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1110 Northwood DrINSPECTION RECORD CiTY. OF EAGAN PERMIT TYPE: :;Ili l f?1H(-1 ? 3830 Pilot Knob•Road Permit Number: ' Eagan, 11llinnesota 55122-1897 Date Issued: (612) 681-4675 ? SITE ADDRESS: , , APPLICANT: ' •i ? i ;?? ? , , ,? I.aR ? ,. . f A6AN Nii/!141-HAl1f /NU ( til.? 1 HtiB- v99?? . •`? ft! !?1o iyl l lIAN {I HI PERMIT SUBTYPE: TYPE OF WORK: r., , I . . I Permit No. Permft Holder Date Telephone # ? ELECTRIC a?.?I e IAOA /'A'? 00 -PLIJIVIBIN /?' /11 HVAC ? -7 ! ; 'D S Inspect{on Date Insp. Comments FOOTINGS D??//rG ??j- ???G Gl?,B' ??/o'??l?9G ?'J? FOUND FRAMING ROOFING HOUGH PLUMBING PLBG AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYP BOARD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL w BSMT R.I. BSMT FINAL UECK FTO DECK FINAL a-? „?s4 INSPECTIOIo1 RECORD C1TY. OF EAGAN PERMIT TYPE: ' 3830 Pilot Knob.Road Permit Number: E?agan, Ivlinnesota 55122-1897 . Date Issued: (612) 681-4675 SITE ADDRESS: FAI;ItN I'WfiAtFl1f?llt ?141) PERMIT SUBTYPE: APP?ICANT: TYPE OF WORK: ,:: . . , ;tu1 1.nI Nr, 1 I (:t!"i/'+fi L?S 7o? ? 1Y i YJ INSPECTION .. . .. ?ri ,,?., . ? r? i • „ , . ? L_ ? _.? Pertnlt No. Perm@ Holder Date Telephone ELECTRIC PL'qMBING HVAC Inspectlon Date Inap. Commente FOOTINGS FOUND FRAMING ROOFING ROUGH PLUM8ING - -?" ? PLBG AIR TEST ROUGH HEATING GAS SVC TEST -1--e INSUL GYP BOARD FIREPLACE ' FIFEPLACE AIR TEST FINAL PLBG FINAL HTG I ORSAT TEST BLDG FINAL v BSMT R.I. BSMT FINAI DECK FTG DECK FINAL ? af Wagan . Mcpartraettt af !8uitbing 3ailpectiun r? This Certifitate issued pursuant ro the requireinents of the Unifarm Bui(ding Code ' cerrifying that at the time of issuance this structure was in compliaRCe with the various ondirtances of the Ciry regatating building cor+struction or use. For the fo!lawing: . ' Use Classificatian- ?DGDU Bldg. Permi[ Na. 29207 O-Pancy Tra RI f S3 Zo,,;ng p;su;c PD Type Conu. VJER/lFR owner or stii,ain?•Y-RE?'S: IlV?' n," 14601 gETANIi RD, MRKA Building Add. 1 110 NORTHW00D IyRIVE I-liryL I B 1 F?1C'1±1POtBAM 2NID nate: • . au;wng ar,cig - - PaST IM A CONSPIGUOUS PLACE ,r SITE ADDRESS ' ? Unit # pennft # -990201 L ? B Sect./Sub. da4.12as, QW-Xed? INSPECTION INSPECTOR EOATE COMMENTS ?- ? J Lr u..-' .t) 77077? f 71,47 L?t 1.,. ?7C 't (J a-f ?/ 'C_ U, ct ? , , . , . SI-FE ADDRESS Unlt # Permit # B l Sect./Sub. Z'Se r, ee -- pe,eL.,«4 ... 7 Ni,?p INSPECTION INSPECTOR DATE COMMENTS !D? ?QG LLLfb I?V3 ? ? ! 4 I/ - '? ?,- iW3 ?s- ?• ' f4 s leVOI swAN-l'rr Or.j ? l?z7-f7 w-? ?" 'ei c,/h;ys .-P 6. ' - .2 -3-41 7 / INSPECTION INSPECTOR DATE COMMENTS /n - _?& h V ? f' -2 L C,? C: -f •? c? r,?9 ? E G d? ?f?'/ $- Z Z v B?N _ t1 ?e ?ti /3 l-/$''i7 0?'?4?-?? s? ?„' s -l% lJ J ?fkIw?v "n??? ?'??' 7-48y°17 ` Na•.I?. {,, lws? ?? L' „ rr ? ? fi VJ/ ?'l a ?J? /?r ?c% '?-?-, ra. /? Tt M?tw-r s?n. ?• u,.?' 3- 3 ?? ? ai' 17 "47 Z ?w: ta ?" A'/!,' &.0 ' V r^ ? SoN. ???" 41v? . / ?? ?'1'N? ;.., 97 0o G' < ` ? l 2 1 1- 3 71 ? O ON4? Thrs requesl void I B months (mm validafion dare pnnted in this boz. /FFI US /?G ?V? . 6'?'575 , O ??O do PLEASE PRINT OR TYPE / Request D.I. Raugh-in incpedion raquir fYYes ? No ll h h d InspMion Olher Thon Rouqh-In: 0 Ready N. X WIII Co11 Om R d ipedor w rou must m I e ns e, reo y) e ea y: licensed contracior ? owner hereby reques} inspection of the above eledriml work af: Jo6 PAdr<ss (Siroel, B r kooro No.) / i r0 w, w? PM t?-? Gry ?- Zip Cade -5?2 z S«tian No. Township Name ar No. Ranga No. Fire No. Counry v47L'b )-:4L Occopom Phone No. I'Orv? n ao?d. Powsr SupplierH? D Address Eleclnwl Conhatlor (Company Name) Conhador License No. Mask, lic No. (Plom EI«x. Only) aE ? $CCVr, CNoo Moiiing lddress ?Cammnor or ovmer PeAam?ing Ins?ollanon? VQL! tocK Trk: M/l1 .SSa77 Authonzedono w rPeAorminBlmlallanon) PhoneNo. EB-OOWA/95 STATEBOARDCOW-SEEINSTRUCTIONSONBRCKOFYELLOWCOPY IIII REDUEST FOR ELECTRICAL INSPECTION?G ?I N I? I II I II II I I II II ? I I? ? I1'I -47821 Univessity AvearRm} S7128 CSt Paul MN 55104 * 0 2 7 7 3 7 1 L* Phone (612) 842-0800 //G0? Home Duplex Apt. Bldg. Ot-her: fojK? New Addn Commercial Industrial Farm Remod Re air Air Cond. Hfg. Equip. Water Htr. Load Mgmt Other. D er Ran e Elec. Heat Tem . Service "X" above the work covered 6y this request. Enter remarks in this spare and on the batk of fhe white copy only. 6 VZ'?FEQ4?(? , Calculote Inspection Fee - This InspecKon Requesf will nof be accepled without the wrrect fee: Other Fee # Service EMronce Size Fee # Circuils/Feeders Fee Mo6ile Hame Pork Stall 0 to 200 Amps O to 100 Amps $}reef L}g./Traffic Sig. Above 200 Amps Above 100 Amps TransformedGenerator INSPECTOR'SUSEONLV TOTAL ^ (? $ign/Oufline Lig. Xfmr. ? v ? « O•"? Alarm/Remate Con}rol C Swimming Pool -fed the decfiml im scnbed herein an Me daks slakd I henb c<T thol ins Irrigaiion Boom Raugh-tn Dah S ecial Ins edion p p Invesfigative Fee Final - ??.Al THIS INSTALLATION MAY 8E ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 78 190tiTHS 01?qo 457i - 2007 COMMERCIEIL BUILDING PERMIT APPLICATION City Of Eagan 3830 Pilot Knob Road, Eagan Mn 55122 Telephone # 651-675-5675 L Ptans are considered public information unless you state they are trade secret and why. • Structurel Plans (2) sets • Civil Plans (2) • Certificate of Survey (t) • CodeMalysis (1) ° • ProjectSpecs (1) • Spec Insp 8 Testing Schedule (1) " • Soils RepaA (1) • Meter size musl be esta6lished SAC determination - call 657-602-1000 • Soils Report (1) • Cetlificate of Survey (1) - Slructurai Plans (2) • Architedural Plans (2) sets . FIVAC units req'd. on bldg elev. I site plan • Civil Plans (2) . landscaping Plans (2) • CodeAnalysis (i) " • EnergyCalalations (7) " • Emergency Response Sile Plan (1) • Spec. Insp. & Testing Schedule (1) " • Electnc Power & Lighting Form (1) " • Projec[ Specs (i) • Master Exit Plan (1) • SAC determination - call 651-602-1000 . Fire Stopping Submittals . Fire SuppressionlAlarm Form . Architectural Plans (2) sets . CodeMalysis (7) " . ProjeGSpecs (1) . Key Plan (1) . MasterEzitPlan (1) • Energy CalculaUons (i) nol ahvays" . Elec. Power & Lighting Fortn (1) not always" • Meter size must be established-if appliwble • SAC determination - cail 651-602-1000 Call MN Dept of Health at 651-201A500 for details regarding food & beverage or lodging faciGties. Contac[ Building Inspeclions W see if it is required and for a sample. ? "• Permit for new bvilding or addition will not 6e processed without Emergency Response Site Ylan. ?/j ? I? y? •? Date / 2 SiteAddress Tenant Name ! (/?/ `? 7 I Construction Cast ? b I U oL"" o?D -?, Unit/Ste # ?J"e LO °1<S Former Tenant Name Description of Work 'c r w-J "c c44, y?, Property Owner Telephone # ( ) Applicant is: Contractor _ Owoer ? Coutractor GD/& '11F,e? Contact #: (p? z) 34' Address State oz( 3 1 j"\ V\ City Cvo saqOr ? / Zip -57Y ?' ° T Telephone #(6/L )??-5 7 7 7 v Arch/Engr Address State Registration # CitY Zip Telephone # ( ) Licensed plum6er installing new seweAwater service: Phone #: (_) I hereby apply for a Commercial Building Permit and acknowledge that the information is complete and accurate; that the work will be m conformance with the ordinances and codes of the City of Eagan and the State of MN Statutes; I understand this is not a permit, but only an application for a permit, and work is not to staR 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. p,Pi?C ( < ?'?------?- Applicant's Printed ame Applicant's Signature `1CPa-4S" zoo6 FIRE SUPPRESSION SYSTEMS rERMiT arrLicATrorr City Of Eagan 3830 Pilot Knob Road, Eagan Mn 55122 Telephone # 651-675-5675 Fax # 651-675-5694 Requirements: 2 complete sets of drawings and specificarions ?-? cut sheets on tnaterials and cmmnnnrnts m I?- - - -- ---' v i . I Date\2?_ / _V-) / cu_ SiteAddress: Tenant / Building Name: C n?? The Applicant is: _ Owner ? Contractor _ Other PROPERTY OWNER Address: City: State: Zip: CONTRACTOR MNLicense#: Address: City: ?A . ?Ckj'-LS? State: Zip: Phone #: ESTIMATED COMPLETION DATE: FIRE FERMIi TYPE: Sprinkler System (# of heads Fire Pump _ Standpipe _ Other: P'? o ??11?P ?-- WORK TYPE: _ New _ Addition Alterations Remodel ? _ Other: ?? n p _ DESCRIPTION OF WORK: ?Commercial _ Residen6al _ Educational _ Other: G- 1 Please continue on reverse side PERMIT FEE: $50.50 Minimura Fee (includes State Surcharge) Contract Value $ x .O1 _ $ F)f) . UQ Permit Fee If Permit Fee is $1,000 or less, add $.50 => If Permit Fee is over $1,000, add $.50 per $1,000 Permit Fee 3/4" Displacement Fire Meter - $167.00 TOTAL FEE: State Surchazge 5z,-) .5? I hereby apply for a Fire Suppression System permit and acknowledge that the information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan and with the Minnesota Building/Fire Codes; 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 pian in the case of work which requires a review and approval of Applicant's Print?d Name DO NOT WRITE BELOW THIS LINE PERMIT ckGqo4o ?. +CITY OF EAGAN 3830 Pilot Knob Road PERMITTYPE: guzLolNG Eagan, Minnesota 55122-1897 Permit Number: 0 2 9 2 0 7 (612) 681-4675 Date Issued: 11 / 2 5/ 9 6 SITE ADDRESS: 1110 NORTHWOOD DR LQTs 1 BIOCK: 1 EHGAN PROMENADE 2ND DESCRIPTION: B L D G 6 B`uil _ di,ng-.Permit Type 6ui1'ding l4,rk Type WBC 9ccuparSOY? Constructiiin Ty'p`e % Zoning Buil"ding' Gengtih f Bwil?iin,g Wzdth g}x'l,:di'ng stnries ?,qluare Fe e.t %.E.?n,a . ? . 3 ? LA?" APT./LODGING NEW R-1 5-3 V 1HR/1FR PD 306 103 3 28,935 105 5 OR MORE FAMILY Gi =1?1 T ?. i^ P l REMARKS: FEE SUMMARY: VALUATION Base Fee Plan Review Surcharge Total Fee $8,460.75 $4,230.38 $976.20 $13,667.33 $2,254,000 CONTRACTOR: - Applicant - OWNER: WEIS BUTLDERS INC 28589999 HEALEY-RAMME INC 1550 E 79TH ST 10601 SMETANA RD 122 MINNEAPOLIS MN 55425 MINNE70NKA MN 55343 (612) 858-9999 (612)931-2220 I herehy acknowledge thaC'Y have' read Chi`s appliea'Cion an-d state that the infinrmat3an is avrrect and agree, tcr comply wath all appliCaale State of Mn. 5tatutes and City ofi Eagan Ordinences. APPIICANT/PERMI7EE SIGNATURE IS ED B SI T RE ? CITY OF EAGAN $IQI L ;" ri 3830 PILOT KNOB RD - 55122 ? ? ??1996 BUILDING PERMIT APPLICATION (RESIDENTIAL) 681-4675 New Canstruelion Reauirements RemodeVReoair Reauirements ? 3 regislered site survays ? 2 copies of plan ? 2 wpies ot plans (include beam & window sizes; poured fnd. design; ete.) ? 2 site surveys (exterior additions & decks) ? 7 energy taloulations ? 1 energy calculalions tor heated additions ? 3 copias of tree preservation plan ff lol platted a0er 711193 required: _ Yes _ No DATE: / Z o? CONSTRUCTION COST: Z,Zi?;3? 7'? 04 DESCRIPTION OF WORK: STREET ADDRESS: ?"/?'??'?/f•A'07 LOT BLOCK SUBD./P.I.D. #: pf''m65m d ' / £'i? PROPERTY OWNER CONTRACTOR ARCHITECT/ ENGINEER Name: i?Al£ y- AZ/lV'-A5' Phone #: Z 2 Z o .yr rwn Street Address: iDC 0/ Ifb Svi 2y- / Z Z City: 1'1/.Iic'S Ta.r/?GA State: zVllt/ Zip: .5-:53-14 3 Company: i,v0 S BL//G 2) 97/P5' i??G Phone #: 4358 - 9Y57 ?7 Street Address I.? 50 ?. 7I'yST License #: City: /?J/NN?/??4G? S State: /"IA? Zip: SSIf Z-,5- Company: ,Q/QGf/ L'GNJFS:S hone #: :3 -3 9 - Sj Name: ?1C'iG/it/ r£G" /s Registration #:z 7 y , - 00 ? Street Address: S T _S'OV7/a City: State: i"?/'? Zip: Sewer 8 water licensed plumber. ..]-B?CiP-b NI9-'CiY,4,4116Zqj Penaity applies when address change and lot change are requested once permit is issued. I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable SWte of Minnesota Statutes and City of Eagan Ordinances. ? Signature of Applicant: OFFICE USE ONLY ???ENED Certificates of Survey Received _ Yes No SEP 7 0 9996 • Tree Preservation Plan Received Yes No '°°°"?"°"°°°` - OFFICE USE ONLY BUILDING PERMIT TYPE ? 01 Foundation ? 06 Duplex ? 02 SF Dwelling ? 07 4-plex ? 03 SF Addition ? 08 8-plex ? 04 SF Porch ? 09 12-plex ? 05 SF Misc. ? 10 _ plex WORK TYPE ,Pr--331 New ? 33 Alterations 0 32 Addition ? 34 Repair GENERAL INFORMATION Const. (Actual) 011 FR (Allowable) )1?h??R. UBC Occupancy Q-1 S-3 Zoning P D # of Stories 3 Length 3 0 6 Depth /0 3 K11 ?g?/Lodging ? ? 12 Multi Repair/Rem. ? ? 13 Garage/Accessory ? ? 14 Fireplace ? ? 15 Deck 0 36 Move ? 37 Demolition Basement sq. ft. Main level sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. Footprint sq. ft. APPROVALS Planning Building r. • -'ti . . d 16 Basement Finish 17 Swim Pool 20 Public Facility 21 Miscellaneous MClWS System City Water Fire Sprinklered -4- PRV Booster Pump Census Code. y/JS 2? 93 SAC Code ?D Census Bidg Census Unit Engineering Variance Permit Fee Surcharge Plan Review License MC/WS SAC --' City SAC Water Conn. Water Meter -? Acct. Deposit -r- S/W Permit ? S/W Surcharge Treatment PI. Road Unit Park Ded. Trails Ded. '- Other Copies Total Valuation: $ S ,oco ) % SAC - SAC Units -? C.T.'CV J'•= [:F:r;Atv C?r;ii:I:E:}2a MC; 1E:RN:I.Nfi:t._ P!p;t 538 (iA'rE::°: i.p/:I.E3/96 I:[N'ii::: 023004 I D S ' NAi'E,, Nl-;:S k;l!TI...DG:I;S INC I!(oo P256 .,?.. '-Ufli ? ,?. . `, i? !p f21'Nl+b:iilrl cE,7,,r.i "1c..,.: p: 900112P .. . .,.ll, n:?..?:•., ir'-r.rI-i,i'x('I11......r. 1 !?)7? , ......?Sif?G.,,, ?., _'?c. 2.:.. ; ,.y,.??l.. .:r1(l{ 4407 ;v.. .f.ii'"(I-I?"IJt]LI 66,5S4.75 r..t_..?t? ?i..:...?... rlro Y l,._?ri.':1.:1 c... ;Cif,;l. ?? ?? ? i. ? r rli:.?1:^?v,l: ..?...- '-?c i.,i S59. [....: CR06I,:: (.I t: z,' IIC;!:'R ID.. h1A1iLYflr.:l C.f.'YY fp'' ('.Af:>ki `'.:??#:FII:L??:, t''1' ?[i:Rt•iT_?i^t_ ?0;; `_i'3?; D9iki:r I.CI/:iEl/`:'?ti. ']:t11_:. C7"? ?" :Ch.. L? ?:'?1t? ? i?; . ;.,:.?_ '_'-s. t?tOc',• ?.r..r1lI.1JC ? ' ?'.2n. i3:1 ,;- , 900.11. . £_? CITY OF EAGAN . ' 3830 Pilot Knob Road " Eagan, Minnesota 55122-1897 (612) 681-4675 SITE ADDRESS: PERMITTYPE: suxLozNs Permit Number: 0 2 9 0 9 6 Date Issued. 10 J 17 / 9 6 1110 NORTHWOOD pR LOT: 1 BLOCK: 1 EAGAN PROMENADE ZND DESCRIPTION: ermit Type FOUNDATION g+grrk 7ype NEW R -1 S - 3 ir;Ct r°?qe V 1 H R/ 1 F R PD 306 cSrgth '1"k sdtFr 103 ?a 28,935 105 5 pR MORE FAMILY t? ?e??„ &Er sr?; ??g ? ? v?,a; >??su e;M REMARKS: 5&W CQNTRACTOR - J-BERD MECHANZCAL FEE SUMMARY: Base Fee Surcharge SAC SAC % SAC Units Subtotal W-EIS BUILDERS INC 1550 E 79TH ST ftIN;VdEAPOLIS MN (612) 858-9999 I hereb Y'. in'Fo rma'ti. 5tatut8.? .: VHLUATION $162.25 $5.00 $33,300.00 100 37 $33,467.25 - Applicant - 28589999 55425 APPLICANTIPERMI7EE SIGNATURE PE1ZMIT ? ? ? ? D;j `? J $10,000 CITY 5AC WATER CONN S&W PERMIT S&W SURCHARGE 7REATMENT PLANT ROAD UNST Total Fee $3,700.00 $28,120.00 $100.00 $.50 $14,652.00 $12.765.00 $92,804.75 OWNER: HEALEY-RAhIME INC 10601 SMETANA RD MINNE70NKA MN 55343 (612)931-2220 ISSUED B' : IGNATURE 122 '? ,P1f3 s ' CITY OF EAGAN 3830 PILOT KNOB RD - 55122 ? 1996 BUILDING PERMIS 1?s I? ATION (RESIDENTIAL) 7 New Consirudion Reauirements RemodeVRenair Reauirements ? 3 registered ske aurveys ? 2 copies of plan ? 2 copies of plans (inUude beam 8 window sixes; poured fnd. tlesign; ete.) ? 2 sile surveys (exterior addlHons 8 decks) ? 1 energy ealeulations ? 1 energy calwlations ior heated addilions ? 3 eopies oi tree preservation plan H lot ptatted after 771193 /v required: _ Yes No DATE: `I rZo Z 9 4r ? ?CTION pST: = ?11,? . DESCRIPTION OF WORK: APr .G'ZDL<' EsuiG .Dl.vG ? G STREET ADDRESS' z`i94hAl ?u7?or Li ?s?,q•,? a.Qo.?-r? ??b F LOT BLOCK SUBD./P.I.D. #: . ?c?o5 ? a ' 7 £.4G.9-J ?/t'Orl E-vA ? ? ?'"? ? Q D / '>/a•v PROPERTY Name: r/ i? AJ S Y- Aff?/VC lNC Phone #: Z Z o OWNER ...; . .. = - -5treetAddress- 10401 -- - - Ciry: M/N419 7oAvuA State: *,ti ? Zip• S5: 4 3 CoNTRAC7oR ; Company: ?J£/S Bl//G D:6,RS /?tIG Phone #: g?g - 9999 Street Address: 1550 9. 79'?ST License #: City: 11'I1NAv?ff.?4G./ S State: A'IA? Zip: ARCHITECT/ Company: QfrGt/ ?G?v'?55 f'/Qll//T?C?hone #: 3??9 - Sj??' ENGINEER Name: J(°)/?A/ Registration #.Z 7 y 9? r Street Address• 7D0 T6/i.Qp S T. SOVTy City: State* 1"??'? Zip: S--4 /-T Sewer & water licensed piumber: ..i-B9i°b i?If-Crlfr'/'?/G=I$?/ Penalty applies when address change and lot change are requested once permit is issued. I hereby acknowiedge that I have read this application and state that the information is correct and agree to compiy with all appiicable State of Minnesota Statutes and City of Eagan Ordinances. Signature of Applicant: ? O-W-? OFFICE USE ONLY ???ENED Certificates of Survey Received _ Yes No SEP 2 0 1996 Tree Preservation Plan Received Yes No ? "`° - OFFICE USE ONLY ?v?'??i`axl ? (0 BUILDING PERMIT TYPE 11101rl"4?4 Dr " X 01 Foundation ? 06 Duplex ? 11 Apt./Lodging ? 16 Basement Finish ? 02 SF Dwelling ? 07 4-plex ? 12 Multi Repair/Rem. ? 17 Swim Pool • 0 03 SF Addition ? 08 8-plex ? 13 Garage/Accessory ? 20 Pufilic Facility ? 04 SF Porch ? 09 12-plex ? 14 Fireplace o 21 Miscelianeous ? 05 SF Misc. ?. 10 ; plex o 15 Deck - WORK TYPE 31 New ? 33 Alterations ? 36 Move ? 32 Addition ? 34 Repair ? 37 Demolition GENERAL INFORMATION • . _. . _ ':•_ -__ __. . . Const. (Actual) -LI-?,?1f?`Basement sq. ft. MC/W5 System (Allowabie) ?(1 NK /?jfR Main level sq, ft. City Water UBC Occupancy R? °3 ` sq.,ft.. Fire'Sprinklered Zoning , . sq. ft. ' PRV # of Stories --- ` sq. ft. -Booster Pump Length _ 3D6 ~ sq. ft. Census Code. GS Depth '/d 3 . Footpr t sq..ft. -SAC.Code. /o ?-----. ? - -----=Cen'sus Bidg ° / Census Urnt ._.._.. siy w•.y`fIG'??k.)- APPROVALS _.. . _ . . . __ _ _..?. - Planning - - Building Engineering - " 'Veriance Permit Fee Suroharge - ? Pian Review License •-- ; - MClWS SAC 3 3?3 o d 9?? x 3? City SAC . 3200 lo&y 37 WaterConn. 2. 1'2 O ?(Oy_ 3;? Valuation: $? Un?"f-? -3? Water Meter Acct. Deposit S/W Pertnit /06. S/W Surcharge .570 Treatment P.I. Z 3 96,,- 3 7 Road Unit / z. s 3 ParkDed. 6 6 VU/ ?o11 7,-4 cf Trails Ded. Other Copies Total: % sa,c;_ ,: ; - _ SAC Units ?, ,?,•, - . ClTY OF FAGAN CFlSHIf:fit 1S TEhMINAI_ N0: OtE, DAIEc 01/f.N/00 TT.NfF: 14:08c40 IU: NAHr- r,IEFTSI_:N COMFANY 32:I.0. 90C1i 111.0 NOF;THWOD Ii 1 y 105.75 215500dl. 1110 NORTNNOLi D 60.00 i 250r.C101 1110 NOfiTFIWOD Ii (i.io ?.t To+,a1 Fier_eipt Amoun+„ 17:L7i..f35 Cfi:LE2423 1J51_li TT): JAN 2000 BUILDING PERMIT APPLICATION (COMMERCIAL) CITY OF EAGAN 651-681-4675 Requirements ? -? Foundation On New ConstruCtion Interior Im rovement • Structural Plans (2 seb) • Archkectural Plans (2 sets) • Architectural Ptans (2 safs) . Civil Plans (2 aets) • Strudurel Plans (2 sets) • Code Analy&is (1) •• • Code Malysis (1) • Civil Plans (2 sets) • Prqect Spacs (1 set) . PraJect Specs (1) • Landscaping Plans (2 sets) • Key Plan • Spec. Insp. & Testing Schedule " • CodeAnalysis (7) " • Master Exit Plan • SAC detertnination letter from MClES - • SAC determinaUon letter from MC/ES - call • 5AC determinedon IeUer from MC/ES - call call 651-802-1000 857-602-1000 651-602-1000 • Spec. Inap. & Testing Schedule (7) " • Energy Calculffiions (1) not always " • Project Specs (7) • Elec. Power & Lighdng Portn (1) not aMrays " • EneigyCalculationa (1) " • Electric Power 8 Lighting Fortn (1) " • Master Exit Plan • Soils Re rt 1 " Contact 8uilding Inspections for sample Food 8 6everege or bdging facllRies: Plan must be submitted to Minnesota Department of HeaRh - call 651-2150700 fw details. DATE: 0"kc, WORKTYPE: _ NEW _ REMODEL DESCRIPTION OF WORK: /-Ir'E AelG fr TENANT NAME: fl! 4 mF v?dd= , Qn 1e--5 SUITE: ? al3 FORMER TENANT NAME: aKz (? SITE ADDRESS: I11O ?a r//?- wu a? // y LOT ? BLOCK ? SUBD F?u? PO VVl-Q.4t?. ?r n r o mx V? Name: TTEa ? J'G ++? mF Phone#: ((' I'L ) 9i6 -?sy y PROPERTY Last First OWNER Street Address: t19 7 5C4 e S-/ N ?? A- City fl.-JiCeo? JrkI rf e State: Zip: f 57 3 Company: (rr e r15 F? ifo M,?° a,. Phone 13- "1-,466 CONTRACTOR Street Address: RAIU Dri G4? ?r )J F CItY 6-66ln ?L+;Z $IStC: Zip: i ARCHITECT/ ENC;INEER Company: Phane #: ( ) Name: Regstration #: ? Street Address: City State: Zip: SeweNwater licensetl plumber fif installina sewerJwaterl: Ptwne #: 1 hereby acknowledge that I have read this applicafion, state that the informaCwn is CoAeCt, andall applicable State of Minnesata Statutes and City of Eagan Ordinances. Signature of Applicant JlL?-a / ? CONSTRUCTION COST: 1 O OOQ OFFICE USE ONLY BUILDING PERMIT SUBTYPE ? 01 Foundation ? 26 Public Facility ? 32 Ext Alt - Apts. ? 14 Apartments ? 27 Commerciai/Industrial ? 34 Ext Alt - Comm. 15 Lodging ? 28Greenhouse ? 35 ExtAlt - PF ? 25 Miscellaneous ? 29 Antennae WORKTYPE ? 31 New ? 34 Repairs ? 37 Demolish Bldg. ? 44 Siding/Soffits/Facia ? 32 Addition ? 35 Tenant Impr ? 38 Demolish (Interior) ? 45 Fire Repair );? 33 Alterations ? 36 Move Bldg. ? 42 Reroof ? 46 Windows/Doors GENERALiNFORMAnO Census Code Zoning sq. ft. SAC Code ? # of Stories sq. ft. No. of Units Length sq. ft. No. of Bidgs. *77? Width sq.ft. Const. (Actual) I' Basement sq. ft. MC/ES System (Allowable) First Floor sq. ft. City Water UBC Occupancy -[ sq. ft. Fire Sprinklered MISCELLANEOU3 INSPECTIONS ? Gas Service Test ? Heating ??. l4;i? Planning Building Engineering Variance ,.VALUATION:$ Pertnit Fee Surcharge L0,0 0 Plan Review MC/ES SAC % SAC _ City SAC SAC Units _ Water SuPply & Storage Meter Size _ 5/W Permit S/W Surcharge Treatment Plant Park Dedication Trails Dedication Water Quatity Other Copies ? Insulation ? Plumbing ? Stucco/Stone Z-0 64d r Total I ` ?, is -? ? L BL CITY USE ONLY RECEIPT #: ? qa SUBD. _teg h 1`Q ?R a'- Y RECEIPTDATE: r'J- I-O0 PERMIT# J `Sl0 1 2000 PLUMBING PERMIT (RESIDENTIAL) CITY OF EAGAN 3830 PZIAT IQQOH RD EAGAN, tMI 55122 651-681-4675 _ ?Please oDmplete for: ? single family dwellings ? townhomes and condos when pertrrits are required for each unit ? 6ackflow preventer for underground sprinkler system FIXTURES EAGN !t TOTAI AlteraHons to existing dwelling - minimum fee Describe: xEmonEL $ 30.00 , Bath tub $ 3.00 x 1 = $ 3.00 Floor drain 3.00 x = $ Gas piping oudet " minimum - 1 3.00 x Z = $ 6.00 Hot tublspa 3.00 x = $ Kitchen sink 3.00 x i = $ 3.00 Laundry trey 3.00 x 1 = $ 3.00 Lavatory 3.00 x 1 = $ 3.00 Septic System new/refurt,ishea • reyuires nnpc iic. 75.00 x = $ Septic System abandonment 30.00 x = $ RPZ new installatioNrepair/rebuild 30.00 X = $ Rou h o ening 1.50 x = $ Shower 3.00 x 1 = $ 3.00 Underground sprinkler if dwelling is under construttion 3.00 x = $ Undergroundsprinkler if existing dwelling 30.00 x = $ Water closet 3.00 x = $ 6-00 Water heater 3.00 x = $ Water softener If dwelling under construction 5.00 x = $ Water softener ff existln0 dwelling 30.00 x = $ Watertumaround 30.00 x $ State Surcharge 50 -> -> -> $ .50 TOt01 $ Reminder. Call for inspections of alterations, i.e. water heaters, water softeners, etc. ? ----------------•-------------------------------- I he26y adcnowledge that I have read this applicetion, state that the iniortnetion is correc[, and agree to mmpy with all applicable City of Eagan ordinances. k is the applicanYs responsibility to notily the property owner that the Ciry of Eagan assumes no liability for any damages caused by the City during its nortnal operational and maintenance activities to the facilities constµicted under this pertnit wkhin Ciry p operty/right-of-way/easement. 'Yl 6 ? ?4 ?L W-fiZ?U ? SITEADDRESS: 111o-rreux3?4ve6a?flRrvE ? OWNER NAME: : TELEPHONE #: (AREA CODE) INSTALLER NAME: KLAruM rEcHANrczaL CONTRACTORS, 2tvc. TELEPHONE #: 512-890-4858 (AREA CODE) STREET ADDRESS: 12409 CovrrTY Roan #11 CITY: BuRNsvzLLE STAT ; ZIP: SIGNATURE OF PERM1TfEE CITY USE ONLY LOT l BL ? PERMIT #: SUBD. S__?ZCx Vk I"YCIYYI.f.VIL41 RECEIPT RECEIPT DATE: 9 57'a I ? ?y?13 c) 2000 MECHA13ICAL PERDdIT (RE5IIIENTIAI,) CITY OF EAGAN 3830 PILOT FCNOB RD Eacax Msr 55122 Date: 651-681-4675 Complete this section anlv if you are installing HVAC in a single family dwelling, townhome or condo under consuuction and not ownedoccu?ied. • HVAC: 0-100 M B T U ADDITIONAL 50 M BTU • Gas outlets (minimum of one required @ $3.00 ea.) $ 30.00 6.00 State Surchazge .50 Total $ Complete this section onlv if you aze remodeline, addinQ to, or re airin an existing single-family dwelling, townhome, or condo. Please indicate if it is a new item, alteration, or repair. _ New _ Alteration 2epair ? Fumace ?- ? - _ Air exchanger _ Other Air wnditioning Other &_Qj_ V'V? Fee State Surcharge $ 30.00 .50 ? Total $ 30.50 Reminder: Call for SITE ADDRESS: -kt Z/ OWNERNAME: PHONE#: - ?r (AREA CODE) INSTALLER NAME: PHONE #: (o /2?- STREET ADDRESS: 1? u-?r1 S ? I vP rv ? Srj- )Vw (AREA CODE) C[TY: Adr e1, (i< +i STATE: lk?L- ZIP: SS 3 U ?/ _ ?- gv?? SIG ATURE OF PERMITTEE L BL CITY USE ONLY PERMIT #: SUBD. RECEIPT#: APPROVED BY: , INSPECTOR RECEIPT DATE: 2000 MECHANICAL PERMIT (COMMERCIAL) CITY OF EAGAN 3830 PILOT KNOB RD EAGAN, L+N 55122 651-681-4675 Please complete for all commerciaUindustrial buildings multi-family buildings when separate permits are not required for each dwelling unit DATE: '21 1?2 / U J WORK T1'PE: New construction Install U.G. Tank ? Interior Improvement ? Remove U.G. Tank _ Processed Piping When installing/removing underground tank, call 651-681-4675 for inspection by fire marshal and p[umbing inspectoi. rt Description ofwork: ,Zf ,..?_ ??r,iu?e ? ff c° v T Fees: 1% of coutract price OR $30.00 minimum fee, whichever is greater. Underground tank removaVinstallation = minimum fee Contractprice: $ ?2apJ xl%=$ c?a sU State surchazge , 50 TOTAL $ 3 G - S0 ---------------------- -----°-----------------------°-----__ '/ ? I I C) SIT'E ADDRESS: ?- /U?7 r ?i+ uIUJ c) ?r OWNER NAME: TENANT NAME (IMPROVEMENTS ONL1): (Base-Fee) calculate at 5.50 for each $1,000 Base Fee ?L PHONE #: (AREA CODE) WAS THERE A PREVIOUS TENANT IN THIS SPACE? Y N. NAME: INSTALLER: L In,vt p S MPc In a n ,'? ?/ --t-4, ? ?), f . ve ADDRESS: 15t(46 S i )vPrjl S? '1? w PHONE 1 Z _ L/ 2-1 - Z y l?j (AREA CODE) CIT'Y: STATE: Jt"" ZIP: 57 3 4)? IGNATURE OF PERMITTEE ?P) / OFFICE U3E ONLY V L? BL ? RECEIPT,#: G?7 SUBD. (Q ULYHErLRO?Cr a,4? DATE: 1996 PLUMBING PERMIT (COMMERCIAL) CITY OF EAGAN 3830 PILOT KNOB RD EAGAN, MN 55122 (612) 681-4675 Please camptete for. . all commerciaVindusfiai buiVdings. ? muiti-tamily buildings when separate permits are = required for each dwelling unit. DATE: Io I Za Icl (s CONTRACT PRICE: '* I(!? 1LIoD WORK TYPE: )( NEW CONSTRUCTION _ ADD ON _ REPAIR DESCRIPTION OF WORK: PI uMb, k.)? l'CM26\. ?ki IS WATER METER REQUIRED? X YES _ NO. IF 50, PLEASE PROVIDE THE FOLLOWING: WATER FLOW: Zi fa GPM. ARE FLUSHOMETER!i TO BE INSTALLED7 _ YES Yj_ NO. FAILURE TD PROVIDE THIS INFORMATION WILL RESUL7' IN A DELAY OF METER ISSUANCE. WILL YOU BE INSTALLING A METER FOR A FUTURE U.G. SPRINKLER SYSTEM7 L4 YES _ NO. IF SO, YOU MUST APPLY FOR A SEPARATE U.G. SPRINY(LER PERMIT. FEE: $25.00 minimum fee or 1% of contract price, whichever is greater. State surcharge of $.50 per $1,000 of r i fee due on all permits. CONTRACT PRICE x 1% I? l?y STATE SURCHARGE ? TOTAL f j j D !, / f9 ?? SITE ADDRESS: kla&-4AW?30d- ,?ie-- t? TENANT NAME: OWNER NAME: )rA e,?l? STE. # INSTALLER: J- a@ (ZO ADORESS: 33Cu0 °Ja'ror" tsa.j D2w..Q_ ciTr: C?t, STATE: ZIP: Q30/ PHONE 43ZD ) CoSZo - Uw7 SIGNATURE: APPLICANT tr /AFICE USE ONLY METER SIZE: ,-" GOD?E:'i INSPECTOR: CITY USE ONLY L ? BL RECEIPT# & / V4 / SUBD. RECEIPTDATE:IIOP V9?7 1997 MECHANICAL PERMIT (COMMERCIAL) CITY OF EAGAN 3830 PILOT KNOB RD EAGAN, MN 55122 (612) 681-4675 Please complete for: . all commerciaUindustrial buildings. ? multi-family buildings when separate permits are not required for each dwelling unit. DATE: 1-1-51 CONTRACTPRICE: 1Z (0;?`-??- WORK TYPE: X NEW CONSTRUCTION INTERIOR IMPROVEMENT DESCRIPTION OF WORK: \AU!-\C FEES: ? $25.00 minimum fee or 1% of contract price, whichever is greater. ? Processed piping - $25.00 ? State surcharge of $.50 per $7,000 of ep rmit fee due on all permits. CONTRACT PRICE x 1 % PROCESSED PIPING STATE SURCHARGE TOTAL 1ZC?0 J 12ca1 ? 1 \ ? ? 6 .? .. vr? nL, i.Q ?8' : /j, +! 4V SITE ADDRESS: OWNER NAME: TELEPHONE #: TENANT NAME: (innPROVEMENTS oNLv) INSTALLER: :y - &Y Q fy\e'Q? ADDRESS: 3-6 C. r> Qz- - CITY: CAjn.AA STATE: Ita_ ZIP: S6&-30 PHONE#: 300- CeSZP- Qpy2 51GNATURE: 1? SIGNATU E OF PERMfTTEE CITY INSPECTOR '" ° -- - ?' CDWWOPwro mre 6i??197 Serial # /?4407?\ Chip # / 0 ?, `'/ -SyG(. O Permit# /o290D7 ? ?- • ? Address: //!b Noe-l?ju2rv( dh 1 AGREE TO COMPLY WITH CITY OF EAGAP! ORDINANCES z, ? Signature:_ 9 4 ?. ?_ N• 1.::T^• (''! Er":gA"r: i ;:,?.. "1'C;??' ?:_?'r?'I;;: f'?.! ,?': f _ .,.. .... . N(};, PJ'. ,, 14 (-.i=.... '2/97 :7. ....g 1000.G... ... . ; ..:.. ,.... _. .. ,.... _:. ^ r.r;•::: r; "?? n.r.p•-. ? ?_.....,.. .......:.: ...... ?,?y .° ..:1.??'L... _.?fiF., :, c(J '"[N:j•'IiE ,.:., ..:.. i:.'.\iD Pom : 11674.0 i y -lkn ?jw) Q a 4P 7 ._ , ., . o . ?e:: Dt r_,ir::: .=r,t ; ; , ,? ,.. R!,:..?.i.??i =. _..-,. , ..-..,. ;•• l..i I:: h.r..T;..i L _I (+ ;.:? ..+ ? RECORD OF COMPLAINT Date 12`/yl I 7 Complaint taken by Type o Name Address l// D l?dy? cz??o? dt"d' ? 22.5? f buflding ?iv 1-7 c ? ?' e??Pi^ / C> ? ? V?GS 7? - ??, -e 1?i 2:/'G r.? (i s4 ?? ?? . Ixgal description Phone number Compiaint D r? (-, .' Action taken il Ld f,S' ? ?i:l ? G 1-/,P..• r Comments ZZi-s t?'-' Ci ? Cr 4Ja ei- s? L 6 C ? ?!? ??l c l ??o L ? r C?-? ?- r L% L-f - , ' U' p' -e N ?S city oF eagan THOMASEGAN pnavor November 21, 1997 PATRICIA AWADA BEA BIOMQUIST SANDRA A. MASIN THEODORE WACHTER Council Members THOMAS HEDGES CiN Adminisirator CERTIFIED MAIL-RETURN RECEIPT REOUESTED HEALEY-RAMME 10601 SMETANA RD #122 MINNETONKA MN 55343 MR PETER DESAI WEIS BUILDERS 8009 34T" AVE S MINNEAPOLIS MN 55425 RE: GAS FIREPLACES PROMENADE OAK5 TOWNHOMES TO WHOM IT MAY CONCERN: This letter is a follow up to a meeting on Monday, Noven Builders; a representative from Automatic Door Company; about the gas fireplaces at the Promenade Oaks Townhomes. E. J. VAN OVERBEKE City Gerk ber 17, 1997 with Mr. Les Larson, a representative for Weis Inspector Dirk House; and myself, to discuss concems raised During installation, a wood uim piece was placed over the black metal portion of the fireplace which, in turn, becomes very hot and may cause a 5re. The representative from Automatic Door Company, stated that these fireplaces were installed according to the manufacturer's instructions and he would fax information to this effect to my attentioa As I did not receive ffiis information by this moming (November 21), I called the Heatilator Company in Iowa and asked that they fau me the information on propec installation of these fireplaces. Upon receiving this fax, I find that the fireplaces that we observed do not have the recommended clearances requved in the manufacturer's instructions. The City is requesting that you send letters to all tenants immediately asking that they discontinue using their fireplaces until corrections have been made. We are also asking that these corrections be made within 30 days of receipt of this letter. Please contact me at 681-4677 to discuss this issue with me as soon as possible. Thank you for your anticipated cooperation in this matter. Thank you. Sincerely,. ; . , ,. ? William Adams Consdvction Inspector (Plumbing) WA/js cc: Resident Manager, 1160 Northwood Drive, Eagan MN 55121 Automatic Garage Door, 220 NE 77"Avenue, Fridley, MN 55432 Mr. John Fegis, BRW Elness Architects, 700 Third Street South, Minneapolis MN 55415 MUNICIPAL CENTER 3830 PILOi KNOB ROAD EAGAN, MWNESOTA 55122 -189% PHONE'. (612) 681 4600 FAX'. (612) 68) -46 f 2 iDD. (612) 4548535 THE LONE OAK TREE THE SYMBOL OF STRENGTH AND GROWTH IN OUR COMMUNITV Equal Opporfuni}y/Affirmative Action Employer MAINTENANCE FACILITY 3501 COACHMAN POINT EAGAN. MINNESO7A 55122 FHONE: (612) 681-4309 FA%: (612) 681-4360 7DD: (612) 454-8535 443 Lafayette Road N. St. Paul, Minnesota 55155 www.dli.mn.gov 9/7/2012 Mary Jo Harvotich 1110 Northwood Dr EAGAN, MN 55121 It MINNESOTA DEPARTMENT OF LABOR. & IND J!STRY i (651) 284-5005 1 -800 -DIAL -DLI TTY: (651) 297-4198 APPROVED FOR USE RE: RES STAIR CHAIR LIFT Elevator ID# ELV-1007223 Site: Mary Jo Harvotich 1110 Northwood Dr Unit 221 EAGAN, MN 55121 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. Sincerely, CONSTRUCTION CODES & LICENSING Tim Warren State Elevator Inspector c: City of Eagan Building Official ABILITY SOLUTIONS ElFormCE2R This information can be provided to you in alternative formats (Braille, large print or audio). An Equal Opportunity Employer Apr. 25. 2017 1 :05PM No. 1283 P. 2 , . 4.,t�� Use BLUE or BLACK Ink \y,r )4(/''' � ;For ofiCe us11-/2:1651 j z A.{ ✓~^•r Permit#: %j (s • Cityof Eau. I 6 Permit Fee: CQ�� 3830 Pilot Knob Road Eagan MN 55122 .' Date Received: l Phone:(651)676.6676 �� Fax:(651)675.5684 Staff: r .1 CA ti,0 2017 COMMERCIAL FIRE ALARM PERMIT APPLICATION 4/25/2017 1110 Northwood Drive Date: Site Address: Tenant: Promenade Oaks Suite#: • r oy. ,',-,w 1E .::4,2“.1,„•:, Nighthawk Properties LLC/Promenade Oaks Apartments LLC 651•-686-8600 .. �r�,;;';,w,:,:,,.;i�:',.•,.i�:°�;* Name: Phone: pro004V.Ow.ij r' 2320 Lexington Avenue S, Mendota Heights 55120 ,. Address/City/Zip: ',V ;i,�I'',�, ;i:.! :4 Applicant is: Owner Y Contractor • :'•. h '' •.�;•, J'~ Description of work: Add Telguard Cellular Unit for communicating to Central Station .. •.•: �..."7'••dw�•:!;':.�'.'•:.� � � .......,......:...,, Com..: 825"00 �� . ._ � ♦..:: .L... fi �: 5-8-2017 ,....... e ' w'';;;r;:•`': •C•.. '. Name: Total Life Security License#: TS721594 ' ,,ri:'..,�; .;! ' ,;,' 321 Wilson St NE Minneapolis y. ,-„.:.,:.•.•:.:,,,r., Address; City: • o ttyactrs :., . 'w r. ', Mn 55413 (612)676-2020 41:61:,:' ;.'::{';::; ;:. ':;s State: Zip: Phone: • `` '!''",'! T: `" Melinda inspection@totallifesecurity.com 6,`r < : t . Email: Contact !•".V : 1!i'��,H,'",1.:`Y\: dip"; •: • • •• , •T.3,v-. i,W':�t",..iso{%e,,:6'.,ry'Tef:"i'2:a``:•¢:••'.i.,' "• , r 'i ''- 4'47 . .'""V-".• ,7 :-.'. ..'...7. �. .., . ,� �' "'a f.� 'New . , �RemoZlel" ' '..� ': stark'Tyge"k' k. —AdditionAdd Cellular unit to remove Analog phone lines , ;.r:'. •,,. ., v,,•.,, �Other Vit;; I,;:. r!:, . . .•. .a• Alterations DESCRIPTION OF WORK: ✓ Commercial _Residential _Educational FEES ' Contract Value$825.00 x.01 $60.00 Permit Fee Minimum _ 60.00 -$ ' Permit Fee Surcharge=Contract Value x$0,0005 =$ .41 Surcharge' if the project valuation Is over$1 million,please call for Surcharge _ 00.41 $ TOTAL FEE . '"Requirements:2 complete sets of drawings and specifications,cut sheets on materials and components to be used I hereby.,apply for a Fire Alarm permit ago acknowledge that the information Is complete,and accurate;that the work will be in conformance.yryttl„lhe, • • ordinances and codes of the City of Eagan and with the Minnesota Building/Fire Codes;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, , Melinda Plzal$CIZ zoiioazsrzmaz� X Melinda Plzak ,..•/ ApplIcant's Printed Name 'Applicant's Signature .+. '. C,'i 13E'n.,:,.•:.,,,,,, ::..,,.,,,,,,' itidP$• "r�i.'f^1•,,',,1 �Y�%z^,? ,:fit':; ,:., . �t ..fir% U.�,r,,H, - .• e�rlet!e ` > Date ; ' a: .z, •Ai'C�:^ n '715.... e'•. pp :. ,� eiz ;15.,,. „!...•. .w�ry JRi.. 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