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2930 Burnside AveCity of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 2930 Burnside Ave Lot: 2 Block: 3 Addition: Country Home Heights PID:10- 18300 - 020 -03 Use: Description: Sub Type: e- Windows/Doors Work Type: Windows/Doors - New/Replacement Description: House Census Code: 434 - Zoning: Square Feet: 0 Comments: Fee Summary: Valuation: 3,000.00 Contractor: Renewal Andersen 1920 County Road C West Roseville MN 55113 (651) 264 -4777 PERMIT City of Eaan BL - Base Fee $3K Surcharge - Based on Valuation $3K Applicant/Permitee: Signature - Applicant - Construction Type: Occupancy: Carbon monoxide detectors are required by law in ALL single family homes. Improvements to the home require smoke detectors in all bedrooms. If altering window openings, call for framing inspection. Call for final inspection after installation. $88.50 $1.50 Total: $90.00 Owner: George L Willmarth 2930 Burnside Ave Eagan MN 55121 Permit Type: Permit Number: Date Issued: Permit Category: 0801 9001 I hereby acknowledge that I have read this application and state that the informa of Minnesota Statutes and City of Eagan Ordinances. on is correct and agree to comply h all applicable State Issued By: Signature Building EA090934 08/31/2009 ePermit SEiVERAWATER PERMIT CITYUF EAGAN 3830 Pilat Knob Rd. Eagan, MN 55122-1897 DATE UF.C 30, 1991 51TE ADDRESS 2530 BURhSI DE AVE LOT 2 BLOCK 3 SEC/SUB COUNTRY KOME iiEIGHTS APPLICANT:. ADDRESS: _ CITY, STATE PHONE: - PLUMBER: WENZEL PLUMBING ADDRESS: 1959 SHAiJNEE RD CITY, STATE EAGAN MN Zip 55122 PHONE: 452-1565 OWNER: ROSEMARY FISCHER ADDRESS: 2930 BURHSIDE AYE CITY, STATE EAGAN MN ZIP 55121 PHONE: 454-1796 METER # CHIP # ONLY PERMIT DATE 21126192 PERMIT # 12472 METER SIZE XM RECEtPT # C 016652 ISSUE DATE W. RECEIPT DATE 1 Z 30 91 _ PRV _ BOOSTER PUMP PERMIT REQUESTED ? 9 X SEWER - WATER _ TApS ? _ COMMlIND X RESIDENTIAL A NEW X EXISTING , ZIP Lawn Sprinkle Meters are to be Installed Ahead of $_s M ers on Water Line. Cr'e? I O t3?e?n fo? Deduct Meters. ? I AGREE TO COMPLY WITH CITY OF EAGAN ORDINANCES SIGNATURE WHEN METER ISSUED ! ALLOW TWO WORKING DAYS FOR PROCESSING. CALL 454-5220 FOR INSPECTIONS. FOR STORM PERMITS, CONTACT ENGINEERING DEPT. CITY OF EAGAN Remarks addition Countr Home Hei hts Lot 2 Rik 3 Parcel lU 18300 020 03 owne? Street 2930 Burnside Ave. state Eagan, MN 55121 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING ye SAN SEW TRUNK 1968 $100. 00 $3. 33 30 PAID * SEWERLATERAL & Stub 1972 2359.00 $117.95 20 I, WATERMAIN * WATERLATERAL & Stub 1972 20 WATER AREA STORM 5EW TRK 1984 495.00 33 . 00 15 STORM SEW LAT CURB & GUTTER SIOEWALK STREET LIGHT WATER CONN. $2$0. 00 3$17 7-12-71 BUILDING PER. SAC PARK t .'" DATE: JAN 8, 1992 RE: 2930 BURNSIDE AVE (ROSEMARY FISCHER) X Your Sewer $7SdQ=r Permit for the above properry has been completed. It will be held at the Public Works Garage (3501 Coachman Road) until the meter is picked up. BE SURE TO CALL PUBIIC WORKS (454-5220) FOR YOUR PERMANENT WATER TURN ON. Your Sewer & Water Permit for the above property cannot be completed for the tollo.wing reasons: _ Your Sewer & Water Permit for the above property has 6een completed, but the meter cannot be issued or occupancy aliowed