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4977 Pine LaneDate: City of Eapli 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Use BLUE or BLACK Ink For Office Usepp�� U� Permit #: 1 V 0 6 Permit Fee: Wkli -' Date Received: ?- Staff: Staff: 2013 RESIDENTIAL BUILDING PERMIT APPLICATION Resident/ Owner Site Address: Name: :_pfvC�Y� 1/}, -C'�V��s%/\ Address / City / Zip: Phone: Unit #: Applicant is: A. Owner Contractor Type of Work Contractor Description of work: v- C) LISA= Construction Cost: 1/ d, cO 0 Multi -Family Building: (Yes Company: SA v\ t.E 1`7%/ OP c "c> Contact: Address: / 0 `) C(- i' City: ----/ Yl 't -,-c' State: 7` Zip: 5 "5-0 77 Phone: C 5 f — S d //l / CIr' CLS" " a? K., joy #: FCC' Lead Certificate #: If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) Q-0 aot 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: Mechanical Contractor: Sewer & Water Contractor: Phone: Phone: Phone: NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that they are trade secrets. 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.gopherstateonecall.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 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. 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. Applicant's Printed Name JLO App icar t Signature Page 1 of 3 SUB TYPES Foundation Single Family Multi 01 of _ Plex WORK TYPES New Addition Alteration Replace Retaining Wall DESCRIPTION Valuation Plan Review Li -01 71 DO NOT WRITE BELOW THIS LINE Fireplace Garage Deck Lower Level Interior Improvement Move Building Fire Repair Repair (25% 100% y ) Census Code # of Units # of Buildings Type of Construction V'1 REQUIRED INSPECTIONS Footings (New Building) Footings (Deck) Footings (Addition) Foundation Drain Tile Roof: _Ice & Water Final Framing Fireplace: Rough In )( Air Test Insulation �\ / Sheathing Sheetrock Reviewed By: Porch (3 -Season) Porch (4 -Season) Porch (Screen/Gazebo/Pergola) Pool Occupancy Code Edition Zoning Stories Square Feet Length Width Final Siding Reroof Windows Egress Window Exterior Alteration (Single Family) Exterior Alteration (Multi) Miscellaneous Accessory Building Demolish Building* Demolish Interior Demolish Foundation Water Damage *Demolition of entire building - give PCA handout to applicant MCES System SAC Units City Water Booster Pump PRV Fire Sprinklers Meter Size: Final / C.O. Required Final / No C.O. Required HVAC _ Gas Service Test Gas Line Air Test Other: Pool: Footings _Air/Gas Tests _ Siding: _Stucco Lath _Stone Lath _ Windows Retaining Wall: Footings _ Backfill Radon Control Erosion Control , Building Inspector Final Brick Final RESIDENTIAL FEES Base Fee Surcharge Plan Review MCES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies TOTAL 7,/.7� 2 5,/Lip Page 2 of 3 l??j P ?3s( ? fa8?'y I ) `" ? ? ? ' Q /? ( 005 RESIDENTIAL BUILDING PERMIT APPLICATIONM ? ?o%? '70 • S O ,?'a !