4666 Pello CirCASH RECEIPT
+ CITY OF EAGAN'
3795 PILOT KNOB ROAD
EAGAN, MINNESOTA 55122
DATE 19
RECEIVEG
FRpM
AMOUNT $ I
?
!k DOLLARS
too
? CASH ? CHECK
FOR " . __ . i _ . . . .. . . . ?
Thank You
?•
SY
White-Payers Copy
Yellow-Posting Copy
Pink-File Copy
Receipt '
1. Date '` j 2. I nsta
3. Job Address
4. Owner :. . . , ..
•:,r i.' .?
5. Contractor • Phone
6. Address ?
7. City State
Zip '.r 27
8. Building Type: Residential 12 Commercial ? Institutional ?
9. Work Description: New Ftl Add ? Alter O Repair ?
10. Describe '' i,L-1-7- forcecl 3i r17ie;!.ti.;_ Fuel Type •'t
11.
No.
1 Equipment BTU - M. Ea.
Forced Air No. Equipment CFM
Air Handlin
:
Mfg, g
Boilers
Mfg. Mech. Exhaust
Unit Heater
Mfg. Other
Air Cond.
Mfg.
Gas, Piping Outlets
12. 1 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
Permit No. '
Fee ! . S/C
Tot.
MECHANICAL PERMIT
CITY OF EAGAN
Fill in numbered spaces
Type or Print legib/y
?
Receipt PLUMBING PERMIT Parmit No. -
CITY OF EAGAN
Fee Fill in numbered spaces S/C .•'=?
Type or Prini legibly To?
i
1. Date 2. Installation Cost
3. Job Address y? (o ?v 7 r i 1 ' Lot !`-r Blk. Tract
4. Owner 36? )1 1n? 1,•)?C t 1
5. Contractor ui I1 i c M I Phone
6. Address
7. City i th_: '4l1J State i 1 11V Zip
8. Building Type: Residential ? Commercial ? Institutional ?
9. Work Description: New a Add ? Alter O Repair O
10. Describe
11.
No.
i Fixtures
Water Closet No. Fixtures
?
Bath tubs Cesspool/Drainfield
Lavatory Septic Tank
Softner
L Shower
_
Kitchen Sink Well
Urinal/Bidet
j
Laundry Tray Other
•?r
?
?
Floor Drains ,
, ?
Drinking Ftn.
Slop Sink
Gas Piping Outlets
12. 1 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
CITY OF EAGAN
3795 Poof Kwob Rood Ee9oe, M!1 SSI"
PHONEs 454-8100
BUILDING PERMIT
va _ nnn
Sire Address
Lot Block Sec/Sub.!?
Porcel
ec Nome ?A irlui:?J?vn ?ic?utec?
W
? AddfQSS
.-«. ;5 "? , ..+ `-`733?
t?. ?
$ Nome Lv?'•er
i? Addrsss
H ru., nN.
Nome _
Address
I hereby acknowledge that I have reod rhis applicetion and stote that
the informotion Is correct and agree to comply with oll applicoble
State of Minnesota Statutes and City of Eoflon Ordinonces.
Sipnoture af Pertnittee
A Bullding Pertnit is issued to: _
ell work sholl be done in xcord
Bulldirp Officlal
Receipt #
E?ed ? Occuponcy
/?Iter ? Zoning
Repoir ? Fira Zone
Enlarge C3 TYpe of Const.
Move p # Stories
DemoHsh p Length
Grode ? Depth Sq. Ft.
Approvals feea
Assessment Permit
Woter b Sew. Surchorys
Police Plan check
Firo SAC
Enp. Water Conn.
Plonner Woter Meter
Caundl Rood Unit '
Bldp. Off.
APC Totol on the expross candition Ihai
oll oppliwble State of Minnesoto Stotutes and City of Eoflon Ordinances.
Psrmit No. Permit Holder Misc. Permit No. Holder
Plumbinq .ZS q`r
[
H.V.A.C. 2(,0(0(0
WNI
Weter
Disp.
Sawer
Elemic s&4?s7
Inspection Date Insp. Other
Footinyt ? . /
Foundation
Framinp
Rouqh TPIbg.
