HomeMy WebLinkAboutBuilding Permit 95-0145
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Qttrtifirat! of UDrrnpanry
CITY OF PRIOR LAKE
J)epartment of _uUlIing Jnspettion
o Final Permitted ci'conditional C,Q, Expires Il.. 2. 7, tj Ii
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 ordi1/Q1lCes of the
City of Prior La/ce regulating building construction or use. For the following:
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Use Oassification tv\.t cl...c cY ~'-(. .. ,,' r Bldg. Permit No. q s.. I Lj :;
Occupancy Type ,',,' 2.. Type Construction \ \ N Fire Zone N ~ Zoning District N A
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. V. 2 ~ -1'-) Date:
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r- CITY OF PRIOR LAKE
R=A 'J 3 ml \, BUILDING PERMIT,
I · :~~~rT.' 1~~CC~~NO:C~?ON~Np~~~~PLlANCE
Permit No,
1. DATE
DIRECTIONS
SPACES NUMBERED 1 THRU 17 MUST BE FILLED IN
BEFORE PERMIT IS ISSUED (Please Print or Type and sign at bottom)
2. SITE ADDRESS
2.-tlS,t ~'\ ~~lr-'~~ ~ S~.
3. LEGAL DESCRIPTION I ~ I..
i,J.." . =; '.0 -,? ~ 1":2 L--
LpT ~/tp. I " I Z" BLOCK ~ PID
~~, ~ ,A1JO/T7..J~ -10 t..VE?5t~"3'~Y1<'.' P.)NDS
4. OWNER . (Nal!lE)) , (Address)
, 112J11.t;:J...,J hV':A. 1"fJ'fl- ~~. 5~(L5:l
5. ARCHITECT (Name) (Address)
SI,J...~I--6Y L: ~-rert- N' YBi7l ~ [r.Y/..1, fA~
6. BUILDER (Name) (Address) (Tel. No.) ~i4 -~;5- Z--
51 . kLft-'7'.Ko'~ ,(~~r 1..; 1l.X-. I: 2?x.~. If-~ J&.- a...~
7. TYPE OF WORK Fireplace 0 Septic 0 Heating 0 Plumbing 0 Reroofing 0 Porch 0
New Construction K. Alterations 0 Addition 0 Finish Attic 0 Residing 0 Finish Basement 0
Chimney 0 Misc.
8. PROPERTY AREA OR ACRES
Sq. Ft. . u-y. t;:.-;;84..)-;t:
rJ-.
-9$-
(Tel. No.) c...-/2 - (.;.7 V5
ALIN "-. (,1[".( P/':<'.
(Tel. No.)
10. CULVERT SIZE
tf0
9. PROPERTY DIMENSIONS
..71 Depth:f; Z3?-+3
Yes
1. While
2. Pink
3. Yellow
File
City
Applicant
9~ 14.~
13. TYPE OF CONSTRUCTION
<Gtrr.l..J~T S'f?!!!1!ft.13f?lGK.. -
14. FLOOR AREA APPORTIONMENT USE
/ .c>O-.gO/Df?jL
.A'1.)~7
15. NUMBER OF OCCUPANTS OR SEATS
OCCUPANTS 96
SEATS It/A-
16. ESTI~.ATEDVALUE .,,,,_
~ '5t;., . O<.~t(' -
17. COMPLETION DATE
<$.. /-'ls-
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 on proper!}' .'1 construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the
buildingoJliC oke th r us! cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X .M N I D*OODTO 5"5'" ~ -:2 '/-7">-
re Weense No. Date
Amount Brought FOlWard ..... ~1j""'"'' $
Park Support Fee '1 fj/:~, ~... ,......... $
SAC ...1.~~~"'"''''''''''4''''''''' $
Collective Street Fee ~.~~..........,.. $
Sewer Tap ................................... $
License Check Fee ,........................ $
\ 'IL
Pressure Reducer .......................... $
Meter Hom ................................... $
I" \.
Water Meter r..;;,oa~~..'Ji........... $
o Sewer & Wat9r'ConneCtlon F~ ........... $
o Water Tower Fee '7..~>.<...1'............ $
Water Tap .................Ji................ $
Builder's Deposit ... ,C:!, ,'6 ............. $
Other ......................................,.. $
Total Due ,.......................,..... $
Paid 1....J I tf'l.J Recei t No.ol
Date~
FOR ADMINISTRATIVE USE
SETBACKS: Required
Actual
Side
Side
Front
Back
PROPOSED GRADE FOUNDATION
IN RELATION TO CURB OR CROWN
OF STREET
USEOFBUILDING ~(c-\CI \'",.c..'-
OFF STREET PARKING
SPACES REO.
SPACES ON PLAN
PERMIT VALUATION <6 s;: ~> (:) (::) ~ ~
City:
TYPE OF CONSTRUCTION: I (ij)IIIIV V N
......
Occupancy Group A@E I H R M
DIvision 1@3 4
Permit Fee ............................,...... $ 4~ '(~ .. ,.., )::
Plan Checking Fee ................,......., $ 2-~ :1.. ~
~2s;... ~
If ~L-
UP' '\-t~
------
State Surcharge ............,........,......, $
Penalty .......................,........,...... $
Septic System ............................... $
Other ........................................, $
'7 e-4 "1.... 3:,l{
Check if
Deferred
By
mes Your Building Permit When Approved.
Date lj. -2 ~ -C) ~
Certificate of Occupancy
Issued
MATERIAL FILED WITH APPUCATION
SOIL TESTS 0 ENERGY DATA ?-
PILING LOGS 0
PLANS & SPECS ~
SURVEY ~
PLOT PLAN 0
PERCOLATION TESTS 0
SETS
COPIES
"L.
,j. ~(., ob
Lt t~. ~
-4 ~ 00<:"':)- COO
z..., <{ Oc:\, 6b
above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as r
a temporary ~~'!! ~iance and allows construction to commence. Before occupancy, a Certificate of
Date Special Conditions n any
24 Hour notice for all inspections 447-42309:00 a.m. '10:00 a.m.
1!J- - )'-/S
10'
Tho Con tor of tho Lab Country
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
I
NAME OF APPLICANT ,-:J j., r ,i / (~, .L
APPLICATION RECEIVED 2/./..3/15'
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at: X It ) I. I '?
Denied
Corrections
Accepted
Reviewed
Date: 'f ~d1 \----
(
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."
:t1l~~_"."
Th. C..,.. of Ih. Lib Counlry
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT J){J."fd.#, ~
APPLICATION RECEIVED >>.2...31?5'
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at: of / /P, 17, I!
Accepted With Corrections
+
Accepted
Denied ---F-;
Reviewed BY:/~
Comments: (. A.;:- ~<-
;). ~~~A- \~~
Date: S-l- C; .;:
~
-
~.2 .a\~ '\2.2:-u~~
\. \-'
~~~ <.J~' G:::w.....f\z~
~
-S.~-~~~~ p\~~~ ~<- ~'r,~ ~a<~Gr.
c- ~~
~~ PcJ2A~\s.. ~'-J'~ ~',
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~ 8~C-~l'~\..
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/~p~r-::..~ ~\.-.J..e:..~
,..........\=~.
<---,
--...> .
~-
~~.
~~
'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,"
,~
qs:-/~
Th. C.nl.. of Ih. Llk. Country
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT ..)J.J.y,.(j, (j".L
APPLICATION RECEIVED 21.2...3/?5'
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at: ;( I~, /7, I!
Accepted
Accepted With Corrections
Denied
Reviewed By:
"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."
iliff!
1. Blue
2. Gold
3. Yellow
File
City
Applicant
CITY OF PRIOR LAKE
PLUMBING PERMIT hv~... ~ Qs-/ti3
Applicant: ~hf A?~HAP'~~A/~hone: "'"11..1/ g J
:::Jj(Jf$~~ K/J /JIl/!~ ~ ?5lIZ;7
Legal Description: Lot I Block L_ Sub: .1-"< ~ /.J' ~ . t:
Site Address: '"r I 'fir
Building Permit # fir -0 11j..~ PI D # 1.s- -dJ tj - () /) S- -b
NOTE: This permit will not be processed without complete information.
FIXTURE UNITS
Unit
Quantity Type of Fixture Amount Total
Bath Tub with or without shower $ 6.00
Dishwasher $ 6.00
Floor Drain $ 6.00
Lavatory (bathroom sink) $ 6,00
Laundry Tray (1 or 2 compartment sink) $ 6.00
Shower Stall $ 6.00
Sinks: $ 6.00
Bar Sink $ 6,00
Water Closet (toilet) $ 6,00
Rough-ins $ 6,00
Water Heater $ 6.00
Water Softner $ 6.00
Stand Pipe (washing machine) $ 6,00
Sewage Ejector $ 6.00
Backflow Assembly (RPZ, Double Check, PVB) $25,00
Backflow Assembly Test $10.00
Lawn Sprinkler $25.00
Other $ 6,00
~ 1&. Minin .tlll. r1f'e 1% Jm e,6r $25,00 ftJ 2.. ~
.,too
SURCHARGE ,50
A..nz 6P
GRAND TOTAL $ ?EQ: -
This permit is granted upon the express condition that said
contractor, shall comply in all respects with the ordinances
of the State Plumbing Code and the amendments thereof.
.- 4 ~ RECEIPT NO, '/u/?(' DATE
. ATIEST
Call for all i
4629 Dakota St. S.E" Pnor Lake, Minnesota 55372 / Ph. (612) 447-4230 / FAX (612) 447-4245
AN EQUAL OPPORTUNITY EMPLOYER
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I
GREEN - FILE
YELLOW - APPlICANT
GOlD - CITY
CITY OF PRIOR LAKE NO. liS -$I?
SEWER AND WATER PERMIT
NOTE: Sewer and Water
contractors must
be registered
with the city.
APPLICANT: l/q&I-I;c.A 0. //JG , PHONE: gZ.9~ 9882-.
ADDRESS: ~~ ~ S 1ikJ),,/~TE: q.y'9.r;-
SIGNATURE. v ~ BLDG. PERMIT #96- t4-~
SITE ADDRESS: 4(S/ t1lJI/t'?ttJOOd ~+.. PID# zs-... (~~OO~-()
FILL IN THE BLANKS
1. Estimated length of water service /f/C/
feet.
2. Size of water service ~
.'
inch(es) .
3. Location of any couplings from structure
feet.
4. Type of sewer pipe. ABS
PVC ~ Cast Iron
5. Estimated length of sewer line /L7c?
feet.
6. Clean out (if required), located at
structure.
feet
from
------------------------------------------------------------------
------------------------------------------------------------------
This application becomes your permit when approved.
By~JJwrf' DATE: t/..!Jf.5
=====- =========~1===========================~====================
FEES:
$
$
$
35.00
.50
35.50
Sewer and water line connection permit.
Surcharge
TOTAL
* Fee for either sewer or water individually is $20.00 plus
$ .50 surcharge.
* Sewer and water permits issued for new construction must be
recorded on the building permit card at the time of issuance
to insure that no duplicate sewer and water permits are
issued.
DATE PAID ~/s-/,.r
RECEIPT # lJpllJ
AMOUNT PAID JS.~lJ
REC'D BY ~_j:,
4629 Dakota St. S.E., Prior Lake, Minnesota 55372 / Ph. (612) 447-4230 / Fax (612) 447-4245
AN EQUAL OPPORTUNITY EMPLOYER
MWCC 92C
Service Availability Charge (SAC) Commercial Detail
PROJECT lYPE :
IfX New BLildlng Only 0 Alteration (change In use )
D Addition D Demolition with New Use
(Attach to Form MWCC 92A )
D Demolition Declaration Only
(A:ttach to Form MWCC 920 )
i
Healthcare
Building Permit No.
Date Issuecl
4/25/95
CALCULATION OF SAC CHARGES:
Use
Total Square Footage
10,300
SAC UNI1S
Quantity
Retail
Office
Warehouse
O~er Medical Clinic - Outnatient
1 SAC per 17 fixture units
61 fixture units divided bv
Determination Made by: Gary Staber
sq,ft, @ 3000 sq,ft, Per SAC =
sq,ft. @ 2400 sq.ft, Per SAC =
sq.ft. @ 7000 sq.ft, Per SAC =
=
=
17 =
Date: 4/25/95 TOTAL CHARGES
=
3.59
(in urils)
.":.:.:
";:.:lIt::;::
Previous Occupant
Site Adctess
Demolitla1 Permit No.
Demolltla1 Date
Total Square Footage
CALCULATION OF SAC CREDITS:
Was previous use in existence prior to 1973? D yes D no
If no, Original Bl.ildlng Permit No, Date Issued
Actual SAC paid for space i'Ivolved: (choose one) D Enti'e Building
Additional SAC paid for space Involved: Bldg. Permit No(s)
SAC UNI1S
D Portion ct BLildi'lg =
Date(s) =
TOTAL CREDITS = (
If yes, Use
1973 Retail
1973 Office
1973 Warehouse
O~er
Quantity
(In unIIs)
sq.ft, @ 3000 sq,ft, Per SAC =
sq,ft. @ 2400 sq.ft, Per SAC =
sq,ft. @ 7000 sq.ft, Per SAC =
=
=
Actual SAC paid after 1973: BlcIg, Permit No(s)
Determination Made by : Date:
{{{J~orabOwsectlOri s ::1tiOW;8OUtCtfOtSAOdetifffllnatlOrittW:tttttt/:/,{,/r ....
Date(s)
=
TOTAL CREDITS = (
)
(In urils)
It a determination for flls location was made by MWCC,
please reference date of letter or attach copy,
UNITS - 4.0
0.5 nlUndI to whole number In unb
It NET SAC UNITS Is a CFEOrr BAlANCE. please
indicate how many wID be ressved 88...
Site-specific units of aedit (Form 92Ra:l)
or taken as..,
City-wide unltsofaedlt (Fam 92-'),
NOTE: Determinations based on phone
conversations are only estimates.
MEMORANDUM
DATE:
TO:
FROM:
RE:
October 30, 1997
Jay Scherer, Building Inspector
Jenni Tovar, Planneuf~
Certificate of Occupancy issuance #95-145 Fairview Clinic
The following landscape issues need to be completed prior to Planning
Department sign off as per city code and the approved landscape plan on
file:
· 2 feet of sod is required adjacent to the curb of all parking areas. It
appears to have been seeded,
. The plan indicates seeding of disturbed areas, The permit was issued
in 1995 and it is presumed that the seed was spread at that time
(1995), The City has had numerous weed complaints on this site. It
appears that the seed has not taken and weeds are a problem.
Therefore, the site must be reseeded (hydro-seed) or sodded.
. 1 Dead Scotch Pine on the western property line.
. 1 Dead Black Hills Spruce tree located on the north side of the building
and 1 Black Hills Spruce tree missing.
. All shrubs on the east side of the building (south of the sidewalk) are
not in place,
C:\JEN NI\CERTOCC\95-145. DOC
MEMO
TO:
FROM:
RE:
JA Y SCHERER, BUILDING INSPECTOR
VERL YN RAAEN, ENGINEERING TECHNICIAN IV
F AIRVIEW CLINIC ENGINEERING PUNCH LIST, PROJECT 95-42
BUILDING PERMIT #95-145
NOVEMBER 18, 1997
DATE:
The attached punch list is compiled from site inspection notices dated 9/26/95 and
10/18/95.
1. The area of the bituminous parking lot referenced in the City's 9/26/95 inspection
notice which called for corrective work is rescinded based on my site inspection
today,
2. All gate valve boxes in the area of the installed hydrant must be adjusted so that
the lid is flush with the final grade, Gate valve boxes must-be plumb.