`?d4, City Of Eagan p1E) •1-0 3830 Pilot Knob Road, Eagan MN 55122 03S3 Telephone 9 651-675-5675 FAX # 651-675-5694 lew Consimctian Re uir i ts 3 registered site surveys showing sq. fl. of lot, sq. ft.bf house; and II 77r (20% maximum lot coverage allowed) ?Td pp,?( W. ?I ? 2 copies of plan showing beam 8 window sizes; poured found desig , etc. L/' 1 set of Energy Calculetions ? 3 copies of Tree Preservalion Plan iF bl platled afler 71`1/91-ro 6Ne15 9, 8??/ AJ . I RemodeUReoair ReauiremeMs 2 copies of plan 1 set of Energy Calculations for heated additic 1 site sutvey for additions & decks Addition - indicate i(onaite septic sysfem j/ Rim Joist Detail Optrons selechon sheet (buildngs with 3 or less units SW '. -7D:316 Date Site Address y 9zz J conatruction Cost 3ig0/ p00 "/?9P L71? UniUSte # Description of Work S/?79?P !- aiqi /V WD&i,?7 Multi-Family Bldg _ Y? N / Fireplace(s) _ 0 X 1 _ 2 Property Owner Telephone # ( ) Contractor tjeV- CJdxS W+ ! I' ? C#161,-S3 Addresa S State h. z vL. City Fa9o,A- Zip 5-512-3 Telephone#(6S/) ?z.3 "95-5,P COMPLETE THIS AREA ONLY IF CONSTMfGZING A NEW BUILDING ? ta Rules 7672 Minnesota Rules 7670 Cateeorv 1 Energy Code Category ??. ?[` ew ner Code Worksheet . ResidenUal Ventilation Category 1 Worksheef U(i . gy (?1 submisslon type) Submitted '0- _' 1p Sidimitted • Energy Envelope Calculations Submitt/ ? ?S N. In ihe last 12 months, has the City of Eagan issued a permit for a similar plan'b`ased on a ma er plan? _ Y -7Y N If yes, date and address of master plan: Licensed Plumber 4/iy Telephone #( 6S1) V23 ' 373d Z- Mechanical Contractor 6ro-ff5' ltLc?l/?t4 Telephone #(6S/) 423- 3Y e Sewer/WaterContractor 161&4'iI//f.4 Y ZFXC Telephone #(9SL) f4f ?4 - ?/ 5Z/ I hereby apply for a Residential Building 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 State of MN Statutes; 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. w? ?7 C? x 51 algyml Applicant's Printed Name ApplicanYs Signature OFFICE USE ONLY Sub Types ? 01 Foundation ? 07 OS-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg ;Rr, 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Muiti ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 EM. Alt - SF ? 04 02-plex ? 10 OB-plex ? 18 Deck ? 23 Porch (screen/gazebo) ? 36 Multi Misc. ? OS 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-plex Plbg_Y or_ N ? 25 Miscellaneous Work Types r63.. 31 New ? 35 Int Improvement ? 38 Demalish Interior ? 44 Siding ? 32 Adddion ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair ? 33 Alteration ? 37 Demolish Building" ? 43 Reroof ? 46 Windows/Doors ? 