Rauph HVA
Inwlation
Final Plbp.
Finel NVAC
Final
Wrnr Describa Location:
1MNI
Sswer ? .
Pr. Ohp.
?
?
? ?-
•S
PERMIT #
MECHANICAL PERMIT RECEIP7 #
CITY OF EAGAN ?'""
3830 PIL07 KNOB ROAD, EAGAN, MN 55122 DATE: PHONE: 454-8100 For Office Use Only:
? Name
? Addre
c City -
? Name
c Addre
O ciN -
TYPE OF WORK
Forced Air
Boiler
Unit Heater
Air Cond.
Vent
Gas Piping Outlets #
Other
BI.DG. TYPE
Res.
Mult
Comm.
Other
WORK DE3CRIPTI4N
New
Add-on
Repair
Phone -
phone_
M BTU
M BTU
M BTU
M BTU
CFM
FEES
RES. HVAC 0-100 M BTU
ADDITIONAL 50 M BTU
(RES. HVAC INCLUDES A/C ON NEW
CONSTRUCTION)
GAS OUTLETS (MIN{Ml1M - t PER PERMIT)
COMM/IND FEE - 1% aF CONTFiACT FEE
APT. BLDGS. - COMM. RATE APPLIES
TQWNHOUSE 8 CONDOS - RES. RATE APPLIES
MINIMUM RESIDENTIAL FEE - ALL ADD-OM &
REMQDELS
MINIMUM COMMERCIAL FEE
STATE SUFiCHARGE PER PERMIT
(AqD $.50 S/C IF PERMIT PRICE GOES
BEYOND $1,000)
- $24.00
- 6.00
1.50 EA.
- 12.00
- 20.00
- .50
FEE -
SIGNAT TT
S/G:
„.
TOTAL• FOR: CITY OF EAGAN
le i 1 ?;/" gz: ?? /- '12e, w
CITY OF EAGAN Remarks
Additlon RidsA6?if-f- Ilir5t Addrl. Lot 16 Blk 2 Parcei #1(L6398[1 10 09
wner '?1 ?
O 10,A., ?j Street - 4666 Pello Circle scate Eagan, MN 55122
Improvement Date Amount Annual Years Payment Reoeipt Dete
STREET SURF.
STREET RESTOR.
GRADING
SAN SEW TRUNK 14 .62 CO 6 5 2-18-82
SEWERLATERAL -100 1982 1305.42 5 1305.42
WATERMAIN
WATERLATERAL 1982 1260.79 S 1260.79 C007616 12-23-51
WATER AREA ••1$-82
STORM SEW TRK 1982 638.24 5 638.24 t007616 12-23-81
STORMSEWLAT 1982 955.45 5 955.45 C007616
Services 1982 637.75 5 637.75 C007616 12-23-81
CURB & GUTTER
SIDEWALK
STREET LIGHT
Road Unit 185.00 26387 8-19-81
WATER CONN. 335.00
BUIIDING PER.
SAC 525.00
?t
n
PARK
CITY OF teAGAN SEWER SERVICE PERMIT
3743 Pilot Kmb Redd PERMIT NO.:
E9gan, MN 55122 DATE:
Zoning: No. of Units: '
OWnCI: (ie-Tj.L? il_r`,":L?FiQr!
Address:
$ite AddreSS:
Plumber.
1 sgree to eomply wlth Nro City of Eagon Connection Charpe: -'-'
Ordinenoes. Account Depositt
By
Date of Insp.:
CITY OF EAGAH
$745 Pilot Kno6 Roed
Eagon, MN 55122
Zoning: ?
Owner,
Address:
, .. ?.
Site Address: -
Plumber: '
Meter No.:
5ize:
Render No.:
1 egroe to eomply wiH+ !he City of Eagae
Ordinanoa.
ey
Date of I nsp.:
Permit Fae:
Surchorge;
Misc. C:horges:
Totat:
Dcte Pcid:
WATER SERVICE PERMIT
PERMiT NO.: -
DATE:
_ No. of UniYs:
u b 82 RUail CLiffA_I
_ COri11LKt10rf C14f$8:
_ Account Deposit:
_ Permit Fee: ?
