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1875 Deer Hills Tr CITY OF EAGAN nJ° 10 3 5 9 * `• 3830 PiIM Knrob Road, P.O. Box 21-199, Eagan, MN 55127 PHONE: 454-9100 BUILDING PERAAIT Receipt # Te !e wmd fm SF DWG/GAR Est. Value $58,000 Date JUNE 6 19 5 Site Addren 1875 DEER HILLS TR Erect IR Occupancy R S Lot_2 elock 6 ?ec/Sub UN CLIFF ].ST Remodel ? Zoning Rl . Repair ? Type of Conet. V Parcel No. Addition ? No.Stories Neme KEYLAND HOMES Move ? li D h ? l.enqth 38 Z 3471 W 173RD emo s ST Depth 42 ? q?rms mt lmPr. ? Sa. Ft. city JORDAN pnone 492-6646 Install ? g SAM 435-3323 Avwew4 i"s Zu f? s f Name E Phone FW Name HALLQUIST & SONS _? p?,K, 5001 W 80TH ?W ct<y BLMTN pnone $31-1875 I hereby ockrowledge that I hava rcad this upplication and srore that fha Informotion Is correct ui yd-"ree to comply with oll aDOliwbls Stata of MinnesoM Stotute an Ci? of r' wncas. Siqnaturo of PermiMea A Buildinq Permie I: Issued to: KEYLAND HOMES dl work zholl be done in occordonce with oll ofmlitoble Sfote Mir Asseumenr _ Water d Saw. Polica _ Firo Erp. Plonrror _ Councll _ 5 BIdg.Off. 6/3/8 APC Var. Date aermit S 307.0( SurCherge 29.0( Plan Review 153 . $ ( SAC 525.0( wetar Conn. 500.0( water rneter 63.0( RoadUnit 280.0( . rc Pi. 132 . 0( ? Perka Couies I raai 51,989.51 _ m fhe sxpren caditian Ihai and City o£ Eapon Ordinancas. Buildirq Official INSPECTION RECORD CITY OF EAGAN PERMiT TYPE: 3830 Pilot Knob Road Permit Number: Eagan, Minnesota 55122-1897 Date Issued; (612) 681-4675 SITE ADDRESS: 1875 OEER SUN CLIFF iST PERMIT SUBTYPE: DECK .: 10-72975-020-0f LOT: 2 BLOCK: HIILS TR 6 APPLICANT: FORSBERG JOEL (612) 687-9378 TYPE OF WORK: NEW BUZI.pING 025893 06/28J95 , . , . ., .. ? -. ., ., ? a ? _: ' '.. . ` -:.. ... : :.;_. . . ?; _;?.. . . . ....? ?-.. ? .??....... ., . .. . . .._e ?..e.. . .,?_ ,.,,?_._,.? INSPECTION RECORD CITY OF EAGAN PERMIT TYPE 3830 Pilot Knob Road Permit Number: Eagan, Minnesota 55122-1897 Date Issued: (612) 681-4675 auzLpxtiG 025894 06/28/95 SITEADDRESS: P•I•N.: 1e-72e75-e2e-e6 APPLICANT: LOT: 2 BLOCK: 6 1875 DEER HILLS TR FORSBERG SUN CLIFF 1ST (612) 687-9378 PERMIT SUBTYPE: TYPE OF WORK: SWTM POOL DESCRIPTION ? L JOEL NEW A.G. POOL ? ? REMARKS: SEPARATE PERMIT REQUIRED FOR ELECTRICAL WORK BUILDIN G PERMIT To N mud fer Site Addresa ? Lot Block Parcel Nq, ag Neme Addresa Citv 'J1RD71'!,j Phane (Vame CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 Name tFwt I hove rcod this oppiicotion ond state thct rrcct and ngree b comply _with all appliceble Stprtature of Penmiftes A Building Pertnif Is issued to: `. ?; .• .`' oll work sholl be dons in occardonce with oll opplicab Buildinp 4ificiol ^ 10359 Receipt ? ` J bote . , 19 ? _ ? Erect ? Occupancy Remodel ? Zoning Repair ? Type of Conat. Addition ? No. Stories MOYe ? Length r , - Demolish ? Depth Int Impr. ? Sq. Ft. Install ? Approvala Feea ? Assessment Permlt • 00i ? Wcter d. Sew. -, • oo Surcharge Polite Pian Revfew : 3 • 50 Fin SqC r..:?.QU, Enp. Water Conn. • 0 Q Plonrer Water Meter • 00 Council Road Unit ' 0• 00 81dg. Off. Tc PI. '- 2 • 00 i APC Perks i Var. Date Copies ? rotal , on the expre3s cOndition tha? ? wsota Statutes nnd City o? Eepon Ordinances. Pwmit No. Pwmit Holda DaH TNephono s Plumbina Sq ?i.cr? ZIV7 - s d rI.v.n.c. / g /0 7 - A t ? EbeMc Soiternr Irnpection Date Insp. Other Footings 1 Footinga 11 - Foundatlon Framing Roofing Rough Plbg. VVIOA- Rough Htg. Insul. Firoplace . c- Final Htg. Flnal Plbg. Final Cert/Occ. Watar Dsseribe Locstion: Well Sewer Pr, Disp. Receipt MECHANICAL PERMIT Permit No. i CITY OF EAGAN Fee ? Op FiQ in numbered spaces S/C Type or Print legib/y s? Tot. 1. Date 21918i 2. Installation Cost I-T UO /875 ?.er 1? 1` s T?o., I .? i? c,. ( C•? 3. Job Address Lot C Blk.? Tract 4. Owner t,"'"1 ?A.-- I 5. Contractor Phone 6. Address 19 4 01 N.1p 7. CitY 04 f V--dL? IA.- State 2ip ?? 3) Z 8. Building Type: Residential4 Commercial ? Institutional ? 