until further notice. COMMERCIAL PROJECTS ONLY: Please pay for meter at City Hall. Meter size must be confirmed 6y Bill Adams or Dirk House (Plumbing Inspectors - 454-8100) before issuance. WARNING: BEFORE DIGGING, CALL LOCAL UTILITIES - TELEPHONE, ELECTRIC, GAS, ETC. - REQUIRED BY LAW. CONTACT COMMUNITY DEVELOPMENT DEPARTMENT FOR WATER TURN ON POLICY. Secretary, Building Inspections Dept. ? ?0,QQQ 4/4 , Request Dale Flre No. Ro - Inspection ui ? Now 0.011 Nofdy Inspector eatly I O- =iYes When Reatly? I? licensed contractor ? owner hereby request inspeciion oF above electrical work aY Job Adaress (Siree1. Boz or R e NoJ 3q 30 Ciry? ? Sectlon No. Townsni0 Name or No. Range No. Co n t n r? Occ p ( RINT) Phone No. ) a- ? Power Supplier AOtlress Ele n onVactor 1 ompany Namel? . ?- -Y ((i- '?..? ConV? cbr§?L}ica/ns?e \No1.U^ \ ?1 ?Ll1\ l CX Maimq A\tlO`rg1 I o"n?vacror or er Makinq Insta?laM1O <t- T CCO-1-C ?D ? A ?nZeO 5' naWre ?CO vactarrpwne, Making ?In5?allalion) U ? Pho Nu ef ? MINNESOTA STATE OANU OF EL CTPICITV Grlg9%?ItlwaY B - R ? St] 1821 Univer5ity Ava.. aul. 106 Vhane(61Y)840-O80p THIS INSPECtION REQUEST WILL NOT BE ACCEPTED BV THE STATE BOAFD UNLESS PROPEF INSPECTION FEE IS ENCLOSED. REQUEST FOR ELECTRICAL INSPECTION ee.ooo?ms-oe K 2 g 3 9 9 0- See Insimctior,5 for co-pleting this lorcn on back of yellow copy qo??E,/Q 9b y? O?CO "X" Be/ow Work Covered by This Request ??. • ew Add Rep. TypeoFBuilding AppliancesWiretl EquipmeniWiretl Home Range Temporary Service Duplez Water Heater Electric Heating Apl Building Dryer Other-(Specity) CommJlndustrial Fumace Farm Air Contlitioner Other (specify) ConVactor's Remarks: -tr ?ftAc41or) A/C? Compute fnspection Fee Below: # Other Fee # ServiwEnlranceSize fee # CimuiTS/Feetlers Fee Swimming Pool D to 200 Amps 0 to 100 Amps Transbrmers Above 200 _ Amps Above 100 _ Amps SigllS InspMOr§ Use Only: ? 7Q7 ?71 Irrigation Booms J?,? ?? ? Speciallnspection - Alarm/Communication THIS INSTALLATION MAY BE ORDERE ONNECTED IF NOT Other Fee COMPLETED WITNIN 18 MONTHS. I, Ihe ElectriCal Inspector, heteby h Rorqn-in oate cerlify t at the above inspection has 6een made. F;,,ai Date OFFICE USE ONLY • Thls request voitl 18 months lrom EAGAN TOWNSHIP BUILDING PERMIT Ownet ........... _ :r.?:.t:_. V ....... : _.. _" /? "'........"' _ ........ _.__" Address (presenS) .... ?? f.:3?._...r,%?' . ..............---...'°'---------------_ Builder Address --------- ------------------------ ___--------- DESCRIPTION N° 924 Eagan Township Town Hall DaSe ??? s wJ6 •a_ ....._...--................. .'................. Stories To Be Used For Fron! Depih HeighY Es1. Cosf Permii Fee Remarks n?.?.,?y? .av zy A3rso a, OT '? v LOCATION Sixeel, Aoad or olher Deseripiion of Loeation Lo! Block Addifioa or Trael This permit does noi aulhorize the use of sireeis, zoads, alleys or sidewalks nor does it give the owner or hia agenS the right to create any sifuation which is a nuisance or which presenSs a haaard !o the heallh, safely, convenience and geaeral welfa:e Yo anpone in the community. THIS PERMIT MUST BE KEP?T7 ON_THE PREMISE WHILE THE WORK IS IN PROGRESS. This is to certifp, khal--_- _--7.<`.t.°.'?C.?..%..."