34 Replacement 'Demolition (Entire Bldg) - Give PCA handout to appliearrt Valuation lMP[/?V Occupancy ?'lAb MCESSystem Plan Review 100% or 25% I Census Code I bI Zoning ? L City Water SAC Units L21 Stories ? Booster Pump # of Units I Sq. Ft. PRV # of Bldgs I Length Fire Sprinklered Type of Const V n Width ,7? REQUIRED INSPECTIONS ? Footings(new bldg) FinaUC.O. _ Footings (dcck) FinaUNo C.O. Footings (addition) p]umbing ?C Foundafion HVAC _ Drain Tile _ Other Roof Ice & Water Final Pool Ftgs Air/Gas Tests Final ? FraminB Siding SN Brick ? Fireplace -? R.I. -yAir Test XFinal Windows ? Insulation I Rataining Wall A d pprove By: Buil ding Inspector Base Fee Surcharge Plan Review MC/ES SAC City SAC Utility Connection Charge S&W Pertnit & Surcharge Treatment Plant License Search Copies Other Total ?rrs F ?( 07 X 4d-7,-Z S71I= 20 100 = 2 VI los, 4 77 ?' 2, o r? ? ?J, c'o Pr Development N1 Lot Number ? Block Num6er ? Address 7? LF\lVE/ euimer U?w, kI1u'CTNnZ_ Co N.i l: PHONE NUMBER: b?n' LIZ3 - ctSSv CONTACT: C?SI,Ui Tree Protection Reauirements: -125- Tree Protection Fencing Installed On Slte Oak Tree Pruning (Immediately seai wounds durfng April 1 to Juty 31) Therapeutic Pruning Retaining Wall Other: Realacement Trees: Not Required , ' ? A5 Follows: Itl' ' l FM? Attachments: ? Yes No W FOi4ESTAY Dli/ISf Ofti Additionai Notes: R?reWrn , Bv DATE H:lghove\2004file5treepreslTree Preservation Plan Summary-2004 (PLEASE READ ATTACHMENTS) 6514234332 ? F'RO!1 : HLJTTER HOMES jree FRX N0. : 6514234332 Rug. 15 2005 07:27RM P1 J ??,G>S???'U?=7?io.c. `'`?_ - ? / ?cf` b lee, ree c? ?aGf 7"?/e?? oze s? ? n afw,?e 5a? /yo V-tk Y97? ?%? Z'? , rx ree s 2-0 re A y. ? S,,-) Ue z 30' P??e ?exco?e ' 30 3 • .30` y Pi? r?'ao-e . ?s? ?? ?ssay Fax ?s? yz3 v33? / ldlr - ree 54- Alt? C ci$?jr C?d??ioKS S",qnr?rcT-is 44 Trees keAaoed _k" 14xv-yX?? ?rf? 4?1/o-rc. T 5 P??c? ??? ? l 2- ? ('" ?f? ??.,,o /,e Pernrit Number REScheck Compliance Certificate Checked By/Date 2000 Minnesota Energy Code REScheckSofiwaze Version 3.5 Release le Data fifename: Unritled.rck PROJECT TITLE: nevanen GOFJNT'Y: I>akota STATE: Minnesota ZONE: 2 CONSTRUCTION T'YPE: Single Family BATE: 08110105 DA TE OF PLANS: 5 3 OS PR07ECT DESCRIPTION: 4977 pine ln DESIGNERJCONTRAC'[ OR: hu[trier eans[ COMPLIANCE: Passes Maximum UA = 603 your Rome CIA = 497 17.6% Better'Than Code (UA) Gross Glazi°K Area <x CavFtY Gotii. or Door pernn¢ter R Value R-Vatue U-Factor UA Ceiling 1: Flat Ceiling or Scissor Truss 1915 44A 2.0 50 16° o.c. Wal? 1: Woad Frame 4508 19.0 3.0 209 , VYiAow i: Above-C.rade_Yinyl Frmme:Double Paue witte Low-E 424 0320 136 Door 1: Solid 38 6.350 13 Door 2: Glass 105 0350 37 Basemecrt Wall 1: Ivlasonry Block with Empty Cells 458 11.0 2.0 52 Wa1S 6eight: 4.0` Deptb below grade: 8.0' insulation depth: 8.0 proposed aad Maumnin il-Fnkor Averagcs proposed Maximum Ave[age U-Fxtor Allowed U-Facror Abave-Grade Whidows and GPas.c Qoors 0326 , 0.370 Includes Foundation Windnws> 5.6 112 65C? ? it?Mi"as herc L4 O?SCtt EXFS?iffiL T COMPLIANCE $IATFMGCf:1: 7'hC p y _ ? lK'f?hCZ?. 41.lG p3?iT 8? ?7 BIId OItlCC C81CtT?lO[IS SUbIIlil[fd WI[ q C G.F['1('E! 141?{j ?Y((ll(l€4F F 6 t ? t?; - Mionesots Faiagy Code teqimemcnts ffi RES chedr Version 3. Release la (fornwdy klREechec4 god ta coneply with khe nmpdWxy requiremetrts listed m ihe t' . BuilderlDesigner ? Date? s Cities Digital The following image represents the best available image from the original page. Every effort was made to capture the content from the original page. REScheck Inspecteon Checklist 2000 Miitnesota Energy Gode REScheckSaftware Version 3.5 Release le DATE: 08l10/05 PROIECT Ti'1T,E: nevanen PLAN REYIEW AND LNSPECTIOti I'.:SU'?`'? ThiS list of itCmS il78y he hel[tful foc P18n Rf+ki€:wets asa<i Ftt::FEEeng 1ncpe":$Ftc :EZ zt?- a? K ve?u4r tcec e ntcfreira? ?.? e- :i_ie?., v f.; Ljl?":;tSp R. 3 OCE::Ip3:sv3es,.D3te-etld[-i3Tfli?vI£53f?Eilt xs. ?S ? ...£v.t££ } r..3e3x?i3 _ i i.a} -. z SSo31 23+A ast 2Ax L:k?S ss esF... 2#'sc#i:'? ;_". } R:.: . .L-4:M F?N? - ---- ------ - , [ J all pene:rations between conditioned and unconditioned spaces made prior to framing inspmtion are sealed' Interior Air Barrier [ j all fire sto}u are air sealed I I PiPeS,. d11C15, WIrES, CQUIPmCll4 3Fid fltICS 3'9Q CLi=:x_W.Ys 4ixr._a__ u`=.e E}w ix_ls?_aur n;z . .. , [) a sealed continuous mienar air barrier is instaik-s t.a et4f tam. _ ikd__- ... - . . . ,? ..,..: , ; _ ,. .-:- y u _.. ?.-. .... ?,- ,_,.. _ ? 1. .............,,,,, ? ..I ,_ u_.... , _, ..,,.??..?.....,: ? ? . ..?., - .... .. .. ... .... ...? ..?. ? ._ _. - - ..:. . _. ; .. ;.?_.._ -._ ,. }. .. .-,u rt ;.:... .. :. ?_ ..__. . . _a .._ . . -.,... ' _ _ _- LOT SURVEY CHECKLIST FOR RESIDENTIAL BUILDING PERMITAPPLICATION d PROPERTYLEGAL: M"• DATE OF SURVEY: 7I 8 LATEST REVISION: ?e ¢ Oz ? 0 pr o 's ° gr ? ? 0 'z ? .2f ? ? 0 0 d m c ? s U ? 9 a ? 0 ? ? ? ? ? ? ? 0 ? ? DOCUMENT STANDARDS . Registered Land Surveyor signature and company . Building Permit Applicant . Legal description • Address . North arrow and scale . House type (rambler, walkout, split wlo, split entry, lookout, etc.) . Directional drainage arrows with slopelgradient % . Proposed/existing sewer and water services & invert elevation . Street name . Driveway (grade & width - in R/W and back of curb, 22' max.) . Lot Square Footage . Lot Coverage ELEVATI ONS Existin ? O ? • Property comers ? ? ? . Top of curb at the driveway and property line extensions ? ? ? • Elevations of any existing adjacent homes pf ? ? . Adequate footing depth of structures due to adjacent utility trenches p 16 ? . Watenvays (pond, stream, etc.) Proposed ? ? ? . Garage floor ? ? ? . Basement floor jg p ? . Lowest exposed elevation (walkouUwindow) ,B ? ? . Property corners 'or ? ? . Front and rear of home at the foundation PONDING AREA (if applicable) p '0 ? . Easement line ? ? ? . NWL ? r? ? . HWL p ?j ? . Pond # designation ? ? ? . Emergency Overflow Elevation ? R( p . PondNVetland 6uffer delineation y ?N . Shoreland Zoning Overlay District y ?l • Conservation Easements DIMENSIONS R( ? 