1765 Hickory HillCITY OF EAGAN
Addition w?i
a.
16
22
Improvement Date Amount Annual Years Payment Receipt Date
STREETSURF. 1974 8.52 1.70 P2.1.d
STREETRESTOR. 1976 1034.75 3 .92 3 Paid
GRADING
5AN SEW TRUNK T97 11 .72 ----7.64 1 Pa3d
;46EWER LATERAL . 197 30.71 1022.90 3 Pa3d
WATERMAIN
3tWATER LATERAL 197 3
*NATER AREA 197 3
3CSTORM 5EW TRK 197 3
-1£STORM SEW LAT 1976- 3
CURB & GUTTER
SIDEWALK
STREET LIGHT
WATER CONN.
BUILDING PER. 1
sAC 425.00 31 6-3-75
PARK 120,001 1 ? ?
CITY OF EAGAN ?1 ,{?
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 '11`? 1a
PHONE: 454-8100
BUILDING PERMIT ??.,?,,,a
To be used tor BAS?P?T ?? Est Value 7,
Site Address 1755 HICKQRY HILL
Lot-1 69fock 6 Sec/Sub. WIDeE"T
W Name ?? PItOFF
o Address SAMF
Ciry Phone ??52-33t?8
=o Name Dt+VID SC}1{+fEICH COh'ST
? a Address
~ CitV Phone 447-86J8
Address
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 ,' ?'---? ? •- ' '-•"°?
Receipt # ?
Oate .1ArlUA1tY 7 .19 86
Erect ? Occupancy -
Remodel ? Zoning
Repair ? Type of Const
Addition ? No. Stories -
Move ? Length
Demolish ? Depth
Int. Impr. El Sq. FL
Install ?
Approvals Fees
Assessment
Water & Sew.
Police
Fire
Permit 62.50
Surcharge 3 - ?
Plan Review
SAC
Water Conn.
Water Meter
Road Unit
Tr. PI.
Var. Date I Copies
Total 66 - UU
, A Building Permit is issued to: AW'?QLQ P170FF on the express condition that
all work shall be done in accordance with all applicable State ot Minnesota Statutes and City of Eagan ardinances.
t Building Official ?
I I Psrmlt No. I Psrmit Ndder I Date I TNephons # I
Occ.
Ftg.
Disp.
--_ ___- - 1R???3RIf
CITY OF EAGAN PERMIT TYPE:
3830 Pilot Knob Road Permit Number:
Eagan, Minnesota 55122-1897 Date Issued:
(612) 681-4675
SITE ADDRESS:
.,?U?.IA! k :'Nl?
a 4; BLA,CIK APPLICANT:
, , ,i ..( 1. ? I ?.i ?
( r. i.' 1 t;'OO 47!'1;
PERIIAIT SUBTYPE: TYPE OF WORK:
,:; Ia
I ?ARVf, :• rttr._XHE: Y/r tM M I tS) U fit i r- rFs) Etf F0iiF Cs:vt RrNr;
F
L . .. ?
c??1?r?1??H
---------------
Permit Holder Date Telephone #
PLUMBING
HVAC
Inspection Date Insp. Comments
FOO7INGS
FOUND
FRAMING
ROOFING
ROUGH
PLUMBING
PLBG
AIR TEST
ROUGH
HEA7ING
GAS SVC
TES7
INSUL
GYP BOARD
FIREPLACE
7
FIREPLACE
AI R TEST
G(?Q
FINAL PL(iG
FINAI HTG
ORSAT
TEST
BLDG FtNAL
DOMESTIC
ME7ER
IRRIGATION
ME7ER
FLUSH
MAINS
CONpUCTIVITY
7ES7
HYDROSTATIC
TEST
BSMT R.I„
BSMT FINAL
DECK FTG =F
DECK FINAL
YILLAOE OF EA6AN
3795 Pilot Krnb Rood
Eagan,idN 55122
zoning: 14ID
Owner: NeT
Address: _T
Site Address: _I 7g
Plumber: •+ p
?
WATER SERVICE PERMIT
PERM[T NO.: 1762
DATE: 6/19/75
No. of Units:
Merer LJ Connection Charge:140.00 Dd
Size: ? Account Deposit:
Reader No.: ? Permit Fee: 10.00 pi Pd
1 ag.ea fo eomply with fAa Village of Eagan Surchazge: • 50 por pd
By -
Date of
? Misc. Chargna•
Total:
Date Paid:
Insp.:
VILlAOE OF EAOAN SEWER SERVICE PERMIT
3795 .^:'::i Knoa Read PERMIT NO.: 2523
Eugon, MN 55112 DATE: 6/19/75
Zo*u+16: PUll No. of Unlte:
Owner: nlniv Horizon Hom c- 4•loodfja Ti
Addrese:
Site Addrees: 1765 fiicxorv Ifill
Plumber: _ Thompson Plwnbinq Co.
1 eprw ro eanyly wkh fM Villa" o/ Eagan Connectlon Chazge: 425.00
Ordi^?ne"• Account Depoei[:
Permit Fee: 10.00 pri „a
Surcharge: • 50
BY: M1sa Chazges:
Date oF Inep.: Total:
Inep.: Date Patd:
:i . . :
? ?
? CITY ofEAGAN N?2 3603
- ?
I BUILDING PERMIT
-]?_ 3795 Pilo! Rnob Aosd
Own?:?I ............................/.?°....... .......................................... Eagan. Mlmewla 55IZ1
Addre? (Dsaen!) _..?•i a-UL ............................................. ? . 454-8100
?
Bultdot .................................................................................."-........... ?
b-3->s-
aat•
•••• ..... .................. ...._.._._.......
I LOCATION ? o, S a
Slroel, Road er olhes DNeeiyilon oE xetiaa I Le! loek Add on m is?e!
+
This rmit doas aot aulhorise the wa of ctceo2s, rosds, allsps or ddswalks nos dow it glv* !6e evnes or Lb ypn!
the rt !o erssle sny dlualion whlcL L s au4utm os? whieh prp"ds s hszard !o the heallh, safelt, coavmlOneM aad
qonee Welfera !o aoyoae in the aommuailp.
THIS LAMIT MUST 8E BEPT ON YIiE PAEMISE WHILE THE WORB ffi IN PR06AESS.
Th4 !e certlft. ffiat_`7L.? .N ..... . .......... ..... . . ..............has wsmiulon !o e»et d.a.Zl...... .......... ? .. .. n
- •:L??"?...._.___ Pm
the va deseribed yremiee su63eet to !h sovieions of all epplteeble Ordlnancea for the Cilq o! egan. .
........... I ........................ ?..._`....41...r..::?`-:.?............... Per ....... ...................f??`?.......0..'`? ........... .. _ , .............................
, Mayor <r ?j ' _ suuata?
BUILDING.PER7VIIT
Receipt M
To be used 1or BASEMENT Est Value 7,000 Date JANUARY 7 19 86
1765 HICKORY HILL
Site Atldress Erect ?
Lot-Ijjglock A Sec/Sub. WQ(111C=ATR 9 Remodel ?
Parcel No. Repair ?
Addifian ?
?NOLD PROFF Move ?
a Name
?
i Demolish
o
Address SA? ?
I
I
nt
mpr.
Ciry Phone 452-3386 Install ?
o Name DAVID SCHWEICH CONST Approv
i
?¢ Address ASSessment.
? ciry Phone 447-8808 Water & Sew
Police _
W W Name
Fi
re
Address E
¢ i ng.
<W Ciry phone Planner_
Council-
Iherebyacknowledgethatlhavereadthisapplicationandstatethatthe
information is correct and agree to comply with all applicable State of gldg.Off.-4;,
Minnesota Statutes and City of an Ord' anc s. APC
??
i /f ?
?
Var. Date-
Signature ot Permittee J[? C,?'UJ+
CITY OF EAGAN N2 11419
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 ??
PHONE: 454-8100
Occupancy
Type ot Const
No. Stories
Length
Depth
Sq. Ft.
Feas
Permit 62.50
Surcharge 3.50
Plan Heview
SAC
Watar Conn.
Water Meter
Road Unit
Tr. PI.
Parks
Copies
Total 66.00
A Building Permit is issued ta: ARIdOLD PROFF on the express condition Mat
all work shall be done in accordance wi?t„( /aflI applic?ble Stete of?rylinnesota Statutes and Ciry of Eagan Ordinances.
Buitding Offiaal ? ?-?-k-v ?JP ,?`i
GEO. SEDGWICK HTG. & AIR COND. CO. -2-2-2 355-
17(?3 ?JHOUSE HEATING TEST RECORD
ADDRESS ? ?.(, CITV (?irl??ti+'?J GLI ?' -Z?
OCCUPANT nwNpp
HEAT LOSS
SOLD BV _
Electrical Work By
TYPE OF HEAT GA_
INSTALLED BY
Gas Line By -
HW_ STEAM_ SPACE HTR._UNIT HTR._OTHER_
C1GAS DESIGN CONVERSION
MAKE L
Model rrI'? IOS -nLSerial
INPUT
???r CONTROLS
THERMOSTAT Heat Plug
Valve U-Sf-/T7-
Limit r 7`('
Limit Setting
Fan Setting 70'? j¢L
Pilot Type
Pilot Make
Pilot Modei
Pilot Timing L.W. Cut Off
Pressure 'De PercentC02 b-3
Input CFH LoS Percent O 9•3 S• ? 5.?1
Stack Temp.-7 Percent COZ 0,0 G-n Q, 0
DATE HTG. INST.
MAKE OF BURNER _
Model
Max. BTU Rating -
MAKE OF FURNACE
Model
Vent Size 4- ?`
KIND OF LIN?R ?? SIZE NONE
Draft Hood ? RAeulator
Filters Size/X(?XZr Num6er ?
Chimney Location Inside ? Outside
Chimney Construction
Smoke Bomb
Dreft 6
Door Pressure
Wiring 1? .
Test Tag
Lighting Inst.
Date Tested
Company
Name of Tester ??!?-? ? ?7
Form 235
i?_ Z, w 6 4r-
CITY OF E,?GAN
3795 1'ilot Knob Road
Eagan? Minnesota 55122
PERNIIT NO.: 763
The City o£ Eagan hereby grants to Geo. Sedgwick Aeating & A/C Co.
a
pf 1001 Xenia Ave. 30.
a AEATING Permit £or: (Owner) New Horizon - Woodgate
at 1765 Hickory Hill ? pursuant to application dated 11/20/75
Fee Paid: $20.00 dated this 21 - day of Nov. ? 19 75 ,
.50 s c
Building Inspector
Mechanical Permits:
Bid Total:
t,
?
/('a _. Z'/ G() '?? -%?
CITY OF fiAGtAN
3795 Pilot Knob 3oad
Eagan, Sdinnesota 55122
PERivlIT NO.: 571
The City of Eagan hereby grants to Thanson P1+?*u?{-pg oo.
Of 12201 M1Tnahp YA BZVCI•
a ornwatra: Permit for: (Owner) New o - Wood4jete
1775,76,74,72,70,68,66,64,62,60,58.56, arid 54 lialnut Lane and 1757?59,61,q,67,
at »6a.7i1 ,,,,A sa K nke?r?r wL?ursuant to application dated 6/16/75
Fee Paid: __$42n_nn dated this lg? day of Juee , 19 75
10.50 s/c
Building Inspector
P;echanical Permits:
Bid Total:
CITY OF GFlGAN
CASHIER: S TERMINAL N0: 869
DFlTE; 07/16/98 TIME: 14:27:00
ID:
NAME: ALLIED FIFiEaILE INC
3210 9001 4511 OA1: CHASE 50.00
2155 3001 4511 OAY GHASE 0.50
3210 31701 1765 HICF:QI;Y HI_ 50.00
2155 9001 1765 HTCF(01'tY HL 0.50
r
t
Tnt,al Receipt Amnun+,; J.01.00
Cfi09^i3 r 3
USER I0: NANCY
# ?kX?%c #?#k?X??kXcXcXcXc?C?XcXc? ##?x??%?#X??X ?%#%?Xc?k?k?Xt?k %cXc?C
C1TY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
SITE ADDRESS:
P.I.N.: 10-84601-160-06
PERMITTYPE: BuxLozNc
Permit Number: 0 3 2 5 4 2
Date Issued 0 7/ 16 / 9 8
1765 HICKORY HILL
LOT: 16 BLOCK: 6
WOODGATE 2ND
DESCRIPTION:
&eril?fiFr=g, Permit Type
j8uilding ?Weork Type
e`Census Codey ^.
f ?
§
Y
?C? I L
FIREPLACE
NEW
434 ALT. RESIOENTIAL
l,
/?° ?-.._, ?? ?f • , ? ?aW _ _ .-.. _? - - .._, i. ? _
REMARKS:
CHIMNEYJFLUE MUST BE INSPECTED BEFORE COVERING
FEE SUMMARY:
Base Fee $50.00
Surcharge ,$.50
Total Fee $50.50
CONTRACTOR: - Applicant - ST. LIC OWNER:
HEAT-N-GLO FZREPLACES 18900758 2009091 PROFF RRNOL?
3iefi 0 W HWY 13 1765 HICKORY NILL
BURNSVILLE MN 55337 EAGAN MN
(612) 890-0758 (651)452-3386
?
I hereby ecknowledge that I have read Chis
inPo,r.mation is aorreot and agree to oomply
Statutes and City of Eagan Ordinances.
APPLICANT/PERMITEE SIGNATURE
PERMIT
application and stete that the
with all applicahle state ot Mn.
?
<
SUED Y: SIGNATURE
CITY OF EAGAN
3830 PILOT KNOB RD - 55122
1998 FIREPLACE PERhIIT APPLICATION
681-4675
DATE:?1?
DESCRIPTTON OF WORK: _ Construct new fireplace
_ Install pas insert oolv _
Other
JOB ADDRESS: ( / (o
LOT: i(o BLOCK:
APPLICANT (c'vcle one only):
/
PERMIT FEE: $50.50
Alterations to existing
Install ees line onlv
I?
? SUBDMSION/P.I.D. #: LU d
OWNER CONTRACTOR
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.
PROPER71'
OWNER
FIREPLACE
INSTALLER
GAS LINE
INSTALLER
Name: E \0 ?'F u)? ,(I Phone t!: Sc? `
Last ' First
Street
City
Street
?n fh
State: / 7I nf , Zip:
Street Address: '
City ? (A;t 1) , State:_?` Zip:
OFFICE USE ONLY
BUILDING PERMIT TYPE
? 14 Fireplace
WORK TYPE
? 31 New ? 33 Alterations
? 32 Addition ? 34 Repa'v
GENERALINFORMATION
Census Code. 434
SAC Code Ol
REMARKS
Chimney/flue must be inspected before concealing.
?
1985 BUILDING PERMIT APPLICATION - CITY OF EAGAN
NOTE: ALL CONTRACTORS MUST BE LZCENSED NITH THE CITY OF EAGAN
COt4fERCIAL
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 • L'V?i?SrMFA/7-
SINGLE FANILY DYfELLINGS
INCLUDE 2 SETS OF PLANS
3 CERTIFICATES OF SURVEY
'1 SET OF ENERGY CALCULATIONS
Valuation:? O o ? Date:
Site Address /?7??C
Lot IL Block 4
Parcel/Sub JJ oC (_qkq
Owner
Address i7lL
City/Zip Code N'`Gri'?
Phone
Contractor
Address led;'?
CiLy/Zip Code
Phone
Arch./En
Address
City/Zip
Phone !1
OE'FICE USE ONLY
Erect
? Occupancy
Remodel Zoning
Repair ? Type of Const
Addition {l of Stories
Move ? Length
Demolish Depth
Int.Impr. Sq Ft
Install ?
APPROYALS FEES
Assessments Permit
Water/Sewer , Surcharge
Police Plan Review
Fire SAC
Engr Water Conn
Planner Water Meter
Council Road Unit
Bldg Off :? Treatment P1
APC Parks
Variance Copies
TOTAL
5O
?----------------i
I F.onO(tice:Use
? Permil#:.T.?
I I ?? I
? Permit Fee: ?J
I
? Date Received: ?
I I
? Staff: I
I
2008 RESIDENTIAL BUILDING PERMIT APPLICATION
Date:??//?b[° t1 Site Address:
Tenant:
AAlr 16r.
Suite #:
RESIDENT I OWNER Name: ?(aa A?SV-P Phone?Q? -1 &
Address/CitylZip:ntOS 1?ft C-?..Oiti1 Llit`
Applicant is. x Owner _ Contractor .
TYPE OF WORK Descnption of work: (?_ tC
Construdion Cost: Multi-Family Building: (Yes No _I,
CONTRACTOR Name: License #:
Address:
City: State: Zip:
Phone: Contad Person:
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Cateqorv 1 Minnesota Rules 7672
Energy Code . Residential Venfilalion Category 1 Worksheet • New Energy Code Worksheet
CategOry Submitted Submitted
submission type) • Energy Enveiope Calculations Submitted
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 masler plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer 8 Water Contractor: Phone:
supporfirigdocurnents that you submit are consitlered idbe public;informadon
`NOTE: Plansand Portions oi:."
,
. „
tBe informatwn may be class??ed as non p,'ublic ?f you provrde speci?c reasons thet would permrt the Cfity fo! •
. ,_..
,
conciude that,the' are?trade secrets_
I hereby acknowledge that this information is complefe and accurate; that the work will be in conformance wi[h the ordinances
Eagan; that I understand this is not a permd, but only an application for a pertnit, and work is not to start withoa a pe
accordance with the approved plan in the case of work which requires a review and approval of,plans.
?
/
Applic Ys Printed Name A plicai ign ure :odes of the C"Ry of
x lL N x% ?
lhe work will 6e in
Page 1 of 3
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA127531
Date Issued:10/03/2014
Permit Category:ePermit
Site Address: 1765 Hickory Hill
Lot:016 Block: 006 Addition: Woodgate 2nd
PID:10-84601-06-160
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Furnace
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Daniel Thelen
21034 Chippendale Ave.
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 -
Sayaket M Phoutinane
1765 Hickory Hill
Eagan MN 55122
(612) 275-7232
Farmington Plumbing & Heating
21034 Chippendale Ave
Farmington MN 55024
(651) 463-7824
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA127532
Date Issued:10/03/2014
Permit Category:ePermit
Site Address: 1765 Hickory Hill
Lot:016 Block: 006 Addition: Woodgate 2nd
PID:10-84601-06-160
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Water Heater
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.
Daniel Thelen
21034 Chippendale Ave.
Farmington, MN 55024
Fee Summary:PL - Permit Fee (WS &/or WH)$55.00 0801.4087
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 -
Sayaket M Phoutinane
1765 Hickory Hill
Eagan MN 55122
(612) 275-7232
Farmington Plumbing & Heating
21034 Chippendale Ave
Farmington MN 55024
(651) 463-7824
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA127775
Date Issued:10/15/2014
Permit Category:ePermit
Site Address: 1765 Hickory Hill
Lot:016 Block: 006 Addition: Woodgate 2nd
PID:10-84601-06-160
Use:
Description:
Sub Type:Reroof & Siding & Windows/Doors
Work Type:Replace
Description:
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please print pictures of ice and water protection and house wrap and leave on site.
When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to
ensure maximum ventilation to attic. Call for final inspection after installation.
Valuation: 12,000.00
Fee Summary:BL - Base Fee $12K $221.25 0801.4085
Surcharge - Based on Valuation $12K $6.00 9001.2195
$227.25 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 -
Sayaket M Phoutinane
1765 Hickory Hill
Eagan MN 55122
Viking Exteriors
901 N Concord St
South St. Paul MN 55075
(651) 256-1061
Applicant/Permitee: Signature Issued By: Signature
For Office Use I
` i 1 1,# Permit#: /5--6/ 43 I
%., `... .0 .., E AGA N
I
its• +�.+t
rmit CEFVED iP° °
6 --,2 -f r t Date Received: '�
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651)675-5675 I TDD: (651)454-8535 I FAX: (651)675-5694I
buildinninspections(a�citvofeagan.com JUN 22 2018 Staff: j
2018 RESIDENTIAL PLUMBING PERMIT APPLICATION
Date: 6/20/18 site Address: 1756 Hickory Hill Drive
Tenant: Suite#:
Resident/Owner
Name: Invitation Homes Phone: 952-563-1929
Address/City/Zip: 1210 Northland Drive Suite 180 Mendota Heights, MN 55120
Name: Metro Heating & Cooling License#: PC642529
Contractor
Address: 1-220 Cope Avenue East City: Maplewood
State: MN Zip: 55109 Phone: 651-294-7798
Contact: Carley Email: invoices@metroheating.corn
Type of Work —New CReplacement _Repair _Rebuild _Modify Space Work in R.O.W.
Description of work: Replace existing water heater
(RESIDENTIAL
V 1 Water Heater
Water Softener
Lawn Irrigation( RPZ/_PVB)
Permit Type Add Plumbing Fixtures( Main/ Lower Level)
Septic System
New Water Turnaround
Abandonment
RESIDENTIAL FEES:
$60.00 Water Heater,Water Softener, or Water Heater and Softener(includes State Surcharge)
$60.00 Lawn irrigation(includes State Surcharge)
I $60.00 Add Plumbing Fixtures, Septic System Abandonment,Water Turnaround*(includes State Surcharge)
*Water Turnaround(add$280.00 if a 3/4"meter is required)
$115.00 Septic System New(includes County fee and State Surcharge) TOTAL FEES$60.00
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
You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update on the City's
` `'` website at www.citvofeagan.com/subscribe.
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 pe 'mat the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Fos Carley Ferrie
X
Applicant's Printed Name Applicant's Signa
FOR OFFICE USE Reviewed By: Date:
Required Inspections: Under Ground Rough-In Air Test Gas Test Final
Meter Related Items: Meter Size ` Radio Read Manometer Staff: