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Home My WebLink AboutBldg Permit 01-1328 CITY OF PRIOR LAKE BUILDING PERMIT, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE AND UTILITY CONNECTION PERMIT Date Rec' d I. White File 2. Pink City 3 . Yellow Applicant (Please type or print and silm at bottom) ADDRESS 171o~ W.lderne.H' 6n/A.rt' RI LOT II BLOCK LEGAL DESCR.1.t'uON (office use only) PID 205.....37D - nl J- 0 OWNER (Name) (Address) ADDITION ~-ter-f1~l J. ./ (Phone) BUILDER 1\ Q" A _ ~ ^ (Name)-----.L.>. . 1jlN'~/ (Contact Name) --5+eve... Ul ~o;, (Address) 20 Brao I<t-rbYl~ec+. s+~. I fYD LA.l-lttvt ll-L .M t'\ t;c;Dt.fy , . 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 building official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may ;terupon(\o~(frl dinspections. cRoou 5(P57 /O/?JO/OI o Si~ V Contractor's License No. ' Dlte I Permit Valuation I (pe ."f!J.OO r CJ:) I Park Support Fee # $ A:5lJ .0lJ Permit Fee $ '1~'7 'l . 6S I SAC ~ # $ ,. /.::y) "tL $ M3 .~ I WaterMeter Size~; I"; $ " / Q5,tJ"{J $ eC/. ~f)O I Pressure Reducer $ t.f.S,OD $ I Sewer/Water Connection Fee # $ I,~.. t.JC> $ loO..C!) 0 I Water Tower Fee # $ 'J{)t).O 0 $ I () 0 r &.::0 I Builder's Deposit $ I. Soo . $(:) $ 3~4s-n lather $ $ Cf(j .~ I TOTAL DUE $P,.I q,. 5 J I Paid trtx-,cl1, Sf - -l I Date I)..... :J''l-O J , TYPE OF WORK o Misc. (Phone) qr.;~-q Bt;:;- 7808 (Phone) '15d--- 22(,," ,;~~ ...... ~ New Construction OLower Level Finish OPorch ORe-Roofing ORe-Siding o Deck ~ Fireplace OAddition OAIteration OUtility Connection PROJECT COST IV ALUE (excluding land) $ /"*1, '7'1 a. Plan Check Fee I State Surcharge I Penalty I Plumbing Permit Fee I Mechanical Permit Fee I Sewer & Water Permit Fee I Gas Fireplace Permit Fee /J /7 . n B omes Your Building Permit When Approved Jl-~-Ol Date ... Receipt No.lf O'l'? Bv ~ t"'/ 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 issued. lL(2-t~ ~k~Mr~~.~ ..... Planning Director Date ' Special Conditions, if any 24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 Th. (..nt.r of Ih. Llk. ("ounlry White - Building Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT [),C( r) () y f:.o AJ APPLICATION RECEIVED ) 1- J- 01 The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: /1 dOO\ V /_L11?.iZ1/7l~_ ct- Accepted ~ Accepted With Corrections Denied Reviewed By: ~ ~ Date: (7 "-.J !JL/ J,f),( 0 { Comments: 1'4.0 ~Lz<M '6 <~/o.2L'1:'Ve ~~~evo.~ ~AAO~ M.\w VfA.lM-1 ..s I J-vuW tAlrJ.-/1 ~~__ \d fVtfl(lMj !~, "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 erntr, or thr bkr Country ()1-/3?~ White - Building Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT D J? 'f:1 () r-fjo AJ APPLICATION RECEIVED ) /- /- 0/ ./.' i.' .'..-" ;.