0 • Lot lines/Bearings & dimensions p? ? ? . Right-of-way and street width (to back of curb) ' ? ? ? , porches, etc. . Proposed home dimensions including any proposed decks, overhangs greater than 2 (i.e. all structures requiring permanent footings) jd 0 ? • Show all easemenfs of record and any City utilities within those easements ? ? ? . Setbacks of proposed structure and s rd setback of adjacent existing structures ?f ? ? . Retaining wall requirements: Reviewed By: DateVZ G:/FORMSlBuildin9 Permit Application Rev. 11-26-04 ?3- MendotaHeightsOffice P12NEERengineefing 2422EnterpriseDrive Coon Rapids Office CIVQ.ENGP7EER5 I,pNDPLANNERS LANDSURVEYORS LANRSCAPEAItCHITbCLS 20185thAvenueN.W. Mendota Heights, MN 55120 (651) 681 1914 Fax;681 9488 Mendota Heights Of?ce -?? ?P??, MN 55433 Certificate of Survey for: HUTTNER CONSTRUCTION - 4977 PINE LANE, EAGAN, MINNESOTA x 968.1 C x969.0 ? 972.2 N89'41'S2"E x970.3 FQoP05ED . ?ETruNiNG W ??t C?src???? ?` B?k.T ? 971.2 , x972.1 071 9 \ 138.29 HOU 974.8 N. ? ? $ Nr (V 10' y Ix ? o x 979.6 974. ; o/ p ? I x 976.2 -?---- 55.0 - -- I ^ I 976.8 -- ' PR 14. 0 8J8 6 ' HOL ? ? ? ?? . 3= 10.00 /h ?J. ` 3 977.01 976.8 p/ OC) 1 M j ^14.17. I ? k976., 976.5 976.9 , 0 ? i to 9he_2 or-------4 977.2 (b r! - _ - _ - _g."?c)a_ 9772 },977.1 976.8 I V77.9 52.33 977.41 J¢ FENCE LINE'? N ^ e78 5 saa.s h ? I ZQ 0- 985.1 ? p /4489*41'52"E 138.42 986.4 ? ? 9 R '??'? EXISTING ? ? a HOUSE BENCH MARK: I - TOP OF SPIKE ELEV.= 976.97 ? < ? ! l 4 /97 ?S? I N e n.7 i a . 977.6 977.9 ,?. , 976.7 1 10 0 6.0 -- 30.01--+ ? sn.o o N tl o ? 47`.6 0 3 ? a o?I ?o ?--J ac I o 1'?_ J 1?0 y?_? ? 9 9.4 979.9 gy o w 985.0 Date 985.1 r piAyAN E67V G D0 984.9 , LOT AREA = 12,452 SQ. FT. DRIVEWAY AREA = 866 SQ. FT. HOUSE AREA = 1,606 SQ. FT. BUILDING COVERAGE = 19.49 GARAGE AREA = 813 SQ. FT. PORCH/ PATIO 120 SQ. FT. IMPERVIOUS COVERAGE = 27,37 = ? 979.Cy, -r o- _???-? ? 1 1 ` VI ? l 1 I \ BENCH MARK: 70P OF SPIKE ELEV.= 979.89 30 ?I 3? --- I 60. rR.O. . a? ?N MAdri 4N,?i?. TUIF ESTABLH ?, L _ 977.3 I I )) 77.4 ? ° DRIV?? O i ? ? - w I? I L ? 