HomeMy WebLinkAboutBldg Permit 03-1476
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Main File
Date Rec'd
16.24. OJ
; ~i~i:' ~:;y I PERMIT NO. 03 ~1,,1-7/-
3. Yellow Applicant ~ I c.o
(Please .!VP~ or D int and sim at bottom)
ADDRESS
50 J I ~+ ~ <POLJ l)fl'Lk-SE
LEGAL DE~ CRIPTlON (office use only)
~ - Id lo;tk.
LOT [lo BlOCK ADDITION ~ r( 'L l
OWNER
(Name)
(Address)
(Phone)
ZONING (office use>
It-(
PID 25. fiJl. Olw.O
BUILDER-I' "'" I I l
(Name) . J , k.... NOUOv\.. Tnt.. .
(Contact Na[l~'~;^- ,W~ '''}:. " '\' ~b
(Address) [~)lltt^frim~ilZ?- ~ 100
(Phontq'5~9B5-7?J)(')
(Phonelj~ /p- 1732-
~ ..J ,
i /,
TYPE OF W::lRK
o Misc.
~ew Construction
DLower Level Finish
DDeck
DPorch
ORe-Roofing
ORe-Siding
o Fireplace DAddition DAlteration DUtility Connection
PROJECT COST IV ALUE (excluding land) $ I S'5) q'l A
I hereby certify l1at 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 ageo! 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
;t~;;~:t4~:ns dOOOSG5'7 /O(~3-o3
~ dSignature Contractor's License No. Date
I Permit Valuati m
I Permit Fee
I Plan Check Fe ,
I State Surcharg, ~
I Penalty
I Plumbing Pern lit Fee
I Mechanical Pe mit Fee
\ Sewer & Wate' Permit Fee
I Gas Fireplace. )ermit Fee
It5?_ 000,00 I
$ f I
I.M7.3S
$ ~,,~. 72 I
$ 7S.oo I
$ ~ I
$ I"(J.(J 0 I
$ /tJO. tJo I
$ 35.5"" I
$ <(tJ.OO I
This Applicati. In Becomes Your Building Permit When Approved
~ ~ ::/e.JJf-J II /tJ",f /0 ~
Building Official
bate
I Park Support Fee
I SAC
I WaterMet0z;~; I";
I Pressure Reducer
I City SAC and WAC
I Water Tower Fee
I Builder's Deposit
lather
I TOTAL DUE
I Paid
I Date
(7J /0.(,../
J/ J1.~O)
#
#
#
#
$ El.<;tJ.OO
$ /2-7'5'.00
$ zS'o. 0 0
$ #'S:'. ao
$ /Zaa. QO
$ 700,00
$ /Soo. 00
$
$ 8. 330. ~.3
I
I Receipt~o. 4% 0 JJ.-
By /j,..,.
iJ
This is to certify th Lt the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
~~ Plli~emporWY ceru;;e~Zo;~;limce and allO~:; to~. Befor:ocru:~. a Certili:~"upan~ mUSlbe
-1lanning Director 'Ie.. Date Special c~
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372
-, ----________________ ~_____^_______,__"______ ..._. .__~,,_~___________ - _______ _m____ __~________.______~
.. .
White - Building
( !;ianarv - Enqlneerui~
Pink - Planning .
Th..('nr.., flflhpl.a.....COllnlry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NJ.ME OF APPLICANT
AF PLICATION RECEIVED
/ / /
~./
~ "' '",-" , L .I
-":j;t---' (j/--J
,/(1 . i- 4 . (:..?
Th e Building, Engineering, and Planning Departments have reviewed the building permit
ap Jlication for construction activity which is proposed at:
5(~/ /
I' / ,'C'o" ."__
I V t ~.i,l (/-//(-
'7- Li k:- .
Ac :epted
x
Accepted With Corrections
DE nied
Re viewed By:
M4R
. ~
Date:
J 1-4--63
Ccmments:
See Reverse Side for Additionallnform::ltinnl
(}/lr~"/1 File
,",PO> A tt"l'.nmpnts: 1) GradinQ Plan. 2) Erosion Control Measures
"Tille issuance or granting of a permit or approval of plans, specifications and
COI nputations shall not be construed to be a permit for, or an approval of, any violation of
an I of the provisions of this code or of any other ordinance of the jurisdiction. Permits
prE isuming to give authority to violate or cancel the provisions of this code or other
orclinances of the jurisdiction shall not be valid."
Main File
White - Building
Canary - EnQineering
~"---- Planni~
-
The ("enl.. nflh..l,.k..('ount~.
