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3434 Washington Dr 0�/90/2015 08:�8 FAX 952641a6i0 DCI 1�001 UseBLUE or BI.ACK Ink �------_�-----------, � For Office Use � C�tof Ea an ; Fennit#: �� 1 ; � � , �� , 3880 Pilot Knob Road i Pgm'�e Fe�: , Eagan MN 5612� � Date Recelved; � Phone:(651)6T5-66�5 Fax: �ss��srs.5ssa ; ; i sr�� -_--------------�__� 2015 COMMERCIAL BUILDING PERMIT APPLICATION Date: 3�27-2015 Site Address: 3434 Washin�ton Drive Eaf�an MN 55122__ Tenant Name: Holida, I�Express (Tenant is:�„_New/ E�dsting) Suite#; Forttier Te�ant: . Name:__Holiday Inn Expre.�, Phane: 'PCOperty�Ow�e�-..`: qd�ss/City/Zp: 3434 Washa��ton Drive E;�an MN 55122 _.. v i :. Applicant is: Owner ConGactor I ' Descripaon of wohc: DemQ existin�restauraunt Type:of'Work � Construction Cosx Name: Swan COmpanies Inc. �.icense#: - .Contt�dCtor Address: 682 39th Av�� City: Columbia HeiQhtS .�^,. � State:��L Zp: 55421 Phone: 612-490-5111 � Contact: i Emai�: Kyle@swancomnanies.net Name: N/A Registration#: Architect/E�nginee.r., Add�ess_ c�cy_ State: Zip: Phone: - Contad Pe�son_ Email: lieensed plumber installing new sewer/water senriCe: N/A , � Phone�: NOTE:Plans antl serppomng'documents'that you•:submit�are considered,to be publfc'informsHon: Portions oi the irlformation<may be classlf'ied.as non-pubfic.if.y+ou p►vvide.spec"r!"rc r+�sons.tha€wou/d�perr�it,the CFty to : , . , conclude that.ttie .are�t►ade secrets. . CALL BEFORE YOU DIG. Gall Gopher S�ba One Gall at(651)454-0002 for protection ageinst underground utility damage. Call 48 hours beforc you intend to dig to recelve locates of underground utiMies_ www.aooherstateonecali.ora I hereby acknanAedge th8t tltis information is complete and accurate; that the w�ork will be in confoRnance with the orclinances and codes of the City of Eagan;that I understand this is not a pennit, but o�ly an application fo a pertnit,and work is not to start without a pertN�that the wonc will be in accatqance with Me approved plan in U�e case of i ui and approval of plans_ X Kyle Hi�dem x Appllcant's Printed Nsme Ap an Slgnature PaAA 1 of 3 � Use BLUE or BLACK Ink - . . . r---------- � i For Office Use i �/)j` , ~� /_,,/ L.J� RE��Vl�l� � Permit#: �J�f-6� . I,,-�� Clt :of �� a� � �� Y � P t; � I Perrnit Fee: � � I 3830 Pilot Knob Road �i� � :° ?�� `�°i� Eagan MN 55122 � , � � Phone: (651) 675-5675 � Date Received: � '� i �i�/� Fax: (651) 675-5694 / , / � � �� /� �� (�,� ! ��`7`..`� � Staff: � I Gr/L ln o 1 : �-----------------��1 2014 COMMERCIAL BUILDING PERMIT APPLICATION ��ys� Date: �2 7O ' Site Address:��'. �/4�If`�1"("D� ��V�, � _ , : ,�,�a.f� Tenant Name:�'C�L/p�l►,Y 'p�� t{a�.�fj L'�. �jV, (j�l� (Tenant is:�_New/. -. <. .�xistic�g) Suite#: :� � �� `` . ,. ' Former Tenant„ . .,:; . . _ . . § Name; :�Go��?-1�-'�. � LL.L Phone: 7�03-24�.-d S7C.r Property Owner ' ; v ''p � � _ � �� J Address/Cit /Zi : _��4 �I�.Il.r�.l; �ya/�t �,0�&tp�, � f Y �� ,�, .� �. , ��- 5 ;: Applicant is: Owner Contractor _X� .t}►�,G �,� �. �� ., � ��j- �� ; "� =Tyj�e O'f�IV�rIC � Description of work:,��' �'�'Df Z`�� 9�j (J,�IT -�"GC�(.. - ��-� _� �:� � _ = Construction Cost: 3'7�0�; O�o � _ _ - � : _ — Q� _ _ _ __ - ° � �` Name: r�G� �c��/�✓S �C• License#: �/D 1�o,,�n1�-e w N � �Z , � ry: ��Lc r n�an�f� � � `� Address: l a Ci L � s � �Cor��`rac�arrr�, � 5 .��'�-� �� , } � State:l��. _zp: S�n D3� Phone: ��`�-o29�L-`o''t�� '�� AI� R ;� `� x� ��_ Contact: M'�[� F7DNaSerQ Email: /Ltl�e��c,�ll�Id�ers�nc . Caw� ,�.. - _ �`� - ,; ' � �,u$ , d � _: Name:G tTl tc5 � �t}�IT�t'T'�7 _Registiration#:: � - � � �,�� - � � Address: �03 l5►'"' � I�� City: :,�1��2. `� _ � � m � } A r��f��t/Er g rn ee r- � � � � - � State: M�l Zip: ��p2d 1 Phone: `32�l�—z3S- ?`77 ''r',�' '_ _ " Contact Person: �11�t� tt'#�Se�t� Ema�1,�{'�A r'4 Nt .Go�► �_ � . ,,; _, . Licensed plumber installing new sewer/water service• �� '�� (ie#: ��-�7�' ��"`��"�� • — - �._�_ NOTE:Plans and supporting documenfs-.that you supn,��a,� .,.,..,.idered to be public information. Portions of_ the information may be classified as non-public if you provide specific reasons that would permit the Cify to . conclude.fhat the are trade secrets. CALL BEFORE YOU DIG. Call Gopher State One Call at(651}454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www:qt>pherstateonecall.orq I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes o`the City of Eagan; that I understand this is not a permit, but only an applicatior� for a ermit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which re ' and approval of plans. X �.Y�t-� M• �sorl Applicant's Printed Name� App ic nt's_ i n•'ture � / Page 1 of 3 �I c;`iA�. � �- .L�oi~�,lA-'"j.t�t�P1 ��Z,�2'UL/1 , . �y�� s��`n -��u� ��', � ,�� .� DO NOT WRITE BELO�THIS LINE: I��- � , SUB TYPES � _ Foundation _ Public Facility _ Exterior Alteration-Apartments ✓Commercial/Industrial _ Accessory Building _ Exterior Alteration-Commercial _ Apartments _ Greenhouse/Tent _ Exterior Alteration-Public Facility Miscellaneous Antennae WORK TYPES �New _ Interior Improvement _ Siding _ Demolish Building" Addition _ Exterior Improvement _ Reroof _ Demolish Interior _ Alteration _ Repair _ Windows _ Demolish Foundation _ Replace _ Water Damage _ Fire Repair _ Retaining Wall SalOn Owner Change : � •� •� ' t,...