HomeMy WebLinkAboutBldg Permit 01-0865
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
(Please type or print and sign at b~;;~~.)
ADDRESS
11;)" 75" ~t11Y- Jl?
LEGAL DESCRIPTION (office use only)
LOT I S BLOCK a ADDITION ()6Gf J: Ian 2.nJ....
OWNER
(Name)
(Address)
1. White File
2. Pink City
3. Y.llow Applicant
(Phone)
Date Rec'd
L -6J
ONING (office use)
R\
PIDJS--~7~- OW-t)
BUILDER
(Name) 0.((.. ~47lY\1nL_ (Phone) q~~-"B~-7B0'1
(Contact Name) S+~V'(...- ~ c.-14lJYl.-. (Phone) !1fid.-~I?-I1:>3'1
(Address) dO~OKe-v'lb(1~ M. ~~.IOO ~.flI et./c../
TYPE OF WORK
plNew Construction
OLower Level Finish
o Misc.
o Deck
o Porch
OAddition
ORe-Roofing
o Fireplace
OAlteration
PROJECT COST/VALUE (exc1udingland) $
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 building official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may
enter upon property to Pt,-;~..., e inspections.
'"-""'"
s~re
x
v-
I Permit Valuation
Permit Fee $
Plan Check Fee $
I State Surcharge $
I Penalty $
I Plumbing Permit Fee $ I Of) . 00 I
1 Mechanical Permit Fee $ lee> .0iJ 1
1 Sewer & Water Permit Fee $ 1%. S-O 1
I Gas Fireplace Permit Fee $ 40. ~ I
~iS } atio~ecomes Your Building Permit When APp.roved
1>- 8 -.2.~{
uildi/g Official Date .
B5'J eJOO , oa
P88.7s
S'1'l . (,4
42 .5V
1 Park Support Fee
1 SAC
1 Water Meter si(e~ 1";
I Pressure Reducer -
I Sewer/Water Connection Fee
I Water Tower Fee
1 Builder's Deposit .
lather Dou.-b Ie .sl uJ -fee
1 TOTAL DUE
_......... ._.. I
I Paid $'"8'~ 7, If 4
I Date 8.... ~ty 0/
~tJ()IJ,~'1
Contractor's License No.
ORe-Siding
OUtiIity Connection
~f4f)t/ I
. -
~~DJ
I Date -
#
$ e8).LJO_
$ ',\ 5"c.m
$ 1~.~,cX)
$ -4,C):oa.
$ J JlCJO -(90
$ . '71J(LLjZ) 1
$ . . 1) -I
$ 35'/~S-O I
$5ii1, 94 I
#
#
#
~~lpo~d-j
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
w~'" Ci~ _~ ro"",m~ , 'mp","" C"","", of """'" _fum~ "",.n~ ,~""_ '" ro~. """" _, ,C...... of()""""", ~,'"
~sue .~~~ fS/~/et ~~ ~~
t/ Planning Director Date - Special Conditions, if any
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
Th~ ('~nt~r of th~ I..k.f COun111'
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
~
R ~--D-Ll~
7- d'-O/
The Building, Engineering, and Planning Departments have reviewed the building permit
application for c~~;ti7;;tivity tv~i::?~
Accepted X Accepted With Corrections
Denied
Reviewed By:
AA4 is
Dafe:
g - ~ -0 l
Comments:
See /Ylc:,"j'\ F,'/(
: ;
~
'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."
The ('enlef of Ihe takr Counlry
White . Building
Canary - Engineering
Pink - P'anning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
;:)
R~
7- d' -0/
The Building, Engineering, and Planning Departments have reviewed the building permit
application for C7~;1i7;IiVitY i(l is proposep at: ~
. I
Accepted
Accepted With Corrections
?<-
Denied _
Reviewed BY:C:J;:f ~k
Comments:
f ~ +L. M~:V\. ~ Le
Date: 8 - 2 - 2a::,/
"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."
