HomeMy WebLinkAboutBldg Permit 04-1196
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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
/1./5:04-
Main File
I. White File
2 Pink City
) YeHow Applicant
PERMIT NO. ()9" 1/1~
(Please type or print and sign at bottom)
ADDRESS
ZONING (office use)
\145 c.o tA,-v ~\ab D'Q..\..\Je ~~
c<.z.
LEGAL DESCRlPTlON (office use only)
LOT 15BLOCK z.. ADDITION ~\"=I """ \\~
PIDZS. ~7. 038.0
OWNER
(Name)
(Phone)
(Address)
BUILDER
(Company Name)
(Contact Name)
(Address)
p. Q \ \Aoe-\t).J l~<:-
N\.\\.l.e \ND\AN 0\J"t~
20~loO Y-~~~ a. s-re \00
I A.ve \111 ~ F: ~ 'S$C)44.
(Phone) Q51. -4Bs- -180B
(Phone) CfS1... - 2"U.o - 41 ~ 2
TYPE OF WORK ~ew Construction ODeck o Porch ORe-Roofing ORe-Siding OLower Level Finish 0 Fireplace
DAddition DAlteration DUtility Connection 0 Misc.
CODE: ~.R.C. DI.B.c.
Type of &nstroction:
Occupancy Group: A B
Division:
w.. Ur3C)
I II III IV
E F H I
1 2 3
V
M
4
A
R
5
B
S U
PROJECT COST IV ALUE $
(exduding land)
1~31 fo
I hereby certifY that I have htmished mformation 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
a. bove-menl1oned proPf't and that al construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
:ftCial can revoke thiS pr;:zr Just ause F1l11hermore Ihereby agree that the CIty offic~~;e~a~n~ upon the property to perform needed l;:/~c~l/~
~gnature Contractor's License No. Date
I Permit Valuation #, '-1/, /)00,00 I Park Support Fee # $ I
I Permit Fee $ ( '2.. ~ ~ I ~O I SAC # $ 13$"0 .t)O I
I Plan Check Fee $ St.{ Lr. ,,~ I I Water Meter{Size 5~ I"; $ Z-CSO. lJ 0 I
I State Surcharge $ 70,50 I Pressure Reducer $ L(~. 00
I Penalty $ I Sewer/Water Connection Fee # $ tUX>. 00
Plumbing Permit Fee $ IOD,t9a I I Water Tower Fee # $ 700. () C)
Mechanical Permit Fee $ roD,DD ] I Builder's Deposit $ I~OD,Do
Sewer & Water Permit Fee $ 3'S. s-o I I Other $
Gas Fireplace Permit Fee $ '-l01 Da I I TOTAL DUE dmMrrJ (1.1,.U 4- $ '7; 53!:;. /8
/
This Application Becomes Your Building Pennit When Approved Paid 15"./)/ fd I ReceipVNo. tf'f ? j' -f
:Bu~~ /(~?/o., Date I cJ.. . J'. (} If' I By /I
0
ThIS IS to certifY Ihat the request in the above applical10n and accompanying documents is in accordance wilh the City Zoning Ordinance and may proceed as requested. This document
~'~m_~C'~ifi""or;?;z;'"~w'''ro"iO~ :;;"~;;;:;:!1:W'OC
PlannIng Director ' , Date' SpeclaI Conditions, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372
~~
~ain File
White - Building
~ -F . eering
\ ~ ~~n~ - Plan~nin
Tht' ('('nln or Ihe I.ab COUnll")'
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
}~.
..:--
,
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
<t
r f C.-, "-;
!~- .
~
\._"
Accepted
Accepted With Corrections
/
Denied
Reviewed By:
~~
~
,
'~ Date: ////9!otf
I
.... ~/J ~/~J
CL.A-t' ? CJ .
V ~-
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."
}fain File
(""White - Bullan'i'q::)
Canary - Engineering
Pink - Planning
Th(' Cf'nlt"r nf lhf' l..kt ('ountr,.
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
D. )<:. HOrGlotJ
1(.15.04-
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
17~5 fo D65~(6L.D DIG. 56
Accepted
Accepted With Corrections
/
Denied
Reviewed By:
(;? , r
p;~ ~ Date: 11/ICj~t/
~o-h,~ r
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."
Main File
ThE' Crn'rr of the I..ltr Counlry
White - Buil~ing
~i'!.ary - En~ineerinp
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
I. C' /...:.-11. r-, --1-"/, r .1
L..../. \'- I; '_.J I''-.~,,! '......
Ii is. (4-
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
1,1 '--I.} 4- t.., (r. L)f [j< ~ ( E L-1J Die.
I -~E
Accepted
)(
Accepted With Corrections
Denied
Reviewed By:
;/#/J
Date:
J 1- 30 ,- 0,-/
Comments: See Rever~p. Side for Additional Information!
!n""V"l FI/(
See Attachments: 1) Grading Plan. 2) Erosion Control Measures
"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 shalt not be valid."
.. ~:43 FAX 6513226147 GENZ-RYAN
~ 002/009
Date Rec'd
CITY.OF PRIOR LAKE
SEWER AND WATER PERMIT
(Please tYPe or Drint and si2l1.at bottom)
I ADDRESS '-,
\ '1 L/VJ7P . heLJe{1\€,trL lJrL ffi
~: ~=w ~ii~~ I PERMIT NO ~ 1141
l. Gold Applicant ..,. ~
ZONING (office use)
LEGAL DESCRIPTION (office use only) .
LOT 1-t5 BLOCK a ADDITION Wl.VW ~{l 1111A
PID
OWNER
~ame) DR HQrton Custom Home~
(Phone) _ 96.2 -q85- ,8LV,\
(Address)
41&00 ~BK\t:t;e C:r S'r~.1 M
(Address)
.La~\J i lie..
(City)
.'5COL1 U
(Zip Code) .
APPLICANT
~ame) Genz-Ryan Plumbing & Heating
(phone)
651-423-1144
(Addres~ 14745 So Robert Trail
(Contact Person) _ . GNdsfl~~flL '--- /) .
! "'.JCANTSIGNATURE (~~jjJlll J/ ::ritE/)
(Phone)
DATE
55068
(Zip Code)
651-423-1144 r
] 1-:2?-o4
Rosemount. MN
(City)
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 line connection
Sewer connection only
FEE SCHEDULE
$35.50 Industrial, Com'l & Multi-family 1% of job cost with a $39.50 minimum
$17.50 Water connection only $17.50
Estimated Cost $
Building Permit #
SEWER AND WATER PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$ '-
S
.50
(Omce Use Only)
This Application Becomes Your Building Permit When Approved
i
,
....-
Building Official
Date
I Paid
Date
DEr UillJ4
I Receipt No.
By
f
24 hour notic:e for all inspections (952) 447-9850, fax (952) 447-4245
11/22/2004 MON 9:44 FAX 6513226147 GENZ-RYAN
~ 006/009
CITY OF PRIOR LAKE PLUMBING PERlVuT
Date Rec'd
(Please tyJ)e or print and sign at bottom)
ADDRESS1Llt/j1p -ha/(fietcL 'j( 'tf
LEGAL DESCRIPTION (office \Ise only)
LOT r0BLOCK f) ADDITION 'WjI2Ji~lcl } I L/1;v
I. Blue file
1. Gold CilY
3. Yellow AppliClnl
I PERMIT NO"_ )1 q(.
ZONING (office use)
PID
OWNER
(Name) DR Horton Custom Homes (phone)
(Address). 2O~(oo KeVlB~l tlG.e... Cr S/e IDO
APPLICANT
(Name)~M_T.l~'a:g Plumr-f,.,~ & HeatiuJ
(Address) 14745 So Robert Trail
Rosemount
(City)
(Contact Person)
l (Address)__
. /k1 t{l f;1 ' -zr /l s .~
(1{1JlAfJ -1iLlI ~
,...... -v
APPLICANT SIGNATURE
! r
962, q ~ f) - 7<6lJ(J
Ut lu.vi I Ie.. jlU N 56b4 L/
(phone) "" 1_1.11_11 ltlt
MN
55068
(Zip Code)
(Phone)
651-423-1144 ~
II-d;.2 (J<L
DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity
6f-
t
I
,1
Type of Fixture
Bath Tub with or without shower
r Dishwasher
I Floor Drain
1 Lavatory (Bathroom Sink)
I Laundry Tray (lor 2 compartment sink
I Shower Stall
I Sinks
I Bar Sink
I Water Closet (Toilet)
Quantity
3
i .
