1662 Mallard DrCITY OF EAGAN Remarks
Addition Ma11 ard Park Second Addi ti on Lot 7 e1k 2 Parcel # 10 47251 070 02
Owner street 1662 Mallard Drive state Eagan, MN 55122
' Sc ? i:ZL
Improvement Amount Annual Years Payment Receipt Date
STREET SURF. 7o'1. i 1751.47 350.29 5 C
•
STREET RESTOR. d ?
?
GRADING
SAN SEW TRUNK
iSEWER LATERAL 981 2430,43 486.09
WATERMAIN
VATER LATERAL 98
WATER AREA ? H 05,
STORM SEW TRK yfJ 445.37 89.07 5 7Q.1
16TORM SEW LAT 1981
CURB & GUTTER
SIDEWALK
STREET LIGHT
WATER CONN. .
9UILDING PER. 10669
sac 525.00
PARK
IXJ RASU[, 853-3721 CITY OF EAGAN
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
" PHONE: 4548100
BUILDING rERMIT aeceipt
.
r? a. ....? ?.. F.s V.I.
. .. . n?._ , e Site Address
Lot Block Sec/Sub. -
Percel No.
W Nar+ie
; Address ,
b
g- Neme
SU
i Address
F C:iw Phnnw
Name
Address
City
Phone
Erect ? Occupsncy
Remodel ? Zoning
Repair ? Type of Const.
Addition ? No. Stories
Move ? length
Demolish ? Depth ,
Int Impr. ? Sq. Ft.
FNs
Assestment
Woter 3 Sew.
Poliu
Fin
En0•
PianM?
Council
Permit ?
5urcha?ge ?
Plan Revfew
SAC
Water Conn. • i
Water Meter '
Road Unit
1 hereby ocknowiedpe tFwt 1 how rood this appl+totion cnd srote that Bidg. Off . ?,? ??•' Tr. PL
the inlormotion fs correct and aqrce to comply with oll opplicobl* APC Parka
5tate of Minnesota Statutes ond Gty of Eogon Ordinonces.
Var. ?ata C??
5iqnoturc of Permiftee ?
Total
A Buildinq PMnif Is isswd to: ' on the -ycpraas corditlon Ihot
dl work sholl be daw in acoordonce with all appliaoble State of Mlnnesoto Statutea ond C1fy ot Eoqan Ordinoncss.
Buiidinp Offitipl ?
J
Pwmit No. Pwmk Holder Daw TeIephone ?
P?urnbilig ? ?-Ty s
H.VA.C. Cor-f
?( c3 ?f I b
Z
. ; ,.
,
• , ; . ?
,',j.
K,C. C C_
Soitoar
Irapsetion Date Insp. OMK
Footinqs I
Footinys il
Foundation
Framing
Roofing
ROUQh Plby.
ti
Rouyh Htg.
Inwl.
Firoplace
or K ar . y' ` R.
k S v 6 E. .
Final Htg.
Finsl Pitp.
Flnel p ? 49
Cort/Occ.
Water Dose?i6e Loeation: ,
w.u
Sewer
Pr. Dlsp.
Receipt j PLUMBING PERMIT Psrmit No. '
, CITY OF EAGAN
Fee '
" Fi!l rn numbered spaces ' S/C
Type or Print legrb/y Tot
1. Date 2. Installation Cost
;, - ,,,? . • *. ? , :
3. Job'Address Lot i` Blk. Tract
TT
4. Owner 5. ContractorV? 4- 4, ./ Phone
6. Address
..? /A . ..? .
7. City State .' ? Zip j
8. Building Type: Residential ? Commercial ? Institutional ?
9. Work Description: NevuZ Add ? Alter ? Repair O
1 10. Describe
11.
No.
- Fixtures
Water Closet No. Fixtures
Cesspool/Drainfield
i Beth tubs Septic Tank
Lavatory Softner
i St?ower Well
Kitchen Sink
Urinal/Bidet Other
! Laundry Tray
,
Floor Drains
Drinking Ftn.
Slop Sink
Gas Piping Outlets ?i
12. I hereby certify that the above information is true and correct, and I agree to
comply with all ordinances and codes governing this type of work_
Signed : for
Rough Final
Inspections: Date Insp. Date Insp.
This is your permit when numbered and approved.
Approved CITY OF EAGAN 454-8100
I
Rw?ipt
?
MECHANICAL PERMIT Permit No. CITY OF EAGAN FN
fill !n numbered spacea S/C
Type or Print legibJy Tot
1. Date 2. Installation Cost ?
?. ?.
3. Job Address /Vrl Lot Bik. Trect
4. Owner
, ?.
5. Conuactor ? Phone
6. Address
7. City State • ? ? 2ip
8. Building Type: Reaidential 0- Commercial ? Insiitutianal ?
9. Work Description: New 0' Add ? Alter O Repair ?
10. Desixibe Fuel Type+
! 11
No. EpyiRalspL 9TU - M. Ea.
Forced Air L No. Eauiament CFM
Air Handlin
:
Mfg. --. ?y g
BO1lers
AAfg. Mech. Exhauat
Unit Heater
Mf9.
Air Cond. Other
Mfg.
Gas, Piping Outlets
12. I hereby certify that the abave information is true and correct, and I agree to
comply with all ordinances and codes governing_this type of work.
Signed : - - - - i for
Rouph Final
Inspections: Date Insp. Oate Inap.
This is your permit when numbered and approved.
Approved CITY OF EAGAN 464-8100
INSPECTION RECORD
CITY OF EAGAN PERMIT TYPE:
3830 Pilot Knob Road Permit Number:
Eagan, Minnesota 55122-1897 Date Issued:
(612) 681-4675
SITE ADDRESS: ? ?' ? `1++1 r
frtPERMIT SUBTYPE:
h' 9/9
7 fil.Oi.: APPLICANT:
..:? i:j•.
, f6i,>> br"--98I3
TYPE OF WORK:
r1i 1FRAT [??M ,.j .; ; ; - ? IO:s izr?D RoOr• nuER PorTt: H I
I i : rlAFtKSz t2tlOF' i'; NOT TU FXT'fWf1 FAST EXISTTN?'i Rltxlt'?1NiQ t INI
? II
ts^ ?,?-C?
Permit No. Permit Holder Date Telephone M
ELECTRIC
PLUMBING
HVAC
Inspection Date Insp. Comments
FOOTINGS
FOUND
FRAMiNG
ROOFING
ROUGH
PLUMBING
PLBG
AIR TEST
ROUGH
HEATING
GAS SUC
TEST
INSUL
GYPBOARD
FIREPLACE
FIREPLACE
AIR TEST
FINAL PLBG
FINAL HTG
ORSAT
TEST
BLDG FINAL
BSMT R.I.
HSMT FINAL
DECK FfG
DECK FINAL
I1'Y OF EAGAN Wp? SERVICE PERMlT
A Pilot Krwb poed
' . (J. Box 21199 PERMIT NO.: `
Eagan. MN 55121 DI17E:
Zoning: No. of unln:
? pwner.
i ? Addr'eas: I?5 % :1??71?:?A??'???r?i?T•' ; 777.7 _ 7:: .
Reoe.d No.: ..d..&1.r
I e0g" !v eeukolp wNii
`- Pemeit Fae:
nr . -Surchtrryer
Misc. Chorges;
Totol:
"r _ ' ? DOt! POid: _
Dote of Insp.: ? Inep.:
:CITY OF EAGAN
.3830 Pilot Knob Rosd swo SOV" PuMrt
P. O. Box 21199 PERAAIT NO.:
iEagan, MN 55121
, D,,TE: .
'Z0?ing: ' No. of Units:
Owner.
Ilddress:
Site Mdross: : >•-
Piurriber. -
.. ?.?:J. ? "' ....
? NfM ?O ?O?r v?" as City of y"w C4N111QCti011 (hQ/gQ; 41S_
Accoix+r oeposic: i _5 , fJCI :
Bv
Dote of Insp.:
CITY OF EAGAN
3830 Piiot Knob Rosd
P. O. Box 21188
Eagan, MfV •55121
Zonirg: _
Owrwr:
llddrom
Sita Addren: -,- :, d 3 ?.rd Dr.
Pluir+ber.
Meter No.:
Sise:
Raader No.:
i*lwe te amplp wft /M Cih Oi EON*
OerFN
By
Date of Insp..
Permlt F«:
Surchor+pe:
Mist. Chorpss;
TotaL•
Dah Pold:
WATER SERVICE PEItMIT
PERMIT NO.: D11T'E: ' ' -
. No. of Units:
Connsctian Chorps:
Accourit Oeppsif: _
Per?nit Fee:
SuRhorpe:
MIx. Ghorgss: -
Total:
Dots Paid:
? CASH RECEIPT •
• CITY OF EAGAN
P. 0. BOX 21-199
EAGAN, MINNESOT 55721
DATE _ °t 19 ?'
N[C61V6D ?r- -
VROM
' AMOUNT $ I
8 DOLLARS
ioo
E] CASH g-E+tFCK
/G ?oZ . GE
va
//jv" o ?' ?v.? ? /?G ?"?.?_eP?,???P.?/•
ruHO cooe wmourvr
G ?
Thank You
B Y
N_ 55786
WM1ita-Payen CoPy
Vellow-Pocting Copy
Pink-File Copy
CITY OF EAGAN N° 10 6 6 9
3830 Pilot Knab Road, P.O. Box 21-199, Eagan, MN 55121 - , /
PHONE: 4548100 ?Dg?l
/
BUILDING PERMIT Receipt #
Te 6, awt 1a SF DWG/GAR Ei, Value $96.000 Date JULY 29 19 85
SiteAldreu 1662 MAI,LARD DR Erect 19 Occupaney R3
MALLARD PK
Lot 7 elock Z SeclSub ND Remodel ? Zoning Rl
. Repalr ? Type of Conrt. V
Percel No. Addition ? No. Storiea
M.W. JOHNSON CONST Move ? Lenqtn 60
W Name
BOX 134
O
P Demoliah ? Depth 2(
;
a .
Addreas
•
432-6838
FARMINGTON Int ImOr. ? Sq. Ft.
phone
city Install ?
? $AME, AyOrovala Fen
ZO Name
u? Addrest
? City Phone
GW Name
U? Address
??.=i City Phone
I hereby ockrawtedga tFwt I have read this application ond stote thot
tha inlormetion is correct and agree to comply wirh oll upplicoble
Stah of Minnesom Statutes and Ciry of Eogan O?rdei?rances.
Sip?wturo of Permiffae "???L ? L(J?"?-?-"Q?+
n Buuding Perma I: isswd ro: M.W. JOHNSON CON
oll work sholl he dona in occordcnCe w/iµ-?? .aliaoble tofe o A?Aii
Buildinp Officlol 4 ?',
?
Assessment
Water & Sew.
Police
Firo
Eng•
Plonnar
Council
Bidg. Off. 7/25/$ !
APC
Ver. Dete
aermit 5 421.00
3uroherge 48.OC
Plan Review 210 .$C
SAC 525 0(
Water Conn. 500.0(
waterMeter 63.0C
RoadUnit 280.0 (
rr. Pl. 13 2. 0 C
Parke
Coples
I 7otal $2, 1 7 2 5(
_ an fhe axpeess conditlon that
ord City o£ Eapon Ordirontea.
lb-
This requesl witl
?78g n ?+ 7` L
?n!?.1
FleQUesl Date /
/
? Fire No. Rough-fn Inspection
flepuired?
?Ready Now?K?ll No/it¢ Insoec-
Wr When fl
d
es ?Ha ea
Y
QLicensed EI¢cVical Contracmr I ?r?
y rqpuest inspection ot ebove
? Owner elac4icel work insteiled at
Street Atldress, eox or floute No. City
14WG Z- O ? e? r ??i''ot "
ecLOn o. 7owvis m N or No. Pange No. C my
Ct ' C_"
Occupam IWi1ND
J4 l oce No.
.
t- -0?
Power uPVlier
4- K4 f?- f 4
r Adtlress
e
.
. ,
-... .`
EI lrica Contr c ?Co Namr. Con actor s License No_
r ,? e v .99
' mp Address (Contra mr or Owaer Ma bg IMtai a[ion)
Authwized SiB?ture (CO? ctw Owner king IreWllacion) ?M1O mnber
0-?3
YINNESOTA yTp7E eppRp pF ELEC7AILITY TNIS INSPECTION REQUEST WILL NOT
Gripga-MitlWay BIAy. - Room N-197 BE ACCEPTED BY THE STATE BOARD
1821 University Ava.. SC Paul, MN 55104 UNLE55 PpOPER INSPECTION FEE IS Phonn (612) 2972777 ENCLOSEO.
REQUEST FOR ELECTRICAL INSPECTION EB'°°°°'-0+
O. ?????' See imtruetions for completinq this fdm m beck ot yollow copY.
-'X'" Below Work Covered by This Request
M..{aaairteo.1 Trae o+ s,awino ? ADOliamea wo-w ... w?.ee I
??- Home Ranqe Temoorarv Service
p Fee ServieeEntraaeSize d F¢e Feeders/SuEteeders b Fee Circmts
0 m200 Anips- 0 to30Am 6 Oto 30Am
A6ove 200 Amps 31 to 100 Amps 31 to 100 qm
Swinmi Pool Above 100-Ampsi Above 100_Amps
Transformers Irtigation Booms Pattial.'Other Fee
Signs Special Inspection /
Remerks $y4•J^O TOTRL E
? (FE?-oG^
qouph-in D/nre the E16cttical
? Imcpsctor? hereby
? cartifV lAal thg abov0
Final DAs/te^ ispeetion has been
made.
tW? myuest vaW 18monW 1mm
REQUEST FOH ELECTRICAL INSPECTION
, See InstrueUOns for compleunB this form on beck oi yellow copµ
443..1 1 "X" Below Work Covered by lhis Request
lNftAAddi Fev. Tyoe ot BwlCmg AOClaancea W,roE Equiumanl Wvad ?
EI
I I I I Industrial Blda. 1 I Air Conditioner 1 1 Bulk Milk Tank I
PP
p Fea Service EnttancaSiza tt Fee Fexdera/5ubfeaders M Fee Circurts
0 to 200 qm s D to 30 Am s 0 tn 30 Am )
Above 200 qmps 37 to 7 00 Amps 37 to 100 q y
Swimming Pool Above 700_A
mps Above 100_Am s
Tran
srormers Irrigationl3ooms ParLal"Other e
signs yueciai insUection $
? q. SQ -/F .??
Nemxrks q TOTAjlFE
? ,. / . ( ?
IA fl[?' ??
the El
7 ? ,nspectvr. he,eby
??) ?? • ? artify Ihet tha above
? IL?, D" .i'fsoeclion hes been
.1 ? ?c?? • ? G
This repae5l witl
/8 mpn(hs (rom . p
C 4 4 311l--7?,2
7-2 ;1 _SG
flequest Date / Fire No. RouPh- inInspeclion
Renuired,
?Ready Nuw?Will Noufy Inspeo
Nes ?Nn [ur Wpen Heady
Licensed Elec[rical Conlractor
1 hereby reQueat mspection af abova
?Owner eleciricel work installed at:
Sveet Address, Boz or Pou[e No. Cny
ectwn o. TOwnShiD Name or No. Ran9e o. County
Qa s("o7`a
Occupnnt (PqINT)
2-eo /V Phone No.
853-372/
Power Suppliar
,e2po7; Adtlress ? fl'1')11'L
Electncal Convector IComOanY Namel Cnn[rnclor's Lwense No.
Mailina /+tldress ICOmractor or Owner MakinB Instailauonl
AuMonzed SignaWre (ConiractodOwner Making Installntion) Phone Number
MINNESOTA STATE BOAflD OF ELECTNICITY THIS INSPECTION PEQUEST WILL NOT
Griyga•Midwey Bldg. - Noom N-797 BE ACCEPTED BV THE STATE 90qRD
1821 Umversi ty A ve., St. Peul, MN 55104 UNLESS PROPEfl INSPECTION FEE IS P6..ne 18121197.2111 ENCLOSED.
RESIDENTIAL
BUILDING PERMIT APPLICATION
CITY OF EAGAN
3830 PILOT KNOB RD, EAGAN MN 55122
651•681-4675
New Conatruction Reouiramenb
. 3 registered srte surveys showinq sq. fl. of lot, sq. R of house, and aU mafed areas
(20%mavimum lot coverage allowed)
. 2 copies of plan showiig beam & wuMow sizes, poured found desgn, etc.)
• 1 sel of Erreyy Calculations
. 3 wDies of Tree Preservation Plan rf lot platted after 7/1193
. Rim Joist Detail Options selacNOn sheel (bidgs vnth 3 or less uniLs)
DATE h??Os2
SITE ADC
TYPE OF
TI-FAMILY BLDG _Y ZN
REPLACE(S) _ 0 _ 1 _ 2
APPLICANT
STREET ADDRESS CITY&2?F mL?STATE /W ZIP_4a7?WV
TELEPHONE # 9VJy?45_90 CELL PHONE # Aa-aia-7737 FAX #
PROPERTYOWNER TELEPHONE# GIa2-.?IG3OG7l?'
----------------------------------------------------- °------------------ ------- --------------
COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY
Energy Code Category MINNESOTA RliLES 7670 CATEGORY l MINNF?? Ib??
t r r I.•
(4 submission type) • Residential Ventilation Category 7 Worksheet Submitted • New E? ? ? Cle, rksheeM ?ttec
• EnergyEnvelopeCalculationsSu6miited ?? ?U(? 2 7 qoo7 h1 U C C
Plumbing Contractor: ___
Plumbing system includes:
Mechanical Conhactor:
Mechviical system includes:
Sewer/Water Conhactor:
Phone #
Phone #
Pcc: $70.00
----°--------------°----°--- °---------.. _..---------° --------------------------------------°----------------------..
I hereby acknowledge that I have read this application, state that the information is correct, and agree to comply
with all applicable State of Minnesota Statutes and City of Eagan O dinances.
Signaiure afApplicant i•? ?+'??.??/?
--------------------___..°°--------.°°°---____°-"------- -------------- ___--------- - _----- -----------
OFFICE USE ONLY
Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _
Updated 4/02
Water Softencr
Water Heater
No. of Bat}is
_ PI70RC #
Lacvn 5prinkler
No. of R.I. Baths
_ !lir Conditioning
_ HeaL Recovery System
?"') r °Z'
RemodeVReoair Reauiremenis
. 2 coPies of plan
• 7 set of Energy Calculations for heated additbre
. 1 site survey for e¦[enor adddions d decks
. Indirate if home served 6y septlc system for additions
VALUATION 4tSS?Sb'6b
OFFICE USE ONLY
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? OS 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 EM. Alt- Muiti
Cl 03 Ot of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 E#. Alt - SF
? 04 02-plex ? 10 08-plex O 18 Oeck ? 23 Porch (screened) ? 36 Multi
? OS 03-plex ? 11 10-plex ? 19 Lower Zevel ? 24 Storm Damage
? 06 04-plex ? 12 12-plex Pibg_Y or _ N ? 25 Miscellaneous
? 31 New ? 35 lnt Improvement ? 38 Demolish (Interior) ? 44 Siding
? 32 Addition ? 36 Move Bidg. ? 42 Demolish (Foundation) ? 45 Fire Repair
? 33 Alteration ? 37 Demolish (81dg)• ? 43 Reroof ? 46 WindowslDoors
? 34 Replacement *Demolition (Entire Bldg only) - Give PCA handout to applicant
Valuation Occupancy MC/ES System
Census Code Zoning City Water
SAC Units Stories Booster Pump
Nbr. of Units Sq. Ft. PRV
Nbr. of Bidgs Length Fire Sprinklered
Type of Const Width
REQUIRED IN SPECTIONS
_ Footings (new bldg) Final/GO.
_ Footings (deck) FinaUNo C.O.
_ Foohngs (addition) Plumbing
_ Founda[ion HVAC
_ Drain Tile Other
Roof _ Ice & Water _ F inal Pool Ftgs Air/Gas Tests Final
_ Framing Siding Smcco Srone
_ Fireplace _ R.I. _ Au Test _ _
Final Windows (new/replacement)
_ Insufation _ Retaming Wall
Appraved By
Base Fee
Surcharge
Plan Review
MC/ES SAC
City SAC
W ater Supply & Storage
S&W Permit 8 Surcharge
Treatment Plant
Plumhing Permit
Mechanical Permit
License Search
Copies
Other
Building Inspector
Total
".11`.:;I-•::.?::I;r .., 'f?_R;Sl.n?r?_ ii(!: ?`..
35
A'?1?1f:'^ i'?ll. .?F?C:(lld;a(.ilE! ;:(.'•iv`:?'r?i
IJ"n.,.', i,r?; i•i^?J.f.'?';
PERMIT ?
CITY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
PERMIT TYPE:
PermitNumber: BUILDING
030906
Date Issued: 10 J 0 6/ 9 7
SITE ADDRESS:
1662 MALLARD DR
LOT: 7 BLOCK: 2
MALLARD PARK 2ND
P.I.N.: 10-47251-076-02
DESCRIPTION:
ADD ROOF QVER PORCH
ermit Type SF (MISC.)
7ype ALTERATION
rr.,
er=;?'? 434 ALT. RESIDENTIAL
?E,"
$p
J.v,°wfl?W4?52 A.
gS ?
?
jr c
REMARKS: I
ROOF IS NOT TO Ex7EN0 PAST EXISTING BUILDING LSNE.
FEE SUMMARY:
VALUA7SON $1,600
Base Fee $51.25
Surcharge $.80
Total Fee $52.05
CONTRACTOR: _ ppplicant - sT. Lzc OWNER:
JACOBSON CONSTRUCTION 15789$73 2001250 RQZNOWSKT BTLL
6120 VALLEY CREEK RQ 1662 MALLARD DR
WOODBURY MN 55125 EAGAN MN
(612) 578-9873 (612)454-4592
04---
APPLICANT/ RMITEE SIGNATURE ISSUED B SIG UR
1997 BUILDING PERMIT APPLICATION (RESIDENTIAL) ?`Sa• 0 S
(? CITY OF EAGAN
? O l O 5830 PILOT KNOB RD - 55122
r{675
New Conatruction ReauiremeMS 681 RemodeVReoair Reauirements ?J
? 3 registered aite surveys ? 2 capies of plan
• 2 coDbs af ptans (indude beam & window sixes; poured fid. design; etc.) ? 2 site surveys (extedor etlCitions & dedcs)
? 1 enargy calculations ? 1 energy celculetions kr heated eddftions
? 3 coplea of tree preservetloan if lot platted after 7l1193
required: _ Yes No ? DATE: Q 1 q_I CONSTRUCTIONRosr: ?SSa
• - ' - ' ? ?-
DESCRIPTION OF WORK:
210?- 1-A??? d11
SUBD.lP.I.D. #:
- /ML '1"3
S7F
,ET ADDRESS:
LOT ' BLOCK
oP
PROPERTY Net11e: Phone#: 45q -454z--
OWNER ?
Street Address: ?(0? .?..
M'A L?-J? I?
City: EA6d1 N State: /1/1 t-i Zip: 6Z-
4
CONSRACTOR Company: C?i L Sco P,Sony CdNS%-- Phone#: S`7R?912:;,
Street Address: t,9 1z.0 Uhc.c?j CI-'W License #: 2221z So 3
City: W State: M?J Zip: 55 1 2.5
ARCHITECTI Company: Phone #:
ENGINEER
Name: Registration #:
Street Address:
Ciry: State: Zip:
Sewer 8 water iicer.ged plumber (new conshuction onty): . Penalty applies when address change
and lot change are iequested once permit is issued.
I hereby acknowledge that I have read this appliqtion and state that the infortnation is correct and agree to compty with all applicable
State of Minnesota Statutes and City of Eagan Ordinances.
RECEIVED /
? Signature of ApplicanC
SEP 17 1997
IBY: OFFICEIUSE ONLY
Certificates of Survey Received _ Yes _ No
(.?W ?£v??NB?
Tree Preservation Plan Received _ Yes _ No _ Not Required
? V???
OFFICE USE ONLY
BUILDING PERMIT TYPE
0 01 Foundation ? 06 Duplex o 11 Apt./Lodging o
a 02 SF Dweiling ? 07 4-plex o 12 Multi RepaidRem. ?
? 03 SF Addition o 08 8-plex n 13 Garage/Accessory o
0 04 SF Porch ? 09 12-plex ? 14 Fireplace n
X 05 SF Misc. ? 10 _-plex a 15 Deck
WORKTYPE Acprjl til(l ?2WF- pVC4r PQ(Ltj
0 31 New ? 33 Alterations ? 36 Move
0 32 Addition ? 34 Repair o 37 Demolition
16 Basement Finish
17 Swim Pool
20 Public Facility
21 Miscelianeous
GENERAL INFORMATION PCOF IS 061- TD -FKTID ftr nrsnn?& auxa, UW!".
Const. (Actual)
(Allowable)
UBC Occupancy
Zoning
# of Stories
Length
Depth
APPROVALS
Planning
_ Basement sq. ft. MC/WS System
_ Main level sq. ft. City Water
_ sq. ft. Fire Sprinklered
_ sq. ft. PRV
_ sq. ft. Booster Pump
_ sq. ft. Census Code.
_ Footprint sq. ft. SAC Code
Census Bldg
Census Unit
Building fm- Engineering Variance
01
f)
Permit Fee Valuation: $
Surcharge
Plan Review
License
MCNVS SAC
City SAC
Water Conn.
Water Meter
Acct. Deposit
S/W Permit
S/W Surcharge
Treatment PI.
Road Unit
Park Ded.
Trails Ded.
Other
CdJQ-L. tl- Conic(L4{'? $?Q l`?a4"j?
Copies
Total:
LWE w?L(.- M?TZ,* wt-rtF -rc.`?tsTlN4
% sac n?L -tttT-- S-rt?-ti r i s`rtw-,
SAC Units
?1?t4 _ T?wt?S
?????sd??
612 735 3305
CRLVIN JACOBSON 612 735 3305 P.01
rr
CERTlF'ICATE OF SURVEY
G1evaCions sfiown .are cxis(i;tg Qctides
and arc astitnned daCum.
Proposed fiarage Floor clevaeion = AB-O
9j•b
MA«ARp pRIVE9? '7
s s??s4,z8• e
9o.7q
O
M o:
yR i5.]5 l
6 _Fl`y 9 ?
? M 24 22 a
r Gqrt pR?PoYEn ?n
i9 N ?se :'
w
?
N ?.
M ?
? L
N
LOT 7
BLOGK r--
fl?
? o
I NEw
M . '1?noF
Lo • ?R
a1 3Tby7
?
1 W
?
f ?
S ?
? g8
?v3 V ?n
?
I
? UscAiNn(-'e E I :
?uT?LITY EA5EM6N'r I
?I X !)n nn
rv i55? eb'.sm' ?
[ 111v..L. iI. CI.JL LI.... ....,..L ,.?., ..,,L..l..,. ..( ., .... . ?.f.
I.ut 7. RlVek 2 "IALLARD Pr`.RF: SECOND-ADDI"fION. Dakota Cnuniv. Minnesotn.
accor,ling tu [hi• Yacr+rdrd p1aC tbcrenf-
aml th.IP 1 am a?Inlv r,ciatcTCd 1and siirvr}•nr under thr lawv nC thv Stnlo 01 ?iitinosot'e.
(;rne l.. Jacobson, h . Re?,. ho. 7735
pated this 15[h bay 0[ Julr. 1985
? DR. 8Y GrJ SCALE - 1" - 40' r o DEN07E5 IRON MON. BEARINGS ARE ASSUMEU DATUM.
`PFtEPAR£D FOR: JAGOBSON SURVEYORS P
IJ. SohnFOn
o uox 130
ITarmin:;LOn, MY 'i5024
IAKEViLLE, MINN. 55044
PHONE 469-4328
I
;lr
' i
1? Ah
C
/84
,
r
CITY OF EAGAN
\ APPLICATION FOR PERNIIT
-' SETdER AND/OR WATER CONNECTIODI
(PLEASE P9INT)
1) PxP= AoDREsS: c?iF'IlJL-
r.Fr`w DF_SG2I_ti171C:I:
(Iot/31ock/Subd_tvisicn or Ta:c Parcel I.D. Niuc?ber)
=`:G ST :L'C:",': -,
u. Crl^ C_ a " ORIGAL EuIL.,?' ^G _ --_?S'" . :C.:
S,--v,= ip-%ffT_,y -
? R-2 DUP= ('?tii0 U?IITS )
? R-3 'IC'I.vNHCLiSE (TI-LRE"' + WITS) ( WiS'_'S)
p a_d poApm!a-;m/CCmCi,=lIL:•I ( U?II=Si
? C'?
'^iEP
C
I
A
I,/RETAIL,/Ot'FICr:
T
[^?
T
?
T
Q 1W11VtLJ
Is
Q P.`dST2T'u'PICNAI,/Ca-ERI,1=
2) rL°PLT_G??7P (PLEd?E PRINi)
NF??,"E' /? ? U" ?V ???•l7?.
aonREss: ?y UX 1:30
crrr. sTaTE, zIP: 5*6G1/A?lz, 77?w ?- z a-y
PxoNE: y3? /? 8a 12
3) Pu?1EER.
? FOR CITY t1SE OHLY
?
?;
anDREss: Z 4745 S . .
II
PLS NS :
CITY, STATE, ZIPt
ROSEMO o 0
' dctive
FExpir
PHO''E=', ` PLUMBER I.ICENSE N????J?'j_ ? t oi Record
?
F
- r lni[1a
4) cxkV«ast YHINI)
ruuME:
ADDRESS:
CITY, STATE, ZZP:
PHO`IE:
5) INDIC,TE W[-IICH PE^r1•LIT IS SEItiG REQUFSTLD;
v ? ;=rION 'I17 CITY SE?•]ER
:I[JFI'TICN M CITY L e?'PER
? C7I'E'.ct (PLEASE DE.,,?ugE)
oJ C::-? .
,??, /P=E F:OIlI rlPP2pVEp PER%lIT fYJR PICK-UP BY ONE OF ABOVE
???°LE?SE_ ?*AYL- APPROV'a PIIt•LiT 'R7 1, 2,C-D 4 APg,IE ?l
? ` -- - -- - (Circle -one) - '
7) siCZZ.-n.:E: - ???'' oaTe:
e
R C I T Y
PERytIT " ISSUED
FrES : $ ZU. si%
$
$
$ IS .JV
$ li-6-0
$ 5_21
$
`i 2 S?o u
$
$
$
$
$ ? o c•
U 5 E O N L Y
rr.:. _, i L--c, nrn?tT^•
?T•?••?"^.- nrc;v?^)
.... _ ?.?..,?-.. ?u...._.""
WATER PEI2I4IT (ZNC?,UDE SURCY.aRGE)
WATER METER/COPPERHORN/OUTSIC=- RE-,GER
L9ATE.°. TaP (Ii;CiCiDE CCRPGRAT=OV 5^C?)
SE:]E3 .P.P
ACCOU.IT GEPOSIT - 5EWER
ACCOliNT ?EPOSI'^ - WA.ER
WAC
SAC
TRU:1Ii ?4ATER ASSESS.3E:7T
TRliV:: SEivER ASSESSMEtiT
LATE°.AL BENEFIT/TRUNK SE?CER
LATEP.AL BENEFIT/TRUNi%, WAT°R
OTHER $ TOTAL -
$ ??? • ? ?'' ADSOU:]T PAID/RECE I?T ; 51-74(6
DOES UTZLITY CONNECTION REQUIRE EXCAVATION IN PUBLIC RIGIiT OF LvAY?
YES IF YES, THEN A"PERMIT FOR WORK WITHIN
PUSLIC ROADWAY" MUST BE ISSUED BY THE
NO ENGINEERIDIG DIVISION. LIST AS A CONDI-
TION.
SUIIJECT TO T(iE FOLLO:QING CONDITIONS:
APPROVED BY:
TITLE:
DATE:
Ma s r0 Nas wMWl.4w MOM fa ?]M wtMwam wlf?_M w06 wa *cM190 OF r NW rR wa wt MsM wi+ F*-M mmr w wm
?
o.*
421•00+
48•00+
210•50+
525•00+
500 • 00 +
63•00+
280•00+
132•00+
2, 179•50*
1985 BUILDING PERMIT APPLICATION - CITY OF EAGAN
NOTG: ALL CONTRACTORS MUST BE LICENSED 1dITH THE CITY OF EAGAN
INCLUDE 2 SETS OF PLANS
3 CERTIFICATES OF SURVEY
-' 1 SET OF ENERGY CAL CULATIONS
To Be Used For: Valuation : dI(o,fX70 ou Date:
Site Address: OFFICE USE ONLY
Lot: ? B1ock ? Sect/Sub mallQrj Erect ? Occupanc.y }Z-3:
?p Remodel Zoning ?-1
Parcel 1! Repair
O
/Y)
J Enlarge
wner
. j,<1.
o hn5on l.DI15? Move
" Demolish
Address _?(). ?py( /,30 Grade
City/Zip Code ra{'mlylG?TDh? --------
_ Type of Const 'V-
# of Stories
_ Length (PO
Depth 2LP
Sq Ft
Phone APPROVALS
Contractor w. JOhyL4py) 0-4K? Assessments Permit
Address
City/21p Code
Phone
Arch./Engr. _
Address
City/2ip Code
Phone #
Water/Sewer Surcharge
Police Plan Review
Fire . SAC
Engr Water Conn
Planner Water Meter
Council oad Unit '
Bldg Off y
APC reatment P1
Variance
TOTAL
21,
?
210.-
SZS. °
Soo.m
?3 p
280."
132 ='
2-D
r?
,?.? .
. '
/
? j
/
2?0 ? 3? ` q'3co K 5 4- 50s44
13x2= 'a l ` lC) co f=:>
Z4 ? 2Z_ - ?2t? x (? - 580?
?5?14-
CERTIFICATE OF SURVEY
93- 14
C1evaCions shnwn are er:isting grade?
and aCC assumed daLum.
Proposed garaKe Floor cfevation = 9B 0
W
dN r
4-?
cr
? r
o-
0
LO
0 I
9 a?b ?
I ?
N
?
LOT 7
Bl.ocK 2
MALLARp DRIVE9G 9
S b??54,28?
cl: 90.79
O ?
O
o S _-` -- _,_ o ? '-
M I o,
F is7s 5 m
6 ~-- - fli 9 I M.
I u? o Q ?4 ---_+ I5- tv ,
I M 24 ZZ ? a^ I9 N UAft P?U 5En m .
5
6 24 N
3(0
9 ?
2
R
pKAINAFF r-
viILITY EASEMENT
y O
qc.0o
N 890 251 36°E
I herehvi certiCv thaL Lhic is a corrrrt reprt'sentation ol a ciir?ey u(Lo t 7. Rl(,c k 2. PIALLARD PARK SECnN D-Al)DII'ION. Dalc1,ta Cnun[c, neta.
accorilin;t tt) t-lic rort+rd, - ? l p1aC Clicrco f.
and that 1 am i ?fulv ri•kisicrcd Lnnd ?urvevor ander the lawti uC the Stato ot Plinnesota
Crnc L. Jacnbson, t?t . Re2. IN,). 773+
Uated this 15Ch Day uC Julv, L985
DR. BY GF:J SCALE - I= 40' o DENOTES IRON MOPL. BEARINGS ARE ASSUMEO DATUM.
PREPARED FOR: JAC08SON SURVEYORS
M. [J. .iohnsoa Constr.
r.o sox iso LAKEVILLE, MINN. 55044
F2rmin?Con, tiLN 55034
PHONE 469 - 4328
EXTERIQR ENVELOPE AVERAGE "U" C6MPUTATION ' .?. .
? ... ' OifNER
, _ , _ . -. .
? - - - -
, ,, -:. - - - -
; --:.._:.__ -.. ..=•?;_:., - _..__ _ _ - __ . . . _ ... - _.--_ = :.
SITE ADORESS
? . . .- _,. . . _ r..._ _; •' :=__".•'-:.??_? - - •? - -.
? - - ' COt1TRACTOR: '.t"L ; W , ?01-1??.??? ' `• ? ? DATE : : . PHONE --
• Determine working square footage of each.
, 1. Total exposed wa11 area ...... Zn y'"? ? CI Lo sq. ft. x???, ? "zo1 . 4
2. Total roofJceiling area .... IOy? sq. ft. x_?p??= •+?{I
Total expo.sed wa11 area above fioor = 23?'l,Z
a. Total wall window area ..................:........ ZyS.lo
b. ?otal door area ................................. ? 6 '
c. Total s7iding glass door area .................... y 4
d: Total fireplace wall area................. '....... v8
e. Total wall framing area (averaqe ZOA)...:........ 7.02.11O .
r. Total net wa17 area above floor ................. ?Bpg,94
g. Total rim jeist area ............................ Zio?
Total expDsed foundation area = f?,G,'lLo
h. Total foundation window area .....................
i. Toal net r"oundation area aoove orade ............
Det=rraine "U" valu= of ea::h wa1] sec-ent.
a. Z45. lo x ":c" , 55 = 135.08
y 38 X „U,1 , i3 = 5,Z8
c. `4 4 X liu„
d. 48 X ?-r , 3l0 7.8_
e. ZoZ,IU X "U" ,091A = y
r. I goa,4 4 x tiu" , 0y 3 = 7`l . 8
9. X 1.U11 ,?y l = 10,9
n. -- x „U11
;. 84•9 Lo x tiuti , ? = 15.5 1.0
. r?`?.!p...To?z, _ ?03,36
3 .....................
?r item r3 is the sam° as, or less than item '1 , you hzve met the in'ent
fjf 53C 6005 (c)2.
Total exposed roof/ceiling area = 1(Ci?
? Total gross roof/ceiling area = l09=? •.
_ j. Total skylight area ........................
. k. Tota1 roof/ceilinq framing area .
1. Total net insuTated roof/ceiling area....... .7
Determine "U" value for each roof/ceiling segment.
,. ? .. X lluto
k. I o9 .3 x,lu° , Oz = Z, Lo
?. 1 CJ'-i iri XPUn ?- OZZ^ a .?1 •Lo
4 .................?004 ?L ..........Total
. ?
,
If total af #4 is the same as, or less than #2, you have met the intent of
SBC G006(c);.
?
To utilized the total envelope system method, the values established 6y the
sum of items #3 and $4 shall not be greater than the sum of itens 91 and #2.
i. - 3oj.qy
s. '?) 03.38
MATERIALS
Ezterior Air
5lding Material
SheathiTtg
Insulation -
SheetroCk
Interiox Air
Studs
Rim
Conc. Blks.
+ z. 28.?i1 = 330,35
+ a. 3ZQ?58
Therm. Resistance "R"
.19
,45
2.pU
I cl_
,45
' Lo a-
?
I.S
1,2
SY?P/X 5`"
S r? ? ?-das'uioesr
F==F=`I
?
? Pirr 1 pier Pie
$ts
Zxa "?.refr?k
16 ?09 GPn71 v
I
y Pier
hra? a6evs
/o?vei 6<?
I. _ I
c?
2
?
P/er
v
G/P?Pr?PG.f
h
?
?
?
?
J
?CJ
?
/? Joisfs
z"xs„
re.-
r?egr?wAO?
, PPr
P "X }''? f te 6oa.a
Aio?rnm/ 62'X S ?r
han9i-9
07aa?CC,f . /14- / l
?c°c?Co?rsTi?rcfo.. P/ao
?--?d?9n /?9liJry
2'-rio I
?c-is 5rG e/ra?o 8?i...tnr co??r?7"p I
t
?
?? llA?/ri's?/W?rure? C7/JdI G?eG/I/H? ?+?
\
. Q 2X6 /okrr? dre.f JpisYs
?
I Q ZXS up???-???,FJoisTs
Z X (o Gd9s7`??a,?c° /r"??aooa?
0
• ' i r O I
/ oazssax
? •.? ? ??.1 b / . .. ? ti :?t.?k ', ` ? ' '
l\ w?b'' e+A ?
, ' ; ?,_? J ' ? 4A, .•'` ?': RPww14R1?<e , / //IOwPR /? 6?'"R? ..u , ._ . .,
36, t hl,
?WD,
?. , ,e ? ?, ,?,m ? .? / ? '}???' ?' ???t?'•??? ,? % ? •
IeO.
. ?, oY ?{t? yb• { . . ,? ?i? . . , .? ? ?: t ? i
-S , ,7 • ,-M
1
? " - ?R r ' i ,m• , rk ' ' /""'`y?'* : ? ,' , '
' 4 • ? .- t ,. , q_ ? '??a? , ?^? ?? j ? , t «n "?o1PS + ? . . ? - ? r •, p t, 4 ,?; .,. ?.
. r 'i?? 5 '? .??$. .:? , i ,µ, ^ .? ? ? w•., ?
v A ? ??'. ' ." ar y ?, .r.,?: . s .,' i
,Y . ? dJ., r ? ? ? " ' , , . _ ? ' ? _?/- ' ' M • ,
• ? ' ? . , _ ? ? - ? . ?
: iM0 +Mrln h piop±rty? 01 4elurn'& 1ne MI':
rim v uw d tld6 "'witlww Adrw'i rrinp . . . . ? . ? , - ? . . . ' , . . .
e Mfib ^Pt W'Alewed. IAwIMritOd ur 4uil . ? ? ' . , . , °. ? .. .. ; . . , . ' . , .
aJ?rrn1 hK. p JI 40n.Wr eaurd bM weh '
MMN?Pq? f?• kM v?M. drMw r ? , ' ? `. . ; ., .' - ? . . ? . . _ „ ? ? . . . . ' ? ,???:9 ?,
M IMd N4nMM?a ?, • , . " ? ? , , ' . ? '. . , . ? ? ?:5?' ?
, ? • . . . ? ' . .. ' . ' , , , . ' ? ? . ' ' , ?? . _ , ?. ` ,. ? .
. • , , i ? `t Y 1 /'.?f. 7 , ?? 7 1! lf Y . ? ' . " ' . ' ? ? 4P.:Q
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA123554
Date Issued:06/10/2014
Permit Category:ePermit
Site Address: 1662 Mallard Dr
Lot:7 Block: 2 Addition: Mallard Park 2nd
PID:10-47251-02-070
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.
Earl Arneson
7803 Drake Rd
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 -
William T Roznowski
1662 Mallard Dr
Eagan MN 55122
(651) 454-4598
Arneson Heating & Cooling Llc
7803 Drake Road
St Paul MN 55125
(651) 459-3360
Applicant/Permitee: Signature Issued By: Signature
C•
1 0 all
Mike Maguire NOTICE OF BOULEVARD
Mayor SIGHT DISTANCE OBSTRUCTION
Paul Bakken
Cyndee Fields June 1, 2016
Gary Hansen
William and Susan Roznowski
Meg Tilley 1662 Mallard Dr.
Council Members Eagan, MN 55122
Dave Osberg
City Administrator Dear Mr. &Mrs. Roznowski:
The City of Eagan actively manages its right-of-ways and, by ordinance, regulates
the installation and maintenance of trees, shrubs and landscaping within or
affecting these areas. The ordinances are intended to protect and promote the
safety and welfare of the general public.
Municipal Center
3830 Pilot Knob Road Please be on notice that your property located at 1662 Mallard Dr. has been found
to be in violation of the City ordinances pertaining to the installation and
Eagan, MN 55122-1810 maintenance of trees, shrubbery or landscaping within the street right-of-way.
651.675.5000 phone Eagan City Code, Section 7.08,provides, in part:
651.675.5012 fax
651.454.8535 TDD Subd I.D.3 Any trees, shrubs or landscaping planted or installed within a street
right-of-way shall be at least ten (10)feet from the back of the curb or twenty
(20)feet from the edge of the road surface where no curb or gutter exists.
Maintenance Facility
Subd. 1.D.4 Trees, shrubs and landscaping shall not be planted or maintained
3501 Coachman Point on public or private property in such a manner as to obscure or impede the
Eagan, MN 55122 visual sight lines required to ensure the safe and efficient circulation of vehicles
651.675.5300 phone and pedestrians on streets, intersections, trails, and sidewalks. Trees, shrubs or
651.675.5360 fax landscaping shall not be planted as to block the visibility of any regulatory,
651.454.8535 TDD warning or street identification sign or block the illumination of streetlights...
Your p o erty is in violation because:
Shrub(s) or landscaping is/axe impeding a sight line or creating a
www.cityofeagan.com physical obstruction. (Removal or trimming by the property owner is
required.)
❑ Tree(s) is/are impeding a sight line or creating a physical obstruction.
(Removal or trimming by the property owner is required.)
L) Other:
The Lone Oak Tree
The symbol of (Over,please)
strength and growth
in our community.
Specifically, during a recent drive-by inspection, the shrub closest to the street
that was an issue last year is once again growing to a point that it is causing a
sight obstruction. City Code requires a clear zone between 2.5' and 8' above the
surface of the street. Please either trim or remove the bush to conform to this
requirement.
A copy of the City's "sight clearance" standard plate is included for your
reference. If you would like more information on the ordinance, the City code is
available on-line at www.ciiyofealzan.com. If you have any questions regarding
this notice please feel free to contact me at 651-675-5641 or
dwestermayer @cityofeagan.com.
Thank you in advance for your understanding and cooperation.
Sincer ,
Dave Westermayer
Engineering Technician
City of Eagan
Enclosures: Sight Distance Standard Plate
G:Boulevard Obstructions/Forms/1'Notice
1
For Office Use I
I : /3/119 �CC
� � � $ � � Permit#: `
EAGAN
a ,a
Permit Fee:
Date Received:
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651)675-5675 I TDD: (651)454-8535 I FAX: (651)675-5694 Staff:
buildinginspectionsacitvofeagan.com L
2018 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: ,_ ?' /' Site Address: /6 C,-, 2 Ale, c(/Lt -i'-L. Unit#:
Name :? t I � ?(97/1(9"–)S1(—:j Phone: tF G/O J (lt`'/
Resident! '�
Owner Address/City/Zip: / 6, 2 � nct-�/4✓cX /
1A.Qe1/4-�l'ell i/1 4 Ai
Applicant is: Owner L—ontractor (J '�
Description of work: I,tW)I ')iJ..) 0(4(re
�-`2 I �iic c ex) ‹1
i - _
Type of Work (�
Construction Cost: /2 ()an , Multi-Family Building: (Yes /No )
Company: `, C`t)I I/ ( .CI rCi vL LLC Contact: ? A SCAT i"Q'
Address: t7 = 1IX
Contractor
/(r) "--
`0�. f r c C. (/ City: ��CiL C�
State: �'lt/Zi : `-)sx7Phone:� /5CQ3.SEmail: C�h ,51Are- SAC ' iS41k/4c
License#: b[6 - 7//2- Lead Certificate#:
If the project is exempt from lead certification, please explain why:
kUSe. 1L 19v/ %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:
€ Licensed Plumber: • Phone:
(
Mechanical Contractor: Phone:
i
Sewer&Water Contractor: Phone:
Fire Suppression Contractor: Phone:
3 NOTE:Plans and supporting documents that you submit are considered to be public information. Portions of the information may be
classified as non-•ublic if •u 'rovide s,ecific reasons that would.••milt the Cit to conclude that the are trade'secrets.
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.
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.
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.00pherstateonecall.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 wit t a permit; that the work will be in
accordance with thee
li . oved plan in the case of work which requires a review and approval, plans. ,
x „1/.4e ,a11'C:.k-h x �
A .�nt's Printe• Name lic• `'s Sign r
/