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HomeMy WebLinkAboutBuilding Permit 12. 1061,13-0137 W �Z 1 1 J E U. re W E w O z W W y O' p W i 0001:100 cc CCo 2 0 N 0 aaQ m zsi .114 C , ci _ re pp8pti - O U 0 WI I-Z 2 0 O_ _O0a F y W oC () a. 0 W Za Z � W V1 O Cl) ��O d m2W � m2 '� a 0 Z �.' • 0 111 1 0I- 6nW p p z H p k a25wa. 2 w w W W �� 000000 0 0 Z z oC re re o p J ~ 0 IQ YVZ 0 Z V Li. cy � O C`O Z N V O z Ww �,,,O i- a., co ci z zozg z W N u.1 v w Ov W W O02 < '� ° p a 0 0 ooU.z1y 0 3 C.) 0 �' v () ? < 0 a 0000'0 () ❑ 0 5. c ? � A,; Ai xA ,.,)-C , A v,, .: :A , ,.. , ‘\ Crrrfi irafr of ®rtlzlrnx r CITY OF PRIOR LAKE prparfutrilf of r uil Mzt ns i tftu 2'Final Permitted ❑ Conditional C.O.Expires • This Certificate issued pursuant to the requirements of Section 110 of the❑Residential/❑International Building Code certifying that at the time of issuance this structure was in compliance with the various ',h', ordinances of the City of Prior Lake regulating building construction or use. For the following: ✓ Use Classification -- F-D Bldg:Permit No. / 2 -- /0 Occupancy Type P Type Construction Zoning District Legal Description �y�^ Owner of Building Site Address / 521 (-I t' �c, � KCo actor's Name&Address KL � i f V l r t 1n J City Planner Building Official Date: 1� f YAAt Date: POST IN CONSPICUOUS PLACE i J a z - H F J K u. x ui V 44 Z00 < kn Z 4 4 . , id Vii: tLC7 W t000000 0 Z w O x y� u. N W O a.=a < m c O W J t x O Q - - 0 V 0 OS ca la 2 0 000 < V c Ui X Z fr Z _ . xzr4 CZ al ,? 2 N CO) a 2 V FUl Z G O Z a. 0 1- p LU Lit w w w X 14. I`• a � 3rna. :E . v w a Z oC ❑ ❑ ❑ OD ❑ y °x cc o z a. a. a X 0 .� o a � o 1 44 Y g -+ 'ifi 49 x kco z O — z w w'NVI W u.SE 0 N re Z 1= zz5 -1 a O x z V C Oa Z w z °oo �a4r.r. iu 1_- 2 d ,!� o 0 0 G o u au. _ u. v, p 3 c) c) j N 0 D 5 -6= a 0 a ❑D ❑❑X❑ v � CSI X J - -J F- P. Li re W W < T Ili i W Z F, �,, t o ❑ ❑ ❑ ❑ o a U co1 Lu cc Q .._./ N O W � u ° » a m § o 0 ad ~ i2 0Ya -� 6 O I U IQ _ Z a C=) ��_ O W z � at) - W v. 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Applicant / �I (/t (Please type or print and sign at bottom) ADDRESS r- ZONING(office'40 1 fI iN ED(,EwArEIL. c1g1.4.e ME r Patio*, (.Ali{stmN S'53-71- f2/S.0 LEGAL DESCRIPTION(office use only) LOT 7 BLOCK ADDITION M Ase riN soN XS tie 0 PIDZ5, 057. 009. 0 OWNER (Name) - GFR`{ WtAMA L. (Phone) fotz.tBZ.5 a5t (Address) 152-1•1 ED&EtmAr'Ea- c i at.t..t NE f PIE,..t LALs M N 55.3'72.. BUILDER (Company Name) TBD Ole 3vf 19- &Y owau E 4. (Phone) l 2.i 8 z.c8rZ (Contact Name) (Phone) _ (Address) TYPE OF WORKew Construction ©Deck ©Porch °Re-Roofing, ORe=Siding DLower Level Finish 0 Fireplace odition tjAiteration [futility Connection CODE: QI.R.C. ILB.C. 0 Misc. _ Type of Construction: I II III IVV A 67 Occupancy Group: ABE F Hi R S U Svtc.. PROJECT COST/VALUE $ I�i a0 O Division; 1 2 3 4 3 I (excluding land) ..__/ ���\ 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 coostntction will conform to all existing state and local laws and wilt proceed in accordance with submitted plans I am aware that the buihling official can revoke ibis permit for just cause Furthermore,I hereby agree that the city official or a designee may enter upon the property to perform needed mxpcnnms x L.\ LLC__ 04410/6 IL 9.1 T.17 Signature Contractor's License No. Date Permit Valuation ZZ k t ©,moi ' Park Support Fee # $ Permit Fee $ SAC # $ _ 1'11 et 50 Plan Check Fee $ ( l C%'. 105 Water Meter Size 5/8";1"; $ _ State Surcharge $ C lv SO Pressure Reducer $ ` Penalty $ Sewer/Water Connection Fee # $ Plumbing Permit Fee $ v Water Tower Fee # $ N a Mechanical Permit Fee $ 5--4 .CO Builder's Deposit Sewer&Water Permit Fee $ Other $ a. 1, Gas Fireplace Permit Fee $ f 4.,5 TOTAI DISE C� l�/i6/I - S�i� . '� lttitiM ThisAppii t B ,'suesYour Building Permit Wil A roved Paid 3Z(Q,/e R ipt Na. ( ,7z6 7 ` 1 Date !'Ze.'/ � tilt g 'lii' ... ate / 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 oustttu. , mporaiy Certificate of Zoning compliance and allows construction to commence. Before occupancy,a Certificate of Occupancy must be issued r---g 7« ff Plannin S hector DateSpecial Conditions,if any 24 hour notice for all inspections(9s2)447-9850,fax(952)447-4245 4646 Dakota Street Prior Lake,MN 55372 ORiot. CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd TEMPORARY CERTIFICATE OF ZONING COMPLIANCE 2 c AND UTILITY CONNECTION PERMIT , 2.0. 4.3 rt frPteigViar/O4 40+NBScio. 1. White File 2Pink City PERMIT NO. /3 /3 7 . 