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1879 Covington Lane;CITY OF EAGAN (V 2 11861 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 XlaO BUILDING PERMIT Receipt p 7obeusedior SF DWG/GAR EstVaNe $84,000 Date APRIL 28 1986 SiteAddress 1879 COVINGTON LN Erect ?] Occupancy R3 Lot6_Block 1 Sec/Sub. PARK RIDGE 2ND Remodel ? Zonin9 R Parcel No. Repair ? Type of Const Vn Addition ? Na. Stories W Name RUSCON HOMES INC Move ? 48 Length ? 14530 PENNOCK AVE Demolish ? Depth 36 Address ? o 432-1433 A V Int. Impc Sq. Ft ciry • ' Phone Install ? SAME APProvs o Name oa Address AsSesSment _ . ? City Phone Water & Sew. Gw = I Name L+IARK NAGEL/PROBE ENGR tw p Address SAME a W City Phone 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 'ty o( Eagan,?Qidinances. \? Si9natwe of Permittee ?J Police - Fire Eng. Ptanner- Council Bldg. Off. 4/28/86 APC Var. Permit " "'-.-" Surcharge 42.00 Plan Review 192.50 SAC 575.OQ Water Conn. 500.00 Water Meter 63.50 RoadUnit 290.00 Tr. PI. 156. 00 Parks Copies - - 0 0 0 4 Trf.l / A Building Permit is issued to: RUSCON HOMES INC on the axpress condition that all work shall be done in accordance with all applicable Minnesota S t es a ' o( Eagan Ordinances. Builtling Oflicial ??9-'d'-' . _?._ • CITY OF EAGAN Pl 2 11861 ` --- ^3830 Pilol Knob Road, P.O. Box 21-199, Eagan, MN 55121 BUILDING PERMIT PHONE:454-8100 i # R ece pt To be used 1 or SF i]WG/GAR Est. value $ 84 000 Date APRIL 28 , tg $? Site Address 1879 COV INGT ON :.iJ Erect in Occupancy 123 Lot-fi Block 1 Sec/Sub pAKK iZ IDGE ZiND Remodel ? Zoning R1 Parcel No . Repair ? Type ot Const. yn . Addition ? No. Stories ? Name RUSCON HOMES ItvC Move ? Length 48 = 14530 PENNOC K AVE Demolish ? Depth 3.(?- o Addres Ciry s A.V. Phone 432-1933 Int Impr. Instau ? ? Sq. Ft. a N8me SAJ,,1E Apprcvals Fees 0 Q Address Assessment Permit ? ? g5 . 00 ~ City Phone Water & Sew. Surcharge 42.00 ?i ¢ t•1A1?.K NA(?EL/PROBE E1+1GR Police Plan Review 1'?2 - SA F Z Name S?E Fire SAC 57 5- 00 ? Z Address Eng. Water Conn._5?.00 i W Ciry Phone Planner Water Meter 63 - 50 Council Road Unit 290- 00 I hereby acknowledge that I have read this application and state that the i i gldg. Off. 4 f 2 a/tl 6 Tr. PI. 15 6_ U 0 in ormat on is correct and agree to comply with all applicable State of Minnesota Statutes and City of EaganQrdinances. APC Parks Var_ Date Copies Signature of Permittee l!; ... ? Total $2,204.00 A Building Permit is issued to: RUSCON FIDMS INC on the express condition that all work shall be done in accordance with all applicable State f Minnesota Statutes an City of Eagan Ordinances. Building Official ,.? ?" " ? ? ! - I I Prm+N No. I PennK MoWw I Dob I Tdsphons A 1 S Hfy. Final Frmq. Dbp. _ _ . , vr tAGAN Remarks 6 V-,,? V64" A,ddicion pARV_RIEIGF. 2ncl Lot 6 BIk 1 Parcel 10 56751 060 Ol Owner screet 1879 Covi ngton L.ane state Eagan, MN 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. 613 1982 4 16.15 10 STREET R ESTOR. 19$5 492.00 32.80 15 GRADING SANSEWTRUNK 19$2 159.37 10.62 15 SEWERLATERAL 1985 626.16 41.74 15 I , wATER^^AiN 00 1985 642.54 64.25 10 WATER LATERAL WATER AREA 1982 159-37 10-69 15 i STORM SEW TRK C 7 370.93 24.73 15 STOFIM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. BUILDING PER. SAC PARK INSPECTION RECORD ? CITY OF EAGAN PERMIT TYPE: +;" t 1 1' 1 H? 3830 Pilot Knob Road Permit Number: 0;?' 7!'HC' Eagan, Minnesota 55122-1897 Date Issued: q H r`' f? (612) 681-4675 SITEADDRESS: 1 „l N ,. APPLICANT: ? :.; •, ? W; INli 1 liN I HNi . •.??, , . , , r t IiF MN 1 Ni. '+Itt, it 1 Util .'iJH i- t. ? . 1 Gh1.ft , PERMIT SUBTYPE: ; I M I c I TYPE OF WORK: f+f •.I R t f' i t i'M RFF`A1K ,;X(lYNA/`.[IFf'TT/FAtii.' f11, ? ? Permit No. PermR Holder Date Telephone • ELECTRIC PLUMBING HVAC Inspection Dato Insp. Comments FOOTINGS FOUND FRAMING 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 BSMT R.I. BSMT FINAL DECK FTG DFrh ? .•.;AL - , ' --- ! . ? ? ? ? ' CITY'OF EAGAN WATER SERVICE PERMIT j 3830 Pilot Knob Road P. O. Box 21199 PERMIT NO.: , ; Eagan, MN 55121 DNTE: Zoninp: NO. of Units: Ownar: ?MiRCOn ar;: - Add?ess: _ , 7c Covin?tr:-, Site Address: , t.: 7; ifr:.-1 Plumber _ . ? . Meter No.: ??? , 5tu: " . r , (ME. 4 ? Q? Reoder No.: r0.i?/ e t . ' I ..me to em* **h *MyQ*RED sb* 4 pe?iw?nor, Misc. Chorpes: ? Totol: - gy 17+v,//?1 Date Paid: Dote of Insp.: lntp.: CITY OF EAGAN 3830 Pilot Knob Road P. U. Box 21199 SEWER SERVICE PERMIT , - - , PERMIT NO.: Eagan, MN 55727 DATE: 4-2 Zonin0: "j No. of Units: ? Owner. Rusceo .:o:Les c Address: ? Site Addi ? Plumber: I pros to easift wM6 IM Cihr of Eego¦ Ordiwpnr.m 8y Dote of Insp.; Conn,etiw, C}wrpe: 475.00114 ACWUf1t DEp0wf2 PdnMlit FAl: ? Q. dopf2 Surcha?ye: '? L ?d Mise. CMrym Tatol: . • , / ??L' ? 1986 HIIII.DING PE9MIT APPLIC6TION - CITY OF EAGAli NOTE: ALL CONTRACTOR3 (+1QST BE LICERSED SiITB THE CITY OF EAGAN COI4MBCIAL SINGLE F9MIILY Diifi[.LINGS INCLUDE 2 SETS OF AHCHITECTIIRAL INCLUDE 2 SETS OF PLANS & STRUCTIIRAL PLANS, 1 SET OF 3 CERTIFICATES OF SURVEY SPECIFICATIONS AND t SET OF 1 SET OF ENERGY CALCIILATIONS ENERGY CALCULATIONS $2,000 LANDSCAPE BOND C6?/?+ To Be Used For: Single Family Valuation. ??, Bt? Date: ? Site Address 1879 f'nvinn+nn I an OFFICS USE ONLY Lot -41- Bloek Ereet ? Occupancy -,Q-3 Remodel Zoning T Pareel/Sub partc R;rtqP Repair Type of Cons t ? _ Addition 1F of Stories Owner UOSHELL, Dana Move Length ? _ Demolish Depth Address 4728 West ,;nd Traii _ Int.Impr. Sq Ft Install City/Z1p Code Fanan, 55199 ---°----- -- ------------- ------- Phone 452-6408 AppgppgLS gEES Contractor RUSCON HDMES. INC. Assessments Permit 52SS77 Water/Sewer Surcharge s Address 14530 PENNDCK AUE. Police Plan Review Fire SAC ? City/Zip Code NPPLE UALLEY, 55124 Engr Water Conn ? Planner Water Meter Phone 432-1433 Council Road Unit qq? MARK NAGEL Bldg Off r-/ --jr6 Treatment Pl ? Arch./Engr. PROBE ENGINEERING APC Parks 14530 PENNOCK AUE. Variance Copies Address1000 E. 146TH TpYgI, APPLE VALLEY, 55124 City/Zip Code BURNSllILLE, 55337 Phone # 432-2044/432-3000 NOTE: ADDRESSES FOR CORNER IATS - COPTRACTOR/HOMEOfiAEE MQST DESIG$ATE iiHICH ADDRFSS IS DESIRED. NO CHANGFS HILL BE ALLOfiED ONCE BQILDING PER1iIT IS ISSIIED. k z.,o ? zZ ' ?'e, ?Z = 7?5ZgjP ? 30 ?Z? = ?-o?c z14 = -?q?SO -(1-(?-> x???Z= 4C) >e, .A • /AOBE CpHSUlTINO EHOIHEEAS ENGiNEEAiNG PlAN8EA2 and tAHD ?UBYEYOf15 COMPRNY, iNC. 1000 E115T 1461h 57AEET, 8UflN5VILLE, YINNESOTa 59-337 P4i 432'300o Cerz%?i ccz?e ?urzr'e c? LO-47 c1 Qeacr?o?iorz: LOT 6, BLOCK /, P,9RK R/OGE 2N0 AoD/rraA, DA41079 COUNTY, M/NNESOTfJ. CL COV/N6TON ? 8 1 ?--J.OO% L='l000 1 /VOR TH SCAL E. /"= 30' 4= R= 293.949 S 89°3?'34". S6. O/ GANE O O M ? (923.oJ (923.3 A TPRoyoSFP I 2o.ooN ? v ?. u5E 1'? N I I ? ? ? 23A `V o 1?j ?.00 -` . 2/.q? ? ? ? ?N I N ?l N I (923.0) o ? I I922?3? N\ I ? L D T 6 5 '00'/ ?G L% rf ? 920s` I ?5 PENOTES EX/ST/NG ELEXAT/ON (92-7•5 ) DENOTES PROPOSED ELE!/i9T/ON /ND/CATES D/RECT/ON OF SUR?ACE AR,4/NAGE gz3.?3 = f/N/Sh'ED 64R19GE FLDO.P EL EV/? T/ON Ed°il G. AY CI REVIEIME @ 8Y ( yLO,?) vl -.ft? "- +, Wl t?c<. 2ow DRA/yAGc ? UT/L/rY S 89°? s834"E ?92a.e} E•95EMENT I her:by cartify that thia in a t:ue and correct reprasentation of a tract of land as sho+m'and deacribed herzcn.• Aa preparnd by me on this /y? day of A*V-i '- , 19 8'(. . Hinn. 1e9. No. /baBS - • . f . ' ... . . . ' " " -.. ? . . .'? .^ .?.. a . , :?1?=i.r^ . . . ?.. . .. . .. r . . •-•:- . -. . =•,•?;;..,: . . • EXTERIOR ENYELOPE AVERAGE "U" CDMPUTATION _ . • ..:_, ;?? . • , ' OWNER . - .. . ,-. ? ?._...:'_ - . . . . . ... - . .. . ,-,. s. • .... -.... . -.. , :•. _...' • : , .r;_ , ?+• ...?_,..': ?:,r:? ?:.,:? ? r s ??~SITEAODRESS•' = - . , ".'}?.s?,?r;,t::_i:? . ?+.; - ?"'' , F, -,• ? '•:::,.??+- • . .. . ? "?:.w:C ?1 . . r . . qT ': • :: ?. . '. . ?,.'? ?.tf!. .4 . . ,?:r . . _ _ •-. '. . ' UATE. • . .FNONE??iA?;? ?-3-' CONTRACTORIZu?C:o? 41or.?' - . ,. . .. . ' ' ... ; . ? _ a•. . - . - •• Deterntine working square footage of each. /. 1. Total exposed wall area ......sq. ft. x LI l . :. e 2. Total roof/ceiling area ...... _JjQ40_ sq, ft."x 0. Zb ° 7otal_exposed wall area above floor = Z?? :..:........ a. Total wall window area ......... ....... b. Total door area ................................. 58 ' . c. Total sliding glass door araa .................... •• • d: Total fireplace wa]1 area ..................:..... -r . - e. Total wall framing area (average 10%)...:.... .... . •f. 7ota1 net wall area above floor ................. '• -LI g. Total rim joist area .............................. . . Total exposed foundation area = 117--4 . h. Total foundation window area ..................... --- ' .... ? 