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Home My WebLink About04-983,1040,1102,1103,1161,1055 CITY OF PRIOR LAKE BUILDING PERMIT, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE AND UTILITY CONNECTION PERMIT Date Rec'd I,White File 2 Pink City 3 Yellow Applicant PERMIT NO''''4- - "'\b ~ Please or ADDRESS LEGAL DESCRIPTION (ollice use only) LOT PID 25,102, -02/.0 BLOCK ADDITION ZONING (ollice use) C,4 OWNER (Name) ~L t-1A-lLG- ~P6(2..IiCS (Phone) L,~,L.. . (Address) (Phone) ? ..5';}" ~ 9 o. Ss5 ~ (l~;2L7.S0-33.30 co (Contact Na l.. (Address) TYPE OF WORK 0 New Construction ODeck OPorch ORe. Roofing ORe.Siding DAddition DAlteration DUtility Connection 0 Misc. CODE: Dr.R.C. Mi,B.C. IT ~IV V A ../7 TypeofConstructioni" r ~ ~ Occupancy Group: A B E F H r I'M) R S U Division: 1 2 3 ~ 5 DLower L $ 50 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 ion will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building hermore, I hereby agree that the city official or a designee may enter upon the property to perform needed Inspections. Contractor's License No. # # Permi aluation 5V -- Permit Fee $ .SO Plan Check Fee $ _'13 State Surcharge $ - Penalty $ Plumbing Permit Fee $ Mechanical Permit Fee $ Sewer & Water Permit Fee $ $ Park Support Fee SAC Water Meter Size 5/8"; 1"; Pressure Reducer Sewer/Water Connection Fee # # Water Tower Fee Builder's Deposit Othet TOTAL DUE c..~ Date $ $ $ $ $ $ $ $ $ This 15 to certify that the request in the above application and accompanying documents is in accordance with the C Zon' Ordinance and may proceed as requested. This document when sign the City Planner constitutes a lemporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy musl be issued Date Special Conditions. if any 24 hour notice for all inspections ( 52) 447.9850, fax (952) 447-4245 16200 Eagle Creek Avenue Prior Lake. MN 5S372 CITY OF PRIOR LAKE BUILDING PERMIT, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE. . AND UTILITY CONNECTION PERMIT Date Rec'd /O.lZ, 04- '1U /"; 0+, ~3 : =- ';!::,. PERMIT NO. A A., /040 ] YtIDw AppIicInI V -r S I ZO~~__) I ~type <<prim.... "'It 7 I ADDRESS 1~2'3. H/6I1WA Y /.." LEGAL DESCBIPTION (ollke... ODly) LOT ADDmON BLOCK I~ (Add!ess) PID Z5. 902. 1J2./. () (phone) (Phone) (phone) h9 - '77( -87)7<-( S"",,..,...,e- Ow- Level Finiah 0 Fireplace $~o/'tJ{) ~ TYPE OF WOlUC 0 New C~ ODed< OPcm:h OJle.Roofina ORe-Siclia8 OAcIdilion ~Iion OUIiIlIyC_oo 0 Miac. . CODE.: OI.R.C. OI.B.C. PROJECTCOST/VALUll Type of COlIItIII<don: I n m IV V A B (ucladlDc I.....) O....,..ey Group: A B E PHI M R S U Diyiaioa: 1 Z 3 4 5 I heRby ccrtit'y thai I haft fUmishctl information oa Ibis lPPikadoD which is 10 the bat of my knowkdlr true and comet. I alia certify tbat I atn the owner or IUdk:lrizOO.,ent for the aboYe-mmboMd ~ IDd that aU CtXIItnICtiDa will eontonn to all esiRina: lUte and local laws aDd will proceed in acccrdanc:c with IIIbmined plans. 11m aware that the buildinl oft1daI WI...... thisr'.~::;::~:~~::.:.hmby..... thatthecily olIlda1ar. dcsipee.... .......upoo the _toperform......ed ~sl/ X ~ (1-{jBe= 10 0'1 Cooltnolor's Liceott No, Dale Permit Valuation I Permit Fee $ Plan Check Fee S SlateSUJCharse S Penalty s P1umbins Permit Fee S Mechanical Permit Fee S Sewer & Water Permit Fee S Gu Fireplace Permit Fee S . Y-IIaIIdIaI- WlIea AppIOftl! H7.9653 Y l12:J 2 -0 I in Offlcill Date Park Support Fee 1# S SAC 1# $ Water Meter Size 5/8"; 1"; S Pressure Reducer S Sewer/Water Connection Fee 1# S Water Tower Fee 1# S Builder's Deposit S Other . S TOTAL DUll S t10. ZI I Paid Date q~. f:/ /0 I .0 ~ I~ TbJs is to certify rhat me request in die above apptication and accompanYlna documents bin accordance with _ City Zonina: Ordinlncr and may proceed as rcqUl'ltcd. nis ducument when siped by the City Planner constitl.ltn a temporary Certilkate of Zoninacomplianct and allows construction to c:onunence. Rebc l)(tUplftCY', a Certificate ofOccuplncy must be issued. PImWaa- Dale S 24 holr 80.... ror .1118.....6... (9511 447-91!lO. r.. (952) 447-4245 16200 I!Igle Cleek Avenue Prior Lake, MN SS372 C ..........".iflllY }X:T-2S-2004 09'37 C lTY OF PR I CR LAKE 9:;24474245 P. Ell/Ell Date Reef. CITY OF PRIOR. LAKE PLUMBING PERMIT to.l-f"". rJ r- ~ .~H-Q9S.r ;.a;- lPE~ NO'~J(()4 L/ Q c./ OK...... J7V ~ I ZONING!......) t ~bDclll__...IiD..\.a- " I ADDRJlSS / ~ 7.7! /IWV 15 I LBOAL D1!SCIUPTION (oI&ce -...,) LOT BLOClt ADDmON PID ~ I I &=lhl(~ U6tOllIJa--/- / . (AddmI) =r..k.&~ ,./ ~ .fe.. (PhoDe)l1J ~-r~.r;lro (AddJas) ~ Z;(r d.,.c y NY ~ <5'..a--~ A-I. ~J~ (AddreIs) (City) (Zip Code) (COIIlact Person) ~ ~~ -1'.. ~ (Phone) (PhoDe) APPLICANT SIGNA11J DATE u WI Disw floor am a (B Tray (lor S'- Stall n ...S' w.. Ioset (Toilet) APPUCANT PLEASE COMPLETE BELOW or 1)pe 0 ..n wet. sink, SIInd- . )- €Jeetm. I't.. ~ '....I~..B<:.: ( 3ro- /~- tl.a;d.R1i", New Oao A Tw....FIItIily $99,SO Rcsi4oftlial. AddIIIans.. A.....Qooo$ S39.'0 Blllkllll& Pennlt #~ 4-. II u Z. " PLUMBINQ PBRMlTFEE S. -f- STAlESURCHARClE s':-- t ~-;- TOT.u..~BJ.p s. -M~~~;::-..~P:~~ff~ lall .. Cnelf. 1m., IlL, "'" Leb, )011 SD'l).l?l. TOTFl. P;M- OCT-25-2004 09:37 CITY OF PRIOR L~E 9524474245 P.0t/0l CITY OF PRIOR LAKE PLUMBING PERMIT Date Rec'd 10. l-r...d {- I...... ,... ~. 091. c., ,_v...... .,.0- (PIe... lYDc:.. Dri:DI:... tia Ie bo&tD1D) I ADDRJlSj ~ pi I/wY IS AT - -. Sk.- C- I ZONING (_11M) ! I LEGAL DIlSCRIPTION (ollie. use only) LOT BLOCK ADDmON PID [ I I OWNER =~II"'f'" ~"t'~. ^tr;fl.lnIL Cm~~ (Phone) APPLICANT (...., or \ (Name) ~rCAN~ ,qae:H. (Pho~~ ~~<::-$";z. 76 (Address) ~f:S ~V ~N' NO .x~1:. ~~~ A j,J:"'~l'(.'" (Address) (City) (Zip Code) (Contact Pet!On) (Phone) lStjL 12.Sf c4 H'" APPLICANTSIGNATU DATE AI APPLICANT PLEASE COMPLETE BELOW Quantity Type o' Fillture ...tity Type of illmn Bath U Wit or without shower Dishwasher A"U! L- floor am lavatory (Ba room 1ft U ry Tray (lor 2 com ent sink Shower Stall y Sinks est Bar Sink er Water loset (Toilet) FEE SCHEDULE Indus"'.!. Commen:iaJ &: MuJU-f1mily !'Y. Olf Job east willi. 539.50 minimum llcsiden.ill. New One "Two-F....i1v $99,50 Rcsiclenliol. AddiliOlU a. AIIO<". . $39.50 Estimated Co.. ~. - Builcllnc Permit # ~ tI--, ( I o.J PLUMBING PERMIT FEE S -61:>, .... ' ' ,/ \, STATE SURCHARGE S .Cbr TOTAL PERMIT FEE S ~. J"O , - ., hi & 0 .J"?; DOlt if)..J.-r. CI -'P" NO~ 3 ( ;). By 14Mur Ilatiet for an I..~ (951) 447-9150, I.. (951) 447-414. "* Ilacle Cmk Ave. S,L. .rior loa.... MN .5371.I7U TOTAL P,0l CITY OF PRIOR LAKE HEATING/AIR CONDITIONING/FIREPLACE PERMIT (P..... type or print and sign at bottom) I ADDRESS 1& ~3/ IJbU,/ /3 LEGAL DESCRIPTION (office use only) M,o~ LOT BLOCK ADDITION I OWNER (Name) (Address) Date Rec'd 11.17.04- I. Pink File 2_~n City 3. Yellow Applicant PI L- E- V1/, PERMIT NO. I ZONING (offic:eus,) I ~~ PID -(};).J 0 (phone) APPLICANJI-, I (Name) ra.U/.5 S lIc..e r Me-:fcd. (Address) DON J::r" m c. r y (Address) (Contact Person) / tJ/ ~ - If a 1A-1 f' fi./ If v. APPLICANT SIGNATURE "e <>- .f" (phone) )- //0- ,-;l3i../-7?07 7?, c. e. .L~ e.. (phone) WI (Zip Code) I I .5 Y 6-6 II I') () .s 9 C<..hI/ l!?