-'---_------_---haspermission !o arect a .......... ' ...... upon ---- .................. the above described pxe?e s?ec! !o ffCe provisions of the Building Ordinance for an Town ?ip adopSed April 11, 1955. . .".'.. -?!_._'_.______'........ ......_"-?f? f"=.`.-.....----------••-.;"----"'-'----....'-"------'......... Per ....'_....._. -a.!-'---------------"'....-------... Chairmarf of Tnwn Board Buildin9 InsPeclor EAC;AI`I 'rOWNSI°IIP Ownex Addxess Builder Address BUILDING PERMIT DESCRIPTION N° . . 710 Eagan Township Town Hall +I ' 9 9 1,0 Dafe ??? ti 1 ...'--°-------'--------------'•-'--.... Siories To Be Used Fos Frani Depih 3s Heigh! Est. 16 Cos3 Permif Fee Remarks LOCATION Sireei, Road other Descripiion of Lacation La! I P.lock Addition or Tract - . ? ? ?/??i'J[Y1?SJq ?tc?! I a 3 / This permii dces noY auihorise the use of sireeSS, roads, alleps ox sidewalks nor does i! give the a ner or his age the righ! !o create any sifuaiion which is a nuisance or which presenls a hasard fo the healfh, safe4y, convenienee and genexal weIfare !o anyone in the communiiy. THIS PERMIT MUST BE KEPT ON THE PREMISE WFiILE THE WORK IS IN PAOGRESS. ' This is !o ceriify, lhat---------------------------------------------------------------- has peamission !o erec2 a..... _.................................... _.___."""'_.uPOn the above describ re 'se subje ! fo i -,provisions of the Building Ordinance for Eagan Township adoFied April 11, 1955. Z' r' . ---... - ? - - - -s - - .....: - -- - Per .-------------- .............----...---------..._.-°°---------'---'-...--------"'-.'. - - ---- m- an o Tnwn Board Building Inspecior C air ? _ _ _ - _ _ _ _ _ _ _ _ - ? PorOfficeUse I c? ? Permit #: U -'?:W ? j ? ??O-SC7 i I Permit Fee: ? I ? ? Date Received: I I ? ? I ? Staff: ? L_________________ 2008 RESIDENTIAL PLUMBING PERMIT APPLICATION Date: . "Dt_ Site Address: _ 2' 13c) &VN5 & Nv - Tenant: Suite #: RESIUENT i OWNER Name: &JXY . I, VVY-Vk Phone: VJS kW 1`"` 1YJLq Address I City / Zip: m- CONTRACTOR N ??S - ' ( ? ??? ? ame: lvlvt f?E? I cen t se Address: City: 5%kj\ State: rW-N Zip5501, Phone.y,61--Ae---Inl ContactPerson: ?? lfv ?1.1??}?Q.?i111L1F TYPE OF WORK _ New ? Replacement _ Repair _ Rebuild _ Modify Space _ Work in R.O.W. Description of work: PERMITTYPE RESIDENTIAL Water Heater _ Water Softener TC Lawn Irrigation Add Plumbing Fiutures (_ RPZ /_ PVB) ? Main _ Lower Level) Septic System _ Water Turnaround New Abandonment RESIDENTlAL FEES: 50 Minimum Water Heater, Water Softener, or Water Heater and Softener (includes $.50 State Surcharge) $30.50 Lawn Irrigation (includes $.50 State Surcharge) $50.50 Add Plumbing Fixtures, Septic System Abandonment, Water Turnaround` (includes $.50 State Surcharge) 'Water Turnaround (add $136.00 if a 5!8" meter is required) $100.50 Septic System New ($10.00 per as built) (includes County fee and $.50 State Surcharge) $90.50 Fire Repair (replace burned out appliances, duchvork, etc.) (includes $.50 State Surcharge) c? TOTAL FEES $ i hereby acknowletlge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of tha City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to slart without a itNpaCJd= ??^= wil,_, I_ be In accordance with the approved plan in the case of work which requires a review and approval of plans. D ? ?(7 ? X? X ? , I U IU ApplicanY? s Printed Name App icanYs Signature o?8 FOR OFFICE USE Reauired Insnections: : Under ( A. EAGFN TOWNSHIP 3795 Pilot Knob Road St. Paul, Minnesota 55111 Telephone 454-5242 PERMIT FOR WATER SERVICE CONNECTT.ON Date• December 9, 1970 Billing Name: James W. Fischer Owxter: same Plumber• same tion SIGNED UTILITY AGRSEMENT - NOT HOOKING UP YET. Number: Site Address; 2930 Burnside, St. Paul 55118 Billing F.ddreas same Meter No, I Permit Fee 10.00 pd 12/9/70 Meter Reading IMeter Dep. Meter Sealed: Yes_ 'Add'1 Chg. NO ' Total Chg. Building is a; Residence xxx t4ultiple Ro, Units Commercial Industrial Other Inspected by Date Remarks: sy: Chief InspecCOr In consideration of the issue and deliverq to me of the above permit, 2 here6y agree to do the proposed work in accordance with the rules and regulations of Eagan Township, DakoCa Cpnpty, MinnesoGa. By: ? ea W F scher Please notify the above office when ready for inspection and connection. y EAGFN TOWNSHIP 3795 Pilot Knob Road St. Paul, Minnesota 55111 Telephone 454-5242 PERMIT FOR WATER SERVICE CONNHCTION Number: 677 refer to 511,,1-3 SiCe Address• 2930 Buxnside, Eagan 55121 Billing F.ddress same Meter Size 5 8 Connection Ch7/12/71 Read OUt 6 640 Account Deposit 15.00 pd 7/12/71 Meter N0.11398191 permiY Fee 10.00 pd 7/12/71 Meter Reading0000 Meter Dep. 50 pd 7/12/ 71 S/C Meter Sealed: Yes_ 'Add'1 Chg, a_nn pd 7/12/71 NO iTotal Chg. Date: Jy,L ] . q? 2_1 Billing Name: James W. Fischer Owner: same Plumbex'• same Buiiding is a: Residence xx.y I4ultiple Ko. Units Cammercial Industrial Other Ia consideration of the issue and delivery to me of the above permit, I hereby agree to do tte proposed work in accordance with the rules and regulations of Eagaa Township, Dakota Coun , Mlnnesota. , By:,-. ames W. Fischer Inspected by Date Remarks: ?. ..... .._ ...... ._?..UI\ F i_C ?U?1 INPRUPERLY INSTALLED METERS. By: Chief Inspector Please antify the above office when reaflq Eor iaspection and connectiou. l ? ? r I EAGAN TOWNSHZP DAKOTA COUNTY, MINNESOTF. I/We here6y request of the Township of Eagan permission as followe:. 1. To connect the s?a 8Ye1 ervice line fram my residence/ Bvrnside "commercial building at 2930 Yt? to the sanitary sewer J.ateral located 2930 Burnside 2. 3. It is understood that I/we will not haok up and use the service until I/we have paid Co Eagan the necessary connectioa fee for such hookup. It is further understood that 1n the event that I/we do hook water up aud use said xxxlamgDmonax service before paying the required connection fees, that I/we will be required to pay the Township a sum in addition to the connection £ee of $ 100.00 I/we also understand that I/we will also be required to pay to the Township in addition to the Eees required above the normal inspection fee for each inspection by the Eagan utilities departmeat. Dated: i]nrtamht+r 9- 1970 Sigaed: amu?' 2930 Burnside CITY OF EAGAN 1991 SEWER & WATER CONNECTION CHARGES EXISTING RESIDENTIAL PROPERTIES Sewer Connection Char¢es SAC $750.00 Date previously paid Receipt # Account deposit 15.00 Sewer permit and surcharge 15.50 Subtotal C-/5780.50 ?