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1637 Ashbury Pl CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 BUILDING PERMIT Receipt # To be used for Est. Value 1 ti ' 4 Date r 1 19 Site Address `t ASRI!t_I::'r OFFICE USE ONLY Lot Block Sec/Sub. Parcel No. Occupancy k FEES ZoningZ W Name Ll CITY (Actual) Const Bldg. Permit 4. C o Address 6-370 1513T ST (Allowable) V 51.OCl Surcharge City A E P! L WALL 2 phone 454-55j n # of Stories Plan Review 327.00 Length =p Name Depth 50, SAC. City } "'(J 00 Address S.F. Total < SACMCWCC 5r City Phone S.F. Footprints r On Site Sewage Watej Conn F Ow W Name On Site Well Water Meter '4C - \ W 1 1, Address MWCC System z t Acct. Deposit C . o c r City Phone City Water PRV Required • S W Permit I hereby acknowlege that I have read this application and state that the Booster Pump SiW Surcharge 1 . CV information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Treatment PI = 28.00 Signature of Permitee APPROVALS Road Unit %40, CO A Building Permit is issued to: COLLL GE CITY Planner Park Ded. on the express condition that all work shall be done in accordance with all Council applicable State of Minnesota Statutes and City of Eagan Ordinances. Bldg. Off. Copies _ Building Official Variance TOTAL Permit No. Permit Holder Date q~ Telephone # WATER ~:1 ' a SEWER PLUMBING C~ y cv c/~ . GG - H.V.A.C. 7 CL o~~/ I ELECTRIC Inspection Date Insp. Comments v Footings I 2!/ Foundation A Framing 3-,f 3 rd ,,m~ ~+LaLt Roofing Rough Plbg. Rough Htg. zy" Isul. ` Fireplace / f4 Final Htg. 1v Final Pibg. ~70 Const. Meter Pibg. Inspector - Notify Plumber Engr./Plan Bldg. Final Deck Ftg. Deck Final Well Pr. Disp. Cities Digital Quality Control The following image represents the best available image from the original page. Every effort was made to capture the content from the original page. PERMIT # PLUMBING PERMIT RECEIPT # ' - CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: CONTRACT PRICE: PHONE: 454-8100 Site Address t BLDG. TYP WORK DESCRIPTION Lot Block Sec/Sub Res. New Mult. Add-on Name Comm. Repair Address Other C City Phone RES. PLBG. ONLY - COMPLETE THE FOLLOWING: NO. FIXTURES TOTAL Name Water Closet - $3.00 $ ! Bath Tubs - $3.00 3 Address Lavatory - $3.00 p City Phone Shower - $3.00 Kitchen Sink - $3.00 FEES Urinal/Bidet - $3.00 COMM/IND FEE - 1% OF CONTRACT FEE -Laundry Tray - $3.00 APT. BLDGS - COMM RATE APPLIES --Floor Drains - $1.50 TOWNHOUSE & CONDO - RES. RATE APPLIES -Water Heater - $t 50 MINIMUM - RESIDENTIAL FEE -$12.00 Whirlpool - $3.00 MINIMUM - COMM/IND FEE -$20-00 -Gas Piping Outlets - $1.50 STATE SURCHARGE PER PERMIT - .50 (MINIMUM - 1 PER PERMIT) (ADD $.50 S/C IF PERMIT PRICE GOES Softener - $5.00 BEYOND $1,000.00) Well - $10.00 Private Disp. - $10.00 Rough Openings - $1.50 SIGNATURE OF PERMITTEE FEE: STATE SIC: ' FOR: CITY OF EAGAN GRAND TOTAL: C"_ . PERMIT # MECHANICAL PERMIT RECEIPT # CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: CONTRACT PRICE: PHONE: 454-8100 For Office Use Only: Site Address ` + _ ' " BLDG. TYPE WORK DESCRIPTION Lot Block' , f Sec/Su~ New r,. Res. Mult Add-on Name T Comm. Repair Address c City Phone ' Other !FLA FEES Name RES. HVAC 0-100 M BTU -$24.00 c Address t ADDITIONAL 50 M BTU - 6.00 p City i phone = I ' (RES. HVAC INCLUDES A/C ON NEW ? CONSTRUCTION) GAS OUTLETS (MINIMUM - 1 PER PERMIT) - 1.50 EA TYPE OF WORK COMM/IND FEE - 1% OF CONTRACT FEE Forced Air M BTU J APT. BLDGS. - COMM. RATE APPLIES TOWNHOUSE & CONDOS - RES. RATE APPLIES Boiler M BTU MINIMUM RESIDENTIAL FEE - ALL ADD-ON & Unit Heater M BTU REMODELS - 12.00 Air Cond. M BTU MINIMUM COMMERCIAL FEE - 20.00 STATE SURCHARGE PER PERMIT - .50 Vent. CFM (ADD $.50 S/C IF PERMIT PRICE GOES Gas Piping Outlets # ~ $ ~BEYOND $1,000) Other FEE: A _ 1 • ~ ~ ~ c ►ti twice SIGNATURE OF PERMITTEE S/C: y TOTAL FOR: CITY OF EAGAN a Trrtifiratr of Orrupaury Citp of (Eagan lorprwmt of tuning jMWrrtiou This Certificate issued pursuant to the requirements of Section 306 of the Uniform Building Code certifying that at the time of issuance this structure was in compliance with the various ordinances of the City regulating building construction or use. For the following use ca.seification SF I7G GXAR Wj Permit No. 16161 OaoP-y Type R3/)41 zoning Dimia