9. Work Description: New Aj Add ? Alter ? Repair ? • 10. Describe Fuel Type ND? 11. No. ? Eauinment BTU - M. Ea. Forced Air 7V' "6 No. Equiament CFM ndli Ai H : Mfg. Cq ? r ic V' r a ng Boilers ? Mfg. . Mech. Exhaust Unit Heater Mfg. Other Ai r Cond. Mfg, ? Gas, Piping Outlets 12. I hereby certify that the}?bave information is true and correct, and 1 agree to comply wirning this ty pe of work. Signed: for Rough F(nal Inspections: Date Insp. Dete Insp. 7his is your permit when numbered and approved. Approved C17'Y OF EAGAN 464-8100 Receipt PLUMBING PERMIT. • Permit No. -- CITY OF EAGAN Fee I Fill in numbered spaces S/C Type or Print legibly Tot . 1. Date ?r ,• / .? 2, Installation Cost 3. Job Address Lot Blk. Tract f 4. Owner . 5. Contractor Phone - 6, Address 7. City State J?; e Zip ?- 8. Building Type: Residential 21 Commercial ? Institutional O 9. Work description: New o. Add ? Alter ? Repair ? I 10. Describe I 11. No, Fixtures Water Closet No. Fixtures Cesspool/Drainfield Bdth tubs Septic Tank Lavatory Softner Shower W e I I Kitchen Sink Urinal/Bidet Other Laundry Tray Floor Drains Drinking Ftn. Slop Sink Gas Piping Outlets 12. 1 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 INSPECTIO ' Eagan, (612) 6 Road ta 55122-1897 PERMIT TYPE: 10111 1? i M1 Permit Number. sj .• 1F,f11i t Date Issued: ct i., ;: t3 / v! SITE ADDRESS: ' ' " ? " ' •' `' ; '' c+ . • H O" 1 ?rr .' 1?1 !t? k ?: ? t: }I1 1 l•. I? f f 11 i ? i i ? i I PERMIT SUBTYPE: ? 1 11 o„l iI Wr,: I APPLICANT: TYPE OF WORK: I I hJRI ? _ - ------------------- Pertnit No. Permit Holder Dats Telephona N ELECTRIC PLUMBING HVAC Inepwdon Dete Insp. Comments FOOTINGS FOUND FRAMING ROOFING ROUGH PLUMBING PLBG AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYPBOARD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG dRSAT TEST BLD(i FINAL BSMT R.I. BSMT FINAL DEGK FfG 7 3_ ? OECK FINAL ??a NSPECTION RECOR CITY OF EAGAN PERMIT TYPE: I +l I rooi 3830 Pilot Knob Road Permit Number: ti 1a +1 Eagan, Minnesota 55122-1897 Date Issued: G?,/;?+ ??? 5 fy (612) 681-4675 SITE ADDRESS: 10 '` 'I`' /`' 0'1" `" APPLICANT: r ?? ?: . ?+? i?? r . .. ,?; ? ? ?i i ? i i i ,,; ,?. ,,. PERMIT SUBTYPE: TYPE OF WORK: I 1?? ? i 1 I t I??1? I ! h11, t 1 Ni1 I ro : '-k 11 t'A itr'?) I f'F P hl l I !:t Ull l V{ I) f 1JV f I 1, I It IiA{ Ilf lV 1 Iut I i1 1, F'ti1?1 ? ? wr,nn No. Pennie Hola.r Dae. Telepnone: ELECTRIC PLUMBINO HVAC Inspectlon Qate Insp. Comments FOOTINGS FOUND FRAMING ROOFING ROUGH PLUMBING PLBG AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYPBOARD FIREPLACE FIREPLACE AIR TEST FlNAL PLBG FINAL HTCa ORSAT TEST BLDG FINAL BSMT R.I. BSMT FINAL DECK FfG 01, DECK FINAL n ? ? ? (? CITY OF EAGAN Remarks ?.,.. ? Addition M CLIFP 1ST Lot 2 slk _ owner , r= ?'- L- I ':' ',!•'•+. ?z,/ st,eet 1875 DEER HILIS TRAI L Improvement Date Amount Annual Years Payment Receipt Date STREETSURF, ss 2220.64 C0102 6 --g STREET RESTOR. GRADING SAN SEW TRUNK 976 76.54 3.06 25 27.58 C0102 ( - -$ *SEWERLATERAL 5 1985 547.94 ?.59 2838.36 C010276 --8 WATERMAIN * WATER LATERAL 1985 WATER AREA 12.56 (i' 1 2 Ej --8 STORM SEW TRK 105 1971 322.29 16.11 20 80.64 C0102 6 - -8 ? 570RM SEW LAT 1985 * Services 1985 ' CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. ' BUIIDING PER. sAC 525.00 T+ ?? PARK . CITY OF EAGAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number: Eagan, Minnesota 55122-1897 Date Issued: SITE ADDRE lit4 : 1 1) ; I PERMIT I I ; itvti1 , Ll?? • :`0 (sl UfK• , . , lill 1'; lF? tf Ii I I u, M eA.?() <c;1 GiH!! I!<)! ? APPLICANT: , • , , . , , ? TYPE OF WORK: E'. , : ! i i ,sr I flkpl 11Apifi(O F L Pertnit Holder Date Telephone i PLUMBING HVAC Inspection Date Insp. Comments FOOTINGS FOUND FRAMING ROOFING 9'll , G ROUGH PLUMBING PLE3G AIR TEST ROUGH HEATING GAS 5VC TEST INSUL GYP80ARD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL DOMESTIC METER IRRIGATION METER FLUSH MAINS CONOUCTIVITY TEST HYDROSTATIC TEST BSMT R.I. BSMT FINAL DECK FTG OECK FINAL a,d• ^L TY f)F EAGAN WATER SERVICE PERMIT I ' W-?i!Io.t Knc,b Road CASH RECEIPT 0. gox 27199 PERMIT NO.: - Man, MN 55121 oATE: CITY OF EAGAN nirg: i< ' ?+ of Units: ? r„er: Kevland ???' i ? M "'°° ? P. O. eOX 21-199 b„ess; J??,jpxE,a= ?;;T r,,.! :n?al utiiities EAGAN, MINNESOTA 55121 • Addrcss: - , r rS, ii1 f' f 1^ . Jmber: ?c . .?..`L3'li DATE Meter No.: (M 1: bJ i/A 8 K LLJ D 1 Cd64'eflbls Chorye: Jk, v. v v yu 51u: Aocount aeposit: 15.00 Reoder No.: Permit Fee: i?•I)? I yfiM f0 OOINply M?uh !bN rrlfr Of Kow11 $U1'ChGrgl: • r O Orllw.ne... Misc. Chorpas: 132.00 ? ol: - 63.00 pci n.eter 6y ZjLr? s Poid: pate of Insp.: 9=14--iz ? fnsp•t CITY OF EAGAN 3830 Pilot Kr,ob Roed SEWER SERVICE PERMIT P. U. Box 21199 PERMIT NO.: Eagan, MN 55721 D/1TE: - - Zonlnp: No. of Units: Owrsr: 1 AddfE53: - S1T! AddfOS5: Plumber: - ? ? ' .r. . • . : 1 ym h eowply wiM !6e Cihr of Eewn Connectlon Chorpa: OIaIMdON. ACCOUM' DIGpeWf: PermK Fee: Surcharye: gy Misc. Cfwrpes: Qcte of I nsp.: Totol: Insp.: Doh Poid: RtGtlVtD ? . FROM' AM04j'h1T gk ooLLwws I60 ? CASH ? CHEGK Y funo cooE arnouNr Thank You 1 ' ? "BY ? ? ? (r;?,r`rJ %7 White-Payers Copy Yellow-Posting Copy Pink-File Copy This request void 18 r11frRa' 4- 6 ? Request Date Fire Mo_ Rough-in I c n •? + _? F1e uir . EIHeady Now [or YYheo Ready ec- J es ? No icens Ele rical Contrector 1 hereb y request inspection of ahove ? Owner eleclrical work irstalisd at= Street Ad ress, Boz or No. CitY ectio o• To w ip Name or No. Ranee o_ Coumy Occupant (PRINT Phone No. Power Su r ? Address r= .. s - s? f_ Elec Acal o tr ctor IConwany Nartie) ootract s LicerySe e Nlailin r (C(Mractor or r Making 1 t ailation) - ? L?? ? ?, Authorized ture o actor i InsWl ion) PMo r C=i ? • , ?% j// . MINME TA ST?ABOARD OF CTItICITY Gri -Midwa - Room N-797 1821 University Ave., St. Paul, MN 55100 Phorre (612) 297_2711 THIS INSPECTION REQUEST NIILL NOT BE ACCEPTED BY THE 5TA7E BOAND UNl.E55 PROPER INSPECTION FEE IS ENCLOSED. ?? ???? R€QUEST FOR ELECTRICAL lNSPECTION Ee-ooooT-a , See irutructions for completinp tAis fwm on beck of Ysilow copY. B33 3 8 8 "X" Be1ow Work Covered by Thrs Revuest Add TVPe of 8uildin9 ADDIianCes wired Equipment Wirrl HOrne ilo ?9? Tertiporary Service Diiplez Nfater Heater Lightiny Fixtures Apt. Building Dryer Electric Heatin Commercial Bldy. Furnace Silo Unloader Inckistrial Bldg_ Air Corxlitioner Bulk AAflk Tank Farm Ocne? pec?fy cher (Sper:fy) ther SVecifY Othor Ottegr ompute Inspection Fee BeJow M ef"". Service EntranceSize q Fee Feedess/S.b(eeders 7t Fee Circuiis .1?t1 0 to 200 Amps 0 to 30 Am rd 0 tn 30 Am Above 200 Amps 31 to 100 Amps , 31 to 100 Arrsis Swimming Pool Transiortners Above 100_Arnps Irrigation Boorrs ? Above 100_A - Partial. Other Fee SignS Specia! Inspec±ion --? Remarks s1711 ? TOTAL FEE 1 Rough-in ? ? Date • i? ?!N ? , t1e Electr?ca? Ir?pecta, hereby Final ce?tih thet the abovs ? Date " - p?teon has baen n.se .e ......... ....?. , o ---.? .v? _ J..? nade. 1 ? ? • ?.- f w.v?`al/ - , z/sa C!4t, ( . % " CITY Or EAGAN '14VI1 APPLICATION FOR PERMZT • -' SEWER AND/OR WATER CONNECTIODT (PLEASE PRIN7) 1) PRoP=rDnREss : r.FrAr DESCRIT?TTCV: ?C.,- (LOt/Block/Subclivisicn or Tax ?arcel I.D. Numner) ? .Tr ST??C=RE , DAT? OF ORIGi ItIL riiILDI:-? T_SS.;AN=. PDESL.T Z-?T'1i7+/?T?OPCSL C7.C: , cZ'1 SL= Tj,Y ? R-Z DL1PL= (2?%'O L^'ITS) ? R-3 'IC'.v1II?CC7SE (TT-= + U:7IT5) ( Wi Z^'S1 ? it-1 tn;I?,-?1 ( [JDiI?Si ? CCi/LME.°.CL?I./R?,^'AT,L,/OP:'IC:: (3 INOliSTRSr1L Q IPISTITC,TIOJIAL/GGVEPNnE::T 2) APPI.IG7-.2;T (PLEasE aeiNr) / ADCRESS: CTT'!, STITF.', ZIP: ??r; r• ?Uf?i:? /??i?'?,t? ?_°i` S ?? ?: PxoiNE: ?g 2- C- G- Y?- 3) PLL?ffiER DIF1["]E: (PLEASE-VFIYi): , ? cs - 7t?= ? - ? PoR CITY USE ONLY ADDRESS: - : ' - - PLUNBERS UCE45E: Activ CITY, STATE, ZIP; e Ezpired PHOrrE: " MAac? y?`j-S ??? PLUMBEA LICEYSE N?32zlnvj ? Not of Record arr nitia 4) OCCUPANP/a?TIEF2 krLcn5t Nnirirj NAME: ?/11 [= i?c' .?Y -=? ADDF2ESS- Cl'I"1, STATE, ZIP: PHOrIE: 5) INDIG*,TE W[-]ICH PERfd2T IS BEING REQUESTID: CO:v'NF.C.TI0.1 'I-0 CITY ScF7ER ? CONN .IO:I 'IU CITY SVATER ? Cl^iIIE12 (PLPr1SE DFSCRZBE) 01 - 1.CrU1l1?!:: U.`ir;: 7) SICaT[iF2E: ? PL°.NSE f?OID APPP,OVm PER+IIT FOR PZCF:-L'P BY ONE OF ABGVE ? PIFASE :T.'1IL APPFtdVfD PERbLiT ?'Q 1, 2,?, 4 AFiOVE . ll n Ct L(CirCle one) DATE: cs.. C. ? P?N•. . . . ? a? s•.+r ?.??:aa+w a? s??a:a:a a ie :faa?ss.r ? ??? ai?saa? F O R C I T Y PE?2.MIT °- ISSUED F°ES: $ sD $ $ G 3?L S S $ /S-?a $ $ $ S3s "° $ S $ S S U 5 E O N L Y S°:-iER ?'E4Mr; (I:?CL:;'`: SU°C!i?RG,) WATER PER[IT (Z`:CL.;DE SuP.CF:AaGi) WATER METER/COPPERHORN/OUTSIDE READER WATER TAP (INCLUDE CORPORATION STCP) SE:vER TAP ACCOUNT DEPOSIT - 4)ATcF WHC SP.C TRliNK WATER ASSESS:?E:1T TRli:7K SESdER ASSESSMENT LATERAL BEDIEFIT/TRUNK SE;•:ER LATERAL BENEFZT/TRU:IK WATER OTHER kZz?u7iLoa?nv%r? ??cvh?-?lGc?44-- TOTAL AMOU::T PAID j qECEI?T DOES UTILZTY CON[VECTION REQUIRE EXCAVATION IN PUBLIC RIG'rIT OF WAY? ? YES IF YES, THEN n"PERMIT FOR WORK WITHIN PUBLIC ROADWAY" MUST BE ISSUED BY THE C=E??[VO ENGINEERING DIVISION. LZST AS A CONDI- TION. SUBJECT TO TEiE FOLLOWING CONDITIONS: APPROVED BY: TITLE: DAT° : 7/./ /h ' on winwomE?s?a???wES?w?wW?n MUM Rawc40 wRNM wPI w.ar* W saGbsM@ w.asW M rM sJU IN M I ? 4 103 ?-? .?_. ? F 1985 BUILDING PERMIT APPLICATION - CiTY OF EAGAN NOTE: ALL CONTRACTORS !{OST BE LICENSED MITH THE CITY OF EAGAN INCLUDE 2 SETS OF PLANS 3 CERTIFICATES OF SURVEY 1 SET OF ENERGY CALCULATIONS To Be Used ? /? Fors?j ?e l?"luatio S%pOtJ 7 p n: L? Date: "7 O S Site Addres s: IY?5 Bee2 ?/ IWS r OfiFICE USE ONLY Lot: =:? Block ?i Sect/Sub Ereet 2< Occupancy ?-3 Remodel - Zoning Q-I Parcel II S Repair Type of Const ? L/ Enlarge _ 1! of Stories Owner ? Move _ Length 38 Address ,173? Si Demolish Grade Depth c?2 Sq Ft City/Zip Code T0,z017,,, i S"53S 2? Phone -6 6,/ 6 ql 4{3S `33 ?-3 Contraetor Address City/Zip Code /oy Phone Arch./Engr,5'(?iS i ? .San/ Address J"?3-0/- City/2ip Code 0 Phone $ F 3 APPROVALS Assessments Permit ?0-1 , ``0 Water/Sewer Surcharge E5?1- Police Plan Review i5 .$O Fire SAC 5Z5. Engr Water Conn g?- Planner Water Meter fo3.°• Council Road Unit Z.g?J.° ,, Bldg Of? Parks APC Treatment Pl 13Z.°= Variance TOTAI p ?Jr? c , 20x `?¢_ ??ox s4? ?Cp?2? l(o ? I? ' Zg8 ?? i IJ?SZ , 201? Zz " 440 ? i? = 4-54? W. . . ? Y" For: REY-LAND HOMES NOTE: o Denotea Woodeti Stake Proposed Garage Floor E1.903.33 (903.0) Denotes Proposed Finished Ground E1. -aq-- Denotes Direction Of Surface Dralnage Vertical Datum - N.G.V.D. 1929 el U/, rt , /y r p, nOqE D 4 ? .. ? ? o? rn 1;3 y L3? ? ri C r C. R. WINDEN 6 ASSOCIATES, INC. LANO SURVEYOtS Ta4 946-3646 I381 EUSTIS ST., ST. ?AUL, MINN. 65106 Scale: 1" = 30' O Denotes Iron Monument J I =. . ? 045? 31"E C?ye o, ' -_ / ? ? ZO 8 22 ? ? ? I N N o '" ?`? ? 1 O y 3 ij /' '??98 D} 1 > Na J Lot 2, Block 6, SUN CLIFF FIRST ADDITION, Dakota County, Minnesota. N /Cz?'?S'%??: ? n? ? 2 WE HEIIElY CERTIfY THAT THIS IS A TRUF AND CORRECT REPRESENTATION OF A SURVEY OP THE BOUNDARIES OF THE IAND AlOVE DfSCaI6E0 AND OP THE tOCATION OF ALl 6UIlDINGS. IF ANY, TMEREON, AND All V15161E ENCROACMMENTS, If ANV, FROM OR ON SAID LAND. Dolod iAit doy ef P1av A.D. 1985 C. R. y'INDEN 6 ASSOCUTES, INC. br .ki?'U??'?'t. - Su.voyor. Miene.eto Ropisvation No 772,k c9e i or v EXTER[OR ENVfLOPE AYf.. - ? itAGE "W" COP1('11T,1'fi(IP1 %* 33U : a. . . --- ---- - _ OwNER:_ _ nnTr: ?.116_ SITE ADDRE55: PIIONf: CONTRACTOR:?`? Determine working square footage of each 1. Total exposed wall area..... 11(1_sq. tt. x.11 = Z fD . S 2. Total roof/ceiling area..... 1040 sq. ft. x.026 = 7!1 Total exposed wall area above floor=-- I -?`f ''I_ ' - a. Total wall window area ......................... .................. b. Total door area ................................ ...... . c. Total sliding glass door area .................. . .......... ............... d. Total fireplace wall area ...................... ... ............. e. Total wall framing area (average IOw)..:....... ..... ? .................. f. Total rim joist area........................... ............. g. net wall area above floor ................... . ?TZ .... .... h. wall area above floor ................... .............. ? ....... i. ' wall area a6ove floor.... ......... .... ........... ............... j. frame wall area at foundation ................. . .. ....:............. Total exposed foundation ai-ea=_ _ f0(Q ~ k. Total foundation window area ................... .... .? 