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870 Lakewood Hills Rd NCITY OF EAGAN Remarks Addition Lakewood Hi 11 s ? Loc 12 eik 1 Parcel 10 44350 120 00 owner dorc St?eet $70 Lakewood Hills Rd. state Eagan, MN 55123 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 STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. SUILDING PER. #3711 651 7-75 sac 425.00 651 7-14-75 PARK INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number: ?' -' • Eagan, Minnesota 55123 Date Issued: (612) 681-4675 II SITE ADDRESS: APPLICANT: ? PERMIT SUBTYPE: Ip: iI t ?[ , 1 111 , ll tN f111, TYPE OF WORK: iitlt,it IfJ I'I I I NAI kF.f'hift (i0lUf Ihil'yl Permit No. Permh Holder Date Telephone M S/W PLUMBING HVAC ELECTRIC ELECTRIC Inapection Date Inap. Commants Footings I Foundation Framing Roofing Rough Plbg. Rough Htg. Isul. Fireplace Final Hig. Orsat Test Fnel Plbg. Pibg. Inspec[or - No[ify Plumber Const. Meter EngrJPlan Bldg. Final Deck Ftg. Deck Final Well Pr. Disp. /y ?- ? r Site Address Lot _ 1. ? rvame r ?j Address c Ciry PERMIT # _ PLUMBING PERMIT CITY OF EAGAN RECEIPT # _ 3830 PILOT KNOB ROAD, EAGAN, MN 55722 DATE: G PHONE: 454-8100 Phone L Name 3 Address 4 . ? O City Phone ? FEES COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS - COMM RATE APPLIES TOWNHOUSE & CONDO - RES. RATE APPLIES MINIMUM - RESIDENTIAL FEE - $12.00 MINIM'UM - COMMlIND FEE - $20.00 STATE SURCHARGE PER PERMIT - .50 (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND $1,000.00) FOR: CITY OF EAGAN BLDG. TYPE WORK DESCRIPTION Res. New Mult. Add-on Comm. Repair Other RES. PLBG. ONLY - COMPLETE THE FOLLOWING: NO. FIXTURES TOTAL -Water Closet - $3.00 $ _Bath Tubs - $3.00 -Lavatory - $3.00 _Shower - $3.00 _Ki?chen Sink - $3.00 _Urinal/Bidet - $3.00 _Laundry Tray - $3.00 _Floor Drains - $1.50 -Water Heater - $1.50 _Whirlpool - $3.00 _Gas Piping Outlets - $1.50 (MINIMUM - 1 PER PERMIT) _Softener - $5.00 -Well - $10.00 ?1(^Private Disp. - $10.00 _Rough O enings - $1.50 1 FEE: ??•,. . ? `,' STATE S/C: A.1•y" ° - H ` GRAND TOTAL: i `"? BUILDIN6 PERMIT Tw I.e ....J i... CITY OF EAGAN 3795 Pilot Knob Road Eagan, MN 55122 N2 4500 PHONE: 454-8100 Receipt # G8r 1 Date ` eQ Site Ad_d?ress elceWOOd P.13. Lot Block 66' Sec/Sub. Parcel # _ w Name ?E'd r?' ?ua1s _ 3 Address Lak@wOOCj Rd, agan 452-5094 ' Name _ 0 ?a Address f ?:... Name Address Assessment _ Water & Sew Police Fire Eng. Planner - Council _ Permit _ Surcharge _ I Plon check _ ' SAC I Water Conn. ? Water Meter Erect n Occupancy Alter ? Zoning Repair ? Fire Zone _ Enlarge ? Type of Const. Move ? # Stories - Demolish ? Front - ft. Grade ? Depth ft. Aooeorals Fees I hereby acknowledge that I have read this application and state that gldg. Off. the informotion is correct ond agree fo comply with all applicable •State of Minnesota Statutes and City of Eagan Ordirwnces. APC - Total $ignature of Permittee •-""?'-?-ry1_ A Building Permit is issued ta. `:oeCk tGt an the express condition that all work shall be done in accordance with all applicoble $tate of Minnesoto Statutes and City of Eagan Ordinances. Building Official 77 P?M # Dab Iwrd rawiItfN Plumbing Mechanical INSPECTIONS I DATE INSP. RapF-in Final Footings Dafe Intp. DaTe Inap. Foundation Plumbing Frame/ins. Mechanicol Final Remarks: / z% CITY of EAGAN fBUILDING PERMIT .....••• •......... . . .............. .•• -° ...................................... owae: ,?,.j Addsess (Presea!) ..... ,?[.Q•5......... . .. ... 6i.r?,.-z ?" - ?, J`t or . . .......°.-.............................. ? n 75' ?X-,? Builder ...?L?e?-q?u?-?`? .............................:............. , ...................... ... ............. Address ...?o?...??-`.:`::'t"C!?`..:? E'.Z-v........... ??--?f•-?° ??"9? DESCRIPTION .? j. N2 _3711 3795 Pilot Knob Road Eagan, Minaesota 55122 454•8100 Dale ...?•••• / ?. ....... ... ............. 6toriea To Be Used Fos Fzon3 Deplh Haight Esl. Cos! Permf! Fsa Remazki 7 39i-?90 /? ? /v3c, ?? ` LOCATION ??fSD Street. Road or oiher Descrip2ion oi Loealion I Lo! Block Addiltoa or Trac! ? 7,' 7,?,ze-, 9,e / a. G o This permii does not sulhorise the use of sireets, roads, alleys or sidewalks nor does it give !he owaee os hia agen! !he righ! !o create aap silualion which is a auisance or which prasents a ha:ard !o !he health, safely, conveniencs and general walfare to anpone in !he communiip. THI3 PERMIT MUST BE EPT ON THE PAEMISE WHILE THE WORK IS IN PROG ESS. i Thfs is !o certiip, thal... ..:.. ........... haspermissioa !o ereet a. ' ?ez p . . .. ..• •-•-•••. ..... .••••- - • .... ....................... ..u oa the above described premise bject to the provisions of all applicable Ordinances for 3he 3y of Eaga .................... ..----`:`.?? ••---...__...............__............. Per ----------........----°--?..`................................................................. Ma or ? Su Im actos 77 CITY OF EACsAN 3795 Pilot Kno6 Rood Eagan, MN 55722 PHONE: 454-87 00 BUILDING PERMIT APPLICATION $4,000 ReceiPr # . T. L. ...va s,,. GaraBe n„te SeF Site Address Lot /,2- Block ? Parcel # s iName Jerry Undis Z Address 870 Lakewood Rd. 9 Citv E8g8n Phone 452-5094 ? Name HgTOld SpeCktoi z° 1643 Lilac 0' Address en O 8 S 454-4617 Cit Aone FWW Nome t- _;-. Address I hereby acknowledge that I have read this application and state that the informotion is correct ond agree to comply with all applicable Stote of Minnesota Statutes rv City of an rdinances,r,? Signature of Permittee N2 4500 7591 tember 29, .1977 Erect ? Occupancy Alter ? Zoning Repoir ? Fire Zone _ Eniarge ? Type of Const. Move p #k Stories Demolish ? Front ft. Grode ? Depth ft. Approvals Fees Assessment _ Water & Sew Police _ Fire Eng. Planner - Council _ Bldg. Off. _ APC _ Permit 15,00 Surcharge 2.00 Plan check SAC Water Conn. Water Meter 00 H. Total A 8uilding Permit is issued to: aTOld S eCktol on the express condition that all work shall be done in ac ance w I licable State of Minnesota Statutes and City of Eagan Ordinances. Building Officiai -- ? ia o -o? CI'?'Y OF EA?:.?N 3795 Pilot Knob Road Eagan, ;viinnesota 55122 PERv,aT NO.: 595 The City of Ea.-an hereby grants to n,1hGmpcen BltimbinR S.^ dF 1220 1 N'inn[?tonka Ylvd- J. iJndis a pl ;n„ Permit for: (Owner) F[aaire ewood Hills & at A? -- - f , pursuant to application dated G/26/75 Billed Fee?: ??n pn da.ted this _2fi_day of p,uq. , 19 75 • 1.00 s/c Building Inspector N.echanicsl Permits: Bid 'lota.l: 54 a? ? RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB RD, EACAN MN 55122 657-681-4675 <,r New Constructian Reauirements • 3 registered site surveys showing sq. ft. of lot, sq. ft. of house; and all roofed areas ? (20% maximum lot coverage allowed) • 2 copies of plan showing heam 8 window s¢es; poured found design, etc.) • 1 set of Energy Calculations • 3 copies of Tree Preservation Plan if lot platted after 711193 • Rim Joist Detafl Options selection sheet (bldgs with 3 or less units) DATE C) 2-` SITE ADDRESS ? TYPE OF WOR_K P ? APPLICANT dA?-/33-e ? RemodellRepair RequiremeMs . 2 copies of plan • 1 set of Energy Calculations for heated additions • t site survey tor exterior additions & decks • Indicate if home served 6y septic system for additions 3. 7-? o:1 VALUATION srJ_e. MULTI-FAMILY BLDG _Y N _ FIREPLACE(S) _ 0 _ 1 _ 2 STREET ADDRESS 4=? CITY s STATE'(-'ZIP TELEPHONE #b? ? ?F-'ff_ CELL PHONE # PAX # PROPERTY OWNER 4 ?I? ??N jt 5 TELEPHONE # COMPLETE FOR "NEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 MINNESOTA RULES 7672 (4 submission type) . Residential Ventilation Category 1 Worksheet Submitted • New Energy Code Worksheet Submitted • Energy Envelope Calculations Submitted Plumbing Contractor: Plumbing system includes: Mechanical Contractor: Mechanical systern includes: 5ewer/Water Contractor: Phone # Phone # Fee: $70.00 I hereby acknowledge that I have read this application, state that the information is correct, and agree to comply with all applicable State of Minnesota Statutes and City of fa§an 0r)ir5$.nces. Signature of OFFICE USE ONLY Water Softener Water Heater No. of Baths Phone # Lawn Sprinkler No. of R.I. Baths Air Conditioning Heat Recovery System 53?? aus''N Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4/02 ? INSFECTIDN RECORD CITY OF EAGAIV PERMIT TYPE: 3830 Pilot Knob Road Permit Number: Eagan, Minnesota 55123 Date issued: (612) 681-4675 SITE ADDRESS: Ln T: 12 B L 0 C K: APPLICANT: 870 LAKEWOOD HILLS RD ALLSTAR CON51" INC LAKEWOOD HILLS (612) 593-5326 PERMIT SUBTYPE: sF (MZSC.) TYPE DF WORK: DESCRIPTIQN BuzLtrzNG 024862 11/18J94 REPAIR (ROOFING) INSPECTION .A . .A FRAMING ROUGH IN PLBG ROUGW IN HTG FINAL ___ , . ., w. ._ !.° .;. _?- -- PERMIT ?C? CITY oOF EAGAN I ur?/????5'' PERMIT TYPE: e Eagan, Minnesota 55123 Permit Number: 024862 (612) 681-4675 Date Issued: 11,/ 7, S/g q SITE ADDRESS: $70 IAKEW00D HTLLS RD LOT: 12 BLOCK: LAKEWdOD HIL.L5 DESCRIPTION: (ROOPING) B?ilda:rtgi?,,Permit 7ype 5F (MZ5C. ) 8 1 Ul1di:ng Wdrk Type REpAIR ED 4 REMARKS: FEE SUMMARY: VALUATION $5,000 Base Fee $72.00 Surcharge $2.56 7ota1 Fee $74.50 CONTRACTOR: - AppLicent - sT. LzG. OWNER: ALLSTAR CON5T INC 15935325 0003247 UNDIS BETTY 3315 N NWY 10e 870 LAKEWOOD HILLS RD MINNEflP(ILIS MN 55422 EAGAN MN 55123 (612) 593-5826 - (612)452-5094 , I hereby aeknowlodge that-_Z have reait this a?ppL??atltsn ant!' stat? tha'C the =- , inf'armation as cwrreot'ond' agree tQ "camply with` a].l applicable, Stato 'o'F Mn. L 5tata+tes and City, of, ??0,o•?s Ordinances. _. ._ . _...? ?Y APPLFCANT/PE ITEE SIGNATURE ? ISS E SIG TURET iLliti CITY OF EAGAN 1994 BUILDING PERMIT APPLICATION 681-4675 414, -IIJO SINGLE & MULTI-FAMILY 2 sets of plans, 3 registered site surveys, 1 copy of energy calcs. COMMERCIAL 2 sets of architectural & structural plans, 1 set of specifications, 1 copy of energy calcs. Penalty applies: 1) when permit is typed, but not picked up by last working day of month in which request is made, 2) address is changed or 3) lot change is requested once permit is issued. Date Valuation of work / Site Address:]O la/LS WDOd kql STREET 9 SUI7E !1 T N ? / ? / enant ame: (commerci al only) _ ;? Q , ? LOT ? BIACK SUBD. d? `?U,,I ? ,f P.I.D. # Descri tion of work: ? ,F P F' The applicant is: ? Owner Contractor ? Other (Describe) Name jlcy?/ Phone Property LAST 7- ?FrRsT Owner qddress ? 7 0 ?-kk d 4 gL, d o STREET STE # City ?4:2 5tate ???N Zip Company 4115C on. Phone Contractor Address ?31S IV Hw, lOD License # 3-_2 Exp. '3 Jr"j? City M?2L4 State Zip Company Phone Architect/ Engineer Name Registration # Address ' City State Zip Sewer & water licensed plumber . Processing time for sewer & water permits is two days once area has been approved. 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. Signature of Applicant: ?• - . 4"a c't5:7` ce Wellr/(lw.?ez• e,.;zd L'-?=? We]_1 Location State (:ai.'iCE,' NGe Compar_ r PerMit No. ? I?i?33"G Addre s a ? ci Lot B1.ocx Date 70iUT R:t"?-GRD ti'iLLA:GE OF E :Gt^N ,-> L196'1-366 Telepl:c°:;e ze of UIe11,41_ Inclles ? TnTater Lavel41, , ?E;et 47e11 Depth^_/F'?-et ; Draa Dob /c:q?3 Feet at!::PP4. Gaoing Deptli Feet ? Capacity Gallons ?G'[P Per/FTas, i Thicla:ess Star-ted I Eiided i of e`r x ? np, ,La o y' ?.Yf n/?? ? (a 4V ?? / 103 ?z ! ?... . ?ti'l"?t-? i?.? 31 E;r.terior Spac?-, A:=,xnd Casing 5ealed With: FJCement Grout )?`Pu.dd?ed ClayywG`vuo-<-,sr L'Otlier D-,:,?iniect<<.nt LTSed Houis Laft in Well? 'Eu? Drille s S?_gnatuxe MTU='N 'THIS FECORD Ar TER CObEPLETION o-f r ormU.tion MASTER CARD LOCATION jr?0. OWNER V C STRUCTURE AND S? ? D?4 LAND USED AS PermiT No. Issued ? Issued To Contractor Owner BUILDING PWMBING ? . ? Ks, ? ? CESSPOOL - SEPTIC TANK WELL ELECTRICAL -- HEATING GAS INSTALLING SANITARY SEWER OTHER I OTHER Items Approved (Initial) Date Remarks Distance From Well FOOTING ? SEPTIC FOUNDATION 7, rlA..7 CESSP L FRAMING IELD FT. FINAL ELECTRICAL HEATING DEPTH OF WELL GAS INSTALLATION i"--- SEP71C TANK 7 Z,"3-' CESSPOOL 7-? „ _ •t j•,. 7. DRAINFIELD PLUMBING } ..a q S--? f!/ WELL SANITARY SEWER „?? ' iations Noted on Back COMMENTS: / -??- _ ? DATE '7 BUILDING PERMIT APPLICATION Include 2 sets of plans, 1 site plan w/elevations and 1 set of energy calculations. To be usec3 for ??C11/1i? ?-- Site Address: Lot Block Sec./Sub. r? 1 Owner .1%C-., ? -? Address ^ ' ??_??s?;?? Valuation r? --- Parcel Number Telephone Contractor Le Telephone Address i Arch./Enq. Address Erect Alter Repair Enlttrqe Move Demolish . Grade OFFICE USE Date of Approval & Initial Assessment U7ater/Sewer Police Fire Eng. Planner Gbuncil Aldg. Off. A.P.C. Telephone OE'FICE USE Occupancy Zaning Fire Zone Type of Const. # of Stories Front Depth FEES o^o Pennit ? s Surcharge a ' Plan Check SAC Sftlater Conn • tdater Meter TOTAIi ) 7 ? .... L 1?, ?oo WASHED SAND AND GAAVEL ?" B[TUMINOUS AGGREGATES F[LTERMAYEAIAL L CLISewD0d PIIIS , GAAVELBASES ? nrt? ur??tern ?,gg??gtttP,s Phone 423-5521 Lak,eville, Minnesota ?? 410 0' C'-6? ?-zg Q_. ? ? ???? ? Rf°'' s-zs- ' ?.??e..- fv?S .. ,. JERRY UNDIS SOIL PERCULATION TEST 870 Laketiaood Hills Road Eagan, MN 1. A three (3) bedroom house has a daily flowage of 450 gal- lons per day. 2. Due to the fact that various soils were encountered in all four (4) holes, some extremelyfast with fine sand some slower naterials going to the east, I suggest using 1.67 sq, £t. ner gallon of flowage. 3. Using three (3) foot wide trenches and one (1) foot of rock under the pipe, would require two hundred one (201) lineal feet as a minimum. I suggest using entire area if possible. This should give you approximately two hundred sixty (260) lineal feet of trench area. 4. The existing cesspool is to be pumped, remove the top and filled with granular material. 5. The existing septic tank may be used if top is removed and new baffle used if needed. The septic tank must be pumped and cleaned. ISTS #00666 Dakota County #P-666 Thank you for letting A-1 Perculation be of service to you. Cory and Brett Lucking CL,BL/el J 5 ':' ?ui": 1 ? - ? y '' \ l ?r fYw 3? ?CIo.:3 ? s,J... ?t &4 i ? \ ? p? ?d r ' \ \ , :-, C?rnra^tq + l ? ? ? 2 70 ZAKe W oocY l?:?ls Rci- -L7 r r Ue (k) ?. Y \ ? \ ' ?, . :? PERCOLATION TEST DAT.4 SHEET Test hole locacion :rJn11.l ?tllkle nu^ber Da[e-test hole was prepcred Depth of hole botton, Diameter of hole, (, inches. Soil data from test hole: inches. Depth, inches Soil teature O? b p? R r(? 1. G+ jq YrJ\ fa -.' 1?? „B ir ` ? /l4 ? ? rrr? c. ( ( 4?C ?• ? ?Y c- t ?^ J L'J .? A N,ethod of scratchinq sidewall A ,Q ,p }? o I Deptn ot pea-sized .-rsvel in betto;,i o: hole, ? inches. Da*_e and hour o= initial water filling af - S- - Depth-of initial water iilling, /'X ir.ches above nole bottcr. Ne[hod used to naintain at lezst 12 incnes o: c:zter depth in hole =cr at lea=_t 4 hours ?rl Cr l9{!L'!1 ,?;? itiac .(. Percolation test readings made by CO ,,,, j` ?c, ? on .a-'Jw. (- starting at 77 :':aximum water depth above hole bottom (date) during test, inches. - Time Tine Interval, *finutes *fezsurenent, inches Drop in water leti=e]., inches ?ercolation rate, minutes per inch Remarks .a , L 14 b ? , "v t{ ? , ? ? y L ( • ? ,? ; ,3,_? -?' I I I I f ! ? i I I Percolatioi7 rate = 1,_11 minutes per inch. ," . PERCOLATION TEST DATA SHEET Test_ hole location,f'erpv U,,,A:•- Q')Qj_pk.&U,1ao? Role number Date test hole a•as prepared 14,•:? -ary' , Depth of hole bottom,_3fo inches. Diameter of hole, inches. Soil data from test hole: Depth, inches 5oi1 texture 6 1C ).-. a W wr : l-- ? n „ 1}?. - a " 4a Method of scratchinQ sidewzll rr A r^'? ?h? Cn n I, Depth of pea-=ized gravel in botton oi hole, ? inches. Date and hour of initial water filling j-'53?=y Depth of initial water tiiling, j7- _ inches above hole oottcui. Netnod used to mziatain at least 12 incnes oi kater deptn in hole for a*_ least 4 hours so ('YACi.n r s i,nkav? - Percolztion test readings m2de by (vo-1^ : i}c ll `yti,e 8q starting at '. Maximum water depth above hole botto:n (date) duri..g test, ?';L- incnes. - Time i-_;;,o Interval, Minutes t-?easurenent, inches Drop in water level, inches tercoiatien rate, minutes per inch ie-narks . 7o : l C7 y 1- Q ? l L L -ao I I ., I ? ? Pzrcolation rate = -1), ? a, minutes per inch. City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 870 Lakewood Hills Rd N Lot: 12 Block: 0 Addition: Lakewood Hills PID:10- 44350- 120 -00 Use: Description: Sub Type: e - Air Conditioner Work Type: New Description: Air Conditioner Comments: Expired Permit - Closed w/o Required Inspections. Letter sent. 12/10/2008 pf Fee Summary: Contractor: Controlled Air 21210 Eaton Ave Farmington MN 55024 (651) 460 -6022 X253 Questions regarding electrical permit requirements should be d 952- 445 -2840. ME - Permit Fee (Replacements) Surcharge -Fixed Total: Applicant/Permitee: Signature PERMIT City of Eaan - Applicant - Permit Type: Permit Number: Date Issued: Permit Category: ected to Mark Anderson, State Electrical Inspector, $50.00 0801.4088 $0.50 9001.2195 $50.50 Owner: Elizabeth K Undis 870 Lakewood Hills Rd N Eagan MN 55123 Issued By: Signature Mechanical EA082949 05/08/2008 ePermit 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 ü ù ÿ ÿþþ ýîýü úþþøûèìñêþ ò ÿþö þýüûúùø ÷öñöýûúù øöûúùø ÷öõ ÷ôùó öùòý ñýñíýùú ð þïýöî óùöìóóöïýöóöüöóë êö ù ÿêöêöó þ ùëñêöêùêöë ñöüóéöööïýöüú êóúóë îçæçååëåëå õú þýöö èýçæçëäëä èýÿë ôó öòñ ùù ø þ Úüæ áíìåÞ òôõ øþ ãõ àáßáå öüú ìöùùêöóöö öóùú ùùüþ êãþýñúê íöë ùù÷ ýúþ ýö PERMIT City of Eagan Permit Type:Building Permit Number:EA114976 Date Issued:09/20/2013 Permit Category:ePermit Site Address: 870 Lakewood Hills Rd N Lot:12 Block: 0 Addition: Lakewood Hills PID:10-44350-00-120 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are not acceptable in lieu of inspections. Carbon monoxide detectors are required by law in ALL single family homes . Sue Lameyer Valuation: 4,000.00 Fee Summary:BL - Base Fee $4K $103.25 0801.4085 Surcharge - Based on Valuation $4K $2.00 9001.2195 $105.25 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Elizabeth K Undis 870 Lakewood Hills Rd N Eagan MN 55123 (651) 451-6835 Beissel Window & Siding Co 1635 Oakdale Ave W St Paul MN 55118 (651) 451-6835 Applicant/Permitee: Signature Issued By: Signature