HomeMy WebLinkAboutBldg Permit 01-0818
CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT '-7- I q - 0 J
1. While File
2. Pink City
3. Yellow Applicant
I PERMIT NO.O/_{)g/ ~
(Please type or orint and silm at bu..v....)
ADDRESS
5 ~.CoD .' FwVl ~OW ~ ~6
LEGAL DESCRu-llON (office use only) 'BLt) 6,:\C \2. UtI\...+ ~ L{ ,.,
LOT ct BLOCK l ADDITION ~&;:r..cu;\ J. ?NJ Vi \\.ti-J
OWNER
(Name)
(Address)
(phone)
BlnLDER n
(Name) O. Q. \11JY'1-yy, Xn l ,
(Contact Name) _ M \.KL LV.a.n n O'U- t I( a ~
(Address) ,;JtJt;&JO J<<.+1brt~ d. ~-h:.1 DO t..tJ4v1IJ61.AA 1J
TYPE OF WORK
'~New Construction
OLower Level Finish
ODed
o Fireplace
ZONING (office use)
(2~
PIDd5 -313- ()M--()
(Phone) !JGJ4 -4:}'~ ,",-~
(phone) ~&!X -aalt" t1?J2
Ch7JLI c.-/
OPorch
OAddition
ORe-Rooting
OAlteration
o Misc.
PROJECf COST IV ALUE (excluding land) S /}~. In 0
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 lam 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 pcmorm n d inspections.
x
V
Permit Valuation
12 ."-YM. C9d
/4/. 711:) l
~l B . c:;-<f I
~ .a?
Permit Fee $
I Plan Check Fee $
I State Surcharge $
I Penalty $
I Plumbing Permit Fee $ 100. (;;,I 0
I Mechanical Permit Fee $ (I!)(). C) (;)
I Sewer & Water Permit Fee $ O~,
I Gas Fireplace Permit,Fee $ t:{ 0 . C!>CJ ~ .
57 -J::-~7.;;::
Bu' ding 0 al Date
~/JO{)~~lJ
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
Water Tower Fee
Builder's Deposit.
Other
TOTAL DUE
Paid 5"Q9',;;)..~
Date r i-~~ /~/
#
#
#
#
1-lfro I
Date
$ ~ 5"O.t!JO
$ I. I VO-. Ot>
$. C-
$- 0.-
$ 1.~OO.~
$ '7~f ()C)
$ l)-
$
$
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
Wh~:d~ by the City Planner constitutes a temporary Certificate of Zoning compliance and allows cons, auction to commence. Before occupancy, a Certificate of Occupancy must be
issU?, /to..'" '
~t ~ ~t!"-~~. 7/30/~ ~ ~~~
- Plannj~ J.J .'Ector Date Special Conditions, i any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
White - Building
Canary - Engineering
Pink - Planning
Tht etnl.. nr tht I.akt ('ountry
BUILDING PERMIT APPLICATION DEPARTMENT CH~CKLlST
NAME OF APPLICANT
APPLICATION RECEIVED
j) i2 IJCnl CY'---'
7-jQ-o J
The Building, Engineering, and Planning Departments have reviewed the building permit
aPPlicationfS~ZC~ra1:;;s~~
Accepted
rJ..
Accepted With Corrections
Denied
Reviewed By:
Comments:
/tI',(J/3
,
Date:
7- ZS'-CJ I
s~_ ~4 F/(r
"
"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."
f
._-~'-~..-
The Cenler nr Ihe toke ('ounlfy
White - Building
Canary - Engineering
Pink - Planning
.."';,"::~gr-;"_:'(^;''i
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
o f( Id G-J CY*'
7-jq-(j /
OJ-'{)({; g
..-
',.
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at: /'
S Llc:' 0 :?a//J71 >>U!Cd()-{f(~-
~
Accepted With Corrections
Accepted
. I
..'" .
.,,'~
Denied
Date:
7/Ze/e {
~'''~
.
i.A-
i I
,/
Reviewed By:
Comments:
~
/-
r
l
,
1
5.'/li~~ J.9
liThe 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 ('on... 01 tho L.ko Counlry
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
fJ/2..lJO-J(Y'-
7-jq-6 I
~
The Building, Engineering, and Planning Departments have reviewed the building permit
apPlicationfs7izc~na~=s~~
Accepted
Accepted With Corrections
x
Denied I/) ()/J L
ReViewed~()~ 'r
Comments:
~- +R-t ~~ Rv
Date:
?-(e;r-~I
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."
