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995 Kettle Creek Rd. . ...,,:r,T .,,, ..nca.?.:::?atE+rt+ •s;:,M•e?x!?-;:?.?.r-v+v?l?l!!?4:;:.trA++n -."'^'? CASH RECEIPT CITY OF EAGAN 3830 PILOT KNOB ROAD ? EAGAN, MINNESOTA 55122 DATE necerveo F? AMOUNT ?{? CJ ?. FUND ? ? n 4-0 x ii ? CASH ? t ?- Thank You ,-_ ev `G-r L .. . . ? r. ¢' .-? . White-Payars CoPY .. ? a ?. . , . Vellow-POStingCopY Pink-FileCOpy ,?5' .._-.,- . •. ;::;? JrttL F"Ic. ?aPoRC,vEs cR?;?}f OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHON E: 454-8100 BUILDING PERMIT Receipt# To be used for ocF flW(;/GAR Est. Value $77 9000 Date MARCH 25 Site Address _ Lot ` 2 Block Parcel No. a Name "'?TW MSt?O!{ R(M9 = Addres6 P.O. BUX 1049 ? City WRNSVI[.LE Phone 454-4383 oName 4 SAtuR ? Q Address ?ff City Phone ?Q ? W Name ? W _ ? Address Q W CiW Phone I heieby acknowledge that I have read this application and state ihat the information is correct and agree to comply with all aPPlicable State of MLnnesOta Statutes and City of Eagan Ordinances. Signature ot Permittee A Buildimg Permit is issued to: I'[ETRO ClT$TOA"i ?l01`1ES on the express condition that all work shali 6e done in accordance with all applicabie Stale of M/?i?n?nesota Statutes and City of Eagan Ordinances. BuildingOfficial .CIuLC4 ???ZIl 19 3 Sec/Sub.LEXINMp OFFICE USE ONLY On Site Sewege OccupanCy R-3 MWCCSystem x Zoning pOIR""1 On Site Well (Actuaq Const vn City Water x (Allowable) vn PRV Required # of Stories BoosterPump _ Length . Sg, Depth 381 S.F. Total Footprint S.F. APPROVALS Engr./Assess. Planner Council BIdg.Off. Variance FEES Permit Surcharge Plan Review SAC,City SAC, MWCC WaterConn. 462.00 36•00 231.00 100•00 550•00 550400 WaterMeter 57•00 Road Unit 3ZS+00 Treatment P1 _204-M Parks TOTAL 2, `i^.i.flt? BLDG. PERMIT N0. rI? 01-3210 Bldg. Permit OU 01-3422 Plan Check C) O 01-3445 Surch./Adm. I 01-3446 SAC/Adm. ' C) 01-2155 Surcharge Ij 3860 Road Unit Gu 20-2275 SAC . 1744 20-3865 Water Conn. 20-3868 Water Trmt. 20-3716 Water Meter 20-2252 Acct. Dep. 20-3713 Water Permit 20-3743 Sewer Permit 79-3866 Sewer Conn. !Li c:; 4 ?3855 Park Ded. TOTAL :-:? , ..?.... - .,.-. . . ....A.? . _ ...: ^,.^"'?+'?*!'++f?+?+.ra?-++.'T a•aw-? CASH RECEIPT ~ CITY OF EAGAN ' 3830 PILOT, KNOB AOAD EAGAN, MINNESOTA 55122 DATE 19? . MMIVEO , i • lAL?/i?- AMOUNT $ 8 DOLLARS im ? CASH q CHECK AMOUNT e Thank You BY -. _ ?'- .. .. ..,w Wbite--Payers CoPY 'j. Vellov-POSfirg Copy . . . . Pink-File CoPY PERMIT q ` PLUMBING PERMIT RECEIPT fi CITY OF EAGAN X3830 PILOT KNOB HOAD, EAGAN, MN 55122 QATE: - ' ?- CONTRACT PRICE: PHONE: 454-8100 Site Address ` ?? j` ' LotBlock ec/Sub ? Name m Address c City _ Phone ? Name c Address 0,.1, . +' 0 Cih, . , r :. -. Phone'" FEES COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS - COMM RATE APPLIES TOWNHOUSE & CONDO - RES. RATE APPLIES MINIMUM - RESIDENTIAL FEE - $12.00 MINIMUM - COMM/IND FEE - $20.00 STATE SURCHARGE PER PERMIT - 50 (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND $1,000.00) , .? ? SIGNATURE OF PEFiMITTEE 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 _Kitchen 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 PERMIn _Softener - $5.00 ' -Well - $10.00 _Private Disp. - $10.00 _Rough Openings - $1.50 FEE: STATE S/C: GRAND TOTAL: BUILDING PERMIT To be useif for - D r5 ? (rw.? ?S • s /a ??a sr t7?88ClTY OF EAGAN b oad, P.O. Box 21-199, Eagan, MN 55121 I PH O N E: 454-8100 I Receipt # i Est. Value • • Date Lot Block Sec/Sub.` Parcel No. OFFICE USE ONLY On Site Sewage Occupancy , MWCC System ' On Site Well Y 1.•. -;;'lj,sr.'. CityWater _ a Name W PRV Required = Address ; . 8ooster Pump o r.iw "' `? ? cti,,.,o ? _ . ¢ Name ti.<r 0 ?` Address p- City Phone Name_ Address City_ Phane 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 Permittee --_- A Building Permit is issued to: on [he express condition that all work shall be done in accordancewith all applicable State of Minnesota Statutes and City of Eagan Ordinances. BuildingOtticial______ . APPROVALS Engr./Assess. Planner Council Bldg. Off. Variance Zoning (Actuaq Const (Allowable) # of Storiea Length Depth S.F. Total Footprint S.F. FEES Permit Surcharge Plan Review sac, atv SAC, MWCC Water Conn. Water Meter Road Unit Treatment P1 Parks TOTAL 8-3 PI? s VYe VP e 462*OQ ? I F?t . >? r _ Permit No. Permlt Holdar Date Telaphone # Ptumbin9 ?" 7?' H.V.ItC. eiectric Softener Inspection Date Inap. Comments Footingst ?, Footings II Foundation Framing 41 Roofing Rough Plbg. Rough Htg. Isul. Fireplace Final Htg. 5=2 6 Final Plbg. Z,f Bldg. Final ? Cert. Oca W;' Temp. LP Deck Ftg. Deck Final Well Pr. Dlsp. 9' • .• (Itr#ifiratt of (IDrrupttnry Citp of (tagan Ep}1tlY'bllFttt of gltdbiM JWPI'tlQlt This Certificate issued pursuant to rhe requiremenu of Secfion 306 ojthe Unijorm Building Code certifying that at the time ojissuance this sducture was in compliance with the various ordinances of the City regulating building rnnstruction or use. For the fallowing.• Ihe Cleanifinuon '•'?.rid"`?lt Bldg. Pormit No. oocuaay rya R? zon;nq asu;u rya caM Ownef of Building Addnns . . , 1 • ,? . ` . ' . " <<' g2 a Buildiog Addrese Layfity Date: {,r . 8uilding OffiviJ POST IN A CONSPICUOUS PLACE . ?: CONTRACT PRICE: Site Ad?re ;s ' Lot? 1 Bpck Sec/Sub m Name 1. ' ' m ?+r. - j ?%!A! Address ? ( • c Ciry Phone ? Name 3 Address p 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 MINIMUM - COMM/IND FEE - $20.00 STATE SURCHARGE PER PERMIT - 50 (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND $1,000.00) ;. SIGNATURE OF PERMITTEE FOR: CITY OF EAGAN PERMIT tk PLUMBING PERMIT ? `` ` ( .r._j CITY OF EAGAN RECEIPT # 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: PHONE: 454-8100 y BLDG. TYPE WOHK DESCRIPTION Res. K New X? Mult. Add-on Comm. Repair Other RES. PLBG. ONLY - COMPLETE THE FOLLOWING: NO. FIXTURES T(?TAL -J-Water Closet - $3.00 - $ ?8ath Tubs - $3.00 Lavatory - $3.00 -? -Shower - $3.00 ?Ki!chen Sink - $3.00 ? -Urinal/Bidet - $3.00 I Laundry Tray - $3.00 ? --J--Floor Drains - $1.50 -J_Water Heater - $1.50 1 ? _Whirlpool - $3.00 __j__Gas Piping Outlets - $1.50 (MINIMUM - 1 PER PERMIn _Softener - $5.00 ' -Well - $10.00 Private Disp. - $10.00 ?-Rough Openings - $1.50 ? ' y PEE: . STATE S/C: '- GRAND TOTAL: , . •, MECHANICAL PERMIT RECEIPT q CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: )NTRACT PRICE: PHONE: 454-8100 ' Site Address ? Nan ?o Add c Ciry Phone ? Name c Addre O Cih' ? TYPE OF WORK ? Forced Air ? M 8TU Boiler M BTU UnitHeater - = M BTU Air Cond. M BTU Vent CFM Gas Piping Outlets # ? Other FEE: S/C: TOTAL: BLDG. TYPE WORK D CRIPTION Res. 11z New Mult. Add-on Comm. Repair omer FEES RES. HVAC 0-100 M BTU -$24.00 ADDITIONAL 50 M BTU - 6.00 (RES. HVAC INCLUDES A/C ON NEW GAS OUTLETS (MINIMUM - 7 PER PERMIn - 1.50 EA. COMM/IND FEE - 145 OF CONTRACT FEE APT. BLDGS. - COMM. FATE APPLIES TOWNHOUSE & CONDOS - RES. RATE APPLIES MINIMUM RESIDENTIAL FEE - ALL ADD-ON & REMODELS MINIMUM COMAAEACIAL FEE - 12.00 .. - 20.00 ' STATE SURCHARGE PER PERMIT - .50 (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND $1,000) SiGNATURE OF PERMITTEE `J• FOR: CITY OF EAGAN j CITY OF EAGAN Permit No: 3830 Pilot ICnpb Road B/P No: `°-`' Date: l Date: P.O. Box 21199 ; Eagan,"MN 55171 ? r' Owner. _ - ; ? _ :Iome^ C Site Address: Plumber. MWCC: , . ; : Zoning. ; Cily Chg: No. of Units: Acct Dep: Permit Fee: -- I agree to comply with the Cily of Eagan Surcharge: ' Ordinances. i Misc.: By L SEWER SERVICE PERMIT CITY OF EAGAN Permit No: Date: 4 14- F? 3830 Pilot Knob Road Meter No: Size: ? P.O. Boz 21199 Reader No: Date: Eagan, MN 55121 Owner. Site Ad ? B3 Lezineton Sa 7 Conn. Ch 9? J 51 • "I Ne Zonin Acct Dep:_ 15• 0 020 No. of Units: Permit Fee: y ?? •'' `?P?' 5urcharge: • 5 ',^' I a ree t 1!; " o com I 9 Ph wlth the CMy of Eegan ; ^ Tc Plant : Ord(nances. Meter. - <7 r• ?Pi Misc.: B y WATER SERVICE PERMIT CITY OF EAGAN Permit No: •' 3830 Pila; Knob Road Meter No: ? Q 3 Date: ' P.O. Box 21199 Reader No: ?/?? Z S? Size: ? Eagan, MN 55121 Date -:E- ?i - S-L-? Owner. MPtro ''veton; :?;;:e? SiteAddress: le Ctee'r .T%o1d ? ?? '' _ 7-1 Plumber. bViYlAgonsf-. Conn. Chg Acct. Dep:_ Permit Fee: Surcharge Tr. Plant_ Meter. _ Misc.:_ ,i 1-` • Q ca ???'l?ilr?ies ??$?g- of rgitF? ? CiRPC - (Y ??(?.??IPIY `with the Ciry of Eagan ,. ? rd?:PA-v" es. By WA TER SERVICE PERMIT NO C/0 UNTIL ENG. APPROVES GRAbW OF EACAN . 3830 Pilot Knob Road, P.O. Box 21-199; Eagan, MN 55121 ?o- 14726 BUILDING PERMIT PHONE: 454-8100 Receipt # U CA To be used for SF DWG/GAR Est. Value $72,000 Date MARCH 25 19 88 Site Address 995 KETTLE CREEK ROAD OFFICE USE ONLY LEXINGTON SQUARR Lot 22 Block 3 Sec/Sub on Site Sewage Occupancy R-3 . 7TH ADDITION MWCCSystem X Zoning PD,R-1 Parcel No. Vn On Site Well (Actual) Const e Name METRO CUSTOM HOMES Citywater X (Allowable) Vn ? P.O. BOX 1049 Address PRV Required _ # of Stories a City BURNSVILLE Phone 454-9383 Booster Pump _ Length 55' DaPtn 3$' p Name SAME S.F. Total o? AddreSS FootprintS.F. U< P City Phone APPROVALS FEES I-M "W W Name Engr./Assess. Permit 462.00 W Planner ?g Address Council _ Plan Review 231.00 a W CityPhone Bldg. Off. SAC, City 100.00 I hereby acknowledge thet I have read this application and state that the Variance SAC, MWCC $50.00 information is correct and agree to co ly with all applicable State of Water Conn. 5$0.00 Minnesota Statutes and Cit gan nances. Water Meter 67.00 i ? Signature of Permittee _ Road Unit 325zQ0 A Builtling Permit is issued to: METRO STOM HOMES Treatment P1 _204_..011 on the express condition that all work shail be done in accordance with all Parks applicable State of M in nesota Statutes a nd City of Eagan Ordinances. 525 00 2 /? , / Building Official?L.71ed, TOTAL . , ? ` REQUEST FOR ELECTRICAL INSPECTION ee-ooooi-os Il, See instructions lor completing this form on back ot yellow copy. D`9 408 6 "X" Below Work Cavered by 7his Request New, AAd ReO. Type ot Building ApplianCes Wired ?quiVment Wired Home Range emporery Service Duplex Water Heater Lightiny Fixtures Apt. Building Dryer Electric Heatin Commercial Bldg. Furnace Silo Unloader Industrial Bldg. Air Conditioner Bulk Milk Tenk F•drm Q(hYl Ve?Hy iher (5oorlfY) t er SUCCily Other Othcr Comnute Insoection Fee Below q Fea Service EntraocaSize R Fee Fexders/Subleeders # Fee Circui[s C) to 200 qm s 0 to 30 Am s 0 to 30 Am Above 200 qmpy 31 to 100 Amps 31 to 100 Am s Swimming Pool Above 100-Amps Above 100_Am s Transformers Irriyation Booms Partial,?Other Fee Signs - Special Inspection I TOT pEE Remarks ? y „r h Da1e 1, the ectricai I spector. herohy L nl ,D,^t? ' inspection has been d me a. Thie reQUest vo10 19 moMlls irom ? 9 This requesl void ??fj? 76 nwn(hs from ? !J D. 94086 o? Req t Date Fire No. RouPh-iri I eciion D ? Hequired? ' ?Ready Now Q Will Notify Insuec- .% ?Yes ?No tor When Ready MINNESOTA STATE BOARD OF ELECTRICITV THIS INSPECTION REQUEST WILL NOT Gripgs-Midway Bldg. - Room N-191 --..> eE ACCEPTED 8Y THE STATE BOARD 1.Q?1.,Unipersity_Ave., St. Paul, MN 55104 , UNLESS PflOPER INSPECTION FEE IS ' Fhone (612j 642-0800 ENCLOSED. L.1'ucensetl tiectncal Contractor I hereby requastinspection of above ? Owner electrical work ins<alled at: ???/8'8` REQUEST FOR ELECTRICAL INSPECTION jift ee-oooai-os See instruCtions lor completing this form on back of yellow coCV• If, a D. .9 41n ?JJ ""x" Below Work Covered by 7his Request H NeO. Type of BuiltlinA APPlinncea Wired Equipment Wired -A Home Ranye Tem orary Service 1 0 Duplex Water Neater iyhtiny Fixtures Apt. Building Dr er Electric HeaUn Commercial Bldy. urnace Silo Unloader Industrial Bldg. Air Conditioner Bulk Milk Tenk Farm cher Speci v Other (speclfy) l P.! SVCI;Ify OSf1Cf Oth(+f Comoute lnsoection Fee Below p Fee SerViCe EnlrenceSize 8 Fee FeeJers/Subteeders k Fee Circuits 0 to200Am s 0 to30Am s 0 to30Am s Above 200 qmps 31 to 100 Amps 31 to 100 Am s Swimming Pool Above 100_Am s Above 100_Am • Transiormers Irrigation Booms Partial-"Other Fee i Signs Speciallnspection ? TOTA E NBrtr3rks ( ? J M.1 Rough-in tq 1. Ihe Ele cal ? IISpOCIOf, hBre y certify that the above Final ?'' insvection has been ,y ? / mede. L%. fhis reQuest void 18 monlns from This reVUest void 16 months troT D Q1d 4103 r :0, Reqyyy??? st D'ate'! Fire o. RouP ?i InsVectip 1 Re.qu?r ? ?Ready Nuw ?M Nolify. Insper.- I s ?No ? tor When Ready iaLicensed Electrical Contractor I here6y request insDection ot above ? Owner electrical work installed at: St t A ress. Box or te No. Citv 9)1 014k ec ion . Township ame or No. Range o. County Occ peM (P INTI E a rvi I-? b 6 s Phone o, Pow up0lier AddreSs 1 Electrir.al Coniractor ICompany Namel Contracto 's Licensc No. ro? ? a ntractor or Owner Making Instailation) m ELFCnTC Auth r ?!L daT?'1,C?nL akiny Insialla[ion) PPL 1tllJ NE A Phone Numbe r MINNESOTA STATE BOAHD OF ?ELE(:?N7C?V7IG?-g THIS INSPECTION REQUEST WILL NOT Griggs•Midway Bidg. - Hoom N-191 BE ACCEPTED BY THE STATE BOAHD 1821 Universitv Ave.. St. Paul, MN 65104 UNLESS PROPER INSPECTION FEE IS Phone(612) 642-0800 ENCLOSED. *dtV oF eagan PATRICIA E. AWADA Mayor PAUL BAKKEN PEGGY CARLSON CYNDEE FIELDS MEG T[I.I.EY , Counal Members THOMAS HEDGFS CiryAdtninistrator Municipal Centtr. 3830 Pilot Knob Road Eagan, MN 55122-1897 Phone: 651.681.4600 Fas: 651.681.4612 TDD: 651.454.8535 Maintenaace Facility: 3501 Coachman Point Eagan, MN 55122 Phone: 651.681.4300 Fax: 651.681.4360 TDD: 651.454.8535 www.ciryoFeagan.wm THE LONE OAKTREE The rymbol ofstrength and growth in our cnmmuniry October 16, 2002 Steven & Susan Stafford 995 Kettle Creek Rd. Eagan, MN 55123 Re: Vacation of Public Drainage and Utility Easement - 995 Kettle Creek Rd. Dear Mr. & Mrs. Stafford, Recently, you submitted a petition to the City Council to vacate a portion of an existing drainage and utility easement located adjacent your northwest property line to accommodate an addition to your current home. This request was scheduled for a public hearing before the City Council on Oct. 15, 2002. Notification of this public hearing was published in the legal newspaper and sent to all potentially affected utility companies as well as reviewed by the City Public Works Department As a result of this review, it was determined that a 48-inch diameter storm drainage pipe is located within this easement approximately 20 feet deep. Due to the depth of this pipe and the needed setbacks for excavation access, the City did not believe that it would be in the public's best interests to allow this requested encroachment and related vacation of the utility easement. Subsequently, the City Council denied your petitioned request at the close of the public hearing. I'm sorry that we were not able to accommodate your request. If you have any further questions regarding this matter, please feel free to contact me at your convenience. Sincerely, Thomas A. Colbert, Director Department of Public Works a-- RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 P1LOT KNOB RD, EAGAN MN 55122 851-881-4675 New Constructlon ReauiremeMa • 3 regislered site surveys showing sq. ft. ot lot, sq. ft. oi house; antl ?II roofed areas (20% maximum lat coverage albwed) . 2 copies of plan showing beam & window sizes; poured tound design, etc.) • 1 set of Energy Calculations • 3 copies of Trea Preservation Plan tl lot platled after 711l93 • Rim Jolst Detail Options Selectbn sheet (bidgs wrth 3 or less units) DATE (C2 I Y /?? SITE ADC NPE OF APPLICANT A STREET ADDRESS TELEPHONE # g AULTI-FAMILY BLDG _ Y xN FIREPLACE(S) _ 0 _ 1 _ 2 WQ4, d-uC. ?N&/ CIN &oioml STATE /LAIZIP65-? Wly CElL PHONE # 61,2 -.?? 6- 7?VO FAX # 95 2 -oS F9V S _ PROPERTY OWNER 31AL Af.(f1?t72 (i( TELEPHONE # ------------------------------------------------ ----- --------------------- --------------------- COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 MINNESOTA RUI,ES 7672 (4 submission type) . Residential Ventilation Category 7 Worksheet Submiried • New Energy Code Worksheet Submitted • Energy Envelope Calculations Suhmitted Plumbing Contractoc _____ Pluxnbing system includes: Mechanical Contractoc Mechanical system includes: Sewer/Water Contractor: _ Water Softener Water Heater NO. of Baths 4C f 3.75 RemodeVRe ag h Re,putremeMs • 2 copfes of plan • lsetotEnergyCakulatbnsforheatedadditions • 1 slle survey for eMerior additions 8 decks • Indicete if home served by septic system for addRions VALUATION 0 5, D O O Phone # Lawn Sprinkler No. of R.I. Baths Air Conditioning Heat Recovery System Phone # Phone # Fee: $70.00 -------------------------------------------------------------------------------------------------------------------------- I hereby acknowledge that I have read this application, state that the information is co ly with all applicable State of Minnesota Statutes and City of Eagan O^dir?a c.' ?? ????f m n Signature of Applicant OFFICE USE ONLY Fee: $90.00 Certificates of 5urvey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4/02 OFFICE USE ONLY ? 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 O 16 Fireplace ? 09 07-plex ? 17 Garage ? 10 08-plex ? 18 Deck ? 11 10-plex ? 19 Lower Level ? 12 12-plex Pibg_Y or_ N ? 20 Pool Q 21 Porch (3-sea.) ? 22 Porch/Addn. (4sea.) ? 23 Porch (screened) ? 24 Storm Damage ? 25 Miscellaneous O 30 Accessory Bidg, ? 31 Ext. Alt - Multi ? 33 Ext. Alt - SF ? 36 Multi ? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding ? 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair ? 33 Alteration ? 37 Demolish (Bldg)" ? 43 Reroof ? 46 Windows/Doors ? 34 Repiacement 'Demolition (Entire Bldg only) - Give PGA handout to applicarwt Valuation Occupancy MClES System Census Code Zoning City Water SAC Units Stories Booster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs Length Fire Sprinklered Type of Const Width REQUIRED INSPECTIONS _ Footings (new bldg) _ FinaVC.O. _ Footings (deck) _ FinaVNo C.O. _ Footings (addirion) _ Plumbing Foundation HVAC Drain Tile Other Roof _ Ice & Water _ Fina] _ Pool _ Ftgs _ Air/Gas Tests _ Final _ Framing _ Siding Stucco 5tone _ Fireplace _ R.I. _ Air Test _ Final _ Windows (newheplacement) _ Insulation _ Retaining Wall Approved By Base Fee Surcharge Plan Review MC/ES SAC City SAC Water Supply & Storage S&W Permit & Surcharge Treatment Piant Plumbing Permit Mechanical Permit License Searoh Copies Other Total Building Inspector 1988 BUILDING PERMIT APPLICATION - CITY OF EAGAN SINGLE FAMILY DWELLINGS INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OE SURYEY, 1 SET OF ENERGY CALCULATIONS NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WIiICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED. MULTIPLE DWELLINGS RENTAL QNITS FOR SALE UNITS # OF UNITS INCLUDE 2 SETS OF PLANS, CERTIFICATE pF SURVEY - CHECK WITH HLDG. DE 1 SET OF ENERGY CALCULATIONS " CONIIMERCIAL INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS, 1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS To Be Used For: PEC.k, Valuation: Site Address GtC?? ??Le- (JRPsK ? Lot 127. Block 73 Parcel/Sub I Owner ?EV? C-4 Address -mS LSe4L £ bae(c 1u. CitylZip Code F-p a s,u ?A U ?_S! 13 Phone 44r(o c) 10 tt Contractor n/1 Wttc) Address Y City/Zip Code Phone LJ Sq °13 ?3 Areh./Engr. ?S*A&0- L@ kQ . _ Address ' "S4p.(? N w City/Zip Code Phone # sr2+s 1'714('. Date: . ? . ;.. OFFICE USE ONLY On site sewage _, Occupancy MWCC system ? Zoning On site well ? Actual Const City water _ Allowable PRV required _ # of stories Booster Pump _ Length Depth S.F. Total Footprint S.F. APPROVALS FEES Engr/Asaess Permit ? G Planner Surcharge Couneil Plan eview Bldg. Off. SACt C Varianee SAC, MWC Water Co Water ter Road it Trea ent P1 AL /1?E7R.o L'U57bM L?nntE5 pLANNEAS ondaLAHD SiURYEYOltS B?K ioo ?ENGIN Ef ?ING CCHSULTIHO PAGc 44 C4MPANYI INC. ?? 1000 EJ?ST Ii6Ct 57AEET, BURNSVILLE s YIHHE507A SS337 PH 432'j000 CeTZ ?4c1 zort: LoT 22, BWCK 3, LEX/NGTON SOUA2E 7TH ADDIT/ON, MiNNESOTA DAK07-A counM- (,P,az, 9) ?sea:9, OR4/N.<!GE AND ' uT/LI TY EASEMEA/T s ? ? 0 30' BU/LD/N6 ?• `1 lY2 l2? ? / ?? ? `?'= ? L82,4-; _ ? /^ l $E i BAGC L/A/E I \ ?? 1 <) Pz;4 . ? D ? 3O a ? 3?? ?? ? S /" _ 30, Acl.v??? • ? rv<. 0 ? - ? 0 OD _s% D6N07E S EX1971N6 ELEVAT/O/V ???'?. o?'sa?,' \? ?e??3R? ??, ? (889:s) DEn/OTES. P?2oPaSEO ELEt/AT/0A1 /NO/CATES ,b/RECT/OA! OF SuRFAeE 09WNA6E ?a ,zez '884.83 = F/N/S.?ED 6RRA6E ?\at FGooR ELEV9714N I her:by cartify, that thia ia a t:ue and cflrrsct repraeentition oi a tract ot land as ahcwn'and deacribed herson.• Aa prspared by me on this Z? ?Alp day of /YIA.ect/ ? 19_. • ?..,,. - xinn. Raa. XO#01?640 - ; ? U" r ? tto If A*xv % . Z- - ??c?-- ( . Q ? 41 ?4 .?. i gOOr'I ru?? :i io?? 0 (,? ??ior, ? ` - -- .?? ?C.??F1 V/a/L"(?? , ? i ? z. f '€ • ? • , .,'..?„ . ? L'NO P017t T? ?11eN6. ?M * • y?._..?.?,? ? o ?, , - - -o - ,...?,..? , .... ?, ? ?-- ?- ?? , Q ? -Z Xl O 14 r _ ?p ? Q "? ?4 f A , R ? ? ?` ??'?. p _?.?. - ? ' ?: •t%?IS v ? `' ???? . ..1l??a'i . ? ? ? ? ???,.K ?y?. ' ' ,„ :i ? ?? ?..? .v ? ? .: ?•r . ? '?J?: ? , gq? .}•- ?-;.• -;?2:-,?;- . ?0';? x . . .?9?_,G?ic Yc T,:' . '. - ?, ? ?. - I r_, 1988 BUILD G PERMIT APPLICATIOP - CI'TY OF EAGAN, SINGLE FAMILY DWELLINGS INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OE SURVEY, 1 SET OF ENERGY CALCULATIONS NOTE: ADDAESSES FOA CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE HUILDING PERMIT IS ISSUED. MULTIPLE DWELLINGS RENTAL UNITS FOR SALE UNITS # OF UNITS INCLUDE 2 SETS_OF PLANS,. CERTIFICATE OF SURVEY - CHECK WITH BLDG. DEPT.;- ' 1 SET OF ENERGY CALCULATIONS CONMERCIAL INCLDDE 2 SETS OF ARCHITECTUftAL & STRUCTURAL PLANS, 1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS - To Be Used For: Sinele Familv Dwe?lyaluation: "4. gog--gg- Date: Ma.rnh 99. 1988 Site Address 995 Kettle Creek Road Lot 22 Block _'i_ Parcel/Sub ?xin t,on ,q.. _ 7th Add;t;c,n Owner MPtro (',nct.nm Hnmas Address P.O. Box 1049 City/Zip Code 3jjrnsyjj ?Mn. 55'?q7 Phone 454-9_?8? Contractor Sa.me AddrAss City/Zip Code Phone Areh./Engr. qamP ? Address City/Zip Gode. Phone li ' OFFICE USE ONLY 7Z oco" e On site sewag e_ Occupancy R' 3 MWCC_system ?/ Zoning p. R"? On site well Actual Const ? V-N City water w- Allowable v-hi ? PRV required _ # of stories ? I Booster Pump _ Length_ . $S ? Depth 3 S.F. Total Footprint S.F . APPROVALS - FEES Engr./Assess Permit y6z,00 Planner Surcharge 3l0,00 Council Plan Review B1dg. Off. =*2S-SAC, City 2 ?,00 I00 100 Uariance ' SAC, MWCC a 00 ' Water Conn SgO, c V ; Water Meter 69, OJ ? Road Unit 3Z , po - Treatment P l Zpy , 00 ' Parks Copies TOTAL a,?"as ?-- VA ?.UATioN ? GaR?GE •_ . ' , ZLIY-L2 = 52g x Iti= ?39Z i??? 3q X Z.S =qso x 13 W ?2350 h-lousC _-ftft 3 SX25: 9S`O Ix I?. = IZ )e i ab?r x yR ? szIS_ ?tg?8 , . R A ? 3a' FRoNT Bv/L.0iN 8 $ETBACX L/NE ?, \ z ??,g 6J ? DO CerZZ?i ccz?? ??Ye c? DRA/N.AGE AND UT/L/TY F,49EMEN7- - ? ? ? \ (• ? Ol .? \ 1LJ QO <'s o ? "f'o \40 )WXa eU67NM ;dt/26Z,d/ COH511L71NC3 E!{OINEEtlS goolc 100 PIANHEflI cnd LAliD iUt1VEYORS pq`E 44 BURHSVILLE I 41NNE507J1 56337 PH 432-3000 (Eez• ) (8BZ,911 s / ? ) ?o ?8R /S R / > a- ?- ?°e BR?:, zs t '6° . , , \ J ?S . \ ?a ? .? ?.' 9C41-E : /" = 30, DEN071E S EX1971N6 ECEVAT/aN (88q-, 5 ) DENO71E,6. P/2oPOSEC ELE V4T/ON s? 1ND/CA71E$ b/RECT/ON 0F ,guRFACE 9R41NA6E gg¢,83 = F/N/SNED 64946E FGOOR EL&I197-14N I hareby cartify that thia ia a t:ue and carrect rnprneentition of a tract of land aa aho++n' and deacribed hereon.• Aa prepared by me on this 2r?!, day of w/YIAzc.y , 19 SS • ,?.,,. s.,.:? Hinn* lles. Ho• .? IR46E ENGiNEfR1NG COMPRNY, INC. 1000 EJ?57 1461h STREET9 ? ?aQcl ..Dr?scriP2iorz: LoT 22, BLOCK 3, LEX/N67-dN SOUARE 7TN ADD/T/aN, DAKOTA CouNTY, M/NNESOTA . ***************#******?*******#****# C I TY O F E A A i? *?': ?'AYS?IFTTC OF FEE AT TIME pF ? . *APPLICATION DOFS NOT CONSTITVtE ? ? APPROVAL OF PERriIT. * APPLICATION FOR PERMIT * * * INSPFX.TION oF SEWE12 AIVD/032 MTIIt ,*f • , '.. ,?*, =11=0NS WII.L N02 SE SCEED- * SEWER AND/OR WATER CONNECTION * ? ?? PERMT Em Bm * . . • * APPROVED. * ?, x* * * * ... ********************,r*t*:*********?* / P ease Print ?:1) PROPERTY ADDRESS : v/ 9,17 t0 ... LEGAL DESCRIPTION: i . tLOL/niocK/subaivision or Tax Parcel ID-I)-- If' EXISTING STRL'C-MME, DATE OF ORIGINAL BOILDING PEF2A2iT ISSL'ANCE: - _ y •- PRFSENT ZONING/PROPOSID (;SE: (Nbn Year q corMERciar,/RErAtL/oFFzcE Q INIDUSTRIAL ? INSTIZUTIONAL/GpVERDIl+g,'NT ?. R-1 SINGLE FAMILY ? R-2 DLPLEX (Two Units) ? R-3 TOWnII-iOUSE (Three + Units) ( Units) ? R-4 APARTMENT/CONDOMINiUNI ( Units) 2) ? NAME: /t F- S F/6r2 ?,f' C • - ADDRESS: 0. .3 Vj t 41N =-ni C--1$- . CITY. STATE, ZIP: A-ePL L C:,4t Z? y /?,? • ?,?'/.? ?y! PHOIVE: y 3 - S2 % L . 3) • c ?- NAPE: ADDRESS: CITY, STATE. ZIP: PHONE: yo ? 9 MASTER LICEDISE# 3 b `11 AA ? Plumbers License: a Active Expired ??. Not recorded staf Initial 4) •• • _ ADDRESS: . CITY, STATE, ZIP:?'? ?. ?,.; i v L L?? i?J?? ' PHoNE: ys-y= ys€?3 •5) . ?. CONNEC.'TION TO CITY SEWER ? CONNECPION TO CITY WATER ? OTHIIt .- 6) ?? • i q PLEASE HOLD APPROVID PERMIT FC)R PICK-UP BY ONE OF ABiOVE Q PLEASE MAIL APPROVID PERMIT TO 1, 2, 3. 4, ABOVE :. 7' ? ? ? ,ti• (Circle one) _ . ., TOR CITY USE O{VLY PERMIT # ISSUED Pd w/Bldg. Permit FEES: $ $ SEWER PERMIT (INCLUDE SURCHARGE) $ $ WATER PERMIT (INCLUDE SDRCHARGE) $ /,o o $ WATER METER/COPPERHORN/OUTSIDE READER $ $ WATER TAP (INCLODE CORPORATION STOP) $ $ SEWER TAP $ $ ACCOUNT DEPOSIT - SEWER $ $ ACCOUNT DEPOSIT - WATER $ 0-6 $ WAC $ ?p SU • U C? $ _ SAC $ $ TRLNK WATER ASSESSMENT $ $ TRUNK SEWER ASSESSMENT $ $ LATERAL BEIVEFIT/TRLNK SEWER $ $ LATERAL BENEFIT/TRLNK WATER $ 4?`-?` 4 Z/ $ WATER TREATMENT PLANT SURCHARGE $ $ OTHER: $ /?z' I e7 Ll $ TOTAL ? RECEIPT RECEIPT BOES LTILITY CONNEC TION REQLIRE EXCAVATION IN PUBLIC RIGHT OF WAY? F_'_j YES IF YES, THEN A" PERMIT FOR WORK WITHI[V.PLBLIC Q NO ROADWAY" MUST BE DIVISION ISSL?ED BY THE ENGINEERING . LIST AS.A CONDITION. SU BJECT TO THE FOLL OWING CONDITIONS: APPROVED By: TITLE: DATE : ; LoT Z Z `[3 t aac- 3 ?,EX/Nb?7C?/v ? EXTERIOR ENVELOPE AVERAGE COMPUTATIQN DETERMINE WORKING S9UARE F00'fAGE 1) WALL RREA: 1460 *,.i1 =_ 166.6 2) ROOF AREA: 1103 *.4'026..= 28.67 TOTAL tXPOSED WALL ARFA 146b A) WALL NINDOW AREA $9,5. B) DOOR AREA yd C) PA1'IO DOOR AREA . ° D) ?,IRE??LA'C?L? WALL AREA " ' D ;: . E) WALL FRAMIMG AREA 1'46 F) NEt WALL AREA G) RIM JOIS1` AREA ?123.;: TaTAL EXPdSED FQUNDA7I0N`AREA 0 H) FdUN4ATI0N iJIN60W l4aEA? p ? T) tOTAL NET.FOUNDATION.AREq ;.0 OETERMINE U VALUE OF EdCH WALL SE6MENT ' A) 89.5 4U .55 = 49.22 B) 40 *tJ .07 = 2,8 C) 80 *U .55 = 44 D) 0 *U .359 = p E) 146 *U .096 = 44.01 : F) 981.5 ?wU .043 = 42.2 G) 123 *U .028 = 3.44 H) 0 *i1 .55 = D I ) ? -wU .07 = 0 . 3) TOTAL ? 152.24 NOTE; IF ITEM q3 152.24 tS THE SAMp A$, AR lESS tHAN ITEM 1l1 160.6 ?YOU HAVF Mf T tHE'INTEHT 4F SBC 606(C)2 T07A1 FXP05E0 ROOF AREA= 1103 J) SKYLIGHT AREA p K) ROOF FRAMING ARf_A 110.3 L) NET'INSULATED ROOF`AREA. 992,7 ' DETERMINE U VALUE FdR EACH RQOF SEGMEN'f J) D*U_55=0 - K). 110.3 -;U .026 ? 2..86 L) 992.7 +Ft7 .O21 = 20,84 IF TOTAI OF Jt4 23.71 IS THE 511ME qSj OR LESS THAN ITEF1 #,2 .28.67 ' THEN YOU HAVE MET 7HE IN7ENT. OF SBC 66D6(C)1 pLTERNATE BUILDTNG ENVEIpPE DESIGN TO UTILI7E TOTAL ENVELQPf SYSTEM METHOD VALUES ESTABLI3HED BY.THE SUM OF ITtNfS 03 AND i/4 SHALL AOT BE GREATER THAN . THE SUMS dF ITEMS q1 AND #2. T) 160,6 + z) 28.67 489.27 3) 152.24 + 4) 23.71 = 175.95 . . . , - .? : . . ? T?I 1 hl, r RESIDENTIAL BUILDING Permit Application City Of Eagan 3830 Pilot Knob Road, Eagan Mn 55122 Telephone # 651-675-5675 FAX # 651-675-5694 -9 °73. &v Cu,l,?.cpt? ? I L?l ?03 New ConsWction Reaui2ments RemodeUReoair Requirements OTfice Use Onlv 3 registered site surveys showing sq. fl, of Iol, sq. ft of house; and all roofed areas 2 copies of plan Cert of Survey Recd (20% maximum lot coverage allowed) 1 sel of Energy Calculations far heated addi6ons Tree Pres Plan Recd 2 copies of plan showing beam & window sizes; poured faund design, etc. 1 site survey for additions & decks Tree Pres Not Reqd 1 set of Energy Calculations Addition - indicate if on-site septic system _ On-site Septic System 3 copies of Tree Preservation Plan if lot platted afh:r 711193 Rim Joist Detail Options selection sheet (bldgs with 3 or less units Dated4(J Construction Cost / SiteAddress Qz,(c ? • UniUSte # Description of Work e- ?a- c,(L Multi-Family Bldg _ Y _IfK N Fireplace(s) _ 01 _ 2 Property Owner 7f?c /gC.Le_ Telephone #(&Q' ) qs{oxi ?0?( '6 Contractor E U-CQ Address - City State Zip Telephone # ( ) COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING - Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672 Energy Code Category . Residential VenUlation Category 1 Worksheet • New Energy Code Worksheet (J submission type) Submitted Submitted • Energy Envelope Calculations Submitted Licensed Plumber Mechanical Contractor Sewer/Water Contractor Telephone # ( ) , - _ T I 7p13'one i Telephonek L_ ?f " I _ •- - ._. ?J I hereby apply for a Residential Building 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 State of MN Statutes; 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. _ ApplicanYs Printed Name , 0 Applic s Sign ture OFFICE USE ONLY, ? Sub Types ? 01 Foundation ? 02 SF Dwelling ? 03 01 of _ plex ? 04 02-plex ? OS 03-plex ? 06 04-plex Work Types ? 07 05-plex ? 13 16-ptex ? 08 06-plex ? 16 Fireplace O 09 07-plex ? 17 Garage ? 10 08-plex 6 18 Deck ? 11 10-plex . ? 19 Lower Level ? 12 12-plex Plbg_Y or _ N ? 31 New ? 32 Addifion ? 33 Alteration ? 34 Replacement Valuation Census code SAC Units - Nbr. of Units Nbr. of Bldgs Type of Const Footings (new bldg) ?- Footings (deck) _ Footings (addition) Foundation Drain Tile Roof Ice & Water Final _ Framing _ Fireplace _ R.I. _ Air Test _ Final _ Insulation Base Fee Surcharge Plan Review ' MC/ES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant License Search Copies Other Total ? 20 Pool ? 21 Porch (3-sea.) 0 22 Porch/Addn. (4-sea.) ? 23 Porch (screen/gazebo) ? 24 Storm Damage ? 25 Miscellaneous ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 ? 37 Demolish (Bldg)* ? 43 Reroof ? 46 'Demolition (Entire Bldg) - Give PCA handout to applicant Occupancy MC/ES System _ Zoning City Water _ Stories Booster Pump _ Sq. Ft. ? PRV _ Length ? Fire Sprinklered _ Width ? .. ? 30 Accessory Bldg ? 31 Ext. Alt - Multi ? 33 Ext. Alt - SF ? 36 Multi Misc. Siding Fire Repair Windows/Doors REQUIRED INSPECTIONS FinallC.O. ? FinaUNo C.O. _ Plumbing HVAC Other _ Pool _ Ftgs _ Air/Gas Tests _ Final _ Siding Stucco Stone _ Windows (new/replacement) _ Retaining Wall Approved By ? Building Inspector ?E7Ro [?US?M L?o?,ES • A O p e E (pNSUtTiHO EH8IHEEltS BcoK loa N ?tING PIAHNEFII ond LAND illRVEYO!!S PA?? ENGiNEf ? CoMnANY, 1NC. ??1000 EAST 146th 57REE7, 9URNSVILLE, YIHHES/TJl 55337 P H 422-3000 CeT?Z?Z Ct3?? V?LLi ?"'Y'e [? ?aqal ?ti .T ? p?i ort: LoT 22, Bl.OCK 3, LEx/NGTON SouARE 7TH ADD17I0N • DAKOTA Caun/7Y, M/NNESOTA &z, ) \\",-(ggz DF?A//VAGE AND vTiC.?TY ??'EMEti/T s ? \ 2s R?O f/ p Cj ?\ ?I 9S' STS. / ?DO ?O / ? 3a' 0 / ` O Q , ) FROiIlT ? ? ? n° \ RU/LDI/V 6 `• ; \ L8z ( ic ?7BAC.jC L/NE •- p 82 ? `S ? ???sJ ?? ?s , ?'eg a? o ?? p0 -j • ?8.. ?? ?'OQ ?? a ??a ?• o / fl Q ? ? DENOTE,-.? EX/977N6 G[.GVATIQAv ' o ? . . ? ? ??3R. C? ? ?, ? (884 S ) DENOTc'S. P.QOPO.Sc:: ?'? ELEI?AT/On1 ?/ /ND/CATES D/RECT/C/V ?8 OF S?/RFACE 09411VA6E 9a ??889:83 = F/N/?'.=/ED 6RR46E ?;. F?acfZ E-EVAT/oN a I heriby cartify that thia ia a t:ue and carrsct rnprasentation of t trict of ltnd as aho+m'and deacribed hereon•• As prsPared by me on this Z?ND dsy °f ? NJA,?c?/ , 19 a8. • ,?..,. ?iinn. ?tes. - :o PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA123223 Date Issued:06/02/2014 Permit Category:ePermit Site Address: 995 Kettle Creek Rd Lot:22 Block: 3 Addition: Lexington Square 7th PID:10-45081-03-220 Use: Description: Sub Type:Residential Work Type:Replace Description:Air Conditioner Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952) 445-2840. Janel Behrends 122 West 3rd S Fee Summary:ME - Permit Fee (Replacements)$55.00 0801.4088 Surcharge-Fixed $5.00 9001.2195 $60.00 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 J Stafford 995 Kettle Creek Rd Eagan MN 55123 Haley Comfort Systems 122 West 3rd St Hastings MN 55033 (651) 437-0338 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA168572 Date Issued:04/26/2021 Permit Category:ePermit Site Address: 995 Kettle Creek Rd Lot:22 Block: 3 Addition: Lexington Square 7th PID:10-45081-03-220 Use: Description: Sub Type:Residential Work Type:Alteration Description:Adding backup sump pump run by water pressure system Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size Comments:Please call Building Inspections at (651) 675-5675 to schedule a final inspection. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Building Code). Fee Summary:PL - Permit Fee (miscellaneous)$59.00 0801.4087 Surcharge-Fixed $1.00 9001.2195 $60.00 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 J & Susan K Stafford 995 Kettle Creek Rd Saint Paul MN 55123--151 Riser Plumbing Inc 2233 105th St SW Montrose MN 55363 (952) 215-2951 Applicant/Permitee: Signature Issued By: Signature