3 Yellow Applicant (Please type or print and sign at bottom) ADDRESS ZONING(office use) 1 c 2 l '( EbGe )Ar et4LL 111E LEGAL DESCRIPTION(office use only) LOT BLOCK ADDITION PID OWNER (Name) J 4-4-f.1 l v e.ti ale( (Phone) 4 i 2 .zg'2, S$S 2. (Address) i s 21 K b 661,4J ATe rt C l tt-C t.E iV 6- BUILDER (Company Name) O wAJL fZ- (Phone) (Contact Name) (Phone) (Address) TYPE OF WORK 0 New Construction DDeck ['Porch ❑Re-Roofing ORe-Siding , Lower Level Finish 0 Fireplace ❑Addition ❑Alteration ❑Utility Connection CODE: DLR.C. DI.B.C. 0 Misc. Type of Construction: I II III IV V A B PROJECT COST/VALUE $ Occupancy Group: A B E F H I M R SU (excluding land) Division: 1 2 3 4 5 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 dust cause Furthermore,I hereby agree that the city official or a designee may enter upon the property to perform needed inspections. X 1'''l CALL" 2. . zo , l 3 Signature Contractor's License No. Date Permit Valuation 4/ p 00 . U p Park Support Fee # $ Permit Fee $ F-1 Z$ SAC # $ Plan Check Fee $ Water Meter Size 5/8"; 1"; $ State Surcharge $ 0 U Pressure Reducer $ Penalty $ Sewer/Water Connection Fee # $ Plumbing Permit Fee $ _ .-.4 $1J Water Tower Fee # $ Mechanical Permit Fee $ Builder's Deposit $ Sewer&Water Permit Fee $ Other $ Gas Fireplace Permit Fee $ TOTAL DUE $ /43 7_5-- ,moi3 ..-- /� This Application Becomes Your Building Permit When Approved Paid 7 '/-f Re ipt No. (b Date 2 , Z—c). /S B , Building Official Date / 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 temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy,a Certificate of Occupancy must be issued_ PlanningDirector Date Special Conditions,if any 24 hour notice for all inspections(952)447-9850,fax(952)447-4245 4646 Dakota Street Prior Lake,MN 55372 4< r O� PRI() ti trr White -Building Canary -Engineering 4fINNESOtt. Pink -Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT APPLICATION RECEIVED '/ . /- - 1 The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: '- Accepted Accepted With Corrections Denied Reviewed By: / / ;. Date: 7--.77-i2 �� 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." (0; PRIp4 U xm White -Building Canary -Engineering �INNESO Pink -Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT APPLICATION RECEIVED 9_ /3-/2__ The Building, Engineering, and Planning Departments have reviewed the building permit: application for construction activity which is proposed at: /5214' � EG✓•9 T2 . Accepted ` Accepted With Corrections Denied Reviewed By: Date: //2-1.04- Comments: I - 63n--05 (4."7T -cam Wl F&-APC4A—T. cc•vt "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." h' `.} 1 4 4 p4 PRIp� White -Building Canary -Engineering 4flNNESOs•P Pink -Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT 64 ���� APPLICATION RECEIVED 43./2_ The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: /5a/4- 6736611//) CJ,- Accepted Accepted With Corrections Denied Reviewed By: Date: 7' Iz-- 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." I ' t vire), CITY OF PRIOR LAKE Date Reed 0 •4 li,-%-re HEATING/AIR CONDITIONING/FIREPLACE PERMIT : 1444* i Vo:C• * , 4444yEscitt. II Ihrik Fite PERMIT NO. 2.Yellow Applic (Please type or print and sign at bottom) 2 Green City ant ADDRESS i"S Ziele --Er-.,-- coil- de etRet - 4J5 ZONING(office u ie) PxioRLA-12Z- inAl s 37 2._ LEGAL DESCRIPTION(office use only) LOT BLOCK ' ADDITION PID ._ , _ .... OWNER (Name) -70-Ryt 1-4)0A10r--Z--- (Phone)oitZ, ---Vt-ec—o 7 S (Address) _ ,a , _ 44,,4„---,,- 0, A APPLICANT (Name)..S7M-A)04/A020E./66eXiet4„/ /14.547,414P4-C1014i6 41"fho..ne) (See —679 0-.--- 7 i (Address) LTV('e /4.7: ‘ # alx 4 A/4M 401 ( dress) (OW (Zip Code) (Contact Person) IA ....., 4 ' 6 P (Phone) , 7,7A — " f' _ -. 7 APPLICANT SIGNATURE-Orli 1.4•.! .40 N i 0 ' DATE4 ...... M '707 i ,.- APPLICANT PLEA E COMPL ,I " BELOW IRNEW CONSTRUCTION 0 REPLACEML T 0 ALTERATIONS FURNACE MAKE AND MODEL ...41 ats., 4 ' Pli)WPWZre-0/4 FUEL FLUE SIZE S Al RETURN a PENINGS INPUT kotoot OUTPUT C;f4 0-19 ] TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE: Air Conditioner 0Wann Air Plants 0 Steam Units and Fireplaces Cannot Encroach 0Gravity 0 Hot Water into Required Side Yard Setbacks. N... 0 Mechanical 0 Radiation Fireplaces with Box Additions or DAir Conditioning 0 Special Devices OVent.System 0 Other Devices Cantilevers to the Outside of Buildings Require a Building Permit. FIREPLACE MAKE AND MODEL FEE SCHEDULE Industrial,Commercial&Multi-Family I%of job cost Residential,Gas Fireplace $49.50 $49,50 minimum Residential,Heating&A/C(New Construction) $149.50 Residential,Additions&Alter mv. PAID WITH Residential, Residential,Heating Only(New Construction) $64.50 Residential,AC Only iLDIN riAU G Zsmn Estimated Cost$ Building Permit # The Minnesota Statutes,. '326E1.148 "SU RCI1ARGE"has been changed for one HEATING PERMIT FEE $ year effective STATE SURCHARGE $ .50 July 1,2(110.until June 30,2011. TOTAL PERMIT FEE $ The minimum surcharge for a"lied fee"permit (Office Use Only) is 1,5,,beginning Jul) 1,2010 This Application Becomes Your Building Permit When Approved Paid ' Receipt No. Date By Building Official Date 24 hour notice for alt inspections(952)447-9850,fax(952)447-4245 4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 .. .. . . PRIp4. Date Rec'd CITY OF PRIOR LAKE /D. /O. /7.-- g SEWER AND WATER PERMIT GYerellow en FCitiley PERMIT NO.iz 3. Gold Applicant (Please print and sign at bottom) ZONING(office use) (.S WeVIC Ci.,rC.I oV, LEGAL DESCRIPTION(office use only) LOT BLOCK ADDITION PID OWNER (Name) (Phone) (Address) (Address) (City) (Zip Code) ) bie-R ?