1275 Promenade Pl
PIE.R 1 IlMPORTS
,
CerttftC?f¢ nf cCC1tpQ1iC? .:
OftV of Cfagan
?eyart- aettt of Znitbing auj3pecrian
This Certifcate issued pursuant ro the requirements of the UniforM Building Code
certifyirtg that at the time of issuartce this structure was in compliance with the various
ordinantes of the City regulating building construction or use. For the following:
;
Use Classification: COMMfIND MISD Bldg_ Permic Na 28720
IIS NORTHWEST LLC Addmu 44UU BltEN ttll E, MrxA
S P_DE Pi.ACE ?;ry L8, B2, EAL'aAN MfN"
Dm.
IN A CONSPICUOUS PLACE
PIER 1 11rIPORTS
e"'d"?= S"' ? +
??" .... . . .
. ? ,
C?;???ica?e n?°?ccuvanc?
Kit4 o? ?gan .
modrialmt ? ??? 3*04cco.x
Tlus Certifccate issued pursuant to the requirernents of the Uniform Building Code
certi,fying that at lite lime of rssuartce lhis struclure was in compliance wrth the various
ardinances of the City regulating building construction or use. For the following:
usecawuawadm: COMM/1ND M1SC sldg.Pemnpo. 28720
O-up-Y TyPe Zoning Maki 7'Ape Const.
Owmdswwbm OPUS NORTHNEST LLL' Ad6,,., 9900 BREN RD E., !l1NNE'IONKl1, !3N
BuildwS Addrcss
1275 PROMENADE PL L,,,cwi,y L8, B2, EAGAIi PROMENADE
Dre: NCIVRMRFR 6_ IQQ6
B.M?.
POST IN /1 CONSPICUOII?s PLACE
1
?
` 'CIT Y OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-189
(612) 681-4675
SITE ADDRESS:
I ,!j
1 At,AIM VRIII?Ft-1VAl?1
PERMIT SUBTYPE:
I!Mn i ril. ,.I 1 ',i
INSPECTION RECORD
PERMIT TYPE:
Permit Number:
? Date Issued:
}; H i o( I APPLICANT:
1 . , ,j„1
(t,i.') '113 ll, pit/)
TYPE OF WORK:
pF%t:HIp i'iFIH
141111 ac,
F!?ii 1 : 0
At) tA I i kii 1.
1 F 11AN1 t 1 N1 ;H
?r-j f rr I I ai•ok is l
INSPECTION D . .
f• {Illll?? 1 fJ i! { ?? i 1 W111 I'! Itf.
f 1 Nf,) I1 {?? i I 1?s:'?!
? ?
s
?.
Permit No. Permit Hotder Date Telephone M
ELECTRIC
9/ o • flvcl?
PLUMBING (p
V
HVAC 7 I ? 0 giTj 6/
Inspectlon ate I nsp. Comments
FOOTINGS
FOUND
FRAMING
ROOFING
ROUGH
PLUMBING
- (7 ?y
P
AIR LBGEST
ROUGH
HEATING
GAS SVC
TEST
INSUL
GYP90ARD
FIREPLACE
FIREPLACE
AIR TEST
FINAL PLBC3
FINAL HTG
S
U
ORSAT
TEST
BLDG FINAL
BSMT R.I.
-?-
BSMT FINAL - -
DECK FfG
DECK FINAL
2 6 3?Q?O ? NLY This requast void IB momhs from mlidafion dak pdnted in Miz box.
OFFI E
US O
goz*
_ ' i?
? m
?
PLEASE PRINT OR TYPE
Request Dore
?C
% Rough-in inspedion requiredd es ? No Inspetlion OlherThan Rough-In: 0 Ready Naw Will Call
h
d
R
d
?
t ?
,5
lYao mast mll fhe inspecror w
n re
y? fe
eu
y:
I, licensed conNador ? owner hereby request inspedion o fhe above edri<ol W? .?"
Jab Pddress (Stree; Boa, or koum Na.)
V
t
'
t
?) Ciry
E
SS\2_I
q
1
e,
j.
'oomr' w o.v,
SecNan No. Township Name or No. Range Na. Fim No. Coon
Occupont
te S. Tw, ? Phone No.
Power Supplier ` Aildress
Elennml ConVatlor (CompaM Nome) Conkacbr Licen No.
O Moskr Lic. No. (Plam Elect Only)
om? ?.J ?ec?vi -
Mailing /ddress (Commrnr or akrtning Insmllonon)
0(aA "V vv' 0\rvT .i2
Aulf?onzad naNm (Contratlor or Owner PeAarming InsmllaNOn? Phan??
fl ?
EB-00OOlA-10 6/95 " STATEBOAp CO -SEEINSTflUCTION50NBACKOFYELLOWCOPY
I I11?II II I?I IIWII IIII?I?IIII ?I? II?I REQUEST FOR ELECTRICAL INSPECTION?p
Minnesofa State Board ot ElecViciry
1821 University Ave., Rm. $?12 $tiPaul, MN 55104
* 0 2 6 3 8 6 0 9* Phone (81?a 64&0600 0% /?o
Home Duplez Ap}. Bldg. Ofher: New Addn
Commercial Indusfrial Farm Remod Re air
Air Cond. Htg. Equip. Woter Fkr. Load Mgmf. "e'n
D r Ran e Ele<. Heat Tem . ice
"X" above ihe wo1ic covered 6y thit request. Enter remark n this spoce and __ e whiM copy only.
Calculafe InspecFion Fee - This lnspection Reques} will nof be accepted without fhe correcf fee:
qher Fee # Service ce $'ae
Enhon Fee # Circuih/Feeders Fce
Mobile Home Park Sloll 0 to 200
Amps 0 to 100 Amps 0 CQ
Sireet Ltg./TmfFic Sig. Above 200 Amps Above 100 Amps ?E
Transformer/Generator INSPECTOP'SIISEON TOTAL ?31??
Sign/Outline L}g. Ximr. ? j01 S{y e.SO
Alarm/Remota CoMrol 1 r 33A .:S
Swimming Poal
I hert ce Ihm I im Med nnml inalnliation deecnhed hercin an Nrc doks sMfd
Irrigotion Boom Ro?yh-i? oam
Special Inspection
Final
Investigative Fee
THIS INSTALLATION MAY BE ORDERED DiS CTED IF NOT COMPLETED WITHIN 18 MON7HS.
REDUEST FOR ELECTRICAL INSPECTION ?° ??, eaoooowe(?'
? See instrudions tor completing this form on back oi yellow copy.
?
CU `+ 1 31 O "X" Be/ow Work Covered by This Request
ew Add Rep. Type of Building AppliancesWired EquipmentWired
Home Range TempOrary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Loed Management
Comm.llntlustrial Fumace Other (SpeciTy)
Farm Air Conditioner
Olher (specily) LonVactor5 Remarks:
Compute Inspeciion Fee Below:
# Other Fee 8 ServiceEmranceSize Fee 8 Circuits/Feeders F e
Swimming Pool 0 to 200 Amps 0 to 700 Amps
Transtormers Above 200 A _ Amps
Signs inweaor
? ? TO7AL
IirigationBOOms ?
b
• ?1:50
Speciallnspection ?
?
Alarm/Communication IS IN TALLAT MAV BE DISCONNECTED IF NOT
Other Fee COMPL ITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in oa+a
certify that the above inspection has
been made. F;,,ai oeie
OFfICE USE ONLV
This requesl voitl 18 mon[hs Imm
94
C3 419,1 Q g (P
Repuest Dete Fire No. Rough-ln Inpsection ReQWratl
(YOUmusl IlnSpedorwhenreaEy) I?s ectlan Other Than Rough-ln
? qeitlyNOw ? WiIINaMy?Glm
/-
{?! y Yp ? NO DateRead
?
?
?
licensed contractor 7 owner hereb y request inspection oi above
e
ical
Job Ftltlmss (Slreel. Box or Roule No.)
1;7-75-
6-1 Ciry
$ection No. Township Name ar No. Range No. Coonry
A`/,
Occupant(PRINT) Phone No.
r?? - ?/C S
Power Supplier Atltlress ?S? ?,
DVANKA::17106, C1,l&c--f{?? G p '? FPZA 6IWQtrii?
Electtical Camractor ICOmpany Namel
A/ Contractor5 License No.