3. Seed or sod according to the landscape plan any areas where turf is not well
established. One of these areas is westerly of the parking lot and driveway,
16200 Eagle Creek Ave. S.E., Prior Lake, Minnesota 55372-1714 / Ph. (612) 447-4230 / Fax (61~
G:\PROJECTSI1995\FAIRCLIN.DOC AN EQUAL OPPORTUNITY EMPLOYER
MEMO
TO:
FROM:
RE:
JAY SCHERER, BUILDING INSPECTOR
VERL YN RAAEN, ENGINEERING TECHNICIAN IV
F AIRVIEW CLINIC ENGINEERING PUNCH LIST, PROJECT 95-42
BUILDING PERMIT #95-145
NOVEMBER 17,1997
DATE:
The attached punch list is compiled from site inspection notices dated 9/26/95 and
10/18/95.
1. The area of the bituminous parking lot surface approximately 50' south of the
clinic entrance which holds water must be reworked so that it drains.
2, All gate valve boxes in the area of the installed hydrant must be adjusted so that
the lid is flush with the final grade, Gate valve boxes must be plumb,
3. Seed or sod according to the landscape plan any areas where turf is not well
established. One of these areas is westerly of the parking lot and driveway,
16200 Eagle Creek Ave. S.E., Prior Lake, Minnesota 55372-1714 / Ph. (612) 447-4230 / Fax (612) 447-4245
G:\PROJECTSI1995\FAIRCLIN.DOC AN EQUAL OPPORTUNITY EMPLOYER
MEMORANDUM 16
TO:
FROM:
DATE:
RE:
Jay Scherer
Michael Leek, Associate Planner
October 19, 1995
Fairview Clinic Final Inspection
I visited the site this morning, We do have a letter of credit on file for the landscape
improvements. This letter of credit will, of course, remain on file until final acceptance
of the improvements after one year. At this time it appears that all ofthe tree and shrub
planting has been done, but that some sodding and seeding remain to be done.
The trash enclosure is a problem in that Resolution 95-20 approving the Conditional Use
Permit (a copy of which is attached) requires the enclosure to be constructed of brick to
match the exterior elevations of the building. If the enclosure is the only issue
outstanding, my suggestion would be that the City issue a Temporary Certificate of
Occupancy rather than impeding progress toward the clinic's operation,
DOC2.DOC
1
JUL -1 ':J-l 'J''::)'5 [,:.:::: 2:::: FF'Drl '31<.AF'F'HIJL (JJtj~;T, CiF:DUP I tH':: TD
.447 :2~i~~
F'.1]2
(1 CONSULT ANTS
AMERICAN . GEOTECHNICAL
, .., -MATERIALS
j ENGINEERING _ ENVIRONMENTAL
TESTING INC,
..,.PORT OE WELDED AND eOl'tED COtiNECTION QBSERV A TIONS
PROJECT:
REPORTED TO:
FAIRVIEW CLINIC
4151 WILLOWOOD ST SE
PRIOR LAKE, MN
SKARPHOL CONSTRUCTION GROUP
12360 RIVER RIDGE BLVD.
PO BOX 1497
BURNSVILLE MN 55337
AET JO.9 NO: 95-1809
A1TN: MR MIKE PETERSON
DATE: JUNE27, 1995 cc:
~~-'-,---_...---' I" <' ,"1 ""==' r-;:;"'. 1
.' :::..-:--, rc F.i '! "VI If:' II t"
: : lj ,~r ir t.r~ ~\ 'I ~""':l I i
,-.. ,,,, .. I'
. i' ~!i "~':'
( J UN 2 9 1995
,
,
t 3;<i,~4:=\..jC:... GOi'~ST GF:Ol...'?
I
SMILEYGLOTTER
A TTN: JERI FINK
PAlANISAMI & ASSOC.
CITY of PRIOR LAKE
A TTN: GARY ST ABER
Date of Observations: June 23, 1995
Reference Documents: Drawings available on site. AWS D1.1 and D1.3 Structural
Welding Code. AISC Specification for Structural Joints
Using ASTM A325 or A490 Bolts,
Personnel: Eric C. Evens, ASNT Level III, AWS-CWI.
Scope of Work: Visually observe field welding of structural steel and bar
joists.
VisUi:ltlyop~eryer09t~ec~ welding and fasteners,
Visually observe high strength bolted connections for
washer installation and ply contact,
Visually observe field welding of light gauge steel.
Results:
Visual observations of accessible field welding on structural
steel, bar joist, and light gauge steel, satisfy the
requirements of the above referenced code and project
specifications,
~6; M~ 1'11.1t'"
'AN AFFIRMATIVE ACTION EMPLOV1:R'
2102 University Ave. w: . Sf, Paul, MN 55114. '12-659-9001 . Fax 612-659w1379
Duluth. Mankato . Rochester. Wausau
UL--1 '9-1 '3'3''::; [1:3 : 2'~~ FF'Of'l ~=;~<HF'F'HOL COH'3T. GROUP I tJC TO
.::J474:~W:~
F'. [13
fA
95-1809
Page 2
Deck welding and mechanical fasteners satisfy the above
reference code and project specifications,
--
Visual observations of accessible bolted connections
indicate washers are installed and ail plies are in intimate
contact.
Equipment Used: Hammer, Brush, Light, Ultrasonic flaw detector and transducers.
Test Methods: Visual weld observations were performed in accordance with the
requirements of Section 6 of the Structural Welding Code (Steel),
or Section 70f the Structural WeldirigCode(Sheet Steel).
Individual welds were judged for quality, size and l~ngth.
The high-strength bolted connections were observed for intimate
contact of all plies and that a washer was installed behind or
under the nut, The bolts used were of the alternative design
intended to indicate a predetermined tension or torque. Within the
specified scope, all bolts were observed to ensure the tension
indicators were fractured as required by the referenced codes and
the project specification,
Remarks:
Our work was authorized by Mark Carriveau, Skarphol Construction
Group, Inc.
Report Prepared By:
GC
Eric C. E;ve_ns
NOT Manager
r
(' ^-~~
TiJTRL P, 03
~
p
~
Egan & Sons CO. MECHANICAL CONTRACTORS
Building Integrated Solutions-
7100 MEDICINE LAKE ROAD . MINNEAPOLIS, MINNESOTA 55427
TELEPHONE 544,4131 . AREA CODe 612
LETTEI OF TIAISIITTAL
Date June 21, 1995
TO: City of Prior Lake
4629 Dakota Street S.E,
Prior Lake, MN 55372
Transmittal -
Job No.
2499
Re. Prior Lake Clinic
ATTENTION: Mr. John Scherer
Item No.
Gentlemen:
o sepia
o prints
o copy of letter
o shop drawings
THI! FOLLOWING:
o for approval
o with final approval
o approved as noted
o for coordination
o returned for correction
o for your information
o as per your request
o for distribution
o for estimate only
WI! ARE SENDING YOU:
[i] herewIth
o under separate cover
o by bearer
COPI ES DWG. NO, REV, DESCRIPTION
IP NO. DATE
1 Plumbinq permit application with check
1 nprmit rlnnlirrltinn with rhprk
1 Plumbina license aoolication with check
I
Remarks Pl ease review and call me at 591-5524 vJith any qlJP-sti ons or requests,
COPIES W/ TRANSMITT AL TO:
V.ry truly your., EGAN. SONS CO.
BY:
Tom Sheehan
PER:
OCT-18-1995 10:54 FROM FU PARKING-SECURITY
TO
'34474245
P.0..:.
Fairview Riverside
Medical Center
24,50 RiVli'l"$idt! ~"'(t!
Mtnn('(Jpo/fs, MN .55454-1400
GI2-3il-6f}(j()
A Diui.cion of r."~Jtt!W
00
DO
October 18, 1995
Mr. Jay Scherer
Building Inspector
16200 Eagle Creek Avenue SE
Prior Lake, MN 55372
Dear Mr. Scherer:
The purpose of this letter is to provide you information regarding
Life Saf~ty monitoring for the new RidgeValley Family Physicians
Clinic located at 4151 Willow Wood Street, Prior Lake.
At this time, I have confirmed that our system is operational and
final testing is complete. The Life Safety systems that will be
monitored include general fire and trouble. The system will be
monitored by our 24 hour Security/Safety Central Monitoring St&tion
located at Fairview Riverside Medical Center in Minneapolis.
The alarm signal is transmitted via our internal network system. In
the event the network should fail, the system converts to secondary
notification and transmits the signal via telephone modem.
Upon alarm notification, the central monitoring station will notify
Prior Lake POlice/Fire immediately.
Please feel free to contact me at 672-4152, should you have any
questions regarding this information.
Sincerely,
~ ->>1~
Ron McKinnon
Director, Security/Safety and Parking
cc. Rick Thompson
Mike Peterson
TOTRL F'. 02
-
AMERICAN ENGINEERING TESTING. INC.
EARTHWORK QUALITY CONTROL INFORMATION
Excavation Base Evaluation
Judgments of supporting soils are based On soils exposed, and On local samples of soils retrieved by hand augering and
probing. Because conditions in the subsurface are hidden, it is not possible to fully characterize the subsurface conditions.
Therefore, the client must accept that our judgments are limited to those soils which are directly observable to us.
As soil conditions may be variable at depth, it is best that excavation base observation be aided by deeper exploratory test
borings (usually done prior to construction). Although these deeper borings may not totally reveal what is in the subsurface,
they greatly reduce the risk of deeper poor soils going undetected.
The presence of ground water within the excavation can also limit the supporting soil evaluation process. Also, if standing
ground water is present, there is a risk to the client that compressible soils may not be observed and remain beneath the water
during excavation. The compressible materials can become trapped beneath or within the subsequently placed fill.
Filline
Structural fill placement is commonly monitored by performing local compaction tests, which entails comparing a field density
test to a laboratory Proctor test to arrive at a percent compaction, Density tests of fill only provide the compaction level of
the fill at the location and elevation of the test. As many factors control compaction, such as fill lift thickness, moisture
content, material type and compactive effort, compaction variation within fill can exist which may not be represented by the
tests, Density (compaction) tests are considered representative when used in a conscientious program of controlled fill
placement, where the factors influencing compaction are closely monitored. Conclusions about fill suitability to support
structural loadings from the results of a limited number of compaction tests includes increased risk, unless the individual
drawing the conclusions has complete knowledge of the afore-mentioned variables during placement. For this reason, part-time
testing on a "trip" basis includes more risk to the client than .fulI-time" monitoring/testing,
Oversizine
Structural elements also exert loadings laterally; and because of this, the excavation and subsequent fill system needs to be
oversized to accommodate these loadings. The extent of lateral oversizing is normally associated with the movement sensitivity
of the structure and the strength/compressibility properties of the soils remaining along the excavation sidewalIs. Oversizing
on the order of! (horizontal):! (vertical) is typically provided for foundations in .normal" conditions. However, oversizing
on the order of 1112:1 or more is usually needed in highly compressible situations such as swamp deposits.
AET does not practice in the field of surveying and must rely on location and elevation staking of proposed construction by
the client or their representative, Our measurements in the field are made in relation to those stakes or other location and
elevation information provided to us. The reliability of AET's opinions, conclusions and recommendations based on those
measurements is dependent on the accuracy of the staking or information provided by the client or their representative,
Freezine Weather
Soils which are allowed to freeze will heave and lose density, Upon thawing, these soils will not regain their full original
strength and density. The extent of heave and density/strength loss depends on the soil type and moisture condition; and is
usually more pronounced in finer grained soils, and particularly silty soils, Foundations, slabs, and other improvements
affected by such frost movements should be protected from frost intrusion during freezing weather. If filling takes place during
freezing weather, all frozen soils, snow and ice should be stripped from all areas to be filled prior to new fill placement; and
the new fill should not be allowed to freeze during or after placement. For this reason, it is usually more beneficial to perform
excavate/refill operations during freezing weather in smaller plan areas where grade can be attained quickly rather than
working larger areas where a large amount of frost stripping may be needed.
Structural Support on Uncontrolled Fill
Risks are associated with supporting structures on fill which has not been placed in a controlled and well documented manner.
Even where existing fill appears to be well compacted (including when soil borings have been performed), hidden poorer or
looser soils can potentially exist below or within the fill; or previous excavation and extension of the compacted fill may not
have been provided with sufficient oversize in all directions to accommodate the new lateral loadings, Risks can be reduced
by means of increasing the amount of testing and observations.
(1
AMERICAN
ENGINEERING
TESTING, INC,
CONSULTANTS
. GEOTECHNICAL
. MATERIALS
. ENVIRONMENTAL
REPORT OF DENSITY TESTS
PROJECT:
REPORTED TO:
FAIRVIEW CLINIC
FIVEHA WKS AVENUE SE
PRIOR LAKE, MINNESOTA
SKARPHOL CONST. GROUP, INC.
12360 RIVER RIDGE BOULEV ARD
PO BOX 1497
BURNSVILLE, MN 55337
ATTN: MARK CARRIVEAU
cc: CITY OF PRIOR LAKE BLOG,
INSP., ATTN: GARY STABER
AET JOB NO: 95-1615
DATE: JULY 3,1995
FIELD DENSITY TEST DATA
Note: Proctor values adjusted for variable gravel content; and accordingly. values shown on Proctor list are not necessarily the
value used in calculating % compaction,
Dry Moist, %
Test Test Test Dens, Cont. Oversize Proc, Percent Specified
M2.. ~ Location ~ a -L- Material lfu.. COIIlDaction Minimum
1 5/15/95 15'N & 25'E from SW 981h 104 16.4 6 1 95 95
Corner of Slab Backfill
2 5/15/95 15'N & 53'E from SW 981h 106 15.3 8 1 96 95
Corner of Slab Backfill
3 5/15/95 30'W & 56'S from NE 98 l02th 17.8 2 2 90 95
Corner of Slab Backfill
Method: Sand Cone (ASTM 01556) -1L.; Nuclear (ASTM 02922)_
To protect the addressee, the public, and ourselves, this report (and all supporting information) is provided
for the addressee's own use, No representations are made to parties other than the addressee.
p~~
Reviewed By
Robin L. Flickinger
'AN AFFIRMATIVE ACTION EMPLOYER"
2102 University Ave, ~ . Sf, Paul, MN 55114 . 612-659-9001 . Fax 612-659-1379
Duluth. Mankato . Rochester. Wausau
AET #95-1615 - Page 3
FIELD DENSITY TEST DATA
Note: Proctor values adjusted for variable gravel content; and accordingly, values shown on Proctor list are not necessarily the
value used in calculating % compaction.
Dry Moist. %
Test Test Test Dens, Cont. Oversize Proc. Percent Specified
N!L. ~ Location Ela. ~ ~ Material ~ Comvaction Minimum
4 5/15/95 ITS & 20'W from NE 98 981h 19.5 3 2 861h 95
Corner of Slab Backfill
5 5/15/95 15'S & 47'W from NE 98 1051h 18.1 4 2 921h 95
Corner of Slab Backfill
6 5/15/95 17'E & 13'S from NW 971h 1011h 17,7 3 2 89 95
Corner of Slab Backfill
7R 5/16/95 Retest #4 98 1051h 19.2 2 981h 95
8R 5/16/95 Retest #5 98 1031h 19.7 2 1 97 95
9R 5/16/95 Retest #6 971h 1031h 20.8 2 1 97 95
10 5/16/95 75'E & 15'S from NW 99 1031h 18,6 2 1 97 95
Corner of Slab Backfill
11 5/16/95 50'N & 20'E from SW 99 1091h 15.4 5 2 95 95
Corner of Slab Backfill
12R 5/16/94 Retest #3 98 112 13.3 3 2 98 95
LABORATORY MOISTURE-DENSITY RELATIONS OF SOILS (PROCTOR)
N!L.
Soil Description ~
Opt, Moisture
Content %
Max. Dry
Density pcf
1
2
Sand with silt, fine to medium grained, brown (SP-SM) A
Silty sand, fine grained, brown (SM) A
17.8
16.3
107.1
113.8
Procedure & Method: Standard (ASTM D698) -X-; Modified (ASTM D1557)_
I]
AMERICAN
ENGINEERING
TESTING, INC,
CONSULTANTS
. GEOTECHNICAL
. MATERIALS
· ENVIRONMENTAL
REPORT OF EXCA VA TION OBSERVATIONS
AND DENSITY TESTING
PROJECT:
REPORTED TO:
F AIRVIEW CLINIC
FIVEHA WKS AVENUE SE
PRlOR LAKE, MINNESOTA
SKARPHOL CONST, GROUP, INC.