-ed-4-7 AN(Name) (Phone)(Address) P (1 ?s �. s6--37R (Address) (City) (Zip Code) (Contact.Person) . J. (Phone) APPLICANT SIGNATURE, .. .►; ! V DATE iC/ � rd.-- APPLICANT PLEASE COMPLETE BELOW Size of water service inches. Location of any couplings from structure feet. Type of sewer pipe. El ABC ❑ PVC ❑ Cast Iron Estimated length of sewer line feet. Clean out(if required) located at feet from structure. FEE SCHEDULE Residential sewer and water line connection $51.50 Industrial,Com'l&Multi-family 1%of job cost with a$51.50 minimum Sewer connection only $25.50 Water connection only $25.50 Estimated Cost $ Building Permit# SEWER AND WATER PERMIT FEE $ STATE SURCHARGE $ .50 TOTAL PERMIT FEE $ 8 01 ha p ID WITH t vG (Office Use Only) This Application Becomes Your Building Permit When Approved Paid Receip Ai. Buildine Official Date Date ! It . BY VIE_ —_ I 24 hour notice for all inspections(952)447-9850,fax(952)447-4245 4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 04 RI Date Rec'd CITY OF PRIOR LAKE PLUMBING PERMIT I # I 6 0 I.Blue File 2.Gold APERMIT NO. �n City 3.Yellow Applicant V0 I v 1l (Please type ' t and sign at bottom) ADDRESS ZONING(office use) / 5-7- 4 c 06-& ci'c2-cLi LEGAL DESCRIPTION(office use only) LOT BLOCK ADDITION PID OWNER (Name) (Phone) (Address) tame T C.��GC , vvi'''t 4 1`w G- ice/`"(------ r.o,- •ddr-ssT " &1O & r_-&7- On - p 4-------5--7 . (Address) (City) (Zip Code) ontact Person 1446112. CC./.....!,....de (Phone) / 2-- V/Z- rk.4/ - .' T SIGNA • ///// DATE /--/‘-2-/3 mall / APPLICANT PLEASE COMPLETE BELOW Quantity Type of Fixture Quantity Type of Fixture Bath Tub with or without shower Rough-ins Dishwasher Water Heater Floor Drain Water Softener Lavatory(Bathroom Sink) Stand Pipe(Washing Machine) Laundry Tray(1 or 2 compartment sink Sewage Ejector Shower Stall Backflow Assembly Sinks Backflow Assembly Test Bar Sink Lawn Sprinkler Water Closet(Toilet) Other FEE SCHEDULE Industrial,Commercial&Multi-family 1%of job cost with a$49.50 minimum Residential,New One e a- amt y •1,'. t Residential, ' a ons&Alterations $49.50 Estimated Cost $ Building Perm' .. The Minnesota Statutes§326B.148 LJ (J \/ "SURCHARGE"has been extended PLUMBING PERMIT FEE $ until June 30,2013, ;TATE SURCHARGE $ .50 UR �►►//(1 at(—The minimum surcharge for a COTAL PERMIT FEE $ 3 "fixed fee"permit is$5.00 ._...•.-.YY=a....tszvm vc�.,aava I VW Duuutng Permit When Approved Paid Receipt No. Date By Building Official Date 24 hour notice for all inspections(952)447-9850,fax(952)447-4245 4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 ENT OF HOMELAND SECURITY ELEVATION CERTIFICATE EMERGENCY MANAGEMENT AGENCY OMB Na.16600008 nal Flood Insurance Program knportant Read the instructions on pages I--L" Explahan Dail.IWy 3'I,2015 SECTION A-PROPERTY INFORMATION f 1Rt0 , Al. Building Owner's Name Jerry Wendel A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. ri 15214 Edgewater Circle NE City Prior Lake State MN ZIP Code 55372 A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) Lot 9,MARTINSON ISLAND,Scott County,Minnesota(PIN=250570090) A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)Residential A5. Latitude/Longitude:Lat.4443'43,4" Long,93-25'48.8"Horizontal Datum: 0 NAD 1927 N NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) sq ft a) Square footage of attached garage sq ft b) Number of permanent flood openings in the crawlspace b) Number of permanent flood openings in the attached garage or enclosure(s)within 1.0 foot above adjacent grade within 1.0 foot above adjacent grade c) Total net area of flood openings in A8.b sq in c) Total net area of flood openings in A9.b sq in d) Engineered flood openings? 0 Yes ❑ No d) Engineered flood openings? ❑ Yes ❑ No SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION B1.NFIP Community Name&Community Number B2.County Name B3.State City of Prior Lake,Minnesota 270432 Scott Minnesota 94.Map/Panel Number B5.Suffix 86.FIRM Index Date B7.FIRM Panel B8.Flood $9 Base Flood Eleva6xi(s)(Zone 0002 C 7/26/1974 Effective/Revised Date Zone(s) AO,use base flood depth) 11/19/1997 X&AE 909.0 B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9. 