R) Type ComL VN Owner oreaildi g(IL CM Add. 6970 151ST ST., APPLE VALLEY BuMng Address 1637 ASHilRY PLACE LocAty L4, H4, NAQ0WK GLEN 2ND Date: MAY 10, 1989 B".9 Mend I POST IN A CONSPICUOUS PLACE ' .CASH RECEIPT CITY OF EAGAN ' 3830 PILOT KNOB ROAD EAGAN, MINNESOTA 55122 DATE IECENED FROM ! l~✓. AMOUNT $ C~ -T 1 & DOLLARS j roo ❑ CASH Q,CHECK FUND OBJECT AMOUNT Thank You BY C White--Payers COPY 4do YeNow-Posting COPY PNc--FUe Copy a BLDG.;PERMIT NO. 01-3210 Bldg. Permit 01-3422 Plan Check 1 f (i 01-3445 Surch./Adm. _ 01-3446 SAC/Adm. 01-2155 Surcharge 75-3860 Road Unit ¢0-2275 SAC 20-3865 Water Conn. ` r= 20-3868 Water Trmt. 20-3716 Water Meter 20-2252 Acct. Dep. ' 20-3713 Water Permit 20-3743 Sewer Permit 79-3866 Sewer Conn. i 28-3855 Park Ded. TOTAL SEWER & WATER PERMIT OFFICE USE ONLY CITY OF EAGAN PERMIT DATE 3830 Pilot Knob Rd. WATER PERMIT # SEWER PERMIT # P.O. Box 21199 METER # B.P. RECEIPT # Eagan, MN 55121 READER # B.P. RECEIPT DATE METER SIZE ISSUE DATE YX PRV -BOOSTER PUMP SITE ADDRESS % r PERMIT REQUESTED LOT BLOCK SEC/SUB Cr SEWER - WATER - TAPS APPLICANT: ADDRESS: 5 r . ' -COMMAND -RESIDENTIAL CITY, STATE _ ZIP ' PHONE: NEW -EXISTING 1 PLUMBER: ADDRESS: I AGREE TO COMPLY WITH CITY OF CITY, STATE Zip EAGAN ORDINANCES: PHONE: .r OWNER: ADDRESS: r} ' 'h'am ' '9 SIGNATURE WHEN METER ISSUED CITY, STATE I r ZIP PHONE: PLEASE ALLOW TWO WORKING DAYS FOR PROCESSING. FOR STORM SEWER PERMITS, CONTACT ENGINEERING DEPT. INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number: Eagan, Minnesota 55122-1897 Date Issued: ' (612) 681-4675 SITE ADDRESS: APPLICANT: ,;.i I t N Pf(1 ! t f .'r A I PERMIT SUBTYPE: TYPE OF WORK: INSPECTION TYPE DATE INSPTR. INSPECTION TYPE .DATE INSPTR. 1,ra,;are;, Permit No. Permit Holder Date Telephone M ELECTRIC PLUMBING HVAC Inspection Data Insp. Comments FOOTINGS FOUND FRAMING Z-27~r9 fvJ,3 ROOFING ROUGH PLUMBING PLBG AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYP BOARD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL Z BSMT R.I. BSMT FINAL DECK FTG DECK FINAL L SEWER & WATER PERMIT OFFICE USE ONLY CITY OF EAGAN PERMIT DATE i ' 7 /8 3830 Pilot Knob Rd. WATER PERMIT # _ 10 ~ i 5 SEWER PERMIT # P.O. Box 21199 METER # AI 1 7J? B.P. RECEIPT # C 1142 Eagan, MN 55121 READER # -'71V 961 V B.P. RECEIPT DATE 3 14 84 METER SIZE o ISSUE DATE XXX-- PRV _ BOOSTER PUMP 7 ~ "tif SITE TDRESS PERMIT REQUESTED LOT BLOCK SEC/SUB a J! SEWER WATER -TAPS < o/~e r` o t~ J APPLICANT ADDRESS: 7 0 S J S _ COMM/IND - RESIDENTIAL CITY, STATE Y c ZIF'-sue °Z PHONE: _ NEW _ EXISTING PLUMBER: ~9 i " )v ; Y7 ADDRESS16 ' r rqC Q I AGREE TO COMPLY WITH CITY OF CITY, STATE 0 Zlp- ' -EAGAN ORDINANCES: PHONE: l OWNER: r / r o ADDRESS: ('.S SIGNATURE W METER ISSUED CITY, STATEQ" n /`I r ZIP Ssl PHONE: PLEASE ALLOW TWO WORKING DAYS FOR PROCESSING. FOR STORM SEWER PERMITS, CONTACT ENGINEERING DEPT. r CITY OF EAGAN r_ 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 BUILDING PERMIT Receipt # To be used for Dw`- ~t•,~ r Est. Value 04 r 01-~D Date I`U►RCN 14 tglkl-i- Site Address 1637 ASHHURY PLACC , Lot Block Sec/Sub. "L' .C!'A1,rX' GLEN OFFICE USE ONLY Parcel No. 21D Occupancy R-3 ?~i-: FEES Zoning-1 W Name .L CITY (Actual) Const V-N Bldg. Permit 654.00 o AtdreSs 0970 151ST S'i' (allowable) Surcharge 52.00 City APPLE YAt.1. Phone 4 54-- i ISM # of stones Length Plan Review 32 7 - 00 o Name SAME Depth r SAC, City 100.00 0- 1 Address S.F. Total SAC, MCWCC 575.00 (OJ < City Phone S.F. Footprints Water Conn 580-00 On Site Sewage w W Name On Site Well Water Meter 90.00 U= Address Mwcc System AaK Deposit 30.00 MW City Phone City Water $ PRV Required S/W Permit 20.00 1 hereby acknowlege that I have read this application and state that the Booster Pump S/W Surcharge 2.OD information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Treatment PI 728.00 Signature of Permitee APPROVALS Road Unit 340.00 A Building Permit is issued to: COLLEGE CITY Planner Park Ded. on the express condition that all work shall be done in accordance with all Council - applicable State of Minnesota Statutes and City of Eagan Ordinances. Bldg. Off. Copies Building Official Variance TOTAL 00 CITY OF EAGAN 16191 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 BUILDING PERMIT Receipt # 7 To be used for SF DWG/GAR Est. Value $104,000 Date MARCH 14 1889 Site Address 1637 ASHBURY PLACE OFFICE USE ONLY Lot 4 Block 4 Sec/Sub. BLACKHAWK GLEN Parcel No. 2ND Occupancy R-3 MM1 FEES Zoning RR=1 W Name COLLEGE CITY (Actual) Const -)L--N Bldg, Permit 654.00 o Address 6970 151ST ST (Allowable) VV=N Surcharge 52.00 City APPT E VAT T FPhone 454-55,96 a of Stories - Length 56! Plan Review 327.00 o Name SAME Depth 501 SAC, City 100.00 u< Address SF Total SAC, MCWCC 575.00 F City Phone S F. Footprints On Site Sewage water Conn 580.00 W w Name On Site Well Water Meter 90.00 X3 Address MWCC System XX of Acct Deposit 30.00 aw City Phone City Water X}1 PRV Required XX_ S/W Permit 20.00 I hereby acknowlege that I have ad this A Icatio and state that the Booster Pump S/W Surcharge 1.00 information is correct and agr to comp) with alf applicable State of Minnesota Statutes and Ci o "Fxagan Or f ance Treatment PI 229-00 Signature M Purnitee/ APPROVALS Road Unit 340.00 A Building Permit is issued to COLLEGE CITY Planner Park Ded on the express condition that all work shall be done in accordance with all Council applicable State of /M1i A,1nnn~esotta Statutes annyd~ C L4 L1 itity of Eagan Ordinances. Bldg. Off Copies Building Official 1119 1l~' Variance TOTAL z,997.00 DATE: 3/17/09 r RE: 1637 ASRBTIRY PLACE, L4, B4, BLACKRAWK GLEN 2nd %1< bur Sewer & Water Permit for the above property has been completed. It will be held at the ,Ogublic Works Garage (3501 Coachman Road) until the meter is picked up. BE SURE TO .bALL PUBLIC WORKS (4545220) FOR YOUR PERMANENT WATER TURN ON. Your Sewer & Water Permit for the above property cannot be completed for the following reasons: Your Sewer & Water Permit for the above property has been completed, but the meter cannot be issued or occupancy allowed until further notice. COMMERCIAL PROJECTS ONLY: Please pay for meter at City Hall. Meter size must be confirmed by Bill Adams or Dirk House (Plumbing Inspectors - 4548100) 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. DATE: 3/17/894 RE: 820 SHORTLINE, L2, B5, STAFFORD PLACE 1637 ASHBURY PLACE, L4, 114, BLACKRAWK GLEN 2ND ,ax nur Sewer & Water Permit for the above property has been completed. It will be held at the -Vublic Works Garage (3501 Coachman Road) until the meter is picked up. BE SURE TO CALL PUBLIC WORKS (454-5220) FOR YOUR PERMANENT WATER TURN ON. Your sewer & Water Permit for the above property cannot be completed for the following reasons: Your Sewer & Water Permit for the above property has been completed, but the meter cannot be issued or occupancy allowed until further notice. COMMERCIAL PROJECTS ONLY: Please pay for meter at City Hall. Meter size must be confirmed by Bill Adams or Dirk House (Plumbing Inspectors - 454-8100) before issuance. WARNING: BEFORE DIGGING, CALL LOCAL UTILITIES - TELEPHONE, ELECTRIC, GAS, ETC. - REQUIRED BY LAW. 1 4 , CONTACT COMMUNITY DEVELOPMENT DEPARTMENT FOWWATER TURN ON POLICY. Y Secretary, Building Inspections Dept. Jj`z i 88 7 892671 3 `7 " Request Date Fire No. 1Rough-m Inspection -;2^ Regulred' ❑ Ready Now ill Notdy Inspector Yea ❑ No When Readyl I Licensed contractor ❑ owner hereby request inspection of above electrical work at: Job Address (Street, Box or Rod a) City 1639 o' y rs~ Section No Township Name or No. Range No County Occupant (PRINT) Phone No Power Suppller / Address Electncal tractor (Company Name) Corer License No YJ K/ P/L V/Yi Mailing Address (Contractor or Owner eking lma:11ah n) 0 Auth"ad Srg r Contram n r a Ing s tenon) Phone Number Ilia MINNESOTA STATE ARD OF ELECTRICITY THIS INSPECTION REQUEST WILL NOT GHggs-Midway Bldg. - Room S173 BE ACCEPTED BY THE STATE BOARD 1821 University Ave., St. Paul, MN 55106 UNLESS PROPER INSPECTION FEE IS Phone, (612) 662-0800 ENCLOSED REQUEST FOR ELECTRICAL INSPECTION E80MOM-07 ► 89267 See nstructions for completing this form on back of yellow copy. "X" Below Work Covered by This Request V ~e% Add Rep Typeot Building Appliances Weed Equipment Wired Home Range Temporary Service Duplex Water Heater Electric Heating Apt. Building Dryer Other (Specify) Comm./Industrial Furnace Farm Air Conditioner Other (specify) Contractor§ Remarks. Compute Inspection Fee Below # Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee Swimming Pool 0 to 200 Amps / 0 to 100 Amps Transformers Above 200 _ Amps Above 1 0 _ Amps Signs Inspector8 Use Onry: TOTAL Irrigation Booms Special Inspection V v1 Alarm/Communication Other Fee I, the Electrical Inspector, hereby Rough-in oat certify that the above inspection has Final Ca / been made. OFFICE USE ONLY Thw request void 18 months fro. 1989 BUILDING PERMIT APPLICATION - CITY OF EAGAN SINGLE FAMILY DWELLINGS I G I q ' INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED. MULTIPLE DWELLINGS RENTAL UNITS FOR SALE UNITS # OF UNITS INCLUDE 2 SETS OF PLANS, CERTIFICATE OF SURVEY - CHECK WITH BLDG. DEPT., 1 SET OF ENERGY CALCULATIONS COMMERCIAL INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS, 1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS VAR 0 9 1989 To Be Used For: Valuation: -rJ v v v v u Date: 97 Site Address / 6- ] Ll r Aye- m, /6)9, oaa'~ OFFICE USE ONLY Lot Block Occupancy R-3 M-1 FEES / Zoning Q-1 Parcel /Sub 0~- qL-' (i/ro Actual Const V-N Bldg. Permit ~~Sy J Allowable y - T( Surcharge S Z Owner CA 14 / rs y V # of stories Plan Review 3 Length ! SAC, City /Oo Address B-3-' / V 6r e e,2 i • u a LID Depth SO SAC, MWCC S 2S S.F. Total Water Conn spa City/Zip Ccde, 7 11'~)r1 S~~o2a2 Footprint S.F. Water Meter 30 Acet. sit -20 Phone On site sewage_ S/WPermit ) On site well S/W Surcharge / Contractor (f-0 ))d s e ~4ti Cojij MWCC System ri Treatment Pl. 2Z Y 6170 T City water ✓ Road Unit 3 90 Address )-S-) /i s~ PRV required Park Ded. I f f Booster Pump Copies City/Zip CodeO/ /e L/I TOTAL 1v4~ ~0 /r APPROVALS Phone Planner G~ Council Arch./Engr. Jq m c ~o r~~, Bldg. Off. 24;Tj~-3/2 v s Variance Address Council City/Zip Code Phone # NOTE: Sewer & Water Permit fees and account deposit fees will be included in the building permit fee. Processing time for sewer and water permits is two days once a licensed plumber has applied for a permit at City Hall. VA A-MCNJ GARAGE Z3 k Zo = L4 xI5 = X9 0 y 2(-XgGI- Jzys '6 Xy - 32 2 y is 3e It, X LJ 4o ~ Y cs r2,H ltii4X Jy= 19~o1G Juxl2=i2~K~d= ~lfrOv 15-T F c.o or2 13`7n47 = lyF4 x16 = r~ 1 yk~ x SO X 2400 ~o 3 ~R~ I * * 2422 Enterprise Drive * PIONEER Mendota Heights, MN 55120 eng * eering • • (612) 681-1914 Certificate of Survey for: LOLL ZR7E CITY 60N5'7- ~Qw 19.9 Q ~ z o h~° Duttfa9VAY 7a 9i7•, J v" ho . ~ 2~ F; i 9i4' , 'a,ot'~ '~o a Q' '"B•33 oh ~Q1 ~ , as ma'r' %s \ ~ ~ ~ Nh R°Q,~~ 5 " ? t 19 -S° ti U [Roy, REQUORCD1 V :.~V`.' By c> Da#ero~9 r._ EAGX23 900-0 Denotes exisfin4 Eleval on PROPOSED NOU5E ELEVATIONS • 900.o Denotes propvged Elevation Lower Foor E eve ion g1 7.o Denotes Oraina je f 6111'li y Easement Top o, Block Elevation 20.0 -sa-Denotes DrainccYYSe Row 4rrows GarajeSlab Elevation sig. s D Denotes monument Bearin~s shown are assumed Sub e' d to Easements or'Record LOT 4, 8LOCu 41 SLAC99AWk GUAI 2ND ADD. 1 hereby certify that this survey, plan or report was per/ veered by and y direct sup I ion and that I am duly Registered Land Survey" under the laws of the State of Minnesota. Dated this-94/4 day of A.D. 19 . Scale 1 &c °40_, B Roe ERNICH L.S. G. NO. 141191 "7 f n^ I EXTERIOR ENVELOPE AVERAGE "U" C014PUlAhON OWNER C rl a r ~°1 ' 4 ~ r~ SITE ADDRESS . b7 7 ur ` e - CONTRACTOR , o~~EGE C DATE -7 ! PHONE 41 Determine working square footage of each. 1. Total exposed wall area 2019 sq. ft. x I_ ° tzZ 2. Total roof/ceiling area 1' 33 sq. ft. x oZ(n = ' A.bb 'Total exposed wall area above floor = i2i a. Total wall window area 2 S 7 b. Total door area y _4-4 _ e. Total sliding glass door area 40 d. Total fireplace wall area e. Total wall framing area (average 10%)............ f. Total net wall area above floor g. Total rim joist area Total-exposed foundation area ° °(O h. Total foundation window'area L Toal net foundation area above grade 9. Determine "U" value of each wall segment. ° a._ ZS-7 X "U" .3A110 b ~d- X "u" . X28 C; Pun d _ X "u" e. 1Cfj X "U" f. 1319 2 X "U" o A 9 13I X "u" . Ct A- I ° h. O x "u" ° - ' i. 90 X "U" .o ° 3 .......................Total -1 same as or less than item fl. yO iave et the intent If item i!3 is the of SBC 6006(c)2. Total-exposed roof/ceiling area t 33.3 J. Total skylight area k. Total roof/ceiling framing area (average 10%).,, 1. Total net insulated roof/ceiling area .....~L Determine "U" value for each roof/ceiling segment. X bull k. I JJ A x Mu" 1. I 1 q~ x "ull , ozz zb ..................................Total . i If total of 14 is the same as, or less than :2. you have met the intent of SBC 6006(c)1, Alternate Building Envelope Design To utilize the total envelope system method, the values established by the sum of items 13 and 14 shall not be greater than the sum of items 11 and 12. 1. + 2. p 3. + 4. Mo U. M4.L A /Y n F ~ rJ ~ .i•••{~' • •i.raia nA IV _r~ r~ Y.')~tr.~•E- ~'%1'1~10._ 1'YI NDoW AREA TYPji of W)N-PGW S 6/a" iNSVL. cuss Tag W"OoNJ IJufrs gArt 8X1• rPra•O /o¢ "IQ ~VALµL~ TNIY Aki As 1.49140 Z~~• A6049 4-yo m4if O! 4341/4410 .1A pssi`.V [+Art1 VAL.6,44 OF •4j"0 INCLND INC AIA /4LM5 1111 =1/mil ~ 1/ . ooTwgt. -~fo•TAaR•~~~ ~ FOLINDA710N WmDPW AR>:A t TYPL of W,040OW : TNC VVJNOO W Udirs 1440I. AOLS4 rLSriP PoR'A= VAUasr rNLY ARt Ai I1 .+s3 ways Au4 m4r ar AbSJJQLO A O&SOISS40^040 VA&•ua Coos vj"%' All ►ILMS . •j1i: 1/`III • foarwy4 ♦ l~ooMyi + SLID1Wgi (•7LASS Dour. AREA: TYPL 00, DOOR: 51-0014Q 4L435 00005 11AVL OLL&1 'rL31T&Q For"R- YA&-KRy 'MLY 4" " WATAa Abaft Ado N141 Br Ai.519IN06R A DXi14F1CSAPI) VAL1146 06169L'~s .Z69 ,uc~rel... Ali i11.1451 y~ 119! • V 4u r. 1/ + t~y~ Fv.T~ 4t. v DooR /}ReA : Tree oR Dom: 7-t4EQ:MA..7- -mu DOOIZ U#Jrrs HAVE. OLiN resrcA A,Na ►ouwO To NAY& AM 'R'-VAuL4& of 7 1 Nfj A14 r►6N11, . / Z 8 FCOTAt L SA 4b1 t I/RI, S PECIA LS TYPE TbRM 9-1 1*Ajm.% ~~r"~ 51CflLA . . \ ry/vV ti Yi '~+z .n•w•.+~: T'~ :y.. vY :YY .G:':.~s~llbiS.`~F.~._a~ RIM UGIST AICf.A ; "R' - VALUE • 1O1 ,1 P4 T E R. 109- At 4: fl L. M 00 19.0 6 IusuLArIoq cot./? ) 2-06Z.0.SH9ArINCr uILT,RITE- .to7 tAP $loll-lq_ 1/Z,1 _ 1,68 14" S00WOOD I; _EXT6RI0R AIJL r-11-01 2 TorA L.'gw!j' VAI-ILI Tom rmrAq Fount O AT I014 WALL AREA CA' WVL CgKA01[.3 "R" ✓A L u 6 t#Jrrlt)Ok AM fit-,w\ 11,0 F:aejw.&~ 6..j~E09A.10R, AIM IILM 12.b3 TorAL VALu.l- 9a lla l~ (Zle3 . ~o~~ 7'07Al N:MTAC*L IDAw 1.1 10*V*k Wit 51 W10_ Sru0 / FKAM Miq A'L F;". VAU,.LR .-4iIuregioR ovot Fit." YzZ GYvfam WALOROoiRa ~ ~,9~,5 J/"LSoIrWo~O -1.06 2 Z 'sows 1N4 1 - .Tx. r_ b7 1 w P A VAA*e DAROUM ..L~[rtAlOk A,1C MI4.M (x,83 orAL.' L. %AL r TOTAL MOTAGC -f-NSIL.I.A'rl o AICIA BrrwcaN -STUDS "R" VA Lw L • b~ =uragioa A,/t /,bH . 45 ,I 4YPl,4M y✓AL4dOAe~ 19.o Ius"LAT )a 04 (1L,17 "06 ! 5NL,%YN/N4aVIL-r?A: m Ao Ih. S I G I M Q ~1P F vAP V 14 IDA41t.4t R. 'Lr&ILI4M AM ML.M. ZI.9LrOTAi. Pi ou VALIAC. IOTA. MOM4A. lb vAP[i ~~~YSO~. y3s'/- 01fo ^o `f H . a e~o~`>a~ 'a'~'aim^'~:5a~ x✓.~`:£..'::.::. *z~"i<`e4f'Y :n'u>»i"y.. .i•[. .3,c"tl,..[~S.y [.=:3w.t3: v:. .v=,~a< s :::.:<:i ..[:[.,a,.. %.w:m<::x:<[a, n:a.w,x.,w.... c.<ae.:a,..:n,;d::~£;„ "q•~f~.:' 1994 PLUMBING PERMIT (RESIDENTIAL) CITY OF EAGAN 3830 PILOT KNOB RD / EAGAN MN 55122 (612) 681-4675 PLEASE COMPLETE FOR SINGLE FAMILY DWELLINGS. ALSO, FOR TOWNHOMES AND CONDOS WHEN PERMITS ARE REQUIRED FOR EACH UNIT. - - - - - - - - - - - - - - - - - - - - - - - - - - NO. FIXTURES EACH TOTAL SHOWER l .nn WATER CLOSET 3.00 BATH TUB 3.00 LAVATORY 3.00 KITCHEN SINK 3.00 LAUNDRY TRAY 3.00 HOT TUB/SPA 3.00 WATER HEATER 3.00 FLOOR DRAIN 3.00 GAS PIPING OUTLET • minimum • 1 3.00 ROUGH OPENINGS 1.50 WATER SOFTENER 5.00 PRIVATE DISP. • Dat.Cty. lic. 20.00 U.G. S CI ER • &u~mje der cont. 3.00 TERATIONS • to 20.00 U U WA 20.00 STATE SURCHARGE .50 1 TOTAL: ~0 SO SITE ADDRESS: 1657 A 5 /4 tg U 2 y P(_ (4-c e OWNER NAME: Cw P 2 LE S Fo 3 is INSTALLER: ~i m s @V ,a L f r Lj PL Lc + 6"J G ADDRESS: P o b r y a el a- CITY: 0 5 5 F o STATE: ^J ZIP CODE: 5S~ 5 PHONE 14 SIGN RE OF P RMITTEE i yy~~ :.~2 .:.A,'C',{.iy..i.">:'yJd):'r~'irir~::'::;:1B:1e.:r>:i :~~!'s.i 'rev`Y;~ya.,£.'i,3:#.~":~5:':'i ":kfai<.•y:;. :..,w„ x 1 <~y:a#:1A5k::~::1:i.: f: :':iV<': Sib: ,.d.~Sy. ..•-,.n "<.:w,».a,'<. :w;i»SA a<w. a 5:.?i,>.,, aas>2»: «'"#>..g Spat e$.>$%L.:. e'SGa "bi.., cN~>zs+" `gg.?E^~1..„., o aa$ d:'.r.~' g iW.aT,.£:v _ "o„6"ayrb, ~:1<ajt .,.b,......nr..3..J:.1;r?::.us..n.•.~»1.:..i.SR<.'Rt3:`h'a'.,S.R.S<,:.i..#.}.>#.A'<s~,~w:. v. n:'`y.~Yss.;. wnoa:n"'. 1994 PLUMBING PERMIT (COMMERCIAL) CITY OF EAGAN 3830 PILOT KNOB RD EAGAN MN 55122 (612) 681-4675 PLEASE COMPLETE FOR ALL COMMERCIALdINDUST'RIAL BUILDINGS. ALSO FOR MULTI- FAMILY BUILDINGS WHEN SEPARATE PERMITS ARE NOT REQUIRED FOR EACH DWELLING UNIT. NEW CONSTRUCTION _ %ILD ON REPAIR WORK DESCRIPTION: CONTRACT PRICE: $ FEE: 1% OF CONTRACT FEE. STATE SURCHARGE $.50 FOR EACH $1,000 OF : FEE. MINIMUM FEE.'$ 25.00 CONTRACT PRICE X 1% $ STATE SURCHARGE $ TOTAL $ SITE ADDRESS: TENANT NAME: STE. # OWNER NAME: INSTALLER: ADDRESS: CITY.. STATE: ZIP CODE: PHONE FOR: CITY OF EAGAN APPLICANT YF?::lv~I*),(;CrX?AYtH`.'Y>V:i;Y.(~r}:d:,;:7~iaH<Yd:'tRt":);!)X;ti$:Y:?",Y.:} c1n, OF Ii'AGAN CASHER: MG 1! RM NAL N02 313 nATEn WNW TIME: 0:4001 tr WiD 900t ib37 F}S!..IFU!u A :1.4:.75 205 9001 %37 i'iFl°BURY 4 .`id1 3433 9601 i637 al`i'-!ORY PL. 0.25 Total pwelDt 151.51, CP 061 36 USER 19r MARY-N PERMIT CITY OF EAGAN 3830 Pilot Knob Road PERMIT TYPE: Permit Number: B U I L D I N G Eagan, Minnesota 55122-1897 0 2 9 4 0 2 (612) 681-4675 Date Issued: 01 / 14 / 9 7 SITE ADDRESS: 1637 ASHBURY PL LOT: 4 BLOCK: 4 BLACKHAWK GLEN 2ND P.I.N.: 10-14351-040-04 DESCRIPTION: (INCL DECK) Puildino-,,Permit Type SF PORCH ,Building Work Type NEW J- census Code. 434 ALT. RESIDENTIAL " ax k- 41 ~I"; 414 REMARKS: FEE SUMMARY: VALUATION $9,000 Base Fee $149.75 COPY $.25 Surcharge $4.50 Total Fee $154.50 Subtotal $154.25 CONTRACTOR: - Applicant - ST. LIC OWNER: PANELCRAFT OF MN INC 17216628 0002179 FOYE CHRISTINA 3118 SNELLING AVE S 1637 ASHBURY PL MINNEAPOLIS MN 55406 EAGAN MN 55122 (612) 721-6628 (612)454-5586 ,I hereby acknowledge that I have read this application and state that the information is correct and'agr'ee to domply tin'-alI, applicable State of-Mn. Statutes and City of Eagan Ordinances. APPLICANT/PERMITEE SIGNATURE ISS BY. SIGNATURE CITY OF EAGAN 3830 PILOT KNOB RD - 55122 lqm4041 1996 BUILDING PERMIT APPLICATION (RESIDENTIAL) 681.4675 New Consfruefien Reauhements Remodel/Repair Requirements ♦ 3 registered site surveys ♦ 2 copies of plan ♦ 2 copies of plans (include beam d window sizes; poured fnd. design; etc.) ♦ 2 site surveys (exterior addelons d decks) ♦ 1 energy calculations ♦ 1 energy calculations for heated additions ♦ 3 copies of tree preservation plan K lot platted after 711/93 required: _Yes _ No Q DATE: 1-7-9-7 NSTRUCTION COST: C , )cn~ DESCRIPTION OF WORK: C' Sh" : I n~ h STREET ADDRESS: I fir l~ 1-6. 1,rk LOT BLOCK SUBDJP.I.D. A I,1 PROPERTY Name: Fo V l . F 1 rt-c 1 r>cr , Phone L~~L=)L/-'55CSA OWNER Street Address, 7 PSh ku ry City: State: M 0 _ Zip. CONTRACTOR Company: Phone* Street Address: License city:. rn-P LS, \j State: M f) Zip ARCHITECT! ENGINEER Company: Phone # I Name: Registration Street Address, City: State: Zip: Sewer & water licensed plumber. Penalty applies when address change and lot change are requested once permit is issued. 1 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. L' CA 0 Signature of Applicant: OFFICE USE ONLY RECEIVED Certificates of Survey Received _ Yes _ No JAN 0 8 1997 Tree Preservation Plan Received _ Yes No BY: Mg i OFFICE USE ONLY R BUILDING PERMIT TYPE 1► " ❑ 01 Foundation ❑ 06 Duplex ❑ 11 Apt./Lodging ❑ 16 Basement Finish ❑ 02 SF Dwelling ❑ 07 4-plex ❑ 12 Multi Repair/Rem. ❑ 17 Swim Pool ❑ 03 SF Addition ❑ 08 8-plex ❑ 13 Garage/Accessory ❑ 20 Public Facility ,204 SF Porch ❑ 09 12-plex ❑ 14 Fireplace ❑ 21 Miscellaneous ❑ 05 SF Misc. ❑ 10 _ plex ❑ 15 Deck WORK TYPE -2, -Sev,!_ . ! h-e-C4 ❑ 31 New ❑ 33 Alterations ❑ 36 Move ,a' 32 Addition ❑ 34 Repair ❑ 37 Demolition GENERAL INFORMATION Const. (Actual) Basement sq. ft. MCANS System (Allowable) Main level sq. ft. City Water / UBC Occupancy sq. ft. Fire Sprinklered Zoning sq. ft. PRV # of Stories sq. ft. Booster Pump Length sq. ft. Census Code. tl Depth Footprint sq. ft. SAC Code a i Census Bldg Census Unit c~ APPROVALS Planning Building NT9 Engineering Variance Permit Fee Valuation: $ 0 9(,00 0 . Surcharge Plan Review License MC/WS SAC _ City SAC - - Water Conn. Water Meter Acct. Deposit A S/W Permit /Vtvsi ~Ur co- "ct o~osec SAN Surcharge Treatment Pl. Road Unit / Park Ded. Trails Ded. Other Copies r -k- 'YVl Total: % SAC U SAC Units * * 2422 Enterprise Drive * PIONEER Mendota Heights. MN 55120 i engineering_ (612) 681.1914 I i Certificate of Survey for; CDLL R7[ CITY 6'0N4ST v Q ~z e~h ~ ~ ~hti` ss o - M N^ t Qro t. o^ \°i deg _ b h ~9 0, ? ;a h / o 19 P.R.V. RE QU1Rzs I `,T C~ r j q . soo.o Denofes exIA-n Elevation o rE N u F FLEVATI~Ns • soo.o_ Denofes propdeo' Elevation Lowes Floor Eleva ion g17.3 Denofes Droinojef (lfili~ Easement- Top o, Block Elevation 82ao Denofes DrainccYYSe Flow Arrows Gara~e Slab Elevation 819.8 o Denofes monumeof Bearin¢s shown are assumed Sub e* d to Easements of Record L 0 T 4, 8LDCAI 4, 9LACk9AWk1 G4 [A/ 2ND ADD. 1 hereby certify that this survey, plan or report was Pr red by ma undo y direct rup,111vi/JJtan and that I am duly Registered hrM Surveyor under the laws of the State of Min/newta. Dated this day of A.O. 19 . ROBERT S, FIEG. N0. Ie891 ^ PERMIT# l ` i l ~a3(~~X RECEIPT DATE: ~1 i✓~o 2002 RSIDENTIAL pLUMBINO p$ftMff AppLICATION CITY OF EAGM 3$30 PILOT KNOB RD SARAN, MN 5518E j1 r$ (f~l R 651-681-4875 l~lS~ I4 OR 2 9 2002 Please complete for: single family dwellings, townhomes and condos when permits are required for a unit, i l backfloowjwprevennter for irrigation system 1 SITEADDRESS: I/G / I l ~1 /LI~I By OWNER NAME:: l ip S }-/j(1 0 TELEPHONE (A(R~~n- `)f INSTALLER NAME: Q I I - WGUIRE & $QNg~° TELEPHONE b0 12Th Avenut South (AREA CODE) STREET ADDRESS: }JO~knc +nh CITY: STATE: ZIP: _ SEPTIC SYSTEM, new/refurbished (requires two sets of plans and MPC license) $ 100.00 includes $40.00 County fee Note: Additional consultant fees may apply • MODIFICATION/ALTERATION TO EXISTING DWELLING UNIT, INCLUDING: - Adding fixtures to lower levels or room additions, excluding water softeners and water heaters. $ 50.00 - Abandonment of septic system. - Water turnaround - existing dwelling unit 5/8" meter if needed - $118) Other: - RPZ: new installation/repair/rebuild $ 30.00 - lawn irrigation system Replaoemen dditional: water softener water heater $ 15.00 State Surcharge $ .50 Total $ 1 hereby acknowledge that I have read this application, state that the information is correct, and agree to c mply with all applicable City of Eagan ordinances. It is the applicant's responsibility to notify the property owner that the City of Eagan assumes no liability f any damages caused by the City during its normal operational and maintenance activities to the facilities constructed under this permit within Ci ope ht- f-way/easement. SIGNATU O PER E 1/02 PLUMBING (RESIDENTIAL) Permit Application City Of Eagan 3830 Pilot Knob Road, Eagan Mn 55122 Telephone # 651-675-5675 FAX # 651-675-5674 Please complete for: Single Family Dwellings T~ownhomes and Condos when permits are required for each unit Date 034 Unit Site Address # Property Owner Telephone # (V!J i Contractor Address 1 /{~`1 - City (~~D / ! Y T State f / I.i' L Zip Telephone # The Applicant is Owner Contractor Other Septic System _ New _ Refurbished Submit 2 sets of plans and MPC license $ 100.00 Includes County fee. Additional consultant fees may apply. Alterayons To Existing Dwelling Unit, Including $ 50.00 Adding fixtures to lower levels or room additions, a eluding water softener and water heater - Abandonment of septic system 2 8 _ Water turnaround ((++"5!S" meter if neeeded- $121.00) Other: room &#14 l3y - v - RPZ _ new installation _ repair - rebuild $ 30.00 Lawn irrigation system - Water softener _ Water heater $ 15.00 replacement _ additional $ .50 State Surcharge Total $ T hereby apply for a Residential Plumbing Permit and acknowledge that the information is complete and accurate; that the work will je in conformance with the ordinances and codes of the City of Eagan and with the Plumbing Codes; that I understand this is not a permit, but only an application for a permit, and work is not to start thout 't; that the worVwffl be in actor nc I with the approved plan in the case of work which requ' e a review and approval( f ans. n) r va fi~a~ (-L:JjM1,a ~ Applicant's Printed Name Applicant's Signature RESIDENTIAL MECHANICAL Permit Application t~ City Of Eagan 3830 Pilot Knob Road, Eagan Mn 55122 Telephone # 651-675-5675 Please complete for: Single Family Dwellings & Townhomes and Condos when permits are required for each unit Date q / 30 0 Site Address (0i, ~ Unit # Property Owner Telephone # ( ) 4(:54- b-5%:7 Contractor t6co L o~ C-- Street Address '*D 1t k4~ cmco w ((A City ~ t^ rip State ` 1 Zip SS)04_ Telephone # Bond M Expires: The Applicant is Owner Contractor Other Add-on, modification or alteration to existing dwelling unit $ 30.00 - furnace replacement air exchanger air conditioner _ New Replacement ~~O vja other yD State Surcharge $ .50 Total $ I hereby apply for a Residential Mechanical 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 Mechanical Codes; that I understand this is not a permit, but only an application for a permit, and work is not to start without a pe t' the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. .A+ Applicant's Printed Name Applicant's Signa n ~[L n f '~oCgJse My of EalaR ~ QC 1 Ga i (}U~ 'i'~~~ ~ Permit I I 1 1 Permit Fee: • 00 1 3830 Pilot Knob Road I 1 Eagan MN 55122 gy . _ Date Received: I Phone: (651) 675-5675 I Fax: (651) 6755694 I Staff: y9 I 2008 RESIDENTIAL BUILDING PERMIT APPLICATION Date: 00-00 Sheaddress: &22/~ 76?r/a I ~~V Tenant: Suite S: RESIDENT/OWNER Name: e: OK& Address/ City/ Zip: _d ku 67S /S _✓0"Applicant is: _ Owner VllContractor TYPE OF WORK Description of work: 7 " la Construction Cost: Mufti-Family Building/:: (Yes-/ No T } CONTRACTOR Name: //Vs C p ,/License Address: J CCd (Jt_i l(fo..- I~ Sttate°~'~' _i Zip: CJ Phone: ~`.nn Contact Person: f COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 Category 1 _ Minnesota Rules 7672 Energy Code . Residential Ventilation Category I Worksheet New Energy Code Worksheet Category Submitted Submitted (J submission type) • Energy Envelope Calculations Submitted In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? _Yes _No if yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: phone: Sewer a Water Contractor: Phone: NOTE. Aeons and stipporting documents that yau'subWN,'Ore con4Odelertto;bePublic.btfcinpation; `.Portions of. the IntognafW maybe classified; as non_, _ beta of pu yotr.provide spegt(ic rea3ons Mail' Idpeitriit the ChY ta''. conclude that the =are trade sedrets' 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 of to start without a permd; t t the work will be in accordan{Jcwith the approved plan in the case of work which requires a review and Trial of Applicant's Printed Name Ap cet s ignflture Page 1 of 3 Use BLUE or BLACK Ink r---------------- 1 For Office Use V j Permit City of Eqd I I J ~a _ . I Permit Fee: 3830 Pilot Knob Road r I Eagan MN 55122 j Date Received: 11-,913 Phone: (651) 675-5675 1 staff: Fax: (651) 675-5694 1 - - - - - - - - - - - - - - - - - J 2009 RESIDENTIAL BUILDING PERMIT APPLICATION Date: 01 Site Address: J S 1 Tenant: oL*~ Suite RESIDENT /OWNER Name: 1' QX~S Phone: Address / City / Zip: Applicant is: Owner 4 Contractor TYPE OF WORK 1 Description of work: ~14a n-" Construction Cost: 6 1 5,3 2- rX~ Multi-Family Building: (Yes / No"X-7) em I, CONTRACTOR Name: a Is ~ t Ills Raja I)Ovg as 114" Saga License Address: Hastings, MN 55033 City: State: Zip: V I Phone: Contact Person: lrlld~c5 COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? _Yes _No If yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NOTE. Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that the are trade secrets. 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 appr ved plan iinyt~he`case of work which requires a review and approval lans. / Applicant's Printed Name Appli nt's Signature Page 1 of 3 PERMIT City of Eagan Permit Type:Building Permit Number:EA116012 Date Issued:10/02/2013 Permit Category:ePermit Site Address: 1637 Ashbury Pl Lot:4 Block: 4 Addition: Blackhawk Glen 2nd PID:10-14351-04-040 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are not acceptable in lieu of inspections. Carbon monoxide detectors are required by law in ALL single family homes . Patrick Swanson 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 - Trinity Exteriors Inc 4204 Park Glen Rd Minneapolis MN 55416 (952) 920-9520 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA116013 Date Issued:10/02/2013 Permit Category:ePermit Site Address: 1637 Ashbury Pl Lot:4 Block: 4 Addition: Blackhawk Glen 2nd PID:10-14351-04-040 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are not acceptable in lieu of inspections. Carbon monoxide detectors are required by law in ALL single family homes . Patrick Swanson 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 - Trinity Exteriors Inc 4204 Park Glen Rd Minneapolis MN 55416 (952) 920-9520 Applicant/Permitee: Signature Issued By: Signature