HomeMy WebLinkAboutBuilding Permit 01-0082
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
0~Q4
Date Rec'd
1-}6'-OI
/ ~<2.~-ol
I. White
2 Pink
3 Yellow
file
City
Applicant
(Please tvee or print and sign at bottom)
ADDRESS
I~Z N/6HTltlqI7L6
LEGAL DESCRIPTION (office use only)
DITION k ho6 tI r 1/ 41J.
030
PID ZS-3foZ~ ~-O
OWNER
(Name) Sco~ a h eL-r z (') tv
(Phone)
(Address)
BUILDER
(Name) 'J{,H4 flm/_.e.
(Address) C(Q7 7AcO~< /Jr S~!",t:'t"""E,c>
(Phone) ___kDJ.- l.f.L.4 - 70/7
TYPE OF WORK ~ew Construction ODeck
Sri)
OLower Level Finish 0 Fireplace
OPorch
OAddition
ORe-Roofing
ORe-Siding
OAlteration
OUtility Connection
o Misc.
PROJECT COST IV ALUE (excluding land) $ 2~/o~.d:)
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 upon the property to perform needed inspections.
M- 7..... / --
Slgnature
'-I{9</
Contractor's License No.
-btJ -01
Date
x
I Permit Fee $ ! c;-.~~. 7~- Park Support Fee # $ R~.t9Z) I
I Plan Check Fee $ (~d j,q<( SAC # $ I. I StJ. Oa I
I State Surcharge $ Water Meter Si~; 1'" $ I I
/bt1 .tge) , J ~<;'.OQ
I Penalty $ I Pressure Reducer $ tis-. no I
Plumbing Permit Fee $ J (') (!). l!J ZJ I Sewer/Water Connection Fee # $ 1/2 ("Jf'') . CJ?)
Mechanical Permit Fee $ 1t'JI"J .n-T'l I Water Tower Fee # $ . JIJO.f}r)
Sewer & Water Permit Fee $ :JO. ~a I Builder's Deposit $ 1.<;'fXJ .00 I
Gas Fireplace Permit Fee $ t{O,tJ~ Other $ . I
CH~ 1$ 8,SOt? /8 I
s Y OUT Building Permit When Approved TOTAL DUE 2-13~OI
I RecriPc . 3101 1
By /.&
,
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and miy proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
~,u,,~ . A 1 - ~ Z--/tt/l9\ ~ ~~. ~~ ~e.rCtt~~
~rrector . Date .' S~cial Conditions, ifany
24 hour notice for all inspections (952) 447-9850. fax (952) 447-4245
/-'2-'2.- O(
Date
I Paid ~507' /08
I Date "2-;/'1- 0/
~~
'uer
o \-oor~
Tht{'tnlfroflh.l-abCountry
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
T (+1 +--\ ( L- i~i e;
I---:)~I- ( I
APPLICATION RECEIVED
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
I 4 /t / ") '. I / .i~'~,! /- ., ,-
'''1' '{t.- J\, (,-(+1 I 11\lc:"f'll_c
,.
Accepted i/
Denied
Accepted With Corrections
Reviewed By:
~ ~- V~<
Date:
J-/l2/ot
Comments:
2. L{ .~~ ~ \('~v\M.MA I::vWJAl-r"U1 (A)'t'dbb:; ~
nB0\ ~L~ ~1 VJ.., o '/A) \0 ~,
'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."
~~
O~~O()~~
Th.. C"nl... of th.. I..k.. Counlry
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
Tn~ UnLJ-1c
I-~I-nl
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/ 4-4--02- /\/1 GHTI r\l6AtE
. ,-
Accepted
Denied
Accepted With Corrections
I
Reviewed By:
-------
Date: L -6"""""'2-'-'-"::::::::,
Comments:
~~ ()d1~ ~p~
"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."
Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
3-20-01
I. Blue File
2. Gold City
3. Yellow Applicant
.\16 ~
I PERMIT NO. Of -oo~z--I
(Please type or DruIt and sign at bottom)
ADDRESS
ZONING (office use)
I Lit.lB2
t--\.,~~~ Cr.
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID -;)5- 3G.;;t -030-1)
OWN!W.n-
(Name) -1Cl\M. \1,.,,\ 1M-
('~,
(Phone)
(Address)
APPLICANT JJ j")
(Name) ^EIr1c-Z rt.t/M6/1l/6:J:/vC.
