4728 Covington CtCITY OF EAGAN
3795 Pilot Knob Road Eagan, MN 53142
PHONEs 454-9100
BUILDING PERMIT
To be utad for SF DWG/GAR Est, ya
Site Address 4728 Covington Court
7 6 S
60,000
Lot Blak Sec/Sub. eacon ..
Porcel # 10 13500 070 06
a Name Wesley Construction
W
z nddreu 9401 %ylon Ave. So.
?.. Rlnnminotnn ?. 91LG-7nQ7
p JN.me Owner
r
u0 Addrett
?- r:•., w.....e
Nome _
Address
I hereby acknowledge tFwf I hove read ihis npplicotion ond state thaf
the inlormotion is corred und o9ree to comply with all applicable
$tote of Minnewta $tatutes and Gty of Eagan Ordmonces.
Slpnoture of Permittee
es ey onstruction
A Bullding Pertnit is issued to:
oll work shall be done in accordonca with all applica e/St te ot '
Buildinq Officiol ? ?/ ? -?-
N° 8412
Receipt .# ?Y-J"Lo
Erect ? Occupancy
Alter p Zoning
Repoir ? Ftre Zone
Enlarge ? Type of Const.
? # Storles
Demolish ? Length 63
6rode ? Depth 29 Sq. Ft.-
Aoororals Fees
Assessment _
Woter & Sew.
Police -
Fire
Eng.
Plonner -
Cauncil _
Bldg. Off. _
APC -
Permit -'i' • VV
Surcharge 30•00
Plan check 156.50
SAC 525.00
Water Conn. 450.00
WaterMeter 60.00
Rood Unit 250.0?
Total $1784.50
_ on tha express condlfion ihni
and City of Eagon Ordinancez.
?U
CITY OF EAGAN
BUILDING PERMIT APPLICATION
EYect ?
'Ib Be Used For J???G l?{?1?valuation f ("? 0, -)C7,-) Date
site Address yW Gvvi'c.+s•X0a.l ?x
Iot -,? sloc-x (? sec./s,b. &ir4c4f 1411
Parcei #: /0 - I35d-? - 070-aG
OFmer: ,(' c
Address: L)
City/Zip Code: J/?jvyri nk'jD't ?
.?
Phone # : e Z.
Contractor:
Address:
City/Zip Code:
Phone #:
Arch./Eng.:
Address:
City/Zip Cocle:
Phone #:
Alter
Reua;r
Enlarge
Nlove
Dernolish
Grade
Include 2 sets of plans,
1 site plan w/elevations &
1 set of energy calculations.
,? 5 3
OFFICE USE ONLY
OcCuPancY
Zoning
Fire Zone ,(J
'Iype of Const.
# Stories '
Front ft.
Depth 0? ,91 ft.
APPFtOVALS P'F.ES
Assessnents Pernri t 3 77
Tqater/Se,aer _
Surchan7e
Police Plan Check?
Fire SAC ,6-0S' -?
Eng. Water Conn. SO .?-
Planner Water Meter
Council Road Unit ,?,5-6 AT
Bldg. Off.
AFC
'ICYPAL
cIrY oF EAGAN 41. 3795 ?ilat Knob Road Eogon, MN S51 Z2 ,
-• ?
PHONEs 454.8100
BUILDING PERMIT Receipt # , -
re `. ...e fe. Sr USF,/GAI: F?, v.,l,.. $60,000 n.,.e AuSust 23 ,a 83
S+te Ndoress ....,. .....?..?,",.. ...,... ?
Lot ? Block Sec/Sub. Beacon flill
Parcel # 10 ]_3.5)() U70 06
ac Nome
Z llddress 9401 Yylon Ave. So.
? T
Rloomliiatnn 94
o Name
?? ?
/lddre
? Ci
u
WW Nome
I hereby ocknowledge that I hovo read this applicotion ond state thot
the inlormofion is correct and Cgree to wmply with oll applicoble
State of Minnesoto Statutes and City of Eogon Ordironces.