"
The ('.nl.r of lh. "ak. Counlry
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
-
\
NAME OF APPLICANT ~
APPLICATION RECEIVED
!~, r' \ )'; / '-~'
7- (, (//
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/ <7:J. /7 5' ~ l'al~k" liy.>/(__._/
Accepted
~
Accepted With Corrections
. ~
Denied ~
Reviewed By: ~A..1- ^ ~...P..~
.;" ~-
Com~ts: ('; I' /\
~ ~ ,~It'le.- ~e,~~ /727'
l/\eR4~&9 ~~ ~ ~~\{~~SJ
-- -- ~ -
Date:
RJ/qC,fJ I
&0'
"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
HEATING/AIR CONDlI10NING/~lKEPLACE PERMIT
Date Rec'd
(Please type or print and sign at bottom)
ADDRESS
~::':n ~!~ PERMIT NO.() /,0 f//,_ 5'
3, Yellow Applicant ~ IP
111:1'3
I) e.er +1 fA lei
-"-
Dr' \it. SE.
ZONING (office use)
R(
L~:~::::;n;N :::=: (0 'w1iM ~ rVc
&~e~RD~, Horron Cusbm HO(Yle~
(Address)do2loo ~ridC)p.. Qt. ~QkeV; l1e. M~
APPLlCANTA II' 1 M ----
(Name) rCAr1T e~ 1.,~. (Phone) 0/-45:L-tf/775'
(Address) 3<050 fl. e.n11 e b ec... J:x.. Sie. #/ .1--: a -9 on 55/.22
(Address) (City) (Zip Code)
(ContactPernon) ~f'.pr~ Z;r-nmprfT) Q.n (phone) fp51-A./5~- .:l77!:i
APPLICANT SIGNAwk..~LU t14?~ DATE
V (J . V
APPLICANT PLEASE COMPLETE BELOW
!0NEW CONSTRUCTION o REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL 1Jr~4n+ 3S31(A-vb'VU>'o FUEL l\Jo.~lAm.'
FLUE SIZE If.''cI(1,S~ ~ RETURN OPENINGS '+ INPut 1C.l>DO OUTPUT 6lD..tJOO
TYPE OF SYSTEM HEATING OR POWER PLANT
PID dS ~ 7,:)- aba'-S
(Phone) C;5a- q~ -7~7.:L
550~.l..1
OWarm Air Plants
DGravity
o Mechanical ,
~ Conditioning
Ql'Vent. 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 & A/C (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-FaI11i1y
$39.50
$39.50
HEA TING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Building Pennit #
r~"\B:~\'llA\\
eu}~\\'
\--
$
$
$
Estimated Cost $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid
Date
AUG 2 0 2001
Building Official
Date
ReceiPj 7iJ
BYfL
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
9:02AM
GENZ RVAN PLUMBING AND HEATING
No.9431
p. 5/13
Date Rec)d
CITY OF PRIOR LAKE PLUlVIBING PERl\uJ.
/ I
,
...<<:......
.Jl'1CB1iC !"Fe ot 1iint -.nd !i@"QboQl)m)
ADDRESS-' -' ,
ll~~~ ~~~'d1 0.", T)~
i ~ ~~ I PERMIT NO.O I, 0 (7/_ 5'
J, 1'........ "'1lP1~ 0 lt7
~.~
ZONING (affia! 1ISe)
~\
LEGAL DESCRIPTION (ottia: use a.nIy)
. LOT (SBLOCK '2- ADDmoN'I>J!'f Q e.l n 2J....:J D
:Pro ;At;-:~-t%c.~
OWNER
(Name), DR Ho;rton Custom Homes
(A~~~ 3459 Washington Dr Ste 204 Eagan, MN 55122
_ (Phone) 651-454-4663
APPLICANT
(Name)Cgag-Py-- 'DWahi:A.8 &- J;1u....~"'{J (phone) i\"l_t..?l_l1L.A
(A~~S)14745 So Rober~ Trail Rosemoun~ MN 55068
(Address) (City) r. ' (Zip Code)
(Contact Person) Max-y Olson ,L II (.f.1l1ltl.e) 651-423-1144
APPLICANT SIGNA'I1..T.&E LA I_ ~ ~ - ' DATE B / eelo r
; ( APPL~piEASE COMPLETE ~OW' .
QQan1ity / Type of Fixture Quantity Type of Fixture
I I Bath Tub with or without shower Rough.ins
, I Dishwasher J I Water Heater
\ I Floor Drain 1<:1 1 I Wa.1:er Softner
'Z.. 1 Lavatory (Ba1l!room Sink) I I Stand Pipe (Washing 1'4achine)
, I LaundIy Tray (lor 2 compar1ment sink I Sewage Ejector
J I Shower Stall I Bacldlow Assembly
I I Sinks I Backtlow Assembly Test
I Bar Sink I Lawn Spttnlder
2- I Wa-oor Closet (Toilet) '-Other
.1I'j!;j!; SL.ltJLJJ ULE
IndustnaJ, COffi;D1crclal &: Multi~famtly 1% of job cost with a $39.$0 minimum .