12360 RIVER RIDGE BOULEVARD
PO BOX 1497
BURNSVILLE, MN 55337
ATTN: MARK CARRIVEAU
CC: CITY OF PRIOR LAKE BLDG,
INSP" AITN: GARY STABER
AET JOB NO: 95-1615
DATE: mLY 3,1995
INTRODUCTION
This report presents the results of the soil observations and testing we performed for the
referenced project, Our services were conducted on a part-time basis. The scope of our work
was limited to the following:
· Observing the bottom of the mass excavation for the clinic under construction,
· Drilling shallow hand auger borings in the bottom of the excavation,
· Performing hand cone penetrometer probes in the bottom of the excavation,
· Evaluating the suitability of the exposed soils to support the fIll and anticipated building
loadings,
· Conducting compaction tests in wall backfill placed to slab subgrades,
· Summarizing the results of our services in a written report,
"AN AFFIRMATIVE ACTION EMPLOYER"
2102 University Ave, ~ . St, Paul, MN 55114.612-659-9001. Fax 612-659-1379
Duluth. Mankato . Rochester. Wausau
AET #95-1615 - Page 2
Our work on this project was authorized by you on May 15, 1995,
CONCLUSIONS
Based on the results of our observations, hand auger borings, hand cone penetrometer probes, and
our review of the available information, it is our judgment the soils exposed in the mass
excavation bottom for the clinic building were suitable for support of the fill and structural
loadings.
The results of the soil compaction tests taken during filling operations indicates that all fmal tests
met or exceeded the minimum recommended compaction level at the elevations and locations
tested, In areas where the tests did not meet the specified compaction levels with the initial effort,
the soils were removed and replaced with sand fill. The results of these retests met or exceeded
the specified compaction levels,
These conclusions are intended as a summary, Read the remainder of the report for specific
information,
DESIGN INFORMATION
We understand or assume that the construction underway will:
. Have two above-grade levels,
. Have an assumed first floor elevation of 100.0,
. Be supported by conventional spread footings designed using an allowable soil bearing
pressure no greater than 3,000 pounds per square foot (pst),
. Have bottom-of-footing elevations at about elevation 96 throughout,
AET #95-1615 - Page 3
· Use masonry block construction,
· Have normal tolerance to settlement,
· Be constructed according to applicable building code requirements.
Deviations from the above design information could necessitate altering our conclusions and
recommendations, Contact us if the information stated is different from the actual project design.
Building location and elevation information obtained at the site, and presented in this report, was
referenced to location and elevation offset stakes placed by others,
BACKGROUND INFORMATION
To our knowledge, a preliminary geotechnical exploration program has not been conducted in the
area of the proposed building, Because of this, we cannot comment on the soil conditions at
depth, Our judgments reported herein are based only on those soils which were observed in the
excavation and those probed by our shallow hand auger borings and hand cone penetrometer
probes. To further explore the soil conditions, deeper penetration test borings are needed,
EXCAVATION OBSERVATIONS
We observed the mass excavation for the building on May 5, 1995, We were not present at the
site on a full-time basis, Our services consisted of a single visit to the site, coordinated with the
contractor, which allowed us to observe the entire excavation, In addition to observing the soils
exposed in the excavation, we conducted shallow hand auger borings and hand cone penetrometer
probes in the bottom of the excavation, The soils encountered were classified in general
accordance with ASTM:D2488 and estimates were made of their strength properties based on their
resistance to advancement of the hand auger and the hand cone penetrometer readings.
AET #95-1615 - Page 4
The soils exposed in the base of the excavation were classified as naturally deposited coarse
alluvial sands. The bottom of the excavation was at about elevation 96 (planned bottom-of-footing
grade) throughout, The observed soils were judged suitable for support of the fIll and building
loads,
No standing water was observed in the bottom of the excavation.
FILL COMPACTION TESTING
During the period from May 15 to May 16, 1995, we conducted 12 density tests in fill placed at
the site. The density tests were conducted on an intermittent trip basis. The field density tests
were compared to the laboratory standard Proctor maximum dry density (ASTM:D698) to arrive
at a percent compaction level for each test. The test results are attached,
The results of Tests #3, #4, #5 and #6, did not meet the specified compaction levels with the
initial compactive effort, We recommend the soils in these areas be removed and replaced,
Retests (designated "Retest") taken after this corrective effort indicate the specified compaction
levels were met or exceeded at the locations and elevations tested.
CLOSURE
To protect the client, the public and American Engineering Testing, Ine" this report (and all
supporting information) is provided for the addressee's own use, No representations are made
to parties other than the addressee,
AET #95-1615 - Page 5
Our services for this project have been conducted to those standards considered normal for
services of this type at this time and location, Other than this, no warranty, either express or
implied, is intended,
Report Prepared By:
Report Reviewed By:
p-;/. ~-
Robin L. Flickinger
Geotechnical Engineer
%(~ l? ~~
Michael P. McCarthy, PE
Principal Engineer
MN Reg, #16688
Attachments:
Report of Density Tests
Earthwork Quality Control Information
----
~ /-- (h ~ CONSULTANTS
ril AMERICAN ::::::. ------ · GEOTECHNICAL
1 ENGINEERING · MATERIALS
T I · ENVIRONMENTAL
ESTING NC,
. ....PORT OF WELDED AND BOLTED CONNECTION OBSERVATIONS
PROJECT:
REPORTED TO:
FAIRVIEW CLINIC
4151 WILLOWOOD ST SE
PRIOR LAKE, MN
SKARPHOL CONSTRUCTION GROUP
12360 RIVER RIDGE BLVD,
PO BOX 1497
BURNSVILLE MN 55337
AET JOB NO: 95-1809
ATTN: MR MIKE PETERSON
DATE: JUNE 27, 1995
cc: SMILEY GLOTTER
A TTN: JERI FINK
PALANISAMI & ASSOC,
CITY of PRIOR LAKE
ATTN: GARY STABER
Date of Observations: June 23, 1995
Reference Documents: Drawings available on site. AWS D1,1 and D1,3 Structural
Welding Code. AISC Specification for Structural Joints
Using ASTM A325 or A490 Bolts,
Personnel: Eric C, Evens, ASNT Level III, AWS-CWI.
Scope of Work: Visually observe field welding of structural steel and bar
joists.
Visually observe roof deck welding and fasteners.
Visually observe high strength bolted connections for
washer installation and ply contact,
Visually observe field welding of light gauge steel.
Results:
Visual observations of accessible field welding on structural
steel, bar joist, and light gauge steel, satisfy the
requirements of the above referenced code and project
specifications.
'AN AFFIRMATIVE ACTION EMPLOYER.
2102 University Ave, w: . Sf, Paul, MN 55114.612-659-9001. Fax 612-659-1379
Duluth. Mankato . Rochester. Wausau
95-1809
Page 2
Deck welding and mechanical fasteners satisfy the above
reference code and project specifications.
Visual observations of accessible bolted connections
indicate washers are installed and all plies are in intimate
contact,
Equipment Used: Hammer, Brush, Light, Ultrasonic flaw detector and transducers,
Test Methods: Visual weld observations were performed in accordance with the
requirements of Section 6 of the Structural Welding Code (Steel),
or Section 7 of the Structural Welding Code (Sheet Steel),
Individual welds were judged for quality, size and length,
The high-strength bolted connections were observed for intimate
contact of all plies and that a washer was installed behind or
under the nut. The bolts used were of the alternative design
intended to indicate a predetermined tension or torque, Within the
specified scope, all bolts were observed to ensure the tension
indicators were fractured as required by the referenced codes and
the project specification,
Remarks:
Our work was authorized by Mark Carriveau, Skarphol Construction
Group, Inc,
Report Prepared By:
GC
Eric C. Evens
NOT Manager
c
( ..A_/-~~/
m
Minnesota Department of Health
121 East Seventh Place
P.o. Box 64975
St. Paul, MN 55164-0975
August 22, 1995
Egan & Sons, Company
7100 Medicine Lake Road
Minneapolis, Minnesota 55427
Gentlemen/Ladies:
Subject: Plumbing for Fairview Prior Lake Medical Clinic, Prior Lake,
Scott County, Minnesota, Plan No, 952764
We are enclosing a copy of our report covering an examination of plans and
specifications on the above-designated project, Also enclosed is a copy of
the report and transmittal letter to be forwarded to the project owner, A set
of the identified plans and specifications is also being returned to you, It
is the project owner's responsibility to retain the plans at the project
location.
It is the plumbing contractor's responsibility to contact the Minnesota
Department of Health for inspections as discussed in the paragraphs in the
report pertaining to inspections, If you have any questions in regard to
plumbing inspections, please call 612/215-0841.
If you have any questions in regard to the information contained in this
report, please contact me at 612/215-0840,
Sincerely,
~~
William G. Deneen
Public Health Engineer
Section of Drinking Water Protection
WGD:thl
Enclosure
cc: Project Owner
Mr, Jay Scherer, Plumbing Inspector
TOO: (612) 623-5522 (Twin Cities) 1-800-627-3529 (Greater Minnesota)
An Equal Opportunity Employer
MINNESOTA DEPARTMENT OF HEAlJH
Division of Environmental Health
REPORT ON PLANS
Plans and specifications on plumbing: Fairview Prior Lake Medical Clinic, Prior Lake, Scott County, Minnesota,
Plan No. 952764
Submitted by: Egan & Sons, Company, 7100 Medicine Lake Road, Minneapolis, Minnesota 55427
Ownership:
Date Examined: August 16, 1995
Date Received: August 16, 1995, May 22, 1995
SCOPE: This examination is limited to the design of this particular project only insofar as the provisions of the
Minnesota Plumbing Code, as amended, apply, and does not cover the water supply or sewerage system to
which this plumbing system is connected. The examination of plans is based upon the supposition that the data
on which the design is based are correct, and that necessary legal authority has been obtained to construct the
project. The responsibility for the design of structural features and the efficiency of equipment must be taken by
the project designer. Approval is contingent upon satisfactory disposition of any requirements included in this
report.
INSPECTIONS: Special care should be taken to insure that the material and installation of the plumbing system
are in accordance with the provisions of the Minnesota Plumbing Code. It is necessary that the State Health
Department make roughing-in and final inspections of the plumbing system to determine whether it complies
with the code. Provisions should be made for applying an air test at the time of the roughing-in inspection as
outlined in Minnesota Rules, part 4715.2820, of the code. It is the responsibility of the owner, or contractor, as
the owners agent, to notify the State Health Department when the installation will be ready for a test and
inspection.
No acceptance of the plumbing installation can be given until inspection and testing of the roughing-in work
(Minnesota Rules, part 4715.2820, subpart 2), finished plumbing (Minnesota Rules, part 4715.2820, subpart 3),
and inspection of the completed installation by a representative of the State Health Department indicates
compliance with the provisions of the code.
REQUIREMENT(S): NONE
Authorization for construction in accordanc~ with the approved plans may be withdrawn if construction is not
undertaken within a periOd of two years. The fact that the plans have been approved does not necessarily mean
that recommendations or requirements for change will not be made at some later time when changed
conditions, additional information, or advanced knowledge make improvements necessary.
Approved:
~. !2~0--
William G. Deneen
Public Health Enginser
Section of Drinking Water Protection
612/215-0840
, , . :~I: \
--.,,"
. ,,'cP/:/'" ~y.-:r'fI HOUSE 'H EA TING TEST RECORD.
~~~~;~~~Y/~fO,~<ft}
HEAl LO~' DATE }'flG. lN)1, -;t;c ~
~CLD BY' Pdt/ ME'I?/(p.ii~~AJtr~k/?I;Rf .' IH'STALLED.BY
Electrical Worle By q~~ ~ (t.~i Gc.s Line By ;t'1...t4tJ <+ <;'" "" ~
TYPE. OF HEAT,"" GA'..:.--FA ....:/:--HW _STEAM_SPACE HTR. _UNIT HTR. _OTHER
~~~~~~~:D::~~~~ :d:~ OF BURHER COHVERSlOH
S-iol .' '::2-Ltl\S'{~d-O~Ol Mu. BTU Raling
INPUT' . '"l Z; r{)[}'D MAKE OF FURNACE
",' '., ":." 0" ~o::. ~ o. M~cI.1
:~~~~~S~;~/ . 'H w' CO,~:O~I:g Vent Siu
Valve .,~ ..-
Limit " . '~\)
Limit Setting' .,~
Fan S.rt'i~g . .":;'\~~ .
pd~t Ty'pe "$~QX.
Pliot Male. .,' ~il....llQ.....q,;\\..,
Pilot Moclel
?i1ot Timing
L.W. Cut Off
, J \'\)) V
Preuure fl r:; .
'Input CFH ."11-\ c...f.. t'\
"2..-0 0
APT. _FLOOR _CITY
OWNER
SUBURB PO,.I 1912.... La..~
~
(Lv,) f-c~ p
KINO OF LINER
Oroft Hood
SIZE NONE
RegulclTor '1-;:). \ - ~
Number I C-"-f- 7 \' '/... L.
;)-..
Fih.rs Siu
Chimney Location
Chimney ConstNction
Outside
Inside
Smoke 80mb
Craft
V
Door Pre.ssur._ ..
..../
./
./"
Wiring
Test Tag
Lighting Inst.
l/
Stadt i' emp.
F.;..m 2JS
Percent CO2
Percent O2
PC1'c.nt CO
~I(
V. ~
tJ
Oat. Tested q -I~<\<;;
Compcrny Tuting . '\ ~,~ .t- <;of\S
Hame ar Tosler Y\Io. oI\\? ~ Q\-\l.A~ ~,\...
. /J1i//:/'" -:y.-:prr HOUSE 'H EA TING TEST RECORD_
~~~~i:~f1~l~J:A~II;~dfl
HF-A r LO~' . OA TE ;0 G. IN..>>, -;t;c 7"
$CL.o BY' ~iht.l IJ!IJ!'I1~tJ'o'~~~~;IU INSTALLED. BY
l.:l.c:t-ric:ol Worle By ~N 'If\ I ~~i Gas Line By ~(AHJ <+ ~A ~ <,.
TYPE. OF HEAT.'" GA'..:-FA-4--HW _STEAM_SPACE HTR. _UHIT HTR. _OTHER
.J.~~~'~~~~AS DESIGN MAKE OF BURNER ' CDNYER"DH
Mod.1 ~ T___ - - - .s'DII~'Pr Model
S-iol .' 'J.l1o.s-(.,..;).O~()l Max. BTU Rating
INPUT' '""=114 ,OD'D MAKE OF FURHACE
': '. ":. .. ,'- . .. --:-.::. f'~ ~d.1
, ..... ~".. ..' .....~ . .. CONTROl.S
:~E~M~S~~ -t: '"H ~J
Valv~. :, :~~ .,-
Limit _ - ~\)
. Limit Setting' .\ ~
Fon S.rti~g ...,:'\\~~.
Pli~f Tyope "S~QX..
Plior Molc~ ..' ~-Q..,li\L~
Pilot Mod.1
APT. _FLOOR _CITY
OWNER
SUBURB PILI 19{L LaJ4L
.,..
(0<.) f l~ P
,H-.t Plug
Vent SiJ:e
SIZE HOHE
ReguloTor "13 \' - ~
Humber I~'f 7 \'/... L
KIHo OF LIHER
Oroft Hood
Filters Siu
Chimney Location
~i,"n.y ConstNction
.,/
:;2...'
Outside
Inside
Smoke Bornb
Draft
V-
Door Pr'tSsure_ ..
Wiring /'
Tesr Tog
Lighring Inst. /
t/
?i1ot Timing
L.W. Cut Off
, --1 1'\0 V
Preuur. . ~ ' R
'Input CFH .... '1'1 c"f-
Stack i' amp. 'l.O /)
FcW'" 235
G'(
. ~
ti
Dote Tested q -1~C\<;'
Company Turing '\ ~'N +- SoAS
Home of Tosrer - "'^ AI? V-- Q"'\t..\~~''\..,
Perc:enr CO2
Percenr O2
Perc:.nt CO
:'\:;.
.,,:
,'.':
;~..,
...,
.' . ". . /'~):/... -:y.-:f';rT HOUSE 'HEATING TEST RECORD. 9"-"". I~r .
:: ~C~R~'S .1$ ~ ,:!:/~'r;; 15f4'/). APT._FLOOR_CITY SUBURB \1Lj~Q ~
'." OCCIJPANT _ '-hi_I//. ___1.1'- OWNER
~~ HE..... T l.OSS .' . DA TE }on G, INST, .
,;'. .~~LD BY' E"i$A1i, 'MCt!.~rSl-ft//n<~,,:. tJry~d""4~:/U INbINSTALLED. BY. 5b~:-
.: . l.:1.clTical Worle By t:~tJ \\1\( r~1' Cas Line By 'l (.....iAtJ ~ SONS
.:.:TYPE. O~ HEAT.... GA.~FA-A-HW _STEAM_SPACE HTR, _UNIT HTR. _OTHE~ R""Ot:-llO\,
.' . ," .." ,.' . . :~'.~ . ,', .
...'.. ..: ~.". .', . . GAS DESIGN
-..... ~
';". MAK L.A-Q f) .\-<1_0
~.:'~:: ":'d'~~t~~~~- - <)0\--
'.:,: I NPU.T : . '.'{ 1'5' G.f~
.' ". .' ': '... . ,_ .:' .":':~. .. ,0
.:.... -.: ,.." .. .... '. '-
:~ ...'nie~M~s~~l t-\vJ
':" Vain . ~:JJ \l...-
>" Llmi; ." 4&500 {j..,u-, - ~ \ l,c n~
. ."."",6
::' Limit Setting 'I~
;?, :;i:t~j':g~~ .
~: Pliot Malc~ "'C~~.M.a..
: ~ . Pilot Modol
Pilot Timing
L_W. Cut Off
, :1, ,.... "
Prouur. ~;2 W, (... .
'Input CFH \ \ c;
Stelc:1c '.mp. ~30o
FOr... 235
~.
CONVERSION
MAKE OF BURNER
Modol
Ma... BTU ROling
MAKE OF FURNACE
Mt.e101
CONTROl.S
,HlI4.C Plug
Vont Size
tJ(A-
KINO OF LINER
Draft Hooel
Fi h.rs Sizo
Chimn.y Location
Chimney Construction
SIZF
HONE
'1,~ <: - -=?
IV'j-7-Sf7-
~
RoguloTor
Numbor
-.
Insido
Outside
. OJ .
Smoko Bornb
Draft
Door Pre..ssur.-L.
v-
Wiring
T ost Tog
Lighting Inst.
P.rc:en, CO2 1
Perc.nt O2 8
PC"l'c:ent co 0'
Oato Tosted
CompGny Tuting
Nome of Tostor
')- (~~q~
_ f: t'rP<N oj- ~a,.J S.
\"" 'AI<. K If4.UL~ ~ ~t1
/J.-'i):/' /:. '~I
. .' /'/1" ; .t~-:f'1 HOUSE 'H EATING TEST RECORD.
:, ~~~::~,;.7%lvf!:Vi1;; l!/N)
~; HE..... i l.OSS .' . DA TE }of' G, INST,
:', .~~i..D BY' '~./IllAAL~lrllif'2//0/J1~ ~/~1H!nJ)l.( INSTALLED~
: ,l.:loctrical War Ie By . ~ \j)\\r Y...D... '\ Cas Lino By cz...~ +- ~~
:.:TYPE. OF HEAT.'" GA'___FA~HW _STEAM_SPACE HTR. _UNIT HTR, _OTHER
. .'. .......
:..'.il'~~ ~.. '~~f! 0,:,' OESlON MAXE OF BURHER ' CONVERSION
"Model ~~_ - - - 5'0 I G. (\ Modol .
.' S-ial "I~G~(Y~O~()t.l Mu.BTURating
,: INPUT: . -rS'O ,00 MAKE OF FURNACE
-. ..': '. -:. . .." . '. '~-::. ,.'. Mt.e101
~.'.' .." ..... . ....~ ..
'>n:;E~M~S~~l .~ \\)
':. ~;~~: .:, ;' ~~
:' Limit Setting' . t~O
. ~...,-
,;. Fa,". Se tt:i,;g . .... )ll\.l-~'
. Ptlot Type ~~~'L~
Pliot Malc~ ..' '0\(1\\.""1\.1
-
, PlIot Model
APT._FLOOR _CITY
OWNER
SUBURB ~,o\l2, Lc,JLc
~
~")t' .(2 -Cq')
CONTROl.S
,Hoo.t Plug
V.nt Size
KIND OF LINER
Draft Hood
Filt.rs
SIZF
NONE
3d$'~3
(\o-{- ') \7-'1-
Sizo
?--
RoguloTor
Number
O\imnoy Location
O\imnoy Construc:tion
Insid.
Outsido
Porcen, CO2
Perc:ont O2
PC"l'c.nt CO
~/h
(,,}h,.
D
Oat. Tosted
Compcny Tuting
Name of Testor
Smoko Bornb
Draft ~
Door Pre..ssuro _c.-:::
q - t -0 ...-q c;-
_f(~-.)~ Sc1\-.S
" rv\ lA.1Il \L '~~".r i''L
Wiring
T ost Tag
Lighting Inst.
~J
~/
c-/
?lIot Timing
L,W. Cut Off
" 3,rll I. '\, L'
Pr...suro ,) ll....I
'Input CFH I~O
Stelclc '.mp. ~Ll()
FOr... 23S
--,"'---
. ,/)17J:/':,f:-7',1J HOUSE 'H EATING TEST RECORD..
, ~:::~/?!tJrI;;j(1l~~;m/)
~. HEAT LOSS'" DATE }11G, 1 T, ...
~Ci..D BY . 0\ .IiSTALLED Y
... ,l.il.ctTicgl 'Horle By Gcu Line By <) i,~A0 + ~,," '\
.:: : TYPE. OF HEAT. ,'. GA''':-'- FA ~HW _ STEAM _ SPACE HTR. _UHIT HTR. _OTHER
-: :.,'~</. ~.'. :-~'~.'.' GA'S DESIGN CONVERSION
.;... MAKE . 3 (~UL.\.un.., MAKE Or- BURHER
~ :'Mod.1 ~ \\J <i.o 05 - (,~ ,- ~ - Mod.1
... S-ial 7lTlfS'b- ~J1 \'d.. Mgx. BTU Rgting
.". 'INPUT' .n.s' cf:-\-\ MAKE OF FURNACE
.. ~. .. .: '. - .:-. ..... 1M' d I
.;..., '.', ":'" ~. '~".<~' . ~ CONTROLS 0 e
:~ ....THE~M~S~~l ~ \N ,H~ Plug Vent Size
':" Valve .;' w R- KIND OF LINER
;,'" Limit " ...t:\'l ~ ~ Draft Hood
:::'LimjtS.~jng' -:\~O Filters Size
.:.; Fon Setting ....:-~\~~ Chimney l.ocation
'.F' Pli~t TY'IN ~. b\>"lL~ o,imney Construction
. Pliot Malc~ .. . e~\-t.1ll ,
.'
.. . Pilot Mod.1
Pilot Timing
L.W. Cut Off
.3, ~'\ \ u) ,l.;
\\S'
~ 40
APT, _FLOOR _CITY
OWNER
SUBURB PI!A,\...~L L~,
~.
P,tC,,-, \' L{l-{l
SIZ~
NONE
. {riC:; - :~
I to"> y:. 7-\"/0- t.-
:l..
RegulaTor
Number
Insid.
Outside
Smoke Bomb
Wiring /"
Test Tag V /'
L. h' I t V
19 ling ns,
V
Draft /
Door Pre:ssur.-L.
Pr...sur.
P.rcent CO2
Percent O2
PC1'c.nt CO
~Ir
(t,,\
()
Oat. Test.d
Company Tasting
Name of T .st.r
q'lB'(\<J
-S (~l\J *' S",,)-l\S
,~ >Ar\0V-- P.(..l~\ ~-u'\ ,
'Input CFH
StQck T.mp.
For... 235
.......-
,,oJ....r r/, ",,' ..-
, ,,;II/: , ,Y.-7'/1 HOUSE 'H EA TING
;,~~~~=:SHt!4J~/1~~/t ~
,. .... ..
:: HEAT LOSS' . DA TE }11 G. INS
:, ,~~i..D BY"
.: . cl.ctl'ical Worle By
.:: :!yPE. BOF HE.~~. ~.. GA''':-'- FA
: ':':~",,~/, ,... :.: ". " GA'S DES1GH
.;.... MAKE '. . L~(L.'\I...\lftl
~ ., Mod.1 ". '-t ~-r e.,O(C) L\ - - - :') D I CrA
, S-ia I " 'd-~ q 5 (;r-"J.o '60 V
'::.: I.NPU.T: ' .... ''1tf r D()t)
'(~~~~~S~~~ CO,::O~,~
.,.. Val.... . ,u-.j'L'
;,'" Limit" P.H~t\
:.: . Limit Setting' . \'5'0
:;; Fon Se rt'i~g ..~ \ """-..\').
'.::' PIi~r T;IN -. ,<I~\l
:. Pliot Malc~ ..' .G~
:: 'Pilot Mod.1
TEST RECORD_
APT,_FLOOR_CITY
OWNER
SU8UR8}tw (L[a/4-.
INSTALLED BY
Cas Lin. By' fft-"N 't- <;.0 (l~ ~.
HW _STEAM_SPACE HTR. _UNIT HTR. _OTHER J.m()f-"Q,~
COHVERSION
MAKE OF BURNER
Model
Max. BTU Rgting
MAKE OF FURHACE
~del
Vent Size
Fi Iters Size
Chimney Location
o,imn.y Construction
~
SIZF NONF
R.gulaTor ?~ 5 - ')
~umb.r I \.0 -I- "2- r- 'I- "1...-
Outside
KIND OF LINER
Draft Hood
Insid.
Smoke Bomb Wiring
DraFt 1/ Test Tog
Door Pr.~sure______~ LightinSl Inst.
Percenl CO2=!=: Dot. Test.d q'-~~
Perc.nt O2 · Compony Tasting kN _, ~ S
Pd~" CO H._.F T...., . " V 1',,,,"\0. 'j'''''-
~
/' /
/'
,0"3,
Pilot Timing
L_W. Cut Off
Pr.uur. 3, ~I\ W.e..
" L.\
,?,IO
'Input CFH
StQck T.mp.
For... 235
'/JJi7/:/' /" ~
" , .. ..' tk- ~' ~c~. .,y:,-7'i/ ~ HOUSE 'H EATING TEST RECORD..
j' ~CORESS ,. ~ 'tJ..et:/;; -1;0/) APT. _FLOOR _CITY
:::. Ocr..:uPAHT' .I . '! ..-' . OWNER
" ~ . .
.; HEAT LOSS ' DATE in G'l&T. j ...
;'. ~ci..D BY 't4.MJ.HiJflIt::tHJI~ '/~tfZVZ-s /h~:1HSTALLED.?Y, \
.. . electrical Work By ~lN\t\..\ ~ (. ~ Cas Line By -; IJ~-j-\/0 + ~"<\ c:.
.:. :TYPE, OF HEAT .-, GA'..:..-.-FA ~HW _STEAM _SPACE HTR. _UNIT HTR. _OTHER.
. ,.". .. ",,'" ,', .
":' :<{, ~",:: ". . GAS DESIGN
';.' MAKE . 3 (~Ul..H....lJl,
~ :' Mod.1 ~~:_:if(T ~ ).. (I () 5- (I~ 1- ~-
.. S-iol ~llS'{'-~I\"6-
::,:INPU.T: . .r-\5'c\="
J'~.." ': '. -.. . ,- .:' .-:.:~. f ,"
:t.'\~~~~~s~~i .~ ~
':" Valv. .;. w R-
~'" Llmi; ....t=\'l~t\
'~.: . Limit Setting' . :, '50
.:;; Fan Sert'i~g . ...:-t, ~~
'.::' pli~t T;pe ... 7>Q~\L~
.: Pliot Male~ ..' . eM..t\'t..\IL
.'
.. . Pilor Mocl.1
SUBURB r~cl.'\'l-- L~
~..
P'trl't,~' T(,,~
CONYERSION
MAKE OF BURNER
Modal
Max. B TU Roring
MAKE OF FURNACE
M:'cI.1
CONTROLS
,H~ Plug
V.nt Size
KIND OF LINER
Droft Hood
SiZe:
HONE
,?8<' - n
/(,.,y. 7-'C'-;'" J-
Filters Si~.
Chimn.y Location
Chimn.y Con$truction
:).
R.gulaTor
Humb.r
Insid.
Outside
Smoke Bomb
V-
Draft /
Door Pr,,-ssura~.
Wiring
Tut To;
Lighting Inst.
/
1//
V
?i1ot Timing
L.W. Cut Off
Pr..aur. J,-r\\uJ.l:
'Input CFH \ \>
StQck. '.mp. ~J.lO
Foe'''' 235
p.rcant CO2
Perc.nt O2
P....c.nt CO
SI\
(p . \"
()
Data T.st.d
Compony Tuting
Nom.. of T estar
q - l S -q 5
---1J.' (, ~\ t-.:.\ ....
,1'-"\ ~(0~
(- ..:.
;;.....,'" .)
r..c- Le;~ ~ -<AI ,
. . ,~/:/: .-:f:-,-7'/1 HOUSE 'H EA TING
:. ~~~;:~t~J;t~~~,~~
,. HEAT LOSS" , DA TE in G. INS
. . . ~ci..D BY .
,: . l:l.ctricol Worle By
.:: :!yP E, BO F HE.~,~. ..... GA....:-- FA
: ...... .~/. .' . . :.: ", ," GA'S DESIGN
.;.~.: MAK E' . ~Q..,'\\..',,j\ I
~ '. Mod.1 '. ~H-r e..OIl) L\ - - - L) 0 I G-A
;' S-ial .'&-4(;\5 &-~~ov
,:,:INPU.T: . .". "ilfrl)6tl
(1~j~~~:?'~~. CO,::O~,~
':" Valv. . :u..J~"-
,. . Limit ." t:-\'l~t\
:": . Limit Setting' . \,';0
;; Fan Se';'I~g . ::,;,:,,\ ~\).
;: . pli~t T;pe ...,') ~\~
: Pliot Male~ ..' .C-~
. Pilot Mocl.1
?lIot Timing
LoW. Cut Off
3,,-11,:,.(,,-
Pre..aur. ~ I.V
'Input CFH ..., 1.\
StQcle '.mp. ,?IO
TEST RECORD"
APT. _FLOOR _CITY
OWNER
SUBURB]~dLLQiL
INSTALLED BY
.' . f fHdJ C (LS ..,
GelS Lina By <I- ;u) ,
HW _STEAM _SPACE HTR. _UNIT HTR. _OTHER _l2m() F-""Cb~
CONVERSION
MAKE OF BURNER
Modal
Max. a TU Ro linll
MAKE OF FURNACE
~cI.1
Vant Size
KIND OF LINER
Draft Hood
Filters
Sin
d-.
SIZF HONF
R.guloTor 1'& ~ - ')
Numb.r (~-f ")... \'1- '--
'.
Chimney Location
Chimn.y Con$truction
Inaid.
Outside
Smoke Bomb Wiring
Draft V Tut To;
Door Pr.~sura_~ Lighting Inst.
P.rc.n: C02~: Oat. T.st.d '1'-~~
P.rc.nt O2 I Compony Tuting ~N _,~ S
p<<~.. CO Ho..ofT...w - . V P:-'T~ 'j<""
~
/ /'
/
,01
Foe'''' 235
. , . . ,.' ,/JJi7/:<' -:F.~1T HOUSE 'HEATING TEST RECORD" ".., Itf'.s-'
:: ~O~,,~SS .~ ~ ij!:'tf:'::; ~ APT._FLOOR_CITY SUBURB Piu~\1 ~
'. ocr..:uPAHT _ tJ7 .--:.i//. _ ___u. OWNER
~: HF-A T LOSS " . DA TE in G. INST.
:=. ~~i..D BY '-E"iiA1t/ 'Mt,;t!.~p-N(a~,-: ~_4~7?r I~INSTALLED BY > ~:-
.: . l.:loctricol Worle By' fG--ib.rJ 0( r~1..{ Cas Lina By 1L....IA,j ~ SOI\\S
:,:TYPE. OF HEAT,'" GA'..:..-.-FA~HW _STEAM_SPACE HTR. _UNIT HTR. _OTHER. R....of-,oo\>
.. . . ~ . '-'. . .
.:...... .~'t~.... .:.: ". ," G.A'S DESIGN
- .... ~
';':: MAK' L~Q f} .\-LG
~:.~:: ":'d'J~t~~~~- ~ <)O~--
'.:,:INPUT' . ..tr5'C---t~
~.
CONYERSJON
MAKE OF BURNER
Modal
J'~.:': '.." .:- ~ :._:-<;.1'.
.;:". '~' ."'. .. .'.. '.. CONTROLS
:~ ....~E~M~s~~.i.. 't-'W' ,H~ Plug
.,.. Vain . i:}J \l,..-
~"'Llmit '. ~seo ti"'~;'1'--~\I..c.n~
.~.:. Limit Setting ./'.0"
}. ;;i:t~:'~g ~~;;: .
~: Pliot Male. ,,'CP;Q:ij,A...ea
:: . Pilor Moclel
Max. aTU ROling
MAKE OF FURNACE
M:'clel
Vant Size
tJlA-
KIHD OF LINER
Draft Hood
Filters Sin
Chimney Location
Chimney Con$truction
SIZF
HOHE
'1,:;1 < - -=?
/V'l-7-S., l.-
~
ReguloTol'
Numbel'
-,
Inside
Ouuide
. OJ
Smoke Bomb
Draft . V-
Door Pre.ssure-L,
Wil'ing
Tut Tog
Lighting Inst.
P.,.cent CO2 '1
Percent O2 8
Pei'cent co 0'
Dot. Tast.d
Company T osting
Nome of T.ster
'1- is -q~
_ ~1r~N + ~arJ S
\{"" AI< \<. 1f~L..L~ ~ ~ll
Pr.~sure
F~", 2JS
. ,,/J-j1/: (. <i~-7'1T
~: ~c~r.;~ss .ft~/ Mt-l//Ju/ WIJlJ1)
..., ocr.:uPAHT" '1J1/Z-'lIltW tf.,uNlb
,. .. '
.; HEAT LOSS'-' DATE inc. IHST.
.:'. .~~L.D BY . '4~/ Mt7'lrlPH.//O/J?/ a(')/"~M/7Jlt( INSTALLEDB'r:=:::2
.: . t:lectrical Worle By . 'L~ ~!' IJ..D.. '\ Cas Lina By' cz.~'M\I 'I- ~S
.:. :TYPE. OF HEAT,'-' CA''':''-'-FA~HW _STEAM_SPACE HTR. _UNIT HTR. _OTHER
:;:,\.l~ ~ ~~.,~ ~S DESIGN MAKE OF BURNER CONVERSION
: .. Model '" Yf tJ - - - So I Go (\ Model
~,' S-ial ,'f;).9.<; o--~{)~t')L.\ Mu. BTU ROling
:,:IHPU.T: ' .\SO,OO MAKE OF FURNACE
~. : ': " '.. . :' . " .':-<:. ' ,'. M:'clel
,;..'.._..~' ", -:.~~~.,: . CONTROLS
~ ....THERMOSTAT ~ \0 ,He4.t Plug
;.: Valv~. .;. ~.l-
.. Limit ." _I~~
:':' Limit Setting' . ~5'O
. .~
{;;i:t~;~g ~"~Q:~~'
Pliot Male~'" ,~,\{'_\i\....
. Pilot Mocl.1
Pilot TimlnlJ
LoW, Cut OEE
, 3,rl", '\, C'
Pr...sure ~ ll...I
-
,~O
~Lj<>
HOUSE 'H EATING TEST RECORD
APT._FLOOR_CITY
OWNER
SUBURB ~so~2" Lc......ILc
~
k:"'~t) f: T~
Vant Size
KIND OF LINER
Croft Hood
Fi Iters
SIZF
NONE
3'd$'--3
I l.o-f-") '\"f-'1-
Size
'd--
RegulaTor
, Humber
Chimney Location
Chimn..y Con$truction
Inside
Outside
Percent CO2
P.rcent O2
Pei'c:ent CO
'D'h
(,,'h
D
Dot. Test.d
Comp..ny Tosting
Home of T ostar
Smoke Bomb
Draft ~
Door Pro~sura_V
q-l'O --<{<;-
--1 (,.r\-!'.j T ~'1\...s
" n,\AIQ..\L !{.iQ..~.r {"L
Wiring
Tut Tog
Lighting Inst.
J)
........... .
c..../ ....
'Input CFH
StQck 'amp,
F~m 2JS
'\ .
~
p
~
fgan & Sons Co. MECHANICAL CONTRACTORS
Building Integrated Solutions-
7100 MEDICINE LAKE ROAD . MINNEAPOLIS. MINNESOTA 55427
TELEPHONE 544-4131 . AREA CODe 612
LETTER OF TRA.SMITTAL
0.., qftJ )~
TO:
aTY ;(IP &/V bh~
~=::~~ :::":;j~q ~M
ATTENTION' JAY - kiUJW~ Atu/~-WI'. No. 1;;~ ;:/1S"
Gentlemen:
WE A~E SENDING YOU:
~ewlth
o under separate cover
o by bearer
o sepia
o prints
o copy of letter
o shop drawings
THE FOLLOWING:
o for approval
o with final approval
o approved as noted
o for coordination
o returned for correction
~o your information
as per your request
for distribution
o for estimate only
COPI ES DWG, NO, REV, DESCRIPTION
"" NO, DATE
~ 10" " - n~~,~~..r?' ~.... 17
, " ,,,
.111/ ~ LrJ..J, i A I it .7210 x---
I'
I
Remarks
~: 13A1/~~~ ~m
~f ~ehT ~ W#7#
COPIES W/ TRANSMITT AL TO:
V.ry lr~ur.. eGAN. SONS CO,
BY: &?~M~~
PER: 59/; ~~ ~
'OCT-18-1995 08:57
FAIRUIEW
~,727124
F',04
L
POWER
OF ATTORNEV
SAFECO 'NSUl<ANCE COMPANY OF A...Ei'lIeA
GENERAL INSURANCE CO...P...... OJ' A...E~ICA
HO....c OFF I CE; SAFEeo PLAZA
SfATTlE. WASHINGTON i'lllS
No.
3728
KNOW ALL tv THESE PRESENTS:
TNU $AFiO:CO INsuRANce COMPANY OF AMERICA an,j GENERAL INSURANCE COMPANY OF AM('RJCA, eacT'l a VJa.~tJi,gTOfl
corporatIon, ~oes eacn hereby ap"o.m
...MEREDITH .F SHIAN; NATHAN J, ESP[; SUSAN M, SULLIVAN; Mlnneapol is. Minnesota...............
ils ,rlltl ilrld lawful aTTorn~s)-in,facT, .....iTh full authOrity to execute on its behalf fid&lity and sureT'; tlonas or unaertllkil'l')$ and oThAr
dOc\$n9nts of a simil,"" character issued in The course of its business. 3nCl to Oind TM respective ccrnpany T/'lereby.
IN WliHE;;S WHEREOF. s"nco INSUAANCE COMPANY OF AMERICA and GENERAL INSURANCE COMPANY OF AMER1CA l';"v0 ..~ct,
execUled iIf)(1 atTesl(td Thes. preSc;nts
TI\.S
24th
day 0 t
October
19 94
CERTI~ICA TE
Extract fr()1"l the By-laws of SAFECO INSURANCe COMPANY OF AMERICA
ana of GENERAL INSURANC~ COMPANY OF AMERICA:
'Article V, Section 13. - FIDELITY AND SURETY BQI.IOS . . , the Presidenr. any Vice Presidel'l1. the Secretary, and any ASSIstanT \lice
Pr<tsld..nl .11)\.IOII1T,;.1 f.;jr that purpose try tM officer in cl'large of suret.,. operation:!!, 5!l~f1 each have aurl'loriry TO appoinT Individuals itS
at10rN.y~-i"-fil.::T or \,lI'JdGi OTI'I&( Jcpropdaro rirl9~ ....irT'l 3\4thcrilY to execute on oel'lalf of The canpal"'f 1ideliry lIncl 5UI'!!ty bC'l'l(ls and
other docu"notltS of similar Cl'\3t'3CTet Issued by TM ccrnP3ny il'. TM course of iTS busine~s . , . On anv inS'lnrnent making or e"'deflcing
S",~h appo.nllnsn!. rhli sj~nat\Jr..s rr.~ be affixed t:Jy f;;csimile, On any in5TrU'T"\8nT conferrin~ Such 3uTT'loriTy or on any bor-a or 'JP1erlalorlf')
of lh" C(JT.I).3fl'1'. Ihe .$&..1. or a facsimile tl'lereof. may De impressed or affixed or in Ilrry OTher manner reproduced: prOVided, however,
thaI tl'l4 seal Shan not be necessary to The va/i,jitv or Jny such InstrlJ'Tlllnt or undertaking.-
EX'TracT fl'Orl a l=lesolullon of The Board at Oirectors of SAFECO INSURANCE COMPANY OF AMERICA
aM of GENERAL INSURANCe: COMPANY OF AMERICA adOPTed JUly 28, 1970,
'On any ctlniflcallt flxecuted Dol The Stlcretary or an assistant secreTary of 1M Ccrnpany setting out,
(i) The provi$iOrlS of ArlI Chil v, SectIon 13 of the By-Laws. and
(ji) A cop.; of The power-of-.l1torney ap"Oinrmenr. execuI.,d pursuant thereto. and
(iii) Certofylng tMt said DO_er-OI-ancrney appointmenT is in full forCll and effeCT,
the sJgnarure of the certifying officer ~ be Dy facsimile. and The seal of The CC7Tlllany may t.>e a facsimjle ThereOr:
I, R A. !:'efson. s..C;'IlW'f of $AfECO INSURANCE COMPANY OF AMERICA anct of GENERAL INSURANCE COMPANY Of AMERICA,
00 hereby certify Tl\aT TlIlt foregoing extraCTS of tl\., By-Laws and of a ReSOlution of The Soard or Qirectors of these corporalio"~, ~nd
of a f:>ower at AnOrneoy Issued purSU3lit thereto. are true and correct, al'ld ThiU !lotl'l the By-Laws. the Resolution and t"oiI Power ot
Attorney are still In full force and liItlecl.
IN WITNESS WHEREOF. I ,,3\09 I'lereUl'\TO 5..r my I\and and affixed rhe flIcslmlle seal at said corporallon
tll,S
16th
dav or
OC'lDBER
19 95
-,
-,
-'
S-07L1fP t/83
- -.
<S> ll11g;:stero<l traelO"'8'. ot SAF~CO Corp'" at."I1,
".. .........
Faxed
October 12,1995
Mr, Raymond Piirainen
Assistant Director,Property Management and Development
Fairview Hospital and Healthcare Services
2312 South Sixth Street
Minneapolis,MN,55454
Dear Mr, Piirainen:
Jay Scherer from our Inspections Department asked me to contact you regarding an
outstanding item for the new clinic building on Highway 13. It seems that a letter of
credit for the landscaping has not been provided to the City, This is an ordinance
requirement and I have included a copy of the ordinance section, .
If the irrigation system which was called out on your landscapin~ plan has not been
installed, this should also be covered by the letter of credit. The letter of credit must cover
125% of the cost of the landscaping improvements and shall run for one year,
Please call me if you have any questions.
~~incer.e. lY. '
~'~J! /
Donald Rye J
Director of Panning
cc:Jay Scherer V'
16200 @g~rQl~f~ek Ave, S,E.. Prior Lake. Minnesota 55372-1714 / Ph, (612) 447-4230 / Fax (612) 447-4245
AN EQlJAL OPPORTUNITY EMPLOYER
RESOLUTION 95-20
RESOLUTION OF THE PRIOR LAKE CITY COUNCIL TO APPROVE THE CONDITIONAL
USE PERMIT FOR A MEDICAL CLINIC FOR PROPERTY IN THE R1 URBAN RESIDENTIAL
ZONING DISTRICT.
MOTION BY:
WHEREAS,
WHEREAS,
WHEREAS,
WHEREAS,
KEDROWSKI
SECONDED BY:GREENFIELD
Fairview Hospital and Health Care Services has made application to the City
Council for a Conditional Use Permit under Section 5-3-3 of the City Code for
the purpose of constructing a medical office building within the R1 Urban
Residential District for the following legally described property:
Lots 1,2 and 3, Block 2, Westbury Ponds Second Addition.
City Council has considered the advice and recommendation of the Planning
Commission and the effect of the proposed medical office building on the
health, safety and welfare of the occupants of the surrounding land, existing
and anticipated traffic conditions, the effect of the use on the Comprehensive
Plan, and compliance with the intent of the Zoning Ordinance, and
The Prior Lake City Council has determined that the proposed medical office
building complies with the criteria for granting a Conditional Use Permit
contained in Section 5-6-5 (c) of the City Code, and
The contents of Planning case file CU95-01 are hereby entered into and
made part of the public hearing record and the record of decision for this
case,
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF
PRIOR LAKE, MINNESOTA, That it hereby approves the Conditional Use
Permit for a medical office building at the above described location subject to
the following conditions and exhibits attached hereto:
1. The site shall be developed, used and maintained in accordance with
Exhibit A, the site plan, Exhibit S, the landscape plan, Exhibit C, grading
and drainage plan and Exhibit OJ Elevations.
2. The trash enclosure on the westerly side of the building shall be
constructed of brick to match the exterior elevations of the office
building,
16200 Eagle Creek Ave,. Prior Lake, Minnesota 55372-1714 / Ph, (612) 447-4230 / Fax (612) 447-4245
AN EQUAL OPPORn:NrTY EJ"1PLOYER
3, The rooftop screening should be constructed of materials which are
architecturally compatible with the medical office building.
4. The drainage plan shall be modified to redirect drainage from the west
toward the ditch along the north side of State Highway 13.
5, The applicant shall pay the landscape plan review fee of $300,00.
6. This Conditional Use Permit shall not become effective until the City has
received evidence of the recording of the final plat of Westbury Ponds
Second Addition,
Passed and adopted this 3 rd day of April, 1995.
YES
NO
Andren X Andren
Greenfield X Greenfield
Kedrowski X Kedrowski
Scott* Scott
Schenck X Schen
*Scott had vacated her chair from the discussion ,
{Seal}
'CU01RS'
MEMORANDUM -6
TO:
FROM:
DATE:
RE:
Jay Scherer
Michael Leek, Associate Planner
October 19, 1995
Fairview Clinic Final Inspection
I visited the site this morning. We do have a letter of credit on file for the landscape
improvements, This letter of credit will, of course, remain on file until final acceptance
of the improvements after one year, At this time it appears that all of the tree and shrub
planting has been done, but that some sodding and seeding remain to be done,
The trash enclosure is a problem in that Resolution 95-20 approving the Conditional Use
Permit (a copy of which is attached) requires the enclosure to be constructed of brick to
match the exterior elevations of the building. If the enclosure is the only issue
outstanding, my suggestion would be that the City issue a Temporary Certificate of
Occupancy rather than impeding progress toward the clinic's operation,.
Document2
1
TO:
FROM:
SUBJECT:
DATE:
MEMORANDUM
GARY STABER, BUILDING OFFICIAL
VERL YN RAAEN, ENGINEERING TECHNICIAN
FAIRVIEW CLINIC, LOTS 1,2, AND 3, BLOCK 2, 2ND ADDITION
TO WESTBURY PONDS
MAY 3, 1995
I have reviewed the Fairview Clinic site"grading and drainage, utilityJ and detail plans,
sheets CA1.0, Cl, C2 and C3 respectively, My comments are as follows:
Sheet Cl
1.
2.
Sheet C2
1.
2.
3.
4.
Catch basin # 1 "emergency overflow" needs to be indicated on the plan
sheet at the highest point which the water will attain as it begins to flow by
gravity to the street. Indicate the proposed elevation at this point.
Does the easterly parking lot in the area of the handicap stalls drain?
Water service should be 6" D, from stub in boulevard into building. The
plan indicates "4" water service",
Note on plan that hydrant must be installed five feet back of curb.
The drainage and utility easements at the common side lot lines of Lots 1,
2 and 3 must be vacated.
The proposed Willowwood Street curb lines and median west of Five
Hawks Avenue should be accurately shown on all sheets.
VMEM02,DOC,\C, DRIVE
DATE MAY I J Jcrt5
TO Grr-( Of -p,::..;oJZ LA-~E.
ATIN: 6A~ STAJ3E.'R..
PROJECT-pR/OR- LA:1<E- r!eDlt-A.t- CuAJ/G
COMM NO Q430. 00
We are sending you:
la""drawings
o specifications
o shop drawings
o
o enclosed
o separate cover
o our 0 your messenger
o
COPIES
Z
DESCRIPI'ION
GA (/ 0/, C- 7..., (,,3) LI
.
'7 5u~tJG'1
o for your approval
o for your infonnation
o for your review & comment
~ requested
o approved
o as corrected
REMARKS
COPIES TO
Sincerely
~' (.;7-/
DATED
1 /I z../9~
SGN
Smiley
Glotter
Nyberg
Archirccts/Planners/Intcrior Architects
1021 LaSalle Avenue
Minneapolis Mimlesora 55403
Tel: (612) 332-1401
Fax: (612) 332-1405
transmittal
o UPS
o first class
o air express
o
BY
$(;N
o Nar approved
o revise & resubmit
ENeL
TRANS
Fairview Riverside
Medical Center
2450 Riverside Avenue
Minneapolis, MN 55454-1400
612-]7/-6000
A Division of fuirview
CO
DO
October 18, 1995
Mr. Jay Scherer
Building Inspector
16200 Eagle Creek Avenue SE
Prior Lake, MN 55372
Dear Mr, Scherer:
The purpose of this letter is to provide you information regarding
Life Safety monitoring for the new RidgeValley Family Physicians
Clinic located at 4151 willow Wood Street, Prior Lake.
At this time, I have confirmed that our system is operational and
final testing is complete. The Life Safety systems that will be
monitored include general fire and trouble. The system will be
monitored by our 24 hour Security/Safety Central Monitoring station
located at Fairview Riverside Medical Center in Minneapolis.
The alarm signal is transmitted via our internal network system. In
the event the network should fail, the system converts to secondary
notification and transmits the signal via telephone modem.
Upon alarm notification, the central monitoring station will notify
Prior Lake Police/Fire immediately.
Please feel free to contact me at 672-4152, should you have any
questions regarding this information.
Sincerely,
cJ:Z 77l~
Ron McKinnon
Director, Security/Safety and Parking
cc. Rick Thompson
Mike Peterson
DATE
COMM. NO.
PROJECT
SUBJECT
PRESENT
MEMO BY
COPIES TO
February 24, 1995
9430.00
Prior Lake Medical Clinic
Code Review
Gary Staber, City of Prior Lake
Ray Piirainen, Fairview
Charlie Skarphel, Skarphel Construction
Jeri Fink, SON~....z-.
Jeri Fink '"'7Ccr
Those PreSent
Julie Sherfinski
Jeff Arsenault
1021 LaSalle Avenue
Minneapolis, MN 55403-2082
(612) 332-1401 Fax 332-1405
Architects
Planners
Interior Architects
S,c. Smiley, F.A,I,A,
J,8. Glotter, A,I,A,
G,R, Nyberg, A,I.A" A,S,I.D,
A meeting was held on Friday, February 17, 1995 at Prior Lake City Hall. The discussion during the
meeting was as follows:
1. The building is Type n N construction, Occupancy B-2 and fully sprinklered.
2. The total building area is 10,000 s.f.
3. The building will be reviewed under the 1988 UBC.
4. Corridor walls will not be rated as per UBC 3305 (g) Exception 5. The Medical Clinic is
considered office space, because patients are capable of self-presentation. No general anesthesia
will be administered in the Clinic.
5. SON to verify that outswinging electrical closet doors do not infringe on required exit width as
per UBC. Refer to UBC Sec. 3305 (b) and (d). Electrical closet doors may be bifolds.
6. SGN to verify number of toilets provided meets the Minnesota State Building Code requirements.
7. The water meter may be located inside the building some distance. It does not need to be located
at the exterior wall.
8, The parking requirement is five (5) spaces per doctor plus one (1) space per employee.
9. 5 % landscaping is to be provided within the parking lot.
10. Ray Piirainen is to send a letter to the City of Prior Lake stating why the City ordinance requiring
a split offset trash enclosure gate should be waived for the Medical Clinic.
11. Panic hardware is recommended for the building exits, but is not required by code.
If any of the above does not meet with your understanding of items discussed, please notify this office
in writing as soon as possible.
-'( ';';- z ,.
->
PLAN REVIEW'
PRIOR LAKE MEDICAL CENTER
1. Smoke detectors shall be installed in all exit corridors, per as manufacturer's
recommendations, in less than one (1) hour rated corridors,
2. Special inspections required for all bolting and welding. The inspector shall verify
and submit conclusions,
3, Drinking fountain required,
4. Separate permits required for fire suppression system, plumbing, mechanical,
electrical etc,
5, Trash encloser must meet city ordinance or to be stored inside the building,
6. All interior surfaces shall have a flame spread classification of Class I,
7. Walls within two (2) feet of the front and sides of a water closet or urinal shall be
covered with a smooth nonabsorbent surface to a height of four (4) ft,
8, Exit doors shall be openable from the inside without any special tools or
knowledge or effort or use of a key,
9. This structure is to meet all state building code requirements for handicap
accessibility.
10. Roof drainage shall be conducted under public sidewalks.
11, Interior roof drains, if any, shall comply with State Plumbing Code.
12, Roof mounted mechanical equipment installed on buildings shall be screened
from ground level observation at all points on adjacent streets or property. The
screening must be visually compatible with the building it serves,
PLMEO.wRT
16200 Eagle Creek Ave" Prior Lake, Minnesota 55372-1714 / Ph, (612) 447-4230 / Fax (612) 447-4245
AN EQUAL OPPORTUNITY EMPLOYER
PALANISAMI & ASSOCIATES, INC,
Consulting Engineers (612) 533-9403
FAX (612) 533-9586
5661 International Parkway
MINNEAPOLIS, MINNESOTA 55428
form6.dwg
JOB PRIOR LAK MEDICAL BUILDING
SHEET NO. RC2,l 3 OF .3
CALCULATED BY
CHECKED BY A J2 e
SCALE: NONE
DATE
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DATE:
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PALANI,SAMI & ASSOCIATES, INC.
Consulting Engineers (612) 533-9403
FAX (612) 533-9586
5661 Internotional Parkway
MINNEAPOLIS. MINNESOTA 55428
form6,dw'l
JOB PRIOR LAKE MEDICAL CENTER
SHEET NO, RC1,2 2 OF 3
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PAlANISAMI & ASSOCIATES, INC.
Consulting Engineers (612) 533-9403
FAX {612) 533-9586
5661 Internotional Parkway
MINNEAPOLIS. MINNESOTA 55428
form6,dwg
SHEET NO, RC 1 . 1
1 OF 3
CALCULATED BY
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!!ISAMI a ASSOCIATES. INC.
CONSULTING ENGINEERS
May 16, 1995
Mr. Jeff' Arsenault
Smiley Glotter Nyberg Architects
1021 LaSalle Avenue
Minneapolis, MN 55403
Re: Prior Lake Clinic
PAl #C95001
City Review Comments
Dear Mr, Arsenault:
The following is our response to the City of Prior Lakes Plan Review comments.
Plan Review Sheet
Item #10
The entry vestibule drains onto a grassed area which slopes into the parking lot.
The building roof scuppers along the north elevation drain onto a landscaped area.
The drain outlet is located 2S' back from the property line and proposed sidewalk
along Willowood.
Verlvn Raaen Comments
CI,l Emergency overflow elevation for catch basin #1 is 973'-0". See attached sheet
#RCl.l.
Cl.2 The spot elevation 973' at the east side of the parking lot has been changed to 972'.
See attached sheet #RCl.2.
C2.1 Per telephone log sheet dated 5-9-95 from Jeri Fink the Owner has approved
changing the 4" sanitary sewer to 6". See attached sheet RC2.1.
C2.2 A note has been added to the plan indicating the 5' setback. See sheet #RC2.1.
C2.3 See Architects letter.
C2.4 See Architects letter.
If you have any fbrtb.er questions, please give me a call.
Sincerely,
PALANISAMI & ASSOCIATES, INC.
~C~
Aaron Eckroad
enc.
5661lnternafional Parkway. ~Inneopolis. Minnesota 55428. (612) 533-9403. FAX (612) 533-9586
May 16, 1995
Mr. Gary Staber
City of Prior Lake
16200 Eagle Creek Avenue SE
Prior Lake, MN 55372
1021 LaSalle Avenue
Minneapolis, MN 55403-2082
(612) 332-1401 Fax 332-1405
Architects
Planners
Interior Architects
RE: Prior Lake Clinic
Comm. No. 9430.00
Plan Review Comments
S,c. Smiley, EA,I,A,
J,H, Glotter, A.l,A,
G,R, Nyberg, A,J,A" A,S,I.D,
Dear Gary:
I have addressed each issue listed on the City of Prior Lake Plan Review.
Comments to the Plan Review:
1. Jim Harmon of Egan-McKay electrical has been notified that smoke detectors shall be installed
in the exit corridors per manufacturer's recommendations for less than (1) hour rated corridors.
He has addressed this issue.
2. Skarphol Construction is aware and planning special inspections required for all bolting and
welding with American Testing and will submit conclusions. They will contact the City in this
regard.
3. One drinking fountain is required in the building per Minnesota State code. Two drinking
fountains will be installed (one high, one low) to meet the Federal Americans with Disabilities
Act
4. Skarphol Construction is aware that separate permits are required for fire suppression system,
plumbing, mechanical, electrical, etc. and will obtain these as required.
5. Ray Piirainen will write a letter to the City of Prior Lake in regards to the trash enclosure needing
offset doors and why offset doors will not provide the needed access and security required for
Fairview's medical waste.
6. All interior surfaces have a flame spread classification of Class 1.
7. All toilet room walls have ceramic tile wainscot to 5'-0" A.F.F.
8, All exit doors are openable from the inside of the building without any special tools or
knowledge, effort, or use of a key.
9. This structure meets all State building code requirements for handicap accessibility.
to. Refer to Palanisami Associates' letter dated May 16, 1995,
.
Mr. Gary Staber
May 16. 1995
Page 2
11. There are no interior roof drains on the project
12. Roof mounted mechanical equipment will be installed near the center of the roof for minimal
impact and will have screening visually compatible with the building.
Feel free to call if you have any further comments.
Sincerely.
SMILEY GLOTTER NYBERG
r~n ~...
Jeff ~\. ~chitect
JA/lc
cc Ray Piirainen (Fairview)
Rick Thompson (Fairview)
leri Fink (SGN)
Jim Harmon (Egan-McKay)
Tom Sheehan (Egan & Sons)
Mike Peterson (Skarphol)
May 16, 1995
Mr. Verlyn Raaen
City of Prior Lake
16220 Eagle Creek Avenue
Prior Lake, MN 55372-1714
1021 LaSalle Avenue
Minneapolis, MN 55403.2082
(612) 332.1401 Fax 332.1405
Architects
Planners
Interior Architects
RE:
Prior Lake Clinic
Comm. No. 9430.00
City Review Comments
S,c. Smiley, EA,I,A.
J,H, Glotter, A,I.A,
G,R, Nyberg, A,I.A" A,S.I.D,
Dear Mr. Raaen:
I have reviewed and addressed the following May 3, 1995 comments in regards to Fairview's Prior Lake
Clinic.
C2.3 Fairview Clinic will work with the City of Prior Lake to vacate the side lot lines of Lots 1, 2 and
3.
C2.4 As per our telephone conversation, the City will not require any changes to street curbs and
medians as shown on SGN drawings dated 2/15/95.
See the attached letter by Palanisami Associates dated May 11, 1995 for the additional comment responses.
If you have any further questions, please give me a call.
Sincerely,
SMILEY GLOTTER NYBERG
~~C_
Jeff Arsenault
JNlc
Attachments: Original Memorandum
Letter from Palanisami Associates
cc: Gary Staber, City of Prior Lake
Ray Piirainen, Fairview
Rick Thompson, Fairview
Jeri Fink, SGN
Aaron Eckroad, Palanisami
Mike Peterson, Skarphol Construction
Mf-W-03-1995 17: 38
f3.irview
FAIRUIEW
6727124 P,01
lJu.pjj(J/ (/./d J/w./I1}('(.f'(' ~(m'i<'C'$
..!j 1:.1 Suull-) Yi;,\.-tb ,'rn:~\d
i\lfbU1Cd/)()IJS, .Wi'; 55.;i5.7f- /395
(JJ2-672.63(J(J
Fa.\- 6/.J.672-6.1O.;
May 3,1995
Gary Staber
Building Inspector
City of Prior Lake TeL 447-4230 (fax 447-4245)
16200 Eagle Creek Avenue
Prior Lake, Minnesota 55372-1714
Re: Issuance of Building Permit
Agreement to consolidate parcels and vacate interior easments
Dear Gary:
Per my telephone conversation with City Manager Frank Boyles at about 5:00 p.m,
today, Fairview will proceed to have Lots 1,2, and 3, Block 2, Second Addition to Westbury
Ponds, consolidated and the interior easements vacated as soon as reasonably possible.
Fairview understands that a certificate of occupancy for the building will not be issued until
the consolidation and vacation is completed,
Also per that telephone conversation, I have directed Mark Carriveau, Construction
Supervisor (Skarphol Construction), to be at your office at 8:00 a,m. Thursday moming May
4 to pick up the building permit and to contact the discharged site and concrete crews to
attempt to be ready for work Thursday morning,
Please contact me if there are any further questions.
Raymond E. Piirainen
Assistant Property Director
672-6963 (fax 672-7124)
cc: Rick Thompson
Michael Pedersen and Mark Carriveau (894-9882)
Paul Torgerson, D & W (340-2600)
TOTAL P.01
TO:
FROM:
SUBJECT:
DATE:
MEMORANDUM
GARY STABER BUILDING OFFICIAL
VERL YN RAAEN, ENGINEERING TECHNICIAN
F AIRVIEW CLINIC, LOTS 1,2, AND 3, BLOCK 2, 2ND ADDITION
TO WESTBURY PONDS
MAY 3, 1995
I have reviewed the Fairview Clinic siteJgrading and drainage, utilityJand detail plans,
sheets CAI.O, Cl, C2 and C3 respectively. My comments are as follows: '
Sheet C 1
1.
2.
Sheet C2
1.
2.
3.
4.
Catch basin # 1 "emergency overflow" needs to be indicated on the plan
sheet at the highest point which the water will attain as it begins to flow by
gravity to the street. Indicate the proposed elevation at this point.
