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1220 Town Centre DrCity of Eapu 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax_ (651) 675-5694 Use BLUE or BLACK Ink For Office UsE Permit#: Permit Fee: 6 Cj - o Date Received: aft: 2011 COMMERCIAL PLUMBING PER T APPLICATION Date: 5/25/2011 Site Address: 1220 TOWN CENTRE DRIVE Tenant: DAKOTA COUNTY CDA / O'LEARY MANOR Suite PROPERTY OWNER Marne: DAKOTA COUNTY CDA Phone (651)675-4500 CONTRACTOR Name: RVP License #: 065956 -PM Address: P.O B. 40145 City: ST. PAUL State: MN zip: 55104 Phone: (651)233-3519 Email: JAMESVINZANT@YAHOO.COM TYPE OF WORK New Replacement Repair X Rebuild Modify Space Work in R.O,W, _ _ £?escription ofwor#c• PERMIT TYPE COMMERCIAL New Construction Modify Space _ —_-... Irrigation System (_.__., yes / __, no) C_.__ RPZ I Rain sensors required on irrigation systems Avg. GPM (2" turbo required unless smaller size allowed by Public Works) Meters Call (651) 675-5646 to verity that tests passed prior to picking up meter. Domestic: Size & Type Fire: 1 Avg. GPM Iii to dem nd devices? Yes No Flushometers ___Yes No COMMERCIAL FEES: $55.00 Minimum (includes State Surcharge) OR Cantract Value S x 1°t0 Required 1f the Pe trnit Fie 3s less - $ Permit Fee on ALL new buildings and boulevard irrigation systems -3 - $ Radio Meter Read man $10,010, the surcharge is S5.00 = $ Meter(s) the Pern It Fee is > 510,010, the surcharge increases by S.50 for each 31,000 Permit Fee Permit Fee mires a S5.50 surcharge) _ $ State Surcharge (i.e. a 510,010-511,000 Following fees apply Call the City's Engineering when installing a new lawn irrigation system. $ Water Permit Department, (651) 675-5646, for required tee amounts. $ Treatment Plant Water Supply & Storage $ State Surcharge TOTAL FEES $ CALL. BEFORE YOU DIG. Call Gopher State One Cali at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. l heieb' ae:k owiodge that this information is complete and accurate; that the work will be in con r ; understand this is not a pernit. but only an application for a permit, and ut+:rrk is not to start wit of ;rtan in the case of work which requires a review and approval of plans. x JAMES VIN ZANT Applicant's Printed Name FOR OFFICE USE Required Inspections: th - _ ordinances and codes of the City of Eagan; that I the , x It he in accordance with the approved Approd By: Under Ground Rough -fn _Air Test Gas Tes Date: PRV Required: ot'3 2006 COMMERCIAL PLUMBING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN MN 55122 651-675-5675 6(7/, 56 Date ( / t /09 j --re. O1 Unit # Site Address / D ri, (- -"T 7 y Tenant Name 0 t i...�agyf-ij"),f Former Tenant Name Property Owner Telephone # ( ) Contractor f k --z- C -5c)r., p i...4 Q Address 1 `-1 -7 i Cr))el d L-0 N E City 11.0,1 v - State on n Zip co)1-(t-{. Telephone # (-7w3) `j ?c . - LiS Li CD License # (3 Lo i 4 IG(- Fir Expires: I -) -0 The Applicant is Owner x Contractor Other Work Type New Bldg Modify Space — RPZ — PVB: _ Rain _ Irrigation System** Yes _ No Work in public r -o -w / easement? New _ Repair/Rebuild Replace Remove sensors are required on irrigation systems Description of Work rC p. £LC L � .j')C,t.. i� t'L- .. C1 `C i« To inquire if Pressure Reducing Valve is required on new service, call 651-675-5646 Meters - Call 651-675-5300 to verify that hydrostatic, Irrigation Size & Type conductivity, and bacteria tests passed prior to picking up meter. Avg GPM 2" turbo req'd unless smaller size allowed by Public Works Fire Size & Price 3/4" meter $167.00 Avg GPM Includes high demand devices? _ Yes _ No Domestic Size & Type Flushometers Yes No PRV Required Yes No _ _ Permit Fee $50.50 minimum (includes State Surcharge) x 1% = $ 62/,-00 Permit Fee Contract Value $ Co 1 � , (`- Required on all new buildings & boulevard irrigation $ Meter(s) systems $ Radio Meter Read Following fees apply when installing new lawn irrigation Call the City's Engineering Department, 651-675-5646, $ , SO State Surcharge If permit fee is less than $1,000, surcharge is $.50 If permit fee is more than $1,000, surcharge is $.50 for each $1,000 owed. system $ Water Permit for required fee amounts $ Treatment Plant $ Water Supply & Storage $ State Surcharge $ (e/ - SD Total Fee I hereby apply for a Commercial Plumbing Permit and acknowledge that the information is complete and ordinances and codes of the City of Eagan and with the Plumbing Codes; that I understand this is start without a permit; that the work will be in accordance with the approved plan in the case of wo Applicant's Printed ame urate; that the work will be in conformance with the it, but o an application for a permit, and work is not to quires r- 'ew and(Approval of plans. Applicants Signa r cityofEaaau 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Date: /a - Tenant o - Use BLUE or BLACK Ink Fr * 7se Permit#: / (1/ ✓J� Permit Fee: % -76'- Date Received: Staff: 2010 COMMERCIAL BUILDING PERMIT APPLICATION Tenant Name: Site Address: /2 as 7Ow"l C'Cfrt-` /0 °- or ,„ - ",— Existing) Suite #: 0461;ts y at, OA - (Tenant is: New / Former Tenant: PROPERTY OWNER Name: /361 kni a. (/ L w. NIL, C D �f Phone: 6a 1-(7-r -4-/L// 0 Address / City / Zip: /� air e ( Le 11-1,-t Pr ! G�,ox M1/ Applicant is: ) Owner Contractor TYPE OF WORK / A Description of work: RYfile e -e Ct d'- y 136,-/a(70.1/ Construction Cost: P-.) i 100 CONTRACTOR Name: gcc /e Eyre n srs Z✓I C, License #: t3 CS -- Address: a21).5-0 Lec le -.�f 4,t City: L- ra ke vo' i t'f State: .4/1 4/ Zip: SI-Ociti Phone: 95-2 _ g Shit /„ a- iI. //6 y Contact: K tiS s g6 4 fir`tY. (Email: r C er / � �'v�11;7n, ',IA �Gt ARCHITECT / ENGINEER Name: Registration #: Address: City: State: Zip: Phone: Contact Person: Email: Licensed plumber installing new sewer/water service: Phone #: NOTE: Plans and supporting documents that you submit are considered to be public info►mationn. Port ons.of the information may be classified as nonpublic if you provide specific reasons that would permit fha City to conclude that they are trade secrets. CALL BEFORE YOU DIG. Cali Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.aooherstateonecaliorq I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. x t, ss/L1 f, s -e A icants Printed Name X X2 Applicants Signature Page 1 of 3 Date: Tenant: /4 AS ick (•C_C-eJv- City of Iaau��� 3830 Pilot Knob Road Eagan MN 55122 Ap Phone: (651) 675-5675 Fax: (651) 675-5694 Use BLUE or BLACK Ink For Office Use lo3G-7g Permit #: Permit Fee: Date Received: Staff: Pr-) 2012 COMMERCIAL FIRE ALARM PERMIT APPLICATION* y- a -1 a Site Address: 1 a a o '/o�,J Cervi r Drive EapAii,1'1�N 557,23 �9' Lege.