Residential, New One &: Two-Family $99,50
R=idGxltial, Additions &: Altmltions .$39.50
Esfunatecl Cost $
Building pemrit #
- ;>>.p~~tf.
t/. ~
r
PLUMBING PERMIT FEE $
STATE SURCHARGE $
TOTAL PERMIT FEE $
(Office Use OOly)
I This Applic.tioJl ;Becomes Your Building Permft'Whcn Approved .PiiCl
i
allUdlnl Official
D,re
DapUG 202001
By
14 hour \lotice for all inspections (951) 441-9850, fax (951) 447-4145
Aug. 6. 2001 9:04AM
GENZ RVAN PLUMBING AND HEATING
No.9431 p. 11/13
Date Rec'd
LJl i ,OF PRIOR LAKE
SEWER AND W AJ.~.K PERl\tlll
, ,
.III,",,:':' ';'
i ;;w ~;, PERMIT NO.{)/ () rY / r:"
,o"ld Appfi_t. - J (p ::;
f!'!:ase ~ M F!!Ir an4 SWlU bw.......)
ADDRESS' " .' '. .
\\l-16,,",\Zfl.r\{f?OO W
ZONING (9~ oae)
-~F_ R \
LEGAL DESCR.IP110N (omce use only)
LOT \ SaLOCX L-ADDITION 11 P A () ~ f) 2A'.J2)
PIDJ..tJ~:; Id. ... 00o-C
OWNER
(Name) n, 'Q"''''-:+'I''IT\ r..a"'QIll. Romg~
(phone) 651 454 "-~~~
Eagan, MN 55122
(City) (Zip Code)
(A~~ 3459 Washington Dr Ste 204
(Address)
APPUCANT
(Name) Genz-Ryan Plumbing & Heacing
(phone)
651~423-114.4,
(ContactPeIfoll) Mary Olson
I,' "'LI~SIGNATURE-Ll
, ~ -
.~
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from stIUcture feet.
Type o~ sewer pipe. 0 ABC 0 PVC 0 Cast Iron
Estimated length of s~wer line feet.
Clean out (if required) located at feet llV.LU. structure.
\~).
(Phone) 651-423-1144
;ATE !B I (n J D f
.
55068
(Zip Code)
(A~~~ 14745 So Robert Trail
, I (Addn:Is)
Rosemount. MN
lIJ!.i~S,--J:U!J)ULE
Residential sewer and water line connection $35..50 Industrial. Com'l & MuJtHamily 1 % of job cost with a $39.50 mInimum
Sewer connection only $17.50 Water connection only $17.50
Estimated Cost $
Building Permit #
,SEWER AND W A.lJ:!..K PERMIT FEE
. S.TATE,SURCHARGE
TOTAL PERMIT FEE
$
$'
S
.5,?~~~~~~t-A\"
6\Jn..O\
I
f
!
(Office UK Only)
/, This Applieanon Becomes Your BlliJdiDg Permit Wben App~v~ Paid I RCc:eiP'liJtt.
i.',',~ Dllte Date AUG L U LOOI I By , I. _
:SlUldllll Offidld
-". .. h....otI<o (or" ...-... ~) "';,...sO;liii (.g)~- --_./ I
NOV.09'2001 15:08 651 633 8884
FIRESIDE CORNER
#4599 P.005/009
CITY OF PRIOR LAKE
HEA J.U ~GI AIR CONDITIONING/J:lLKEPLACE PERMIT
Date Rec'd
(Please J:Vl)e or PrinJ: lIDl'i "KIt at bodm:n)
ADDRESS
~: =." ~~ I PERMIT NO. \ - q J ~
J V_IIt>tt "''''''Iao~l 0 l,P::J
ZONING (offiCI: Ilse)
II ~ IS ~()+#eP ~.