I
I
0<
I Type of Fixture
Rough- ins
Water Heater
I Water Softner
I Stand Pipe (Washing Machine)
I Sewage Ejector
I Backflow Assembly
I Backflow Assembly Test
I Lawn Sprinkler
I Other .
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a $39.50 minimum Residential, New One & Two-Family $99.50
Residential, Additions & Alterations $39.50
Estimated Cost $
Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $
TOTAL PERMIT FEE $
(Omec Use Only)
This Application Becomes Your Building Permit When Approved
,
, I
Building Official
Date
24 hour notice for all inspections (952) 441-9850, fax (952) 447-4245
.50
!
r
Paid
Receipt No.
Date
1 2004 I1lY
(h
-/J
DEe
CITY OF PRIOR LAKE
HEA TINGI AIR CONDITIONINGIFIREPLACE PERMIT
Date Rec'd
(Please tvDe or urint and silm at bottom)
ADDRESS
~. ~:n ~:~ PERMIT NO A_ - . j ~.
3. VeHow Applicant ~ ~
ZONING (office use)
17456 DEERFIELD DRIVE S.E.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION
PID
OWNER
(Name D.R.HORTON
(Phone)
(Address)
APPLICANT
(Name) ALLIED FIRESIDE DBA FIRESIDE HEARTH & HOME
(Phone)
651-633-2561
(Address)
2700 NORTH FAIRVIEW AVENUF
(Address)
ROSEVILLE
(City)
55113
(Zip Code)
(Contact Person)
BRENDA HUSTON
(Phone)
651-633-2561
APPLICANT SIGNATURE
BRfNI)A HUSTON
DATE
1/24/05
APPLICANT PLEASE COMPLETE BELOW
xD NEW CONSTRUCTION 0 REPLACEMENT 0 AL TERA TIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
OWarm Air Plants
o Gravity
o Mechanical
OAir Conditioning
OVent. 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
Industrial, Commercial & Multi-Family
HEATN GLO SL-750TR-D
FEE SCHEDULE
1% of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential, Additions & Alterations
$64.50 Residential, AC Only
$39.50
$39.50
$39,50
FIREPLACE MAKE AND MODEL
Residential, Heating & NC (New Construction)
Residential, Heating Only (New Construction)
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Building Permit #
$
$
$
.50
fHO~
fJJ\\..QIIG
(Office Use Only)
This Application Becomes Your Building Permit When Approved
Paid
Receipt No.
DatgAN 2 7 2005 By
Buildine: Official
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
,JUN-16-2005(THU) 08: 47
P.001/004
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.. .:,,' In:ri~iaI.;ccim3ncici;il;;l,M~lii:F'lilhii1.:'':: :', ;.-:- 'l%ofjob coSt. ;. . :Res(d~~ ~'Fi~pl~. ',.' ..... '.- ,: .'.; ~.; :~.:::., ,::: ;'~'::'S39~9":"~ .,,'.. '.
.:'.;'"'.::.'. :~:~::> :;. .~~:-t:':~\:;f::x~;~~:rf.?r;~;J:~..::.'.'.::' "$39.s0'm'iriim~ . '-:..; i.~\'.;!~}:~~::.::';::~.;;~~.<;- . I" ;,. :":""~:~-.~';:~;";<:':'''.:'''':'::''~..~'''i~::\:-~~.:\.;....;. ..
:. F#:~d~ritja( ~~~}ing ~~.~lli~\0~~~4iO~) $9.9.50' .R:~i~~#Jii;'~d~~~nS!4 iut~~~'::':' ,:'. ;"';;;:', ,> .... ;<s),f~~C ::>.' '. .
