HomeMy WebLinkAboutBldg Permit 01-0597
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White . Building
Canary - Engineering
Pink - Planning
Thll- ,",nlff of lhf L.kr ('ountn
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
J) p ~~
(p- /-Q/
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
5 (}CJi- I Q ~/~Ad/ L/LJ
( ,
Accepted
Denied
x
"
Accepted With Corrections
Reviewed By:
M4is
c,-{~ VV'lu;"1 [';/c
Date:
~-/~- 0 /
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."
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
(Please.!VDe or Print and sim at bottom)
ADDRESS
~ d(;f\
ULCr-(:;P \d
LQ~.
c.O r~
-,---,. J:::.. .
LEGAL DESCRIPTION (office use only)
Date Rec'd
Co- 1-9
I PERMIT NO~llf -05'171
L White File
2_ Pink City
J_ Yellow Applicant
I .
ZONING (office use)
1</
LOT I (p BLOCK
ADDITION [') c (' r C ,'{J \ A ,";! 1\0\
PID X--3/d-.. -()/b-O
OWNER
(Name)
(Address)
(Phone)
BUILDERf\-
(Name) \ \ Q I-+n,-+-ff"'(""\ (Phone)
(contac;;;:'me) i_ (\J..U<C1. Dr; nl . (Phone)
(Address) Q:!C%I..",C 1[-". r-brlC'.{q.e, C~ T-., '":-::>-t'- I(J[)
I n II , AJ, I I '" . ~ (\) e:;.--J (l U L./
TYPE OF WORK
~ew Construction
DLower Level Finish
o Fireplace
PROJECT COST IV ALUE (excluding land) $
OAddition
/o?-, I~ '7
OUtiIity Connection
ODeck
o Misc.
q~}~ - q<6l)- /'?;O-,
OPorch
ORe-ROOfing
OAlteration
ORe.Siding
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 confonn 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 pennit for just cause. Furthermore, I hereby agree that the city official or a designee may
ent:w, upon roperty to pe'~orm need5'\inspe~ons.
X n A-cAA...t {J'_l J ('-1 ;::;rrD506 ']0 'd9 -OJ
Signatur~ t- Contractor's License No. Date
~
I Permit Valuation
I Permit Fee
I Plan Check Fee
I State Surcharge
I PeRoltc,
I Plumbing Permit Fee
I Mechanical Permit Fee
I Sewer & Water Permit Fee
I Gas Fireplace Permit Fee
~ /1 A
es Your Building Pennit When Approved
$
$
$
$
$
$
$
$
1'1-.. ~o a:) I
'Y~<1. 7" I
rr, ';ft. 7Cf I
lilY J')(!J I
/Oe) ,00
WI.,.,O
~).:':>-o
'I6.0e
('-7"'~
Date
I Park Support Fee
I SAC
I Water Meter Si~"; 1";
I Pressure Reducer
I Sewer/Water Connection Fee
I Water Tower Fee
I Builder's Deposit
I Other 5.l1V R"
I TOTAL DUE
#
#
#
#
$ ~qJ.t') d
$ !,/'\..f'!oQ:'J
$ 'i2s:.00
$ C/c;: cJo
$ /,'2'00. 00
$ ?([/?Cl'J_
$ 71--
$ 3.r. ~O I
$ (,. oZ-2.. 4q I
I Paid
I Date
o
(PI) -DJ ~L'1
'R-/~-nl
I ReceiotNo.
Bv
-
yt~
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
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
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~
Planning Director
Date Special Conditions. if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
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White . Building
Canary . Engineering
Pink - Planning
Tht Crnt~r of lht I.ab ('ountry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
i
!
i\
t
(~ i,----,
, I / /
f - -/-,
'.P , '.j'
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
,
6.^~ ' (j ,/ -
.-' 1'1 .-'
L. ;tJ
Accepted
~
Accepted With Corrections
Denied _ _ I
Reviewed By: ~~ Date: c; 1/2/6(
Comments: '
~ ~ R'1e-. A~e.&~ ~f;l ~ ~
~~. Fw- C~~<. ~ d I:
'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."
