HomeMy WebLinkAboutBldg Permit 01-1014
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
(Please type or print and si~ at bVLLv,,,)
ADDRESS
5;AO B (kW-h~d Dr. $f
LEGAL DESCRIPTION (office use only)
LOTa~ BLOCK
~rr~ ~I'\).,
ADDITION
OWNER
(Name)
(Address)
BUILDEIY\ II
(NameLJJ.JZ. ~N\..Lk.L.
(Contact Name) .s'k ~V1dL~
(Address)~()8t,() Ku...hndat. e1-. ok. / fJ ()
~~ II-l, J A/l'fl ~I./:L/
TYPE OF WORK
~ew Construction
OLower Level Finish
ODeck
o Fireplace
Date Rec' d
1. White File I PERMIT NO.
2. Pink City
3. Yellow Applicant
PIDds~ 37;;-6~-c)
(Phone)
(Phone) ~) 'lY;-7BO(i
(Phone) ~Ja;j~- ~"
o Porch
OAddition
ORe-Roofing
OAlteration
ORe-Siding
o Misc.
PROJECT COST IV ALUE (excluding land) S / t)~ /5"/
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
submitted plans. 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 upon e operty to perfo n 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
Sewer & Water Permit Fee
/ 0iiJ, tl?O . C2b
q~_~.7) I
fd1S.1-1
SrJ . 00
$
$
$
$
$ IDO .00
$ too .(f) l)
$ 3:). ~U
Gas Fireplace Permit Fee $ 40 .od
c:/J;$;t'YO~B-;~;~7vOO
Buildingj5fficial Date
~o () SkS"" 7
Contractor's License No.
I Park Support Fee
I SAC ~
I Water Meter Si~; I";
I Pressure Reducer
I Sewer/Water Connection Fee
I Water Tower Fee
I Builder's Deposit
I Other Sf-tJ ~
I TOTAL DUE
Paid ~ 070. fo q
Date 17-11 " 0 J
, ,
#
#
#
#
(j /~()/ () /
Date
I
$ 8:i'J. t::Y) I
$ 1,1511.00
$ , laSrt:JCL
$ _ / t:./.C; ~t) 0
$ 1800.00
$ ; '700.tJ tf) I
$-"'0 - I
$ ::K-"sQ
$ ~ 076 ~ b!f-
Rec~ t?r1:r1I I
BY~~ . I
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
~~ "J/L;j81 ~~;~::.~~
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
Aug.L7. 2001 3:40PM
GENZ RVAN PLUMBING AND HEATING
No.0949 p. Ill/15
Date Rec'd
Ll1 i ,OF PRIOR LAKE
SEWER AND W Al Jf,,l( PERlVul
(Please type or prlxlt and sSg!l :a.t bv_~)
ADDRESS
62D?; OLeA ei /) ViP- .'t:-
LEGAL DESCRIPTION (office use only)
LOT 'ZZ-BLOCK ADDmON ~ e...O n
OWNER
~~e)~y ~~~~~~ CU8~Qm Rgm9~
(Address) 3459 Washington Dr Ste 204
(Ar.UU-c:ss)
. APPUCANT
(Nwn~ Genz-Ryan Plumbing & ffea~ing
(Address) 14745 So Rober~ Trail
, (Addte:ls)
r
(Contact Person) Mary Olson
~UC~ SIGNATURE t J..
I. tmcn rile
:. y..~ Cit;'.
3. Gold Applilanl
PERMlTNO.O/_ /014-
ZONING (..,m.:e Wi")
Rl
2uD PfD;J5-37-;).- OJ..;;--O
Eagan, MN
(Cry)
(phone:) 651 454 (ttiif?
55122
(zip CQCk:)
(phone)
651-423-1144 .
55068
(Zip Code)
Rose1ll.ount:, MN
(<;ify)
(Phon~ 651-423-1144
~ PATE~DJ
0r0 ~ 0-
"( ~
APPLICANT PLEASE COl\-.u .l.JETE 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.