GINT
Meiling AEtlress ICOnVactor or Owner Making In5[
t
Aulh ?zetl ignature 1 onV tou ner Making Inslallationj Phone NumEer
(?q--i6i-z-5w
E TA STATE BOARD OF EL . ICITV
' IEwey Bldg. - Room Sd73
° SL Peul. MN 55104
wwww'_
THIS INSPECTION REOUEST WILL NOT
BE ACCEPTED 8V THE STATE 80ARD
UNLESS PROPERINSPECTION FEEIS
ENCLOSED.
•?
;,cra??X?skc???X**#,kk:# 0 •X, v,c:x0 * ;gUU;r;c
CITY OF E"AG;At?
(:iAci!-I:I:E:Ft; S T'ERMINAL NOc 24
BF?fF:: 09/03/96 'il:Ml'i.: L4'54:58
IDg
NAMEs OF'Uc
3210 9(:)01 1275 f-'RC?MEPIAIIE :t7362.i?5
3422 9001 J.c r:, F'FiC1t"f(,NADf= 1385.46
205 9001 1275 PFiOMENAT..iE 37.50
7oi:a:1. Rt=rF_,ipi; Amnuri+,a i..'.p34.:r.27.
Cfi063 i":)C)
tJ:31cfi TD: NANCY
CITY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
PERMIT
PERMITTYPE: auxLDxNG
Permit Number: 0 2 8 7 2 0
Date Issued: 0 9/ 0 3/ 9 6
SITE ADDRESS:
1275 PROMENADE PL
LOT: S BLOCK: 2
EAGAN PROMENADE
DESCRIPTION:
(PIER 1 IMPOR75)
Permit Type COMM./IND. MISC.
4prk Type TENANT FINSSH
di-? 437 AL7. NONRES.
' $??
? $? ? ?,n'+ ''?f it v ?6 ?
'sfi?
REMARKS:
FEE SUMMARY:
sase Pee
Plan Review
Surcharge
Total Fee
CONTRACTOR:
OPUS GORP
VALUATION
$195,000
$1,362.25
$885.46
$97.50
$2,345.21
- Applicant -
29364671
9900 BREN RD
MINNETONKA MN 55440
(612) 936-4671
?
? tY??"eby s?
inforrri:ti?i?
u?`t?tu??G..•c
L _ X-`,-.
OWNER:
OPUS NORTHWE57 llC
9900 BREN RD E
MINNETONKA MN 55343
(612)936-4444
l;i I Y ur cHUArv
? -1111ift"6 BUILDING PERMI68 ? ?15ATlON (COMMERCIAL) ? ?t??? ?i
?
The following are required with appropriate certification for all new construction: -j U
2 each: architedural plans; mech. & elec. plans; fire sprinkler plans; structural plans; site plans; IandscaFing plans; gradingldrainage/erosion contrU
plan; utiliTy plan
1 each: set of specifcations; set of energy wlcufations; electrical power & lighling fortn; Special InspeCions 8 Testing Schedule
Letter from MClWS (phone #222-3423) inCiwting SAC delertnination
Code analysis indicating: Codes used; occupancy dassifications; setbacks; maximum allowable area as per Building and City Codes along with sq.
ft. per floor, type of construction (synopsis of construCion components) 8 any occupanry ot area separation walls:
occupanq loads; exit synopsis wkh a diagram indicating exiting loads from each room or area, travel paths 8 all rsi_d
wrridors; plumbing fxtures; and parking.
QATE: aigu5t 7 0. 14ll5WORKTYPE: X NE•N _ Re?AODE!
DESCRIFIION OF WORK: ipnant Imoravaments for tanant s DacP =h at E3oan PrnmFnadF
CONSTRUCTION COST: S195, 00a TENANT NAME: Pi er I Tm=r+-s
1275 Promenade Place
SITEADDRESS:
SiRE_R M.
LOT 3 BLOCK 2 SUBD. Eaaan Promenade P.I.D.
PROFEZTY Name: Ocus Northwest L.L.C. Phone n:
OWNEt `"" 11ReT
Sire=i Address•700 Opus Center, 0000 Bren
Rd. Easi
Clty: Minnetonka St2T2: M?J Zip:
GONTRP.CTOR ComP"anY? Oous Corooration PhOne #: 936-4211
Stree! Address 800 oous Center. 9900 6ren Rd. East
Ciry•: ^1innetonka MN Zip: 5-31;
ARCHITECTi Company: Oous Architects & Enaineers Phone #-0=6-"-Ec0
ENGiNEErZ
Name: Grant Peterson Registration #" 12a93
Stre=t Address' 700 Opus Centzr, 9900 6ren Rd . Eas'
: hlinnetonka
Cit State: niN Zip: 55343
y
Sewer&waterlicensedplumber. G.R. Mechanical
I hereby acknowledge that I have read this application and state that the
applicable State of Minnesota Statutes and Gity of Eagan Ordinances.
is correct and agree to comply with all
Signature of Applicant:
BUILDING PERMIT TYPE
? 01 Foundation
ia 18 . Comm.llnd.
WORK TYPE
0 31 New
? 32 Addition
GENERAL INFORMATION
Const. (Aciual) (Allowable)
UBC Occupancy
Zoning
# GT SiOfIES
Lencth
Decih
APPROVALS
OFFIGt USt vlvLr
?
.
? 19 Comm.llnd. Misc. ? 21 Miscellaneous
? 20 Public Facility
? 33 Alterations kq, 35 Tenant Finish
? 34 Repair ? 37 Demolition
Basernent sq. ft. MC/WS System
First Floor sq. ft. City Water
sq. ft. Fire Sprinklered
Sq. ft, Census Code
sq. ft. SP,C Ccde
Sq, g, Census Bida.
Footprint sq. ft. Census Unit
Flanning Buildina
Engineerina
Variance
Permit Fee Valuation:
Surcharge
Plan Review
MCNVS SAC
City SAC
Water Conn.
SJ'W Permit
SM/ Surcharge
Treatment Pi.
Road Unit
Park Ded.
Trails Ded.
Water Qual.
Other
Copies
Total:
% SAC
SAC Units .
Meter Size
$ ?.n00
Sii3D
VE%1 ?.E?Ei?T t cYS???
z°rZI°Z DATE
?
JQB
OW HE.R
)
-?'f--:
?-
? _, •
;
?-• ?? ,,?, ,
' J
M,?:?:
:DY c.15e 3E ADVI'?„e,D ':;??,^ ,;r.r.?'f.3E .?.5 A L' Sri0$'"A,?.., OH ':? A30VE
?.eCTfiICAL ihSTALI.A:'SCH IN :".-,' A2SOUHT OF $ z ?
SHOR^'AGm ?Si15i 3E ?A7D WgI"_?i=,y 24 1y1:5,
REYaRXS
30 =mo. c__ u+-5= fn
31 *_o !00 amv. circuits= Z13
RETU?tN A COPY OF IHIS FORM WITH BEMITTafTCE•
3/9(-
P°RMIS!A & - Z/`q 10
OBIG. R:CZI2IfP 2 z;.125
REL'EIPT OATE 6rz,Cj?
i?-
OFFICE USE ONLY
L BL RECEtPT #: 6P ?
SUBD. y DATE:
7996 PLUMBING PERMIT (CC)MMERCIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, MN 55122
(612) 681-4675
Please complete for: ? ali commerciaVindustrial buildings.
? multi-family buildings when separate permits are not required for each dwelling
unit.
DATE: CONTRACT PRICE:
WORK TYPE: NEW CONSTRUCTION k ADD ON REPAIR
DESCRIPTION OF WORK; 7e??? ? ? e ? Z +"` ?S
IS WATER METER REQUIRED? _ YES 4N0. IF SO, PLEASE PROVIDE THE FOLLOWING:
WATER FLOW: GPM. ARE FLUSHOMETER:i TO BE INSTALLED? _ YES I NO.
FAILURE TO PROVIDE THIS INFORMATION WILL RESULT IN A DELAY OP METER ISSUANCE.
WILL YOU BE INSTALLING A METER FOR A FUTURE U.G. SPRINKLER SYSTEM? _ YES X'NO.
IF SO, YOU MUST APPLY FOR A SEPARATE U.G. SPRINYLER PERMIT.