(Address) 110 E. MAiN S'r
(Address)
(Contact Person) t! 0 I.. Y R.c, "'1~ t..
&n, R~~~~
-~ --
SViTC#~
(Phone) ~ S~ - 75 ~ ~ /99 I
Nl.../ rr,,~,vc:_ 5bo 7/
(City) (Zip Code)
(Phone)
APPLICANT SIGNATURE
DATE
3 /.:to lot
'-"
Quantity
APPLICANT PLEASE COMPLETE BELOW
Type of Fixture I Quantity
Bath Tub with or without shower I
Dishwasher
Floor Drain
Lavatory (Bathroom Sink)
Laundry Tray (lor 2 compartment sink
Shower Stall
Sinks
Bar Sink
Water Closet (Toilet)
Type of Fixture
Rough-ins
Water Heater
Water Softner
Stand Pipe (Washing Machine)
Sewage Ejector
Backflow Assembly
Backflow Assembly Test
Lawn Sprinkler
Other
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a $39.50 minimum Residential, New One & Two-Family $99.50
Residential, Additions & Alterations $39.50
wrr:'
Estimated Cost $ Building Permitr" p",'O _ ,
r 9\l\U>II'lV . ~
PLUMBING PERMIT FEE $ I:
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
Date
I Paid
I Date
Receipt No,
ecomes Your Building Permit When Approved
) - U> -0 (
By
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
GREEN ~ rILE
YELLOW. APPLICANT
GOLD . CITY
CITY OF PRIOR LAKE NO. 0 { - 0052-
SEWER AND WATER PERMIT
NOTE: Sewer and Water
contractors must
be registered
with the City.
APPLICANT: KII'f\<:\"b<.f,-,\ G-l(.
~Xt,
SIGNATURE: ~ !~
SITE ADDRESS': \ l..{ l...( ~ r
OUj\...*"; '^ 311-1.>
FILL IN THE BLANKS
PHONE: C1.5Z - 4L/7- I.S"'r7
DATE: 2-2-~-OI
BLDG. PERMIT # 0 (- 0082-
PID# z.~-3"2--03C - ()
ADDRESS:
1. Estimated length of water service \(J
feet.
2. Size of water service
inch(es) .
3. Location of any couplings from structure
feet.
4. Type of sewer pipe. ABS
PVC v" Cast Iron
5. Estimated length of sewer line
feet.
6. Clean out (if required), located at
structure.
feet
from
------------------------------------------------------------------
------------------------------------------------------------------
This applicat'
_:~~::~:_::::~:::::~::~~:_~::_------
BY ...-
===(----L=
FEES:
$
$
$
35.00
.50
35,50
Sewer and water line connection permit.
Surcharge
TOTAL
* Fee for either sewer or water individually is $20.00 plus
$ .50 surcharge.
*
Sewer and water permits issued for new construction must be
recorded on the building permit card at the time of issuance
to insure that no duplicate sewer and water permits are
issued,
REC'D BY
~t>-\O ~~t?-\.tl\'\
e\j\\..t>\\~
DATE PAID
RECEIPT #
AMOUNT PAID
4629 Dakota St. S.E., Prior Lake, Minnesota 55372 I Ph. (612) 4474230 I Fax (612) 447.4245
AN EQUAL OPPORTUNITY EMPLOYER
~i
6 ("'6D~7/
Thf Ct'nlC'r of lhe' L.k1 Counll')'
White - Building
Canary - Engineering
Pink - Planninll
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
invl i-t()I~H~
I-~I-()I
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
14-tf-0Z. 1\1 (6+-1T1 f\f6AI /C
, ,
V
Accepted
Accepted With Corrections
Denied
Reviewed By:
LLL-
Date: 2 -/?-()/
Comments:
See Reverse Side for Additional Information!
See Attachments: 1) Grading Plan, 2) Erosion Control Measures
3) Erosion Control Plan
"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."
..;
IS)
"-
..;
IS)
(L
\D Date
If)
.,.
IS)
..;
\D
ill
Owner'. Name -,-0 "'"
Address .
. \
Healing Contractor \I , p. n - \L-
Address
F=' 'i r D..f', ~
.
-s
Telephone It
Furnace Make & Model >fv\6..' ......Hr
Model Size _ ~" .~ h" 'K ...)
TYPE OF SYSTEM
Warm Ai, Plants _F=":' r",,QLc:'.rJ
Gravity
Mechanical
Air Conditioning
Vent. System
HEATING OR POWER PLAtrr
S1eam
Hot Waler
Radiallon .
