HomeMy WebLinkAboutBldg Permit 01-0815
CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERn~'lCATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT '7- I q-
(Please type or orint andsi2I1 at bottom)
. ADDRESS
5'151
. .
I. White File
2. Pink City
3. Yellow Applicant
f7w)Vl VV\u.4ow Ctww.. US
LEyAL DESCRIPTION (office use only) 'BLt) &,..\l: \"'2- U.." ,,+ ~3 , . ,
LOT 1 BLOCK r ADDITION ~r..h~\ d ~ J Vi \ \a..J P~S--~ 73- e;{)g-[)
OWNER
(Name) (Phone)
(Address)
BUILDER IJ
(Name) O.Q. ~ .xn\ '
(Contact Name) _M, ~ L\,)annO"u-fl(a j
(Address) dtJ!!J&JO I<<.v,bvt~ d. f>tE.1 00 t~I)6J ~ 1J
TYPE OF WORK
'~New Construction
OLower Level Finish
o Misc.
(Phone) !Jt;Jt ...qg {;"'-~
(Phone) ~~a-Baf.!, ~ 41?J2
Q-,7Jt.J c..)
ODeck
o Fireplace
OPorch
OAddition
ORe-Roofing
OAlteration
PROJECT COST /V ALUE (excluding land) $ /'}~. In ()
ORe.Siding
OUtility Connection
,
\
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
submitte ans. I am aware that th uilding official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may
enter up, n e property to p~orm n d inspections.
x
v
I Permit Valuation
I Permit Fee
I Plan Check Fee
I State Surcharge
I Penalty
I Plumbing Permit Fee
I Mechanical Permit Fee
I Sewer & Water Permit Fee
I Gas Fireplace Permit Fee
7;?'."~ . 001
-'97. 7C\
~/e.SC1 I
JC-.OO I
I
I
$
$
$
$
$
$
$ -
$
I~o .040
/ ~o .00
0-
40.00
- -
C?Jlru--:Y=B--g;~~~;;...
BuildittlOfficial Date
~I)OO~7p5""1
Contractor's License No.
I Park Support Fee
I SAC
I Water Meter Size 5/8"; I";
I Pressure Reducer
I Sewer/Water Connection Fee
I Wat~TowerFee
I Builder's Deposit
Other
TOTAL DUE
I Paid
I Date
5~9.;;J..~
g.,/).6)
#
#
#
#
'1- If.:,.-- 0 I
Date
$ esO.OC
$ I_(SO.~
$~O -
$- c> -
$
$
$
$
I ~ .C!JlJ'
-, '7Q[J .t:Y'J
o --
$ 5' L/ qJ. " ;;;.q
~s-t>
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
~bym.j(";;::::::C-:;;;:=md'-~Ar~~:C~::-~
~ !t~ng Director Date SpecIal Condlttons, I~'
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
/
~
White - Building
Canary - Engineering
Pink - Planning
Tht ('tntt. of Iht I.ok< ('ounlry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT D 72 I/lJLlO7\..-I
APPLICATION RECEIVED 7- /t:j -tJ )
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
~L/5'7 7'zuon/JUt{ckuJ (l~
'^
Accepted With Corrections
Accepted
Denied
Reviewed By:
Comments:
M'ff7:,
Date:
7 - Z )"-a (
5-t:L JYlc.,,:/1 ~< ((
"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."
Tho ("onl.. nr tho toko Country
White - Building
Canary . Engineering
Pink . Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT D 72 lJa1.../ 07\......J
APPLICATION RECEIVED 7- /'1 -() J
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
~'-I ~ 7 ~ /J(le_Ctckrw (l ~~
. ,
Accepted
~
Accepted With Corrections
Denied - ~ A..
Reviewed By: V Ot .r-
/
Date: 7- ~O~~I
Comments:
Sa, ~ Ma.t'LA !?'-l~
'The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
any of the provisions of this code or of any other ordinance of the jurisdiction. Permits
presuming to give authority to violate or cancel the provisions of this code or other
ordinances of the jurisdiction shall not be valid."
,,-
White - Building
Canary - Engineering
Pink - Planning
Tho ConI.. of tho Loke Country
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT U Ie:. I/o"l.. / O/\..J
APPLICATION RECEIVED 7- /7-~J
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at: //
L-Ljr7 ~: "....... /1'1/ J / if
,-::;):J "7 ~ f'/ /l,l C1a.(/UJ (i ../A./)/Ye..,.
Accepted
(~
Accepted With Corrections
1
r
\
..
Denied ..-,
Reviewed BY( C'i
Date:
7/3e/ol
Comments:
_'Se.-~l(,~lf6vl~ \0. ~~ H~
~Pz~cAS ~~3 ~ ~~) ~~~
Ii,
"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."
Jul.25.2001 6:56AM
GENZ RVAN PLUMBING AND HEATING
No.8621 p. 26/30
L:.l~ r OF PRIOR LAKE PLUMBING PERl\'ll;l;
:pat~ Ree'd
; .
J1. 2 ~ 2001
(Please type: ar'Plim mcl'rign itA.. ..:, ..J
ADDRE~ : -,..:-:-- .'.
~y.E:(J__. 'F:AU \~ '\
U\...l r>~ ~tl~ \P__
CJLorlit J. n ~
--'-"'-',,-- '~- ...._, ~/
i:; ~ I PERlWJ .loltfU., /- -c
J.Y'" ~.' I~
ZONlNG (oJIicz:lIlIrl)
-
~ -
fQ
I LEGAL DESCRJr nON (omce'UJe 0!I1y)
, LOT ~ BLOCK 'ADDmON
PID d5-373 -c;o:g-<).,
OWNER
(Name) DR Borton Custom Homes
~) 3459 Wash~ngton Dr Sea 204 Eagan, MN 55122
cPhon~ 651-454-4663
APPUCANT
(Name) ~~all-.i.y-- 1'] .......~1~g + U., - +--4_:':',.;j
(Phone) " " 1 -4 ? ~- 1 16.6.
(Address) 14145 So Robert! Tra~l RosemoUl),t MN . ~ ~55068
(A~.......) (~). ,): (Zip Co~)
(COntad:P~~~ Mary Olson 1 ~) 6S1-423-1l44
~c.ANl' ~ONATURE.I 1. ~~ _~ ""~:ff'TB r .25/0
APPLICANT PLEASE CO:MPLETE BELOW
Quantity Type ofFmllre QlWltity
I . Bath Tub with or without shower
, Dishwasher
J Floor Drain
~ . 1 La"ol.v~j (Bathroom Siuk)
I I Laundry Tray (lor 2 comp_ ~ent sink
I Shower Stall
I Sinks
I Bar Sink
z.. I W &11=r Closet (Toilet)
Type ofFtrtare
I
I
I
I
I
I
I
I
.. \ .
fJ-/ ,-
I
Rough-iDs
I W~ Hca.t.er
l w. Softner
I Stand Pipe (Washing Machine)
I Sewage EjeCtor
Backtlow Assembly
Backtlow Assem.b)y TeSt
Lawn Sprinkler
I Other
.l'J!;J!; S\....D.JIdJULE
Industnal. Coaun.ercia1 & Multi~family 1 ~ of job cost with a $39.50 minimum Resideo1iaJ. New One 4: Two--PamUy $99.'0
Reside.n1iJI, Additiana 4: AI.....,...:..:~ $39.50
Estimated CDst S
Building Pomrit 1#
PLUMBlNG PERMIT 1: J:,J:, $
STATE SURCHARGE $
TOTAL PERMIT FEE $
.50
E3 PAID
UILDING I/I/Irti
1€R'"v:;r
)Ola: Use OIIly)
This AppJicatioD .Becomes Y OIlJ" BllOding Permit When Approvea Paid
.....ttiq omdal
JMc.
~ \ ~/1-o I
I :RecciptNo.
I
By
.'
14 bour DotK_ tor an iupectiolP f.'SZ) 447~'8!0, fu (95]) ....1-4245
at-
U
/
CiTY OF PRIOR LAKE
HEATING/AIR CONDITI0NING/~lKEPLACE PERlVui
Date Rec'd
~: ~ ~!~ PERMIT NO. I.-Y1'S.
3, Yellow Applicant I' () I,
(Please type or print and si2Il at bottom)
ADDRESS
, %1 K1WnffifJUDW 04y.v~
. ZONING (office use) .