-'f. " , Th'e' Building, Engineering, and Planning Departments have reviewed the building permit application for conptruction activity which is proposed at: I 11.dO~ V~~~/ X , Accepted Accepted With Corrections Denied Reviewed By: IJA-f3 Date: I /-~-O I Comments: See Reverse Side for Addition~1 Inform~tionl ('"t- ::7!t" J .,>( /' >,. '/""-" ~~--:~'_::~ ---- See Attachments: 1) Grading Plan, 2) Erosion Control Measures 3) Erosion Control PI::ln . "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 Tht Ctnler nf Iht takt ("ounlry BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT D R .k) () rf;O AJ APPLICATION RECEIVED ) /- J- Of The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: /1 dO;). W ~~ @:j- Accepted ~ Accepted With Corrections Denied Reviewed By: ~ Comments: Date: I \ -I t../ -of _~ a.m a ~O_ ~AAol ~ul-s "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." 15:04 651 633 8884 FIRESIDE CORNER #0567 P.003/003 CII oj OF PRIOR LAKE Date Rec'd It~ATING/AIR CONDITIONINGfFlREPLACE PERM11 I. Pi ,.. Fit. I PERMIT NO 3. omm C111. .. 1'\ (_ J ?,., (J ,. y~ AppI..... (J ,:/:n (Please ~. I)l' orint mil nilD "bol:l:Dm) L- ADORESS . ZONING (oll'i<<llllll) /1 J--oJ. IJJ,'/ ~..1 &J LEGAL DESCRIP110N (office uaa: only) LOT BLOCK ADDITION PID OWNER ~ (Name) . /) ~ ~ (phone) (Address) APPLICANT (Name) ALLIED FIRESIJ:lE OBA FIRESIDE CORNER (Address) 2700 N. J1'.AJ;iVIEW AVPlNUE (Address) (C P ) BRENDA HUSTON. I (pI.. ontact . erson u( n.e) APPLICANTSIGNATURE~. I-ju~ _ _. DATE APPJ..ICANT PLEASE COMPLETE BELOW ~EW CONSTRUCTION 0 REPLACEMENT U ALTERATIONS FURNACE MAKE AND MODEL FUEL FLUE SIZE RElURN OPENINGS INPUT OUTPUT TYPE OF SYSTEM HEATING OR PO WBR PLANT DWann AI.r Plll1lts 0 StClIm BGrav,ty J Ho, Wa~ MectumicaJ :J Radhl1ion Air CDnditionlTlg 0 Special DcvlcCo'l OVcnt. Sysbcm 0 Other DcvlcCB . (Phc ine) f:)Sl-633-2,Sf,1 ~MN (city) 651-633-2561 ~I:,ll~ (Zip Code) 1/31/,,7 , PLEASE NOTE: Air Conditioner Unifs CannotEncrDachin~ Required Side Yard Setbacks FIREPLACE MAKE AND MODEJ.. J:J.e.6-l P ~(;:o .sl. IJ1,)7l.- FEE SCHEDULE . J % of jDb cost. ResIdential. 0 IS Fjrcpl~ $39.50 minimum $99.50 Re."ldenual. A Jdltions &. AI_mons $64.50 Rc:.,ldential, A:: Only Industrial, Commercial & Multj.FlU1lily $39.50 Residential, Hesting & NC (New ConstructJon) Residential, HCllling Only (New Constnlction) 539.50 139.50 Estimated Cost $ Building Permt # HEATING PERMIT FEE STATE SURCHARGE TOTAL PERMIT FEE $ $ s ,sp'rpA\O W~1:~: . . . -;- 'BU'" l\"'\\lI...\G \ -' ",.. ..,.,'" '1~1~"J'o '-.,- ,:3?:::'Y l, ~ - - ----- ~- (omc:e Use OnlY) This Appljation BccomlM Your Buildlne Permit When Approved Paid Bu"II'''1 01'6C:'11 .h h: calls I 4 I ~pl~/Ji By ~_ %4 hour notice for allln.pactlon. (?!5Z) 447...,150, f.: . (9SI) 441-4245 Nov. 7.2001 1:08PM GENZ RVAN PLUMBING AND HEATING No.5701 p. 3/3 Date Rec'd C.1'.1 Y.OF PRIOR LAKE SEWER AND WATER j-~.iO'.ll1 , ,I i ~ ~ I PERMIT NO. 1- / 3 'JAJ J, Gold 4.ppll~ 0 ~ (Please: type orp.tiD.t lQId _ .at b.._..,J ADDRESS 1"1'2..02 U)~ ~DL.V~ C" ZONING (o1Iia: UR) ~\ . LEGAL DESCRIPTION (office use only) LOT IJ BLOCK .1 ADDmONJyf'~ OWNER (Name) N'_ ~gr~gll ':'.,'':''tQm llgm.t':;' (Ad~~s) 3459 Washington Dr Ste 204 CAd.drds) ProJ~~- 37()- Oll-i:p (phone) 651-1. ~I._I.