.' ',"R~iil~t~;Hc:ati.t.1g.P~IYJ!f~~~~~on)' $b450 Rd:i~~~.ACI:)~li". ~'::-.~ .,\'.1;-.'::,: :~.;~~> "';',;~.~9.~(}~:.;":
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. .~ ::' :'~,~~ed Cost $ Building ~emiit' if. '. . . . ..':-
.... '. '.:,.;':~.~',.;:";;.X:.:::~'..: .:." HEATING PERMIT fEE' .. ~'.::J)h ~ ,\~ 'wiTH: . <.: . ,'.
";';~:;'~~~~S~:E ;~.... :"eUllD1NG-~RMrr.
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(O,q1ce Us~ Only): . . .
. 'ThisApplicatlon ~~.nies.'YO\lr BuUdiuf Per~it When Approved.
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\:. :')4 'h~u~ notice for 311 inlSpcctioM (~S~)'\?3~~r:-.~(9S:Z) 44?"j24?
.,,!
PRIOR LAKE DEPARTMENT OF ~VIain File
BUILDING AND INSPECTION
INSPECTION RECORD
. .
SITE ADDRESS -I.:7 'lSJD Ot.c. ~ FI c~,;~ SE,
NATURE OF WORK NE~ QIJ'(~Ja-I'f.)
USE OF BUILDING S,P:; A. ·
PERMIT NO. 04 ,/Ifftp DATE ISSUED -.llJ-.(q 101.(
CONTRACTOR 1>.((. ttltlT4)tJ J- I fJ~ I PHON~ - Z2.""'.'2rL
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
INSPECTOR I
/1/4- ,
t FOUNDATION (Prior to Backfill) ;1VI/,^ ~Y~A~"" ~~ I ~-7;-:z:f 7 ;.'
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN'SiGNED
ROUGH - INS ,
SEWER I WATER I SEPTIC ~,
FRAMING fliP,
INSULATION ~
ELECTRICAL
.,
PLUMBING ~ ..2/f"/oS-
HEATING (if required) . . fl///: }. '-/7' OS-
FIREPLACE " ., /1;Y./ J-.t..- /J- vb
GASLlNEAIRTES~rh rr/! A/ 4r/cJr
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
~~~~I~ALS _ I
GRADING (Prior to Sodding) . N {~ ,.
BUILDING ~~~ C' ~ 0.,,1i/ ~6s-~ 6,)-~..r
ELECTRICAL
PLUMBING
HEATING
DO NOT OCCUpy UNTIL ABOVE HAS
NOTICE
I FOOTING
,
~4-,
~
DATE
I /;1 /'l/cf.
"
/~o,/o/
r~ II~ tJS'
,2/22/05-
jJl;Y~5
~O~a.r-
?~?/"S:-
4//~--
BEEN SIGNED
This card must be posted near an electrical service cabinet prior to rough-in inspections
and maintained until all inspections have been approved. On buildings and additions
where no service cabinet is available, card shall be placed near main entrance.
FOR ALL INSPECTIONS (952) 447-9850
Ql~rtifitat~ nf (0ttupauty
CITY OF PRIOR LAKE
~tpatfmtnf of ~uil~tng J1nsptrfton
iFinal Permitted [] Conditional C.O. Expires _
This Certificate issued pursuant to the requirements of Section 110 of the 0 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 FAMILY 04-1196
Use Classification
Bldg. Permit No.
Occupancy Type
R3
_ Type Construction
115, b2, deerfield 11th
VN
Zoning District
R2
Legal Description
17456 DEERFIELD DRIVE S.E.
Owner of Buildinj! Site Address
D.R. HORTON, 20860 KENBRIDGE COURT, 11100, LAKEVILLE 55044
Contractor's Name & Address #- ,-
ROBERT D. HUTCHINS JANE KANSIER
City Planner
_ /;%Ui ing Official
Date: q / .-2,{./ 0 '" Date:
, / - -
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
ADDRESS
/7~ - 17~ Z.
OWNER
CONTR.
PHONE NO.
PERMIT NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
~AL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
COMMENTS:
~, /
/--?/1~ (
,
..4 /
C:/{C
TIME
DATE
~b{icS"
~6LL)
4- .119~
o EXIGRADIFILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
n.m ~
~) ?
(f_'/aSe /7/e-/,
\.......- --------
~ORK SA TISFAC I UK w, t"KUCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, ~A;;7R REINSPECTION BEFORE COVERING
Inspector: .II~ Owner/Contr:
, ,
~.
/.- /
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
INSNOTl
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY/
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS /7l/S'b
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
~L
o SITE INSPECTION
DATE TIME
SCHEDULED
9-2J.~
Dce~(;'~11 lh.
CONTR. D 1(. JI()~~
PERMIT NO. Dl./-1/1f,
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
~~!~~ING
.....0 C6lll~LAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
COMMENTS:
hrc,k:>- ol(
Cv ,6 i30f - "tC..
s'rr
azhvoRK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: ~ _ Owner/Contr:
CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.,
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
/NSNOT1
~A E TIME
CITY OF PRIOR LAKE ':'-/
INSPECTION NOTICE SCHEDULED ~ ~O.s-
ADDRESS /7Ys6 /ker4et'dd
OWNER
CONTR.
PHONE NO.
PERMIT NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
~L
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
.,.I2f'1iECH FINAL
CJ y-//7'b'
o EXIGRAD/FILLlNG
o COMPLAINT
o FIREPLACE RI
~EPLACE FINAL
o GASLINE AIR TST
o
,-C9MM~TS: "\ I /
7/~?j7lGt-1 /7~1t I &'-e
ay /,.. '" J /! .....
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(31 G/'/ */ t-fh~ (qr""ck C:;L~
v '/
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j!7~eed vod-/-/r-LCS /#e/ ~V.~.I~
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/-?re' /7~ce
,
7~J~' C: Of
/
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C//t 7i /
J ?~~-5-
/ /'
7'// /oS
.
o WORK SATISFACTORY, PROCEED
~RECT ACTION AND PROCEED
o CORRECT WORK, CAL OR REINSPECTION BEFORE COVERING
Inspector:
Owner/Contr:
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYI
lNSIion
ADDRESS
/7Y)6
DATE TIME
SCHEDULED ~~~
/k~y/J~/d a-
CITY OF PRIOR LAKE
INSPECTION NOTICE
OWNER
CONTR.
PHONE NO.
PERMIT NO.
CJr-//?'~
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
~MBING FINAL
o MECH FINAL
o EXIGRADIFILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
COMMENTS:
/,~d /
///-e/1~/#-t'T~'
/'
/ / /
(,cJT- @,/(
~
// / ~/
7/<.k~' / LYle
V u;k:v cftJa / A.,- / se ,/ (,J
--:/k/ S ~!h-L (';,
/ .
.,._./ /7~ /, ----- ..
/' .h ~r.~ ~ B)~ /Ct~ C /-/ h~ /
. . .~D J!9 W RK SATISFACTORY, PROCEED
~ORRECT ACTION AND PROCEED
. 0 CORRECT WOR':. ~~rREINSPECTION BEFORE COVERING
Inspector: #'~ Owner/Contr:
~/f-
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
INSNOTl
.
~
APPLIANCE
PERFORMANCE TEST
Attach to gas fine adjacent to regulator
Heating Contractor ,1I1At-f ~ d/
Name of Tester /irtZt:::!..B
Date .$ /:? /t1 r
Job Address
Heating Contractor
Name of Tester
Date
Percent 02
Percent CO
Percent C02
Stack Temp
/7Vf&' J,/~#,
,4/4 J4r'7 ft4-cl!'4"
/hd/rl R.,
5'/3/ ~~
'8,1-' 2v
~..t'hV
. /.~CJ 7d
3"7/ ~
Combustion air is adequately supplied per
UMC Sec. 606 j/./f
input ~~ ~ ~rd