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
N!\ME OF APPLICANT
APPLICATION RECEIVED
n e Building, Engineering, and Planning Departments have reviewed the building permit
a~ plication for construction activity which is proposed at:
'-7' /_ 1__
.._ Ac cepted
Accepted With Corrections ~
DElnied
~~.V1
.
--2 e,~
nil
~
Date: -'1/3,..;0:$
.al-"-i~
~~
/'JH~L. ~~. . \
C< Imments:
,
/
"T he issuance or granting of a permit or approval of plans, specifications and
cc mputations shall not be construed to be a permit for, or an approval of, any violation of
ar y of the provisions of this code or of any other ordinance of the jurisdiction. Permits
pr 3suming to give authority to violate or cancel the provisions of this code or other
orjinances of the jurisdiction shall not be valid."
~:i PRIGii' <:
t ~'~
u . rn
Main File
C:--1I'{~jtE.: - B~
Canary - t:nglneering
Pink - Planning
The ("enle or lhe 1.akr ('ounln
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NJ\ME OF APPLICANT
0. /G. /IO/&TlJ;J
10 .~~. M
APPLICATION RECEIVED
Tt e Building, Engineering, and Planning Departments have reviewed the building permit
a~plication for construction activity which is proposed at:
50/ / vV err tJA'/C-- /'( O/e-.
A( cepted
Accepted With Corrections v
DE'nied
RE ,viewed By:
~
~ ::4J2u
4~~~
Date: /1/3/0 'S
.
~"JJJ ".j. /-. ,-t-~
C< Imments:
"T 1e issuance or granting of a permit or approval of plans, specifications and
ccmputations shall not be construed to be a permit for, or an approval of, any violation of
ar y of the provisions of this code or of any other ordinance of the jurisdiction. Permits
pr 3suming to give authority to violate or cancel the provisions of this code or other
or jinances of the jurisdiction shall not be valid."
Novl4! ~003 i~~8PM
GENZ RVAN PLUMBING AND HEATING
No.041 i
P ~ I 6
Date Rec'd
~~710" \
f L~<~)
,,';;.""\':r-h
';'\M;~i<~:\\"'.~
''''~;~'I#NESO''''''
CITY ,OF PRIOR LAKE
SEWER AND WATER PERMIT
t. ""'" 'n. I PERMIT NO
~ Y.JOw C';<T . ':;) -ILl 7/
]. Gold Afpl~' .--;)0
(Please fVpe OT n.dnr IUld !i-'tllit bottom)
ADDRESS .
1/))l\ V~esJOa~ \)6/\0t tJ11. ~S
ZONJNG (offi!:o 0'0)
LEGAL DESC! lPTION (office... ollly)
LOT\ ltJ BLOCK r ADDITION i1ur2.f1 e (J I C'-fi'l.;
PID
OWNER
(J'Jame)--DB..--M....r...~... r:..':":'~_-bO
(phone) _ qs2..q '8.5- ! g l'I':
(Address)
2pflr{) ~Bi<..\t:(:R... Cr Srt?IM
(Addre,,)
La~\j I \Ie..
(City)
"5ea-!U
(;lip Code)
APPliCANT
(Name) Gem-Ryan Plumbinll, & Heating
(phone)
651-423-1144
'.ICANT Sl }NATURl!
n (Ad~")
\ ,t1 1,1 r &n rt1 II \ ~
e j{ S'i-.} ~J Ol./)
Rosemount. !1N
(City)
55068
(Zip Code)
(Addre.",) 14745 So Robert Trail
(Contact Person) .
(phone) 651-423-1144
DATE._ 1 J - IL{ 133
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches,
Location of any couplings from structure
Type of sewer pipe. 0 ABC 0 PVC
Estimated length of sewer line feet.
Clean out (if required) located at _ feet from structure.
feet.
o Cast Iron
ResldenlJal sewer l/ld water line connection
Sewer connection mly
FEE SCHEDULE
$35.50 Industrial, Com'l &: Multi-family 1% of Job cost with a $3950 minimum
$17,50 Watr:r connection only $17.50
Estimated Cost .$
Building Penmt #
SEVIER AND WATER PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
.$
$
.50
PAID WITH
BUILDING PERMIT
(Office Use Only)
I This Applieatiol Becomes Your Building Permit When Approved
Paid
I Receipt No.
'NUV2 6 ZOO~ By
~
Date
,
'-
Jlulldu,g C flici.1
Date
24 hour notice for.1I in'peetions (9S'2) 447-98S0,!,,~~52) 447-4Z45
~003 1~:~8PM
GENZ RVAN PLUMBING AND HEATING
No.04il P.J.i6
Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
t BI.... Pttol
2. Gold Cil"l
), yellow Applle:u1.t
I PERMIT NO"8 -/Lf'i/:; I
q'1ea.se CUle or 'OriDI: . nd :!j$tU .I,l.t bottom)
I AD;@f. S~SI ( .
V) 0 fJ (J S +- fitlKPni nt IYVL ~S.
ZONlNG (offi"u.<<)
LEGAL DESCR CPTION (office use only)
LOT 11oBLOck r ADDITION 6A{(rj Irlth
PID
OWNER
(Name) DR Ho.,ton Custom Homes (phone)
(Address)
962-C/Xli -7BDC
'1r'\~I_"'"
,~b\.Vu
ken P)~Il;lGe... C r
Sre ! DO
udu.villG iot-lN 56bLfLl
I AJ>PLICANT
(Name:)...G,..........._l):........ 'P,.._1...o{....~ r. ..Ji4.a.t-~....8
(phone) ~ <1 _L..? 1_ 1 1;.1,
Rosemount
MN
55068
(Zip Code)
(Address) 14745 So Robert Trail
(.Address)
(Contact Person) rAil. kS .
(City)
~ ( O. (phone) 651-423-1144
J ~ I~ DATE 11- rL)-a.~
_-,________ n. _
APPLICANT Sll >NATURE
Quantity
;.,J.,
r
I
r)
'- ...,
\
;)
APPLlCANT PLEASE COlVIPLETE BELOW
I Type of Fixture
I ]'lath Tab witb or without shower
) lishwasber
I !'loor Drain
] .avatory CBathroom Sink)
~,allJJdry Tray (1 or 2 compartment sink
~hower Stall
$ inks
I liar Sink
1 vater Closet (Toilet)
Quantity
.3
I'
'll.-'t.
I Type of Fixture
Rough-ins
I Water Heater
Water Softner
I Stand Pipe (Washing Machine)
! Sewage Ejector
I Backflow Assembly
Bacl<fJow Assembly Test
I LlIWIJ Sprinkler
I Other
FEE SCHEDULE
Inousrnal, Commf rClal & Multl~famlly 1 % of Job cost WIth a $:3950 minimum Res1denoal. New One &. 'T'wo-Famlly $9950
Residential, AdditiOllll & Alteration! $39 50
E sllmated Cost $
Building Pemllt #
PLUNIBlNG PERMIT FEE $
STATE SURCHARGE $
TOTAL PERl\fiT FEE $
50
PAIOJWITH
BUILDING PERMIT
(Otticc Use Only)
This Applicatiol Become. Your Building Permit When Approved
Building C rtlUI.J
Dl.tc:
I Paid Rece}pt No
I Date NOV 2 6 2003 By
~
((
24 hour ootlce ior .11 inspection.. (952) 447-9850,r... (952) 447-424$
"'--------
CITY OF PRIOR LAKE
HEA TING/AIR CONDITIONINGIFIREPLACE PERMIT
(!'lease ~ or orint and sien at bottom)
ADDRESS
6U/l1 ~ ~ ~/~ a.
LEGAL DE SCRIPTION (office use only)
LOvl~ LOCK J ADDITION
OWNER 1> R HORTON
(Name) -: 0860 KENBRIDGE CT
(Address) I AKEVILLE, MN 55044
APPLICAJoo T /'J, /. /2.
(Name) /~///~ //7-',......../~/.,..a./
(Address)..(,~ ~",-.61 ~ a
'5!:AddreS
(Contact Peson) A 4V< _' ~"<-~
APPLICAl'oTSIGNATURE . _ ... - __
Date Rec'd
#273cr
;~~ ~:~ 1 PERMIT NO, ,2_;.'//7(1
3_ Yellow Applicant -)" '-'/ fc::?
ZONING (office use)
.,---/.. -
.~c.':-
PID
(phone)
(Phone) 6,5~ 4~""?-~.?.?.s-
~4!'.A4A' ~5:'t--: "!
- (C1llif{ - (Zip Code)
(Phone) ~- .;/~--177~
DATE
APPLICANT PLEASE COMPLETE BELOW
,
~NEW CO~TRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MOD~/r"",; ~ :?/oAAtA::::/d':/07~ FUEL,,( ~ _,4...;~ ~
FLUE SIZE' V ~~...A RETURN OPENINGS 4 INPUT ~ ~ /-AA../ OUTPUT 6"Z_~
TYPE OF SYSTEM HEATING OR POWER PLANT
FEE SCHEDULE
1% of job cost Residential, Gas Fireplace
$39.50 minimum
$99,50 Residential, Additions & Alterations
$64,50 Residential, AC Only
DWann Air Plants
DGravity
o Mechanical
~ir Conditioning
}IilYent. System
o Steam
o Hot Water
o Radiation
o Special Devices
o Other Devices
FIREPLACl: MAKE AND MODEL
Industrial, Co nmercia! & Multi-Family
Residential, t: eating & NC (New Construction)
Residential, f eating Only (New Construction)
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
$39.50
$39.50
$39.50
Estimated Cost $ . ~ a:::> Building Permit #
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
(Office Use 0, Iy)
This Application Becomes Your Buildiug Permit When Approved
$~/ .&...I/~
$ _ .50
$ t?
S~d!/i) k
~O 'VI,...
,o~ 17
i9fi b.
'VII)"
I Paid
I Date
Date D- -
--- . .. ..[ "iUU3
24 hour notice for all inspections (952) 447-98SP; fax (952) 447-4245
Bu Iding Official
Re~eipt No,
By
7-
,
'----
i
._-,.~._-_. _. ---_1
Cl~ l'RII~
~f2l~f)~
~""
""',yES"
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
Date Rec'd
I. Pink
2. Green
3, Yellow
File
City
Applicant
,
I PERMITNO.~
(Please ~ 01 'Orint and siltll at bottom)
ADDRESS
ZONING (office use)
5011 W. OAK POINT DRIVE S.E
LEGAL DI :SCRIPTION (office use only)
LOT B LOCK ADDITION
PID
OWNER
(Name D] l HORTON
(Phone)
(Address)
APPLICAI rT
(Name) AT.T .TED FIRESTDE DRA FlRFSTDF HEA RTH &: HOME
(Phone)
651-633-256]
(Address)
?700NORTHFAlRVlEW AVENUE
(Address)
(Contact Pe 'son)
BRENDA HUSTON
ROSEVILLE
(City)
(Phone) _651-633-2561
55113_
(Zip Code)
APPLICAt T SlGNATURE
BRENDA HUSTON
DATE
1/13/04
APPLICANT PLEASE COMPLETE BELOW
xD NEW CONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE I1AKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM
HEATING OR POWER PLANT
DWarm Air Plants
DGravity
D Mechanical
DAir Conditioning
DVent System
D Steam
D Hot Water
D Radiation
D Special Devices
D Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FlREPLAC] i MAKE AND MODEL
HEATN GLO SL-750TR-C
Industrial, Co nmercial & Multi-Family
FEE SCHEDULE
1 % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential, Additions & Alterations
$64.50 Residential, AC Only
$39.50
Residential. I- eating & Ale (New Construction)
Residential, .. eating Only (New Construction)
$39.50
$39.50
Estimated Cost $
HEATING PERMlT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Building Pennit #
$
$
$
PAID WITH
~.~LDING PERMIT
(Office lJsc 01 Iy)
Bu-i1dine Official
Date
I Paid
tfl rtlteli.
\lJJLI40,
Receipt No.
This 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 JmDRESS StJ/I W~/' OAJL fJ,"AJr bt./II. ~.'
NAT~E OF WORK NeW ClJlJsrllJ<<ri~
USE F BUILDING s.;:: A . '
PER IT NO. O,5-/4:Z?' .DATE ISSUED /113l,2
CONTRACTOR DJt. H.ltn~ 11-Je.. PHONE'9.S2 · -.- fl"Z.
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
DEPARTMENT OF
BUILDING AND INSPECTION
Main File
INSPECTOR
DATE
I FOOrlNG J/J~ I 1/--17-03
I FOUNDATION (Prior to Backfill) I JI1~ /~ Itr ~~,~ / / ~-4rt0
'LACE NO CONCRETE UNTIL ABOVE H~S BEEN SIGNED"
ROUGH - INS
~11 ulo1ih ~
~
Y/ff
SEW i:R I WATER I SEPTIC
FRAI..ING
INSULATION
ELE( :TRICAL
PLUlnBING
HEAtiNG (if required)
FIRE PLACE
GAS LINE AIR TEST
i2 -24- d3.
1- ';1-01.-/
I-).-;'Di/
-
YW"
t/Vy'7
Yl/7/
~/
1- / J '(/vl
I-.l!-o,!
{,.-.l-I- ()'I
1',l./-P'1
,
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
L:;t.\u\.~'^") I Vl,.f/ I 1- /'}(fl/
FINALS
'#'8
.
~ ?/('/df
,. .J' /i9/~~
[NY' ?-(I-dlf
~ 9-/~/a.r-
OCCUPY UNTIL ABOVE HAS BEEN SIGNED
NOTICE
GRA DING (Prior to Sodding)
BUI~ING
ELE TRICAL
PLU BING
HEA'r1NG
DO NOT
'rhis card must be posted near an electrical service cabinet prior to rough-in inspections
i Ind maintained until all inspections have been approved. On buildings and additions
, vhere no service cabinet is available, card shall be placed near main entrance.
FOR ALL INSPECTIONS (952) 447-9850
QIrrfifirafr of OOrrnpant'l,!
CITY OF PRIOR LAKE
~rparfmruf of ~uilMug J1usprdiau
~inal Permitted 0 Conditional e.O. Expires _
/
This Certificate issued pursuant to the requirements of Section 307 of the Uniform 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:
Use Classification
SINGLE FAMILY
Bldg. Permit No._ 03-1476
Occupancy Type
R3
Type Construction
VN
Fire Zone
N/A
Zoning District
Rl
Legal Description L 16, B 1, DEERFI ELD 10TH
Owner of Building
Site Address 5011 WEST OAK POlNT DRIVE S.E,
Contractor's Name & Address D.R. HORTON, INC... :>0860 KENBRIDGE CT., SUITE 100, LAKEVILLE
ROBERT D. HUTCHIN~j"~~ City Planner_ DON RYE
...., / B9ilding Official -
Date: 7/~o'//'J ,- Date:
DATE nME
z;4d.r
so// w~/ CJ:;-~ p/ ~
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
ADDRESS
OWNER
CONTR.
PHONE NO.
PERMIT NO.
D FOOTING
D FOUNDATION
o FRAMING
D INSULATION
~L
D SITE INSPECTION
D PLUMBING RI
o MECH RI
D WATER HOOKUP
D SEWER HOOKUP
D PLUMBING FINAL
~CH FINAL
-9.9MI!IIENTsr .
Z:-{-<Cp,~/
........
/-;x../
- ./ -----
~~d" h~/
/1'... Lot!',~...,f ~;-Sc; ~
h~-r /
4? - /~76
D EXlGRADIFILLING
o COMPLAINT
D FIREPLACE RI
~REPLACE FINAL
D GASLlNE AIR TST
D
d/;7./o~
. /
&{C.
~,ir
------- .
/~ ~
( C-'IO i-r'" h /~ )
4RKSAT~PROCEED ~
;;; ~~RRECT ACTION AND PROCEED
D CORRECT WORK, 7~;:0; REI~ION BEFORE COVERING
Inspector: ~ Owner/Contr:
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE..
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH <I SAFETY!
INSNOTI
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS
t:;{)(/
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
COMMENTS:
-(j)
(L.f Y1Mf)..J
,
SCHEDULED
IN. tXtt
CONTR.
PERMIT NO.
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
)eoLUMBING FINAL
o MECH FINAL
,r1iT>/-WJ
DATE TillE
:S'II~~I
pf- tJ~
~-1L{7L
o EXIGRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
o WORK SATISFACTORY, PROCEED
tCORRECT ACTION AND PROCEED
o CORRECT w:r;,K~ ~L FOR REINSPECTION BEFORE COVERING
Inspector: -ZJL.1't/ Owner/Contr:
CALL 447-9850 FOR TIl': NEXT INSPEC:TII1N 24 I<OIIRS IN ADVANC:S
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
IN$NOn
DATE TIllE
CITY OF PRIOR LAKE
INSPECTION NOTICE SCHEDULED </-//-04/
ADDRESS ~Oll !.fIeri aK #1. Dr.
OWNER CONTR. '[),~, t)?/k.Vl
PHONE NO. PERMIT NO. _t? ~ - 1'fL'
o FOOTING
o FOUNOATION
o FRAMING
o INSULATION
@INAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
;;('EXI~ILLlNG
o COMPLAINT
o FIREPLACE Rl
o FIREPLACE FINAL
o GAS LINE AIR TST
o
COMMENTS:
br",-,h-tc> 1("
r. ,/1'-' 8M f., t91t-
~ORK SATISFACTORY. PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTlON BEFORE COVERING
lnspector:~ _ ......iner/Contr:
.'- -
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
lNV<<Jn
.,
.
APPLIANCE
PERFORMANCE TEST
Attach to gas line adjacent to regulator
Heating Contractor
Name of Tester
Date
11//;;h// ,.,.CI/-
I/-..v".... 6
3 -tf-Of-
Job Address -5'0 l( W.tN4!: p-r;M.
Heating Contractor ~ /Il1fi~
Name of Tester .~
Date 3- 1(-0-+
''\.5 'to
.J;V~
/;,3. %
IO~oF
Percent 02
Percent CO
Percent C02
Stack Temp
Combustion air is adequately supplied per
UMC Sec. 606
y-",S'
8qcto~-t-u
input