Loading...
1686 Oakbrooke WayAddress lb ? I.ot ' I S THESE ITEMS WERE / WERE NOT COMPLETE AT THE TIME OF THE FINAL INSPECTION. Date: L/-ap- p 1 Yes No Inspector: ? Final grade (6" ftom siding) x' Permanent steps (garage) Permanent steps (main entry) Permanentdriveway Permanent gas ? Sod/Seeded grass TraiUcurb damage Porch ? Basement £nish x Deck K, Please verify with 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. Contad engineeting division at 681-4645 before working in rightof-way or installing underground sprinkler system. ? Whitc - Ciry Copy Yellow - Resident Copy Pink - Conlractor Copy CITY USE ONLY ? L ? S BL I RECEIPT #: SU6D (3aIIC C C RECEIPT DATE: PERMIT # 2000 PLLTMBING PERMIT (RESIDENTIAL) CITY OF EAGAN 3830 PILOT ISNOB RD , EAGAN, MN 55122 651-681-4675 Please complete for: ? single family dwellings ? townhomes and condos when pertnits are required for each unit D backflow preventer for underground sprinkler system FIXTlJRES EACH # TOTAL Alterations to existing dwelling - minimum fee Describe: _ $ 30.00 Bath tub $ 3.00 x = $ ? Floor drain 3.00 x $ ? Gas piping outlet ' minimum • 1 3.00 x = $ Hot tub/spa 3.00 x = $ Kitchen sink 3.00 x = $ Laund tra 3.00 x = $ Lavatory 3.00 x = $ Septic System newJrefurbished ' requires MPC lic. 75.00 X = $ Septic System a6andonment 30.00 x = $ RPZ new installation/repaidrebuild 30.00 x = $ Rough opening 1.50 x = $ Shower 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 = $ !i - Water heater 3.00 x = $ ? Water softener If dweiling under construction 5.00 x = $ Water softener if axisting dwelling 30.00 x = $ Waterturnaround 30.00 x --- _ $ State Surcharge 50 --> --> --> $ .50 Total --> -> -> ---> S.3 (J Reminder: Gall for inspections of alterations, i.e. water heaters, water softeners, etc. -------------- •----=------------------ ----•------------------------------------------°------------ ------------------------ I hereby acknowledpe that I have read this application, state that the infortnation is corteG, and agree to compy wRh ali applicable City of Eagan ordinanoes. It is the applicant's responsibility to notify the propeRy owner that the City of Eagan assumes no Iiahility for any damages caused by the City dunng its normal ope2tional and maintenance adivities lo the facil@ies constructed under this permit within Ciry propedy/right-of-way/easement. SITE ADDRESS: /U' o Y L/LC i"--t///'UUI--C - [/L11 OWNER NAME: : TELEPHONE #: (AREA CODE) INSTALLER NAME: (/ G p'1 , Av, 4 TELEPHONE #: STREET ADDRESS: ? (AREA CODE) t?,' CITY: TATE: Y'? ZlP: OF PERMITTEE \.iL I UOb VIILI : 43132. PERMlT M .. SLMo. Oq kbroo k -? - REC ENT #: RECEIPT'DATE: 808014IEGHANICA1. PERM1T (fiESIDENTIAI.) . crcYoFEAenx _ 3830PuAr xxos su - ` . EAs,axeixs5122. .. 1 651-e$1-+675 Date: _ :- . .: Complete this secrion onlv if you are installing HVAC in a single-family dwelling, townhome or condo under construction and not owner/occupied. • HVAC: 0-100 M B T U eADDITiOPIfiL 50 M BN • Gas oudets (minimum of one required @$3.00 ea.) State Surcharge Total $ 30.00 6.00 3.00 .50 $ ?? .. , . . , ,?... .,,. . . ? Comp]ete this section onlv if you aze remodeling, adding to, or renlacing an exisung single-family dwelling, ? townhome, ar condo. Please indicate if it is a new item, altezation, or replacement• _ New _ Replacement _ Other ? Fumace Air conditioning _ Air exchanger _ Other Fee $ 30.00 State Sluchaurge .50 Total . $ 30.50 Reminder: Call for frnal irrspection. SI'fE ADDRESS: OWNERNAME: PHONE#: (a51 . lf5a-SaC10 _ (AREA CODE) INSTALLER NAME: ?4 YVLS?