R'^-
LEGAL DESCRIPTION (office use only) ~
~' r. . .. cl
LOT li~BLOCK 1'2- ADDmON (, P RJ.~ i) y PID;:2 ~- ~'73-0og-;)
~~e~R l)(Z \1Dv'fIil (phone)
(Address) -3l~ W~S{U~Jl1yt AvL Sui-k 1JJ4 ~ MJJ 55/1-2-
~~;~~~UDM m(thCU1lcaJ (Phone) Lcf51 45l-l115l
(AddreSs)~D mnfbf0"\)r ~~il-kr \
) r:. , · (Address) . (City) (Zip Code)
(Contact Person) ~~:l'r~ . LJ1~ (Phone) ---'.i5 I 45Z-2.175
APPLICANT SIGNATURE ~_~.l1.i mm.tYfrlI1/I ClJIJflJ DATE ,(30 101
APPLICANT PLEASE COMPLETE BELOW
[BmW CONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL BJrlJtn ~ 2,g ?JILA-V Dl-4b 1 D . . FUELl\i1fturU
FLUE SIZE 4l\UaSS E> RETURN OPENINGS 4- INPUT '1DI DDD OUTPUT 5lc. bOO
TYPE OF SYSTEM HEATING OR POWER PLANT
OWarm Air Plants
OGravity
o Mechanical ,
~ir Conditioning
[j;P(Cnt. System
o Steam
o Hot Water
o Radiation
o Special Devices
o Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroac:hinto
Required Side Yard
Setbacks
I
FIREPLACE MAKE AND MODEL
Industrial, Commercial & 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
$39.50
$39.50
Residential, Heating & NC (New Construction)
Residential, Heating Only (New Construction)
Estimated Cost $ Building Pennit #
HEATTNG PERNITT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
lJu/ J::>~/()
Il..()/It/i l1-ZI'1
Gj:J~7-t
A,"v:,'l'"
(Office Use Only)
This Application Becomes Your Building Permit When Approved
Paid
I R..l'~ipt Na,
Building Official
Date
Date 8" <S -0 I
By f'
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
/'
FIRESIDE CORNER
#6031 P.007/013
DAte Ree'd
ell t OF PRIOR LAKE
I:I.Jf.A ~ uiG/AIR CONDITIONING, ~ udPLACE PE~lll
DEe I 3 2001
~:=. =.,1 PERMIT NO'OJ-08Ib.
(Please CYpe or"riDt IDd .ip at bGlmm)
ADDRESS
'SlIs? .. 9tLln. .!1u4"L.J f!w,~ ...r~.
ZONING (ol1lct:me)
r..EGAL DBSCRIPTION (DfJIce use only)
LOT
BLOCK ADDITION
PIO
OWNER
(Name)
'7J V2 ~
. (phone)
(Ac1dtess)
APPLICANT
(Namc\ ALLIED FIRESIDE DBA FIRESIDE CORNER
(Addless) 2700 N. FAIRVmL}I.VENT.m
(All&b:e$J)
(C P ) BRENDA bLJS'l'ON
ontac:t erson . D
APPLICANT SIGNATIJRE r ~~ldf)L
,(Phone) ~51-S3~-~61
ROSEVTU.1l! MN
(Ciry)
(phone) 651-633-2561
,",~"":l
(Zip Code)
d~_nc
_ DATE
1;)..//1 j,JI
APPLICANT PLEASE COMPLETE BELOW
ISifNEW CONSTRUCTION 0 REPLACEMENT 0 AL'l'EMTIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN vrJ:.l~IN(jS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER. PLANT
JWann Air Plants J Steam
:JOr.v":y :J Hot Water'
J Mechanic:al :J Radiation
:lAir CDnditionmg :J Special Devices
JVenL System J Other DcvIl:C$
FIREPLACE MAKE AND MODEL _tJ,a. /J t:~ ?- 1.n,,1JL
PLEASE Nu &.:.:
Air Condftioner Units
ClDacn BJJctDllch into
R.equired Si~ Yard
Setbacks
Industrial. Commercial" Mulli-Family
FEE SCHEDVLJt
I % of Job co:n bsidcntilll. Gas PircplllCe
$39.'0 minimum
$99.50 Rcsidentio.~ AdditiDns &. Alterations
$64.50 Residcrrtial, AC Only
$39.50
Residentllll, Heating & Ale (New ConstrJ,u:tion)
Rcsitjc:ndo1, H'ct\tlni Only (N~ Construction)
SJ'J.50
$39.S0
Estimated Cost $
Building Permit 1#
REA TINO PERMIT FEE
STATE SURCHARGE
TOTAl.. PERMlI' t. 1l"J!,
$-
$
S
['" PA\D WiTH,... -
.50 euU.D1NG p~
~ ---
,..~..--
(Oftlce Vile o../y)
our Baildllll Permit WIlen. Approved
IE t A 2001
Paid
Receipt No.
Date
By
D.lit
:341 "oar ootlo for .IIJlUpect'''''' <"2) "7-'8SO, fill: (952) 447.4245
.. .' n s- I-\.a.~... ~l...
PRIOR LAKE I ~uftD~'i~D~~SPECTION O/-OS/f
INSPECTION RECORD
...
SITE ADDRESS Sl/~7 {:;~II\ ~ eu...~
NATURE OF WORK tJeu.)
USE OF BUILDING &,4-
PERMIT NO. (!J/-t) tiS DATE ISSUED ~-?~ - ~I
CONTRACTOR ..DR. ~ PHONE Cf'S~ ~ -l{7P
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE. PERMIT IS BY SEPARATE DOCUMENT
.
INSPECTOR
DATE
FOOTING I . /1;rt I f8/11(),
l FOUNDATION (Prior to Backfill) I f;p,. 1'le/oJ I ~r, I~ 1t>/3//) I ~'
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
SEWER I WATER I SEPTIC
FRAMING. ~ '.'& <:J~ ,/J,b2.
INSULATION 4-z I (AJ) ~. J II III Z @:r~ 113/az.,
ELECTRICAL I'. I
PLUMBING ~ \.l.G\. ~ jD/1fD J ~, 1/;r4 (d/lJI.!cl P9. /&/J~)(J)
HEATING (if required) ~, hiT I ~. ro/'!>(C' ~"4: ~Y' /D/,'ltJI :aiiJ 2.-
FIREPLACE ~ \9 ~',;t\ n..
GAS LINE AIR TEST ~ _ r, '"_ t) ~ t
COVER NO WORK UNTIL ABOVE HAS B EN SiG'NED
,~ th. lif/tt(4( I ~ ~ ~1.~l,!oZ-
FINALS
/v13/?!3
/h, · ~ d-d/()a- 0 fJ
- I
GRADING (Prior to Sodding)
BtJlLDlNG1A~.Df f.t1Jl q./ l J {yt-
l
EItECTRICAL
PLUMBING
HEATING
DO NOT OCCUpy
q- /;;L-~
q I (~I J./
I' ,
- " ""-J
N ~
c;. \j"->
I~ / dkriT/lJ;L-J
. .
UNTIL ABOVE HAS BEEN SIGNED
NOTICE
This card must be posted near an electrical servlce c-ablnet 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.
Call between 8:00 and 9:00 A.M. for all inspections
FOR ALL INSPECTIONS 19Sa\ 447-9850
",~'.
. 1'-;0- /I'-~
'~~. ...';7~:.:~ '><~~'~
;;,,~.-. ':.'J:..,..,
Irrtifuat.e of ODcmpanry
CITY OF PRIOR LAKE
iBepartment of Jluilbing In'pettton
~ Final Pennitted 0 Conditional C.O. Expires
17ais Certificate issued pursuant to tM requirements of Section 307 of tM Uniform Building Code
certifying that at tM time of issuance this structure was in compliance with tM various ordil'llJllCes. of the
City of Prior UlU regulating building construction or use. For the following:
SINGLE FAMILY
UICCIIII',,~ ~,,:. ,
Bldg. Permit No
01-0815
Occt''',_.'Type R3 .TypeConstruction VN FireZone _N/A ZoniDgDistric:t R2
Lepl Description L8, B1, DEERFIELD THIRD (BLDG 12, UNIT 63)
Owner of BWldinl
SiteAddress 5457 FAWN MEADOW CURVE SE
D.R. HORTON, 20860 KENBRIDGE CT., SUITE 100, LAKEVILLE
C4., ,..,'s Namc.t.Address
ROBERT D. HUTCHINS ~
BWldiIll Official )/l/
t7 - I;';) -();)..
City PIIIIner
Date: .
DON RYE
Date:
OA TE TIME
..ITV OF PRIOR LAKE
INSPECTION NOTICE SCHEDULED Z;u.;..".. 1 ~ , C
ADDRESS Sc.{ S 7 F~ ~ ~.
OWNER
CONTR.
PHONE NO.
PERMIT NO.