1. Total net foundation area above grade .......... .... Determine "u" value of each wall segment (e.g. window; (loor, each separate wall section) a. f5? x b. 38 x 'lu„ .31 = 11.? C, 4o x.,u.. d. X „u.. _ e._ 1717_ X „u„ , f. 137, x„U„ 01 ' 5 9. 1315 _ x „u „ .05 = ??-: --- h. X Itut. _ i. X 1, U.. ? j, X k. X y Il l ? ?, ?ll??f w ? 3 . ..................................Total a 14 C.l., 1f item R3 is the sani as, or less <than i tem B1, you havr. met.the Intent of SaC b006 (c ? .. . . *e=-'i5 . , Px r1ar-?Snvelopo Average "?°=Computation '- -?a9e:Z_of 4 --- _ -=- - - -: _- _ - -,_ . • . ,_ •? . ,.?; , +'i .. . . y . . , . ' .. : '- . . . . ,. . . . . . . . ..TT` .. . _ . .._ _.. . r . . . . .... .a_ .... i ..-._:, - Total exposed roof/ceiling area = ? - m. 7bta1 skyliqht area ............................ ? n. Total roof/ceilin, framing area (avcraqe 108)... , Q4 o. Total net insulated roof/cciling rirea........... a? 1/-.7«- - Determine "U" value for oach roof/ceiling segment M. - _ X uUn _? - a n. - fpe a ,?u- o. 13(o_ X „U„ oL , a ............................ lbtei = . zi ,Z If total'of ,y9 is the same as, or less Lhait 92, you have met the intent of SBC 6006 ?c) 1. . . Alternate Buildin Envelope Desiqn - ? To ut-ilize the total envelope 'systen method, the values established by tlie s:un of itens p3 and #4 shall not be greater than the swn of items fll and N2. 1• + z. Z3 = Z37.S 3' ---??-? + 9. ZI •2 = 2 l fo;?_ I _..._ , l. 11 T: !'.iy„ •r,.?: '¢: U:-c a,s of npbciuc wall nrea Lor ? _. linI114 CGhfitTUCI lun {.pn.:trucl inir_- R-Va1u'1 . . _.._...?? ? .?_.__.. ? _ _?_--__-(?? -• ?,!?YP.._BD_ ...._.__.-..-_._9? , " 3. - ,???:i??ti ,. ?i? •..,:,;? ? ?_------ ?- ._.._ -----.._._ ._---G7 a. ? ?_p ; • _S.,.D.??r.to _ ?Z F.r.lcriur air (i;m ^ 0.17 AL[. +Z, Z?7 `. --- `W - ! ? ? ?' •°g F1U. N1 T'GPVI1I7 OF INSUI.- . FIIAltE HALL 1. Tntrrlor ...'--0.671 ?. ?? u-tss24?-------------?3:a , . • 4. ; . s. ._ ? r?u??6... _- -- .. __._._ __._.... . .. _...VL G. ExCcrior air Lilc, • ' ? D.1'1 £IG. 12 q'oCal? O=IIOrs . ,-•? 1. ]ntei4iM,itr film U.60 ? . ^ • ? ?? ? { ? 2 ------°--- -- .._.?_?,._ • - • JN?+?J...__..3?"8.. J .c ----------:? 3. _zKr.t:? ------ 1?-?- ? -----(? 4. ? -? &- ' ,SeaC.A : ?.? - ----•-------?'-?a "_ _'_`? 5• --.?,?La1Nb_..__ .. _?4rZ "' i ---? 6. }:xt'r-rlor nir fiJm ??'? ????.Tl?? ?I -----?-------{?? ----- - --Yoc;ol_..1?? ?. : . ? r:;, ? ??> ?. v • .. 9 ?L Vo ? `?•:':?? U _._...._._..? _....---..__...._.--._._ Qi ? _a 1 r f i 1!:?? 0. C.R a' 1• _. --- - . _.. .._ -.-. .- - -- - L o? n•. ?? }• 1?._?2NG• Et..i: _. ..J,.2$ ,,i. , •o. •____.._.__.-{lj . a, Z' _54yva V . • u k!innp? 5. ---- ?-- - ---- ?•.' ., L ..•_ ?l`• '?' ? r ?.jj,~' G. I::ctcrirr •?. . ' -----?-------._..- --------...-----`-'-- -?.-; . ?. , ?IoL:il Z L3 , , ? . u •? .? . - ----. ._ _ ._._..._...- -- _- ----•--....- i ? . . . • .. . .C.I?A?F-li? ,, . , , ',, •,, ' . ? r' ?' t' ? .?' ; /f( //??_. /h ? . • s . ' /iiri}':. f ` ??? ? } • . ? . l(I v; . Fil;. 04 /!/ # i ? !(t lC J //(? . y 1' 1 ? ? • . ? .-- - __' ? 3 ? -----1 ;1??•iY:: ?ndi,_ntc Vy?,c, dc??:tli anc4 ?. '?.:?' , ... ? ?•?_ ' 1 . . pl.??enr•,iC o( i;;?;?:i..zCton. _ i ? , ._ ?? ._.__. . :: _ _ . .. .... ... ; . ? . . ._ ? _ .._ _ 1 ? -. - - -.- ?, . : PLAQ ? 33zs i, . ? . ? LitmE.4L FT, EXposEp W,4LL =ULL(?;?? = v l.l. Z. : ?-- _ - 4 RrE '?1AcE ; - ,. ,., IZ t t?-t : ,? ( 3-tr , SGt . ?T, S1CP05ED WA L,_L AiZ.EA I' L.OGfC', 137. x, S ' ?eCr V-Kj EE; 13Z X S- ;, . ? PuLL l ; 13z X Fu LLIIIZ ; Fp '' k = . , ,. '??? ? 3 Z- }C ? = ?3z il - . ? - To tA L, = f a I? ?KP OSE--D GEILfUC{ LGx4D = /agp ?? 1N D v11S 1?1 ? D oo izs t?'J h-4 3' ' 38 il! 70(?o t? ? Z s ?ATf o DRS. 135M,4 U+Ur+s ? _ nno,r•/ceiLZNc znted TIG. QS COD9t? O - _ . _ }?„VAIUC , r: 1. Intc=ior aiT film 2. yi G --f T3P 3. W:524. 44•Oa ;, Extcri.or aii filn (still)- OTT ?- To« 2 4s8a . . : _ . . • ?_ .02 ' . Fti.4+rt ? • . 1. Intorlor nir f31m , 0.61 z. G 13p 3- 38.35 d. F:xtetier air Liln (sta.l . Total U =?.oZ4.. Heat flov up • r?.j?_t?-r;.v?:^??"??, `?,.??y_•.,,L"_?JnV.?"1 -- - - -? ? -- - - - -- =-r /)i???11J?1! 'll,.llll??.'IiUl.l!J?!'rl_?1111, .- ? ? Y.ecc flov up • 2 -vented . • TSG_ d6" . _. . ?-. . Con.y??cvcri mr.__ _ Znsldc air filin 0.61 Z_ . 3. . . 4. U. 17 S. Outsidc air filin Total .?'.C?'1•-? E 2. Inside air filin _ 0:61 . 2. 3. ' . . 4. S. Outsidc air film •17 Total . . . . .` -? J.. Ynside air filin 0.61 2. ' - 3. 4_ 5. putsidc air filin 0.17 Tota1 . . . ,, Note: Uso additional sheets if morc spaco i: ? necdea tor deGails and talcu?ativns. . , . ' v v ' - ' bQ:7-VINTZA . ? _ ' . lteet • ilov up • ' . ... • . .. - $Z ._ 27 • ' '•' r ---- ..•....?.?,.... . _?- --_- PERMIT CITX OF EAGAN 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 PERMIT TYPE: Permit Number: Date Issued: ?D suxLozHe 025893 06/28J95 SITE ADDRESS: 1875 DEER HILLS TR LO'ic 2 BLOCK: 6 SUN CIIFF SST P.I.N.: 10-72975-020--06 DESCRIPTION: B411dlhg.„Permit 7ype DECK I Puild3ng 40,rk Type NEW ?a • ,. ? A; ° a , J , y 41-1 y , W,av? :fi At'o-.>r? ?vt.r i ? ? Y ? m ? y Y ??smi w . ? $3?,'cnR REMARKS: FEE SUMMARY: Base Fee Surcharge Total Fee CONTRACTOR: $30.00 $.50 $30.50 OWNER: - Rpplicant - FoRSSEae aaeL 1875 DEER HILLS 7R y EA6AN MN (612)687-9378 ? T'hsrffby acknowledg:e khaG I have inftsrmation is co-rra6t4ad agro"O_ Ststates ansl City of EaqAr'n DrdiiP' APPUCAN /PER ITEE SIGNATURE . . ? ..?. . .. CITY OF EAGAN ? -3 ? 50 3830 PILOT KNOB RD - 55122 ? ?j S 7995 BUILDING PERMIT APPLICATION (RESIDENTIAL) 681 -4675 r ? New Construction Reauirements RemodeVReoair Reauiremerrts ? 3 registered site aunreys ? 2copies of plan ? 2 copies of plena (indude beam & window sizes; poured fid. tlesign; etc.) ? 2 aRe survey4 (eaterior addttions & decka) ? t energy plwistions ? 1 energy celculations Tor liealed addkions ? 3 copies of Vee preaervation plan if lot pletted after 717193 mquired: _ Yes No . DATE: &4ii CONSTRUCTION COST: ?S e-0 DkSCRIPTION OF WORK: - ?S5?M?2 CleCI? ?--r^oU?1? ,?60 ?. 1/ // STREET ADDRESS: ' 1375 (? JP ? r ?? n"+ ! l5 7 ?' -& 1 ? LOT ? BLOCK i? SUBD./P.I.D. #: StIeV C(i PROPERTY Name: 4:?5err?- ? OWNER u°T Street Address- 1275 ?2e/ I CONTRACTOR ARCHITECT! ENGINEER ? , i 0 Phone b ? 7 ? ?-2 78"" ? !'r4i-/ City: ? H9ff i? State: AN` Zip: Company: ??nnre- Phone 5treet Address: License #: City: State: Zip: Company: /Ud.vf-- Phone #: Name: Registration #' Street Address, City: State: Sewer & water licensed plumber: Penalty applies when address change and lot change are requested once permit is issued. I hereby acknowledge that I have read this application and state that the information fs correct and agree to comply with all applipble Stafe of Minnesota Statutes and City of Eagan Ordinances. Signature of Applicant ?• OFFICE USE ONLY Certificates of Survey Received Tree Preservation Pian Received i i _ Yes _ No _ Yes _ No Zip: - ??CEVED J U N 2 0 t99§ --------------- OFFICE USE ONLY BUILDING PERMIT TYPE 0 01 Foundation ? 06 Duplex 0 02 SF Dwelling ? 07 4-plex 0 03 5F Addition ? 08 8-plex ? 04 SF Porch ? 09 12-plex 0 05 gF Misc. 0 10 = plex WORK TYPE aB:? 31 New o 33 Alterations 0 32 Addition ? 34 Repair GENERAL INFORMATInN Const. (Actual) (Allowable) UBC Occupancy Zoning # of Stories Length Depth APPROVALS Planning ? 11 Apt./Lodging o 0 12 Muki RepaidRem. o ? 13 Garage/Accessory o 0 14 Fireplace o ,,,2415 Deck ? 36 Move 0 37 Demolition 16 Basement Finish 17 Swim Pool 20 Public Facility 21 Miscellaneous Basement sq. ft. Main levei sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. Footprint sq. ft. Building Permit Fee SurCharge Plan Review License MCNVS SAC City SAC Water Conn. Water Meter Acct. Deposit SNV Permit SMI Surcharge Treatment PI. Road Unit Park Ded. Traiis Ded. Other Copies ,?-f Total: MClWS System City Water Fire Sprinklered PRV Booster Pump Census Code. ?/3y SAC Code o/ Census Bidg Census Unit _ Engineering Variance Valuation: $ /ZOO % SAC SAC Units / n '7 r' I v i..+ C. R. WINDEN 3 ASSOCIATES, INC. LAND SURVEYORS TO1 645•8648 1381 EUSTIS ST., ST. PAUL, MINN. 6510e FOR: KEY-LAND HOMES N Scale: 1" = 30' O Denotes Iron t4onument COSe?n; ? ?. l '91 0fl /i "y 4 ` ? 10 Z ? 9 r Lot 2, Block 6, SUN CLIFF FIRST ADDITION, Dakota County, Minnesota. EO? ? ?t '0e ? 