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Home My WebLink AboutBuilding Permit 01-0683 CITY OF PRIOR LAKE BUILDING PERMIT, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE AND UTILITY CONNECTION PERMIT MAl N J=1L.6 q"lease!VD~ or orint and si2ll at bottom) ADDRESS ~'1 ~ <t ~r'\ l.ek.r-f. Se LEGAL DESCRIPTION (office use only) LOT bBLOCK \ ADDITION I. Whice File 2. Pink City 3. Yellow Applicant GLl>b-tl:-" V.....+~'2-\ 'DE~/Z..f' I e'L..D '?:.r..L OWNER (Name) (Address) BUILDER (Namp\ C\ ,11,. Irb~ (Contact Name) vn.1Lf VVohn~~ (Address) 2.0~(PO ~~bn-~E "t. 5+<. 100 ,~ l.._IU'/III.1' ,I/VI '" ~) yU TYPE OF WORK ~ew ConstIUction ODed: DLower Level Finish o Fireplace PROJEcrCOST/VALUE (excluding land) S -'WIl --- --- o Misc. fJ 2,1n:l.a'J ~'7 IJ~ .~,,., .-.;Cf 3~ .00 (phone) 3 ZONING (ofliceuse) ,€Z- PID2.5~.J7..3 - /JOb-O (phone) !3.1<c:- 1}iok (phone) &76'2.-22&'-4.132 OPorch ORe-Roofing ORe-Siding Dutility Connection # $ ~.~ $/ ~ I ~.C!lO> $ . 2q-r~ $ t)nf' $ . - ...-... f, ?~.~ $ ., 7C::X::>.d:5 $ / .~~-t"'\ .<'111 $ I hereby certify that I have furnished information on this application which is to the best of my knowledge true and conect. I also certifY that I am the owner or authorized agent for the above.men ed r."r-.J. and that all construction will conform to aU existing state and local laws and will proceed in accordance with submitted plans. I am aware that tI: ilding official can revoke this permit for jwt cause. Furthermore, I hereby agree that the city official or a designee may enter upon ther;" ~W__j' to perf~ d inspections. X ~ .t,a <I fd..ts: ::J.CIIlTJ t;;lL !;""'1 -..fr'L ()-o I \ si Contractor's License No. Date II I Permit Valuation I Permit Fee $ I Plan Check Fee $ I State Surcharge $ I Penalty $ I Plumbing Pennit Fee $ f ()O . ~ I Mechanical Permit Fee $ J (JIJ _ 00 I Sewer & Water Permit Fee $,J 5'. ~~ I Gas F1laCe Permit Fee $ fln.tM 7:lIJ:i?Y-/.;?~ Buil g rcial Date DAddition DAlteration # # # $ 7J~4-7. 7Cl , , I ~~~NO. '-I'LII U 7 U 's 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 ligned by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before _w.'~r""'w}, a Certificate of Occupancy must be Planning Director I Park Support Fee I SAC . I Water Meter Size 5/S"W; I Pressure Reducer I Sewer/Water Connection Fee I Water Tower Fee I Builder's Deposit I Other I TOTAL DUE I Paid I Date "{3 If'1 ' -"1'1 '7- J 3-0 I ....pate Special Conditions, if any 14 hour notice rOt <"".pection. (951) 447-9850, rax (951) 447-4145 --... i . i , ---- , "" I '-./ ThtC,al"of'h,l..ktCoua,ry White - Building Canary - EngIneering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT 2).11.. eN ~ APPLICATION RECEIVED !/J --a-)-O/ The Building. Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: 51/39 ~~ (P~f5r Accepted Denied Reviewed By: . . jVJ4{J........ ><-- Accepted With Corrections Date: )-(.-0/ Comments: See Reverse SidA fnr Arfrfitionallnforma+i,:,,,1 1YIe-,'" F,'k , ~ee Attachments: 1) Grading Plan, 2) Erosion Control Measures <:\\ ~r"cion r.nntrnl PI",n , ,1' " '., '.""'".....oU...... .,,"' "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.' ~~ White - Building Canary - Engineering Pink - Planning Tht'C"pnlll'roflht l.lh('ounll'}' .BUILDING Pe:RMIT APPLICATION DEPARTMENT CI-iECKLlST NAME OF APPLICANT l[).J?.. cJ,./ 6ili:i-tu APPLICATION RECEIVED /'" -Cfl-D/ The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: Sl/39 ~~ /!~f5r y Accepted Accepted With Corrections Denied 0;; It 11 Reviewed By: Vy (D...P I Date: (P-27-~)/ l ~ -v ~t{ ttff~ t~~ G.e"'~ M.ulkL:\u ~J. ~~ ? .c.....~~....~.-u--=-. "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." , TM Cll'nltr of the Lake Co..try White . Building Canary . Engin_ing Pink . Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT V /1. 'II cn)thG --- . APPLICATION RECEIVED I/J -a-)-Ol /1 '"' The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: 51/39 .~~ 11#1j')/f~r Accepted ,. ./ Accepted With Corrections ? /7-/& I .- Co ments: ...: ~~~. ~ .V~~~ ~Pfl~(iS.tw~f?-- . . Denied _ Reviewed By: ~~~~ Date: '"" "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." \ Jun.28. 2001 2:03PM GENZ RVAN PLUMBING AND HEATING No.6964 P. 101 Date Rfi:'d CITY ,OF PRIOR LAKE SEWER AND WATER PERMIT fl;. q'lcu= tVDc ormW.ad ~ ..tbciuo1b, ADDRESS . : f)Le'f\L./ i ,;'f\I. h \ r'l ,.L2JL} 0 ....Y?- FAwr-.J 1\..A QiWcru..) - . . . :: s:- ~_ / PERMIT NO. 1- b2 .3 I (' 11 V',JP ,'i: _ Z~G(_...) h'd... . LEGAL DESCRIPTION (o!Ila use oaIy) ~ LOT ~ BLOCK 1 ADDmON '- ~ Y_ Q Jib p C rQ ?,d.- oWNER. p~3~3-00~-o (Name) p~ liort;Q1il ('1.U?tQ:lll 1I _.g (Phone) t.51_/1~4 (,,:.~_? (Address) 3459 Washington Dr St" 204 (,Addlao) Eagan, MN 55122 (Clty) (ZIp Code) Al'PLlCANr (N~d Ganz-Ryan Plumbing & Baacing (Pho.ue) 651-423-1144 (Address) 14745 So Rohn Tr,a:jJ, . GMh=) (Contact P~~) Marv Olson "U~ SIGNATURE ~~ Rosemount. MN (Clty) 55068 (Zip Code) DATE 651-423-1144 . f/J/"2..f6/nf ", ()^ (Phone) ., ", APPUl.A~J PLEASE COMPLETE BELOW Size of water service inches. Location of any couplings from stIucture Type of sewer pipe. 0 ABC 0 PVC Estimated length of sewer line feet. Clean out (if required) l~d at feet from structure. feet.. o Cast Iron FEE SCHEDULE Residential $""'or and; water line connection $3550 Indu3trl8l, COllI'1 & Multl-fanlily I % of job cost with II $3!l..50 mInim= Sewer connection only $17..50 WaW' coanection only $17.50 Estimated Cost $ Building Penn.it # SEWER AND WATERPE:RMITFEE STATE SURCHARGE TOTAL PERMIT FEE $ $' $ .50 l3 P~/O , lJ1l.O'NG ~'!JI: ' ~/7' (M.. U.. Oaly) I This Applic:atloD JJecaml8S Y our BuMiD~ Penan WIleu Approved, llaildl.q OllicW Date I Paid I ~ '--7-2... ()- r 0 , I ReoeiptNa. I- lay~ I 24 hOllr DOm. for all iDopectIaDl (lISJ) 447-98S0, fu (952.) 447-4245 - Jun.28. 2001 2:02PM GENZ RVAN PLUMBING AND HEATING No.6964 p. 5/11 Date Rec:'d CITY OF PRIOR LAKE PLUMBING PERMIT . . ~tyll'!.,!!...,;,u:_......"'bo_) I ''''DRESS ,"-. . " ..... ,r).L-' ,.....- '" _ ~?..,C1 ,p"At..l~~ Cr S-E- ~=- a- I PERMlTNO,) - ~ 0'3 I zp;:__' I LEGAL DESCRIPTION (o1IIce we 0Dly) , LOT (OBLOCK , ADDmON il flJ ~'e1l_D 51L.o PID A,-'1-r:r--c6fa-C) oWNER (N-~\ DR lio1Ot:"n Cust:om Hames (Phonc) 651-454-4663 (A~) 3459 Washingt:on Dr Ste 204 Eagan. MN 55122 APPLICANT (Namc)r-_.............ll)'G." -p1u_'l....:....'i ~...