1674 BoardwalkParcel Files Cover Sheet
Unique ID: 1936
1674 Boardwalk
103190010003
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3Itv of ??? ??a ,.v V?ATgR SERYIC? P?RA?1?
P.O. 21199 PkIZMIT NO.: 8052
Ea9tn; h+lN 55121 DA7'E; 10-20- 6
Zor+lrvy .: Ri No. of Units: 1
Owner: Frontier Midwest
/ldd?esa:
Sito qdd,eu. 1674 Baardwalk M L10 B3 HMton HeighCs
Pturnber: 3tar-Plumbin
, Meter No.: ??6,3 /D tI/ L O parge: 504. t3{?pd
; size: ,Sfn Roort v? 15 . dflpd
? R+eadar hto.: 47o7a9 $8{pre diQ?i11$ B. 10.0
t egr,? tw Me •?. , S0pd
? ?W? ?.
Byl
??QU'RE15Otdt:"!6bA\6j 1
61 `?0mA ?ror
Date Paid•
af FResp.: IrAp.:
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01-3422 Plan Chiack
0I-1445 SurGhr /AUlllr }re?
01-3446 SAC1Adm, ,
01-2I55
k' Surcharge
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'17-3860 . . . .
Road Unit . ..
,
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20-2275
5AC ,
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20-3$65 Water Conn. DO e-cJ ?
20-3868 Water Trmt.
20-3716 Water Meter
20-2252 Adct. 'Dep.
20-3713 Water Permit
20-3743 Sewer Permit
79-3866 5ewer Conn. ?
11-3855 Park Ded. ' f
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, . . CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-198, Eagan, MN 55121 N2 ,.. 12326
? PHt3NE:454-$100
BU{1.DING PERMIT Receipt #
To be used for $F DWG! GAP- Est. Vatue $64R000 Date '?ULY 23-j 19 6
Site Address 1674 BOARDWALx Erect ? Occupancy
Lot I?Block 3 Sec/Sub. ?"TON HTS Remodel ? Zoning gp
Parcei No Repair ? Type of ConstU;
. Addition 0 Na Stories
ac
Name PARrrINr RxLK & 'u`nl?IEJA• B.
Move ?
Length 40
W .??? ????$? ?"? ?
Z3 Address 5
Demolish ?
?
Depth 47
? ? ity ??sS Phone ???"fi?.t.? IM. Impr.
Install ? Sq. Ft
14IMMST 10
o Approvals Fees
Name
z?
? ? ? AddresS
Assessment
Permit . *
~ City' Phone 633
? Water & Sew. Surcharge
-
Police Plan Review
?
? F a Name
? Fire SAC?? s #
?? Address
a W Eng. Water Conn.
r
city Phone Planner V6la#er Meter
[ - . Gouncil Road Unit
G 1 hereby acknowledge thatl haYe read this application and sta4e that the
Bldg. Off.
Tr. PI.
' information is correct and agree to comply with alf applicable State of
Minnesota Statutes and City of Eagan Ordinances. APC Perks ?
Signa#ure of Pertnittee Var. Date Copies?.?.?a,.? :
?
Total
A Buitding Permit is issued to: on the express cond+tion that
alt work shall be done in accordance with ali appli Ye State of inne
~ ?tatutes and C ity of Eagan Ordinances.
Building Official ? ?
'?1??'? --?- r?? ` _"„^"•"=
` Permit No. PerrnN tloldar Date TslAphone #
Ptumbing
H.Y.A.C.
Eleceric 74
SoRener
Inspection Date Insp. Comments
Footiogs I
FooHnga 11
' Foundadon
Framing
? RooNng
RouQh Plby.
' Rough Ntg. H ?
inaul.
' Fireplsce
finat Htg.
Final Pibg.
Bidg. Final
' cert. oca
Deck Ftg.
Deck Frmg.
Well Descrtbe Locatbn:
Pr. Disp.
R . .. W. - :. :. _20
_ PEf?iNIT #
` • ? PLUM?N?`a PERMIT
RECEIPT Q %,
GTi( QF EAtSAN
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3830 PIL sAN, MN 55121 DATE:
OT KNOEi ROAD, EAi
CONTRACT PRICE PHONE: 454-8100 '
Site Adc?r@ss ? BLDG. TYPE WORK D?CRlPTttiFl ;
Lot C..? Block Sec/Su
? ?
Res.
' - New
?
Ebi
Name WENZEL M
I
t
Mult Add-on
?o .NNE
Addres
,
`?' ?? Comm Repair '
c City ' Phone , Other y
8
L Name N0. FIXTURE
Water Closet - $3.00 ?.?
c ?
3
p Address
Ciry ?? ?'? Phone ` Bath Tubs -$3.00
=Lavato
ry - $3.00
??
Shower - $3.00
I ,..?.
2?00
-Kitchen Sink - $3.00
-
FEES
,
Urinal/Bidet - $3.00
COMM/IND FEE - 1% OF CONTRAGT FEE
-??undry Tray - $3.00 „?.
MINIMtJM - RESIDENTIAL FEE _ $1p.pp -?Floor Drains - $1.50 ?
; MINIMUM - COMM/IND FEE _ 20.00 ?Water Heater =$1.50 ?.
? STATE SURCHARGE PER PERMIT _ ,50 -
Whiripool - $3.00 .;?..
?
?(ADD $.50 S/C IF PERMIT PRICE GOES ?- Gas Piping Outlets -$1.? Q.
? BEYONO $1 ;(?Q0.00) Softener - $5.00
Well - $10.00 °
j ? Private Disp. - $10.00
3_Rough Openi,nqs - $1.56 --?
SIG URE 017,0CRMITTEE FEE; a?S.
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Name WENZEL MECHOICAI. ? ?y? @R? .
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? ? Ackir?s3600 Kennebec Uriva AdO-m
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? C;ty Eagan PI? 452-1565 n. R
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k` FRONTIER t?OI+[pAt?]IES
t+?me ? ? ? 4
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?iclress3408 Sibley Memoxja?. H?
+r . RES. HV?4C a-100 M BTl1
- ;
0 city Esgan Phone 4 54-0433, ADDiTK3Ad,Ai. 50 M BTtJ -
v`
?- AdD-tDld AIR GC?htD. 0-24 BTt! ' - 'f
?- TYPE OF WORK ?. ADDITIOlUAL 6 M BTU
?
