HomeMy WebLinkAboutBldg Permit 05-0160
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
I. Zt,. oS"
White File I PERMIT
Pink City NO. OS-. 0 {(PO
Y.llow Applicant
(Please type or print and siJPl at bottom)
ADDRESS
/ -1-..3 9 () W 1'In:;:.e.f e:.o ~6 7JV'1 / '-
LEGAL DESCRIPTION (office use only)
LOT 20 BLOCK
ADDITION ~()tJ.o/AfS MANOL
PID2.6": //9. 01". 0
(Phone) Cff;J.. -1.f3r- 7.10 y
(PhonefGl.L. z.z./. "390
~'J 5>.1 0 ~
OWNER
(Name)
.
J
~(tJ,~hU6
t.J~ ~G6 T(l.Ail..J
(Phone)
(Address)
CofUJ
/Cf3Gfo
BlITLDER \
(Company Name~~ ~ C~s \.('"" f' :o\U.)II\
(Contact Name) A-\ c...,..~ ""'k .-.rS c.. ~
~r..-Jc, IL \.UA- ~E
(Address)
I~I Ot? ?-r-k
b~
1!>VI I?f 0,1; lie
TYPE OF WORK Q)lew Construction ODeck OPorch ORe-Roofing ORe-Siding
94Addition o Alteration OUtility Connection 0 Misc.
CODE: ~.R.C. DI.B.c.
Type of ~~struction: I II III IV V A B
Occupancy Group: A B E F HIM R S U
Division: 1 2 3 4 5
OLower Level Finish
PROJECT COST IV ALUE $
(excluding land)
ZONING (office use)
;<../5D
J2I ~/lAU JI1 AI
o Fireplace
I hereby certifY that I have filmished mformation 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 existmg state and local laws and will proceed in accordance with submitted plans. I am aware that the building
:fici~~mit ~ ust cause Furthermore, I he~ agree that the city off:a~: a d~;n;;aY enter upon the property to perform nee~e~,;p~2~s
Signature
r Permit Valuation ~3~.Qoo"O()
I Permit Fee $ 61:;0, Go
I Plan Check Fee $ 3bl,o<;.
I State Surcharge $ I'Leo
I Penalty $
I Plumbing Permit Fee ~ $ 'I() .t) 0
I Mechanical Permit Fee ~ ' $ 4(),00
I Sewer & Water Permit Fee ;
I Gas Fireplace Permit Fee ~ $ 4d, () a
Contractor's License No.
Park Support Fee
SAC
#
#
Water Meter
Size 5/8"; I";
Pressure Reducer
Sewer/Water Connection Fee
Water Tower Fee
Builder's Deposit
Other
#
#
TOTALDUE tN-uel:J 3.2.0$
Ti:::::TQBulldm.;;;:VN
Building allicial bate
/'OSlJ.oO
- .3. ~.oS"
Receipt ,No.
BY~
Paid
Date
Date
$
$
$
$
$
$
$
$ I
$ /, 050_.G8 I
H93.J 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 COnSl1lUtes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
;""~_~:,,~ 1/ L IDS 1v1~ ~~~m~ ~
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 ~1O ~
(t. 16200 Eagle Creek Avenue Prior Lake, MN 55372
FEM.A
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEV A'IION CERTIFICA'!'E
AND
INSTRUCTIONS
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
PAPERWORK BURDEN DISCLOSURE NOTICE
FEMA Form 81-31
The public reporting burden for this form is estimated to be 3.0 hours per response. TIle burden estimate includes the time
for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing,
reviewing, and submitting the fonn. You are not required to respond to this collection of information unless a valid OMB
control number appears in the upper right comer of this form. Send comments regarding the accuracy of the burden
estimate and any suggestions for reducing this burden to: lnfomlation Collections Management, Federal Emergency
Management Agency, 500 C Street. SW, Washington, DC 20472, Paperwork Reduction Project (3067-0077). NOTE:
Please do not send your completed form to the above addres..~.
PURPOSE OF THE ELEVATION CERTIFICATE
The Elevation Certificate is an important administrative tool of the National Flood Insurance Program (NFIP). It is 10 be
used to provide elevation information necessary to ensure compliance with community floodplain management
ordinances, to detemrine the proper insurance premium rate, and to support a request for a Letter of Map Amendment or
Revision (LOMA or LOMR-F).
The Elevation Certificate is required in order to properly rate post-FIRM buildings, which are buildings constructed after
publication of the Flood Insurance Rate Map (FIRM), for flood insurance Zones A l-A30, AE, AH, A (witp BFE), VE,
VI-V30, V (with BFE), AR, ARIA, AR/AE, ARiA l-A30, AR/AH, and AR/AO. The Elevation Certificate is not required
for pre-FIRM buildings unless the building is being rated under the optional post':FlRM flood insurance rules.
As part of the agreement for making flood insurance available in a community, the NFIP requires the community to adopt
a floodplain management ordinance that specifies minimum requirements for reducing flood losses. One such requirement
L.. for the community to obtain the e.]evation of the lowest floor (induding basement) of all new and substantially
improved buildings and maintain a record of such information. The Elevation Certificate provides a way for a community
to comply with this requirement.
Use of this certificate does not provide a waiver of the flood insurance purchase requirement. Only a LOMA or LOMR-F
from the Federal Emergency Management Agency (FEMA) can amend the FIRM and remove the Federal mandate fora
lendiRg institution to require the purchase of flood insurance. However, the lending institution has the option ofreq\liring
flood. insurance even if a LOMAlLOMR-F has been issuedbyFEMA. The Elevation Certificate may be used to support a
LOMA or LOMR.;F request Lowest floo~ and lowest adjacent grade elevations certified by a surveyor or engineerwill be
required if the certificate is used to sUp.I:>Vlla LOMA or LOMR-F request.
This certificate is used only to certify building elevations. A separate certificate is required for floodproofing. Under the
NFlP, non-residential buildings CM be floodproofed up to or above the Base Flood Elevation (BFE). A floodproofed
building is a building tha1 has been designed and constructed to be watertight (substantially impermeable to f1.oodwaters)
below the BFE. Floodproofing of residential buildings is not pennitted under the NFIP unless FEMA has granted the
c.oD1munity an exception for residential floodproofed basement... The community must adopt standards for design and
construction of f1.oodproofed basements before FEMA will grant a basement exception. For both floodproofed non-
residential buildings and residential floodproofed basements in communities that have been granted an exception by
FEMA, a floodproofing certificate is required.
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ELEVATION CERTIFICATE
a.M.B. No. 3067-0077
Expires December 31,2005
Important: Read the instructions on paF'es 1 - 7.