Surcharge:
Misc. Charges:
Total:
_ Dote Paid:
- Insp.:
r REQUEST FOR ELECTRICAL INSPECTION q-1 EB-OWOL03
?^ SBe iflstluctiofis (Or compl8ting lhi5 folm orl bpCk ot YellOw COpy.
T . ,?6 9 8 7? /,,C?
`'X?" Selbw Wor?C Covered by This Request 10
1
r:
N-? AOd R.P. TYPe ol Buildiny Appliances Wired Equipmenf Wired
Home Range Temporary Service
Duplex Water Heater Lightiny Fixtures
Apt. Building Dryer Electric Heatin
Commercial Bldg. Furnace Silo Unloader
Industrial Bldg. qir Condi[ioner Bulk Milk Tank
Famt Oiher oauty ihe, (Specifyl
Cornpute lnspectron Fee Below
tt Fen Sarvica EntrenceSixe # Fee' Feeders/Svbtexders ? ee Circuits
0 to tUQ q s- 0 to 30 Am s 0 to 30 Am s
"'1'Qi t; QO mp$ 31 m 700 Amps 37 to 100 Am>s
o Ain?ys' - Above 100_Amps Above 100_Amps
rar??6rm -' Rcmute Control Circ. , tLvL Fee
Signs Special Inspection
'
O }-
T
pr„?,ks ?-J TO
AL EE.r?,
Rouph-in /-1,, .{?( (r?11d !y//
?
?
? I, the Elechical
s if`?? / -?T f
J
% Inspacloq here6y
if
Final ceri
Y that the above
'nspection hes bean
/ ? ? 3 da.
rnis .eacest vod
18 moMhs hom
CITY OF?EAC?N
. 3-
?Q / SUILDINC; PEEtNIIT APPLICATION
? `F'a.YC.°`- 'U
Iriclude 2 sets of plans,
1 site plan w/elevations 5
1 set of energy calculations.
7b Be Used Fbr Valuation o Date 'PS-0-6 I
sire naaress: P L, ncL.. (joZ)C: Mt E. oFerCE vsE aNu,Y
Lot 1(0'? H1ock ? ?_??Sec./sub.'Rj p?c.?, 1FFC_?t ?_ 'Y
Parcel #: ? f O(? 3``r SfC7 lla o a ZCFt fLST ? Alter 2oning
Repair Fire Zone
Enlar4e TYPe of Const.
Oaner: _
Nbve # Stories
jkjdrp,sg; a DiJSion ot U. S. Home C Daratim DHrolish FIOnt ft.
1JI KINS CROSSROAD GrddO D2Pt1 ft.
Cli-y/Zlp COd2: MINNETONKA. MINnI s53A?
Phone #: 544-1333 APPFOVALS F?
Contractor: ORpini -runnnorn HOM.ES
P[3dr25s: a Division of U. S. Home Corporation
City/Zip Code: MINNETONKA, MINN. 55343
Phcne # :
Arch./Ehg.:
Pddress:
City/Zip Code:
Phone #_
Assessments
Water/Sewer
Police _
Fire
En4 •
Planner
Council
Bldg. Off.
APC
Permit a 7 5'
Surcharge ??
Plan Check L3 /?
SAC 6w5 es
water Conn.
Water Meter
Road Unit ?
T17I'AL 4' 15 40 ' C) Q
BUILDING PERMIT
CITY OF EAGAN
9793 Pibt Knob Raad Eagan, MN 63112
PXONFs 454-8100
N? 6833
Receipt #
Erect W Occuvancy R-3
Alter ? Zonirg PD
Repair ? Fire Zone MA
Enloige ? TvPe of Const. V
Move p # Stories
Demolish ? Length 58
Grode ? Depth 26 Sq. Ft.-
Aowovals Feea
Site Address 4000 reliv %jircie
Lot 16 Block 2 Sx/s„b. Ridgecliffe lat
p„ui # 10 63980 160 02
w I Name auwuF+avai ?a
; Addreas 1712 Hopkins Croesroad
a :_. Mtlte. 55343 ., 544-7333
,.
p Name Owner
ot
Address
ru.,
Name _
Address
I hereby acknowledge tFat 1 have reod this applicatian ond stote that
the inlormofion is correcf ond ogree to wmply with all applicoble
Stote of Minnewtc Stotutes and City of Eagan Ordirances.
Sipnature of PermiMee -
A Building Permit Is issued to:
all work shall be done in occa
Asxssmenf
Water 8 Sew.
Poiice Permit 4 /4•w
Surctwrge 24.OO
Pian check 137•00
Fire snc _ 525.00
Erq. Water Conn.335.00.
Plonner
Council
BIdO. Off. Water Meter 60_00
Rood Unit 195_00
APC Total $1540.00
on fha express mndifion thm
a0 apQli . bl Staro of Minnewto Statutes and Ciry of Euyon Ordlnancea.
Bufldinp Officiol
(ger#iftrtttr uf (IOrrupttnrg
Citp of Cagltt
lgrpttrtmnit nf lNuilling Jnsvertimc
Tbis Catifiratt ricued parauant to the +equiremrnu of Srrtion 306 of the Ur+ifo.m BuiWing
Codt mtifyittg thut at the time o/ issuarar thir rtruaroe wus in romplioncr w]tb the various
ordinancu o f the City rrguluting building conrtruaion or urr. . Far the folloudrtg:
SF DWG/GAR W,,.,Im;t No. 6833
1he CWeGa?m
ira R'3 hP Cm.wcuan V Pirc 2on NA z?e wma ?
B.o?e0rrin Thompson „aa. 1712 Hon7cina (`rcrd , Mtk
e?aam:nama. 4666 Pello Circle ,?;,Y Lot 16 Block 2 Ridgeclif
,..?
.Q.PJ7? Br:
p,,,. OrtohPr 30, 1981
..,,s <<om
56987
30 e) c'?)
z-7t & 7
AP.riest ate • I F No. FouGh-in InsVection
Reqmred? . .
?Ready No ?il Noufy In
ec-
J?-? Cl No Y
or When Read
?Licensed ElacVical Co?ctor .. V
- i h ¢by request inspaction oi above
,???ner . -, elactrical work instelled at
Stree[ Atldress. B okaoir No.??
? Citv ?
QQ
cuon o. TownShiV Name 01 No. ?nge No: (; nt? ?{\/?. . .a-e
?R? f ?w1
Occupa/n?t(?P?p_INIT) +?.?,.? /y ' (
O/1 • ',V ? 1+"1 ?ly`^ w1 •..r
? Phone No.
Power S_ upplier Atldress ??'?^u ?+n'i "tl??
EI?G? tr?i 1' Contrac[or.ICOmpany Namel . . C?????nha mr"sry?License No. ,
Ly
Mailin8AdJresslCOnUactoror,OwnerMakin9lnstailationl .. ' I' C-L4W "i
AutAmizetl SiOmnt r IC Vactor Owner MakinB Installation) Ph??owye.ey/,MumO[e?r' . Q { t' 17?QS-?
NINNESQiA dTATE BUARD'Oi'ECECTIIICITY ' ? ?• TNIS INSPECTION NFOVFfT IIryLL' NOT
OJipp?.MiAre?.SIJ?: - Illeaw Nd91 ... 4E ACCEPTED'6Y THf S7AR bAIID
1821 - Vnivereity Ave., St. Paul, MN 55104 . .. . UNLESS-PPOVEN.INSPECTION FEE IS -en...,e''atli oov?'ll ' ' - ENCLOSED. -
??/ RL
2007 RESIDENTIAL MECHANICAL PERMIT APPLICATION
City Of Eagau
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675
Please complete for. single family dwellings & townhomes/condos when permi[s are required for each unit
Date yL_ / pC I / 0 V
Site Address ??p (n /
f0 ?el(n V(/?' C:l'" Pi'
Unit #
Property Owner ?? ?,(,? ?G ?i 0?? ??/7/D?CQ ? Telep6one #(&,I jl S? J D?J?l?