- -/ " (G ✓l th' Suite #: Name: Dokkc*& CownA es0A/1 f Address / City / Zip: as8 1 0WA.I .rd r Ort ue Applicant is: Owner Phone: 611. 7 5- YNOo Description of work: UP' f ""' e a►I( 1:1're Alarm deUiceS To aMreS3461e f mink -k c Construction Cost: ..re S Setur:4y License #: 7180 IJorikI(Ina ( rc4e '138 City: Rr„6LlyrJ PAak Phone: 763-Y78- ac3SS Email t� tor6a a t ff-- "YIN • Corn Contact FEES $60.00 Minimum (includes State Surcharge) - If the Permit Fee is Tess than $10,010, surcharge is $ 5.00 - If the Permit Fee is > $10,010, surcharge increases by $.50 for each $1,000 Permit Fee (i.e. a $10,010-$11,010 Permit Fee requires a $ 5.50 surcharge) OR Contract value $ lb U.00 x 1% =$ 6•a8 Permit Fee = $ q Surcharge =$ (9o. a ! TOTAL FEE *Requirements: 2 complete sets of drawings and specifications, cut sheets on materials and components to be used I hereby apply for a Fire Alarm permit and acknowledge that the information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan and with the Minnesota Building/Fire Codes; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. x TQ h r) AMQ i f -c Applicant's Printed Name J Applica is Signature r l) 01' Use BLUE or BLACK Ink Lr '� For Office Use • , / dV �/� 1Permit#: .'w? *''Cityof Eaian -C1"" Permit Fee: i0 f, 7 os?/ i 3$30 Pilot Knob Road C.i --j 7 - Eagan MN 55122 � Date Received: Phone:(651)675-5675 Fr^ k w,,i • buildinginspectionsacitvofeaaan.com Staff: Sirry1 `� 2011 2017 COMMERCIAL FIRE ALARM PERMIT APPLICATION Date: Site Address: a ron CCI fICJr NVe, �,t/l to� i 1 � �1 ► �IL 9 Tenant: 0 L�Yy Man0� Suite#: 0 Requirements: 2 complete sets of drawings and specifications,cut sheets on materials and components Name: 1RC� Phone: — 15 141-10._____ Property Owner Address/City/Zip: . C124 Applicant is: Owner X Contractor Type of Work Description of work: ;"'�rl'�C 'e.,Xi 1y1 (e. ci\Gl 'p�� 1 GI . Construction Cost: Estimated Completion Date: Name: e "Vo Vcko\r( M 1 License#: -1-J0 U V2Z1i , , Address: 1►. t)1— Q . City: +- q,uI Contractor {�{ r� `,� State: I i. Zip: 0� Phone: �5 V (2�2 Contact:, �,�Q�nlr �ill' Email: � � \t tiyr �.ie 1r �� a��•C U New Remodel Work Type Addition Other: Alterations DESCRIPTION OF WORK: X_Commercial _Residential _Educational FEES Contract Value$J, - t x.01 $60.00 Permit Fee Minimum =$ �0 Cs° Permit Fee Surcharge=Contract Value x$0.0005 =$ 1.12. Surcharge* If the project valuation is over$1 million, please call for Surcharge �t' =$_ 16 TOTAL FEE 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.citvofeastan.com/subscribe. I hereby apply for a Fire Alarm permit and acknowledge that the information is complete and accurate;that the work will be in conformance with the ordinances and codes of the City of Eagan and with the Minnesota Building/Fire Codes;that I understand this is nota permit,but only an application for a permit,and work is not to start without a permit;that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. /'� ..„-2( , Applicant's Printed Name Applicant's Si. ' .''ure FOR OFFICE US 4 #, thr„.Reviewed;B .-- .,. r • e '' : 4~ XX' X /4xX”' " '4,,, „, ...„ '.* Required inspections: t Rou h-n ' Final t a NMC #75594 Use BLUE or BLACK Ink TFZJ1 v �� For Office Use41 1 , I NOV 19 2018 1 Permit 3Cit of EaRanI I Permit Fee: 3830 Pilot Knob Road I I Eagan MN 55122 �� �'O Date Received: � I Phone: (651) 675-5675 Fax: (651) 675-5694 Staff: _L--------------,�— 2017 COMMERCIAL PLUMBING PERMIT APPLICATION Please submit two (2) sets of plans with all commercial applications. Date: 11/15/18 Site Address: 1220 Town Centre Drive Tenant: O'Leary Manor Property Owner Name: Dakota County CDA Name: Northland Mechanical Contractors, Inc. Suite #: Phone: License #: PC643880 Contractor Address: 9001 Science Center Drive City: New Hope State: MN Zip: 55428 Phone: 763-544-5100 Email: permits@northiand-mn.com Type of Work New _ Replacement Repair Rebuild Modify Space Work in R.O.W. Description of work: Water heater replacement COMMERCIAL New Construction Modify Space 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) Meters Call (651) 675-5646 to verity that tests passed prior to Picking up meter. Domestic: Size & Type Fire: 1 Avg. GPM High demand devices? _Yes _No Flushometers Yes No COMMERCIAL FEES Contract Value $13,550 x .01 $60.00 Permit Fee Minimum $ 60.00 Permit $60.00 PVB/RPZ Permit (includes State Surcharge) _ Fee _ $ 0.00 Surcharge Surcharge = Contract Value x $0.0005 If the project valuation is over $1 million, please call for Surcharge _ $ 60.010 TOTAL FEE Following fees apply when installing a new lawn irrigation system $ Water Permit Contact the City's Engineering Department, (651) 675-5646, for required fee amounts. $ Treatment Plant $ Water Supply & Storage $ State Surcharge = $ TOTAL FEE CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. \ I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is n,q a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in ac�Spreha ce with the apprroved plan e e w rk which requires a review and approval of plans. likait's PH X Applicant's Signature FORLOFFICE USE Approved By: Date: Required Inspections: Under Ground — Rough -In Air Test Gas Test 'Final PRV Required: Yes 'No Meter Related Items: Meter Size Radio Read Manometer Staff: Page 1 of 3 For Office Use Permit#: % `? 1c, Permit Fee: / W-7 4v ( ' C Staff: 3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810 Payment Recvd: _Yes No (651)675-5675 I TDD: (651)454-8535 I FAX: (651)675-5694 Email: buildinainsnectionsacitvofeaaan.com Plans: Electronic Paper Plan Submittal: eplans(ci).citvofeaaan.com L 4\`\11 0 2020 COMMERCIAL MECHANICAL PERMIT APPLICATION A C Please submit two(2) sets of paper plans with all commercial applications as well as an electronic set of the submittal, submitted via email, CD or flash drive Date: 1/27/2020 Site Address: 1220 Town Centre Dr Tenant: Suite#: Owner Name: Dakota County CDA Phone: 651-675-4475 Address/cit /zip: 1228 Town Centre Dr, Eagan 55123 Name: Erickson Plumbing Heating Air Electrical License#: Contractor Address: 1471 92nd Lane NE city_ Blaine State: MN Zip: 55449 Phone: 763-783-4545 Alex permits@ihearterickson.com Contact: Email: New 1/ Replacement Additional Alteration Demolition Type of Work Description of work: replace two air handlers and two condensers NOTE: Roof mounted and ground mounted mechanical equipment is required to be screened by City Code. Please contact the Mechanical Inspector for information on permitted screening methods. COMMERCIAL New Construction 1 Interior Improvement Permit Type Install Piping Processed Gas / Exterior HVAC Unit Under/Above ground Tank ( Install/ Remove) COMMERCIAL FEES 10800 Contract Value$ x.015 $60.00 Permit Fee Minimum $75.00 Underground tank removal, includes State Surcharge =$ 162 Permit Fee $ 5.40 Surcharge Surcharge =Contract Value x$0.0005 167.40 If the project valuation is over$1 million, please call for Surcharge =$ TOTAL FEE 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.citvofeaqan.com/subscribe. I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan;that I understand this is not a permit,but only an application for a permit,and work is not to start without a permit;that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. xAlex Jindra x �� Applicant's Printed Name Applicant's Signature FOR OFFICE USE Required Inspections: Reviewed By: Date: f V/D, Underground Rough In Air Test Gas Service Test In-floor Heat Final HVAC Screening For Office Use I Permit/4// #: ..4,0 E AGA N Peimit Fee: ♦eeo / I./7 /JI/ ov �r.Qaa�-aa�i—m�am�a 3830 PILOT KNOB ROAD 1 EAGAN, MN 55122-1810 EPayment Recvd: Yes No (651) 675-5675 TDD: (651) 454-6535 FAX (651) 675-56 JLIN E1 7 Z� � Plans: Electronic �( )(Paper I Plan Submittal: eolans ofirofeaaan.com BY: 2020j COMMERCIAL BUILDING PE APPLICATION Date: - tb.-2 Site Address: < 220 l®LL)f'1 Oa -TAT 2- Tenant Name: ®-r_I .>G� R�/ _ 9�1 N b �L l Ct)�) (Tenant Is: New / KEdsdn9) Suite #: !! Former Tenant Pl*operty Owner Name: CO U.A A CIA Phone: Address / City / Zip: Applicant is: 1 � � l C1 b1 . Owner k° Contractor of Work Ypei Description of work Construction Cost P '1 t j 1Ck t ric) i rdi v.i Q) 6 U1. S 1 1 1 1- ti C.3 0 Contractor Name:- CC.SC1 ji1.8t. crni U--Q Ucense #:, 1 -1 Address: 4' 4O 2_ ( l ttl - city State:Irk) Zip: ED C-1 I 1 Phone: LID t 8' - Contact ..314 m-t ii"-A--+ Email: Cgi, o) 010 OCiralitialiCrfN Architect/Engineer 09 Name: � % t . Registration #: Addre,sTI cO A Th its �- city: t n�- State: Mk. D Zip: GL1 I G Phone: (112--3 - EE)C Contact Person: Email: Licensed plumber installing NOTE: Plans and supportlrrg classified as non-public if new sewer/water service: Ni7' 1 Phone #: documents that you submit are considered to be public intonnalion. Portions of the ► ferinaUon may be you provide specific reasons that would peza nit the City to conclude that they are trade secrets. ; 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 websfte at www.cltvofeaaan.comisubscribe. CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0082 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.ciopherstateonecall.orq I hereby acknowledge that tills Information is complete and accurate: that the work will be in conformance with the ordinances and codes of the City of Eagan: that 1 understand tt?is is not a permit. but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. - x Lit 1 c� Applicant's Printed Narlre DO NOT WRITE BELOW THIS LINE SUB TYPES Foundation ✓ Commercial ! Industrial — Apartments Miscellaneous WORK TYPES New Addition Alteration _ Replace Salon Owner Change DESCRIPTION Valuation Occupancy Plan Review ✓ Code Edition (25% 100% d Zoning Census Code ' Stories # of Units Square Feet # of Buildings r Length Type of Construction V • A Width ,e1 Public Facility erior Alteration -Apartments _ Accessory Building _ Greenhouse !Tent Antennae Interior Improvement Exterior improvement Repair Water Damage 51 G) OCR. s-6 REQUIRED INSPECTIONS Footings _ New Building Deck Addition Foundation Foundation Before Backfill Vapor Barrier Framing 30 Minutes 1 Hour Insulation Sheetrock ✓ Roof: _Decking Insulation Ice & Water _Final �� Siding: Stucco/Lath Stone Lath _Brick _ EFIS ✓ Windows Fireplace: Rough In Air Test _Final Pool: _Footings Air/Gas Tests Final Schedule Fire Marshal to be present Yes ✓ No _ Exterior Alteration -Commercial Exterior Alteration -Public Facility `/ Siding Reroof V Windows Fire Repair Demolish Building* _ Demolish Interior _ Demolish Foundation Retaining Wall 'Demolition of entire building - give PCA handout to applicant F . 2- MCES System 2620 M bG 3 SAC Units City Water Booster Pump PRV Fire Sprinklers Drain Tile Retaining Wall Erosion Control Steel Reinforcement Street/Curb Cut Inspection Other. Meter Size: -7 Electronic Set of Final Revised Plans Final CIO Inspection Reviewed By: Reviewed By: f..5 • Final !C.O. Required Final / No C.O. Required , Planning New Business to Eagan: Cr r 16 , Building Inspector FEES Base Fee Surcharge Plan Review MCES SAC City SAC SAW Permit & Surcharge Treatment Plant Treatment Plant (Irrigation) Park o..alcation Trail Dedication Water Quality 3534 •?S' Storm Sewer Trunk 2S$ .60 Sewer Trunk 2248 .$1 Water Trunk Street Lateral Street Water Lateral Stormwater Performance Security Landscape Security Other. TOTAL: 6og3. 4.4 Page 2 of 3 CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 4th Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minnea olis.mn.uslmdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS - OWN ER/OCC U PANT/CONTACT PERSON: 74 n I CONTACT PHONE: C/ DEVICE LOCATION:? FLOOR #: SERVES WHAT SYSTEM: MAKE: � / � f � / r MODEL #: 7f �� SIZE: X INSTALL DATE (MONTH/DAY/YEAR): OVERHAUL DATE (MONTH/DAY/YEAR): (DO NOT PUT A FUTURE DATE IN THIS BOX) e,e,�2 ROOM #: SERIAL #: TEST DATE (MONTH/DAY/YEAR): #2 CHECK VALVE #1 CHECK VALVE PSI/DIFF RELIEF PSI/DIFF TEST BEFORE REPAIRS FINAL TEST DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE- REMOVED): ,( j TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): WL 4 r2 (' 111 C-A CERTIFICATION NUMBER: U --] COMPANY NAME: Er , t %,SD,, f o � MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS: 1_471 L ;1 C'1 Gl I\N COMPANY PHONE #: ��G'1� _) CITY: l !1 STATE: ! , ,N ZIP: �'5 q 1t CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUM BING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 4th Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minnea olis.mn.us/mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: OWNER/OCCUPANT/CONTACT PERSON: � CONTACT PHONE: #1 CHECK VALVE PSI/DIFF RELIEF PSI/DIFF #2 CHECK VALVE TEST BEFORE REPAIRS FINAL TEST �-�" 21 DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE. REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): P]L. /�-n J�) c/--\- �-' CERTIFICATION NUMBER: �j�'Gj 7 % ATTACH THIS COMPLETED TEST REPORT TO PLUMBING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 4tn Street — Room 300 Minneapolis, MN 55415-1316 www.ci.minneajooIis.mn.us1mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: A. .I , OWNER/OCCUPANT/CONTACT PERSON: A , . CONTACT PHONE: #1 CHECK VALVE PSI/DIFF RELIEF PSI/DIFF #2 CHECK VALVE TEST BEFORE REPAIRS FINAL TEST l DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE. REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): CERTIFICATION NUMBER: /; ) ' ? '? 