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Home My WebLink AboutBldg Permit 01-1016 ~~ M~~~ CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd TEMPORARY CERTIFICATE OF ZONING COMPLIANCE AND UTILITY CONNECTION PERMIT (Please type or print and sign at bottom) ADDRESS 5.;lJ ~~tt:&LL tAn,. Sf LEGAL DESCR1yuON (office use only) I. White File 2. Pink City 3. Yellow Applicant LO~5BLOCK I ADDITION ~~R!L~nJ.-, OWNER (Name) (Address) BUILDER r\ (\ (Name) J If:(, ~. Xnr. (Contact N~me) SI7 tJL e;, cJt:5'~ (Address) '2-0e(,.0 ~bnA4~ 61-. ste., DO I fA k.tA/I ,'~ .. ~ 'h".;)v'It.! . . - TYPE OF WORK !)rNew Construction OLower Level Finish (Phone) PERMIT NO. ONING (office use) RI PIDd5- 37..:L .O~D (Phone) q~;;? -q ~f:.8d1 (Phone) o Deck o Porch OAddition ORe-Roofing PROJECTCOST/VALUE (exc1udingland) $ II)~. J..... I . '- 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 the~~~l; official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may ;ter upon th pr erty to perforI!1 nee~1J::~~ A () () p Sl,S'l ~/:l1 b I / Signature ..../J'CIlf"- Contractor's License No. Date 1/ V Permit Valuation o Misc. Permit Fee , OOI~DO.&O ,,~. Ie;' c,tfS". q <{ 5o.ou $ $ $ $ $ I O~ .00 $ /t)tJ .00 $ :t).sO Gas Fireplace Permit Fee $ '10 .~ r/r!t:n~q:5:: ~isl5fficial Date Plan Check Fee State Surcharge Penalty Plumbing Permit Fee Mechanical Permit Fee Sewer & Water Permit Fee o Fireplace OAlteration # # # # ~, ORe-Siding OUtility Connection $ $ $ $ 45'. (!)lJ $ L,2fYJ. 00.. $ 7f2PJ .on ~--O -I $ 3S.SO I $(,070.~q I - ./ ~hrr AS.'J. ~ /1 i 50 . Ot; , 12~ oZJ 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 ~;:tt.:=VYCmfia~~:~:-md-.~muruOOIDro~re -C~'~;:~:M Planning Director Date ~ditions, iraiiy 24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 I Park Support Fee 1 SAC 1 WaterMeter Si~; 1"; 1 Pressure Reducer Sewer/Water Connection Fee Water Tower Fee Builder's Deposit Other S +- U) ~ TOTAL DUE Paid M7 ~( Date ,Li ...... J ""!L/ - The Center of the l.lke ('ounlry White - Building Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT APPLICATION RECEIVED () 7C 4J-nr--I-frJ ~/~Lf-OJ The Building, Engineering, and Planning Departments have reviewed the building permit application for con5;/aVi~ WhO ;;:&~ oY [,AJ Accepted Y Accepted With Corrections Denied~ ,. .~ Reviewed By: ' . 7 .7 Date: 9~CaDI Comments: ~i-A JlIk~,VL 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." c. White - Building Canary - Engineering Pink - Planning Th. e.nl.. nl th. tok. Counlry BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT ;) jr C / i ,u;;:/ .2//--- /1 APPLICATION RECEIVED The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: I' ...~ C (' 1-:- , T) ,_) J h / / (L /0 .:d c Accepted ~ , j Accepted With Corrections Denied ReVieWedBy:~~4?