? Fvroad Air 80,000 nn B,-u 24. oo GAS oun.Ers
C[}fidlM/IPIC1 fEE - 196 (F CONTPACT FEE
° soiw M BTIJ M1N1AAUM - RESdDEhITtAL FEE
; RJnit HeaW AA B7'IJ Mit+iiMUM - COMM/IND FEE
` Air Gotu9. M BTU STATE S?J€?hIARGE f??F? PER?'"
T .? 'i
GFM (At7fl $.50 SlC IF PEWMIT PF??? "
?
Gas Pi?g 0u?ts #
1.50
.
?YC1ND ???) `
?.
. Other
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Fg, 25.50
; S SIGNATUflE t'!F PERMa E t t W??
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AGAN
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CITY OF EAG AN
3830,Pilot Knob Rdad, P.O. Bqx 21 -199, Eagan, MN 55121
, PHONE:454-8100 . `±
BUILDING PERIIAIT Receipt #
To be used for "4 Est. Value ?390M Date XU 2 * LL , 19A*- :
Site Address 1674 JAWN"
OFFICE
t1SE ONLY
Lot 10 Block 3 Sec/Sub. VAWMM IMIOM
Parcel Na occuPancy - FEEs
W
Na1718 lic? ?"Lim Zoning -
(Actual) Const -
Bldg. Permit
o Address 1674 BQUWWAU (Allowable) - Surcharge
City RAQU PhOnB 01'"941 # of Stories - ,,
Length ??? 12&12 Plan Review
, o Name Depth - SAC, City
ou
04 AddfBSS S.F. Total
-
SAC, MCWCC
¢ City Phone S.F. Footprints
e Water Conn
On Site Sewag
-
I f„
w w N8t1lQ On Site Well - Water Meter
? z
o?
I
AddreSS
MWCC S stem
Y -
Acct. Deposit
Wz U Clty PhOn@ City Water
PRV Required _ S/W Permii
I hereby acknowlege that I have read this application and state that the Booster Pump - S/W Surcharge
information is correct and aqree to comply with all applicable State of
?
Minnesota Statutes and City of Eagan Ordinances. Treatment Pl
?
F Signature of Permitee APPROVALS Road Unit
A$uildirq Permit is issued to: ?? I'AfttX Planner - Park Ded.
on thQ express condition that all work shall be done in accordance with all Council - ??
•
applicable State of Minnesota Statutes and City of Eagan Ordinances: gld9. pff, Copies
Building OffiCial =
. . . Variance
-
. . ,,.:_ ; . .?.. w TOTAL
„?.??..,.?.•
Permit Nc. Permit Hoider Date Telephone #
WATER
SEVYER
PLUMBING
H.V.A.C.
ELECTRIC
Mspectiort Date Insp. Comments
Footings 1
Foundation
Framing 4 oLT S
RooFing
Rough Plbg:
Rough Htg.
IsuL
Fireplace
Finai Htg.
Final Pibg.
Const. Meter Plbg. Inspector - Notify Plumber
Engc/Plan
Bidg. Final
Deck Ftg.
. Deck Final
• Well
Pr: Disp.
CITY OF EAGAN N? 16 51$
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
BUILDING PERMIT
DECK
To be used for S(;RF.I
r PHONE:454-8100 C
?l ??
? Receipt #
PORCH Est. Value $3,000 Date MAY 24 , 19 89
Site Address 1674 BOARDWALK
Lot 10 Bl ock 3 Sec/Sub. HAMPTON HEIGHTS
Parcel No.
W Name RICHARD PARLIN
Address 1674 BOARDWALK
o City EAGAN Phone 681-9461
o Name SAME
,
z?-
0
?
Address
0
? City Phone
U?
W
Name
W
w
F
;
Address
?
<W Ciry Phone
I hereby acknowlege that 1 have read this application and state that the
information is correct and agree to comply with all applicable State of
Minnesota Statutes and City f Eag n OrdiVn/1??2(???
2
Signature of Permitee 4 /
A euilding Permit is issued to: RICHARD PARLIN
on the express condition that all work shall be done in accordance with all
applicable State of Minnesota Statutes and City of Eagan Ordinances.
Building Official
1
OFFICE USE ONLY
Occupancy -
Zoning
(Actual) Const
(Allowable)
# of Stories
Length Porch 12x12
Depth
S.F. Total _
S.F. Footprints _
On Site Sewage
On Site Well • _
MWCC System _
City Water _
PRV Required
Booster Pump
APPROVALS
Planner
Council
BIdg.Off. -
Variance -
FEES
Bidg. Permit 54.00
Surcharge 1.50
Plan Review
SAC, City
SAC, MCWCC
Water Conn
Water Meter
Acct. Deposit
S/W Permit
S/W Surcharge
Treatment PI
Road Unit
Park Ded.
Copies 20 . 00
TOTAL 75.50
CITY Uf EJKQAM WATER SEROM lO
3M PiMt i4nab RoW ?
8052 ? ._
P. Q, Box 21499 .
PERMIT NO.: .
Eapn, li1Ni •85121 ' DA1tE: I0q20-8$.
z,a,?i„9; No. o# i1rits•
Qwner: ?+?ttie?'
Addross:
Site I?ddrm:, i1 674 Bt?t????al ?_y._110 B3 HeL&$tu
Plurwxr. StaP Plu bitt -;
- '
; .. .
Meter No:"- -
Connection CFW?00: ?•
st:et Acawnr Qeposi#k ?
` Reader No.. Potmit Fee: i104W
? 1 te eawn0y wk6 ds C'ity af E"ee Surchorge• ?- .,5bd
? O.Nwoeaa. Misc. CFwrues:
?. fiotoi: A3 5120...Are .:
By Date Raid: ?.._ ?
Dete of Insp.: Irmp.: „
- ? ,;
' CITY OF EAGAN SEVVER $ERYlCE PEmff ?
' 3830 Pif+ot Knpb Road
9204
.
; t'.'O. Bcx 21199 PERMIT NO:: ?
