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HomeMy WebLinkAboutBldg Permit 04-1233 O~ PH/O", ;;., (' '" " - :>: u " ""J''''NESO~\'' CITY OF PRIOR LAKE BUILDING PERMIT, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE AND UTILITY CONNECTION PERMIT Date Rec' d I"Z-. c,. c4- See Main File White Pink Yellow File City Applicant I PERMIT NO. 04-. / z33 (Please tvne or mot and sip at bottom) ADDRESS nY-I;;> ~.a"+;-=(Jl. 0v. S. t:::.- ZONING (office use) 1<- Z. LEGAL DESCRIPTION (office use onl~ LO~ BLOCK g. ADDITION l).,-..,.--0 ~\& not!'\. PID Zb-" 4-01. 04- S. 0 OWNER (Name) (Phone) (Address) BUILDER ~ R I-\ov-to,",,- ~ (. (Company Name).j....J. . (Contact Name) M;'L-.:.... LLJoh",ou....-{ ~ (Address) a.o~1coO K","'b.-,~c-'i(. (':::si-c:.. \= ~V..,...".. L~"I -,'SD.....'-l- (Phone) CfS'd- "l'i::';';.- I~~ (Phone) ctS;}- d:d-<."... ~f38- -J TYPE OF WORK. -Xl New Construction DDeck OPorch ORe. Roofing ORe-Siding DLower Level Finish 0 Fireplace '[]').ddition DAlteration DUtility Connection 0 Mise. CODE: DI.R.C. ~I.B.C. Type of Construction: Occupancy Group: A B Division: I E II F (fJ IIIIV@A(!) HIM@SU 2 3 4 5 PROJECT COST/VALUE $ (excluding land) \ d- '4, 300<2- 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 authoflzed 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 lhe building official can revoke this pe~ause Furthe~ore. I hereby agree that the city official or a designee may enter upon the property to perform needed Inspections X Q/ ,~ ;;Loa:;$b <;;;7J ----<: . . Signature Contractor's License No. Date " Permit Valuation ~(L(I. OO(J.QO Park Support Fee # $ I Permit Fee $ ., SAC # $ /35'0,00 I l2.qq .50 Water Meter < ~5/~ 1"; Plan Check Fee $ g'lt{, foR' $2~(], 00 I State Surcharge $ 7o,.('"l') Pressure Reducer $ 4':;.00 I Penalty $ Sewer/Water Connection Fee # $ I ZttJO. 00 I Plumbing Permit Fee $ /O(),tJ d Water Tower Fee # $ 700,00 I Mechanical Permit Fee $ !O(J.OfJ Builder's Deposit $ I Sewer & Water Permit Fee $ 65,$"0 Other $ I Gas Fireplace Permit Fee $ 40, {Jo TOTAL DUE $ (p, 0.56 1f31 ..., This Application Becomes Your Building Pennit When Approved Paid f..O.!CIX' ~~ce?- "ff"" r. 0 Je' ~ ~ /dtilot( Date fL z-z. 01- Buildl11!'! omcial r 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 requcsled. This documenl ~~=~ Plann~po,,~ C,nifi,,,, ~~;.o~~2n~'nd allow, "'nstwetinn to smee"oIVl'afil"FiIe most b, P".omng Duoet"' 0 Dale Special Condition,. it any 24 hour notice for all inspections (952) 447~9850. fax (952) 447-4245 16200 Eagle Creek Avenue Prior Lake. MN 55372 ~~ See rVlaJD }"ile White - Building Canary - !;!1",ineering ,.... t-l'1~K~ - ....Iannlng~ Th.. C..nle. of lh.. 1.8k.. Counl~ BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT / j., . / ">-(/' . 