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4684 Horten PtCITY OF EAGAN Remarks Addition Kidgecli tt 3rd Addn Loc 2 Rik 7 Parcel #10 63982 020 07 Owner'-..'.i?! L Street 46A3 Stavern Pni nt State--Eag3tl - A'1N 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF, STREET RESTOR. GRADING SAN SEW TRUNK SEWER LATERAL WATERMAIN WATER LATERAL WATER AREA STORM SEW TRK 1982 246.22 5 246.22 C007616 12-23-81 STpRM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT 8 0 WATER CONN. BUILDING PER. SAC 525.00 20370 srs/so PARK CITY OF EAGAN Remarks Addition Ri li f 3rd A dtl Lot 3 Blk 7 Parcel #10 63982 030 07 owne? `' 1 d street 4687 Stavern Point state Eagan. MN 55122 , Improvement Oate Amount Annual Years Payment Receipt Date STREETSURF. STREET RESTOR. GRADING SAN SEW TRUNK SEWER LATERAL WATERMAIN WATER LATERAL WATER AREA STORM SEW TRK p 1982 246.22 5 246.22 C007616 12-23-81 STORM SEW LAT CURB & GUTTER ' SIDEWALK STREET LIGHT 20370 318180 WATER CONN. BUILDING PER. 6068 sAC 525.00 20370 S 8 80 PAR K CITY Oi? EAGAN Remarks Addition_.R?dseciiifff 3-r-d-?dd? Lot ? eik 7 Parcel 910 63982 9100-7 Owner???k?? ` 1?•? t)Qi-}+?&i_ t Street- 4fi4 Hnrtc?n Pnint State Eaganr N1N 55122 (mprovement Date Amount Annual Years Payment Receipt Date STREET SURF, STREET RESTOR. GRADING SAN SEW TRUNK SEWER LATERAL WATERMAIN WATER LATERAL WATER AREA STORM SEW TRK ?? i(r, 1982 246.22 5 246.22 C007616 12-23-81 S70RM SEW LAT CURB & GUTTER ' SIDEWALK STREET LIGHT WATER CONN, g 80 BUILDING PER. sAC 20370 8 80 PARK CITY O` EAGAN Addition R;rigec7;ff 3rrt Arldn, Lot 4 eik 7 Parcel._#1-0-G.3.Q82_8q.p-Q7 Owner I' Street 46RR HnrtPn Pnint State_Eags9n, MN 55122 • I;??? ;? , -r r. ?j + Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK SEWERLATERAL WATERMAIN WATER LATERAL WATER AREA STORM SEW TRK ° 1982 246.22 5 246.22 C007616 -- 12 23 81 STORM SEW LAT CURB & GUTTER ' SIDEWALK STREET LIGHT WATER CONN. BUILDING PER. 6069 SAC 818180 PARK ' CASH RECEIPT ' CITY OF EAGAN 3795 PILOT KNOB ROAD ? EAGAN, MINNESOTA 55122 DATE 19 RGC6IVED PROM AMOUNT $ I DOLLARS ?eo ? CASH [:1 CHECK FOR A 1 -7 L White-Peyers Copy Yellow-Posting Copy Pink-File Copy Thank You r gY ?l? • . • CITIf OF EAGAN 3795 Pilot Knob Road Eagan, MN 55722 PHONE: 454-8100 N° 6068 BUILDING PERMIT tteceipt # Site Address ? 0ZE:'?er'1 ' 5 Lot Blotk 7 Sec/Sub. ??-'I ZE'C11 f F2 ? Porcel # cc Name ..} ,- . .,, ,- - •F> ? ,,, ---- - - - - - - - - - ? Address ? ?'?-2 liOpklllS Crsrd. 'i r.,n?nr?olr 11dn &;l / _11 '2'IZ ae Ncme ?o oU Address u? f" Ci Phone F 2 w Name Ered f} Occuponcy - Alter p Zoning _ Repoir ? Fire Zone Enlarge ? Type of Const. Move ? # Stories Demolish 0 Front ft. Grade fl Deoth ft. Water & Sew. Police Fire Eng. Planner Council Bldg. Off. APC I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with oll applicoble State of Minnesoto Stotutes und City of Eagan Ordinonces. Permit - $urcFarge - Plon check SAC Water Conn. Woter Meter Road Unit Total I + ;7 Z ' • Signature of PermiKee I A Building Permit is issued to: on tAe express condition that oll work sholl be done in accordance with oll cpplicable State of Minnesoto Stotutes ond City of Eagan Ordinances. Building Officicl P?nnM # Oeh Iwwd Pumkfw Plumbing ? - l? . ` Mechanical - - o LUQ J INSPECTIONS DATE INSP. Rouph-1 n Finol Foptings Dafe Insp. Dats Irnp. Foundotion Plumbing Frame/ins. Mechonical Finol 2 -S-FlI Remarks: ?- / 7-$6 CITY OF EAGAN . ? 3795 Pilot Knob Rood Eogen, MN 55122 NS 6067 . PFIONE: 494-8100 Receipt # of Site Address 4- ?) - Lot Block Parcel # ? RidgeclifYe 3 Erect ? Occupancy , - Alter ? Zoning Repoir ? Fire Zone Enlarge ? Type of Const. ' Move 0 # Stories Demolish ? Front ft. Grode ? Depth ft. Apao vnls Feee oWC Name 'rrin Thompson Homes 3 Address - 1y12 Hopkine Crsrd. 0 o Nome _ z? o? Address u Name _ Address I hereby acknowledge tlwt I hove reod this applicotion ond state thot the infortnotion is rnrrect ond ogree to comply with all opplicobie State of Minnesota Statutes ond City of Eagan Ordinances. Woter & Sew. Police Fire Eng. Plonner Counci I Bldg. Off. _ APC Permit '- L $urchorge Plan check SAC 'i2r? . ., ? Woter Conn. - - Water Meter Road Unit Total Signature of Permittee - I A Building Permit Is issued to: on the express condition that oll work shall be done in otcordance with oll applicoble Stcte of Minnesoto Stututes ond City of Eagan Ordinances. Building Officiol P*neit # Dat* laued PWMIMM Plumbing f - f (, :?& ? _., Mechanical I a -ope ? INSPECTIONS DATE INSP. Rouph-In Finol Footings Dote Insp. Date Inap. Foundation ? Plumbing ;? -0 _ R Frame/ins. p? Mechonicol Finol Remarks: ?"??3Sv CITY OF EAGAN • ? 3795 Pilot Knob Rood Eogon, MN 55121 N2 6069 PHONE: 454-8100 BUILDING PERMIT Receipt # __ To be used Foe - Est. Volue Date , 19 Site Address , Erect Occupancy Lot f Block Sec/Sub. i?:IreCil,'i e` Alter ? Zoning Porcel # urTe`''c)T,!Fxd Repair [] Fire Zone ? - Enlarfle ? Type of Const. v m Name W :omQS i'nc,-r:;2--ozl Move ? # Stories Z Address Demolish ? Front ft. Ci ' phone Grode ? Depth ft. p Nome _ ? 06 Address z Nome _ Address I hereby ocknowledge that I have read this application and stote that the informotion is correct ond agree to comply with all opplicabie Stote of Minnesota Statutes and City of Eagnn Ordinances. Woter & Sew. Police Fire Eng. Plonner Counci I Bldg. Off. _ APC Fees Permit ?-= '• - Surchorge ?- , Plan check ' • f SAC Woter Conn. 3^ Water Meter ' Rood Unit Total ? ? ? 5 " Signoture of Permittee I A Building Permit is issued to: 'Z•r' ' on the express condition that oll work shall be done in occordence with all opplicable State of Minnesota Statutes ond Ciry of Eagon Ordinances. Building Officiol P*nnk # Dah lawd ionnNtw Plumbin9 / ,S` ' / 6 Mechaniccl ^ 523 / i.?- i 9 -?c? - INSPECTIONS DATE INSP. Rough-In Final Footings Dote Inso. Dofo Insp. Foundation Plumbing - Frame/ins. Mechnniwl Final Remorks: //- 3 = b0 ?o-t ? • CITY OF EAGAN ? 3795 Pllot Kno6 Rood Eogan, MN 55123 N2 6066 . PHONE: 454-8100 B'UILDING PERMIT ReceiPt # --- Site Address = ti07 Lot Blotk 7 Sec/Sub. P (1_7, ' orcel # `( 1 eC' oc Name :-'?'1?? ?'?"'-n??''S?",: L??o'';?•:' 3 Address C. •.. r? Phone ° Erect :0 Alter ? Repnir ? Enlarge 0 Move p Demolish ? Grode p Occuponcy Zoning Fire Zone . Type of Const. # Stories Front ft. Depth ft. °C Name ,o Approrals Feea U Assessment ' Permit ? Address Woter & Sew. Surcharge Ci Phone Police Plon check t?W Nome L Fire SAC ?? Address Eng. Water Conn. ?W Li phone Plcnner Woter Meter Council Road Unit I hereby acknowledge thot I huve rend this opplication und state that gld9. Q{f, the inforcnetion is correct and agree to comply with all applicable APC Total SYote of Minnesota 5tatutes ond City of Eogun Ordinances. Signature of Permittee A Building Permit is issued to: on the express condition thot oll work shull be done in ocmrdonce with ell applicabie State of Minnesota Statutes ar?d City of Eogan ardinances. Building Official Pwmk # poN hnad Pwalttee Plumbing I Mechonical INSPECTIONS DATE INSP. Rough-In Final Footings Oote Insp. Dote Inap. Foundativn _ Plumbing Fmme/ ins. Mechaniw I ? Fincl a -?-$r ? Remarks: ? //- 3 -?56 No. cirr oF EAGAN 3795 Pilot Knob Road Eogan, Minne:ofs 55122 Pheee: 454-6100 PERMIT Date: 1 -• i 2- Site llddress: Lot Block Sub/Sec. '' ? ' "?? • Nome ' !rri n `?''hm=unn nr.i,?•• . ? Address ? City ?' lP'tGlr?::? Phane: Name p. y ?p AddrE55 O V City Phone: INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS Receipt No.: $ingle I Residentinl Multi Res., Comm./Ind. I New/Alter./Repcir Cost of Instollotion Permit Fee Su rcha rge Tofal 20. 5C This Permit is issued on the express condition that all work sholl be done in uccordance with all epplicoble State of Minnesoto Stotutes and City of Eagan Ordinances. Building Official No. ' ? 51 cirr oF EAw?N 3796 Pilot Knob Read Eogon, MinneaoM SSiZZ P6one: 454-8100 INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS tin ' PERMIT pate; 11- - Site /lddress: ?? j'pI'ten -'' Lot Block Svb/Sec. ?' Ncme ? -?!1 .OT' ?. . e Address `• 'U ? City ?'T.iTLTI@t.OZll:B , Phone: Nome ''iY 'Vielter 11@8-t1'.;' . ? Address ? r'i1.Cnr-o Azv? , e ? City Phone: 544--'i j `7 Receipt No.: 5ingle I Residential Multi Res., Comm./Ind. I New/Alter. / Repoir Cost of Instollotion Permit Fee 5urchorge Totol This Permit is issued on the express condition thot oll work sholl be done in accordance with ull opplicable State of Minnesota Stotutes ond City of Eagon Ordinonces. Building Official CITY OF EAGAN " • - 3795 Pilof Knob Road No. Eogon, Minnesota S5122 - PheTM: 4544100 -` ' PERMIT Oote: 11 ' - Site Address: 4683 atave2'ri Pt. Lot Block Sub/Sec. ?' -c'-iffW 3 INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS Receipt No.: Single I Residentiol Multi Res., Comm./Ind. I Name i=1 Th0m80T1 /Alter air N /Re . ; Address . p ew . Cost of Instollotion O City - -,Orld. 'T1. Phone: = 41*'7333 Permit Fee . Name 5urthorge ? ? Address 46,37 2LlCS,?O 1? VB .:1. ? City 41• Phone: Total This Permit is issued on the express condition that all work shall be done in accordance with all opplicabie Stote of Minnesoto Stotutes and City of Eogan Ordinances. Official No. • Date: CITY OF EAGAN 3795 Pilo! Knob Road Eoqen, Minnesota 55122 PAoee: 454-8100 PERMIT 4f 8lr Horten Pt. Site Address: Lot 1 Block Sub/Sec. ?-dCecIiffe 3 Nome '''rir: Tt10TRUeOri HOT•1CS . ? ? ?, ,.11,q ?•,,9T?? . ? Address ? City Phone: '33? Name ;'.E?y '?te1tFl^ . ? Addreu 37 GYl--'C`:f'' e e V City Phone: This Permit is issued on the express condition rhar oll work sholl be Minnesota Stotutes ond City of Eagan Ordinances. INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS Receipt No.: ' Single _ I Residenticl Multi Res., Comm./Ind. I NewfAlter./Repair. Cost of tnstollation Permit Fee Surchorge Total done in xcordanu with all opplicable Stote of Building Offitial CITY OF EAGAN 3795 Pilof Knob Read No. ' Eayan, Minnesote 55122 INSPECTOR NOTIFICATION Phom: 454-8100 REQUIRED BY LAW . „?? . . FOR ALL INSPECTIONS - - - - PERMIT , ? ... ^^ Date: Receipt No.: + Single I Site /lddrcsa: Residential ' • r, Lot Block Sub/Sec. Ridgecliffe 3 Nome "riri T10mp30ri I :C*'lP, s New /Alter./ Repair ? Address -'lti IIopkine Crsr? , Cost of Installation Cif Phone: ? '7r•. Y Permit Fee Nome - ?' Ry an . ' ? Surcharge g Address ' ? 0 V •, ?.. -i - , , _ City Phone: - Total This Permit is issued on the express condition thot oll work shall be done in accordonce with all appliooble State of Minnesoto 5tafutes and City of Eagan Ordinonces. Official ' - - CITY OF EAGAN 3795 Pilot Knob Rosd • Eogen, Minnesote 55122 "°.. - wom: 454-8100 ' ' •?r-i, ? ., PERMIT Dote: 9-1b-80 Site Address: 4&14 `arten Pt. Sub/sec. ?'eciif±'? 5 1 Lor si«k / `? Nome n Thmn80n flOm@s ??? ? Address 1712 Hopkina Crsrd. ? "-t.nnetonka, 1.n. City Phone: Nome GEI12 Ry8T1 g. y Address 14 7 11+ 5 S. .O:,r? . _.? . ? City Phone: " This Permit is issued on the express condition that all work shnll be Minnesote 5totutes ond City of Eagan Ordinances. INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS Receipt No.: Single 1?. pl@7C Residential ' Multi Res., Comm./Ind. New/Alter./Repoir - Cost of Installation ; n,n,r, Permit Fee Surcharge Total done in accordanu with all applicoble Stete of Buildirg Oificial Receipt ? PLUMBING PERMIT Permit No. , CITY OF EAGAN Fee Fill in numbered spaces S/C Type or Prini /egrb/y Tot. 1. Date L- 2. Installation Cost ? 3. JobAddress? /f/l.ot' Blk.Tract ; ? , a 4. Owner '?/I/L`?s ?, ti` L?C-/?%'!-s '? 1_ f'c?/ ` i 5. Contractor Phone ? 6. Address _ 7. City State Zip J 8. Building Type: Residential ? Commercial O Institutional ? 9. Work Description: New ? Add ? Alter ? Repair O 10. Describe I 11. No. Fixtures Water Closet No. Fixtures ool/Drainfield Cess Bath tubs p Septic Tank Lavatory / Softner Shower well Kitchen Sink Urinal/Bidet Other Laundry Tray 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 - cinr oF EAGAN ` • 3795 Pilet Kwob Reed No. . . Eayaw, Minnesoto 55122 INSPECTOR NOTIFICATION Pken.: 454-8100 REQUIRED BY LAW i'PERMIT FOR ALL INSPECTIONS Date: ?-16 -Lr? Receipt No.: Single I !>(),:'} SL"t ?eS'Tl Ft, Residential Site Address: ? Lot Block ' Sub/Sec. •" '?`"li'? ?' IMulti Res., Comm./Ind. Name OI'Y'iII TlOPIpBOII H0rPS New/Alter./Repolr ^?r ? /lddress 219 - - Cost of Installation City Phone: Permit Fee ' Name '?-:Z t?,,YeSI . ` Surcharge g Address e 0 City ` ' - Phone: Total This Permit is issued on the express condition that oll work sholl be done in otcordonte with oll opplicable Stote of Minnesota Statutes and City of Eogan Ordinonces. Officiol ' cirr oF EAGAN • 3795 Pilot Knob Road No. , Bo9an, Minnesofa 55122 P6one: 454-8100 - PERMIT Dote: 9-16- 3U Site ^ddress: 4688 Horten Pt. Lot Block ` Sub/Sec. 11dl;eClii'f8 3 INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS Receipt No.: Single ? I Residentiol Multi Res., Comm./Ind. Ncme Oz"-'3n Thon[peon Home9 New /Alter / Re air . p ; Address - ?-? ''_?t '?Z';^'•?. Cost of Instollotion O City Phone: Permit Fee Nome " - Surchorge . ? ..1745 S. ! -,, . Address ? City Phone: ? Totol This Permit is issued on the express condition thot all work shall be done in accordance with oll applicabie State of Minnesoto 5tatutes and City of Eagan Ordinances. Buildiny Official cirir oF EAcaN 3795 Pilof Knob Road Eagon, Minneseta 55122 INSPECTOR NOTIFICATION No. Phowe: 454-6100 REQUI RED BY LAW - PERMIT FOR ALL INSPECTIONS Date: Receipt No.: Single Site /lddress; nt .. •":L ?:,iF',Il ? Residential Lot ` Block ( 5ub/Sec. Multi Res., Comm./Ind. Name New/Alter./Repoir . 3 Address Cost of Installution O City Phone: Pertnit Fee ` Name - C[?:T-1E?rs {i`;{? T-7atur $urcharge •''? ? ? Addreu __ ? ' ? C . • ?t ,,. . ; ; - City Phone: Total This Permit is issued on the express condition thot all work sholl be done in accordance with all opplita6le Stote of Minnesoto Stotutes ond City of Eogcn Ordinances. Buildinfl Offitiol No. cIrr oF EAcAN 31F95 Piloc Knob Reed Ee9ew, MlenesoM 55122 Phone: 454-8100 I - PERMIT INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS Date: Recelpt No.: Single Site Address: Residentiol Lot ? Block l Sub/Sec. Multi Res., C Nome . ? Address ? City Phone: Nnme _ ' -' - ? ? Address - City Phone: This Permit is issued on the express condition thct oll work shall be Minnesoto Statutes ond City of Eagan Ordinonces. Y New/Alter./Repoir. - ` Cost of Instollation Permit Fee I SUrChOf9E Totol done in occordance with all opplicable Stote of Building Official ? CITY OF EAGAN 3830 Pilot Knob Road ? Eagan, Minnesota 55122-1897 i (612) 681-4675 TION REC4RD PERMIT TYPE: Permit Number: Date Issued: riU i F 1.1 i n?r, ??+ f i 1 /1i6 SITE ADDRESS: ' ` . " ' + fh 19 "" ",' " 9 ? t ,+1 - ;- fsi ?• k? i???r ? i ? r I E sk?? ?MIT SUBTYPE: N1ii i i I , f•f s 1 3 I I 1;o oF i NI I NF. l9ARK `; : I Idr t tfllt ', F L_ ? APPLICANT: h4?r TYPE OF WORK: ttF l'A1R ( {?(lt) r 114Fi? Permlt No. Permit Holder Date Telephone t ELECTRIC PLUMBING HVAC Inspectfon Date Insp. Commente FOOTINGS FOUND FRAMING ROOFING ROUGH PLUMBING PLBG AIR 7EST ROUGH HEATING GAS SVC TEST INSUL GYPBOARD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL ?,JC q? I ?jry? BSMT R.I. _ BSMT FINAL OECK FTG DECK FINAI ? CITY OF EAGAN 3795 Pilof Knob Road Eagan, MN 55122 Zoning: Owner: Address: Site Address: Plumber: 1 agree to eomply with tha City of Eagan Connection Charge Ordinanc9s. Account Deposit: Permit Fee: Surchorge: By Miu. Charges: Date of Insp.: Total: Insp_: Qate Paid: I CITY QF EAGAN WATER SERVICE PERMIT 3795 ailot Knob Road . PERMIT NO.: Eagan, MN 55122 DATE: Zoning: No. of Units: Owner: Address: Site Address: Plumber: Meter No.: Connedion Charge: 5ize: Account Deposit: Reader No.: Pescni# Fee: 1 ogree to eomply with the Gity of Eagan Surcharge: Ordinances. Misc. Chorges: Total: ' BY ' Date Poid: CITY OF EAGAN SEWER SERYICE PERMIT 37!'3 Pilot Knob Road PERMIT NO.: Eagan, MN 55122 DATE: ZaOr?9: No. of Units: Owner: Address: Site Address: Plumber: 1 agree to comply wifh the Cifr of Eogon Connection Charge: Ordinanees. Account Deposit: Permit Fee: Surchorge: BY Misc. Charges: Date af fnsp.: Totol: Insp.: Date Paid: SEVIfER SERYICE PERMIT PERMIT NO.: DATE: - No. of Units: cin oF LAGAN 3745 pilotr Aeob Road WATER SERVIC PERMIT NO.: E PERMIT Eagan, MN 55122 DATE: Zonin9: No. of Units: Owner, Address: Site Address; Plumber: Meter No.: Connedion Charge: Size: Account Deposit: Reader No,; Permit Fee: 1 agree M eanply wit6 the City of Ea9on Surcharge: Ordinonees. Misc. Charges: Totul: BY Dute Paid: Date of Insp.: Insp.: IO SEWFR SERVICE PERMIT GITY ( EaGaN 3795 Pilot ICno6 Road PERMIT NO.: Eagan, MN 33122 ' DATE: Zoning: _ No. of Units: Qwner: Address: Site Address: Plumber: 1 egree to compFr with the City of Eagan Connection Charge: - Ordinanees, Account Deposit: PermiY Fee: ' Surcharge: BY Misc. Chorges: Date of Insp.: Total: insp.; Dote Paid: WATER SERVICE PERMIT crnr 05 EAGAN 3745 YitoF Knob Raad PERMIT NO.: Ecyon, MN 55122 DATE: Zoning: _ No. of Units: _ Owner, C, Address: Site Address: "•'' Plumber: Meter No.' Connection Charge: Size: Account Deposit: Reader !Va.: Permit Fes: 1 agree ro eomply wilh !he City of Eagon Surcharge: Ordinanees. Misc. Charges: Totol: BY Date Paid: Dote of In CITY OF EAGAN 3795 Pilot Knob Rood Eagon, MN 55122 Zoning: Owner: Address: Site Address: Plumber: ,30Ii SEWER SERVICE PERMIT PERMIT NO.: DATE: No. of Units: C1 10U.00 r.c I egree fo tomply wifh fhe Cify of Eagan Connection Charge: Ordinaaees. Atcount Deposit: Permit Fee: Surcharge: By Misc. Charges: Dote of Insp.: Total: - Insp.: Date Paid: CITY fyf EAGAN 3795 Pilot Keob Rood Eogon, MN 55122 Zoning: Owner. - Address: Site Address: PI ur'nber: Meter No.: Size: Reader No.: 1 agree to comply with ihe CiFy of Eogon Ordinanees. By Date of Insp.: WATER SERVICE PERlIA1T ? PERMfT NO.: DATE: No. of Units: Connection Charge: Account Deposit: Permit Fee: Surchorge: Misc. Charges: ToYal: . Dote Poid: . I nsp.. ' CITY OF EAGAN 3795 WIM Knob Road Eagan, MN 55122 PHONE: 454-8100 BUILDING PERMIT APPLICATION Receipt # Sire Address 4eo4 nortien rti, Lor 1 Block 7 5ec/Sub. Ridgeeliffe 3 Parcel # unrecorded w Nome _ nrrin ThoY con Hnmas ; Address 1712 Hopkins Crsrd. 0 o Name _ ??rAddress f r:... Name _ Addrew 1 hereby acknowledge thot I have read this opplicotion and state that the information is correct und agree to tomply with all opplicable State of Minnesota Statutes and City of Eagon Ordinances. N°_ 6066 '-Pa37C) Erect A$ Occupancy R3 Alter ? Zoning PD Repair ? Fire Zone 3 Enlarge ? Type of Const. _ V Move ? # Stories Demolish ? front 24 ft. Grade ? Depth 24 ft. Aoorovals Feea Woter 8 Sew. Police - Fire Eng. Planner - Council - Bldg. Off. _ APC Permit 11U. ]U Surcharge 19 .00 Plan check 55.25 SAC 525.00 Water Conn. 305 _ 00 0 Water Meter 60.0 Rood Unit l RS _ (10 Total l . 959 . 75 Signoture of Permittee I A Building Permit is issued to: (lrri n ThojmSOn HOIn2S on the express mndition that oll work shall be done in actorylpnce v/ith all ypplicat2le Stare of Minnewta Statutes and City of Eagan Ordinonces. Building Of{icial CIT'Y OP FACAN Include 2 sets of plans, 1 site plan w/elevations 6 r? BUILDIW, PERNrIT APPL7CATIdN 1 set of energy calculations. 3FS, a-U-O 7b IIe Used For ??p?Nfe Valuation?3}t-g@ro0 Date ?"uLy 3l?980 ?- Site Aaaress: y 6 e y RogIEN Pr, o?ICE oSE oNLY Lot 1 Block ? Sec./Sub• R14GF?1F? Erect ? Occupancy Parcel #: THtRD Alter Zoning ? Repair Fire Zore ? O.mer: EnlarSe _`IYPe of Const. Nbve # Stories ?y AdClZ25S: a Division o/ U. S. Home C r • Derrolish Front ft. ft. KI?dS CFOSSROAD GrdaE D2Pt?1 0? 5? C1tY/ZlP CAde: •M WNETONKA A'rJN 5.3? g ax a a- Phone #: .54y- l33 3 APPROVALS FEES contractor: gRRIN TH9MPS9?d-H8 "-S PddreSS: a Division of U. S. Home Corporation 1712 . .vr i.o i,nO rtv Cli'y/Zip COC7E: MINNETONKA, MINN. 55343 Phcne # : Arch./Eng.: Pddress: City/Zip Cade: Phone #: Assessrents Pesmit J/0 ? Water/Sewer Surcharge / q ? Police Plan Check ,Sz;- aa-- Fire SAC 5;?jy ?- gnq, Water Conn. 3 o;s` = Plannes Water Meter ? Council RDad Bldg. Off. P.PC TO'i'AL CITY OF EAGAN ' 3795 Pilot Kna6 Rmd Eagan, MN 33722 PHONE: 454-8100 BUILDING PERMIT APPLICATION Site Address knao nortien rti, Lot4_ Black 7 Sec/Sub. Ridgeeliffe 3 Par"l # unreeorded w Nome nrrin Thnrrmenn Hnmaa ; Address 1712 Honkins Crsrd, ° ,.;,,,Minnetonka, Mno,,,_„ 544-7333 o Nome _ 0?5 Address Name _ Addres5 1 hereby acknowledge that I have reod this applicotion ond stote that the informotion is cOrrect ond agree to wmply with oll applica6le State of Minnesota Statutes and City of Eagan Ordinances. 000 N4 6069 Receipt # Erect [RX Occupancy R3 Alter ? Zoning PD Repalr ? Pire Zone 3 Enlarge ? Type of Conrt. V Move ? # Stories Demolish ? Frant 24 ft. Gmde ? Depth 24 ft. Approvals Fees Woter & Sew. Police - Fire Eng. Pianner - Coundl - Bldg. Off. - APC Permit 11V.JU Surcharge 19.00 Plon check 55.25 5AC 525.00 Water Conn. 0 .00 Woter Meter 60.00 aoad unir 185.00 Totol 1,259.75 Signoture of Permittee I A Building Permit is issued to: f)rri n Thn=GOn HoIDeS on the express condition that oll work shall be done in accor e'th oll qpplica e State of Minnesota Statutes and Ciry of Eagan Ordinances. Building Official ? v/?-???'-J / ° CI'I'Y OF FlG1N Include 2 sets of p ?p ?,?`( 15 ?? - AUII1?:??H; PL?2MIT AF'PLICATION 1 site plan w/elevat3ons 1 set of energy calculation5. o-o--o 3 7b Be Uscd For Valuation ? ?- Date 3"uLy 3l ?]980 Site Address: I6 9 a Hoftff;:p P7-• OFFICE USE ONLY Lot _4 BlocJc Sec./Sub. P\4_GEg!-IEEU Erect (X Occupancy d? ? Parcel THI RD Alter Zoning Repair Fire Zone 3 Enlar9e TyPe of Const. f/ Owner: _ Nbve # Stories Address: a Division of U. S. Home C r • i DeJrolish Front Cl,ty/ZlP COde: ' [ FTUI'Klf"S •IAINtJETONKA z A'(NN 5 Grade Deptl'1 e?y ft. 3 53 . Phone E44- 1333 APPFCVALS F'FES /S Contractor: ORRIN THB?+ 4PS9N H9 h Assessrents f, Permit . P[3di255 i S- ? " a Division of U. S. Home Corporation w ter/sewer Surcharge p1 'k C? /q S?y ? .vr w ?,n ?nU POZICE d71 1? S City/Zip Cocle: NINNETONKA, 611NN. 55343 Fire - SAC 5a? ? Phone #: ?J• Water Conn. 3a5 ?- - Planner Water.Meter o (o Arch./Ehg.: Council Road Unit /gs °T Bldg. Off. Pddress: APC City/Zip Code: Phone #: 'ICYI'AL CITY OF EAGAN * 3795 Pilet Knob Road Ea9an, MN 35122 N2 6067 PHeNE: 454-8100 BUILDING PERMIT APPLICAT? Receivr Te be uted for 1 of Q pleX Est. Value 38,000 Date 8-8 , i9_$4__ Site Address 4hg3 St aVE'T'n P Erect )Q Occupancy R3-- Lot 2 Block 7 Sec/Sub. R1dgeCliff2 3 Alter ? Zoning pn Parcel # unTecorded Repair ? Fire Zone 3 E l t T 4 C V n arge p ons . ype o w Name 4rrin T homnsan Homes Move ? # Stories - 3 Address 1712 Ho pkins CT'ST'd. Demoiish ? Front 24 ff. ° CI Phone 544-7323 Grade ? Depth 24 ' ft, x Approvals Feea Zp V u< f Nome _ Address Name _ Address same I hereby acknowledge that I hove reod this application and state that the information is correct and a9ree to,mmply with oll applicoble State of Minnesota Statutes and City of Eagan Ordinontes. Assessm6Np 6-?'-bU Permit 11U.9U Water & Sew. $urcMrge 19.00 Police Plan check55.25 Fire SAC 525.00 Eng. Water Conn. 301, 0? Plonner 0 Woter Meter 60.0 Council Road Unit 185.00 Bldg Off . . APC Total 1,259.75 $ignature of PertniMee I A Building Permit Is issued to: nTrin ThnIICjJSnII Hnmea on the express condition thof all work shall ba done in occor4qAte with oll opplicable StaM of Minnesota Statutes ond City of Eagan Ordirwnces. Building Officiol ' CITY OF FAG7+N include 2 sets of plans, ? 1 site plan w/elevations & BU?LD?N(; PE12t4IT APPLTCATION 1 set of energy calcvlations. 'Ib Be Used For RES,psNcP Valuation'?31, ?pp,op Date S'uLY al?]984 site Aaaress: y 683 sT'qv C-Rrt 'QT> Lot 2-_ elocx -7 sec./sub- R?QGF9llFF6 Paroel #' THt RD Oaner: Pddi255: a Division o1 U. 5. Home C ? v 1112 KIfJS CROSSROAD C1ty/ZlP Cod2: -MINNE70NKA. li I"JN 5?q? Phone #: . 544- 1333 OFFICE USE ONLY Erect Occupancy plter Zoning ? Repair Fire Zone 3 Enlan3e _ Type of Const. V hbve # Stories Deirolish Front 2.ft. Grade Depth a ft. . qo-. ?GXZi APPROVALS F'EES _ Contractor: 9RRIN TH9MPS9N ??61uAIrc - Assessrents -c? P13dr255: a Division of U, S. Home Corporation water/sewer Police Cliy/Zip ('_Ode: MINNE70NY.A, MiNN. 55343 Fin2 Phone #: AYCh./L-ng.: Pddress: City/Zip Code: Phone #: EYxJ - P1annPs Council Bldg. O APC PP17nit Surcharge Plan Checlc SAC WatPS Conn. 3 0 3S Water Metes/ Road Qnit-'? ? 'InTAL ciTr oF EaGAN 379$ Pilm Knob Road Ea9an, Mw SSSR2 PHONE: 454-8100 BUILDING PERMIT APPLICATION N? 6068 Receipt .fk To be ua¢d fer ZOf /+ A12X Esf. Volue 38,000 Date 8-8 , 19_80__ Site Address 46$7 StaveTri Pt. Erect jj Occuponcy Lot_3 Block 7 Sec/Sub. RidgeCliffe 3 Alter ? Zoning PD Parcel # unrecorded Repair ? Fire Zane 3 E l V T f C t n orge ? ype o ons . z Name flrrin Thnmpgnn Hnmac Move ? # Stories 3 Address 1712 Honkins r.I'STCl. Demolish ? Front 24 ft. ° ci Minnetonak, MPhona 544-7333 Gmde ? Deo+h 24 rt. ? Apvrovals Fees p Name _ 0? Address Name _ Address 1 hereby acknowledge thot I hove read this opplication ond stute that the intormotian is correct and agree to compiy with oll applicable State of Minnesoto Statutes and City of Eugan Ordinonces. Water & Sew. Police - Fire Eng. Planner - Council _ Bldg. Off. _ APC Permit 11U.7U Surcharge 19.00 Plan check 55.25 5AC 525.00 Water Conn. 305 .00 Water Meter 60.00 Road Unit 185,00 Toral 1 259.75 Signature of Pertnittre I A Bullding Permit is issued to: OTTiri ThOIDjJ80ri Homes on the express condition ihot oli work shall be done in ccmrdarAe with oll up9ljca6lQ Stote of Mlnnesow Statutes and City of Eagan Ordirwnces. Building Offfcicl ' CTTY UF F1+c',HA1 Include 2 sets of plarLS. 1 site plan w/e]evations &. G ?k ?, L?? P BUIIaINC. PLTtI?iIT APPL?CATION 1 set of energy calcvlations. j ?r 'Ib Used FOi P -LSjp-P-NC f, ValuationDate 3"u?y 31}1980 site paaress: %07 grAvcal) Pr• Lot 3 sloc)c Z sec./sub. gVpy Parcel TH1RD Qaner: AC3dreSS: a Division of U, S. Home C r ? v G KI?S CROSSROAD Clty/ZlP CDae: •MINNETONKA. li IUN Ft?4,2 Phone #: . 54`{-1333 OFFICE USE ONLY Erect Occupancy i 1'q3 _ ? Alter Zon ng Repair Fire Zone 3 Enlarge _ 'Iype of Const. Nbve # Stories De?rolish Front _ft. Grade Depth o2y ft. Contractor: G_RRIN T-'HDMP-S9Pl-I-!9?^ES?- Addre55: a Division of U. S. Home Corporation 1712 .,vr u?J ?n JitV City/Zip Code: NINNETONKA, hnINN. 55343 Phane #- Arch./En4.: Arldress: City/Zip Cade: Assessrents 1,7ater/SeN,7er Police O Pezirtit Surcharge Plan Check sr,c s.2 s ? Wates Conn. 0 5--.2- Water Meter Road Unit t g, Or- a" Fire EnJ • Planner Council Sldg. Off. APC Phone #: qVFAL Thisrevoid 4 '% /?° 7 `5 ?5-10 ja°G, 18 mon . rom ? Date of his Request I O Fire No. + 4031 I, aLicensed Electrical Contractor OOwner, do hereby request inspection of the above electri - cal ?ung instaUed at: ?t Address or Route No. ?`??? J11??ititl 1 ? C,i,t?y? ction Township Range County Which is occupied by Is a roughin inspection required on this job? No ? Yes4!!L- Ready Now ? Will Ca1C<_ Power Supplier ? Address `IwY `vv6TCPJ Blectrical Contractor ?L467M 1G Contractor's License Nd 1-+t,505 I ? (COmaan ? ? ?? Mailing Address C- I? e trica ontractor or Owner Making Thls Installation) Authorized Signature Phone No. 3 (Electrical Contrac[or or O el Makin9 Thls Installatlon) ?? /;,?[}{j?? (7 ?Q?? (? ?? ???,?}/j This inspection requert will not 6e accepted hy the f'?',] ?' ?? State Board unless proper inspeetion fee is enclosed. V L1p4y1411Y Griggs Midway Bldg. - qoom N191 1821 University Ave., St. Paul. Minn. 55104 - PFwne 297•2171 ? --f*BUEST FOR ELECTRICAL INSPECTION CHEA'KZELOW WORK COVERED BY THIS REQUEST EB-00001-02 4031 Type of Building Ne , Add. Kep. Check Appliances Wired For Check Fquipment W'val For Home ? ? Rangc Temporery Wixing ? plex ? ? ? Water Heater ? Lighting Fixtures . Bldg. ? ? ? Dryei Electric Heating ? mmercial Bidg. ? ? ? Fumace Silo Unloadet ? Industrial 81dg. ? ? ? Au Condi ' Bulk Milk Tank ? Fazm ? ? ? List ) List ) O[h ? ? ? 2ehets} O[ h ers} ex 1 ? ? 1 COMPUTE INSPECTION FEE BELOW Seivice Enteance Size: # Fee Fcede[s&Subfeedets: # Fee Circuib: 10 , Fce 0 ta ] 00 Am s. 0 m 30 Am eres 0 to 30 Am eres 101 to 200 Amps. 31 [0 100 Amperes 31 [o 100 Am ems Above 200 Amps. Above I00 Amps. Above 100 Am s. Trxnsformers RemoteConttolCirc. PartialotothetCee Signs 1 1 Special lns ection Minimum fe Remazks TOTALF 6,*„JC q? 1, the Electrical Inspector, hereby certify that the ?- 3^S'6 (Final) This request void 18 months from minnesoia aia[e ooaro or necUnciry Griggs Midway Bldg. - Room N791 1621?iversiry Ave., St. Paul, Minn. 55104 - Ptwne 297-2111 1 ? --,.BEQUEST FOR ELECTRICAL INSPECTION °- CHECK BELOW WOKK COVERED BY THIS REQUEST T EB-00001-02 4032 Type of Building New Add. Rep. Check Appliances W'ved Foc Check Equipment W'ved Foc Home ? ? Range Temporary Wiring ??. Duplex ? ? Wxtec Heater Ligh[ing ?ixtures ? t. Bldg. ? ? ? Dryer Electric Heating ? mme,ccuil Bldg. ? ? ? Fumace ? Silo Unloader ? dustrial Bldg. ? ? ? Av Conditioner ? Bulk Milk Tank ? Fazm Lis[ List Othec ? ? ? ptheis Heie ? Othexs Here COMPUTEINSPECTION FEE BELOW ServiceEnuanceSize: # Feik Fceders&Sub(4 • F' :C'vcuits: # F 0 to 100 Am s. 0 to 30 Am e?es V 30 Am etes 101 to 200 Amps. 31 l0 100 Am eres to 100 Am ies O Above 200 Amps. Above 100 Amps. Above 100_Amps. Transformers RemoteConvolCiic. Partialorotherfee Signs Special lns eclion Minimum fee Remaiks TOTAL F EPj I, the Electrical Inspector, hereby certify that has been (Final) This request void 18 months from ' °O T'his reques?void 7, 12,; S l ? Ap 1B mrtn!hs from . Date of this Request Fire No. 1- 4032 I, Licensed Electrical Contractor 0 Owner, do hereby request inspection of the above electri- cal ui g installed at: Street Address or Route No. _AlD 07 .7r4N UCP" TtV ,' J C'itt`y. ??P ?ion Township Range County v?ow Which is occupied by ? Is a roughin inspection required on this job? No ? YJX.,_ Ready Now ? Will COW, Power Supplier F???r Address MR-Y067&° Electrical Contractor fEL(-- v'"`"melL- Contractor's License NoMz (COmpany Name) Mailing Address ? LzFF kb. (Elgc I al htrac?tot or? Ownar Making This Inztallatlon) O!?? Authorized Signature -Y? 2+ Phone No. (EleCtrical Conbactor or Owner IG7akinq 7hlz InstallaHOn) `?? i? u? nw?? ? ?/ Q.(???J This inspection request will not be aceepted by the ?5??E? ?? ir ?i State Board unless proper inspection fee is enciosed. ?oia s t o ] 8, from ? Date of his Request Fire No. ? 4 019 d, aLicensed Elecirical Contractor ? Ownet, do hereby request inspection o( the above electri- cal ?J?iiin installed at: Street Address or Route No. q(ODT t dU''^??" I 1' c?Dyp?f? ?on Township Range County li-? 1Vhich is occupied by_ Is a roughin inspection required on this job? No ? YeV&_ Ready Now ? Will CallDIC Power Supplier _ KAF Address ' W??JA&-j-DAI Electrical Contractor Contractor's License Nd.L3K25 g (GOmpany CName) r Mailin Address LEI c rica Contra tor or Owner Making This InstallaHOn) ?+^ Authorized Signature Phone No. (ElectNcal Contractor or Owner Makin9 Thls InstallatloN RAVE ?p, ???? ????(j , This inspection request will not ba accepted hy the ?j ?'f State Board uniess proper inspectian fee is enclosed. Griggs Midway Bldg..- Room N191Y /7 Q EB-00001-02 Jniversity Ave., St. Paul, Allinn. 55104 - Phone 297-2711 5 I CHECK BELOW WORKOCO EREDTBY' THIS EQUEST'ON ? a T 4 019 , Type of Building Ne - Add, Rep. qieck Appliances W'ved Fot . Check Equipment Wi[ed Foi. Home ? ? Range ? Tempo[ary Wving ? Duplex ? ? ? Water Heatei ? Lighting Fixtures GQ Apt. dldg. ? ? ? Dryer r%Q?T Electxic Heating ? dbpmercial Bldg. 0 ? ? Fumace Silo Unloader ? IIIIIIIIustrial Bldg. ? ? ? Au Conditionet ? Bulk Milk Tank ? aM El El D List L ist Othei ? ? ? p Here151 p Hehers? COMPUTE INSPECTION FEE BELOW Service Entxance Size: Fee Feeders&Subfeedecs: # Fee Circuits: # Fce 0 tu 100 Am s. 0 to 30 Am eres 0 to 30 Am eres 101 to 200 Amps. 31 to ] 00 Amperes 31 to 100 Am res .fN Above 200 Amps. Above 100 Amps. Above 100 Amps. Transformers Remo[eControiCiTC Pa[tialorotherfee Signs Special lns ction Minimum fee $5 Remazks I, the Ele . Dal /I04??ta TOTAL FE jr recertifythat th ve in conihas been made ?i?/?iL,, •----?-- ••-,- (Final) 7'his iequest void 18 months from This req g - mor.dhsuest 1 ..rom - Date ? this Request 11 Fire No. T 4021 I, Licensed Electrical Contractor ? Owner, do hereby request inspection of the above electri - cat win g installed at: Ot Address or Route No. 4y8 City Ww°f bl- Section Township Range County ? 1?-? / Which is occupied by suj ?rvame or vc panc) Is a roughin inspection required on this job? No ? Y Ready Now ? Will Power Supplier Address I la(?{1?6! u'? Electrical Contractor Contractor's License NA?s? MailingAddress 1ql1 E. Authorized (eleCtrlcal Contractor or owna Gl i7 f LI E BOW'TSRD COf7 W RD, >r or owner Making Tblz Instaliatlon) X(A/1 a; Phone No. Makinq rhls Installatlon) This inspection request will not 6e accepted 6y the State Board unless proper insPeetian fee is enclosed. mmneso[a stace noara ot Hectncity Griggs Midway Bldg. - Noom N191 F J? EB-00001-02 7821 U liversiry Ave., St. Paul, Minn. 55104 - Phone 297-2111 NEUEST FOR ELECTRICAL INSPECTION T 4 0?? CHEOK BELOW WORK COVERED BY THIS REQUEST Type of Building Ne Add. Rep. Check Appliances WireQ For Check Equipment Wired Fm Home ? ? Range Tempoiaxy Witing plex ? ? Water Heater - Lighting Fixtures ? t. Bldg. ? ? ? Dryei ? F,lec[ric Heating ? Commercial Btdg. ? ? ? Fumace Silo UNoader ? Industrial Bldg. ? ? 0 ? Au Conditioner Buik Milk Tank El Parm st List Othe ? ? ? ? ? ? thers ?r ere ? ers COMPUTE INSPECTION FEF, BELOW 2i 1111 ! 11 to, Remarks I, the Electrical Inspector, hereby certify that 31to1 Above JO (Final) This request void 18 months from r? 2005 RESIDENTIAL MECHANICAL PERMIT APPLICATION City Of Eagan ?V 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 Piease comple[e for. single family dwellings & townhomes/condos when pennits are required for each unit Date U? l?I dl / ?S Site Address VkVI Pol n?- Unit # Property Owner Telephone # ( jp,j ) ) L4 ? ?o - 9a.sa Contractor BURNSVILLE H 459 W, Bumsville Paricway Street Address SUIYB 120 Cit3' State umsville, MN 55337. Zip Telephone #(Q,jA ) gqL4" OWS Bond q: Expires: The Applicant is _ Owner ? Contracror _ Other Add-on or aiteration to existing dwelling unit $ 30.00 V f l t Additi l ? R urnace ep acemen ona _ ' air exchanger 7 i di i / R l t N a rcon t oner acemen ew ep _ ` other State Surcharge $ .50 Total g , 30 . SO I hereby apply for a Residentiat 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 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. &*M NiQ-1_er56n Applicant's Printed Name ' ApplicanYs Signature ., w 3 2005 ? _ . . - -- -J 2005 COMMERCIAL MECHANICAL PERMIT APPLICATION City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 Please wmplete foc commercial/industrial buildings . multi-family buildings when separate permits are not required for each dwelling unit Date Site S[reet Address Unit # Tenanf Name (ifapplicable) Previous Tenant Name Property Owner Telephone #i ( ) Contractor Street Address City State Zip Telephone # ( ) Bond #: Expires: The Applicant is _ Owner _ Contractor _ Other Work Type New Construction _ Underground Tank _ Install _Remove `*see 6elow fnterior Improvement _ Install Piping _ Processed _Gas Nature of Work: **When installing/removing underground tank, ca/l for inspeciion by Fire Marshal and Plumbing lnspector P¢t'Ini4 Fe¢S: 570.50 Underground tank installation/romoval 550.50 Minimum (includes State Surcharge) or Contract Value $ x 1% _ $ Permit Fee • If ep rmit fee is $1,000 or less, add $.50 => $ State Surcharge If ep rmit fee is over $1,000, add $.50 for every $1,000 ea rmit fee $ Total Fee I hereby apply for a Commercial Mechanical Permit and acknowledge that the information is complete and acwrate; that the work will be' in conformance with the ordinances and codes of the City of Eagan and with the Mechanical Codes; that [ 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. ApplicanYs Printed Name ApplicanYs Signature Approved By: Inspector Date: CITY OF EAGAN 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 4687 S7AVERN PT (LOT 3) 4684 HORTEN PT (LOT 1) PERMIT TYPE: Permit Number: Date Issued: BUILDING 028757 09/11/96 SITE ADDRESS: 4683 STAVERN PT LOT: 2 BLOCK: 7 RIDGECLIFFE 3RD P.I.N.: 10-63982-020-07 DESCRIPTION: (ROOFING) 9uildin?,gPermSt Type i?BuiTding"'lJork Type ! -Census Gvde ^-- ? ...,s T _ t! . 4 ? r w? 1 MULTI. (MISC.) REPAIR 434 ALT. RESIDENTIAL 'f'i REMARKS: INCLUDES FEE SUMMARY: Base Fee Surcharge Total Fee PERMIT VALUATIpN $74.75 $1.50 $76.25 4688 HORTEN PT (lOT 4) $3,000 CONTRACTOR: - Applicant - sT. LIC.OWNER: 6& G ROOFIN6 16452531 0009369 RIpGECLIFFE ASSOCIATSON ' 11677 HALL AVE 1745 KARIS WAY NOR7HFIELD MN 55057 EAGAN MN (507) 645-2531 ? Ihereby acMnowledge thatI h,&be read thisa'pplication and state tPiat the inParmatbork is aarreet and agree to eamply wtith a1.1 app,l3-0abSe: Stat»of.Mn. Statutes and City,of Eagan Ordinances. ? A APPLICANT/PERMITEE SIGNATURE ISSU V: SIGNATURE ? CITY OF EAGAN ? 3830 PILOT KNOB RD - 55122 •-a' ? 16, 996 BUILDING PERMIT APPLICATION (RESIDENTIAL) 681-4675 oair Renuirements New Conatrudlon ...44j.,'1?,?"?,6{7L?:., ? 3 registered aite surveys :. .- ° ?• ` : • ' _ `. ? • ., -? ,:. ? 2 copies of plan , ?.?::..?,.. ? . .. ;, . ? 2 eopies of plana (indude beam d window sizes; poured tnd. design etc.) ? 2 site surveys (extenor addRiona 8 deeks) . ? 1 energy cakulatlons . ? 1 energy caleuladons for heated addilions • ? 3 eopiea o/ tree prexrvetion plan H lat plaHed eRer 711193 • roquired: Yes No DATE: AU a ?. el ?? Ca CONSTRUCTION COST: DESCRIPTION OF WORK: STREET ADDRESS: `A ? LOT BLOCK ? d- L-I SUBD./P.I.D. #: -? T`- l.. ( ,d-., . L3 . _ . -....__._._. ?,:.-tc ':3;:.i•.:y'.. _,,, ti ? . .- .;?i? ...... .._..,.. { Strrs?'.°?e .. ?.«..::_......,_.. `C ?a 1(4??<'i ..,. •......?...:..f..,... ?. •?+'? ? _..3?."'', ii?Fr'? ?-n?...., \k' ?? ?.°:}?? )' . PROPERTY - T Name. '_? __.Phone # . ,LO,i c1 FI.., . - .,.... _ . ? '- . .. OWNER........ ; ._...?? . __._. - • • - Streef Address" _.." - - . _.,.,..___. . _.... ?' ? .. city' State. Zip' ?.. , . coN7w?c7oR' Company: Phone ??'v? G 4S? ??l , ..,-S}fPA} AfIfIfPSS .,*.?? C _;. License.#: ? _... .?? .__ -Cify;? .?state. ---2ip ?.?x_- - _«.+-. .....:.-..c:-c-•-a-'"';?.'T-a`u:,_.._ .•:???tr??.. -. ; ` . .._ ,i'. ARCHITECTI ? Company: ENGINEER Name: Registr t n #' - ?v Street Address. . . . .. ...____ _.?'_'. ,r'•r:?:t:?ts??'." City: State: -- - Zip" ,', q •??>r.;r? Y' . . .....?.......? ....r r?4?1.?):?I, t...n.r? e . , ? ?A! ' /J Sewer & water licensed plumber: . Penalry appiies when aildress change,and lot change are requested once permit is issued. . . ; . . - . .. . . . . ? _. . `:. .?i?'u u?4 ;. . I hereby acknowtedge that I have read this appUcation and state that the i rmation is.correct and;agree to-:complyw? ? applicable State of Minnesota Statutes and City of Eagan Ordinances. ?? __?.,. _??•? Signature of Applicant: . . . 1 -. . ' . . . - ' - . . . . . . . . :'t?_':z { . _ OFFICE USE ONLY, Certifiptes of Survey Received _ Yes _ No Tree Preservation Plan Received Yes No OFFICE USE ONLY BUILDING PERMIT TYPE?.--= 1. .. - ? _ -- -• --- _ ?._.: ., ( . ; ' . _ _ . 16;:?Basement F?rnsh?:? ? rt:o ,?o ?411 r Apt;/Lodging 0 01 ,o •?Of Duplex ?x ?x Joundation ?, x ,?,, , 0 02 8F Dwelling o';07"4-pfex ?'?`^> • 0 ? ?f' ;$ 12 Multi?Repai?/Rem. ? o `17 Swim ? 03 SF Addition ? 08 .8-plex ,. ?. ' 0 13 Gatage/Accessory ? 20° Public Facility ? 04 SF Porch o 09 12-plex ?? 14 Fireplace ? 21 Miscellaneous .' 10 = plex ? 0 05 SF Misc. ? 15 Deck .. ? . ... •?•.? •:- • . ,. 1 ,.? ?y <.? . _ .. . ,,' _. _...?__._ .._.??.__?..__-...?:..._.. _....._'?r;•,.. ,_?;?. ' , - ., \ ? . ^ ; ? •t, ?ii':':....,,.. , i- ' i " ",-_ -.._.,_. __._....__'",.?_ ' _... ......._ __._._ ._.._. ._... ?" ,.? --4... ,? .... „ < "J 1!...... 'i.. _. _ . 0 31 New o 33 Aiterations ? 36 'Move 0 32 Addition __ o- 34.__Repair. _ ...., .__ ... ._ a ..37_.._Demolition._..__ ._. ., . .___. _..__. _ . .. - . GENERAL INFORMATION_. ?_...._.,?__.___. ??,. _. ._?. .„ .:, w . •, ?.?: ?.. , , ... Const. (Actuaq Basement sq: ft. ?-? "? M? W MC/VVS Syste"m (Ailowable) Main level sq: ft. -? City Water ? UBC Occupancy ,r S?r 0t`•q s ft,.. .,? q•.. ?.. . . : - Fire Sprinklered .,,40 .,,,,?; . ._. ."_. ?? Zoning ?- sq. ft. l, ?.t.,z?.. PRV # of Stories___. -. Boostec. Pump Length sq. ft. ? Census Code. , Depth Footprint sq ft:) y SAC Code,. ? Census Bidg 1` :., - t? _?., ?,.???s . ,.?; : . ? ?! _ _. . :-e t"7 f ??? '? `) d Gensus Unit,'; +. 3? 1.+< ?Ti'k.' ?-1Y3?'f ° T` :? 3C ' ? ? k ? '? ti , ?r ?.-? 1.-+... APPROVALS + •. r ;Y.. n,. l l 7 . y . n . j ty,,H4 ? ` . l' \S " # 8 Piantirri ari (1C@ . , . ,' ? ?^ y• 7 S ? Valuation. Permit Fee : Ptan Review ??bs:?::?? • ? - ? ;, License.-,.....4 MC/WS SAC -A ioiSTt: Water Conn _ Water Meter-,j v Acct. Deposit S/W Permit Sl1(V.Surcha rg.,n r'1.. Treatment Pl. : Road' Unit ,. . . ctiBarlC bECl:: ? Y? 8 hre ?:.•.:' ? ?,L ? a ? • r ? J't? i??.?n??3 ?S?x v; Trails Ded. ? - • • Other ? ? ,. • ----Copies-- -- ' ? `??.':??_ ?. ? .._ , ?: _,± , , •.°?;,;" 'Y4 :..Total: "%+. SAC SAV Unit$ rV:1.C iii? .. .,.._ .. a?:?'q? .....--f? . ? ' . . , ._ . . . " - CITY OF EAGAN 3830 PILOT RNOB ROAD EAGAN, MN 55122 PHONE: (612) 454-8100 PLEASE COMPLETE UPPER PORTION ONLY FOR SINGLE FAMILY DWELLINGS & TOWNHOMES/CONDOS WHEN PERMITS ARE REQIIIRED FOR EACH UNIT. WORK DESCRIPTION NEW CONST _ ADD ON REPAIR SOI.HE I M RYRN - OWNER NAME: ?? ?? ?INT _ ERCM , 55123 SITE ADDRESS: H N 787-7584 ? LOT:-4- BLACK ? SUBD. INSTALLER: ADDRESS: / 90 A ci?: rMA1NNEAPOLIS. Mkf?iE50TA 55208 `"-?,`827-4033 ? 8274311 PHONfi.#: 0 -- _ iDPn O 1ri SIGNATURE OF PERMITTEE COMPLETE THE FOLLOWING: N0. FIXTURES EA. TOTAL ADD-ON MINIMUM 15.00 SHOWER 3.00 WATER CIASET 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 3. W _ FLOOR DRAIN 3.00 Gr.S PIPING CBT. _ (MINIMUM - 1) 3.00 _ ROUGH OPENINGS 1.50 _ OTHER _ WATER SOFTENER 5.00 _ PRIVATE DISP. 15.00 _ U.G. SPRINKLER 3.00 SUBTOTAL $ co ST. SURCHARGE .50 TOTAL: S ?S - '5? FOR CITY USE ONLY PERMIT # RECEIPT # DATE: /0'1 PLEASE COMPLETE THIS PORTION FOR ALL COMMERCIAL/INDUSTRIAL BUILDINGS AND MULTI-FAMILY BUILDINGS WHEN SEPARATE PERMITS ARE NOT REqUIRED FOR EACH DWELLING UNIT. _________________°°----____----°____------______-°___°--° CONTRACT PRICE: OWNER NAME: SITE ADDRESS: LOT: BLOCK _ SUBD. INSTALLER: ADDRESS CITY: ZIP: PHONE #: FOR: CITY OF EAGAN FEES 18 OF CONTRACT FEE. gmemg grTpr'KqpGE - $.SQ FOR EACH $1,000 OF PERMIT FEE. $25.00 MINIMUM FEE. CONTRACT PRICE x 18 $ STATE SURCHARGE $ TOTAL: $ (SIGNATURE) 2004 RESIDENTIAL BUiLDING PERMIT APPLICATION City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 ? Telephone # 651-675-5675 FAX # 651-675-5694 ? New Construction Reouiraments RemodeUReoair Reauirements Office Use Onlv 3 registered site surveys showing sq. k. af lot, sq. ft. of fwuse; and all roofed areas 2 mpies of plan CeAof Survey Recd _ Y_ N (200b maximum lotcoverege allaxed) 1 set of Eneyy Calculafions forheated addiUons Tree Pres Plan Recd _Y _N. 2copies of plan show'mg beam & window sizes; poured found design, etc. 1 sile survey for addi6ons R decks Tree Pres Required _ Y_ N isetofEnergyCalculations Addmon - irrdicatetlonsttesepticsystem OnsiteSepticSystem _Y _N 3 copies of Tree Preservation Plan if lot platted after 711/93 Rim Joist Dehail Options selection sheet. (bldgs wiN 3 or less unAs Date '3 / l C7 / O?4 trucUon Cost ??a , C? C? O.?? Con s Si[e Address ?0 4 ( ? Unit/Ste # L" Description of Work V4O Multi-Family Bldg _ Y_ N Fireplace(s) _ 0 _ 1 ? 2 Property Owner ? (SA- QSSU C.( A'PateAtsne # ( 9`?? Contractor ? ?.... Address Pru +i Q V-Z ?J Cityr?? l?d V\'5 V.? X c State Y?j Zip Telephone # 'rl C5'-l - (09 COMPLETE TNIS AREA ONLY IF CONSTRUCTING A NEW BUILDING - Minnesota Rules 7670 Catesorv 1 Minnesota Rules 7672 Energy Code Category . Residential Ventilation Category t Worksheet ? New Energy Code Worksheet (Jsu6missiontype) Submitted Submitted • Energy Envelope Calalatlons Submitted Have you previously constructed a building in Eagan with a similar plan2 fee applies. Licensed Plumber Mechanical Contractor Sewer/Water Contractor Y_ N If so, 25% plan review Telephone #( Telephone #{-)----- - G y Telephone #(?I J? 6 I hereby apply for a Residential Building Permit and aclnowledge that the infornia on is complete and curate; that the work will be in conformance with the ardinances and codes of the City =-Bag?he-Stat of MN Statutes; I understand this is not a permit, but only an application for a pernut, 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 ofplans. ?, (? ??? Applicant Printed Name Appli Ys Signature OFFICE USE ONLY Sub Types ? 01 Foundation ? 07 05-plex ? 13 18-plex ? 20 Pool ? 30 Accessory Bldg ? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Multi ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF ? 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (saeenlgazebo) ? 36 Multi Misc. ? OS 03-plex ? 11 10.plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-plex PIb9_Y or _ N ? 25 Miscellaneous Work Types ? 31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding ? 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair ? 33 Alteration ? 37 Demolish Building* ? 43 Reroaf ? 46 Windows/Doors ? 34 RepleCement 'Demolition (Entire Bldg) - Give PCA handout to applicant Valuation Occupancy MCES System Census Code Zoning City Water SAC Units Stories Booster Pump # of Units Sq. Ft. PRV # of Bldgs Length Fire Sprinklered Type of Const Width REQUIRED INSPECTIONS _ Footings(new bldg) FinaUC.O. _ Footings (deck) FinaYNn C.O. _ Footings (addirion) _ Plumbing Foundation HVAC Drain Tile Other Roof _ Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests Final _ Framing _ Siding _ Stucco Stone _ Brick _ Fireplace _ R.I. _ Air Test Final _ Windows _ Insulation _ _ _ Retaining Wall Approved By: Base Fee Surcharge Plan Review MGES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant License Search Copies Other Total Building Inspector C.R. WINDEN & AS50CIATEB, 1NC. IAND SURVEYORS ToI. 6AI5 • 3646 1381 EUSTIS ST., ST. PAUI, MINN. 55108 FOR: U. S. HOME CORPORATION CERTIFICA'"E OF SURVEY N \ O ? ?o Note: Buildings shown are proposed As of this date Ridgecliffe Third Addition has not been recorded. Scale: 1" = 20' o Denotes Iron A 9 Lots 1 through 4 inclusive, Block 7, Ridgecliffe Third Addition,_Dakota County, Minnesota. WE HEREBY CERTIFY THAT THIS IS A TROE AND CORRECT REPRESENTATION OF A SURVEY OF THE BOUNDARIES OF THE LAND ABOVE DESCRIBED AND OF THE LOCATION OF ALL BUILDINGS, IF ANY, THEREON, AND ALL VISIBLE ENCROACHMENTS, IF ANY, FROM OR ON SAID LAND. Dated this29+hday of JUJV A.D. 1980 ? C. R. WINDEN S ASSOCIATES, INC. BY ??.. ?Cl. Surveyor, Minnesota Registration No.1094? ? ? \ o O0 , \ a? ,, o ro ?uPC? V? ? ?4 ? k RESIDENT OWNER Name: jr /1 4 Phone: Address City Zip: 1 /ag �)'ih' i 1 P Applicant is: Owner Contractor TYPE OF WORK Description of work: flery5 Construction Cost: Multi Family Building: (Yes No CONTRACTOR Name: t.Q,, W CoAte -0 CAW04 v5 License ZO (p"4) 6 Address: ,v aisvS C(ov 1Z '.(-1,52.. Y D't vt City: (1/hC9 14.0■ Sttatte: c �3t 'n1 Zip: Phone: CAL CC t Contact Person: v€-- y`wn COMPLETE In the last 12 months, has No If yes, THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING the City of Eagan issued a permit for a similar plan based on a master plan? date and address of master plan: _Yes 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 they are trade secrets, 4 City of Evan Date: f Site Address: Tenant: pp 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 ant's Printed Name x Appi' ant's ignature For office Use Permit Date Received: Staff: 2009 RESIDENTIAL BUILDING PERMIT APPLICATION Use BLUE or BLACK Ink Suite Permit Fec. 8 00 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.gopherstateonecall.or_q 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 hout 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 p ns. A li Page 1 of 3 City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 4684 Horten Pt Lot: 1 Block: 07 Addition: Ridgecliffe 3rd PID:10- 63982 - 010 -07 Use: Description: Sub Type: e- Fireplace Work Type: Gas Insert Description: Census Code: 434 - Zoning: Square Feet: 0 Comments: Fee Summary: Valuation: 3,000.00 Contractor: Fireside Hearth & Home 20802 Kensington Blvd Lakeville MN 55044 (952) 985 -6675 Permit closed without required inspection(s). Letter sent to applicant on 4/17/09. (pf) Chimney /flue must be inspected prior to concealing. Smoke detectors are required in all sleeping rooms prior to final inspection. When wall studs or ceiling joists are exposed, hard -wired detectors are required. Battery operated types are BL - Base Fee $3K Surcharge - Based on Valuation $3K Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply of Minnesota Statutes and City of Eagan Ordinances. h all applicable State Applicant/Permitee: Signature PERMIT City of Eaan - Applicant - Construction Type: Occupancy: $88.50 0801.4085 $1.50 9001.2195 $90.00 Owner: Kristen A Weingartz 4684 Horten Pt Eagan MN 55122 Permit Type: Permit Number: Date Issued: Permit Category: Issued By: Signature Building EA086528 10/01/2008 ePermit Use BLUE or BLACK Ink i r----------------- I For Office Use J 1 Permit City of Eq,~ rr11, 01 Permit Fee: ICJ 3830 Pilot Knob Road I I Eagan MN 55122 Date Received: Phone: (651) 675-5675 I'L Fax: (651) 675-5694 1 Staff: I 2013 RESIDENTIAL BUILDING PERMIT APPLICATION 16, Date: f Site Address-4/4631- 6f 'osr 70Y vi.64 i0-17i4 Unit Name: fE" Phone: Resident/ i Owner Address / City / Zip: Applicant is: Owner Contractor d _ F _ Description of work: 1h, Type of Work Construction Cost: Z)dV Multi-Family Building: (Yes i~ No Company: gdW2_ H4f-A,/47 Contact: Contractor Address: dJ City: 5La E State: A Zip: 1S ?7 J 7 Phone:,` License 3 ~D (coo'"' Lead Certificate If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) 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 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.gopherstateonecall.org 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. App ant's Printed Nam Applicant's gnature Page 1 of 3 Use BLUE or BLACK Ink r________________� I For Office Use � � � � Permit#: / ��'�"` �� Clty of ��a� � / ` -^� i Permit Fee: `"'�/�� O� � 3830 Pilot Knob Road Eagan MN 55122 � Date Received: � Phone: (651)675-5675 I I Fax: (651)675-5694 � Staff: I I I 2015 RESIDENTIAL BUILDING PERMIT APPLICATION �ate: Y ` f�' vl� Site Address:�l S`�,�� D�Ph�� .�-%;��f's 7 �-t��•�Gz /�init#: ,. �` ` � �� n �, n � � � £ l� ✓J�'e��.��e �Z`'r�� Phone: �� .. ' ;� _� Name:_� � Resrdent� � � ,� �wne� � Address/City/Zip: �;, ,� �, � '°: � { �� ; Applicant is: Owner �Contractor � � `� _: ,p ,�1 ��'�� , � � C � �_ �' �° � � Description of work: �' �S ✓�-- �Type of�tVork � }� ��,�,�� Construction Cost 27 �v� Multi-Family Building:(Yes� /No ) � �., �. �� .; �� Company: F�1� ��YI �'l� ��'l j� Contact:�� C��7'U}� �'f ° � �� — / ��"�`��` Address: ' S�U� .�'t�%6 � l+el'-� � _City: �/�'�v�Gl� , � Contractor � � �� " �� State�'l�Z�p:S S 33 � Phone: �� `��' /��mail: �� ` �� ; / ,,,�� „ µ �' �' • � (7� � " '# ,� �'.�,a, License#: �� Lead Certificate#: If the project is exempt from lead certification, please explain why: (see Pa�ge 3 for additional information) 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: �.- � � � e � � �. � �;.. NQTE P/ans and support�ng docume�t�that yousubm�t are cor�scderetl�ta��publ�c�r�f��rmat�a�, Po�fion � �� .� �,... ,� : � �,� ,. , �, ;; .... �*��"��a- �,s� ra�s a � »� ��'rn,ff� c„� . .�#he�nformat�oit rr�ay be classrfed as non public�tf yo ro►�r�e spec��c r�ass�n,��tl� f:tnioultl e ��t�Ci ', o ,u.. ;�� .�� ,�,�, �"�.��..��`,�� `;s conc%ude„#ha#,��l�e'..:arefradeseci%efs� �. �'��=,"��'�' � � �.v.��,- 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.qoaherstateonecall.orc� I hereby acknowledge that this information is complete and accurate;that the work will be in G�nformance 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 ildin ode must be completed within 180 days of permit issuance. � / �.. X � � �� ; %"�i' ,�'/- X � ApplicanYs Printed Nam ApplicanY ' nature Page 1 of 3