~I:;.? Eagan, MN (Cky) 55,122 (Zip Code) . APPLICANT (N~~ Genz-Ryan Plumbing & Heating (phon&:) 651-423-1144 (Ad~es~ ,14745 S~ Robert Trail Rosemount, MN 55068 (Address) (City) (Zip Code) f (Contact Person) Mary Olson (phone) 651-423-1144 -UCANTSIGNA1URE \A /~ D-- DATE II J--,ID J , . APPLIC~L l"LE COMPLETE BELOW Size of water service inches. Location of any couplings from stru.etu:re feet. Type of sewer pipe. 0 ABC 0 PVC 0 Cast hon Estimated length of sewer line feet. Clean out (if required) located at. feet from sttucture. Residentlal sewer and water line c:onnect1Oll Sewer connection only .If.EJ!,; S~.I1J!J)ULE $35.50 Industrial, Com'l &: Multi~family 1% of job cOSt with. a $39.50 mioimmn $17.50 Water eormec:tion only $17.50 Estimated Cost $ Building Permit # SEWER AND WATER PERMIT FEE STATE SURCHARGE TOTAL PERMIT FEE s S. $ .50 (':1 ~ f:;:y! A. -..J~-l~C ..t-~ r,. '~ ~- _. t ~^ 'i ........ 'J.j..l~ -~ ,...... l'-'.. -'.., ! /",l . ! (om"" v." Oo.ly) This AppJi~ation Becomes Your Buildiog Permit When Apptov~ Paid .. .,.. '. I Building otJici.1 Date Dltte - / j-d7-1 I Receipt No. BY~ J4 hour notice for aU inspedioDJ (952) ~7~9850, t.x (95:2) 447-4245 -::::::--'r-;- - CITY OF PRIOR LAKE \ ,'I'.:: Date Rec'd [' I HEATING/AIR CONDITIONING/FlREPLACE PE~WN 28200\ (Please type or print and sign at bottom) ADDRESS ~ . \12ffL- \ \ ,tcifrtSS C,r I. Pink File PERMIT NO 2. Green City . . . ^ I ... /3? a 3. Yellow Applicant V ~v ZONING (office use) LEGAL DESCRlPTION (office use only) LOT I \ BLOCK I ADDITION PID H()'(' +(')V) ~/ac;h"n'3~-on fro Sfe,fFc:loA/ ~~~;~jANT AI i ant M eehQn I (I Q \ =me (Address) 3& 50 1~V1(1ebe~ -:Dr. LQc{Qn (Address) (C~) (Contact Person) ~ e., rr Zi mm ermQY) '1 (Phone) X 620 I APPLlCANTSIGNATU~~. ~ATE _ JI/t7/Pl . APPLICANT PLEASE COMPLETE BELOW . IXJNEW CONSTRUCTION 0 REPLACEMENT 0 AL TERA TIONS FURNACE MAKE AND MODEL K""d~l"-t 9:i % FUEL "-Jo.t. G Q S FLUE SIZE o? Y2- DV~ RETURN OPENINGS INPUT /tAQ/t'O 0 OUTPUT 80. 01H> ,- TYPE OF SYSTEM OWNER ~ ~ (Name)LJ. I~. (Address) J 1../.5 q (Phone) Ea9an (Phone) tD'1-.t./ 5 c51- &J 775 661d~ 55/otbL (Zip Code) REA TING OR POWER PLANT DWarIl! Air Plants DGravity o Mechanical &Air Conditioning OVent. System o Steam o Hot Water o Radiation o Special Devices o Other Devices PLll!:ASE 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 $ 1000. o-v Building Permit # HEATING PERMIT FEE STATE SURCHARGE TOTAL PERMIT FEE $ $ $ r. PAID VIlli I, .50 . ~i ftlLDlNG PEB;JH' ~ fiJf;:6 __ (Office Use Only) This ApplJ?};y, Jifomes_Your Building Permit When Approved U~ ~-(J I B....ilding Official Date .- ~ Date ~ By 24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 1 : o7PM GENZ RVAN ~LUMBING AND HEATING No.5701 p. 2/3 Date Ree'd L.ii i OF PRIOR LAKE PLUMBING PERl\t111 1:11... rile I _1\..rrr NO 2. Clold City rJL~y,l..&"" ".,.- /2. IC...