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1530 Thomas Lake Pti CITY OF EAGAN 38M Pilot Knob Road P.O. Box 211" Eagan, MN 551 1 Zoning: Owner. Domna in Address: Site Address 1530 The Plumber. Consolid 12-31-8E 1 agree to comply with IM Ordinances. By Date of Insp.: Insp.: CITY OF EAGAN 3S30 Pilot Knob Road P.O. Box 21199 ,.Eagan, MN 551;1 j Zoning: -? Donai :Owner Address 530 Site Address Conso Plumber. - I agree to con" with the City of Eagan Ordlnaneaa. No. of Units: 4, 8 80.00TM t 1? m nn„a Connectipr!{Charge: Account?POsit: permit Fee: Surcharge: Misc. Charges: By Total: Date of Insp.: Date Insp.: CITY OF EAGAN 3630 Plot Knob Road P.O. Box 21199 Eagan, MN 55?1?1 Zoning: Owner Domair Address Site Address::.-15 30 T Plumber. Cansol SEWER SERVICE PERMIT PERMIT NO.: 9 n 06 DATE: No. of Units: 60 & 1 Car Wash Vnit ` .. "-.,Vu 4 , 880.00it I agree to comply with tM City of Eagan Connection Charge: 23 . I Ptl _ f)Q-A Ordinances. Account Deposit: Permit Fee: Surcharge: 5 pga By Misc. Charges: SEWER SERVICE PERMIT PERMIT NO.: 9806 DATE No. of Units: 60 i 1 Car Wash unit Misc. Charges: Total: Date Paid: SEWER SERVICE PERMIT 9306 PERMIT NO.: Date of Insp.: Total: Insp.: Date CITY OF F.AGAN SEWER SERVICE PERMIT .5830 a 061 Knob Road 0t 7 P.O. Box 21199 PERMIT NO.: Eagan, MN 55121 DATE: 5-1 Zoning: R.4 No. of Units: 60 F. r_ar 1:a,07 Owner. Domain Const. Fn it AAAre - I agroe to comply wkh the City of Eagan Connection Charge: - 73.160.00pd OrdkMUWM. Account Deposit: Permit Fee: 10. GOpd Surcharge: 0114 i By Misc. Charges: Date of Insp.: Total: Insp.: Date Paid: L r--l own Pilot Knob Road Meter No: _ k 21199 Reader No. n, MN 55121 Date: 4-- 20-37 Size: Date: mn. Chg: ", vuu. Ul)pd Zoning: R•i ct Dep: No. of Units: 60 1 rur Wt'h U rmit Fee: 10.00pd rcharge: 50 d I agree to comply with the City of Eagan Plant 7 625. 00pd Ordinancw WATER SERVICE PERMIT LVtJ TR PERMIT $1,725, Site Address 1530 TiI MAS LAKE PO I NT.E Lot I Block 1 Sec/Sub. THOMAS LAKE PO] Name 3 Addre 0 d o Name DOMAIN CONSTRUCTORS INC 6 Address ' Receipt ff r` 3 DECENIBER 31 13039 86 Erect Occupancy R1/81 PI) r ? 'A & del RepUir ? Zoning I Type of Const HR I IN SPR Addition ? No. Stories I y ? Demolish ? Length 3 27 Depth_ Int. Impr. ? Sq. Ft 101-' 0 0 0 Install ? Water 8 Permit 5 4,495.5( Surcharge 790. o l Plan Review 2. 2 4 7. 1 SAC =0.060. UO Water Conn .2 4= 0 U j- Water Meter 14ZA Road Unit 13-92U.0( Tr. PI. 7,625.0( Parks ?J/h Copies T-+.1 5 81, 11F. W 2`_ Name JOHNSON, SHELDON • SORENSEN Police W Address 10249 YELLOW C IR DR Fire - Eng. 4CW City ''KA Phone 9 3 5- 6 3 3 7 Planner Council I hereby acknowledge that I have read this application and state thatthe Bldg. O(f information is correct and agree to comply with all applicable State of Minnesota Statutes and City offo gan Ordinances. APC Var. Date Signature of Permittee t DOMAIN CO TRUCTORS IN CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 A Building Permit is issued to: C on the ex ress condition that all work shall be done In accordance with all applicable State of Minnesota Statutes and City of Eagan Ordina Building Official 1_ Pat W No. Permit "older Daft Telephone 0 PldmbNq -7 % M.VAxi. n Elachic I?38/ was ? ? °?' Inspection Daft Imp. Conanwft Fool Mgs I !t' Foolk It Foundatlon Framing hrg Roolling R h Plo d- -17 ?a?? 0 7 • U 64W. R 7 W ,e z lot ?o.it p• . ty . OL lo - ? 9 - F 7 W 3 T F HIW i r,d Deck Ftg. Deck Frmg WON Pr. DNp. w? /iii / I.) I.I C • ?• d+ ?9 .i .,•?C: ? l Ttrti#tratr of Mrrupanry (Citp of eagan atwftnt of Swat" inwrtim This Certificate issued pursuant to the requirements of Section 306 of the Uniform Building Code certifying that at the time of issuance this structure was in compliance with the various ordinances of the City regulating building construction or use. For the following: U. tlae0nrioe An ELDG -60 Ul i ' J Md{. Permit No. 13099 OMUPEWY TYPE p-1 /8-1 ZmW DwIsid 1C Tnv romy 1 1 W I ;T `TT TNK oar a B,, %V7 `? T `?' ii[?1. 7NG r 3146 HAR", LN, Building Addreg " •'? ul LOMMY I3 , B I , I? 1R4?: POST IN A CONSPICUOUS PLACE L ! r ? .4 CONTRACT PRICE: Site Address Lot Block m Name Address Z c City - Name 3 Address O City Phone FEES COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS - COMM RATE APPLIES TOWNHOUSE & CONDO - RES. RATE APPLIES MINIMUM - RESIDENTIAL FEE -$12.00 MINIMUM - COMMAND FEE -$20.00 STATE SURCHARGE PER PERMIT - .50 (ADD $.50 S/C IF PERMIT PRICE GOES FOR: CITY OF EAGAN PERMIT N PLUMBING PERMIT RECEIPT 4 CITY OF EAGAN 3530 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: 7 Ucv' PHONE: 454-5100 Phone BLDG.'TYPE Res. Mult. L? Comm. Other WORK DESCRIPTION New Add-on Repair RES. PLBG. ONLY - COMPLETE THI N FIXTURES ater Closet - $3.00 Bath Tubs - $3.00 JAA avatory - $3.00 ?? hower - $3.00 _j4i kitchen Sink - $3.00 Urinal/Bidet - $3.00 Laundry Tray - $3.00 70Floor Drains - $1.50 Water Heater - $1.50 Whirlpool - $3.00 Gas Piping Outlets - $1.50 (MINIMUM - 1 PER PERMIT) _ _Softener - $5.00 Well - $10.00 Private Disp. - $10.00 Rough Openings - $1.50 FEE: TOTAL S GRAND TOTAL: STATE S/C: -97 7 40 ra - 7 .D . /j. %-I - 93 ,g7 4.9 .,uraar?e o? a o o PSG •?!??SA l 0 7- /a y- /? c pt s y C TYPE OF WORK Forced Air LC. Boiler Unit Heater Air Cond. Vent. Gas Piping Outlets # Other MECHANICAL PERMIT RECEIPT # CITY OF EAGAN 01 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE ?Sb Cif PHO : 454-8100 MW I" BLDG-TYPE WORK DESCRIPTION k_ Vub Res New '9Cc0 M BTU M BTU M BTU M BTU CFM FEE: S/C: TOTAL- FOR: J1 FOR: CITY OF EAGAN Mull kf_?- Add-on Comm. Repair Other FEES RES. HVAC 0-100 M BTU -$24.00 ADDITIONAL 50 M BTU - 8.00 (RES. HVAC INCLUDES A/C ON NEW CONSTRUCTION) GAS OUTLETS (MINIMUM - 1 PER PERMIT) - 1.50 EA. COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS. - COMM. RATE APPLIES TOWNHOUSE & CONDOS - RES. RATE APPLIES MINIMUM RESIDENTIAL FEE - ALL ADD-ON & REMODELS - 12.00 MINIMUM COMMERCIAL FEE - 20.00 STATE SURCHARGE PER PERMIT - .50 CITY OF EAGAN 3830 Plot Knob Road, P.O. Box 21-199, Eagan, MN 55121 N2 12946 PHONE. 454-8100 BUILDING PERMIT Receipt N t r! To be ussd for FOUNDATION Est Value Date DECEMBER 5 tg 86 Site Address 1530 THOMAS LAKE POINTE Erect [J? Occupancy Lot 3 Block 1 Sec/Sub. THOMAS LK POINTW&model ? Zoning Parcel No. Repair ? Type of Const Addition ? No. Stories W Name THOMAS LK HOUSING ASSOC Move ? Length 314 0 HARBOR LN Demolish ? Depth Address Int Impr. ? Sq. Ft City PLYMOUX4ne 559-1711 Install ? o CONSTRUCTORS INC Name DOMAIN Approvals Fees Address SAME Assessment Permit $15 . 0 0 City Phone Water & Sew. Surcharge ?: Police Plan Review t: W Name Fire SAC U o Address Eng. Water Conn. i W City Phone Planner Water Meter Council Road Unit I hereby acknowledge that I have read this application and state that the Bldg-Off. 12/5/86 Tr. PI. information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. APC Parks Si f P t i Var. Date copies gna ure o erm ttee Total DOMAIN CONSTRUCTORS INC A Building Permit is issued to: on the express condition that all work shall be done in accordance with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Building Official .- - I PermN NO. I PMmM MokW I ON" I TNophom A Plb¢ mg• HW OMP- SITE ADDRESS Unit Permit # -O/o 9 L B f Sect/Sub. • /L=2 C? ? LINSPECTION DATE INSPECTOR OTHER FRAMING ROUGH PI K ROUGH NTG. !li4 a/ 41,40'r gl.wt INSUL FA ? ?? dT FIREPLACE FINAL NTL FINAL PLU. UNIT FINAL CERVOCC INSPECTION DATE INSPECTOR COMMENTS r ti ? T CITY OF EAGAN t-10 18713 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 + PHONE: 454-8100 BUILRING PERMIT Receipt # To be used for STOaRia M Est. Value =11000 Date F23 15 is 41 Site Address Lot Parcel No. - W Name ...rasnv A-pw" a.vwvas w ~m%~ 1 Addres o City HIRNEAPOLIS Phone 559-1495 c Name Address City Phone have read the 01 Signature of Permitee TH M" LAKE )E MSING AN A Building Permit is issued to: on the express condition that all work shall be done in accordance with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Building Official I Sec/Sub. OFFICE USE ONLY Occupancy D-1 B-2 Zoning FEES 25.00 .50 (Actual) Const Bldg. Permit (Allowable) # of Stories Length Depth S.F. Total S.F. Footprints On Site Sewage On Site Well MWCC System City Water PRV Required Booster Pump APPROVALS Planner Council Bldg. Off. Variance Surcharge Plan Review SAC, City SAC, MCWCC Water Conn Water Meter Acct. Deposit S/W Permit S/W Surcharge Treatment PI Road Unit Park Ded. Copies TOTAL 26000 Permit No. PW" Holder Da" Telephone # WATER SEWER PLUMBING H.VAC. ELECTRIC Ytpecdon Dolt trop. Conan- b FootingsI Foundation Framing Roofing Ragh Pttg. Ra+p?+?d8- OL GA2r?- U ?- Iwl. Fireplace Final ft Final P". Cont. MsMr Plbg. Inspector - Notify Plumber EngrJPlan Bldg. Final Deck Fig. Deck Final WeR Pr. Disp. I his request void 18 months from C- 714421 ax,?, ;.? '50 S/n -V s54s'oo Request Date 3 ?l Q File No. Rough-in Inspection Req utred ?yes ?No []Ready Now ? Will Notify Insoeo for When Ready LJ Lmensed Electrical Contractor I hereby request inspection of above ? Owner electrical work installed at: Street Address, Be. or Route No. / ss 4 City ( f - /S.36 ;AS LA.llE 'Irc ecb o. Township Name or No. Range No. County Occupant (PRINT) Phone No. Pow r Supplier Address ??%A ?EE72iC off/Lnini?Ti?i? ? ?f??? Elects Contractor (Company Name) Contracto 's License No. iFO .?dca Mailing AddresslContractor or-Oii,mar Making Installation) 0?3?3 /67f/ A'6F1Y1'A - .5? - /9 /DO Fits /?i! Author d f nature IC ntract O ner Making Installation) Phone Number a35-oSo? MINNESOTA STATE B01RD OF ELECTRICITY THIS INSPECTION REQUEST WILL NOT Griggs-Midway Bldg. - Room N•191 BE ACCEPTED BY THE STATE BOARD 1821 Uni~lity Ave.. St. Paul, MN 55104 UNLESS PROPER INSPECTION FEE IS Phone (612) 6420800 ENCLOSED. yliola KtulltSl FOR ELECTRICAL INSPECTION EB-0000011--0e j??! r? If See instructions for completing this form on back of yellow copy. C ' 74 (+/ 1 -V Below Work Covered by This Request Add Bep. Type of Bwlding Appliances Wired Equipment Wired Home Range Temporary Service Duplex Water Heater Lighting Fixtures Apt. Building Dryer Electric Heat, t l Commercial Bldg. Furnace Silo Unloader Industrial Bldg. Air Conditioner Bulk Milk Tank Farm Other pert v Omer 1Spccifyl /C a_0Jp t ,r Sueu V Other , O1hur/f?,1yG Inspecuun Pee below p Fee Service Entrance Size N Fae Feeders/Subieeders p Fee Circuits A,1 I / d,,fo 0 to 200 Amps Above 200 mps d r4 0 to 30 Amps 31 to 100 Amps d / DO• 0 to 30 Am s 31 to 100 Am s -- __ _Swinuning,Pool _ /pt Above 10 0? Ants . _ - -Above -100_Am s Transformers Irrigation Booms gQ Partial 'Ot ee Signs Special Inspection 4. pemarks , ? /G ?r'f/G O'? TOT 5F !'r Hough-In r t? I, th Ical ^4ML / Inspector, hereby Final certify that the above e eotton has been de. Thla request void la months from This 18 n styn,d5/?9/b? 7--?40& ti VI-1--v" ..?e...??w? I hereby request inspection of above ? Owner electrical work installed at Street Address. Box or Route No. 1530 --;? Z ?1 City 6m az c? ? ??? ? Section o. Township Name or No. Range No. cciuma? V 4tt OccuP I (PRINT) t Phone No. ewer Supplier Address E act ical Contractor ICy^ party Name) Con rartor'S License Nor ° M ,ling AAJ ress ICa ractor or Owner `?`?l ? S c Making Inst acv a,lauonl l1? 71 /V S S <<f 6 Authorized gnature (Contra tbcr/ caner aking In stal iron) Phone Number MINA STATE BOARD OF ELECTRICITY THIS INSPECTION REQUEST WILL NOT Gn s-Midway 9,d . _ Room N-191 BE ACCEPTED BY THE STATE BOARD 181 University Ave., St. Paul. MN 55109 UNLESS PROPER INSPECTION FEE IS vi.....e 19121 797.7111 ENCLOSED. REQUEST FOR ELECTRICAL INSPECTION Ise-Oaat-na See instructions for completing this feint on beck of Vellow copy. J 7 69 ?17 "•X" Below Work Covered by This Request NVV4 Addj Rep. Type of Bulld?ng Aophances Wired Equipment Wired Home Range Temporary Service Duplex Water Heater Lighting Fixtures Apt. Building Dryer Electric Heating Commercial Bldg. Furnace Silo Unloader. Industrial Bldg. Air Conditioner Bulk Milk Tank Farm Other Specs y lhm ISponfy) t ,t Succdv Olher Olhut ?o )p( 19EZ a Uri ree Derow p Fee erv ce Entrance Size 11 Fee FeedeterSubfeedere p Fee circuits s+,oove ?uu Amps 31 to 1 Ull Amps 31 to 100 Ampswimming pool Above 100_Anms Ahove 100_ - Amud F( 2 (1,pU/ Rough-in - --- Dare I, the Ele E 7 /T4 Ins p: c , hereby Final D•2ie certify that the eve w ?C inspection has been 1lr J madp. This request d)ld t B memae nom r -, This request void 16 n»nths /tom 7 U D 41105 ?. 3 ,.., Repwretll ?Ready Now ? WUI Notify Insoer ?yes ?NO for When Ready 'Licensed Electrical Contractor I hereby request inspection of above ? Owner electrical work installed at n Street Address, Box or Route No. &/_V_ ;//? / City aCIIOn NO. Township Name or No. ange No. C y / 1Cl'?? Occupant tPRINT) Phone. No ,Oam'4 ,/) Ir?ST [?G? s Power Supplier -- - - - - - -- -- - Address E ..t,ical Co actor tCompany Name) Contractor's License No. :? D UI?L Mailing Address (Contractor or Owner Making Installauon) 3 ?3 a.? S. yylc?nh e ?'» Author' ed n Lure t ontra1or/Ow er Making InstallaL On) one Nwnber +' (? _0 C'' d-++ MINNESOTA STATE 119A"lliSD OF ELECTRICITY THIS INSPECTION REQUEST WILL NOT Griggs-Midway Bldg. - Room N-191 BE ACCEPTED BY THE STATE BOARD 1821 University Ave.. St. Paul, MN 55104 UNLESS PROPER INSPECTION FEE IS Phone (612) 642-0800 ENCLOSED. y/97 REQUEST FOR ELECTRICAL INSPECTION M. EB-0000p 9 1.06 ? See instructions for compfpting this form on back of yellow copy. 6 D 41105 R'- BeloW Work Covered by 1hfs Request 7 AdJ Rep Type of Bu,ldmg Apohances Wirad Equipmen, Wired Home Range Tenqporary Service Duplex Water Heater Lighting FlxtuieS Apt Building Dryer Electric Heatiil Commercial Bldg. Furnace Silo Unloader Industrial Bldg. Air Conditioner Bulk Milk Tank Farm Othe, peel v -ih,;r ISpri.i fy) tMer oec,'Y iher other Compute Inspection Fee Below p Fee Service Entrance Size H teeders N Feo Circurts 0 to 200 Amps 0 to 30 Awns Above 200 Amps ps 31 to 100 Am Swimming Pool Amps Ahove 100_Anips Transformers oms Partial.'Other Fee Signs ection - /-/,j rks (Y TOTAL FEE Hough-in / F mal t Dqt ??• r the Electrical nspector, h meby certify that the a boys plc been ?do. CMS request void 18 months from .2 q CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 BUILDING PERMIT Receipt If To be used for FOUNDATION Est Value Date DECEMBER 5 19 86 Site Address 1530 THOMAS LAKE POINTE Erect Cf Occupancy Lot 3 Block 1 Sec/Sub THOMAS LK POI NT&model ? Zoning Parcel No Repair ? Type of Const . Addition ? No. Stories w Name THOMAS LK HOUSING ASSOC Move ? Length 3140 HARBOR LN Demolish ? Depth o Address PLYMi 559-1711 Ci Int. Impr. 11 ? Sq. Ft. ty Install o Name DOMAIN CONSTRUCTORS INC Approvals Fees Address SAME ? City Phone F w Name R Address - a w City Phone I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordin c Signature of Permme v cif A Building Permit is issued to: DOMAII CONSTRUCTORS all work shall be done in accordance with all applicaNe State of Mi nesc Assessment Water 8 Sew. Police Fire Eng. Planner Council Bldg. Off. 12 / 5 / 8 6 APO Var. Date INC N2 12946 r YC2 -2 Permit $15.00 Surcharge Plan Review Water Conn. Water Meter Road Unit Tr. PI. Copies__-,-? on the express condition that and City of Eagan Ordinances. Building Official /6z „9 Q- ti 60 UNITS - RENTAL CITY OF EAGAN L 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 N 2 13069 PHONE: 454-8100 / BUILDING PERMIT Receipt # ?V APT. BLDG. E T b d f V l $1,725,000 D DECEMBER 31 86 e use or st a ue o ate 19 Site Address 1530 THOMAS LAKE POI NTE Erect n occupancy R1 /B1 THOMAS Lot 3 Block 1 Sec/Sub LAKE POIWHodel ? zoning . Repair ? Type of Concr V I HR I IN SPP Parcel No. Addition ? No. Stories 9 a Name THOMAS LAKE HOUSING ASSOCIAVLto3e ? Length 3 77 w 3140 HARBOR LN Demolish ? Depth 6 7- o Address MPLS 559-1711 Int. Impr. ? Sq. Ft. ------ 1 Or000 Phone City Install ? o I Name DOMAIN CONSTRUCTORS INC i• $ Q Address SAME City Phone iE Name JOHNSON, SHELDON & SORENSEN m ?? Address 10249 YELLOW CIR DR aw City MTKA phone 935-6337 I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and CjiyeyEagan Ordinances. Signature of Assessment- Water & Sew. Police Fire Planner Council Bldg. Off. 12/8/86 Var. Fees Permit $ 4,495.51 Surcharge 790.01 Plan Review 2. 247 .7'. SAC 28, 060_ OC Water ConnZ4- QQ- 01 Water Meter Road Unit 1-1,920.01 Tr. PI. 7. 625. 01 Parks N/A Copies Total 81,138.2! A Building Permit is issued to. DOMAIN CONSTRUCTORS INC on the express condition that all work shall be done in accordance with all applicab tare of Min Lutes and City of Eagan Ordinances. Building Official A (GARAGE LEVEL) CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 ?? 18713 PHONE: 454-8100 nn II? BUILDING PERMIT Receipt N lJ 4GC To be sed for STOREROOM Est. Value $1,000 Date FEE 15 19 Site Address 1530 THOMAS LAKE POINTE Lot 3 Block 1 Sec/SubTHOMAS LAKE POIN' Parcel No. a Name THOMAS LAKE H014TNG ASSOC o Address 1340 HARBOR LN City MINNEAPOLIS Phone 559-1495 :. Name SAME D0 Address UE City Phone ww Name ua2 Address <w City Phone IN I hereby acknowlege thatI have read this application and stNe that the information is correct and agree to comply with ppli State of Minnesota Statutes and City o1,E§2jan Ordinancery. // Signature of Permit A Building Permit is issued to: THOMAS HOUSING ASS on the express condition that all work shall be done in accordance with all applicable State of Minnesota pStatutes and City of Eagan Ordinances. Building Official ?'JHITIl;91! ,I IIL,CI OFFICE USE ONLY Occupancy B-1R-2 Zoning -R-4 FEES 25.00 .50 (Actual) Const 1--ER Bldg Permit (Allowable) N of Stones Length Depth S F Total S.F. Footprints On Site Sewage On Site Well MWCC System City Water PRV Required Booster Pump APPROVALS Planner Council Bldg. Off. Variance Surcharge Plan Review SAC, City SAC, MCWCC Water Conn Water Meter Acct. Deposit S/W Permit S/W Surcharge Treatment PI Road Unit Park Ded. Copies TOTAL .50 26.00 SEWER=WATER JOB NUMBER TESTS & INSPECTIONS 1 V5- ? RECORD ?7ONTH 9AR A. FILL OUT THIS CARD COMPLETELY. B. IF NO INSPECTOR; HAVE CONST. SUPT. SIGN. C. GIVE THIS TO YOUR SUPERINTENDENT FOR HIS APPROVAL. D. GIVE A BRIEF LOCATION OF WHAT WAS TESTED AND MAKE DRAWING ON BACK OF THIS SHEET: WATER LINE TEST:' ANSWERS WAS HYDRO STATIC PRESS. USED FOR TEST? MAXIMUM PRESSURE IN LBS. USED? HOW MANY HRS. WAS TEST ON? HOW MANY LBS. DID IT LOSE DURING TEST? boo ? j3S CONDUCTIVITY TEST - PARTIAL ? COMPLETE ? SEWER LINE TEST: VISUAL ? AIR TEST ? OTHER: PARTIAL - SANITARY SEWER TEST ? COMPLETE - SANITARY SEWER TEST E] PARTIAL - STORM SEWER TEST F-1 COMPLETE - STORM SEWER TEST E] FINAL INSPECTIONS: COMPLETE - SANITARY SEWER INSPECTION ? COMPLETE - WATER SYSTEM INSPECTION ? COMPLETE - STORM SEWER INSPECTION ? INSPECTED BY -?7 F7 INSPECTOR SIG - C FOREMAN OK ' EMPLOYEE SIGN FORM 35 ppp? HOUSE HEATING TEST RECORD IC7Z40 p??t ADDRESS ?T-APT..FLOOR CITY SUBURB ___1? OCCUPANT OWNER HEAT LOSS DATE HTG. INST. (I P7 SOLD BY V,r'?v rC t-1 I<ccc, t 'Ip lam'' INSTALLED BY Electrical Work By A,0.4 ,;?, t-?(,T Gas Line By N- TYPE OF HEAT GA L/FA(-- HW -STEAM -SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE `? 0-1 I -'-` MAKE OF BURNER Model ?.+ ; '1r r - C i? Model Serial Gi`J? t110 F.7?f37 Max. BTU Rating INPUT r 5_iX`X? MAKE OF FURNACE Model CONTROLS THERMOSTAT Heat Plug Vent Size ! ?G Vo Iva < 7- IJ aL-) KIND OF LINER f7 '/??r'f?j^ST• SIZES- NONE Limit .^?C-/ Draft Hood Regularor Limit Setting 770 Filters Size / Number Fan Setting J?C'J nN Chimney Location Inside Outside '-? Pilot Type Chimney Construction /_%/-;Z 1122 - %? -`?k - Pilot Make - Pilot Model F2 ??r7 Smoke Bomb Wiring ?j Pilot Timing Draft r, Nest Tag L.W. Cut Off Door Pressure Lighting Inst. Pressure Percent CO 2 Date Tested Input CFH Percent 0 5- Company Testing Stack Tamp. •--1'-2' Percent CO ^ 6.L4) Name of Tester - -m 235 gg79 ' HOUSEHEATING TEST RECORD fS?U(] ?/ ' l S ? 1"c ?? ?) r 4ir ADDRESS r APT. -FLOOR CITY 4 UBURB , OCCUPANT OWNER f7-2'r'J rf[/0 HEAT LOSS CZ' DATE HTG. INST. - SOLD BY I1Uc?Sc% Z771--C // INSTALLED BY Electrical Work By 4J 1117 Gas Line By Sr' /? tLC TYPE OF HEAT GA _ FA _HW " STEAM-SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION _ MAKE MAKE OF BURNER Model M R . , n B Model Serial ON IV 14 - -_ Max. BTU Rating INPUT /C'5q) n-x-) MAKE OF FURNACE Model / `/ ?I?&//C/ONTROLS THERMOSTAT _ ?> Heat Plug - --- Vent Size 7 Valve KIND OF LINER IL/ :%<t) SIZE e2 NONE Limit Draft Hood yA, <c_ Regulator Limit Setting Filters Size Number Fan Setting Chimney Location Inside Outside Pilot Type Chimney Construction lh- "Tc % r? Pilot Make Pilot Model _ Smoke Bomb Wiring I - Pilot Timing ?• fL-' - praft Test Tag of _ L.W. Cut Off _J;/ L a /_/ !- !1AEDI Pressure - Lighting Inst. c? Pressure =' , .5 Percent C02 `/' lj? Date Tested Input CFH Percent 02 /C;, Company Testing Stack Temp. J-`1n? F Percent CO /?S• Name of Tester Form 235 HOUSE HEATING TEST RECORD = 4 ?-C22 1 ?6 ! -11 i ADDRESS APT. _F LOOR CITY !? BURG OCCUPANT OWNER I )r'lii?1 d'klel) C•n.! 1S HEAT LOSS ? DATE HTG. INST. SOLD BY 14 INSTALLED BY ! ?I0f E,(f Electrical Work By , ?C!e? h? CC Gas Line By S?(t TYPE OF HEAT GA _ FA HW ? STEAM -SPACE HTR. -UNIT HTR. -OTHER ?GAS DESIGN CONVERSION / _ MAKE MAKE OF BURNER Model Md 3(e0 1 Model Serial Max. BTU Rating INPUT ?TjU yCX? MAKE OF FURNACE i Model fI t)" ? ?A 111 CONTROLS -1 4 , ? ? . ?? ? THERMOSTAT --(P /(l Heat Plug Vent Size Valve No NarUrrJr-"?/ KIND OF LINER SIZE %U t NONE Limit Olt Draft Hood /, /W7 O+? Regulator .jam =5' Limit Setting /4ny Filters Size Number `- Fan Setting -- Chimney Location Inside Outside _ Pilot Type )r - Chimney Construction _ f?'1X=r.A-U S Pilot Make - _ - - - - - - - -- - - / Pilot Model Smoke Bomb v Wiring Pilot Timing Draft Test Tag L.W. Cut Off O eA4-1 Z ZJ ?cilrh"-0?r?Door Pressure Lighting Inst. / I Pressure ??-5 Percent C0 Date Tested % -y- -?? - 7 2 Input CFH L,^3 C) Percent 02 Company Testing rty` t' ? ? w?-? Stack Temp. - ?C'2f Percent CO C5 /U Name of Tester ??G?tl.Srl yJ Form 235 HO US E HEATING TEST RECORD G /?? ?? '? ti ' ? /? I? SE? / ? ADDRESS ir, ( . i ?'! = L APT._FLOOR CITY SUBURB OCCUPANT OWNER C'?S1757- HEAT LOSS DATE HTG. INST. SOLD BY 1 c (,) SCr INSTALLED BY Electrical Work By 1-74 e 0 _ 7? Gas Line By CSC CSC" TYPE OF HEAT GA _1z:f_FA i-?HW -STEAM SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE 7?tTC=CAM MAKE OF BURNER Model ? l C•. l7 44 - /O L'Y Model Serial -5,q Max. BTU Rating INPUT MAKE OF FURNACE i Model CONTROLS THERMOSTAT 5. U' -"- Heat Plug Valve O,. hf/.S !lift J Limit fw rr- ?rl /L-?? Limit Setting , Fan Setting ?c3YJ ...? 9?1 Pilot Type - - -`3p?jF1? - - - - - - Pilot Make Pilot Model So -7152-1 Pilot Timing L.W. Cut Off Vent Size KINDOFLINER NONE Draft Hood Z?' ffll niaJ Regulator 2'-;?"5 Filters Size Number Chimney Location Inside C__?Outside -? Chimney Construction J?7r?.•'(1Li? = Si TFi f Smoke Bomb r- Wiring Draft i - Test Tag Door Pressure Lighting Inst. Pressure '?"5 61J? Percent C02 ?'-?/G Date Tested 1?--?? pl Input CFH Percent 0 2 y.572'5 Company Testing dy74 Stack Temp. Percent CO .?.? = Name of Tester __ / - ?fT ?S lam/ ?- Form 235 HOUSE HEATING TEST RECORD 3a ADDRESS Z5__ i5 e? IOA? ?"A ? ? . AP T. _FLOOR CITY SUBURB OCCUPANT OWNER r7?MTiw ?.-tis7^ HEAT LOSS DATE HTG. INST. 1116 SOLD BY c+r xr-- /??e-c f/ /f INSTALLED BY Rocs Sr' e-/7 r Electrical Work By ?,-d 'Cr?r7f Aj1,C Gas Line By /77,z- /-/ TYPE OF HEAT GA ? FAi-HW-STEAM -SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model E-6- a3 -U 74-? W - -rz Model Serial e- 6431) /o1F TP S7 9,7 Max. BTU Rating INPUT 2 6;2-;v MAKE OF FURNACE - Model CONTROLS THERMOSTAT Heat Plug Vent Size Valve KIND OF LINER SIZE Limit - Draft Hood & "/' Regular,, 5.7-5 3 n Limit Setting e /l Filters Size 46X.?,c/ Number Fan Setting 4 : ,& n Chimney Location Inside Outside Pilot Type-_ Chimney Construction L'd?r3 Pilot Make _,Z>,L''?C/S /?*tt] _ - - _ _ - - - - _ - - - - - -- - Pilot Model 5 /? 7,-5`,4 Smoke Bomb Wiring J Pilot Timing Draft z_ "w Test Tag L.W. Cut Off Door Pressure - Lighting Inst. Pressure ?..r?%rJ G Percent CO2 ?• ?/? Date Tested ./ Z-7--19?7 7 Input CFH Percent 02 3 fo Company Testing - Stock Tamp. Percent CO e!-> Name of Tester Farm 235 HOUSE HEATING TEST RECORD %kU1 6 `' ADOR ESS APT. FLOOR CITY 1 SUBURB OCCUPANT OWNER _,I c7yA bt1 ?V /',-?1t> f / HEAT LOSS DATE HTG. INST. SOLD BY ` `'?`= rLtl INSTALLED BY 'h.OVSr' V?-\L'z-L-F Electrical Work By \(/CS/' w /[71- Gas Line By c--(:- TYPE OF HEAT GA _FA _HW-STEAM SPACE HTR. -UNIT HTR. OTHER ? GAS DESIGN CONVERSION ?, MAKE _ /? fll yG MAKE OF BURNER Model L_ IG - /Y Model Serial -/7 R 77 2.2-3 °?3 i? Max. BTU Rating INPUT m ?y n MAKE OF FURNACE Model CONTROLS THERMOSTAT Heat Plug Vent Size !°> Valve ?*?"?"?? ?? c-tl/- ?? KIND OF LINER SIZE !Z/ t NONE Limit ?,?{isk[7 !? 1 SL _ Draft Hood -=Nl? r ,rf & Regulator Limit Setting Filters Size Number Fan-Setting Chimney Location Inside Outside - - Pilot Type= 7 r?-!?rGt-?4 _ _ _ Chimney Construction s 17A=/? _ - Pilot Make -'-' - - - - - - - - - - - = '- Pilot Model Smoke Bomb Wiring - _ Pilot Timing Draft X:; ocGC Test Tag L.W. Cut Off Door Pressure Lighting Inst. c ?O P P D - -? ressure ercent C02 ate Tested Input CFH Percent 02 ?C? yv Company Testing ItiUU SC% ?I?h t Stock Temp.Percent CO 'y' Name of Tester S%F-"t/ t=`='U.?V•^-? Form 235 HOUSE HEATING TEST RECORD/ k? ,- ADDRESS APT. -FLOOR 6EV?CITY SUBURB OCCUPANT OWNER HEAT LOSS I? DATE HTG. INST. 7 SOLD BY 5?//,?-- fLl e.?/-/ INSTALLED BY ??SLI '-C Electrical Work By /Z/c! ?t Ile ?.7sC Gas Line By ntJS L- TYPE OF HEAT GA FA _HW -STEAM -SPACE HTR. UNIT HTR. OTHER j GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model Model Serial Max. BTU Rating INPUT - / ?yi000 MAKE OF FURNACE Model ONTROLS THERMOSTAT / 63 Heat PI uy Valve ,? t N Limit Limit Setting Fan Setting 7- Pilot Type ?/ /;7•V/I/N! Pilot Make - - - Pilot Model Pilot Timing L.W. Cut Off Pressure Percent CO Input CFH 2 l ?? ^ Percent O Z lU ? ? Stock Temp. 'x Percent CO ?J^ Form 235 Vent Size _ KIND OF LINER 73-1SIZE ? NONE Draft Hood Regulator Filters Size Chimney Location Inside Outside Chimney Construction Smoke Bomb -- Wiring Draft _ltJ?'U?C`Y Test Tag Door Pressure Lighting Inst. Date Tested Company Testing Name of Tester ??r-_?/ ??7'?FG?-? HOUSE HEATING TEST RECORD ??Ayy,?P ADDRESS APT._FLOORA CITY/ SUBURB OCCUPANT OWNER Do•^??/?s/ Cr?ni? HEAT LOSS DATE HTG. INST. 168 2 _ SOLD BY } x?: ?z?z INSTALLED BY Electrical Work By / k-7 ylJr ?C' r9vSc." " Gos Line By /7/ TYPE OF HEAT GA_ FA_HW-STEAM -SPACE HTR. UNIT HTR. v? OTHER GAS DESIGN CONVERSION _f MAKE MAKE OF BURNER Model Model 1 Serial G,E?73 775 Max. BTU Rating INPUT MAKE OF FURNACE Model THERMOSTAT Valve Limit Limit Setting _ Fan Setting - Heat Plug Vent Size SIZE NONE KIND OF LINER Draft Hood -7 1'.JL?GG c/ Regulator y5- - Pilot Type J?,? C//C Pilot Make Pilot Model Pilot Timing -3 dY?L L.W. Cut Off Pressure 2?- Percent CO2 Input CFH ?S Percent 0 Stack Temp. Percent CO2 -3 y-, Form 235 Filters Size Chimney Location Inside r / Outside Chimney Construction ,?t-Tn S Smoke Bomb Wiring - Draft L?"J41 c.lC_C" G Test Tag Door Pressure Lighting Inst. Date Tested oZ Company Testing ??/?? U`l(L-G Name of Tester HOUSE HEATING TEST RECORD ? f, ADDRESS APT (DI'? FLOOR CIT OCCUPANT . - OWNER Y SUBURB y?=?-`">?(? r?•</S HEAT LOSS ? DATE HTG. INST. 7 //--? SOLD BY ?c?LSl? z/ INSTALLED BY !-`GAS c-- /?J?L?/ Electrical Work By - r ill y"IGY Gas Line By TYPE OF HEAT GA _ FA _HW -STEAM -SPACE HTR. UNIT HTR. BOTHER GAS DESIGN ? / CONVERSION MAKE ? ?'- « MAKE OF BURNER Model Model Serial E375? C/.-71?? Max. BTU Rating INPUT MAKE OF FURNACE Model CONTROLS _ THERMOSTAT Heat Plug ?- Vent Size 7 /0-3-- Valve N?'??L-? KIND OF LINER - S SIZE / NONE Limit Draft Hood L<J[) ?'=G-!C Regularor Limit Setting Filters Size Number Fan Setting 7- Chimney Location Inside Outside `-f Pilot Type a%f}L?.?I"}(<<?c/- Chimney Construction - - - - - - -- Pilot Make -? - - - - -- - - - - - _ - Pilot Model ?- Smoke Bomb ? - Wiring t? Pilot Timing Draft - /d/V/)U ( /-r Test Tog L.W. Cut Off Y- Door Pressure - - Lighting Inst. Pressure Percent CO n Date Tested rJ Percent 02 100 Input CFH Company Testing ??O(15?-? /^4/-( / Stack Tamp. Percent CO Q 1 ? Name of Tester Form 235 HOUSE HEATING TEST REC?RQ ? / ?//? S ??N'K 30 f? ? ADD ??/ C J )3 ` I / a i Z rn - RESS / APT. _ FLOOR CITY ? SUBURB OCCUPANT OWNER ??'?o^?\I-^•-I Vim'-1?)yS % HEAT LOSS ? DATE HTG. INST. ) n SOLD BY -? c--- !<-GJ -C9<J': INSTALLED BY Electrical Work By ? Gas Line By l77/--G/7/ TYPE OF HEAT GA /FA HW STEAM SPACE HTR. -UNIT HTR. OTHER GAS DESIGN ll CONVERSION _ MAKE MAKE OF BURNER I Model ?Co?® f ??. lG Tk Model Serial C N?n f07 7F: -3`107 Max. BTU Rating INPUT-wn MAKE OF FURNACE Model ? CONTROLS ? i' / C THERMOSTAT Heat Plug cam ? Vent Size Valve c?lJC7"%3.?/rl-[? KIND OF LINER ???=7r=I-?JtS7u/SIZE NONE Limit Droft Hood ?[Ji ?f`??ttJ Regularor 'T Limit Setting Filters Size c2Q-?a?X? Number ) Fan Setting Chimney Location inside Outside V Pilot Type t? - ------ Chimney Construction- --Pilot Ma ke J-?c')z.l 1?'S?? _ _- --- _ - - _ --_------ ------ - - --' - Pilot Model ?? Smoke Bomb Wiring Pilot Timing Draft l- ?' e Test Tag L.W. Cut Off Door Pressure Lighting Inst. P P C > D T d - ' ressure ercent O2 ate este Input CFH Percent 02 Company Testing JJt/S[%r /2'F"Z /L Stock Temp. 1 f-" Percent CO Name of Tester Form 235 HOUSE HEATING TEST) RECORDS $? / , ADDRESS /7A PT.?FLOORL_CITY ???5/UBURB OCCUPANT / OWNER lb 1,61 t9A7- HEAT LOSS DATE HTG. INST. ,Ll7 SOLD BY . DD 5_ r" INSTALLED BY S??_ /C/7c-Cl Electrical Work By a-tf -(s? Gas Line By d'21 /??"? TYPE OF HEAT GA 1--? FA L-? HW -STEAM-SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONV MAKE MAKE OF BURNER Model L11? Model Serial Z2E! Max. BTU Rating INPUT -?? MAKE OF FURNACE Model THERMOSTA Valve ONTROLS T Heat Plug ?- nP/.-S?ifC,? Limit ?/U('( Ut`??? Limit Setting Fan Setting ?.p?CJ p'? ?'L2 /'t Pilot Type TPIT - Pilot Make --- Pilot Model - SP7/Si`? Pilot Timing ? Vent Size LO KIND OF LINER rF' _ 70> SIZE /2 NONE Draft Hood O?/ Ci d? Regularor Filters Size LPLX Number Chimney Location Inside v? Outside Chimney Construction Smoke Bomb Wiring Draft Test Tag L.W. Cut Off Door Pressure -? Lighting Inst. 7 C ?+ Pressure Percent CO2 Data Tested ??ncJSL Input CFH Percent 02? Company Testing Stack Temy „3Percent CO ?? Name of Testar Form 235 HOUSE HEATING TEST RECORD ADDRESS APT./b9 FLOOR CITY _6i6UBURB OCCUPANT OWNER Al"o (•OA.5/ HEAT LOSS DATE HTG. INST. ?1_R z __ 7 ? ` ov5 SOLD BY t?7c-! /-/ ' 7 C INSTALLED BY J c I Electrical Work Byte h V L 0,,rt Gas Line By JAG` n ?G Tr TYPE OF HEAT GA ?A -,LHW STEAM SPACE HTR. -UNIT HTR. OTHER GAS DESIGN ONVERSION LL MAKE - MAKE OF BURNER Model f C Dh -02 Model Serial ?sfV'Z?yUf)'???261' ?a-73 Max. BTU Rating INPUT 7? MAKE OF FURNACE Model ONTROLS //f THERMOSTAT Heat Plug ? Vent Size Valve 6+75f?-SrF? KIND OF LINER _771? SIZE NONE Limit 11 CyY//JL° l? - Draft Hood?/??t7/ZV Regularor L Limit Setting- Filters Si-- 16 k.,?O k Number o / ? •?1'O ri Fan Setting / ? Chimney Location Inside Outside e? ? p ? ? Pilot Type °3' Chimney Construction z2? ?/"n/6 Pilot Make 'r --- - _ - / - - --- Pilot Model -? 7/37,41 Smoke Bomb ng Pilot Timing Draft Test Tag L.W. Cut Off Door Pressure Lighting Inst. ? q Pressure - • ??1.?G Percent C0 Date Tested 2 Input CFH Percent 0 ?{,r Company Testing' ZO VS_L J //?C? 2 Stack Temp. 3? er Percent C012z 9?• Name of Tester _??//,!-cam rv<s? w'- Form 235 HOUSE HEATING TEST RECORD ADDRESS OCCUPANT HEAT LOSS DATE HTG. INST. SOLD BY ?Electrical Work By L/ TYPE OF HEAT GA _FA--' HW. r4??1' / .? 7 APTI.,? FLOOR ,/CITY &UBURB OWNER fMsQ i?? <-mw3/i t/ ca?2 2-I-( _ INSTALLED BY Cx?SG'? ???N .C!lc'C Gas Line By ri"!? to, c-l -STEAM SPACE HTR. -UNIT HTR. ' OTHER GAS DESIGN CONIVERSIO MAKE MAKE OF BURNER Model -P( (-A Model Serial (-.A)?f_' C1c, F36,02y %.Z Max. BTU Rating INPUT loo c?y MAKE OF FURNACE Model eo ?/ THERMOSTAT, He.tPl a PIu9 Va lye Ul Limit <??? Limit Setting E-L-upc Fan Setting Pilot Type SF Pilot Make Pilot Model Q Z?fA Pilot Timing -2 L.W. Cut Off -l 7'le ) C Pressure -fir -5 CIL - Percent C0 Input CFH 2 Percent O G pr7 Stack Tamp .. -3l Percent CO Z O?d Form 235 4e; ? Sri Vent Size KIND OF LINER SIZE '5:77" NONE Draft Hood Jti U/Zr- CYtJ Regulator -3 Filters Size Number I Chimney Location Inside i Outside Chimney Construction Smoke Bomb - - Wiring ? - - - Draft L- d,-/ Test Tog Door Pressure I Lighting Inst. Date Tested Company Testing Name of Tester )4?-?-f /5?b HOUSE HEATING TEST RECORD _ ADDRESS ?1?c5.ar/ ? A< fr'!-fix' ? APT{?L ^ FLO OR CITYk?SUBURB OCCUPANT OWNER ,? ?ti'l l? Crli./s 7 HEAT LOSS DATE HTG. INST. //--CE 7 SOLD BY ?'J c.? Ts=L INSTALLED BY Electrical Work B r 1 ?C Jc.`G ? L Gas Line By J'I ??? TYPE OF HEAT GA FA cr/ HW -STEAM SP ACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE ?1?/ 9L:-h,'t` L MAKE OF BURNER Model Model Seriol - !=/f-t .7 (?J t-x/(67 R.J?.?17 Max. BTU Rating INPU T MAKE OF FURNACE Model ; /p CONTROLS ? THERMOSTAT 1.c Heat Plug Vent Size d ? Valve _ 1%2 P7 ?fFA-c_e? ' ? y? KIND OF LIN a"r .fL<_CL r SIZE NONE EER Limit J Draft Hood ?•G/ Regularor 3?'S 3 1/r Limit Setting o Filters Size Z6'r 2ak4 Number Fan Setting ?cl Gs^? C-> Cam. Chimney Location Inside Outside Pilot Type Chimney Construction S Pilot Make Pilot Model Smoke Bomb Wiring G,-? Pilot Timing SCl Draft 4;:?-G/ -Test Tag E_? L.W. Cut Off Door Pressure Lighting Inst. Pressure ??,5`lGtl c? Percent CO2 l?r ?jp Date Tested / Input CFH ` Percent 02 Company Testing Stack Temp. ? S Percent CO j? Name of Taster 'T? ` ? f"?IrCG`??Q/c? Form 235 HOUSE HEATING TEST RECORD ADDRESS 1,5-30 2?-v+>.fS APTA _5_FLOOR ?'f?CITY 4 - SUBURB OCCUPANT OWNER- HEAT LOSS L-? DATE HTG. INST. / /' ' 17 SOLD BY 177,- _ INSTALLED BY Electrical Work By i. () f l -7f X"7/CC Gas Line By TYPE OF HEAT GA - __!f::?'FA HW STEAM-SPACE HTR. UNIT HTR. -OTHER -!? GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model Model _ Serial Max. BTU Rating -2 -1 INPUT MAKE OF FURNACE Model THERMOSTAT. Valve Limit Limit Setting - Fan Setting Pilot Type - Pilot Make - Pilot Model - Heat Plua Vent Size ??/ ?/ ? f/// _ KIND OF LINER SIZE NONE Droft Hood ?L/???/ ?r/i-? Regularor?S `J Filters Size I VXaOX? Number Chimney Location Inside ------- Outside Chimney Construction - ?!?'- /Sc3Ti? S Smoke Bomb- Wiring s'/ - - - - Draft e c_ Test Tag f Door Pressure Lighting Inst. Date Tested - ?- ?S -? 7 Company Testing ??r-' SC l?JG 2- Name of Taster ???' •-.1?!-'{?C iil/s <t?n? Pilot Timing -2- L.W. Cut Off l Pressure Percent C02 Input CFH S- _ Percent O2 y?qq Stack Temp. Percent CO U/cam Form 235 HOUSE HEATING TEST RECORD / '-- ?,c.? 5?J ADDRESS r-3n ?/?fo sp'?¢ c / /Sd -FLOOR CITY UBURB OCCUPANT OWNER ,1?.?"1?-11hV HEAT LOSS DATE HTG. INST. O-S?- SOLD BY vC ? L INSTALLED BY °3tJS( J ??'f I L-C Electrical Work By Gas Line By Chi X (; L_C TYPE OF HEAT GA FA HW STEAM SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE > MAKE OF BURNER Model V-,& - OcllrC-C.P( Model Serial C9 AJ :317 7Uc F/D°[- 1?2,& Moz. BTU Rating - INPUT MAKE OF FURNACE Model ? C NTROLS THERMOSTAT' r?Heat Plug "- Valve Limit i62U_ f IIkrf Limit Setting -L Z2 Fan Setting ]O p?V Z2 Pilot Type- Pilot Make '21CT - - Pilot Model Vent Size -?L /< KIND OF LINER. Draft Hood( Filters Sizez Chimney Location Chimney Construction SIZE -2 NONE or-;' Z Pilot Timing L.W. Cut Off Smoke Bomb C- Wiring Draft ?•?o? Test Tag Door Pressure Lighting Inst. Pressure -3;'- r r(JC- Percent CO2 6 In Date Tested --? Input CFH Percent O L'G' Company Testing ???s-C'? !"'Is?G 4 e!? ??1L?fr??J`-f Stack Temp. ?.?C7 Percent C02 ?rfE? Nome of Tester z-I14-77 Form 235 HOUSE HEATING TEST RECORD ADDRESS ? APT FLOORC Y X(6dL SU .? IT BURB OCCUPANT OWNER •"?If=?/t'J HEAT LOSS PATE HTG. INST. 7 SOLD BY d c .? L e.G INSTALLED BY G^CJ7?= ??/%r? Electrical Work By KLrZ Kl ?4V L_c-C- G.s Line By -7?r-.tJSL^? /L'?y'C-? ILA TYPE OF HEAT GA ! --FA ? HW -STEAM SPACE HTR. - UNIT HTR. OTHER 1J GAS DESIGN CONVERSION MAKE A?'? MAKE OF BURNER Model j? Cc I)P4 'V?r-??- -t /f• _ Model Serial ? D10 1'aI` ? Max. BTU Rating INPUT y"/S r/`?GY> MAKE OF FURNACE Model CONTROLS ?- 5i % _ / / THERMOSTAT Heat Plug Vent Size /? U S _ / i(CJ?? /.S V.Ive? f KIND OF LIN R 7?? SIZE r„ NONE / , Limit Draft Hood " 1 Regular., -? s Limit Setting %c Filters Size X?-1' 0u/ Number Fan Setting Chimney Location Inside Outside Pilot Type > a4??" Chimney Constructi on Pilot Make' c.;L./ Sf?/fL? -= - - - -- - _ - -- - --- ---- - _ -- Pilot Model Smoke Bomb Wiring Pilot Timing Draft l R?'?T Test Tag L.W. Cut Off Door Pressure ? - Lighting Inst. '? yl Pressure Percent C02 Date Tested Input CFH ?? Percent 0 /?' ? Company Testing c9d%C' /'li't-y qq Stack Tamp. Percent CO Name of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS ?? ??? ?i`>?i/9ffS Li9i?` /'/ APTJO_g FLOOR /5 CITY,?- ?691?SUBURB OCCUPANT OWNER (?,??YL?/rtJ 4'_ -2 + HEAT LOSS --? TE HTG. INST. SOLD BY w - ?'vQ r'y f? INSTALLED BY I1?brJ'4 rte` l{=G Electrical Work By Gas Line By TYPE OF HEAT GA ?A ?HW-STEAM SPACE HTR. -UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model Model Serial ??l7 ?U/n r/?ufti? Max. BTU Rating INPUT MAKE OF FURNACE Model THERMOSTAT Valve Limit Limit Setting _ Fan Setting Pilot Type - Pilot Make - Pilot Model - Pilot Timing - L.W. Cut Off _ Plug. Vent Size / + ?O J R) r - < cr SIZE NONE KIND OF LINE Draft Hood LfIU/ Tel '? Reg .I„tor 3 Filters Size IG Number - Chimney Location Inside / Outside Chimney Construction _r/--.T= Smoke Bomb -- Wiring - Draft I-,- ?° ^ Test Tag - Door Pressure Lighting Inst. Date Tested Company Testing ?/??on?Sr`` /?7?'?f' Name of Tester 6,6 Pressure -5+ Percent C02 ? Input CFH ?J Percent 0 c Stack Temp. 2 Percent CO Farm 235 HOUSE HEATING TEST RECORD ADDRESS APT. AL_ LOOR CITY AASUBURB OCCUPANT OWNER HEAT LOSS _ ATE HTG. INST. 7 SOLD BY - l 9USC! ?Me-Y.FF INSTALLED BY ,/ Electrical Work By .r?r% Gas Line By TYPE OF HEAT GA '_? FA? H W STEAM-SPACE HTR. -UNIT HTR. OTHER (J GAS DESIGN CONVERSION . MAKE t\V"? MAKE OF BURNER Model o R -0 y 1:_-C_-CA Model Serial f?10 41 ?36o Mox. BTU Rating INPUT MAKE OF FURNACE Model / iCONTROLS THERMOSTAT 130 Heat Plug Vent Size Valve ?n `h.:2-/S'???"-<-? KIND OF LINER _ `SIZE NONE Limit ??•"?°?? "?` ? T ?szs- Draft Hood /32 1 urJ Regalaror 3 Limit Setting Filters Sized ?n-V/ Number Off/ ?? c Fan Setting !f-3 ?/ Chimney Location Inside Outside z? ^ ? Pilot Type 75 T - Chimney Construction ?/. ?/,-DTI `% /? _ S%c )C' ?S Jif.^Pu1'- ' Pilot Make ?rJ - - ? - - - - J p Pilot Model Smoke Bomb Wiring / Pilot Timing S?Z Draft t,= c"0 r' Test Tog L.W. Cut Off Door Pressure Lighting Inst. P P C D T d ressure ercent 2 O ote este Input CFH Percent OZ ??', Company Testing rfc)iC?_ ?/.-CA Stack Temp. Percent C04 Nome of Tester Form 235 HOUSE HEATING TEST RECORD 66 77 SS? ADDRESS ZT APT. LL0 FLQOR CITY - SUBURB OCCUPANT OWNER I IA,) r'oti S % HEAT LOSS DATE HTG. INST. SOLD BY Mt- - INSTALLED BY Cx rL'? ?C Electrical Work By , lc.Q L-7,-c Gas Line By r"?cJSr•'' ?VIr-C?-fj TYPE OF HEAT GA IL FA HW -STEAM SPACE HTR. -UNIT HTR. OTHER ?? 1) GAS DESIGN CONVERSION MAKE .{ 6 MAKE OF BURNER Model lh e,hcA ?0°7 C'c "•C Model Serial Z0 Maz. BTU Rating INPUT S-"- ? MAKE OF FURNACE Model THERMOSTAT Valve Limit JTROLS Heat Plua ?- Vent Size KIND OF LINER Z ..?Ti: cfy? s SIZE NONE Draft Hood i? / C7i2-? Regularor `l 7-? ?3 Filters size %ki??J k7 Number- I Chimney Location Inside /L"?' Outside L Chimney Construction C 5 Smoke Bomb Wiring l Draft G Test Tag Door Pressure Lighting Inst. Limit Setting /Cl Fan Setting 3O G"N `r"C/ Tj ` Pilot Type /?y?? --- Pilot Make Pilot Model Pilot Timing .SGC L.W. Cut Off Pressure Percent C02 7 /;/0 Date Tested Input CFH Percent 02 Company Testing ?EJrJ C? J?IC C Stack Temp. Percent CO 6:1 ??2 Name of Tester ;?7!y/? Form 235 HOUSE HEATING TEST RECORD ADDRESS Z_5- 0 AP T.1I ,IFL(?,OR CITY L&Cr!'"SUBURB OCCUPANT OWNER McQ-ILU r-c ,J5 % HEAT LOSS r? DATE HTG. INST. ?l '7 SOLD BY r- - INSTALLED BY P_C__?JS ' Electrical Work By / Al/L4, G7,:C Gas Line By ?Jr JS C? c•_IL' ?/T TYPE OF HEAT GA ?FA _/ HW-STEAM -SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model _(LLA -C?L.IL c. -C t0 Model Serial L ?L ,?.7-r^:3 Max. BTU Rating INPUT MAKE OF FURNACE / Model CONTROLS THERMOSTAT Heat Plug Vent Size / v y>y// c r?A?cJ Valve R e KIND OF LINEER f"7;411 A_5111 SIZE tS NONE J I Limit 1'TJn1rY r ?n>L= ( Draft Hood .15L"(17 0`0 Regularor Limit Setting yV Filters Size '0,0 Number Fan Setting 0 O N % Chimney Location Inside Outside Pilot Type ? Pfl Chimney Construction .??C??i-? ?? C ""-/ frS -- Pilot Make Pilot Model Smoke Bomb Wiring Pilot Timing Draft Test Tag L.W. Cut Off r- Door Pressure Lighting Inst. Pressure Srr W ? Percent C02 ? 2 6", Oe( Date Tested Input CFH ?5 Percent O Z q ?? 92 q Company Testing ?JCltcr? ?'?/` L? Stack Temp. %' ?55 Percent CO Name of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS P AQ R ? S A T FLOO CI TY UBURB OCCUPANT OWNER 7c2Yj HEAT LOSS QATE HTG. INST. / % I p SOLD BY /? Sr_' G ??,cGt? INSTALLED BY 1^?`` °? 1'?7ti?y A Electrical Work By x «?O'YL .?!TL Gas Line By A V S?% /'Ar<C TYPE OF HEAT GA 1FA r/ HW STEAM -SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSIO MAKE MAKE OF BURNER _LO iq `?rJ•C-C ?G? Model Model Serial G iV Z `>l r U .??'?? Max. BTU Rating INPUT MAKE OF FURNACE Model CONTROLS `i THERMOSTAT eHeat Plug ° Vent Size 5 Valve o?cc? 5(iAr .,? KIND OF LINER Z!jcST,SIZE NONE Limit /-w NC'Yi.tJG ?? Draft Hood//'??T nv? Regulator ?---?- - 3 Limit Setting 1 %U Filters Size ???? X?r9X? Number Fan Setting ro UN 94- -41 Chimney Location Inside ', Outside Pilot Type Chimney Construction -, /' "-Pilot-Make__,- Pilot Model .SP7/r. Smoke Bomb Wiring Pilot Timing -2- S? ?- Draft Test Tag L.W. Cut Off Door Pressure Lighting Inst. cs 9 Pressure Percent C02 Date Tested Input CFH S Percent 02 Company Testing Stock Temp. Percent C0 Name of Tester -????? •-t%r???'?U{?'cJ Form 235 HOUSE HEATING TEST RECORD ADDRESS /TAp T./(7 FL09R CITY 'SUBURB OCCUPANT - OWNER f:?: /`l A, act lo.Li S T HEAT LOSS 9 TE HTG. INST. k-g Z SOLD BY `- INSTALLED BY Electrical Work By y' I l/L-f' f£/ [-? -Gas Line By e,. ?S r/ /?s`!r/' TYPE OF HEAT GA ?A -_HW STEAM SPACE HTR. -UNIT'HTR. -OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model (.. 6/? tn?^ -C _ Model Serial C2 N Max. BTU Rating INPUT MAKE OF FURNACE Model 1 a/ CONTROLS THERMOSTAT _at plug Valve j% ?FY {Ne? -?IfFW Limit H-o Yw?""?I Limit Setti, Fan Setting Pilot Type Pilot Make Pilot Model Pilot Timin L.W. Cut Ott J q Pressure Percent C02 Input CFH ??? Percent 0 ?'?--?' ?? Stack Temp. Percent CO2 ?o Vent Size KIND OF LINER- /1%F/ lx TTri, SIZE r? NONE Draft Hood Regulator Tom` Filters Siz-le!4 ? Number// Chimney Location Inside rJ Outside I--? Chimney Construction Z"2 -:7__ JG gmC. Smoke Bomb '- Wiring Draft (- - Test Tag L? Door Pressure, Lighting Inst. Date Tested •S7 Company Testing ?7 ?1d>'C gGl Name of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS ZZ APT. If J FLOOR CITY F- kSIUBURB 5? L) OCCUPANT OWNER ???Me41ry Cb,?S? HEAT LOSS DATE HTG. INST. SOLD BY „c' 6,1 cr/I ? t'?r, sc? ?17Frrf -INSTALLED BY ?'? t Vr-`?/ Electrical Work B / r't JCc?w C?? Gas Line By TYPE OF HEAT GA L_,?FA' HW-STEAM SPACE HTR. -UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE f, ki afi--, MAKE OF BURNER / Model i<r I?I.a --oyez -CF, Model Serial ?fuhh Ifs P.a-n (37-J??i Max. BTU Rating INPUT 4?S'irz-? MAKE OF FURNACE r , Model 'CONTROLS ? THERMOSTAT l? rHeat PIu9 Vent Size Valve . S KIND OF LINER fG7,e'i.? ?C f SIZE I NONE Limit fi?c'yc%f'? Draft Hood Regularor 3 J S =3 Limit Selling ? 90 Filters Size 14?,?dnf I Numb or - Fan Setting 5'o /s <l' / Chimney Location Inside Outside Pilot Type SI l7tl?__ Chimney Construction i?lo, Pilot Make Pilot Model 5???.5`?'? f- ' Smoke Bomb / Wiring Pilot Timing S! r' Draft /=,_.,'A Test Tag ' L.W. Cut Off Door Pressure Lighting Inst. J Pressure f/iL?L Percent C02" Date Tested Input CFH ??? Percent 0 f?a Company Testing c9dSri Stack Temp. 0`4 Percent CO'- Name of Tester 4.71 C!/GLS'w'i Form 235 HOUSE HEATING TEST RECORD S??? % ADDRESS -fT ' ? ZS/ t r - iy ? ? epT. I 1 P FLOOR CITY / 19 SUBURB OCCUPANT OWNER AC,) E?V7T 1 I-? HEAT LOSS DATE HTG INST . SOLD BY . 14 I INSTALLED BY 4=USt- . L--cI Electrical Work By t--cK?- !?" ( ?,/(,?rQ ? ) - r Gas Line By /).A1 h:G TYPE OF HEAT GA -iLFA .-?'H W STEAM SPACE HTR. UNIT HTR. OTHER GAS DESIGN CONVERSION _ MAKE "t= MAKE OF BURNER ." Model 6oiq U`/ L'z? 'C,,f Model Serial OC? Max. BTU Rating INPUT //-?/ C!? MAKE OF FURNACE Model CONTROLS THERMOSTAT /??/ Heat Plug Vent Size Valve S-s KIND OF LINER ?'"?= T?.•?J•TSTcs SIZE NONE Limit ?N?'???•`-?J _ Draft Hood 1?5 ['/ ?T c?-"?CJ Regularor'?? 3 Limit Setting Filters Size Number Fan Setting /3<-_7 .?%? !? O. Chimney Location Inside Outside Pilot Type 7 ?•e _ _ -_ _ _ _ -Chimney Construction --F3'?- =5''',-btl -Pilot Make - - / - -- - ? -_ - -- - - _ - f Pilot Model Smoke Bomb Wiring Pilot Timing Draft Test Ta g L.W. Cut Off Door Pressure Lighting Inst. Pressure Percent CO 2 Date Testedl?J - Input CFH Percent 0 2 Company Testing eo Stock Temp. Percent CO Name of Tester ZfZ??Z=4?? Form 235 HOUSE HEATING TEST RECORD ? ADDRESS ?7??di'%??' L,rJ'.?r" /5 LL? A APT. _ FLOOR _ CITY UBURB OCCUPANT OWNER --?J/JM14I1n 1 ./0??5 HEAT LOSS DATE HTG. INST. SOLD BY JVS m J Ik f INSTALLED BY <j ?t=l ff Electrical Wor k By 1?/ 5a 11C&v ' 5L Gas Line By W^`•,- f/L4 =2L- f7 TYPE OF HEAT GA ?A ?HW STEAM -SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE N? - MAKE OF BURNER Model (L)[4--nt1uz-- r_e Model Serial ? _ Max. BTU Rating INPUT ?'2'%? MAKE OF FURNACE Model A CONTROLS THERMOSTAT z? H Pl r V Si eat ug ent ze Valve `-+(?/n-T?-1r eJ KIND OF LINER, SIZE NONE Limit Draft Hood " Re ularor -?L25- f Limit Setti ng / Filters Siz.4? ,3 %'4 Number Fan Setting ?.7n Chimney Location Inside Outside Pilot Type- Chimney Construction ??/ Pilot Make rP?`-/c%SF/if[? - - - - - - -- - - - -- r _ _ _ Pilot Model 1_0 Smoke Bomb - _ Wiring y ?- Pilot Timing .-2 _ / Draft wTest Ta g L.W. Cut Off Door Pressure Lighting Inst. Pressure Percent CO '6d ,i Dote Tested -1-?- -C37 Input CFH Percent 02 • c- 1_%_/,__ P_ Company Testing I<- 7 ?-? Stack Tamp. Percent CO % Name of Tester ?I?Z= Form 235 HOUSE HEATING TEST RECORD ADDRESS 2?APT LLFLOOR Z CITY ?/? OCCUPANT . a SUBURB OWNER 1?r+,'N.`3'RU Cc)??S 7 HEAT LOSS ? DATE HTG. INST. JJ_ SOLD BY .G G- INSTALLED BY _ lit-2c1?>N IVT/CGfI Electrical Work By i 1/, P Gas Line By j? EJCljC_ /dj!'r_ TYPE OF HEAT GA ?A -'HW -STEAM SPACE HTR. UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE ?cL??'? MAKE OF BURNER Model k) C Or?'G( G'GT,'--CiL Model / Serial 6,/U 3n/n P? 77v Max. BTU Rating INPUT C?CS i'r?CJ MAKE OF FURNACE Model / CONTROLS THERMOSTAT ? Heat Plug Valve 0? Limit 1-111/-rc Limit Setting Fan Setting. `.ja d/? ?/n o /` Pilot Type Pilot Make --- Pilot Model Pilot Timing Sr_ I L.W. Cut Off i/ Pressure ?i,S G?c_ Percent CO 2 c Input CFH Percent 0 1?1 Stack Temp. -•3'S? Percent C02 cry Form 235 Vent Size ?X _/6 KIND OF LINER, Draft Hood LC._ Filters Size Chimney Location Chimney Construction _ S?°S SIZE NONE RegulaTor ---e Smoke Bomb Wiring Draft Test Tag I Door Pressure 'r- Lighting Inst. Date Tested o c?<7G /?irG Company Testing Name of Tester Outside - HOUSE HEATING TEST RECORD ADDRESS ?S dry f// .d1,4-S ,49 f ?/-'/ APT. L11- FLOOR ?CITY/C 'PVSUBURB OCCUPANT OWNER 7 HEAT LOSS -DATE HTG. INST. / - SOLD BY na- .'Z'f INSTALLED BY ?nUS 'LI B Electrical Work By 1-- R i Vt 7L- 1s74--r Gas Line By Xou i TYPE OF HEAT GA _=-_:?FA c/HW -STEAM SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model ;?7(al> ti -/77L's?'C6f Model Serial r,?7 •'. D/r)A df-'3S=? 'i ?, 7J Max. BTU Rating INPUT MAKE OF FURNACE - Model NTROLS /i/ '/ THERMOSTAT Heat Plug jo lp Vent Size Valve / G'C9?T5/1 i+r r,J KIND OF LINER //zJs SIZE / NONE Limit '' // DraftHood vi// O?? Reguloror Limit Setting Filters Size A/?k?7X/ Number 7 Fan Setting Chimney Location Inside L? Outside ? Pilot Type Chimney Construction Pilot Make uJ - _- - _ - - - - - _ Pilot Model Smoke Bomb Wiring Pilot Timing .Z L.W. Cut Off ? Pressure 7 S (?G Percent COZ (y' Input CFH ?S Percent O 31/a`F ' Stack Temp. Percent CO n y? Form 235 Draft - era,7 Test I Door Pressure Lighting Inst. Date Tested /;:;2 Company Testing Name of Tester _ HOUSE HEATING TEST RECORD ADDRESS It3o l ?A-S <r?- ?? APT./-b FLOOR c CITY'-J(0d/"?UBURB OCCUPANT OWNER 6oySi HEAT LOSS I DATE HTG INST . . SOLD BY INSTALLED BY rte: r? i?c_ Electrical Work By Gas Line By _QLe!Y r'? TYPE OF HEAT GA ?FA ' HW -STEAM -SPACE HTR. UNIT HTR. -OTHER GAS DESIGN e CONVERSION MAKE I- t ?C MAKE OF BURNER l ?G s -U7L ?d? M d o e Model Serial 'U 31)/(,)rh' F?YT ?3r 5 5? Max. BTU Rating INPUT MAKE OF FURNACE Model ?7,CONTROLS T E S H RMO TATS Hear Plug Vent Size Valve Limit KIND OF LINER f?/,?T??'?JGS/rxS 1. Draft Hood ??CL??Tr7ctJ Regularor Limit Setting O' 6 Filters Size ?'OX I Number Fan Setting Chimney Location Inside Outside n Pilot Type Chimney Construction -Pilot Make - ?l^G./ft1?/"?- -- - __ _ _ _ _ Pilot Model S?, /r Smoke Bomb Wiring Pilot Timing Z Draft Test Tog L.W. Cut Off Door Pressure Lighting Inst. Pressure -7 •? Lr?G- Percent CO, 7 Data Tested Input CFH Percent 0 Company Testing Ot/SC i???:Z/y Stack Tamp. U Percent CO4 Name of Tester ??i/^-Yz^'r???jC? Form 235 vvJL IIL/ylll\V ICJI RGL..VRV / ) 4 ADDRESS AP Tc?F '1 _,,?? ft(Sti* 0? OR ?' CITY SUBURB OCCUPANT OWNER f.,?"%`7At/L (may t?ST HEAT LOSS ? DATE HTG. INST. f? 'f SOLD BY - INSTALLED BY Q'>Sc- ?ti7LJ Electrical Work By ?.?: ,?.?r ?G? G Gas Line By ?o L'S- ejf elf TYPE OF HEAT GA 'HW -STEAM SPACE HTR. - UNIT HTR. OTHER ?II GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model 1)A -07Le1 -L/Z Model Serial &1%4 3 !Uf? "ap'7 F283i Max. BTU Rating INPUT MAKE OF FURNACE Model \ /CONTROLS THERMOSTA T Heat Plug // T Y ?? Vent Size__!P o Volvo O CC f2 C7%S.4/.4rcJ KIND OF LINER SIZE NONE Limit /Y /- ?i?G '?WL if d fcJ/fTf7sz/ Draft H ' 2 S--3 T R l oo i , ator s egu Limit Setting =.:v Filters Size f/,f..20X I Number Fan Setting p /?l2 oi? / U cs`.? Chimne Locati id I - y on ns e Outside Pilot Type _ 5;P4F'0r _ Chimney Construction .?7? T 51'?dGSh S Pilot Make __- Pilot Model - ? p rT/ r/7 Smoke Bomb W iring Pilot Timing .?- S c- e- 4a Draft T T _ est og L.W. Cut Off 0' Door Pressure l Lighting Inst. ? Pressure 2 S1 6c1L Percent CO2 6/ 12 Date Tested G Input CFH y Percent 02 79 d Company Testing Stack Temp. D Percent CO Name of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS ZI 3(3 ) /f/ni'>ifl ??fK - /"?PT{? FLOOR ?CITY?yZfF?t'-SUBURB OCCUPANT OWNER L?CA?"fA-/? /lJ.U S% HEAT LOSS DATE HTG. INST. Work B ?, V- 1'2?z; etz At, / i> D Ly/ 2 INSTALLED BY Electrical ??SL•' /??? SOLD BY Y /?3 Gas Line By ?i??JSr L?j?:Z TYPE OF HEAT GA =-__FA JLHW STEAM -SPACE HTR. -UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE T{ /?'c2'?"'1 MAKE OF BURNER Model 2,e(-)i4--07 /s-A Model Serial C '43D1013 i38S7 7,Z Max. BTU Rating INPUT MAKE OF FURNACE Model ONTROLS S / THERMOSTAT Heat Plug -- ,/rr Vent Size 6 l! Valve KnhtiQ % 4dAco KIND OF LINER ,/,-ZW Ct 2-1J SIZE NONE Limit f1c'rb e:r i AJe-1 Draft Hood V/? rt.? T,15 -3 Regularor _. T Limit Setting l? Filters Size dGY/Cl(??Number Fan Setting 432 Chimney Location Inside Outside Pilot Type _nP4.Q,,k - _ Chimney Construction z77F/a4"7 ? S Pilot Make P,A ? - S/_(,4uJ- Pilot Model ?7y rA Smoke Bomb ?- Wiring ? Pilot Timing -Z -`r -7 Draft Test Tag L.W. Cut Off Door Pressure Lighting Inst. Pressure r =1J?uJL Percent C02 (,'° Date Tested -41--C5, Input CFH ? C Percent 02 / s Company Testing Stack Temp. 'm Percent CO C2 yr, Name of Tester l:"yi¢/7 `f?C7?LVrJ Form 235 HOUSE HEATING TEST RECORD ADDRESS a ? e) ) APT LOOR °1 CITyl `^ SUBURB OCCUPANT OWNER tgd- ,A) Ccbv'57 HEAT LOSS ? DATE HTG. INST. fl 7 SOLD BY INSTALLED BY __9 d?5v- Electrical Work By f1t`?-4-21?zi-)Q zr/!-C Gas Line By TYPE OF HEAT GA ? FA ?HW STEAM SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE ?? MAKE OF BURNER Model /Z 6 p /J l T/? - Q6? A L1? Model Serial ?o A ?3bioo 3BB7 Max. BTU Rating INPUT MAKE OF FURNACE Model ONTROLS -- THERMOSTAT Hear Pl Plug Vent Size Valve hr'/°T-SN/IL.J KIND OF LIN ER S SIZE NONE Limit a /-fnn]r'?i?>? Draft Hood Ov?? dAI Regula,or 3 Limit Setting ° Filters Size Number Fan Setting _Z3=,_o 5?0 of? Chimney Location Inside Outside Pilot T _ ype -s`?-? - /r?.?" Chimney Construction Tff'?IJCSJu S Pilot Make - V(1j4GC7 92A2Z Pilot Model 5P71S,4 Smoke Bomb Wiring Lam/ Pilot Timing Draft 6 Test Tag C? L.W. Cut Off Door Pressure Lighting Inst. Pressure Percent C0 Date Tested _l - Input CFH / T 2 '???_-_?Percent 02 Company Testing h[ISG? Stack Temp. YOo4: Percent CO C:2 Nome of Tester Form 235 HOUSE HEATING - TEST RECORD ADDRESS pPT,20Y FLOOR -K CITY f: /bUBURB OCCUPANT OWNER HEAT LOSS ???????"""D"ATE HTG. INST. ?Z r07 SOLD BY ??H INSTALLED BY Electrical W k B K //Xt1lL-1? .L ?L C Gas Line By r/'7i r-lf' TYPE OF HEAT GA?FA ??HW-STEAM -SPACE HTR._UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE FA=Z"'n MAKE OF BURNER Model :g(,DA -I)Lez -COQ Model Serial [H ?lb$lo C,, .4 7 ?61 Max. BTU Rating INPUT ra+r, MAKE OF FURNACE Model ?/`CONTROLS THERMOSTAT /A7F Hear Plug Vent Size Volve KIND OF LINER. 7 At5_Z S SIZENONE LimitDraft Hood llc/i?rio/r? Regulator 3..?-S z Limit Setting Filters Size A?1,e-'0,"?f Number ' Fan Setting min ON fG_? n1 Chimney Location Insides Outside -? Pilot Type ??,pRA2kf Chimney Construction /r Pilot Make Pilot Model Smoke Bomb Wiring V Pilot Timing SC'Z Draft Test Tag L.W. Cut Off Door Pressure Lighting Inst. L/ Pressure 3.S c.JC Percent CO G Dote Tested 2 c Input CFH ? Percent OZ h Company Testing ?n USG /77c1l?i? Stack Temp. Percent CO O f Name of Tester Form 235 IF- HOUSE HEATING TEST RECORD ADDRESS ,??JJ APT.o,,???LFL00R CI TY ?G4AUBURB OCCUPANT OWNER mA-f cgzA4 7- HEAT LOSS DATE HTG. INST. SOLD BY r >v c ?77h-C INSTALLED BY Electrical Work Ry ? I ?G 2' ??G-G Gas Line By CeSt! ?C%L? TYPE OF HEAT GA f% FA ? HW -STEAM SPACE HTR. -UNIT HT-R. OTHER j( GAS DESIGN CONVERSION MAKE --9 t II'?'?1 MAKE OF BURNER Model ?2 A -d`F(•'L - C-P Model Serial GN??/(J/ r?l/g7 7 £3 J`J Max. BTU Rating 'INPUT MAKE OF FURNACE Model CONTROLS ?- THERMOSTAT _ Heat Plug Vent Size /v , /44-:Lf Valve h?"P KIND OF LINER T c rf SIZE NONE ? im`" " Limit ?NC-, r - ; w/ Draft Hood Affil / U? Regularor Limit Setting ° Filters Size Numb ' Fan Setting «o .sN G!D r Chimney Location Inside ? Outside 4-f 9 _ Pilot Type -- -? Chimney Construction -o hL[::e Z&A?buJ Pilot Make -- _- - - - - -- _ - - - /- - - - - -- Pilot Model ?P Smoke Bomb - Wiring f J Pilot Timing ?' S CL Draft ? ;;; Test Tag J L.W. Cut Off Door Pressure -? Lighting Inst. Pressure ? _5?_kAlc Percent CO2 Data Tested Percent 02 Input CFH-- C4,2 Company Testing Stack Temp. Percent CO . t C?7 9 Name of Tester `??•?' -/`?fG7??? Form 235 HOUSE HEATING TEST RECOR?D? `/Y ?? ? ADDRESS /? APT. FLOOt? CITY Eit SUBURB OCCUPANT OWNER ??M???.l C?.vST HEAT LOSS DATE HTG. INST. SOLD BY ?xs ,?- d INSTALLED BY r.?U„5.ty Electrical Work By kaa c, Gas Line By ?ts(A ? r?>?/4 TYPE OF HEAT GA ? FA ? HW-STEAM SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model Model Serial h,r?3?(O/O?(n _13r3p Max. BTU Rating INPUT 4?irG^?o MAKE OF FURNACE Model ONTROLS THERMOSTAT Heat Plug Vent Size 70 Val 5 r PGc 7'%?r+?-' KIND OF LINER i? Valve SIZE - NONE Limit Draft Hood 17u[11- Oaf Regularor 3+??? 3 Limit Setting ?. q Filters Si.. 161 ?,2 I Number Fan Setting 1?, 52 oe4? Chimney Location Inside /L Outside Pilot Type Chimney Construction S Pilot Make -?=-Pilot Model -5?7/?>Q - -- -- ---Smoke Bomb ----- Wiring ---- - - Pilot Timing 1- 5C L.W. Cut Off Pressure Percent G02 Input CFH Percent 02 1"r, ZI-/o Stack Temp. Percent CO 0 /? Form 235 Draft Z Test Tog Door Pressure - Lighting Inst. Date Tested ?T Company Testing Name of Tester r HOUSE HEATING TEST RECORD ADDRESS 1"?,7 APT-e!24 FLOOR CITY LL? ?SUBURB OCCUPANT _ ?/L!A-ld? C.c?tiS-/ OWNER HEAT LOSS L,--- DATE HTG. INST. Z? ,27 <JSL? J SOLD BY J 7?Gf/ INSTALLED BY pp Electrical Work By Tin. ?? ?L7? g5 ct r _ Gas Line By I? « [T TYPE OF HEAT GA _ FA -? HW -STEAM SPACE HTR. -UNIT HTR. -OTHER r'7 GAS DESIGN ONVERSION MAKE MAKE OF BURNER Model IL C,-D..4 Model Serial Gns3D(()& G!/P7 ZP Max. BTU Rating INPUT -?? MAKE OF FURNACE Model /CONTROLS / -- THERMOSTAT Heat Plug Vent Size Valve taJ KIND OF LINER SIZE 4?: NONE ?J Limit A)G?I (,.???? /? Draft Hood TU[14./C7'/t? Regul arorJY:2 3 " ? Limit Setting Filters SizeNumber ( Fan Setting /_?5,O cp/U ?Q Chimney Location Inside Outside Pilot Type 50Q?-? Chimney Construction _,-22?` y p np?cd-ISJ?/?, Pilot Make - 715;::A Pilot Model S r Smoke Bomb Wiring _ _ Pilot Timing 57Z-Z'- ;n Draft ?. Test Tog L.W. Cut Off ?- Door Pressure - Lighting Inst. i/ Pressure Per<ent C02 Date Tested -z4? Input CFH S? Percent 0 2 Or YC? L- Company Testing Stack Temp. S? Percent CO o ?/? Name of Tester 3?fSt?GT??U?- Form 235 HOUSE HEATING TEST RECORD /y - ADDRESS APT ,_e6 FLOOR ?_CITYLJ '?> SUBURB OCCUPANT OWNER ?A-LV lax HEAT LOSS DATE HTG. INST. SOLD BY Pr11?-+<7INSTALLED BY "5 r= mrt'l c-'??'"