J u I ' 25. 2001 6 : 55 AM
GENZ RVAN PLUMBING AND HEATING
No.8621 P,23/30
D.ate Rec'd
Ll1. i OF PRIOR LAKE PLUMBING PERl\'.u..l ' JJL 2. 4 2001
, ,
,... .......,
I ,... ll/c
1. QokI Cil7
~. 'Y...... 4ppIi...
P~R1\illl. NCXf-t) 7
I
/Please ~ or TUiJ.r.ailcl sip.a! J:,pUDm)
ADD~SS _~~. .
~... .. 'P'l:\'Ws"" ~U q.a:anA~ ttl~\L .\E_
ZONING (al!busa)
R~
LEGAL DESCRlr HON (olJice'use QD1y)
LOTq BLOCK / ADDmON (Jg Q v--fi, 0 0 ,~
PIIb7 ~- 3 / ~- ZX:Y::i-o
OWNER.
~wm~ DR Horton Cus~om Homes
(phone) 651-454-4663
(AWh~~ ~4S9 WashingLon Dr Ste 204 Eagan. MN 55122
, ,
, ,
APPLICANT
(Nll.1Xle)..Gar-_l1~P"'" ~1."9i.;1g ~ u...+.f-a (phone) _6.s..1-lr. H_11"
(Address) 14745 So Roberti 'trail Rosemounc MN . .' .55068
(Address) (qty). . ~ (Zip Code)
(Contad:Pc;rs~n) Mary Olson II (f~p.e.) 651-423-1144
APPUCAN1-~IGNATURE 11 ~jJj\ (~ .," pATE r 26/D I
L----' '.~ f !
At: ;t.JCANT PLEASE COMPL.It.l J!, BELOW
Quantity Type of FIXture I Qllutity
I Bath Tub with or without shower
I Dishwasher
J I Floor Drain
.~ . 1 Lavatoty (Bathroom Sink)
, I Launchy Tray (l Of 2 c;omp...~ent sink
I Shower Stall '
I Sinks
I Bar Sink
2- I Water Closet (Toilet)
Type ol:n,,~ ,,,';"
I
I
I
I
I
I
I
. , .
IZ-/I
J
Rough-ins
W_ H.....~...
I Wa:tei'Softner
I Stand Pipe (Washing Machine)
I Sewage Ejector
I Backflow"Assembl]
I Backflow Assembly Test
I Lawn Sprinkler
I Other -
~.AJL S"'J:LLUULE
Ind\1strial, Co~ll,tC:lal 8/, Multt-famiJy 1 % of job cost with a $39.50 minimlUO hsidcntllll, New One &; Two-Family $99.50
Rcsidmtial, Additions &: AJtmtions S39.'0
E.stimated Cost $
BuUding Permit #
. BUIL641D 1117'i
INGp -,..,
~Fil~/'r
PLUMBING PERMIT to'hI:; $
STATE SURCHARGE $
TOTAL PERMIT FEE S
50
(OOice Use 0Dly)
I This Application BcCOIllIlS You... BoiJdiag Permit WheD Approvca
['
Paid
Receipt No.
BddlllC alBa.!
D_ill
Date R'~vJ
JOy 9-,C
24 bour Dotice for .U i.'lMdioRlI ~) 447-9850. tu (952) 447-4245
CITY OF PRIOR LAKE
HEATmG/AIR CONDITIONlNG/~1.KEPLACE PEAAu J.
Date Rec'd
(Please tvDe or orint and si2ll at t ~~~~)
ADDRESS
. 64-LoD K1Wnffifl1f.DW 0A1vvtJ
I. Pink File
2. Green City
3. Vellow Applicanl
PERMIT NO. I_;(!~
ZONING (office use)
D~
l -
----
LEGAL DESC~/ON (office use only) (.
LOT51BL~CK l'2-ADDmON i~o~d! ,qrJ
OWNER -,.......() I L. .........
(Name) V K... \10Y'. tI\
,(Address) -~L'61 Wa.~k AvL Sui-k 1))1)
~;;~~ANttlllln+ me,tJtltU11~aJ (phone) Jt:6/
(AddreSs)~D mnfbf0 '1)r \.~i,+e,l \
r c. (Address) . (City) (Zip Code)
(Contact Person) ~-r1T~ . l ~YYlfYIel;~ (Phone) -1e5 1,15Z - 2--"175
APPLICANT SIGNATURE ~f, ~ (ffJIJJJJDATE 7 ~
/ APPLICANT PLEASE COMPLETE BELOW
~W CONSTRUCTION o REPLACEMENT 0 ALTERATIONS
FURNACEMAKEANDMODEL Br'jtnf- ?}6~ILAVD2J/blD . FUEL~aJ'
FLUE SIZE 4'\ cla.sS &_ RETURN OPENINGS. 4- INPUT '1D. DDD OUTPUT 5w~ bOD
PIrb{s- '173 -cdi'-o
(phone)
~ NLI\J 55/22-
452,-2.1"15)
TYPE OF SYSTEM
OWarm Air Plants
OGravity
o Mechanical .
lBAir Conditioning
[illv'ent. System
HEATINGORPO~RPLANT
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
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 #
REA TING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$
$
.50
au ,!6iN1DGWp. "!H
I;;;M"V:IT
(Office lIse Only)
This Application Becomes Your Building Permit When Approved
Paid
Receipt No.
-- ---
Building Official
Date
Date 9 -3-0;
BY~
;
24 hour notice for all inspections (952) 447"9850, fax (952) 447-4245
FIRESIDE CORNER
#6031 P.012/013
Date Re4:'d
""it Y OF PRIOR LAKE
.tl~A TING/AIR CONDITIONING, r adPLACE PER1\u.l .
DEe I 3 20m
{/?lase l:Y?= Qf mini: lIDd siJlD "bGttJ:)m}
ADDRESS
5t.;G?() ~~. (h p()L-w flv.~ c)i5"
LEGAL DESClU.r. J. LON (am.:e \)Illl only)
LOT. BLOCK ADDITION
OWNER ,I
(Name) r:tYK. ~
(Address)
APPLICANT
(Name" ALLIED FIRESIDE DBA FIRESIDE CORNER
(Address) J700 N. FAIRVIEW AVENUE
(Addrcs.)
BRENDA HUSTON
(Conract .Person)_ " }
APPLICANTSIGNATURE('" ~/~/L. ~
~=- S.., P~aL~U.~ N?.OI-08Ifj
ZONING (OIficeWIC)
PID
(Phone)
(Phone) 651-633-2563.
SOSEV'I'T oJ: .F. MTIl
(Ci'Y)
(phone) 651-633-2561
DATE j:J. (1- 01
l;~11~
(Zip Code)
APPLICANT PLEASE COMPLETE BELOW
~~W CONsnucnON 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FtUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR. POWER PLANT
:JWIIm Air Plants 0 StA:1\JJl.
JOnvIty 0 HDI W$r
J Mechanical . J Radtatlon
JAir CondltionJng J Special On-ices
JVenl. System ] other Devices
FIREPLACE MAKE AND MVlJJ:oL..iJ&u JJ /;iA S',- -''7J'b
PLEASE NOTE:
Air Conditioner Units
ClIIlnot Encroac:h into
Rcquired. Side Yard
Setbacks
Industrial. <AmmcrclaJ & MUltj.Famil)'
Residential. HeatiDS & Ale (New CanlltnJc:tion.)
Residential, Heating Only (New Conpction)
FEE !k..n .s.DULE
J ~ Df job cost Residr:::lltlal. GIll Fireplece
$39.50 minimum
$99.50 Residential. A.dditions & Aller8tions
$64.'0 Residential, AC Only
$39,5Q
$39.50
$39.50
Estimated Cost $
HEA TINO PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
(omC:I: Use OnlY)
Tht. Appllc
Bulldlnl Permit When Approved
1 jfC t 4 2001
Pate
Building Permi.t ##
s
S
$
.~~~~~~~IT.
Paid
Receipt No.