0 FIS Profile FIRM 0 Community Determined 0 Other/Source: B11. Indicate elevation datum used for BFE in Item B9: N NGVD 1929 0 NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑ Yes N No Designation Date: ❑ CBRS ❑ OPA SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) Cl. Building elevations are based on: ❑ Construction Drawings* 0 Building Under Construction* N Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations-Zones A1-A30,AE,AH,A(with BFE),VE,V1 V30,V(with BFE),AR,AR/A,AR/AE,AR/A1 A30,AR/AH,AR/AO.Complete Items C2.a-h below according to the building diagram specified in Item A7.In Puerto Rico only,enter meters. Benchmark Utilized: Vedical Datum NOVO 1929 Indicate elevation datum used for the elevations in items a)through h)below. N NGVD 1929 0 NAVD 1988 0 Other/Source: Datum used for building elevations must be the same as that used for the BFE. Check the measurement used. a)Top of bottom floor(including basement,crawlspace,or enclosure floor) 909.3 N feet 0 meters b)Top of the next higher floor 910.2 N feet 0 meters c) Bottom of the lowest horizontal structural member(V Zones only) 0 feet 0 meters d)Attached garage(top of slab) 17.1 N feet 0 meters e)Lowest elevation of machinery or equipment servicing the building IJ feet 0 meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished)grade next to building(LAG) 992.3 N feet 0 meters g)Highest adjacent(finished)grade next to building(HAG) gizo N feet 0 meters h)Lowest adjacent grade at lowest elevation of deck or stairs,including structural support 2Q2.2 N feet 0 meters SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation information.I certify that the information on this Certificate represents my best efforts to interpret the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a Check here if attachments. licensed land surveyor? N Yes 0 No Certifier's Name Scott M.Swanson License Number 42309 Title President Company Name Valley Surveying Co.,P.A. Address 16670 Franklin Trail SE City Prior Lake State MN ZIP Code 55372 Signature = Date 12/13/13 Telephone 952-447-2570 •N CERTIFICATE, page 2 •RTANT:In these spaces,copy the corresponding information from Section A. FOR INSURANCECOMPANY USE Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Poky Number 15214 Edgewater Circle NE City Prior Lake State MN ZIP Code 55372 Canpiuy tM1C Nrrraber SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED) Copy both sides of this Elevation Certificate for(1)community official,(2)insurance agent/company,and(3)building owner. Comments The subject home is a walkout rambler.The enlcosed lower garage/storage area has an existing finished floor elevation of 909.3.,the main lower level floor is at elevation 910.0 and the first floor is at elevation 920.8.All elevation are on NGVD'29adj. 7 Sig - Date 12/13/13 SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WITHOUT BFE) For Zones AO and A(without BFE),complete Items E1-E5.If the Certificate is intended to support a LOMA or LOMR-F request,complete Sections A,B, and C.For Items E1-E4,use natural grade,if available.Check the measurement used.In Puerto Rico only,enter meters. E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade(HAG)and the lowest adjacent grade(LAG). a)Top of bottom floor(including basement,crawlspace,or enclosure)is 0 feet ❑meters 0 above or 0 below the HAG. b)Top of bottom floor(including basement,crawlspace,or enclosure)is ❑feet ❑meters ❑above or❑ below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions),the next higher floor (elevation C2.b in the diagrams)of the building is 0 feet ❑meters ❑above or 0 below the HAG. E3. Attached garage(top of slab)is 0 feet 0 meters ❑above or ❑below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is ❑feet 0 meters ❑above or❑below the HAG. E5. Zone AO only: If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? 13 Yes ❑ No 0 Unknown.The local official must certify this information in Section G. SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION .....ter. The property owner or owner's authorized representative who completes Sections A,B,and E for Zone A(without a FEMA-issued or community-issued BFE) or Zone AO must sign here.The statements in Sections A,B,and E are correct to the best of my knowledge. Property Owner's or Owner's Authorized Representative's Name Address City State ZIP Code Signature Date Telephone Comments J1 Check here if attachments. SECTION G-COMMUNITY INFORMATION(OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E),and G of this Elevation Certificate.Complete the applicable item(s)and sign below.Check the measurement used in Items G8-G10.In Puerto Rico only,enter meters. G1.0 The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor,engineer,or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2.❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or Zone AO. G3.❑ The following Information(Items G4-G10)is provided for community floodplain management purposes. G4.Permit Number G5. Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been issued for. 0 New Construction 0 Substantial Improvement G8. Elevation of as built lowest floor(including basement)of the building: 0 feet ❑meters Datum G9. BFE or(in Zone AO)depth of flooding at the building ske: 0 feet 0 meters Datum G10.Community's design flood elevation: 0 feet 0 meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments ii Check here if attachments. CI) January 30, 2014 Comfort Innovations L L C 9601 245th St E Lakeville, MN 55044 Attention: Mr. Rick Berg Our Reference: 13CA33163 Subject: Field Evaluation of Vented Direct Vent Gas-Fired Fireplace Dear Mr. Berg: UL has completed a Field Evaluation of the above subject equipment. Please find attached one electronic copy of the final report(s)for this project. With the issuing of this report,we are closing this project and notifying our accounting department to invoice you for any outstanding charges. This report should be reviewed to verify that the information provided is complete and correct, and to determine whether further action may be required by the AHJ for final approval of the installation. If you have any questions, or if we can be of service in future projects please do not hesitate to call anytime. Kind regards, Cathy Sledjeski Administrative Specialist I Field Engineering Services Direct Line: 813-253-9489 Email: Cathy.Sledjeski@ul.com CC: Mr. Paul Baumgartner- Building Inspector, City of Prior Lake UL LLC 333 Pfingsten Road,Northbrook,IL 60062-2096 USA T:847.272.8800/F:847.272.8129/W:UL.com Ch) Field Evaluation Services Final Report For Vented Direct Vent Gas-Fired Fireplace (01) Requested by: Comfort Innovations L L C 9601 245th St. E Lakeville, MN 55044 Project Number- 13CA33163 Installation Site and Authority Having Jurisdiction: Jerry Wendel, 15214 Edgewater Circle NE, Prior Lake, MN 55372 City of Prior Lake, Prior Lake, MN Report by: Ro-b-e4f J. Zi. -im.a.w Reviewed by: kj 1 Cast en. Robert J. Zimmerman Jr. Christine A. Hansen UL LLC 333 Pfingsten Road,Northbrook,IL 60062-2096 USA T:847.272.8800/F:847.272.8129/W:UL.com Report Date: January 15,2014 Table of Contents 1 Executive Summary 3 2 Conditions of Acceptability 3 3 Referenced Standards 4 4 Product Description 4 4.1 Nameplate Data 5 4.2 Field Evaluation Label 6 5 Evaluation Discrepancies 6 6 Evaluation Details 6 6.1 Critical Components 6 6.2 Combustion Chamber and Exhaust System 6 6.3 Fuel System 7 6.4 Grounding and Bonding 7 6.5 Guarding of Live Parts 7 6.6 Ignition System 7 6.7 Mechanical Protection 8 6.8 Mounting of Components 8 6.9 Wiring and Wiring Methods 8 7 Test Results 9 8 Test Equipment 9 9 Photographs 10 2013-5411-FE Field Evaluation Services Report Page 2 of 10 1 Executive Summary Federal OSHA requirements mandate that all electrical equipment in the workplace be certified"or subjected to a complete and thorough evaluation before use(29 CFR 1910.303 and 1910.399). Many state, county and city electrical jurisdictions have similar requirements.A UL Field Evaluation is an accepted approach to meet this requirement; UL conducts an unbiased, independent assessment of products at a specific location to essential requirements of applicable product safety standard(s). UL's engineering assessment informs regulating authorities who make product and related installation approval decisions. Please note that the regulating authority for the final installation site provides final approval of this equipment and the installation. This project's purpose was to evaluate a product that was not Listed or otherwise certified by a testing laboratory recognized by the authority having jurisdiction. Products undergoing this evaluation process do not acquire a UL Listing, UL Recognition, or UL Classification. UL has not established factory Follow-Up Services to determine the conformance of any subsequently produced, relocated, or otherwise altered product(s)or system(s). Installation model codes are referenced in this document where necessary to ensure the product can be properly installed according to the code(e.g. National Electrical Code, NFPA 70). At the request of Mr. Rick Berg of Comfort Innovations L L C, a Field Evaluation project was initiated. A Final Evaluation was completed at: • Jerry Wendel, 15214 Edgewater Circle NE, Prior Lake, MN Based on the inspection,testing, and evaluation completed, UL considers the product to be suitable for application of the Field Evaluation Product Mark and for use in accordance with any conditions of acceptability stated in this report. 2 Conditions of Acceptability Except where otherwise stated in the product description and evaluation sections of this report,this evaluation and the application of the Field Evaluated Product Mark is subject to the following Conditions of Acceptability. 2.1 Except for like-for-like component replacement in the event of component failure, no change or addition to the product or system shall be made that would alter its construction, operation, function, layout, source of supply, physical location or operating environment. If such changes or additions to the product occur,the Field Evaluated Product Mark shall be considered invalid, and a separate evaluation shall be required to determine compliance with applicable product safety standards under the changed conditions. 2.2 The completed evaluation and application of the UL Field Evaluated Product Mark by UL does not assume liability on the part of UL and does not relieve the manufacturer, installer, user, or other relevant parties of their responsibilities.The product evaluation is based on adherence to sound engineering practices, and compliance with the applicable product safety standards and installation code. 2013-5411-FE Field Evaluation Services Report Page 3 of 10 2.3 This evaluation considered the risks associated with electric shock, fire, and casualty hazards as specified in the evaluation section of the report only. No other hazards were evaluated during this evaluation. 