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4241 Jasper Dr CITY OF EAGAN 3830 Pilpt Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 BUILDING PERMIT Receipt # To be used for -' C? Est. Value u ?ocx1 Date MAY I? , 19 E,9 Site Address 4241 JASPEk aR Lot ` Block 5 Sec/Sub. C EL'AR GROVE 2ND OFFICE USE ONLY PBfCBI N0. Occupancy - FEES W Name JOH? ??ERSON Zoning (Actual) Const Bidg. Permit 26•00 ? o Addres s ??Z41 3A SPEk L?R (Allowable) - S h ?Q • l urc arge ( City 11?-14 Phone 454"W6 - # or stories ,o Name ?? ?a Address .' }` )4 kFzCV3$LfRfi; Ltif r CitV Phone '?; s-•'-471a Address Phone I hereby acknowlege that I have read ,iinformation is correct and agree to 0 Minnesota Statutes and City of Eagan ( •}- Signature of Permitee ! A Building Permit is issued to: Al on ttie express condition that all work : ? applicable State of Minnesota Statutes Building Official with all Length _ Plan Review Depth - SAC, Ciry S.F. Total - SAC, MCWCC S.F. Footprints - On Site Sewage _ N/ater Conn On Site Well - Water Meter MWCC System - _ City Water Acc t• Oeposit PRV Required _ S+W Permit Booster Pump - S.,W Surcharge Treatment PI APPROVALS Road Unit Planner - pazk Ded. Council 1.00 81dg.Off. _ Copies Variance - TOTAL 27 • 50 Permk No. PermN Holder Date Telephone # WATER SEWER PLUMBING H.V.A.C. ELECTRIC Inspection Date Insp. Comments Footings I Foundation Framing Roofing Rough Pibg. Rough Htg. Isul. Fireplace Fnal Htg. Final Plbg. Const. Meter Plbg. Inspector - Notify Plumber Engr.lPlan Bkig. Final Dedc Ftg. C /vs Declc Final weli Pr. Disp. CITY OF EAGAN Addition Cedar 10 state Ea,gan,MN 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. 1985 1266.95 84.46 15 STREET RESTOR. GRADING SAN SEW TRUNK 3b SEWER LATERAL 1972 13 •QQ 2 . 2 (']$ 08 C00$372 $-$-$3 WATERMAIN # WATER LATERAL 972 WATER AREA STORM SEW TRK STORM SEW LAT CURB & GUTTER SIOEWALK STREET LIGHT WATER CONN. ' BUILDING PER. " SAC PARK ry . BUILDING PERMIT To be used for DECK CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 Est. Value $1, 000 11TO. 16495 Receipt # C!, Z C) `?n Site Address 4241 JASPER DR Lot 4 Block 5 Sec/Sub. CEDAR GROVE 2ND OFFICe USe ONLY PBfCBI NO. Occupancy _ FEES Zomng - w Name JOHN ANDERSON (Acluap Const _ Bldg. Permit 26.00 3 Address 4241 .IASPER DR (niiowwie) - S h .50 ° EAGAN City Phone 454-1486 darsrories um arge - Plan Review lengih _ o Name AME Depth - SAG Cdy , g¢ Address 2804 VICKSBURG LN sP 7otal - r ?ilfY PL]'[]OjJ'I'H Phone 553-9274 SF Faatprints SAC,MCWCC - Water Conn On Srte Sewage - ww `- Name On Site Well - Waler Meter z? AddfQSS MWCCSyslem - oO <w City PhOne City Water Acct. Deposn - 5/W Permil PRV Reqmred _ I hereby acknowlege that I have read this application and stale Ihat the BoosterPump - SiW Surcharge information is correct and agree to mply with all applic Stat f Minnesota Statutes and of Ea Ordinances. 7reatment PI Signature ol Permitee APPROVALS Road Unit A Building Permit is issued to: AMZ Planner - park Ded. on the express condition that all work shall be done in accordance with all Caunal - 1.00 applicahle State of Minnesota Statutes and City of Eagan Ordinances. gldy pry _ Copies tfu,?('1 1 ?? Builtl?ng Official ?? \ Variance - TOTAL 27.50 9 % EAGAN TOWNSHIP BUILDING PERMIT N° 3095 Ownex ........... ......./. ...... ......................... Eagan Townahip Address (P=eseni) ----'Y Yi .........?.--_.----......_--_.---. Town Hall i Builder ...--- --._.........'?,7?..-...?"..".:..^...!.".......?::.°..._..`'e.°.:.-TL?..--.......... ' . ? Dale .............................. Address ...... ...........---------------------- ------' v DESCRIPTION Sfories To Se Used For Fron! Depih Heighf Esi. Cos! ermif Fee Remasks ?G'wf/?-??C/ 4?'?? 1?/ d ' ?4-e or This permit does not auShorise the use of aireala, roadn, alleps or sidewalks nor does it give the ownes oe hia agan! the right !a eseaie anp si2uation whieh is a nuisance os whieh presenis a hazard !o the heallh, safeip, eonvenience and general welfare !o anpona in the eommunity. THIS PERMIT MUST BE AEPT ON THE PAEMISE WHILE THE WORIC IS IN PROGRESS. This is !o cerlify. 2hal...... 1?,... Q-±?.'...^.?.^-J .................hes permisaion !o ereat a..... C ....-'....... ............... _upon the above deseribed premSse subjec! !o the provisioas of the Suilding Otdinance for Eagaa Towaship adopled April 11, 1855. ? . ?Q _ ?? ..................._-'---'-'°?...... ..._0.....°- .................. Per ---.._.._...........L`.:...?.`.:?......... ? ............................ -'-..................... Chairman of Tn Soard Buildin Inc actor (5 EAGAN TOWNSHIP N0 1451 BUILDING PERMIT Owaei ........... IF?.cv-.,.J----°----....----- Eagan Township . . -... -_- _"---- ? . Address (Presenl) ......... . ....? <?cJ ..._.......-......... . Town Hall - ? Builder ......- --...-c?'.< <...---- .................... ..... Dafe .......... ?,. Address .... .......................... .............. _....... -°------"-----"-?------------- DESCRIPTION Stories To Be Used For - -- Front Depih Heighi Esf. Cos! Permi! FeE Aemarke ? " LOCATION Sireef. Aoad or ofher Descripfion of Loeafion _ I_Lo! Bloek Addifion or Tzaet This permit does not aufhorise the use of sixeels, roads, alleps or sidewalkc nor does it give the owner or his agent the righf So ereate anp siluafion which is a nuisance ox whieh presen3s a hazard !o the healih, safe2p, eonvenience and general welfare !o anyona in the communifp. THIS PERMIT MUST BE ngEPT ON THE PAEMISE WHILE THE WORK IS IN PROGRE55. This is !o cerlifp, iha2.-..}f'---.-e--4e'f?..--"-_...'-'_has permission to erect a.....--_-_r.--_•?-'°:r1c?-"_'-"----......upon the above descri6ed preuffse subjee! !o the provisions of the Suilding Ordinance for Ea ' ' TownsFfp adopfed April 11, 1955. ?/?7 /•/ ,.-.? /Cr^r.?,? Per .- -.._........ 'x" ct a-L'?<1--??C?-r-!?` --._._._. "'__........._.....L::?_=L.<??.....!"'_L....."_'_."___..__._. .._.._"'.."_"..'.._...._... Chairman of Tnwn Board Building InsPeelor 4 t6 - EAGAN TOWNSHIP No 650 BUILDING PERMIT Address (preseni) Buildez ------"_' Addzess ......_. DESCRIPTION Eagan Township Town Hall Daie!l/'--?? -l<<?.-----?- 5iories To Be Used For Fronl Depih Heiqht Esl. Cosf Permif Fee Remarks °-?- - - -- -- Q' LOCATION ' Sireei, Road or,ofher Descripfion oE Lacation Lo! I Rlock Addition or Tract - -? ---I-- -- ---- - - This permif does noi aulhorize the use of sireeis, roads, alleys or sidewalks nor does ii give the owner or his ageitl the zight to ereale any situafion which is a nuisanae or which presenis a hazerd !o the healih, safely, convenience and general welfare !o anyone in the communify. THIS PEAMIT MUST PT (6?Yp,? TH SE W ILE THE WORK IS IN PROGRESggg , This is !o ceriity, ih ?1.?.has permission !o erecLa.?.: ?:...C?_.... upon the above described premise subject fo the provisions of the Suilding Or nce to -TOwnsh' adopied Anril 11, 1955. . ? t / ,- ? .---- _ ........._- ........... .......... _ . . Per. ._.__.'_.__....... . . /? . i" .. !. - - -- -? -? Chairman oi Town Board ? , ' g Inspecfor APOP Clty of Eagn 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax:(651) 675-5694 e ? I For. ?ffce 66 ? ? Permit #: ? i Permit Fee: ? Date Received: ? i i ? StaN I I ? 2008 RESIDENTIAL BUILDING PERMIT APPLICATION Date: C? /!> d Site Address: Tenant: ?lle- Suite#: RESIDENTlOWNER Name: Phone: Address / Ciry / Zip: Applicant is: _ Owner _?_Contractor TYPE OF WORK Description ofwork: Construction Cost ?6:f_) Multi-Family Building: (Yes _! No ? CONTRACTOR Name: -C'? ZLG License#: "2d?o Address: City L L?W L'?State: ? vZip: ?? Phone: Contact Person: COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 CateqorV 1 Minnesota Rules 7672 Energy Code . Residential Ventila6on Category 1 Worksheet • New Energy Code Worksheet Category Submitted Submitled (4 submission type) • Energy Envelope Calculations Submitted In the last 12 months, has the City of Eagan issued a pertnit for a similar plan based on a master plan4 _Yes _No If yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NOTE: Plans and supporting documenfs that you submit are considered to 6e public information. Portions of the information may be classified as non-public if you provrde specific reasons that wou/d permit the City to conclude that the are trade secrets. I hereby acknowledge that this information is complete and accurate; that the work will be in'conformance wdh the ordinances and codes of the City of Eagan; that I understand [his is nol a permil, but only an application for a permit, and work is not to start without a permit; that the work wdl be m accordance with the approved plan in the case of work which reqwres a review and approv s. ? Applicant's Printed Name ApplicanYs Signature Page 1 of 3 ?Ul 5a VALUATION Yew Construction Reuuirements • "1:npsterea site surveys showing sq. k. of'oC sq R of house. an0 all roo(ed areas (20°o maximum Iot coverage allowed) • ? cccies oi plan snowing beam 3 winCOw s¢es, poured found design, atc ) • 7 szt uf "cnergy Calculanons . 3 sopies of Tree Preservahon Plan if lot platteC aRer 711l93 . Rim Joist DetaA Opnons selecpon sheet (hldgs vnth 3 oi less units) DATE /D cp, SITE ADDRESS TYPE OF WORK? APPLICANT C/,L STREET ADDRESS TELEPHONE i(/? PROPERTY OWNERZ.C- oa ?-- ? UITI-FAMILY BLDG _Y !/P FIREPLACE(S) _ 0 4-'1 _ 2 oZ?. TELEPHONE4?`j/ ??- //? RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB RD, EAGAN MN 55122 651•681-4675 -------------------------------- =----------°----------------------------------------------..._ COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY IINAE:5O'l'A RULF.S 7670 C.A"I'EGORY l ti[IVACSO"1'.A Rt:LI:S 7ii72 Energy Code Cate9orY - N (J submission type) • Resitlenlial VenWation Category 1 Worksheet Submitted • New Energy Code Worksheet Submitted • Energy Envelope Calculatlons Submitted Plumbing Contractor: Plumbing system includes: Mechanical Conhactor: Mcch:uiical Scsicr7i includes: Sewer/Water Conhactor: Phone # rcc: ----°------°---°---------------°-------------°-....---------------------...-----------------------------°----------- I hereby acknowledge that I have read ihis application, state ihat the information is correct, and agree to compiy wrfh ail applicable State of Minnesota Siatutes and City of Eagan O din511ces.z --? Signature of Applicant OFFICE USE ONLY le RemodellReuair Renuirements . 2 copies of plan • 1 set of Energy Calculations fcr ",eated aoditwns . 1 sile survey lor extenor addi6ons 8 decks . Indicale d home served by septw system for atldiUons Phone # ? Water Softener - Iawn Sprinkle n????? rn ?"?1 Water Heater No. of R.I. Ba ?? LJ LS _ Vo. of Baths ?.Illl 12 200? D Air ConcliUOniqg -- Hcal Rccovcn' Sqs[ciii Certificates of Survey Received - Tree Preservation Plan Received - Not Reqwred _ Updated 3102 ? ?, • • ? r i 'I ? ?3y y ' --{a- vi ,??`?' .; . ,. _ 1989 BUII.DIBG PERMTT APPLICATION CITY OF EAGAN 1403 SINGLE FAMILY DflELLIBGS 2 3ETS OF PL9NS 3 REGISTEAED SIYE SQttVfiY3 1 3ET OF ENERGY CALCS. lULTIPLE DiiELLINGS 2 SET3 OF PLAN3 BEGISTBAED SITE SDR9EI5 - (CSEC6 HTfH BLDG DIV.) 1 SE! OF E9BRCY CILCS. COMRCIAL 2 SfiTS OF IRCHISECTURAI. 6 STHUCTORAL PLANS i SET OF SPECIFIClTION5 1 3ET OF F.NEBGS C9LCS. lIULTIPLE DHEL.LINGS AE1PfAL ONTTS FOB SiLS UBI'!S 4 OF OHITS AOTEs IDDRES3F5 FOA COANEA LOTS - COIPfRICTOd/HOI+EOWNEA lD3T DOIG8ATE iiHIC6 IDDAFSS IS DESIRED. BO C99NGES WILL SE ?LL01iED ONCE BtTII.DING PERlIIT IS I3SQED.. SEWER 6 WATfiR PElHiIT FEES APD ACCOtTNT DEPOSTT FE63 BILL BH INCLUDED UITH THE BOILDZNf! PEAFITT FEE. PAOCESSING 42ML POA 3EWEA AAD Q9TEH PF.IaSI15 IS Ti10 DAYS OHCE A PERMIT HAS BEEB COlSPLETED INDICATING A LICEH3ED PLUMBEA. PENALTY 9PPLIFS 6IfiENf PERMIT I3 P10T PAID FOR IN SAME MONTH IT IS REQUESTED. LOT CHANGE IS AEQDESTED ONCE PERP9IT IS ISSUED. 1) iA- ? „,? sEsr?.s ( el Z ?? ? c- J - I S _'Y To Be Used For: Valuati e Date: on: r Site Address q2, 1{( cJt?S?I OFFICE OS6 OPLY Lot ? Bloek Occupaney FEES ? Z L Zoning p? Pareel/Sub IC BU ? Actual Const Bldg. Permit _ Oimer ? ?0 vv S0_7`i Allowable 0 of stories Sureharge ? Sv Plan Review //? /? ' Length SAC, Citq L Address "7 '?/1 Depth SAC, MWCC S.F. Total Nater Conn City/Zip Code Footprint S.F. Aater Meter ? Ys- L( Acat. Deposit it P Phone On site aewage ? erm S/W Contraet Address On aite xell _ MYICC System _ City t+ater _ PRV required _ Hooster Pump r City/Zip I-/PPROVILS r? APhone J?3 - g 2 7zK Planner Areh./Engr. Address City/Zip Code Couneil Bldg. Off. 4ariance S/W Surcharge Treatment P1. Road Uait Park Ded. Copies ,0a 30BTOT9L Penaltq TOTAL 7'1,?0 Phone 9 tv n{{?,? :b . '?.?a ? ? M ti .[. '?1'P ? ?g ??,?. • ' - ;?? ] ? ZI 1, 4J+cF?? S Si t ra.t•Ln ? beS? ° t e','S d' h`}} ?... , f obs e'?"' ? ? Jf t 1??F A ?*t?-tl ! a. t-F r ar'.Yit Rt ? + ?9 ?? ? i . ?1?,R? i • 'i S . lII 4 ?? Tr e?? ? ry„ F 6 - Y? . ? q s? , - _ - ? ` . ? ?u?A;ti?4,a?3?? '?nr?`,?R?.?„3 4? ?` ? K n ? '?? j? .'? i?':a`• p ? F?' - r ?? ??# ??l ? 1 p? z Atr'?i ? ?q t^ ' v. r?1, ??f, ?k` futa ? . Y i ? +Y? . f • y?r?9?ih y y y 'c? YA' t ? ?fl ?$ d?' 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F??'? ? xf ? t ?? y' ? w?pGOJi , '.?G ,? 7 j' i b} p p Jy.?yp F"y{ , i R ? $ 4? ? 4 ? '! V at ?' S? ? 'P 9 1 4 ?? fl f y ??jy 1 1 . l . c°- frN e? lral`t? lw? tfxl.+ ' 1„ 3L ??? ?, ? tq? i' 4"'Mi''?? I'? x '?yqy^.r?l?s.t P.?3r' s ti? ?."Y?? ? i:? «`m ? 'A F ) ?° k . ,? y.' tf t v "E #1 'i'? i ? y. I 5 Y y? Al r V? t t? s y'w 4g ' . r i1 s ?k ? • ° ?'9??J?a,???} ??''??'Y?'y??.j?_?Y a4"'l?F? ?? ,{ ?j ixj ?iC?fi ?a rv _z ?' ?,?s.';, ?,1'M. ?y 3 1 q r i'U ?q n1n?I !i i ?. ! H r r. li? . I t' url ? _ d ? ?.?,?J +,?c??r ?' ' ? ? ?? . ?$ ?? • ??f j4, ? ? ?' n ? i {?3? 6 i ' , t ? ( t . ? 1 ? ? ? ? ? .M t . g r i } - • ?Y > , i 3 ? , t.s?n ? , p rv -' ( ' 7 4 ? e ? 1> ? Fr I i y. E a i ? ??'a l? 2'•? sfian??+ x??9 i. (.4 +?, ???f?` iFt'r? 1 5? ? kie ?.?? .?'?f't? s? ? 5T? n a S ?+. ;I vy , 1, e t?e ' ? ?I?'e`??r@ ?3a???^'.?'F 1'S Y? ° f 'i ?'? ? ' '? e w?r'.4?»...}?? „f • ? ? : '. s y{?+?? ? 1 ? .i 1?? ?.1'?1hj'p,°?t.e?4it?p a , "???t W' eY- ? ?" " ry S3 ??1;as5 ?}, fAih f ?'. rqF? 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J i ? . ? ? .?? . . .r .'i. a r. ? . . :.. . . .. ??. ` . ' , n ? . . . ? . . . ? . . _ , LOCATION MASTER CARD OWNER /7 MdG?SO STRUC7URE AND LAND USED AS Permit I ' No. Issued Issued To Coniractor Owner BUILDING PLUMBING ? ?? r•'L - y_-- ? CESSPOOL - $EPTIC TANK WELL ELECTRICAL HEATING GAS INSTALLING SANIiARV SEWER OTHER OTHER I Items Approved (Initial) Date I Remarks Distance From Well FGOTING $EPTIC FOUNDATION - .7 CESSPOOL FRAMING TILE FIELD F7. FINAL ELECTRICAL DEPTH HEATING OF WEII GAS INSTALLATION SEPTIC TANK CESSPOOL DRAINFIELD PLUMBING WELL SANITARY SEWER " Violations Noted on Back COMMENTS           ùú þýüýû ÿþþ ý üûú ûúù     øýýþþ úùäþ ÿ  á ý Ý â    ÿ  ÿþõ  úù ø÷  öý õ ý ö ø÷ ô ó  öý õ ý ò  úñ ò  ø÷ òýùðýù ú ýôù ï  ôù  úñ  þ ø  ãáùøïýöæ ù  â ûòô   ì ëöúêé öõèç æåæå ôø  úù  ý ü ìä çæ ãæã  óüòü õ ñð ÷÷ý øÖ Ûýòî ø ãáùøïýö Úý ÷  ù  þýüýòô  ëã è   øýó ü  ý ýâ  ý  ý÷÷ýý ý  ý ð ý  ýýü ÷øó ýý÷÷ý  úý  ðò ýúýù ýáøðþýüýí ý æ ÷÷ýé  úüýù  ù øúüýù PERMIT City of Eagan Permit Type:Building Permit Number:EA114375 Date Issued:09/16/2013 Permit Category:ePermit Site Address: 4241 Jasper Dr Lot:4 Block: 5 Addition: Cedar Grove 2nd PID:10-16701-05-040 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 . Jeff Granowski 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 - Kathleen Crary 4241 Jasper Dr Eagan MN 55122 All Craftsmen Exteriors Llc 1020 East 146th St Ste 226 Burnsville MN 55337 (952) 898-4680 Applicant/Permitee: Signature Issued By: Signature � Use BLUE or BLACK Ink � For Office Use T�------� ��• j Pertnit#: 1"� � j �� O������ � Permit Fee: ,L� .� -�� ' 3830 Pilot Knob Road � � Eagan MN 55122 j Date Received: I , Phone:{651)675-5675 I � ' Fax:(651)675-5694 i Staff: I �� � ��.�����������.����J '�. 2015 RESIDENTIAL BUILDING PERMIT APPLICATION I / � ) f �.. ' Date: �/ �'� 1`"� SiteAddress:��`"7 I :���� `'�-� M � �L` �� Unit#: l/ /� Name:�ri�iT_�}')�-�`�b`,.1 C.-�"�`+`�r-�-'" Phone:�'`��''��.�����Z.- !� -~�_ �.rr �►�i il-t.-� ����.�, ��12=�z..- $� Address/City/Zip: `���� �� <�° ` � Applicant is: `�Owner �Contraetor Description ofwo►ic: �� Ll>CJ`L�"Z��.' .C.�' � ��1���.�"�.�"�S , `?�-�.'`� l�.e==�-- Constroction Cost: � �'���� Multi-Family Buiiding:(Yes /No� Com an � ; ~ p Y� �� � L.�.:��r>"�=1_C..� t�� Confact:�.�..�'1 G�v1�"� Address: ��L�C� �• ����.�'/ ►"�� City: ����j1��l.G� State:�s'Zip:, �:�,� Phone�.�7��'!_�',��rfiai(: r.�'''Z't� ��7��� �-` .C=C:i'�' �. License#: �%� "' � Lead Certificate#: a� '`1��'�J�I—�° � �� �'� if the project is exempt from lead certificat6on, please explain why: COMPLETE THIS AREA ONLY IF�ONSTRUCTING A NEW BUILDING in the last 12 months,has the City of Eagan issued a permit for a si�nllar pl�n based on a master plan? Yes �No If yes,date and address of master plan: Licensed Plumber: Phane: Mechanicat Contractor: Phone: S�wer&Wa4er Contractor; _ _ Phone: Fir�Suppression Ca�ntractar:_ Phone: �,. ��.:� dg � CALL BEFORE YOU DIG. Call Gopher Stat�One Ca91 at(651)454-0002 for prote�tion against underground utilitydamage. Call 48 hours before you intend to dig to raceive locates of underground utilities. www.qaoherstateonecall.ora I hereby acknowledge that this information is complete and accurate;th�t th�work will be in confortnance with ihe ordinances and codes of the City of Eagan;that I understand this is not a permit, but oniy an application for a permit, and work is not t start without a permit; that the work will be in acc�rdance with the approved plan in the case of work which requires a review and approval of plans. 8xterior work authorized by a building permit issued in accordance�vith the Minnes ste Bui ing Code must be completed within 180 days at permit issuance. ���.���C�� �'r' >-� � _ X Applicat�Y's Printes!Name Appl t's Signatu Page 1 of 3