FEE: $25.00 minimum fee or 1°h o( wntract price, whichever is greater. State surcharge of $.50 per
$1,000 of pg,j32 fee due on all permits.
CONTRACT PRICE x 1%
STATE SURCHARGE
TOTAL
J?6
SITE ADDRESS:
TENANT NAME: STE. #
OWNER NAME:
INSTAILER: ?/?
/ ,?
ADDRESS: !?o S , S / , ° /?.,, /r.
CITY: z2P9-0--'_?> :*PiPHONE #: SIGNATURF:
ICANT
aFFICE USE ONLY
METER SIZE: ?_" DATE: ?-??` ? INSPECTOR:
CITY USE ONLY
L BL
SUBD.
1996 PLUMBING PERMIT (RESIDENTIAL)
CITY OF EAGAM
3830 PILOT KNOB RD
EAGAN, MN 55122
(612) 681-4675
RECEIPT #:
DA
Please complete for: • single family dwellings
? townhomes and condos when permits are required for each unit
FIXTURES
Shower EACH
3.00
x
Water Closet 3.00 x
8ath Tub 3.00 x
Lavatory 3.00 x
Kitchen Sink 3.00 ;c
Laundry Tray 3.00 :c
Hot Tub/Spa 3.00 ;c
Water Heater 3.00 :c
Floor Drain 3.00 :r
Gas Piping Outlet " minimum - 1 3.00 ;t
Rough Openings 1.50 ;<
Water Softener 5.00 x
Private Disposal ' Dakota Cty. license 65.00
(new and refurbished systems)
U.G. Sprinkler' home under const. 3.00
Alterations * to existing 20.00
Water Turn Around 20.00
STATE SURCHARGE
TOTAL
NQL
TOTAL
.50
SITE ADDRESS:
OWNER NAM
INSTALLER NAME:
STREET ADDRESS:
cinr:
STATE:
ZIP:
PHONE #: (
CITY USE ONLY
L? BL o?- RECEIPT #:
SUBD. ? DATE:
?» CI
1996 MECHANICAL PERMIT (COMMERCIAL)
• CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, MN 55122
(612)681-4675
Please complete for: ? all commerciaUndustrial buildings.
? multi-family buildings when separate pertnits are IIQt required
for each dwelling unit.
DATE: CONTRACT PRICE.
WORK TYPE: _Z NEW CONSTRUCTION INTERIOR IMPROVEMENT
DESCRIPTION OF WORK: T? ?? ^ 4`?' ?-• ?6w-z?
FEES: P $25.00 mtnimum fee QL 1Mo of coMract prioe, whichever is greater.
• Processed piping - $25.00
• Stete surcharge of $.50 per $1,000 of pgmit fee due on all pertnits.
CONTRACT PRICE x 1°k
PROCESSED PIPING
STATE SURCHARGE
TOTAL
I r ??. G0
I+3;s0
SITEAD R SS:.OWNER NAME: O?UlrS TELEPHONE #:
TENANT NAME: (IMPROVEMENTS ONLI)
INSTALLER:
ADDRESS: 4 (o`-kq G t,n.oJ? ? ?K?e • S •
CITY: o
? PHONE #: -qg
SIGNATURE:
SIGNATURE OF PERMITTEE
STATE: Mh? • ZIP. 554}3 1
???C?CITY INSPECTOR
C17Y USE ONLY
L BL RECEIPT #:
SUBD
DATE•
1996 MECHANICAL PERMIT (RESIDENTIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, MN 55122
(612) 681-4675
Please complete for: * single family dwellings
• townhomes and condos when permits are required for each unit
New construction Add-on fumace
Add-on air conditioning Add-on air exchanger, i.e. Vanee system, etc.
Date:
FFFS
? Minimum Fee: Add-oNRemodel (existing residence only) $ 20.00
? HVAC: 0-100 M BTU 24.00
Additional 50 M BTU 6.00
? Gas OuUets (minimum of 1 required @ $3.00 each)
p State Surcharge .50
TOTAL
SITE ADDRESS-
OWNER NAME: PHONE #:
INSTALLER NAME•
STREEf ADDRESS:
CITY: STATE: ZIP:
PHONE #: ( )
S i: ? 0? K7G3? d. l7PtaSytp.,??.4, ¢
?--
7E:1 aECEIPT !f c490II /
tcrEZPT DAIE ?y? ?/?110
?
