HomeMy WebLinkAboutBldg Permit 04-0693
(Please type or print and sign at bottom)
ADDRESS
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
14747
TlM/{EJe WdLr
LOTXBLOCK
LEGAL DESCRIPTION (omee use only)
ADDITION 71IE Wt1(}/)<;'
OWNER ,-
(N ame) I) f3/IJ /lJJ t
Sc!lIV/"eTell..s
J)t?;).. cr e/fsr
\. Whit!:
2. Pink
3 Yellow
File
City
Applicant
T.tf_
111" tv
/JT T#~/Za.s
Date Rec'd
&./7. 04-
PERMIT NO'MAJ6 93
ZONING (office use)
PUt)
PID ~S:Y8'?(J~~'O
~; 7iJ!.
L/J/r ~
(Phone) 2:CJ -q?J. - 33/'(
;t11!/
_ (Address) 3/4/
BUILDER
(Company Name) WeIl/TWt?,tl711 Ct?/'J<)/
(ContactNa~ 3/111 d-dd- c.r PD5r n;JI2
(Address) /' ~ /)Etl/Mt. Sc}fH/jPi.7E/2s
(Phone) b/;) - 730 - /7~q
L:HLA.tt(Phone)~/:J - /.~- S'tJ'ifd /~~,e
TYPE OF WORK ~ew Construction ODeck OPorch ORe-Roofing ORe-Siding OLower Level Finish 0 Fireplace
o Addition o Alteration o Utility Connection 0 Mise,
CODE: ~.R.C. DI.B.c.
Type of onstnlction: I II III IV V A B
Occupancy Group: A B E F H I M R S U
Division: I 2 3 4 5
PROJECT COST IV ALUE $
(excluding land)
'i()~~~
I hereby certify that I have h.lrnished mformation on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authonzed agent for the
above-mentIOned property and that all construction will conform to all exisllng state and local laws and will proceed in accordance with submitted plans. I am aware that the building
'.Jfflcia n evo this permt for JUS use Furthermore, I hereby agree that the City offlcial or a designee may enter upon the property 10 perform needed mspecl1ons,
I Permit Valuation
Permit Fee
Plan Check Fee
I State Surcharge
I Penalty
\ Plumbing Permit Fee
I Mechanical Permit Fee
I Sewer & Water Permit Fee
\ Gas Fireplace Permit Fee
I ~Lj{) 0, () 00, DO
$ ~J'K'~g.S"O
$ 1.'i'5C/. ~J
$ , Zoo. 0 C- I
$ \
$ /OD,oa 1
$ JOD.OO I
$ 35. So
$ I{o,o ~
This Application Becomes Your Building Permit When Approved
~~
Buildlllg Otlieia\
?/~~~ C{
~ --dO~S-L/d){
Contractor's License No,
I Park Support Fee
I SAC
\ Water Meter Size 5/8',--8
I Pressure Reducer
I Sewer/Water Connection Fee
I Water Tower Fee
I Builder's Deposit
I Other
I TOTAL DUE MtA.eYJ 1.'j,()~
Paid /1 JSJ; "7 r
Date ~.o4-
S"-;I.S -(7 L/
Date'
#
$
$
I $
I $
I $
I $
I $
I $ I
))$11" 53. _7aJ
Receip~o, 4-'7 l,;(,("I-"
By ~./.
o
#
'ffS"fJ. ()O
1,~S"o. 0 0
30{J,OCl
70, oc
I ZOD .ot)
700.00
I SDO, 00
#
#
ThiS IS to certify that the request m the above applicallon and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This documenl
when signed by the City Planner conslltutes a temporary Certificate of Zoning compliance and allows consll'uction to commence. Before occupancy, a Cel11ficate of Occupancy must bl
iSS~ ~ '/0 /J ~ (}.1L( ~
- Planning Director 7J;'~ar /~ spe~~~
24 hour notice for all inspections (952) 447-9850. fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372
White - Building
( ~allW--- En9jneerlng~
Pink - Planning
Th. ('.nl.. of lh. I..k. Counlry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
v\ [ ~,FT" \.10 C \CT'H
(! ."'-' {" I C--. -t-l-'
, (,,, ,,"-,..
~--' ,,-,' -......
Ii"' I /
'-.I.'" , : (, '.J L.f--
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
I " -1 i-..,
I';r I 4- I
/ ! r ! r< C it) ,\" / /" ; f II;::: -/ ",t(~ L\ I L..--
I' . .--'L,!.....~/{fv'v\.,.r- "r
I '
{-.J ,'vV
Accepted
~
.,
Accepted With Corrections
Denied
Reviewed By:
/Y){fjS
Date:
{,-:t5-lHI
Comments: S~e'R.ew~~ ~p'fnr Ac1ditinn::111I1forrl1~ti~~1 : ,
See Attachments: 1) Grading Plan, 2) Erosion C'ontroIMeasurp4;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."
t.
~ite - E;I~
Canary - Engineering
Pink - Planning
The C"f'ntrr or Ihe tab Counlr)'
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT W5NTWO~H ~ONSne.-.
APPLICATION RECEIVED ~ . It. 0 4-
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
14-, 4~7
T/Mt36ewOL-F
. \ .W/
1 f6A (t-- ('J
Accepted
Accepted With Corrections
~
Denied
~IL
~J.j ~.
-- IP- ~, 'r~/~~
V ~""
~ ~ ~ ~ ...<~ _8~;:":;_
- Q d J (7
~J' ~ ~ /'''--'
~
. Date:
7 /~~cf
,
Reviewed By:
Comments:
,..
/)-J
"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."
..,.;
, "
Tht" Ct"n't"r of .ht" t.kt Counlry
White - Building
Canary - Engineering
Ct"mK - Planning)
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
i! i \,
jj..,.\
\ j;
I', (i-,
APPLICATION RECEIVED
I
, i
L--
~he Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
I /. ) /~) 'i L ~ (l 1- -/'/ / I \ I (....- r- 1'1 ,\/J
...
.,,~"'-'" -.,
Accepted
Accepted With Corrections
/'
Denied
~~
..
~~
Date: ~~;d i(
~ ~,..JJ
I
"~.
"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."
09/08/2004 15:48
9528947972
LAkE SIDE PLUMBING
PAGE 01
CITY OF PRIOR LAKE PLUM.BING PERMIT
Date Rec' d
(PleA.~c ~e or 'Orint and sif.!l1 at bottoDl)
ADDRESS
14ft/I
'11b~ '''')0 It..,. P.
I. 1'lluo File PERMIT N
4, Oald CllY _' 0'0"'.0'-03
J. Ve''''''' ^pr1iunl ..,.. VI 7,
ZONING (o/lice use)
LEGAL DESCRU:'uON (office use only)
LOT BLOCK ADOITION
OWNER
(Name) ~ =< C;C.h~"
(Address) ~ , "'1,1 ao3_.c...+ &.sJ-
APPLICANT f) 01
(Namt) ~~~ 5..1... tJ\ll"1b..,
(Address) 1 ~~~ 2..:" Ti:1I\ au~
(Address)
(Contact Person) ~IMI'_ ~~~~,
APPLlCANT SIGNATURE ~ .f<...1)JJJ..
Quantity
.;l
1
\
f.c.
I
,
,
'"f
PID
(Phone)
(Phone) ~~- K~oo
So.LM.4""
(City) ...
_ (phone)
APPLICANT PLEASE COMPLETE BELO\V
Type of Fixture
Bath Tub with or without shower
Dishwasher
I Floor Drain'
Lavatory (Bathroom Sink)
Laundry Tra,y (lor 2 compartmc1:1t si,nk
Shower Stall
I Sinks
I Bar Sink
I Water Closet (Toilet)
Quantity
I
I
SSJ..ii
(Zip Code)
s~
DATE
q- f-o"
Type of Fixture:
Rough-ins ~:A I<'
I Water Heater
Watel' Softner
Stand Pipe (Washing Ma,chine)
I Sewage Ejector
i Backflow Assembly
I Backflow Assembly Test
I Lawn Sprinkler
I Other
FEE SCHEDULE
Industri:J1. Commercial &. Multi-family 1% of job COllt with a $39.50 minimum Residential, New One &. Two-Family $99.S0
Residential. Additions &. Alterations $39.50
qq.,U!EAlU W Il'H
11~{J1LDING
l~~a~ L~ ulw ~~1~Ul'
- I ~f!P 1 0 2004 l j I By
Estimated Cost S '1D, 000
Building Penn it #
PLUMBING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$
$
(Office U~t Only)
This Applicatiol1 Becomes Your Building Permit When Approved
Buildin!!, OI'J'killl
Il"te
24 hour notice for all in~pecti.lnt (952) 417-?850, Cax (952) 447-4145
16200 EII~le Cnek Ave., S.E., Prior i!iI.lIl MN S~31I~I-:-;~;-.;.::.::,=..
9-16-04; 8:00AM;
;952 894 0925
# 2/ 3
CITY OF PRIOR LAKE
&EA TING/AIR CONDITIONINGIFIREPLACE PERl\'ul'
Date Rec'd
(please type or print and silw at bottom)
ADDRESS
\L\ll\ I \\f't\~'())( Tr(L~ ~ _ t-J. W .
~: ~ ~!~. I PERMIT NO. OA.. 0 (,0 2.
], v.lJow ApphCllftl -r . I ~
..
~
g
J
J
ZONING (office us"l
LEGAL DESCR.J.r l.iON (office use only)
LOT
BLOCK
ADDmON
PID
I
~=RWQJ\+lk)n'~ (~n(L~
(Address) :~ \ q l - :::lo~ f1.kf (' i ECL. ~+, .
(phone) i.QJ ~ - -. \;;Y--,-ljl./S
Pr,"CI/ l u. ,r (') ,
, APPLICANT
(Name)
(phone)
Burnsville Heating & AlC. LLC
12";8'( RI,ode I.,')'~' Sa.
Savage. MN g-1122
(Contact Person)
APPLICANT SIGNATURE .({ rVL B~~ f..tJf7Mc;t/7
(Address)
(City) (Zip Code)
(Phone) 95J. - XCttt -(YYJS
DATE q-/S -0(/
APPLICANT PLEASE COMPLETE BELOW
li?JNEW CONSTRUCTION
FURNACE MAKE AND MODEL l.p Y1y\()')(
FLUE SIZE RETIJRN OPENINGS
TYPE OF SYSTEM
o REPLACEMENT 0 ALTERATIONS
(.,(0 \ U.oVOfn0(1 'If.:! FUEL ~l :+-,,0/)
\0, INPUT", \() .e'en OUTPUT \0\. 'LCO
HEATINGORPO~RPUUIT
DWann Air Plants
DGravity
o Mechanical
J&Air 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
I
g\.:::,~
:.:~...
......
">;;"..
FIREPLACE MAKE AND MODEL
Industrial, Commercial & Multi-Family
FEE SCHEDULE
1% o{job cost Residential, Gas Fireplace
$39-50 minimum
$99.50
164.50
139.50
Residential, Heating & Ale (New Construction)
Residential, Heating Only (New Construction)
Residential, Additions & Alterations
Residential, AC Only
139.50
$39.50
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Building Permit #
$ \/
$ /\ .50
s
/
(Office Use Only)
This Application Becomes Your Building Permit When Approved
Paid
Date
By
Building Official
Date
?... hnn.. nntll''' rn..all ilL"ioections (952) 447-9850, fax (952) 447-4245
CITY OF PRIOR LAKE
SEWER AND WATER PERMIT
Date Rec'd
7. /~~ O~
1. Green File
2. Yellow City
), Gold Applicant
PERMIT NO, ~ ~ 0'93
(Please type or print and si~ at bottom)
ADDRESS
/4-'14-7 71 n.tf@t.,wtl'-F 7/WTl--
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID Z5.383, (JZ(P" 0
OWNER
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
APPLICANT!/:;:} ~ J f/
(Name) J~~<- if- 1.1 / ~
(Address) t.;tf'.~ ~JfL.. ~
/J (Address~
(Contact Person) /J~}
APPLICANT SIGNA;URE~.f.~
f/
APPLICANT PLEASE COMPLETE BELOW
;]Z)
f,/ >leily)
Jb 3- L/77- 51/ / l..1
S-S1/1
(Zip Code)
(Phone)
).
DATE
7 - It.( - t> <t
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. D'ABC D PVC D 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 $17.50
SEWER AND W A IER PERMIT FEE
SI A IE SURCHARGE
TOTAL PERMIT FEE
Building Permit # Of.... 0 f&J7;$ B f
$ / I7frlD /,0 ~
$ / .50 r Ot/;-
$ // BUiLt
Estimated Cost $
(Office Use Only)
Building Official
Date
~
~4--
R~
By fWL
This Application Becomes Your Building Permit When Approved
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
Date Rec'd
I. Pink File
2, Green City
3, Yellow Applicant
PERMITNO.O+.O(,~
(Please tyve or print and siAD at bottom)
ADDRESS
ZONING (office use)
14747 TIMBERWOLF TRIAL
LEGAL DESCRIPTION (omce use only)
LOT BLOCK ADDITION
PID
OWNER
(Name WENTWORTH CONSTRUCTION
(Address)
(Phone)
APPLICANT
(Name) ALLIED FIRESIDE DBA FIRESIDE HEARTH & HOME
(Phone)
651-633-2561
(Address)
2700 NORTH F AIRVIEW AVENUE
(Address)
ROSEVILLE
(City)
55113
(Zip Code)
(Contact Person)
BRENDA HUSTON
(Phone)
651-633-2561
APPLICANT SIGNATURE
BRENDA HUSTON
DATE
9/27/04
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
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
FIREPLACE MAKE AND MODEL
HEAT N GLO 6000TR-OAK / PIER-HV / I60T (TOTAL OF 3)
Industrial, Commercial & Mulii-Family
FEE SCHEDULE
1 % of job cost Residential, Gas Fireplace
$39.50 minimum
$99,50
$64,50
$39.50
Residential, Heating & AlC (New Construction)
Residential, Heating Only (New Construction)
Residential, Additions & Alterations
Residential, AC Only
$39,50
$39,50
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Building Permit # t?b~r, V'~lf~
$ ~H ~U),t~l!~ pJ:rq~~rr" ,
$ '-' ~5u' ',.W,,,_ "m .
$
(Office Use Only)
This Application Becomes Your Building Permit When Approved ~ ) W<tl8 r[~ 0 IT; i Receipt No.
Buildine Official Date J~ D~tp 2 9 2004 11. By
24 hour notice for all inspections (952) 44' -9850, fax (952) 447-4245
By
P R I 0 R LA KE D"ePARTMENT OF
BUILDING AND INSPECTION
INSPECTION RECORD
SITE ADDRESS 1~?!l7 I i~8.,c, ".J,LI- 7Xl. N.IU.
NATURE OF WORK New ~~...~
USE OF BUILDING S.F:O-
PERMIT NO, M. o~ DATE ISSUED 7/liltJI/
CONTRACTOR ~ ~,." ~~"".,.,... PHON?~.70 .. lL",'
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
. .
FOOTING/aJ ;%1' N /~/~ We., I
"
J FOUNDATION (Prior to Backfill) I I
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
,
SEWER I WATER I SEPTIC~A--' g
f:~
FRAMING 'f' "'.
INSULATION #lA-.
ELECTRICAL
/'I....
PLUMBING m ?-'7J
HEATING (if required} , , l?t.> ,
FIREPL4'CfJ~ ?(1 IDIJ.CA ( !J Ht~ /I//'/~I
GAS LINhlR TEST ~~~~ M~ I'() 1It(I/~~/of
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
-, .
tArNr! ~IT~ I~/!p I
~ 6~uf4..~~~U FINAl~
GRADING (Prior to Sodding) AI ~
BUILDING f (PI
ELECTRICAL
PLUMBING
HEATING
DO NOT OCCUpy
f/bCTOR
DATE
I 7-1"t-o'/
, I
7/';' PI?!'
/0 J '(( (.. /:'Y'
////ffi~
la. I'G. ,0 s-
flJ/
UJ)
~;lf
HAS BEEN ~'GNED
"<
~
UNTIL ABOVE
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
~
QIertifitat~ Itf @ttupantll
CITY OF PRIOR LAKE
~~flarftUtuf nf ~uil~iug JfuSfltttinu
~Final Permitted
o Conditional C.O. Expires
This Certificate issued pursuant to the requirements of Section I J 0 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 04-0693
Use Classification Bldg, Permit No,
Occupancy Type
Type Construction
L26, Bl, THE WOODS AT THE WILDS
R3
VN
Zoning District
PUD
Legal Description
Owner of Building
WENTWORTH CQNSXR"
Contractor's Name & Address /' )~,
ROBERT D. HUTCHINS IJ'V,
Building Official V I
Ii 'i "J
14747 TIMBERWOLF TRAIL N,W.
Site Address
3141 202 COURT E" PRIOR LAKE, 55372
JANE KANSIER
City Planner
Date:
Date:
~:ll_,~~,~_,!':.
~....._.~
"',__,,~~._,.~. ...."..c ~",:_ _,..,'\;.di.l:i';~' t.oWl"Il'L_.~_._,:~~____:~_.,__
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS J 4'147
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
DATE
SCHEDULED ~
~lav 0J '-
TIME
CONTR.
PERMIT NO.
4-(,17
./
o EXIGRADIFILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
)!k PLUMBING FINAL
o MECH FINAL
COMMENTS:
~~~~
'2. I....&~f)..t. ~......~ ('~M ~
-3.~l.w- (.\\~~
~
-;
n-
o WORK SATISFACTORY, PROCEED
~ORRE T N AND PROCEED
o CO EC R ,CALL FOR REINSPECTION BEFORE COVERING
447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
Owner/Contr:
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYI
INSNOTI
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS I q 147
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
'<<' FINAL
~TE INSPECTION
COMMENTS:
SCHEDULED I ~I t7 ~/~
J:wl..u ~
CONTR.
Lf -('?3
PERMIT NO.
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
o EXIGRADIFILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
~~~~1TST
I. F7~ G1'cL~ ..~.Sp' r2L'j ·
{9
- (-
S J- \ t')t,-
'"
o WORK SATISFACTORY, PROCEED
~ORRECT ACTION AND PROCEED
o CORREC~~LL FOR REINSPECTION BEFORE COVERING
Inspector: I .J t~V- ) Owner/Contr:
CALL~~FOR THI; NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
INSNOTl
. ....._.. ,.....~_"^.., ,.,..-.-."t ... n~~,~~_~..~_._.'O'M_"'_'~.~'~_'_~_'~~"'__'_._"~.'""~""
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
lOr /2'Q)'
PHONE NO.
f 41 Lit I," I'1Wwot( 1'/ l
CONTR. W(t1f.~~ ~~1.
PERMIT NO. 0 4. -~J
ADDRESS
OWNER
o FOOTING
o FOUNDATION
o FRAMING
o INSULA liON
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
~E~ILLlNG
o CcJiiiEjJNT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
COMMENTS:
h~L,-()1L
(via ~_Jf- oL
\I' WORK SATISFACTORY, PROCEED
~ORRECl 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 .I SAFETYI
INSNOTJ
BVftN~ -'ILLE
Heating & Air Conditioning, L,L,C.
12481 Rhode Island Ave S, Savage, MN 55378 · 952-894-0005
Ors1at Test Report for Jobl ;'&&~
Address } tI, 47 /,f'V' ),f" [Va/ r 1'/ City f~, o/' In k.A.
Occupant
Date of Install /2 - If - 0 '/
Type of HT. F/A v HW Space HT Unit HT
Other
Make
Model
Serial
Input
Lb1,., b)(
6s1 ~i'v' ~ btilC-- 110' 0 I
SCfo'f IL 2113 0 "1-
tlOJM 0 7?Tvrf
Pilot Type
Pressure
Input CFH
Stack Temp
I'
HOT SURFACE IGNITOR
? ."\ C02 ll'B 70
tl{:) 02/l,t("Jo
pl " F CO ( "S ,0/,,111
Date Tested
Company
Technician
1- 2.1- 0\
8URNSVILLE HEATING & AIR CONDITIONING
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