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616 Lantern Ct ìü í þýýüÿûùøûúø ÷üüýýíøíô íãäøÿüáõ ëíãîíãä þý ÿþýüû ù÷õ ß ø ÿýüû ÷ýüû ù÷õ ß ûáÿ ø ÿ øäåÿûü Ú òÿú ÷ñ ç ææóóçè óïééþ ñÿþç ì û ý ÿóèóÿóçéøææ ûæ é óûçó ññóòÿ ó þó é æ õõû ææó úêàêäíéãîëéëî ó÷ ÿñ Üÿêàêäééíî Üÿé òøùñö ðï ûû Üûø ÿ çýþ ñ í ñõ÷øø øñ ðöîîäë ðöîîíä ïíìëîä ñþüõ ñ ñçñ ûû ññæó óûüõñûûþ æð ÿ øüæ å é ûûßó ÿ ÿü ÿ CASH RECEIPT CITY OF EACAN , 3830 PlLd`f KNOB ROAD EAGAN. MINNESOTA 55122 U ? 0 : ) DATE 19 . . XECEIVED , ? FPpA v ? . f AMOUNT , -F . M? i .?Y ' -?:; i/ . f - & DOILARS p CASH tRl CHECK fi Fan, L/• 0 ? ( -"V tAC.? ? J '- (/ ( C A? ?? i Whit?-Payers Copy Yellow--POSLng Copy Pink-File Copy Thank You BY SEWER & WATER PERMIT CITY OF EAGAN 3830 Pilot Knob Rd. Eagan, MN 55122-1897 DATE I '/? SITE ADDRESS LOT?BLOCK ?SEC/SUB ? - ? F -?j , APPUCANI': % e-?: o I ADDRESS: r i. cn?- ZIP ' ` !Z PHONE: I, PLUMBER: t ? r / Cl(f m U/ &[ ' ADDRESS: ' ?- i ."a 16t4n/ l CITY, STATE . , ? E ? ZIP PHONE: 2-5'~O ' OWNER: _ ADDRESS: CITY, STATE PHONE: _ OFFICE USE ONLY METER # PERMIT DATE 8116189 CHIP # iC 3 PERMIT # JURn5 METER SIZE Tleace B.P. RECEIPT # C 3249 ISSUE DATE LLI? B.P. RECEIPT DATE 8 /2 f?'9 PRV - BOOSTER PUMP ZIP PERMIT REOUESTED - SEWER WATER - TAPS - COMM/IND 4-" RESIDENTIAL -?NEW - EXISTING Lawn Sprinkler Meters are to be installed Ahead of Domestic Meters on Water Line. Credit WILL NOT be given for Deduct Meters. ,X. i : I AGREE TQ COMPLY WITH CITY OF EAGAN ORDINANCES SIGNATURE WHEN METER ISSUED PLEASE ALLOW TWO WORKING DAYS FOR PROCESSING. CALL 454-5220 FOR INSPECTIONS. FOR STORM SEWER PERMITS, CONTACT ENGINEERING DEPT. f I SEWEA & WATER PERMIT CITY OF EAGAN II 3830 Pilot Knob Rd. Eagan, MN 55122-1897 DATE • ; ? SITE AQDRESS A-,/ LOTI_BLOCK " SEC/SUB OFFICE USE ONLY METER # CHIP # METER SIZE ISSUE DATE? ppy - ? APPLICANt: % C_. o ADDRESS: . C ? [ I ?.1 ! / ? ' ' l.? ` ? ' L. ? _ CITY, STATE PHONE: ' - ? ZIP PLUMBER: ? ,A, x: ADDRESS: CITY, STATE PNONE: ZIP -- OWNER: _ ADDRESS:_ CITY, STATE PHONE: ZIP PERMITDATE `'116/89 PERMIT# 1C160', B.P. RECEIPT # ? ? ? 49 B.P. RECEIPT DATE ?' !? / Q 9 BOOSTER PUMP PERMIT REQUESTED - SEWER _ WATER - TAPS - COMM/IND _ RESIDENTIAL I `- NEW _ EXISTING Lawn Sprinkler Meters are to be Installed Ahead of Domestic Meters on Water Line. Credit WILL NOT be given for Deduct Meters. , t:. I AGREE TO COMPLY WITH CITY OF EAGAN ORDINANCES SIGNATURE WHEN METER ISSUED PLEASE ALLOW TWO WORKING DAYS FOR PROCESSING. CALL 454-5220 FOR INSPECTIONS. FOR STORM I SEWER PERMITS, CONTACT ENGINEERING DEM. CONTRACT P Site Address _ Lot a? ? y c m c 3 O MECHANICAL PERMIT CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 PHON¢: 454-8100 BLDG.TYPE iies. Mult. Comm. Other Name Address ' ? ?"?• "? ": ' ?- City. Phone Name City Phone TYPE OF WORK Forced Air ?. ' M BTU ??ler M BTU ' UnR Heater M BTU I Air Cond. M BTU Vent ' -? CFM Gas Piping Outlets # FEE: S/C: TOTAL• PERMIT q RECEIPT# 7? DATE: For Office Use Only: WORK DESCRIPTION New L? Add-on Repafr FEES RES. HVAC 0-100 M BTU ADDITIONAL 50 M BTU (RES. HVAC INCLUDES A/C ON NEW CONSTRUCTION) GAS OUTLETS (MINIMUM - 1 PER PERMIT) COMM/IND FEE - 145 OF CONTRACT FEE APL BLDGS. - COMM. RATE APPLIES TOWNHOUSE 8 CONDOS - RES. RATE APPLIES MINIMUM RESIDENTIAL FEE - ALL ADD-ON & REMODELS - $24.00 ' - 6.00 - 1.50 EH. ' 12.00 MINIMUM COMMERCIAL FEE - 20.00 ? - STATE SURCHARGE PER PERMIT - .50 SJ (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND $1,000) ?. SIGNATURE OF PERMITTEE ' ' `Q` FOR: CITY OF EAGAN • , .. , PLUMBING PERMIT CITY OF EAGAN CONTRACT 3830 PILOT KNOB ROAD, EAGAN, MN 55122 PRICE_??,?-_ PHONE 4548100 Site Address ? Lot < Z Address CRy FEES COMMJIND. FEE - 1% OF CONTRACT FEE APT. BLDGS. - COMM. RATE APPLIES TOWNHOUSE & CONDO - RES. RATE APLLIES MINIMUM - RE8IDENTIAt FEE $12.00 MINIMUM - COMM.IND./FEE $20.00 STATE SURCHARGE PER PERMIT .50 (ADD $.50 S/C PER EACH $1,000 OF PERMIT FEE) For Office Use PERMIT # ? 4-9 -9?L?" RECEIPT # L_?l(1 BLDG. TYPE WORK DESCRIPTIi Res. ? New ?- Muk. Add-on Comm. Repair Other RES. PLBG. ONLY - COMPLETE THE FOLLOWING: NO. FIXTURES TOTAL Water Closet - $3.00 $ Z f' _? Bath Tubs - $3.00 Lavatory - $3.00 ? Shower - $3.00 ? Kitchen Sink - $3.00 _ UrinaVBidet - $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 _ Private Disp. - $10.00 _.?