~ Comments: ~~p c;,./I Date: q/7/B-( f/1;V~ \~le I,iI .... -". ~~~, ; ~ - ~(~;ft~'. ,~2-1 L/ - ., I f\eev-~~O LA~ "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." ., Th. e.nlt< 01 th. t.k. ('ounlry 01 '- I () I? White . BUilding Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT APPLICATION RECEIVED D - JC #r)r~ C? /:J-4-Q) The Building, Engineering, and Planning Departments have reviewed the building permit application for con5~ity Whr; ;~~p {}{J ~/lJ Accepted X Accepted With Corrections Denied Reviewed By: fVf}fS Date: CJ -7-01 Comments: ~(,It1&'I"" hie.., "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 Date Rec'd HEATING/AIR CONDITIONINGIFIREPLACE PERMI~EP 2 1 2001 (Please type or print and sign at bottom) ADDRESS 52/ g () eer +1 tAld lAnft Sf I. Pink File PERMIT NO J 2. Green City . "'.'",h 1_ / 01 b 3. Yellow Applicant {.Y/ - l, ZONING (office use) R\ LEGAL DESCRJPTION (nffire "" nnly) r LOT 25 BLOCK I ADDITION ,&tJ tJ /J ;;, IJ /JcfJ .2 /14- - r)~ ~ \ ~~e~RD.~. Horfon Ou.sbm Home~ (Address)da1loo K.~ridC)p.. (2f" l,Ookevi L1e. MI\J APPLICANT 1\/,. 1 M -- (Name) l:L rOt1T eC!..1..~. (Phone)LR.51-45:L-c:?775 (Address)~{) J<emJehec.-"l:;r. 5f.e. #j ~~aaQY1 55/~ . L: (Address) .J (City) (Zip Code) (Contact Person) ~f'..prt:-}( Z;mmp.rfll Q.n (Phone) (P5/-45~- ;l77~ APPLICANTSIGNATuk )OU/Y-'.d fl.4?~ DATE t/(/ (J . (/ APPLICANT PLEASE COMPLETE BELOW !0NEW CONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS FURNACE MAKE AND MODEL "Br~4n+ 383KA-vb2J.LD'o FUEL l\Jo.fUffi. I FLUE SIZE l.f."cla.s~ ~ RETURN OPENINGS ~ INPUT IC,OOO OUTPUT 6i.D..~O 0 TYPE OF SYSTEM HEATING OR POWER PLANT PII12L;-37a-O;)S-- 0 (Phone) C(5a - q fis -7~7.2.. 550~L.1 DWarm Air Plants o Gravity o Mechanical ~ Conditioning ~ent. 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 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 Residential, Heating & A/C (New Construction) Residential, Heating Only (New Construction) $39.50 $39.50 Estimated Cost $ Building Permit # HEATING PERMIT FEE $ STATE SURCHARGE $ TOTAL PERMIT FEE $ .50 (Office Use Only) This Application Becomes Your Building Permit When Approved Paid r:~ 'n 1/\ 'IT DUll D;l\v 'v H '.. .j'G P ',\e f:"r"/'!-". Receipt No:"" Building Official Date Date q~C7-{-1 By We-- v 24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 Aug,L7. 2001 3:39PM GENZ RVAN PLUMBING AND HEATING No,0949 P, 4/15 Date Rec'd CIT y OF PRIOR LAKE PLUMBING PERl\tUl I :HI"" Pil. PERMIT NO 2. Gold Cil)' '01-101'''. ], Yellow AppflC:lll& \?/ (Please we or print and SlJ!n a.t b_.........) .. ADDRESS - . CQI~ ~ I ff;'f O. n " s~ ZONING (office use) {f) J'L_q R' LEGAL DESCRJ.ruON (office use OlI1y) LOTZ~]3LOCI( { ADD~ON (}..eyfi e-O 1) 2/0 D PID cd 5'- .3 YJ .2- ad- 5 -p OWNER QNillme) DR Horton Cuscom Homes (phone) 651-454-4663 (Address) 3459 Washingr:on Dr Ste 204 Eagan, MN 55122 APPl1CANT (Nillme)~"'_"Rya.., lU.u.mt~~g 1<. Ua..H~:~ (Address) 14745 So Rober~ Trail (Address) (phone) ';';1-la.?':l-1..1.QI' Rosemount MN 55068 (Zip Code) (City) :::::to::::S~ (})~ Q (pbb..) DA::l-~7~~ in! : ";PL~~)~E~S~O~LETE BELOW [Quantity Type of FixtUre ~ I Quantity I Bath Tub with or without shower I I I Dishwasher I I I Floor Drain I .2.. 1 Lavatory (Bathroom Sink) I I LaunchyTray (l or 2 compar1ment sink I. I Shower Stall I I Sinks !