2 WE MERElY GERTIfY THAT TNiS IS A TRUE ANO CORRECT REPRESENTAiION OF A SURVEY Of THE lOUNDARIES OF iME LAND A60VE DFSCRI6ED AN D OF THE IOCATION OP All 6UIlDINGS, IF ANT, TMEREON, ANO ALl VI516LE ENCROACMMENTS, IF ANY, FROM OR ON SAID LANO. Dotod thi, 16?k der oF_ma- A.D. 1985 C. R. WINOEN d ASSOCIATES, INC. Ho?.SC Gxolec? ?u/yB, /985?e?? ?J?o ? ?/..?+c.? br . Svrrayor, Minnowta Raqisfrafion No. 772? - /.i Dror'?°9e ?1 ?t°? 6?? I / ? ? , ? I \ 4 ` ly11- N O ~ Do ? CP,? iO s 1 G'J g6 ? 11'i Jj vt i PERMIT CITY OF EAGAN 3830 Piiot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 SITE ADDRESS: PERMIT TYPE: Permit Number: Date Issued: 1875 DEER HSLl5 TR LOT: 2 BLOCK: 6 SUN CLIFF 1ST P.I.N.: 10-72975-020-06 azwsa a- BUILDING 025894 06/28/95 DESCRIPTION: A.G. POOL ermit Type SWIM POOL da_rlc, TYPe NEW ?', ?. x IT ";., `? ... m -,r`.r?yWK px?i `e 1 x Yg?y??? ?y REMARKS: SEPRRATE PERMST REQUIRE? FOR ELECTRICAL WORK FEE SUAAMARY: VALUA7ION Base Fee Surcharge Tota1 Fee CONTRACTOR: $1,500 OWNEFI: - Applicant - FORSBERG JOEI. 1875 DEER HILLS 7R EAGAN MN (612)687-9378 ? Z here;by ackn;uwJ,edge that T 1have read this .ap;pl,i,o-i infarmation is corr'ect and agree° iCa compiy ,u3tP? aj St,atutes and:City of° Ela gan dretina-nces = ? PPIICANT/P qMl SIGNATURE ( _ ..+ $48.50 .75 $49.25 J the ? Ain;. c --? G? cinr oF eacAN d S 3830 PILOT KNOB RD - 55122 1995 BUILDING PERMIT APPLICATION (RESIDENTIAL) C,rl 681-4675 New Canstructlon ReouiremeMS RemodeVReoair ReauiremeMs ? 3 repistorod site aurvays ? 2 copies ot plan ? 2 copies of plans (inGude beam & window sizes; poured fid. design; etc.) ? 2 sRe suneys (exterior atldRions & decks) ? 7 eirergy celwlatinns ? 1 energy wlwlatioire for heated addkfons ? 9 copiea o( tree preeervation plen iF IM platted after 7/1/93 mqulred: _ Yes No DATE: / CONSTRUCTION COST: ")Z) ' CD DESCRIPTION OF WORK: -? ?/57H ,I? ?Do U[' ?r ?a r4NC1. 1?? ? ?TREET ADDRESS: I? 75 D P, ef ; LOT ? BLOCK SUBD./P.I.D. #: Su^j PROPERTY Name: -Pn fs b P,v"? Phone #: ?. , OWNER .,. ( Street Address?10 ?5 Deei City: State: Zip: : ?MG -tv CONTRACTOR Company: N0 Ne, Phone #: Street Address: City: ARCHITECT! Company: ENGINEER Name: Phone #• Registration #* Street Address• City: Sewer & water licensed plumber: change are requested once permit is issued. License #: State: Zip: State: Zip: Penalty appiies when address change and lot I hereby acknowiedge that 1 have read this appliption and state that the information is correct and agree to comply with all applipble State of Minnesota Statutes and City of Eagan Ordinances. ? -7 'i Signature of Applicant: OFFICE USE ONLY Certificates of Survey Received Tree Preservation Plan Received _ Yes _ No _ Yes _ No ? ( / 1? i OFFICE USE ONLY BUILDING PERMIT TYPE 0 01 Foundation ? 06 Duplex ? 11 Apt./Lodging o 16 Basement Finish ? 02 SF Dwelling o 07 4-plex ? 12 MuRi RepaidRem.<=aC 17 Swim Pool .9n,?r C<???? ? 03 SF Addition o 08 8-plex o 13 Garage/Accessory o 20 Public Faciliry 0 04 SF Porch o 09 12-plex ? 14 Fireplace o 21 Misceilaneous o OS SF Misc. ? 10 _-plex o 15 Deck WORK TYPE 6f ie:?31 New o 33 Alterations ? 36 Move 0 32 Addition ? 34 Repair o 37 Demolition GENER4l. INFC)RMA?'ION Const. (Actual) Basement sq. ft. MCNVS System (Allowable) Main level sq. ft. City Water UBC Occupancy sq. ft. Fire Sprink{ered Zoning sq. ft. PRV # of Stories sq. ft. Booster Pump Length sq. ft. Census Code. O S Depth Footprint sq. ft. 5AC Code 61/ Census Bldg / Census Unit O APPROVALS Planning Building Engineering Variance Pertnit Fee Surcharge Plan Review License MCNVS SAC Ciry sac Water Conn. Water Meter Acct. Deposit S/W Permit S/W Surcharge Treatment PI. Road Unit Park Ded. Trails Ded. Other Copies Total: ? Vaiuation: $ ?SOo °k SAC SAC Units /R 7S ' I C. R. WINDEN 8 /Q,Q?? ,?1`??? LAND SURVEYORS V 1381 EUSTIS SL, ST FOR: KEY-LAND HOMES ASSOCI/1TE5, INC. f&l 645• 3648 PAUIO MINN, 63108 N Scale: 1" = 30' O Denotes Iron Monument C Ose?n t '?? c. l rn ? ro;na9? ? ??5' 31 E / / ? lJ '164 ? ? c°„ 22 r ZO AP? ? 1 0 Z ? ir X"O ? ?C ,A ? ? r 4 0 ? r? -- ,ao? 1 s o 3 ?'a Y? i / , '(:9 040 ? i 0 ?E ri5 / N M / q)M ?/53 (0 e ? 