HomeMy WebLinkAboutBuilding Permit 04-0945
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF WNING COMPLIANCE
AND UTILITY CONNECTION PERMIT
or "otandsi
at bottom
Date Rec' d
I. White File
2. Pink City
3 Yellow Applicant
~
C,.I.04-
I PERMIT NO. 0+. 094-51
e:Le'1.
Ol'il:.li!!,lOGe
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT
ADDITION
PIDz.5,03',ozz..1
BLOCK
n;:: e~~:4 ~T ~j,-~^~
OWNER
(Name)
(Address)
BUILDER
(Company Name)
(Contact Name)
(Address)
~uo....
D;".-\c
(Phone)
Lo S ' c... ~n "-
L <it'\. 0\~.N'.....
(!.It t-I $
(Phone)~~.<'l... ''t~. 9f\s<l
(Phone) ,. ~,'Z. - CJO' 1
~Ir'~~<PU
2 3 4 5
~o~~mgp9;:2;ved
Building Otlicia] Dat~
Planning Director
......
TYPE OF WORK 0 New Construction ODeck OPo,ch ORe.Roofing
OAddition ~A1teration DUtility Connection P Misc.
ORe-Siding DLower Level Finish 0 Fireplace
-p~ ~. .. ~ i L'J.J L:-.- '
"l,r'
PROmCTCOST/VALUE $ ~
<excluding land)
,
~ mation 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
c nstruction' will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
c e Furthermore, 1 hereby agree that the City official or a designee may enter upon the property to perform needed mspections.
x
Si ature
Permit Valuation
Permit Fee $
Plan Check Fee $
State Surcharge $
Penalty $
,Plumbing Penni,t Fee $
Mechanical Permit Fee $
Sewer & Water Permit Fee $
Gas Fireplace Permit Fee $
n 0 V'\ oCL..
, Contractor's License No.
'-1-0'-(
Date
CODE: OI.R.C. ~I.B.C. .a
Type of Construction: J... \LV
Occupancy Group: A B @ F
Division: 1
Park Support Fee # $
SAC # $
Water Meter Size 5/8"; 1"; $
Pressure Reducer $
,
Sewer/Water Connection Fee # $
Water Tower Fee # $
Builder's Deposit $
Othe, $
TOTAL DUE AlL.."", q. 'J,O.o4- $ /<..f7.1/
I::. 1ft~1
I ~~o""'<V'/8"
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 constifutos.a temporary Cenificate of Zoning compliance and;allows construction to commence. Befort' occupancy, a Certificate of Occupancy must be
issued
Date Special Conditions, if any
24 hou, notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake. MN 55372
,'.('::;
SEP.01'2004 13:19 952 996 0695
AQUALOGIC INCORPORATED
#4195 P.003/003
IMPORTANT
If t~e certificate ~older 19 an ADDITIONAL INSURED. t~e poliey(ies) must be endo....ed. A slBlemenl
on II1ls certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
~ SUBROGATION IS WAIVED. subject to the terms and conditions oflhe policy. certain policies may
require an endorsement. A stalemern ~n !his certlllcate does not confer rights to the certlllCllle
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on t~e reverse side of this form dOes not constitute B contract between
the Issuing insurer(s). autho~ed representative or producer. and the certificate holder. nor does il
aff1rmatively or negatively amend, mend or aller the coverage afforded by the policies listed thereon.
ACO~D 25 (2001/08)
SEP 01'2004 13'19 952 996 0695
AQUALOGIC INCORPORATED
#4195 P 002/003
A~UHU C'ERTIFICA TE OF LIABILITY INSURANCE . -r - DATE (MMIDQ(T'rtYl
'" 06/14/2004
POODlJe.A- (651)489-4119 FAX (651)489-0507 TH,15 CERTIFICATE 15155 MATTER OF INFORMATION
Western Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1740 Rice Street, Suite 200 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
-'int Paul, MN 5S113
;R, A1Iry Lubich INSURERS AFFORDING COVERAGE NAIC_
IN5U1IlED Aqua log'~ Inc INSURER A: United Fire' Casualty
9401 James Avenue Ste 116 INSURER 8:
Bloomington, MN 55431 INSURER c:
INSuRER D:
INSUReR E:
COVERAGES
THE POLICIES OF INSURANCe LISTED BeLOW tfAVE BEEN ISSUED TO"'E INSURED NAMED ABOVE FOR THE POLICY pERIOD IND]CATED. N01WITHSTANDIN
ANY REOUIREMENT. TERM OR CONOITION OF ANY CONTRACT OR OTHeR OOCUMeNT WITH RESpeCT TO WHICH THIS CERnFICATe MAY BE ISSUED OR
MAY peRTAIN/; THE INSURANCE AFFORDED BY THe POLICIES DESCRIBED HEREIN IS SUBJECT TO All THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AG REGATE l]MITS BHOWN MAY tfAVE BEEN REDUCED BY PA]D CLAIMS,
Il~~ TYPIi OF INSURANCE POL'lCYNUMIliER ~ DATE M~~ \,IMlTS
~ ~E""'LIAIllUTY 60054474 07/01/2004 07/01/2005 EACI10ceURRENeE I 1,000,000
X COMMERCIAl. GENelW.l.~elllTV .S &I e I 100 , OOD
I CI.AI~$ MAD! [!] OCCUR MEO VtP (Any one MIlOI'll , S,OOD
A "EF<<SONAI. & NN INJURV S 1 OOO.OOC:
"-
GENERAl. A.GGREGATe, S 2,000,OOC
~N'\, AGGRe~Te LJMl'l' APPUes PEFt: PRODUCTS. COMPIOP AGG . 2,000 OO~
h POLICY 11 ~ n LOe
AUTOMOBILE LIABtLllY 60054474 07/01/2004 07/01/2005 COM81NED SlNGl.E LIMIT
7 (E;Ii:Jecldcnl) S 1 000, 0001
_ AUTO
i-=- Al..L OWNED ~UTOS
I- 8000. Y 11'LIURV .
SCHEDULED "'UTOS (""_1
A I- I1IR'ED "'UTOS
I- BODII. v lMJUR,V S
NONoOWNEO AU1'O$ 1....-'
L-
I- PROPERTY OANAGE S
(Per~"'1)
GARAGE L1ABlUTV AUTO ONl.. y. GA A.CCIDENT S
tj ANv,uro OTHER THAN .....CC S
A\JTOON1..Y; .GO .
[jEiISIUloISAfLLA LlAS"ITY 60054474 07/01/2004 07/01/2005 EACH OCCURRENCE . 1. 000 ooe
OCCUR 0 CL.A.I.... MAoe AGGREGATE S
A ,000,000 s 1 000 000
~ OEDUCTISLE I
RIiTENTION , S
WOIltt(!IItS(lOMflENM.T1ON ANI) 60054474 07/01/2004 07/01/2005 I TORV L1Mn-S I I'...
eMPLOYERS" LlA8lLIT"t e,l, EACH AOCIOENT S 500 000
A ANY 1'ROPR1ETORIPAR,TNe~ECUTIVe
OFFICEAlMEMBEA. EXCL.lJO!D? E.L. DISEASE. EA IMPLOVEE S 500,OO~
lrve!:. (h:!K~nc1er e,L. DISEASE. POtICY LIMIT I 500 OO~
8PeClAl. 19lONS beloW
~~"EIlI 60054474 07/01/2004 07/01/2005 $208,000
usiness Personal
A "'rope rty S500 Deductible
CE30RIPllON OF OPI!RAT10NS I LOCATtONS' ~!",lC ES' ~USIONS ADDEO 8T ENDOASEMl!NT I sPecIAl. PM.O'VfSION$
~~rtificate Holder is an additional insured as respects the Oakridge El ementary SChool pool
~enovation project.
CERTIFICATE HOLDER
CANCELLATION
SHOUL.D JiMV OP TNE ABOve DESCRIBED POL.ICIU 8' CANCIlLLlD 'SPORe TMI
StPIM,'nON DATE TtlEREOF, THE ISlUlNG INCU~EIIt Wll.L eNDEA.VOR TO MAIL.
ISD '719 ~Q.... DAft WRm'IlN NOTtce TO THE CERTlACATE HOLDER NAMED TO THi LIFT.
~ Oakridge Elementary SChool BUT FAlLURI! TO MAtt. SUCH NOTICE '"",-L. lM~E NO OBI.JG.ATION OR lIABILITY
5300 Westwood Drive SE os: ANY teIND UPON THE INSURER. ITS AGENTS OR REPRISINTAnves.
Prior Lake. ~N S5372 A~eDA~q~4~
, Jim Becker CIC CRI'I
ACORD 25 (200ilOl)
eACORD CORPORATION 1981
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DEPARTMENT OF
BUILDING AND INSPECTION
SITE ADDRESS
TYPE OF WORK
USE OF BUILDING,
PERMIT NO. M-. ()9~S DATE ISSUED ~..~.,
BUILDER 8A U./O, ,~. PHONE#~~~
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
INSPECTOR
DATI!
... I I I
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
~~ ,,~I ~..IN' I I
I FINAL ~ ' I rtz-~~r I
FOR ALL INSPECTIONS (952) 447.9850
.
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
ADDRESS
(:;-~O
~
OWNER
CONTR.
PHONE NO.
PERMIT NO.
[] FOOTING
[] FOUNDATION
[] FRAMING
[] INSULATION
!! FINAL
[] SITE INSPECTION
[] PLUMBING Rl
[] MECH Rl
[] WATER HOOKUP
[] SEWER HOOKUP
[] PLUMBING FINAL
[] MECH FINAL
COMMENTS:
'l/:~o/ ;.E,-:-
/DY- ,ee
01-tJ9~t;;
[] EXlGRADlFILUNG
[] COMPLAINT
[] FIREPLACE Rl
[] FIREPLACE FINAL
[] GASLlNE AIR TST
[]
,...,.-,/;,,::.,.;.,
"~~
}lI/WORK SATISFACTORY, PROCEED
[] CORRECT ACTION AND PROCEED
[] CORRECT WORK, CALL FOR REINSPECTlON BEFORE COVERING
Inspector. ~ . Owner/Contr.
CALL 447-8850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
"""""'
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEAL11I & SAFETYI
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