_ Rough Openings - $1.50 • i. ? ?? OF PERMITfEE PERMIT FEE: STATES S/C: 5 - ? ' OF EAGAN GRAND TOTAL: ? f 1 ; «;. •u ? tCertifiratp of (Orrupttnry titp of (Eagan i0r;rttrtmrnr u# iicild'mg jttspedinn This Certifrcate issued pursuant to the requiremenu of SecHon 306 of the Unijorm Building Code certifying that ar the time oJissuance this srructure wns in compliance with the various ordinances of the City regulating building coxstruction or use. For the following.• Use Classifiuuon SF DW-I/C.#?? Bldg. Rrmu No. 1? pa?percy7'ype O?r?l ZoningDistrict R'I TY?cCormt. VN Owner of Building ffi'II'TW OONSIM MON qddres 644 `?OR OaMf F'AGAN BuildingAddrm 616 LAhTTW /JOURT L,,,.n,L27i B3% O('1fAdIIZY HJ[ILJW Dele: ogroM 279 1989 Building Offi&il .'11P- POST IN A CONSPICUOUS PLACE r_. . ?--- -L 1 BUFLDING PERMIT To be used for SP 0 ..? ..'????? .Ff' ,??. '?? '.'. , ? ? . i . ..')' ..'d?.? . .. .. .. .. . . . ?, .. CITY OF EAGAN A 16866 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE:454-8100 ; P Receipt # 14 Est. Value 0"6000 Date AIIC Z , 19-89-_ Si[e Address 616 I.A1R'Sall CT Lot 27 Block 3 Sec/Sub. COMMY HOLLM Parcel No. w Name 3 Address 644 SUP6flI0R CT ° City EAGAN Phone 454-1438 o Name sAME O Q Address J O ?. City Phone W W Name r _z, Address a W City Phone I hereby acknowlege that I have read this application and state that the Building Ofticial USE ONLY information is correct and agree to comply with all applitable State of Minnesota Statutes and City QQpf Eagan Ordinances. Signature ofPermitee ? ["A A Building Permit is issued to: 'BLILIE CORISTRU(,`j'jpli on the express condition that all work shall be done in accordance with all applicable State of Minnesota Statules and City of Eagan Ordinances. Occupancy Ri-3 I" FEFS Zoning 11" (Actuaq Const V-V Bldg. Permit W80 (Allowable) Y? Suroharge 74•00 W ol Stories Len9ih ? Plan Review ?•? Depth SAC.CiIy 100100 S.P. Total - SAC, MCWCC 575•00 . S.F. Footprints - 5W'00 On Site Sewage _ Waler Conn On Sile Well - Water Me1er 90.00 MWCC Systam xx ?.? City Water ? Aocl. Deposil PRVRequired xx S/WPermit 20*00 Booster Pump - S/W Surcharge 1•00 228 • 00 Trealment PI APPHOVALS RoadUnit 340•00 Planner - park Ded. Council BIdg.Olf. _ Copies Variance - TOTAL ??2??? Permit No. Permit Holder Date Telephone # WATER SEWER PLUMBING ? J.:%('? • ??f' /?? J S ? 0 7 ' / C"D H.V A.C. kQA?C?rC-l! ? ?tG? % ?l ELEC7RIC Inspection Date Insp. Comments Footingsl Foundation Framing r ? Faaofing Rough Plbg. ?9h [S,l. fireplace q ' Final Htg. Fnal Plbg. : )Y a "., ??? ?? Lf< / l •-?- -, ??'? ? Cqnsl Meter . Inspector - Notify Plu 4r Engr./Plan Bk1g. Final Deck Ftg. Deck Final we11 R. Disp. j? - • RESIDENTIAL BUILDING PERMIT APPLICATION F OF EAGA 517 p 3830 PIL'OT KNOB RDN 55722 651-6814675 IewConstructionReauirements RemodellRepairRequirements e411-ed 3 registered site surveys showing sq. ft. oi lot, sq, ft, of house; and all roofed areas . 2 copies of plan (20°k ma)imum lol coverage allowed) . 1 set oi Energy Calculations ior heated addilions 2 copies of plan showing beam 8 window sizes; poured found design, etc.) . 1 sife survey for exAenor additions & decks 1 sel ot Energy Calculations . Indicate if home served hy septic system for additions 3 copies of Tree Preservafion Plan if lot platted after 711193 Rim Joist Detail Options selection sheet (bldgs with 3 or less units) ? )ATE "I _ZO?0 ? VALUATION 106 SITE ADDRESS r? IIah4VrV_ C4- F MULTI-fAMILY BUILDING, HOW MANY UNITS? 'ROPERTY OWNER !2E(Zl`P T YfA),pS k 'YPE OF WORK G (.? FIREPLACE(S) _0 _1 _2 _3 kPPUCan kDDRESS 'AGER # E C v - -9 ZIPCODE S=7 CELL PHONE # ,?/,,?1=7/ -q?'QL, f1 FAX # I S-Y - LC57 - do 6 y NEW RESIDENTIAL BUILDING ONLY - FILC OUT COMPLETEL Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 (check one) - Residential Ventilation Category 1 Worksheet Submitted D - Energy Envelope Calculations Submitted _ MINNESOTA RULES 7672 - - New Energy Code Worksheet Submitted Plumbing Contractor: Phone #: Plumbing System Includes: _ Water Softener _ Iawn Sprinkler Fee: $90.00 _ Water Heater ? No. of R.I. Baths No. of Baths Mechanical Contractor: Phone # Mechanical System Includes: Air Conditioning Fee: $70.00 Heat Rccovery System Sewer/Water Contractor: Phone # kII above information must be submitted prior to processing of application. hereby acknowledge that I have read this application, state that the information is correct, and agree to comply with all appiicable State of Minnesota Statutes and City of Eagan Ordinances. r Signature of Applicant :ertificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 1/01 BLDG. PERMIT NO. ?(0?'?? -k3 /Jlirl'hly Qz1flULk) - L-? 01-3210 Bldg. Permit 01-3445 Surch./Adm. 01-2155 Surcharge 3 SO 01-3422 Plan Review L n ? 79-3866 Sewer Conn. • 20-2275 SAC 01-3446 SAC/Adm. ?s 20-3865 Water Conn. S ? ?= 20-3716 Water meter () CTO 20-2252 Acct. Dep. ? 0-0 20-3713 Water Permit CA? 20-3743 Sewer Permit 20-3868 Water Trmt. ? 75-3860 Road Unit 3(40 co 28-3855 Park Ded. TOTAL ? 0 Cfb 14752/-,?7 19(?? Fiequest Date Fire No. Ro -in Inspedion R ui Reedy Now ? Wiil Notify InspeCtor O es o When ReadyT I icensed contractor ? owner hereby request inspeciion of above electrical work at: Jab Address (Stree 6ox or Route No.) Seclion o. Township Name or No. Range No. Co Occupant RINT) Phone No. e ? ? ? -5 Po Su ier pCdress Electri ntreclo (COmpa^ny Name) Co raclor§ License No. 71 Mailirg Address (CoMrddor or er Makirg Inslallation) 99 - Authorized Signatu (Camre Owne ak' si tion) f. _ ` Phone Num6er A ?7^-'? 611NNESOTA STATE 80ARD OF ELEC7RICfTY f ? THIS INSPECTION REQUEST WILL NOT Griggs-1lidwey Bldg. - Room 5773 . 8E ACCEPTED BV THE ST.4TE BOARD 1821 UniversNy Ave., SY. Paul, MN 55104 UNLESS PROPER INSPEGTION FEE IS Phone (612) 642-0800 ENCLOSEO. 0/1?9 P 1475? REQUEST FOR ELECTRICAL INSPECTION ? See instructions for completing this form on back oi yellow copy. )C" Below Work Covered by This Request •r-. ee-aooo"7 q?- e add Re0. TypenfBuif.iing AppliancesWired EquipmentWired Home Range Temporary Service Duplex Water Heater lectric Neating Apt. Building Dryer Other (Specify) Comm./Industrial Furnace Farm Air Conditioner O[her(speafy) ConiradorkRemarks: w Compute lnspection Fee Below: 1 °,,,4h-?- # Other Fee # Se i e Entrance Si Fee # Cimuits/Feeders Fee Swimming Pool 0 to 200 Amps o m ioo a.mps .? Transformers Above 200 Amps Above 100 Amps Sigf1S Inspector5 Use Only: TOTAL Irrigation Booms ? Special Inspection L Alarm/Com m un ication Other Fee I, the Electrical Inspector, hereby Rouyn-in Date certify that the above inspection has been made. Final Date OFFICE USE ONLY This request wid 18 months irom &? r 753 m ? kequa6lDal Fre No. Rou -in Inspection ired? ? Ready Now ?ill NotiTy Inspector n R Wh d ? F J es ? No e ea y e sed contractor ? owner hereby request inspection of above electrical work at: Job Address (Street, Bax or Route No.) ?c - ? CNy Section No. I Township Name or No. Renge No. Counl OcCUpant?PRINn ? .y ? Phone No. / r/ 7 ! Power Su I Atldress Electrical ractor (CompanY Name) n 96ntractwis License No. - ? ?, ' / l1Y?ld.C? ? ??? ? Malling Address (Conlre?pr Owner Makin nstalla ? tja?)' C 7 3 2.6 . Auihorized Signal onira or/Ow " g I tallalion) ? Phone Number o -3 MINNESOTA STATE BO RD OF ELECTHICRY / THIS INSPEGTION REQUEST WILL NOT Griggs-Midway Bldg. - Hoom 5-173 ? BE ACCEPTED BV THE ST.4TE BOARD 1827 UnWersity Ave., SL Paul, IdN 55104 . . UNLESS PROPEF INSPECTION FEE IS Phona (612) 662-0800 ENCLOSED. ?,?5`9 P 14753 REQUEST FOR ELECTRICAL INSPECTION `? See inshucti0ns for compleling ihis form on back ot yellow wpy. "X" Below Work Covered by This Request .r-. ee-00001 -07 e 8d Rep. W Type of Building AppliancesWired EquipmentWired Home Range Temporary Ssrvice Duplex Water Heater Elec[ric Heating Apt. Building Dryer Other (Specify) Comm./Industrial urnace Farm ir Conditioner Other (specity) Condaclor§ Remarks: Compute Inspection Fee Below: # Other Fee # ServiceEntranceSize Fee # CircuiTslFeeders Fee Swimming Pool 0[0 200 Amps . LI&00 0 to 700 Amps Transformers Above 200 _ Amps e Amps ? Signs Inspectar§ Use Only: / /J TOTAL Irrigation 8ooms ? Special Inspection ?w AlarmlCommunication Other Fee I, the Electrical Inspector, hereby Rough-in oat certify that the above inspection has been made. Final - ? o ,?? OFFICE USE ONLV % ?' This request void 18 months from CITY OF EAGAN N 0 16 S$ 6 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 BUILDING PERMIT • " PHONE:454-8100 Receipt # ??J !? 2'1oC4? To be used lor SF DWG/GAR Est. Value $148, 000 Date A11(; 9 , 19_$9-_ Site Address 616 LANTERN CT Lot 27 Block 3 Sec/Sub. COUNTRY HOLLOW Parcel No. _ W Name BLILIE CONSTRUCTION ? Address 644 SUPERIOR CT 0 City EAGAN Phone 454-1438 o Name S? $Q Address ? City Phone ? W w Name f- ? ; Address <W City Phone I hereby acknowlege that 1 have read this appfication and state that the information is correcl and agree to comply with all applieable State of Minnesota Statutes and Cit f Eagan Ordinan s. ti Signature of Permitee L[_ -P ?? ? A Building Permit is issued to: B I on the express condition that all work shall be done in accordance with all applicable State of Minnesota Statutes and Ciry of Eagan Ordinances. Building Official OFFICE USE ONLY Occupancy R-3 M=1 Zoning R-1. (Actuaq Const V-- N Bldg. Permit (Allowable) V-N Surcharge # of Siories - Lenglh (j$! Plan Review 4 " FEFS 808.00 74.00 404.00 100.00 575 nn Depth 0 . SAC, City S.F. Total - SAC, MCWCC S.F. Foolprints - On Site Sewage _ Water Conn 580.0 0 On Site Well - Waler Meter 0 90.0 MWCC System }LX_ 30 00 Ciry Water x? Acct. Deposit . PRV Required XX__ S/W Permit 20.00 Booster Pump - S/W Surcharge 1.00 Trealment PI 228.00 APPROVAIS Road Unil 340.00 Planner - park Ded, Council BIdg.Off. _ Copies Variance - TOTaL 3,250.00 Clty of Eakan 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 ? _ _ _ _ _ _ _ - _ _ - i ? Fo1 ce tJse ? ? Permit ? Permit Fee: ? ? Date Received: ? Staff: L___--_-_-___- __-_? 2008 RESIDENTIAL PLUMBING PERMIT APPLICATION Date: 7`"! 1 -(j $ Site Address: ?o IL- n? C"r Tenant: Suite #: Z RESIDENTlOWNER Name: 5 ,-t 7 Phone: Address / City / Zip: CONTRACTOR Name: ? s? /`? License #: S/n 3G 3 PfYI Address: City: ?.si,?,?..w? State: 7-? /U Zip: Phone: (??fZ -yG 3-/d?a Contact Person: TYPE OF WORK -2LNew _ Replacement _ Repair _ Rebuiid _ Modify Space _ Work in R.O.W. Description of work: PERMIT TYPE RESlDENTIAL Water Heater Water Softener ? Lawn Irrigation Add Plumbing Fixtures ? RPZ /_X PVB) C__ Main _ Lower Level) Septic System _ Water Turnaround New Abandonment RESIDENTIAL FEES: $50.50 Minimum Water Heater, Water Softener, or Water Heater and Softener (includes $.50 State Surcharge) $30.50 Lawn Irrigation (includes $.50 State Surcharge) $50.50 Add Plumbing Fixtures, Septic System Abandonment, Water Turnaround' (includes $.50 State Surcharge) 'Water Turnaround (add $136.00 if a 518" meter is required) $100.50 Septic System New ($10.00 per as built) (includes County fee and $.50 State Surcharge) $90.50 Fire Repair (replace burned out appliances, ductwork, etc.) (includes $.50 State Surcharge) TOTAL FEES $ i nereoy acKnowieage tnat this mtormation 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. X ,/\J:1/ .56L V.)0 Pt ApplicanYs Printed Name X /' Applicant's Signature 'FOR OFFICE USE Re?iewed.By,- D'a'te . .... ` r<< ` ? Requi?ed I'nspect?ons ,?? °? Uncler Ground R,ough=ln ir Test : ?Gas Test ??Final! , .:; . ??. . . : , v ??.? . . . _ . ? . ,,. 77 77 7 RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EACAN 3830 PILOT KNOB RD - 55122 -t' 651-681-4675 New Constructlon Requfremente . 3 registered site surveys showirg sq. ft. o( lot, sq. ft. of house; and all roofed areas (20% maximum lot coverage allowed) • 2 copies o( plan showing beam & window saes; poured found design, etc.) • 1 setof Energy Calculations • 3 copies of Tree Preservation Plan 'rf lot platted after 711193 • Rim Joist Detail Optlons setection sheel(bldgs with 3 or less units) ?- DATE f' le'v Z VALUATION JOB SITE ADDRESS 4e16 LAr/rEt'a CT IF MULTI-FAMILY BUILDING, HOW MANY UNITS? PROPERTY OWNER -StF?? IRei3E'sc• N TYPE OF WORK ???«N ?Ast?HtN-r ?r b2?oa? FIREPLACE(S) _ 0_ 1_ 2 APPLICANT 3-mrvE 1Rr3Fsci-1 PHONE# /, 5l-MV3- 93e I ADDRESS 4, LA#J?oeou C?t- ZIP CODE S?/23 PAGER # CELL PHONE #61z' 710' a 3b)9 FAX # m+1 RESIDENTIAL BUILDING ONLY - FILL OUT COMPLETELY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 (check one) - Residentiai Ventilation Category 1 Worksheet Submitted - Energy Envelope Calculations Submitted _ NIINNESOTA RULES 7672 - New Energy Code Worksheet Submitted Plumbfng Contractor. _ Plumbing System Includes: Mechantcal Contractor. _ Mechanical System Includes: Sewer/Water Contractor: Air Conditioning Heat Recovery System Phone # Phone # Fee: $90.00 Fee: $70.00 All above infoRnation must be submitted prior to processing of application. I hereby acknow?edge 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 Eagan Ordi nces. Signature of Applicant ???"?L`-? ?? Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 2002 Water Softener _ Water Heater _ No. of Baths RemodeUReoairRequirementa . 2 copies oi plan • 1 set af Energy Calculations tor heffied a ditians • 1 site survey for exterior additlors & decks • Indicate if home served by septic system for addi6ons Phone Lawn Sprinkler No. of R.I. Baths 'ot ri o.ob S? OFFICE USE ONLY ? 01 Foundation ? 02 SF Dwelling ? 03 01 of _ plex ? 04 02-plex ? 05 03-plex ? 06 04plex ? 31 New ? 32 Addition ? 33 Alteration ? 34 Replacement Valuation Census Code SAC Units Nbr. of Units Nbr. of Bldgs Type of Const ? ? Other _ Pool _ Ftgs _ Air/Gas Tests _ Final _ Siding Stucco Stone _ Windows (new/replacement) Approved By Base Fee Surcharge Plan Review MC/ES SAC city sac Water Supply & Storage S&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total x 35 ? 36 ? 37 L0 _! ?o-? V-/v ? 13 16-plex ? 16 Fireplace ? 17 Garage ? 18 Deck ? 19 Lawer Level Plbg Y orx N ? 20 Pool ? 21 Porch (3-sea.) ? 22 Porch/Addn. (4-sea.) ? 23 Porch (screened) ? 24 Storm Damage ? 25 Miscellaneous ? 30 Accessory Bldg ? 31 Ext. Alt - Multi ? 33 Ext. Alt - SF ? 36 Multi Int Improvement ? 38 Demolish (Interior) ? 44 Siding Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair Demolish (Bidg)* ? 43 Reroof ? 46 Windows/Doors 'Demolition (Entire Bldg only) - Give PCA handout to applicant Occupancy MC/ES System Zoning City Water Stories Booster Pump Sq. Ft. PRV Length Fire Sprinklered Width REQUIRED INSPECTIONS Footings (new bldg) Footings (deck) ' Footings (addition) Foundation HVAC Drain Tile Roof Ice & Water Final Framing Fireplace _ R.I. _ Air Test _ Final Insulation O 07 05-plex ? 08 06-plex 0 09 07-plex ? 10 OS-plex 0 11 10-plex ? 12 12-Plex FinaUC.O. ? FinaUNo C.O. Plumbing ? Building Inspector L . L- F?111sra (,SCD1ee61zJ u'?I"Ie1? G?Wr> 2004 RESIDENTIAL BUILDING PERMIT APPLICATION City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 FAX # 651-675-5694 ,W7o (DO Z New ConsUuction Reauirements RemodeVReoair Requfrements t?Ffie?« s? 3 registered site surveys showing sq. ft. of lot sq. ft of house; and ati roofed areas 2 copies of plan ioi? (20% maximum bt coverage allowed) 2 co ies of lan showin b 8 i d i d f i d d 1 set of Energy Calculations for heatad additions ?y p p g eam w n ow s zes; poure oun gn, etc. es 1 setofEnergyCakuiations 1 site survey for additions & decks Add'rtion-indicateilonsitesepticsystem ???",,,_, 3 wpies of Tree Preservadon Plan if loi platted after 711193 Rim Joist Dehil Options selection sheet (bidgs with 3 or less unils Date ?p? ? Construction Cost n SW . Site Address [o f?p L.44'TC'/'vl C.,F i UniUSte # / , iK15 b45NYKevI Y?G.:+??.t? ? *f2P5 <-i ?L I N? ?RS h}C v 4Cl'. Descri tion of Work }1 2"r rr?bsrr? o ec Yea!'r r t 4Qu+&4 J Multi-Family Bldg _ YN FSreplace(s) _ 0_ 1 ? 2 ? h Property Owner oTf i-e &4- ?!'e bc-SC Telephone #((„ 5j ) 6 V3 -9.30 ? Contractor Address City State Zip Telephone # ( ) COMPLETE THIS AREA ONLY IF CONSTRUCTII+IG A NEW BUILDING - Ivlinnesota Rules 7670 CateQOrv 1 Minnesota Rules 7672 Energy Code Category . Residential Ventilation Category 1 Workshest • New Energy Code Worksheet (4 submission type) Submitted Submitted . Energy Envelope Calculations Submitted Have you previously constructed a building in Eagan with a similar plan? _ Y _ fee applies. Licensed Plumber Telephone #( Mechanical Contractor Sewer/Water Contractor N If so, 25% plan review Telephone T Teephone ? I hereby apply for a Residential Building Permit and acknowledge that the info ation is complete an accurate; that the work will be in conformance with the ordinances and codes of the Ci te of MN Statutes; I understand this is not a pernut, 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. ,4eileH //P(OPSC'?l ?,?GyL l?'l?L.l? Applicant's Printed Name Applicant's Signature OFFICE USE ONLY Sub Types ? 01 Foundation ? 02 SF Dwelling ? 03 01 of _ plex ? 04 02-plex ? 05 03-plex ? 06 04-plex ? 07 05-plex ? 13 16-plex ? 08 06-plex ? 16 Fireplace O 09 07-plex ? 17 Garage ? 10 OS-plex ? 18 Deck ? 11 10-plex ? 19 Lower Level ? 12 12-plex Plbg_Y or_ N ? 20 Pool ? 21 Porch (3-sea.) ? 22 Porch/Addn. (4-sea.) ? 23 Porch (screen/gazebo) ? 24 Storm Damage ? 25 Miscellaneous ? 30 Accessory Bldg ? 31 Ext. Alt - Multi ? 33 Ext. Alt - SF ? 36 Multi Misc. Work Types ? 31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding ? 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair ix 33 Alteration ? 37 Demolish Building* ? 43 Reroof ? 46 WindowsJDoors ? 34 ReplaCement 'Demolition (Entfre 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 IL IS2 Width REQUIRED INSPECTIONS _ Footings (new bldg) _ Final/C.O. _ Footings (deck) ? FinaVNo C.O. _ Footings (addition) _ Plumbing _ Foundation ? HVAC Drain Tile Other Roof Ice & Water Final Pool Ftgs _ Air/Gas Tesu Final ? Framing _ Siding _ Stucco _ Stone _ Brick _j( Fireplace ? R.I. ?Air Test ?(Final _ Windows y` Insulation _ Retaining Wall 7 Approved By: T i , Building Inspector Base Fee Surcharge Plan Review 69 ? MC/ES SAC ?-- City SAC Utility Connection Charge ` -?J(?? S&W Permit & Surcharge ' ? '" Treatment Plant License Search Copies Other Total F -t -Sfic S u Y? , -?--o k? N-ot"-J121 ,IJdo(J 1989 SUILDIRG PERMIT APPLICATION crrY oF EecK ma ? SINGLE FAMILY DidELLIliGS 2 3ETS OF PL1NS 3 RE4ISTEAED 3ITE SUR9EYS 1 SET OF ENERGT CALC3. o\-?- COMS9EACIAL 2 SETS.OF ARCHIiECTUAAL. i STBOCTORIL PLIINS 1 88T OF SPECIPICATIONS 1 SET OF FaiEBGI CALCS. !lULTIPLE D1IELLINGS HENTIL ONIT3 FOA SdI.E DNITS i OF UNITS IOTSt iDDRESSES FOR ODRNEEi LOTS - COPTR9CTOR/BWlEOWNER MOST DF.gIGAATE i1HICB iDDRFSS IS DF.SIAED. HO CSAt1GFS iTII.L HE iLL0i1ED ONCE BQILDING PERMIT 13 ISSIIED.. SEWER 8 ii9TER PERMIT FEES JLND eCCDQRT DEP03IT FBES iTILL B8 INCLODED iTIT$ ZHE BUILDING PEaHIT FEE. PROCFSSIHG TIME FOR SEWER AAD libTEA PERiITS I3 TIiO DAYS ONCE A PERMIT HAS BEEN COMPLEtED INDICATIAG A LICENSED PLOlBEA. PENALgY APPLIES WHENs PERMIT IS NOT PAID FOR IN SAME MONTH IT IS REQITESTED. LOT CHANGE SS REQUESTED ONCE PEAMIT IS ISSIJED. rJ!!L 2 8 1989 To Be Used Yaluation: ? Dates Site Address Lo 11, L WN +:-? #L) LT / y8, ooo- -- ---- Lot z7 Block 5 Parcel/Sub Go twli).' Owner Address City/Z!p Code Pbone Contractor iJ L' L` S= GO "' S?. Address (p 4Ll ?-u- GZe.?? w C? City/Zip Code \A? Fhone 4E q V3 g Arch./Engr. Address City/21p Code Occupaney R-3 M-I Zoning R-I Actual Const V-N Allowable V-rl 1 of stories Length ?n?• Depth U' S.F. Total Footprint S.F. On site sewage On aite well MWCC Syatem t/ City water tl-? PRV required ? Booster Pump _ iPPHOVAtS Planner Counoil Bldg. Off. Variance FEFS Bldg. Permit c90$, Q0 Surcharge '74,? Plan Review y,Do SACO City ) SAC, MWCC 5'75,00 ifater Conn 580,00 Water MeEer D, co Aeet. Deposit 30,CO S/i1 Permit 2o,cx? 5/fl Sureharge 1.00 Treatment Pl. 22 , 0-D Aoad Unit 34Z) ,oa Park Ded. Copies SOSTaTAL Penalty ?OTAL 3350 ei Phone # 2 3ETS OF PL?NS BEGISITsRED 3ITE SQRVET3 _ (CHECB IiITH BLDG DIV.) 1 SEf OF ENERG2 CALCS. 1/ALU A,--n O ?J C7 A , 0 3LI X l ? X LI = 92 4?$? X 1S = J 3 32.0 30 ? 3?1 = j v? r° I ??? X G.?P ?I G(??f 2 rt p F?.-p on .__,--- ?'? x 31 =! OS?-I X,Sc`? =,`? z`?Dc? / (-(? 6,Kq . . t I . TRI=LAND C0. SURVEYING SERVICES 1260 YANKEE DOODLE ROAD EAGAN, MINNESOTA 55126 LEGAL DESCRIPTION; x SCAL.E: I%40' J? /4 ? ca? ?a.c ?qz V A, ? ^? ?? ? 82 ?<.i ? ??. ? SITE PLAN FOR: BLILIE CONSTRUCT10N LOT 27,BLOCK_Z__ , COUNjRY HOL:LOW ACCORDING TO THE RECORDED PLAT THEREOF DAKOTA COUNTY, MINNESOTA 3 41, 00 .?' I e\ ? ??X F ? 0 ??eQuO I N _w 9?F ? t ?o 2` LE6END I INVERT ELEVi4TI0N AT SERVICE EXTENSION= o DENOTES IRON ONUMENT PROPOSED GARAGE FLOOR ELEVATION= a2ss DENOTES WOOD HUB SET PROPOSED FIRST..FLOOR,ELEVATION.=. ez? e DENOTES EXISTING SPOT PROPOSEDBASEMENT FLOOR = 8?- ELE VATI ON E LE VAT 1 ON DENOTES PROPOSED SPOT ELEVATION ,,-DENOTES pRAINAGE DIRECTION NOTE ' VERIFY ALL FLOOR HEIGHTS WITH • FINAL HOUSE PLANS i hereby certify that ihis stuvey, plon or rsport wos preporsd by me or under my direct supervision cnd thot I om a duly Repistered Land Surveyor under ths Laws ot the Stote of Minnesotc. Bradley Z?enson, Mn. Req. No. 13235 Date : \V. ? `1 i 26 y . ,B h \?. ? a? ? LOT \ DRAWAGE AND UTILITY EASEMENT 8g s wATik 60t+: 27 `0__ ? ?s r, , y " 1276 EXTERIOR ENVELOPE AVERAGE liU" COr-IPUTATION 041NER SITE ADORESS LG`T aqf -e, o -o CON'TRACTOR DATE PfIONE Determine working square footage of each. - -- 1. 7ota1 exposed wall area ...... sq. ft. x-1L = 36.yy? 2. Total roof/cetling area ..... 1.276 sq. ft. x_026 = 33?/? Total exposed wall area above floor = a. Total wall window area ........................... .2?//-6O b. Total door area ... ........................... -' 38 c. Total sliding glass door area ............. .. d. Total fireplace wall area........ . .....:..... a fl e. Total wall framing area (average .:........ -27 3"60 f. Total net wall area above floor ................. ? 2 0 9. Totai rim joist area ............................ - - ??3 Total ekposed foundation area = _ 9D - h. Total faundation window arca ..................... i. Toal net foundation area abcve grade ?O - ............ Determine "U" value cf each ivall segment. a. ;2f11160 x "u11 ,?/?_ _ //46- 3e b. 36 x liuii p 123 = 44167 C. Go x d. 20 X ,.u„ . 7z e. ?73.ea 0_ x "u" , o = ?16? f. 'P/0 7, ko X „u„ , o = ro y, 9. 25/ 3 X „u„ 7z . n. - x ltu° i. 80 X ,iull , 08 = L- ? 3 . ......................... . ..... ..Total If item #3 is the same as, or less than item #i, you have met the intent of 58C 6006(c)2. " WALL SCGT;ONS Nrn'E: Use 15% of opaque wall.area for ?- frame coristruction Sal iSr:AL. Pc:ip,ze.al FRA?iE WAr•r• ? Construckion R-Value ],. rnterior i film 0.6 2 . ? " ? 0/0 . ?/ 3 , ? ?Zi:nches soft woocl 4 . V 11/?T ?f • o! 6. Exterior air film = 0.17 Total 1. Interior air film 0.68 2 . 3. S Z' ?i?Y'.fslZll /rl?Ol/ 4 . 5. 6. Exterior air film 0.17 Totai a3,/ 7 41.r .ay 1. Interior air £ilm 0.68 2. s. 4. 2 Z Bi ? 2, OG 5 . ?.?i? asi.?/??' - - ? 6. Exterior air film 0.17 Total ?2g-,G ev= • ag" FOd:+'D?,TICN k'ILLL FIG. N3 ? `• ?, • , o - ?, ` ? ?cL , ? . ` _ • •. . 1. Intcrior air film 0.68 2, C 44 fY G 4-SO • 3. a'C /. Z • 4 5. ' 6. Exterior air film 0.17 Total ?? G3 4/1=.os SLAS ON GRADE s . ? . . %L 6 ,?lz ?Z?F ( f ?,? • ? ' . '? . ' ? ? • ? , . /(( `i ? ? • . ? Ill "":? ^ 0 • . . FIG. #4 !!l 6 •, o ? x • ?cr??? _ ?rr ? i?? ? NOTE: Indicate tyoo, "?:" value, depth and placement of insulation. . ROOr/CEILING . ? ' ?' - ./:A I •? ? . yaTr • % ?? 1 ? .. Vented Heat flow . uP ' FIG. ?5 ? Paqo Three Conatruction R-Valuo 1. Intcrfor air film 0.61 2. q* ttl!/?'! • 3 . /.2''?/' ?t'Gl,?Sf 3?? PiB 4. Extcrior air film (still 0.6 Total 3?1&. • ?: , o?s . ? - 1. Interior a film 0.61 - - - 2. 3. _ 4. Er.terior air lm :t5,till) : . , Tu 1 f }:eat flow up vented 1. 2. • 3. 4. 5. NO44_,,,;,rM Noi•es Use additional sheets if more space ir. ?.'. '. • needed for detafls and calculations. ..' . Hcac ' • . , Elow up . • • , . • • . F.T.G. F7 • • . *.. ? e . Total exposed roof/ceiling area .. J. Total skylight area............. ...........j. k. Total roof/ceiling framing area (average 10%... 1. 7otal net insulated raaf/ceiling area........... // yb f?f0 Determine "U" value for each roof/ceiling segment. J - X liult -- k. 1.)7• 60 x"u" ? 02? = 3,32 t: //y?, yd X i,u„ , ozs 4 ..................................Tota1 = 3? U3 `?------- If total of #4 is the same as, ar less than #2, you have met the intent of SBC 6006(0l. Alternate Building Envelope Oesign To utilize the total envelope system m2thod, the values esta6lished by the sum of items #3 and #4 shall not be greater than the sum of items #l and #2. 1. 3.36 • Y9 + 2. 33, ? b = 3? 9? 7 3. 29/. 7d + 4. 32.03 7-3 FROM : FRX N0. : Jun. 22 2001 09:33RM P1 r>i VersaO ::\ Outdoor ?.. ? I i'YXGL I. i ? OF ? PAGES I ? Date: G TO: FROM: NQTES: ??ect ' FAX# (651) 453-0064 c+ JUN 2]. 2001 1? . Versadec;k OvCcloor Systems, Inc. 1] 15 Southview Blvd, So. St. Paul, MN 55075 affiCe (651) 453-9406 fax (651) 453-0064 Btdrs. Lics, #8209 FROM ? FAX N0. Larsor Engineering ot Minnesota 3524 Labore Road Whlte Bear l.ake, MN 55110-8100 651 491-9120 Fax: 651 481-9201 5 Larson Renslow Decks and Cazebos Attn: Mr. Shannon Prunty 1115 S. Vicw Blvd. South St. Paul, IvIN 55075 Re: Joist System: Double 2"x 8" at 24" on cemer I.EM 9 001041 Dear 5hannon: Jun. 22 2001 09:33AM P2 Ociober 19, 2000 1've performed the requested calculations on the alove referenced system. "i'he gurpose of thsse calculations was to evaluate the dauble 2 x 8's which canriiever 4'--4" with a bacic span of 6'-0". My calculatians indicate that stresses and defteetians are within acceptabie lirnits for a 60 psf ]ive laad. The joists are to be connected at the house with a mctal hanger (USP double 2 x 8- 10 x 12). This hanger is adeyuate to prevent the joist fram lifting np in the "worst case" cand'stion where there is a full live toad vn the cantiiever and na tive load on the baek span. My evaluation of the deck was ltmited to Chese igsues, Please give ine a oail if you have 8113' OtI]BC (;uESUOII5. Best Regards, Henry Wl?Voth P.E. ,,J D C 0. WEYING ,iERVICES ;0 YANKEE DOODLE ROAD -AGAN, MINNESOTA 55126 3 LEGAL x DESCRIPTION: LOT 27,BLOCK-3, _GOUNTRY HOLLOW ACCORDING TO THE RECORDED PLAT THEREOF DAKOTA COUNTY,MINNESOTA OJ?,??1 S CA L E: I"=40' F P,? . ?, ?- . . ?. ' 9 qlza Q' \ M <D ?? (Z) e2 n ??L'? v 41,9 SITE PLAN FOR: BLILIE CONSTRUGTIQN h? ` L? I L ?i he L Po y? \'W ?,s?y3 /96 ? ? a ? \ ?l $??? WA7SR EG9' ^° LOT 27+33 \a. \ DRAWAGE AND UTILITY EASEMENT ? l, I 28 (t1 O 09 . v?- .?F N ? ur 30t. ouuotc:Ic. 7 z 3?7 50,50 2006 RESIDENTIAL PLUMBING PERnnirAPPLicAZioN CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN MN 55122 651-675-5675 Please complete for modifications to existing residential dweilings. Date !104 L-a-v`'?p??i C'? - Site Street Address Unit # Property Owner Telephone # ( ) Contractor??/Ma ...e_? ( Telephone # Z10 o? Address O T City State«'? Zip ? The Applicant is: _ Owner L/Contractor _Other Septic System _ New !-/ Refurbished Submit 2 sets of plans and MPC license Includes County fee $ 100.00 Per as-built $ 10.00 Aiterations to existing dwelling $ 50.00 , %f Add plumbing fixtures. This fee includes installation of a water softener and/or water T heater at the same time. If you are installing onl a wafer softener and/or water heater, do not complete this section; move to the next section and check the appliance(s) you are installing. I.,?uJ e-r' ??v t l _Septic System Abandonment _Water Turnaround (add $130.00 if a 518" meter is required) Other: Water Softener _ Water Heater $ 15.00 _ new _ replacement Lawn Irrigation _RPZ _PVB _new _repair _rebuild $ 30.00 State Surcharge $ .50 Total $ ? n? I hereby apply for a Residential Plumbing Permit and acknowledge that the information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan and the plumbing codes; that I understand this is not a permit, but only an application for a permit, work is not to start without a permit and work will be in accordance with the approved pian in the event a plan is required to be reviewed and approved. ??? 'r?? ta - 41-L 24/zZ2 Ap canYs Printed ame A IicanPs Sign re City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 616 Lantern Ct Lot: 27 Block: 3 Addition: Country Hollow PID:10- 18275- 270 -03 Use: Description: Sub Type: e - Furnace & Air Conditioner Work Type: New Description: Fumace & Air Conditioner Comments: Expired Perm Fee Summary: Contractor: Boldt, Bob 4310 Trenton Tr Eagan MN 55123 (651) 454 -7760 Total: Applicant/Permitee: Signature PERMIT City of Eaan Closed w/o Required Inspections. Letter sent. Questions regarding electrical permit requirements should be d 952- 445 -2840. ME - Permit Fee (Replacements) Surcharge -Fixed - Applicant - 12 -11 -08 pf ected to Mark Anderson, State Electrical Inspector, $50.00 0801.4088 $0.50 9001.2195 $50.50 Owner: Steven P Trebesch 616 Lantern Ct Eagan MN 55123 Permit Type: Permit Number: Date Issued: Permit Category: Mechanical EA083252 05/28/2008 ePermit I hereby acknowledge that I have read this application and state that the informa of Minnesota Statutes and City of Eagan Ordinances. on is correct and agree to comply h all applicable State Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA168531 Date Issued:04/23/2021 Permit Category:ePermit Site Address: 616 Lantern Ct Lot:27 Block: 3 Addition: Country Hollow PID:10-18275-03-270 Use: Description: Sub Type:Reroof Work Type:Replace Description:Does not include skylight(s) Census Code:434 - Residential Additions, Alterations Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please print pictures of ice and water protection and leave on site. We encourage you to retain an electronic copy of photos until the project passes a final inspection. *Roof permits issued between December and March will be inspected in the spring or when weather warms up. Valuation: 5,000.00 Fee Summary:BL - Base Fee $5K $118.00 0801.4085 Surcharge - Based on Valuation $5K $2.50 9001.2195 $120.50 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Steven P Trebesch 616 Lantern Ct Saint Paul MN 55123--161 (612) 710-0389 Apex Roofing & Siding 944 Oriole Dr Apple Valley MN 55124-0000 (952) 891-1919 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA170738 Date Issued:07/14/2021 Permit Category:ePermit Site Address: 616 Lantern Ct Lot:27 Block: 3 Addition: Country Hollow PID:10-18275-03-270 Use: Description: Sub Type:Siding Work Type:Replace Description: Census Code:434 - Residential Additions, Alterations Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please leave printed pictures of house wrap on site for the final inspection. When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to ensure maximum ventilation to attic. Call for final inspection after installation. When a weather barrier is installed or Valuation: 5,000.00 Fee Summary:BL - Base Fee $5K $118.00 0801.4085 Surcharge - Based on Valuation $5K $2.50 9001.2195 $120.50 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Steven P Trebesch 616 Lantern Ct Saint Paul MN 55123--161 (612) 807-3634 Krech Exteriors Inc 5866 Blackshire Path Inver Grove Heights MN 55076 (651) 688-6368 Applicant/Permitee: Signature Issued By: Signature