Sipnoture of Pertniftee
r
A Bullding Permif is Issued to:
oll work shull be done in occordor+ce with oll oppliwble State of Mir
8uildinp Officiol
Erect ;{$
/11ter ? Zoning
Repoir
? :,..
Fire Zone
Enlorye ? Type of Corut.
Move ? * Stories 6
Demoiish
? 3
Length
Grode ? Depth Sq. Ft.
Approvals Fees
/lssessment
Woter b Sew.
Police
Firo
Eny.
Plonner
Council
81dfl. Off,
APc
Permit J 1 J.V V
??
_3
Surchorye
Plan check 156.50
SAC
Water Conn. 450.00
Woter Meter 60.00
Rood Unit 250'n )
Tota, $1784.50
on the express wridition thai
ond City of Eaqon Ordinonccs.
.
Psrmit No. Permit Holder Misc. P4rfoii- No. Holder
Plumbing (? BT??k?,,iuP((t 2t 'k3
H.V.A.C. -l. -7 5ZCo (
?-7 0 J
•
w.n
Water
Diep.
S"wer
Elsctric
Inspection Date Insp. Other
Footingt ?
Foundetion
Framinp
Rouph Plbp. 91L' G?
Rouqh HYAC
Inwlation ?
?
i4q
Final Plbp. y) _ ' ? .
Final HVAC ,
Final
Wster Doscribe Loeation:
•
YVall _ `
?.;? ? _ , ?
Sewer
P?. Disp. ?
)r? By: October 26, 1983
b)P- °"":
CITY OF EAGAN Remarks
Addition BEACON HILL ADDITION Lot 7 Rlk 6 Parcel 10 13500 070 06
Owner Street 4728 Covington CoUx't State Fagan, h1N 55122
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF. (eq 1982 1848.76 205.41 9 1919 47 12002710 11-4-81
STREET RESTOR.
GRADING (Cq '? 1982 537.84 59.76 9
SAN SEW TRUNK aOV 1976 135.97 9.06 15
*SEWERLATERAL &,n,, 1982 3182.83 353.65 9
' WATERMAIN
*WATER LATERAL 1982 9
WATER AREA 5 1952 202.00 22.44 9
* Stubs 1982 9
STORM SEW TRK ''g Z 1982 367.77 40.86 9
*STORM SEW LAT 1982 9
CURB & GUTTER
SIDEWALK
STREET LIGHT
WATER CONN. 450-00 It to
BUILDING PER. 8412
SAC
PARK
Receipt
: C. ?
1. Date ' 1f-
3. Job Address
, j
4. Owner
5. Contractor
MECHANICAL PERMIT
CITY OF EAGAN
fill in numbered spaces
Type or Print /egib/y
? . e ?.,....u.,.:..., r,.... t
Permit No. -?
Fee
S/C '
Tot. - L)
4? Tract
6. Address - VYk-f? ,Q CJ
7. City x, / / - •T '?? State Zip ? ? -
8. Building Type: Residential ? Commercial ? Institutional ?
9. Work Description: New Add ? Alter ? Repair ?
,/??
10. Describe ••;..+^-':, t' j !7 = . ? ?'? Fuel Type /'-`z'
11,
No,
j-' Eqlipment 8TU - M. Ea.
Forced Air No. EQUiament CFM
Air Handlin
:
Mfg. g
Boilers
Mfg. Mech. Exhaust -•-
?
Unit Heater
Mfg. Qther
Air Cond.
Mfg.
Gas, Piping Outlets
12. I hereby certify that the above information is true and correct, and I agree to
comply with all ordinances apd codes governing this type of work.
.
Signed : for
Rough , Final
Inspections: Date Insp. Date Insp.
This is your permit when numbered and approved.
Approved CITY OF EAGAN 464-8100
- ? ,
Receipt
i
--I
i ?
PLUMBING PERMIT Permit No. -7
CITY OF EAGAN -
L • Fee - ?
Fill in numbered spaces S/C ?
Type or Print legib/y -: ?
?
1. Date ? .1v 2. Installation Cost
?-- . ?
3. Job Address Lot / Blk. ? Tract
?•-
4. Owner
5. Contractor
6. Address
7. Citv/?fQ 14. 17 ' 1'?4 1Slate `P d,1 Zip .ss 31.lyd
•?--
8. Building Type: Residential,?P' Commercial ? Institutional O
1
9. Work Description: New O Add ? Alter ? Repair ?
10. Describe
11.
No. Fixtures
Water Closet No. Fixtures
Cesspool/Drainfield
? Bath tubs Se
tic Tank
Lavatory p
ft
e
S
Shower n
o
r
Well
= Kitchen Sink
Urinal/Bidet n
iOthe
Laundry Tray r
Floor Drains
?
Drinking Ftn.
'•
??? '
Slop Sink
Gas Piping Outlets ?
12. I hereby certify that the above information is true and correct, and I agree to
Comply with all ordinances and codes governing this type of work.
Signed :
for
Rough Final
Inspections: Date Insp. Date Insp.
This is your permit when numbered and approved.
Approved CITY OF EAGAN 454-8100
.r'
?
i
This ?a4?est „a?d °1 -Z (o L ? ? !3 (v i ?S FA Ce/t l? ?' l ?
18 months from
W ?70771 _
3S'7(??
?S.oc?
? REQUEST FOR ELECTRICAL INSPECTION ?- EB-00001-04
r See instructians tor completinp this form on 6ack of yellow copV•
..? „_?_.???_I. ? ? ?., ?,. T?; Ro,,,,a?, 3 g ? ? ?I
n uc r?n nv?n ..v....?-?- --? ....
i - ?-- - --
Appliances Wired
Equiprtient Wired
AAd Rep. ng
Type of Build Temporary Service
Home Range
Dupl?;x Water Heater Liyhtin,y Fixtures
Apt. Building Dryer Electric He?tiri
Commercia! B?dg. Fumace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
Farm
Other Peci y
ther l5uer.ify)
t ,r SVecify Other Other
?om
?I puce ?rf?Ncc.?,v?f rcc ?G????
Fee Ser?iceEntrence5ize
i?
Fee
Feede+slSubfeedere
#
Fee
Circuits
? U to 200 Am s 0 to 30 Am s •dt? Q tn 30 Am s
Above 200 Amps 31 to 100 Amps ? 31 to lU0 Am s
Swimmin Pool Above 100_Am s Above 100_Am 5
'
Transformers Irrigation Booms Other Fee
Partial_
Signs Special Inspection S ? ?TAL FE
o... ..<..L? ... II J ? ?VV
Raugh-in ?? ???^ ? ?31e I, the lectrical
? 4 ?? ,n? nspeCto?, hereby
? 1?• ??.? ^ certify tht?t the above
Pinal ,J`?
i ? j ' j . . .
r '« "?
?? (?? inspection has been
mada.
I ?1
Tnis request vo?a ia moncna ?????? _? ?
Licensed Electrical Contractor I hereby request inspection of above
. . . __ ? ___,. .....,,.??o.? ar?
CITY OF EAGAN WATER SERVICE PERMR
3830 Pilot-Knob Road
P. O. Box 21199 PERMIT NO.:
Eagan, MN 55121 D11TE: ?? =_' 1°?• '
Zoning: No. of Units: 1
1
OWf1Qr• .?c'51eV l,Ol1St
AddIQ55:
Site /,ddroSS: 41 c."> COYlI2' tOil Ct L? :;t: iit;3fAT1 F{l11
Plumber. ??:c} zuel IPr F l bg
Meter No.: Connection Charge: _4 50. GU
51ze:
Reader No.:
1 yrm to aompFy with the City of Eeyan
Ordineaas.
By
Account Deposit:
Permit Fee:
Surchorge:
Mtsc. Chorges: 60.00 pd
Totnl:
Date Poid:
Dote of Insp.: Insp.:
CITY OF EAGAPI SEWER SERVICE PERMIT
3833 Pilot Knob Road ;
P. 0. Box 21199 PERMIT NO.: .
Eagan, MN 551;1j ppTE; `y-?' ???•;
Zoning: ` Na. of Units:
Owner;
Address:
Site Addi
Plumber:
I e4roa !a eomPly wHh the CNy aF Eaoa¦
Oralaenea.
ey
Date of Insp.:
Connectton Charpe: , 425.00 Pd
Account Depoait:
Permk Fee: 10.00 ?"'?
5urchar+pe: . '.i •J -; d
Misc. Chorpes:
Total:
Dote Pold:
?,
, ?J
2005 RESIDENTIAL MECHANICAL PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675
Please complete for single family dwellings & townhomeslcondos when permits are required for each unit
/F3 U, ?y 10
Date o3 / ??-1- / D?J
SiteAddress '4-7dL8 CLo',?'?CYI ei' Unit#
Property Owner CICIC?.. Telephone #((?`'J 1) y`-'4'J) C?
Contractor
c
Wo hlers Southside Htg. & Air, In
Street Address 6950 W. 14e St., #106 City
Apple Va11ey, MN 55124
State ? (952) 431-7099 i Telephone #( )
Bond #: Expires: S9
The Applicant is _ Owner -jL Contractor _ O[her
Add-on or alteratian to existing dwelling unit $ 30.00
? furnace _Additional ?Replacement
air exchanger
airconditioner _New _Replacement
other
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 Ciry 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 permit; that the work will be in accordance with the
approved plan in the case of work which requires a review and approval of plans. l
Cho-ci. ?1C?h1 e?s OV41,t - -- -
Applicant's Printed Name ApplicanYs Signature i
I' ' 5 20L'5 '
??
?g-1 I Io
2005 RESIDENTIAL PLUMBING PERMIT APPLlCATION
CITY OF EAGAN
3830 PILOT KNOB ROAD, EAGAN MN 55122
651-675-5675
Please complete for modifications to existing residential dwellings.
Date 02, / uq / 66
.1.
l1J? ? ?- l, Unit #
Site Street Address ?l9 2.U 1.a1(IT?L?
,
Property Owner AaUL. Q120L. Telephone #(11pi1 )45L4 51 (?(O
Contractor CR" PIri 11V(51lt+C?Z, Telephone# (IpSi ) W5 13LR)
Address 3ind f)[)dd Rd City Q? i'1 State mn Zip 51 2-3
The Applicant is: _ Owner ? Contractor _Other
Alterations to existing dwelling
, Add plumbing fuctures (excludes water softener and/or water heater--complete next
section if installing these appliances).
_Septic System Abandonment
_ Water Turnaround (add $125.00 if a 5/8" meter is required)
Other: $ 50.00
Water Softener ? Water Heater
_ new I replacement $ 15.00
Lawn Irrigation _RPZ _PVB _new _repair _rebuild $ 30.00
State Surcharge $ 50
Total $ 115`50
I hereby apply for a Residential Plumbing 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 the plumbing codes; that I understand this is not a permit, but only an application for a
permit, work is not to start without a permit and work will be in accordance with the approved plan in
the event a plan is required to be reviewed and approved.
M indq W,! ? 0 TT
ApplicanYs Printed Name ApplicanYs Signature
? FEB 1 1 2D05 D
2000 STORM DAMAGE PERMIT APPIICATION (RESIDENTIAL)
CITY OF EAGAN
3830 PILOT KNOB RD - 55122 1-4 -? c) 651-681-4675 f\j I ?
Reaulrements ( (? , 2] _ C) ?
? 2 copies o1 plan
DATE: CONSTRUCTION COST: ? I? •°??
DESCRIPTION OF WORK: Y??"-5???+•^^ - S?`? ??? ?KS?IE-??Mlf ulfi-famlry bldg., how many units?
c.
IMDICATE THE FOLLOWIMG EQIIIPMENf TO BE REPLACED AND BY WHOAA:
_ Plumbing _ Homeowner Q Contractor Name
_ Mechanical ` Homeowner gr Contractor Name
"Note: If somebody other man the homeowner is performing plumbing or mechanical work, they must applyfor appropriate
permit. Only licensed plumbing contractor or homeowner may complete plumbing work.
SiREET ADDRE55: '17??
LOT: ?
PaoPEanr
OWNER
BLOCK: (o SUBD./P.I.D. #:
VA'Z l
Name: 4-6Iavi?
LMIJ Flrst
Street
C?F
("?- I . 4 sq- ?- / Slea
Phone#: lz(' -I94" gt34'
Cliy ? Vkti Sfafe:
>
ZIp: ? ? ? 2(Z
Company: Phone #:
(area code)
CONTRACTOR
Sheet Address: License # _
City
State:
Zip:
I hereby acknowledge that I have read this application, sfate thaf fhe information is correct, and agree to
of Minnesota Statutes and City of Eagan Ordinances. „/-'? /-\ I
Signature of Applicanf:
?.,..,4yr? '.t_'sx •. ? ..??3?a w?{`r .'xa ?e,?;.,w e' ?t ?', ? .
rc.
k,; ?I 1 a J. / '`il ?p?? F F'!•{
dfAUlJR&M?.
DELMAR H. SCHWANZ -
,?
?LAND SURV EVOw ?
? ' .
RpUtMOtl Untlk L?S of TM StN* of Minntleta
tl/t - iMTil {TNBET W. - BOX M ROWMOUNT. M14p7U07A 060i6 IM10ME 02 422-77p
?
SURVE CERTIFICATE ?
"?`'. ` • .
rs ?
SCAi.'r'.:
? =? ! inch = 301 feet
? i
;:• . ,-Y",
.o ?
?
141
. ? ?
?,;' / ` ? - ? - ''$ ? • , ?
nk
s ?
I
i'
?.,
4?4
?
'k<
b' .
?
:a
41
?
?
I hereby cartify that th:.s is :i true and correet repreaentation oP I
LAt 7, i;lock 6, B:ACC333 HIi,i, according to the reecrrded plat thereof,
17akota Courtty, Minnesota.
DAted : June 18, 1479 ,?, .
MiNNE80TA RE61ST0.AT7QN NO: , /
1
• EXTERIOR FtJVELOPE AVERAGE "U" COtiPUTATIOP!
0I•1tvER SITE ADDRE55
CONTR{IC]"OR DATE 71193 PHONE
,
Determine worl;ing square footage of eacli.
1. Total exposed wall area ...... /"%(,G? sq• ft. x.185
2. Total roof/ceiling area .... sq. ft, x.04•_ = S?
Total exposed wall area above f]oor
a. 7ota1 rrall windo:a area ........................... ;2S
b. Total door area . . . . . ... . . . . . .. . . ...... ........
c. Total sliding glass door area ......:............ f'gp
d. Total fireplace wall area ........................ - ?
e. Total wall framing area (average lOh)...:........ -5 4' ?2
f. Total net wall area above floor .................
g. Total rim joist area . .................... „ 135
7otal eicposed `oundation area = ,97
h. Total foundation windovr area ..................... /, ?r?"
i. Toal net foundation area abeve grade ............ a„-,.2 Detcrmine "U" value of each wa11 segment.
a. X „ul. ,.55" - ? ."• ?S?
_ ;•; ,;
b. x l.ull
23
.,
C: 11 'x uull
t"r
d. ` X_Dull --
e. /5 41. X ?????
";y:'
X I.W. g. /.?.S,6G X )lu.,
n. /'..?rf x „u„
,^
-•.? x „u„
n ?
3 .....................................Tota1
If item n3 is the same as, or less than item li1, you have met the intent
of S[iC 6006(c)2.
4.7
wntU 5L'(`SIONS
e: v" lSt of opaquo vall area tor
frame construction
-4@
Constructinn
Rtvalue
a.
4. --? rr ? --------_-_
-
- ? ? _
5 . •?[ un? !y!P/Ir,',I_' ?
- ---
- . .s_
6. Exlt•ri-r ai:r film ? .17
'i 3 l 11 ? j ed, <
f?- _ • 42?.
^S,il
FOO:?Ja,TZCN
" k'1J.I.
l. Intcrior 3ir fi7r., O.GII
2. -
3.
4.
5. 7.'
6. °xter.ior air fzlra 0.17
J Total
?. .,
I?f
1. 2nterior air film 0.66
2. .
-41j?.e":"?.?i
? ?;
3. v lG'
4. /'` C. ,P7f?tt? r f• F"M
s. 10m ,?i?,?.x?•x L'=
6. Exterior air film 0.17
Total
1.
z.
' 3.
' 4.
$.
' G.
SI.AB ON GRADE
Interior air fil.m 0.68
Az?
Exterior air film 0.17
Total
.? . ? • • ?? ..
r ?
K(?- , . ? •
lr? " , ' ?• . ' i 11 `
_ TIG. N3 ?
/ . . d \
.. ?
.
•F. , o - . ? ty •
. ? • ? ' •
_ ?. _ .
a? . .? . , d .
FFUitE: iQA?.L
. y • • I ..
//i . •? . . _ ( I t
FIG. N4
. ./// ?
i?l = Irr = r?i ?
NOTE: Indicate tyoo, "^" valUe, denth aild
placenent of insulation.
-?-
- - .--,w.". -- -- - - - - -
L `I gL & CITY USE ONLY RECEIPT #: 'Y1 0 r?
SUBD\?? ?X-L RECEIPT DATE: 11144096
1998 PI,UMBING PERMIT (RESIDENTIAL)
CITY OF EA6AN
3830 PILOT IQIOB RD
EAGAx, !•P7 55122
(612) 681-4675
Please complete for: D single family dwellings
? townhomes and condos when permits are required for each unit
D backflow preventer for underground sprinkler system
FIXTURES EACH #
Shower 3.00 x =
Water Closet 3.00 x =
Bath Tub 3.00 x =
Lavatory 3.00 x =
Kitchen Sink 3.00 x =
Laundry Tray 3.00 x =
HgLlubLSSW 3.00 x =
Water Hea 3.00 x =
Floor Drain 3.00 x =
Gas Piping Outlet ` minimum - 1 3.00 x =
Rough Openings 1.50 x =
Water Softener ` for dwellings under construction 5.00 x =
Water Softener ' for existing dwelling 20.00 x =
U.G. SpflfiklBf " for dwHling under wnst. 3.00 =
U.G.Sprinkler "forexistingdwelling 20.00 =
AIter8ti0nS ' to existing residence 20.00 =
Water Turn Around 20.00 =
Private Disposal System ` MPC iic 75.00 =
(new and refur6ished systems)
Private Disposal Systems " A6andonment 20.00 =
STATE SURCHARGE
TOTAL
TOTAL
.50
s°
o!ro ?
- - --- --
t here6y acknowledge that I have read this appluaUO?, sWte thst the infamstion a cortect, encf agree to comply wkh all epplicable City of Eagan ordinances.
It is the applicaM's responsibility to notity the property owner that the City of Eagan assumes no liability for any dameges caused by the City during its
normel operational and maintenance activities to the facilities constructetl under this pertnk within Ciry propertylright-of-way/easement.
SITE ADDRESS:
OWNER NAME:
INSTALLER NAME:
TELEPHONE #: (1 a y 26 y
STREET ADDRESS: 7/3? Cd l U i^e? d //Ju`?-S? L`
aN: STATE: "e"w` ZIP: ??YI
?, ?---- -,
SIGNATURE OF
JSIFORMS BLDG/PLBG PERMIT (RESIDENTIAL) 1998
!"
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8"#$% &&9'(())* &&"/,$*&D)##
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PERMIT
City of Eagan Permit Type:Building
Permit Number:EA158784
Date Issued:10/31/2019
Permit Category:ePermit
Site Address: 4728 Covington Ct
Lot:7 Block: 6 Addition: Beacon Hill
PID:10-13500-06-070
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:Two or More Windows/Doors
Census Code:434 - Residential Additions, Alterations
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: 5,000.00
Fee Summary:BL - Base Fee $5K $118.00 0801.4085
Surcharge - Based on Valuation $5K $2.50 9001.2195
$120.50 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 -
Armeya Saroufiem
4728 Covington Ct
Eagan MN 55122
(651) 214-3118
Home Depot Usa Dba The Home Depot
2455 Paces Ferry Rd
Atlanta GA 30339
(763) 852-1044
Applicant/Permitee: Signature Issued By: Signature