Emjm. MN 55127 DATE: 3.0--2e."?4S
Zw?iryQ: - B1 No. of U»tta: I
Owrw: Ej=t ior Midwe3t
Address:
Site ,4ddresst } 1674 ' arr?nlk i I-G'- B3 HflmY>taPa Heighfis
Ptumtmr: Stir PZt73Rbin?
7-24-«86 65001 100.0004
I GYras +e ampy wft do Cfty ef Eawe Coranectian Chorpe:
? Acaount pepoWt:
Permit Fee•
r
SUICj10tQQ:
BY Mim G`horym
`
` i?ate o# insp.: Tatol:
I^sp.: DeM Pald:
,
.
,.;,
void
WW3 pm .
A 7 19 ,6 3, 5, e , Ha rti-, p?? r? Ht"`_5 '192-00'
Re st Date n Fire No. Rou h-in spection'
Requir
[:]Ready Now . otifY. InsPec-
- l/ ?'?-' es ? No tor When Ready
H`Licensed Eiectrvcal Contractor I hereby'request inspeetion ofabove
? Owner electrical work installed at:
Str eYAddress, Box or ute No.
4Y Ci'ty l
' /1
ecuon 14o. Towns ip Name or No. Rartge No. ' Counzy.,
Occu nt (QF,tINT)
?(?a- - Phone No.
Power S Pl ier' Address
y f ,1 1 t_..-.c? •
Elec f.ql3?Lao,j
N om?nV ?Name) ???????
I K ?ntror's Lic?se No. _
Mailing Address q4?3a4WZ ?F]QLh7p?wryl0lpg??qst{ ?t?r}?
"'3'?J .?.?r1Y1V ?elL. Lt''?jl?
A
Authorized: S
e nt M1¢a s Phone Number
MINNESOTA STATE'BORRD OF ELECTRICITY THIS lNSPECTION REQUEST WILI NOT
Gciggs-Midway Bidg. - Room N-181 ` BE ACCEPTED BY THE 57ATE BOAcRD
1$21 University qve'., St. Paul, MN 55104 ' UNLESS PROPERJWSPECTtON fEE IS
Phone (612) 297.211'1 ENCiOSED.
REQUEST FOR ELEGTRICAL INSPECTION E8-00001-04 ?
? Il, See iostructions tor eomvleting this form on back of Yellow covv..
3 4 719 "X" 8e/ow Work Covered by This Request
Nv4 Addj Aep.?j Type 01 Building Appliance3 Wired €quipment Wirerl
Home Range Tem rary Service
` Diiplex Water Heater ? ightin,y Fixtures
Apt. Buiicting Dr Electric NeflUii
Gommercial Bldg. urnace Silo Urtloader
lndustrial Bidg. Air Conditioner "Su{k Mi1k Tank`
Fafm . Other Peci y ...Other (Specity)
t.r uecify t er Other
ompute lnspecFion Fee Below
# Fee ServiceEntranceSize 1i Fee `Feeders/Subfeeders # ` Fee CirGUits
U to' 200 Am s O to 30 Am s 0 to 30 Anj s
Above 20 qmFas' 31 to 100 Amps 31 to 100 q;
Swimmin Pool Above 100_Amps Above 100_Qm '
7ranstormers frrigation"l3ooms PariiaJ-'Other'Fee `
5igns Speciai Pnspection
TOTQt
Rema rks
v
9 1
Rough-in Daie 1, the Elec icgl
nspector, hereby
certify that the a6ove
Final ? te 12 insPection has been
L ? O msde.
fhia request void 18 montAS from
CITY OF EAGAN _
' 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 N2 12326
BUILDIN'a PERMIT PHONE: 454-8100 Receipt # j"
To be used for SF DWG/GAR Est. Value $64,000 Oate JULY 23, , ig 86
SiteAddress 1674 BOARDWALK Erect Occupancy R3
Lot HAMPTON HTS
10 Block 3 Sec/Sub Remodel ? Zoning pn
Parce .
l Na Repair ? Type of Const. Viz :
Addition ? Na Stories
¢
Name PARLIN, RICK & SMIEJA, B.
Move 11
Length 40
Demolish O Depth 47
Z 5723 XERXES AVE SO
Address Int. Impr. ? Sq. Ft.
o Ciry MPLS phone 929-6919 Instan ?
lx
o FRONTIER MIDWEST HOMES
Name Approvals Fees '
?? Address 3908 SIBLEY MEM HWY Assessment Permit $ 325.00
? City EAGAN phone 4 5 4- 0 4 3 3 Water & Sew. Surcharge 32.00
? Police Plan Review 162. 50
F W Name Fire SAC 575.00
xz'
? Address
Eng.
Water Conn. 500.00
a W City Phone Planner 'Water Meter 63 . 50
I hereby acknowledge that I have read this application and state thatthe
information is correct and agree to comply with all applicable State of
Minnesota Statutes and Eity o Eagan Ordi a s.
Signature of Permittee
A Building Permit is issued ta FRONTIER MIDW '
all work shall be done in accordance with all annlU41e State o Minngs9
Building Official
Council Road Unit 290 . 00
Bldg. Off. 7/23/86 Tr. PI. 156.00
APC Parks
Var. Date Copies '
2.10 4. 0 0
Total
MES on the express condition that
Statutes and City of Eagan Ordinances
'
?7
. ?0q,
1989 BUILDIAG PERMTT APPLICATION
` . CITY OF EAGAN
14??
SINGLE FAMILY DWELLINGS
? SETS OF PLAIJS
REGISTERED SITE SOR9EYS
SET OF ENERGY CAI.CS.
MLTIPLE DWELLINGS
2 SSTS OF PLANS
?GISTMD srrE soavEYs -
(CIM iTITH BLDG DIO. )
1 SET OF F.NERGY CALCS.
?.
COWIE RCIAL
2 SETS OF ARCHITECTURAL
& STatfiCTQRiL PLANS
1 SET OF SPECIFICATIONS
1 SET OF ENERG? CALCS.
MJLTIPLT Di1ELLINGS RENTAL DNITS FOR SALE ONTTS iOF UNITS
NOTEt IDDRESSES FOR CORNER LOTS - COATRACTOR/HOMEOWNER !lOST DESIGNATE iiHICH iDARESS
IS DESIRED. HO CHANGFS WILL BE ALLOiiED ONCE BUILDIlOG PERMIfi IS> I33tJED..
SEWER & W141'EA PERiIT FEES 1ND ACCOOi1T DEPOSIT FEES WILL 8S INCLqDED iTITS THE BUILDINti
PERMIT FEE. PROCESSING TIME FOR SEWER kND iFgTER PERI'iITS IS TWO DAYS ONCE • PERMIT HAS
SEEN COMPLETED INDICATING A LICEN3ED PLUMBER.
PENALTY APPLIFS WHENt PERMIT IS NOT PAZD FOR IN SAME MONTH IT IS REQUESTED.
LOT CHANGE IS REQOESTED ONCE PERMIT IS ISSUED.
13 c R
?- t ??4
To Be Used For?: ??C, e-C-.?
Site Address
16`lq /,?-
Lot LLO Block
parcel/Sub
,
Owner k,/?
Address
CitylZip Code ??5
Phone Ll,-Pe/- ? 414- ?
Contractor
Address SQi?I? f??
,, c ?
City/Zip Code
Phone c
Areh./Engr.
Date: 2 ? "c?' 11
Occupaney
Zoning
Aetual Const
Allowable
# of stories ?
Length Po,2cil 12`
Depth
S.F. Total
Footprint S.F.
On site sewage
On site Well
MWCC System
City water
PRV required
Booster Pump ?
IIPPROVAIS
Planner -
Council
Bldg. Off.
Variance
Address
City/Zip Code
Valuation : 3
x
FEES
Bldg. Permit
Surcharge
Plan Review
5AC, City
SAC, MWCC
Water Conn
ilater Meter
Acet. Deposit
5/W Permit
S/W Sureharge
Treatment Pl.
Road Unit
Park Ded, ?
Copies
3QBTaTAL ?
Penalty
TOTAL ? ?. Phone f
,', S1GMA US,E CERT I F I CATE FOR;
?+oµe eui? oe c+s
8 U RVEY1 NA ?..?,.¦¦.w, IANU[)EVEIO{•ERS
sERVicES x? NEAITUR;i
?
3908 Sibtey Memarial Highway FRQN
W COMPANI?S
Eagan, Minnesota 55122
Phone: (612) 452•3077
'.?.?
MODEL: 5'rAFFOR0
?
?.j .?-r .. ? 1 1
gcnLE; 1"=40?
0
? to
-rY
? 1 ,? fr?,???° M?•
-r8
?La'r io ?
f'c4R46'?,
\
?
-i?fiii9`?"
O Denotes Iron Maxmnt
+n Denotes Wad Hub Set
x a48.`' Denotes Existirg Spot Elevatian
(x :ROw? ) Denotes Proposed Spot Etevat ion
_,.---- Denotes Dra inaga Direct icn
-PWRtY DESCRIPTIpV-
l.OT 10 . 9LGrK ._I..._
HAMPTON HEIGHTS
accor-dirg to the recarded plat thereof,
Dakota county, Ilinnesota
-1
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,t,,ay
? vQ
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?$43?
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WAYNE D.
- _ = caRDFu
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--- 14675
-
;
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R?1?,?„s, ?
PROPOSED GARAGE FLO10R EtEVATION? 0 -50•0
PROPOSED top ot Biock ELEVATION- 850.1
PROPOSED BASEMENT FLOOR ELEYATiON- 5y-13_
IbTf` Verrfy all floor heights with Final House Plans.
Lq?AIEY_0RS (?R'r1FlC _ IaV
1 hereby certify thet this survey, plen or repor't
was prepared by me or 4rder mY direct supervisian
ard that I dm a dulY Registered Lard Sur'veYor
under the lews of the Stste of Yinnssota. alAL- Adte: ??zl _186
Wayne . Cordes, Yinn. Reg. No. 14675
. .
•' , 'R
d
,° •t?:r?
•??
111?
.,
' 2/84
CITY Or EAGAN
APPLICATIuN FOR PER11tiIIT
SEWER AND/OR WATER CONNECTIODJ
(PIEASE PRINi)
1) PROP= ACDRESS: 1674 Bo.ardwalk, Eagan, MN. 55121
r.?ar• DESR-=i'TICJ1: Lot 10 Block 3 Hampton Heighbs
(IAt/Bloc.k/Su: c'tivisicn or Tax Parcel I.D. Nuroer)
I'r' :.':I-S__-i, STFI;?T:tE/ DaT:: 0F CRTG.i:AL ISS??-..N:C3:
y
PP°Sr :I' ?^`1Ii?:/Pa0P0? I'S': N R-1 SZ7.=- ? P?t1LY .
? R-2 DUP??{ ('Ir a L':1ITS ) '
. 0 R-3 TG::1i t??rrTCE (I*F.ro,^ ; + Z-.TITS) ? TU'NI': S ) .
? 2?.- 4 LJ111- j?
? CCi?2%= Ci-AL/RETAIL,/OFF:.=
Q ITINIDCSTRL:?L
Q L%ISTI T?,'I'IC?1AI./GGV??n
2) APPLIC=?'iT (PLEAJE PRINi)
tUV•IE= Frontier Midwest Homes Corporation
ADD`tESS: 3908 Sibley Memorial Hwy. Bldg. E
CIT`!, STnTr, ZIP: Eaaan, MN. 55122 -
PHO`E: 454-0433 ,
3).
` Pic,•1Eav,
NA1''E= (PLEASE PRINi)
Star Plumbinq
FOR CITY USE 04LY
PDDRESS: 1018 Mound Springs Ter. PIUHBERS LICEvsE:
Active
' CITY, STATE, ZIP: Bloomington, MN. 55420 Expired
PHOUE: H?icr
884-4149 PLUMBER LFCENSE # 3329 Not of Record
' arr initia
t
4) OCC't,Tpp,l?]'I'/Cty'r1m (PLEASE PRINi)
TIALME: PARLIN, RICK & BONNIE SMIEJA
ADDRESS: 5723 Xerxes Ave. So.