- i'/~ APPLICANT PLEASE COMPLETE BELOW ?- i or ~ ~ DNEW CONSTRUCTION 0 REPLACEMENT 0 AL TERATIO FURNACE MAKE AND MODEL FUEL FLUE SIZE RETURN OPENINGS INPUT OUTPUT TYPE OF SYSTEM OWann Air Plants OGravity o Mechanical OAir Conditioning OVenl. System DATE HEATING OR POWER PLANT 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 FEE SCHEDULE 1 % of job cost Residential. Gas Fireplace $39.50 minimum $99.50 Residential, Additions & Alterations $64.50 Residential, AC Only ...5,)....00.'-/ Building Permit # FIREPLACE MAKE AND MODEL Industrial, Commercial & Multi-Family Residential, Heating & NC (New Construction) Residential, Heating Only (New Construction) Estimated Cost $ HEATING PERMIT FEE STATE SURCHARGE TOTAL PERMIT FEE I Paid S. Date., / ; notiee for all inspections (952) 447-9850, fax (952) 447-4245 16200 Eagle Creek Avenue, Prior Lake, MN 55372 $39.50 $39,SO $39.50 $ $ $ 5',) .00 ,50 ,,"),,2 . h-O fE SeA PE Fire Protection Escape Fire Protection 89 Bates Avenue 5t. Paul, MN 56106 Phone: (651) 771-8874 Fax: (651) 771-8875 Escapeflreprot@msn.com . Wednesday, October 06, 2004 To: Paul From: Jason Gahm Escape Fire Protection Regarding: Prior Dale Mall Project: Base building sprinkler renovations Scope: Paul, we are planning on dropping 2 sprinklers into new ceiling tile in new bathrooms on the north end of the facility. We are also planning on providing upright sprinkler protection in back conidor. Total sprinklers =14 . Included with our scope for this phase we will perform full hydrostatic test. Please call if you have any questions. If you have any questions I can be reached @ (651) n1-8874 or on my cell phone @ (651) 248-5861 Thank You, Jason Gahm Escape Fire Protection . Residential Fire Systems . Commercial Fire Systems . Service . Inspections . 24 hour Emergency Service . Fire Pwnp Installation LU/UIIU~ mUN 11:" rAX 612447424, CITY OF PRIOR LAKE l4IOOl CITY OF PRIOR LAKE BUILDING PERMIT. TEMPORARY CERTIFICATE OF ZONING COMPLIANCE AND UTILITY CONNECTION PERMIT RtA:; W 04-.0183 ~:~~. rl'ERMlTNO'04.1055 1 ,. y.Uow Applianc L ' I I ZO~~o&tUKl I Date Rec'd (P..... _ at llriat IIld aiID at bollllml . I ADDRBSS /~'l31 1I/6HW/lY /3 :5 LEGAL DESCRIPTION (olllto 11IO oll1y) LOT BLOCK ADDmON PIDzSJ10Z. Oz.f. 0 OWNER (Name) (Address) V/t.-L-I1c?(5 LJ QUol2.. S () if 7H L../f/C-C VI {..- &rt GtE: (phone) BUll.DER (Name) (Contact Name) (Address) Sentry Fire Protec-tion. Tnc. John Weber (phone) (phone) 7h'l_h~R_L...l..A':l 763-658-4481 4439 Hwv 12 S.W. Box 69 Waverlv. MN OLower Level FiDiah ODed< Cl Firoplacc [JPotdl (JAddi1lon ORe-RoofiDS IXlAltcnllon 01le.Sidiag OUliJily Ccmueaioll TYPE OF WORK o New Construc:t:ion o Misc:. PROlIlCTCOSTIVALtIB (ad . land) S 4 7 I benby ca1i~ rhal I Ila.. fumilhtd iIlfoml1lion on rhls application which Is 10 rhe bal oflny kaowlodp DUe and cozm:l. I also cenil'y IIJal11llllbe OWDet or aull10rized aaem tor the aI>....menlioncd propertY and lI1ac III COlISlnIClion will _1bnD to III alIdn& ...It and local laws and wiD proeoed iD u:cotdancz ,,;1Il .ubmiaod plana, I am awan Wllhe bui!diDlI ollidal can _Db .1Ii1 pcpnit for just .._, PuI1hemIore, I heroby _ dlac the oily olIicUI or a daIpco 11I11 cn....uponrhepro pafilrmneeded' 'om, X COOl 10-11-04 Si lUre CouttllClOr'. Lieeue No. Date Permit Valuation Park Support Pee # S Pl!tmit Pee $ SAC # $ Plan Check Fee S Waurr MeIer Size 5/8"; 1 "; $ Stale Surcharge S Pre..ure Reducer S Penalty S Sewer/Waurr Connection Fee # S Plumbing Permit Fee S Warer Tower Fee # S Mechanical Pennil Fee S Build..'. Depo5i[ S Sewer&: WaterPermil Pee S Other S :(' Ga. Fireplace Pennit Fee TOTAL DUB ~ 10,14' .04- s .1 BuildiDg Permlt Whetl Appo>ed fPaid /~~i:~ ~m- ] Date Daro , This is.. c:cnif1.... raquut in .......... applJ<aliaa and ''''''.'"..'';'1 documcnllla In _ ..1dI.... Cily ZDnillI 0rdiD0nce 1IId ..., pn>e<<d 11...-. 'I1Iia_ ...... .lp<dlll'.... Cloy __... a......,Ary CeniIime oIZooinrtlllllpliance IftdaJI__" ~_."', _OCCllJIUICY, a.c_or~...ltbc iaucd. DIM'l"j".ni..,.r.tnr 0..: Special Condition., ;(IIIY ""~'~";"'L~~...~.,;,:""~~""~,,;"""'",,,,~.........,.;.;o,,,'~o..;;'-;"t,.,,;...,~l;o.,.'~'_ ,.~._ .. _>: 16200 Eagle Creek Avenue S,E, Prior Lake, MN 55372-1714 September 29, 2004 Mr. Joe Mahoney Joe Mahoney Construction Company Inc, 4102 174th Street Prior Lake, MN 55372 RE: Village Liquor tenant finish Dear Mr. Mahoney, Following are the results of the plan review for the Village Liquor tenant finish. Our review was based on the 2003 Minnesota State Building Code (MSBC) which adopted with amendments the 2000 International Building Code (mC) with handicap regulations of the Minnesota Accessibility Code Chapter 1341. Also requirements of the 2003 Minnesota State Fire Code (MSFC) which adopted with amendments the 2000 International Fire Code (!FC), '--' 1. Submit signed sprinkler plans, May be submitted at a later date. Permits are required for HV AC, plumbing, and sprinkler work. The plans for the HV AC and plumbing have been submitted, 2, Address mc sections 711 penetrations of plumbing pipes, sprinkler pipes, flues, heating pipes ventilation, exhaust pipes, electrical and communication wires and 712 fire-resistant joint systems, 3. Provided, a HDCP accessible horizontal counter space of 36" with a maximum height of 36" above the finished floor is required for a sales counter. MSBC 1341.0720 Subpart 1. 4, Provide soils and structural steel connection engineering for new footing and steel structural framing, If there are questions call 7~u Robert D, Hutchins Building Official , . ... WVNJ. cityofpriorlake ,com Phone 952.447,4230 / Fax 952.447.4245 '- - - PRIOR LAKE INSPECTION RECORD \fo 13{ TeN~~;V"~:l~~ S USE OF BUILDING I (c::. .eo.. /", PERMIT NO. c::>~... "8,5 DATE ISSUED ,Jnto "" CONTRACTOR .4oe: l'1A~eNe:'~ c_... c:..~ PHONE A\C;'Z ..Zt;o~~n.. N,OTE: THIS IS NOT A PERMIT OR ANY OF THE INSPECTIONS BELOW THE PERMIT IS BY SEPARATE DOCUMENT DEPARTMENT OF BUILDING AND INSPECTION SITE ADDRESS NATURE OF WORK I I_II PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ROUGH - INS INSPECTOR J/Vt/ . DATE I FOOTING FRAMING INSULATION ELECTRICAL PLUMBING jl-q /l/q- 10. l]-tft . I GAS LINE AIR TEST COVER NO WORK UNTIL ABOVE~AS BEEN SIGNED ~E.K I ( ~ I 11-/Pf-V4 FINALS . 