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Home My WebLink About2017-01633 - plumbing • CITY OF ORONO 111 Ii. 7 I 0i li i6'I 3i* 20 31'I 1w 2750 KELLEY PARKWAY DATE ISSUED: 12/15/2017 ORONO, MN 55356- (952) 249-4600 FAX: (952) 249-4616 ADDRESS : 800 OLD CRYSTAL BAY RD N PIN : 28-118-23-43-0010 LEGAL DESC : N/A : LOT 000 BLOCK 000 PERMIT TYPE : PLUMBING PROPERTY TYPE : INSTITUTIONAL-SCHOOL CONSTRUCTION TYPE : BACKFLOW DEVICE/TESTING/REPAIR ACTIVITY : BACKFLOW DEVICE APPLICANT BACKFLOW PREVENTER TESTING/REPAIR 10.00 STATE SURCHARGE FLAT-ADDITIONAL 1.00 COMMERCIAL PLUMB&HEATING INC. TOTAL 11.00 24428 GREENWAY AVENUE Payment(s) FOREST LAKE,MN 55025 CREDIT CARD 8934 11.00 (651)464-2988 OWNER Orono School District 278 685 OLD CRYSTAL BAY RD N PO BOX 46 LONG LAKE,MN 55356-0046 AGREEMENT AND SWORN STATEMENT The work for which this permit is issued shall be performed according to the approved plans and specifications,applicable City approvals,and the State Building Code. This permit is for only the work described and does not grant permission for additional or related work which requires separate permits. All provisions of laws and ordinances governing this type of work shall be compied with whether or not specified herein.This permit will expire and become null and void if construction authorized is not commenced within 180 days of the date of issuance,or if construction is suspended for a period of 180 days at any time after work has commenced. The applicant is responsible for assuring all required inspections are requested in conformance with the State Building Code.This permit may be revoked at any time for due cause. Applicant Permitee Signature Date Issued By Signature Date • ' Dec. 12. 2017 9:47AM �No. 4291 P. 2 , t ' , Jo 1 Mailing Address Street Address FOR CITY use ONLY scitfrP.O.Box 66 2750 Kelly Parkway Date Received; Crystal Bay,MN 55323 Orono,MN 55356 permie�f �C�7 " '`� '`y� Lt Phone:952-249-4600 Fax:952.249-4616 Approved ay: �'') .t C', Website: Www.ci.orono.mn.us Date Issued: 1 L /5T t/7 • CITY OF ORONO — BACKFLOW PREVENTER TESTING PERMIT PERMIT CODES:City of Orono, Minnesota State Plumbing Code,Backflow Device Only t� iN S � N7p , !+raiMI VAGOV`.rr ,m uA t a.&,,>a ."i:..Tsonrt14RV';n: l , ,ari ',), -hE ,•.b: t t .,it if0, ,,, Job Site Address:SCib, lcL Q[ (� (3Q Owner: ()>'C) J( C��' 1.`-�` I 0 elephhoone Number:c Q • 4 i-i"'I ' `6 9 Mailing Address: d f) 1; ,18. C.q 1iS�c& V)--;o. . K> ' City: �A'lf?L �F' Ail Zip:Zip: , �e--•)Ln .. Contractor. i► a •e.° 0 i : /AI L.d .1 •lephone Number 0]I' 4f,,9-• ` `(s'(1) Contact Person: 1 P- \1 y'V ,ly, '4 I� V, License# PC L I 1 Mailing Address gLI- '3- 6.-,v--6, e' ✓1L.11Cuj A-ve Dv e__---,--)- Lei / y) 5La.3 WATER SUPPLY: Lake❑ Well❑ City❑n BACKFLOW DEVICE: AVB❑ PVB❑ Quantity .� COMMERCIAL 1' RESIDENTIAL ❑ GENERAL INFORMATION 1. All testing reports shall be submitted to City Hall after work has been completed. 2. Provide the following information on all reports: • a. Job address,Owner/Occupant. b. Testing person's name,certification number. c. Company name,address, phone and contact person. d. Description of work:test,repair or replacement.(New installation requires a separate permit) e. Location of device(s)and system being served by the backflow preventer(s). f. Make,Model,Size,and Serial Number of each device. g. Testing cycle year,testing date and or overhaul date. h. Testing results and comments. I. Report must be signed by person doing the work. • PERMIT FEE CALCULATION 1. Permit Fee: $ 10.00 2. State Surcharge: $ 1.00 3. Mail-In Fee: $ 2.00 4. TOTAL PERMIT FEE(Add lines 1-3 above) $ The undersigned hereby applies to the City of issuance of a Backflow Testing Permit,agrees to do all work in strict accordance with the ordinances of the City and State regulations,and certifies that all statements made on this application are complete,true and correct. Applicant: Date: Page 1 Dec, 12. 2017— 9:47AM — 1� �� No, 4291—P. 3 — 24428 Greenway Avenue ANNUAL TEST FORM 1- MN 5P 65a #OMMENCIAI *rn ? aar.wcti kii..ram: BACKFLOW PREVENTORS Fina:6�Ln spa dh.ec u CUSTOMER' ih ••I• .•Is. \ ! tot • STREET ADDRESS btc . 1.4 1 MAILING ADDRESS P(D. 1-1.1::). '-:r---T--)3:31„, NEV INSTALLATION❑ EXISTINGEO REPLACEMENT El OLD ASSEMBLY S.N. LOCATION OF ASSEMBLY: CAI 111 lir " '-'. A, : tY1 TYPE OF ASSEMBLY: ��(XR""PZ' DCVO PVBE SVBD SIZES �`, E INSTALLATION DAT MANUFACTURERS \IMODEL: knt -ZZ- SERIAL IS: I LLC RELIEF VALVE CHECVALVE K#� CHECK VALVE #1 CHECK VALVE #2 pressure Sp1ll DOUBLE CHECK VALVE Vacuum Resistant Back Pressure In Direction of In Direction of Breaker Vacuum En Direction of Test Flow Test Flow Test Breaker Flow Test Opened a 11 Leaked I=1Leaked El Leaked Air Inlet opened at #1 #2 s1 ElClosedTight El pqj ❑Leaked Leaked p ❑ Closed Tight Differential Pressure ❑ Closed Tight Did Not Across check valva Dld Not Open Closed Closed !]pen Differential Pressure Check Valve ❑ Li Tight ❑ Tight . Across check valve (Must Be psi Leaked 2 PSI Beor (Must Be At Least Psi 3 PSI Higher Than Greater) The Relief Valve) held at psi -psi psi PASSED PASSED f, PASSED El PASSED ❑ PASSED PASSED 0 PASSED❑ FAILED FAILED ❑ FAILED ❑ FAILED ❑ FAILED ❑ FAILED FAILED CHECK ALL THAT APPLY ❑Cleaned Only ❑Cleaned Only EICleaned Only ❑Cleaned Only ❑Cleaned Only #1 #a Replaced Replaced! Replaced( Replageit Replaced' ❑Cleaned ❑Cleaned Only Only Rubber Klt— Rubber Kit_ Rubber Kit_, Rubber Klt— Rubber Kit— Replaced' Assembly_ Assembly_ Assembly'. Assembly.. Assembly. Rubber Ki Rubber Kit— Disc_ Disc Disc