--. + Sewer tap Total -;C- SAC Date previously paid _ Water connection ,,,, Date previously pai&, Account deposit `^1 Sewer & water permit and Water meter Treatment plant fee Plumbing permit and surct Subtotal + 5ewerl& water taps Date Account deposit Water perarit & Water meter Treatment plant Plumbing permit Subtotal + Receipt # Receipt # paid 55G.C0 30.00 30.50 95.00 276.00 15.50 $1,857.00 $ 15.00 15.50 95.00 276.00 15.50 $1,077.00 OFFICE USE ONLY PRV 41-h No. of taps ? Assessments Waiver ! Property owner RoSFMAxY FTscxEx Telephone no. 454-1776 Address 2930 BORNSIDE AVE IAi 2 Blk 3 SCCt COUNTRY HOME HEIGHTS P I D # 10-18300-020-03 tap . . SPECIAL ASSESSMENT SEARCH SUMMARY AS OF: 11/29/1991 PROPERTY ID: 10-18300-020-03 S/A# ASSESSMENT DESCRIPT. YEAR TM RATE TOTAL ANN.PRIN. PAYOFF CD 100040 SAN SW TRK 1967 30 6.0000 100.00 0.00 0.00 CL 100136 SW/WAT LAT 1971 20 8.0000 2359.00 117.95 0.00 LY 100803 STORM SEWER AREA 1983 15 12.5000 495.00 33.00 231.00 ------ SUMIIMARY OF LEVIED 2854.00 150.95 231.00 ****** 1991 P&2 CERTIFIED 193.38 ------ SUMMARY OF DEFERRED 0.00 0.00 0.00 ------ SiJNIIMARY OF PENDING 0.00 0.00 0.00 ------ SUMMARY OF CLOSED 100.00 Press ENTER; or F1, F4, F5, F7, F8 d??; Q 3, ? Ordinanx No. 114: WELL CONSTRUCTION AND ABANDONMENT WELL PERMIT DAKOTA COUNTY PUBLIC HEALTH DEPARTNffiVT INVIltONMENTAL HF.AL,TH SERVICES SECITON WATER QUALITY MANAGEMENT iJ1VIT 14955 Cralaxde Ave., Apple Valley, MN 55124 Telephone: (612)891-7556 WBEREAB, the NON-TRANBFERASLB PERMITTEE/DBA: Kimmes-Bauer Well Drilling I88IIED TO # 19 521 ADDRE88: 21830 Lillehei Avenue RBVISW&D SY BW Hastings, MN 55033 Pemvt No. 91-9241 has submitted a permit application, has paid the swn of one hundred ($loo) dollars to the County of Dakota as required by ordinance Number 114 and has complied with all of the requirements of said Ordinance necessary for obtaining this permit to permanently seal the well(s) described herein: • An abandoned well(s) with a casing diameter of 4 inches, depth(s) of 195 feet and completed in in the drift will be permanently sealed. The well(s) shall be cleaned of equipment and debris, disinfected, neat cement pressure grouted and terminated at least two feet below grade. The well is located in the municipality of Eagan as follows: Well Location: Property Oxner and Nell Ovner and Addresa (if different) Address.(ff different) 2930 Burnside Avenue Rosemary Fischer Eagan, MN 55121 NOW, THEREFORE, Kimmes-Bauer Well Drilling, Znc. is hereby permitted and authorized to permanently seal the well(s) described and located above for the period October 1991 to October 1992 subject to all provisions of said Ordinance, the Minnesota Water Well Construction Code and any conditions attached on the reverse side of this permit form. Given under my hand this 17th day of October, 1991. ?IIA mA ATTEST - ? _ ENVIRONMENTAL HEAL ERVISOR ?E?EN?A.<.s AL ? 1 HEALTH DIRECTOR ?. r EAGAN TOWNSHIP BUILDING PERMIT Ne 2563 Owna: ....... ..?-?::!??: ° ... .......i?-a-e?(c?? ............................................... Eagaa Township Addrese (Pre en!) ..?..°.?...?'.5.._--.................................................... Town Hall Builder - -??'? -- - ._ ............................._.................... - --- ??3?/ / ? na:e ..... ------? - - • ? ............... Address :.... ........."----°' .........................'--.......---' °'---......-'-------.......-°'°-- DESCAIPTION Sloriea - To Be Vaed For Froa! -- De !h p Hei h! g Eel. Coa! Pazm[! Foe Remarke c+?.2?e--,? -?7`c?o-,-.?..c1 I ,S/7d0 ?a•s-e os ? 1 -3 1 e, Hp- This pesmit does aot aulhoriae the use of aleeeffi, soada, alleps or sidewalks aar does it g3ve the owner o: his agen! the righ2fo ereale any sifuatian which is a auisance or which presents a hazard !o the kealth, safety, eoavenience aad general wel£are to anpone in the eommuni2y. THIS PEAMIT MUST BE PT ON THE PREMIS£ WHILE THE WORK IS IN PROGRESS. This is !o aerlifp, ihal-----_' ... .?r.^? .....................haspezmission !o erea! a.......Q??.:" ?. ..... .._upoa the above desoribed premi e eubjea! to !he provisions of !he Building Ordinance for Eagan Township adopled Aprfl 11, 1855. " l-..-.?.... "- .......... ?--? :.................. Pex ..... .._--' ..._" ----.'_?..?..?.'?_ " "...i°..........-..._.r' ::,."... .......... ................ Cheirma of Tnwn Board Building InsPecior ? ? MASTEA CARD • LOCATION OWNER o .t - 3 e A?r?' STRUCTURE AND ? LAND USED AS 4?? • • Permit No. Issued Issued To Contracfor Owner BUILDING PLUMBWG s 3 9.JO-,r I I I CESSPOOL - SEPTIC TANK WELL EIECTRICAL HEATING - GAS INSTALLWG ? SANITARY SEWER i OTHER j I OTHER I Items Approved (Initial) Date Remar ? - Distance From Well FOOTING $EPTIC fOUNDATION Iw . I• ? CESSPOOL FRAMING ? ' TILE FIELD FT. FINAL ELECTRICAL i HEAT-ING - DEPTH OF WELI GAS INSTALIATION SEPTIC TANK CESSPOOL DRAINFIELD PLUM8ING ? WELL SANITARY SEWER Violations Noted on Back COMMENTS: \ e7Ill ?? I ?\/ ? d' • r EAGAN TOWNSHIP 3795 Pilot Knob Road i St. Paul, Minnesota 55111 Telephone 454 -5242 PERMIT POR WATER SERVICE CONNECTION Date: Jul 1/ 1971 Number: 677 - refer to 5i1 Billing Name: James W. Fischer Site Address: 2930 Burnside, 1., gun 55121 Owner: same Billing Address sums Plumber: same Location of Connection Meter Size 'IR Connection C14.240.00 Pd 7/12/71 Read (jilt 6'36469 i,ccount b pabic 15.0 pd 7/12/71 1....471) Meter No.1139d191 Permit Fee 10.00 pd 7/12/71 .5J pd 7/12/71 Meter Readi 0 000 Meter Dep, yy- q3 - Meter Sealed: Ye Add'1 Chg. si ran 1 .4 7/12/71 NO .r�Total Chg. : Inspected by Date 7 -/5 -7/ Building is a: Remarks: Residence xxxxx Multiple No. Units $25.00 RE ItJION FOR . Commercial IMPROPERLY INSTALLED SPECS MET ERS Industrial By: Other Chief Inspector In consideration of the issue and delivery to me of the above permit, I hereby agree to do tle proposed work in accordance with the rules and regulatione of Eagan Township, Dakota County, Minnesota. -� By: l ';. ,,,..�� //1 ,� �/ James W. Fischer Please notify the above office when ready for inspection and connection. PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA149772 Date Issued:06/08/2018 Permit Category:ePermit Site Address: 2930 Burnside Ave Lot:2 Block: 3 Addition: Country Home Heights PID:10-18300-03-020 Use: Description: Sub Type:Residential Work Type:Replace Description:Air Conditioner Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952) 445-2840. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State 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 - George L Willmarth 2930 Burnside Ave Eagan MN 55121 (651) 210-6222 Bonfe's Plumbing & Heating 455 Hardman Ave South St. Paul MN 55075 (651) 228-7140 Applicant/Permitee: Signature Issued By: Signature