/It' I Bar Sink 2- I Water Closet (Toilet) Type ofFbtw"e , 1- e/, I Rough- ins I Water Heater I Water Softner I Stand Pipe (WaShing Machine) r Sewage Ejector I Backflow Assembly I Backflow Assembly Test I Lawn Sprinkler I Other , I ..l"..(l.;JI.; Sl..;.l:U!iDULE lndl,lstnal, CommClrc~al &. Multi~family 1% of job eost with ll. $39.50 minimum Res(dential, New One & Two-Family $99.50 Residential. Additions &; Alterations $39,,50 Estimated Cost $ Building Permit # PLUMBING PERMIr..t'~ STATE SURCHARGE TOTAL PERl\'llT FEE. (omc~ us~.9fI:Y) , r ;1 1 f Tbi~~9iej~"~~.:)ur~pdjng p~~t When Approved ' ,'.oj .~.~~ 5EP I 92001 " $ ~ $ , p~\O t~f;~.fJr .!lU\,-?\~ ~ 1 " l Building Omclal DlIte ~ Da~ '1-/tJ-OI R~ l]3y~ \.-l~" -.-.---.'--........-...'.. 24 hour Dotia! fo... all jnsp~tions (952) 447~98S0, fu (9~2) 447-4245 Au~,L7. 2001 3:39PM GENZ RVAN PLUMBING AND HEATING No.0949 P, 5/15 Date Rec'd CITY ,OF PRIOR LAKE SEWER .AND WATER PEAAIIT I. Greca File I PERMIT NO 2. nil;"" CJ~. '()/-IO/I- 3_ llaJd A!'I'i1...... '?-' (1'leM~ tYJ;le c:n: pnm: lID4 sign :at by_...) ADDRESS 621~ ~,fit?OO &;u1. () ~ !~ r ZONING (0J&..ue) ~l LEGAL DESCRlPTION (o1flce use only) C\ _n .J"I ()._ , LOT :l7BLOCK J ADDITION ~J 7A,lQ P!Dd5'-_~7~- 0<:15-(,) OWNER (Name) "!'~_ ::.::n:t:QR Ctls'tQm Rom-:-:: (Address) 3459 Washington Dr Ste 204 . (Adt:h1:ss) (Phone) _1:.<:LL..54-4~~~ Eagan, MN 55122 (City) (Zip Code) APPUCANT (N~~ Genz-Ryan Plumbing & Heating . Qrhone) 651-423-1144- APPLICANT PLEASE COMPLETE BELOW Size of water service inches. Location of any couplings from structure feet. Type of sewer pipe. 0 ABC 0 PVC 0 CastIron Estimated length of sewer line feet Clean out (if required) located at feet from structure. Rosemount. MN 55068 {9hY) (Zip Code) ~hon~ 651-423-11~ . _, 1 P-- ... pAn: _.:]1 '21-fD I (Address) 14745 So Robert Trail , (Address) (Contact PerlOD.) Marv olson ~UCA;IT SIGNATURE \ J FEE SL.I::lJ1jDULE Rc:siden1Jal sewer and water line connection $35.50 Industrial, Com'l &; Multi-family 1% of job cost with a $39..50 minimum. Sewer connection aui}' $17.50 Water connection only $17.50 Estimated Cost $ Building Permit # \Nrn"\ , p~\O B pe,Rt-!\\1 . .u.D\~ -- ~ 1 ( SEWER AND W AlER PERMIT FEE $ STATE SURCHARGE $. TOTAL PERWT FEE $ (OfU,,, Use Only) I. This ~plicatlon Becomes Y our :au~)ding Permit Wh~~ Approve~ /\/'<' J. . .,' ~t~ \ 9 LOOl V V/ 11' ",I.., r ' . BuihliAg OWej... " ~. Date . ;;J . .J....".~.- --' \. 24 bour tlotice!oulJ jl1sp.,."iQJl* (Q<2).447-9850, fa): (952) 447-4245 ~,,,,--,,,,,"''-'' . ~ I DlitYf~-/4 -0 / IRec~ IByA~ I' ~._~----------...-:.-- DEC.31'2001 13:12 651 633 BBB4 FIRESIDE CORNER #6920 P.004/004 Date Rec'd CITY OF PRIOR LAKE l1.J4.JA 1 J.i ~G/AIR CONDITIONINGIFIREPLACE PERMIl ~: =.. ~~~ PERMIT NO,O 1- , 0 f 1- 3. yell..... AppIiGIll! , ~ (Plase ~ m Ilrillt IU1C1sillD lit bottom) ADDRESS ZONING (QfIleolllle) I 5;;}tg 7Jf#' ~ LEGAL DESCR.o: 1. J.ON (clfice IJSC only) ADDITION PID LOT BLOCK OWNER ~ eN ame) '.J--' It e;)o.Vg. . (Phone) (Address) APPLICANT (Name) Ar..T..I.ED FIRESIDE DBA FIRESIDE CORNER . (Phone) 651-633-25J~1 p~~ (City) 651-633-2561 _ (Phone) DATE _ . _ ". -.