2.4 Unless otherwise stated in the product description,this product was evaluated for installation in an indoor, dry, normal environment only.The product was not evaluated for installation in any hazardous classified location as defined in the latest edition National Electrical Code as adopted by the National Fire Protection Association.The product was not evaluated for installation in an environment subject to rainfall,water spray, steam, or exposure to any corrosive chemicals that deteriorate the enclosure or components. 2.5 The UL Field Evaluated Product Mark shall not be considered as equivalent to the UL Listing Mark, UL Recognized Component Mark, or UL Classified Product Mark.The UL Field Evaluated Product Mark indicates compliance with the applicable parts of the Standards referenced in Section 3 at the time the Mark was applied, and considering only the final installation site.The applicable parts included in the evaluation are the construction review, markings, and those testing protocols that are non-destructive. 3 Referenced Standards • CSA-AM Z21.50,Vented Gas Appliances, 5th Edition, Revised 02/01/2009 4 Product Description Equipment Name: Vented Direct Vent Gas-Fired Fireplace (01) FY1 , 2013-5411-FE Field Evaluation Services Report Page 4 of 10 Description: The single sided vented natural gas-fired fireplace employs a firebox size of 5 ft.wide by 16 in. high by 22 in. deep. The unit is installed in a residential family room against a non-combustible wall. The unit is surrounded with non-combustible cement board at the top, bottom, and sides of the unit. The unit employs a tempered glass panel on the outer opening. The inner opening employs a ceramic glass panel inner.The glass panels are mounted into a glass frame,which is retained into the"U"channel frame.The unit hearth consists of a layer of decorative rock that covers the firebox bottom pan,with the exception of the burner tube area. In the center of the firebox bottom is the burner assembly,which runs left to right for the full length of the firebox. The burner assembly is contained in the center of the assembly and employs a layer of sand covering the burner tube; it is retained by a metallic containment. The burner is ignited by one intermittent pilot ignition assembly manufactured by American Flame Systems Inc. The ignition system is operated by an on/off switch mounted to an adjacent wall. The igniter is located at the center at the back of the burner assembly. Access to the gas components is through the removal of the glass doors and base pan of the unit by screws. Products of combustion are vented through a UL Listed 6 in. ID Type B Gas Venting System installed off the unit top via a venting run of 90 deg. elbow off the unit top to 4 ft. horizontal to 90 deg. elbow to 17 ft. vertical, then terminates to a certified power ventilation system. The ventilator is wired to the ignition system of the fireplace where, if the ventilator does not operate,the unit then will not operate. The venting system is enclosed with non-combustible cement board maintaining a minimum clearance of 6 in. to the vent.The exposed front of the fireplace and vent chase are covered with decorative brick. A combustible wood mantle circles the front and sides of the fireplace assembly.The mantle is sized 8 in. above the glass top surface,6 in. deep, and 4 in. high.The front opening above the fireplace employs a combustible wood face for a flat panel TV. The wood panel is mounted to non-combustible cement board sized 71 in. long by 43 in. high. Manufacturer: Comfort Innovations LLC Model Number: 016 Serial Number: Not Specified 4.1 Nameplate Data Electrical Ratings Volts 120 Vac Amps 1.2 A Phase 1 Wire 2 Frequency 60 Hz Gas System Combustion Gas Natural Max. Manifold Pressure 3.5 In.W.C. Min. Gas Supply Pressure 1.5 psig 2013-5411-FE Field Evaluation Services Report Page 5 of 10 4.2 Field Evaluation Label UL Engineers have determined that the subject product complied with the Standards referenced in Section 3 and the following UL Field Evaluated Product marks were applied. • FE-373986 Date Applied: 12/02/2013 5 Evaluation Discrepancies This section details the non-compliant findings of the preliminary evaluation. Unless corrective actions are described, a final evaluation is necessary to complete all remaining tests and verify that changes have rendered the equipment compliant. • No Discrepancies Found. 