1-' APPLICATION RECEIVED J L' ( 4-- The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: / / ~~ / / ,i ;'J C: /. ,':"-/ i~ t. .~ 1-/ // Accepted ,,/' Accepted With Corrections Denied Reviewed By: ~ ~t.; Date: Ie-It.! jot! 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." . , \ ;-' . \1 " '" ,@~:fPKjOI? < '"' . !5 ~?; See IVIaiu File C'Alhit" . Buil~ Canary - Engineering Pink - Planning Ih~ C~nl~r..f lh~ L.k~ Counlr~ BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT D. 12-. HO/2-tol'j /2.- A, 04-' APPLICATION RECEIVED The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: 174-7 Z- OCt:/Z-F/6 (J) PIZAVb Accepted ~ Accepted With Corrections Denied Reviewed By: ~ . 9-~ Date: ;z/; <(;IoY I Comments: See l\tairrFilc "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." " ~~ u.~ White " Buil!!in!!. _ . C:Canarv _" En9lneem!!1-> Pink - Planning ,r ThC'('rnlC'r <If the' 1..krCounlMi BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT APPLICATION RECEIVED I .i<..:. _ (:" . !., -4--'" The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: ; ';.-f / / '<-1' <---- .l.) t:': / t.~-" /,/(.... j,) / V"t:'- Accepted x " Accepted With Corrections Denied Reviewed By: 1h4/S <e~ /J1&.1 /. h I ( Date: J z -/~'c:J/ 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," 12/14/2004 TUE 16:46 FAX 6513226147 GENZ-RYAN ~ 006/009 Date Rec'd CITY ,OF PRIOR LAKE SEWER AND WATER PERMIT q'lease t'tP~ ororin~andsim'atbottOm) ADDRESS. I I "1 'I-.. n'1 . 1;).1 ){~J2,h Jl (al 1)11- ~/f;- ;~:, ~\~ I PERMIT NO,O+ 1?..,T;l 3. Gold Appb"'lIl . ,J~;:J ZONING (offir,u,,) LEGAL DESCRIPTION (office use only) LOT(#BLOCK ,:;2.. ADDITION b..tt i<l.h p( rJ 1I-UO Pill OWNER (Name) D~ liQrtol< (;'1--"- Ilom€: (Address) 2o'iXoO ~Bi<-\bCe Cr SwIM (AddIe,,) (Phone) _ L.au~ i lie.. (City) o/~-q85-18()/\ 06'JWU (Zit) Code) - APPUCANT (Name) Genz-Ryan Plumbing & Heating (phone) 651-423-1144 (Address) 14745 So Robert Trail ~JCANT SIGNATURE r;& 1 ~rS~ fn 11 S _ /l (1) tJith ) i11ll j) Rosemount. MN (Cily) 55068 (Zip Code) (Contact Person) . (phone) 651-423-1144 ,I DATE ( ;:) -{ J-{)l/o APPLICANT PLEASE COMPLETE BELOW Size of water service inches. Location of any couplings from structure feet. Type of sewer pipe, 0 ABC 0 PVC 0 Cast Iron Estimated length of sewer line feet. Clean out (if required) located at feet from structure. Residential sewer and water linc connection Sewer connection only FEE SCHEDULE $35,50 Industrial, Com'l & Multi-family $17.50 Water connection only I % of job cosL with a $39.50 minimum $17.50 Estimated Cost $ Building Pennit # SEWER AND WATER PERMIT FEE STATE SURCHARGE TOTAL PERMIT FEE $ $ $ .1WD wrrH ~PBUT (Office Use. Only) j This Application Becomes Your Building Permit Wheu Approved , -- Building Official I Paid I Date - Da" r~c 'I 7 ?nn~ 24 hour notice for all inspections (951) 447-9850, fax (951) 447-4245 , Receipt No. I By I, I MAr'-12-2005!THUi 16: 0:3 p, 004/004 .'