Contractor _
O'CONNOR'S ONE HOUR
Street Addre! 1904 VERMILLION ST. City
State HASTINGS, MN 55033
Telephone #( fp S? ) 7 J? ?- 7l'? `I
Bond #: Expires:
The Applicant is _ Owner _zcontractor _ Other
Fire repair (replace bumed out appliances, ductwork, etc.) $ 90.00
This fee applies when extensive mechanical repairs are made to a building.
Add-oo or altera[ion to existing dwelling unit $ 50.00
? fumace _Additional ?Replacement _ New
air exchanger
air conditioner
heat pump
other
State Surcharge NPp O2Cop $ 0
Total $ ?v
I hereby appty for a Residential Mechanical Permit and acknowledge that the information is comple[e and accurate; that the work will
be in conformance with the ordinances and wdes oFthe City of Eagan and with the Mechanical Codes; that I understand [his is not a
permit, but only an application for a permit, and work is not to start without a pertnit; that the work wil] be in accordance with the
approved plan in the case of work which requires a review and approval oFplans.)
Applican4's Printed Name Ap6ricanYoignature
4666
• • ?'n
FOR: ?
U. S. HOME CORPORATION
?
?
V
?
Vo
Oo
J
W
a
Lot 16, Block 2, Ridgecliffe First
Addition, Dakota County, Minnesota.
/
WE MEREBY CERTtFY TMAT TMIS IS A TRUE AND CORRECT REPRESENTATION OF A SURVEY OF TME
BOUNDARIES OF THE IAND ABOVE DESCRI6ED AND OF TME LOCATION OF ALL 6UIlDINGS, If ANY,
THEREON, AND All VISIBIE ENCROACMMENTS, IF ANY, FROM OR ON SAID IAND.
Do1od Ihis 224h_day ol,.BLqILL?A,D. IDS/ C. R. WINDEN 8 ASSOCIATES, INC.
bv 6^"
Survoyor, Minne?ola Ropiurotien No.772r,
DRA INACE
EASL-n.t r,, ,
C. R. WINDEN & ASSOCIATES, INC.
lArlD SURVEYORS TeI. 646•3648
1381 EUSTIS ST., 5T. PAUI, MINN. 55108
N
Sc,qLE 1"=30'
o DENOTES lRoN
Nrn1v
s
to33-7 ? 2004 RESIDENTIAL PLUMBING PERMITAPPLICATION 46 10-
CITY OF EAGAN
3830 PIL!J'T KNOB ROAD, EAGAN MN 55122
651-675-5675
Please complete for modifications to existing residential dwellings.
Date Z / Z? ! dT SOUPHAPHONE,BOUNMY
I
4666 PELLO CIRCLE
Site Street Address I EAGAN, MN 55122 I Uttlt #
. = (651) 452-0318
Property Owner ` l Telephone # ( )
Contrector 612 827-4033 .
Telephone # (
)
,r'11-' 1.^
,4ddress 2905 GAR
-
F.vE. .?'., 0, City State
- -
Zip
'7h
,
The Applicant is: , Owner 'Y-\ Contractor _Other
Alterations to exisRing dwel!ing $ 50.00
_Add fixtures to rooms, excludiny water softener and water heater
_Septic System Abandonmenf
_Water Turnaround (add $121.00 if a 5!8" meter is required)
L Other:
Water Softener X Water Heater $ 15.00
X replacement _ additional
_ Lawn Irrigation System RPZ_ new _ repair _rebuild $ 30.00
State Surcha?ae $ .50
rotal $ IS.SO
I nereby apply for a Residential Plumbing 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 the plumbing codes; that I understand this is not a permit, but only an application for a
permit, wori< is not to start without a permit and work will be in accordance with the approved plan in
the event a plan is required te be reviewed and approved.
J`? ?t) (-U c,v v` --
ApplicanYs Printed Name
City of EakaIl
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
-----------
--Fa--- Otfice--Use ?
? ?
I - I
; Pem,tL4710 ;
? Permit Fee: ?
? Date Received: I O' j
i n'? ?