J...EGAL DESCR.l.l:' uON (gtfiJ:e use only) ~: (
LOT /~LOCK ~ADDmON.. cQ
. ( -
OWNER ~ e ~Aivl-
(Name)
"R_ \
d,JJd-
PID ;;_7'- 31;).-(;(;,0-0
(Phon.e)
(Address)
APPUCANT .
(Name) M..LIED FI:RESIDE DBA FIRESIDE CORNER
(Phone) 651-633-2561
(Ad.dress) 2700 N. FAIRVU:W AVW!lB
(Acldn=ss)
BRENDA r:roSTON
(Conta.ct Person) - I I
APPLICANT SIGNATTJ~ ~a... ~ ~
RQ!S~'l'Tr.r~E: MN
(C~)
(phone) 651-633-2561
DATE /1- 4. QI
1;1;11':1
(Zip CQde)
APPLICANT PLEASE COMPLETE BELOW
~w CONSTRUCTION 0 REPLACEMENT 0 ALTERATr.ONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INpUT OUTPUT
TYPE OF SYSTEM. HEATING OR POWER PLANT
OWIlml Air PIMt5 :J Sleam
o Gnw;ty :J Hot Water
o MeehMicBI :J lbdi81ion
OAlr Conditioning :J Special Devicel'
OVent. System ..J Other Devices
PLEASE NOTE:
Air Conditioner Units
Cum.Ol Eucroaelt into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
~ ~ (;lJ:3
...Sf- 70J 0
IndU.strill.1. Commcrc:ls.l & Multi-Family
FEE SCHEDULE
1% of job cost Residential. GfJ..~ FireplB.Ce
$39.50 minimum
$99.50 ResidentIal, AddItions &; Alterations
$64.50 Rcsideatilll. AC Only
$39.50
Residenr.lll.], Heating & AlC (New Construclion)
Residential. Heatin.g Only (New Ccnstl'1Jctlon)
$39.~O
$39.S0
Estimated Cost S
Building Permit #-
HEATING PERMIT FEE $
STATE SURCHARGE $
TOTAL PERMIT FEE $
.50
;'
" . !
~ ,. ,," ,0 fA
4..., 1'/ VI/I]';
~ejptNo.'~
'/ Itfl;-
(omr.:e Use: Ortly)
Tbill ApplicatiDn Becomel Your B.lildlng Permit When Approved Paid
BlIlIIS'Jlg omcJn'
Dire
Date (Jj /3)/
By
~
U
14 hOI.r notlee for 1I11ln1pC1:tions (9$1) ..7-!J8SIl, fu (95~) 44'7-4%45
PRIOR LAKE
INSPECTION RECORD
SITE ADDRESS t i"J ~ T"{5 h~J- ~\ e \I'~ ~r
NATURE OF WORK JJ6...)
USE OF BUILDING ~')F4-~
PERMIT NO. ~,.~ DATE ISSUED 8 - 2.... ~I
CONTRACTOR -D. ~. I~~~~ PHONE ;;;J.;l~- 133</
,
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
\ ~~ .H-e fV\.o.c'v\ +:: 4
DEPARTMENT OF - ..-Jk. - ..:.
BUILDING'AND INSPECTIOI7/)1- a3
INSPECTOR DATE
FOOTING I 6:p 11/5"'/0 (
, FOUNDATION (Prior to BaCkfill)t'~~ I fi9- ?/;tJ/o, I ~.. 9/;? ~/
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIG'NED
ROUGH - INS
SEWER I WATER I SEPTIC
FRAMING
INSULATION
ELECTRICAL
PLUMBING u..~. ~ t:t/~5/61 I~rf;
HEATING (if required)~..[.b' A- 'i/dP1 . {:h...
FIREPLACE {$;t-.
GAS LINE AIR TEST ~ ~, F:f1, ~.
/J
Pr
#<r
12/Lf/1) (
1z17/() 1
1//;; r,(D/
Jlz.! L( jtJ f
L Z4 i-/ /fJJ
,'1 g~1
I
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
I I
FINALS
GRADING (Prior to Sodding)
I BUILDING ~c.,D, iJJ <6'(I! t/l-' 4. ~/J. ~ft z.
ELECTRICAL
PLUMBING 4. 1117 /O~
HEATING ~ _ {j,.3'/~~
DO NOT OCCUpy UNTIL ABOVE HAS BEEN SIGNED
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.