00 I J ? op N W 979.5 11 30 i 30 I HOUSE TYPE 13 - C WALK OUT SANITARY SEWER INVERT ELEVA710N = 969.6 (PER PLAN DATA PROVIDED BY CITY OF EAGAN) NOTE: PROPOSED CRAOES SNONTJ PER GRADING PLAN BY: E.G. RUD & SONS, INC. NOTE: BUILDING DIMENSIONS SHOWN ARE FOR HORIZONTAL AND VERTICAI, LOCATION OF STRUCTURES ONLY. SEE ARCHITECNRAL PLANS FOR BUILDING AND - FOUNDA710N DIMENSIONS. vOfop I_C` NOTE; NO SPEpFIC SOILS' IN?S7IGATION HAS BEEN COAIPLETEO ON THIS LOT BY THE ) Sl1RVEY0R, THE SUITABWTY pF SOILS TO SUPPORT THE SPECIFlC HOUSE PROPOSED IS NOT THE RESPONSIBILITY OF THE SURVEYOR. NOTE: THIS CERTIFlCATE DOES NOT P PROPOSED HQ U VATION LOWEST FLOOR ELEVATION: q16-5) TOP OF BLOCK ELEVATION: 1 SA•3) GARAGE SLAB ELEVATION: ' R?3•Z? URPORT TO SHOW EASEMENTS OTHER THAN X 000.00 DENO7E5 EXISTINC ELEVATION THOSE SHOWN ON TME RECORDEO PIAT. ( 000.00 ) OENOTES PROPOSED ELEVA710N NOTE! CONTRACTOR AIUST VERIFY DRIVEWAY DESIGN. --- DENOTES DRAINAGE AND UTIl1TY EASEMENT DENOTES DftAINACE Fl.OW DIREC710N NOTE: BEARINGS SHOWN ARE BASED ON AN ASSUMEO DANM -A- DENOlES SPIKE -B DENOTES OFFSET HUB WE HEREBY CERTIFY TO HUTTNER CONSTRUC710N THA7 THIS IS A TRUE AND CORRECT REPRESENTATION OF q SURVEY OF THE BOUNDARIES OF: LOT 1, BLOCK 1, PINETREE FOREST SECOND ADDITION DAKOTA COUNTY, MINNESOTA IT DOES NOT PURPORT TO SHOW IMPROVEMENTS OR ENCROACHMENTS, EXCEPT AS SHOWN, AS SURVEYED BY ME OR UNDER MY DIRECT SUPERVISION THIS 18TH DAY OF JULY, 2005. avsad: SIGNED: ?V NEER ENGINEERING, P.A. 07-26-0 STAKED SCALE : 1 INCH = 30 FEET BY: ( 4] 105166000 D.C,RWD Peter J. Hawkinson License No. 42299 • ? ? ?P?_ r-.nn?.? 5., ;n.l?_ ?.."..S ? ?r f1?Ot= vErJTS ?(` TREqTED W00D PAl1Y .^-.7?'.i p.;R!-: QN STAfRS OF FOUR OR MORE RiSERS, r ? •- ,„A F ?RIPABLE HANDRAIL EQUIVALEP;T TQ ? '" TQ2" DIAME7ER .4ND MCGjii=D ..Un Lv%- -=13 ?.;EEfJ 34" TO 38° ABOVt TREAD SUI'FLiER FOF# MOFt E I N F O R M AT1 9 N. ' -IUE?OF THE STAIflS. O N AT LEAST ONE .??._.?.. .. •? ? µ '._ ----- - --- - -? ?- ' ?- -- - DECKS SHdLL AIOT ' ---- _! -- -- (2 BE $UPPO ED BY -? ? CANTILEVERED I-JOIST HOUS FRAM - - : - -- _.._ _____.. Il 8 * - 4yITHOUT SPECIFIC ENGINEFF NG. --..._ --------° - .. t;p .._^.._.... .,T. ._ . .. ...._ .._.._--- ?--. .._. " - _. _?..--'----_ .__ _.. . .. ---' 2+c 25 ----- -- - . _. 3 --- . _-=- - A?PROVED PLAf?15 M ": t ;_: = - ":- „ -4r- = -- - - `? ' _ ? ?,R.• E L.E ?%4Tf OtJ "LGER MUST 9E ATTACHED NIim L?? T ;:iIN!N!UM (2) p3?/8?° X??p4?"fu / L?A aV?6 SCRE6'Vu ( p., , . ,, • AltiT?y/dQCNEGRai?YL--4---- STAIRS SHALL BE PROVIDED WITH ILLUMINATION IN THE IMMEDIATE VICINITY pF THE TOP LqNDING. ??AN - - GREATUi THAN -Z, _ ----_------; " .-- _ 20"? ABOVEAREA KLUUIKt _ _ -- -. _ __.... _.._ . .. ._. . . f . 79RAILS MINIR9UM 36" IN -_ . :.. I : AND DESIGNED SUCH THAT _ _ ?• , ' •;... f ETER SPHERE flMY NOT ?3t1BP??irA G INS'? _.._? _. . ... .: _ ....,,:? ?,• ?'HSS IhROUGH J _ ?.. _ :o OP-ro ; . ? ;? : ?? c?z. , - .Z? ? _„ ? -?? _ . . ' ZBIoDG (pQx (oD P?GTJ zE ?._-- PICAlr PQ:T FfG? ? ? == -- - - , ,. ? , 4' •.-?` ! ? rrL_ iJ?SiG?.IE a? 2? IOCu. 25Ai J5 -ZirJ ( I 'O ? 