CIT"L, STAZE, ZIP: Minneapolis, MN. 55410
PHO.lE: 929-6919
5) INDICI"iTE ,till-IICH PERi•LIT IS BEING RE(tUES'IT1D:
? C0?1NECrION TO CITY SD1ER Please mail gold copy to
? CONNDCrIGV 'Io CITY WATErt Wenzel Mechanical
3600 Kennebec Dr.
'
Q c7?
E?ER (PLEASSE DF.,SC:ZIBE) Eaqan, MN. 55122
6) i.'DIGs::.
? PI
P
aSE
`
'
-
..
.
.
F?OID APPP,C7VID PER
^.IT FOR PICK-L
P BY Ot1E OF AEGUE
P=-,SF- :112 APPIR= PEF,:•LIT TJ 1, 2 3, 4 AEOTE
(Circle one)
7) SIa,-ATL'-RE"
DATE: July 16, 1986
?
'? ?
' ,4v
F O R C I T Y U S E O N L Y
pE°HIT " rSSUED
FEES: $
S
S .
S
$
?
T
$
$
$
$
$
$
$ .
$
$
$
JUDCLiAR.r.?G.)
WATER PE:trtIT ( Ii3CL'uDE C-u r CHARGL )
WATER METER/COPPERHORN/OUTSIDT--" REtiDER
WATER TAP,(INCLG'DE CORPORATION STOP)
SE:vER TAP
`v..rV?iT ..ir? ??1? ? ?.?• ...?
ACC:OUNT Dt:PC`•SIT - PlAmER
wac
SP.C
TRliNK WATER ASSESS:?-=.1T
TRli:1K SEWER ySSESS4"iEYjT
LATEP.AL BEINiEFIT/T:?Ui1K SE::TEP,
LATERAL BENEFIT/TRU?1K WAT°R
WATER TREATMENT PLANT SURCHARGE
OTHER: TOTAL
AMOL'::T PAIDjRECEIPT ;
DOES UTILITY CONNECTION REQUIRE EXCAVATION IN PUBLIC RIG'riT OF WAY?
? YES IF YES, THEN ti"PERMIT FOR *aORK WITHIN
PUBLIC ROADWAY" MUST BE ISSUED BY THE
? iV0 ENGINEERING DIVZSION. LIST AS A COIVDI-
TION.
SUEJECT TO THE FOLLOWING CONDITIONS:
APPROVED BY: •
: TITLE: DATr:
M! Wo-M wFJM i4 W!WW4}\ !=! gFM Wi /am 14 wlf on M
S ^ '
a.
f
. . _. . - - .- . . . .. ?YtYex?txx7r7c7r7c?cx?cxx?c?c?c?cR?cacaeacaracar?c??[?cacx?cao' , ..
C I TY O F E A G A N N-Xw?: PAYMP.Rr OF k'F,E M.TIM OF *
_ ?. APPLIcATIoN DoES Nar ooisrsTM *
. * APPROVAI, OF PEE2NrT. ?
?
APPLtCATION FOR PERMIT ?
?. INSPEMON OF SE'fnffit AM/t.R`1VfM *
x?
JL U.r.ATIONS WILL ND'r ft ,*f
SEWER AND/OR WATER CONNECTION ??? MRM F'ERMT HAS BEM *
. x?
. ? APPROVID. *
. ,i.
?
__, *********************?*******??r*****
. P ease Print
1) PROPERTY ADDRESS:
LEGAL DESCRIPTION: •~
: Lot Block Subdiva:sion or Tax Parcel ID )
IF EXISTING STRL'C'ILiRE, DATE OF ORIGINAL BL'ILDING PEf2MIT ISSL'AIVCE:
?
. PRESENT ZONING/PROPOSED LiSEz (Mon Year
CONME2CIAL/RETAIL/OFFICE ? R-1, SINGLE FAMILY
r7 INIDL?STRIAL ? R-2 DLPLEX (Twu Lfiits) .
n INSTITOTIONAL/GOVERNMENr ? R-3 'IIOWNHOLSE (Three + Units) ( Linits)
? R-4 APARTMf??VT/CONDOMIIVIL'Nl Units )
2)
. NAMEz
• ADDRESSc
CITY, STATE, ZIP:
PHONE:
, 3) • ?c ?• NAME: For City LTSe .
Plumbers License:
ADDRESS: Active
. Expired
? CITY, STATE, ZIP: . ' Not recorded
PHONE: MASTE2 LICENSE# Sta ffI-n tial
4) •a ?,.i?i?;?
. NANIE t
ADDRESS: • .
CITY, STATE, ZIP:
PHONE:
'S) 1? • MC ' • ?i, : ? • • ' ??
.. [? CONNEC.'TION T0 CITY SEWF?2 Q CONNDCTION T+0' CITY WATER ? dI'HER .. .
6) T& '• iq PLEASE HOLD APPROVID PERMIT FOR PICK-DP BY ONE OF ABOVE --- -- -
.
[:3 PLFA.SE MAIL APPROVED PERMIT 'In 1, 2, 3, 4, ABpVE
• Cizcl
t e one
)
7)
e+ . . ?
?rn i •.u 1 =!!'TT ^t s e?71 . . . _. . . . . . . . .
. . ' ' _ ? .. - Glv? ? ? ? ? ? ?? ? ?? ',? ?r ? ??• f ^ •.` .
.. . . :? , , .. . . ? . . . ?? ? .
t 'l? f %
X_ ;;? ` _
:?FOR :CITY USE ONLY . ,
PERMIT # TSSUED
Z ? Pd w/Bldg. Permit FEES: ?
$ 11O%!5U $ SEWER PERMIT (INCLUDE SURCHARGE)
$ $ WATER PERNIIT (INCLUDE SLRCHARGE )
$___ $ WATER METER/COPPERHORN/OL1TSIDE READER
$
$
$
$
$?,, e?o
$ o-o
S
$
$
$
$ WATER TAP (INCLLDE CORPORATION STOP)
$ SEWER TAP
$ ACCOUNT DEPOSIT - SEWER
$ ACCOUNT DEPOSIT - WATER
$ WAC
$ SAC
$ TRLiNK WATER ASSESSMENT
$ TRLNK SEWER ASSESSMENT
$ ,
$
$
LATERAL BENEFIT/TRUNK SEWER
LATERAL BENEFIT/TRLNK WATER
WATER TREATMENT PLANT SLRCHARGE
$ $ : OTHER:
TOTAL
R CEIPT RECEIPT
DOES UTILITY CONNECTION REQUIRE EXCAVATION IN PUBLIC RIGHT OF WAY?
? YES IF YES, THEN A"PERMIT FOR WORK WITHIN PLBLIC
? ROADWAY" MUST BE ISSUED BY THE ENGINEERING
NO DIVISION. LIST AS A CONDITION.
SUBJECT TO THE FOLLOWING CONDITIONS:
<
APPROVED BY:
TITLE:
DATE : l ? 12- L If ?
,_ ?
IPARLIN
srra?W01g)ZP
:
?
1986 BIIII,DING PERMIT gPPLICATION - CITY OF EAGAN
NOTE: gLI. CONTRACTORS MUST BE LICENSED WITH THE CITY OF EAGAN
COMKERCIAL SINGLE FAMIILF DWSLLINGrS
INCLUDE 2 SETS OF ARCHITECTURAL INCLUDE 2 SETS OF PLANS
& STRUCTURAL PLANS, 1 SET'OF 3 CERTIFICATES OF SURVEY
SPECIFICATIONS AND 1 SET OF 1 SET OF ENERGY CALCULATIONS
ENERGY CALCULATIONS~
$2,000 LANDSCAPE BOND '
G'Y000
To Be Used For: SINGLE FAMILYValuation:' sa54-9" Date: July 16, 1986
Site Address 1674 Boardwalk OFFICS IISE ONLY
Lot 10 Block 3 Ereet 2K.__ Oecupaney ---00
Remodel Zoning Ar
Parcel/Sub HAMFTON HEIGHTS Repair Type of Const ?,/
Addition' # of Stories
Owner Parlin, Rick & Smieja,Bonnie Move Length ?Q
Demolish Depth V47_
Address 5723 Xerxes Ave.S. Int.Smpr. Sq Ft
Install
City/Zip Code Minneapolis, MN. 55410 -------- ---- --------------
Phone 929-6919 APPROYALS FEFS
Contraetor FRONTIER MIDWEST HOMES Assessments Permit sLs-
Water/Sewer Sureharge 3Z
Address 3908 Sibley Memorial Hwy. Bldg E golice Plan Review /6Z. SQ
Fire SAC sJr
City/Zip Code Eggan, MN. 55122 Engr Water Conn
Planner Water Meter 63. D
Phone 454-0433 Couneil ?Road Unit ?p
Bldg Off??Treatment Pl !SG
Arch./Engr. APC • Parks
Varianee Copies
Address TOT9I. Z/647-
City/Zip Code
Phone #
NOTE: ADDRFSSES FOR CORASR LOTS - CONTRACTOR/BOMEOiiNER MUST DESIGNATE iiHiCB
ADDRESS IS DESIRID. NO CHANGES WILL BE -ALLOWSD ONCE BtTILDING PERMiT
IS ISSUED.
. ?
8113 MA H.OaS,E CERTIFICATE FOR;
? NOME R1ritOENS
S U AVEYI NG ?R LANG C1tvELOPfRS
S E R V I C E 8 HE,?t TOp;
3908 Sibley Memorial Highway FRQNT VdMPAN(ES
Eagan, Minnesota 55122
Phone: (612) 452•3077
rww?.?
' MODEL: STAFFORb
, ,._? , ,
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ScAt,E; i''=4o'
?'? = _ 1??- ?:?? _-i:.Y.Fa?t? 41'.?+?_I?l ? ?
_---- DRA I NAG-?E ,
? j -- ?- ; Iu-ra. i TY _
?
A* ,•-•- •s
Lo-f io
, r 1 ?`85p,?, `l/?kia°a o f X8ts,o O
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p
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- s 1\?,?\1\\\11111i10llfl/!!/fll/??
?,???e? 1?,,N E ?S 0 ry oi
?.. .... ,'. ?, ?
w? \.L ?,,.•• •' ii?
?.? V"JAYNE D. •,.`, "
C;+_^. ?`i C? FS
146e -5 ?
. . . . r.?y ..
? i'/j? `• X.A i'A t\,
?GEND_ PROPOSED GARAGE FLODR ELEVA T IOM =
O lknotes Iron Morx.rnent PROPOSED Top of B l ock ELEVAT ION= a5o•3
a Denotes Woad Hub Set PROPOSED BASEMENT FLDOR ELEVAT lON= S`f -13
x 8`f8•4 Aenotes Existirg Spot Elevation
MOTE: Verify all flovr heights with Final Ha,rse Plans.
(x s?? ) lknotes Proposed $pot Elevation
'..------- Uenotes Ora inaga Direct i an -S)p14M CERT IFICAT IaV-
i hereby certifY that this survey, plan or repa't
-PROPERTY DESCR I Pf ION- was p^epared by me or urder rtry d i rec t supervi s i an
LOT 10 BLGrK 3' ard that I am a duly Registered Larr! Surveyor
HAMPTON HEIGHTS urder the laws of tha State of M?nnesota.
CS4-- accordi to the recarded p1at thereof,
8
i
?? b Q-I iDate : -'/i
Dakota County, minnesota Wayne . Cordes, Minn. Reg. No. 14575
Page 1 of 4
` ' • EXTrRIOR CNVELOF'C AVCR/iGE "I?" C0WUTIITION
% WN E R . ,,,,..., .
nnTr .?
- --- :----? ?s --?
SITE ADDRESS:
CONTRACTOR: F4Z6P-.)'Tt '-r.
Determine working square faotage cf each
1. Total exposed wall area..... (,(?L?. ? Sq, ft. x l; _
2. Total roof/ceiliny area..... ,q, ft. x.026 =
Total exposed wall arca a(,ove floor=_ l??t ?r
a. Tota1 wall window are,i.,.........
..
b. Total ...........................
door area .....................
c. Total ........................
sliding glass ilaor arca ..........
d. Total ..
fireplace wall area ..............
.
e. Total .
...............
wall framing area (average lOM)...............
.
f.
Total .
..
.......
rim joist area ..........
g• net ..... ,
wall area above floor. . .Z.?4.?'?.
h• wall area above floor..........
i• .....................
. . . . . .
wall area above floor......
j frame ...
wall area at foundation ...................................
Tota1 exposed foundation ai°ea= ,7-5
- L-2 -
to S
O
-- b?
--?- I
k. Total foundation window area.........
1. Tota1 net foundation area above grade ............. -?
,
Determine "u" value of each wait scymc;-iC
(e,g, window, door, each separate via111 section)
a. I ZS X
• b• X
-c. ?-Z X
• d• X
' e• ? ?(???5 X
• f• I -2-,O r
. 9• 1 ??) E) ? , ?? X
• h.
•i.
• j.
' F..
„u„ 45 CD
„u,i
- ---
ituli
„u„ 15
„J„ 03 = ? ?
„L111 .c3 = /,r .A
X ?1 Ll If
X liu,t
X "U"
X "u "
?• ?s X
.,i • • • • • • • • • . • . • • • • • . • • • • • • • • . • • •
('E(ONE :
„u„V ?5 = .75
•..Total
??s
If item #3 is the-saa
as, or less than -`i tez
you have met..tFie'
intent of S8C..600,
( ?.
`• ?,•1 ,i?1
•'.•? 4• ;r?
• :.?-il-?tbrjor J:nvclape nvcr<zge "U" Compurat:ion
• / , 4, ' , '; .
Pago 2 of A :
' Total exposcd roo[/ceiling arca = ?10
m. lbtul skylight area ............................
n. Total roof-/cciling framing arca (.lvcragc 10?).. .. ? p` ,(o
o. Total net insulated roof/ceiling area...........
. Determine "U" value for eaclZ roof/ceiling segrient
?
M. X
n. _? p ( • (p a
o Z --- ?,
a. a„??? ? 0
4 ........................... ToL-al
If tota.l of ;p9 is the same as, or less i:han 112you have meL- the i»L•ent of
Sbr 6006 (c) 1.
Alternate Building Fnve].ope Desiqn
'ib utilize tne total envelope 'system method, the values established by the s:im of
items #3 and #4 shail not be greater than the sum of items #2,
"
09 + 2. Zo. -41 _ 4 Z i '
3. + 4. Z-C-,-)1 7 3
?
?
- • ;tnl.r. ;',r.r•t?t????? ??y
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If:iR1•1 (:(.tit.l CUCI lu(1 t..??u'.l : u? . t:•n ? V,t l??•?
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?_ •?, ` ?• ? ',...I.??. ',?„ .V t{? . . . _. . ... .1..?_?
- - ---? ? ??2??,? 1?? . ,.?i ? • ,,. t 4-38
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??? . . ? . . . 7- 00
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G. tt•r<<,r n it 11,
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?
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f IC. 11 TOPVI'cSJ OF ?
FIU?tt$ l1nt,I, ?/`?. Intrr;nr I. :ilnl Q.Gl1
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to 5 . A?v?,_ .sc r?s? . . ._...... _... . . ..?.?t
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C IG. 02 TlJt.il l
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G . 13 ?.,_.,?.?,. "- ? - `---- ??- ?- ? -\ ---•?? -- ; ? ? ( ? ?
lcr/o1;'
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O ? , ??- • ? f
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• ?.. , - nMr%cEiLZNc , . -
. . .
.
? . - , • • ..
• ?% Canstruction . R-Valuc
• i . .
Intcrior air film . . 0,61 .
?' ? ? 8-- _f ?( ?F3 U S'R
`
1 n.?-!?UL. ? 44 .aa
?•??` ??????,??^`I?(r?' ? . .t. Extcri.or air filn (st.ill) 0.?
Total ?
;, ??.; . . . .
- ' ? . ' ? F R.?r-•rr o= ? . ? . . ?
HeaC floc.r ? 1• Interior nir film ? 0.61
: n t ed ! U P . . 2- G'1SID -. S?
. . . 3. ?. ? ??svt? 38.35
, , • ? • 4. F:xtrtia=rir Liln (stl.l .b
Tota1 p.
rIG. 95 • . ,
. , ? . . .. . . . . ? ? .V - . oz?..
- . - ?. - .?? . .
v C ri
,.?„_..,?-,-.-.,,:r.-`-.'`•,=?'--...? ?swr..?n?c:??,?.? : ITSSidc air fi.Iin 0.61
?- • J? _ 1 2' , ' .
/l 3_ '
? . • . ' ? 4_
S, Outsidc air fil:n fl.l'I
Tatal.
?? ?I „? : ? ? 1,.? ? _ ? ..? - - - . .
.? O 2 3 ?'" .? • ?_ Insidc afr Pi1Tn 0:51
? . , . 2. - . . • .
?Hezz flou vp . f . i•vented ? 3- ?
. . . 4_
• . , ' ' - ' . ' ' ?_ Outside air f:.lzn 0.17
- . .?G_ ? 6.? . - - ' • . ' ? . . ' : . Total .
-...... - -- • -? --• - - . ..
• 3 ? FO' Xnsiclc air filzn
. ? -
2_ . ?
, ..c,!! ??'; ??'"` : : •.: : ?? ? ;? 3_ ' ' .
•- -?. o••:e???-'-'.:,..'..:?.••?..=-?^''--/ ' 4-
?? ?.,,lY-• ,;•:•" '?- - ? 7
???-?-?. •?.? j• j?' ,? ?. ?. `?it:; i.ctc .? i.r. f iltn 0. 1
v.-' • ., . . ? '?:-?"'?` . TOt31
. . . . . ?..:- . . . . ? .
. ??I_?,-? ?.• . : Rate: Use additionaZ sheets if morc Spaco i_
"_' •. . ' • necdecl for cletails and calculatians.
, . .
?. ? . . . . . .
. HcnL ' • •
• .• - .
• • ; : • flow ip • ' . . ' .
• Pzr_ !?7 • ?? . • .. ?• .. _ . . .. `
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t;pollun w,lll nren tor
fri,lnV: GGll:ill'UCI.Svl1 ^? _. .... .._.. I?^V.l_iv'. c•;'Y
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SIC lt,,j, ' ?^' G. '?:r.lc•;•i„r .il? U.17 , .1
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4"1 U= ,3Cs• .
FIG.'.M1 ' TG1'VIF1q OF
F, .
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FIG. hfl 2 ,1'ut.al-^--
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RESIQENTIAL
17_6.2S' BUIIDINC PERMIT APPLICATION
-?, CITY OF EACAN
3830 PILOT KNOB RD, EAGAN MN 63122
651-681-4e75 New ConsVuctbn.AeauiremeMS RemodeUReoair R2gulremeMs
• 3 registered sRe surveys showing sq, ft. of bt, sq, ft. of hause; and ?ll roofed areas • 2 copies of pian
(200/a maximum bt coverage allowed) . 1 set of Energy Galculafions for heated add#Jons
• 2 copies of plan showing beam & window sizes; poured found design, etc.) • 1 site sunrey for exterior additions & decks
• 1 set of Energy Calculations • Indicate'rf'home served by septic system for additions
• 3 copies of Tree Preserration Pian if bt platted after 7hl93
• Rim Joist Detail Options Selection sheet (bldgs wtth 3 or less un'ds)
DATE (o l?y / 02,.. VALUATION S 6010102
SITE ADDRESS I(Q7q ?da,rrlwc?.I I?, MULTI-FAMILY BLDG _Y 1/_/N
TYPE OF WORK ?oF, FIREPLACE(S) _ 0_ 1_ 2
APPLICANT IJa ,la,irPI 4100!9
STREET ADDRESS Saq? V2 , 5 CITY STATE AAJ ZIP _t)6Z--
TELEPHONE #6S!439- 182-e CELL PHONE # FAX #?S?
PROPERTY OWNER TEI.EPHONE #:G51 - 06 3'2-20 C)
COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY
Energy Code Category _ MINNFSOTA RULES 7670 CATEGORY i MINNESOTA RULES 7672
(4 submission type) . Residential VeMilation Category 1 Worksheet Submitted • New Energy Code WorksheefSubmitted
• Energy Envelope Calculations Submitted
Plumbing Contracror: --- ---r _-- Phone # _
Plumbing system includes: N Water Softener Lawn Sprinkler ~ Fee; $90.00
? Water Heater _ No. of R.I. Baths
No. of Baths
Mechanlcal Contractor: Phone #
Mechanical system includes: N Air Conditioning Fee: $70.00
_ Heat Recovery System
Sewer/Water Conhactor: Phone #
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i hereby acknowledge that I have read th+s appHcation, state thdt the information is correct and agree to comply
with all applicable State of Minnesota Statutes and City of Eagan Ordinances.
,fn4_- Signature of Applicant
d ?_ (a--,- 1_6\_? (.-----
OFFICE USE ONLY
Certificates of Survey Received ? Tree Preservation Plan Received _ Not Required
Updated 4/02
"
OFFICE USE QIdLY
0 01 Foundation 0 07 05-plex 0 13 18-plex 0 20 Pool ? 30 Accesswy Bidg
O 02 SF Dweiling ? 08 06-plex 0 16 Firepiace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Mufti
E3 03 01 of _ plex O 09 07-piex ? 17 Garage ? 22 Parch/Addn. (4sea.) ? 33 Ext. Aft - SF
0 04 02-plex 0 14 08-p{ex O 18 Deck E3 23 Porch (screened) C] 36 Mufti
O 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage
0 06 04plex ? 12 12-plex Pibg_Y or _ N ? 25 Misceilaneous
0 31 New ? 35 Int improvement q 38 Demalish (interior) 0 44 Siding
? 32 Addition 0 36 Mave Bldg. 0 42 Demolish (Foundation) ? 45 Fire Repair
0 33 Alteration 0 37 Demalish (Bldg)" 0 43 Reroof 0 46 WindowslOoors
13 34 Replacement 'DsmolitMn (Entire Bidg oniy) - Give PCA handout to appiicant
Valuation Occupancy MC1ES System
° Census Cade Zoning City Water
SAC Units Stories Booster Pump
Nbr. of Units Sq. Ft. PRV
Nbr. of Bidgs Length Fire Sprinklered
Type of Const W idth
REQUIRED INSPEGTI4NS
Footings (new bldg) , FinaUC.O.
_ Footings (deck) FinallNo C.O.
_ Footings (addition) Plumbing
Foundation HVAC
Drain Tile Other
Roof Ice & Water Final Pool Ftgs _ Air/Gas Teats _ Fina1
_ Framing^ , Siding 5tucco Stone
_ Fireplace _ R.I. _ Air Test _ Final _ Windaws (newlreplacement)
_ Insularion Retaining Wa11
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--- Approved By
-- - ----- - --- - ----
-- - , Bui{ding {nspector
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Base Fee - - ------- - -- ---- - -- - - ------ - ---
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Surcharge
Plan Review
MC/ES SAC
City SAC
Water SuPplY & Storage
S$W Permit & Surcharge
Treatment Planf
Plumbing Permit
Mechanical Permit
License Search
Copies
Other
Total
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA144268
Date Issued:07/19/2017
Permit Category:ePermit
Site Address: 1674 Boardwalk
Lot:10 Block: 3 Addition: Hampton Heights
PID:10-31900-03-100
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:Two or More Windows/Doors
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow
windows, call for framing inspection. Call for final inspection after installation.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Valuation: 4,000.00
Fee Summary:BL - Base Fee $4K $103.25 0801.4085
Surcharge - Based on Valuation $4K $2.00 9001.2195
$105.25 Total:
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 Ordinances.
Contractor:Owner:- Applicant -
Steven J Filippini
1674 Boardwalk
Eagan MN 55122
(651) 253-0461
Home Depot At Home Services
2455 Paces Ferry Rd
Atlanta GA 30339
(952) 345-6057
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA150696
Date Issued:07/19/2018
Permit Category:ePermit
Site Address: 1674 Boardwalk
Lot:10 Block: 3 Addition: Hampton Heights
PID:10-31900-03-100
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Furnace & Air Conditioner
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088
Surcharge-Fixed $1.00 9001.2195
$60.00 Total:
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 Ordinances.
Contractor:Owner:- Applicant -
Steven J Filippini
1674 Boardwalk
Eagan MN 55122
(651) 683-9560
Home Energy Center
2415 Annapolis Lane N #170
Plymouth MN 55441
(763) 476-1990
Applicant/Permitee: Signature Issued By: Signature