/11 ?L ? f ?t(1. A- 'A I L' . PFIONE 95Q- - $W-MS (AREA CODE) , . sz?xEEr nnoxESS: -.? ?trt fLh od_e?j IS'lc? ? CITY: ? . STATE: df'tA--' ZIP: 63 7 SIG ANRE OF PERMITTEE L SUBO BL CITY USE ONLY PERMIT #: ----RECEIPT#: ? APPROVED BY: INSPECTOR RECEIPT DATE: £000 E+1££CiiANICAL f'EiiMiT' (EOMMCilkL) afYOF iu4akN 3$30 f'U.OT KNOB iiD Ek6u4N, MN 55122 651-6$1-4675 Please complete for all commeroiaUndustrial buiidings , muld-family buiidings when separate pertnits are not required for each dwelling unit DAT'E: ."' - . . _. - ., . ' - WORK 1'YPE: New construction • Install U.G. Tank _ Iaterior impraven'ienc _ Rnmev! L7.G. Trnk _ Processed Piping . When ixstaUingjremaving undergrouxd tank, cal! 651-681-4675 for inspection 6y fire marshal and plumbing insprrtor. Description of work: Fees: 1% of coatract priee _O$ 530.00 minimum fee, whichever is greater. . . : . . UndergrouadtankremovaUinstallarion=?icumuu!.fe? _, ,.'a._ : ;_ ,. . • . , ; . .. •' . Contract price: S . x i% (Base Fee) calculare at 3.50 for each $1,000 Base Fee Sace surchacge \r? TOTAL ' $ • SITE ADDRESS: ,. . OWNER NAME: . TENANT NAME M'1PROVEMENTS ONL1): PHONE #: - (pREA CODE) WAS THERE A PREVIOUS TENANT IN THIS SPACE? _ Y_ N. NAME: IIYSTAI.LER: " ADDRESS: C11'Y: PHONE#: (AREA CODE) STATE: 7-IP: ,, y .? SIGNATURE OF PERMIITEE City o# Eagar, Ca=h Receipt Receipt GatH 10i4100 Time Frinted 14;32:48 Receipt Number IiNB F'ULTE iiplTEk B[fILDEk 1686 dpKBRQOY.E NAY 4228.4600 840.00 BP 430t78 9228.4507 591.@g EF 430ii8 y220. a589 114.00 BP 43088 922$.46$5 492.08 BF 43d3i3 9001,2195 50.50 BF' 43086 9220.4532 58.00 BP 43198 90411.4246 11.00 EP 438$8 9220.2275 009.00 BF' 4318kf TeSal Receipt umeunt 41475.43 Usef NMi:i;F'RW City of Eagan i.ash Receipt 4081.4222 rF' 43088 9379.4681 RF 47@B8 9001.4885 5P 43888 92?8.2252 dP 4'a0SE 644.58 108.0@ 499.35 36.01 TG'sdi Ke'CF1Pf !i@OuTit 4a4'r5,4' =`_" N(iCGRHW 2000 BUILDINC PERMIT ARPLICATION (RESIDENTIAL) . CITY OF EACAN '-l 3 U g ? 3830 PILOT KNOB RO - 55122 651-881-4875 J ConshucNen ReaAremenh > 3 reylaferetl sNe surveys showinp sQ• (L of loT, W. ft. ol lwuee andaft roO1ed creCS =X mmdmian bt covemae allowem D 2 copiea of plana (ahow b9pm a wlndpw sl:es; pouretl fnd. desipn; e1cJ D 1 tef of enerpy cdculptlpm ? 3 coPies of tree Preaervallm plen R loT plcMecl tANr 7/1/93 DATE: DESCRIPTION OF WORK: STREEt ADDRESS: LOT: \,Z;s COSi: Name: Phone g: PROPERTY last flraf OWNER C7cx) Sheet Addreas: city State: Zlp: ComPanv:`C?,? Phone #•,?_??'? (area code) coNreacroe sneer nadress?ucen? # 13'? 1 E?ca?.? 3i Ul CHy?? ZiP: 4RCHIiECT/ cNGINEER ComRssny: Name: Tetephone M: ( Sfireet Address: Registratlon #: citY Stcte: LP: ewer/water Ilcensed plumber (i/ Instailina sewer/water): Phone #: !wereby xknowledge lhaf I have read thls appiicahon, alpte thaf ihe In is , a agree W comply wilh aA app6oable State ? MinnesoTa Slalutes and CNy of Eapon Ordinances. Sipnalure of Appliean OFFICE USE ONLY V srtificates of Survey Received ? Yes _ No ' 7 ee Preservation Plan Received _ Yes _ No ? Not Required 2 eoWes ol plan 1 set d anetpy cdcWalions for hBafetl oddlMOnt isre awey ra eXrena aaae«,a a aacw SEP 2 9 2000 BLOCK: ? SI1BD./P.I.D.i: OFFICE USE ONLY BUILDING PERMIT SUBTYPES ? 01 Foundation Q 07 OS-plez ?G 02 SF Dwelling p 06 06-plex r? 03 01 of _ piex 0 09 07-plex O 04 02-plex O 10 08-plex E3 05 03-plex ? 11 1 0-plex ? OB 04-plex ? 12 12-plex woRK nrPE 0 31 New O 32 Addition ? 33 Aiteration ? 34 Repair ? 73 16-plex ? 21 Porch (3-sea.) O 31 Ext Alt - Multi ? 17 G2rage O 22 Parch/Addn. (4-sea.) ? 33 Ext. Alt - SF ? 18 Deck ? 23 Poroh (screened) ? 36 Mufti O 19 Lower Level ? 24 Storm Damage Pobp _Y w_ N 0 25 Miscellaneous a 20 Pool Q 30 Accessory Bidg. O 36 Move Bldg. ? 43 Reroof O 37 Demolish (Bidg)' ? 44 Siding ? 38 Demotish (Interior) O 45 Fire Repair O 42 Demolish (Foundation) 0 46 Windows/Doors ' Give PCA handout to applicant for demolition permit GENERAL INFORIUTATION SAC Code D ? No. of Units ? No. of Buildings ? Const. (Actuai) (Allowable) UBC Occupancy Zoning p- A # of Stories Length Width Basement sq. ft. Main level sq, ft. 6r sq.ft. sq.ft. MISCELLANEOUS INSPECTIONS ? Stucco/Stone APPROVALS h. ?v ..?5 ? sq.ft. sq.ft. Footprint sq.ft. Census Code MC/ES System City Water Booster Pump PRV Fire Sprinklered ?7 /? 6s" G D/ Planning Building Gld, Engineering Variance _ _ Permit Fee Valuation: $ l_ t-1)_ l D=°= . Surcharge PlanReview Le?lel License MC/ES SAC =O(F7? ??l '?(' 0- City SAC Water Conn. Water Meter Acct. Deposit a SIW Permit `?`rGk?6 ? ? Oy S/W Surcharge Treatment PI. Park Ded. I? `l 2a-1 Trails Ded. Other Copies Totat: SAC Units % SAC JOB INITIATI4N ORDER Pulte Homes of Minnesota Corporation 1355 Mendota Heights Road. Suite 300 Mendota Heights, MN 55120-1112 Phone. (651) 452-5200 Fax' (651)452-572', CONTRACTOR/SUPPLIER JOB NO. 0550 ? 215 1 01 LEGAL DESCRIPTION. coMMUnlirv. Oakbrooke Infinity ADDITION 4th BUILDING ADDRESS: 1686 OBkb(OOkQ Way CITY: MODEL NAME y'CrySY81/ S12b ' MODEL NUMBER: 17941 BUYER'S NAME: ? CURRENTADDRESS CITY: Eagan STATE MN ZtiQ 55122 ELEVATION3 GAR.4GE LEFT RIGHT HOME PHONE: BUSINESS PHONE: SALES REPRESENTATIVE Kathee Sheldon LOT 15 BLOCK 1 UNIT 21501 Fxl F-I DATE OF ORDER' 9I14I00 STATE: ZIP BUSINESS PHONE: _ . 9 r 0000 ?. Ps. - iE' .??f t BASE PRICE ? 190,990 ---- LOT PREMIUM 0 1 18031 ELEVATION # 3 4,275 1 35039 Four Season Sunroom 5,825 1 23005 2 Ton A/C 1,650 1 36019 Waterline Future Icemaker 125 TOTAL $202,$65 APPROVED BY BUYER(S): ? APPROVED BY SALES: EQUAL HOUSING RELEASED TO START CONST.: oPPORTUNiTv This constitutes a contract between the Seiler and the Purchaser(s) for the above items Builder's License #0001371 LOT SURVEY CHECKLIST FOR RESIDENTIAL BUILOING PERMIT APPLICATION ? PROPERNLEGAL Lnr I? -J?WY I O,4IC3ennKe 4TN MLxTZOrJ _ n DATE OF SURVEY: -2- 5 ? CTO H ? w LATEST REVISION. (Y- o DOCUMENTSTANDARDS Q O ? i?y. ? • Registered Land Surveyor signature and company ? • Building PermitApplicant ? ? ? • Legal description p-'o ? • Address ? • North arrow and scale m?'a ? • House type (rambler, walkout, spGt wlo, sp5t enVy, iookout, etc.) ?? ? • Directional drainage arrows with slopelgradient °k i & i l UOn d t t P / p i ? • er serv ces nver e eva ng sewer an wa ropased e st O'? ? • Streetname 9?p 0 • DmewaY ra? ? ? v • Lot Square Footage L C o ? • overage ot ELEVATIONS Ew'stina ? ? • Sewer service (or Proposed) ra? o ? • Property corners cu-'o o • Top of curb at the driveway ? m?p • Elevations of any ebsting adjacent homes ? p/ o Adequate footing depth of sUUCtures due to adjacent utiliry trenches Prooosed ?o o • Garage floor ?? ? • Firstfloor qy" ? ? ? Lowest exposed elevalion (walkouWvindow) Q-? ? ? / • Property comers f d i ?? a • oun at on Front and rear of hame at the PONDING AREA (iF aoolipWe) ? ? • Easement line a V/ ? V ? • • NWL HWL ? v? • Pond # designation ? ip/ ? • Emergency Overflow Elevatlon ?A ? . DIMENSIONS Lot IineslBearings & dimensions ¢? ?? • Right-of-way and street width (to back af curb) ?? ? • Proposed home dimensions induding any proposed decks, overhangs greater than 2', porches, etc. / (i.e. all sWdures requinng permanent footings) cV o? • Show all easements of record and any Cily utiGdes within those easements crll ? ? / ? • Setbacks of proposed struc[ure and sideyard setback of adjacent exisUng sVuctures o r ? • Retaining wall requirements, if any _ / Reviewed: - .2 - 00 / Date March 7998 CRA1GI3LDGVRMT.FM - - ,S'urveyor's Certifieate ' SURVEY FOR :PULTe DESCRIBED AS : Lot ,s, Block 1, OAKBROOKE 4TH ADDITION, City of Eagan, Dakota County, Minnsota and reserving eosements of record. ? ? I?ate /??J - 2 EAGAN EATGINEERING DEFT ?Y ? 5i x 442.a y± ; rl x 99 3.0 r 1.J aW LLoVo RMLU,1M EM I& j LOT SQ. FOOTAGE = 3,608 HSE. SQ. F00TAGE = 2,367 LOT COVERAGE = 661'o Plan # 17951 PROPOSED ELEVATIONS Top of Foundation =q4Zo Garage Floor =qqs.q Basement Floor = nin Aprox. Sewer Service = q32,ot Proposed Elev. _ ? Existing Elev. Drainage Directions = - Denotes Offset Stake = • SCALE: 1 inch = 30 teat BENCHMARK, rNHLD W. rje0.,jav.13 MIN. SETBACK REQUIREMENTS Front -25 House Side - Rear - Garage Side- .108 N0: HEDL[!ll/D I HEREBY CER7IFY iHAT THIS IS A TRUE AND CORRECT REPRESENiAT10N OOR-468 OF THE BOUNDARIES OF 1HE ABOVE DESCRIBED PROPERN AS SURVEYED BY ME OR UNDER MY DIRECT SUPERNSION AND DOES NOT PURPORT TO BOOK: PAGE: PLANNING 6NGINESR/NC SURV6YING SHOW IMPROVEMENTS OR ENCROACHMENTS, EXCEPT AS SHONN. 2005 Pin Ook Drive ? Eogan, MN 55122 OA7E -9-/UPP D• AD'flLE: Phone: (651) 405-6600 E Y. INOGREN, LAND SU YOR Fax: (651) 405-6606 MINNES LICENSE NUMBER 14 76 OAKBROOKE SGP 7 4 2(iOCI ' MRt'-12-2000 14 :04 P. 03/0' . ?. MNCheCk COMPLTANCE REPORT Minnesata Energy Code hSicheck 3oEtWAra VgrBion 3,0 CoUNTY: nakoea STATE: Minneaota ZONE: 2 CONSTRUCTSON TXPE: single Family DATE: 5-12-2000 DAT$ oF PLAN3: 5/12/00 TITLE: DIAMOND 9LA8 90/PORCH EL.2 PROJECT INFORMATION: OAKSROOItB COMFLYANCE: P?LSS$8 Required UA - 526 Your Home - 609 22.3* Bettar Than Code Permst # ChecCe by DaLe 1+rea or Cavity Cotst. Glaaing/Door Perimeter R-Valua R-Value U-Value ------------------------ .--------------------------------------------°----^ CESLTNGS 1887 44.0 0.0 WALL9: wovd Frame, 16" O.C. 1875 19.0 2.0 1 4LAZ2Nf3: W'indowe OY Doors, Above Gz'Ede 27¢ 0.35d DOOR9 38 0.350 9LA8 FL60R5: LRlkleated, aa.o• iriaul. 206 10.0 1 HVAC EQUiPMELZ'P : Furnace, 92.0 AFVE ------------------------------------------- ?---------------------------___. COMPLIANCE $TATBMENT: The proposed building design described here is conaistent with tha building plans, epecificatione, and other calculatione eubmitted with the permit applicaCion. 'rhe propoaed building has been designed ta meet the requSrements of the Minneeata Bnergy Code. 8uilder/Deaigner nate - - e0) raTaL P.a3 ,. Site address: 0a k-- , Wa Lotal 5- Block r? ? Subd. (JT'SZ?" G"?????J[4 On April 15, 2000 the Minnesota Energy Code, Category I Building Requirements for insulation protection, air tightness, and 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 sVucture: will he constructed M meet more restric6ve requirements of Chapters 7672 or 7674 APPLIANCE GA5 ELEC MANUFACTURER MOUEL BTU'S VENTINGTYPE water Heater , P R f b Z ?? Fumace f r ?- S L`J kK 11b ' o C3 W° Dryer EXHAUST 5YSTEM LOCATION TYPE MODEL CFM's VENT.ED YES No Kitchen kitchen Bathroom 7 e, -o ? FI?'C?' Q ? Bathroom 2 I?S?r dSV-C) Bathroom 3 Bathroom 4 Other FIREPLACE S LOCATION GAS DDD MANUFACTURER MODEL BTU'S VENTING DIRECT ATMOS ' o MAKE•UP AIR MODEL TYPE CFM.'s yt kr I hereby acknowledge that the above information is correct and agree to comply with the Minnesota Energy Code and City of Eagan requiremenGs. ? lle Z, tr a ? atu)re Dat ??{/ I?71?ar.1 6-? ??GtbL1? CompanyName ' This form is the responsi6ility of the General Contractor PERMIT Permit Type: Building City of Eagan Permit Number: EA105955 Date Issued: 08/06/2012 Permit Category: ePermit Site Address: 1686 Oakbrooke Way Lot: 15 Block: 1 Addition: Oakbrooke 4th PID: 10-53763-01-150 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: 4,000.00 Total: $105.25 Contractor: Owner: - Applicant - Krech Exteriors Inc Mona A Wolney 5866 Blackshire Path 1686 Oakbrooke Way Inver Grove Heights MN 55076 Eagan MN 55122 (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:EA126154 Date Issued:08/15/2014 Permit Category:ePermit Site Address: 1686 Oakbrooke Way Lot:15 Block: 1 Addition: Oakbrooke 4th PID:10-53763-01-150 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. Valuation: 4,000.00 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 - Mona A Wolney 1686 Oakbrooke Way Eagan MN 55122 Property Claim Solutions Llc 2005 Pin Oak Dr Eagan MN 55122 (651) 994-2028 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA127800 Date Issued:10/15/2014 Permit Category:ePermit Site Address: 1686 Oakbrooke Way Lot:15 Block: 1 Addition: Oakbrooke 4th PID:10-53763-01-150 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please print pictures of ice and water protection and leave on site. Carbon monoxide detectors are required by law in ALL single family homes . Lisa Nyberg Valuation: 4,000.00 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 - Mona A Wolney 1686 Oakbrooke Way Eagan MN 55122 Property Claim Solutions Llc 2005 Pin Oak Dr Eagan MN 55122 (651) 994-2028 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA168875 Date Issued:05/06/2021 Permit Category:ePermit Site Address: 1686 Oakbrooke Way Lot:15 Block: 1 Addition: Oakbrooke 4th PID:10-53763-01-150 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:Two or More Windows/Doors Census Code:434 - Residential Additions, Alterations Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow windows, call for framing inspection. Call for final inspection after installation. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Valuation: 5,000.00 Fee Summary:BL - Base Fee $5K $118.00 0801.4085 Surcharge - Based on Valuation $5K $2.50 9001.2195 $120.50 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 - Mona A Tste Wolney 1686 Oakbrooke Way Eagan MN 55122 Great Lakes Home Renovations 14690 Galaxie Ave, Suite 100 Apple Valley MN 55124 (952) 891-3400 Applicant/Permitee: Signature Issued By: Signature