-_'_-:,--',- 1:',1;1 1 ~ (Zip Cot1e) (Address) 27DO N. F~IEWAV~ (Address) BRENDA E1USTON (ContaCt Person) _ APPLICANT SIGNA~~~...Itb,.G;::;_ APPLICANT PLEASE COMPLETE BELOW ~j;w CONSTRlICTION 0 REPLACEMEN'1" 0 AL TERA nONS FURNACE MAKE AND MODEL ' FUEJ.. FLUE SIZE RETURN OPENTNGS INPUT OlITPUT lYPE OF SYSTEM HEATING OR PO"WER. PJ..AN'T OWann Air Phmts 0 St.epm DGravll:y 0 Hot Wllter o Mcehllnlcal 0 RadillliQJl DAir Condltioning 0 Special Devices DVent. S)'st~ 0 Oth~ Devices Fl~PLACE MAKE AN)) MOD:EJ.. ~ J.J G(.j) ,J'" 7lD1'rl- PLIi:ASE NOTE: Air Conditioner Units Cannot Encroadl into Required Side yard Setbacks Rcsidenthll, Heating &. Ale (New CtmSt.ructlon) Rc:ridcntls.L Heating Only (New ConslT"Uaion) FEESCBEDULE 1 % of job cOSl Residential, GIl$ Fil'lCplllCe $39.50 minimum $99.50 'Residential. Addipons II. Ah:emtions $64.50 Residential, AC Only $39.50 $39.50 539.50 In<llJ,strial. CommercllJJ &. Multi-Family Estimated Cos!: $ Building Permit {# HEA 'fINO PERMIT FEE STATE SURCHARGE 'tOT AI.. PERMIT FEE $ $ $ ;( ~~,,\t ~ .S~\..g\NG (omc:c Use OnlY) This Application Becomes Yo,l' Sulldlng Permit WIlen Approved Recejpt No. Paid Date By BlliJd'JIl omdld DMz 24 hIlI'r IIotlce for nlll"lIpectlons (952) 1U'7-98Sn. fn. (9!1) 447..4245 /~"- 1/ s~ +~ MOo,',^- f7'l-e DEPARTMENT OF BUILDING AND INSPECTION PRIOR LAKE INSPECTION RECORD SITE ADDRESS S~\7\ Dall"C elJ ~ NATURE OF WORK N.av..J USE OF BUILDING ~FA- PERMIT NO. rJ/- 0/0/0 DATE ISSUED q-S -24I::J1 CONTRACTOR D. R \-b~ Sleu., PHONE &fS..< .~~~ 78D~ NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW THE PERMIT IS BY SEPARATE DOCUMENT INSPECTOR DATE I FOOTING I t/;;. /fJI If /01 FOUNDATION (Prior to BaCkfill)V~ I ~ IC/I~/~ J I PLACE NO 'CONCRETE UNTIL ABOVE HAS BEEN SIGNED ROUGH - INS ~,~ hih-. ~~ SEWER I WAT-ER I SEPTIC FRAMING INSULATION ELECTRICAL. PLUMBING~. llG.: /Z".. \\ "/0 I HEATING (if required) FIREPLACE . GAS'.LlNE AIR TeST M...F ~V ,}O~ , COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED I I FINALS (l. ~ '/? f7;r GRADING (Prior to Sodding) BUILDING,- Lt), ~ r1 L! ITl-- ~ '3f I~ (D 2- ELECTRICAL PLUM~ING HEATING DO NOT OCCUPY UNTIL ABOVE HAS NOTICE ...., 0-~ /6/1 CtJ J t:J I J'/~h > J 7'5110 J- I/Jilo1/' J / -;}... ~ ~ 2--' f J / ::J- "I /D '2--- , , 7!r7!O'v 7 /~L/ / ()t:..- { , , '3//5/lJ V B'11/~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 sl1all b(! placed near main entrance. . Call between 8:00 and 9:00 A.M. for all inspections FOR ALL INSPECTIONS (952) 447-9850 .4JP.;;;=--=.=-..-=--=- -~ - - - - - =-=--:_ - ~ --..- -.= - -~.- --- (....~ ... ." ..:~.... ..~.~:~~s~~<!1-..t ...........~~~_~ ~M...M..l! ~ > ~.~~~~t~ .~t~,~~.~~r,;~..,;~~,. '~~~ t;~ ..... ....~..;~.~t.-,~~~.,.~'-;:.~,~..:.~,j~~: l (. . r ..... '11- -, oj., JUf!.~ -11- ~~-, ..- ....--,.,.".""' t :, ~~ ~ l,) QLtrtifuatt of (tlnqtUJtty :r ~ :t:~ CIIV OF PKlOR LAKE ?i :~~ : 1gepartment of _uilbing Jn~pettion ~ N,-......I :~: ~Final Permitted 0 Conditional C.O. Expires l ' I -. This Certificate issued pursuant to the requirements of Section 307 of the Uniform Building Code ~. ~. certifying that at the time of issuance this structure was in compliance with the various ordinances oftheL(. I City of Prior 1AJce regulating building construction or use. For the following: I SINGLE F&~ILY I' 01-1016 Use Oassification B dg. Pemut No.. R3 VN N/A R1 Occupancy Type . Type Construction . Fire Zone . Zoning District Legal Description L25. B1. DEERFIELD SECOND ADDITION Owner of Building _ C;ile Address 5218 DEERFIELD LANE SE D.R. HORTON. 20860 KENBRIDGE CT.. SUITE 100. LAKEVILLE Contractor's Name &: Address City Planner Dale: DON RYE CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED DATE TIME 3J..rJ) 0 'l-- UJ : ~ ADDRESS Sz/? &-~~ CONTR. OWNER PHONE NO. PERMIT NO. Of-/Ol ~ o EX/GRAD/FILLING o COMPLAINT ~D FIREPLACE RI (]:JI JO FIREPLACE FINAL o GASLlNE AIR TST o o PLUMBING RI o MECH RI o WATER HOOKUP o SEWER HOOKUP ~ PLUMBING FINAL UJ/ r- MECH FINAL COMMENTS~ ~~ . .^ A A........ -.1J ~.~ ~ ~ ~ ~_n_ .__~ ~~ ~-' /, ~ ~ ct: Wk 0 " &}~~. &)~~. ~ L,L(~.~, o FOOTING o FOUNDATION o FRAMING @ o INSULATION ~ FINAL o SITE INSPECTION I" A '\(QA~.-b.ie 81 ( JI'J'Z- l ( ~ ~~ - ~ ~~ o WORK SATISFACTORY, PROCEED '1Z!1CORRECT ACTION AND PROCEED 10 CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING Inspector: ~ ..... Owner/Contr: '(7f l CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. INSNOTl CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY! DATE TIME CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED ~tJ z.. ItJ ~ tJfJ ADDRESS .52./8 ~~. OWNER CONTR. PHONE NO. PERMIT NO. ~/-/O/fo o FOOTING o FOUNDATION o FRAMING o INSULATION o FINAL o SITE INSPECTION o PLUMBING RI o MECH RI ~D WATER HOOKUP o SEWER HOOKUP ~ PLUMBING FINAL b MECH FINAL o EX/GRAD/FILLING o COMPLAINT o FIREPLACE RI o FIREPLACE FINAL o GAS LINE AIR TST o COMMENTS:@ ~ \~ (l~ ~.~ -~li tA~ ~ ~ o WORK SATISFACTORY, PROCEED )t:7CORRECT ACTION AND PROCEED o CORRECT WO~ALL 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 & SAFETYl INSNOTI / CITY OF PRIOR LAKE INSPECTION NOTICE OATE 1h9~'L A. {, . 52/4:, / (,.' /B {)66I!:.F/GL-D LN. TIME SCHEDULED ADDRESS OWNER CONTR. PHONE NO. PERMIT NO. /-/015. /0/7. 10/to , . COMMENTS: o PLUMBING RI o MECH RI o WATER HOOKUP o SEWER HOOKUP o PLUMBING FINAL o MECH FINAL .5I;/) /7lU E, ;",..; I o EX/GRAD/FILLING o COMPLAINT o FIREPLACE RI o FIREPLACE FINAL o GAS LINE AIR TST o -. o FOOTING o FOUNDATION o FRAMING o INSULATION o FINAL o SITE INSPECTION ~ , I ~ ekz ~,...,~ ... ~ - L9~ i:jJ~ J V1 "WORK SATISFACTORY, PROCEED o CORRECT ACTION AND PROCEED o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING ~, ~1+- '--AA~' ~ Vr-/ 1,,/"1/0 z..". Inspector: Owner/Contr: . , CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY! INSNOTI A APPLIANCE PERFORMANCE TEST Attach to gas line adjacent to regulator Heating Contractor Name of Tester Date A\ \ .~-\,. M-e t..L- _~ . 't' ID (...~-.. 3 -I)'-<:)~ Job Address S~, <t ~v~;""'~ l.-_ Heating Contractor 1\\\ ,- -\ )--" t v--. Name of Tester K ~:~ "- Date ~-\ 1-o""'&... Percent 02 C, . '-f Percent CO Percent C02 -0_ Stack Temp Combustion air is adequately supplied per UMC Sec. 606 '(...) input 'ifi I oC)e> go" Jho