Call between 8:00 and 9:00 A.M. for all inspections
FOR ALL INSPECTIONS (952) 447-9850
QLtrtifirau at ~rrnpanty
Cll'f OF PRIOR LAKE
Jlepartment of J,iuilbing Jn~pettion
~inal Permitted 0 Conditional C.O. Expires
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 of the
City of Prior Lake regulating building construction or use. For the following:
Legal Description
. VN .
Type Construction Fire Zone
LOT 15, BLOCK 2, DEERFIELD 2ND
R3
Bldg. PermitNo.01-0865
Z . D" Rl
onmg Ismet _
Use Classification
Occupancy Type
Owner of Building SileAddress 17275 DEERFIELD DR SE
C~......w;j)r'sName&Address? R IDRTON, ~860 KENBRIDGE CT STE 100, LAKEVILLE 55044
1/1/V/
}' V / City Planner DON RYE
ROBERT D HUTCHINS
I luilding.. Official
- -0 L.f
Dale:
Dale:
POST IN A CONSPICUOUS PLACE
"," .
-
~
CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
ADDRESS
17275'
,
(J-r'~f7-( C
OWNER
CONTR.
PHONE NO.
PERMIT NO.
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
~~J /1~:s
I
COMMENTS:
DATE TIME
Il-o'-I
1- 8""' r-
o EXIGRAD/FILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
---- ---.....:...---
/ /If '\
/ / III c.,. [:) _ )
{ ~vJ~. '-~
" ~
-
~RK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CA~R REINSPECTION BEFORE COVERING
Inspector: 1./1 n- Owner/Contr:
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
I/,;J?~l- /1J.'bO
(
~
I
ADDRESS
/?d-75
OWNER
CONTR.
PHONE NO.
PERMIT NO. --LJ I - J>c1, S-
o FOOTING 0 PLUMBING RI 0 EX/GRAD/FILLING
o FOUNDATION 0 MECH RI 0 COMPLAINT
o FRAMING ~ 0 WATER HOOKUP r@J 0 FIREPLACE RI
o INSULATIO 0 SEWER HOOKUP ''Iq FIREPLACE FINAL
J!!. FINAL ?f\\O. PLUMBING FINAL '8' GASLlNE AIR TST
o SITE INSPECTION ~ MECH FINAL 0
COMMENTS:((J p~ ~ tJ~....)
- ~, I ~r~.~ r
4!~~. -~ d~~
ro ~ t:~ .~,.~J,~ .'
~ IA_^_~ ; ) ~ ~ ~
~/)dJ~ il (
TrL. (), 1iJJ ~r, / () 'Z-
, ,
/J1AAf ~
o WORK SATISFACTORY. PROCEED
!A 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!
INSNOTI
ADDRESS
J?d- 75
DATE TIME
SCHEDULED ~ z... II: 3"
1j~
CONTR.
CITY OF PRIOR LAKE
INSPECTION NOTICE
OWNER
PHONE NO.
PERMIT NO.
or - ?G~
o FOOTING 0 PLUMBING RI 0 EXlGRAD/~ING
o FOUNDATION 0 MECH RI 0 COMPLA~=
o FRAMING ~ WATER HOOKUP 0 FIREPLACE RI
o INSULATION '1\ i' 0 SEWER HOOKUP 0 FIREPLACE FINAL
o FINAL r\ PLUMBING FINAL 0 GASLlNE AIR TST
o SITE INSPECTION 0 MECH FINAL 0
COMMENTS(D ~ ~ ~
~ ~IIIJ.
(p~'~ ~I
M~ ill u).~,
l~ l~~~ I
-
~
o WORK SATISFACTORY, PROCEED
9' CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: ~ ~ J Owner/Contr:
CALL 447-9850 F~ THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYl
INSNOTl
.
APPLIANCE
PERFORMANCE TEST
Attach to gas line adjacent to regulator
Heating contractor^ \l,,--\ '^'C!.C..L....
Name of Tester \CL',rl.
Date ,- lu -t):z...
Job Address 17.;l7rO<.....f.JA.Dr,
Heating Contractor 1\,\ . -~ t""c2d-.
Name of Tester \<...&.. '.~-
Date t-.o ~O~
Percent 02
Percent CO
Percent C02
~.(
-0_
Stack Temp
Combustion air is adequately supplied per
UMC Sec. 606 '( .. ~
input C c.. .0(:) 0
<if-. Lf
(<i{.Jo