Disc Disc, air In Assembly Assembly=Diaphragm_ D-rings_ D-rings ❑-rings_ Disc, CV D1sc Disc Spring_ Spring_ Spring. Spring Spring, air_ [primps D--rings: d-rings_ Either Other Other 0-ring Spring Spring_ Either Other Dither Other_ Describe Repairs' la'. k ''Z , ... Mika_ _ k MIM1121 Opened at Differential Pressure Differential Pressure Air Inletpsi Check #1 ❑Closed tight Across check valve Across check valve psi _psi psi psi Check valve psi Check #2 psi Opened shut off #10 Opened shut oFF #2111 Water Pressure Test Kit SN Remarks: I hereby Certify that this date Is accur4 and ref ects the proper operation and maintenance of the assembly,TESTER'S NAME (PRINT) � r4 r CERT, # to TESTER'S SIGNATURE S___.Q _ DATES 11. 11._ TIME COMPANY C�C:z —Dec, 12. 2017— 9:47AM — — b�� No. 4291—P. 4 24428 Greenway Avenue. NNUAL TEST FORS Poi 65 4 4-29.86S SCOMINIII0M1,.n,�u�vn Ftk.�7'i4u BACKFLOW PREVENTORS Fax:. 651-464-2425 ab.co'i; CUSTOMER!. m 41i _ '-L \ `. . I , •1 STREET ADDRESS N 1c �k' 1,VV (e=0,1)) LI MAILING ADDRESS' Q 'r't�Y1Qj �o NEW INSTALLATION[] EXISTING' REPLACEMENT ❑ OLD ASSEMBLY, S.N. L❑CATI❑N OF ASSEMBLY' T+. "� " c .....!,-A iii, x. TYPE OF ASSEMBLY! RPZ] DCVO PVC] SVB❑ SIZE' a INSTALLATI❑N DATE! MANUFACTURER' MODEL'C I•ll 9-&—r SERIAL #a. t)V-t RELIEF VALVE CHECK CHECK VALVE #1 CHECK VALVE #E spill DOUBLE CHECK VALVE VALVE #'c Pressure Resistant Back Pressure In Direction of In Direction of Vacuum Vacuum In Direction of Test Flow Test Flow Test Breaker Flow Test Opened at n Leaked 0 Leaked 0 Leaked Aft- Inlet opened a± ill #2 Psi n Closed Tight L� psi ❑Leaked ❑Leaked ❑ Closed Tight DIFFerentlpl Pressure ❑ Closed Tight Did Not ❑ Across check valve Did Not ❑pen Closed Closed Open nlFferentlnl Pressure Check Valve 111 ❑ Tight ❑ Tight Across check valve (Must Be psi Leaked ❑ 2 PSI Be CMus't Be At Least - psi 3 PSI Higher Than held atpsi Greater) The Relief Valve) psi psi • PASSED 1:21PASSED j PASSED 14 PASSED ❑ PASSED ❑ PASSEbn PASSED❑ FAILED ❑ FAILED ❑ FAILED ❑ FAILED ❑ FAILED D FAILED❑ FAILEDf CHECK ALL THAT APPLY _ ❑Cleaned Only ❑Cleaned Only ❑Cleaned Only nCleaned Only ❑Cleaned Only #1 #2 Replaced $epi.aceri Replacet Replaced: Repllaced' ❑Cleaned Cleaned Only ❑ Only Rubber Kit Rubber Kit` Rubber Klt" Rubber KIt_ Rubber Klt— Replace' Assembly` Assembly. Assembly_ Assembly, Assembly Rubber Klt—Rubber Kit-- Disc Disc r Disc 'V- Disc_ Disc, air In AsseAsseDbl y_Diaphragm_ 0-rings O-rings_ 0—rings,.. Disc, CV Disc DlgcSpring _ Spring_ Spring_ Spring` Sprin�, air^ a-rIngs_ ❑-rings =O-rings, Other Other Other_ ring Spring_ Spring_Other_ Other Either Ether Describe Repairs'. i/ � i V Opened at Differential Pressure Differential Pressure Air Inlet sl Check #1 psi E]Closed tight Across check valve Across check valve P psi ,- psi psi Check valve psi Check #2 psi Opened shut off' *in Opened shut off #20 Water Pressure Test Kit SN Remarks' I hereby certify 'that 'this date is accura a and reflects the proper operation and maintenance of t e assembly. TESTER'S NAME (PRINT).. A`, V CERT, # T � _ TESTER'S SIGNATURE DATE_ 1 6�- II TIME COMPANY C.,- (:\ Dec. 12. 2011— 9:47AM 1141 L. No, 4291---P: 5 • 24428 Greenways Avenue ANNUAL TEST FORM 51-442gg#0MMHG,AL.sm'Vri.•.Yp KWnT/NtC BACKFLOW PREVENTORS tax. 631-4sa-2425 Email; infa@cpandh,cclis CUSTOMERI, Z', �(" I\ 1 �1 )\ STREET ADDRESS ►r. +. 4 ►• flat , t.ati - . MAILING ADDRESS' 0 rb Ylb )M,1-\ • S -27 4__• NEW INSTALLATzgND EXISTINGN REPLACEMENT ❑ OLD ASSEMBLY S,N LOCATION OF ASSEMBLY1 `C TYPE OF ASSEMBLY' RPZ[J DCVO PVBD SVBE SIZE' 1 _ INSTALLATION DATE' MANUFACTURER' - MODEL' c'1 to C SERIAL #' x.)0131'1 RELIEF VALVE VALVA CH #z CHECK VALVE #1 CHECK VALVE ##2 pressure Split DOUBLE CHECK VALVE Vacuum Resistant Back Pressure In Direction of In Direction of BreakerVac'" '' In Direction of Test Flow Test Flow TestBreaker Flow Test Opened at ❑ Leaked 0 Leaked El Leaked Mr In(e4 opened at � #1 #2 LA' Lf sl 0 Closed Tight psi Leaked ULeaked p ❑ Closed TI ht 9 DlfFeren*lal Pressure ❑ Closed Tight Dlol Not ❑peri Closed Closed Did Not 0 Across check valve DIPferentlal Pressure Open LJ Across check valve Check Valve ❑ ❑ Tight ❑ Tight (Must Be % - psi Leaked ❑ 2 PSI or (Must Be At Least psi 3 PSI Higher Than held nt Greater) The Relief Valve) psi P51 psi PASSED El PASSED 'E PASSED EJ PASSED ❑ PASSED EI PASSED( PASSED❑r FAILED E] FAILED ❑ FAILED El FAILED ElFAILED [] FAILEDE FAILED[] _ CHECK ALL THAT APPLY ['Cleaned Linty Cleaned Only DCleaned Only ! ❑Cleaned Only ❑Cleaned Only, #1 #2 Replaced Replaced! Replaced' R,placed' Replaced' ❑Cleaned Cleaned Only Only Rubber Kit Rubber Kit— Rubber Kft,_ d Rubber Kit_ Rubber K1t— ReQlace ' Assembly_ Assembly_ Assembly_ Assembly_ Assembly_ Rubber Klt''Rubber kit—' DIS c_ Disc DISC Disc Disc, air In Diaphragm.. D-rings_ ❑-rings_ ❑--rings_ Disc, CV _ Assembly=AsseDbly Spring_ Spring_ Spring Spring, S ring, air DISC Disc_ d-sins_ Other Other Other Spring, — R-piing— ❑Sprng_ Other_ — 9 _ Spring— Spring_ — Other Either— Other — Describe Repairs i a. a - -.1 _+ .Q citi 1x\1 l V- °pened Qt Differential Pressure DIPPerentlal Pressure Alr Inlet sl Check RI Closed ti ht Across check valve Across check valve P psi Psi psi psi Check valve psi' Cheek *2 psi Opened shut oF•F #1❑ Opened shut off 420 Water Pressure Test Kit SN Remarks' — I hereby certify that this date Is accuradif and re lects the proper operation and maintenance of t e assembly, TESTER'S NAME (PRINT) G,' 0 A. - • CERT. # QInloa I TESTER'S SIGNATURE ,•.. ! r/_ ./&-r.s DATE i< 'll i 1 .TIME COMPANY C �