4 -- j BUILDING ELECTRICAL PLUMBING HEATING DO NOT OCCUpy UNTIL ABOVE HAS BEEN 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 DATE nME CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED /I- U.oy ADDRESS _Vr/l4,e tf(()lJV ~ ~ OWNER CONTR. PHONE NO. PERMIT NO. [J FOOTING [J FOUNOA TION [J FRAMING [J INSULATION c-1INAL [J SITE INSPECTION [J PLUMBING RI [J MECH Rl [J WATER HOOKUP [J SEWER HOOKUP [J PLUMBING FINAL [J MECH FINAL [J EXlGRADlFILLlNG [J COMPLAINT [J FIREPLACE Rl [J FIREPLACE FINAL [J GASLlNE AIR TST [J COMMENTS: (VL 10 /)0'1 [J WORK SATISFACTORY, PROCEED ~ORRECT ACTION AND PROCEED [J CORREff 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 & SAFETYI ...,ffm DATE Tl1IE CITY OF PRIOR LAKE /(--(q~oCf INSPECTION NOTICE SCHEDULED ADDRESS V1 II,,~.. 11tllOr OWNER CONTR. PHONE NO. PERMIT NO. ()- t.(tf1t3 o FOOTING o PLUMBING RI o EXlGRADlFILLING o FOUNOATION o MECH RI o COMPLAINT o FRAMING o WATER HOOKUP o FIREPLACE RI o INSULATION o SEWER HOOKUP o FIREPLACE FINAL o FINAL o PLUMBING FINAL o GASLlNE AIR TST o SITE INSPECTION o MECH FINAL 0 o WORK SATISFACTORY, PROCEEO ~ CORRECT ACTION AND PROCEED /0 CORREC; ;r~L FOR REINSPECTION BEFORE COVERING InspeClor: ~ Owner/Contr: CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEilLTH & SAFETYI l1i$IIOn CITY OF PRIOR LAKE INSPECnON NOTICE SCHEDULED ADDRESS --1li~ f~,,~ DATE TIME 14a- OWNER CONTR. o EXlGRADlFILUNG o COMPLAINT o FIREPLACE Rl o FIREPLACE FINAL o GASLINE AIR TST o f::. ~_ <;. pn ~ \A. \.'-0- Vi 'S (pj( ~.... .m'\ ~ /M--; at-01.O. t.'~ PHONE NO. PERMIT NO. 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 o PLUMBING FINAL o MECH FINAL COMMENTS: ~PMA tIOLD '2, Pr#UI'~ '-1,- 10 ~~ o WORK SATISFACTORY, PROCEED ~CORRECT ACTION AND PROCEED o CORRECT , CALL FOR REINSPECTlON BEFORE COVERING Owner/Contr. Inspector. CA R THE NEXT IN PECnON 24 HOURS IN ADVANCE. MENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYI INSNOT, Contractor's Material and Test Certificate for A, roee ure on orms to A 13-19 4 Upon completion of work, inspection and lests shall be made by the conlractor's representative and witnessed by an owner's representative. All defects shall be corrected and system left in service before contractor's persOMeI finally leave the job, A certificale shall be filled oul and signcd by both represenlatives, Copies shall be prepared for approving authori- ties, owners and contractor. It is understood the owner's representative's signature in no way prejudices any claim against contractor for faully material, poor workmanship, or failure to comply with approving authority's requirements or locaJ ordinances. All "No" answers shall be explained in the Comments portion of this fonn. Property Name: Villa2e Market ill ~ property Address: ] 6760 Toronto Ave Date: B. Plans Prior Lake. MN J. Accepted by Approving Authorities (Names): 2, Address: 3. Installation conforms to accepled plans 4, Equipment used is approved C, Instructions, 1, Has person in charge of fire equipment been instructed as to location of control valves and care and maintenance of this new equipment Ilil Yes 0 No 2. Have copies of the following been len on the premises: a, System componenls instructions IlII Yes 0 No b, Care and maintenance instructions IlII Yes 0 No c. NFPA 25 IlII Yes D No 0, Location ofsystem - Supplies building: //2 E. S rinklers Make Model Year Made Orifice uantit B IlilYes DNo IlilYes DNo Ce Tem ralure 1550 1 t F. Pipe and Fittings J. Type of Pipe: Allied XL & Sch 40 2, Type of Filtings: Maliable G, Alarm