+-........g ~n~ ~51_~?~_1144 (Address) 14745 So Robert Trail (Address) Ilollemount: MN 55068 (Zip Code) (City) (Contact Po:r.lo;") ~;ry Olson . (Phone) 651-423-1144 (~I.ia"ATURE lA. ~~~~~=w ,d ~Inl Quantity I Type of Fixtare I Q1lantity I. Type ofJbtu.-e I I Bath Tub with o{ without shOWeI" RoiIgh-iDs t I Dishwuhe{ I /. I Wate!' Heatcl:' , I Floor Dt-ain I If J I I Water SoftnCl{ :;L . 1 LavatQ{y (Ba%btoOll1 Sink) I r - I Stand Pipe (Washing Machin~) I I Laundly Tray (I or 2 compartment sink I I S~age ~cctor 1 I Shower Stall I I Backf.lo<v Assembly J I Sinks I I Backflow Assembly Test I Bd!' Sink I I Lawn Sprinkle!' ~ I WateI- Clo$et (Toilet) I I Other I I I I I I I I FEE S\...EU!..UuLJ: lnduma!, Co=lal &. Mulll-fllmIly 1 % of job cost with a $3950 minimum Ilooidonllal, Now OlIo &. Two-Foonlly $99.50 RosidGltial, AdditiOJlS &. A.lb:mtioDs $3950 Estimated Cost $ Building P= # PLUMBING PERMIT FEE S STATE SURCHARGE S TOTALPERMlT FE:E S .50 ,eu/~"'/{) ;;.' V1\tG l1q}-~ .Q~J::>A_ . "Iif/,. )fti.. T.l.. Ololy) This AppllClltioll &cOIO" Y Ollr Buildill& PemLlt Wllq APP{ove4' I I Paid , ___ l.Joco;!" -.rn . _ 1Ia'" . 'Dai8i/P)(} J -' By ~ :u hour gotJ..l'or all JuSp.ct\OIl' (95%) 447-9850, 6u. ~ . lluil_~ CITY OF PRIOR LAKE HEATING/AIltCONDITIONtNGIFlREPLACEPE:RMIT ~':~R l)tZ. \..rov-M (phone) (Address) .?;~ Wl\s1u~hnAvL Suik1D~ EaJtn MfIJ 55/~Z- ~;;~~~t1'lant vY\eLhtu1/caJ (phone) J./f51 L/-'5l~ lT6' (Address) 3f.t6D IW1neJXiJ ''Dr ~)u'l~ \ , f. (Addteis) . (Contact Person) . JttirlY . C", ~ APPLICANT SIGNATURE :1:1$iLb.l/ ~ 'WIi U . APPLICANT PLEASE COMPLETE BELOW (BNEW CONSTRUCTION 0 REPLACEMENT [JALTERAnONS FURNACEMAI<.EANDMODEL~~'~llJ- 'b8?JjUWD~4b1(). " FUEL=t\llb.ual FLUESIZE L.\"da.sS& RETURN OPENINGS 4-" INPUT1D,ODD oUTPUT 51o.bDD TYPE OF SYSTEM :HEA'11:NG OIUOWER PLANT (Please.!l'Pe or print aDd silm at bottom) ADDRESS 6LJ3Ct KJvWn C:t LEGAL DESCRIPTION (office use only) & I , LOT 21 BLOCK to ADDITION Date Rec'd 1 ~ S_I PERMIT NO. 1-(08"6 I ZONING(olliceuse) !2~ ~/cL tOb~ I'nQ5<31?3 - (City) (Zip COde) (phone) ~5 I 45t - ZTJ6 lffJ/lf))OATEi/J!! 01 I PLEASE NOTE: Air CotIditioner Uniis Callnot :llnctOacll into Required SideYlltd Setbacks OWatm Air Plants OGravilY o Mechanical . Wir Conditioning UJX'ent. System FIR:l!PLACE MAl<EAND MODEL a Steam o !tot Water o Radilltion o Special DeVices o Other DeVices _,_~';':.;.:~..:..4 FEE SCHEDuLE Industrial, Commercial & MUlti.Family 1% of job tOst . ReSidential, GaS FireplaCe' $39.50 minimuin Residential, Heating 8< NC (New construction) $99.50 ReSidential, AddltioDs 1ft AI_ions Residential, Heating Only (New ConstrUction) $64.50 Residential, At: only Estimated Cost $ tIEA TINa PERMIT FEE STATE SuRCHARG:ll 10TALPERMIT FEE (Office U.e Only) - This Application Betomes Your Building Petmit When Apptoved Buildlnl. Official n.te 14 hout notite for an in.pectlon. (957:) 44M1l50, fb, (952)441....7:45 $39.50 , $39,50 '\ $39.50 tlliildittgpermit # $ $ $ r SO PAID WI-' , .13l)/I.OING" I Paid I Dale , .,~>?-QI I Receipt No, .'1 By ff- .:--- #3556 P.001/006 vaa: _c.... t ~ !L I PERMIT NO. /-,&83 ~ioMI: I'R" or_an4';llIlot_l APDBBSS ZONING (""'cc..., SV31 ~~ (Jf- s:g. LEGAL DESCRIPTION (Om..1IIC l>IIIy) _ I LOT fa BLOCK / AuJ.-'luON , PIDQ5- 3/3-o04>~ OWNER. (Name) (Address) ~~ (phone) APPLICANT (N~) ALLIED FIRESIDE DBA FIRESIDE C_,,",~~ (Phone) 651-633-2561 (Address) 2700 ll'. FAIRVIEW lWENllE (Ad.cIMs) (Contact Person) BRENDA HU5'1'0liI_ APPLICANT SIGNATURE 1.f,'~fJ. , ROSEVTT T.F. JrO,T (City) (Phop~) 651-633-2561 ;j, - DAn Sr:..l''} (Zip Code) to/D/dl = APPLICANT PLEASE COMPLETE BELOW ~w CONSTRUCTION 0 MPLACBMEN'T 0 AL'TERATIONS FURNACE MAKE AND MODEL FUEL FLUE SIZE RETURN OPENINGS INPUT OUTPUT TYPE Of' "."u::.M HEATING OR POWER PLANT DWonn Air PlllIlts J SlO8m DOravll)' ::J Hal W_ o M<:dwIieal J Radillion DAlr Conditioning J Sptc'oI Devices DVonL Systoln JOllIer D"ices FIREPLACE MAKE AND MODEL ~;.) {f; (0) ~ 7S1l !ndustrio/, Commerci.llJr. Mufd.FIIIllUy R.e.idcnlial. He~ling IJr. AlC (New ConSUllcllon) R.osidcnulll. Holllins ODly (Now ConRrUOli",,) FEE SClJI!.DULE I'lli of jab casl Resld""I;.', G.. l"lrcpl_ $39_50 minimum $99.50 Il.ooidcnliol, AddiliollS &< A1~ons $64.50 RosidClltlaJ, AC Only Estimated. Cast S Bufldln, Pennit It HEATING PERMIT FEE STATE SURCHARGE TOTAL PERMIT FEE $ $ $ .50 (om.. u.. 0.'1/ This ApplicstlOll aecom~ Your Bulldlnl Permit WIt.... Approved I Pllid BuYdl.. 0llIe..1 24 hoor notl.. ror :'::Dopeotion. (95%) 447.'~:: X(44'1~: PLEASE NOTE: Air Conditioner UnIts ClWlot EnorDsch Into Requirmd Side yatd SetbllCks $39.50 539.50 $39.50 ,....-. I3fJIL~tD 14"7'H GPf:> I'..,.,..;j"'" /l.llC:..tptNo. B~ ,. PRIOR LAKE DEPARTMENT OF BUILDIt-.lG AND IINSPECTION . ;Y) a I 1\1 rl e..- INSPECTION RECORD c.t. SITE ADDRESS 5'1.3' FaWIA NATURE OF WORK ~..e...J USE OF BUILDING S FA PERMIT NO. {)J~ n(n9J3 DATE ISSUED r;. -z 7- "2C>t:1! CONTRACTOR D. K. I+~ PHONE :J2~ -t/?-32- NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW THE PERMIT IS BY SEPARATE DOCUMENT INSPEr, I FOOTING ~ t)r ~h-!tJ1 p;y. I 7//Il/tJl I FOUNDATION (Prior to Backfill) ^.1/ I 1M"" l!h ?/3(~r'" - '3-01 PLACE NO CONCRETE UNTIL ABOVE HA'S BEEN SIGNED ~l1---\\~ o\<-t>~8~-1>1 ROUGH - INS SEWER' WATER' SEPTIC FRAMING INSULATION ELECTRICAL PLUMBING HEATING (if requ ired) u;-.. . FIREPLACE GAS LINE AIR TEST D",TE th rf5: , ItJ/SI/OI I~ll / (J} , - .. . IJJllf IJl "'" /-<.,... K ~~v I K- /.'"..1 _ ~".... lie e.9 ,-:;>~ fdh /D ~"I ~~ f/;ij/6) ~- ItJ/3t!tJl ~ ~/3tj~ J ~~.F,p.~. ' /&hl/II . COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED .r04~ h. /~7/01 I J FINALS GRADING (Prior to Sodding) /Y-6 BUILDINGT.C.o. tiJf rfr/6'Z. /tJ;r. Ih/,,... ELECTRICAL ) , PLUMBING HEATING DO NOT /)-/1)-1)3 M-h .~. "'0-, , OCCUpy UNTIL ABOVE HAS NOTICE ./Z113/t)y I I~/D Z. , . BEEN SIGNED This card must be posted near an electrical service cabInet prIor to rough-in inspections and maintained until all inspections hJve bt,en approved. On buildings and addItions 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 CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED ADDRESS ~3q F/(.J.AM t":. 1- OWNER CONTR. 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 5d-c::!.. / r /'e< S / COMMENTS: _ f /' ((l<,. <...---" \ ;., f./(L, DATE TIME q-lA I-~f""> o EXIGRAD/FILLING o COMPLAINT o FIREPLACE RI o FIREPLACE FINAL o GASLINE AIR TST o .e P"WORK SATISFACTORY, PROCEED o CORRECT ACTION AND PROCEED o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING Il~ t1 -)-( Inspector: Owner/Conlr. CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. lNSNOTl CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH .t SAFETY! CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED DATE Tille ~ IO,'~() ADDRESS Stt -?9 ~ OWNER CONTR. PHONE NO. PERMIT NO. tJ{- ~~3 o PLUMBING RI o MECH RI o WATER HOOKUP o SEWER HOOKUP o PLUMBING FINAL po MECH FINAL COMMENT$:1J ~ ~. ~ . ~)~_ ~f-. ~r--rll A:-I .J 'I-r-. - , I · r:. I A.JUL...4 .::2JJ-" . . . r ; o FOOTING o FOUNDATION o FRAMING @3 o INSULATIO Cf FINAL ti SITE INSPECTION o EXIGRADIFILLING o COMPLAINT o FIREPLACE RI ,Jit.. FIREPLACE FINAL o GASLINE AIR TST o .r 77 (!.. tJ. t;:J..f v:r;/ / /a ~ ~ R17"'LI<~ o WORK SATISFACTORY, PROCEED .8 CORRECT ACTION AND PROCEED o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING Inspector: ~ '( CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. OwnerfContr. CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY! INSNOTI DATE nME CITY OF PRIOR LAKE 17/;10/ II: t)O INSPECTION NOTICE SCHEDULED ADDRESS 51./ '3. q ~ OWNER CONTR. PHONE NO. PERMIT NO. o 1- Id'i'3 [] FOOTING [] PLUMBING RI [] EXIGRAD/FILLING [] FOUNDATION [] MECH RI [] COMPLAINT [] FRAMING [] WATER HOOKUP [] FIREPLACE RI [] INSULATION ~ SEWER HOOKUP [] FIREPLACE FINAL [] FINAL PLUMBING FINAL [] GASLINE AIR TST [] SITE INSPECTION [] MECH FINAL [] COMMENTS:6) (&rl ~ , I " (), c... ~:::. c~ - ~ [] WORK SATISFACTORY, PROCEED IIIJ CORRECT ACTION AND PROCEED r~ CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING Inspector: ~I OWner/Contr: CALL "7-98&0 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE REQUIREMENTS AIlE FOR YOUR PERSONAL HEALTH & SAFETY/ ]NSNOTl CITY OF PRIOR LAKE INSPECTION NOTICE DATE TIME L/- ,,,-03 S-'fJ ~ 9-- r->) L/LI/ h:J.d rn d- -5LJ'IO ~ .,!i:h..~ ratV;V li1e84ow~ PERMIT NO. ~ {- 6' $?J SCHEDULED ADDRESS OWNER PHONE NO. o FOOTING o FOUNDA nON 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 o EXIGRADIFILLING o COMPLAINT o FIREPLACE RI o FIREPLACE FINAL o GASLINE AIR TST o COMMENTS: (,rl:u;{ot.,r & K- 6 v" Wi" t-", rs2L ~ORK SATISFACTORY, PROCEED o CORRECT ACTION AND PROCEED o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING Inspectorl?1~ _ _ Owner/Contr: CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH ~ SAFETY/ INSNQTl .. ------ .~ APPLIANCE PERFORMANCE TEST Attach to gas line adjacent to regu'ator Heating Contractor Name 01 Tester Date ~ 1.~ .0 " Job Address 5'13? n-tiV" cr Heating Contractor ~r#k;' Name 01 Tester ~ 2 Date _/~/AJ- Percent 0. 9.S% JI:fr:'tt. .5"J 'F Percent CO Percent Co. Stack Temp Combustion air is adeq~9t~.1X supplied per UMC Sec. 606 't f"> input I 01QtW