HomeMy WebLinkAboutBldg Permit 04-0890
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
"'Oi PRIO,," ""
"" ~
- :<
w '"
+'NIVESO'\:'"
(Please type or print and silm at bottom)
ADDRESS -
33'-'S wtldI.JooJ TV'~; I
N.W,
Date Rec' d
8'- /tl-oV
I PERMIT NO. 04-.0 Btt'O I
While
Pink
Yellow
File
City
Applicant
LEGAL DESCRIPTION (omce use only)
LOT II. BLOCK I ADDITION WtJoJs JfI-;-~e. W, iJs.
OWNER
(Name)
/LIt, KbI H-~j ~
7" 'I 'I J 2.-~ s.T. kJ
A-H~
/ "
(Address)
(Address)
f!:,.1t. )(0/ ~J .kc
f~UL ~r-'
'7/' '1'1 I 2.-~ ~/. W , 19.// .
I
BUILDER
(Company Name)
(Contact Name)
ZONING (office use)
PuO
PID;(S-.3' F? -3 -01 cX.- <)
fl1;J
(Phone)
(Phone)
S'DLY
TYPE OF WORK ~w Construction DDeck DPorch ORe-Roofing ORe-Siding o Lower Level Finish 0 Fireplace
DAddition OAlterarion DUtility Connection 0 Misc.
CODE: WI.R.C. Dr.B.c.
Type of Construction:
Occupancy Group: A B
Division:
I
E
II
F
I
illIVVA
HIM R
2 3 4 5
,
B
S U
PROJECT COST/VALUE $
(excluding land)
40000 ()
I hereby certil)r that I have furnished mformation on this application which is to the best of my knowledge true and correct I also certify that I am the owner or authof1zed agent for the
above-mentIOned property d thaI all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans I am aware that Ihe building
:fici" coo ,",ok h" p 17'f:!1- Fmlh"mo". [ h",by "'" th" the "ty offici,[ m , ;',5; 2: eot" opoo the pcoperty to p,,[o,m o"d'~h;/~ f
I Signature Contractor's License No. . Date '
Permit Valuation ##I)O,OOtJ.OlJ I
Permit Fee $ . ,!)~5g. So I
Plan Check Fee $ ~I ~ S<{. 7[1 I
State Surcharge $ 200.6)0 I
Penalty $ I
Plumbing Permit Fee $ /00. Do I
Mechanical Permit Fee $ 100, () II I
Sewer & Water Permit Fee $ 3S: 5""0 I
Gas Fireplace Permit Fee $ ~tJ,()1 I
~:~io:\co~mgpe;;;~;d
BUlldllli!. Otlicial Date
~ q,z,.o4- $/0.303./8
Receipl1o. 4-"77'f(~
By .-(.
()
Park Support Fee
SAC
#
#
$
$ 1:<;' SO. ()e
$ S~O. QO
$ 7~, 00
$ 'ZOO.OO
$ 700,00
$ ISeo,co
$
ThiS IS to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance andmay 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 Cerlificatc of Occupancy must be
i"~ ~~ 9~/(JY
Planning Director Date Special Conditions, if any
24 hour notice for all inspections (952) 447~9850. fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake. MN 55372
Water Meter Size 5/8'(l!P
Pressure Reducer
Sewer/Water Connection Fee
Water Tower Fee
#
#
Builder's Deposit
Other
TOTAL DUE
Paid
Date
10, '1()J, -, J'
'9 /d, d+-
~1
Wh~~ - Builflinq
rr.i1 .. IV - Engineermp
Pink - t'lannmg
Tht' Cfftlt'f of lht L.kf Countf}-'
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
.
" _1.".-
"
,/~.
The Building, Engineering, and Planning Departments have reviewed tlie building permit
application for construction activity which is proposed at: _
..~~.: L::>
,~
i , ',/
l~.
Accepted
x
Accepted With Corrections
Denied
Reviewed By:
rill
Date:
f/'
r.!o,lo<.t
Comments: Sp.e Reverse Side for Additional Information!
See Attachments: 1) Gradine: Plan, 2) Erosion Control Measures
"The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to bea 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 - 5!'. ineering
c;PIfiK - ..,ann,"
Th~ C~nler uf the I....e COUnlr)
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
c.
.(.
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
..--
"
,
C
Accepted
Accepted With Corrections
/
Denied
Reviewed By:
.. Comments: ~
~~~
Date:
a.eP
,
~ JL,,(,-O::;AA__..f?.. ~:::(:; ~ ~ .
~~ AI'''''A'~-,",-~.
-
9/110 if
, " ..
A.c,~
.........:.t; en ~
~~
"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."
~~
~
0}'hi,e . Buildiri"O-::>
Canary - Engineering
Pink - Planning
Th~ C~n!rr IIf lhr I..kt COUnlr)
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT 1C 14- ((0-1-
APPLICATION RECEIVED f:?'- I q -0 t/
~
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
33L:.5'" IP/.i~~:)k,
Accepted
Accepted With Corrections /'
Denied
Reviewed By:
~
~
~ ;.1},u Date: 9/1 /0 ~/
. I
a..Lt' ~.
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,"
9524512155
CITY OF PRIOR LAKE
DASEN CONTRACTING
PAGE 01
952'I4~'424S F. 01/01
1.J._.~"_'lo6
CITY OF PRIOR LAKE
SEWER AND WATER PERMIT
. C~_<ll.Otmal...d'il!D..bolI:ll~l
ADD~~3U6 Luncl,wQ1. ~.0.
~ S- ~'.3 I PERMIT NO. 0+.0 g 90 I
ZONlHG(IIict"", I
LEGAL DE.:.CRIP'.:xON (ollI.. '* OIIly)
. LOT BLOCK
At'OmON
PID
~~;R~A tot "1-\D""Q.R (Pkcue)r&-4'~(3 -tf~ .
(Addrlss) _ 7(o~ ??rPtt UIl)' ~t4tb..n
{.""'-l - ~ )T;7t: ro"" r';
~ -- . 1-
'i;?,;~ ~_0<.2> {0 ~ -b;t ~~\.O 1- ::>-l(Yl -;-
(Addc>:ss)Q~_>" UC:...1\Jc1~ .L M If n \ \1 0 (\ ~_
.~') .'~ (ZipC,do)
(Conc..c:tpeuon) _\l41f0b1.6./~ /J_ (Phone) ~I';?-~,
APPUCANr:;IO;'lATUlU. a1~~ DATE _ - -
- ~l....' -
_~:!L.
==
APPLICANT PLEASE COMPLETE BEl ,OW
Size I~fwatcr seniCI:: ;Achcs.
Loea.joIl. of any couplings from stroCture'
Type of sewer pipe. 0 ABC 0 PVC
Estimated length of !ewcr line feet.
Clean out (if required) locate, i at feet from stIUcture,
feet.
o Cas; roo
FF.E SCHEDULE
ROfid.:ntlal,,,,cr aCId wmer be OOl1llecciOD 535.50 Ind\l..rla~ Com'l &. Multl-flIcnily 1% of job _ wi:b. a 539.50 Dcillimum
S...... connection only S17.S0 WmfconllecttDll 0lI.Iy 117.50
EstirtattJd Cost S
Building Permit # __
SEWER. AND WATER PERMIT FEE
STATE SURCHARGE
TOTAL PfRMlT mt
s
S
$
_ ----:111
-'~dllfi;;;Qmti...
Da..
I Fila
IDatc
PAID WIll-!
Blil'I;'a".JlNG
~~
,-
(om., u.. o.,ly)
Th" App.!lcallDr. komes YDur Bulldlac Permit Wh.,. App...nd
:l4 hour no<l.. for III ""po<<I... (951) 4047....50, tu ('~) 4 7...c~4S
Ton'L P. 01
12:1217PM
MATTHEW DAN! ELS, rr,c.
423 312117
P.01
lJate Kec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
~. ~ ~:~ I PER1\-lIT NO. '-/_ 00'1'\
1 'r'elklw AP9IiUlll . 6 Y
rp1eMc= ~ OT grine and siED at bottOm}
I ADDRESS
-.3C"O )//jJ, I' ,--;;U~
ZONING (oIIlc, u..)
LOT
LEGAL DESCRIPTION (ollic, use only)
BLOCK
ADDITION
PID
g.~~RC?() .~. ~
(Address) 7(,q4~ 1~-;1.J..h -..M-. W.. (] /all,. Yn.J/1t, "-t/..()
7 'l
APPLICANT ~
(Name) ~Ttl Ol{) /J/I; 111,(, J. ~M (i. (Phone) _ t,SJ. 4.:1-"'. d'1..'{n
(Address) /.~~ (lJ/;' J, A J J 1'1 pl. ..,1'" I; q4nLd 1'1 1 t...::::tJ ;) ..s::s-o~8
(Address) V ; (City) (Zip Code)
(Contact Person) iJl J. ; 1 4) C \. f.L ~ ') (Phone) ~f>J. ./.3,3 . ."'~
APPLICANT SIGNATURE b. ~J~ 'tJC:!fUA J Jlll~~/ DATE IJ,d"A);;;;) It}.., {UJ(J4_
APPLICA~P~EASE COMLETE BELOW
I Type of Fixture I Quantity
Bath Tub with or without shower ,-3 . Rough-ins
Dishwasher I I Water Heater
Floor Drai!, 11<1- Water Softner
Lavatory (Bathroom Sink) I i Stand Pipe (Washing Machine)
Laundry Tray (lor 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) Other
Quantity
I
I
l
.3
J
~
I
/ M.
&.
(phone)
-5s I;).J
tEJ- ~- ~
Type of Fixture
FEE SCHEDULE
industrial, Commercia! & Multi.family 1% of job cost with 3. $39.50 minimum Residential. New One &:. Two.Family $99.50
R~$idential. Additions & Alterations S39.50
(om" u.. Only)
Estimated Cost $
Building' l?errnit #
qq. CD 'h-- '-Ilii:J
.sO
IlJlJ.iJtJ ~ ~ , .
,'" '.
~ ;"[ .::' .. 'I"', ~ '!. ;,. '",.7
. '.J
"':"';'l'f"~".. "" .
\:l,' 1...",'. ", :.,.
I
I ..
PLUMBING PERMIT FEE
STATE SURCHARGE
I TOTAL PERMIT FEE
$
$
$
Building Official
~m~ I ~ 7;cci i c;fl..1 i-c. ~ejpt No.
I'" ILJ . C, . i I ~ i ,'I
. - Ij
Dlte . ~fft OCT 1 3 2004 !.' ~
24 hour notice tor all inspeetions (951) 447~~sa~(9~) ~7-4145 .._
--1--_.__
This Application Becomes Your Building Permit When Approved
TOTAL P.I2I1
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIT
Date Rec'd
(Please ~ or 'Print and sim at bottom)
ADDRESS
i~" ~:~ I PERMIT NO.O 11.. thI{)
3. Yellow Applicant ~.
3365 WILDWOOD TRAIL
ZONING (ofliceuse)
LEGAL DESCRIPTION (omce use only)
LOT BLOCK ADDITION
PID
OWNER
(Name RA KOT
(Phone)
(Address)
APPLICANT
(Name) AJ.J.TRDFTRRSTnR DRA FTRRSTnR HRARTH & HOMF.
(Phone)
651-633-25/\1
(Address)
2700 NORTH F AIRVIEW AVENUE
(Address)
(Contact Person)
BRENDA HUSTON
ROSEVILLE
(City)
(Phone) _651-633-2561
55II3_
(Zip Code)
APPLICANT SIGNATURE
BRFNDA HUSTON
DATE
10/11/04
APPLICANT PLEASE COMPLETE BELOW
xD NEW CONSTRUCTION 0 REPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
DWarm Air Plants
DGravity
o Mechanical
DAir Conditioning
DVent. System
o Steam
D Hot Water
o Radiation
D Special Devices
D Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
HEATN OLO PIER-HV-IPI
Industrial, Commercial & Multi-Family
FEE SCHEDULE
1 % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential, Additions & Alterations
$64.50 Residential, AC Only
$39.50
Residential, Heating & NC (New Construction)
Residential, Heating Only (New Construction)
$39.50
$39.50
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
Building Permit #
$
$
$
.50
." '.1
, '. -,-,,' ...:' ;. ~ '" ,
"(1 r-" .:.1_"" """'l'\~"~
'.>...Wih\.,:; t\;.,~.,\.
(Office Use Only)
HuUdinl!: Official
I\_.~'i~ (l~: \~ IJ .\fl ~ r~leceiPtNO'
\\~~te OCT 1 3 2004 y
'Ill
UC'
24 hour ootice for all inspections (952) 447-98 ;0, fax (952) 447-4245
By _---------,
Date
This Application Becomes Your Building Permit When Approved
CITY OF PRIOR LAKE
HEA TING/ AIR CONDITIONING/FIREPLACE PERMIT
Date Ret'('
/0./1,04-
"
~ ~ or orin1 II' 1 URIJ, at bormm)
, ADDRESS /
53GS-:- tu,ldwcJ~d Tal;'
i ~ :'":, I PERMIT NO.~ I.)II(lp)
" YlIlloow A,Hilr.anl . ""'. .,..~."
I ZONlNG ',,,",,,,,,,) i
LEGAL DESCR: .'TlON (oflIce lilt on!)')
tOT BLOe: :
ADDITION
PID
OWNER
G'll-'1'.e) I? ,A Ked- )../'-;J'Ut!:-S
(Phone) 6S1- f/;2.s-og,;?c;:l
Y\ddf'"..s.) 76.94' /;;;j8"-r1tl s+d~T /~e<:,' ~J"''''Jd'J7'1U!/ ~<:::JRzt;l
, APPLlCA.'lT
'(Nome) A.nbe/I-,,f::L1Z.;~ (Phone) ,B..J.74/,(-s;;;Ja.d
I ,.ACdIess) / 0l.;1 S:3 ;u, ,:.-?II~!' ~ ,,.,... Snu-rV '-elL/Ins./! /h <:".~~ ~ '"7
(AiIdrc>>) IC!!)') IZ1P Co';')
'll (Ccntactperson; _~~KJ j ~Y1t<e/J . . (Phone) 9S;;;-7,/(,-~od
APPUCANTS!,NATURE ~::..___ .~~ DATE~-13-ac/
. , ... ~ANT PLEASE COMPLETE BELOW
I . ~EW CONSTRUCTION 0 REPLACEMENT 0 ALTERA TIONS
I F1.iR..<ACEMAII ;;ANDMODEL".8.....JtlJ-.;?<$.;V..141/0~flfit1dFUELt!.L!:!L-t-
i FLUE SIZE ~:" P IN__' RETlJm OPENINGS / / INPUT lac> 000 OUTPUT ~6'V
TYPE OF SYSTEM HEATING OR POWER PLANT
, g40rm Air Planl3 0 Stelll1
~"ity I!.'IHot WeJJ1l
.<lan;",1 [ R&.di&tion
Condltionini [ Sp.ci&! Device.
.' .nt 5yllem [ Other Dev;...
PLE.A.5E Non:
Air Condlt:oner Vnlts
ClJlIlot Encroach into
R.quired Side Yard
Selbad.
I FIREPLACE M, K.E AND MOnEL
I
Icd\.:$~JI.J, Comml cia.! &:. Multj~Fwily
/R,~den1I.I. Heal, lolL AlC (N,w C""'tNclion)
,,,identi.!. Heall g Only (New Coostnlclion;
FEE SCHEDULE
I % of job 0011 R..I~CllII&!. 0., Pireplace
539.50 mill11ll1.1n1
S99,~0 R"idcntial. ^<!dillon. &; Altmtion,'
S64.l0 R"ldentlal. AC Only
\39 \~
l3950
lJ9SQ
E.ltimawd Cost S
Buildin& Permit #
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$
S
Bulldi ,O(llcl.,
.,"
!' _A--.lI) WI 1 11
~~...-~. - -
[f1U6 l':>J]J;llJ ~ .' b
i!~'fCT 2Jf _I L I; ':1'
%4 noor oOli.. (or ,lila.p"aon, (9'1) <<7. \S,p, (11 (%2) ~7-41<l5 . .-1
Dlle
1---
J--
(oroce Uu Only)
This AppUClI .on &tom", Your lluUdlni Parmit WIlen Approvod
PRIOR LAKE
INSPECTION RECORD
SITE ADDRESS 33fo5 \tJlLb~()~O \~k.. tJ.yj.