~~
White . Building
Canary . Engineering
Pink - Planning
Thf ('rolfI' of lhr Llkr ('Ollnll'}
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
1)R ~
. -
G:,- I-Qj
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
5CXJi- lQ.#-I~~dJ L/LJ
U
Accepted Accepted With Corrections '-7--
Denied (),~. ~
Reviewed BW,tJlbz../
Comments:
Date:
t;-~ 7- ?t:JJdl
g~ \-k Yw~ ~-~
"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 un. 4. 2 II II 1 3: 28 PM
GENZ RVAN PLUMBING AND HEATING
N0.5214 P.3:14[]
Date ReI;' d
Lay OF PRIOR LAKE PLUMBING PERMIT
6w'l
n&P'y~-()~n L"l, ~F-,
i.:-~ ~l;, I PERMIT NO./_ cc'n
, ), Yllllllo>w" ...,,,1._ J / /
I zo/?(r.-WO) i
C?1CASl: .!'!Pc:. or 'Dnnc and. sim u l;Joaoml
ADDlU!SS
LEGAL DEsClUJ?TION (otlice use ooly)
LOTlloBLOCK I ADDmoNTPt9K:'-~dO Z"-.JO
,
PID;:)~-g1')-O( /, ~
I OWNER.
(Name) DR Horton Custom Homes
~~&tte~) 3459 Washington Dr St~ 204 Eagan. MN 55122
(Phone) 651-454-4663
APPUCANT
(Name) ('aJ>._lI)-C- '>1.-t-~~g <, ulic.~-.3
(Address) 14745 So Roberti Trail
"(Address)
. (Phon") ~/.?<_ll ':':--_
Rosemol.1nt
MN
55068
(Zip Code)
(Oty)
(Contact Person) Mary Olson (phone)
APPLICANT SIGNATURE l A. 0 P _ DATE \.0 \ ~ \ D I
APPLI(;Al'll ,.LEASE COMPLETE BELOW
I Type ofFixtul"li I Quantity I
I Bath Tub with or withont shower Rough-ins
I Dishwasher I - - - I Waf<< Heater
I FloorDrain R I, I WaierSofJner
j Lavatory (Bathroom Sink) I I StandPipe(WasbingMacbine)
I Laundry Tray (I or 2 coropa:rtll1elrt sink I I SeWiIjl;e Ejector
I Shower Stall Backflow Assembly
I Sinks I I BackfIow Assembly Test
I Bar Sink I Lawn Sprinkler
2.-- I Water Closet (Toilet) I I Other
651-423-1144
Quantity
,
I
,
2-
Type ofFinnre
I
I
j
I
i
I
I
I
FEE SLJ:1JL.uULE
lndustnal, Comrnc:rolaJ &: Muln.f,1IT111y 1 % of Job co,t wilil. $39.50 miojro""" ResidentW, N..... One &: Two,Foxnlly $99_50
Resi4eotial. Additions & JlJt=ltion, $39..50
Estimated Co,t $
Building PetnJ.!t #
PLUMBING PERMIT FEE $
STATE SURCHARGE $
ToTAL PERMIT FEE $
.50
,-ilf
Su PAID WITH N'
ILDING PERMIT
om..e Use Only)
This Applil:ation Becomes Your Building Permit When Appro..ea .
Paid
Receipt No.
Bwllllng Olli....
D...
D1"o -/9-{)!
BYqc.
(/
24 hour notice for on in'pedio", (9s::l) 447-9850, f.u (952) 447-4"-"5
J un. 4. 2001 3: 28 PM
GENZ RVAN PLUMBING AND HEATING
No,52!4 p. 34/40
Date Ree'd
CITY.oF PRIOR LAKE
SEWER AND WATER PERMIT
on"
'i. ~ ~ I PERMIT NO. r--rr:71
l..OOlll ~ '")7
rrlca.:l:e w~c or"Print Uld. si~ 'at bottozn)
ADDRESS
521J1
'I::u..v-HeLo
LN.
SG-
ZONING (olfia...)
1<(
LEGAL DESCRu HVi'! (office "'" only)
LOT I ~BLOCK ADDITrON'IlP P /" go ~ 0 0, 2- J'-} w
PID ;}5/Y7;).-o I fe, .-:0
OWNER
(Name) DR. Rf':"'"'-O:"'" ~u['l""m B"owlCLr'
(phone) _<"'-I.,,~<.,
(Address) 3459 Washington Dr Su 204
(Address)
Eagan, MN 55122
(0",.) (zmCod<)
I APPUCANT
. (Name) Genz-Ryan Plumbing & Heaeing
(Phone) 651-423-1144
(Addres~ 14745 So Robere Trail
(Addr=)
ROBeDloune. MN 55068
(0",.) (2JpCodo)
(Contact PeI5on) Marv Olson
"PUCANT SIGNATURE \ A.
o
~
APPLICANT PLEASE COMPLETE BELOW
Cl'hOlle) 651-42~-p44
DATE l () W-a..J
Size of water service inches.
Location of 1W.y 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
FEE SL.I:1.I!..UULE
R.eSldentlaJ Sewer and water Jine coonection $35.50 Industrial, Com'1 &. Multi-family 1% of job cost with" $39,50 minnnum
Sewer connection only $17.50 Water connectiOll only $17.50
Estimated Cost $
Building Permit #
SEWER AND WATER PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$'
$
.50
au PAID WITHj il.i
ILDING PERMIT
.~
Dftic.c. Usr O.uly)
Thi~ Application BecODl"" Your Building Permit When Appl"Ov~ I Paid
BulldIDg omdal . j)... -, I Dil! r () I
24 huur UUDee fur all i"Sp~D."S (952) 447-9850, fU (95:;:) 447-4245
I Receipt No.
I By dL---
.[/
I,
I
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONINGIFIREPLACE PERMIT
Date Rec'd
(Please ~e or orint and sign at bottom)
ADDRESS
'S'2()1 () eer.p l""JrI
I. Pink
2. Green
3. Yellow
~::, I PERMIT NO. ,.-; /- e:-:zq
Applicant V O.
. ZONING(o ceO"')
RI
Lctn e.,
Sf.
LEGAL DESCRIPTION (office use only)
PID r?~ - ;3 rp-{)!~~
LOTI~BLOCK I ADDITION ~-'~d2 A,bd
~~e~RD."A. Hor1on (ludom H()~p_~
(Address)df)f{(nO .kcx-iJric\Of (U. Lo,kevi/{p M~
APPLICANT 1\ II. t M h-
(Name) rtllr(.lr1 et!.. ..LV(' (Phone) 0/-.<.I5:L-cfl775
(Addressh3loS0 ftennebe(' L:r. :S+E'. #/ Fa_Qon 55/.22
(Address) v (City) (Zip Code)
(Contact Person) ~t't're-V Z;mmp.r.rn GAn (Phone) (p51-,q~,!)- ~7'7!:J
APPLICANT SIGNATU~_ (!(j:1~g4~ DATE ~(D I
. ~~ANT PLEASE COMPLETE BELOW
0NEW CONSTRUCTION DREPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL "Br~+ ~~A-vtoill>" () FUEL (0a.hAl'"l'A I
FLUESIZE4-IICIQ.s~ "EL RETURN OPENINGS J..l.. INPUT ,O,ODO OUTPUT '$lD.l>OO
TYPE OF SYSTEM HEATING OR POWER PLANT
(Phone) C(5b1,Q'i?S-7017..2..
,t:j f)o~.p-I
OWarm Air Plants
OGravity
o Mechanical
~ Conditioning
[!'Veot. System
o Steam
o Hot Water
o Radiation
D Special Devices
o Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
Residential, Heating & Ale (New Construction)
Residential, Heating Only (New Construction)
FEE SCHEDULE
1 % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential, Additions & Alterations
$64.50 Residential, AC Only
$39.50
Industrial, Commercial & Multi.;Family
$39.50
$39.50
HEATING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
~U/~"l/()
III\tG 11ft;,
,0.::::-"
f I,~
'.
Estimated Cost $ Building Penn it #
(Office Use Only)
This Applicntion Becomes Your Building Permit When Approved
. Paid
I Receipt No.
Date
Y~7--O/
,
I" 'J-ee
Building Official
Date
24 hoor oolice for all inspections (952) 447-9850, fax (952) 447-4245
DEC.11'2001 07:39 651 633 8884
FIRESIDE CORNER
#6031 P.001/0l3
CITY OF PRIOR LAKE
HEATING/AIR CONDlTIONINGIFIREPLACE PERMIT
Date Rec'd
: =.. s'"., I PERMIT NO-0I-0sq7 I
(pIe... ~ orJriDpmd. .jllll. "bo~m)
\ ADDRESS
.a.;;;lo -J I\I'J~il ;./,17
~
LEGAT" DESCRIPTION (ollk:e ... only)
ZONING (o_u..)
~.-
LOT BLOCK ADDITION
PID
~=~R '..n? /.Iud b)
(PhOIll:)
(Ad.dn:s5)
APPLICANT
(Name) llLLII!:D FIRES!DE DBA FIRESIDE CORNER
(phone) 651-633-2561
(Ad.dres5) 270D N. PURVIEW AVENUF
(Add,..",
BRENDA !IlJ5'l1ON
(Con.tad: Petson)
APPLICANT SIGNATUR~ ~P",O.
I
./J,,,itAi...,
Rn':::~l'rT.T,1=': '!M
(Ci<y)
(Phone) 651.-633-256J.
o;~11,
(Zip Code)
_ DATE
J.J./..J.J..l.9.1
APPLICANT PLEASE COMPLETE BELOW
~EW CONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL . FUEL
FWE SIZE REroRN OPENINGS INPUT OUTl'UT
TYPE OF SYSTEM aBATING OR l:'OWF-R. PLANT
JWonn Air Pion", J Steam
::JOrnv;ty J flot Waler
::J Mechanical J Rodiwon
::JAir Conditioning J SpeeioJ novices
JVonl. System J Other O.V;CCll
PLEASE NOTE;
Air Conditioner Units
C8JJ11ot Encroach i.nlo
Required Sid. Yord
Setba~k.,
Indus,,'.!. Commercilll & M"Jti'FomUy
FlREPLACBMAKEANDMODEI. _~_t-J Ge- St.. '7Jc
FEESCHEDVLE
I % of job eost R""I~cnti"'. 00. Fircpllll:C:
539.50 minimum
599.S0 Re;identillJ. Addidon. IIr. All..",d.on.
$64.S0 ResidentillJ, AC Only
539. SO
$39. SO
$39.S0
Residential, HClIting I'< iVe (Now ConstMlClion)
R<sidcntial. H..ting Only (New Con91I'llClion)
HF~TINGPERNOTFEE $
STATE SURCHARGE $
TOTAL PERMIT FEE $
0/- OSq1
r"'~' 0 wrH-\ "
.50 'eu~NGPe.fii.f'1 r
~ .
Esttmll!ed Cost $ Building Petmit #
lome. U.. Only)
This AppJ";~""'~r Buildinl Permit Whon Approved
r;1f1':r f/ ~ II, () I
BDndl..Offlcl.1 Dolt
I POId
I Dote
I R""eipt No.
I ~y
ze ~pur notl.e for on Inspection. (!1SZ) #7-9850, fu (95Z) ot474Z45
._'-_."--'~~"-- ---.------.-.---
'"
PRIOR LAKE
INSPECTION RECORD
I pe.e. t4..M.c.t.... \-,' l~
DEPARTMENT OF
BUILDING AND INSPECTION
SITE ADDRESS 5~C>1 D.....f'...~\.Lll ,I:,."..
NATURE OF WORK 1\.).e.V'
USE OF BUILDING ~ \=\,60-
PERMIT NO. 0/- ()51LDATE ISSUED u-7- 240/
CONTRACTOR ..ok. (J.... PHONE q~-7~O?
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
INSPECTOR
DATE
'FOOTING ~~. IfIJlf!DI I
, FOUNDATION (Prior to Backfill) r-p:;;.. I ~. '6f I -:;(" I 11a7. ~ I ;);.-j()I
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
SEWER I WATER I SEPTIC
FRAMING
INSULATION
ELECTRICAL A
PLUMBING v..G-l. \I tSI ~, '/7/f) f g , / Z/ ( c/o.;
HEATING (if required) f _ ~, (Z./:UJ"OI
FIREPLACE lZr l?/?.Il!")
GAS LINE AIR TEST I...\..-. (i.;t, 't".f ~.r.L. F. /. @.. (dl-401
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
,~ k) PIllkA I
U FINALS I
GRADING (Prior to Sodding) fl.. rL. 7/17/07/
BUILDING -C:C.6, ~ <f!~Joz- f:3.:, 1/.1.:ii6 z-- tk- ~v-
ELECTRICAL '
PLUMBING ~, _
HEATING 4
DO NOT OCCUPY UNTIL ABOVE HAS
NOTICE
~
J?p
t:q..
r;.}~/b I
12/z./ }nJ
;J-jq 10 l/
,';lfr5"lt1 Z.
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.
Call between 8:00 and 9:00 A.M. for all inspections
FOR ALL INSPECTIONS (952) 447-9850
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
Z -/~ -02- .f/AJ"'lJ
ADDRESS
5207 OF:.-fSfL..-'f) b L{)
OWNER
CONTR.
PHONE NO.
PERMIT NO.
(-597
o FOOTING 0 PLUMBING RI
o FOUNDATION@ 0 MECHRI
o FRAMING . 0 WATER HOOKUP
o INSULATION 0 SEWER HOOKUP
)(FINAL .r.\\e PLUMBING FINAL
/i:i 'SITE INSPECTION !"V])I MECH FINAL
COMMENTS:~ ~ .J--.v-. ~. ~
;r~' ~ '
~ sY,o -t, c-h~
o EX/GRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
.,-; QAl ,-tlJJ2 'i? ) I I /)7-
[
/~~ 1?1/.~
o WORK SATISFACTORY, PROCEED
~ CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector:
~,
Owner/Contr:
J
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
INSNOTl
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS
5U7
SCHEDULED ~'{/(f?'- tt: ~
~~.
tI
OWNER
CONTR.
PHONE NO.
PERMIT NO. tJ I - 571
o FOOTING 0 PLUMBING RI
o FOUNDATION 0 MECH RI
o FRAMING 0 WATER HOOKUP
o INSULATION ~ 0 SEWER HOOKUP
o FINAL ~ PLUMBING FINAL
o SITE INSPECTION 0 MECH FINAL
o EXlGRADIFILLlNG
o COMPLAINT
.., FIREPLACE RI
L. ."IREPLACE FINAL
o GAl:L1NE AIR TST
o
COMMENTS:~ ~fVrtfr"f'n~ ~ ~1J.a
M~- Ptu_
I~ ~.v ~~
o WORK SATISFACTORY, PROCEED
~ CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: ~ I Owner/Contr:
CALL 447.985~ FJ THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY/
INSNOTl
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
DATE
TIME
~
/r.7'
uJ
ADDRESS 520/..3. 5. 7 OE6~6L.O
OWNER
CONTR.
PHONE NO.
PERMIT NO. 1-59~ S9S. 59~
....
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
o PLUMBING FINAL
o MEcH FINAL
COMMENTS:
S6D/7706
I
o EXlGRADIFILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
[;J 12& !../
I
- //~ ~
~ }1"..-........ 'I- /?J,/-.~ .
o
.
IL
. 10
l'..LNV"' ,~
V'-'/ 1;01/
"'V'
ft'WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector:
Owner/Contr:
~
. I
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
i/O/SHon
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
APPLIANCE
PERFORMANCE TEST
Attach to gas line adjacent to regulator
Heating Contractor
Name of Tester
Date
f\\\,........... V'\t.O-..
\<.e:+,-
-:l.- I -()";)..
Job Address S-~..., (k<"'~'<.\A Ik.
Heating Contractor AI' ;~1- M",-,-
Name atTester ~
Date ':1-- 1-0",,-
Percent 0, I..J
Percent CO - <:>-
Percent CO, ~,'-I
Stack Temp ~ 1 J"
Combustion air is adequately supplied per
UMC See, 606 '1..,5
input
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