6 Evaluation Details The following specific areas were evaluated using the methods described.All items comply with the applicable parts of standard(s) referenced in Section 3.0, unless stated otherwise in Section 5.0 of this report.Additional characteristics and features unique to the product were further addressed as deemed necessary considering the final installation site, or as required by the applicable product safety standard(s). 6.1 Critical Components Method: The following critical components were inspected for evidence of Listing or Recognition according to UL policies: - Switches and Controllers - Transformers and Power Supplies - Wire and Cables - Safety Shutoff Valves - Fittings/Piping Results: The critical components are Listed or Recognized by a testing laboratory acceptable to UL according to UL policies. 6.2 Combustion Chamber and Exhaust System Method: Heating components and surfaces of the combustion chamber and exhaust system are visually inspected for suitability. Results: Design and assembly of heating and exhaust system construction are acceptable when considering the materials employed and the strength, rigidity and durability necessary for the intended use. 2013-5411-FE Field Evaluation Services Report Page 6 of 10 6.3 Fuel System Method: Burner piping components such as the main automatic gas shutoff valve, main manual gas shutoff valve, pressure regulator and the like are examined for suitability of the installation, whether factory or field installed. Results: Each main burner supply line is equipped with a safety shutoff valve or valves that close, independent of external force,to provide tight shutoff under normal operating conditions. Manually operated shutoff valves are suitable for the working fluid, accessible and permanently marked with their operating positions. Gas pressure regulators are provided and suitable for the installation. 6.4 Grounding and Bonding Method: All accessible metal parts are verified(visually and/or by test)to be bonded together and to be connected to the supply equipment grounding conductor.Where applicable, a bonding continuity test is conducted and the results recorded. Results: The product is grounded and bonded according to applicable standards referenced in Section 3.0 and Article 250 of the NEC. The product has an identified terminal to connect the supply equipment grounding conductor or a suitable cord with an integral equipment grounding conductor. 6.5 Guarding of Live Parts Method: The product is visually inspected to ensure that all components were housed in a suitable enclosure and made effectively inaccessible to unauthorized persons.An articulated finger probe is used to measure access where necessary.Vent openings are verified not to align with potential discharge paths of gases expelled from circuit breakers when clearing fault conditions. Results: Enclosures prevent contact with moving parts, electrically energized parts and hot parts. Enclosures provide an acceptable degree of protection for internal components(according to the product's installation environment). All electrically live parts external to the enclosure are guarded as required by the applicable standards. No electrically hazardous energized parts are accessible from the exterior of the ultimate enclosure as required by Section 110.27 of the NEC. 6.6 Ignition System Method: The electric ignition and/or pilot flame system is examined for compliance with the reference standard. Results: The ignition system is suitable for the firing rate and design of the equipment. The electric igniter, pilot burner and pilot and main burner flame-sensing devices are installed as appropriate and fixed in position.The ignition cable voltage rating is equal to or greater than the rated secondary voltage of the ignition transformer. 2013-5411-FE Field Evaluation Services Report Page 7 of 10 6.7 Mechanical Protection Method: Moving parts,such as rotors of motors, chains, pulleys, belts and gears are evaluated for risk of injury to persons.The degree of protection required depends upon the general design and intended use of the product. The factors considered in judging the acceptability of exposed moving parts are: a)The degree of exposure, b)The sharpness of the moving parts, c)The likelihood of unintentional contact with the moving parts, d)The speed of movement of those parts, and e)The likelihood of fingers, arms or clothing being drawn into the moving parts, such as at points where gears mesh,where belts travel onto a pulley or where moving parts close in a pinching or shearing action. Results: Exposed moving parts are enclosed or guarded to reduce the risk of injury to persons. 6.8 Mounting of Components Method: Components that support live parts and uninsulated current carrying parts are secured to prevent them from turning or shifting in position if such motion may result in a reduction of spacings below the minimum acceptable values. Friction between surfaces is not acceptable as a means of preventing shifting or turning of a live part. Result: Components are mounted such that they are fixed in place and protected from a reduction in electrical spacings and strain on wiring terminations. 