Valve or Flow Indicator T e Make Model Max, Time to 0 rate Throu Ins, Test $V .s;". H. Dry-Pipe Valve I. Make and Model: 2. Serial Number: I. Quick Opening Device (Q,O.D.) I. Make and Model: 2, Serial Number: J. Dry-Pipe System Operating Test Without Q.O.D. 1. Time to trip Ihrough lest connection': 2. Water pressure psi. Air pressure 3, Trip point air pressure psi, 4, Time water reached test outlet': 5, Alarm operated properly D Yes D No K. Dry-Pipe System Operating Test With Q,O.D. 1. Time to trip through lest connection': 2. Water pressure psi. Air pressure 3, Trip point air pressure psi. 4, Time water reached test outlet': 5. Alarm operated properly L. Deluge and Pmction Valves I. Make and Model: 2, Operation: D Pneumatic D Electric 3. Piping and detecting media supervised 4. Does valve operate from manual trip and/or remote control stations 5, Is there an accessible facility in each circuit for testing DYes D No 6, Does each circuit operate supervision loss alarm lJ Ves D No 7, Does each circuit operate valve release DYes D No 8, Maximum time to operate release: M. Pressure Reducing Valve I. Location and Floor: 2, Make and Model: 3. Selling: 4, Static Pressure: Inlet _ psi, Outlet _ psi 5, Residual Pressure (Flowing): Inlet_ psi, Outlet_psi 6. Flow Rate: gpm 'measured from time inspectors lest connection is opened atlOna Ire prm er ssoclahon, . . ox psi. psi. DYes DNo D Hydraulic DYes D No DYes DNo Aboveground Piping N, Test Description Hydr.stotie: Hydroslatic tests shall be made at not less than 200 psi (13,6 bars) for two hours or SO psi (3.4 bars) above slatic pressure in excess of 150 psi (10,2 ba..J for two hours, Din.renti,1 dry-pipe valvc clappers shall be left open during test to prevent damage. All aboveground piping leakage shall be stopped, Pneumatic: Establish 40 psi (2.7 bars) air pressure and measure drop, which shall not exceed 1.5 psi (0.1 bars) in 24 'us. Test pressure tanks at nannal waler level and air pressure and measure air pressure drop, which shall not exceed 1.5 psi (0.1 bar.) in 24 h... 0, Tests I, All piping hydrostalically tested at.20.0... psi for -L hours 2. Dry piping pneumatically tested DYes C3 No 3, Equipment operates properly ra Yes D No 4, Do you certify as the sprinkler contractor that additives and corrosive ,chc;,rnicals, sodium silicate or derivatives of sodium silicate, brine, or other corrosive chemicals were not used for testing systems or stopping leaks? III Yes D No 5, Drain Test: a, Slatic pressure reading of gage located near water supply connection ? 0 psi. b, Residual pressure with valve in test connection open wide?o psi. 6, Underground mains and lead in connections 10 risers nushed before connection made to sprinkler piping and verified by copy of form No. 13.U DYes D No 7, Flushed by inslaller of underground piping IlII Yes D No 8. If powder driven fasteners are used in concrete, has representative sample tesling been satisfactorily compleled? GiI Yes D No P. Blank Testing Gaskets 1, Number used: 2, Locations: 3, Number removed: Q. Welded Piping. If welded piping was used in the system, complete the following: J. Do you certify as the sprinkler contractor that welding procedures comply with the require- ments of at least A WS 010,9, Level AR-3 IiiI Yes D No 2, Do you certify that the welding was performed by welders qualified in compliance with the re- quirements ofalleast A WS 010,9, Level AR-3 Il!l Yes D No 3. Do you certify that welding was carried out in compliance with a documented quality conlrol procedure to insure that all discs are retrieved, openings in the pipe are smooth, slag and other welding residue are removed, and the internal diameters of piping are not penetraled 19 Ves lJ No R. Cutouts (Disks) Do you certify that you have a control feature to ensure that all cutouts (disks) are retrieved? 