Sy
Date
Z4 hOllr ..otiCII for _II in.peed8n. (95Z) 447""50. flUE (952) 447-4245
PRIOR ("K
INSPECTION RECORD
, , .t(
8JJILDlNG AND INSPECTIONtJ1_ g/j
SITE ADDRESS ~j tuCAJ\A ~ CuH..t-ll
NATURE OF WORK N~
USE OF BUILDING SF-A
PERMIT NO. tJl-O~!~ DATE ISSUED ,""'2.&J-?401
CONTRACTOR -DJ2.. ~~ PHONE ~ - ;J;>t.,..1!1s::L
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
INfPECTOR DATE
t FOOTING I fJ;n I ~3d.f, I I
FOUNDATION (Prior to Backfill) I ~. /(fJ.}1I I~, I~~;" I .(), T/ I
PLACE NO CONCRETE UNTIL ABci'Vi HAS BEEN S'I NED
ROUGH - INS
SEWER I WATER I SEPTIC
FRAMING ~ .' ;Jl~,>~
INSULATION~. t:J. ~ IJI7/c~ ~ ~~ J ) ~'O2--
ELECTRICAL - . l. 'I '
.. PLUMBING O-r ~'t, 4, 1~i{I'( Ju.u, I7.tJdt ,I/)' {p+-. ll/~fil
,..t-.jiEATING (If required) -rMl'4' 17. Ii 4Y' ef.1/o I I ~, ~ - t4 II ~ /, I
FIREPLACE . ~ ~ ~ ' J I ~I 02-
GAS LINE AIR TEST _ '~~~ _ ,()~J()1-
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
. -
. ~ $:r. IJ-Itt ftJ/ I ~ ~ I ~/:r~IIf~
v FINALS
NtJ) JOB
315~ z,' ptJ
GRADING (Prior to Sodding)
BUILDINGT.t..&. "'[U(? f('h IDZ-- @-.,.
ELECTRICAL
PLUMBING
, HEATING
DO NOT
q ~ 1;;2 /' tJr;.J
Cf- /d-.- 02-
A
15, ()~
I:k.J
.
OCCUPY UNTIL ABOVE HAS
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.
d/I'//(J~
s15/tJ ,)--
I J
BEEN SIGNED
Call between 8:00 and 9:00 A.M. for all Inspections
FOR ALL INSPECTIONS (952) 447-9850
Irrtifuutt otlcrupanry
CITY OF PRIOR LAkE
1Btpartmtnt of JlJuilbingJn'ptttion
~ Final Pennitted 0 Conditional C.O. Expires
This Certificate issued punuont to the requirements 0/ Section 307 0/ the Uniform Building Code
certifying thIJI at the time ofisSUQllCe this structure was in compliance with the various ortliNmces. of the
City of Prior I.oJce regulllting building construction or use. For the following:
SINGLE FAMILY
Use Clusific:aliolL-
_ IDdg. Permit No.
01-0818
Legal Descripcion
TypeC. ...... ....on VN rue Zone -1!/ A Zoning Distrkt R2
L9, Bl, DEERFIELD THIRD (BLDG 12, UNIT 64)
SiteAddress 5460, FAWN MEADOW CURVE SE
20860 KENBRIDE CT., SUITE 100, LAKEVILLE
Occupuq Type
R3
Owner of Building
D.R. HORTON,
Con.... ..,,'sName&Address
ROBERT D. HUTCHINr))b
Building Official 1..;1""
9-/::1- 0 ;:;.-
If
City PIInDer
Date:
DON RYE
c .
Dare:
POST IN A CONSPICUOUS PLACE
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
ADDRESS
/5t.J~ 0 1?1u/~
OWNER
CONTR.
PHONE NO.
PERMIT NO.
DATE TIME
-;s -r -02- () jy'
O,-a?/!
o FOOTING 0 PLUMBING RI
o FOUNDAT106W 0 MECH RI
o FRAMING 0 WATER HOOKUP
,qtINSULATIO 0 SEWER HOOKUP
~ FINAL /';1 0 PLUMBING FINAL
J SITE INSPECTION \\lJ ~ MECH FINAL
. COMMENT~ ~
{:P; ~ .-l. ~ ~"
(~ ~ S:t~-DJ1
~~ ~:-(~ ..