� ,; . ,,;' "R�SnnGtio�+of entire building–give,PCA handout to'applicant � — . .. , . ' . . . . • _ DESCRIPTION � � . � ` � � ,.,;;,, ` Valuation ��4001000 �'Occupancy �"� � '� 'N10ES•System ye.5 Plan Review � /' �eS Code Edition a067 MS�- S�AC Units ��`f Le�{e✓ (25%_100%� Zoning PD� , C:ity Water ��S Census�oile� ' •• - = - Stories • b ; . _�:=; ' �. • ��toost�r Pump #of Units = Square Fee�.. F'RV h #of Buildings ` ' ` " ' LengtFi �" "�` ` ' Fire Sprinklers ��eS Type of Construction - •Widtl�• , . ... . . `� .., , REQUIRED INSPECTIONS • -- . ✓Footings(New Buildirtg)' � ' ' ` ' ` � ' �F ' � ✓�fi�e'�rock Footings(Deck) ✓. :Finald_�.0. Required Footings(Addition) � Final/No C.O. Required �Foundation Other: Drain Tile Pool:_Fc�otings _Air/Gas Tests _Final �/ Roof; Decking _Insulation _Ice&Water_Final Siding:_Stucco Lath Stone Lath _Brick �Framing Windows �ireplace:_Rough In _Air Test _Final Retaining V�✓all nsulation ' Erosion Control Meter Size: • t5- Final G/:O;Inspectionr Schedule Fire Marshal to be presenty. .°Yes;j,T�lalo�� x � -; Reviewed By: Mi�� L • , Building Inspector � Revievued 8y: , Planning s. COMMERCIAL FE�S�, � , . , - . . . ; � Base Fee a9', �56.,7$- Water Quality . Surcharge� � ' �� j � 1,(o�Od:DU Water Sampling Fee� r {�--�" ��• � d Plan Review /g� �'�/• � Water Supply 8� Storage (V'VAC) MCES SACr 27 �r��`� �j Q��'dD Storm Sewer Trunk City SAC �'7 f1(1.�1(� Sewer Trunk S8�W Permit& Surcharge _f,,'�,�"(�} Water Trunk Treatment Plant � ,fiL� Street Lateral Treatment Plant (lrrigatian) Street Park Qedicatian ' .(x�`�'`�; '�'G` Water Latera! Trail Dedication Other: �.rn,'��Sc'�-6�'- T ��C��-' • � Water Quality r . . . TCITA /9 Q�� f�f'- �p� � , �,ad ip �2Gt,C� � /'�,5`�,f O Page 2 of 3 i43,o��:l� / ��ly� Dale Schoeppner December 23, 2014 Chief Building Official City of Eagan 3` Pilot Knob Road EQyan, MN 55122-1810 Dear Mr. Schoeppner: The Metropolitan Council Environmental Services (MCES) Division has determined the SAC to be charged for the wastewater capacity demand for Holiday Inn Express & Suites. The project is located at 3434 Washington Avenue within the city of Eagan. The City will be charged 27 SAC Units for this project, as determined below. SAC Units Charges: Hotel/Motel 93 rooms @ 2 rooms/SAC , 46.50 Office . 412 sq. ft. @ 2400 sq.ft./SAC 0.17 Breakfast Only(Complimentary) 1290 sq. ft. @ 15 sq.ft./seat @ 45 seats/SAC 1.91 15 ft@ 1.5 ft/seat @ 45 seats/SAC 0.22 Breakfast Only(Complimentary)Outdoor Seating 485 sq.ft. @ 15 sq. ft./seat @ 45 seats/SAC x 25% 0.18 Total Charges: 48.98 or 49 Credits: Future Demolition AI Baker's (19 SAC paid 4/80 + 3 SAC paid 6/98) 22.00 Net Charc�e: 27.00 Please be aware that the demolition credit is being taken ahead of the actual building demolition and no other credit will be available. All demolitions must be reported within one month of the end of the calendar year during which the demolition permit was issued, in order for the prior use to be eligible for any credit on the property. The demolition must be properly reported on the MCES SAC-D Demolition Declaration Form. At the time of the��ctual building demolition note on your SAC- D form that the credit has already been applied to a new use. The business information was provided to MCES by the applicant at this time. lit is also the City's responsibility to substantiate the business use and size at the time of the final inspection. If ther�e is a change in use or size, a redetermination will need to be made. If you have any questions email me atLssica.n e a metc.state.mn.us. Sincerely, � w�� Jessie Nye Supenrisor, ES Finance(SAC) _ JN:an: 14122364 Determination expiration: 12/23/2016 cc: Kevin Hanson, Cities Edge Architects(email) --' Amy Griffin, City of Eagan (email) �- File, MCES ---_._.____- � -..- . . � :� �� -- - � x� ' � - • •� �� - • •� � • • �•�� - . . . . METROPOLITAN � C O U N C I L Use BLUE or BLACK Ink � �-----------------, ' � For Office Use I t Cl� Of�� '�� ' ( I Permit#:� ��(p ` I I —� � 3830 Pi�t Knob Road �� I Permit Fee: � /. �� ,/,�'3•/�� Ci C/ I ,�/,� �� Eagan MN 55122 � � Date Received: � Phone:(651)675-5675 � � Fax:(651)675-5694 � Staff: 1 � ��J 2015 COMMERCIAL PLUMBING PERMIT APPLICATION ❑ Please submit two(2)sets of plans with all commercial applications. Date: Site Address: ��_�� 11�C�1 i�'1�r�Y1 ��"��i��- < ' Tenant: � ��i :� ' �S� �<S ' �� Suite#: P��y �� . / "�1NC�#�� - Name: `J�(A,��t��-#�.�� 1..��_- Phone: � � y �� 1 �y�c �_ j��-t � 7 �- � Name: ��C-�� ,�S � � � �� ' � License#: � � �0��C�� C ,-� ��-�- , ��,Il+(��' o�. ' P �l ��-'. �� Address: � � �� l.� '��U City: l C° � State:��'�� Zip: --�J��' s�_ _ � � :� �� .,�, �� Phone: �� Email: i h � � � �New Replacement _Repair _Rebuild _Modify Space Work in R.O.W. t*�;��R�� -- �� ', �� , ' � Description of work: � � �� COMMERCIAL _New Construction _Modify Space w'�� ia i� —Irrigation System(_yes/_no)(_RPZ/_PVB) C' �„il�� :�� • Rain sensors required on irrigation systems �y'��'��' i�� P�r a ��,� • Avg.GPM (2"turbo required unless smaller size allowed by Public Works) �,� ``� Meters Call(651)675-5646 to verity that tests passed ior to ickin u meter. � '�� Domestic:Size&Type"" � �'� Fire: 1 � i'�� '�� Avg.GPM,��High demand devices? Yes No Flushometers_Yes�No � COMMERC/AL FEES Contract Value$ �7�, �� °�� x.01 $55.00 Permit Fee Minimum =$�n_��,`'� Permit Fee "If contract value is LESS than$10,010, Surcharge=$5.00 =$ ��a��' Surcharge* "'If contract value is GREATER than$10,010, Surcharge=Contract Value x$0.0005 Z� � � *""If the project valuation is over$1 million, please call for Surcharge -$ 1 � � `x �� TOTAL FEE Following fees apply when installing a new lawn irrigation system $ water Permit Contact the City's Engineering Department,(651)675-5646,for required fee amounts. $ Treatment Plant $ Water Supply&Storage $ State Surcharge _$ TOTAL FEE CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage. \ I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. X x A plicant's Printed Name Ap icanYs Signa ure ,Q�7 �#(t��*�i' ia �ii i�u — �i i - y_ �m;i ; _ i ,.i .. f��iX�E.� �y � i=a � �� p ili�� h �� _ o. ij t �i ! i __ i � t ,i II��i i�`i6 Ij��R� � "��prt� ,Nl��r i �� i k�� i � � �i� ��_ i r , i u e�"ii � 11 ' r- �i n��w li' " . �,._ i i: �h ��'4. �� (��i� P' -i��li�Y �i��5 _� t �� x � ��h�� _ - c"�',�� =i�� °��#��Cn�� °��` r � ' �r�� Tn�� ir��= 1 ��t� ��k��;��f� �_ ��` ,'�« ,,,��; �a. �=�i � "�� r �� i �4� — � i 4�`��h��) in �� t�7Ih ��'�iW _i � ii8h � m ��T' ��Cl��1�� r ,� i��t�I�� _- '9�IP��'"�'�' ��U��' ��p,i� _ �y u — Page 1 of 3 Use BLUE or BLACK Ink r————————————————i � i ��"�� I For Offlce Use � � • �i��/�,� wr� /_" � �y ' � � � ��- C�t of �a a� � � (� ��G� i Permit#: �� i (� �`� f � � "' � Permit Fee: � 3830 Pilot Knob Road I I Eagan MN 55122 � � Phone: (651)675-5675 i Date Received: � Fax: (651)675-5694 � Staff: I �-------------��[� � 2015 COMMERCIAL FIRE ALARM PERMIT APPLICATION �,, ��'� � `i �('� 7 Date: , , .3 U ^��Site Address: 3`'� � 1 �"�S'Y�!�`��t�tN `�, Tenant: Suite#: � �` � �� Name: ��`��Y 1 �1�'U Phone: `� � � \ ��,� ��t��M" �,: Address/City/Zip: ��13 y w �5��V��I(�r�.J� ��. � � �� s' � g�, „� Applicant is: Owner Contractor �ti�� f g� � Description of work: ��. �"L��^'� �� '� �� e� , P �� `��,,��, ,,��; .y�� Construction Cost: Estimated Com letion Date: � �� ,�� Name: �b 1:��H�4(..�� Rf' �� S�G�-��'.�:y License#: ��S e,�v'7ry S" £ �� 5�gs i3 �T �� y �1e c�� r«s ��`i��'� - Address: � vi74 Ral�% Cit : �� ,�? s State: 1'�vlJ Zip: S 6 `{�`Z. Phone: �� 5 (- C��1 Ci� ;�� ,�°,� �,�'�� ..:.�y�� Contact: �� 5 EmaiL \F�� F � � �� 3: \\ � New _Remodel �"�� „� �,�, Addition _Other: E y� & - ��r _ Alterations DESCRIPTION OF WORK: ommercial Residential Educational FEES vc�U Contract Value$ ss/ • x.01 $60.00 Permit Fee Minimum, includes State surcharge _$ Permit Fee *If contract value is GREATER than$2,010, Surcharge=Contract Value x$0.0005 -$ Surcharge" If the project valuation is over$1 million, please call for Surcharge _$ TOTAL FEE **Requirements: 2 complete sets of drawings and specifications,cut sheets on materials and components to be used I hereby apply for a Fire Alarm permit and acknowledge that the information is complete and accurate;that the work will be in conformance with the ordinances and codes of the City of Eagan and with the Minnesota Building/Fire Codes;that I understand this is not a permit,but only an application for a permit,and work is not to start without a permit;that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. � ____...__,_� X ��s��a (� ��5;��; � X Applicant's Printed Name App' nYs Signature �� e' `n°a*��.'R ��,� e'a F \� ;; `e R2" 1 �.�, �'v�y'[ ��i�� sc�� ,y -: �,T� �. /._ _ . 1 ��i .. � � p� ; ��^��, �,' � � �� a.w ,\ Y�� 4 � ` ��z��,��r� R+aq�r��.� ` .... � �s� . ��,�",��ug�: ��. ,� ��_�,�� , � �� F r��, � � ,,,,. .. �.,. .r �..�a. .. .. .:.: : ..�a��,�,.. :, , ... �,. Use BLUE or BLACK Ink /�i�� j----------------, G�� /�.�� For Office Use �� I • '�' � � � ��' � ��U �� 11 r�G G��G�� I Permit#: I .v/� � � Permit Fee: 1 ��"�� I 3830 Pilot Knob Road � I Eagan MN 55122 � Date Receive� �/O�/Z I Phone:(651)675-5675 � Fax: (651)675-5694 AUG 10 2015 i Sta��G/ � . !��____��J . 2015 FIRE SUPPRESSION SYSTEMS PERMIT APPLICATION Date: � Site Address: cJ 7'J 7` G�i��lC7�`� ��Je' Tenant: Suite#: � , � �''�. �t :'.\y��E ��.E � . .... � . . Name: � �V 1�S Phone: R PI'C3�t'#jt,�WCIE��' Address/City/Zip: ��3'T �j(/f��fl/��Z/o/1! �l✓�. �AC�Art1 _ m N. '' � �., � Applicant is: Owner Contractor ��'�� ; �,�� .�.�p�� Description of work: t �: �- � ' Construction Cost: Estimated Completion Date: �,,; /►� � F� �� ' Name: ��+f��tl Zf'�l/ ,�i/�Lc- f/�p License#: C�l��o � � 8�� ST�.�/�CIC� �e2!�� City: ��OS e.�0"�,,,, ��,��,� � Address: �� '�� State:�Zip: ��P�1 T'1` Phone: ��3 — 3�l"O� 8 '�. �� ; � �� u � �; �. .�� ` �` � Contact: � ��.tf� �� Email: Z.�/Z�i• �� FIRE PERMIT TYPE WORK TYPE ,Z Sprinkler System(#of heads� �New _Addition Fire Pump �Standpipe Alterations _Remodel Other: Other: DESCRIPTION OF WORK: Commercial Residential Educational `' FEES �3 o S''o'o ., $60.00 Permit Fee Minimum, includes State Surcharge Contract Value$ x.01 "If contract value is GREATER than$2,010, Surcharge=Contract Value x$0.0005 - $ � ��• SD Permii Fee If the project valuation is over$1 million, please call for Surcharge = $ 3�p, ^rj 2.. Surcharge* $100.00 Residential New(includes State Surcharge) _ $ � � QZ— TOTAL FEE 3/4"Displacement Fire Meter-$270.00 = $ Fire Meter _ $ TOTAL FEE **Requirements: 2 complete sets of drawings and specifications,cut sheets on materials and components to be used I hereby apply for a Fire Suppression System permit and acknowledge that the information is complete and accurate;that the work will be in conformance with the ordinances and codes of the City of Eagan and with the Minnesota Building/Fire Codes;that I understand this is not a permit,but only an application for a permit,and work is not to start without a permit;that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. . X X � ApplicanYs Printed Na Applicant's Signature ��/ G��-s�►��r� �� a-�� ,�E � � . . . �. REQiJ1�ED iMSPEC'fiQNS ,; ;-. ,,.?�...�"" }-{ydro�#�t�� "FlowAlarrr� Drain T�st` �ugh ln ` > ! Y,\:, Tr�p ?P.,�mp�'esf G�nfral'Statior� �:,' �Final,; �.. �:; ��. �. .< ; . °� ��ndi�ian�of Is��Ge, � � � �:. c �� "� :.a€ �- �; �' . �,..: : _ . ... : �a� ! + � � . . . . � 1 .{� �� 7'ermit��vieV+red��iy'''� C��te: , :�.; Use BLUE or BLACK Ink ------------�--, i For Office Use D�� I I �1�� V�IJ��1! v�� I Permit#: � � � �� I X �/ � Permit Fee: � 3830 Pilot Knob Road • L I � Eagan MN 55122 j �- _ '� �'� �,!`5 � j Date Received: �� I Phone:(651)675-5675 � I Fax:(651)675-5694 � � t � Staff: ____��__________J 2015 MECHANICAL PERMIT APPLICATION Please submit two(2)sets of plans with all commercial applications. Date: '�� "� Site Address:�� !.(�d�s�1t��2 ��✓ Tenant: �< <G�r' � ' "�" >t � Suite#: �� X� ' Name: Phone: �@S`I,C��EI'��Wtl@C , ,�= Address/City/Zip: '. :: : Name: ��c:�f'"�[�t�. W�✓ssY�r.z4 �£T"��°� nse#: 1� � G'..� ,: .,. � = Address:��..S�L�c�f'�i�/�t`.��` �� ity: ��titi��`� ��"��'' Cc�ntrac#ar. ,: �,�y � �- ;. ,::,. State:i///�/ Zip: 5�f T' S6" Phone: f��-'` �a'/8'` ��j� . T � y Contact:/�l�+� '�"'��L��` Email:/✓�/�.� � �tfT�t�ldL'�K � C�C9'�'[ � ;; ,,, New Replacement Rdditional Alteration Demolition ,.. ;::'�TYP�;�f WaFk �� Description of work: ` ��J��..,� �, �.,--�- �1�,�r= ' �.r�lo �� { `� '�� ' NOTE:[�cxx�f mourrted�r�c�g�u"'nd mcu'nted"tnech�nic�l equ�pmen��s requ�ret�ta Fae s�reenei�"by City ' ' Godet Piease carw��x�se NtechanicaC,�r�sp�cfcsr for infcrmatia�i�o�permit#ed screenfng meti�c�ds. t:. ,r., �� _,.:_: ,, �� ,,,,,, RESIDENT/AL COMMERCIAL , , .. _Fumace �ew Construction _Interior Improvement ' Air Conditioner Install Piping Processed Permtf Type — — % _Air Exchanger _Gas �Merior HVAC Unit _Heat Pump Under/Above ground Tank �Install/_Remove) Other RES/DENTIAL FEES $60.00 Minimum Add or alteration to an existing unit, includes State Surcharge $100.00 Residential New, includes State Surcharge =$ TOTAL FEE COMMERCIAL FEES Contract Value$�i�� '"c,.2� � x.01 $60.00 Permit Fee Minimum,includes State Surcharge 7 � $70.00 Underground tank installation/removal =$ ��P� � Permit Fee '`If contract value is GREATER than$2,010,Surcharge=Contract Value x$0.0005 _$ � � Surcharge� If the project valuation is over$1 million,please call for Surcharge =$ �/'�� TOTAL FEE 1 hereby acknowledge that this information is complete and accurate; that the work will be in confortnance with the ordinances and codes of the City of Eagan;that I understand this is not a permit,but only an application for a permit,and work is not to start without a permit;t the,work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. . - ��'J • ,., . -..... x��/�� :�<GC.G�!/`�� x , r'', A Applicant's Printed Name p i ant's igna ;,.., FOk�CiFFIG�i��,_ ' � � :;. Required lnspections.,, : ` RevieVvetl By .,..' ,�,,,,Rate� ' � Undergraund , 'ough tri Air Test.�?. G;as'Seruice Tes#; '1'ri-flo�irHeat. ,...Finai HUAC Scr��nsng Use BLUE or BLACK Ink r-------___- -----� I For Office Use I �� I U/'I�� Oj'�,ln�nn � Permit#: 1 r,Q Qll � Permit Fee: ��v� I 3830 Pilot Knob Road - '��S3 I I Eagan MN 55122 �/ � Date Received: � Phone: (651)675-5675 ��`� �� i i Fax: (651)675-5694 � I Staff: �-----------------� 2015 COMMERCIAL PLUMBING PERMIT APPLICATION ❑ Please submit two (2)sets of plans with all commercial applications. Date: /�'�� Site Address: � -/ � 'I �� (: � Tenant: � �'" l Suite#: .,.�..�,.��. ,� .w��,�,�,,.�,�,...� ., .�,,,�,,.�,�� .� Prc�per�y � � Name: Phone: � OVY�IE:Y Name: V C'e�.k w�-�1' N/�G�A tnl�G�.L License#: � �Q��ar Address:� 1 7 y0D ,�p0-�l� ��.� �„Qity:_��1�(-R.� State:�Zip: �� O � ' Phone: ��3 �6�' ��.5.�Email: S A�� {�Cu�,'�' ,2 �e . o►�.. �� New� Re lacement � Re air Rebuild '` Modify Space � Work in R.O.W. TJfpe 4f�#fQl`� " — — p — p — . — — Description of work: C MMERC/AL New Construction _Modify Space �� j Q� � Irrigation System(_yes/_no)�RPZ/_PVB) � ��"" �` �' � ^n � • Rain sensors required on irrigation systems �Y\��. �' �'el'tll°I'�'��i�@ ' . Avg.GPM (2"turbo required unless smaller size allowed by Public Works) � _Meters Call(651)675-5646 to verity that tests passed prior to picking up meter. Domestic:Size&Type Fire: 1 ' Avg.GPM High demand devices? Yes No Flushometers_Yes No COMMERCIAL FEES Contract value$ x.01 . � $60.00 Permit Fee Minimum =$�- � u �� ?ermit Fee � $60.00 PVB/RPZ Permit(includes State Surcharge) ` I _$ / ` �� Surcharge � � Surcharge=Contract Value x$0.0005 �, If the project valuation is over$1 million, please call for Surcharge =$ TOTAL FEE � ! Following fees apply when installing a new lawn irrigation system � �$��f-�. Q � Water Permit �� '� Contact the City's Engineering Department,(651)675-5646,for required fee amounts. $ Treatment Plant $ Water Supply&Storage $ �/ . �� State Surcharge �� _$— �`7.j�(��j —TOTAL FEE CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage. 1 I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. x /�Q,C Ca�, ,�-�,�Ka.� x � ApplicanYs Printed Name Ap licant's Sign e FflFt QFFIG� US� 'App�oved By;', t?ate: ' Required lnspec#►pns: l�nder Grou�d Rough=ln ,_,,;�A��Te�t Gas?�st Ftna1 PFfiI%'Re�uires�:�Y�� lo M�ter Rela�sd l�ms: 11l��t�r ai��, 'R�dic�:R�ad� J�lar�o�rieter�, �k�f�; '' Page 1 of 3 Dale Schoeppner From: Bjorklund, Gary (DU) <Gary.Bjorklund@state.mn.us> Sent: Thursday, April 28, 2016 1:20 PM To: 'shelly.cambridge@kone.com'; Dale Schoeppner; DU.EIevator.ETrakit Subject: Final Approval for Permit Work at 3434 Washington Dr, EAGAN KONE INC: The ELV INSTALL permit work has been completed and approved for the following project: Permit Nu Project N Site Location. • e: Holiday Inn Express & Suites Car 1 434 Washington Dr, EAGAN The Department of Labor and Industry is required to inspect and provide approvals on elevator related devices prior to allowing them to be placed into service. An Inspector from the Elevator Safety Section recently performed an inspection of the work performed under the permit listed at the site above.The new installation is in compliance with the Department rules for elevators. NOTE: Compliance with Minnesota Rules and the ANSI/ASME A17.1, Safety Code for Elevators and Escalators does not necessarily assure compliance with the Americans With Disabilities Act of 1990. CONSTRUCTION CODES & LICENSING DIVISION Elevator Section 1 Dale Schoeppner From: Sent: To: Subject: KONE INC: The ELV INS Bjorklund, Gary (DU) <Gary.Bjorklund@state.mn.us> Thursday, April 28, 2016 1:26 PM 'shelly.cambridge@kone.com'; Dale Schoeppner; DLI.EIevator.ETrakit Final Approval for Permit Work at 3434 Washington DR, Eagan i work has . een it Number: ELV1511-00149 Project Name: Holiday Inn Express & Suites Car 2 Site Location: 3434 Washington DR, Eagan ted and approved for the following project: The Department of Labor and Industry is required to inspect and provide approvals on elevator related devices prior to allowing them to be placed into service. An Inspector from the Elevator Safety Section recently performed an inspection of the work performed under the permit listed at the site above.The new installation is in compliance with the Department rules for elevators. NOTE: Compliance with Minnesota Rules and the ANSI/ASME A17.1, Safety Code for Elevators and Escalators does not necessarily assure compliance with the Americans With Disabilities Act of 1990. CONSTRUCTION CODES & LICENSING DIVISION Elevator Section -14 1r /30 f9(3 City of EaRan WoMb TO: Scott Peterson, Building Inspections #30 Jon Hohenstein, Community Development Mike Ridley, Planning Darrin Bramwell, Fire Marshal Russ Matthys, Engineering John Gorder, Engineering Aaron Nelson, Engineering Dave Westermayer, Engineering Leon Weiland, Engineering Jon Eaton, Utilities Eric Macbeth, Maintenance Gregg Hove, Maintenance Lt. Mike Fineran, Police FROM: Mike Lence, Senior Building Inspector DATE: December 10, 2014 RE: Plan Review For: Holiday Inn Express 3434 Washington Dr Lot 1 Block 2 Bicentennial III The plans are in our plan review section for your review and comment. Please return this form to my attention with your signed comments within 7 days. Please indicate any concerns you have with these plans and resolve these issues with the affected parties. If you are requesting that issuance of the building permit be held, please submit the proper"hold request"form to me. Comments: Indicate below any fees that are to be collected with the building permit. Amount ❑ Yes 0 No Landscape Security Required Zoning: ❑ Yes 0 No Water Quality Dedication Meter Size: ❑ Yes 0 No Park Dedication ❑ Yes 0 No Trail Dedication ❑ Yes 0 No Tree Dedication ❑ Yes 0 No PRV Required Signature Date G:\Building Inspections\FORMS\Commercial Bldgs Final & Plan Review Letters 40' City of Eaaau Y8MO TO: Scott Peterson, Building Inspections #30 Jon Hohenstein, Community Development Mike Ridley, Planning Darrin Bramwell, Fire Marshal Russ Matthys, Engineering John Gorder, Engineering Aaron Nelson, Engineering Dave Westermayer, Engineering Leon Weiland, Engineering Jon Eaton, Utilities Eric Macbeth, Maintenance Gregg Hove, Maintenance Lt. Mike Fineran, Police FROM: Mike Lence, Senior Building Inspector DATE: December 10, 2014 RE: Plan Review For: Holiday Inn Express 3434 Washington Dr Lot 1 Block 2 Bicentennial III The plans are in our plan review section for your review and comment. Please return this form to my attention with your signed comments within 7 days. Please indicate any concerns you have with these plans and resolve these issues with the affected parties. If you are requesting that issuance of the building permit be held, please submit the proper"hold request"form to me. Comments: itleec4 i-e,r1+ p � 'J 4 ue a&s. e`y .u i b o to 04' Q c�- b y �55 ati e lvitt e e,r Indicate below any fees that are to be collected with the building permit. Amount ❑ Yes 0 No Landscape Security Required Zoning: ❑ Yes 0 No Water Quality Dedication Meter Size: 0 Yes 0 No Park Dedication ❑ Yes 0 No Trail Dedication ❑ Yes 0 No Tree Dedication ❑ Yes 0 No PRV Required P z. I I 5 I 4.( Signature Date G:\Building Inspections\FORMS\Commercial Bldgs Final & Plan Review Letters 4,6') City of Ea a Mello TO: Scott Peterson, Building Inspections # 30 Jon Hohenstein, Community Development Mike Ridley, Planning Darrin Bramwell, Fire Marshal Russ Matthys, Engineering John Gorder, Engineering Aaron Nelson, Engineering Dave Westermayer, Engineering Leon Weiland, Engineering Jon Eaton, Utilities Eric Macbeth, Maintenance Gregg Hove, Maintenance . ' ie - - • Police F,,OM: Mike Lence, Seni r Building Inspector DAT --- •-r 10, 2014 RE: Plan Review For: Holiday Inn Express 3434 Washington Dr Lot 1 Block 2 Bicentennial III The plans are in our plan review section for your review and comment. Please return this form to my attention with your signed comments within 7 days. Please indicate any concerns you have with these plans and resolve these issues with the affected parties. If you are requesting that issuance of the building permit be held, please submit the proper"hold request"form to me. Comments: 40,4 Indicate below any fees that are to be collected with the building permit. Amount ❑ Yes ❑ No Landscape Security Required Zoning: ❑ Yes ❑ No Water Quality Dedication Meter Size: O Yes 0 No Park Dedication ❑ Yes 0 No Trail Dedication ❑ Yes 0 No Tree Dedication ❑ Yes No PRV Required Signature Date IlbIN le G:\Building Inspections\FORMS\Commercial Bldgs Final & Plan Review Letters City of EaaaliWeMO TO: Scott Peterson, Building Inspections # 30 Jon Hohenstein, Community Development Mike Ridley, Planning Darrin Bramwell, Fire Marshal Russ Matthys, Engineering John Gorder, Engineering Aaron Nelson, Engineering Dave Westermayer, Engineering Leon Weiland, Engineering Jon Eaton, Utilities Eric Macbeth, Maintenance Gregg Hove, Maintenance Lt. Mike Fineran, Police FROM: Mike Lence, Senior Building Inspector DATE: December 10, 2014 RE: Plan Review For: Holiday Inn Express 3434 Washington Dr Lot 1 Block 2 Bicentennial III The plans are in our plan review section for your review and comment. Please return this form to my attention with your signed comments within 7 days. Please indicate any concerns you have with these plans and resolve these issues with the affected parties. If you are requesting that issuance of the building permit be held, please submit the proper"hold request"form to me. Comments: k e 1,d re.„, r `r vL_ 0-c e-e yikeAid- • zdA1_6 Leite ?" .cy,‘ita6t9)-1, at Indicate below any fees that are to be collected with the building permit. Amount Cg Yes ❑ No Landscape Security Required 17 D Zoning: P 0 Yes No Water Quality Dedication Meter Size: co Yes 0 No Park Dedication .4//,(, 4/i 0 Yes Eit No Trail Dedication ❑ Yes Ii No Tree Dedication la 0 Yes 0 No PRV Required 4///5"-- Signature Date G:\Building Inspections\FORMS\Commercial Bldgs Final & Plan Review Letters 44/ . City of Eta! Vero TO: Scott Peterson, Building Inspections # 30 Jon Hohenstein, Community Development Mike Ridley, Planning Darrin Bramwell, Fire Marshal Russ Matthys, Engineering John Gorder, Engineering Aaron Nelson, Engineering Dave Westermayer, Engineering Leon Weiland, Engineering Jon Eaton, Utilities Eric Macbeth, Maintenance Gregg Hove, Maintenance Lt. Mike Fineran, Police FROM: Mike Lence, Senior Building Inspector DATE: December 10, 2014 RE: Plan Review For: Holiday Inn Express 3434 Washington Dr Lot 1 Block 2 Bicentennial III The plans are in our plan review section for your review and comment. Please return this form to my attention with your signed comments within 7 days. Please indicate any concerns you have with these plans and resolve these issues with the affected parties. If you are requesting that issuance of the building permit be held, please submit the proper"hold request"form to me. Comments: Indicate below any fees that are to be collected with the building permit. Amount ❑ Yes 0 No Landscape Security Required Zoning: ❑ Yes 0 No Water Quality Dedication Meter Size: O Yes 0 No Park Dedication O Yes 0 No Trail Dedication ❑ Yes 0 No Tree Dedication 0 No PRV Req ' ed / r //--// Signature ` Date G:\Building Inspections\FORMS\Commercial Bldgs Final & Plan Review Letters idel ' City of EaaR WeMo TO: Scott Peterson, Building Inspections #30 Jon Hohenstein, Community Development Mike Ridley, Planning Darrin Bramwell, Fire Marshal Russ Matthys, Engineering John Gorder, Engineering Aaron Nelson, Engineering Dave Westermayer, Engineering Leon Weiland, Engineering Jon Eaton, Utilities Eric Macbeth, Maintenance Gregg Hove, Maintenance Lt. Mike Fineran, Police FROM: Mike Lence, Senior Building Inspector DATE: December 10, 2014 RE: Plan Review For: Holiday Inn Express 3434 Washington Dr Lot 1 Block 2 Bicentennial III The plans are in our plan review section for your review and comment. Please return this form to my attention with your signed comments within 7 days. Please indicate any concerns you have with these plans and resolve these issues with the affected parties. If you are requesting that issuance of the building permit be held, please submit the proper"hold request"form to me. Comments: Indicate below any fees that are to be collected with the building permit. Amount O Yes 0 No Landscape Security Required Zoning: O Yes 0 No Water Quality Dedication Meter Size: O Yes 0 No Park Dedication O Yes 0 No Trail Dedication ❑ Y No Tree Dedication O e o PRV Required f/(1j 3(3e(i Signat re Date G:\Building Inspections\FORMS\Commercial Bldgs Final & Plan Review Letters P City of Eaaafl W8M0 TO: Scott Peterson, Building Inspections #30 Jon Hohenstein, Community Development Mike Ridley, Planning Darrin Bramwell, Fire Marshal Russ Matthys, Engineering John Gorder, Engineering Aaron Nelson, Engineering Dave Westermayer, Engineering Leon Weiland, Engineering Jon Eaton, Utilities Eric Macbeth, Maintenance Gregg Hove, Maintenance Lt. Mike Fineran, Police FROM: Mike Lence, Senior Building Inspector DATE: December 10, 2014 RE: Plan Review For: Holiday Inn Express 3434 Washington Dr Lot 1 Block 2 Bicentennial III The plans are in our plan review section for your review and comment. Please return this form to my attention with your signed comments within 7 days. Please indicate any concerns you have with these plans and resolve these issues with the affected parties. If you are requesting that issuance of the building permit be held, please submit the proper"hold request"form to me. Comments: Indicate below any fees that are to be collected with the building permit. Amount ❑ Yes ❑ No Landscape Security Required Zoning: ❑ Yes 0 No Water Quality Dedication Meter Size: ❑ Yes ❑ No Park Dedication ❑ Yes ❑ No Trail Dedication ❑ Yes l' No Tree Dedication ❑ Yes 0 NPRV Required Signature Date G:\Building Inspections\FORMS\Commercial Bldgs Final & Plan Review Letters 4,1110". 1 0f E � all Mike Maguire December 12, 2014 Mayor Kevin Hanson Paul Bakken Cities Edge Architects Cyndee Fields 103 15th Ave NW Gary Hansen Willmar, MN 56201 Meg Tilley Council Members RE: Holiday Inn Express 3434 Washington Dr Eagan, MN 55122 Dave Osberg City Administrator Dear Kevin: We have started our review of the construction documents submitted in pursuit of obtaining a building permit for the above-referenced project. This review is not intended to be an exhaustive and comprehensive report. Unless otherwise noted, all references are to the 2006 I.B.C. It is our goal that this review will help you in complying with the Municipal Center applicable codes and we are, therefore, requesting that the following items be 3830 Pilot Knob Road addressed: Eagan, MN 55122-1810 651.675.5000 phone J� Provide a Met Council SAC determination. J• Provide 1 Special Structural Testing & Inspection Schedule. (Example Enclosed) 651.675.5012 fax / Submit firestopping details for specific penetrations and materials. (PVC, CPVC, 651.454.8535 TDD conduit, HVAC) Maintenance Facility If you should have questions please contact me at 651-675-5676 or email 3501 Coachman Point mlence a cityofeagan.corn. Eagan, MN 55122 Sincerely, 651.675.5300 phone 651.675.5360 fax651.454.8535 TDD Mike Lence Senior Building Inspector www.cityofeagan.com Cc: Dale Schoeppner, Chief Building Official The Lone Oak Tree The symbol of strength and growth in our community. Mike Lence From: Mike Lence Sent: Friday, January 23, 2015 2:38 PM To: Kevin Hanson (khanson@ramaker.com) Cc: Dale Schoeppner; Craig Novaczyk Subject: Holiday Inn Express Kevin, I have completed the review for Holiday Inn Express located at 3434 Washington Drive. The following items need to be addressed. 1. Incidental use rooms to resist the passage of smoke. IBC Section 508.2.2.1 2. Provide occupant load calculations for the assembly areas and egress width requirements. IBC Section 1004 3. Sound transmission of corridor wall F2 gives a rating of 34. I believe a STC of 50 is required. IBC 1207.2 4. Roof access hatch located within 10 feet of roof edge a guard shall be provided. Mn Rules 1305. 1209.3.1 Item 6 5. Door and window schedule does not identify safety glazing.This will be required in all hazardous locations per IBC Chapter 24 If you have questions or comments please contact me. Sincerely, Mike Mike Lence I Senior Building Inspector I City of Eagan • City Hall 13830 Pilot Knob Road I Eagan,MN 55122 1(651)675-5676 1(651)675-5894(Fax)I mlencet citvofeaaan.com CAC I , , of THIS COMMUNICATION MAY CONTAIN CONFIDENTIAL AND/OR OTHERWISE PROPRIETARY MATERIAL and is thus for use only by the intended recipient. If you received this in error,please contact the sender and delete the e-mail and its attachments from all computers. 1 IPINE 11111 CITIES EDGE ARCHITECTS March 26,2015 Mike Lence Senior Building Inspector City of Eagan 3830 Pilot Knob Road Eagan, MN 55122 Regarding: Holiday Inn Express&Suites 3434 Washington Drive Dear Mr. Lence: This letter is in response to your Plan Review dated 12-05-2013. We have reviewed the items identified and provide the following responses. The responses are numbered to correspond to your comments. 1. Incidental use rooms to resist the passage of smoke. IBC Section 508.2.2.1 Will comply,rooms will be built accordingly. Contractor has been made aware as well. 2. Provide occupant load calculations for the assembly areas and egress width requirements. IBC Section 1004 Occupancy load calcs are included on the attached plans. 3. Sound transmission of corridor wall F2 gives a rating of 34. I believe a STC of 50 is required. IBC 1207.2 IBC 1207.2 does not apply to R1 occupancies;that said,there is a type-o on that wall type. Wall type F2 actually has a 57 STC rating. 4. Roof access hatch located within 10 feet of roof edge a guard shall be provided. Mn Rules 1305. 1209.3.1 Item 6 The roof hatch is specified to be equipped with an integral guard rail,see specification Section 07 7200 Roof Accessories. 5. Door and window schedule does not identify safety glazing.This will be required in all hazardous locations per IBC Chapter 24 Safety glazing will be provided at all required locations. If you have any questions or need any additional information, please feel free to call me at(608)644-2281 or e-mail me at khanson@citiesedgearchitects.com. • Sincerely, Kevin M. Hanson Project Manager Cities Edge Architects CC: Brian Ruschy—Tech Builders File lierracon December 16, 2016 Tech Builders Inc. 410 Downtown Plaza Fairmont, MN 56201 Attn: Mr. Brian Ruschy President Telephone: (507)236-2119 Email: kathy@tpimn.com RE: Project Certification Letter Holiday Inn Express 3434 Washington Drive Eagan, Minnesota Terracon Project No. 41151510 Dear Mr. Ruschy: Terracon Consultants, Inc. (Terracon) provided testing and observation services relating to soil, structural concrete, reinforcing steel, structural wood framing, EIFS, and structural steel from April 20, 2015 through May 16, 2016. To the best of our knowledge, information, and belief, based upon observations and tests made by Terracon representatives, the soil, structural concrete, reinforcing steel, structural wood framing, EIFS, and structural steel observed and tested by Terracon were constructed in general accordance with the project plans and specifications provided to Terracon. It should be noted that our testing and observation services were performed on an as-requested basis, and only when requested by the above-listed client or their designated representative. We offer no opinion regarding materials not tested or observed by Terracon representatives. This letter is provided solely for the benefit for the above-listed client and does not impact in any way the rights and obligations of third parties, including contractors and subcontractors who may have provided the materials and/or construction services tested or observed. If additional information regarding the observations and testing performed by Terracon is requested, final reports can be provided. Sincerely, TERRACON CONSULTANTS, INC. /74-- Josh a J. SchillinAndrew T. Schmid, P.E. Project Manager Department Manager, Construction Services I hereby certify that this plan,specification, or report was prepared by me or under my direct supervision and that lam CC: Client(email) a duly Licensed Professional Engineer under the laws of the Tech Builders(email) State of Minnesota. /1/&. ° Andrew T.Schmid,P.E. Date: 12/16/2016 Reg.No.48982 Terracon Consultants, Inc. 3535 Hoffman Road east mite bear Lake, minnesota bout) P [651]770 1500 F[651] 770 1657 terracon.com Geotechnical • Environmental • Construction Materials U Facilities ANNUAL TEST FORM BACKFLOW PREVENTORS CUSTOMER: STREET ADDRESS: MAILING ADDRESS: NEW INSTALLATION EXISTING REPLACEMENT OLD ASSEMBLY S.N.: LOCATION OF ASSEMBLY: TYPE OF ASSEMBLY: RPZ DCV PVB SVB SIZE: INSTALLATION DATE: MANUFACTURER: MODEL: SERIAL #: RELIEF VALVE CHECK VALVE #2 Back Pressure Test CHECK VALVE #1 In Direction of Flow Test CHECK VALVE #2 In Direction of Flow Test Pressure/Spill Resistant Vacuum Breaker DOUBLE CHECK VALVE In Direction of Flow Test Opened at ________ psid Did Not Open Leaked Closed Tight Leaked Closed Tight Differential Pressure Across check valve ________ psid Leaked Closed Tight Differential Pressure Across check valve ________ psid Air inlet opened at ________ psid Did Not Open Check Valve Leaked held at ________psid #1 Leaked Closed Tight ________ psid #2 Leaked Closed Tight ________ psid Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed CHECK ALL THAT APPLY Cleaned Only Cleaned Only Cleaned Only Cleaned Only Cleaned Only #1 Cleaned Only #2 Cleaned Only Replaced: Replaced: Replaced: Replaced: Replaced: Replaced: Replaced: Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Assembly Assembly Assembly Assembly Assembly Assembly Assembly Disc Disc Disc Disc Disc, air in Disc Disc Diaphragm Spring Spring Spring Disc, CV Spring Spring Spring O-rings O-rings O-rings Spring, air O-rings O-rings O-rings Other Other Other O-ring Other Other Other Other Describe Repairs: Opened at ________ psid Closed Tight Differential Pressure Across check valve ________ psid Differential Pressure Across check valve ________ psid Air Inlet_________ psid Check valve ______psid Check #1 ________ psid Check #2 ________ psid Opened shut off #1 Opened shut off #2 Water Pressure: Test Kit SN: Remarks: I hereby certify that this date is accurate and reflects the proper operation and maintenance of the assembly. TESTER’S NAME (print) CERT. # TESTER’S SIGNATURE DATE TIME COMPANY Davis Mechanical Systems Inc. 21225 Hamburg Ave Suite 3 Lakeville MN 55044 952-854-3654 ANNUAL TEST FORM BACKFLOW PREVENTORS CUSTOMER: STREET ADDRESS: MAILING ADDRESS: NEW INSTALLATION EXISTING REPLACEMENT OLD ASSEMBLY S.N.: LOCATION OF ASSEMBLY: TYPE OF ASSEMBLY: RPZ DCV PVB SVB SIZE: INSTALLATION DATE: MANUFACTURER: MODEL: SERIAL #: RELIEF VALVE CHECK VALVE #2 Back Pressure Test CHECK VALVE #1 In Direction of Flow Test CHECK VALVE #2 In Direction of Flow Test Pressure/Spill Resistant Vacuum Breaker DOUBLE CHECK VALVE In Direction of Flow Test Opened at ________ psid Did Not Open Leaked Closed Tight Leaked Closed Tight Differential Pressure Across check valve ________ psid Leaked Closed Tight Differential Pressure Across check valve ________ psid Air inlet opened at ________ psid Did Not Open Check Valve Leaked held at ________psid #1 Leaked Closed Tight ________ psid #2 Leaked Closed Tight ________ psid Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed CHECK ALL THAT APPLY Cleaned Only Cleaned Only Cleaned Only Cleaned Only Cleaned Only #1 Cleaned Only #2 Cleaned Only Replaced: Replaced: Replaced: Replaced: Replaced: Replaced: Replaced: Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Assembly Assembly Assembly Assembly Assembly Assembly Assembly Disc Disc Disc Disc Disc, air in Disc Disc Diaphragm Spring Spring Spring Disc, CV Spring Spring Spring O-rings O-rings O-rings Spring, air O-rings O-rings O-rings Other Other Other O-ring Other Other Other Other Describe Repairs: Opened at ________ psid Closed Tight Differential Pressure Across check valve ________ psid Differential Pressure Across check valve ________ psid Air Inlet_________ psid Check valve ______psid Check #1 ________ psid Check #2 ________ psid Opened shut off #1 Opened shut off #2 Water Pressure: Test Kit SN: Remarks: I hereby certify that this date is accurate and reflects the proper operation and maintenance of the assembly. TESTER’S NAME (print) CERT. # TESTER’S SIGNATURE DATE TIME COMPANY Davis Mechanical Systems Inc. 21225 Hamburg Ave Suite 3 Lakeville MN 55044 952-854-3654 ANNUAL TEST FORM BACKFLOW PREVENTORS CUSTOMER: STREET ADDRESS: MAILING ADDRESS: NEW INSTALLATION EXISTING REPLACEMENT OLD ASSEMBLY S.N.: LOCATION OF ASSEMBLY: TYPE OF ASSEMBLY: RPZ DCV PVB SVB SIZE: INSTALLATION DATE: MANUFACTURER: MODEL: SERIAL #: RELIEF VALVE CHECK VALVE #2 Back Pressure Test CHECK VALVE #1 In Direction of Flow Test CHECK VALVE #2 In Direction of Flow Test Pressure/Spill Resistant Vacuum Breaker DOUBLE CHECK VALVE In Direction of Flow Test Opened at ________ psid Did Not Open Leaked Closed Tight Leaked Closed Tight Differential Pressure Across check valve ________ psid Leaked Closed Tight Differential Pressure Across check valve ________ psid Air inlet opened at ________ psid Did Not Open Check Valve Leaked held at ________psid #1 Leaked Closed Tight ________ psid #2 Leaked Closed Tight ________ psid Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed Passed Failed CHECK ALL THAT APPLY Cleaned Only Cleaned Only Cleaned Only Cleaned Only Cleaned Only #1 Cleaned Only #2 Cleaned Only Replaced: Replaced: Replaced: Replaced: Replaced: Replaced: Replaced: Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Rubber Kit Assembly Assembly Assembly Assembly Assembly Assembly Assembly Disc Disc Disc Disc Disc, air in Disc Disc Diaphragm Spring Spring Spring Disc, CV Spring Spring Spring O-rings O-rings O-rings Spring, air O-rings O-rings O-rings Other Other Other O-ring Other Other Other Other Describe Repairs: Opened at ________ psid Closed Tight Differential Pressure Across check valve ________ psid Differential Pressure Across check valve ________ psid Air Inlet_________ psid Check valve ______psid Check #1 ________ psid Check #2 ________ psid Opened shut off #1 Opened shut off #2 Water Pressure: Test Kit SN: Remarks: I hereby certify that this date is accurate and reflects the proper operation and maintenance of the assembly. TESTER’S NAME (print) CERT. # TESTER’S SIGNATURE DATE TIME COMPANY Davis Mechanical Systems Inc. 21225 Hamburg Ave Suite 3 Lakeville MN 55044 952-854-3654