7 COMPANY NAME: L v- I MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS: r 'i f L COMPANY PHONE #:76 3 —7 3 ^ 1I > "1 5 CITY: STATE: DUI �// ZIP: "� CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUMBING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 41' Street - Room 300 Minneapolis, MN 55415-1316 Www.ci.minnea olis.mn.us/mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: / RD �I OWNER/OCCUPANT/CONTACT PERSON: L / t� DEVICE LOCATION: SERVES WHAT SYSTEM: � � /� J ,-- MAKE: t _ - FMODEL #: 66 1 - SIZE: INSTALL DATE (MONTH/DAY/YEAR): OVERHAUL DATE (MONTH/DAY/YEAR): (DO NOT PUT A FUTURE DATE IN THIS BOX) OOR #: CONTACT PHONE: ROOM #: SERIAL #: PO `1 / J TEST DATE (MONTH/DAYIYEAR): -3 #1 CHECK VALVE PSI/DIFF RELIEF PSI/DIFF #2 CHECK VALVE TEST BEFORE REPAIRS FINAL TEST DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE. REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): ,n j „ Isr1 C 1-)A CERTIFICATION NUMBER: 6-3 `7 COMPANY NAME: L r 1 c^ Q E MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS: 1.4 71 12, /-\ cL. L 6k e- E COMPANY PHONE #: 1793 qS qb CITY: >a M 551cj STATE: ZIP: � l � CONTACT PERSONIPHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUMBING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 41h Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minagqnqjjg,Mg,ygi/mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: / � f ? OWNER/OCCUPANT/CONTACT PERSON: / l//� CONTACT PHONE: v���Z.C�' DEVICE LOCATION: �1 ak FLOOR #- AY A ROOM #: SERVES WHAT SYSTEM: / MAKE: MODEL #: 0 !� E: T/-Z- SERIAL #: INSTALL DATE (MONTH/DAY/YEAR): OVERHAUL DATE (MONTHIDAY/YEAR): TEST DATE (MONTH/DAYIYEAR): (DO NOT PUT A FUTURE DATE IN THIS BOX) #1 CHECK VALVE PSI/DIFF RELIEF PSI/DIFF #2 CHECK VALVE TEST BEFORE REPAIRS FINAL TEST DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE. REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): CERTIFICATION NUMBER: COMPANY NAME: L r C k SOn MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS:71 l Z,-\d L a,\ e A/ F COMPANY PHONE #: 763 T 79 CITY: g 1 O, I r\e STATE: / V\ A/ ZIP: � i "1 q CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUM BING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 rzr CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 41h Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minneapolis.mn.us/mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: � '�-) OWNER/OCCUPANT/CONTACT PERSON: L V CONTACT PHONE: DEVICE LOCATION: I cc:[FLOOR #: OOM #: SERVES WHAT SYSTEM: MAKE: �� 1 )T MODEL #: 00 SIZE: SERIAL #: M� ae-E i YL 1 INSTALL DATE (MONTH/DAY/YEAR): OVERHAUL DATE (MONTH/DAY/YEAR): TEST DATE (MONTHIDAY/YEAR): (DO NOT PUT A FUTURE DATE IN THIS BOX) �-� - - '2 #1 CHECK VALVE PSI/DIFF RELIEF PSI/DIFF #2 CHECK VALVE TEST BEFORE REPAIRS FINAL TEST / x? 1 r DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE- REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): WL"a-y-x- 6. /Y-/ &' CERTIFICATION NUMBER: CJ % 7 COMPANY NAME: E L i� � Q n P H A F— MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS: 71 11 L COMPANY PHONE #: CITY: 1/ ((� 1 ' STATE: /1AA ZIP: CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUMBING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 l � �� kL �_ CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 41' Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minnea oiis.mn.uslmelr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: OWNER/OCCUPANT/CONTACT PERSON: CONTACT PHONE: #1 CHECK VALVE RELIEF #2 CHECK VALVE PSIIDIFF TEST BEFORE REPAIRS /3PSI/DIFF 6 G FINAL TEST DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVI. E- REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): CERTIFICATION NUMBER: �r�� 0 ?-7 COMPANY NAME: L_ c I C f\s a ,� P 4 N �— MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS: l "1 -7cl 2 d [- c Al F COMPANY PHONE #: 6 3- 7 93 `(� CITY: � l 6` I STATE: / ` AV ZIP: '95 �f (11 CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUMBING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 41' Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minnear)olis.mn.us/mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: �. e eTa OWNER/OCCUPANT/CONTACT PERSON: CONTACT PHONE: l #1 CHECK VALVE RELIEF #2 CHECK VALVE PSI/DIFF PSI/DIFF TEST BEFORE REPAIRS e7` FINAL TEST DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE- REMOVED): J TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): �. � � I ��CERTIFICATION NUMBER: � yfAyV COMPANY NAME: C r t' C k-S 0 e-, P AF MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS: [ 71 L A'1 e-- YE COMPANY PHONE #: 7-67g 3 -- "! 5 LfS CITY: b ` 6� (^ STATE: /V` AV ZIP: 55 � � ` CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUM BING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 f Application Form RBA01 Minneapolis City of Lakes Development Services Customer Service Center 505 4th Ave S, Room 320 Minneapolis, MN 55415 Office 612-673-3000 or 311 TTY 612-673-2157 www.minneapolismn.gov/mdr Office Use Only A/P LIC # Date: Amount REGULATED BACKROW ASSIPMRI Y IRRAI nppi irATinN Cnann /TCCT QConoT COMPLETE JOB ADDRESS (INCLUDE Apt/�U,niit/#) NAME OF BUILDI G, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER APPLICANT C�IIMPANY NAME CONTRACTOR LICENSE # CONTACT NAME AND PHONE NUMBER 1 C643 ADDRESS CITY A SSE Z y-p ��� EMAIL TESTER NAME u TESTER CERTIFICATION # rb 6 �;)- --? . PHONE TESTING EQUIPMENT CALIBRATION DATE TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUIPMENT SERIAL # Mo Yr TYPE OF WORK AND FEE INFORMATION (check one) FEE: $41.40 PLUS $1.00 STATE SURCHARGE PER EACH DEVICE FEE: $41.40 Install Relocate Remove Replace and SN# of Replaced Device Rebuild Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): _ Reduced Pressure Principal or Pressure Principal Fire Pro ction _Reduced Pressure Detector Fire Protection —Double Check Valve _Double Check Detector Fire Protection Pressure Vacuum Breaker Spill Resistant Pressure