() I -f/S
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
AiJe PLUMBING FINAL
~ MECH FINAL
COMMENTS:!{JJ ~ ~
@~ ~. .~'"'" '
~~~~,
f9~-~~~J
@) ~ ~, ~
o FOOTING
o FOUNDATION
o FRAMING ~
o INSULA TIO ts'
Ii FINAL
B SITE INSPECTION
o EXIGRAD/FILLING
o COMPLAINT
41 FIREPLACE RI
FIREPLACE FINAL
GASLlNE AIR TST
o
#.~
~
''':';'~
,.fL10. ~ ~; ,;~
, I
~~
o WORK SATISFACTORY. PROCEED
'yI CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: ~
. 0/
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
Owner/Contr:
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYl
INSNOTl
DATE TIME
...1 rv OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
Z-IS.O '2... 2~ ~
ADDRESS 5457. 58 .cA WN
OWNER
CONTR.
PHONE NO.
PERMIT NO.
Ol-B/~
I'JI-PJI(P
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER !:lOOKUP
o SEWER HOOKUP
~PLUMBlNG FINAL
o MECH FINAL
o EXIGRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
COMMENTS:
I. ~~ VLe>J;-~
z, ~CU hJ Q.bj CJvt \-
o WORK SATISFACTORY, PROCEED
~ORRECT ACTION AND PROCEED
o CORRE(]6' CALL FOR REINSPECTlON BEFORE COVERING
Inspector: . Owner/Contr:
. f--./ '
CALL 447.9860 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYI
.."LW,li........
COMMENTS:
DATE
SCHEDULED 91eJ- t);J.... I
I
::faam IJ1Ltlb) IIu AAJ
CONTR. - .."""I OJ~I
01- till I:Jlf;i:% <Y t
PERMIT NO. ?O:!.,1 0/ I ~~I
o PLUMBING RI 0 EXIGRADlFILLING
IJ MECH RI IJ COMPLAINT
o WATER HOOKUP 0 FIREPLACE Rl
o SEWER HOOKUP 0 FIREPLACE FINAL
IJ PLUMBING FINAL 0 GASLINE AIR TST
o MECH FINAL 0
a-f-/
TIllE
CITY OF PRIOR LAKE
INSPECTION NOTICE
5Lj33 -
, ~ ''ffat)
ADDRESS
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
/)/'
VI'--
f\ / . ij~
( (J tifJL- 7 )
~: V
<'
o WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED-
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: /()~ Owner/Contr.
( 1/
CALL 447-050 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH &: SAFETY!
J 1
, --
DATE
TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
OWNER
5'153 (qWYl !J1{(J/oWLv/I/t'.
CONTR. D~ HO/~t'7
PERMIT NO. 6 I - g/ I
)
ADDRESS
PHONE NO.
[J FOOTING
[J FOUNDATION
[J FRAMING
[J INSULATION
[J FINAL
[J SITE INSPECTION
[J PLUMBING RI
[J MECH RI
[J W" TER HOOKUP
[J SEWER HOOKUP
[J PLUMBING FINAL
[J MECH FINAL
[J EXIGRADIFILLING
o COMPLAINT
o FIREPLACE RI
[J FIREPLACE FINAL
[J GASLlNE AIR TST
o
I
COMMENTS:
5Lf5...."5 - L()~/I ,,,,10,/1 l/~/vt rJv~t, wlf~SEd
54 ~ 1/- h/~/.t - <.? It-
5Y 55 - &f~/t'- ()~
~
/'
I ( 1
Ok \ I)
L , G;'- ,
; \0 /
v-o.. 0
(j v ~
I\" G\ /' 1 <;:r
SLJ C)~.:- b'<<-1"~ - V f(
c; Lf 5 I - &' er I, - I)/t...-
5ift> 3- (..d41/f- GJ~
.
54S t-&c.,,{t..-O!<-
/' I_/"
'5 '1" ().,.- Dle("" - v (.....
[J WORK SATISFACTORY, PROCEED
~ORRECT ACTION AND PROCEED
X CORRECT WORK, CALL FOR REINSPECTlON BEFORE COVERING
InspectDr:/!;!'~~'. Owner/Contr:
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH cl SAFETY/
.
-
APPLIANCE
PERFORMANCE TEST
Attach to gas line adjacent to regulator
Heating Contractor 1\" " c....-\l '~
Name of Tester \Lt...~~,--
Date ';1-- ) - ~~
Job Address ~S"7 F",_ ~<.e.""" (."~c...
Heating Contractor A\ \, ~ ~~~.
Name of Tester \<......\ ~
Date ':)- , - a~
. Percent 02
Percent CO
Percent CO2
c...~
- ~-
Stack Temp
Combustion air is atjequately supplied per
UMC Sec. 606 y~.)
input c." 000
g-.~
")CJ ~.