Does the easterly parking lot in the area of the handicap stalls drain?
Water service should be 6" D. from stub in boulevard into building. The
plan indicates "4" water service".
, Note on plan that hydrant must be installed five feet back of curb.
The drainage and utility easements at the common Slele lot lines of Lots 1,
\
2 and 3 must be vacated.
The proposed Willowwood Street curb lines and median west of Five
Hawks A venue should be accurately shown on all sheets.
MEM02,DOC.\C, DRIVE
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C~r~e f'-
Donald Rye
Planning Director
City of Prior Lake
16200 Eagle Creek Avenue
Prior Lake, MN. 55372-1714
April 24, 1995
Mr. Ray Piirainen
Fairview Healthcare Services
2312 South Sixth Street
Minneapolis, MN. 55454-1395
Dear Mr, Piirainen:
As a follow-up to the recent approval of the Conditional Use Permit for the
Fairview Clinic, I would like to remind you of the following items:
1, We have not yet received the corrected Landscape Plan you were to have provided
dealing with the changes on the north and west sides of the building.
2. We have not yet received evidence of recording the final plat of Westbury Ponds
Second Addition,
3, You need to make arrangements to record the Conditional Use Permit resolution on
the title of the Clinic property
a:1tpfJ
Donald R.~- ~
Planning Director
cc: Jim Allen
16200 Eagle Creek Ave" Prior Lake. Minnesota 55372-1714 / Ph, (612) 447-4230 / Fax (612) 4474245
AN EQUAL OPPORTUNITY EMPLOYER
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When column depth 8XClllds 38", install additional'''. stud,ln
each web rlcess Inside and along column Danges and at the ~.b
center. Set .!uds in ronners placed hortmntally, pll'lllel tel web
between column flanou and spaced max.. 8' a.c. vertically. Fasten
studs to rl.loners at top lInd bottom with IJlType 5-12 pan head
screws. Appty gypsum pane" horl%ontally and sttgger lolnts
betweeolay8rtl it least: 12..
1.8.1 UL Design XI1H Itr.
"ttlch Inner laYllr It' SHEETROCk brand Gypsum Panels, FIAfCODE C
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web over web face sIde 01 column. Fasten base layel'1 with '" Type S
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layer It' SHEETROCK brand Gypsum Pa.nels, flRECODE C Core, applied
vertIcally aver Hr 5teel stUdS positioned at comers. Attach base
layer to studs ~Ith 1" Type S sr:rews spaclld 12" c.c. and attach face
layer with 1"" Type S screws spaced 12" Q,C, and staggeret.:l6" from
bale layer s~relNs. Apply carner bead at corners; lInlsh wlttljolnt
compound,
1.1 Wall f.rrtll.lnstallatlan
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exterior walllll1d a possIbility af water p.natrallon through walls
exists. Insu.ll aspnalt telt ptotectlon strip betwllel11urrlng thannAI
Intf wall.
Appty gypsum panlils (parallel to channels) (perpendicular-to
channels). Position aU edges over furring channels In ~a'aIl81
application; cUI ends over frlmlng 11'1 ~erpend!eular applicatton wfm
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ment of fixtures and furnishings.
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Architectural Specifications
S.t 11..-0" Applitat1CU1
I Jolat SystetD-flnlsh 111l1acs panel joints and intemal angles
with a Unltl!ld States Gypsum Company joint. &~mm In.lled
ICtGrdlng to manufacturv's airectJons. Spot exposed fastaners
on far..alayerl and finish comar bllad, control joints and triM IS
rsquired, with at least three coatt of joint compOIIACI. feathered
out omo panel Tlce. and sanded smooth.
I Lallllnnlng AGII.,ve-Spread to provide It'' adhesive beads 4W'
D.c. for fullsheat WTlinatlon. For strip lamination. apply adhulve
In verti~1 strips to Clm., llano both edges of faGe panel wnl'l
metal spr88der having W'l ~ min. nD~h.s spaced mIX. 2" o.~.
C C.rner ..all-RliIlnforce all vaftlcal and hOriUl111a1 exterior
corners wltJ'J eomelr bud fastenel1 with "'" galvanized mples gw
O.C. on botn flanges along entire IDflqth of bead,
D Metal Trtll-Whsre assembly tenTIinClteB against masonry or
oUler dIssImilar MITOrial, apply metal trim over pinel edge amI
futln with "-" galvan~ &taPI88 go. o.e.
I P~1 Viav' Trbn--&IIp trlm ov.r panel with long ftange behInd
panel. InSflll panel with trtm f1nnt)' abutting sur1lce.
. Scrl1lt-flower.drlve at least Jr from eages or ends 01 panel to
provide unIform dimple )M- deep.
S C.ntral "alnts-Break panel D8n1nd Joint and baCk Dy dDuble
framing memDenl (and z. Wiele gypsum panelltrlp). Apply
lCoustlctl sealant to 1111 gap Ind attach control joInt to ficlllayBl'
\&11th SV galvanized staplellpacld S" o.e. on both flanges along
Grrtlre length of joint.
Part 4: Exterior steel Framed win Erectio.
4.1 ErectIon
4,1.11t11dslld lunne...
A Align runners accurately IlCcording to IltIIr!or wtlllayout aoo
&aCUte to base a.nd head with pOW!r-driwn tasteMr spaced ( )
O.C.
B Position studs vertically in runners and splice no grutllrthln
(12'") (1 8") {24j (choose spaclno rrom Tschnlcsl Ollts BOlts),
Sllcurilty anchor 63ell S'tud to runnl!f with four <*i 0''') Type SW
12 pin head or ~ Type S,' 2 low-proflle head screws. two at top
and two It bottOm, witt! one scraw In each f1lnge.
C For the slip track svS'tBm. allow W' to r c1UrdMe betwMn top of
stud. and CR deep IaCI runnar. Do nat futon Itudl to CR deep
leg runner, InStlII1!(' cald-rollet! channel lateral braelng within
10" to 12" of tops 01 studS, Connect ~racing 10 each stud using
w.lded or screw--attached clip angle,
4.1.2 EIlert.t .buthlng
Screw--alUch SHEfTROCli: bl1lnd Gypsum Sheathing or GYP-LAp
Gypsum Sheathing to axf1Irior at eactl !lud with 1" (drywall) (So If-
drl1llnQ) corroSion-resistant 9crews ~paeed W' from ends and edgu
al'ld apPfOll 8" o.c. Apply Slalant around sheathing perimeter at
interface w1ttl o1Jier materials and Install flashIng as Indlcatl(l on me
driwlngs, (Inmllasohalt felt horizontally III/Ith 2" overtiP and e"
endlaD I1Id fasten with cOlToslo"'re!li~tant s'laDlas as specified.)
(Install TWuc shaet according to manufaCturer's directions; fatten
to shaathinQ IMith stlple.s.) When stucco e:i1erior '41111 be applied,
sheathing may be tackad In place wllh strews, since application of
.elHumng meta! lath will completll shllthlno ancnoragl. All sheill!l~
ll'lg tacked in this manner must be covered wittl mltRllath Immet1iBt11y,
4.1.1 ldarlar MltIllIttl an' Ace...,I_
A InsUlt SHEETROCK Zinc ContrCll Joint No. 100 where indicated on
the I1rawlngs. Back conlrollolnts with 6" wide UJlhalt fill AnaCfI
wlltl Bostltth W "aW staples or equal, spated fj" apart on MC"
flange. Break 'L1flportj~ members and sheathing behind conlrol
joints. Apply sealant at all splice,;, interudlons end terminals.
OCT-20-1':3% 11:2':3
RIDGEURLLEY FRM PHYS
612 226 2601 P,05
:r.r')._ta.~1a.t.:L<:>rl.
Pre- I: nsta.lla. tl.<:>r1,
Contin.ued
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WARNING: Obey all bt.fnlctfon. of tire ehemfctJl.a manu-
lacfvN!T. and folio", till recommended ao..fety preCdU-
tlons ",hen handling. a.in&, GIld dit;posing of chemical..
The following plumbing requirements are recommended
for installation of the Mud-Medleal Proeessors:
1) A flow controlled water source for wash water and
for cleaning the processor,
2) A sink, with running tempered water. approximately
12" X 16", for use when cleaning rack modules.
3) A drain suitable for dumping photographic chemical
wastes.
,\
Caution: In aome locales. enDironmental rerulations
may require the capfl,fling and safe tlisposol of photo-
graphie processing fDCJStes other than in the smdtary
aewer system.
Check with your local authorities if you are unsure of
regulations in your area.
NOTE: The replenisher and drain connections may he run
out of the front of the processor In standard
configuration or, using the optional Side Drain Kit
pin 9992305002, these lines may be routed out either
the right or left side of the processor. See See rion
7, Accessories for additional details.
W'No Plumbing"
System
Option.
The avallable ''No Plumbing" wash water recirculation
system, pin 9992305003 (110 VAC) or pin 9992305004
(220 VAC), 8110ws the installation of Mini-Medical
Proeesaors without the need for an external water
supply or drains. If this system is being installed
wIth the processor, refer to the Instructions packed
with that unit and to Section 1. Accessoties. In this
manual.
This completes the pre-installation preparations you
are expected to have completed before the processor
installation date.
8/1/92
2-3
"ini-Medi~.l Sex i..
OCT-20-1995 11:30
RIDGEURLLEY FRM PHYS
512 225 2501 P,05
.:r~sta.:J....1.a.t.1.~~
Installation
NOTE: Do not unpack the processor until you have tho-
roughly inspected the shipping container for evidence
of damage. If there Is any damage, contact your ship-
per immediately for instructions on ftung a claim.
Set t..Jp
Unpack the processor and accessory boxes and inspect
for any visible shIpping damage. As above, if any dam-
age is discovered after unpacking, contact the shipper
immediately for instructions on flllng a claim.
Remove the processor side covers. Remove each of the
rack modules and any packing material from the tanks.
Inspect each of the racks faT ioose parts or screws.
A.ssemble
Stand
Following the Instructions In Seetion 1, Aeeeaoties,
unpack and assemble the Included processor stand.
POSition
Processor
Using two people, carefully position the processor on
its stand.
Using a level placed across the walls of the process-
ing tanks, adjust the leveling feet until the proces-
sor is level In both directions,
Connect
Replenishmen t
The processor may be set up to operate Its replenish-
ment system in either "Replenish" or "Batch" mode.
In "Replenlsh" mode the chemicals wlll be replenished
wIth fresh chemicals trom the replenisher supply and
the overflow wlll be collected for disposal or routed
directly to a drain.
In "Batch" mode the developer and fixer chemicals
will be recycled from the replenisher supply to the
processing tank and back to the replenisher supply.
6/1/92
2-4
Mini-M_dical Serie.
GCT-20-199S 11:33
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Rep~enish.
RIDGEURLLEY FRM PHYS
512 225 2501 P.01
:r.n..sta..:L.:La.t~C>r1
.l\I[<:>de
In "Replenish" mcxJe, fresh replenisher w1l1 be pumped
tram the replenisher supply to the processing tank.
excessive chemicals In the processing tank will flow
out of the tank at an overflow port and Into either a
contaIner for disposal or an appropriate drain line.
In thIs Jnanner constant processing chemical strength
may be maintained for longer periods of operation.
TO Install the processor for "Replenish" mode replen-
ishment operation proceed as follows: (See Figure 2-2)
1 ) Attach the red developer replenisher pickup tube
from the developer replenisher pump to the developer
replenisher reservlor fitting.
2) Route the red developer drain line and red over-
flow line from the processor to an overflow container
or drain line.
3) Attach the blue fixer replenisher pickup tube from
the fixer replenisher pump to the fixer replenishment
reservlor fitting.
4) Route the blue fixer developer drain line and blue
overflow line trom the processor to the overflow con-
tainer or drain line.
o 0
rO Repl. Pumpl.;
To
DEV FIll
Figure 2-2, Replenish Mode Operation
8/1/92
2-5
MiDi-Medical Seri..
OCT-20-199S 11:28
RIDGEUALLEY FAM PHYS
512 225 2501 P.0J
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:rr1&tEl.1:La.t.:L~n..
24.S"
Introduction
ThiS section includes instructions for Pre- Installa-
tion, Installation and Check Out of AFP Minf-Medieal
x- Ray film proceS&OfS.
Pre- I nstalla.t:ion
Pre-Installation includes instructions for preparing
the processor operating site.
Haoe these operations eompleted before the seheduled
bt.t4Uotfon date.
If the installing teehnicf4n fa delayed by incomplete
aife prepdTatiDn. you mGy be eharged fOT eosts during
the delay.
Locati.on
AFP Mini-Medical Series processors must be operated in
a darkroom suItably safel1ghted for the film being
used.
8/1192
2-1
ftiDi-".4i~.l Serle.
OCT-2~-lgg5 11:28
RIDGEUALLEY FAM PHYS
612 226 2601 P,~l
~~.' :JI/o..l cG~ ~ ~ lAUe)
r:fWM~ Ul ~ (I~~~S)
$?6' ~ ~~ ~A.J iu
AFP
X -RA V Film Process_ors
"Mini-Medical" Series
Installation, Operation,
Maintenance, Service &
Parts Manual
Applications:
Mini-Medical (PIN 9992305000)
Mini-Medical/gO (P/N 9992305300)
Mini-Medical/EP (P/N 9992305600)
itr,
IMAGING
Rev. August '. '992
250 Clearbrook Road
Elmsford. NY 10523
(914) 592-6100
PIN: 0000061122
OCT-20-1995 11:28
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RIDGEURLLEY FRM PHYS
Section 2
Installation
- General Index -
Section 1 - Introduction
Section 2 - Installation
Section 3 - Operation
Section 4 - Maintenance
Section 5 - Service
Section 6 - Parts
Section 7 - Accessories
Section 8 - Tech. Notes
512 225 2501 P,02
AFP Mini-Medical
X-Ray Film Processor
OCT-20-199S 11:23
RIDGEVHLLEY FHM PHYS
612 226 2601 P.04
Mini-Medical Processors occupy 8.0 SQuare feet (22.5"
24") (57 X 61 cm.) of floor or COWlter space.
The processor should be positioned to allow easy
access to all sides of the unIt for routine cleaning
and preventive maintenance. Drain tubes~ leading out
of the "front" of the processor, below the feed tray,
must be readlly accessible.
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Dimensions
VVelght
The Mini-Medical PrOCftlOTS weIgh approx. 110 lbs.
when empty, and approximately 160 Ibs. when operating.
To support thIs weight a Processor Stand A-lI\bty is
included. Instructions for the assembly of this stand
can be found In Section 7. Acceasorla. If the stand
Is not used~ a sturdy. stable and level stand. table
or counter must be provided.
Ventilation
WARNING: Some proenatng chemical fumes may irritate
eyes ond/or l'espirQtory aystems whim used In d poorly
ventUated area. 1[ the pr~essor ~ to operate in a
conflned drea. pro"lde for Qt lecut ten complete chan-
ges of air per hOUT.
Provide adequate ventilation for proper machine opera-
tion and operator comfort. The processor generates a
moderate amount of heat when operating and must not be
placed in a confined space, such as a closet.
For best processing results, relative humidity should
be between 40% and 60%.
Electrica.l
Electrical connections must include a ground and con-
fonn to local codes. The processor plugs into a stan-
dard 120 VAC, 60 Hz. 15 amp.. 3 wire outlet. As a fac-
tory installed optIon. Millf-MedCcal Processon may
also be configured for 220 VAC. 50 Hz, operation.
Through-the-VVall
Insta.llatlon.
I f your processor is to be Installed through the
darkroom wall~ refer to Section 7. pages 6 and 7.
a/lf~2
2-2
M~~\-"..~~.\ ~.~~..
~
.."..,....