JCB
V^NER
; •. ,.. . . ???, ..? ? .. >'w,...? ?
i
i?
nAi.?''.?
1 1_ -
17
;/ f 1?/?'.:?+`_?l's, ? . ?
r
P?-( .?
P3.:.15E 9E ADVIc„^mD ^:'?-:&:' idOE IS A r"""_., SiIGR'."AC^, ON T3^, AA?7YE'
• •
rZcCZRIC.IL ::STAI,;,A:ZOH IN ?'HE aM0UN1' OF $ C t ''' /ry ?
SHdRT.'aGa MiST 3E ?AiT, +iHI"_'.{ZH 14 IkY$.
?v
'_-cui_s=
-. ., ?:.. `
RETU?tN A COPY OF iHIS FORM WITH 4EMZTTA'ICE.
?J
?p•>.r C?YPa`L.?o.,>r. 40 4-<-?Y^< -
0.vna,?,a?} 5?;1\ ow?d2. w2 ?n?,vz l- Ltl?o tQ -?e?D
0.",& 1- 2ocA -FePn fo-Erar-?s ,ra? ?r?v u-r-? ?f.? ? .
wz l?lc?„e enc 1oSed ct chcCk. Iy, fY,e avna?.?f-
O-F
-W cc ,"r
l
,; ??Ov
ORIG• 3ECEIPTII??
a I
RECEIPT DATE
? i t t"t ;l1
Use BLUE or BLACK Ink
For Office Use
of Eapo. Permit#: Lj -�1
3830 Pilot Knob Road r, "'R iQr� 'V,• Permit Fee:
Eagan MN 55122 If,'t, ' `
Phone: (651)675-5675 � Date Received: 51 O^^��� )1
(NQ
Fax: (651)675-5694
19Q
Staff:
J
2017 MECHANICAL PERMIT APPLICATION LI'vk
❑ Please submit two (2) sets of plans with all commercial applications. /.�t?��
el-
Date: Site Address: j --7_S Pi-c,iii" 0 u er C a,
Tenant: Y ,'' r 1- Suite#:
Resident/Owner Name: Phone:
I Address/City/Zip:
Name:( i4 oL/f.-7 et r,i, o,u/it`d License#:/`^ 6 6,0 . 'i l i
Contractor
Address: (A D 37 fro n 7 c-t_ S city: 12/C In r?C'J J
i State: -M Zip: SSS-t. Phone: 6 f) t61 - -1.3Se
I Contact: (30,-- J -" ' " Email:
New Replacement Additional Alteration Demolition
Type of Work Description of work: ce PIa L- c ii s4 i'^ ti Jo -o4-, roc,fre-ppf s. .4,—,. ;,,.. s ,'t'",''
NOTE: Roof mounted and ground mounted mechanical equipment is required to be screened by City
Code, Please contact the Mechanical Inspector for information on permitted screening methods.
RESIDENTIAL COMMERCIAL
Furnace New Construction Interior Improvement
Permit Type Air Conditioner Install Piping Processed
Air Exchanger Gas /( Exterior HVAC Unit
Heat Pump _Under/Above ground Tank ( Install/_Remove)
1 ; Other
RESIDENTIAL FEES
$60.00 Minimum Add or alteration to an existing unit, includes State Surcharge
$100.00 Residential New, includes State Surcharge =$ / y S 0 t' 'an TOTAL FEE
COMMERCIAL FEESx.01$G^c. "'
Contract Value$
I $60.00 Permit Fee Minimum
$75.00 Underground tank installation/removal,includes State Surcharge =$ / S- -Gv Permit Fee
=$ Cr .) Surcharge
Surcharge=Contract Value x$0.0005
I If the project valuation is over$1 million, please call for Surcharge =$ / 9 '1-as TOTAL FEE
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 13 D A ! c r ``i C — x 0 L —.0'°
Applicant's Printed Name Applicant's Signature
FOR OFFICE USE
Required Inspections: Reviewed By:' Date: 5 1 I�
Underground Rough In . Air Test: Gas Service Test In-floor Heat Final HVAC Screening