Vacuum Breaker Manu;'acturer: L'I 1 %� _ Model # Serial # / Size: (inches) System Serviced Location in bldg C i r # Room # TEST RESULTS: Pass Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW) Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) — TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Closed Tight _Yes _No Closed Tight —Yes —No Closed Tight _Yes No Test Pressure Drop Across Check Valve #1 psid Opened at psid Final Closed Tight —Yes—No Closed Tight —Yes _No Closed Tight —Yes—No Opened at psid Test Pressure Drop Across Check Valve #1 _psid Double Check Valve or Double Check Detector Fire Protection (DC) — TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight _Yes _No psid Closed Tight _ Yes _ No psid Closed Tight _Yes No Final Test Closed Tight _Yes _No psid Closed Tight _ Yes No psid Closed Tight _Yes No Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open _Yes _ No Closed Tight _Yes No Closed Tight Yes No Opened at 1,12 psid Pressure Drop Across Check Valve # psid — Final Test Closed Tight , Yes No ^ Opened at � psid Pressure Drop Across Check Valve #1 psid Closed Tight — Yes — No I Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to State of Minnesota Plumbing Code, Chapter 4714. TESTER'S SIGNATURE MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHAR [ALL MAJOR CREDIT CARDS ACCEPTED ACCOUNT# V011.19 TO and that the' es d de a is functioning in compliance with — EST DATEW" CVV# EXP DATE: Mo Yr CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 4th Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minneapolis.mn.us/mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: � STD OWNER/OCCUPANT/CONTACT PERSON: , ; f a CONTACT PHONE: DEVICE LOCATION: ��o V'Yl ` � ` r ` FLOOR #: ROOM #: SERVES WHAT SYSTEM: MAKE: / }i� ! r Z r MODEL #: /r / SIZE: `% 4� SERIAL #: INSTALL DATE (MONTH/DAY/YEAR): OVERHAUL DATE (MONTH/DAY/YEAR): TEST DATE (MONTH/DAY/YEAR): (DO NOT PUT A FUTURE DATE IN THIS BOX) #1 CHECK VALVE PSI/DIFF RELIEF PSI/DIFF #2 CHECK VALVE TEST BEFORE REPAIRS FINAL TEST f � � � ,� 04 DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): CERTIFICATION NUMBER: COMPANY NAME: E: r I Lek S o MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS: 1471 / 1 q l (\ eI L- o� r\c NE- 61 COMPANY PHONE #: 1 6 3 - 7S � — /f 5 ��5 CITY: ^ e STATE: /A � IV ZIP: 55 q "1 l-1 CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUM BING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 41h Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minnea olis.mn.us/mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: , 016 OWNER/OCCUPANT/CONTACT PERSON: -) / CONTACT PHONE: #1 CHECK VALVE PSI/DIFF RELIEF PSUDIFF #2 CHECK VALVE TEST BEFORE REPAIRS FINAL TEST DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE, REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): COMPANY NAME: E Y ' L kS O � 1 %t �,a COMPANY ADDRESS: 0 7 t q2,Aj L a,,e- CITY: F I a( 1 t STATE: My CERTIFICATION NUMBER: 6 —? 6 J�� MPLS CONTRACTOR LICENSE #: / " E COMPANY PHONE #: -76 3 - 793 - q "� i1 ZIP: SS 1 "1 CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED TEST REPORT TO PLUMBING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEEj 7/30/2007 V f-C 1✓� o I a r CITY OF MINNEAPOLIS, REGULATORY SERVICES INSPECTIONS DIVISION 250 South 41h Street - Room 300 Minneapolis, MN 55415-1316 www.ci.minneppolis.mn-us/mdr BACKFLOW PREVENTOR (RPZ) TEST REPORT JOB ADDRESS: OWNER/OCCUPANT/CONTACT PERSON: Z'ge' , �1 o CONTACT PHONE: f #1 CHECK VALVE PSUDIFF RELIEF PSUDIFF #2 CHECK VALVE TEST BEFORE REPAIRS FINAL TEST DESCRIBE REPAIR IF ANY (IF THIS IS A NEW INSTALLATION AND REPLACES AN EXISTING DEVICE, INDICATE THE SERIAL NUMBER OF THE DEVICE. REMOVED): TEST DONE BY (PLEASE PRINT FIRST & LAST NAME): CERTIFICATION NUMBER: j 36 d 7 '? COMPANY NAME: L r i L rC 5o ^ P H A F- MPLS CONTRACTOR LICENSE #: COMPANY ADDRESS: 71 Z +� d Q /� [ v F- COMPANY PHONE #: 7 63` ! 93 t S 5 CITY: 6 � /\ STATE: A A/ ZIP: �'r CONTACT PERSON/PHONE#: ATTACH THIS COMPLETED'TEST REPORT TO PLUMBING/GASFITTING/RPZ PERMIT APPLICATION AND SUBMIT WITH FEE 7/30/2007 i Application Form RBA01 Minneapolis City of Lakes Development Services Customer Service Center 505 4th Ave S, Room 320 Minneapolis, MN 55415 Office 612-673-3000 or 311 TTY 612-673-2157 www.minneapolismn.gov/mdr Office Use Only A/P LIC # Date: Amount REGULATED BACKROW ASSFMRI v ORRnt naafi ireT1n1UCnDRA /-rrc-r ornr,oT COMPLETE JOB ADDRESS (INCLUDE Apt/Unit #) NAME OF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER APPLICANT COMPANY NAME I �r Cti'si , P kF1 CONTRACTOR LICENSE # P(- cv33` CONTACT NAME AND PHONE NUMBER ADDRESS 71 g2tkd L Q e- lV CITY �i STATE MA/ ZIP .s5 W EMAIL TESTER NAME IJ � de, TESTECERTIFICATION # PHONE -7 6 3— 7 5 If-5 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUIPMENT SERIAL # TESTING EQUIPMENT CALIBRATION DATE Mo Yr TYPE OF WORK AND FEE INFORMATION (check one) FEE: $41.40 PLUS $1.00 STATE SURCHARGE PER EACH DEVICE FEE: $41.40 Install Relocate Remove Replace and SN# of Replaced Device L Rebuild Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): _ Reduced Pressure Principal or Pressure Principal Fire Protection _Reduced Pressure Detector Fire Protection _Double Check Valve _Double Check Detector Fire Protection _Pressure Vacuum Breaker _Spill Resistant Pressure Vacuum Breaker Manufacturer: 7 C11'll Model # ,Z13r v2- Serial # q / I- �. Size: (inches) System Serviced A.S/� C' l;/i- Location in bldg Floor # Room # TEST RESULTS: UPass 0 Fail (COMPLETE APPLICABLE ASS MBLY TYPE SECTION BELOW) Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) — TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Closed Tight Xyes —No Closed Tight 7Yes _No Closed Tight Yes _ No Test Opened at��1 � psid Pressure Drop Across Check Valve #1psid Final Closed Tight —Yes—No Closed Tight —Yes _No Closed Tight —Yes —No Test Pressure Drop Across Check Valve #1 psid Opened at psid Double Check Valve or Double Check Detector Fire Protection (DC) — TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight —Yes _No psid Closed Tight _ Yes _ No psid Closed Tight _Yes No Final Test Closed Tight _Yes _No psid Closed Tight _ Yes No psid Closed Tight _Yes No Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) —' cST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open _Yes —No Closed Tight —Yes No Opened at psid Pressure Drop Across Check Valve #1 psid Closed Tight Yes No — — Final Test Opened at psid Closed Tight _Yes _No Pressure Drop Across Check Valve #1 psid Closed Tight _ Yes _ No Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to be cor Qct„and that th tested device is functioning in compliance with State of Minnesota Plumbing Code, Chapter 4714. _ � TESTER'S SIGNATURE '� �'�.