1 Staff:
i
? ' J
2008 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: ? Z9 O SiteAddress: 'Twa(a }7r'll0 l.trdL
7enant: 77 SDUph O-pk o/12. Sulte#;
RESIDENT/OWNER Name: ?3 Sn+-Pkg?eh6A2 Phone: fa,S(- '45-7,' 0316
Address/CityJZp: 4(a(o? ?eltq l.erde. E4r(A? rnN 557122-
Applicani is: _ Owner ? Contraetor
TYPEOFWORK Description of work: Tea.Y b?f
Construction Cost: 13, 000 Multi-Family Building: (Yes _/ No
CONTRACTOR Name: AZ+2C Ron-Pv.a CisxS6A ow License #: 2D13 Q !40
Address: o4l D5 gS?`t AVF? f?
C ?rao?
iry: 1Nn Y"
State: N1N Zip: .S3`44 3
Phone: 71b3-3 ? S- OQ 30 Contact Person:
CLt.uki na.s
16:"e-1
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Cate9orv 1 Minnesota Rules 7672
Energy Code . Residential VenGlation Category 1 Worksheet • New Eriergy Code Warcsheet
CBtQgOry Submitted Subrnitted
(4 submission type) • Energy Envelope Calwlations Submitted
In the last 12 months, has the City of Esgan issued a permit tor a similar plan based on a master plan9
_Yes _NO If yes, date and address oS master plan:
Licensed Plumber: Phone:
Mechanical CoMractor: Phone:
Sewer & Water Contractor: Phone:
NOTE: P/ans and supporting docements that you submit are considered to be pu6ltc Fnformatlon. Porttons of
the informetion may be classifled as non-publfc if you provide specific reasons that would permit the City to
conclude that the are trade secrets.
I hereby ackrrowledge that this information is complete and accurate; that the work wili be in coMormance vdth the oNinances and codes of the City oF
Eagarr, that I understand this is not a permit, hut onty an application for a permit, and work is not to start withou[ a pertniG ihat Ihe xrork will be in
accordance wi[h the approved plan in the case of work which requires a review and approval i plaris.
z
Applicant Printed Name Applica s SigrmNre
Page 1 of 3
------------------
?
j Permit #:
? Permii Fee:
? Date Received: ID ?
I Staff:
I '
-----------------
2008 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: i0 -9- O A' Site Address: lo?`!o C,.e.
7enant:
Suite #-
RESIDENT/OWNER Name: .?1119,Wp17i5WE7 _50Phone: 69- / `fSeZ'79'73
Address / City / Zip: /)¢-L/ dk
Applicant is: _ Ovaner _ Contractor
TYPE OF WORK Description of work: 5i.Oi26 -?2
Construction Cost: /; 0 0 o Multi-Family Building: (Yes No I
CONTRACTOR Name: e"?2??Z Licenseil: o2D?.?l';40
Address: 4"10.6- - /v , -o/020 /
City: 2o ! ?v State: /na/ Zip: 75`??3
Phone: 95 ;2 -Y9.i -OOyQ Contact Person:
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Cateaorv 1 Minnesota Rules 7672
Energy Code . Residential Ventilation Category t Worksheet • New Energy Code Worksheet
Category Submitted Submitted
(4 Submission type) • Energy Envelope Calculations Submitled
In the last 72 months, has the City of Eagan issued a permit for a similar plan 6ased on a master plan?
_Yes _No If yes, date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: Phone:
' NOTE: Plans and supporting documents thatyou su6mitare considered to be publlc Information. Porfions of
oU/d permit the Cil
to: "
` the intqrmatioq t11ay be classifred as non public Jf yoa prdvrdespeciiio reaSOns thaf
y
?v
`.M=.conduile tM9tthe are:tr'"9de secrets. ' , `" ' '
I hereby acknowledge that ihis information is complete and accurate; that the wwk will be in conformance with the ordinances and codes of tNe City of
Eagan; ihat I understand this is not a permit, but only an application for a pertnit, and work is not to starl 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.
x &dl/1l.f /12'o?Y/iJal/ X ?e??a?rto
ApplicanYs rinted Name ApplicanY ignature
Page 1 of 3