? Electrical Work By fJ f/i /L,_r ?cC Gos Line By Oc75 mot/ ,G'C- TYPE OF HEAT GA -"FA ?HW -STEAM SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model -O quc--C a Model Serial ?iA-T (U (I8-7 O3 Xd Max. BTU Rating INPUT MAKE OF FURNACE i Model ONTROLS THERMOSTAT, Heat Plug Vent Size Valve ` r KIND OF LINER SIZE S? Limit Draft Hood///?? Regularor !?Z'-2-57- Limit Setting Filters Size loo .I'?OX / Number Fan Setting / 3o ON -;5Z2 Chimney Location Inside Outside Pilot T e Chimney Construction ?l?T ?JGST S yp - - - - - - - Pilot Make ` _ _ - - - - - - - - - - - - - - - - - - - - -Pilot-Model q - 7!S'rT - Smoke Bomb . - - - - _ - - - - - Wiring Pilot Timing _ 2- Tr-r Draft cf, m Test Tag L.W. Cut Off Door Pressure Lighting Inst. Pr s / r++?C-Percent CO L11 f? Data Tested es ure Input CFH ?S Percent 02 9-5-? Company Testing wsG- !L Stack Temp. Percent CO e>,17, Name of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS ?;'C-2 APT .Z_t-FLOOR N CITYg/11,AfSUBURB OCCUPANT OWNER `a Zip C:no, ZS% HEAT LOSS ? ATE HTG. INST. SOLD BY INSTALLED BY '4ed L) S&-- 1t1,nC,14 Electrical Work By Gas Line By nJSC- Mw=G? TYPE OF HEAT GA FA v HW STEAM SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE r?ct_:wl MAKE OF BURNER Modal Model Serial GA?? ?b 'P11R 12 7e97 Max. BTU Rating INPUT MAKE OF FURNACE Model / f?ONT ?'- r? s v THERMOSTAT ? Heaat t Pl Plug Vent Size -/ O bre 7-S-1fffw Valve f KIND OF LI ?7 ER?y ?-t SIZE, NONE G Limit ^ ? Draft Hood Regularor_?.?N 7 Limit Setting Filters Size X7oX Numb ar? Fan Setting ?.30 Aet/ r10 off" Chimney Location Inside Outside t? Pilot Type Chimney Construction Pilot Make _ Pilot Model sf 7/?Q Smoke Bomb °r Wiring ?/ Pilot Timing ?sC7 Draft ??? Test Tag L. W. Cut Off Door Pressure ?-- Lighting Inst. T Pressure 3, S a1?L Percent C02 A:? Ig Dare Tested Input CFH Percent O 2 Company Testing 1;1Zr Stack Temp. ?.1CL?Percent C0 Of/J Name of Tester Form 235 _ HOUSE/ HEATING TEST RECORD % ADDRESS LS ?!> ?"/?+J ?/lr!?' ?TAp T20 FLOORS CITYI'TT_SUBURB OCCUPANT OWNER 7- HEAT LOSS L ATE HTG. INST. 7 SOLD BY c/ -c INSTALLED BY Electrical Work By K-- i 0'_-Z c-T- Gos Line By OU SC f2?;^G? TYPE OF HEAT GAC-?FA--? HW STEAM-SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE ?`?? t%?'t MAKE OF BURNER Model AC??TMJ? C9f4_e -Gee Model Serial C.?OJ3 ?-z 7% Max. BTU Rating INPUT MAKE OF FURNACE Model CONTROLS __ ? THERMOSTA ? 2 J,L/L Haat Plug Volvo -- Ohcr?T?f.?AW Limit N'=/- Limit Setting Fan Setting 43> or? 90 0 Pilot Type Pilot Make _ ?6?'%?-T4LC? --- Pilot Model Pilot Timing /? NZ L.W. Cut Off Pressure Z i f LyG- Percent CO4 ? O Input CFH ?Percent OZ Stock Temp. _ ???o d Percent CO en Form 235 Vent Size '7 KIND OF LINER SIZE 1` NONE Draft Hood ESL il;*' f" Regularor 3 Filters Size I Number Chimney Location Inside L,? Outside Chimney Construction ? ?bGS 7`Z33 -- Smoke Bomb ?- Wiring Draft G_ - Test Taa Door Pressure Lighting Inst. Date Tested 4-7-/ Company Testing Name of Tester b°7VLy?f/?C?'`i? ADDRESS /r 5739 APT?FLOOR CITY._SeS BURB OCCUPANT OWNER 7nn4AIA-) cn&G,7 HEAT LOSS . ATE HTG. INST. SOLD BY fJSr ?i3JY INSTALLED BY l pc/S Electrical Work By 7? i ?,0 ° K7<'C Gos Line By t?p 02C P7 ??-??} TYPE OF HEAT GA ?A -HW STEAM -SPACE HTR. -UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE -MAKE OF BURNER Model la Clef DV-GC tl/Z Model Serial 6AL30(O? ?f/ 'J 7f?7-2-- Max. BTU Rating INPUT C=??r7??J MAKE OF FURNACE Model CONTROLS THERMOSTAT Hear Plug Valve ? ? A(µc-cam Limit f??}L. YU?? ?? Limit Setting Fan Setting 13!? Pilot Type 5Pi'IPJl Pilot Make Pilot Model Pilot Timing x et° L.W. Cut Off ?- Gi?G ? Pressure Percent C02 Input CFH? Percent O 2 p Stack Temp.. Percent CO Form 235 HOUSE HEATING TEST RECORD Vent Size KIND OF LIN to T SIZE NONE / Draft Hood L O?J Reguloror Filters Size-irok;?WX Number Chimney Location Inside Outside ?' Chimney Construction /'17 CST 4 - _ _ __ r•-- Smoke Bomb -- - _ - / - Wiring t../ _ Draft Test Tag •? Door Pressure Lighting Inst. 6l / Date Tested Company Testing QcJS?C-+ 1771-'? Name of Tester HOUSE HEATING TEST RECORD ADDRESS /ZZn! are4 /'2' APT.aZ??FLOOR 42L?__ CITY t%?62 UBURB OCCUPANT OWNER vV GoJvST HEAT LOSS ATE HTG. INST. - K?Or FC' Me.:'?fY SOLD BY INSTALLED BY 'KOV S?:- /???=Z-H / Electrical Work By nE?54??, ?12? fc/L Gas Line By xr= .?7 tt7? TYPE OF HEAT GA _LLFA ? HW -STEAM -SPACE HTR. UNIT HTR. -OTHER n GAS DESIGN CONVERSION y ?r MAKE -mil MAKE OF BURNER - Model - fP6OA -Op?c`r- -[ X_ Model Sorial TI IS 7 ??95J Max. BTU Rating INPUT MAKE OF FURNACE Model CONTROLS / THERMOSTAT )) f3T Heat Plug Vent Sire f Valve jFz2 bz.4- KIND OF LINER?r''=-- C SIZE- 7 NONE , 65 Limit f?jrUG?Up?[-? Draft Hood P?? Regulator Limit Setting 492 Filters Size Number Fan Setting /?? 9?0 Chimney Location Inside Outside Pilot Type Chimney Construction- ???JF;?t/6?'STo 5 Pilot Make - bc2t ?SE/.?u/ - _ - - - - - - - -- - Pilot Model Smoke Bomb Wiring Pilot Timing c? 5C! Draft CLr Test Tag L.W. Cut Off -? Door Pressure Lighting Inst. IfC - Percent C0 Pressure S//I "moo Data Tested - I S 2 Input CFH U Percent 02 ?'? Company Testing Stack Temp. 220 Percent CO rl Name of Tester /l ///"///,?`7l[ila?S(i'?? Form 235 HOUSE /HEATING TEST RECORD ADDRESS Z??O I/ of APT?FL`OOR ?? CITY 1- SUBURB OCCUPANT OWNER Lo /rI A i iU C r24t5 i HEAT LOSS ??? DATE HTG. INST. SOLD BY ' r>Sc>` N-1 c,CH INSTALLED BY L Electrical Work By \titl 0? I/c i1 1T?.-v Gas Line By aGt USG' TYPE OF HEAT GA ??A ?- HW STEAM -SPACE HTR. -UNIT HTR. OTHER _ GAS DESIGN CONVERSION MAKE :R A1' ! Yti., MAKE OF BURNER Model c, t) f4 - GtI c2 -c- /z Model Serial G G 04?1i`8 Max. BTU Rating INPUT ?.fxb MAKE OF FURNACE Model ?? ^ __ CONTROLS THERMOSTAT /-?-"__ Heat Plug ? w Volvo Limit rV? k-x%7r Limit Setting Fan Setting ?f?Uc?-v ?o of Pilot Type -Pilot _Make _4762 r_` N{}t_? - - Pilot Model Pilot Timing / 5 Vent Size - 12-- KIND OF LINER - 1 SIZE NONE Draft Hood 23;?2/17 srll Regulator 2?0'2-S -} Filters Size VCr Oyu Number ? Chimney Location Inside Outside Chimney Construction -•--- ---- S ke Bomb Wiri ? ng Draft 4 Y- Test - L.W. Cut Off Door Pressure y? Lighting Inst. Pressure Percent C02 Date Tested Input CFH 1 Percent 02 Company Testing /R--p L".56y'- Stack Temp. Percent CO G y" Name of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS 2 1'?7 APT?FLOORa'? CI TY U B U R B OCCUPANT OWNER AOMA'lrl? Caa?c i HEAT LOSS ATE HTG. INST. 7 SOLD BY ok"' j-nj(cC1Y INSTALLED BY J7??=CH Electrical Work By A Rat/e.?P 6Z, Gas Line By Y'1AFn,_):t TYPE OF HEAT GA _,LZFA ?HW -STEAM -SPACE HTR. -UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model O</C C- t2 Model Serial Q..N}?l??(7 y Max. BTU Rating INPUT S?focr? MAKE OF FURNACE Model Z? CONTROLS THERMOSTAT Hear Plug 'oDa-f?l S1-Fi<.J Valve NC?uJc; Limit Limit Setting Fan Setting N C: r Pilot Type -S tA2 Pilot Make P, 6,:y Isf-oc- Pilot Model 5$7157hc Pilot Timing 5C L.W. Cut Off Vent Size ?T ?d7 KIND OF LINER I'v?F%ff?6CSTri 5- SIZE r ? NONE Draft Hood Sy I (T- c,,o Regularor Filters Size /( A'-LO, -I Number Chimney Location Inside Outside Chimney Construction loot? Smoke Bomb Wiring Draft Test Tag Door Pressure Lighting Inst. -?' p ?e Pressure ?•J t-4-,? Percent C0 s 3 2 ' Date Tested 'Y Input CFH 5- Percent 02 Company Testing ?/?u5c? ?76L Stack Temp. O Percent CO 4:2 y- Name of Tester ,?/r'9"??????C,Z/?SG7.C? Form 235 _ HOUSE HEATING TEST RECORD c? ADDRESS fj-3,0 APT -2? / ??_FLOO_R?CITY /YBURB OCCUPANT OWNER 4 C--2,USl HEAT LOSS ATE HTG. INST. -lI fI') SOLD BY INSTALLED BY ?oU56 Electrical Work By ??2?=?c•'Y Gas Line By OU S L-J?f.=l TYPE OF HEAT GA._.4frA HW-STEAM -SPACE HTR. UNIT HTR. -OTHER MAKE GAS DESIGN MAKE OF BURNER CONVERSION ???cc-?/ Model /?ycz-:2_e _ Model Serial /?.(??T Max. BTU Rating INPUT MAKE OF FURNACE Model PONTROLS O -? THERMOSTAT ? Heat Plug Vent size Valve KIND OF LINER ?' /o SIZE _ NONE Limit tl tc s, )N- Draft Hood 0r/'Z,6?62N?' Regul aror Limit Setting Filters Sizel??c?_Number Fan Setting n iV c Chimney Location Inside Outside •?? Pilot Type Chimney Construction -Pilot Make- -6-ice./ fT?-? - _ - - - --- - - -- - _-- -- - - - --- - - - Pilot Model ?_SJP 71e Smoke Bomb Wiring Uwe Pilot Timing L.W. Cut Off p _a? ? Pressure S, ,S iLL?C- Percent CO2 Date Tested - Input CFH Percent 02 Company Testii Stack Temp. -? P ercent CO n, S Name of Tester Form 235 Draft G zt- `' Test Tog Door Pressure Lighting Inst. 9 ?{'COL?SG- .17F2?? _z ? ?r?5 car-? HOUSE HEATING TEST RECORD ADDRESS /SSO ?r/C?rYiv.° S lf AP T.FLOOR o C UBURB OCCUPANT OWNER 1??M AIIJ C'.6dz5? HEAT LOSS ? ATE HTG. INST. ,, //-g SOLD BY U ? INSTALLED BY eK rte' /77?=G/Y nn Electrical Work Gas Line By V$G?if'/r CA TYPE OF HEAT GA FA _/W - STEAM -SPACE HTR. -UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE ' MAKE OF BURNER Model ?7 C, Z> Model Serial e-r JD / CJ (a Pf(0,2 i Max. BTU Rating INPUT MAKE OF FURNACE Model ONTROLS THERMOSTAT B Heat Plug Vent Size Valve _ KIND OF LINER _l'!?[`? S17F_ NONE Limit {?y? y ??r?7/ Draft Hood _O?'117 d>? Regular,, Limit Setting O Filters Size X995XA5J-' Numb Fan Setting f ?sJ pi`-? ?9G P Chimney Location Inside Outside Pilot Type / Chimney Construction //JJ Pilot Make- - ? Pilot Model Smoke Bomb Wiring Pilot Timing -??-? Draft ?2 rrri Test Tag L.W. Cut Off ?- Door Pressure Lighting Inst. _ i p y Pressure ryiC.S Cl/?_ Percent CO 6 S 2 9O Data Tested Input CFH-5-f Percent O 2 ? 7( Company Testing OC/SL-'- jj?.C?G Stack Temp.--?/o a F Percent CO Name of Tester Form 235 _ HOUSE HEATING TEST RECORD ADDRESS ) ?,APTa_ FLOOR f? CITY [SUBURB OCCUPANT OWNER ?"Jd V 1)S; / HEAT LOSS ATE HTG. INST. _4L:9?_ SOLD BY .cJ 5crL ?,F/ INSTALLED BY US?? _!`77i 21? Electrical Work By ( Gas Line By '? ?? C? ?l<n TYPE OF HEAT GA ?FA ? HW STEAM SPACE HTR. UNIT HTR. OTHER I GAS DESIGN CONVERSION MAKE 1 PJLi ,cry', MAKE OF BURNER Model R r?t),4-0,? r -C.ffl Model Serial G n1 ?s l??O `{ Ftb f3Cr r?-?- Max. BTU Rating INPUT MAKE OF FURNACE Model C NTROLS ^ THERMOSTA T- Heat Plug Vent Size Valve t r-f AI(j KIND OF SIZE NONE Limit Draft Hood Ragularor -Z? Limit Setting / Filters Size AG; Number Fan Setting q Chimney Location Inside : ? Outside - Pilot Type S ???? - - - - Chimney Construction `Pilot Make _ - - ?- _ -_ ?}. -- ---- - --- _ -- - _ - -' -- Pilot Model -5 qD Wiring r? Smoke Bomb Pilot Timing ?- SCl / Draft C Gf T t Ta - es g L.W Cut Off Door Pressure -- Li hti I t f . g ng ns . Pressure-3 !( Percent CO ?/??? Date Tested Input CFH Z q Percent 0 /• Qf P? Company Testing Stack Temp. 2 d Percent CO ID og? Name of Tester Form 235 ADDRESS ZTePTa? FLOOR d_ CITY e`i?-`)SUBURB OCCUPANT OWNER 1,?21-l61-12/ HEAT LOSS ?.?DATE HTG. INST. SOLD BY RFriz??"? M.:cf? INSTALLED BY -7?.°vs?? /NtG=t Electrical Work By -Ic.';t"l ll(: L? ,C'/.:C -Gas Line By ?C?J C'T L4-1 TYPE OF HEAT GA vFA-? HW -STEAM SPACE HTR. UNIT HTR. OTHER GAS DESIGN CONVERSIO MAKE ` MAKE OF BURNER Model QC9 ?,1? -b l„ P??A C_R Model Serial !?,3-7G Max. BTU Rating INPUT 61 r i_ MAKE OF FURNACE Model ? ?-CONTROLS THERMOSTAT ?lai Heat Plug Valve _ len?k-? l? 1f Limit Limit Setting Fan Setting U GN n - Pilot Type ?? - - -- - -Pilot Make --- ,fJeJZ/Si+ie'L?- -- Pilot Model JiPzL5 /4 Pilot Timing -'rte L.W. Cut Off Vent Size f? KIND OF LINER _ DL 7._ SIZE NONE Draft Hood CSC"? Regularor Filters Size Z6?'???JC / Number Chimney Location Inside Outside Chimney Construction ?!'-S?CJS = - - _ - - Smoke Bomb -T- ------Wiring ?- -- ?- ? _ -- _? - - Draft Test Tag Door Pressure -? Lighting Inst. Pressure Percent CO2 Date Tested Ldp!12) Input CFH Percent 0 Company Testing ?C'-' C?Gr Stack Temp. e' Percent C02 l??y Name of Tester HOUSE HEATING TEST RECORD Form 235 HOUSE HEATING TEST RECORD ADDRESS f5 ?/l /hnlr/irs -4-;5"11-1 ? APT.c?FLO`OR-C'iCITY 411JBURB OCCUPANT OWNER C??T HEAT LOSS DATE HTG. INST. --2577 SOLD BY ?oris^^t- -Vl CH INSTALLED BY Electrical Work By _ ,cn A'J VL-z e:-Icr. Gas Line By TYPE OF HEAT GA _L/FA ?HW-STEAM-SPACE HTR. -UNIT HT-R. -OTHER ,/? GAS DESIGN MAKE t&_c"E-7-L MAKE OF BURNER _ Model ?0 - ?' %4-_ "Z_ -7 Model Serial Max. BTU Rating_ INPUT MAKE OF FURNACE Model ON ONTROLS THERMOSTAT Heat Plug Vent Size Valve O KIND OF LINER 7 7L+I SIZE -NONE Limit A;,72, &=54Lz-71K / Draft Hood Y11-f -Qp?Regularor Limit Setting Filters Size -?o?^15?? Number. Fan Setting / 3c, a" %O o//.. Chimney Location Inside Outside Pilot Type Chimney Constructio n/ C -Pilot-Make- - f-z?-? S P,!?'L'`'? 7°? - - _ - ? g - - - Pilot Model Smoke Bomb -- / Pilot Timing ? 9 Draft ?r?r^/ T t To es g L.W. Cut Off Door Pressure Lighting Inst. f Pressure ?? S GZ/C Percent C0 Date Tested Input CFH 2 c Percent 02 //''" Company Testing 7fZ Stack Tamp. =S Percent CO ?'yy?Egggg Name of Tester 71 Form 235 HOUSE HEATING TEST RECORD ADDRESS ???? /'/ APT._7 ? FL OOR-CITY IpptSUBURB OCCUPANT ` OWNER I A? C?/?-15 7 HEAT LOSS I DATE HTG. INST. lZP7 SOLD BY INSTALLED BY Qe->USC=_ l=Z Electrical Work By Gas Line By - 'K TYPE OF HEAT GA ?.G FA ? HW -STEAM -SPACE HTR. -UNIT HTR. -OTHER I/ GAS DESIGN j CONVERSION $t?'2 MAKE -MAKE OF BURNER Model t'?( IJ r?r - O'ZXJ ° C- Model Serial (_tySN I G 9 r.i FJ'?7 70 Max. BTU Rating INPUT 7j? MAKE OF FURNACE Model CONTROLS THERMOSTAT Heat Plug Vent Size Valve KIND OF LINE R ?zTG/C SIZE NONE Limit Draft Hood Regularor _71-57`7 Limit Setting ° Filters Size ;X-2-051Z Number.-( Fan Setting Chimney Location Inside Outside Pilot Type c _ Chimney Construction- Pilot Model -SP ??,r? Smoke Bomb Wiring f / Pilot Timing Draft Test Tag =1___? L.W. Cut Off Door Pressure l? Lighting Inst. L? ?r?lO Pressure Percent CO Date Tested Input CFH_ Percent 0 2 Company Testing wCG? y`'r r-^ Stack Temp. ?Q Q Jr Percent CO ? j e--> S Name of Tester ?(?"?l ? /?'?lL /t?cLY-? Form 235 n UUJC nCA l INN I C.31 KC L.UKU 17 // ADDRESS APT, ?FLOOR.2g CITY?$UBURB OCCUPANT OWNER HEAT LOSS I DATE HTG. INST. Ll` 7 SOLD BY zm d[ INSTALLED BY ZZC?USc- IJ`/ S Electrical Work By t-i?cL4?71 llc--X .tom/ct Gas Line By TYPE OF HEAT GA Z FA r? HW STEAM SPACE HTR. UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE /: f -^'1 MAKE OF BURNER Model .? (r L7f?r-n1 ]r>??C? Model Serial ? nl31 2 Max. BTU Rating INPUT 75'czx? MAKE OF FURNACE Model CONTROL THERMOSTA T Heat Plug Vent Size T Valve ei f7cx?l .SL1 KIND OF LINER_ ftTfY // ?r STr_?5 SIZEIL NONE Limit r/ Draft Hood ?? Tr-z?y ? R l egu aror Limit Setting -IC-27> Filters Size 16X,?,Ok 1 Number Fan Setting 4 Chimney Location Inside Outside Pilot Type _ .S` s Chimney Construction L?// }5 P_ilot_Make - Pilot Model _ Pilot Timing L.W. Cut Off Pressure Percent CO2 Input CFH 75 Percent O y? 2 Stock Temp. yw Percent CO Form 235 Smoke Bomb -- WiringLll-? _ Draft -,IT- Test Tag Door Pressure Lighting Inst. L/ Date Tested ?-- 114- l4F 7 Company Testing 7 Inc c= / Ce& Name of Tester 2741-7- ?i,C?/r^?c?SIN'? HOUSE HEATING TEST RECORD / f/JJ//?,?,((,,// ADDRESS e-iT? /'/ APT?zz FLOOR/CITY-SUBURB OCCUPANT OWNER _/t'!i4-(/IJ CU?vG% HEAT LOSS DATE HTG. INST. SOLD BY v y INSTALLED BY U?'/-' Ll Electrical Wa.4 By ^( Gas Line By / 1c TYPE OF HEAT GA ?A HW STEAM-SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN MAKE MAKE OF BURNER _ Model 07k=f?1 CJI? Model Serial C- A1 ?!f) top P3 ?7 Max. BTU Rating INPUT MAKE OF FURNACE Model CONVE ONTROLS el / ?r ?e, THERMOS T ( Heat Plug Vent Size _1? d , Volvo JI-?G-?"t'.P _ KIND OF LINED US SIZE NONE Limit Draft Hood Regularor "??-.$ r3 Limit Setting -24,22 Filters Size ?INXJG,I/ Number Fan Setting /?2 0_,?2 Chimney Location Inside Outside a? , Pilot Type .? Chimney Construction ?z7 - - Pilot-Make--- Pil t M d el - - - l z /77J 5-- -- - - - - -- - - - o o e , Smoke Bomb - - - - - - Wiring Pilot Timing f Draft ?561•n? Test Tag t__? - -- - - - - - - L. W. Cut Off ? Door Pressure Lighting Inst. ( ? y( Pressure S 16 /.(JC Percent CO „ l-L Date Tested 16 -7 2 Input CFH Percent 02 - /lJ y Company Testing (??L(" o Stack F Temp. Percent CO d,CV Name of Tester Form 235 ADDRESS HOUSE HEATING TEST, ?RECORD7 ?/? r'? l AP T.??L FLOOR ? ? Cl TYdt?4 SUBURB OCCUPANT OWNER /'??/? HEAT LOSS ? DATE HTG. INST. 11-(6-7 SOLD BY C - INSTALLED BY Electrical Work By ,.. y t tlcle L?/GL Gas Line By TYPE OF HEAT GA _L? FA ? HW -STEAM SPACE HTR. -UNIT HT-R. -OTHER GA S DESIGN C NVERSION MAKE lC ffcZ-y? MAKE OF BURNER Model - ?? Model Serial / A/;i? /C29 ? 3r7 17 ? Max. BTU Rating INPUT 6z C1 c>ct9 MAKE OF FURNACE Model ?' ONTROLS THERMOSTAT ?- Hear at Plug ? Vent Size CAL o Valve Pn b&;eTs fda-c.? KIND OF LINE R?n'I-?Z24-;r2 J SIZE NONE Limit p Draft Hood /, /7- o?? Regulator Limit Setting -? Fan Setting 0'v Pilot Type S? Filters Size ?6Yr,-OX ( Numb err O Chimney Location Inside v Outside Chimney Construction 12 q Pilot Make A,?? ?? Pilot Model .SP715`A r?fX??? _ _ - _ - _ '_ - _ _ _ _ - - - _ _ -_ Smoke Bomb Wiring Pilot Timing -z-Sc-r Draft C? oo Test Tag L.W. Cut Off Door Pressure Lighting Inst. Pressure e? ?/? G= Input CFH 150 y Percent C02 yf ,& Date Tested Percent O2 42 5_?,• Company Testing OV, 12-) c-r Stack Temp. M fa / ?%c l?c?sc?rti Percent CO e,?2yam' Name of Tester Form 235 IIVVJL IILN 111\V ICJI RCL.VI[V ?/.? ADDRESS--e S APT?FLnOOR ?? ITY Xv- SUBURB OCCUPANT OWNER raMA-tA2 Go,vcT HEAT LOSS ATE HTG. INST. SOLD BY tr- /Ll'_-T_-/f INSTALLED BY ?o uSL? c-T. Electrical Work By X07: G Gas Line By TYPE OF HEAT GA 4?FA L--? HW STEAM SPACE HTR. UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE K('f"LZM MAKE OF BURNER Model R- 6,4 'a cIeC - <_ Model Serial ?' r?(• ?O (?+ ??g1 7R CG Max. BTU Rating INPUT MAKE OF FURNACE Model / „CONTROLS THERMOSTAT Heat Plug Valve Limit J vNrry?w?- Limit Setting Fan Setting ?cN O Pilot Type / Pilot Make Pilot Model .fP 1117 Pilot Timing S?"C L.W. Cut Off Vent Size 9 KIND OF LINER_ZZ Draft Hood V/? Filters Size-, Chimney Location Chimney Construction Pressure /J ?G Percent CO 2 Input CFH q? Percent 02 ?6 /moo Stack Temp. 777/-a Percent CO 6 3;y Form 235 CE S NONE mar 3 Smoke Bomb - Wiring- C/ - -- Draft le ? e-Y Test Tog Door Pressure Lighting Inst. Date Tested - - R Company Test nV _C` /IL?C Name of Tester ?7? ='???G7*/x? HOUSE HEATING TEST RECORD ADDRESS ?5`-30 f???"r: h=S ?r9'lC.?- ?? APT?Y_LOORIF a CITY ?/ SUBURB OCCUPANT OWNER HEAT LOSS DATE HTG. INST. _14 SOLD BY a/zoJSc 17'7 G F/ INSTALLED BY ip_,: c'- /y(C'C Electrical Work By Cl,Se- L?w>? Gas Line By /Z u5C- /ZZI-'G/y TYPE OF HEAT GA ?FA ? HW -STEAM SPACE HTR. UNIT HTR. -OTHER , ;J GAS DESIGN CONVERSION MAKE /t ?'?"LZ="7 MAKE OF BURNER Model a (? Doi - oyeT_ - C oe Model Serial &,A/ /3 D to (, F1187 7??15' Max. BTU Rating INPUT 60 LY 6) MAKE OF FURNACE Model CONTROLS ? THERMOS T Heat Plug Vent Sire Valve KIND OF LINER SIZE -" NONE Limit Draft Hood Regulator -jr,?'5`3 Limit Setting GO ° Filters Si,, ??nX2ox I Number I Fan Setting ? ?° oN f0 p Chimney Location Inside Outside Pilot Type Chimney Construction r?G?T?bGS 7?3 - Pilot Make ? ?- Pilot Model Smoke Bomb Wiring Pilot Timing Draft 4?"cz Test Tag L.W. Cut Off Door Pressure --Lighting Inst. Pressure ti ??GcIG Percent CO 1 r C? Date Tested IO i Input CFH SAS Percent O ci Str-' ,c-G Company Testing Stack Temp. Z Percent CO ??i Name of Tester Form 235 HOUSE CHEATING TEST RECORDy ?? p ADDRESS i FLOOR tL-CITY 1?Of(o?c?SUBURB OCCUPANT OWNER PnM Al ?o L?S7- HEAT LOSS DATE HTG. INST. / LE 7 SOLD BY ov C 1 INSTALLED BY tioJ 5L! 17-7h Electrical Work By - ?i!AZ Gos Line By _ F-o U % /r7G?G TYPE OF HEAT GA _?ZIFA -? HW STEAM -SPACE HTR. -UNIT HTR. OTHER GAS DESIGN C NVERSION MAKE SIG H'C-'L ?'? MAKE OF BURNER Model -C 2 Model Serial e/ /A/3D is & AW67 7s?9e Max. BTU Rating INPUT 7?t9oo MAKE OF FURNACE Model ???, ^CONTROLS THERMOSTAT Heat Plug Vent Size Valve ??oG L-?7J.?/1.4C/J KIND OF LINER-???? ??TuS SIZENONE Regulator 3?-5-- 3 Limit Setting Filters Size X30K/ Namber Fan Setting /3y O+? 7`'o OCr? Chimney Location Inside Outside Pilot Type_ Chimney Construction /'9ry?i9" ?G-S Tu S --Pilot Make- =U?u?% ffi1? -- - - -- --_---- --- 9 ------- - - - - ----- Pilot Model p ? 1 75-A Smoke Bomb Wiring Pilot Timing -2- Sr-?' Draft < ? C/ Test Tag L.W. Cut Off Door Pressure Lighting Inst. Pressure ,i L Percent CO2 ff? Date Tested X - Input CFH 5 Percent 02 z6 ym Company Testing Stock Temp. -? y0 Percent CO /-n 5,F, Name of Tester "y r • Form 235 _ HOUSE HEATING TEST RECORD ?J W ADDRESS ? yy/ / / = d ;? eAl APT, FLOOR CITY SUBURB OCCUPANT OWNER HEAT LOSS DATE HTG. IN ST. SOLD BY or-'max-' r /-/ INSTALLED BY Zvi,' /77,---Al Electrical Work By L1'C- Gas Line By USA /7 7,z-/-/ TYPE OF HEAT GA ? FA `?HW STEAM SPACE HTR. UNIT HTR. -OTHER ,,// GAS DESIGN kg,Z? CONVERSION MAKE MAKE OF BURNER Model P(e L7/9"'6/C"L r.? Model Serial l-_AIJ??CJ S! ?.36B7 ?3-(0 Max. BTU Rating - INPUT MAKE OF FURNACE Model y?? CONTROLS / THERMOSTA+?- Heat Plug - "-" Yant Size Valve ?Cd&L 7 _T 44u/ KIND OF LINER SIZE- NONE Limit Draft Hood 5v! N Regularor =''2$K' 3 Limit Setting 7yU? Filters Size 1Uk-z'OX / Number Fan Setting /30° o.? So a? ? Chimney Location Inside ? Outside -- Pilot Type -S?/Q?K- ---- - - - Chimney Construction- /77r%f?-??JGS?a-S = -- -Pilot-Make _-_ ?p 6c-=.2{S f,<aF' - - -- -- - --- --_ - - - - - - _ Pilot Model .5? Smoke Bomb ? ng Pilot Timing y?c'z Draft ?moc Test Tog L.W. Cut Off Door Pressure Lighting Inst. Pressure Percent CO 2 7A Date Tested _ Input CFH Percent 0 oaf G Company Testing .? d 1-77 2 Stack Temp. Percent CO d ym Q Name of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS i`S?PO H F^" sic Z-I'X` i Z/ APT,I019 FLOOR Cl TYr'JSUBURB OCCUPANT OWNER po 1A1, ) HEAT LOSS DATE HTG. INST. 11-C5_7_7 SOLD BY kcfU GS - iT7C-cN INSTALLED BY E?Sc" ?'(c-G/'/ Electrical Work By /?Fd L,/7L--e z ;ye- Cos Line By cISL ??? TYPE OF HEAT GA CFA ? HW-STEAM SPACE HTR. r UNIT HTR. -OTHER I GAS DESIGN L CONVERSION MAKE i 7 a MAKE OF BURNER Model (? , I-) A -oye,27 - Gye IC Model Serial / IJ&J)AL,V F-;'0Z2 „Z_?./ 3 Max. BTU Rating INPUT ?S MAKE OF FURNACE Model CONTROLS THERMOST?T Zrz'_. Heat Plug ?- Vent Size Valve 7-_!;A4L.- KIND OF LINER ?7 C7 v "Sr°f SIZE ?? NONE Limit Drafi Hood .,?/ a/t? -/3 Limit Setting Oc? Filters Si" ??X SOX / Number Fan Setting /3y ON J?"V O Chimney Location Inside ? Outside Pilot Type Chimney Construction z2 ?/ a Make= h[:C-/-3'fbfr-?- - -` - - ---- --Pilot - - - - - -- Pilot Model -SP71sly Smoke Bomb l ? Wiring y Pilot Timing--.:?- 5 r- Draft 4,_ eC/ Test Tag L.W. Cut Off Door Pressure -? Lighting 4nst. -? i/ Pressure d??? /-y G Percent C02 57' Date Tested _ . g Input CFH !!/S- Percent 02 ZC SY Company Testing de/jc? /TyCC-?? Stock Temp. Percent CO 6 70 Nome of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS ,`S ??O -:-->v Tr - T/ APT.. FLOOR ?3_?CITY SUBURB OCCUPANT OWNER L7n M.4lrx/ Goa Sr HEAT LOSS DATE HTG. INST. /I---I B SOLD BY 1-77,? INSTALLED BY USG' / Electrical Work By d0 R---f 4,C [ /rG Gas Line By UU 5i! cam! y TYPE OF HEAT GA ? FA -?HW STEAM SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE iC Ka'L'Z"I MAKE OF BURNER Model .l &t>4 -pSIGL ?C/? Model Serial ?/ jQy(oV 4111F7 71FRJR Mo.. BTU Rating INPUT VS, _bc? MAKE OF FURNACE Model CONTROL THERMOS T LP41 Heat Plug Vent Size 7 Volvo bG'.C% ?' ?¢c? KIND OF LINER SIZE ? NONE Limit ?c^?C'? /?c'? Draft Hood /7u /?7?o ti? Regulator 3'.2 5-- ?r Limit Setting yU Filters Size zi? X?kI Number Fan Setting 30 0: `? ?O c Chimney Location Inside ?f Outside Pilot Type' ` L Chimney Construction TT/G 9?ff 41L?T0 S ` vCo ?G %5/???- - _-- - Pilot Make -- - - - - - _ -- - - - - - Pilot - Model S 71?? Smoke Bomb - Wiring Pilot Timing SL= Draft _ C_ GC d Test Tag -? L.W. Cut Off -? Door Pressure Lighting Inst. Pressure 3 -r Ly-` Percent C02 7 sf Date Tested ' v Input CFH Percent 02 S Company Testing ^ !/ Stock Temp. Z.? Percent CO r ? ? Name of Taster / '[2Y??G71/SG??? Form 235 HOUSE HEATING TEST RECORD ADDRESS 775 ?fY ! APT /a FLOORI! CITY BURB OCCUPANT OWNER 4e? 11'I1611L-' e-"-5% HEAT LOSS ? DATE HTG. INST. SOLD BY l? .o?5L r/ '7 INSTALLED BY _ _?otlSG? L79LZ?I Electrical Work By 7-,-41 1Z r (/GNt l JwG Gas Line By ?wU Sc?' /7712/-1 TYPE OF HEAT GA -? FA`s HW STEAM-SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model _ /r a4 -o /CG -C1Z Model Serial 6n13Z>1U61 F11P1 29(G Max. BTU Rating INPUT Vr 2c:' MAKE OF FURNACE i Model .f /CONTROLS - s THERMOSTA T Heat Plug ? Vent Size 7 /O Volvo °b?TSG/ .vw KIND OF LINER /?7 <TA6?5roS SIZE S'r? NONE Limit .U c.?N`?ur-' / Draft Hood '5?d7? eti Regulator. a'S ?3 Limit Setting /fro Filters Size Number 1 Fan Setting /3? ?9n.1 y? 9`,4C Chimney Location Inside Outside Pilot Type fP'9'?? Chimney Construction "77,-- ?y ??CS Td S Pilot Make h.-T -? _ _ _ - __ _ _ _ _ _ _ _ Pilot Model SAf7/S'i4 Smoke Bomb " Wiring Pilot Timing -,.?- S""? _ Draft C. vmL1 Test Ta g L.W. Cut Off ' Door Pressure Lighting Inst. Pressure 3 j Lt/G Percent CO C4/ Dote Tested Z-7? -?' Input CFH 4/r Percent OZ ' 1O /'5 Company Testing Z° Sz' 7 c /ice Stack Temp. -?U Percent CO 67 'F1 Name of Tester Form 235 HOUSE HEATING TEST RECORD ADDRESS fTAPT_W_FLOOR.G-CITYI??SUBURB OCCUPANT OWNER ?4 ^+ A-i.?J Co-,.ITT HEAT LOSS DATE HTG. INST. /lB? SOLD BY t d INSTALLED BY yPC ?Sc I-r-7 c Electrical Work By aV.? 67u-c Gas Line By Ld NCe?- /77:c /-/ TYPE OF HEAT GA -I?'A =HW STEAM SPACE HTR. -UNIT HT-R. -OTHER ll ,, // GAS DESIGN CONVERSION MAKE EWC-C'>? MAKE OF BURNER Model Q(oD,4 -0V6--. -ce Model Serial Wg2 787 Max. BTU Rating INPUT MAKE OF FURNACE Model THERMOSTA Valve - Limit Limit Setting Fan Setting Pilot Type - Pilot Make _ Vent Sire 5- KIND OF LINER c c T SIZE NONE Draft Hood'?? O/? Regularor 3-R5- 3 Filters Size _AXtOX ( Number ( Chimney Location Inside yz?? Outside Chimney Construction ,Z7 / ?'¢'/ 7L, Pilot Model Smoke Bomb Wiring I Pilot Timing Draft <a°'a - Test Tao L.W. Cut Off Door Pressure Lighting Inst. Pressure Percent C02-7 Date Tested ?Z:7=' Input CFH 52/s ? Percent OZ Company Testing v G'? Stock Temp. .Percent CO d Name of Tester ????! c7/e?/Set?? Form 235 HOUSE HEATING TEST RECORD ADDRESS L1 ?d r9iiFS ZZAZ?- &/ APT.JL-)--FLOOR ?i CITY 'tSUBURB OCCUPANT OWNER "AAt?" HEAT LOSS ? DATE HTG. INST. f? -7 ? SOLD BY c _ INSTALLED BY -d v < 1-7 <z l D ?/ Electrical Work By /S.{ tom[ (//? G? T Gas Line By TYPE OF HEAT GA L-frA ?FIW STEAM SPACE HTR. -UNIT HTR. OTHER JJ?? GAS DESIGN ? CONVERSION ytt-r-?-? MAKE MAKE OF BURNER Model C_ DA -Ogfr--G(Z Model Serial 6.l D10( tcdo? 7g 7d Max. BTU Rating INPUT MAKE OF FURNACE Model ._? CONTROLS THERMOSTAT )R 204? Heat Plug / ?r Vent Si., _ Valve 1'0 L?L/ s/y;FtA_) KIND OF LINER M ?<<"S To3 SIZE NONE Limit " ywt"9? Draft Hood S?A/(/7dey Regulator Limit Setting / Filters SizeNumber 0 c, ? ro Fan Setting 13 Chimney Location Inside Outside ?p Qo Pilot Type Chimney Construction / hG's 7iJS Pilot Make /W - Pilot -Model Smoke Bomb Wiring Pilot Timing 7 Sri Draft G ooC/ Test Tog L.W. Cut Off Door Pressure Lighting Inst. Pressure ?i.3'?/?f.? L Percent CO `' Date Tested ??' - - rq Input CFHPercent 02 Z S9 Company Testing U U CL Stack Temp. -3f3? Percent CO /S: Name of Tester 1>7,1 Cflc Form 235 HOUSE HEATING TEST RECORD ADDRESS -gPT_U3_FL00R CITY SUBURB OCCUPANT OWNER HEAT LOSS I DATE HTG. INST. 7 } SOLD BY J G"G INSTALLED BY _ /aaC°US°? %?Tc'+? Electrical Work By -7,r Gas Line By __ A-lJuSc?Cl7?C TYPE OF HEAT GA -FA ?HW-STEAM SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN MAKE ? Ftr2 >"l MAKE OF BURNER _ Model "O - C2 Model Serial ,3 /O/o FfIB7 7,06Y C.A Max. BTU Rating - INPUT r- ,/ MAKE OF FURNACE ? Model CONTROLS THERMOS T Heat Plug Valve 4L e !a-7J_2?f<-? Limit o.?'t!f?uic? Limit Setting o° Fan Setting ?-3o nN ?O o Pilot Type Pilot Make - - - - - - - - Pilot Model- -5,e 7Z 4- Pilot Timing 2 5i2- L.W. Cut Off Pressure 1 C, Percent CO 2 Input CFH Percent 02 ? gs , Stack Temp. 3(o S Percent CO O iZ Farm 235 Vent Size C/r / /mss KIND OF LINER /°Id7riF LX-STr SIZE L57--`' NONE Draft Hood Regularor 'y _2J. '_'-3 Filters Size/ Number Chimney Location Inside Outside Chimney Construction Smoke Bomb Wiring y Draft _c T. st Tag L' Door Pressure Lighting Inst. ?f Date Tested -' Company Testing Name of Tester HOUSE HEATING TEST RECORD ADDRESS l4_:?,50 ,c--l rfl-S L.rrK r- APT_o?L FL00R? CITY 42 4?e"SUBURB OCCUPANT OWNER .?°'M?'/N CO'?S/ HEAT LOSS DATE HTG. INST. SOLD BY ,?s/e? i77i>/•/ INSTALLED BY JZ: ! c?L_ Electrical Work By Gas Line By ?,$r? CT. TYPE OF HEAT GA ?FA ?HW -STEAM-SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE ?L7c r'? MAKE OF BURNER Model Q.a GSIc-r--L se Model Serial GN3 niv-/G?vA7 /a- Max. BTU Rating INPUT MAKE OF FURNACE Model - / ? ,ONTROLS - THERMOSTAT Heat Plug Valve ?.., ?le-LTFL?Fc? Limit -ENG f'LLZ ?? Limit Setting /Y:;2- Fan Setting Pilot Type Pilot Make .6"-Zr Pilot Model ?SP-7Z57-i1 Pilot Timing LSD L L.W. Cut Off ,/ cr Vent Sire -Z 1/77°; s KIND OF LINER/?'? c°f6s SIZE -5t"" NONE Draft Hood ./3 /1y 1`9N Regularor ???`°? 3 Filters Size/?X't?X / Number Chimney Location Inside Outside Chimney Construction ?dr ro S Smoke Bomb Wiring r? Draft /?,;C/`- Test Tog f Door Pressure ?- Lighting Inst. Pressure Percent CO2 Date Tested 8 _ Input CFH 7 'S Percent 0 2 Lam' Company Testing c, SG'? Stack Temp ?'7? Percent CO Name of Tester Form 235 HOUSE HEATING TEST RECORD pc? ADDRESS L,-91ri f =APT--1-5-FLOOR? ? CITYA'h6,?A_`SUBURB OCCUPANT OWNER Ik,'),41AJ CCVU5/ ?r HEAT LOSS DATE HTG. INST../-G3 % 25' c c'YN SOLD BY 4 INSTALLED BY "- T ' _ ? Electrical Work By ZKZI z Gas Line By ,?•>uc?% 177,el-I TYPE OF HEAT GA ? FA I LHW STEAM -SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION Ln/A MAKE MAKE OF BURNER Model 1-104 - t9 C C G.r? Model Serial C D /G y .)C? Max. BTU Rating INPUT MAKE OF FURNACE Model .CONTROLS Heat eat Pl Plug THERMOAT - 7 /cam S Vent Si.. Ci [.:G/?ff.OceJ Valve KIND OF LINER /7rT,6?Sr3 SIZE NONE ' Limit A4 Draft Hood 130, (T owe Regularor ? 5 Limit Setting a Filters Si,, /Co Xd-Ok / Number Fan Setting l30 or? 20 0` Chimney Location Inside Outside Pilot Type Chimney Construction 7 ?223 Pilot Make -Pilot Model Smoke Bomb Wiring ? -- Pilot Timing Draft c, ? al Test Tag L.W. Cut Off Door Pressure Lighting Inst. Pressure Percent C0 Date Tested _ 2 Input CFH 3 Percent O 2 >,7 Company Testing ??OUSa-` /79a'Cl Stack Temp. -77J" Percent CO C9 ?/- Name of Tester Form 235 HOUSE HEATING TEST RECORD J _ ADDRESS PT ?FLOOR3 CITY SUBURB . - OCCUPANT OWNER HEAT LOSS DATE HTG. INST. 7 SOLD BY r 2 11? INSTALLED BY ?oU?f i -Cf Electrical Work By f? t l/c7z- L? (. -C Gas Line By _ OU 5 C /77GZ TYPE OF HEAT GA 'PA t::=-=H W-STEAM SPACE HTR. UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE t'1"tsL? i" I MAKE OF BURNER Model r;- C G - Gz Model Serial 7,FJ3 Max. BTU Rating INPUT MAKE OF FURNACE Model ?- ONTROLS ? V ? s THERMO AT Heat Plug Vent Size r Volvo 1T?,?gW T KIND OF LINER f N? / f SIZE ?- NONE Limit j?o?-/c'?/GtIC Draft Hood a Regula Tor-??? 3 Limit Setting Filters Size lGX3l7X /Number ?i? rp C, Fan Setting l 3?J Chimney Location Inside Outside ? ? p Pilot Type Chimney Construction ??7r'?i4 ?6c-S TcI> - ? oCc? Pilot Make /?n (7G/L-Ya` - - _ - - - - - - - - - - - - - - - _ _ '/S?EI Pilot Model 7 S r Smoke Bomb Wiring e - G Pilot Timing Draft - Test Tag L.W. Cut Off r Door Pressure Lighting Inst. G 7 j ° X Pressure / Percent CO2 Date Tested / - Input CFH Percent 02 ,4.? Company Testing Stack Temp. Percent CO ? Name of Tester !',? Form 235 HOUSE HEATING TEST RECORD ADDRESS /??rA P T. d[L F L 0 0 R.Ki_ CI TY{ SUBURB OCCUPANT OWNER aa3mtJ-lyo cem,57 HEAT LOSS -? DATE HTG. INST. /Z--97 SOLD BY ou G _ INSTALLED BY r, ?3c:? jz1.-Ct Electrical Work By - keyc-Ae !% C Gas Line By - kU US C' /?( N TYPE OF HEAT GA ??FA=HW-STEAM -SPACE HTR. -UNIT HTR. -OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model (2?(O Model Serial « /U 2ef ?2 ??-S-a- Max. BTU Rating INPUT MAKE OF FURNACE Model C-ONTROLS / ? S THERMOrT? AT Z4UZ'::: Heat Plug Vent Size rim ? Valve _lS.s GX-CTSff,.fCJ KIND OF' INER {77C? f%cl SIZE ?5'1' NONE Limit Draft Hood Regular,, 7r ?-?- 7 Limit Selling ° Filters Si z Number ?. Fan Setting ?-,T, Chimney Location Inside L/ Outside Pilot Type Chimney Construction ??l< T.4-/?JG"STv S Pilot Ma ket!.., _ Pilot Model _SP 7/ Smoke Bomb Wiring Pilot Timing Draft- G? Test Tag L.W. Cut Off Door Pressure Lighting Inst. P ?l WC P C 7 D T d ressure - ercent , O2 ate este Input CFH Percent 02/. Company Testing Stick Temp. -v.?? m Percent CO Name of Tester !77zfZ ? -lFYL7U'S?'rJ Farm 235 HOUSE /HEATING TEST RECORD ADDRESS / / APT V-t FLOORIff?CITY??? SUBURB OCCUPANT OWNER HEAT LOSS / DATE HTG. INST. 4Z P 7 SOLD BY - INSTALLED BY )?DUSU- fiJ.CCff Electrical Work By - La°J"-r Gas Line By ?suSC- /// TYPE OF HEAT GA ? FA --? HW -STEAM SPACE HTR. -UNIT HTR. OTHER GAS DESIGN CONVERSION MAKE MAKE OF BURNER Model 06 g-;4 -Ce Model Serial 6s/k1,3C>/OEi F,52VBZ 9T 4C ' Max. BTU Rating INPUT C,41 MAKE OF FURNACE Model CONTROLS l 7 THERMOSTA T le Heot Plug Vent Sire Valve +? P ?C T b F ? C ffclw KIND OF LINER ZZ; 1 7-'J SIZE ST NONE / Limit U ' , Draft Hood Regularor 3lf- 3 Limit Setting rZc-_?5° Filters Size aJ?;OOkl Number Fan Settin g ? / >? Chimney Location Inside `?? Outside Pilot Type Chimney Construction X' -711/-s21S - Pilot Make - ?GTe?iict?- _ - - - - - - - - - - - -- Pilot Model q S! Tl $"? Smoke Bomb Wiring I Pilot Timing Draft - Test Ta I g L W Cut Off Door Pressure -? Li hti Inst . . . g ng Pressure C- Percent CO2 Date Tested Input CFH Percent 02 mil-- Company Testing Stock Temp. Percent CO Nome of Tester Lc/'Tr .C Gt'?.'?J Form 235 HOUSE HEATING TEST RECORD A) ADDRESS PT.? FLOOR=CITY y? Co SUBURB OCCUPANT - OWNER DPM I/tJ cv v5 Z' HEAT LOSS r? DATE HTG. INST. //-87 SOLD BY . , ,5c- /GAZA( INSTALLED BY Electrical Work By _ J R r Pl ?L'Jf! C7-(c"C Gos Line By TYPE OF HEAT GA ?FA t , HW STEAM SPACE HTR. -UNIT HTR. - OTHER GAS DESIGN MAKE W11-5t _m MAKE OF BURNER _ Model ? LQA-07.tf 9 -C2 Model Serial l/?/•3Q/OB >?.7 ??b? Max. BTU Rating INPUT MAKE OF FURNACE ' CONTROLS THERMOSTAT Z87 Heat Plug Valve 2o2 ?/ 5%46y Limit ?cNC%% LtA?? Limit Setting Fan Setting Pilot Type ?As1.2` %?//TfiAcrJ _ Pilot Make -Pilot-Model 7P 7/S%¢ Pilot Timing ?-=5c l L.W. Cut Off Pressure Percent CO2 tc-`-f-rte Input CFH Percent O2 Stack Temp. yOn ° Percent CO Form 235 Model / ?r Vent Size Y CTO 6 KIND OF LINER - SIZE NONE Draft Hood u To.v Regal aror•?"?? 3 Filters Size Zl X?OX Number Chimney Location Inside " ?? Outside Chimney Construction Smoke Bomb Wiring Draft e'- Test Tag Door Lighting Inst. Date Tested 1-2 7 Company Testing ?Uy Name VERSION 1-o - -- 3 f_? l o c-. ?`p vv?as Lc eo't r,- 2004 COMMERCIAL BUILDING PERMIT APPLICATION City Of Eagan 3830 Pilot Knob Road, Eagan Mn 55122 Telephone # 651-675-5675 FAX # 651-675-5694 7? ?, c'g.a? • Structural Plans (2) sets • Architectural Plans • Civil Plans (2) • Structural Plans • Certificate of Survey (1) • Civil Plans • Code Analysis (1) •• • Landscaping Plans • Project Specs (1) • Code Analysis • Spec. Insp. & Testing Schedule • Certificate of Survey • Soils Report (1) • Spec. Insp. & Testing Schedule • Meter size must be established • Meter size must be established 1 • Project Specs 1 • Energy Calculations 1 • Electric Power & Lighting Form 1 • Master Exit Plan 1 • Emergency Response Site Plan 1 • Soils Report • SAC determination - call 651-602-1 000 • SAC determination - call 651-60 (2) sets • Architectural Plans (2) sets (2) • Code Analysis (1) " (2) • Project Specs (1) (2) • Key Plan (1) (1) " • Master Exit Plan (1) (1) • Energy Calculations (1) not always" (1) • Elec. Power & Lighting Form (1) not always" • Meter size must be established-if applicable (1) (1) 1 (1) 1 I 0 SAC determination-call 651-602-1000 MN Dent of Health at 651-215-0700 fnr detadc rroardino fond R hevernoe nr Indoino farilities ++ Contact Building Inspections for sample and if required when it states "not always". +++ Permit for new building or addition will not be processed without Emergency Response Site Plan. ?G O Date 3 / /a / 7 Construction Cost 50,C00 Site Address AS 3 o T4 a- s ?n rz c:. 1?d Unit/Ste # - Tenant Name T kav- s Z- ke- ?r Anfs Former Tenant Name Description of Work (>!s-? J?"? /2e-/bo 4 S f'..?-4 7e? To '1-7 4' ? 1 L fL?T' I, el? Property Owner Va n i i,..? 1 I'?t ...+ Telephone # ( ) //?J 1 4 < ? ? Contractor v •S7 • S Tc , r Address 8(9 Li go / / ? ?}7l ?< C ? < tJ G City State M ti zip SS// -9 Telephone # ((;- 7? ^00 70 Arch/Engr Registration # Address City State Zip Telephone # ( ) i Licensed plumber installing new sewerlwater ervice : Phone #: ?) I hereby apply for a Commercial Building 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 the State of MIS Statutes; I understand this is not a permit, but only an application for a permit, and work is not to start without l permit; that the work will be in accordance with the approved plan in the case of work which re ' s a review an( a val of plans. Applicant's Printed Name Applicant's Signature OFFICE USE ONLY Sub Types ? 01 Foundation C 14 Apartments ? 15 Lodging ? 25 Miscellaneous Work Types ? 31 New ? 32 Addition ? 33 Alteration ? 34 Replacement Valuation _lOa'p Census Code 5{ 3:7 SAC Units - Nbr. of Units Nbr. of Bldgs `- Type of Const ? 26 Public Facility ? 27 Commercial/Industrial ? 28 Greenhouse ? 29 Antennae 30 Accessory Building 32 Ext Alt-Apartments C 34 Ext Alt-Commercial C 35 Ext Alt-Public Facility C 37 Nail Salon ? 35 Int Improvement ? 38 Demolish (Interior) ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 37 Demolish (Bldg)' El,?'46 Reroof 'Demolition (Entire Bldg only) - Give PCA handout to applicant 0-9 Occupancy Zoning Stories Sq. Ft. Length Width Required Inspections Footings (new bldg) Footings (deck) Footings (addition) _ Foundation Drain Tile f Roof L/Ice Pr _ Decking Insul Framing Fireplace - R.I. _ Air Test - Final Approved By: Base Fee Surcharge Plan Review MCES SAC City SAC Water Supply & Storage SAN Permit S/W Surcharge Treatment Plant Park Dedication Trails Dedication Water Quality Copies Other Total MCES System City Water Booster Pump PRV Fire Sprinklered ? 44 Siding ? 45 Fire Repair ? 46 Windows/Doors _ Insulation _ Final/C.O. _? Final/No C.O. Other Final - Pool _ Ftgs _ Air/Gas Tests - Final - Siding _ Stucco _ Stone Windows Planning 12 z Building Inspector 4 & 6 q. as 1986 BUILDING PERMIT APPLICATION - CITY OF EAGAN NOTE: ALL CONTRACTORS MUST BE LICENSED WITH THE CITY OF,EAGAN SINGLE FAMILY DWELLINGS INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS MULTIPLE DWELLINGS - RESIDENTIAL INCLUDE 2 SETS OF PLANS, CER 1 SET OF ENERGY CALCULATIONS COMMERCIAL RENTAL UNITS FOR SALE UNITS OF SURVEY - CHECK WITH BLDG. DEPT., INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS, 1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS, $2,000 LANDSCAPE BOND To Be Used For: ?1JDY.( . Valuation: Site Address 1530 THCM Lam. Fcl T Lot 3 Block Parcel/Sub 'T? - ?-K , ?nnUlhtl Owner M " qduunM /HsC r L,P Address 3t4o /7a?bu2 Cati,c City/Zip Code ?u» ,n ?„l frlh . S?YU/ T- Phone LL Contractor Address 31 yU W-A,& v (a,,,L City/Zip Code F l.n,m.? , //h - tiZyS// -r Phone (0( a - ?S$`7- ( -71 ( Arch. /Engr. \Ulnntin - ?tif I4(fL,- ?ovFh ?n Address ,? ?ti/° t .e (gel c ar. 1 /?,, N r City/Zip Code c ? Phone # ( )5-(-,, 117 Date: Erect ? Occupancy Remodel Repair Addition Move Demolish Int.Impr. Install Zoning Type of Const 1! of Stories Length Depth Sq Ft APPROVALS FEES Assessments Permit Water/Sewer Surcharge Police Plan Review Fire SAC Engr Water Conn Planner Water Meter Council Road Unit Bldg Off Treatment Pl APC Parks Variance Copies TOTAL 15, r- NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR /HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED. 13o 3 1986 BUILDING PERMIT APPLICATION - CITY OF EAGAN NOTE: ALL CONTRACTORS MUST BE LICENSED WITH THE CITY OF EAGAN SINGLE FAMILY DWELLINGS INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS MULTIPLE DWELLINGS - RESIDENTIAL INCLUDE 2 SETS OF PLANS, CER' 1 SET OF ENERGY CALCULATIONS COMMERCIAL RENTAL UNITS 60 FOR SALE UNITS OF SURVEY - CHECK WITH BLDG. DEPT., INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS, 1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS, $2,000 LANDSCAPE BOND / 6c) Jd? To Be Used For: APT, B?(-7 C Valuation: $ 1,725,000 Date: 11/18/86 Site Address 1530 Thomas Lake Pointe Lot 3 Block 1 Parcel/Sub TNomp s LALE PaN Tr-- Owner Thomas Lake Housins; Associat Address 3140 Harbor Lane City/Zip Code Minneapolis. MN 55441 Phone -(612) 559-1711 Contractor Domain Constructors Inc. Address 3140 Harbor Lane City/Zip Code Minneapolis, MN 55441 Phone (612) 559-1711 Arch./Engr. Johnson, Sheldon & Sorensen Address 10249 Yellow Circle Drive City/Zip Code Minnetonka, MN 55343 Phone # (612) 935-6337 Erect V Occupancy 7Z•I /B -I Remodel Zoning PC) Repair Type of Const YIHR. I.A Addition U of Stories 3 Move Length "5 Demolish Depth Co] Int.Impr. Sq Ft 10,000 Install APPROVALS FEES Assessments Permit 4 q 5.? Water/Sewer Surcharge 1q o. Police Plan Review Z 1. Fire SAC 28.0&0. Engr Water Conn 24,000. Planner Water Meter h1/q Council Road Unit 13.9 z0, Bldg Off/ - Treatment P1 APC Parks N/R Variance Copies TOTAL g?t 36. S C S PRt NK, NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR /HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED. ' PCt2M ? T loo,c?oo 4 3 3 I,b251 ooo I?zS Y- Z.5 - 4oco Z. 4 49 5, 5° 4495.s SUKG(-I?ey? 5Uo 1- (. o0o ¢ Y- 1zS,too _ X90 750 PLAN ?cu??? 4195. .2 = ZZ4-7.7s ZZ47.'E Sac 4CflC> x (o I*= 'L.S,O&o ZB,cx? o 4c)o x eo 2q,?o v-,o u/A ?o?o uu? i 23-L x co o = l3? ZO 1 '?5, I zo . -rpG 12 S x Co co Z S I!a ZS + ? PPD'L. FOe- GlPF WA-S}4 53 'l CITY OF EAGAN APPLICATION FOR PERMIT SEWER AND/OR WATER CONNECTION *#x##x##xxxxxxxx#xxxxxx#x###x######xt * * !RUTS': PAYMFNT OF FTE AT TIME OF *f APPLICATION DOES NOT CONSTITUTE APPROVAL OF PERMIT. rt * * INSPECTION OF SEWER AND/OR WATER msTALLATIONs WILL NOT BE scH D- III UNTIL PERMIT HAS BEEN * rt APPROVED. rt rt rt rt P ease Print) ^- ^^ • 1) PROPERTY ADDRESS: LEGAL DESCRIPTION: ..- (Lot/Block/Subdivision or Tax Parcel ID ) IF EXISTING STRUCTURE, DATE OF ORIGINAL BUILDING PERMIT ISSUANCE: ' PRESENT ZONING/PROPOSED USE: (Mon Year) 0 COMMERCIAL/RETAIL/OFFICE R-1 SINGLE'FAMILY F7 INDUSTRIAL R-2 DUPLEX (Two Units) INSTITUTIONAL/GOVERPA= ? R-3 TOWNHOUSE (Three + Units ) ( Units) g;-F-4 APARTMENT/CONDOMINIUM ( <5_0, Units) 2) NAME: ADDRESS: CITY, STATE, ZIP: PHONE: • 3) u c s•?: / ?7? For City Use ?? SS Plumbers License: ADDRESS: C o - c / Active i CITY, STATE, ZIP ??fq rT 4 7 Expired Not recorded PHONE:-:2-7 O f ?,UG MASTER LICENSE# ? e Staff In i ti'al 4) •.. • a• NAME: ADDRESS: CITY, STATE, ZIP: PHONE: CONNECTION TO CITY SEWER CONNE Q CTION To CITY WATER ? OTHER 6) • r PLEASE HOLD APPROVED PERMIT FOR PICK-UP BY ONE OF ABOVE -'-' - - PLEASE MAIL APPROVED PERMIT TO 1, 2, 3, 4, ABOVE ' (Circle one) / ? FOR CITY USE ONLY PERMIT # ISSUED Pd w/Bldg. Permit S FEES: c SEWER PERMIT (INCLUDE SURCHARGE) WATER PERMIT (INCLUDE SURCHARGE) WATER METER/COPPERHORN/OUTSIDE READER WATER TAP (INCLUDE CORPORATION STOP) $ $ SEWER TAP $ $ ACCOUNT DEPOSIT - SEWER $ $ ACCOUNT DEPOSIT - WATER 1$ -? (/, (?1J7J • O 6 $ WAC QO M J . /i G: G • 0-Z) $ SAC $ $ TRUNK WATER ASSESSMENT $ $ TRUNK SEWER ASSESSMENT $ $ LATERAL BENEFIT/TRUNK SEWER $ $ LATERAL BENEFIT/TRUNK WATER $° 76 z C-,d 2D $ WATER TREATMENT PLANT SURCHARGE $ $ OTHER: $ / j s- -0--o $ TOTAL - 61S -733z P RECEIPT RECEIPT DOES UTILITY CONNEC TION REQUIRE EXCAVATION IN PUBLIC RIGHT OF WAY? YES IF YES, THEN A " PERMIT FOR WORK WITHIN PUBLIC ROADWAY" MUST BE ISSUED BY THE ENGINEERING NO DIVISION. LIST AS A CONDITION. SUBJECT TO THE FOLL OWING CONDITIONS: APPROVED BY: TITLE: DATE : 57 / / -t CITY OF EAGAN APPLICATION FOR PERMIT SEWER AND/OR WATER CONNECTION NOTS: PAYMENT OF FEE AT TIME OF APPLICATION DOES NOT CONSTITUTE APPROVAL OF PERMIT. INSPECTION OF SEWER AND/OR WATER INSTATS.ATIONS WILL NOT BE SCHED- ULED UNTIL PERMIT HAS BEEN APPROVED. -xxxx+++*+xx+xx++++xxxxxxx+++x+++xx, (Please Print 1) PROPERTY ADDRESS: 45-30 T/((? ""-G- LEGAL DESCRIPTION: ,3 V] IF EXISTING STRUCTURE, DATE OF ORIGINAL BUILDING2 PERMIT ISSUANCE- PRESENT ZONING/PROPOSED LSE: ( 0 COMMERCIAL/RETAIL/OFFICE ,ru IN DuSTRI-D.L INSTITLTIONAL/GOVERN ENT O R-1 SINGLE FAMILY CC1 R-2 DUPLEX (Two Units) 0 R-3 TOWNHOUSE (Three + Units) R-4 APARTMENT/CONDOMINIUM Units) 2) - - - NAME: ??dICO?Y) IT/C /? CGS ADDRESS: !s? CGr?? ?? CITY, STATE, ZIP:_ ?dQ?t!?'//?L.? PHONE: 3) NAME. / For City Use Pluun s License: . 2V ADDRESS: /S 9 Active CITY, STATE, ZIP: , / Expired /V C', 33) Not recorded PHONE: MASTER LICENSE# /4 Staff Inltlal .J' 4) • '64k 61 U71 I • is NAME: ADDRESS: "0 YP CITY, STATE, ZIP: PHONE:y Ct v CONNECTION TO'CITY SEWER] CONNECTION TO CITY WATER OTHER 6) • PLEASE HOLD APPROVED PERMIT FOR PICK-UP BY ONE OF ABOVE - PLEASE %V. APPROVID PERMIT TO 1. 2.(? 4. ABOVE , ?i.etl//) (Circle one) FOR CITY USE ONLY PERMIT # ISSUED , Pd w/Bldg. Permit FEES: $ $ SEWER PERMIT (INCLUDE SURCHARGE) $ $ WATER PERMIT (INCLUDE SURCHARGE) $ $ WATER METER/COPPERHORN/OUTSIDE READER $ $ WATER TAP (INCLUDE CORPORATION STOP) $ $ SEWER TAP $ $ ACCOUNT DEPOSIT - SEWER J $ ACCOUNT DEPOSIT - WATER I V Ull $ '/ U/17) $ WAC C??' 6 i!) /;/)•/) D $ SAC T' I $ $ TRUNK WATER ASSESSMENT $ TRUNK SEWER ASSESSMENT $ $ LATERAL BENEFIT/TRUNK SEWER $ $ LATERAL BENEFIT/TRUNK WATER aa CID // ^ r ?l?% T 7 '/} D $ WATER TREATMENT PLANT SURCHARGE $ $ OTHER: $ 5 / . 0 G' $ C ti TOTAL V7 RECEIPT RECEIPT DOES UTILITY CONNEC TION REQUIRE EXCA VATION IN PUBLIC RIGHT OF WAY? YES 'IF YES, THEN A " PERMIT FOR WORK WITHIN PUBLIC ROADWAY" MUST BE ISSUED BY THE ENGINEERING Q NO DIVISION. LIST AS A CONDITION. SUBJECT TO THE FOLL OWING CONDITIONS: APPROVED BY: AJ TITLE: ?j DATE : ([ / /? 0 /0 , 19113 1991 BUILDING PERMIT APPLICATION CITY OF EAGAN SINGLE FAMILY DWELLINGS MULTIPLE DWELLINGS i . ! COMMERCIAL 2 SETS OF PLANS 2 SETS OF PLANS 2 SETS OF ARCHITECTURAL 3 REGISTERED SITE SURVEYS REGISTERED SITE SURVEYS - & STRUCTURAL PLANS 1 SET OF ENERGY CALCULATIONS (CHECK WITH BLDG. DEPT.) 1 SET OF SPECIFICATIONS 1 SET OF ENERGY CALCU LATIONS 1 SET OF ENERGY CALCS _# OF RENTAL UNITS # OF FOR SALE UNITS PENALTY APPLIES WHEN: TYPING OF P ERMIT IS REQUESTED, BUT NOT PICKED UP BY LAST WORKING DAY OF MONTH IN WHICH REQUEST IS MADE. LOT CHANGE IS REQUESTED ONCE PERMIT IS ISSUED. NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED. PROCESSING TIME FOR SEWER & WATER PERMITS IS TWO DAYS ONCE A PERMIT HAS BEEN COMPLETED. PERMIT MUST SHOW A LICENSED PLUMBER. 1-3 To Be Used For: Valuation: 00. Date Site Address Lot Block Parcel/Sub f IfT7nfili//Llkl' 'lH t7 Owner /?D ?/X sh- A 6 ? Address 4'e City/Zip Code Phone ,M.c ?,. Contractor A4 h e Address City/Zip Code Phone Arch./Engr. /Voo, e Address City/Zip Code Phone # OFFICE USE ONLY Occupancy W_/' ""'L Zoning Q- L/ Actual Const 2 F/Z Allowable # of stories Length Depth S.F. Total Footprint S.F. On site sewage_ On site well _ MWCC System _ City water _ PRV Booster Pump APPROVALS Plhnner Council Bldg. Off. V' L715:9, Variance FEES ?J " Bldg. Permit J? Surcharge Plan Review SAC, City SAC, MWCC Water Conn. Water Meter Acct. Deposit S/w Permit S/W Surcharge Treatment Pl. Road Unit Park Ded. Trail Ded. Copies L) SUBTOTAL Penalty Lot Change TOTAL t7 D eze? ?J PZi&Q! /211:n=? agrees that all work shall be done in accordance with (Signature of Co ractor) all applicable State of Minnesota Statutes and City of Eagan Ordinances. 1993 PLUMBING PERMIT (COMMERCIAL) CITY OF EAGAN 3830 PILOT KNOB RD EAGAN MN S5122 (612) 6814675 PLEASE COMPLETE FOR ALL COMMIERCIAUINDUSTRIAL BUILDINGS. ALSO FOR MULTI- FAMILY BUILDINGS WHEN SEPARATE PERMITS ARE NOT REQUIRED FOR EACH DWELLING UN-:T. NEW CONSTRUCTION ADD ON _Yr REPAIR `` I 1 I / WORK DESCRIPTION: CONTRACT PRICE: $ / 7 /mss FEE: 1% OF CONTRACT FEE. STATE criRCUeRGE- c,50 FOR FkCH S1,0000 OF RFRJbI" FEE, MINIMUM FEE: $ 25.00 CONTRACT PRICE X I% $ STATE SURCHARGE $ O?ck ^//?0?5 TOTAL $ 10 4 J, 6.55 SITE ADDRESS: LJq, Pro TENANT OWNER NAME: INSTALLER: STE. # ADDRESS:: //C 7 -5Z CITY: / 1_11J2 e K,/7zre STATE: ZIP CODE: s S 3 /? PHONE #: 3j3 '?3? 1 FOR: CITY OF EAGAN 73- PLEASE COMPLETE FOR SINGLE FAMILY DWELLINGS. ALSO, FOR TOWNHOMES AND CONDOS WHEN PERMITS ARE REQUIRED FOR EACH UNIT. NO. FIXTURES EACH TOTAL SHOWER 3.00 WATER CLOSET 3.00 BATH TUB 3.00 LAVATORY 3.00 KITCHEN SINK 3.00 LAUNDRY TRAY 3.00 HOT TUB/SPA 3.00 WATER HEATER 3.00 FLOOR DRAIN 3.00 GAS PIPING OUTLET • minimum - 1 3.00 ROUGH OPENINGS 1.50 WATER SOFTENER 5.00 PRIVATE DISP. • DeLCty. ht. 15.00 U.G. SPRINKLER • home under caret. 3.00 ALTERATIONS • to existing 15.00 WATER TURN AROUND 15.00 STATE SURCHARGE .50 TOTAL: SITE ADDRESS: OWNER NAME: INSTALLER: ADDRESS: CITY: STATE: ZIP CODE: PHONE #: ( ) SIGNATURE OF PERMITTEE 1993 PLUMBING PERMIT (RESIDENI7AL) CITY OF EAGAN 3830 PILOT KNOB RD EAGAN MN 55122 (612) 6814675 DoT 3 BIk THOMAS -AKE Po,N CONTRACTOR'S MATERIAL & TEST CERTIFICATE PART "A" GENERAL PROCEDURE UPON COMPLETION OF WORN. INSPECTION AND TESTS SHALL OE MADE BY 7HE CONTRACTOR '5 REPRESENTATIVE AND WITNESSED BY AN OWNER'S REPRESENTATIVE. ALL DEFECTS SHALL BE CORRECTED AND SYSTEM LEFT IN SERVICE BEFORE CONTRACTOR'S MEN FINALLY LEAVE THE 100. A CERTIFICATE SHALL BE FILLED OUT AND SIGNED BY BOTH REPRESENTATIVES. COPIES SHALL BE PREPARED FOR APPROVING AUTHORITIES. OWNERS AND CONTRAC- TOR. IT IS UNDERSTOOD THE OWNERS REPRESENTATIVE'S SIGNATURE IN NO WAY PREIUDICES-ANY CLAIM AGAINST CONTRACTOR FOR FAULTY MATERIAL. POOR WORKMANSHIP. OR FAILURE TO COMPLY WITH APPROVING AUTHORITY'S REOUIREMBNTS OR LOCAL ORDINANCES. YNUFMHIY NAME DATB 1NamNc 1K? Al 6 P ; ?c?C \ 1i1?y/ _ vaovearr ADOaess 1530 Z660m '_ gri A.l ACCEPTED B APPROVING AUTHORIYI'$1 LJAMeE airyav IRILJ } ( pp? //R 4!-Cy? S,C S• J,V. L' O?I?? lii1?Y ilJr"i ADDRESS - b oeE-<?C b sC, .. ,-F ?'??D P, LOT ???? bd3 PLANS A4o A ,n1 t I L 1 tACiv vtf oouf (!1 i"'J?1) S S 3 All INSTALLATION CONFORMS T ACCEPTED PLANS Yxs NO EQUIPMENT USED IS APPROVED was m./ No IE NO. STATE DEVIATIONS HAS PERSON IN CHARGE OP FIRE EOUIPMeNr BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES AND CARE OF 'THIS NEW EQUIPMENT? YLS NO IF NO. EXPLAIN INSTRUC. TIONS HAS A COPY OF INSTRURION AND MAIN?ENANCe CHART BEEN LEFT AT PLANT? YLP F? No O IF NO. EXPLAIN rI.I'SIII\U flaw be required .it, 111111I eater k clear nN Indicated by no collection of foreign material In burlap bags at ..it." Ouseh as > raid. an Llow-ofM Plush .u flaw. sal le.. INau on GI•dl for 0-Inch due and anmller, 1000 GPM for B-Inch plpe, 1000 GPM for 10-Inch pipe, and 1000 GPM for U1- la, 1, 14a. Whep x.,J, ?,.I n•,I pioduce Mlpal.ited flaw rate., obtain maximum available. TEST HYDROST'AT'IC H,4roatntlc teals rhall be innd• d sat lea. than IN PSI for two hour. or SO PEI above MJUIC prepurc In exeese of 100 PSI. Differrnual dq-pipe %Rhe uhlppein shall he left ,pen during test le Prevent damage. All ahovaground Plot., leakage hall W Mopped. DESCRDT- LPANA(:Ib Sew pipe Iald with rubber g.I.k1,d)o1nl -.01. If the wurknn run p is xx tul.Et.a,. have little or No feelings at the )o1nM. The udml of !Y.ik.me al the Juwla shall nut exceed : pu.ol. Per hour Per 100 Joint. IrreeluvtlcelY of pipe diameter. Th. Irtkn. shall be dle- Iribuled . ill Jaime. If suvh leeingle x • cure at a few Joint. the Installation hall be ...Idarsd uestttbhte0oq and nec.eolrT lelwil. e TION IIutd, \rw pipe Iald with hulked lead orlead-aobntitule 1 Inlx shall. It the evorkm.InahlP I. satlxfaet Sy, have little or no leakage at the Jump An> pant hiomg leakage it nmle Ih, l a "Might dl lli' ur "weruing" shall he reWilied. Twnkaro shall not e.viced 1 os (liquid Ie ore) per ham per inch of pipe diameter per N.int The leakage hall W distributed ocar all Jolnla If much leakage oadm..diuuaeu- tlreH at .1 few Julnm, the Installation .hall be considered ut-illxbutnrp +md necessary repels made. PNE. 31ATIO: Glabll.h e0 PSI ui, is, ..or. and measure drop which shall not exceed IM PEI In Ee hours. Test Pressure Lanka at named water Iete) and air pressure and measure air pressure drop which ahn11 not exceed 1H MI In S/ hour.. PART "B" - UNDERGROUND PIPING Ur •?iu„S PeEDS BLDGS. LOCATION PIPE TYPES AND CUSS TYPE JOINT UNDER- GROUND CONFORMS TO STANDARD Vag O No O IF NO. EXPLAIN PIPES AND DINTS NEEDING ANCHORAGE LUMPED. STRAPPED Oa BACKED IN via No O O A CCORDANCE WITH STANDARD JOINTS IF NO. EXPLAIN TESTS REQUIRED FLUSHING - HYDROSTATIC LEAKAGE NEW UNDERGROUND PIPING FLUSHED ACCDR TO STANDARD V" O BY (COMPANY) HOW FLUSHING FLOW WAS OBTAIN PUILIC WaT TAN[ Og RBtgkYO1R O Ilp FOYP O THROUGH WHAT TYPE 05 ING, FLUSHING HYM Start, create Fin LLAD-INS FLUSHED ACCORDING TO STANDARD Via O TESTS BY (c:OMANY) H FLUSHING FLOW WAS OBTAINED. PUBIC WATM O TAN[ Ox R[ .O1N rJ Fin PDMP O ' THROUGH N•HAT TYPE OPWING Y CONN. TO FLANCK A SPIGOT I] pRN rn O Peas IN. 45 Faxed M U.S.A. C" HYDROSTATIC MR umme TOTAL AMOUNT OF LEAKAGE MEASURED LEAKAGE - GALS'+• HOURS TEST ALLOWABLELEAKAGE ------ GALS. HOURS ' NUMBER INSTALLED TYPE AN B HYDRANTS I ALL OPERATE SATISPACfORILY Yy 0 ND 0 SONVES LEFT WIDE OPEN. rU 0 NO0 F NOR A ER E CONTROL I ST T A R VALVES HOSE THREADS OF FIRE DEPARTMENT CON IONS AND HYDRANTS INTERCHANGEABLE WITH TH OF PIKE DEPARTMENT ANSWERING ALARMt Y{{ ? ND 0 DATE LEFT IN SERVICE REMARKS PARTS A k B NAME OF SP LLR CONTRACTOR MR PROPERTY OWNER ISIGNED) TITLE SPRINKLER CONTRACTOR (SIGNED) DATE SIGNATURES ! TCSTS WITNESSED BY TITLE DATE PART "C" - SPRINKLER k WATER SPRAY ABOVEGROUND PIPING (FILL OUT SEPARATE PART "C" FOR EACH RISER) - SERVES BLDGS.: LOCATION TESTS HYDROSTATIC ALL PIPING It 1 PNEUMATIC: DRY PIPING. DRAIN: REQUIRED EQUIPMENT OPERATION: ALL. 1 - - -' ----MAKE MODEL SIZF. QUANTITY TEMPERATURE RIINSPRINKLERS OR C? b I I - -. . CNFI•JhL 1T• SPRAY ? •, r i3'I SLItL?ii ?( _ -- . .- NOZZLES J /f PIPE AND MATERIAL AND KIND CONFORMS TO Fn2_.?-STANDARD --' IF NONE. EXPLAIN FITTINGS A L A R M D E V I C E MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE - OR FLOW TYPE MAKF. MOl1EL MIN. INDICATOR ils"- !OPERATING TEST RESULTS: DRY MAKE MODEL SER. ?- l'I TO TRIP 1 TRIP TIIROU OUCH TEST PIPE WATER AIR ! POINT TIME WATER ALARM NO. _ _ - I I PpF.55. AIR WITHOUT WITH PRESS. REACHED TEST OPERA'I'f:D PIPE Q. 0. D. Q. 0. D. I PRESS, OUTLET PROPERLY MIN. SEC. MIN. - `y SEG P.S.I. P.S.I. P.S.I. MIN. SEC. YES NO VALVES IF NO. LAIN OPERATION. TncuM ATI[ ? {L[[n?c O RrlnAUUC p PIPING SUPERVISED: Yn 0 No 0 DETECTING MEDIA SUPERVISED. YES 0 NO 0 DELUGE DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS? Ty 0 No 0 } IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT POO TESTINGt Ty 0 No 0 IF NO. EXPLAIN PPERCTION VALVES DOES EACH CIRCUIT OPERATH DOES EACH CIRCUIT OPERATE MAXIMUM TIME TO MAKE MODEL SUPERVISION LOU ALARM) VALVE RELEASE? OPERATE RELE/S& YES NO YES NO MIN. SEC. ALL PIPING HYDROSTATICALLY TESTED AT ._7 U C? PSI MR 7 HOURS DRY PIPING PNEUMATICALLY TESTED: ry 0 No 0 TESTS EQUIPMENT OPERATES PROPERLY: ry 0 NO 0 IF NO. STATE REASON • DRAIN TEST: READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE. RESIDUAL PRESSURE WITH VALVE IN TEST PIPE OPEN WIUE STATIC PRESSURE PSI -7 PSI NUMBER USED LOCATIONS NUMBER REMOVED BLANK SIL/o 4_) TESTING WELDED OR BRAZED P[PI?IO Yy 0 NO Er IP YER. TO YOU CERTIFY AR THE. NPRINKL.F.R M\TRAOTOR THAT THE. WEI.DP.HE OR RRAZERS ARE QUALIFIED POR WMn- GASKETS INO OR RRAZISU IN ACCORDANCE WITH THE. RE UIREMENTS OF ANNE BOILER AND 1'RFASURE VESSEL MDE, RECTION IN, F IO 1ANDARD FOR WELDING AND H AMINO PROCEDURES, WELDERS, BRAZERE, AND WELDING AND BRAZING VC I BP LAMAS Yes 0 NO 0 DATE LEPT IN SERVICE WITH ALL CONTROL VALVES OPEN. REMARKS (I-24- ? NAME OF SPRINKLER CONTRACTOR POA P PC WNER ( NE PART "C" U •U l AC A, ' ,-. ! -' SIGNATURES MR SPRINKLER CONTRACTOR 4SIONED1 - I TESTS WITNESSED BY ` TIRE ( DATE LOT,3, BLOCK I, THOMAS LAKE POINTE MEMO TO: TOM COLBERT, DIRECTOR OF PUBLIC WORKS JIM STURM, PLANNING DEPARTMENT BILL AKINS, ELECTRICAL INSPECTOR CRAIG KNUDSEN, ENGINEERING TECH FROM: DOUG REID, BUILDING INSPECTIONS DEPT DATE: DECEMBER 11, 1987 The Protective Inspections Department will be performing a final inspection for occupancy of 1500 - 1540 THOMAS LAKE POINTE on 19(1,9/,97 Please return within 48 hours with your approval or denial. Failure of response within that time frame will be determined as approval. It will be each departments responsibility to contact the construction firm with necessary requirements before final inspection and notifying the Building Inspections Department when all requirements have been taken care of. Thank-you. DR/js APPROVAL: 10ti,4E7 DENIAL: SIGNATURE & DATE) (SIGNATURE & DATE) C Ce For Office Use f r� (Jr IQ O tf� Ø !kØ - Permit#: -„ E AG N �A� Permit Fee: 1.Y' 1 0 2020 3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810 Date Received: (651)675-5675 I TDD: (651)454-8535 I FAX: (651)675-5694 Staff: buildinginsoectionsecitvofeaoan.com CROSS CONNECTION CONTROL PROGRAM INSPECTIONS --jos* 9p� GAS 33 PERMIT APPLICATION Date: 3/10/2020 Site Address: 1530 Thomas Pointe LII Eagan, MN 55122 Tenant: THomas Lake Pointe Apartments Suite#: Property Owner Name: Nationwide Housing Corporation Phone: 763-512-7720 Name: Jayhawk Mechanical Inc License#: PC644834 Contractor Address: 3307 N 2nd St Minneapolis MN 55412 City: State: Zip. Phone: 612-522-3499 Email: jlee@jayhawkmechanical.com New '/ Replacement _Repair _Rebuild Type of Work Description of work: Replace backflow device with new RPZ. COMMERCIAL Irrigation System( yes/ no)('/RPZ/ PVB) Permit Type • Rain sensors required on irrigation systems • Avg.GPM (2"turbo required unless smaller size allowed by Public Works) Avg.GPM High demand devices?_Yes_No Flushometers_Yes_No Permit Fee $60.00 You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update on the City's website at www.cityofeauan.com/subscribe. 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 penniVFai,1bezwork will be in accordance with the approved plan in the case of work which requires a review and approval of plans. x ✓�v Applicant's Printed Name Applicant's 5�g ature