HomeMy WebLinkAboutBuilding Permit 01-0420
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
(Please tvD~ or print and sign at bottom)
ADDRESS
3t.o'2.. Woof> '/)L(c.-k:.. DfUvE
Date Rec' d
-al
I. Whi<, ';1, I PERMIT N
2. Pink CIty
3. Yellow Applicant
LEGAL DESCRIPTION (office use only)
LOT/'5 BLOCK I ADDITIONTH~ w'ILP5 ~~
OWNER
(Namel,
(Address)
ZONING (office use)
PttD
PID a~-~- 0/3-[,
(Phone)
BUILDER
(Name) J,J..rt...
,
(Address)~3ro ~I..IfClIls: ArJfI! I L.....u~JIUJ;;:.
TYPE OF WORK ~New Construction DDeck
DMisc_
DLower Level Finish
~ Fireplace
(Phone) ~f..~ "lAC; - +11,,"
~Porch
DAddition
DRe..Roofing
DAlteration
PROJECT COST /V ALUE (excluding land) $ ~~, tmo
DUtility Connection
DRe,Siding
I hereby certifY that I have furnished information on this application which is to the best of my knowledge true and correct. I also certifY that I am the owner or
authorized agent for the above.mentioned property and that all construction will conform to all existing state and locaIlaws and will proceed in accordance with
submitted plans. I am aware that e building official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may
enter upon the property to erform eeded inspections.
3$0,0<90
$ 2/Z~/. 751
$ I-+~. /4-_
$ /~5. Of)'
$ 1
$ I DO.rJO1
$ I ()/").O' I
$ 3S-.50 I
$ 40 . OJ I
/)/1
o es Your Building Permit When Approved
x
I Permit Fee
I Plan Check Fee
I State Surcharge
1 Penalty
Plumbing Permit Fee
Mechanical Permit Fee
Sewer & Water Permit Fee
Gas Fireplace Permit Fee
3~~-&rl/
$ 9. 925.'39
I~H'
-~IOJo~QI
Contractor's License No.
I Park Support Fee
1 SAC _
I Water Meter Size 5/8'@
I Pressure Reducer
I Sewer/Water Connection Fee
1 Water Tower Fee
I Builder's Deposit
I Other
I TOTAL DUE
I Paid
I Date
~'2 .$'.3 "
~'Ir-tf/
#
#
f/4/D I
Date
8sQ.d9
#
#
$
$
$ ~c;n r')
$ 1)" ,cr>
$ If 1cxJ.tX'1
$7~~.~
$ /,5'00'.001
$ I
I
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
~0annin-f'oi~: -. 6/;'(&1 ~ ~~t~~~
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 .
,I",
,.
Thll' CII'IUlI'r or thll' L.k~ CO_"try
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPi..enOff'rJEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
~-:/ -17- I (). f (-
?f)/
C6!u,;tV
,/ I
(( -
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
3 J U.d- .j)_)(~//")/) /1..( Ie L) y-
Accepted
v-
Accepted With Corrections
Denied
Reviewed By: C,. ~ ~ /-('...-tUt
Date:
1~/7 /D I
Comments:
~V\AI~lM., 2-y ~ I:d~{ w~Ar
~~~ 1.AMrJ ~'l V1Vij 0l..8<c.J
. -, 1 -
<::w r:vvn"
"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."
. .' ~;:.;.. --
. -.'i). .." .::: ~'-"";,):;.'.~1;".~;' ,;,f-- --'r-
~ (-.."I..rot Ih..I...... COU"'"
White - Building
Canary - Engineering
Pink - Planning
BUILDING PERMIT APPLICATION DEPARTMENLCHECKLlS"(
NAME OF APPLICANT
APPLICATION RECEIVED
'720f2-IO-f(
(;-,.) 7 -() /
CO/J)(V-
~
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at: .
3 J.O d- UJOOrJ/) LJ.-cJ( D y-
Accepted
Denied
><.
Accepted With Corrections
.
Reviewed By:
1iI.fJ: I3
Date:
S-/O -01
Comments: See Reverse Side for Additional Information I
jJ1(/t, f- he.. v( .:l '7D (;, rJ.L 0 w.. y .c;.o o'VI h,,1.I s<.
"
C" ~ .. -
vee i'\~~<;\\,;nmems: ") \,jraomg t-'Ian, ~) l:.roSlon <.;ontrol Measures
3) Erosion Control Plan
"The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
any of the provisions of this code or of any other ordinance of the jurisdiction, Permits
presuming to give authority to violate or cancel the provisions of this code or other
ordinances of the jurisdiction shall not be valid."
