
UMC Sec. 606 W>
input q ~ (JlJtJ