131 Yes D No S. Hydraulic Data Nameplate Provided Il!l Yes D No T. Date left in service (with all conlrol valves open): U. Signatures I, Name of sprinkler contractor: 2, Tesls w'tnessed by: For p woer (Signed): Title: I For sprinkler co tor Title: ,C, - - . Date: /,..-tl6-0'( V. Comments (This section is for additional explanalion and notes, All "No" answers must be eXplained here.) lJ Check here ifcommenls continue on reve..e side of this form Contractor's Material and Test Certificate for A. roee ure on orms to A I -I 94 Upon completion of work, inspeclion and lests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall be corrected and system left in service before contractor's personnel finally leave the job, A certificale shall be filled out and signcd by both representatives, Copies shall be prepared for approving authori. ties, owners and contractor. It is understood the owner's representative's signature in no way prejudices any claim against contractor for faulty material, poor workmanship. or failure to comply with approving authority's requirements or local ordinances. All "No" answers shall be explained in the Comments portion of Utis form. Property Name: Village Liquor Property Address: South Lake Village B. Plans Prior Lake, MN l. Accepted by Approving Authorities (Names): 2. Address: 3, Installation conforms 10 accepted plans 4. Equipment used is approved C. Instructions , I. Has person in charge of fire equipment been instructed as to location of control valves and care and maintenance of this new equipment iii Yes 0 No 2, Have copies of the following been left on the premises: a, System components instructions iii Yes 0 No b, Care and maintenance instructions iii Yes 0 No c. NFPA 25 iii Yes 0 No D. Location of system - Supplies building: E. S rinklers Make Model Year Made Orifice uantit Tem rature Centra TY-FR R Date: IlIlYes ONo !lIYes ONo o F. Pipe and Fittings I. Type of Pipe: Allied XL & Dyna-Flow 2. Type of Filtings: Maliable G. Alarm Valve or Flow Indicator T Make Model Max, Time to 0 eThrou , Test FI otte VSR .so H. Dry-Pipe Valve I. Make and Model: 2, Serial Number: I. Quick Opening Device (Q,O.D.) I. Make and Model: 2, Serial Number: J. Dry-Pipe System Operating Tat Without Q.O.D. l. Time to trip through test connection.: 2. Water pressure psi. Air pressure 3, Trip point air pressure psi. 4, Time water reached test outlet.: 5, Alarm operated properly 0 Yes 0 No K. Dry-Pipe System Operating Test With Q.O.D. I. Time 10 trip through test connection.: 2, Water pressure psi. Air pressure 3, Trip point air pressure psi. 4, Time water reached test outlet.: 5, Alarm operated properly L. Deluge and Preaction Valves J, Make and Model: 2, Operation: 0 Pneumatic 0 Electric 3. Piping and detecting media supervised 4. Does valve operate from manual trip and/or remote control slalions 5, Is there an accessible facility in each circuit for