�--�- TEST DATEz,-f" ,�.2' ` MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHARGE fo ALL MAJOR CREDIT CARDS ACCEPTED ACCOUNT# CVV# EXP DATE: Mo Yr_ V011.19 Application Form RBA01 4 Minneapolis City of Lakes Development Services Customer Service Center 505 4th Ave S, Room 320 Minneapolis, MN 55415 Office 612-673-3000 or 311 TTY 612-673-2157 www.minneapolismn.gov/mdr Office Use Only A/P LIC # Date: Amount REGULATED BACKROW ASSFMRLY (RRA1 APPI irATInN FnRhA/TFCT QVDnQT COMPLETE JOB ADDRESS (INCLUDE Apt/Unit #) NAME OF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER Ow 0%Z. s rl2 ` APPLICANT COMPANY NAME � r l c k 5qn CON�T� OR LICENSE # 1 `ZIP CONTACT NAME AND PHONE NUMBER ADDRESS �f -7 Q p r 7! I 1 2,!1a 1_a^e & G CITY {� R �q i r) e S 1 A I E/ /�11!V EMAIL TESTER ME / 5� /�..-� TESTER CERTIFICATION # --? PHONE 7 �: 3- 7 g V 5 W 5 � 3- TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUIPMENT SERIAL # TESTING EQUIPMENT CALIBRATION DATE Mo Yr TYPE OF WORK AND FEE INFORMATION (check one) FEE: $41.40 PLUS $1.00 STATE SURCHARGE PER EACH DEVICE FEE: $41.40 Install Relocate Remove Replace and SN of Replaced Device Rebuild Test BAC LOW ASSEMBLY DETAIL INfiqRMAX Type ( e Princ tsur�rta#e Protection d e r s e Detector Fire Protection ve ouble C ck r ire n _Press a Va, um Beaker _Spill Resistant Pressure Vacuum Breaker 7 r< Ma factur r:✓ti/,7t� f Model # L_7� /� Serial # Size: (inches) System Serviced /' 4k-C C1�P i33)� Location in bldg6l Floor # ,.Room # TEST RESULTS: NdPass EjFail (COMPLETE Anna seA BLE ASSEMBLY TYPE SECTION BELOW) Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) —TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential r: Relief Valve Initial Closed Tight Yes _No Closed Tight Yes No Closed Tight _Yes _ No Test > Opened atpsid Pressure Drop Across Check Valve #1 psid Final Closed Tight —Yes—No Closed Tight _Yes _No Closed Tight _Yes _No Test Opened at psid Pressure Drop Across Check Valve #1 psid Double Check Valve or Double Check Detector Fire Protection (DC) — TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight —Yes _No psid Closed Tight _ Yes _ No psid Closed Tight _Yes No Final Test I Closed Tight _Yes _No psid Closed Tight _ Yes No psid Closed Tight _Yes No Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open _Yes _ No Closed Tight Yes No 1. — — Opened at psid Pressure Drop Across Check Valve #1 psid Closed Tight Yes — — No Final Test Opened at psid Closed Tight _Yes _No Pressure Drop Across Check Valve #1 psid Closed Tight _ Yes _ No Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by meItotorrect and t at the t sted device is functioning in compliance with State of Minnesota Plumbing Code, Chapter 4714. TESTER'S SIGNATURE `l TEST DATE: MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPART , OR C"MRGE T ALL MAJOR CREDIT CARDS ACCEPTED ACCOUNT# ''"" �,-- CvV# EXP DATE: Mo Yr_ V011.19 4 ./ � Application Form RBA01 Minneapolis City of Lakes Development Services Customer Service Center 505 4th Ave S, Room 320 Minneapolis, MN 55415 Office 612-673-3000 or 311 TTY 612-673-2157 www.minneapolismn.gov/mdr Office Use Only A/P LIC # Date: Amount REGULATED BACKFLOW ASSEMBLY (RRA1 APPI IrATInM CnRIAA1T9:CT QlPonQT COMPLETE JOB ADDRESS (INCLUDE Apt/Unit #) NAME OF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER v f ` /2i k Q-n O ���-- APPLICANT COMPANY NAME j i CONTRACTOR LICENSE # CONTACT NAME AND PHONE NUMBER ADDRESS Iti 92..E ��,� E_ CITY B (u "i .� STATE MN/ ZIP .ssggc( EMAIL TESTER NAME TESTER CERTIFICATION # PHONE 763-7D-1YS'45 TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUIPMENT SERIAL # TESTING EQUIPMENT CALIBRATION DATE Mo Yr TYPE OF WORK AND FEE INFORMATION (check one) FEE: $41.40 PLUS $1.00 STATE SURCHARGE PER EACH DEVICE FEE: $41.40 Install Relocate Remove Replace and SN# of Replaced Device Rebuild Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): _ Reduced Pressure Principal or Pressure Principal Fire Protection _Reduced Pressure Detector Fire Protection —Double Check Valve _ Double Check Detector Fire Protection _Pressure Vacuum Breaker _Spill Resistant Pressure Vacuum Breaker Manufacturer: ' �' ► Model # ) 7 �� Serial # �'7�� Size: �. (inches) System Serviced �l l 4 �i }� �=�"� Location in Bldg Floor # Room # TEST RESULTS: OPass LjFail (COMPLETE APPLICABLE SSEMBLY TYPE SECTION BELOW) Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) — TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Closed Tight Yes _No Closed Tight Yes —No Closed Tight Yes _ No j (� Test Pressure Drop Across Check Valve #1 <l a psid Opened at, 1 �jpsid Final Closed Tight —Yes—No Closed Tight —Yes —No Closed Tight —Yes —No Test Opened at psid Pressure Drop Across Check Valve #1 psid Double Check Valve or Double Check Detector Fire Protection (DC) — TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight _Yes _No psid Closed Tight _ Yes _ No psid Closed Tight _Yes No Final Test Closed Tight _Yes _No psid Closed Tight _ Yes No psid Closed Tight _Yes No Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open —Yes _No Closed Tight —Yes No Closed Tight Yes No Opened at psid Pressure Drop Across Check Valve #1 psid — Final Test Opened at psid Closed Tight _Yes _No Pressure Drop Across Check Valve #1 psid Closed Tight — Yes — No Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to be cor oct ajid that th tes ed device is functioning in compliance with State of Minnesota Plumbing Code, Chapter 4714. TESTER'S SIGNATURE TEST DATE: d'1 MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHARGE TO --- ALL MAJOR CREDIT CARDS ACCEPTED ACCOUNT# CVV# F XP DATE: Mo Yr_ V011.19 J '1 0 f' Application Form RBA01 Minneapolis City of Lakes Development Services Customer Service Center 505 4th Ave S, Room 320 Minneapolis, MN 5S415 Office 612-673-3000 or 311 TTY 612-673-2157 www.minneapolismn.gov/mdr Office Use Only A/P LIC # Date: Amount REGULATED BACKFLOW ASSEMBLY (RRA1 APPI ICAT1(71W IFnRM/TIPCT RI:DnRT COMPLETE JOB ADDRESS (INCLUDE Apt/Unit #) NAME OF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER G► s' `tic G a ��,� c �C)a 0(6 APPLICANT COMPANY NAME CONTRACTOR LICENSE # CONTACT NAME AND PHONE NUMBER j ADDRESS ` r_' ..7 . Q Z� � � �� e � l "1 l N CITY (� j � i � 1J t STATE /vk 1 ZIP � ss ��1. EMAIL TESTER NAME TESTER CERTIFICATION # PHONE TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUIPMEN SE IAL # TESTING EQUIPMENT CALIBRATION DATE ' Mo Yr TYPE OF WORK AND FEE INFORMATION (check one) FEE: $41.40 PLUS $1.00 STATE SURCHARGE PER EACH DEVICE FEE: $41.40 Install Relocate Remove Replace and SN# of Replaced Device Rebuild Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): _ Reduced Pressure Principal or Pressure Principal Fire Protection _Reduced Pressure Detector Fire Protection _Doublrle Check Valve _Double Check Detector Fire Protection _Pressure Vacuum Breaker _Spill Resistant Pressure Vacuum Breaker Manufacturer:�/t/%/ 12�� Model #c2r' Serial # © e3 71 o j Size: � (inches) System Serviced Location in bldg 'W Floor # Room # TEST RESULTS: Pass Fail (COMPLETE APPLICABL ASSEMBLY TYPE SECTION BELOW) Reduced Pressure rincipal or Reduced Pressure Detector Fire Protection (RP) — TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Closed TightxYes _No Closed Tight?LYes No Closed Tight x Yes No C.11 Test 7, Opened at �r,�sid Pressure Drop Across Check Valve #1 < -) /psid Final Closed Tight —Yes—No Closed Tight —Yes —No Closed Tight —Yes —No Test Opened at psid Pressure Drop Across Check Valve #1 psid Double Check Valve or Double Check Detector Fire Protection (DC) — TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight _Yes _No psid Closed Tight _ Yes _ No psid Closed Tight _Yes No Final Test I Closed Tight —Yes _No psid Closed Tight _ Yes _ No psid I Closed Tight Yes No Pressure Vacuum Breaker (P'" "a) or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open _Yes _No Closed Tight —Yes No Closed Tight Yes No Opened at psid Pressure Drop Across Check Valve #1 psid — Final Test Closed Tight _Yes _No Opened at psid Pressure Drop Across Check Valve #1 psid Closed Tight — Yes — No Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to b or ct and that the State of Minnesota Plumbing Code, Chapter 4714. J/�� TESTER'S SIGNATURE ,�1 MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHARGE TO ALL MAJOR CREDIT CARDS ACCEPTED I ACCOUNT# evic�isfunctioning in compliance with / TE TE: CW# V011.19 EXP DATE: Mo Yr Application Form RBA01 ter... Minneapolis City of Lakes Development Services Customer Service Center 505 4th Ave S, Room 320 Minneapolis, MN 55415 Office 612-673-3000 or 311 TTY 612-673-2157 www.minneapolismn.gov/mdr Office Use Only A/P LIC # Date: Amount REGULATED BACKFLOW ASSEMBLY (RBA) APPLICATION FORM/TEST REPORT COMPLETE JOB ADDRESS (INCLUDE Apt/Unit #) NAME OF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER APPLICANT COMPANY NAME r I F CORN OR LIC NSE # � CONTACT NAME AND PHONE NUMBER i C �C t-6q33 ADDRESS , W _7 9) i �� � CITY o\ e [STATE , Z 55 EMAIL W1 TESTER NAME �� Ll"�l�L,"'" TESTER CERTIFICATION # � , d PHONE — 76 3 -791 Y TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUIPMENT SERIAL # TESTING EQUIPMENT CALIBRATION DATE Mo Yr TYPE OF WORK AND FEE INFORMATION (check one) FEE: $41.40 PLUS $1.00 STATE SURCHARGE PER EACH DEVICE FEE: $41.40 Install Relocate Remove Replace and SN# of Replaced Device Rebuild Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): _ Reduced Pressure Principal or Pressure Principal Fire Protection _Reduced Pressure Detector Fire Protection _Double Check Valve Double Check Detector Fire Protection _Pressure Vacuum Breaker _Spill Resistant Pressure Vacuum Breaker Manufacturer: j1, 6-Model # �S r�Serial # �� f / % �" Size: l (inches) System Serviced �%f iI4-t ©- Location in bldg ���'��� � ,�-- Floor # Room # r TEST RESULTS: Lwass M Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW) Reduced Pre ure Principal or Reduced Pressure Detector Fire Protection (RP) — TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Test Closed Tight _Yes _No Closed Tight _Yes No Closed Tight _Yes _ No � c�r� Pressure Drop Across Check Valve #1„ l d psid { ' Opened at �+ psid Final Test Closed Tight —Yes—No Closed Tight _Yes No Closed Tight —Yes—No Pressure Drop Across Check Valve #1 psid Opened at psid Double Check Valve or Double Check Detector Fire Protection (DC)_ TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight _Yes _No psid Closed Tight _ Yes _ No psid Closed Tight _Yes No Final Test Closed Tight _Yes _No psid Closed Tight _ Yes No psid Closed Tight _Yes No Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open _Yes _ No Opened at psid Closed Tight _Yes No Pressure Drop Across Check Valve #1 psid Closed Tight Yes No Final Test Opened at psid Closed Tight _Yes _No Pressure Drop Across Check Valve #1 psid Closed Tight _ Yes _ No Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to be c �ec�Ltnd that t e t to device is functioning in compliance with State of Minnesota Plumbing Code, Cha ter 4714. p TESTER'S SIGNATURE �����' ^� TEST DATE: MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHARGE TO ALL MAJOR CREDIT CARDS ACCEPTED I ACCOUNT# CVV# V011.19 EXP DATE: Mo Yr Application Form RBA01 4 `low Minneapolis City of Lakes Development Services Customer Service Center 505 4th Ave S, Room 320 Minneapolis, MN 55415 Office 612-673-3000 or 311 TTY 612-673-2157 www.minneapolismn.gov/mdr Office Use Only A/P LIC # Date: Amount REGULATED BACKFLOW ASSEMBLY (RBAI APP1 IrATInKI FnRnn/TFCT QI~DnRT COMPLETE JOB ADDRESS (INCLUDE Apt/Unit #) .3 c2 � 1 L y S1�' � t�,L l,n-- %q �C NAME OF BUILDING, OWNER/OCCUPANT, CONTACT NAME AND PHONE NUMBER 'j� APPLICANT COMPANY NAME E r I ;_ k-sa., PPAE CONTRACTOR LICENSE # CONTACT NAME AND PHONE NUMBER 763 _ 793 ._ '1W5. ADDRESS q JA��ne NC CITY STATE STATE ZIP SS-g4 EMAIL TESTER NAME�l ` �^ C� TESTER CERTIFICATION # 0 J 0 3 PHONE TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUIPMENT SERIAL # TESTING EQUIPMENT CALIBRATION DATE Mo Yr TYPE OF WORK AND FEE INFORMATION (check one) FEE: $41.40 PLUS $1.00 STATE SURCHARGE PER EACH DEVICE Install Relocate Remove Replace and SN# of Replaced Device FEE: $41.40 Rebuild Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): _ Reduced Pressure Principal or Pressure Principal Fire Protection _Reduced Pressure Detector Fire Protection _Double Check Valve _ Double Check Detector Fire Protection _Pressure Vacuum Breaker _Spill Resistant Pressure Vacuum Breaker Manufacturer: Model # Serial # Size: (inches) System Serviced Location in bldg Floor # Room # TEST RESULTS: Pass DFail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW) Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) — TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Test Closed Tight _Yes _No Closed Tight _Yes _No Closed Tight _Yes No Pressure Drop Across Check Valve #1 psid Opened at psid Final Test Closed Tight -Yes-No Closed Tight _Yes _No Closed Tight _Yes _No Pressure Drop Across Check Valve #1 psid Opened at __psid Double Check Valve or Double Check Detector Fire Protection (DC) — TEST RESULTS Check Valve #1 Check Valve #2 Shutoff Valve #2 Initial Test Closed Tight _Yes _No psid Closed Tight —Yes No psid Closed Tight _Yes No Final Test Closed Zight _Yes _No psid Closed Tight _Yes No psid Closed Tight _Yes No ressure Vacuum Breaker (PV?