2 io Lot 2, Block 6, SUN CLIFF FIRST ADDITION, Dakota CountV, Minnesota. WE MERE6Y CERTIFY TMAT TMIS IS A TRUE AND GORRECT REPRESENTATION OF A SURVEY OF THE lOUNDARIES OF TME LAND A60VE DESCRISED AND OF THE IOCATION OF All 6UIlDINGS, IF ANY, THEREON, AND ALL V1516LE ENCROACMMENTS, IF ANY, FROM OR ON SAID tAND. Dotad this 164k doy efMQ?j A.D. 1985 C. R. WINOEN 6 ASSOCIATES, INC. Noci.x Loca/ed ?u/cJ. B, /985?-e?? by J-_? 1 //?,Y &'? Sur.ayor, Minnesota Raqittrotion No. 772/-- /89 - /¢ PERMIT C1TY OF EAGAN 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 PERMITTYPE: BurLozNG Permit Number: 0 3 2 9 3 2 Date Issued: 0 8/ 17 / 9 8 SITE ADDRESS: P.I.N.: 10-72975-020-06 DESCRIPTION: --; ,. . _.,.._.. i REMARKS: FEE SUMMARY: 1875 pEER HIL4S TR LOT: 2* BLOCK: 6 SUN CLIFF 1ST REROOFf STORM DAMA6E Bu;i'1dTng,,Permit Type STORM DAMAGE B,uilding Gfa,rk Type REPAIR Censys Cqde434 ALT. RESIDEN7IAL l?Gf"tC H??I??ryG ? Hppi118950040 20139140 CHRISTIANSON pRVE 1444 CLIFF RD E 1875 DEER HTLLS TR BURNSVTLLE MN 55337 EAGAN MN 55122 (612) 695-0040 (651)688-3423 I hereby ecknowledge that I have read this appiication and state that the information is cprrect and agree to comply with all applicable State of Mn. Statutes end City of Eagan Qrdinances. APPLICANT/PERMITEE SIGNATURE (JSSUED eV: SIGNAT RE I 1998 BUILDING PERMIT APPLICATION (RESIDENTIAL) CITY OF EAGAN 3830 PII.OT KNOB RD - 55122 681-4e75 New Construetion Reauiremants RertrodeVReoair Reauiremenfs ? 3 registered ade surveys • 2 copies af plans (inGude Eeam 8 window s¢es; poured fnd, design; etc.) ? 1 energy plculations ? 3 copies of tree preservation Dlan if IM pWCed aRer 711/93 raquired: _Yea _ No DATE: DESC ION OF WORK: STREET ADDRESS: i q ?5 D?Q re-- 11 I II S -T?-> L LOT: ?-- BLOCK: ? SUBD.IP.I.D. #: 'S lk v` Name: C4f'?M!!Ibn Phone#: LO9D PROPERTY Cast First OWNER Street Address: 12 75 ?P(P? 1'7 1 I15 ` e! City State: mn) Zip: Company: ZZ- ` Phonefl: M6-60yD CONTRACTOR /' Street Address: Q. License # 2 0 1.?1 /? ?-( '`7 D City r) Lag 11 r` I I? State: 10 Zip: ?H?? 7 ARCHITECT/ ENGINEER Company; Phone Name: Registration ff: Street Address: City State: Zip: Sewer & water licensed plumber (new construction only): Penalty applies when address chang and lot change is requested once permit is issued. I hereby acknowledge that I have rd this 9ppliption and state that the infortnas on i; correct and agree to ?Ompiy ? II applicabl State of Minnesota Statutes and Ci of Ea an Ordinances. ? f Signature of Applicant: OFFICE USE ONLY Certificates of Survey Received _ Yes _ No qz 79 ? -I ' I[? 2 copies of plan 2 site surveys (extericr adddions 3 decks) 1 errergy calculations for heated addkions CONSTRUCTION COST; y y 39 JI hr• ., ?. 1 Tree Preservation Plan Received _ Yes _ No _ Not City of Eaaall 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Use BLUE or BLACK Ink r For Office Use Permit #: Permit Fee: 10 5 .aS Date Received: S)33 f Staff: 2014 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: Unit #: Resident/ Owner Name: Ke\%i f 'J l) Q 11Y-1 Phone: 651- 3C6 - 97.Eq Address / City / Zip: I q 7 5 Pte- — /L . IPA) L 1 EM --1)-1\I 5_ 5%c / Applicant is: ' Owner Contractor Type of Work Description of work: V-- S 1 1 W NS(- Construction Cost: Multi -Family Building: (Yes / No ) Contractor Company: Contact: Address: City: State: Zip: Phone: Email: License #: Lead Certificate #: If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) In the last 12 months, _Yes No If COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING has the City of Eagan issued a permit for a similar plan based on a master plan? yes, date and address of master plan: Licensed Plumber: Mechanical Contractor: Sewer & Water Contractor: Phone: Phone: 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 they are trade secrets. CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.qopherstateonecall.orq 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 approved plan in the case of work which requires a review and approval of plans. Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180 days of permit issuance. keu LLN1 Applicant's Printed Name x Applicant's Si Page 1 of 3