9. Toal net foundation area above grade ......... . ,? Uetermine "U" value af eaz?n wall segx:_nt. • a. J77, e g 'lull . b. 516 X ??U" 13 _ . c. X lsuit C. = 21-9. 64 • d. ? X „ual ? t --- e._ ? , ?X ??U- t. 1lp.57. Z(o x"u" . 043 =Iff Z? g. X??U" ? 04 a ?J• ? ? h. ? X ?lull• f = .? ;. lIZ 4 X „U,I 3........? ....................................... Ifitem 13 9s the same as,vr less than item #1, you? et the intent of 59C 6DC5(c)2. . •{a r . f x. ? n P 6 ? ? .? 1 ! ? ? •? 1 . ? ? ..?? ? ? t ???? • }. i? S ? ? ? ?1.?? .:: . 3 / ?' ?. t .???. . . ? '..'/ ' .- ..?. . j. , ? ? ? Total exposed roof/ce9liog area ... _.? ' ? ` _ ,. ' , ? Total gross • roof/ceiling area. _ ? , •? . _ - _.. j. Total skylight area ......................... k. 7ota1 roof/ceiling framingarea ..........,. ^(nD •A? 1. Total nei insuTated roof/ceiling area....... c?Q7. Z ZF1 cH°'°, ?2.3z??lusu? evec: 4 ................................... TOtdl ' ° . If total of #4 is the same as, or less than #2, you have met the intent of, 5BC 6006(c)'I. . . . . . . . • • .. • . ? To utilfzed the total envelope system method, the values.established by the sum of items 03 and 14 shall not be greater than the sum of itens 11 and 82. . Determine "U" value for each roof/ceiling segment. . ,:..... .. .g ... .. X liU" k. •/??? J( ituil . 024' 1. {07 ? x ItUn• (J7i '. a .F ]. '?7Z •?? , • , ? • • . +, 2. 3. + 4.'?7 _ MATERIALS Exterior Air 5lding }fatierial Shealhi'ttg Insulatioa - sheetroCk Interiox Aix Stude Rim Cono. Blks. Therm. Reaistance 111t" • ?Or"J ?I4 4M?• J1_ 5''e . . 17 ._?:+?_?Q+? Pu ?o J,2s +It ? ?s.zi . . ' ,' . 4 CITY OF EAGAN 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 PERMIT PERMIT TYPE: Permit Number: Date Issued: w?(0s1o BUILDTNG 027506 05/08/96 SITE ADDRESS: P.I.N.: 10-56751-060-01 1879 COVTNG70N LANE LOT: 6 BLOCK: 1 PARK RIDGE 2ND DESCRIPTION: SIDING/SOFFIT/FASCIfl ermi.t Type. SF (MISC.) rk Type REPAIR ?fi'<Ibla 434 ALT. RESIDEN7IAL P0 a 1, p ?tt rs a in? ai X? ?t eZ im ?€ ? r"wsrv REMARKS: FEE SUMMARY: VALUATION Base Fee Surcharge 7ota1 fee $199.75 $6.50 $206.25 $13,000 CoNTRACTOR: - Applicant - sT. LzC.OWNER: PANELCRAF7 OF MN INC 17216628 0002179 BANNON PAT 3118 SNELLING AVE S 1879 COVSNGTON LN MINNEAPQLIS MN 55406 EAGAN MN 55122 (612) 721-6628 (612)454=6386 ,T h 8Y$bY. , a..wforenat` ? , Sta?ur?Ce?; APPLICANT/PERMITEE SIGNATURE nala GAlW- ISSUED BY SIGNAT R q r•s iqgoL CITY OF EAGAN ? o?J 3830 PILOT KNOB RD - 55122 ?' d-OG? o?J 1996 BUILDING PERMIT APPLICATION (RESIDENTIAL) 681-4675 New ConsWdion Reouirements RamodelReoair ReaUiremeMs ? 3 iegistered site surveys ? 2 oopies of plan . ? 2 copies of plana (indude beem 8 window skea; poured ind. design; etc.) ? 2 site surveys (exlerior addRions & decks) ? 1 energy calculatiom ? 1 energy calculationa for heated addHions ? 3 aples of tree preeervalion plan H bt pletled efter 7/1 KJ3 roqufred: _ Yea _ - No DATE: CONSTRUCTION COST: I ? ? `? `'? ? • ? DESCRIPTION OF WORK: STREET AODRESS: LOT .?_ 18-79- COVi i BLOCK I_ SUBD./P.I.D. #: 'f LO-n(?? PROPERTY OWNER CONTRACTOR Name: n OV) Phone #: qJ ' - &386 flNfi I Street el City: State: Mn. Zip: Company: 'T)QJ)e, ICrO,F't" DF M IL) Phone #: -VI" 64029 Street Address: aI I g??I ? ? nq License #- c;ty: ?-YY'1 P 15 State: Mn Zip: ARCHITECT! Company: ENGINEER Name: Phone #: Registration #* Street Address, City: Sewer & water licensed plumber: change are requested once petmR is issued. State: Zip: Penalty applies when address change and lot 1 hereby acknowledge that 1 have read this application and state lhat the information is corcect and agree to comply with all appiicable State of Minnesota Statutes and City of Eagan Ordinances. Signature of Applicant: V OFFiCE USE ONLY Certificates of Survey Received _ Yes No Tree Preservation Plan Received _ Yes _ No V 09r_82007 08:40 ? EAGAN ENG+COM DEU ? 96519851745 2007 RESIDENTIAL BUILDTNG rmwarnKAMW City Of Eagaa 3830 Pi1o{ Knub Road, E&gau tViN 55122 Telephone # 651-675-5675 FAX # 651-675-5694 fC oi hause; eM g4 roa(ed erea9 RemadeLRmlt R£StulmdlQnS4 2 copmoiloknahwii4g faoUigs, Deams,101613 1 Jet ufEnmgr Caloufal?ns fcrlieafedatld?oi?s 1 slle survey'.fa addlUon5 & dailcs Adtllbn • Wd'ca7e Aon-dte seplk system g Q Io he plaM an tl6turtmd sos udnAam sizes; poufad fmuid d*n, ek Mmn¢p= machanical ven6laUOn fam - Blenc nre pr,nai.lorod niit,fip ;nftwmaHnn uniess vnii state thev are trade secret and fhe reason, -- j???; Canstenetion Cosi Site Addresa UnitlSte # Descripiton of Work Mulll-FamfFy Bldg _ F V ? F'ireplace{s} 2 PraFerty Owner Telephone 4 (K() ? CQKtfHCLD[ ?iddress ? . Ciry SraRe Zip ? Telephooe # ( /3- 2?- COMPLETE THIS AREQ dN1.Y IF GONSTI2l1CTING A FIEW BUILDING - Mianeaota Rnles 7670 Careeorv 1 _ Kwneyra Rules 7672 i Esergy Code Category , ResWenttal VenGletlon Gleqory 1 Workshaef • New Energy Cade Worksheat - 0 submis6iontype) SubMftd 3uhmiflad , . Energy Envalape CaICU12Nort6 SahmlBed 7n rfi3 iast 72 monttis. has the City of Eagon issued a pErmitFOt o slmllor pi6n based? on a master planZ _ v _ N If yes, dare ond address of mosrer plan, I.icsised Plvmber Mechonical Conhactor Se%erINlaier Contractor Telephone #( Tp-lephone #( N0.848 D92 orrmussaniv CedofSurveyRecd -Y ,_N SoasASpwt----- „Y" _N Yree Pres.. Plan Reo9 _Y _ N. , 7reePreaReqdred _Y _N On,siia SeptleSydam _v ,_N Telepnone # [ ) y apply for a Residentiral Building Permit and acknowiedge that the informalian is complete and acctuase; ? work will be ia conformaiice wi#h the ordinanees and codes o#'the City of Eagan and the State of N_N ; I undersYand this is not a permit, 6ut only an application for a permit, and work is not to start without a that the wark will be in accoxdance vuith the approved plan in the case of work ' 11 ofplarae. ? Ap icani's Pantal Name ?IST?canl's Signaliue CITY USE ONLY l BL RECEIPT M. SUBD. l QY `? !`.lL?s fL d"-" ? RECEIPTDATE: ? 1c-C,/ - l? PERMfT7f 1999 PLU11+IBIIV6 PERbI1T (RESIDEPI'Ii4I) crrYoFEwsM 3830 Mar KNoa sn _ gt48AN, i1F 55122 (651) 681-4875 Please complete for. D single famity dweliings ? townhomes and condos when pertnits are required for each unit ? backflow preventer for underground sprinkler system tP,1 tl1.7?H EACH M TOTAL Raih tt!h ¢ 3 nn - $ Floor drain 3.00 x = $ Gas i in outlet ' minimum -1 3.00 x = $ Hot tub/s a 3.00 x = $ KitChen sink 3.00 x = $ Laund tra 3.00 x = $ Lavato 3.00 x = $ Minimum fee alterations to existin dwellin 30.00 x = $ Private Dis sal 5 stem new/refurbished ' r uires MPC iic. 75.00 x = $ Private Dis sal S stem abandonment 30.00 x = $ RPZ new installationlre air 30.00 x = $ Rou h o enin 1.50 x = $ Shower 3.00 x = $ Under rounds rinkler iFdweilin isunderconsWction 3.00 x = $ Under round s rinkler if existin dwellin 30.00 x = $ Water closet 3.00 x = $ Water heater 3.00 x = $ Water softener if dwelling unaer conswcnon 5.00 x = $ Water softener if existin dwellin 30.00 x = $ Water tumaround 30.00 x $ State Surchar e .50 -> -> -> $ •50 TOi,al -> Rem!»der. Call for inspections of alterations, i.e. water heaters, water softeners, etc. - ?yy- ??? --------•-----•--? --•--•-----•--•--•----------•--•-------•--?---°----•--•-•---------•-------------•-----•--1 a tlut I have read tlus Ication, shate that the infarmatlon is carect, and a tu aomply h all applicade City of Eagan ordinances. wit Nis Me applkanPS responsibility to rrotlfy tlre property owner tliat Ihe Cily of Eagan assurtes no liability for any dartages rdused 6y fhe City during its nomW aperatiaal antl maintenance ectivitles to Me tadlitles wnstructed under fhis permit wilhin (tilly property/rightof-way/easement. StTE ADDRESS: ? I/ \ OWNER NAME: : Dal?l LlGll ?? TELEPHONE #: ?? J???? (AFtEA CODE) tNSTALLER NAME: tx-d, - /1/1,(- - i STREET ADDRESS: 2 6190 TELEPHONE #: ? J97 -05 (AREA CODE) CITY: f! y/0UGr / N STATE: WN ZIP: -? SIGNATURE OF PERMITT PERMIT City of Eagan Permit Type:Building Permit Number:EA116760 Date Issued:10/10/2013 Permit Category:ePermit Site Address: 1879 Covington Lane Lot:6 Block: 1 Addition: Park Ridge 2nd PID:10-56751-01-060 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please print pictures of ice and water protection and leave on site. Carbon monoxide detectors are required by law in ALL single family homes . Audrey Flattum 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 - Daniel J Guite 1879 Covington Lane Eagan MN 55122 (651) 687-9439 Storm Guard Restoration 1355 Geneva Avenue North, Suite 201 Oakdale MN 55128 (651) 738-1698 Applicant/Permitee: Signature Issued By: Signature