~~
White - Building
Canary - Engineering
Pink - Planning
Th. (".nlfr of Ihr L."" COllnlry
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
Kaf-z../(),F{:- CO/VsTv-
(j~d 7-0/
APPLICATION RECEIVED
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
3 d-O~ woon/J /).LI(D y-
~
Accepted Accepted With Corrections
Denied 0/J/2J
Reviewed BJ;:: f( {~-
Comments:
Date: 5-3~ZdJd(
- ~ ()
..~ qJ)J2 ~~ /IrJ(V?~,.,
v
"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,"
Date Rec'd
CITY OF PRIOR LAKE
SEWER AND WATER PERMIT
i ~ ~ii~ I PERMIT NO. ( - /../df)
3. Gold Applicant -,I
~lease ~ or orint and sie:n at bottom)
ADDRESS
3 .2..0 Q lI.J (\ 0 .0 D lA e.. It.
().-t?-
ZONING (officeu..)
PlA.[)
LEGAL DESCRIPTION (office use only)
LOT I~LOCK' ADDITION
r
u)~~rJ.
PIDb25" '" ~1-01.3-v
OWNER
(Name) Q. 14- 'r 2_ I A-F,e
(Phone)
(Address)
(Address)
(City)
(Zip Code)
APPLICANT.
(Name) 0 ~6SIJ.-L-L &-1. t.. .
(Address) Ib J l k :rDI'LrvJ
(Address)
(110\.. TC-j.J
APPLICANT SIGNATURE C' ~ ~. ~. . f\~_
I.Jyq-"f
(Phone) ('q..r.d ~ fI.2 -~ 1J (J t,
ljtVL. sr6l/i/
(City) (Zip Code)
(Contact Person)
(Phone)
DATE
? It; /r, J
.
APPLICANT PLEASE COMPLETE BELOW
Size of water service J inches.
Location of any couplings from structure -
Type of sewer pipe, 0 ABC ~ PVC
Estimated length of sewer line l./ c: feet.
Clean out (if required) located at ~ feet from structure.
feet.
o Cast Iron
Estimated Cost $
$35.50
$17.50
e,O
NOo-
FEE SCHEDULE
Industrial, Com'l & Multi-family
Water connection only
1% of job cost with a $39.50 minimum
$17.50
Residential sewer and water line connection
Sewer connection only
Building Permit #
SEWER AND WATER PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$
$
r .50
t"A1D '-'nTH
,tt1ttDING PEF;.v:IT
(Office Use Only)
This Application Becomes Your Building Permit When Approved
Paid
Receipt No,
Building Official
Date
Dat1_ b-of
B~
14 hour notiee for an inspections (951) 447-9850, fax (951) 447-4145
I
.."--
CITY OF PlUOR LAKE
REA TING/ AIR CONDITIONlNGIFIREPLAlt'E PERlVIIT
'Dak Rec'd
l.Pl~ tvpcr a, criA~ ~4 rie at bamnnl
I ADDRESS
;'Z.O(');;2 (.,.)o",A)
~ ~ ~I~. I PE~IlT NO. /__ 1;-" t?, I
~. ....a.,- ...lJpI'....nl '-1c;:"'"'C/
UGAL DESClllPf!ON (ollir:..... ,mly)
LOT A BLOCK / ADOmON
~~ ~;l"
, y<!
JI/.Lf~ .,;$
-"
N. t.:J ,
I;~:O~'I~I I
pTD-.;:)5337-0(j -C'
OWN.E.ll,..,-, n
(Namel 7<A.J.:,)A J!. ~
(Add=sl L.R(, /
APPLICANT ,I, r\
(Nam<:.)_I':;.A..~rJyJ/kAJ CJJ,..
(....d.<lress) ,;1/~)C G ~--.J A., I ... .
!AW1<=nJ
~;.n~ c::
. (l'hcn,,)&~J 98.s"-sCt~
(Contact l'=cn) ....__..__
APPLICANT SIGNATURE Li.~ . ;(.r.-~
{Phone) _~~) ~~ - ~.;J;:t
~ &d. ,.c;'~O! 4
(f (City) (Zip c."",
(Phone) ~ - ~d:;;t,
DATE C; -/J/-O{
, APPLICANT PLEASE COMPLETE BELOW
,.BNEW col'ISTI\UCTION 0 REPLACEMENT 0 AL TERA nONS
FUIlJllACE MAKE AND MOOEL ~..,,.. /V1.. FUEL ~"t._
FLUS SIZE .-:ed PVC_ kE'rUllN OPENlNOS INPtn OUTPUT
TYPE OF SYSTEM lGATINO OR. POWEllPLAl'IT
OW.,,,, "'ir PI"".. 0 Stum
OOra.it)' 0 110' IV.....
~.<hlUlI..., 0 R.odlatlon .,-,
~Ir Conditioning 0 Spooi,l O..i...'-=H" h,,1'Jr/~
'p.nt. System D.oth.roc.i<..)
Flltl5PLACE MAKE ...!'I'D MOOliL t?auP I R- ..;~
u
fLEASE NOTl:
Air Con<llti..ner Units
C""not i::neroadl illto
Required Sid, Yard
Se"'a<:k.s
IndWiltial, Cumm.rcial 02 Multi-Family
Rosid...i.I, l-1...ting.ll. AlC ('N... C.nBtn1"~Qn)
R.....idlo:ntial. Hl!:I.E:i.ag On.ly (Nc:\I' Canstn.&Citiart)
VIE SCJlll::OULE
l'Yoofjoo cllOt Rcsldttldll. Gas .i"'PI..e
$39..50 mi"imuTTI
S~y,;O
$&4,$0
S:l9.50
HEATING PER.'\1lT FEE
STATE SURCHARGE
TOTAL PtJUnT FEE
s
s
s
\R1lE~'~'V1\t.\D) 1
JUN 1 r; Z001
"'''''D~
.8UILDING JTH..::::::::::::~=::=::
,50 .1 r
RaidcntiaJ. Ad4iLions &: Altaradol\l
R.esidttltill, "C OIIly
Estimated eelS'!: S
BulldiJIi pecmit H
(Orne.. USe' OblYI
,hi! Application Reeom... 'iour .I!hdldinc Permit Wb*n Approved
flid
. UUt.im Nn.
l'JuUd'n, omdlll
Date ,
D.... L-, -/1./.-(')/
I
14 hour 111J1I:'c!I! ti:Jr An i'Upcdlanl ('!:Z) .w1.98s;OI (:Js (952) .d.4":'...a:2.:.iS
B%;;:c...
V
~oolZi
lilY a::rI10l!.LllO:>
9L~909tIS9 XYd ct:LO IHd ~OO~/S~/IO
01-24-02 03:54 PM FROM FGTN PLG HTG
TO 6124474245
POl
"- - ~.'
CITY OF PRIOR LAKE
PLUMBING PERMIT
Applicant: FQ,r~J.... PI! &. Ill..,
Addl'llss: ;At03L1 c..il..,'lf"~rJ... Ie... II sf,.
Signature~- .' 0 IJ -",12.Q.,
Legal Descriplion: Lol Block
Site Address: _~~O~ .......,...-1) ~""< k. a-
Building Permit. PID .
NOTE: This permit wlU not be processed without complete inlormation.
1"'..-
1: (hold
) YIlII_
....
ellY
"ltplU::al1ll
#
01,042.0
Phone: .b<;,-4t.."\. 71(::1."_____
TIl.C"flU'f.r ........... (O.'UIIO
Su"
FIXTURE UNITS
Quanllty Type 01 FiJlture Ouanllty Type 01 Fixture
d- Bath Tub with or without shower 3 Rough-ins
I Dishwasher I Weter Heater
I Floor Drain I Water Sollner
5 Lavatory (bathroom sink) I Stand Pipe (washing machine)
I Laundry Tray (1 or 2 compal1ment sink) Sewage Ejector
I Shower Stall \ Bac:IdIow Asssmbly (RPZ, 00ubII0 Check, PVB)
iii I SinkS I Backllow Assembly rest
Bar Sink I Lawn Sprinkler
3 Waler Closet (toilet) I Other
-....
PEE SCHED~ '" ~
"---/ slrial, commercia~ ~t~
(1% 0 JO 39.50 minimum)
Residential, New One & mlly
Resldenllal, Additions & Aiteratlo
State Surcharge
, --------.-."
'.1,"\ ~.-
S9~ $__
39,50 Co(,~. $
tfJ. ".., $ _.:s.~
<;,,..~( - -I- --_
GRAND TOTAL $
This permit is .ranled upon Ihe express candiliun Iha, .aid
c"".....to,. Ihllll """,pl In.1I reopoc:.. will> the: urdi-..
of lhe Stoll Ph,mbinl .",en_nll thc"",r,
- R Z.'f.O"Z--DATtl
II TreST
Call for all ins tions 24 hours in advance,
16200 Eagle C~ek Av, S,E.. Prior Lake, Minnesola 55372/ Ph, (612) 447-4230' FAX (612) 447.4245
An Equal Opportuni.y Employer
CITY OF PRIOR LAKE
REA TlNGI AIR CONDITIONINGIFIREPLACE PERMIT
Date Rec' d
1,I"iM
,. a...
J. V_It,...
~:~ I PERMIT NO. /- / j-, /), I
A.pph~""l '-1c:;rt:/
lPlc:ue tvTn at orin!: and sim at bal:b)ml
ADDRESS
~O~
l.. 'J~,.,,C)
~~ 1)./1/;,1"
N, t:J ,
I;~{.~'~) I
. LEGAL DESCRIPTION (ollic:, \lSO unly)
LOT /3 BLOCK / ADOmON
J I Jdcf::; ~ rC
p!D=:I:S-337'Of:i .J
OWNER.-.-,
(Name) 'KAAJAflf2
(Address) L~j I
A6_c::
(Phone)~.9&s'- ~S"1
. APPLICANT j n
(Name) ~A..Jfl'olkAl (11/'1
(Address) 0110) 10 IiQ,1.,AJ Au I /"" ,
(Addm.)
(Contact Person)
APPLICANT SIGNATURE L~ -Z~
(phone)
Ai 1-,...)
tt (City)
(Phone) _ ~ - boa:;\..
_ DATE ~ -/4-01
~5"~) -t""" - H7Ld~
-~~.O! 4
(Zip Code)
APPLICANT PLEASE COMPLETE BELOW
~EW CONSTRUCTION 0 REPLACEMENT 0 AL TERA nONS
FURNACE MAKE AND MODEL 2il..J\.le 7ii"Ji.. FUEL ~j..
FLUE SIZE X H PV c.. RETURN OPENINGS rNPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
OWarm Air Plants 0 Steam
OO.!"vity 0 Ho. Wiler
~cchanj<aJ 0 Radiation , _ r:' _ I
~Ir Conditioning 0 Special Devices~); r,'fls IYIt~ e
pent SYStem D,Oth.;rDevicl!Is I
I FIREPLACE MAKE AND MODEL ~VO I 11- -1.4
u
PLli:ASE NOTE:
Air Conditioner Unies
Cannot Encroach ;"to
Required Side Yard
Setbacks
IndU$trial. Commercial &. Multi-Family
FEE SCHEDULE
I % of job cost Residential. 0.. Fireplace
S39.jO minimum
$99..50 R-=sidcntiaJ. Ad.diLions &; AJterations
S64,50 Rcsid<lluaJ, AC Only
539.50
R~ide.nti:,tl, He:atina: & Ale (NI;W Con&lnu:tion)
Residential. Heating Only (New Constn,ll;~ion)
SJ9.jO
539.50
Estimated Cas! S Building Permit 'I.
HEATING PER."Vl1T FEE $
STATE SURCHARGE $
TOTAL PERMIT FE:E $
BUI{G'D WITH
. ING PERMIT
,50 I
(omc. u.. OnlYI
Thill Appli.ation Beeom... Your Building Permit Whln Approved
aulld/., omctal
I Paid -=----
I Date /
. L, ~/'I-T),
24 hour "0"" for oil inspections (9S~) 447.9I1SU, t.x (952) 447-4~45
RloceiDt No.
------
D...
I B%x:.--
r/
looll1l
lfI lIOIlld AJ.:> +-++
lIlY Qa'110lLLNO:>
9LZ909tlS9 YVd 9t:SO ITR1 lOOZ/tl/90
PRIOR LAKE DEPARTMENT OF
BUILDING AND INSPECTION
<
INSPECTION RECORD
SITE ADDRESS ~~; \J..}O",,.J. (J,k f., Dl-
NATURE OF WORK 1
USE OF BUILDING ... t=: \)
PERMIT NO. (){-042-D DATE ISSUED -S' ~ <:"- 2/K)(
CONTRACTOR J2",h lr.~-r. ~ Tw- _ . 95"2~~- If/16'
NOTE: THIS IS NOT A PERMIT FOR ANY Ol~ THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCuMENT
INSPECTOR . O.....TE
I FOOTING ~ feeJ,. ~I I (~\\~ I (~~ \91
, FOUNDATION 1Prior to Backfill) I ~ ~'~ I '7/',() I D I
PLACE NO CONCRETE UNTIL ABOVE' HAS BEEN SIG'NED
ROUGH -.INS I
(~. ~~i.
1'1. ,IIj~;}11l (
f--Ia-h)
"Rr\ 8~
~,~ '? 'VJ
1\1;\-- B~
SEWER I WATER I SEPTIC
FRAMING
INSULATION
ELECTRICAL
PLUMBING
HEATING (if required)
FIREPLACE
GAS LINE AIR TEST
(:l\VM\~ F
o
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
I WALLBOARD I I
" FINALS
GRADING (Prior to Sodding) 1!2 ~ Z/ J
BUILDING-T:UJ,-tJ.t efLfoz.. 61!/\rj dfollJ2-
ELECTRICAL
PLUMBING ~ ~h l\n\D.L .
HEATING 6-'1 ~ z../ fp /~ z-
DO NOT OCCUpy UNTIL ABOVE HAS SEEN SIGNED
NOTICE
This card must be posted near an electrical service cabinet prior to rough-in inspections
and maintained until all inspections have been approved. On buildings and. additions
where no service cabinet Is available, card shall be placed near main entrance.
Call between 8:00 and 9:00 A.M. for all inspections
FOR ALL INSPECTIONS (612) 447-9850
QLertifirau . of ~cmpanry
Clll OF PRIOR LAKE
-J )gepartment of .uflbing .Jn~pedion
r Final Pennitted 0 Conditional C.O. Expires
This CertifiCdle issued PU1'$lUJ1Il to 1M nquiremellU of Section 307 of 1M Uniform Building Code
, certifying rhal at tM time of issUQ1ICe.this structure....... in compliance with tM various ordinances of the
City of Prior Lolce reguJatins- building COII{truction or Il$e, For tM following:
SINGLE FAMILY
UoeCluli_
R3
VN
Fire Z<me
Type ConsIluClion
c ',., . '. Type
Leplr- ,', :."
L13, Bl, THE WILDS THIRD ADDITION
Owner of Buildin,
RATZLAFF HOMES,
CooInctor', Name 4; Addras_
C:~te Address
20730 HOLYOKE AVE., LAKEVILLE 55044
3202 WOOD DUCK DRIVE
ROBERT D. HUTCHINS City PIanaer
{!/l /r~~OffkW
Dale: ~I' 0./,67.,.. Dole:_
I POST IN A CONSPICUOUS PLACE
. -
01-0420
Bid,. Permit No
NIA
ZoninJ Dislricl
PUD
DON RYE
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE SCHEDULED 1-2~.o1 '2-l00
ADDRESS 3;( 0"2 W"''''& \)dr~
OWNER CONTR.
PHONE NO. PERMIT NO, 1-:;{llO
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
A-ii SEWER HOOKUP
n ~LUMBING FINAL
o MECH FINAL
o EXIGRADlFILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
COMMENTS:
~e1r ~eaId
~K SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: ~ _ r () J . , J Owner/Contr.
CALL 447-985~ INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS k FOR YOUR PERSONAL HEALTH & SAFETY!
lNSllOTJ
DATE TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS
3~2...
SCHEDULED I/z.,t/",,-, ./1.. ~
/~
OWNER
CONTR.
PHONE NO.
PERMIT NO.
t'J I - ~4iLt'
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
}il FINAL
o SITE INSPECTION
o PLUMBING RI 0 EXIGRADIFILLING
o MECH RI ~ COMPLAINT
o WATER HOOKUP FIREPLACE RI
o SEWER HOOKUP FIREPLACE FINAL
o PLUMBING FINAL 0 GASLINE AIR TST
~MECH FINAL 0
COMMENTS{i\ f~ ~:, r-t<;" ..
F. f.? t- -p ~ .~ fa &e.
W , ~~\\ALt\ov..-
~^',4A I' ~ ^-." t).Oo;"
~ a.~~ O-<t:.~e-'O(J.
~ ~1:x'1-- ~~ L,L, +v ~LI,! __
~~ p"..e...,.....:-. L. L-, / ~ ,
~ J~ ~-~/~..
, /
~
Cl)
~ ~...:~~
o WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
~CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector: ~ . Owner/Contr:
r/
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
....."
SCHEDULED ~J~7
\.#(9001 ])uu~ Dr,
CONTR. . /?c,./2../" ~
PERMIT NO. . A 1 - 'f z.o
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS ~02
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
COMMENTS:
GI Jib &-, ~~~ k"_
DATE TIME
~ILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLINE AIR TST
o
5.n-
;~WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspector:~
Owner/Conlr.
CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE,
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH'" SAFETY!
INSliOTl
,.
''-.,/
APPUANCE
PERFOflIII&NCE TEST
Attach to gas One adjacent to regulator
Healing Contractor
Name of Tesler Lit
Dale 10-;1') _01
.'
"
JobAddresad;JOJ A./1D1&v,X. .,.."..~
Heating Contractor
Name of Tester ( J.
Dale /0 -,)3. -01
Percent 0 8'. I
Percent CO. 7. 2
Percent co 0
Stack Temp. / 0 '("1"
L