6.9 Wiring and Wiring Methods Method: All conductors were inspected for Listing or Recognition by a nationally recognized testing laboratory according to UL policies. The conductors were examined for proper ratings (voltage, ampacity,temperature, flexibility,flame and environmental ratings)as required for the application.The wiring methods were verified to comply with the applicable standards and provide proper physical protection, including strain relief,where applicable.The wiring terminations were inspected for correct application, number of conductors according to their Listing and correct ampacity based on temperature ratings. Results: Details as follows: 6.9.1 Supply Connections The supply connection point(s) have proper terminals and identification provided. 6.9.2 Wiring Methods Internal wiring methods are in compliance with the requirements of the applicable standard(s). All wiring is routed, secured and protected from moving parts, external heat sources and sharp edges. 6.9.3 Separation of Circuits Unless provided with insulation rated for the highest voltage involved, low voltage and line voltage circuit wires within enclosures are segregated or separated by barriers. The product wiring for low voltage and line voltage circuits outside enclosures is installed in separate raceways or wireways. 2013-5411-FE Field Evaluation Services Report Page 8 of 10 6.9.4 Wire Terminations All wire terminations are suitable for the number and the size of conductor(s) installed. 6.9.5 Strain Relief External conductors, cable assemblies entering enclosures and internal conductors are secured to prevent strain being transmitted to terminations. 6.9.6 Conduit Connections All conduits, gutters, and wireways are properly supported and properly sized for the number and size of conductors. 7 Test Results The following tests verified that the product operates within normally expected parameters. Unless stated otherwise in Section 5.0, all the following items comply with the applicable part(s)of the referenced standard(s). Field evaluation test methods follow the applicable standards as closely as practical, considering the limits of a non-laboratory field setting and the need for the equipment to perform its function following the test. 1. Test Pressure and Burner Adjustments, Sec. 2.3 2. Combustion, Sec. 2.4 3. Burner Operating Characteristics, Sec. 2.6 4. Direct Ignition Systems, Sec. 2.10 5. Glass Fronts, Sec. 2.13 6. Impact Test of Glass Materials, Sec. 2.14 7. Water Shock, Sec.2.15 8. Main Burner Temperatures, Sec.2.16 9. Wall, Floor and Ceiling Temperatures, Sec.2.23 10. Surface Temperatures, Sec. 2.25 11. Evaluation of Clothing Ignition Potential, Sec. 2.26 12. Dielectric Voltage Withstand, Sec. F.1.41 8 Test Equipment All test equipment used to evaluate product(s)covered by this report that may have an effect on test results was calibrated and traceable to the National Institute of Standards and Technology(NIST)or other national metrology institution and managed according to ISO/IEC 17025, General Requirements for the Competence of Calibration and Testing Laboratories. 2013-5411-FE Field Evaluation Services Report Page 9 of 10 9 Photographs r '3` d , „x e ix3 x ,�; 7 } 0 a k i 14,5 OF Photo 1 — Unit Assembl 2013-5411-FE Field Evaluation Services Report Page 10 of 10 12-i01.1 L Foivrisk Everts June 16, 2013 Jerry Wendel 15214 Edgewater Circle NE Prior Lake, MN 55372 Re: Wendel Residence Dear Jerry: At your request, I visited the residence located at 15214 Edgewater Circle NE, Prior Lake,MN. The purpose of the visit was to review the entry framing for the home. Based on my load calculations and observation,the entry framing and loading to the existing garage roof is in accordance with my design requirements. Please contact me with any questions or clarifications. Sincerely, FORENSIC EXPERTS Thomas J. Downs,P.E. FACI President (612) 840-4992 Thomas@ForensicExpertspllc.co m 4913 Three Points Blvd. Minneapolis, MN 55364 PRIOR LAK EDEPARTiAENT OF BUILDING AND INSPECTIONP ECTION INSPECTION R SITE ADDRESS (ca( ' �� - .. C .c NATURE OF WORK A-� I r,e),....1 USE OF BUILDING &s /z PERMIT NO. I Z-- ‘®c -( DATE ISSUED cf iata,72-- CONTRACTOR , iz-tom c NoEt-- PHONE CP(z-agz - Sag NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW THE PERMIT IS BY SEPARATE DOCUMENT ,,�� INSPECTOR DA FOOTING ;� f° ' �„zi"Z R,} - ro f z- I FOUNDATION (Prior to Backfill) ��'9vz D PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ROUGH - INS SEWER/WATER /SEPTIC M* M //AA.,_ FRAMING L yy7; 05 __ /WZY INSULATION ELECTRICAL PLUMBING Af //,I)-, HEATING (if required) ��?i}<;� FIREPLACE GAS LINE AIR TEST ^ d C COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED i' w /PP Si 13 L1 'e /- FINALS GRADING (Prior to Soddi9) , BUILDING rerik --F.Vok-M(9 0 2/5--- ,t ..._ w ELECTRICAL PLUMBING MJF --h t2,( (r7 HEATING _Yf..i V\ lit, - DO NOT OCUNTIL ABOVE HAS BEEN SIGNED 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