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3470 Greenwood Ct S Use BLUE or BLACK Ink For Office Use P non ermit City of EaEd lpermit Fee: 3830 Pilot Knob Road Eagan MN 65122 Date Received: Phone: (661) 675-6675 Staff. I Fax: (661) 676-5694 L 2010 RESIDENTIAL BUILDING PERMIT APPLICATION Date: 5--)41-11) SiteAddress: cr ~Ou-~k Tenant: 80/1 1&4~~ Suite .3170 RESIDENT/ OWNER Name:. R04 Re- Phone: Address/ City/ Zip: 3Lf'70 Applicant is: - Owner A Contractor TYPE OF WORK Descripfionofvvork:.",e_ Construction Cost: PAU '000 Multi-Family Building: (Yes No CONTRACTOR Name: License#: ~C63(0'72z Address: city: State: M141 Zip: 9:2q3l Phone: 9!;'Z - klr6 -3Y'5r-?' Contact: 40 e_ Email: N 4"-h 3,47P QAV" COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? -Yes -No If yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NOTE: Plans and supporting documents that you submit are considered to be public intiormation. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that they are trade secrets. CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.orci I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordanc 9#h the approved plan in the case of work which requires a review and approval of/ans. Appillcant' s Printed Name Apeant's Signature i Vigf 14 Z010 Page I of 2 470 Co2 C ~ (,c7 DD C- , DO NOT WRITE BELOW THIS LINE cllq (I q SUB TYPES _ Foundation _ Fireplace _ Porch (3-Season) _ Storm Damage _ Single Family _ Garage _ Porch (4-Season) _ Exterior Alteration (Single Family) _ Multi _ Deck _ Porch (Screen/Gazebo/Pergola) _ Exterior Alteration (Multi) 01 of _ Plex Lower Level _ Pool _ Miscellaneous _ Accessory Building WORK TYPES New _ Interior Improvement - Siding _ Demolish Building* _ Addition Move Building _ Reroof _ Demolish Interior Alteration _ Fire Repair _ Windows _ Demolish Foundation Replace _ Repair _ Egress Window _ Water Damage Retaining Wall *Demolition of entire building - give PCA handout to applicant DESCRIPTION Valuation Occupancy MCES System Plan Review Code Edition SAC Units (25%_ 100%_ Zoning City Water Census Code ~[~7) Stories Booster Pump # of Units Square Feet PRV # of Buildings Length Fire Sprinklers Type of Construction ILO Width REQUIRED INSPECTIONS Footings (New Building) Sheetrock Footings (Deck) Final / C.O. Required Footings (Addition) Final 1 No C.O. Required Foundation 4L HVAC Drain Tile Other: Roof: -Ice & Water -Final Pool: -Footings Air/Gas Tests -Final Framing Siding: -Stucco Lath -Stone Lath -Brick Fireplace: -Rough In Air Test -Final Windows Insulation Retaining Wall: Footings Backfill Final Meter Size: Radon Control Erosion Control Reviewed By: Building Inspector RESIDENTIAL FEES / Base Fee Surcharge Plan Review MCES SAC s City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies TOTAL Page 2 of 2 CITY OF EAGAN Remarks Additi0n Surrey Heights lst Lot $ eik 7 Parcel 10 73000 080 07 Street '14-7-D-S-.-GxpP*+I+O.ClaCt_. State F.agan., MN S51 2 caidye :,o-F- t? 6A 7 Improvement Oate i Amount - Annuat Years Payment Receipt Date 57REET SURF. STREET RESTOR. GRADING SAN SEW TRUNK i• SEWER LATERAL 1973 3 WATERMAIN • WATERLATERAL 1973 3 * WATER AREA & $tllb 1973 3 * sTORnnsEw J= 1973 801.00 $267.00 3 PATD STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT L ,", ,/ ?, ?-7, U f •?D s-?.. y .? ? ,' ' ?;? n( WATER CONN. BUILDING PER. sAC 240.00 7138 12-29-72 PARK - CITY OF EAGAN Remarks Addition SHT' P,y Heights lst Lot 3 eik 7 Parcel 10 73000 050 07 OwnerbI01') /t V J<<! ?:)h I i - Street 31+7 9 S GreenWnnd Ct - State Eagan- MN 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK ek SEWER LATEFiAL 1973 WATERMAIN * WATER LATERAL 1973 3 WRTER AREA & t S 1973 * STORMSEW 1973 801.00 267.00 3 PAID STORM 5EW LAT CURB & GUTTER SIDEYVALK STREET LIGHT WATERCONN. $110.00 7138 12-29-72 BUILDING PER. ' s,nc 240.00 7138 12-29-72 PAR K CITY OF EAGAN Remarks Addition Surrey Heights lst Lot 1 eik 7 Paroel 10 73000 070 07 Owner( <<1 c?1 l?, !71 ?1F?! ???c st,,,t 3474 S. Greenwood Ct. State EaQan, MN 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SUR F. STREET RESTOR. GRADING SAN SEW TRUNK iF SEWER LATERAL 1973 3 WATERMAIN * WATER LATEFAL 1973 3 • WATER AREA & Stllb 1973 3 * STOFiMSEW 1973 $801.00 $267.00 3 PAID STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. $Z.ZO. 0Q 7138 I2-29-72 BUILDING PER. sAC 240.00 7138 1 - -7 PARK CITY OF EAGAN Remarks Addition Surrey Heights lst Lot 2 ik 7 Parcel 10 73000 040 07 owner11 ''; 1 '. L.Sr- i X• DPmM?Q si,eet 3476 S. Gr enwood Ct. ' scate EaQan, MN 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK ir SEWERLRTERAL 1973 3 WATERMAIN * WATER LATERAL 1973 3 * WATER AREA & Stub 1973 3 * STORMSEWAg 1973 $801.00 $267.00 3 PAID STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATERCONN. $],lO.QQ 7138 12-29-7 BUILDING PER. sac 7138 12-29-72 PARK TOWN OP EAGAN , 3795 Pilot Knob P.oad - Eagan, Plinnesota 55121 PEDIIT N0. 243 The Board of Supervisors hereby grants to Conao:ldateJ I'1'twblAg C0. of I c'op c•L-f ?ioad, agau7i11e. 191 55337 a YLIIFffiI?J(} Permit for: (Owner) Sit3V Iieighi;s D.I3gs. ttcu, BF15 3 70 So. Greenrvood Cow'4 aC (EQO 1'8Pw-E0 6L0) , pu;:suanC to application dated 7/28 ! 12 $20.00 ylue .50 a/c eaah timiL Fee Paid: $SF,n„rjp Dated this 2E'th day o£ ,;;:'lly , 19Z. $ 22,00 s/c Building Inspector aldg. #5 3?i7-??so. Greeo?rooa cwra B].dg. ?f6 3l?1a .e? so. creenmrooa courc B1dg. ,'?7 • 30. (Ft??aarood Cw?rE Bldg. r? 311 30. 0?'e?erood Co1u'E ?8• #9 34 so. aremmooa caaixt B1dg. #10 19sm.No. Qceenwoad Court Bldg. #11 15 .+? T3o. Greernrood Court Bldg. #t 2 t 5 tdo. Grees?wood cwn-e, Hldg. #13 15 Nc. (kraenwood Court H1dg. #lu 1 IdO. Greemood Court Blag. #i 5 151e-4$8-4 No. Qrenwood Court f?? /?? ? 3G? ? D a?o o J . S N? st/f 1 I TO!!N OF EAGAN 3705 Yilot Knob i:oad Eagan; Minneaota 55121 PERNIIT N0. 238 The'Board of Supervieors hereby grants to A. EtLndeT & 306 Imo. of $ttlpx, Weqt St. PiAtl 55116 e HBAM6 Permit for: (Owner) 91u'P4w Hedzhts 74 at ??'?-1lc--70 90. 61'met'mo0d CCux't , purauant to application dated _ 8/2t/72 • Fee Paid: MaOO _ Dated this 22ndday of Auguat , 1932. 2.00 a o Building Inepector EAGAN TOWNSHIP BUILDING PERMIT Owne= ..... /..:'.`.".`................................................................................. ? Address (Presenf) ?V...°..?..... . _?.:.._?_?...-r.....'? ............. Builder ....?V:..:..?.:...:....?I""""'?'""'"':x°..........-........--°° ................ Addrees ................. N° 2721 Eagan Townahip Town Hail Dele .:?.....?:.y.... 7i ................. Blosiea sL To Be Veed Fos -5!- ? Fron! ?''' Depih Heigh! Esf. Cw! 'Pasml! Fea G 2?? G33 ? 48o Remarke , 0 e+ ? LOCATION Sq `fi'Sy 8lreei. Road or oihee DeeeripSion o! Localion I Lo! Bloek Addiiion or Trac! I- I i ThL permit does aot aulhoxise the use oi sleeels, roads, alleys or sidewalka nor does it give the ownas oz hie agen! the rigH!!o creafe any siiuation whiah is a nuisance or which presents a hasard to the healfh, safety, coaveaience and genaral welfare !o anyone in the communify. THIS PERMIT MUST BE? KEPT ON??THE,?P?Rt£M JE WHILE THE WORK IS IN YROGR ?S ?{ This is !o eerHfp, that.l.:!?QL ..:................."__........::..........._'........haspermisaion !o ereei a_'f{ 111.4x4^^?--c" 4Oi6A_1?Pon. the above described psemise subjec! !o the provisions o! the Building Ordinanee for $agaa Township adopled Aprll ll, 1955. ?p ? /j ............................`T.::........ .......... Pez ....._..__.......l.t?'-°`:`.'. ....'............... ................ " Chafrman of Tnwn 8oard ? Bullding Iaspecloz MAST""' CARD ''^' " • • " ..?7d / ? R? 7? " IOCATION OWNER STRUCTURE AND ? tAND USED AS ?? L?t rT '?`?? ?fv?? •r7 ? / Permit I No I Issued Issue o ConTratfor , Owner BUILDING PLUMBING CESSPOOL - SEPTIC TANK 2 J2 / I2 17?_i / I I V?ElL EIECTRICAL HEATING GAS INSTALLING I ? SANITARY SEWER I _ I i i OTHER - _ I I I I OTHER ? Items Approved I (Initial) I Date Remarks Distance From Well FGOTING SEPTIC FOUND"ATION I •,?. 79/ ? ??- CESSPOOL FRAMING II • . ?Y TILE FIELD fT -- FINAL ? ELECTRICAL I - I HEATING i? . ? DEPTH OF WELL - - GAS INSTALLATION i SEPTIC TANK CESSPOO ., . PI?N?I?i"p,? a ;,? ? • ? . WELL ? . , SANITARY SEWER -- - ? ? ? Violations Noted on Back COMMENTS EAGAN T(1WNSHIP 3795 Pilot Knob Road St. Paul, Minnesota 55111 ?jTelephone 454-5242 PERMIT FOR SE4JER SERVICE CONNLCTION DATE: Jul,v 28, 1972 N[1DffiER 1067 ?--? 5,? I-l y=1 ?, ?, _l OWNER: Surrey Heights Bldg. #5 Address_ 1170,-72-74-76 So. Greenwood Court PLUMBER TYPE OF PIPE Hexvy Cast Iron DESCRIPTION OF BUIID ING Industriall Commerciall Reaidential I MulCiple Dwelling I No, of units ? 1 4 Location of Connections: Connection Charge $960•0? Permit Fee 10,00 Street Repairs Total Inspected bq: Date Remarka: Sy. Ch1ef Inspector Ia consideration of the issue arni delivery to me of the above permiC, I hereby agree to do the proposed work in accordance with the rules and regulations of Eagan Tormship, Dalcota CounCy, Minneaota BY Please notify mhen ready for.iaspection and connectioa and before any portion of the work is covered. l ?GAN TOWNsHIP 3795 Pilot Rnob Rosd St. Paul, Minnesota 55111 Telephone 454-5242 PER141T FOR WATER SIIRVICE CONNECTION Date: July 28, 1972 Number:905 Billing Name: Surrey Heights Bldg. 5 Site Address: 470j 2-74'76 So. Greenwood Court OwneT: Gustafson Associatemis Plum3er: Location of Connection y- Billing Address Meter Size Connectioa Chg. .00 Meter No, Permit Fee Meter Reading Meter Dep. Meter Sealed: Yea_ IfAF1 Chg. NO I 1bta1 Chg. Building is a: Residence Multiple xx Ho. Units4 Commercial Industrial Other Inspected by Date Remarks: $25.00 RE-INSPECTION FEE FOR IMPROPERLY INSTALLED METERS. Hy: Chief Inspector In consideration of the issue and delivery to me of the above permit, I herehy agree to do tte proposed work in accordance with the rules and regulations of Eagan Tawnship, Dakota County, Mianesota. By: Please notify the above oftice when ready for inspection and connection. ? CITY USE ONLY LOT ? BL ? RECEIPT #: I Y I SUBD- Zf/X* RECEIPT DATE: ? I/ S l?1 i 199$ M£CHANICAL PEfiMIT (RESID£NTIAL) C11'Y OF gRfiRN S$SU PILOT KNOB iiD EAfii4A 31P 55122 Date: 10-99-9g (612) 661-4675 Complete this section on[v if you are installing HVAC in single family, townhomes or condos under construction and not owner /occupied ' + i-idi1C: n n nV? :fqRT?_? $ 24.00 V?AV ADDITIONAL 50 M BTU 6.00 • Gas outlets ( minimum of one required @$3.00 ea.) • State Surchazge: .50 • TOTAL: Complete this section onlv if you aze remodeling, adding to, or m.pairing existing single family dwellings, townhomes, or condos. Note: Mechanical permit is not required for alterarion/add-on to ductwork in existing residential units; but is required for the following: X Install fiunace _ Install air conditioning Install air exchanger, i.e. Vanee system, etc. _ Other iviinimum fee app3ies to iili remode; or zcid-or.s af cx:si:ng residea:,cs $ 20.00 State Surcharge Total: $ 20.50 SITE ADDRESS: 3 47 L? C? re e r, w oo d C;? . ol-o • owrrExNnME: 41-mc-ndu 8-cnc0a-,dev PHONE#: (D87' nl.? ,,)L_ 1 INSTALLER NAME: PHONE #: 43 f- 7 Dq!j - Wohlers Southside Htg. & A/C, Ina STREET ADDRESS: ? 14732 Pennock Avenue I -,Apple Valley, MN 55124 CITY: STATE: ZIP: : k. L,cIkKPizi:2_ SIGNATURE OF PERMITTEE JS/FORMS BLDNEECH PERMIT (RES) - 1998 CITY USE ONLY PERMIT #: ;l 7/C/ o RECEIPT DATE: I??IIO f KSIDENTIlkL liECIMNICAI. PEgMIT Ai'PLICATIOA crrY or EAsa?x 3930 Pu.or xxos ftn Easax Mx 55122 651-6$1-4675 Please complete for: ? single family dwellings townhomes and condos when permits are required for each unit Date: t.. Owo / SITE ADDRESS: OWNER NAME: TELEPHONE #: (AREA CODE) (AREA CODE) INSTALLER NAME: TELEPHONE #: STREET ApDRESS: / l CITY: OGL(' _ STATE: Place a check mark next to the oermit work tvue ziP: 2?/a2..2_ New residential dwelling unit under constructionand not ownerloccupied $ 70.00 Add-on, modification or alteration to existin dwelling unit $ 50.00 • furnace replacement • air exchanger • air conditioner • other Nature of work: --- State Surchar e $ 50 Tota1 $60.60 Reminder: Cal[ for inspections. Q Y.Lii?e SIG ATU F PERMITTEE Updated 1/01 2006 RESIDENTIAL MECHANICAL PExMiT nrrLicnTCOrr City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 Pleate complete for. single family dwellings & townhomes/condos when permits ere required for eech unit 3o? Date SiteAddras rl 17Yeeyi " olit 5- Unit# ? ovi &1ke v O Telephone 1t (6S ? )9 0 rJ ' 11 L :J wner Property Contracror _ Street Address O'CONNOR ONE HOUR City - 1904 VERMILLION STREET State HASTINGS, MN 55033 TelepAone k(? ? Bond #: Expires: The Applicant is _ Owner ? Contractor _ Other Add-on or slteration to existing dwelling unit $ 30.00 nt l m R l ? New e ep ace ?% fumace _Additiona _ air exchanger V airconditioner heat pump ' j r other I'?v1W11d?T1PY IYlS?ciI? - smtesurcnar¢e SEP 2 2 2006 $ .so 130 $ ?_ Totsl - - [ hereby apply for a Residential Mechanical Permit and acknowledge that the informalion is complete and accurate; that the work will be in confortnance with the ordinances and codes of the Ciry of Eagan and with the Mechanical Codes; that I understand this is not a permit, but only an spplication for a pertnit, and work is not to start without a pertnit; that the work will be in accordance widi the approved plan in the case of work which requires a review and approval of plan JI VC vt C P, ' ?'cz Applican 's Pnnted Name App ant's nature Aug 1. 2012 12:35PM Sela Accounting No 1661 P. 3 Use BLUE or BLACK Ink For Office Use_~. - City of Wan I Permit #:1 I 1- 3830 Pilot Knob Road Permit Fee: Eagan MN 65122 j Date Received: j Phone: (651) 675-5676 I I Fax: 651 675-5694 I Staff: I f I 1 2012 RESIDENTIAL 13UILDING PERMIT APPLICATION Date: / I Z SlteAddress: 3470, 34-7Z, SVY.3y& Greenwizd 0-t S Unit#: Name: t •?tc p s ~ta,::n bl ( T oC, Phone: c)5 t~~~~ 1 3 RESIDENT / ` . rr OWNER Address/ City/ Zip, k. .C-:-lA We-S+ `7 - Gl r' L~;.CI Applicant is: Owner _X_ Contractor Ll L/ Description of work: (tee.. r0C> TYPE OF WORK Construction Cost: v~ ~((1 . U(~ n Muttl-Family Building: (Yes -Y-/ No Company: s C-Aa- Qoo M LJ-J I Nci Contact: ~`~~r t i~ CONTRACTOR Address: LI lCO Excc,, St p r 9 v c~r City: , Louts Ph i-k State: 1/- Y'\ Zip: 1~ 5LI I Lo Phone: 1) 6 J c)-d, L License A, C: 1'Z UCH l Q %U Lead Certificate )VA 'T ~ 2- lf the project is exempt from lead certification, please explain why, (see Page 3 for additional information) COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan Issued a permit for a similar plan based on a master plan? Yes _No If yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NOTE, Plans and supporting documents that you submit are considered to be public Information. Portions of the Information may be classified as non-public If you provide specific reasons that would permit the City to conclude that they are trade secrets, CALL BEFORE YOU DIG. Call Gopher state One Call at (661) 454-0002 for protection against underground utility damage. Gall 48 hours before you Intend to dig to recelva locates of underground utilities. 4y~MV.gopherstateoneeall.orp I hereby acknowledge that this Information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that 1 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 wilh the approved plan In the case of workwhlch requires a review and approval of plans. Exterior Work authorized by a building permit Issued In accordance With the Minnesota State Building Code must be completed within 18o days of permit Issuance. x ALL r t- Ir x U1~1 ~v~. Applicant's Printed Name Applicant's signature (~661A Ga__"7~1~ L, Page Iof3 Use BLUE or BLACK Ink r -+ For Office Use Permit# /q// 7 0/3.51 City of EaRall % Permit Fee: 6-2 3830 Pilot Knob Road Eagan MN 55122 Date Received: Phone: (651)675-5675 Fax: (651)675-5694 Staff: 12017 RESIDENTIAL BUILDING PERMIT APPLICATION Dater l Site Address: ,..-?1.{70 Greeh t"✓oof L -I`, s ' Unit#: i Name: i n `1&�� Phone: Oi7 D 72 �7s Resident/ `„�, c.� 1 OWner Address/City/Zip: -7/ 2D G✓'r-P.7Wo o,/ C. 71- -c', �c,r� 5 S7/ 2 1 Applicant is: Owner ✓ Contractor T ©f Work Description of work: /°C;/7-1 d a 0©r ,...51:),Ile l ,-----7-6--- rt° ._.. Construction Cost: 7 g0. 66 Multi-Family Building: (Yes \VNo ) Company: J e P /9i tS'1'011 C OY►Si-. Inc , Contact: 3 -12 f7r'7 °h / _ 1 Contractor Address: /0 07/ ,t- 5/ /t -d1 City: -e//t' ''moi-1( State://91t) Zip: -S-6 ©// Phone: `7(P3--eZg-i9g`9Email: Jr'e7e 1 9'; Qi i'✓Y. earl License#: C 6, 2 g 3 1 Lead Certificate#: 7T s-e If the project is exempt from lead certification, please explain why: /��T F S$S °"7 - ! COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? Yes No If yes, date and address of master plan: I Licensed Plumber: Phone: t 1 Mechanical Contractor: Phone: Sewer&Water Contractor: Phone: II 1 Fire Suppression Contractor: Phone: NOTE:Plans and supporting documents that you submit are considered to be public information. Portions of I i the information:may be classified as non-public if you provide specific reasons that would permit the City to I conclude that they are trade secrets. CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.orq I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180 days of permit issuance. x J f-ri Pmt S'71 D P) x Applicant's Printed Name Applican ' -' ure Page 1 of 3 PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA149504 Date Issued:05/24/2018 Permit Category:ePermit Site Address: 3470 Greenwood Ct S Lot:8 Block: 07 Addition: Surrey Heights 1st PID:10-73000-07-080 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. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088 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 - Mesfin G Senbeta 3470 Greenwood Ct S Eagan MN 55122 (612) 872-4754 One Hour Heating & Air 11825 Point Douglas Rd S Hastings MN 55033 (651) 437-4177 Applicant/Permitee: Signature Issued By: Signature