- I J. rol'- !./.:_., ,..JCTi7 (please tyee or ptiD,r land siRn ~ botD;m) ADDRESS tJ 2-07- Lj.2J()(%(l~ r,t ZONING (offia:ure) 111 LEGAL DEsr12 r '(HON (office l1SC only) LOT II BLOCK. ( ADPIUON'l'V (J r ..a'P I n - , . PIDOJ5-37o- 6//- D OWNER ~~~ DR Ho~ton Custom Homes . (phone) 651-454-4663 (Address) 3459 Washington Dr Su 204 Eagan, MN 55122 APPLICANT (NameJ..a~~--1>~r- '01.._1.."ug , 1i"7:t~"1:;; (Address) 14745 So Robert Trail (Address) (phone) I; <:; 1 _4 ., ~- 1 1 41. Rosemount MN 55068 (City) (Zip Code) (ContactPason) Mary 01so~ I ~ _. .\1 " (Phone) 651-423-1144 ~PUCANT SIGNATURE \..A....A _. ~ DATE " J -, -7) I . :' . Ax ~ .LJkANT J,;:'SE COMPLETE BELOW Quantity Type ofF:"~...re--' 1 Qllantity I Type of Fixtare z.. Bath Tub with or without shower I ?, I Rough-ins I I Dishwasher I t I Water H.04.L". J I Floor Drairi I' I Water Sofb1er t.+ 1 Lavatory (Bathroom Sink) I I I Stand Pipe (Washing Machine) , I Laundry Tray (1 or 2 compartment sink I I Sewage Ejector I I Shower Stall I I Backflow Assembly t I Sinks I I Backflow Assambly Test I Bar Sink I I Lawn Sprinkler .,? I Water Closet (Toilet) r I Other .. ~.JLJ1;SLJ::U!,DULE Industrial, Commercial & M~tHaml.ly 1 % of job cost with a $39.50 minimUm Residential, New One .,. Two~Famdy $99.50 ResidEntial, Additions &: Alterations $39..50 Estunated Cost $ Building Pmnit # PLUMBING PERMIT FEE $ STATE SURCHARGE $ TOTAL PERMIT FEE $ .50 f I'.. PA' c, ,. -} ,f1j " r '.., - .'"'.... ~D:.'- . r . (Office Use Ollly) This Application Becomes Your Building Permit When Approved Paid Building Omeial .Date Date //-C)7-1 I ReceiptNo. By ~. 24 hour Doth:e for aU iupeetion.s (95l) 447-9850, fu CJ52) 447-4245 PRIOR LAKE DEPARTMENT OF o .; BUILDING AND INSPECTION INSPECTION RECORD SITE ADDRESS l!1~(r~ Wi\&oJ-~~ ~~, NATURE OF WORK ~ USE OF BUILDING SFD PERMIT NO. Q/.- /17 ~ DATE ISSUED I) -I t./ -0 ( CONTRACTOR 1) Q. Ho~ PHONE ~~? -?;2.1o- J~z'l NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW THE PERMIT IS BY SEPARATE DOCUMENT ;ZSPECTOR DATE FOOTING I f /0'- , 11 zJ '-I/o I ,.".. , FOUNDATION (Prior to Backfill) rp:::;. 11?7- /2./7/" r I jj:;..,. I d!/ 3/ OJ PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ROUGH - INS" /5;r. ~\\~ trrJ .. SEWER I WATER I SEPTIC FRAMING INSULATION ELECTRICAL ~ PLUMBING \AI~. 6;r, 1/:V1k" Ia:r . '~71()2., HEATING (if required) , · ~t'\ .J.r ~....O~ FIREPLACE .... ~~\ I '1--.... \-:,.,o~ GAS LINE AIR TEST ~9 r.f?, ~..' 1I1t/1ol.- ) , COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED I I FINALS A'~ I Nd~l ffrr J./ ~ ((') ~ ~, -. . ~~ v, Ik-. , OCCUpy UNTIL ABOVE HAS NOTICE GRADING (Prior to Sodding) BUILDING1:Q.O.W ?II J Jq-c, , . ELECTRICAL PLUMBING HEATING DO NOT J 1..1/7 /(t{ ":L .. I~ ...O~ r.2//9~ z,. I I j ~ tl \Q1 7/11 In '2/ I . , J.f/ / b !lJ7.- ~/~JtrZ/ BEEN SIGNED This card must be posted near an electrical service cabinet prior to rough-in inspections and maintained until all inspe'ctlohs'have b~en 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 -,.::1.1.02- 14 . T: ADDRESS /7202- WIW6iZ-N6S$ ~-r: OWNER PHONE NO. o FOOTING o FOUNDATION o FRAMING @ o INSULATION \Ill FINAL 10 SITE INSPEC'\ION CONTR. PERMIT NO. o PLUMBING RI o MECH RI o WATER HOOKUP o SEWER HOOKUP o PLUMBING FINAL o ME~H/.F.INAL SODIJ . f. l COMMENTS: 0/-/328 o EX/GRAD/FILLING o COMPLAINT o FIREPLACE RI o FIREPLACE FINAL o GAS LINE AIR TST o ')4 WORK SATISFACTORY, PROCEED (0 CORRECT ACTION AND PROCEED o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING 'ospectore ~ Owo.,/eome - CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.. CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH &: SAFETYl INSNOTJ DATE TIME CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED 6 -/ f..eJZ- ADDRESS /7 d()J. WJbleYY1t~ CT OWNER CONTR. D..R. Hoyfun PHONE NO. PERMIT NO. C> J - J 3 ~ f< o FOOTING o FOUNDA nON o FRAMING o INSULA nON .x FINAL - 0 SITE INSPECTION o PLUMBING RI o MECH RI o WATER HOOKUP o SEWER HOOKUP o PLUMBING FINAL o MECH FINAL }i(~R&n/.:Jt.L1NG o COMPLAINT o FIREPLACE RI o FIREPLACE FINAL o GASLlNE AIR TST o COMMENTS: 1)('( .1(1, ~,...O It!- P ff'lItwr::tr cf) {t. w-r ~ORK 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 REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY! l/iSNOTl DATE TIME SCHEDULED $~~2 <J S ~ 0 tJ(LJJ~- "..4.) d-, o PLUMBING RI o MECH RI o WATER HOOKUP o SEWER HOOKUP ~D PLUMBING FINAL (I\f:t)~ MECH FINAL . COMMENTS: ~, _ . (I' po:;i:;&r ~ ~ /~ d~ ~~~;~~~. ~ t,~~-~~ Ii, CITY OF PRIOR LAKE INSPECTION NOTICE ADDRESS /7.;2~~ OWNER CONTR. PHONE NO. PERMIT NO. o FOOTING o FOUNDATION o FRAMING o INSULATION pi FINAL o SITE INSPECTION I) I 7~2.-g o EXIGRAD/FILLlNG o COMPLAINT ~ FIREPLACE RI (~ FIREPLACE FINAL o GAS LINE AIR TST o ~ r ,I It r fI (J " taP l?'/ \ I 0 "1-- l.;l ? ~ ~~ o WORK SATISFACTORY, PROCEED ~ CORRECT ACTION AND PROCEED o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING Inspector: ~ Owner/Contr: CALL 447-9850UOR THE NEXT INSPECTION 24 HOURS IN ADVANCE., CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY! INSl/OTl ADDRESS I 7 Z,O ?- DATE TIME SCHEDULED +/'~/'7..- z: 3e> , I \Nll/06~6S'S CITY OF PRIOR LAKE INSPECTION NOTICE OWNER CONTR. PHONE NO. PERMIT NO. (-(37.9:; o FOOTING 0 PLUMBING RI o FOUNDATION ~MECH RI o FRAMING 0 WATER HOOKUP o INSULA nON 0 SEWER HOOKUP o FINAL PLUMBING FINAL o SITE INSPECTION '-... 0 MECH FINAL ~M:~ ~)~ - __....-tAA? ./~ ~ b o EX/GRAD/FILLING o COMPLAINT o FIREPLACE RI o FIREPLACE FINAL o GAS LINE AIR TST o ,~~~~c ~- --~ o WORK SATISFACTORY, PROCEED (!1 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 '-"....i'<:" ,;.:,~,l~,;".,. :;"';":~t.,;;,(Ii,~",,,_,"I}!_~~~~' .' A APPLIANCE PERFORMANCE TEST Attach to gas line adjacent to regulator Heating Contractor ~\ ,v-.-~ "'" t.vL- Name of Tester ~\.\.- Date y- If( -O~ Job Address n;).'b1- \..y.\ J. U: . Heating Contractor Name of Tester Date Percent 02 Percent CO Percent C02 A\\,....-\ ""t..c.i'-- )(.. to.;~ 4- '<6' 0).. (.-r - 0- Stack Temp Combustion air is adequately supplied per UMC Sec. 606 \<~.s input I VC .0 tJO ~.) \~.Oo