.l4'Jj,;E S\;.I1J!J)ULE
Resideuna.l sewer and water line connection $35.50 Industrial, Com'l & Multi-family 1% of job cost with a $39.50 minimum
Sewer cQnnection only $17.50 Water connection only $17.50
Estimated Cost $
Building Permit #
, 'l'J\\r\ '-\
tr fJ~\O ~~~,l',\
'l_\\$)\~G
~
!.
f
..
SEWER AND WATER PERMIT FEE $
STATE SURCHARGE $ .
TOTAL PERMIT FEE $
(bffl<:e Use Only)
This Applic:atloll Be~omes Your Building Permit When Approve~
, /
SEP i 9200\
'"
L.;;.
BllildiQI O.lJjc,ia,l
Date
p~
r~-i~ .
:~I
24 hoqr notice fgr all i"lSpl!l~Oq, ('51) 447-9850, fax (~2) "'7-424~
3:41PM
GENZ RVAN PLUMBING AND HEATING
No.0949 p. 1115
Date Rec'd
ell t OF PRIOR LAKE PLUMBlNG PEAAJ.Jl
1 Blue Fil.
1. GDIG City
J. Yallo", Ap"IRm
I PERMIT NO. 0/, 10 /A-I
CE'lcase o/f?" or ptint and si2l1 a.t L ....__)
ADDRESS -
57 rJ6 Th..efQ. P_ O.n Lo-nL., ~- S' F-
ZONING (officeu:leJ
I?/
LEGAL DESCR.u' HON (office use only)
LOTZ1.-BLOCK l ADDmON~erq,'~ 2ND
. OWNER
(Nam~ DR Hor~an Cus~om Homes
PlD~S- ~ ?::L-Od-d-2J
(phone) 651-454-4663
(Address) 3459 WashingLon Dr Ste 204 Eagan, MN 55122
APP!1CANT
(Name)...G.<>n"'~~ E.!...~1-..;~g 1<. u......,,~:l
(phone) F;, <; 1-l.t? ~~ 1 ] 44
(Address) 14745 So Raben Trail
(Address)
Rose:mount
(City)
MN
.55068
(Zip Code)
(Contact Pe.rs~n) Mary Olson crb.one) 651-423-1144
APPUCANt~IGNATURE II.. _ baD --' DATE 8127 b I
APPLI P~ASE COl\1PLETE BELOW
I . Type of Fixture I Quantity
Bath Tuh with or without shower I
Dishwasher I
I Floor Drain ,
1 Lavatory (Bathroom Sink) I
I Laundry Tray (lor 2 compartment sink I
I Shower Stall I
I Sinks I
I Bar Sink I
~ I Water Closet (Toilet) I
Quantity
I
j
I
~
Type of Fixture
. I
I!. If
I
Rough-ins
I Wa.ter Heater
i Water Softner
Stand Pipe (Washing Ma.chine)
Sewage Ejector
Backflow Assembly
Bacldlow Assembly Test
I Lawn Sprinkler
I Other
FEE SLJ:UDULE
Industnal, Commercial & MUltI-faIntly 1% of job cost wit.b a $39,50 minimum
Residential, New One &: Two-FBDuly $99.50
Residwtial, Additions &: Altenltions $39..50
Estimated Cost $
Building Pr;nnit #
""'\'\\'\ . f'~
~_Q ,it\~G ~'C.ft'~'\ \
.~/
J.'
PLUMBlNG PERlYfiT .r.J:::..J:::. $
STATE SURCHARGE $
TOTAL PERMIT FEE $
:Ofllce Use Only)
This Application Becomes Your Bmlding PermitWheD Approved
Building Otrlc.i.1
SEP I 9 2001
D.~
::;------
Datea
7 -/tJ-f) /
IRe~
I By -fl~
\:
24 hour Dotili:l!l for all blSplI!r.;tjons (952) 447-9850. fax (9S2) 447-4245
DEC.14'2001 07:30 651 633 8884
FIRESIDE CORNER
#6301 P.OD5/DDS
Da.te Rec' d
CITY OF PRIOR lAI<E
REA TlNG/AJR CONDll.lONINGJ r IKEPLACE PElnUl
DEe I 3 2001
~: ~ ';;n; PERMIT NO. 0 I~/O '4-1
,. YoIl".. ~lIPli"",,, 1 ~ I
Il'lealll: ~ ar print and silm 8t L ww.....)
ADDRESS
.5::U>S' 0)~j'; it..-f~
LEGAL DBSCRJ.J:" l lON (office UlM! OJlly)
ZONING (oI'JiQ: Die)
LOT
13J_OCK
ADDITION
1'1.0
. OWNER 0;) 12 ~~
(Name)
(ph.one)
(Ad.~)
. APPLICANT
(Name) ALTJIED FIRESIDE DBA FIRESIDE CORNER
(Phone) 65J.-633-2561
(Address) 2700 N. FAIRVIlaL.)WENT;W
(Addms)
BRENDA HUSTON
(Contact Persoll) .
AP.PLICAN'TSIGNATU~~~ .~
RgSEVTT.T.F. MN
(Cir;y)
(Phone) 651-633-256J.
DATE LJ,4f./..OI
"'~, , <
(zip Code)
APPLICANT PLEASE COMPLETE BELOW
~J::'W CONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODET... FUEL
FLUE SIZE RE"JRN OPENINGS INPUT Ol.FTPUT
TYPE OF SYSTEM HEATtNG OR POWER. PLANT
DWarm Air Plants 0 S~am
o Grav U:y 0 Hot Water
o Mc::c:hll1li~1 . 0 Radiadon
OAir Conditioning 0 SpeciuJ DevIces
OVent. System I J 0 Oth~ Devices
FIREPLACE MAKE AND MODET... ~IJ ''''' ~t-. J'U
, .
PLEASE NOTE:
Air CDndItioner Units
Cannot E.ncroach into
Reql.lired Side Yud
SeTbacks
Industrial. Corrll'nc~(al & Multi-Family
FEE SCBF.:DUJ..E
1% of job l;O:;t R..~(dcntjlll. Gas Fireplace
$39.50 mlnimJ,Jm
$99.50 Residential. Additions & Altera,tJons
$64..50 Residentilll. AC Only
S39.S0
Resicl.c:ntial. Heating &. Ale (Nc::w Construction)
Resid.c:ntj~J, Heating Only (New Construcl[on)
$39.50
$39.50
Estimated Cost $
Building Permit 1+
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PE~T FEE
$
$
$
.50~rr ~O wrr~
,.
(Omee I)st: Ollly)
Th.is APP~"r Building ;f; ~hi~~pproved
Bllildllll: Offidlll Dllte
Paid
Receipt No.
DiUe
By
:14 hour ,u,dce for nllln.$pection$ (952) 447-9850, flllt (95~) 4414245
CITY OF PRIOR LAKE Date Rec'd
HEATING/AIR CONDITIONINGIFIREPLACE PERMITSEP 2 1 2001
I. Pink File PERMIT NO
2. Green City . 1- /011 /
J. Yellow Applicant .....,
(Please type or print and sign at bottom)
ADDRESS
5Wg {)eer+1~Jd
~e, SE
ZONING (office use)
I?J
LEGAL DESCRIPTION (office use only) r.
. LOTZ'l-BLOCK I ADDITION dtJ./JA)~d{/) d~
. ~('~ .
~~e~RD~. HorTon ()_uslom Home~
,(Address)dtJ8100 K.Mbrid~. at., ~()'kevil(p_ Mk)
APPLICANTA II' M h""""-
(Name) , Qrl. e<!.. .J,.t/YJ..
(Addressh3~5{) f<lennehec.. h-. 5+e. #/ Eaaan
(Address) J (City) (Zip Code)
(Contact Person) ~f'..rre-}{ Z"mmp_rrn Gln (Phone) (P51-~5~- tl77~
APPLICANTSIGNAWk )'1f'DJ (l4J~ DATE
b1 (J . (/
APPLICANT PLEASE COMPLETE BELOW
0NEW CONSTRUCTION o REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL 1Jr~4n+ 3S3KA-vb1&.LJJ1..D FUEL l'JC4.tum I
FLUE SIZE 41'da..S4i>> EL RETURN OPENINGS '-+ INPUT 10.01>0 OUTPUT 6/D..lJO 0
TYPE OF SYSTEM HEATING OR POWER PLANT
PID,dlj --37d--Od;;)-O
(Phone) 95f)... q~ -7~7:L
550A..fl..f
(Phone) u5/- 45:L - cfI775
55/.22
OWarm Air Plants
DGravity
o Mechanical
~ Conditioning
QrVent. 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
FIREPLACE MAKE AND MODEL
Residential, Heating & AIC (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
Estimated Cost $
Building Permit #
REA TING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$
$
.50
(Office Use Only)
This Application Becomes Your Building Permit When Approved
Paid
~'Jf) ~;/Ti-t
~ PEF'nr
tJII",j
By g-c..---
Building Official
Date
Date q:-.~7-1
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
,"._~...~..~..."".,.~.__.....---"". .._,..~_~.~_.~_..~,.~~__...._.._ .~. .....,.t .._.__. ~'_'" ".~ ,_'~_"N'_______~_""_
White . Building
Canary - Engineering
Pink . Planning
The Cf'nltr or the l..kr Counrry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
'j) R ~. 6'[ (CY'f'-./
?- ~~-()f
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity. which is propos?,\at: 1'1 i'/a ) h
'. l' ;<o,f' ~~w. IY-<-
U
Accepted X
Denied r
Reviewed By
Accepted With Corrections
~ ~](- '/-.....,/
Date: <...--' ~/
Comments:
~~ It,u 4:' \-P
"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."
Thr Cf'nlrr of Ihr l..kf Counlry
White - Building
Canary - Engineering
Pink - Planning
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:
,
""_.
Accepted
1/
"-
Accepted With Corrections
Denied --'"""l
Reviewed By: g~
Comments:
Date:
qlt31et
44h4'<-LT:"I"rj\j 2,., ~i'eYl.-";: ~
{1u,.(\ -t ~~ ~(JJ) 22Q,
"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."
,'" .='\',: V\...- '" . ..~~../'~ ,~,.\~: ,.! ~ '''t.:;i: ". ,'~r"'" .';'...., -'....t..." '. ~ l ~". . "I"'" \r',.. "' J ,.,...... ".\1....;-. :k/".f~ '-', ~...f' J:',~' r. ,"',"" ,,11: " ":'~tr:Jl: 'J'; . ,. . ':~
Tht etnlt, nr rht ...kt ('ounl'1'
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT D /2... ~j cn:t-~
APpLICATION RECEIVED X- ;};}--()}
- .
The Building," Engineering, and Planning Departments have reviewed the building permit
application for construction a9tivity which ,is Rroposed at:
. .5 aOI/ l CJ}vc6A-~CQ
Accbpted X Accepted With Corrections
Denied
Reviewed By:
;
,
~ Nit 13
Date:
9-1:J.~O(
.
.,
I
Comments: See Reverse Side for Additional Information!
.; /i1c,/l} hie
.See Attachments: 1 }~rading Plan, .2) Erosion Control Measures
. :i) Frosion' Control Plan
\ "
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. II
_,_"__,.,_""~,--",,,.,_"_"~m~".""'"'''''~'--'~''''' ,-,,,- ,>.,
~ -\-4 \" \At", -1-,- \ e
DEPARTME iT Ut-
. .BUILDING AND INSPECTION
PRIOR LAKE
INSPECTION RECORD
SITE ADDRESS 5'208 ~ ~
NATURE OF WORK kJ ..e~
USE OF BUILDING SFA
PERMIT NO. nj-/O/4-- DATE ISSUED B.~/-o(
CONTRACTOR -D~ (~~ ~ PHONE '52 a:t(, - (~~i
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
INSPECTOR DATE
I FOOTING I tJ.". I 9/;$'/c;t
I FOUNDATION (Prior to Backfill)~ I ~# "h.., /Ot I ifrr J ~/ '-/ /0 I
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
~
.. ~ ~l
f:?:r '
SEWER I WATER I SEPTIC
FRAMING
INSULATION
ELECTRICAL
PLUMBING J~. U.&. ~
HEATING (if required)
FIREPLACE
GAS LINE AIR TEST
.
16/t t/O I
/6 I:?- /d/
1 / (~',,4.
11/ ? Mv
,,! ~.~'. 1-
t .\0 OQ.
.
\~.L
(
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
I I
FINALS
~.(L,
~ ~/!/()v (~
/ ,
GRADING (Prior to Sodding)
BUILDING1.t.o, W Sr \ (oz..
ELECTRICAL '
PLUMBING
HEATING
DO NOT
""
~
"
OCCUpy UNTIL ABOVE HAS
NOTICE
1 l7{ov
7 f if4((JV
31'1ft~
{'W!(j ,9-J
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 sha~t be placed near main entrance.
Call between 8:00 and 9:00 A.M. for all inspections
FOR ALL INSPECTIONS (952) 447-9850
0" TE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
3/S/() 2,.. 10130
OWNER
.5;;-<!JJ> ~~,
()
CONTR.
ADDRESS
PHONE NO.
PERMIT NO.
t:JI-/OI'-/
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
~ 0 PLUMBING FINAL
~~ MECH FINAL
COMMENTS:~ V ;""),.,11 p~ ~ ~
~~~~~~-
C!J ~I 11~:,1~_~~
$~~~-1J --~
o FOOTING
o FOUNDATION
o FRAMING e
o INSULATION
~ FINAL
o SITE INSPECTION
o EXIGRAD/FILLlNG
o COMPLAINT
@i FIREPLACE RI
FIREPLACE FINAL
o GAS LINE AIR TST
o
I
tl
~
-,-, ~, CJ. -t;,IJ
/
l
F
(~
8/,I()G
l I
o WORK SATISFACTORY, PROCEED
~ 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!
INSNOTl
OA TE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS
-:-;:5 Z- 6 ~
SCHEDULED 1/t/~ ~
~
(J
/tJ:'-/5
OWNER
CONTR.
PHONE NO.
PERMIT NO.
&(-/611
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
@ 0 SEWER HOOKUP
~ PLUMBING FINAL
o MECH FINAL
o EX/GRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
COMMENTS:(fj ~ ~ ~ -
~ I tM1_ _~.. S~/ ~~ '
))~ ~ ~,U~
.41
I
~- ~
~~~
o WORK SATISFACTORY, PROCEED
~ CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: ~ / Owner/Contr:
CALL 447-98:0 F:l THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYl
INSNOTl
.....
'" ^ "-~"""'.''".~_._''''''''''.'~'''''--'- ....~,...,~ "'-"~"
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
7JJ!J/o "l- A-. r;
ADDRESS .sZ~ a~.~ OEEteFlbl-O LAl.
SCHEDULED
OWNER
CONTR.
PHONE NO.
PERMIT NO. 1-/ OIZ~ 1013. ItJ/4--
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
o EXJGRADIFILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GAS LINE AIR TST
o
COMMENTS:
so.ol /71.,66 ~ ~
( I
~ ~4~
./6~ lJ.io~ o/~.
. 4j
~.rry
...,.;0
..., " ,. I
)I WORK 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 REQUlREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
INSNOTl
a
APPLIANCE
PERFORMANCE TEST
Attach to gas line adjacent to regulator
Heating Contractor ^\\"~ M e.....~
Name of Tester \ t t..: ~ '--
Date ~-4-~.2-
Job Address S- 'i~ 1ft. ~('~ ~ t,..\~ L~
Heating Contractor }..:\ \ , " '. M ~'-'--
Name of Tester \<-c..~\'"-
Date
Percent 02
Percent CO
Percent C02
"")-'-1 -C)--,
C:..~
-0-
Stack Temp
Combustion air is adequately supplied per
UMC Sec. 606 ~ ~>
input 15 S' C) 00
<i,5
)~;)..~