3521 Federal Dr
Use BLUE or BLACK Ink
I
~~7o~
City of Q(111 Eaj n I Permit
(1 I I
I Permit Fee:
3830 Pilot Knob Road RECFlt1-D I '
Eagan MN 55122 I Date Received:
Phone: (651) 675-5675 JUN 17 2011 I Staff: j
Fax: (651) 675-5694! /
2011 COMMERCIAL PLUMBING PERMIT APPLICATION
Date: U-16 • I t Site Address: ~ 'r-C C1 CV aA 1--)a
Tenant: 2D LA a I oo-y- .-S Suite
PROPERTY
OWNER Name: ~l Y1 Y~(l ['.~.2_ Phone:
CONTRACTOR Name: ju `t-ttiw V- t'YlMJ 1l41i 64-Q. License
Address: 2 5~+' city: rr p lS State: MIj Zip: 55412
Phone: ~(1(Z,• cJZZ • Email
TYPE OF -New _Replacement Repair -9-Rebuild _ Modify Space _ Work in R.O.W.
WORK Description of work: QQ.~ Ill
COMMERCIAL TYPE New Construction _ Modify Space
_ Irrigation System yes / _ no) RPZ PVB)
• Rain sensors required on irrigation systems
• Avg. GPM (2" turbo required unless smaller size allowed by Public Works)
Meters Call (651) 675-5646 to verity that tests passed prior to nicking up meter.
Domestic: Size & Type Fire: 1
Avg. GPM High demand devices? _Yes No Flushometers _Yes No
COMMERCIAL FEES:
$55.00 Minimum (includes State Surcharge) OR Contract Value $A cJ(j . x1%
. Permit Fee
Required on ALL new buildings and boulevard irrigation systems 4 = $ Radio Meter Read
- If the Permit Fee is less than $10,010, the surcharge is $5.00 Meter(s)
- If the Permit Fee is > $10,010, the surcharge increases by $.50 for each $1,000 Permit Fee
(i.e. a $10,010411,000 Permit Fee requires a $5.50 surcharge) • d~ State Surcharge
Following fees apply when installing a new lawn irrigation system. $ Water Permit
Call the City's Engineering Department, (651) 675-5646, for required fee amounts.
$ Treatment Plant
$ Water Supply & Storage
$ State Surcharge
TOTAL FEES $ O
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.ciopherstateonecall.org
I hereby acknowledge that this information is complete and accurate; that the work will be in confo nce 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 witho a permit; that the work will be in accordance with the approved
plan i the case of ygp~rk7which requires a~review and approval of plans.
Applican ' Printed Name Appl' ant's Signature
FOR OFFICE USE Approved By: Date:
Required Inspections: Under Ground Rough-In Air Test Gas Test Final PRV Required: _ Yes No
Page 1 of 3
443 Lafayette Road N. MINNESOTA DEPARTMENT OF (651) 284-5005
St. Paul, Minnesota 55155 1-800-DIAL-DLI
www.dii.mn.gov LABOR I~`~IDU T TTY: (651) 297-4198
Allik
5/10/2010
APPROVED FOR USE
Royal Oaks Apts
3515 Federal Dr
EAGAN, MN 55122
RE: HYDRA ~lL1C SSENGER Elevator ID# ELV-15252
Site: yal Oaks Apts «
3521 Federal Dr 7
Eagan, MN 5 1
Dear Sir/Madam:
Minnesota Statutes Chapter 326B provides that the Department of Labor and Industry, Construction Codes &
Licensing Unit, Elevator Safety Section, inspect and approve elevators and manlifts (endless belt lifts) before
they can be legally used in Minnesota. An Inspector from the Elevator Safety Section recently inspected your
facility and determined it meets requirements of the Minnesota Elevator Safety Code.
NOTE: Compliance with Minnesota Rules and the ANSI/ASME A17.1, Safety Code for Elevators and
Escalators does not necessarily assure compliance with the Americans With Disabilities
Act of 1990..
THIS APPROVAL APPLIES TO WATER DAMAGE REPAIRS.
ALL ELEVATOR RELATED EQUIPMENT IS SUBJECT TO ANNUAL RENEWAL OF THE OPERATING
PERMIT: It is the owner's responsibility to maintain and keep current with all tests in accordance with the
ASME All 7.1 and the ASME A17.3. Frequencies for the required tests can be found in Chapter 1307 of
the Minnesota State Building Code. Failure to maintain and perform the required tests may result in
revocation of the annual operating permit. Operation of an elevator related device without a valid -
operating permit may result in an issuance of a "stop order" from the department and possible penalty of
up to $10,000. For more information see our website at: http://www.dii.mn.gov/CCLD/Elevator.asp
Sincerely, n rI ~7 r
CONSTRUCTION. CODES & LICENSING D 11 ~J L~
. Ci of 1 , ZOO
'Sue Biagini
State Elevator Inspector
c: THYSSENKRUPP ELEVATOR CORPORATION
Dale Schoeppner, City of Eagan Building Official
ElFormCE2
This information can be provided to you in alternative formats (Braille, large print or audio).
An Equal Opportunity Employer
CASH RECEIPT
,
-CITY OF EAGAN
3830 PILOT KNOB ROAD
EAGAN, M I N N ESOTA 55122
DATE 19
RECCIVRD? ' %e PROM .
AM7UNT $ __ I
& DOLLARS
I oo
? CASH M CHECK
!'OR ? .
. . ? . ??. . . .?..
FUNC I COGE I AMOUNT
Thank You . ?
BY ,
White-Payers Copy
Yellow-Posting Copy
Pink-File Copy
BLDG. PERMIT ti0.
- r
i
?
i
I
01-3210
O1-3422
01-3445
01-3446
01-2155
17-3860
20-2275
20-3865
20-3868
20-3716
20-2252
20-3713
20-3743
79-3866
11-3855
Bldg. Permir ?? ' (J , ?
Plan Checic
I
Surch./ndm.
SAC/Adm.
Surcharge
Road Unit
5AC
Water Conn.
Water Trmt.
Water Metei
Acct. Dep.
Water Permi
Sewer Permj
Sewer Conn.
Park Ded.
TOTAL
? 3830 Pilot Knob Ro di P.O. Bo 2G-A199, Eagan, MN 55121 f y 0 128v`
'
w
PHONE: 454-8100
BUILDING PERMIT Receipt
To be used tor FUUN7ATION Est. value Date NOVEAIBER 10 19 86
Site Address 3 521 FEDERAL 13R I.VE Erect ? Occupancy
Lot 2 Block 2 Sec/Sub. ROYAI, OI,K C I RCliBmodel ? Zoning
Parcel No. ZST Repair ? Type of Const.
Addition ? Na. Stories
o? FtOYAL OAK CIR LTD PARTtVER:;HP&ve ? Lengtn
Name
= 1445 13 t AVE NO Demolish ? Depth
o Address Int. Impr. ? Sq. Ft
City FARGO Phone 7 01 2 3 S- 4 031 Install ?
CONST
Ciry L'•' Phone v,, -w -v?'a -.
Name CAi2LS014, bIJORUD A2CH
Address 9 915 +: 3 STH ST
City ?=,r13 Phone 922-6677
Assessment _
Water 8 Sew.
Police
Fire
Planner
Permit V+4 • v v
Surcharge
Plan Review
SAC
Water Cann.
Water Meter
Road Unit
I hereby acknowledge that I have read this application and state that the gldg. Off. 11 14/$ Tr. PI.
information is correct and agree to comply with all applicable 5tate of
Minnesota Statutes and City of Eagen Ordinances. APC Parks
Signature of Permittr!'fAC`.,?? Var. Date Copi
Totai
A Building Permit is issued to: BOR-S0:1 CONST on the express condition that
ell work shall be done in accordance with all applic;pble State of Minnesota Statutes and City of Eagan Ordinances.
Building Official ? - ?
I I wrn* No. I wfmn Haaw I o.e. I TN"M?o" N I
wbg.
Flnal
Occ.
@'"'?.' • .? , . , a . . _ . . . . . ' . - _ ' . . . .
CITY OF EAGAN
,,3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 N2 12987
PHONE: 454-8100
BUILDING PrzRMIT 3 3 UN Z'? R?e+Pt ?? ??? ?ti';
To be used for APT
Site Address 3521
Lot l Block 2
Parcel No.
W Name k01'jX
o Address 1445
city NARGU
o Name B011-
=
Oa Address 2001
T•iPLac
c~i a
W W
f =
czi ?
az
t W
$1,151,000
,ot "I Erect 41 Occupancy R-1/8'-1
OAK CIR Remodel ? Zoning R'
pI) Repair ? Type of Const. V I ??• I z?
Addition ? No. Stories 3 ? PR t NK
PA'3'P1VERSHIPove ? Len9th 1$S
Demolish ?
Int
Im
r
? Depth
Ff 4 t3 ,'l 0( 3 1?LOORS )
S
031 .
.
p
Install ? q.
400 ( GA:Z1aGE )
13
,
Water 8 Sew.
PolirP
Name C..4RLSO:J, JORUD ARCH Fire
Address 4915 W 3 5Tfl ST F,,,,
I hereby acknowledge that I have read this application and state that the
information is correct and agree to complyyvith aIl applicablj? State of
Minnesota Statutes and City of 5agan Ory(nances._ - ,' ; „
Signature of
Planner
Council
Bldg. Of
Var.
Permit ,' .Jrubu.
Surcharge 560
•
Plan Review 1, 5313 .
SAC 18,975.
Water Conj 3, 200 .
Water Meter LN/A
Road Unit 7. 656.
Tr. P I. 5,148.
Parks Pi/A
Copie
Total 4 .5 ' 12.97.
A Building Permit is issued to: BOR-SO:+ CU:1ST on the express condition that
all work shall be done in accordance with all applicable State of Minnesota Statutes and Ciry of Eagan Ordinances_
' PormU No. Permit Holds? Date TNsphone M
?ufro'oin9
?
H.t:p.C.
eWcW
''
4el7
InspecNon Date Insp. Commenb
P F ? ?'?
.
?
. ?d
InsuL
. . ..,-d
Fireplacs ?
Final Htp.
Flnal Pibp.
, 3$ /
,
81d q. Final ,E,?-4 p ? r ?L?
CKt. Occ. ,t 4'17 47/f*-/ awt-t
?
D?vk'?I• ll 1? ?/?i?/ /'//l E?l?'/??2/• -.S' G?/?•
Deck Frmy.
Well
Pr. Disp.
? d ty ? , ? • I ? ?? w5p J
?
MECHANICAL PERMIT
PT
RECEI
#
CITY OF EAGAN ? /`?? ?
- 383
PILOT
a
/r
0
3 ??0 KNOB ROAD, EAGAN, MN 55122 DATE:
CONTRACT PRICE: ? PHONE: 454-8100
Site Address
„ `
BLDG. TYPE WORK D SCRIPTION
Lot Bloc
' k ? 5ec/Sub Res. New ?
Mult Add-on
Name ?
-
' Comm
? Repair
}u Addr ss ?
?er
c City Phone
FEES
? Name 00
RES
HVAC 0-100 M BTU -$24
.
.
c Addre ADDITIONAL 50 M BTU - 6.00
p City Phone
e5
Y
(RES. HVAC INCLUDES A/C ON NEW
CONSTRUCTION)
GAS OUTLETS
MINIMUM
1 PER PERMI
- 1
50 EA
.
.
(
-
n
TYPE OF WORK COMM/IND FEE - 146 OF CONTRACT FEE
Forced Air
8TU APT. BLDGS. - COMM. RATE APPLtES
1
? TOWNHOUSE & CONDOS - RES. RATE APPLIES
Boiler ?
d
BTU
MINIMUM RESIDENTIAL FEE - ALL ADD-ON &
Unit Heater M BTU REMODELS - 12.00
Air Cond. M BTU $ MINIMUM COMMERCIAL FEE - 20.00
STATE SURCHARGE PER PERMIT - .50
Vent. CFM PERMIT PRICE GDES
E
Gas Piping OuUets # ? YOND $1,000)
B
Other
/
FEE J,
, z il-.,
S/C: SIGNA URE OF PEAMI EE
TOTAL• ?-
FOR: CITY OF EAGAN
?' .,.•r . ?it ?,', • ?. ._ ,_; '?.` r' ? PERMIT #
, MECHANICAL PERMIT RECEIPT #
CITY OF EAGAN
3830 PILOT KNOB ROAD, EAGAN, MN 55121 DATE
I CONTRACT PRICE:, PHONE:454-8100
Sec/Sub
Name _
Address
City _
L Name
c Addre;
p City i
TYPE OF WORK
Forced Air
Boiler
Unit Heater
Air Cond.
Vent
Gas Piping OuUeb #
Other
M BTU
M BTU
M BTU
M BTU
` CFM
ApU.&W TOjyt. FEE
S/C:
TOTAL•
BLDG.TYPE
Res.
Mult
?
Comm.
Other
WORK DESCRIPTION
New Add-on _
Repair
FEES
RES. HVAC 0-100 M BTU -$24.00
ADDITIONAL 50 M BTU - 6.00
ADD-ON AIR CONO. 0-24 BTU - 12.00
ADDITIONAL 6 M BTU - 6.00
GAS OUTLETS - 1.50 EA.
COMM/IND FEE - 1% OF CONTRACT FEE
MINIMUM - RESIDENTIAL FEE - 10.00
MINIMUM - COMM/IND FEE - 20.00
STATE SURCHARGE PER PERMIT - SO
(ADD $.50 S/C IF PERMIT PRICE GOES
BEYOND $1,000.00)
SIGNATURE OF PERMITTEE rn?
FOR: CITY OF EAGAN
. • . ' PERMIT #
PLUMBING PERMIT
CITY OF EAGAN RECEIPT #
3830 PILOT KNOB ROAD, EAGAN, MN 55142 OATE:
CONTRACT PRICE PHONE: 454-8100
Site Address ? L
Lot ? Block -?- SeciSub
? Name 1, N G
? Address - ?
c Ciry T OnL F Phone -
Name n
? Address - L P
p City ' Phone 4
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)
j- - /
.
PE ITT E
SIGNATURE OF
I FOR: CITY OF EAGAN
BLDG. TYPE WORK DE?FRIPTION
Res. New
Mult. Add-on
Comm. x Repair
Other '
RES. PLBG. ONLY - COMPIETE THE FOLLOWING:
NO. FIXTURES TOTAI,
?Water Closet - $3.00 $
` Bath Tubs - $3.00
?Lavatory - $3.00
-';L Shower - $3.00
zLS-Ki?chen Sink - $3.00
Urinal/Bidet - $3.00
1 Laundry Tray - $3.00
TFloor Drains - $1.50
_?Water Heater - $1 50
Whiripool - $3A0
;2.-Gas Piping Outlets - $1.50
(MINIMUM - 1 PER PERMIT)
Softener - $5.00
well - $10.00
Private Disp. - $10.00
Rough Openings - $1.50
FEE: 7:? o a a
STATE SlC:
? f?
GRAND TOTAL: ??
CITY OF EAGAN Remarks ??? ? ??xy ?e1k4' -
Addic'son Rny-]Oajt, c}r-cie Lot 2 Bik 2 Parcel 10 64700 g?E}? -
Owner Streec 3521 Federal Drive State?an, MN 5517?
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF,
STREET RESTOR.
GRADING
SAN SEW TRUNK 124
SEWEfi LATERAL
WATERM
AIN
WATER LATERAL
WATERAREA 335 197 Pd und r arcel 016 0-010-04 020-06
S70RM SEW TRK 732 1 9 3 090-06
STORM SEW LAT
CURB & GUTTER '
SIDEWALK
STREET LIGHT
WATER CONN.
SUILDING PER.
SAC
PARK
1
fgerti#iratt of (Orrupanxy
Citp of (Eagan
appal`bLPtTf d s3Iabing 3wPtlwti
This Cenificate issued pursuant w the requirements of Section 306 of the Uniform Brrilding
Code cerrifying that a1 the tlme ojusuance lhis structure wos in compliance with the various
ordinances of the City regulatfng building construction or use. For the jollowing.•
ux cksnfimaon Ut1xT APT ews. Flm"t rb. 7
O-a-y TYm zoning aM;a R-4
owMor suaaft"DYAI. CaW C F_ ndm,, l l?45 l?:"
Tu . P,2. iMiu_ A,t:
Dair -
Bwl&g Offical
POST IN A CANSPICUOUS PLACE
I CITY OF EAGAN
3830 Pilot Knob Road WATER SERVICE PERMIT
P.O. Box 21199
Eagan, MN 55121 PERMIT NO.: f' .'• s5
2oning: DATE: - -
Owner: ,.??OnLR No. of Units:
aval Ooaks
Address
SiteAddess: ???1 Federal Drive L? B,'_ ^oya ()nr.s .r st
Plumber. ?'?flva--rxost
Meter No.: Connection Char e: •
Size: g ? 5
Account Deposit:
Reader No.: Permit Fee: • p
I agree to comply wlih the City of Eagan Surcharge: p
Ordinanaes. Misa Charges:
3y Total:
Date Paid:
;.
OF EAGAN SEWER SERVICE PERMIT
Pilof Knob Rcad
bx 21199 PERMIT NO.: ?'
4 MN 5tip
DATE: ? -
g: No. of Units: lt s
- ^on Royal (?aks
Address:
Site Addr
Plumber.
1 agree to comply with the City of Eagan
Ordinances.
Permit Fea:
B Surcharge:
y
Date of Insp.: Misc. Charges:
Insp,: Total:
Date Paid:
Connection Cha?ge:
Account Deposit: -??
SITE ADDRESS -:g;4ta' ??ii??e.? Unit # ? Permit # 1--?2 9,F 7
. i
L a 8 a Sect./Sub.
?
INSPECTION OATE IN$PECTOH OTHEB
FRAMIN6
ROUGM PLB6.
ROUGH NT6.
INSUL
FlREPLACE
FlN14L HT6.
FINAL PL86.
UNR FlMAI
CERT/OCC
INSPECTION DATE INSPECTOR COMMENTS
- CITY OF EAGAN t?1
.3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121N2 12987
BUILDING PERMIT 33 UNIT PHONE:454-8Y00 Receiptp
Tobaueedfor APT BLDG Est.Value $1.151,000 Date DECEMBER 17 19 86
SiteAddress 3521 FEDERAL DRIVE Erect )U Occupancy R-1/B-1
Lot 2 Block 2 Sec/Sub. ROYAL OAK CIR Remodel ? Zoning R-4
Parcel No. 15T ADD Repair ? 7ype of Const. V 1 HR, I IN
Addition ? No. Stories 3 GPR TNK
W Name ROYAL OAK CIR LTD PARTNERSHIlM°"e ? Length I FS
z Demolish ? Depth 96
3o Address 1445 1ST AVE NO Intlmpr. ? Sq.Ft.40.200 (3 FLOORS)
ciry F'ARGO phone 701/235-4031 Install ? 13,400 (GARAGE)
a BOR-SON CONST Aonrovals Fees
o Name
ou? nddress 2001 KILLEBREW DR
? CityMPLS Phone 854-8444
? w Name ?'-?RT•SA1 , TOR D R H
ox1 Address 4915 W 35TH ST
iw ciry MPLS phone 922-6677
I hereby acknowledge that I have read this application and state that the
information is correct and agree to cq ply with all appl'o ble State of
Minnesota Statutes and Ci ?f Ea Ordina
Signature of Permitl
A Building Permit is issued to: ?vx-?vrv ii:vtvbi
all work shall be tlone in accordance with all applica State of
Buildinq Ofticial ? O
Assessment
water & Sew.
Police
Fiie
Eng.
Planner
Council
Bldg. Off.12/17/8 f
APC
Var. Date
and
w
Permit a J•uoV.Dt
Surcharge 560.0(
Plan Reviewl, 530.2`_
SAC 18,975.0(
WaterCo4 3, 200.0(
water Meter N A
Road Unit 7.656.0(
Tr.PI. 5,14$.0(
Parks N/A
Copies
7otal 50, 129.7_`
- on the express condition that
of Eagan Ordinances.
• 3830 Pilot Knob Ro d! P.O. B x 2G-A1 9, Eagan, MN 55121 N2 11867
BUILDING PERMIT PHONE: 454-8100 Receipt a W
7o be used for FOUNDATION Est. Value Date NOVEMBER 10 19 86
SiteAtldress 3521 FEDERAL DRIVE Erect Occupancy
Lot 2 slock 2 Sec/sub. ROYAL OAK CIRCIFEmodel ? Zoning
Parcel No. IST Repair ? Type oi Const.
Addition ? No. Stories
? Name ROYAL OAK CIR LTD PARTNERSHlWve ? Length
3 Address 1445 lst AVE NO oemoiisn ? Depih
o Int. Impr. ? Sq. Ft
ciry FARGO phone 701/235-4031 install ?
o Name BOR-SON CONST
$a Address 2001 KILLEBREW DR
A
Ciry MPLS phone 854-8444
w W Name CARLSON. MJORIID ARCH
nddress 4915 W 35TH ST
g W Ciry MPLS phone 922-6677
I hereby acknowledge that I have read ihis appl ication and state that ihe
in(ormation is correct and agree to comply with all applicable State oi
Minnesota Statutes and Ciry of Ea n Ordinan s.
Signature of Permitte?,
A Building Permit is issued to: BOR-SON CONST
all work shall be done in accordance with all aJ ?ic le ?Statpfl ?of Mi nes
Building Official I ?
Fces
Assessment
Water & Sew.
Police
Fire
Planner
Council
Bldg. Off. 11 / 10 / 8,
Permit atZ) .uu
Surcharge
Plan Review
SAC
Water Conn.
Water Meter
Road Unit
i Tr. PI.
Var. Date Copi
I esm.oo
on the express condition that
and CitX of Eagan Ordinances.
RE$UEST FOp ELECTRICAL INSPECTION es-oooot.oa
?,. Ilf Sea mstmctions lor comDleti? this form on Eack ol Vellow copv.
' ? ? ? ?3as5
?
4 7 "X" Below Work Covered by 7his Request
.L ,3 L y ys-?
e. ane Rep. Type o1 9ulltlingI- qppl{ancas Wired Eouiumenl Wirnd
I I I I intlustrial Bitlg. Air Conditioner Bulk Milk Tank
N Fee Service EntrenceSixe Ir Fee k F Circvi[s
0 to200qms
Above 200 qm?s iS J n30Ams
to 100 Allis
Swimming Pool A
Transformers
r.....? rtial-' Ihe r Fee
- opeciai msUec[wn S v Re,rerks - s Q L? F_???
T
«e ?aI
InsOactor, hereby
Final p, ?J7? car?i?V ?het the nbave
Jinsceetion has been
Thie requesl
This request void ?/7/8 7
18 rtqnths (wm
C 13247 .-
,q 13, bu ?' /i
Reques[ Date ire No; Rouph-in InsVecI ion ?
Heqwred? AeaAy Now Q WiII Nntify, InsOec-
? ?Yes ?NO ior When Heady
Melficensed Electrical Contractor 1 hereby request inspeclion ot above
? Owner electrical work installed at:
Street Addiess, Box or Rou e No.
I Citv
'65a/
? C d
eclion o. iownship Name or No. fianye o. Cow?l
y
/
'? l_ /
OccuVant IPflINT) . Phon¢ No.
Power 5 DVlier Atldress
ElecUicalContractor ICompany Namel Convecmr'S License No.-
?r'na?cotLa vC9 444a' ?c. Cf39lrk
MailinB Address IConUaclor or Owner MakinB Installationl
/Pv , o ? ?
Auth riz Si na[ure 1 onva ar/Owner Makfng Insiallalion) Phone Number
MINNESOTA STATE BOAND OF EL CITY THIS INSPEC710N flE0UE5T WILL NOT
Griggs-Midway Bbg. - Room N•191 • BE ACCEPTED BY THE STATE 90AHD
7821 Univarsity Ave., St. Paul, MN 55704 UNLESS PROPER INSPECTION FEE IS
Phone (812) 297-2111 ENClOSED.
4//?7 REQUEST FOR ELECTRICAL INSPECTION ee-oooo?iy-os
1 Sae inshuctions for compleling this form on back ol yellow coON
'•- '
?• 7?? a J?
--D 4110 9 "X'' BeloW Work Covefed by 7his Request
Add fleo. Typa of BuilEine Apol4l?caa Wired Equiuaient WireA
Home Range Temporary Service
Duplex Water Heater Liyhtiny Flxtures
Apt. Building Dryer Electric Heatin
Commercial Bldy. Fumace Silo Unloader
Industrial Bidg. Air ConAitioner Bidk Milk Tank
Parm ocnr, PP.r,i v 001e, Isuo,ivl
I e uco y ther Oth?r
..mnpute rnspecrion ree verow
p Fee SarviceEntmncaSiza n Fee Fextlers/SUhlexders k Fne Cirmits
ino
??TO7AL FEE
?w
flouBh-in
I, the Elecvicei
`
` ^ / nspector, herebV
h
Final
'
cartity t
et ihe nbove
C.i'i :? e sPactio?rMs_been
'd
me
e.
mla ropaeat voie 18 montfw imm ?/?
This reques[ void /
18 nwnlhs 7rom , ?G/?J1,F7
D 4110 9L,-?. /-3 a K2? y 42/ ?? •, i?
Request Dale ? Fire No.? U Noogh-in Insoection ? v
9qQuired? C:]Ready Nuw []Will Notifv Insper
?1'es ?NO lor Whe.n Reatly
'? licensed Electriwl ConVaclor I hareby reqaest inspection o} ebove
? Owner elacbical work installed at
F , do or Raute No.
? y
Township Name or No. Range No. Cnu y
Occupant (PpINT) Phone No.
eOASl/h G(/ILf'
Povo¢r Sappliar AAdress
E vical ConV [or (CompanY Namel
f Conlrar.tor's License No.
? L
Mailing AdJress IComrac[or or Owner Makinp Installationl
.e.eu? YI'J.J•
allationl
ft&aV Phone
Number
z-,?
MINNESOTA STATE BOAA[l oF ELECTNICIiY TH1S INSPECTIDN REQUEST WILL NOT
C.riges-Midway Blde. - Room N•791 eE ACCEPTED BV THE STATE BOAND
1821 Universitv Ave.. St. Paul, MN 65100 UNLESS PROPER INSPECTION FEE IS
Phone (612) 642-0800 ENCLOSEO.
, REQUEST FOR ELECTRICAL INSPECTION ea-ooooi-o
See instruetiona lor compleling this fwm on back of yellow copy.
?7 -,5 7 r, ""%"' Below Work Coveved by This Request
AAdI Rep.I Typ¢ ot Buiitline ? APOlianees Wiretl . ? Equiomenl Wired I
(--?? Home Range 7emoorarv Service
I I I I Industrial Bldo. IX I Air Conditinnrr 1 I BWk. Milk Tank I
# Fee Se.vice EnhenceSixa N Fee Fenders/Subteede?s k Fee Clrculta
0 to 200 qm s 0 to 30 qm s 3 f/ . 0 tn 30 Am
p? ?p Above 20 mpy ./-0 31 to 100 qmps m6-t 1 to 700 q y
Swimmin Poot I cI2 /W"%b'Tl Above 100,Am s Above 100_Am s
Transiormer5 rrigation Booms , 50 Partial.Other Fee
L_j _LSigns I 1 ISpecial Inspection
pemerks OTAL FE,; ,?lf,t
7b
1, tne Elec?'c9Y
InsPOCtOq h6re0y
c011+7V thet the nbova
insPection has bean
mede.
Tls repueat wIC 18
This requesl void 7_7?Y;70
monNs.lrom SC S/c. !l' /?^ ? S' C/.
9 2 2 7 6 n:? v'i.s3& . 00
flequest Uate '
3 Fire o. qoagh-in Inspection
Repwred?
1
[-]Feady Nuw QWill Notily. Inspec-
or Wh
t
R
E
1
?Yes ?No
en
ea
y
O'Licensatl Elecvical Convacior 1 heraby reQUas[ inspection of ebova
? Owner eleehical work inetalled et '
Streat Address, eax ot Route No.
8Ld "d ,.;?Q r/o4ea1
Q.e, D e, City
LA6??v
ecU o. Towns ip Name ar No. ange No. County
Occupant IPPINTI • Phone No.
oY?G
Power Suppliar
Z)Af(ra EceT2.c. Adtlress , -
,9,e.n„v /V,/ 1791y
Electl Convactor ICompanv Name) Convar.mr's License No.
4
/!IE/? Z5EG' Z/G ? c__ p Ifo?-
D 9
Mailinp Address (COntractor or Owner Making Ins[ailatioN a3aa 147* Av?uc 17) .A1
Authori 5aw e(Conttact w er Making Installatinn) Phone Number
i?- a36 - 9sid'
MINIVE$OTA STATE WARD OF EL`ECTRICITY TMIS INSPECTION REQUEST WILI NOT
aripps-Midway 81dy. - Room N-781 eE ACCEPTED BY THE STAiE 80AND
UNLESS PNOPEN INSPECTION FEE IS
7821 Universitv Ave., St. Peul, MN 65104
Phone(612)642-0800 . . ENCLOSED.
986 BOILDING P APPLICA OM - CITY OF EAGAN
BOYS: ALL CONTRACfOSS MQST BE LICENSED iiITH THB CITY OF EAGAN
SIKGLE FAMIILY DflE[.LIAGS
INCLUDE 2 SETS OF PL9NS, 3 CERTIFICATES OF SIIRVEYl 1 SET OF ENERGY CALCULATIONS
HOLTIPLE DiiE[.LIAGS - HESIDIIPfIAL REN?AL DHITS FOR SALS UNTTS
INCLUDE 2 SETS OF PLANSo CERTIFICATE OF SORVSY - CHECB iiITH BLDG. DEPT.,
1 SET OF BNERGY CALCULATIONS
COl41LRCIAL
INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS,
1 SET OF SPECIFICATIONS AND 1 SET OF
ENERGY CALCULATIONS,
$2,000 LANDSCAPE BOND
To Be Used For: P?FT. fk-Ck':?. Valuation: k1 S I,ODU Dyte; /? 2S • ??
Site Address 352 / FS<0+5*+t 19R, ?6 ! OFFICE USE ONLY
Lot Z Block Z
Parcel/Sub Zi5w Q,dk Ciq.cF /??AD
Owner Rpcj,OL 0.6k C I ic [TO I?AefNE/yi{i?
Address / `1-T,4 ?g i?Jp
City/Zip Code F,n2., p
??
Phone ?O/= _ Z357 -403 ?
Contractor 7?0/l,he... CQNs?
Address ZD?/ r?«t??? ?2
City/Zip Code 1'h /LS "
Phone vSv- 57444-,
Areh./Engr. C,.{/[(SW, d(jozuO jc1iLC4
Address yq'/$, [!J, 5S ?-?5/
City/Zip Code IVI[J ,
Phone # 92Z -&4 ?y
--?
Ereet ? Oceupaney 2•I /6•I
Remodel Zoning R-
Repair _ Type of Const YINR. LCN
Addition _ # of Stories ?3
Move _ Length i(Os
Demolish
Int.Impr. _ Depth
Sq Ft[FL¢S I-3
? q(o
z
4d m
Install _ CCy?Atac- 13,4cr-:)
APPROVAIS FEES
?
Assessments Permit 'JOCd?.-
Water/Sewer Surcharge 5(001
Police Plan Review (S30. zs
Fire a'SAC l 8-r'I '7 S,
Engr Water Conn ( 200.
Planner Water Meter Wk
Council Road Unit 1(oSro,
Bldg Off Treatment Pl 5148
APC Parks V.I/A
Variance Copies
TOTAL
V.
NOTE: ADDEESSSS FOR CORNER LOTS - CONTR9CTOR/HOAIEOfiNEH MIIST DBSIGNATE [lHICH ADDRESS
IS DESIRED. HO CBANGES WII.L HE ALLOiiED OACS BUILDffiG PHRMIT IS ISSQSD.
4?ff ?2
?
1986 BOILDING PHRMIT APPLICATIOH - CITY OF EAGAN
NOTE: ALL COBTR6CfORS MDST BB LICENSED fiITH THS CITY OF EAGAl1
3I8GLE F9PIILY DWELLIHGS
INCLIIDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS
MIJLTIPLE DWEI.LIHGS -&ESIDENTIAL RENTAL IIDRTS FOR SALS DNITS
INCLUDE 2 SETS OF PLANS, CERTIFICATE OF SUR9EY - C6SC$ WITH BLDG. DSPT.,
1 SET OE ENERGY CALCULATIONS
COHMRCIAL
INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS,
1 SET OF SPECIFICATIONS AND 1 SET OF
ENERGY CALCULATIONS,
$2t000 LANDSCAPE BOND
To Be Used For: ? lN DAT)p?l Valuation:
Site Address 352( L1092<lL- TD(2• i
r.ot Z siock Z
Parcel/Sub 6P-Gf,E ? Sr
Owner
Address
City/2ip Code
Phone
Contraetor _
Address
C1ty/Zip Code
Phone
Arch./Engr. _
Address
City/Zip Code
Phone #
Erect ?
Remodel
Repair _
Addition _
Move
Demolish
Int.Impr. _
Install
arvRnvars
Date:
Occupancy
Zoning
Type of Const
# of Stories
Length
Depth
Sq Ft
Assessments Permit
Water/Sewer Sureharge
Police Plan Review
Fire SAC
Engr Water Conn
Planner Water Meter
Council Road Unit
Bldg Off Treatment P1
APC Parks
Varianee Copies
TOT9L
HIOTS: ADDRESSSS FOA CORNER LOTS - CONTR6CTOA/HOHEOfiNER MQST DESIGNATE WHICH ADDRESS
IS DESIRED. NO CHANG&S SiILL BE ALLOWED ONCE BQILDING PERMIT IS ISSOED.
APPLICATION FOR PERMIT
CITY 4F EAGAN
SEWER AND/OR WATER CONNECTION
*ATE: PAYMhTLC OF FEE AT TIME OF
ArriscAazoN noEs Nom oONSTITUTE
APPROVAL OF PF.RNSIT.
INSPEGTION OF SEWER A@ID/OR WA'IER
INSTAL?a'rIONS WILi. NOT BE SCCZEI>-
UIM UNiTL PERMIT AAS BEM
APPR(7VID.
P ease Printl
?1) PROPERTY ADDRESS: 3 ?5'??
LEGAL DESCRIPTION: •-
_ Lot Block Sub ivision or Tax Parcel ID )
g' EXISTING STRC'CIURE. DATE OF ORIGINAL BC'ILDING PERMIT ISSCANCE: '
PRFSEN!' ZONING/PROPOSID C'SE: Mn ear)
q cor4-EacIAL/xErAIL/0r-F1cE
? IPID[,'STRIAi,
? INSTI1i'TZONAL/GOVERDIINENT
? R-1 SIIQGLE FAMILY '
Q R-2 DUPLEX (7tao C?nits)
? R-3 TOW[s30DSE (Three + (mits) ( L?nits)
? R-4 APARTMENP/CODIDOMINIUM (,JLUnits)
2) ? ?n
NA[?E: ?'.Gn7._?
ADDRESS:
CITY. STATE, ZIP:__
PHONE: ?
3) u i: ?•
_ IVAhIE:
' P,DDRESS:
CITY, STATE, ZIP:
PHONE: MASTER LICQ9SE#
4) ?• ? i?-
IvAME:
ADDRESS:
CITY. STATE, ZIP:
PHONE:
ActiVe
H EScpired
I-1 Not recvrded
t Initial
•5) n ?• ? a?• •?• : a • a? - ??
CR CONNECTION T0 CITY SEWFI2 ? CpNNECTION TO CZTY FlP,TER ? pTiIER '.
6) ?• r
? PLEASE HOLD APPROVFD PERMIT F'nR PICK-UP BY ONE OF ABOVE
? PLEASE MAIL ApPROVID PERMIT 'it7 1,(Z) 3r ¢. pBpVE
(Circle one)
I 13--'?- 3-y- (f--
FOR CITY USE ONLY
PERMIT # ISSDED
ka 9.s--? .
Pd w/Bldg. Permit FEES:
$ $ / b- SZ' SEWER PERMIT (INCLDDE SORCHARGE)
$ $ WATER PERMIT (INCLUDE S[!RCHARGE )
$ ` $ WATER METER/COPPERHORN/OCTSIDE READER
$ $ WATER TAP (INCLLDE CORPORATION STOP)
$ $ SEWER TAP
$ $ ACCOONT DEPOSIT - SEWER
$ ? ACCO[.'NT DEPOSIT - WATER
?6
0
$
WAC
n S sac
$ $ TRCNK WATER ASSESSMENT
$ $ TRUNK SEWER ASSESSMENT
$ $ ' LATERAL BENEFIT/TRUNK SEWER
$ $ LATERAL BENEFIT/TRUNK WATER
$ $ WATER TREATMENT PLANT SURCHARGE
$ $ OTHER:
$ tX `7; 1,?l J } O O $ oZ ?v z` TOTAL
/,57y??/
RECEIPT s?
RECEIPT#
DOES UTILITY CONNECTION REQUIRE EXCAVATION IN POBLIC RIGHT OF WAY?
? YES IF YES, THEN A"PERMIT FOR WORK WZTHIN PUBLIC
Q
NO ROADWAY" MLST SE ISSUED BY THE ENGINEERING
DIVISION
LIST AS
DI
ION
O
. .
A C
N
T
SUBJECT TO THE FOLLOWIIVG CbNDITIONS:
APPROVED BY: rtJ•_,,
TITLE:
DATE: ?? ? ? ??
4 2, AV, ??*? ? ? / iRL
!'M0 T0: TOH COLBERT, DIRECTOR aF POBLIC AORSS
JIH STpRH, pI,AHNING DEp6RTMENT
HILL AgINS, II.ECPRICAL, INSPECTOR
CR6IG SHOASEH, ENGINEERING TECH
FROM: DOOG REID, BIIZLDING INSPECfIOHS DEPT
DATE: i4/rv/k?7
The Protective Inspections Department will be performing a final inspection
for occupancy of ?Qu?y on
35 03, 04, 3'? ?{Qrcuv?-
Please return within 48 hours with your approval or denial. Failure of
response within that time frame will be determined as approval. It will be
each departments responsibility to contact the construction firm with
necessary requirements before final inspection and notifying the Building
Inspections Department when all requirements have been taken care of.
Thank-you.
DR/js
APPROVAL: DENIAL;
(SIGNATURE & DATE) (SIGNATURE & DATE)
2006 CONIMERCIAL PLUMBING PERMIT APPLICATTQN
CITY OF EAGAN
3830 PILOT KNOB ROAD, EAGAN MN 55122
651-675-5675
Date
Sife Address Unit #
Tenant Name 0 al? A(J'?? Former Tenant Name
Property Owner Rp?,?) Telephone#(r?Si ) E.9g'G$,3ro
Contracfor bC-'r-I- 6Y1 echdd` ra) 0-ar-.4N'a,::???C?
Address `-1 L1 S ) U3 • __7G2`k j+- ' City dl a
State m'v Zip 55 ti3 S Telephoue #(?'v~?
License #,?y o0 P m Expires: I a I3 I I?-OCYo
The Applicant is _.Owner ? Contractor _ Other
Work Type New Bldg._ Modify Space _ Irrigarion Sysfem* * Yes No Work in public r-o-w / easement?
L RPZ _ PVB: New _ Repair/Rebuild _ Replace _ Remove
Rain sensors are re uired on irri ation s stems
Descriptionof Work Zr-?Z54a 1 I !l? ew R PZ?,r. ?b? Jer"?eecJ S??l AC??7
To inquire iFPressure Reducing Valve is rzquired on new service, call 651-675-5646
Meters - Call 651-675-5300 to verify that hydrostatic, conductivity, and bacteria tests passed erior to uickine up meter.
Irrigation Size & Type • Avg GPM 2" turbo req'd unless smaller size allowed by Pubtic Works
Fire Size & Price 3/4" meter 167.00
Domestic Size & Type Avg GPM Includes high demaod devices? _ Yes _ No
Flushometers _ Yes _ No PRV Required _ Yes _ No
Permit Fee $50.50 minimum (includes Stafe Surcharge)
ContractValue $H SO Q x 1% PermitFee
$ Meter(s)
Required on all new buildings & boulevazd irrieation svstems Radio Meter Read
$ i SC) State Surcharge
If oermit fee is less than $I,000, surcharge is $.50
If oermit fee is more than $1,000, surcharge is 5.50 £or each $1,000 owed.
' ' ' ' ' ' ' _ _ ' _ ' ' ' ' ' ' ' _ ' _ _ _ - _ _ _ ' ' ' _ ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' _ ' ' ' ' ' ' _ ' ' ' ' - _ _ _ _ ' _ - _ _ _ ' ' _ ' ' ' ' ' ' ' _ ' ' -' -' '
' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' - _ _ _ ' _ ' _ ' _ ' ' ' ' ' ' ' _ ' ' ' _ '
Rollowing fees apply when insta[ling new lawn irrigation system Watet' Peimit
Call the City's Engineering Department, 651-675-5646, for rered f,
IStt(?? D
TreatmentPlant
kn,
?
3 1 20QF $ Water Suppiy & Storage
$ State Surcharge
$ '"?jQ . S0 Total Fee
I hereby apply for a Commercial Plumbing Permit and acknowledge that tlie information is complete and accurate; that the wotk will 6e in conYOrmance wrth the
ordinances and codes of the City of Eagan and with the Plnmbing Codes; that I understand this is not a pertnit, but only an application for a permit, and work is not to
start without a permit; thaf the work will be in accordance witk the appruved plan in the case of work which requices a review aud approval of plans.
O r mcDn
ApplicanPs PrintedName ApplicanYs Signature
,3 47"(;,
2007 COMMERCIAL BUILDING rExMiT nrrLicaTioN
City Of Eagan
3830 Pilot Kno6 Road, Eagan Mn 55122
Telephone # 651-675-5675
Plans are considered puhlic information unless you state they are trade secret and why.
• SlrucWral Plans (2) sets
. Civil Plans (2)
. CertificateofSurvey (1)
. CodeMalysis (1) "
• ProjectSpecs (1)
• Spec Insp & Testing Schedule (7) ^
• Soils Report . (1)
• Meter size musl be established
• SACdelermination-ca11657-602-7000
• CeNficateofSurvey (1)
• Slructural Plans (2)
• ArchiteGural Plans (2) sets
• HVAC units req'd. on bldg elev, ! site pian
• Civil Plans (Z)
• Landscaping Plans (2)
• CodeMalysis (1) "
• EnergyCakulations (1) "
• Emergency Response Sile Plan (1)
• Spec.lnsp,&Testing5chedule (1)"
• Electric Power & Lightlng Form (t) "
• ProjedSpea (1)
• MaslerExitPlan (i)
• SACdeterminatian-ca11851-602-1 000
• Fire Stopping Su6mittals
• Fife Suppre55iOnlAlafm FOrm
• Architectural Plans (2) sets
• CodeAnalysis (1) °
. ProJectSpecs (1)
. Key Plan (7)
. MaslerExitPlan (1)
• Energy Caiculations (1) nol always°
• Elec. Power & LighUng Form (1) not always"
• Meter size must be established-if applicable
. SACdetermination-ca11 651-6 02-t0U0
Call MN llep[ oi Heaith a[ 651-201-4500 for de[ails regazding iood & 6everage or IoUgmg Tacilil
" Contact Building Inspections to see if it is required and for a samp(e.
'•• Permit for new building or addition will not he processed without Emergency Response Site Plan.
Date /0/ &7 Construction Cost ?`1G 2 c/- Yn
Site Address 3 1-Z r F'c n.: z n ? 1":) Z Unit/Ste !1
Tenant Name R?C.AL_ G,o,c.t Former Tenant Name
Description of Work Sro.-..,er '-:>rq.+.n6c? _
PropertyOwner t?cevn.-?ctc?e-? ?oc.dtA? 1 w, ??tro2S t.irtiC. Telephone#( 77'$ 2i$ -/328
Applicantis: Owner K Contractor Contact#: (Qlt ) 717f- 594 I /?c-'v... ?92rot
Cootractor l,.. .,e.,
Address yD7 13cr- C.nve-s 2n s..rd 3ZG City il.,11 a.s
State I X Zip '7 $i y4i Telephone #( srt) 2G `I- gZ G
Arch/Engr Registratioo #
Address City
LUUI
State
Zip Telephone # ( )
Licensed plumber installing new sewer/water service: Phone #: (_)
I hereby apply for a Commercial Building Permit and acknowledge that the informa[ion 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 [his 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 pians. .
I7GVii-a?19ZiOL
Applicant's Printed Name Appfl t's Signature
DO NOT WRITE BELOW THIS LWE
Sub Types
? Ol Foundation ? 26 Public Facility ? 30 Accessory Building
? 14 Apartments 2"?27 Commercial/Industrial ? 32 Ext Alt Apartments
? 15 Lodging ? 28 Greenhouse ? 34 Ext Alt-Commercial
? 25 Miscellaneous ? 29 Antennae ?. 35 Ext Alt-Public Facility
? 37 Nail Salon
Work Types
? 31 New ? 35 Int Improvement ? 38 Demalish (Intenor) ? 44 Siding
? 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair
? 33 Alteration ? 37 Demolish (Bldg)' .,H'43 Reroof ? 46 WindowslDoors
? 34 Replacement •Demolition Buflding - Give PCA handout to applieant
I
Valuation O Type of Const Width
Plan Rev 100°h= 26'l0= /UD Occupancy MCES System
SAC Units - ? - Zoning City Water
Nbr. of Units Stories 8ooster Pump
Nbr. of Bldgs Sq. Ft. PRV
Fire Sprinklered Length
Required Inspections
Footings (new bldg) Fireplace _ R.I. _ Air Test _ Final
_
_ Footings (deck) _
_ Insulation
_ Footings (addition) _ Sheetrock .
Foundation Final/C.O.
Drain Tile FinallNo C.O.
/Driveway Apron
?
? Other
? Roof
Ice Pr _ Decking _ Insul
_ Final Pool Ftgs Air/Gas Tests Final
_ Framing _ Siding _ StuccoLath _ Stone Lath _Final
W indows
Final C/O Inspection: Sch edule Fire Marshal to be present. _ Yes _ No
Approved By: Planning c,?IG Building Inspector
Base Fee
Surcharge
Plan Review
SAGMCES
SAGCity
SNJ Permit
S!W Surcharge
Treatrnent Plant
Treatmenf Plant (Irriga6on)
Park Dedipfion
Trail Dedication
Water Quality
Water Supply & Storage (WAC)
Financial Guarantee
Storm Sewer Trunk
Sewer Laterai
Street
Wffier Lateral
Other
Total ..
Sewer Trunk
Water Trunk
RUG-86-2998 99:10 From:
Clty 0f Ea?BII
3830 Pllot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
fax:(651)675-5694
6127214236 To:651 675 5694 P.2/5
?- - - -^'--^--------i
? ?ar.:OM""ca:kfse i
I Pamdt p: gs
I
j PermN Fee: 1
? i
Q i
? Date Recaived? _... L'..? ?
i
i Sian:-,-__.- _ i
2008 COMMERCIAL BUILDING PERMIT APPLICATION
oaee: site ndaresa: 3SZ-.
fe-C
7onnnt Name:
(Tenant la: _ New IExisting) Suiee p:
PROPERTY dWNER Name Aju.vdGr. t RtV(- c5-m7r- Phone:
Address/C4[ylZlp. rI77 7 N0W41 r?q'1
nppiicantis: _Ownor ._XComractor
TYPE QF WORK Daseription of work /1f7PW1--
Gonetruction Cosl.
CONTRAC'1'QR Namo: ?(,?+r,??7? ee.(1UF License N.
naa.ess: ??a? C . LG7>! ST .
cisr: liuuc?c,s -_._ ... wi.v. _ziP: 33Y
Siaio
Phone: (gl Z- ._. contact Person:. JdC'Z
ARCFIITECT/ Nema- Repistrationp: .
ENGINEEq
Address:
Cily: StAto: Zip:
. Phon@: Contacl Persan:
Licensed plumber inslalling pQ?y sowodwptor sorvlce: Phone a:
N07f: Plans and su
ppojflrtg d6cuments that yau subri?lt a?e eonsldereii to tiq publ/o /n/q'maNan: PbRMrts_of .
1lie inlormatlon niay bp ctarsc"sllled as aqrrpu6llc H yau praylde spealfk reasons that wourd'permlt tha Clfy.tv
conalude.tliat thgw ara trade secrets.
I harGby Acknowladga that Ihis inlormation iu complota oM accwale; that No wwk will 6a in confortnonco with Iho vrdinantaa mid r.odoa of tha Cily ot
Eappn; thai f uM7oreland this ie nut a parmit, but only en appticalan fw a parmil, and wwk in not to Blpfl wltYWUI 4 p0fmi1; that the wwk will bo in
uccortlanW with Ihe apprwed plsn in Ihe caue ot work which requitoo a reviaw and approvel ol plano-
?. ?
x° Jot? c.c'",dwe.d G x i
Applican['s Vrinted Name Appl SlgnAturo
Page 1 013