NATURE OF WORK ~~ CAt-\STA v(.l'",b~
USE OF BUILDING OS .f:. D,
PERMIT NO. ~ 01' .O~~O DATE ISSUED ql. 10 &.( _
CONTRACTOR .~~. ~ T "'1)1'(8 ,~. PHOt-JE~. CoId-4:JIO
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
DEPARTMENT OF
BUILDING AND INSPECTION
.J/lSPECTOR
DATE
I FOOTING C0q ~ I ""-P
I FOUNDATION (Prior to Backfill) I (I/) I c; -~,
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
fI/j
~
fllf/
SEWER I WATER I SEPTIC
FRAMING
INSULATION /-.0.... ~1A.1
ELECTRICAL
PLUMBING
HEATING (if required)
FIREPLACE
GA~ LINE AIR TEST ~~
COVER NO WORK UNTIL ABOVE HAS BEEN S!.9_NED I
. ~Jt.IILrM/I~/J/F I {,r16 / j/l'
rJ6 rJ, ~ 4i- I FINALS 'eo.~UI.l.~ I
GRADING (Prior to Sodding) ~ KP' t: / J ~ ()('-
BUILDING <"J~ ~.-hY"'"tfiL #S
ELECTRICAL
PLUMBING l() c..
HEATING
DO NOT OCCUpy
~ .
'if}
(//7
UNTIL ABoVE HAS BEEN SIGNED
NOTICE
This card must be posted near an electrical service cabinet prior to rough-in inspections
and maintained until all inspections have been approved. On buildings and additions
where no service cabinet is available, card shall be placed near main entrance.
1
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FOR ALL INSPECTIONS (952) 447-9850
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS J:i:;~.,
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
It )NSULA TION
)!l'.ElNAL
o SITE INSPECTION
COMMENTS:
\l \ fY-J(_
-.1~TL_
SCHEDULED ~
tJl"IJ L.')O~
CONTR.
PERMIT NO.
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
I ( )
~N,
TIME
Lf /O~"tO
o EXIGRADlFILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
9lt
)LWORKSATISFACTORV, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECTjK, CALL FOR REINSPECT10N BEFORE COVERING
Inspector: _ Owner/Conlr:
CALL. . 50 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
\)
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYI
...,.,,,
j/;;:6 TIME
CITY OF PRIOR LAKE
INSPECTION NOTICE SCHEDULED
ADDRESS ')'Yv,c.; ~j ,.U LMnJ
OWNER CONTR.
PHONE NO. PERMIT NO. if-er6
o FOOTING o PLUMBING RI o EXIGRADIFILLING
o FOUNDATION o MECH RI o COMPLAINT
o FRAMING o WATER HOOKUP o FIREPLACE RI
o INSULA nON o SEWER HOOKUP o FIREPLACE FINAL
)l/LFINAL o PLUMBING FINAL o GASLlNE AIR TST
o SITE INSPECTION o MECH FINAL a
COMMENTS:
~,,~ ~~ (ifMt;::.~
? t:"\~ Q.--Q q '1\A';fR~ ku&~ ~~
3. \-k..Js.tJL 'D....ilJ-Q i/JN..><. ')s.f ( ttt ~. UWI
t./. ~ID( ~t.A- t3iucclr
'5"- ~~,'fDt- (\1?I'\.~
'~
11 - I
U ,.. \- '() +,...,
B- (-~
~~~'~r~~\
_fu,.,> i)a,.r 1)JjqJ (2..)
, '7
o WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
X CORR"(Jl;K. CALL FOR REINSPECTION BEFORE COVERING
Inspecto Owner/Contr.
::/
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYI
INVIOTJ
'-15<
33'S- W,'{)Wf)()J Tr'
({A K;;f tbllU'A
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS
OWNER
PHONE NO.
o FOOTING
o FOUNDA nON
o FRAMING
o INSULATION
~INAl
o SITE INSPECTION
COMMENTS:
0~-(C)K-
SCHEDULED
CONTR.
PERMIT NO.
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
Lvrb&~ rlK..
OATE TIME
~~LlING
.r Q cdiillrArNT
o FIREPLACE RI
o FIREPLACE FINAL
o GASllNE AIR TST
o
N 0 ~.pr
X.WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
4? /,;.-
InspeC1Q#"~ ',.....:::- Owner/Contr:
CALL 447-9R5P FOR THE NEXT IN!lPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH .t SAFE7T!
,,,,,,,,n
,
~-.,)
Job Address J] (.C"" () l~u::n.O Tt2-
Heating Contractor A.;)U:LL-At,t,E"
Name of Tester Sb*..)~
Date /2 -2<\ .0+
Percent 0 ""i.'-
Percent CO2 1.4
Percent CO D
Slack Temp. LOI ~
,