tesling 0 Yes a No 6. Does each circuit operate supervision loss alarm CI Yes CI No 7, Does each circuit operate valve release 0 Yes 0 No 8, Maximum time to operate release: M. Pressure Reducing Valve I, Location and Floor: 2. Make and Model: 3, Setting: 4. Static Pressure: Inlet _ psi, Outlet _ psi 5. Residual Pressure (Flowing): Inlet_ psi, Outlet_psi 6. Flow Rate: gpm .measured from time inspectors test conneclion is opened atlon Ire pnn er ssoclatlon, . . ox psi. psi. DYes ONo o Hydraulic DYes ONo aYes aNo Aboveground Piping N. Test Description Hydrostatic: HydroSlalic tests shall be made at not less than 200 psi (13.6 bars) for two hours or 50 psi (3.4 bars) above static pressure in excess of 150 psi (lO.2 bars) for two hours. Differential dry~pipc valve clappers shall be Icft open during lest 10 prevenl damage. All abovcground piping leakage shall be stopped. Pncum.th:: Establish 40 psi (2.7 bars) air pressure and measure drop. which shall not exceed 1.5 psi (0.1 bars) in 24 hrs. Test pressure tanks at nannal water level and air pressure and measure a" press drop, which shall not exceed 1.5 psi (0.1 bars) in -- O. Tests I, All piping hydrostatically ested at..2ll.Q.. psi for...2.... hours 2, Dry piping pneumatically ested 0 Yes 0 3, Equipment operates proper Iil Yes No 4, Do you certify as the sprinkler actor th' additives and corrosive chl:l"icals. sodium silicate or derivatives of sodium silicate, brine, or other corrosive chemicals were not used for tesling systems or stopping leaks? Iil Yes a No 5, Drain Test a. Slatic pressure reading of gage located near water supply connection ?O psi. b. Residual pressure with valve in lest conneclion open wide ? i) psi. 6, UndergrolUld mains and lead in conneclions to risers flushed before connection made to sprinkler piping and verified by copy of form No, 13-U a Yes 0 No 7, Flushed by inslaller of underground piping Iil Yes 0 No 8, If powder driven fasteners are used in concrete, has representative sample testing been satisfaclorily completed? a Yes a No P. Blank Testing Gaskets I. Number used: 2, Locations: 3, Number removed: Q. Welded Piping - If welded piping was used in the system, complete the following: l. Do you certify as the sprinkler-contractor thaI welding procedures comply with the require- ments of at least A WS D I 0,9, Level AR-3 Il!I Yes a No 2. Do you certifY Ihatlhe welding was performed by welders qualified in compliance with the re- quirements of at least A WS DIO,9, Level AR-3 Il!I Yes 0 No 3, Do you certifY that welding was carried oul in compliance with a documented quality control procedure to insure that all discs are relrieved, openings in the pipe are smooth, slag and other welding residue are removed, and the internal diamelers of piping are not penetrated Il!I Yes 0 No R. Cutouts (Disks) Do you certify that you have a control feature to ensure that all cutouts (disks) are retrieved? IiiI Yes 0 No S. Hydraulic Data Nameplate Provided Illl Yes 0 No T. Date left in service (with all control valves open): U. Signatures l. Name of sprinkler contractor: ry Fire Protection 2, Tests witnessed by: For peer (S' ned) Tille, Dale: ~" For sprinkler co Tille: ~ Date: W'>'?-t:Jr V, Comments (This section is for additional explanation and notes, All "No" answers must be explained here,) a Check here ifcomments conlinue on reverse side of this form