.. . CITY OF PRIORLAK:E.. . /:~:A;.t:~(;/AJR CONDITIONINC~PLACE PERMIT.. i . .... . '-. -, " ',:,,; '. : ';~ , . .. -'. 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'~'~., ".::';':'~";""::':;"';:!~'~i.~:,~~,C DATP;:::.;:,.:;~,;:I.' ",,~,<:,,'~;~~~'o'9~::~:(d::,;'~;1.:\':;;-,~,.:. .:.:.;,\i;/;ijtt::i'.:'~::':',i?~XJ2~j1;z?!f.~i~~i~~)iffll~AN1;.PLEA$E,6~~~~~i~~i~~{,.;:~)t:;::.X::;lir:iX,~,,1\j;:;ti"fiFi':-g.:,. . .. "i;".:".,:.,;::;:. ..... :''''''.1 :>':"::'''''''''''''~:C01'1$1(l;UCnON' . F,1 REPLA:€B-i"fEf;T",,,:,-,". ' GT;AL'IER:Anoj<:(~.r''', .~:. '; : ",.,,: ...:..,. ,.... " .' "." )~."" 1 '.~;":' :,,'.",,!;:-..~;,,)~~~~::::!~.,;,.....,.~..::-,.,. ,_.,':'.",' .'.. w . .' ';~i ~fV ~"\~ "." -,~; ." ,. ,'" <..,' , , ..-'.} v" '~~ \~'~, ,- .;,..;' ;'1' ,:i:i:nW"'GE~':ii.#D:'&l:'oPl':L~,;g~yA.:~~ ?'11'1A::t:..."d4f~~i:::ji5" '. ~~:,.Briit.::&ri:, :6Al~:;_:;": , hifl%~~5'\:,#~~~~:,:f~r1:KI~~~@mGS ....6.... ";:';~'wr~.;.;~~~.?~.~.'.:9,~~;.i~(~;%~;i " : ;,' ". ;.,.... .,': '.'];'fB-g:<::fE'~-"q;a:.....'.: ,.. HEA1'l}tG,ElR:EOWER,PI:.AN!',;',,;........,,.... u.l.,.."...,"':',."...".~ '. I,:'".' ". :,,'~I:.;,~!;:,~;~lIi.: ~r,.,:-t"ti;~I;;~;~"_:'.;,r": ' '. "d""r~"r~~ ,\ .:.., ~"'l'''. ," . '. ".,' I, ........y;.I!J.:..s:i:o't:.' .,,,,~;q7..,... , '\'(1", -. ,,- .o,J....... i:':i ~,'}:~ ~'1.", ',.,.,-",-,.' :,J;3'LJ::,of';':;,b\,NQ'~'",-~.<,:,~, "',.' . I,. "... QJ'.,.1.I .:1111::.. L ;;1U:;;aI'D, ,~\^t!' ...,...., - .', ". ,.. .,...,....'"'r.:~~:'i;'~I.;l"""~I. . " ......~.....:......',':'.......~....','..,....~,:~.'....:..::....,';...,_~....:~..:....'.,.~.:...:...:,..'..,..,:...':...~..............::..;....:'..:.:,.:~~:~~tt...;.:.~,;,.,~.iillt...'.~.'..:.,...i..:..,.;...g......:,.':..:.....'~...:.;,..'......,....'..:..,..,:,.'.:..... .. ~:;;::~~~!,:>>" ,"., . ',' - " ~~:;::;;::~:~:.:: ...' ., I' ~~~FA:"~~,~:.' . '. ~':.~:~~.~!....... ~:;:.>b..~~,'~.,.~"i.r.'._.;.'.i",.~:~.".'.J.:.',.?;.:.:.::'..,..:.!..,..~~~...~..:~'.:;". :'~\:~~~~~~I~;;;f~; ... . / . !i'll~P.o \;;.J... C.Ii.i. .. '. . .'. :.'.,:.>/~.\:;;:t~,~J:.'.:';~\:{:~\7i'~r~>/.~i;;!~:" <':',' <::'.::<:":'fJ~(f:w~l~t;ff)'.:::, FEE scrm~fiL;;S':,;:':' .:',{',. ":.' ... C:.',' >.;..' . . .In'dtistriat~ Gom:mcrcial:&~'Mula.:FamiIY;;: :' '. . '.. 1%' of job cost. .. ,..:Ttcitddi~a(Gas"F~~l~c:.' " ,.~:,:.~\~.~~~>,:~'t',,:: . '.. .. .,;: .' ~,'.t:.'i.;:.;t?~~?'i~::;.~,r;.'::;. S39.50'minimum ' ,:,.".>r~.:..:....:'~.,;;;r.7_,:;".; " . " .. ' ,. J;'../':-' R;sio<:nti.1, HC:.ti~g&;A(c:,@w:G:oli:itl'UCtion) $9950 Rdiil""tiaL Additiorul & AILi:r.U;on;. . ..-S39,50'. .. .. Roii~~li.I. HCli.tii1~i.)nl?:'Gf~:~f~ciion) $64.50 Rdld'i:Un\1l;ACOrily . . .~'j9.S<i '",' ,'~' ",., .' :~.ted Cost $ ',',' . . REA TlNG PERMIT FEE STATE SURCHARGE . . TOTAL PER!\1IT FEE Building ~etmit # .. . . ......... ... . . . PA'OWITH" ; \i )/\\ '- '~~ex8LJILDING P~RMIT $ \-.".' (O.ffiec.,Ust: Only) . jllls:~ppncation ~~c~.m~:'You~ Building Permit Wlu:J1 Approved Bulldh1t Official Dare I P8.ld .1 Date. Receipt No. By If, f/ '.. . ~'24hour notice: for:an in"'pcction" (9S:!)' 447.9S?O, f3~.(9S2) 447-4.:245 12/14/2004 TUE 16:46 FAX 6513226147 GENZ-RYAN III 009/009 CITY OF .PRIOR LAKE PLUMBING PERMIT Date Rec'd (Please Me or prine and sil!D. at: bottom) I ADDRESS .. i1~1~ MJZ-ne(cl b1z C(& LEGAL DESCRIPTION (ollie. us. only) , LOT ddBLOCK ;). ADDITION b-ta2hAd.l (!-/1rv OWNER (Name) DR Horton Custom Homes (Address) 2OSt.>D I&.VlB~I~ Cr Sre.IDO APPLICANT (Name)ae".-Fyr- '''''-'-'-::: ,. u~;o (Address) 14745 So Robert Trail (Contact Person) ~ [11 ~r~tflt I ! S ? . I ex--;, '-(_ APPLICANT SIGNATURE ,( ,(LU\,;b J 1--rk f.e,/] ,,,.. fi1. I PERMITNO'O+.IZ3~ .1 0014 Cily 3. Yellow ^ppJleml ZONING (office use) PiD (phone) QC,2 - q 'i? fi -,'iSM udu:ville.- ~UN 56b4Li (phone) ~" 1 _I. ,,_ 1 1 H Rosemount MN 55068 (Zip Code) (City) (Phone) 65! -423-1144 DATE I,) - I LI- ('4 APPLICANT PLEASE COMPLETE BELOW I Quantity I Type of Fixture Quantity I Rough-ins Type of Fixture ;:J.. Bath Tub with or without shower I r I Dishwasher ;. I Water Heater I { j Floor Drain f4 I WaLer Softner I I L./ Lavatory (Bathroom Sink) I Stand Pipe (Washing Machine) I I I Laundry Tray (lor 2 compartment sink I Sewage Ejector I I ,;2 I Shower Stall Backflow Assembly I I Sinks I Backflow Assembly Test I I I Bar Sink I Lawn Sorinkler I I 'l- I Water Closet (Toilet) I Other , ) FEE SCHEDULE Industrial, Commercial & Multi4family 1% of job cost with a $39.50 minimum Residentialt New One & Two-Family $99.50 Residential, Additions & Alterations $39.50 Estimated Cost $ PLUMBING PERMIT FEE STATE SURCHARGE TOTAL PERMIT FEE (Office u,. Only) This Application Becomes Your Building Permit When Approved Building Offic.ial Date 24 hour notice for all in'peetioM (952) 447-9850, r.. (952) 447-4.245 Building Permit # ~enMIT $ $ $ Paid Dat.J::C Z ': ZJJ~ I Receipt No. I By CITY OF PRIOR LAKE HEATING/AIR CONDITIONING/FIREPLACE PERMIT Date Rec'd [. Pink 2. Green 3. Yellow ~::, I PERMIT NOL ,.,~ Apphcant .,.... &..::;)J (Please ~ or Print and si... at bottom) ADDRESS ZUlllU'4G (office use) 17472 DEERFIELD DRIVE S,E, LEGAL DESCRIPTION (office use nnly) LOT BLOCK ADDITION PID OWNER (Name n.RHORTON (Phone) (Address) APPLICANT (Name' ATJJEDFTRRSTDR DRA FIRESTDE HEARTH & HOMF. (Phone) 651-6JJ-2561 (Address) 2700 NORTH FAIRVIEW AVENUE (Address) ROSEVTT T 10 (City) 55113_ (Zip Code) (Contact Person) BRENDA HUSTON (Phone) _651-633-2561 APPLICANT SIGNATURE BRFNDA HUSTON DATE 1/24/05 APPLICANT PLEASE COMPLETE BELOW xD NEW CONSTRUCTION D REPLACEMENT D AL TERA TIONS FURNACE MAKE AND MODEL FUEL FLUE SIZE RETURN OPENINGS INPUT OUTPUT TYPE OF SYSTEM HEATING OR POWER PLANT DWarm Air Plants DGravity o Mechanical DAir Conditioning DVent. System 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 FIREPLACE MAKE AND MODEL HEATNGLO SL-750TR-D FEE SCHEDULE 1 % of job cost Residential, Gas Fireplace $39.50 minimum $99.50 $64.50 Residential, Additions & Alterations Residential, AC Only $39.50 $39.50 $39.50 Industrial, Commercial & Multi-Family Residential, Heating & NC (New Construction) Residential, Heating Only (New Construction) Estimated Cost $ REA TING PERMIT FEE STATE SURCHARGE TOTAL PERMIT FEE Building Permit # $ $ $ PA'D W\TH ~'LO'NG PERMIT (Office Use Only) Buildine Official Date I Paid I DaLJAN 2 7 2005 Receipt No, Tbis Application Becomes Your Building Permit When Approved By 24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 PRIOR LAKE INSPECTION RECORD SITE ADDRESS J ~ 'D.fE"t2. Fi E.UJ /:)/1.... SO. € . NATURE OF WORK N.eJ..U ro~~iQ,s-- USE OF BUILDING ~.c::: A.. _ PERMIT NO. 04- , /2...33 DATE ISSUED ~ CONTRACTOR I) ((.. t\Ocz;r~tJ ~ PHON -Z.Zl.-I/71 L NOTE: THIS IS NOT A PERMIT FOR ANY OFTHE INSPECTIONS BELOW , THE PERMIT IS BY SEPARATE DOCUMENT DEPARTMENT OF See Main File BUILDING AND INSPECTION INSPECTOR fATE J I FOOTING I ///{/ J //b'/,,,S I FOUNDATION (Prior to Backfill) I 41 / fi!/b,<j' PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ROUGH - INS , ,. SEWER/WATER/SEPTIC 111/1- 1/ly/aS FRAMING ~ j/F!'/Or- INSULATION ELECTRICAL _ _ / J//s-/r?r PLUMBING!J.(;f. n ~~/~ M- 5//0/05' HEATING (if required) ~- J'j/.Y/or FIREPLACE ./ I' ~ J//I'/t7f GAS LINE AIR TEST~A f f; ;; ,dpY <-tbdd.J COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED . 'LATHE / N41(J"4"~,! / I I ~r ~C/c/ /~ Mrj'~INALS GRADING (Prior to Sodding) , ~ ee ~> h h;/e BUILDING /ko/- S7?'o / Q!--- ELECTRICAL ~ /J.? /Os PLUMBING YI1A 1/ zJ /D5 HEATING ~ S-/.;?-%S'--- , . DO NOT OCCUPY UNTIL 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 I ;ti Final Permitted / , QItrfifitaft of @uupanq! CITY OF PRIOR LAKE ~q1Ctrfmtut of ~uilMulJ Jlusptdiou ::J Conditional C,O. Expires This Certificate issued pursuant to the requirements of Section I/O of the D Residential / 0 International Building Code certifying that at the time of issuance this structure was in compliance with the various ordinances of the City of Prior Lake regulating building construction or use. For the following: SINGLE F&~rLY 04-1233 Use Classification Bldg. Permit No. Occupancy Type R3 VN Zoning District R2 Legal Description Type Construction L22, B2, DEERFIELD 11 TH Owner of Building Site Address 17477 DEERFIELD DRIVE S.E. Contractoc', Name & Addr." n. R. HORT~./.-7},9BhO KENJ\RTDGF. r.OURT. LAKF.VTLT,E. 'll\l <; <;044 ROJ\J.ill.T n. HIJTr,HTNS./~ City Planner .TANE KANSIER >_ / Buil9ing Official ')/ JC/C;.S- Date " / Date: I I I I I I I J ADDRESS /7r?.2 _07 TIME SCHEDULED ~~~~ Vec>,4d /;J CITY OF PRIOR LAKE INSPECTION NOTICE OWNER CONTR. PHONE NO. PERMIT NO. C) fC- - /2..3? o FOOTING o FOUNDATION o FRAMING o INSULATION .-.e1'INAL o SITE INSPECTION o PLUMBING RI o MECH RI o WATER HOOKUP o SEWER HOOKUP o PLUMBING FINAL ~H FINAL CQAII!JlIENTJ' _ / ,/ F/~cft/c~/ hhec cb~ /ke-/, h.h~ / CJI<.- ~ ~ ~ ~/ ;, P ,..( r"Jrs 9' 7"" ~.$ T k~4t'r-> hk</ CJ/;7/ ~ ~/V~ (? ~.rl~--/r:/d o EXIGRADIFILLlNG o COMPLAINT o FIREPLACE RI ~EPLACE FINAL o GASLINE AIR TST o L/~?~;- ~yr/ --. ./'"" (J/ (e ---- -~-------- <[/:;-e ~~) ~RKSATISFr'''.~,''.' PReSEEB -------- /'6 ~~RRECT ACTION AND PROCEED o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING Inspector: ~ Owner/Contr: CAl L ~7-~~50 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY/ 1~1 DATE . TillE SCHEDULED .rk}S- ;JeCy~;j iJ- CITY OF PRIOR LAKE INSPECTION NOTICE ADDRESS IlL/72 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 ~UMBING FINAL o MECH FINAL COMMENTS: aVW~~,.--t, nf -/J "?3 o EXIGRADIFILLING o COMPLAINT o FIREPLACE RI o FIREPLACE FINAL o GAS LINE AIR TST o / 7 ' 7? if 'T C5 A__ ./ aq J / /' rOle ~.-'j /1 / / - / . /- U.i/ ///~ <<I ft/?rV:A.1 ~/ ~ ~ .-./' ,- (_HecK; ~ IZ / ~ (~ 1,,(///&/6 eY , .--:: !t?h~/ o WORK SATISFACTORY, PROCEED ~RECT ACTION AND PROCEED o CORRECT WOR~:7}~~E:INSPECTION BEFORE: COVERING Inspector: ~.J-. Owner/Contr: - / CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. msIIOr, CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH'" SAFETY/ APPLIANCE PERFORMANCE TEST Attach to gas line adjacent to reguletor Job Address 17~ h,;~ Heating Contractor 4/i L..tJ ML/1tI '~~ sild /J (' . m.'J. 7" Heating Contractor Name of Tester Date Name of Tester Date Percent 02 Percent CO Percent Co2 Stack Temp Ji/!,7<M-r "'I'~ ~R S/{4h,' , f 1/'.....4/ I:~ 37D~ Combustion air is adequately suppliad per UMC See, 606 v~~ PIi/H input ---- ----- .