Special Devlces
~ Conn. load
~ FUlll .tJ~ Flue Sizo
'" ~
l.L
'"
U
W
'"
w
::>
Supply Openings
Relurn Opening.
InpUI
Output
Edr. .
Cfm..
Other Devices
['-
n
N Alterations
..;
TYPE OF WORK
..;
IS)
IS)
N
I
en
N
I
'"
a:
'"
Repair
Replacement _ New ConstNclion
Est Comp_ Dale
Building Permilll
\>{,
,.
Est. Cost $
.
HEATING PERMIT FEE $
.50
STATE SURCHARGE $
TOTAL PERMrr FEES $
DWITH
ILDING l-'ERMIT
Receipt It
. Two- Family
indusllial
Com mercial
Fee Schedule
Industrial, Commercial & M uni-Family .
Residential, Healing &. AC
Resklential, Heating Only
Residential, Gas Fireplace
Residential, Additions &. Alte rations
Residential, AC Only
I,Pink
2.. Oree:n
:t. Yellow
File
City ..--I
C6nb'Ottor ~
(L
-.J
a:
f-
o
f-
Public
Muiti-Family
Other
1% of job cost ($39.50 minimum)
$99.50
$64.50
$39.50
$39.50
$39.50
Rememberlo add the Stale Surcharge on the bottom of lhis application.
The price of your healing permit includes one rough-in and one lin.1 inspection.
Additional inspections will be l>ilied at $35.00 e.ch.
House Healing Tesl Record must be submitted wilh bUilding Rermil ~ before build-
ing certificale of occupancy will be issued.
!:lEAI CALCULATIONR REQurRED w~h number of supply and relurn openings listed per
room with CFM's per opening. New struclures 0' additions send 1100' pian with supply
and return locations shown. HEAT lOSS CALCULATIONS, PAYMENT AND
APPLICATIONS MAY BE MAILED TO THE CITY OF PRIOR LAKE, 162~0 EAGLE
CREEK AVE. S.E. PRIOR LAKE, MN 55372.
City Hall business hours .re 6 a.m. - ~:30 p.m_
ALL WORK MUST BE INSPECTED (Re'.JGH-IN AND FINAL). CALL CITY HALL
447-9850
I hereby apply fa, a mechanical systems permit and I acknowledge thallhe
information atlove is complete and accurate; thai the work will be in conformance
with Ihe ordinances .nd codes of the cily and wllh Ihe slale building/mechanical
codes: Ihal this lorm does not become a pe,mit until signed by the BUILDING
OFFICIAL; fhat the work will be in accordance wilh the approved pl.n in the
case of all work which requires review and approval 01 plans.
j~.8wJ.~
(!/(,r!-J.!jt.s Signalure
~'ding OHlca!'s Signalure
') -;}q - 0 \
Dale
Ij~ ;)--/
Date
CITY OF PRIOR LAKE MC
16200 &gle Creek Av. S.E. Pennil No.
Prior uke, MN 55372
HEATING APPLICATION I PERMIT
Dale 5-"t -0 I PIO.
SileAddress -Llfl/J.:l. 1U/9A~t;(/L ~:&
LoI
Book
Add~ion
01-OD02-
1.Pi.o
2-Gow
1. YeUow
FU.
Ci1)'
C......
=
~
,
=
~
,
=
TYPE OF STRUCTURE
Single Family
Commercial
x
Two-Family
Industrial
Fee Schtldule
Ownefs Name "'7Orn UIJ l rIA. 0 ~
Address '1'17 Thq;,[b On
(1 nYlr::. f-.
Ind...trial, Commercial & Multi-Family
Residenlial, Healing & AC
Residenlial, Healing Only
Residential, Gas Areplace
Residential, Addilions & Alterations
Residential, AC Only
Heeling ConlraclDr ~t J1J 1-',' IU /-&u --.hnc. ..L ~ / Cl
Address / :<. Lf j' / J2hocU.. I S I~ i4v .s.
9."2-K'91f~00DS-
n'".." ,.
FurnaOll Make & Modal f1./lnox
Model Size (.,-:u.. ~ 1.(/ S" -15"""
Conn. Load "7:J. nOD
,
Fuel _ f\)r..d . l~Flue Size
Supply Openings t ft;
"
Rtlurn Openlngs
Input ~/)[) D Outlll'
Edr.
Cfm.
AJteralions
Repair
Public
Mull~Famlly
Other
~
~
1 % of job cosl ($39.50 minimum)
~
$64.50
539.50
$39.50
$39.50
~
~
o
51
,
""
~
'"'
'"
~
<:
~
~
~
""
~
>-
-4
'"
'"
R. . '.. to add the S/aIe Surcharge OIl the bottom oflhis application.
AlR CONOITIONER'UNI1S CANNOT
ENCROACH INTO SIDEYAAD SETBACKS.
The price of your hfl8ljng permit includes one rough-in and 0Il8 final inspection.
TYPE OF SYSTEM Additional inspeclioll8 will be biled at $35.00 each.
Warm Air Plants House Heating Tesl Record must be sullmilled with IIIti!l!illg. U!!!lil IlYIlI!lm belore buiId-
Gravity ing certificate of occupancy wiI be Issued.
Mechanical .
AirConditionl I4I1noJr /(JAN511;j 1.. HEM CALCULATIONS REQUIRED w.h number of supply and return .,. . .'; Iisled pe
ng ..,,0..1 room with CFM's psr opening. New structures or additions send lIoor plan willi supply ;l;
Vent. Syslem and mum locations shown. HEAT LOSS CALCULATIONS, PAYMENT AND
HEATING OR POWER PLANT APPLICATIONS MAY BE MAILED TO THE CITY QF ~19R 1,A.~l;. 16200. E~LJ;:
Steam CREEK AVE. S.E. PRIOR LAKE, MN 55312.
HoIWater
Radiation
Special Devices
Other Devioes
~
-
~
....
=
~
~
~
City Hall business hours are 8 a.m.. 4:30 p_m.
ALL WORK MUST BE INSPECTED (ROUGH-IN AND FlNAL)- CALL CITY HALL
-4
'I hereby apply for a mechanical systems permit and I acl<nowledge thallhe :::
Informallon above is complete and accurate; that the work will be in conlormance -
with the ordinances and codes 01 the oity and with the state building/mechanical"
codes; that this lorm does not become a permit until signed by the BUILDING c,
OFFICIAL; that tile work will be in accordanc:e wilh the approved plan in Ihe
case 01 anprk which requires review and approval 01 plans.
~L'WiiI' 3-9-0/
. Applicant'Jf - 'fJf1 DBle
'f.L....-' 3 ~ r ~o I
Phon.: (152) 447_0
R8placement
TYPE OF WORK
New ConslruClion )('
Building P8rm~'
99. s-o
s .50
sit) () .O?) Receipt'.
Est. Comp. Dale
Est. Coal $
HEATING PERMIT FEE S
STATE SURCHARGE
TOTAL PERMIT FEES
tJ I ~ 00 9J 2-
PAID WITH
BUILDING PERMIT
"".:(151)447-4245
~
.
-
.....
~
Dale
PRIOR LAKE
INSPECTION RECORD
DEPARTMENT OF
BUILDING AND INSPECTION
SITE ADDRESS JLN 8~ ~ o.
NATURE OF WORK 1V.eu'
USE OF BUILDING SF[)
PERMIT NO. 01-0082 DATEISSUED J-~/-2JtJol
CONTRACTOR /...,'"'" flo/lAA (1,,~ - PHONE ~, 2 - L/IY-7f1 (I
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
INSPECTOR DI'TE
, FOOTING I <"'~. U(1v-J I "?- ~ /q I (J J
, FOUNDATION (Prior to Backfill) I D' 0/~) I ;L1;z ~i 01
PLACE NO CONCRETE UNTIL ABOV~ HAS BEEN' SIGNED
ROUGH - INS
SEWER I WATER J SEPTIC ;f?;;,
FRAMING 4?Jr
INSULATION FJ::r-
ELECTRICAL
PLUMBING I), C1:':~ r fIJ.:r 4 bUM A k / ~j,;J8/o I 5~ A.r: t ~,,^r.,'
HEATING (ifrequired) ~ J:;q 3/;?()/o/
FIREPLACE h;r. 4/ J.{ / l I
GAS LINE AIR TEST ~~. F: e. b-. 3/~lo (.
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
I I
FINALS
^/f 5 ~ /
/)
/~.
OCCUpy UNTIL ABO~ ~AS
NOTICE
"
GRADING (Prior to Sodding)
BUILDINGj l'jl,--W.Q 'E:f} Inr fr-r, 5/3 t ~ c
ELECTRICAL . {
PLUMBING
HEATING
DO NOT
04-161
41'1/0/
#ts-'/vl
If '-'0- c1J
Cfj~
S",.0-;7 fr/
s.441o/
,
BEEN SIGNED
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 addilions
where no service cabinet is available, card shall be placed near main entrance.