SECTION A . PROPERTY OWNER INFORMATION
BUILDING OWNER'S NAME
Cofer A. M, 1J1oJ,C.H
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
/~39() tv,#r""'~'/Z.s. ED~E - T(2thl...
~o ~
r tlOtL LA.It:.E. mIJ
PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Numbe~Legal Description, etc.)
L.e.r Z-O I f3t)"'OlJV$ mA-....,6rt.. St'o1T l.O","IV1"~. /t>?#J
BUILDING USE (e.g., ~esidential, Non-residential, Addition, Accessory, etc. Use a Comments area, if nllC8S!jlry.)
AOP,110U ,,/ZIa,PEN1UrL &1lrJUtG.E: '1D E"{'S'f"/I>J(. f}6_e
LATIJ"UD~LONGITUDE (OPTIONAL) HORIZONTAL DATUM: SOURCE: I I GPS (Type):
( ## -## - ##.#Ir or ##.####If) ~NAD 1927 U NAD 1983 U USGS Quad Map
.:.:...:.:-:.:.:.:....,....'.-.....:.....................................'......................,......'...................'...........
...:f9~.'@~i#.M~:~fuP.@hy:P.~~~:.:..:...:..:.:.::::
::fflW~:mjMWW:::.:::::::::::::::::::::.::::::::::.::::::.:
......" .... ...................... ............................
....,............................,...................-.............................................................................
.......................................................................................................................
... .....................
.::R~rnr~:I!gtf~.~\.[.:-:-miilli:l:.:.;:.i:
.........:...:.:....:..:..:.::.::::::::::.:.:::.::.:.:...:.::.:.:.:::.:.:.:::.:.:::.:>::...:.:....:.:.:.::...::.::.....:.:.:.:.:::,
ZIP CODE
5.531'2...
~ Other ~ /j;- ts.atL lA~
SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
81. NFIP COMMUNITY NAME & COMMUNITY NUMBER I B2. COUNTY NAM. E I B3. STATE
270 '1J>Z- 5co1f" nw\1AJGSo'T"A
84. MAP AND PANEL B5. SUFFIX B6. FIRM INDEX B7. FIRM PANEL B8. FLOOD B9. BASE FLOOD ELEVATlON(S)
NUMBER /\" J. DATE EFFECTIVE/REVISED DATE ZONE{S) (Zone AO, use depth of flooding)
'2.1D'ISZ-OHZ-C. L- ,'''/eq /I/,qjti1 AI$ Qo8.9
B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in B9.
I_I FIS Profile ~FIRM U Community Determined I_I Other (Describe):
811. Indicate the elevation datum used for the BFE in B9: ~GVD 1929 1-1 NAVD 1988 1-1 Other (Describe):
B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)? 1-1 Yes ~ No
Designation Date:
SECTION C . BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
C1. Building elevations are based on: ~onstruction Drawings* '_I Building Under Construction* '_I Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete..
C2. Building Diagram Number (Select the building diagram most similar to the building for which this certificate is being completed - see
pages 6 and 7. If no diagram accurately represents the building(orovide a sketch or DhotooraDh) .
C3. Elevations - Zones A1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, ARIA, AR/AE, AR/A1-A30, ARtAH, ARlAO
Complete Items C3.a-i belowaccording to the building diagram specified in' Item C2. State the datum used. If the datum is different from
the datum used for the BFE in Section 8, convert the datum to that used for the BFE. Show field measurements and datum conversion
calculation. Use the space provided or the Comments area of Section D or Section G, as appropriate, to document the datum conversion.
Datum IJ&II0 l'fz." Conversion/Comments
Elevation reference mark used orto,.t -~,r( 0' p",..LIrtt()oes the elevation reference mark used appear on t\\4t~~~f'/4~~S ~o
o a) Top of bottom floor (including basement or enclosure) qoq .!:L- ft.(m) Ii '\\"~_.\.\. .' 'S:;}(J..'-:~_
q II> ~\ c.,,"' -"',..'....
Q b) Top of next higher floor ,q ."yft.(m) ~ ~~f:.j~) \ \
o c) Bottom of lowest hOriZO. ntal structural member (V zones only) -. - ft.(m) I.~}~ "\ \. .(.,.
o d) Attached garage (top of slab) qoq . !::!.- ft.(m) ~ ~~ ~ . i. :.
o e) Lowest elevation of machinery and/or equipment CVIIo,.SE 0) ~ ;If '" ,0 f) j
serviCing the building (Describe in a Comments area.) "0'1 . ~ ft.(m) ~ ~~~ ,) '(' ,,:
;.J f) Lowest adjacent (finiShed) grade (LAG) qD3 . ~ ft.(m) ~ ~ ~ 1P .-
;.J g) Highest adjacent (finished) grade (HAG) "to:~ . ~ft.(m) g: -:::~~)~
U h) No. of permanent openings (flood vents) within 1 ft. above adjacent grade 2. ~ '~~.: Nt':',
Q i) Total area ohlt permanent openings (flood vents) in C3.h 11z.L sq. in. (sq. cm) "////11///;,1;;1111
SECTION 0 - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
I oertify that the information in Seotions A. B, and C on this oertfflcate represents my best efforts to interpret the data available.
I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code. Section 1001.
CERTIFIER'S NAME~h.sSElL (). IIA'LVtffflSIJN LICENSE NUMBERM,.; ~/813
TITLE LAAlO .skt.2t1er'o~ COMPANYNAMEJ)7~o ll'lND .$lA~UEYIAJ(;,
ADDRESS 3200 CoflPDtA\1t ~ev'ftrL DI. #/17 CITY 5""IVSVILl~ ",,~TE d~~72DE
SIGNATUR~ $-, DAT':,/rZZ_t3o/' TELEPHONE/'9S-Z) 107- QzQ9
FEMA Form 81-31, January 2003
See reverse side for continuation.
Replaces all previous editions
IMPORTANT: In these spaces, copy the corresponding information from Section A.
BUILDING STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO.
1C{~'i() WA-f7I1t~ ~,,~ 'TPrll,.".
CITY ~~,o, Urtt:tE STATE MAJ S5'3~I~ODE ::~II~f:I~:~II::ii::::i:::::::.:::.::i::j:I'
SECTION D . SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
COMMENTS
c)C'.~nN ~ ,v,1f11E'
~OPo$€D G~4-6E 10
::F9fm~.9imMmP~ilvJJ.AArr . . '.,
:i:8~~I:_I~!~1:i:::ii-:::i:::i~:j::!::jj::::::j::::::!::j:::::,1
wJt,s tz", ISt!€D A BecI~ BFt; (Qo8. q)
gE /rOtJD.;) Ar SIrWE fElf:1V+r/a,.J.
fJt) t:t 0" . 'I l,.j ,q qc, .
I I Check here if attachments .
SECTION E. BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE)
For Zone AO and Zone A (withoutBFE), complete Items E1. throu h E5. If the Elevation Certificate is intended for use as supporting
information for a LOMA or LOMR-F, Section C must be comple
E1. Building Diagram Number (Select the building di am most similar to the building for which this certificate is being completed _
see pages 6 and 7. If no diagram accurately repre ts the building, provide (Sl<eiCh)r photograph.)
E2. The top of the bottom floor (including basement enclosure) of the building is, I I ft. (m) I I I in. (em) LI above or LI below
(check one) the highest adjacent grade. (U natural grade, if available.)
E3. For Building Diagrams 6-8 with openings ee page 7), the next higher floor or elevated floor (elevation b) of the building is
I_LI ft. (m) U--'in. (em) above th ighest adjacent grade. Complete Items C3.h and C3.i on front of form.
E4. The top of the platform of machine and/or equipment servicing the bUilding is I I I ft. (m) I I I in. (cm) 1--' above or I_I below
. (check one) the highest adjace rade. (Use natural grade, if available.)
E5. For Zone AO only: If no flo epth number is available, is the top of the bottom floor elevated in accordance with the cOmmunity's
floodplain manaaement 0 ance? I I Yes I I No I I Unknown. The local official must cerlifv this information in Section G.
SECTION F . PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION
The property owner or owher:'s authorized representative who completes Sections A,B, C (Items C3.h and C3.i only), andE for Zone A
(without a FEMA-issued or community-issued BFE).or Zone AO must sign here. The statements in Sections A, B, C, and E are correct to
the best of mv knowledqe.
PROPERTY OWNER'S OR OWNER'S AUTHORIZED~EPRESENTA TIY~'S NAME
,c"'Mtf3C. D. #A'II~'" ~ hI/?T7I.b
ADDRESS - tit. CITY
32.od t:.bf.Pottl'r'TE l'e=1VraK- ()~,ve ''7 /3",/lNSIIIU4'
SIGNATURE ~tI. ~ DATE //--ZZ-D 7'
COMMENTS
lAlVrI S"'''C)iiiYJ,.)~
STATE ZIP CODE
ffl IV :,.,) .)4"
TELEPHONfqSZ) -107-~Z.qq
~heck here -if attachments .
SECTION G . COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete
Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below.
G1.U The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor,
engineer, or architect who is authorized by state or local law to certify elevation information. (Indicate the source and date of the
elevation data in the Comments area below.)
G2. U A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issuedBFE)or
Zone AO.
G3. U The following information (Items G4-G9) is provided for community floodplain management purposes.
-I G4. PERMIT NUMBER I G5. DATE PERMIT ISSUED I G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY
ISSUED
G7. This permit has been issued for: U New Construction U Substantial Improvement
G8. Elevation of as-built lowest floor (including basement) of the building is:
G9. BFE or (in Zone AO) depth of flooding at the building site is:
. _ ft. (m) Datum:
. _ ft. (m) Datum:
LOCAL OFFICIAL'S NAME
COMMUNITY NAME
SIGNATURE
TITLE
TELEPHONE
DATE
COMMENTS
FEMA Form 81-31, January 2003
II Check here If attachments
Replaces all previous editions
INSTRUCTIONS FOR COMPLETING THE ELEVATION CERTIFICATE
The Elevation Certiticate is to be completed by a land surveyor, engineer, or architect who is authorized by law to certifY
elevation information when elevation information is required for Zones AI-A3o, AE, AH, A (with BFE), VE, VI-V30, V (with
BFE), AR, ARIA, AR/AE, ARlAl-A30, AR/AH, or ARJAO. Community officials who arc authorized by law or ordinance to
provide floodplain management information may also complete this form. For Zones AO and A (without BFE), a community
official, a property owner, or an owner's representative may provide information on this certificate, unless the elevations are
intended for use in supporting a LOMA or LOMR-F. Certified elevations must be included uthe purpose of completing the
Elevation Certificate is to obtain a LOMA or LOMR-F.
In Puerto Rico only, elevations for buildiilg information and flood hazard information may be entered in meters.
SECTION A - PROPERTY OWNER INFORMATION
This section identifies the building, it,> location, and its owner. Enter the name(s) of the building owner(s), the building's
complete street address, and the lot and block number. If the building's address is different from the owner's address, enter the
address of the building being certified.. If the address is a rural route or a Post Office box number, enter the lot and block
nwnbers, the tax parcel nwnber, the legal description, or an abbreviated location description based on distance and direction from
a fixed point ofrcference. For the purposes of this certificate, "building" means both a building and a manufactured (mobile)
home.
A map may be attached to this certificate to show the location of the building on the property. A tax map, FIRM, or detailed
community map is appropriate. If no map is available, provide a sketch of the property location, and the location of the
building on the property. Include appropriate landmarks such as nearby roads, intersections, and bodies of water. For building
use, indicate whether the building is residential, non-residential, an addition to an existing residential or non-residential
building, an aceessory building (e.g., garage), or other type of structure. Use the Comments area of Section F if needed.
If latitude and longitude data are available, enter them in degrees, minutes, and seconds, or in dedmal degrees, taken at the
center of the front of the building. Enter arc seconds to t\vo decimal places. Indicate the horizontal datum and the source of
the measurement data (for example, taken with GPS, scaled from a USGS Quad Map, etc.).
SECTION B - FLOOD INSURANCE RATE MAP {FIRM) INFORMATION
Complete the Elevation Certificate on the basis ofthe FIRM in effect at the time of the certification.
The information for Section B is obtained by reviewing the F JRM panel that includes the building's location. Information
about the current FIRM and a pamphlet titled "Guide to Flood Maps" are available from the Federal Emergency Management
Agency (FEMA) website at http://www.fema.gov or by calling 1-800-427-4661. If a Letter of Map Amendment (LOMA) or
Letter of Map Revision (LOMR-F) has been issued by FEMA, please provide the letter dale and case number in the Comments
area of Section D or Section G, as appropriate.
Item Bl. NFLP Commmrity Name & Community Number. Enter the complete name of the community in which the building
ill located and the associated 6-digit community mrrnbcr. For a building that is in an area that has been annexed by one
- community but ill shown on another Cvum.lunity's FIRM, enter the community name and 6-digit number of the annexing
community. For a newly incorporated community, use the name and 6-digit number of the new community. Under the NFIP,
a "community" is any State or area or political subdivision thereof, or any Indian tribe or authorized native organization, that
has authority to adopt and e.nforce floodplain management regulations tor the areas within it,> jurisdiction. To determine the
Clu..':'ui: cVll.ullunity number, see the NFIP Community Starns Book, available on FEMA's website at http://www.fema.gov or by
calling 1-800-427-4661.
Item B2. County Name. Enter the nanle of the county or counties in which the community is located. For an unincorporated
area of a county, enter "unincorporated area." For an independent city, enter "ind"p,"udent city."
Item B3. State. Enter the 2-letter state abbreviation (for example, V A, TX, CA).
Instructions - Page 1
11
~
- I
Item B4. Map and Panel Number. Enter the 10-digit number shown on the FIRM panel where the building or manufactured
(mobile) home is located. The first six digits will not match the NFIP community number: I) when the sixth digit is a "C," in
which case the FIRM panel is in a countywide format; or 2) when one community has annexed land from another c"u.u.J~unity
but the FIRM panel has not been updated to reflect this annexation. If the sixth digit is a "C," it is followed by a four-digit map
number. For maps not in countywide fonnat, entcr the "cvulluunity panel numbcr" shown on the FIRM.
Item B5. SutfIx. Enter the suffix letter shown on the FIRM panel that includes the building's location.
Item B6. FIRM Index Datc. Enter the effective date or map revised date shown on the FIRM Index.
Item B7. FIRM Panel Effective/Revised Date. Enter the map efIective date or the map revised date shown on the FIRM
panel. TIus will be the latest of all dates shown on the map. The current FIRM panel effective date can be detennined by
calling 1-800-427-4661.
Item B8. Flood Zone(s). Enter the flood zone, or flood zones, in whicb the building is located. All flood zones containing the
letter "A" pr "V" are considered Special Flood Hazard Area,>. The flood zones are A. AE, AI-A30, V, VE, VI-V30, AH, AO,
AR, ARiA, AR/AE, AR/AI-A30, ARlAH, and ARJAO. Each flood zone is defined in the legend of the FIRM panel on which
it appears.
Item B9. Ba,>e Flood Elevation(s). Using the appropriate Flood Insurance Study (FIS) Profile, Flood Elevation Table, or ..,1,..
FIRM panel, locate the property and enter the BFE (or base flood depth) of the building site. If the building is located in more
than one flood zone in Item. B8., list all appropriate BFEs in Item B9. BFEs are shown on a FIRM or FIS Profile for Zones
A1-A30. AE, AH, VI-V30, VE, AR, ARIA, AR/AE, ARlAl-A30, ARlAH, and AR/AO; flood depth numbers are shown for
Zone AO. Use the AR BFE.ifthe building is located in any of Zones ARIA, ARlAE, ARlAI-A30, ARlAH, or AR/AO. In A
or V zones where BFEs are not provided on the FIRM, the cvu....~unitymay have established BFEs or obtained BFE data from
other sources. For subdivisions and other developments of more than 50 lots or 5 acres, establishment of BF.Es is required by
the community's floodplain management ordinance. If the BFE is obtained from another source, enter the BFE in Item B9.
Item BIO. Indicate the source of the BFE that you entered in Item B9.
Item B11. Indicate the elevation datum to which the elevations on the applicable FIRM are referenced.
Item B12.Indicate whether the building is located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected
Area (OPA). Federal flood insurance is prohibited in designated CBRS areas for buildings or manufactured (mobile) homes
built or substantially improved after the date of the CBRS designation. An information sheet explaining CBRS areas may be
obtained on FEMA's website at http://www.fem.a.gov or by calling 1-800-427-4661.
SECfION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)
Complete Section C if the building is located in allY of Zones AI-A30, AE, AH, A (with BFE), VE, VI-V30, V (with BFE),
AR, ARIA, ARlAE, ARlAI-A30, ARJAH, or ARiAO, or if this certificate is being used to support a LOMA or LOMR-F. If
the building is located in Zone AO or Zone A (without BFE), complete Section E instead. To ensure that all required
elevations are obtained, it may be necessary to enter the building (fOr instance, if the building bas a basement or sunken living
rooIll, split-level construction, or machinery and equipment).
Surveyors may not be able to gain access to some crawl spaces to shoot the elevation of the crawl space floor. Ifaccess.to the
crawl space cannot be gained, use the following guidance:
. Use a yardstick or tape measure to measure the floor height to the ''next higher floor," and then subtract the crawl space
he.ight from the elevation of the "next higher floor."
. Contact the local floodplain administrator of the community that the building is located in. The c"u.I1uunity may have
documentation of the elevation of the crawl space floor as part of the permit issued for the building.
. If tbe property owner has documentation or knows the height of the crawl space floor to the next higher floor, try to -verify
this by looking inside the crawl space through any openings or vents.
In all three ca,>es, provide the elevation in the Comments area and a brief description of how the elevation wa,> obtained.
Item Cl. Indicate whether the elevations to be entered in this section are based on construction drawings, a building under
construction, or finished construction. For either of the first two choices, a post-construction Elevation Ce.rtificate will be
Instructions - Page 2
required when con~truction is complete. If the building is under construction, include only those elevations that can be
surveyed in Items C3.a-g. Use the Comments area to provide elevations obtained from the construction plans or drawings.
Select "finished construction" only when all machinery andlorequipment-fumaces, hot water heaters, heat pumps, air
conditioners, and elevators and their associated equipment-have been installed and the grading around the building is
completed.
Item C2. Select the diagram on pages 6 and 7 that best represents the building. Then enter the diagram number and use the
diagram to identify arid detennine the appropriate elevations requested in items C3.a-g. If you are unsure of the correct
diagram, select the diagram that most closely resembles the building being certified, or provide a sketch or photograph of the
building and enter all elevations in Items C3.a-g.
Item C3. Indicate whether the elevation reference mark (benchmark) used during the field survey is an elevation mark on the
FIRM. If it is not, indicate the source and datum for the elevation. Vertical control benchmarks other than those shown on the
FIRM are acceptable for elevation detemrinations. Show the conversion from the field survey datum used to the datum used
for the BFE(s) entered in Item B9. All elevations for the certificate must be referenced to the datum on which the BFE is
based. Show the datum conversion, if applicable, in this section or in the C"uu.u.ents area of Section D. For p,"t'",...o./
experiencing ground subsidence, the most recently adjusted reference mark elevations must be used for determining building
elevatioris. However, when subsidence is involved, the BFE should not be adjusted. Enter elevations in Items C3.a-g to the
nearest tenth ofa foot (nearest tenth ofa meter, in Puerto Rico).
Items C3.a-d.. Enter the building elevations (excluding the attached garage) indicated by the selected building dia~......u (Item
C2.) in Items C3.a-c. lfthere ie; an attached garage, enter the elevation for top of attached garage slab in Item C3.d. (Because
elevation for top of attached garage slab is self-explanatory, attached garages are not illustrated in the diagrams.) If the
building is located in a V zone on the FIRM, complete item C3.c. If the flood zone cannot be determined, enter elevations for
all of Items C3.a-g. For buildings in A zones, elevations a, b, d, and e should be measured at the top of the floor. For buildings
in V zones, elevation c must be measured at the bottom of the lowest horizontal structural member of the floor (see drawing
below). For buildings elevated on a crawl space, Diagram 8, enter the elevation of the top of the <-Tawl space floor in Item C3.a,
whether or not the crawl space has openings (flood vents). If any item does not apply to the building, enter "N/A" for not
applicable.
BUILDING ON
SLAB
BUILDING WITH
BASEMENT
BUILDING ON PILES,
PIERS, OR COLUMNS
A ZONES V ZONES ~" Q AZO. NES ~\' V ZONES
(;) .~, iff! ~I~~';.t~~~1 \"
~\ ~~ ~. ",:' A ZONES .~ ~, . ==-:
:J;;~iffr~ "'^ 1f!1(f~Ii#:~ ;:\~. ~ ~ ~
A ~;r.':.":"""':":;::;" I''.,'':;''i'':~;::'';;'~-'':''''' . '::;i. .~ :~~~
" , '; .;Y., fi ~!
BASE FLOOD ".,.' """'- ~ ~
ELEVATION C ADJACENT }.::: ;~:';f-.:;';~~ BASE FLOOD \\':/ ~ \:::.::.:..::::::.::.::::.:./ ~ .... :.':' ':':".:.
ELEVATION .....;~ .-......::.....:.::. ~ ~o.iAcENT
GRADE :\\\~:;~\!<:><.~.\.::.: ~t~:S~'::"GAAoE
Item C3.e. Enter the lowest elevation of machinery and/or equipment-furnaces, hot water heaters, heat pumps, air
conditioners, and elevators and their associat((d equipment-in an attached garage or enclosure or on an open utility platform
that provides utility services for the building. If the machinery and/or equipment ie; mounted to a wall, pile, etc., enter the
platform elevation of the machinery and/or equipment. Indicate machinery/equipment type in the Comments area of Section D
or Section G, as appropriate. lfthis item does not appZv to the building, enter 'W/A" for not applicable.
Items C3.f-g. Adjacent grade is defined as the elevation ofthe ground, sidewalk, patio slab, or deck support immediately next
to the building. If the certificate is to be used for a LOMA or LOMR-F, provide in the Comments area the lowest adjacent
grade elevation measured at the deck support or stairs if that elevation ie; lower than the building's lowest adjacent grade. For
Instructions - Page 3
Zone AO, use the natural grade elevation, if available. This measurement must be to the nearest tenth of a foot (nearest tenth
ofa meter, in Puerto Rico) if this certificate is being used to support a request for a LOMA or LOMR-F.
Items C3.h~i. Enter the number of permanent openings (flood vents) in' the walls supporting the building, including the
attached garage, that are no highe.r than 1.0 foot above the adjacent grade. Determine the total area of aU such openings in
square inches (square cm, in Puerto Rico), and enter the total in Item C3.i. if the building has no permanent openings (flood
vents) within 1.0 foot above adjacent grade, enter "0" (zero) for each ofItems C3.h and C3.i. Enter in the Comments area
whether the openings are on the foundation walls of the building and/or on the walls of the garage.
SECTION D - SURVEYOR. ENGINEER. OR AR('''HITECf CERTIFICATION
Complete as indicated. This section of the Elevation Certificate may be signed by only a land surveyor, engineer, or architect
who is authorized by law to certifY elevation information. Place embossed seal and signature in the box next to elevations in
Section C. A flat stamp is acceptable only in states that do not authorize use of an embossed seal over the signature of a
professional. You are certifying that the infonnation in Sections A. B, and C on this certificate ."..,."sents your best efforts to
interpret the data available and that you understand that any false statement may be punishable by fine or imprisonment under
18 U.S. Code, Section 1001. Use the Comments area of Section D, on the back of the certificate, to provide datum, elevation,
or other relevant information not specified on the front. .
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO
& ZONE A (WITHOUT BFE)
Complete Section E if the building is located in Zone AO or Zone A (without BFE). Otherwise, complete Section C instead.
Item El. Select the diagram on pages 6 and 7 that best represents the building; then enter the diagram. number. .Ifyou arc
unsure of the correct diagram, select the diagram that most closely resembles the building, or provide a sketch or photograph.
Explain in the Comments area if the measurement provided under Item E.2, E.3, or E.4 is based on the "natural grade."
Item E2. Enter the height in feet and inches (meters and centimeters, in Puerto Rico) of the top of the bottom floor (as
indicated in the applicable diagram) above or below the highest adjacent grade (HAG). For post-FIRM buildings in Zone AO,
the community's floodplain management ordinance requires that this value equal or exceed the base flood depth on the
FIRM. Buildings in Zone A (without BFE) may qualify for a lower insurance rate if an engineered BFE is developed at the
site. .
Item E3. For Building Diagrams 6-8 with proper openings (see page 7), enter the height in feet and inches (meters and
centimeters, in Puerto Rico) of the next higher floor or elevated floor (as indicated in the applicable diagram) above the highest
adjacent grade (HAG). Be sure that you have completed items C3.h and C3.i on the front of the fOrm to show the number of
permanent openings (flood vents) within 1 foot above adjacent grade and the total area of the openings.
Item E4. Enter the height in feet and inches, in relation to the highest adjacent grade next to the building, of the platform
that supports the machinery and/or equipment servicing the building. Indicate machinery/equipment type in the Comments
area of Section E. ~fthis item does not apply to the building, enter "NIA "for not applicable.
Item ES. For those cvuuLlunities where this base flood depth is not available, the community will need to determine whether
the top of the bottom :floor is elevated in accordance with the community's floodplain management ordinance.
SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATNE) CERTIFICATION
Complete as indicated. This section is provided for certification of measurement,> taken by a property owner or l'w.pcrty
owner's representative when responding to Sections A, B, C (Items C3.h and C3.i only), and E. The address entered in this
section must be the actual mailing address of the property owner or property owner's representative who provided the
information on the certificate.
Insttuctions - Page 4
I:l
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, ,
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SECTION G - COMMUNITY INFORMATION (OPTIONAL)
Complete as indicated. The community official who is authorized by law or ordinance to admini'lter the cvuuuunity's
floodplain management ordinance can complete Sections A, B, C (or E), and G of this Elevation Certificate. If the authorized
communityonicial completes Sections C, E, or G, complete the appropriate item(s) and sign this section.
Check Item Gl. if Section C is completed with elevation data from other documentation, including elevations obtained from
the' Community Rating System Elevation Software, that has been signed and embossed by a licensed surveyor, engineer, or
architect who is authorized by law to certity elevation information. Indicate the source of the elevation data and the date
obtained in the Comments area of Sectiop G. If you are both a community official and a licensed land surveyor, engineer, or
architect authorized by law to certify elevation information, and you performed the actual survey for a building in Zones Al-
A30, AE, AH, A (with BFE), VE, VI-V30, V (with BFE), AR, ARIA, ARlAl-A30, ARlAE, AR/AH, or ARJAO, you must
also complete Section D.
Check Item G2. if intOrmation is entered in Section E by the coriununity tor a building in Zone A (without a FEMA-issued or
community-issued BFE) or Zone AO. .
Check Item G3. if the infonnation in Items G4-G9 has been completed for community floodplain management purposes to
document the as-built lowest floor elevation of the building. Section C of the Elevation Certificate records the elevation of
various building components but does not determine the lowest floor of the building or whether the building, as constructed,
complies with the community's floodplain management ordinance. This must be done by the community. Items G4-G9
provide a way to docwnent these determinations.
Item G4. Permit Number. Enter the permit number or other identifier to key the Elevation Certificate to the permit issued for
the building.
Item G5. Date Permit Issued. Enter the date the permit was issued for the building.
Item G6. Date Certificate of Compliance Issued. Enter the date that the Certificate of Compliance or Occupancy or similar
written official documentation of as-built lowest floor elevation was issued by the community as evidence that all work
authorized by the floodplain development permit has been completed in accordance with the community's tloodplain
management laws or ordinances.
Item G7. New Construction or Substantiallmprovement. Check the applicable box. "Substantial Improvement" means any
reconstruction, rehabilitation, addition, or other improvement of a building, the cost of which equals or exceeds 50 percent
of the market value of the building before the start of construction of the inlprovement. The term includes buildings that
have incurred substantial damage, regardless of the actual repair work performed.
Item G8. As-built lowest floor elevation. Enter the elevation of the lowest floor (including basement) when the construction
of the building is completed and a final inspection has been made to confirm that the building is built in accordance with the
permit, the approved plans, and the community's tloodplain management laws or ordinances. Indicate the elevation datum-
used.
Item G9. BFE. Using the applVpl~ate FIRM panel, FIS, or other data source, locate the property and enter the BFE (or base
- flood depth) of the building site. Indicate the elevation datum used. .
Enter YOW' name, title, and telephone number, and the name of the CvUllUUnity. Sign and enter the date in the <lwJ.vl"J.~ate
blanks.
Instructions - Page 5
I
\
I
1
!
t
BUILDING DIAGRAMS
The following eight diagrams illustrate various types of buildings. .Compare the features of the building being
certified with the teatures shown in the diagrams and select the diagram most applicable. Enter the diagram
number in Item C2. and the elevations inltems C3.a-C3.g.
In A zones, the floor elevation is taken at the top finished surface of the floor indicated; in V zones, the floor
elevation is taken at the bottom of the lowest horizontal structural member (see drawing in instructions for
Section C). .
DIAGRAM 1
All slab-on-grade single- and multiple-floor buildings
(other than split-level) and high-rise buildings, either
detached or row type (e.g., townhouses); with or
without attached garage.
Distinguishing Featunt - The bottom !loor is at or above ground level
(grade) on at least one side. .
.;fJ
:\: NEXT HIGHER
I FLOOR
GRADE . BOTTOM '11lOR
f 9 (determined by existing grade)
DIAGRAM 3
All split-level buildings that are slab-on-grade, either
detached or row type (e.g., townhouses); with or
without attached garage.
Distinguishing Featunt - The bottom floor (excluding garage) Is at or
above ground level (grade) on at least one side..
I
~,,=~ NEXTH"H" 1,,0
GRADE BOTTOM FLOOR I
\ OOR. .
t~il:~[lt_ifltl(fll!tI1ti
~ (determined by existing grade)
,DIAGRAM 2
All single- and multiple-floor buildings with basement
(other than split-level) and high-rise buildings with
basement, either detached or row type (e.g.,
townhouses); with or without attached garage.
Distinguishing Fe8tunt - The bottom floor (basement or underground
garage) is below ground level (grade) on aU sides. Buildings constructed
abc.ve crawl spaces that are below grade on all sides should also use this
diagram..
NEXT HIGHER
FLOOR
fJ
.Il.
GRADE
~ BOTTOM FLOOR
flf~ll~t';III~111
.. ~ (~~~~ln~'~~ ~stin~'~~d~) ....... ....
DIAGRAM 4
All split.level buildings (other than slab-on-grade),
either detached or row type (e.g., townhouses); with or
without attached garage.
Distinguishing Feature - The bottom floor (basement orundergrolind
garage) is below ground level (grade) on all sides. BulldingsconstlUcted
above crawl spaoes that are below grade on all sides should also use this
diagram. .
I
I .
GR\~\. 0 ""'~ HEXT~1ER/1P
~;;tt: ~EMEN"D. .
lil!',fil\llfli
~ (determined by existing grade)
'" A floor that is below ground level (grade) on all sides is considered a basement even if the floor is used for living purposes, or a~ an otlice.
garage, workshop. eIC.
Instructions - Page 6
DIAGRAM 5
All buildings elevated on piers, posts, piles. columns,
or parallel shear walls. No obstructions below the
elevated floor.
Distinguishing Feature - For all zones. the area below the elevated floor Is
open. with no obstruction to now of flood waters (open Iallice work and/or
readily removable insect screening is permissible).
NEXT HIGHER
FLOOR
.~
~'
GRADE 'J...'" '" '..::
~;~i1:%)0;;!;~i;!Niiik:m!~~{fM;;;%1~;;;tff;!i\ij
~.~~:~~~;~~~ ~~':~:~~~'~~~;~'~~~'onl~)""c ...... ......
ELEVATED
FLOOR
DIAGRAM 7
All buildings elevated on full-story foundation walls
with a partially or fully enclosed area below the
elevated floor. This includes walkout levels, where at
least one side Is at or above grade. The principal use
of this building Is located In the elevated floors of the
building.
Distinguishing Feature - For all zones, the area below the elevated floor is
enclosed, either pertially or fully. In A Zones, the pertially or fully enclosed
area below the elevated floor is with or without openings" present in the
walls of the enclosure. Indicate information about openings In Section C,
Building Elevation Information (SuNey Required).
I
I
I
'(0
~., .-...'.:;:..:.;......,.;;,"',.:;.::..f..,,'..,..:,;,.,:::;:,..,.;.'.,:,':..:.;'.'.'
~~~~1ir:;~~f~;:~i~:;i~1Wt~Mj::\~:iii&;7.~;~;~::!.;~ti1~%~~f,:!.;i)J;;j;;;;~~f<<~:!.
h i
NEXT HIGHER
FLOOR
/'
DIAGRAM 6
All buildings elevated on piers, posts, piles, columns,
or parallel shear walls with full or partial enclosure
below the elevated floor.
Distinguishing Fe.lure - For all zones, the area below the elevated floor is
enclosed. either partially or fully. In A Zones, the partially or fully enclosed
area below the elevated floor is with or without openings" present In the
walls of the enclosure. Indicate information about openings In Section C,
Building Elevation Information (SuNey ReqUired).
NEXT HIGHER
I FLOOR
~' ELEVATED
~ FLOOR
GRADE """
0i{;%\;~;i1~fif~~~i~V&\!~;'l~~,tr;;;~~:j
r;y-;\ '(deter~in~db~"- .. .,. ...
~ existing grade)
DIAGRAM 8
All buildings elevated on a crawl space with the floor of
the crawl space at or above grade on at least one side,
with or without an attached garage.
Distinguishing Feature - For all zones, the area below the first floor Is
enclosed by solid or partial perimeter walls. In all A zones, the crawl space
Is with or without openings" present In the walls of the crawl space.
Indicate Information about the openings In Section C, Building Elevation
Information (SuNey Required).
I
I
i~~~:~~i~~t~fil1i.1
** An "opening" (tlood vent) is defined asa pemultlent opening in a walllhat allows lor the free passage of water autoOlatit:alIy in both directions
without human. intervention, Under the NFIP. a minimum of two openings is required for enclosures or crawl spaces wifu a total net area of not
less than one square inch for evet')' square foot of area enclosed. Each opening must be on dj;r.;.."..~ sides of the enclosed area. If a building has
more than one enclosed area, each area must have openings on exterior walls to allow lloodwmeT to direct!)' enter. The bottom of the openings
must be no higher than one foot above the grade underneath the flood vents. Alternatively, you may submit a certification by a registered
professional engineer or architect that the design will allow for the automatic equalization of hydrostatic flood forces on exterior walls. A
window, a door, or a garage door is not considered an opening.
Instructions - Page 7
CWhitp - Buildinv
Canary - Engineering
Pink - Planning
Th... C...ntt'r or the I.ab Count'1-'
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT 77-16 M/J..!7JlA.ICTlo IV /t.sso(!,(I'1T6S I I AJe.. .
APPLICATION RECEIVED /. 2 (p . oS
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/4390 W/17&e~eOCi& //2/1//
/
Accepted
Accepted With Corrections
Denied
Reviewed By: ~~, ~p Date: //3/hs-
Comments: ;r.; ~ o--e..f" ~ "t ~
-d,/?9<:..o Ch- /(!F..:r. (H"~ ~. ~~ .~
~~-~ ~.dJ~~~~ _
~ U€ ~ .t'.A.u:n 1-D ~ ~ ~~
~ I . / ~__~7I _. tJ - - - p
~ ~~ ~ ~ J ~~/-!.~ ~JU0
~ "n-' J- ~ r-:t..L ~ ~ r"~ ~
$ -
~ ~ -:J"~ ~ ~.'-"~r
N~~ ~ .~Irl~ ~AJ;;~n~
~~ ~.rfjro~ ~ ~
~ J+.fl ~~.
"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."
~ - Building
(" ~anary-:' t:nameenng,
Pink - Planning
Thr ('tnlrr of .hr Lakr Coun.,.,.'
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
,..... Jr:.
/' /..-;{C.
,{, )..;.!;, ('" ~/ C:.. -:/; (.IV l! :::~ - c (~'l /-1 7t:;- ::: ( / r. C
APPLICATION RECEIVED
.~. . '-
...,.-.--
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
/ 4.3?() tI//7Z:;/~; -:- Gf../{Yc; --I /ijJ/ L-
Accepted
,)(
Accepted With Corrections
Denied
Reviewed By:
nrJfJ
Date: ;( -I-oS-
Comments:
~ Rp-verse Side for Addttional Information I
See Attachments: 1) Grading- Plan. 2) Erosion Control Measures
"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."
..k_._.~._."_...._....______~__._._ .--------.~'4".--,....~-. -.~.~~"__>_,~_^"_~
The Cen.er of thr L.kr Coun.I1"
White - Building
Canary - E'19!.neering
(Pink - Planning..>
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:
,;"
/'
, /
/ ,I / /
Accepted
Accepted With Corrections
Denied
Reviewed B~~Yy\. ~ Date:
Comments: ~ ~~ ~
.~~ ~
~ ~ ~ - u.
~11~Jc>s-
~ ~ 0.-.....
~.
Cwvu..:r I\t ~ eo- ~ ~ '--V'. P.ft~~ ~ ~ 1 \.:f- ~ t
~~ ~ ~<&ti.J.,.. ~ ~ ~.
L~ f~~~ ~ ~&..~ ~ ,Lff ~
~~~.
"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."
-'-~.r-'----""-~----'---'''''''''~--r'. .-..---.-----,-----,----.-.----- --. - .--.- -.-....-. -~._--- ----------...-
:FARMINGTON PLG & HTG
FAX NO. :6514637835
Ma~. 11 2005 08:32AM Pi
CITY OF PRIOR LAKE PLUMBING PERMIT
Date Rec'd
(Plcue Cypc Of PriDllIId lip at bottom)
ADDRESS
ll(j q 0 I A)a..4 er.s ..u:~ (""", '\ r \
. LEGAL DESCRIPTION (o/ricle use only)
I 1M ,.1. PERMIT NO. ~. I'-^
I Gol4 <:.? _ .... . ,....,.
J h"o~ ..,...~
,
ZONING (orri('fU~) .
LOT BLOCK
ADDmON
PlD
OWNER ~ r "
(Name) ~J
(Ad~)
TeA
G!.,^~i r'\M..~'L\OIl\: r'"
(Phone)
:-~~'" WI " ~{..,'" P G.w..b.. "0.& 11 ~(Phone) bSl- 4 (D?' -7 '3?H
(Addreu) dJl23 14 ~nl"'ltlJa..1 ~ A \Je . fu6'(\(\lt/ft+"),/\ s~OaLf
. (Addld.) (Cit)\) (ZIp Code)
. (Cootlct Penoa) J)o.. '^ . (Pboac)
i APPUCANTSlGNA'I'URBD~ l ~ ~ __
--- , LJo__~___
DATE
c;'II-Q~
QlWltitt
t
\
I
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APPLICANT PLEASE COMPLI!.I1l. BELOW
Type of Ilxtare
Bath Tub with or without Ihower
Dilbwasber
Floor DraIn
. LmtOry(B1tbroom Sink)
LBuadry Tray (1 or 2 compartment link
Shower Stall
8rnb
Bar Sink
Water Closet (Toilet)
Qaaattty
.3
I
type or Fixtare
. koap-1nJ '
, W.. HeIta'
\ Water Softnet
~taad l'i to (Washing Macbln~)
Sewa~e ~~
, Backtlow'Aaembly
Baclcllow A.uembl.v Test
~W; Sprinkler .
~~.. S\.dUl,uULE
IaduafriaI.. CGnuaerdaI a. Muld-flmU)' I" of Jab CUlt wtdt. $39.50 IIlInbIsuID RaIdantiIl. New o..e A Two-Funlly $99.SO
RaideaI1lJ. AddItJcllll A AJtcnllGlll $39.50
Estimated Colt S BuUdin&.Permlt .
. .
PWMBlNO PBRMlT PBB S
STATE SUR.CHAllOB S
& ~ aAL PERMIT nE S
...... GaId.I
DIM
. ,
(CHIaI.... 0IlIJt
...... AppUcaClla..... V..r .......'~ WHa Apprcwed
.
2.4 ..., I.&' 'er AU "lpectJeu (9$2) '",.. ~ 'a (H2) ...,~
Bv _....-
_.__.~"_"_______"..m"r._.",,_~.,~, "'~'"__.'_.___'.'____"~____
FROM :FARMINGTON PLG & HTG
FAX NO. :6514637835
Ma~. 11 2005 08:32AM P2
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONINGIFIREPLACE PERMIT
Date Rec'd
.~.
(Please lVl3e or tlrint and sim at botlOm)
ADDRESS
,L(7.,q() l~dAe~. ~e.. '\ r- ,
d
LEGAL DESCRll" 110N (ollice use only)
i ~=w ~J~~.I I PERMIT NO.S JI,tJ I
ZONING (office use)
LOT BLOCK
ADPITION
PID
OWNER
(Name) Ie A
':I.. V\ t..
& ~ lit e.J:JJ Cd' ~ ~ 1"0.-'- k~
(Phone)
(Address)
APPLICANT I
(Name) M:..rVV\ i ,^~-+"t.".. P\o. ~
(J <J
(Address) _n< I n~~ ~ Ch., f. peV1~I~
(Address)
(Contact Person) J ~ VV"'\ / U:e.. '^-'
APPLICANT SIGNATURE .DD.AA It Q L
\.\\...
d
AI/~
(Phone) wS,. 4 LD3 . 78.1-.4
Rt..- (Y\ .' VlClfe>."
(C~)
~SO~}'4
(Zip Code)
(phone)
~
DATE
t'; - l 0 - OS
APPLICANT PLEASE COMPLETE BELOW
ONEW CONSTRUCTION 0 REPLACEMENT ~ AL TERA TIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE REnJRN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
OWo.rm Air Plants 0 Steam
OGravily 0 HOl Water
o Mechanical 0 Radiallon
OAir Condilioning 0 Special Devi~
OVent. System 0 Other Devices
PLEASE NOT~:
Air Conditioner Units
Cannot ~ncroach into
Required Side Yard
Setbacks
FIREPI..ACE MAKE AND MODEL
~ !3l..f.~plte~ Ct.....~
Industrial, Commercial &. Multi-Family
Residential, Heating &. AIC (New Construction)
Residential, Heating Only (New Construction)
~\.
1-' c: 1\.lrl'tS iO " f2U..) 1 lV---
FEE SCHEDULE ~:>'^ PP(St.
1% ofjob cost Residential. Gas Fireplace U
$39.50 mInimum
$99..50
$64.50
Residential, Additions & Alterations
Residential, AC Only
(1 f'c.~~(v6 ;lell\.~ ~~k
$39.50 ~.......
$39"SO
$39..50
Estimated Cost $
Building Pennit 1#
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$
$
PAID WITH
.5~UILDING PERMIT
(omte t1u Onlt)
Thll Application Becomes Your BuildIng Permit When Approved
Dulldlnl Officl.1
Dlle
Receipt No.
By
2.4 hour notice for tlllnspectlonl (~%) 44' 'c9~SO, tll (95%) 447....145
u y___ ...... u.....
-- ,.~-,,,,_,"-
PRIOR LAKE
INSPECTION RECORD
DEPARTMENT OF
BUILDING AND INSPECTION
SITE ADDRESS '!ii/J ~ WI4 7E1CS EMe ~it.
NATURE OF WORK ~11G.E IiND A8111E' '~PNi'"
USE OF BUILDING s: F; f). -.
PERMIT NO. 05.0/(PO DATE ISSUED ,;1./ fi/~s
CONTRACTOR 'T.1IL/.tJAIS'r: AS'nK'. IN~ PH6NE~.2.1rl-iJB)
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
1/;5
FOUNDATION (Prior to Backfill) I V1IV' I t(,/f6'" OS
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH.. INS
FOOTING
.-
!/l/Y/
t/1A/
t/!/P
I/ty7
lW
~
AMING
INSULATION
ELECTRICAL
PLUMBING
HEATING (if required)
FIREPLACE
GAS LINE AIR TEST
DATE
4- g- ,os
r- ~~<- d~
.5'- b?~
s--~
.s:-'/~
f.J-'~
~/..... ~
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
/Arlit / f((JUSE'"/AJ/4lrP I [A;f' I _5- 23'05
..
FINALS
.
. ~AH-. ---, . \Jlwl... .<. ~"lHg)
BUILDING
ELECTRICAL
PLUMBING
HEATING
DO NOT
/I
m/
/'l
((1/ /)
)/ j/ j/
/I
OCCUpy UNTIL ABOVE HAS BEEN
NOTICE
C1,}JVJ
1
I,
'''V
SIGNED
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.
FOR ALL INSPECTIONR (Qf'i?) 1l1l7-QRf'iO
DATE TIME
...TV OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
~ -2.. --t6
ADDRESS
It{] 90
!A/t{ ~ ,.l7C
OWNER
CONTR.
PHONE NO.
PERMIT NO.
r.):y/Co
o FOOTING
o FOUNDATION
o FRAMING
tNSULATION
FINAL
SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
o EXIGRADIFILLlNG
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
COMMENTS:
-------
/ /' 1/\.-4
'" L./( U,X-
"'--
~
~~
r.~ '\
1/4.. )
, J
/
-------
;WORK SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WJ~K&L FOR REINSPECTION BEFORE COVERING
Inspector: 1/ y r Owner/Contr:
,
CALL 447.9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYI
/NSNOTl