'. "-','..",,, '''','''.........
o EXIGRADIFILLING
o COMPLAINT
IiSlo FIREPLACE RI
~ FIREPLACE FINAL
o GASLlNE AIR TST
o
~
'T,~,D~ ~(liOL
, I
~~
o WORK SATISFACTORY, PROCEED
11 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.
lNS1<<1Tl
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH &: SAFETY!
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
(}.-If-o~ ll...~O
ADDRESS
s-44o F"Q.(A)t\
OWNER
CONTR.
PHONE NO.
PERMIT NO.
1-8JE
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
tl-O~RHOOKUP
11 ..e""PLUMBING FINAL
o MECH FINAL
o EXIGRAD/FILLING
o CO".PLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
COMMENTS: r _ .-
WMf);v..PXe,A' t9<L-.
r
')
."
~RK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECJffRK, t:ALL FOR REINSPECTION BEFORE COVERING
Inspector: _.;t) _ ~~I Owner/Contr:
CALL 447-9850 FOR TH: NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
INSIIOTl
COMMENTS:
DATE nilE
SCHEDULED 9'leJ- cO;l
\
~a.am IJtetlkJl)~~~,
CONTR. _ ..-, 011')
01- 811; (f/~1 ~/~.It.Y"--i
PERMIT NO. 8'1J/ (?of to, I g 0 ~/~ t
Cl PLUMBING RI Cl EXlGRADIFILUNG
Cl MECH RI [J COMPLAINT
Cl WATER HOOKUP Cl FIREPLACE RI
Cl SEWER HOOKUP Cl FIREPLACE FINAL
Cl PLUMBING FINAL Cl GASLINE AIR TST
Cl MECH FINAL Cl
~f--r
))/'
Ut-
1\;1 , )111
( (j j cr~ lY- .../
L./' V
..
CITY OF PRIOR LAKE
INSPECTION NOTICE
5'133 -
ADDRESS \ 7)'7" ~o
OWNER
PHONE NO.
Cl FOOTING
Cl FOUNDATION
Cl FRAMING
Cl INSULATION
Cl FINAL
Cl SITE INSPECTION
Cl WORK SATISFACTORY, PROCEED
Cl CORRECT ACTION AND PROCEED
Cl CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: {J-fJ., Owner/Contr:
(1/
CALL 447-050 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH d: SAFETY!
J ~
". -4
DATE
TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
ADDRESS
5L-f53 fGWYl lYI{Ci/OWLulvt'.
CONTR. D~ Ho,/l-tJ.,.,
PERMIT NO. 6 / - ?/ /
OWNER
PHONE NO.
CJ FOOTING
CJ FOUNDATION
CJ FRAMING
o INSULATION
CJ FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
o EXlGRAOIFIWNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
CJ GASLINE AIR TST
CJ
COMMENTS:
5Lfc.} 3 - Lt..../I L.,/o,/I ut-flvt (Ju~f,., WI f~.s&c/
54~ l/ - h/4/t - v It-
5Y55 - &/~/t'-()'L
-
01("( ~ 1
I' ' \ L) 0'- J
~,.~ 00
f ~/l~
S L/ r;; ~..:- b I ~ /1 - V f(
-5lf 5 / - [,'&1 If - ()K-
S If 5 3 - f..7f4f/r - c.? I<-
I
545 I-&~/l-DK
/' 1- ~
5'1" CJ...- D/c(lfO( -v(...
CJ WORK SATISFACTORY, PROCEED
~ORRECT ACTION AND PROCEED
X'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!
l/f8IfOn
I
-
~
~
~
APPLIANCE
PERFORMANCE TEST
Attach to gas line adjacent to regulator
Heating Contractor A' \ \c;.....~ ~ L..
Name of Tester
Date
~i-\ ___
:)- l-a:a.....
Job Address S"-t (.c:) h.-... - "'~- c::-.vt.,..
Heating Contractor"" \ .. -" Me u-.
Name of Tester ~;~
Date ";l- >>- O.3:a-
Percent 02 '- . '1
Percent CO
Percent CO2
-0-
Stack Temp
Combustion air is adequat~supplied per
UMC Sec. 606 'f.~
input (. " .("to 0
~:~
"'3 '6-.0