Call between 8:00 and 9:00 A.M. for all inspections
FOR ALL INSPECTIONS (952) 447-9850
_._.1._.._...,
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
7-10-01
PM
ft-/LfJ?2 a;,ikf ;'~<lc;1t. C
ADDRESS .r
'J
OWNER CONTR. 1-0/11 1101,..,<
PHONE NO. PERMIT NO. OI-f?'L
o .-vv,j,.... o PLUMBING RI ~X~L1NG
o FRAMING o MECHANICAL o LKSHORE LAND
o INSULATION o WATER HOOKUP o COMPLAINT
~INAL o SEWER HOOKUP o SEPTIC FINAL
o OUNDA TION o SEPTIC INSTALL o FIREPLACE
o DEMOLITION o PLUMBING FINAL 0
o FIRE PREV. o SITE INSPECTION
COMMENTS:
CLft., 150'lt , rJ!t:.
&r"J( '0 /<.
XWORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PRoceED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector~~~~ . Owner/Contr:
CALL 447-4230 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY/
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
OWNER
SCHEDULED 5 -~..o I ,I I;j ()
c;u~~_
::1. (/
PERMIT NO. 1- p-~
ADDRESS / LJ 1./ I?- ..2
PHONE NO.
o PLUMBING RI
o MECH RI
o WATER HOOKUP
fi:A 0 SEWER HOOKUP
~PLUMBING FINAL
~)l7MECH FINAL
. OMMENTS:(i) ~~ - .LlL.-d ~ /
!?~ (1~4-4- ~,/ . , V
I. . ~A !JJ ,-~~,/:Z~7'
~ ~~~,. 0
~.J?~ Si--- 11 (7)-' ~
~ ~ t.~ JI2..&-\ '11.,,,# _A_ -"'-. "i-
-' ~~ ~~~
'. ?~;...... ~ l. +:~ ~.;. .atzrr6:'J
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
P'1'INAL
o SITE INSPECTION
o EX/GRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
tJ\..r.- ' I" vJ ' e. ()/-L" _
U~_.. ~~ /~~l
)4 WORK SATISFACTORY, PROCEED ~ ~( t>(.,.....(, .
o CORRECT ACTION AND PROCEED
f1 CORRECT W~K. 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 & SAFETYI
INSNQTl
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS / '-I <-( .f" d-
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
DATE TIME
SCHEDULED ,)bs10! l!:So
A/~~~
CONTR.
PERMIT NO.
o PLUMBING RI
~ MECH RI
WATER HOOKUP
SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
, .
~/''''_ir''''1~
(.?) ri~
f!) ~
COMMENTS~ ~ !~~
.v..rL.__ ~..
. - /
~J-'
q ~t
1
(1 -<-v..J r-
~
I
--.'..J'
U /
, \ A11
lZ_,'\ /
)/'1 Pi/C ~.
01- COrd->
o EX/GRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
4. ~-I-.'. ~
.~~.
~,
,
d7---
~
/" I~ "iL" ~
tJr,-.- v
.1'\...-6 ~. .! " . ~ .-
v
~
/
"it)
Owner/Contr:
INSNOTl
5.#-A,('
-~,
o WORK SATISFACTORY, PROCEED
~ CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
~I
Inspector:
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
BVftN~ .,ILLE
Heating & Air Conditioning, Inc.
1248/ RJoodo I:I<uod AVt. So.. S""",t. MN 55378 . 894-0005
Orstat Test Report for Jobl /7 ~ 7
Address J V'/f'z ;VJ4-J.,),~/ HI., r,Cily //J'~/ Lc. (<..(
Occupant AD Nt JI~ (rlt'! I':~ d.
Dale of InSlalI 5,2' <> I
Type of HT. F/A V"" HW Space HT Unit HT
0Iher
Make & II)/lo)l"
Model ~ 1..b Q l(( S- '/1 ~ ("
Serial _ S?o/c S c.J-;z )-
Input 7 ~ 1> tl c)
PilotType N II
Pressure 'S. \'
Input CFH 7)
Stack Temp /I S-
C02 f~.
02 b. r-
CO ~-.
DaleTested S-20-0/
Companv i? I u ((, 1/ A
Name ofTeslllr f" \ '- \
, ...../<...