% or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open _Yes No Opened at psid Closed Tight _Yes No Pressure Drop Across Check Valve #1 psid Closed Tight Yes No Final Test O Opened at psid Closed Tight _Yes _No Pressure Drop Across Check Valve #1 psid Closed Tight Yes _ No g — Describe parts and repairs when needed: C} �. - V6,C- 6 L,4 I ri 1 CERTIFICATION: I hereby certify the foregoing information provided by me to be correct rrect aid that Athh�fidftecll device is functioning in compliance with State of Minnesota Plumbing Code, Chapter 4714.TESTER'S SIGNATURE ' TEST DATE: S ti MAKt CHICKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHARGE TO ALL MAJOR CREDIT CARDS ACCEPTED I ACCOUNT# CVV# EXP DATE: Mo Yr V011.19 Application Form RBA01 Minneapolis City of Lakes Development Services Customer Service Center 505 4th Ave S, Room 320 Minneapolis, MN 55415 Office 612-673-3000 or 311 TTY 612-673-2157 www.minneapolismn.gov/mdr Office Use Only A/P LIC # Date: Amount REGULATED BACKFLOW ASSEMBLY (RBA) APPLICATION FORM/TEST REPORT COMPLETE JJOVByADDRESS (INCLUDE AypQt/�U�nit #) NAME OF BUILDING, OWNER/OCCUPANT, CON ACT NAME AND PHONE NUMBER APPLICANT COMPANY NAME r �>r c CONTRACTOR LICENSE # Ll It CONTACT NAME AND PHONE NUMBER 3 ADDRESS 10 r ( q I /�I L �� �� � � CITY � 1 `� I � � STATE ,�,-v ZIP ss L� q I EMAIL TESTER NAME ) TESTER CERTIFICATION # PHONE — 7P J f TEST EQUIPMENT MANUFACTURER TEST EQUIPMENT MODEL # TEST EQUIPMENT SERIAL# TESTING EQUIPMENT CALIBRATION DATE Mo Yr TYPE OF WORK AND FEE INFORMATION (check one) FEE: $41.40 PLUS $1.00 STATE SURCHARGE PER EACH DEVICE FEE: $41.40 Install Relocate Remove Replace and SN# of Replaced Device Rebuild - Test BACKFLOW ASSEMBLY DETAIL INFORMATION Type (check one): _ Reduced Pressure Principal or Pressure Principal Fire Protection _Reduced Pressure Detector Fire Protection _Double Check Valve Double Check Detector Fire Protection _Pressure Vacuum Breaker _Spill Resistant Pressure Vacuum Breaker Manufacturer: _ Model # Serial # Size: (inches) System Serviced Location in bldg Floor # Room # TEST RESULTS: Pass D Fail (COMPLETE APPLICABLE ASSEMBLY TYPE SECTION BELOW) Reduced Pressure Principal or Reduced Pressure Detector Fire Protection (RP) — TEST RESULTS Check Valve #2 Shutoff Valve #2 Check Valve #1 Pressure Differential Relief Valve Initial Test Closed Tight _Yes _No Closed Tight _Yes _No Closed Tight _Yes _ No Pressure Drop Across Check Valve #1 psid Opened at psid Final Test Closed Tight —Yes—No Closed Tight _Yes _No Closed Tight —Yes—No Pressure Drop Across Check Valve #1 psid Opened at psid Double Check Valve or Double Check Detector Fire Protection (DC) — TEST RESULTS Check Valve #1 Check Valve #2 Shutoff`, Valve #2 Initial Test // Closed Tight Yes No P psid Closed Tight Yes _ No14— psid Closed Tight A'' Yes _No Final Test Closed Tight _Yes _No psid Closed Tight _ Yes No psid Closed Tight _Yes No Pressure Vacuum Breaker (PVB) or Spill Resistant Vacuum Breaker (SRVB) — TEST RESULTS Air Inlet Valve Check Valve Shutoff #2 Initial Test Failed to Open _Yes _ No Opened at psid Closed Tight Yes No — — Pressure Drop Across Check Valve #1 psid Closed Tight Yes No Final Test Opened at psid Closed Tight _Yes _No Pressure Drop Across Check Valve #1 psid Closed Tight _ Yes _ No Describe parts and repairs when needed: CERTIFICATION: I hereby certify the foregoing information provided by me to be co e t and that e est d device is functioning in compliance with State of Minnesota Plumbing Code, Chapter 4714. TESTER'S SIGNATURE --� TEST DATE: v .-' MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHARGE TO ALL MAJOR CREDIT CARDS ACCEPTED ACCOUNT# CVV# EXP DATE: Mo Yr V011.19 EricREDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT OR Plumbing- Heating•Air•Electrical TESTABLE DOUBLE CHECKS Service Name: oo' I<- ` Contact Person/Tele: Address: e-;Ll Ce City: State: %'VN Zip: � `2 Device Location: C� Serve what system: J Account No: Serial Number: —�2 1 L/,2 J3 Type: Make Rebuild Due Date: Model: —X Size: Test Due Date: 'XIa / Annual Report Check Valve #1 Pressure �� � C Check Valve #2 � Differential Pressure Relief Valve Pressure Opened at psid reduced pressure. Did not open Cleaned Cleaned Cleaned Replaced Replaced Replaced R Disc Disc Disc E Spring Spring Spring P Guide Guide Guide A Pin Retainer Pin Retainer Diaphragm, Large I Hinge Pin Hinge Pin Lower R S Seat Seat Upper Diaphragm Diaphragm Diaphragm, Small Other, describe Other, describe Lower Upper Spacer, Lower Other, describe Sign and date Tag The above is certified corre ct. Signed DateTested: Tested by (Print Name)- L` ' Certification Number U� `�� % Company Name: C k,� Q� ' H Q F Licens e Number ft q3-3qq Company Telephone Number 763-7�3-q5li5- J V EIF REDUCED PRESSURE BACKFLOW PREVENTER TEST REPORT OR Plumbing- Heating-Air•Electrical TESTABLE DOUBLE CHECKS Service Name: &k /Z L j, .G�' / �/C 2!� Contact Person/Tele: Address: /l1 `�� �v�{1� rz'`.� CW-City:'_~14r�01 —,,- t State: �'l�rrt zi : Device Location: �c1�'f,} & �- ( �c. Serve what system: Account No: Serial Numbe Type: Make: C,� Model: Size: Z Rebuild Due Date: Test Due Date: Annual Check Valve #1 Check Valve #2 Differential Pressure Relief Valve Report Pressure o'1 �� Pressure Opened at psid reduced pressure. Did not open J---- Cleaned Cleaned Cleaned Replaced Replaced Replaced R Disc Disc Disc E Spring Spring Spring P Guide Guide Guide A Pin Retainer Pin Retainer Diaphragm, Large I Hinge Pin Hinge Pin Lower R Seat S Seat Upper Diaphragm Diaphragm Diaphragm, Small Other, describe Other, describe Lower Upper c fC - , ii `i l Spacer, Lower Other, describe Sign and date Tag The above is certified correct. Signed %,,sj, -� DateTested Tested by (Print Name) A �� Company Name: F— r 1 t 50 UAL -- Company Telephone Number / b 3 —77 ' 3 ` � � w Certification Number License Number