OCT-20-1995 11:34
RIDGEURLLEY FRM PHYS
612 226 2601 P.02
In "Batch" mode the replenisher wlll be recycled from
the replenisher supply to the processing tank and will
then, via the tank overflow port, return to the re-
plenisher supply to be recycled again. As the chemi-
cals processing stren~h becomes depleted the entire
batch Is disposed of and new chemistry installed.
t
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Ba. tch l'VIode
To install the processor for "Batch" mode replenish-
ment operation proceed as follows: (See Figure 2-3)
I) Route the red developer replenIsher pickup tube
from the developer replenisher pump to the developer
replenlsJunent reservior or to a container of developer
replenisher.
2) Route the red developer drain line and red over-
flow line froUl the processor to the same container
as the developer replenisher pickup tube.
3) Route tile blue fixer replenIsher pickup tube from
the fixer replenisher pump to the fixer replenishment
reservoir or to a container of fixer replenisher.
,
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4) Route the blue fixer developer drain line and blue
overflow line from the processor to the same container
as the fixer replenisher piCkup tube.
..pl, hl.pl.)
Ftcure 2-3. Batch Mode Operation
8/1/92
2-6
"ini-Mc41~.1 S.ri..
OCT-20-1995 11:34
RIDGEUALLEY FAM PHYS
612 226 2601 P,03
.
.I.r1sta1lat.:LC)n.
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Connect
Plumbin.g
Wash water into the processor Is controlled by the
water solenoid valve. When the processor Is in the
process mode the solenoid is actuated. allowing wash
water to flow into the bottom of the wash tank where
It Is recirculated by the recirculation pump. Excess
water in the wash tank flows over overflow port and
down the drain.
To connect the wash water proceed as follows:
(See Figures 2-2 and 2-3)
1) Route the supplied reinforced water hose from the
output of your water panel to the fitting on the wash
water solenoid Wlder the right side of the processor.
2) Route the clear wash water drain line and the
clear overflow line from the utility section of the
processor to the bulld1ng drain or a suItable overflow
container.
CAUTION: If you are draining your processor dlreet~
into a atIIIftdry Nl'DeT. be certtlln thdt luell connec-
tion. tire in dCcordaftCe ",itl. local plumbtng code. ad
eomply fDtth all loedl and federal EPA tutti-pollution
requirement..
DO NOT drain th~ processor Into any drain lines that
are mad~ of copper pipe QI chemical N!aetiDns ",al
qu~Jrly dnmage the pipes.
UNo Plumbing"
System
Option
The available "No Plumbing" wash water recirculation
system, pin 9992305003 (110 VAC) or 9992305004 (220
VAC). allows the installation of any of the Minl-Medi-
eal Serles processors without the need for an exter-
nal water supply or drains. If this system is being
installed with the processor. refer to the instruc-
tions packed with that unit and to Seetion 7. Aeees-
IOrieS, in this manual.
8/1/92
2-7
"1ft1."cG1~.1 &erle.
OCT-20-1S9S 11:34
RIDGEUALLEY FAM PHYS
612 226 2601 P,04
::J:n.sta,1.1a.tic>rl.
Con.trol
Panel
POlsi tion.in.g
In some Installations, such as with the right side of
the proeessor against a wall, it may be difficult for
the proceSSOr operator to view the LED's on the Dis-
play Panel to the left of the feed tray.
If this Is the case, to make the LED Display Panel
more visable, use the following procedure to reverse
the positions of the Power Switch/Circuit Breaker and
the LED Display Panel.
1 ) DIsconnect the processor power cable from its
outlet.
2) Remove the two screws hOlding the control chassis
panel to the front of the processor. Carefully lower
the panel untl1 It is supported by its restraining
straps.
3) Locate the small screw(s) that holds the LED Dis-
play Panel and the Power Switch panei in place. Re-
move the screws.
4) Carefully un-lace the cables for each panel from
the retaining clIps back as far as the center of the
loom.
5) Re-Install the panels In the desired position.
taking care to re-lace the cables through the
retaining clips.
6) Replace the panel securing screws and close the
control chassis and secure It with Its two screws.
7) Return the proceSSOr to servlee.
..
8/1/92
2-8
"ini-"e4ical Seriea
OC1~20-1995 11:35
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Processor
Checkout
Opera tlonaJ.
Checkout
RIDGEURLLEY FRM PHYS
612 226 2601 P.05
:I::~sta..13...a.t.i.c:>~
FOllowing set UP. inspect the proceSSOr as described
below to make sure it is ready for use.
WARNING: Dllt'ing the. iltspeetit)ft. be ~Te thtU the
proeaaor ptJUJeT fa dlaearmeeted elt the fl)all plug_
Inspect and clean the processor tanks, racks and hoses
as described below:
I ) Open the drain valves, on the front of the proces-
sor, for the developer. fixer and wash tanks. Use warm
water to rinse each tank clear of dust and debris.
Close all drain valves.
2) Shine a light through all hoses to check for
foreign matter. To remove anything, disconnect hose at
one end. flush with water, and reconnect.
3) Check, and tighten if necessary, loose hose clamps
and/or hardware on the processor.
4) Check that processor is level from front-to-rear
8.1'ld side-to-side. Correct as necessary.
Read these instructions completely before starting the
processor.
WARNING: Neoer operdte the proeeaoT without an
eleetTical fTound eOll".etfDn.
1 ) Close the tank drain valves.
2) If not already done, remove the three tacks and
set aside.
4) Carefully pour about 1.5 gallons of warm water
into each of the solution tanks. Do Not attempt to fill
the tank to the overflow.
5) Install all three racks In their appropriate tank,
6) With the Power Switch. OFF. plug in the power cord.
8/1/92
2-9
Mini-~diea~ Seri..
OCT-20-1995 11:35
RIDGEvHLLEY FHM PHYS
612 226 2601 P,06
Ir'1sta.l.1a.t.:f..CJn
Operational Checkout.
Continued.
Caution: lYeoer attempt to apero.te the processor mlth-
out liquid in the t4ftJta.
7) Switch the POlDer Switch to On.
8) The transport system will run at Process speed tor
the duration of one processing cycle, the recirculation
pumps will operate and the dryer heaters and fans will
be activated.
9) Inspect all rack modules to see that they are
turning freely.
10) Carefully inspect the undersIde of the processor
for any sIgns of leakage, correct if necessary.
11) Operate the Manual Replenishment switch to run
the replenishment pumps until the developer and fixer
tanks are full of water to the overflow port.
12) Activate the Film Feed switch with a piece of ma-
terial, the Waif Ught will turn ON and, every few
seconds, the replenIslunent pumps w1l1 cycle. Remove
the material from the sensor. in a few seconds the
Wait light wlll go out and the beeper will sound.
13) When the Dev Temp lamp turns OPF. check the temp-
erature of the developer with a metalllc thermometer.
If It Is not correct for the materIal you wlll be us-
ing, adjust the temperature as outlined In Section 5.
Sero~e.
8/1/92
2-.10
MiD1.Ned1cal Serie.
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OCT-20-1995 11:36
RIDGEURLLEY FRM PHYS
612 226 2601 P,07
Insta.11a.1::i~r1
Transport
l\I.[aterial
TranspQrt several pieces of material of your usual
slze(s) through the processor. Inspect and, if nec-
essary, correct fot the following:
1) Film Feed switch operation. The Wait lamp should
stay on continuously until a few seconds after the
trailing edge of the materIal being processed is clear
01' the Film Feed switch.
As the WCJit light turns off, an audible beeper will
solUld lndlcating it is safe to feed in another pIece
of material
The proceSSOr will remain In the process mode for ap-
proximately 4 minutes after the film feed switch is
released.
2) Drift or Skewing. The material should feed thr-
ough the processor in a straight line. If It drifts,
skews or wrinkles, cheCk the racks for proper seating
or loose assembly screws. Be certain you are feeding
the material in straIght before checking racks.
3) Drying. Be sure the dryer Is operating properly.
Material processed In water alone may still be slIght-
ly tacky or damp when exiting the processor,
Complete
CheCkout:
1) Turn the Power Switch OFF, Unplug the power cord.
2) Drain each of the processing tanks and the replen-
ishment containers for the developer and fix replen-
ishment systems, close all drain valves.
3) Wipe any excess water from the racks and tanks,
The processor is now ready to be charged with fresh
chemIstry as instructed in SeeUon 3. OPERATION.
8/1/'2
2-:1..1
"ifti-"ed1~.1 Series
OCT-20-1995 1J:36
RIDGEURLLEY FRM PHYS
612 226 2601 P.08
:r~eta.1::Lat.:i...c>~
Processor
Set 'LJp
Checklist
1) Uncrate processor. Inspect for shIpping damage.
2) Assemble processor stand.
3) Set processor on stand.
4) Level processor.
5) Inspect tank and racks for loose parts.
6) Install replenisher system, replenIsh or batch
mode.
7) Connect wash water system and drain.
8) Rinse out wet tanks, inspect recirculation lines.
9) Perform Operational Checkout.
Pigure 2-4, Setup 0leckJ.1st
---.'."-.--..--.,------ ------.-.--,.--.-~--.. -_.... ._..._-~.~_.._ "__U __~...
'IJ.I'iJ2
2-12
ftin1~"cdj~.1 Sc~ic.
OC'-20-1995 11:37
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C>pera tlon.a1
Checklist
RIDGEUALLEY FAM PHYS
612 226 2601 P,09
Ir1Lsta.1..1.a."t::.:LC>r1
1 ) Close drain valves.
2) Remove racks.
3) Partially fill tanks with warm water.
4) Replace racks.
5) Plug in processor, apply Power.
6) Inspect transport drIve system.
7) Check recIrculatIon plumbing for leaks.
8) Top off tanks using Manu.al Replenishment switch.
9) Check Film Feed swItch and "Beeper" operation.
10) Check temperature control systems.
11) Check developing time.
12) Check for dryer heat and operation of both fans.
13) Check transport of material.
14) Drain Processor.
15) Charge with fresh chemistry.
"
Flgt1t"e 2-5, Operatiooal Check.list
8/1/92
2-13
"1n1-".41c.~ Se~te.
TOTAL P, 09
~=~-~~95 09:29 FROM SKRRPHOL CCNST, GROUP INC TO
4,-\';"4245 F'. [11
DATE: /oj2~/9J
FAX TO:
NAME: JAtt Sdr.e#1~
COMPANY: ~",.;J~ (lfjkA"
FAX NUMBER: '1"1- 'f1,C/:5
WITH THIS FAX TRANSMISSION, YOU SHOULD RECEIVE / PAGES
INCLUDING THIS COVER PAGE. IF Y~O HAVE A PROBLEM RECEIVING ALL THE
DOCUMENTS, PLEASE CALL SJ,AtcM~ AT e?cf-<?rr-z- .
A COPY OF THIS INFORMATION (WIL BE MAILED.
THANK YOUI
REF. JOB r:AtlZVteuJ I'h~((';I .- ~ fAr,_
JOB # tit.(, 9
I '
COMMENTS:
~~eP is It:";)f ~~ )(-~ p,AJ"h~("rl-/
~ pew p..ft!J~~ C /ZP~ I/~ ("'~)
M,~ ~~
12360 RIVER RIDGE BLVD · P.O. BOX 1497 · BURNSVlLLE, MINNESOTA 55337 . (612) 894-9882 . FAX (612) 894-9918
,..~
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'Jr.~T-:z;. "9'5 I',ON 99 :31 AM EGAN MECHANICAL
.. ..",... 1 ". -.. :"J
......... ~ 'till'.. 9 a~._......_...
..'...~:.... 1..."..J ~'- .' . I.::,..... ........._;
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8u"'&ne lC~'l.lt.Utt~ !-....~nu... .
...
44742~5
16125915532
F,iJ2
P.02
BACKFLOW PREVENTER
TEST REPORT
7101.l .\Iadlcl.. ........ .....
,\idIl....,..... .)t1n_lIJ,rJ
"~IJ'
. 11M......... t. ~a"" 1'..._ AA lit,........... _. lie ~ _ ~ ........ II. ..... -.
SIT.:!: A.CDR!SS 41 I? I WlLWv.)cbO m ~~-;-lZ
OCc:tJPANT fAl~J l~ t...v\ n \(., , m. RO. n:s-r OAT!: \0. 2~-9!)
1JEV!C~ t~ AKD MODEL u)f\\\~ SIn \ 12" , SiRLU.' )f0. 2. c;:, ~ 'B (
"
.
DEVICE :r..c:c.A.T:!:ON t;XR"~ ?QE)'VV\
OEV'tC!: smvm ~T SYSmi E ~ ~A.~ \)~ \! G..LO~\=.\<.
crm::< cm:r l'!!:J. l1I? am. OIr .
VALVE #1 VALVE #2 AC3CSS #1 ilID uu:&:r S't!Am:a
c:a:r 0PDrS
ttST r~~ ( ) ~~~ ~ Nan: ~ )
BG"CIU: , CLCSED ( ) ~~ .l'S1 c1'.lltJ )
UP.u:RS
FnrAL CLC.n:D ( ) CLl:5iD 00 B~0 ~~ ~:J.
1'!:ST
Dl'Sc:atBE
UPAJJt
-
CDTIF'ICA1'Iar .
r !\ereby C:er1:1.::'y the !oJ:'eCO:1:Ig uta., to be C02:t'ec1: oU2cl thai: the tlllS'ted. d.ev1ce 1.3
fw.t':1:j.C'lrd,~~ w1th1n tAe lJ.aLta of tA. ~.......
FIIlH NAHE_ t G, A l-\. t'f\ E' Q..\.\ 1'>." \ ~ ~1&mnuss '1lOO 1\2 e. t)\ (?.\ \.I.;;:' L I<. . RooD
s~21~J., ?'.tzIQ.i2- 'l'E:STEII'S CDt%< """'l'IClf NO.~ =. NO.~ \
SIGNATURe Ofl Cl!R1WIID ~S'l'1!R
TCiTAL P, 02
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OCT-23-95 MOH 09:31 AM EGAN MECHANICAL
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8u"lft1I hll.'l;tolMI ~~u,....,. .
16125915532
.J4y~
BACKFLOW PREVENTER
reST REPOAT
P.02
71011 M..tlcIfIIr ~ ICwd
Mfa........ )t ........110&:1
tUoUWIJI
'......"....... ,. C-dHeo T...en.; AIIlnflOl/......... __ 1M .".... ., ~ priIIt... lit ..... 1M.
sm: ADDRESS 41 11 I WU..(.o~ m v,F]?12
OCCUPANT f~~P-V l~ t..t,.\ n \(.. TEL. KO. TEST DA1'3 ~ () - 2 ~ -9!)
.
])EV'IC~ ~ .urn MODEr. UJ J\\'\ ro SID \ 12;' 'mm' NO. '2. 5~E>1
-,
DEVICE LO:.\1'!ON' ~~R~~ ~e~M
DEV!C~ SERVES WHAT SYSm-t ~'f.~A.~ \)~\f\:.'-O~~R
CH!QC cm::r P!E:J. Dl7. P!ES. OIF.
VALVE #1 VALVE: #2 ACaOSS 11 wmr REtm' ST!mlE:a
cmx:JC OPDS
'l'EST r~.4T(ED ( ) r,v1ll:" ~ ) lrQfE ~ )
BEFOlU: , ctcSED ( ) CLCSED ) ~s1 1)S1. CtND )
au ADlS
Fnl'AL CLOSC:O ( ) cum:c 00 S.fo ~~ ~:1.
'1'!:5T
Jm5C!.tBE
REPAIR
.
CEaTInCATICIr .
r buoeby aert:.1:!y the t'orecoi:lc data., to be caznct &z24 that the tested d.evice 1s
t'WSQt10&1~ wi1:hin tne llALta ot tile ~.
PIllIU.w: t G, AM tI\ E e.\.\ l'\~ \ eg ~ IlOO 1\1 e. t>\ l2.1 \le. LIZ. \(l'l~C
BY?"M~rL ?'A.RLJi2- ta't'D'S CDTIFtCA'l'IOlf HO...QQl9.I. TEt. HO.~\
SIGNATURe 011 CEAT1FlED T'!S11!R
...: