1683 Oakbrooke WayAddress
Lot 6 Blk ? Sub 0 A f; P? R 00;t aF H
THESE TTEMS WERE 1 WERE NOT COMPLETE AT THE TIME OF THE FINAL INSPEGTION.
Date: Yes No Inspector.
Final grade (b" from siding) ?
Permanent steps (garage)
?j
Permanent steps (main entry)
Permanent driveway -77
Permanent gas
Sod/Seeded grass ?
Trail/curb damage
Porch ? ?.
Basement finish
Deck
Please verify with the builder the removal of roof test caps froro the plumbing system and the shut-off of water supply to
the outside lawn faucet before freeze potential exists.
Contact engineering division at 681-4645 before working in rig6t-of-way or installing underground sprinkler system. ?
White - City Copy Yellow - Resident Copy Pink • Contractor Copy
AddIC55 1583 OAKB??OOKE WAY Zl[7 5512 2
LO[ 6 BIIC Z SUb OAKBBOOKE 4TH
THESE ITEMS WERE / WERE NOT COMPLETE AT THE TIME OF THE FINAL INSPECTION.
Date: y p ? Yes No Inspedor:
Final grade (6" from siding)
Permanent steps (garage)
Permanent steps (main entry)
Permanentdriveway
Permanent gas
Sod/Seeded grass
TraiUwrb damage
Porch
Basement finish
Deck
Please verify wi[h the builder the removal of roof test caps from the plumbing system and the shut-off of water supply to
the outside lawn faucet before freeze potential exists.
ContaM engineering division at 6814645 before working in right-of-way or installing underground sprinkler system. ?
White - City Copy Yellow - Resident Copy Pink - Contractor Copy
**********??*x**x*xx******?**W* CONTINUE
CITY OF EAGAN
CASHIER: JS TERMINAL N0: 709
DATE: 09/20/00 „TIME: 10:43:20
ID:
NAME: PULTE MAS'PER BUILDER
3716 9220 1683 OKBRKE WY 114.00
3713 9220 1683 OKBRKE WY 50.00
3865 9220 1683 OKBRKE WY 840.00
Total Receipt Amount: 4,381.84
CR137744
USER ID: JAN
*?t***?t,r**?t,r**x*************************
CITY OF EAGAN
CASHIER: JS TERMINAL NO: 709
DATE: 09/20/00 TIME: 10:43:18
ID:
NAME: PULTE MASTER BUILDER
2252 9220
3210 9001
3866 9379
3422 9001
2275 9220
3446 9001
2155 9001
3743 9220
2155 9001
3868 9220
1683
1653
1683
1683
1683
1683
1683
1683
1683
1683
OKBRKE WY
OKBRKE WY
OKBRKE WY
OKBRKE WY
OKBRKE WY
OKBRKE WY
OKBRKE WY
OKBRKE WY
OKBRKE WY
OKBRKE WY
30.00
944.75
100.00
614.09
1,089.00
11.00
0.50
50.00
46.50
492.00
CR137744 ** CONTINUED
USER ID: ,7AN ++ 11*....-.,..--
a4- w -'+ yagv v
, - 2000 BUILDING PERMIT APPLICATION (RESIDENTIAL)
' crrr or eRCnn
14-? 3830 PILOT KNOB RD - 55122
657-881-4675 -??
9_ kg_oO
Remotl6l/R,gt9
D J raosfaretl IHe wrveYs tOwN9 $4 R d bf. W. ROf hauY 2 copiea d Pkln
aW sd rooletl arem (2096 rtwWmian lot coveraae allowadl 1 tbt d anergy cdadaNont 1or heo19C a0d11au
D 2 coWes of Pkns Wlow baen A wlndow tices: Paured 1n4 tlestM atc.) i aife AmreY fa exteAa atlWAau S tlecW
D t seT d anerQy edeWaHOra D S capkc of frea preaervcMOn plan M bf plottad alfar 7/1/93
DATE: VlSde) CONSTRUCTION COST: &D
DESCRIPTIONOFWORK: lVJ57A? %P-?
SiREET ApDRESS: /C')-c93
Lor: _? eLocK: 2- sueu.ir.i.D.
Name: Phone i:
PROPERN wet Flnt
OWNER
Sfreet Address:
CHy
Sfate:
Lp:
CompanY j"?JIte /!'!d Phone tF: 61D 3G7"3S,07
(
CONiRACTOR area code)
Sheet Addreaa: MIJcente 1i J3 UP. -A/o?
CNy aSaT$ ?L? State: AVAI Zip:
ARCHrtECT/
ENGINEER Company: Name:
Telephone #: ( )
Sheef Addreaa: RegishaMon 6:
Gty State• Zip:
Sewerlwatar Ilcensed plumber (N Insfallina sawerMretarl: G/hY Phone #: ('?l)
1?c3 al ? l
-7T-
I hereby acknowiedpe IhaF I have read ihk applloalbn, dcR6 fhaf Ihe igOmr Ibn k corted, and agree b comPh wUh W appicable State
of Minnewfa Stalutes and CHy o( Eaynn Ordinancea
Sipnalure of AppllcaM:
ESEHOFFICE USE ONLY i F Z000
Certificates of Survey Recefved Yes No
Tree Preservatlon Plan Received Y? No Not ReQuired -"-' •?•
OFFICE USE ONLY
BUILDING PERMIT 3UBTYPES
E3 Ot FoundaUon O 07 OSpiex O 13 16-pbx ? 21 Porch (3-sea.) p 31 Fxt. Alt - Muld
tiP 02 SF Dwelling ? 08 06-plex O 17 Garege O 22 Porch/Addn. (4-sea.) O 33 Ext. Alt - SF
? 03 01 of_ plex O 09 07-plex O 18 Dedc O 23 Porch (screened) p 36 Mufti
D 04 02-Atex ? 10 08-plex p 18 Lowet Level ? 24 Storm Damage
13 05 03-piex 0 .11 10-plex Pbg vw_N O 25 Miscellaneaus
O OB 04-plex p 12 12-plex 0 20 Pool O' 30 Accessory Bldg. WORK TYPE
0 31 New O 36 Move Bldg. 13 43 Reroof
0 32 Additlon O 37 Demolish (Bidg)' p 44 Siding
E3 33 Alteration ? 38 Demolish (Interior) 13 45 Fire Repair
D 34 Repair 0 42 Demolish (Foundation) 13 46 WindowsJDoors
' Give PCA handout to applicant for demotition permit
GENERAL INFORMATION
SAC Code
No. of tlnits ?
No. of Buildings
Const. (Actual) ?
(Allowable)
UBC Occupancy -?
Zoning
# of Stories
Length
Width
Basement sq. ft.
Main level sq. ft.
a rd ESq, ft.
sq.ft.
MISCELLANEOUS INSPECTIONS
O Stucco/Stone
APPROVALS
Planning _
Permit Fee
Surcharge
Plan Review
License
MC/ES SAC
City SAC
Water Conn.
Water Meter
Acxt. Deposit
S!W Permit
S1W Surcharge
Treatment PI.
Park Ded.
Treils Ded.
Other
Copies
Total:
Building
?
?
3S `s?
?
5?6 S
sq.ft.
sq. ft.
Footprint sq. ft.
Census Code
MC/ES System
City Water
Booster Pump
PRV
Fire Sprinklered
-Lie- Engineering Variance
Valuation: $
N3slAt l
/j'l ?.tZ'!U 4 r i1r r
e-
??w
','3 s-?
? ?? Y.10. -"=` 1
7z
9C?3/U , ao
?
?
SAC Units
% SAC
71.1' ` n;' '900 13: 53
P. 02103
COMPLI}?NCE REPORT
EneYJy CodO
Software Verqlon 3.0 Pexa1G i
, „? . .
...'°4?? ? DBIt@
? . ? f? ?•?s1:? ;'? ??? ?"4??
?
.??',?'?
- - --`=I0's 'YZPBs 3ingie Family
j o? , I I? r ,
6-7-2000? .t
CF PI.HNBt??.;?;y?.??}??:.St5;,??'J"'.sl?s
?q,
ANBER111"
0A????VA'1`?ON?#1°xy
(??}???y?y ???'??n `1?.'?+^ ??? ??jI??Y I r, ?? a? ?? • ?, ? e, ??? 1 ,
??1???UtlRiLYI.
?Gi
F'Afit, i.ed UA .`3?3.
Y-111, Home - 294?
1°, gatter Thatt;'Code
Area or Cavity `???CoaE;• mgp1a`ssing/Door
` Perimster, R-Value',A-Value?'?U?Value
:-tr;r 11 "S_'--------"'-'----'-----"---- ---- - '-`- '"-..-`'a--..-----'-
122R 46,0 0.0
Wood =same, 16" O.C. 2139 19.0 2.0 1
T•rn? ?.?': :acod Frame, 16" O.C. 1.49 10.C 2.0
9.01 ht/8.31 bg/9.01 ins,il 47 11.0 0.0
n^rt?• C'oRC. 3.5' htf3.1' bg/3.51 1riHu1 20 10.0 0.0
0„n-trtr__; Wir.dowa or poora, Above aYade 334 0.35? 1
38 0.350
11V1,1- f;QVIFMEP7T; Furr.ace, 32.0 AFVE
• ----------- ^---------------------------------------- --- ^ __--_'•---, -
C'?,'.??La1.PiCE ETATEMENT: The propoeed building daeign deecribed here ia
n-*-is-an.t wlth the building plane, specifications, and other calcvlatione
enbmit*ed with the permit applicatiori. The proyosad building has been
tiF±Eigried CO meet khe reguirements of the Minnesota Energy Coda.
Builderi Deeigner As?
'X ; Dfte • ?
rF
. . ? .,: _.'I. . .
?
JOB INITIATION ORDER
Pulte Homes of
Minnesota Corporation
1355 Mendota Heights Road, Suite 300
Mendota Heights, MN 55720-1112
Phone: (651) 452-5200 Faz(651)452-5727
CONTRACTOR/SUPPLI ER.
JOB NO. 0550 1 206 1 02 LEGAL DESCRIPTION'
coMnnuwTr: Oakbrooke Infinity ADDITION. qw
BUILDING ADDRESS: 1683 Oekbr00k@ W0y cin'
MODEI NAME: prpb@r L/O MODEL NUMBER: 17921
Eagan STATE: MN ZIP 55122
ELEVATION: 1 GARAGE: LEFT RIGHT
F-I FXI
BUYER'S NAME: SpCC DATE OF ORDER: 8122/00
Cl1RRENT ADDRESS: CITY: STATE: ZIP:
HOME PHONE: BUSINESS PHONE: BUSINESS PHONE.
SALES REPRESENTATIVE Kathee Sheldon
0000 BASE PRICE 195,990
---- LOT PREMIUM p
1 18015 ELEVATION # 1 p
1 23005 2 Ton A1C 1,650
1 36019 Waterline Future Icemaker 125
1 31011 Laund Tub Sin le Com artment 275
A
TOTAL 19 40
APPROVED BY BUYER(S): 12?
? APPROVED BY SALES:
EQUAL HOUSING
RELEASED TO START CONST.: OPPORruNirv
This constitutes a contract between the Seller and the Purchaser(s) for the above items
Builder's License #0001371
LOT g BLOCK y UNIT 20602
.
LOT SURVEY CHECKLIST FOR RESIDENTIAL
BUILDING PERMIT APPIICATION
? PROPERTYLEGAL Ldr ? ? b ? 62f?B.R70.S'E 47W??QiTr?N
n DATE OF SURVEY:
H
w
LATEST REVISION: ao
?
p DOCUMENTSTANDARDS
O
? a
? .
Registered Land Surveyor signature and company
?
? ? .
BuildingPermRApplicant
? • Legaldescription
m?y a • Address
m/a ? • North arrow and scale
??????'''
V ? • House type (rambler, walkout, split w/o, aplit enUy, lookout, etc.)
? ? Directional drainage artaws wRh slope/gradieM %
? ? :
Proposed/exdsting sewer and water services & inveR elevaUon
? • SVeetname
?/ ? • Driveway
? • Lot Square Footage
? ? ? • Lot Coverage
ELEVATIONS
? Existin
6' ? o • Sewer service (or Proposed)
?? ? • Property corners
?a' ? p • Top of curb at the driveway
? f? • Elevations of any ebsting adjacent homes
??o Adequate footing depth of structures due to adjacent ufiliry Venches
Prooosed
/
m' o ? • Garage floor
? ? ? • Firstfloor
? ? ? ? Lowest enposed elevation (walkouUwindow)
/t ? Properry corners
m' ? ? • Front and rear of home at the foundation
PONDING AREA (if aoolicade)
/
? ? e?'/ • Easement6ne
? ? Y/ • NWL
? ? Af . HWL
? ? / • Pond # designation
? ? ?? • Emergency Overflow ElevaGon
a/ ? ?
March 7989
cnAr3?E?ooannn'.c?+
? •
tr/ ? ? •
? ?a •
DIMENSIONS
Lot IineslBearings & dimenaions
Right-of-way and sVeet width (to back of curb)
Proposed home dimensians induding any proposed decks, overhangs greater than 2', porches, etc.
(i.e. all structures requiring permanent footings)
Show all easements of record and any Cily uGliBes within those easements
Setbacks of proposed structure and sideyard setback of adjacent exissting strudures
Retaining wall reReviewed:
vcr•i?• cvuu i•ocnia-n?uLvirv ?nuiirLuiiiw nu•iadu-r
Surzeyor's Certificate
SURVEY FOR :PULTE
DESCRIBED AS : Lot 6, 81ock 2, OAK6ROOKE 4TH AODITION, City of Eagan, Dokoto County, Mlnneota and
reservfng eosements of record.
Date
EAGAN EA7GIlVEERING DEFT. ?
?
?
?
\
?,\ kv44.?
?
• -----? _
Plon # 17921
PROPOSED ELEVATIONS
Top of Foundotion = 9q7.0
Goroge Floor =qqg.g
Basement Floor =938,0
Aprox. Sewer Service = 432.0-t
Proposed Elev. _ <:?
Existing Elev. _
Drainage Directlons = --
Denotes Offset Stake = .
Propo?ea
Ram6ler
NO,. 9'pcw d/I
9? Garoqe
94S•Z ° y=
..-•---..?_- ._.____.
OAKBR40KE WAY
x
9`
-!E?rLT
R+tl`iE-
LOT SQ. FOOTAGE = 3,608
HSE. SQ. FOOTAGE _ 1,727 wo
LOT COVERAGE = 48%
7fl,?? 6
BENCHMARK, rNH@ Y=
? E¢u• 94to'3
MIN. SETBACK REQUIREMENTS
Front -25 kouse Side -
scaLE, I mcn - ao faet Rear - Gorage Side-
NEADLUNiO I MERfBY CERIIFY 7HAT 7HI5 IS A IAUE AND CORRECT REPRESEHTATON
OF THE BOUNDAPIES OF iHE ABOVE DESCHiBED PROPERTY AS SUR4EYED
BY ME OR UNDER MY DIRECT SUPERVISION AND DOES N07 PURPORT TO
PLANNlNC dNG7NSSRl4VG SURVB'YINC SHOW IMPROVEMENTS OR EN OACHMENTS, E%CEPT S SHOVM.
2005 PIn Oak Orive
Eagon, MN 55122 DaTE o0
Phone: (861) 405-6600 ?+ MIN ESOTALLICEN E NUMBER t4378OF
Fox: (857) 405-8606 U/-/1/-DO Y//1
i"t..& ?
RECEIV[=D qFp 1 8 2000
N0:
OOR-445
f: PAGE:
FILE;
OAKBROOKE
Siteaddress: ??`c e?itiy Lot ?2 BlockZ Subd. ?-?JI ?\F-?
1
On April 15, 2000 the Minnesota Energy Code, Category I Building Requirements for insulation protection, air
tightness, antl ventilation, was adopted. As a result, the City of Eagan is requiring that the following information be
submitted prior to issuance of a Certificate of Occupancy.
_ This structure: is constructed to meet minimum requirements of the Mn Energy Code, Chapter 7670
OR
This structure: will be constructed to meet more restrictive requirements of Chapters 7672 or 7674
APPLIANCE GAS ELEC MANUFACTURER MODEL BTU'S VENTINGTYPE
WaterHeater L?? \O Z?I
Furnace ? ?N? ?J? ?V?}\v b Uloo b?ieA.
Dryer
EXHAUST SYSTEM
LOCATION
TYPE
MOOEL
CFM's VENTED
YES No
Kitchen kitchen
Bathroom 1
\V?
Y
UCJ
Bathroom 2
V
Bathroom 3
Bathroom 4
Other
FIREPLACE S
LOCATION
GAS
WOOD
MANl1FACTURER
MODEL
BTU'S VENTING
DIRECT ATMOS
i? \.0 L-06 6l uuu ?
MAKE•UP AIR MODEL TYPE CFM's
" '1.y fNv i ?
I hereby acknowledge that the above information is correct and agree to comply with the Minnesota Energy Code and City of Eagan
requiremen .
?
Sig re ? V
Company Name
-?' -C\-C?\
Date
* This form is the responsibility of the General Contractor
?7 z CITY USE ONLY
L BL RECEIPT#:
' SU60 nQIE 6O??i ?7I? RECEIPTDATE: I1I-?VJ'l/!1
PERMIT# H?? L/e_
2000 PLUMBING PERMIT (RESIDENTIAL)
CITY OE EAGAN '
3830 PILOT IINOB RD
EAGAN, MN 55122
651-681-4675
Please complete for: 9 single family dwellings
? townhomes and condos when pertnits are required for each unit
? backflow preventer for underground sprinkler system
FIXTURES
EACH #
TOTAL
Alterations to existing dwelling - minimum fee
Describe: $ 30.00
Bath tub $ 3.00 x = $
Floor drain 3.00 x $ ?
Ga5 pipln OUtlet * minimum -1 3.00 X = $ ?
Hot tub/spa 3.00 x = $
Kitchen sink 3.00 x = $ ?
laundry tray 3.00 x = $
Lavatory 3.00 x = $ -?
Septic System newlrefurbished " requtres MPC lic. 75.00 x = $
Septic S stem abandonment 30.00 x = $
RPZ new installatioNrepaidrebuild 30.00 X = $
Rough opening 1.50 x = $
Shawer 3.00 x = $ ,3---
Underground sprinkler if dwelling is under construction 3.00 x = $
Underground sprinkler if existing dwelling 30.00 x = $
Water closet 3.00 x = $ ,
Water heater 3.00 x I = $...P ?
Water softener if dwelling under consVUetion 5.00 X = $
Water softener "rf existing dweliing 30.00 x = $
Watertumaround 30.00 x $
State Surcharge .50 --> ---? ---? $ 50
rotal _' -> _ --> ---->
3 _
$
Reminder: Call for inspections of alterations, i.e. water heaters, water softeners, etc.
- --------- --- ----- -- ---------- -------- ------ • --------------------------- --------------------------------------------- -----------------------
I hereby acknowledge that I have read this appliption, shete tl?at the inforznation is correct, and agree to compty with all applicable City of Eagan ordinances.
It is the applicanPs responsibility to natify the property owner that the City of Eagan assumes no liability for any damages caused by the City during its
normal operational and maintenance activities to the facilities constructed under this permit within City property/right•of-way/easement.
SITE ADDRESS:
OWNER NAME: :
INSTALLER NAME:
STREET ADDRESS:
TELEPHONE #:
(AREA CODE)
TELEPHONE #:
(AREA CODE)
CITY:
SIGNATURE OF PERMITTEE
CihT /.? BL ?
SUBD.
RECEIPT #:
RECEIPT DATE:
I?-?'D b
2000 MECfiRNICAi. PEREdIT (RES1D£NTIAL)
, crrYoFEAsM
3930 eu.or xxos sn
f.EkBAN 6!R 55122
4 651-691-4675
Date:
Complete this section onl if you are installing HVAC in a single-family dwelling, townhome or condo under
construction and not owner/occunied.
• HVAC: 0-10U M 8 T iJ
ADDITIONAL SO M BTU
• Gas outlets (minimum of one required Q$3.00 ea.)
$ 30.00
6.00
-3, do
State Surchazge .50
Total
. . ,.. ,,. ?
Complete this section onlv if you aze remodefinQ, addingto, or revlacinp an exisfing single-family dweliing,
townhome, or condo. Please indicate if it is a new item, alteratian, or replacement.
_ New
Fucnace
_ Air exchanger
Air conditioning
Other
Fee $ 30.00
State Surchazge •50
Total , $ 30.50
Reminder: Call for final inspeclion.
SIGN TURS OF PERMITT_ Replacement _ Other
SITE ADDRESS: b { ,/
OWNERNAME:?I' PHONE(°`-i [ '?( - n152GL
INSTALLERNAME: 37?r SVI ??PFIONE?A qiM_ -
(pREA CODE) , .
STREETADDRESS:?'aZ?I?(C \SLc?r?rC V) ') S -
CITY: C STATE: ?? ZIP:
CITY USE ONLY
' ' ' PERMIT #:
CITY USE ONLY
L _ BL _
SUBQ.
APPROVED BY:
INSPECTOR
PERMIT #: _
RECEIPT#: _
RECEIPT DATE:
€ooo MEcHAvicAL PERMIr ceoaMERcIAL)
crrY oFEAsAx
3830 PaoT xxos ftn
EkfiAN, MN 55122
651-6$1-4675
Please camplete for: all commerciaUndustrial buiidings
multl-family buildings when separate permits are not required far each dwelling unit
DATE:
WpR.K TypF' Ne,w rn.ictr.ictinn L-M.tpn L_T fff. T"k
_ Interior Improvement _ Remuve U.G. Tank
_ Proceued Piping
Wiien installing/removing underground tank, call 651-681-4675 jor inspection by fre marshal and
plumbing inspector.
Description of work:
:.-
Fees: 1% of contract price OR $30.00 minimum fee, whichever is greater.
. Uaderground tank removallinstallarion = minimum fee .,
Coutracc price: $ x i%= $ (Base Fee)
State surcharge calculate at $.50 for each $ 1,000 Base Fee
TOTAL $
SITE ADDRESS:
OWNER NAME: PHONE #: -
(pRFA CODE)
TENANT NAME (IIvfPROVEMENTS ONL1):
WAS THERE A PREVIOUS TENANT IN THIS SPACE? _ Y_ N. NAME:
n.rrret r Fu•
. ADDRESS: PHONE#: -
(AR&+ CODE)
CI-I1,: STATE: ZIP:
SIGNANRE OF PERMITTEE
PERMIT
Permit Type: Building
City of Eagan
Permit Number: EA105493
Date Issued: 07/17/2012
Permit Category: ePermit
Site Address: 1683 Oakbrooke Way
Lot: 6 Block: 2 Addition: Oakbrooke 4th
PID: 10-53763-02-060
Use:
Description:
Sub Type: e-Reroof
Construction Type:
Work Type: Replace
Description: House & Garage
Census Code: 434 -
Occupancy:
Zoning:
Square Feet: 0
If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are
Comments:
not acceptable in lieu of inspections.
Carbon monoxide detectors are required by law in ALL single family homes.
BL - Base Fee $4K $103.25 0801.4085
Fee Summary:
Surcharge - Based on Valuation $4K $2.00 9001.2195
Valuation: 7,700.00
Total:
$105.25
Contractor: Owner:
- Applicant -
Krech Exteriors Inc John E Bergen
5866 Blackshire Path 1683 Oakbrooke Way
Inver Grove Heights MN 55076 Eagan MN 55122--420
(651) 688-6368
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.
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA126585
Date Issued:09/02/2014
Permit Category:ePermit
Site Address: 1683 Oakbrooke Way
Lot:6 Block: 2 Addition: Oakbrooke 4th
PID:10-53763-02-060
Use:
Description:
Sub Type:Siding
Work Type:Replace
Description:
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please leave printed pictures of house wrap on site for the final inspection.
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.
Fee Summary:BL - Base Fee $4K $103.25 0801.4085
Surcharge - Based on Valuation $4K $2.00 9001.2195
$105.25 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 -
John E Bergen
1683 Oakbrooke Way
Eagan MN 55122--420
Property Claim Solutions Llc
2005 Pin Oak Dr
Eagan MN 55122
(651) 994-2028
Applicant/Permitee: Signature Issued By: Signature