7/Pi?7J??i ?G ? -- - - , ? _ I ` gV ///????j I ?; ..,P?GDR?'L ?3•2xG, nF?. DeS?u? ? L F ?l.2c _ f r ? rL : , on -nr& . VF-s? ? J- 117/B' TJ ?'S , - , , , •: ?? . . . r . . r. gVf r 1 Cl V ? .? /'-' U 6 l?(.- /177-v? ? ? . ;, ? ,. i q-q 77 f?? C17? ROYALi?O?IKS ?? REALTY, INC. February 3, 1999 City of Eagan 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 Dear Mayor Patricia E. Awada, and City Councilmembers Paul Bakken, Bea Blomquist, Peggy Carlson, and Sandra Masin: Our company is requesting the Eagan City Council to drop the City's option to acquire street right of way across Outlot A in Pinetree Forest. Condition number 17 of a motion to approve the preliminary plat stated the following: The owner and/or developer shali dedicate upon the plat OutJot A for the futuie constructioR of 120"' Street. The owner/developer shall grent to the City an option for a period offfive years to acquire the property for one dollar for streetpurposes. ? sopr .200z) A copy of the recorded agreement is attached. At the City Council meeting on March 18,1997 and in relation to the approval of Pinetree Forest, discussion was made on the possible future connection of 120I' Street West to State Highway 3 as another neighborhood outlet for traffic. Hence the City wanted to keep their options open and hold Outlot A for a possible realignment of 120t' Street west. We believe for the following reasons that the City Council should release their option to acquire the Outlot: 1. That portion of 120"' Street south of the single-family lots in Pinetree Forest should not be vacated. That existing road not only serves as an access into Pinetree Forest (via Pine Lane) but it elso serves access to a number of rural estate homes in the cities ofi inver Grove Heights and Rosemount. 2. Outlot A is approximately 2000 feet east of the Highway 3 right of way. There is ample distance between Outlot A and Highway 3 to plan a prudent 120"' Street alignment without utilizing Outlot A. 4196 Lexing[on Avenue • Shoreview, Minnesota 55126 •(651) 483-5518 • Fax (651) 483-5642 3.The configuration and location of Outlot A relative to the newly constructed Sycamore Drive does not provide for the proper geometric needed to build a collector street intersection. We currently have a party interested in the purchase of Outlot A for the purpose of constructing a single family home. Lot 10 north of the outlot has been sold, however we are unable to sell Lot 11 (south of the outlot) because people fear that the lot will have a street on three sides. An application for the replatting of Outlot A has been made to the city staff. The final plat hardshells have also been made. The Planning staff did not want to proceed with a request for Final Plat approval until the City Council first discussed the release of the option to acquire the outlot. I plan to attend the February 16, 1999 City Council meeting to answer any questions you may have of our Company. Yours Truly, lr.•.?V-1 U Michaei J. Black °?""'?'°°"°° PINETREE POREST 4_'??,_?v o s ?.M. F I;T -I? "?yea?qw??r.r?.r;°?e:.:-r?•.??:^:,w?.;s°°r.r.:?;:?.,«., r , . . o, . I ' '..ryR . i7ip9.y?i9?...? ?kR , ? ? ': -.;. .. :... :. , ...... .. ?+..-. ? a..?.. N. I. .. r?.:^a?. 3,t.1 -V _ ? • r.n .. . .r?9dS.6P ?? ln _'G?r??•???tw? ?... ?w.u .. m.n.?' ? n?ua. ? C M??' 16 qE 4?C f1 ??• w ? 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"' ?C2 ?'m ,`+i ? cm.,?rsr ..aa?wnrw.„?...a?. a 'r ?iz ? f ? ? ? ? i F' °? ? ? a 4s?.?+ ? ? ....__....ro,lT-'"'r"_.'?d.",p... «.a.:a' :l'"J3 ?:S:R'?° •- a .?._ _ «.. e ? ?.. 120N SIREET NESii. ° ---- -' _ ser?o'v-• v.ti.r - - a ,..».„ ,,..,, ••.,. ? ?•••?•.. ? ?. 6 IYLD 4 60N6, INC.? E WT tsES.• I l N ?D1M • LOT IJ[5 S RAi. YIM'!D BY fl.14 xu 9lpp, - ? ? oplol6 1'wa0?15 ?QaO. MO ?TA110N 9?0?11 Ai MY STANIE gG1IED ?714311 ?1F5 A R.AT ?i nwf rl ! YT wTM bE K.M aI M RfComNG Oi MS RAi. LO YlN10ii 1LL BE KW16.0 BY R.LS Nn 9?py I ? ?S I ? i ?' ??? .::.,::: ??•.:v . . ' • . _ i r ___ \?'--- --- - ?-----r---- . 'i ----- 7--- p . . .. .. 9CN2 p Rf . " . .. .. . / . .-..?. .. . • : : ? .... I foch . 100 R I I _ _ . ._? ... ?? .. . . _.. 1 . .. I ? 1 1 ! ? I I .? :J . . ? :: ? I . . : .. . . ..... ....... . :... ... .. .. .. .. ? ? . I ... .. ? xORM IlE df 11E Y 1/? Of ?ifC Y ?/?- -. ? / I I ? I fi YCTOM U. Y17. R33 I A + ? 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I 6 ? w x P`Oa9 P.i I 1 .. i ..i R xa,, 120th STREET WEST.I..- Ixss __._..-'L-._ . R gg" ? ~ 1336. Z7 „ saUd u[ a n?[ A t/• af TM[ Z i/a o; n ?o w. ! 0 O ? O 2 02;05.90 08:18 FAC 6518383020 LAND TITLE IYC (a 002 t r 0 a - ; . Z : o . ?? 3 1 ? 1 ? ? ? r ? ?i ? ? ? ?. ?- ? ? oMox & wAIVEa ncxEEniVnrc 36U'709 O ON'AGR}?T fs made aad entesad info thiso,M day of 1997, by and between ROYAT, OAKS REALTy, ?TC., a?esota °?? (haeinaRcr "I.audowner") aad the CITY OP EAGt#N, a Ivt'inne?ta uaicipal corporation (heTeinafter WHEREAS, the landowner is the owner of FraPcrtY in the City of Exwa, aad 1eg?,lY descn'bed as dutiot A, Pinetae Forest, Dekora Counry, Mnnesota according to the moorded plat-derzof and WHEREEIS, the Landomier sekrLowladges the beoefita ac.cnriag to it as s result o£ the aPPi'oval bY the Cily of the plat of Pmetree Forrtsst anA wtB cxecute a Development Ageemenf, whicdi A.geement provides for the future conshuction of a road across Ootlot A; aztd WHEREAS, sn coasideratiaa of the appmvel af the Piaetce. Fwrest Addition, the J.andowner doas horeby agree to grant the City an ap6on to. acquize a r4ht-of-waY, draiasge and utility easement over, undcr aad across Outlot't1; Piaetree Forest Addihon, DakDta COuahS M=esota, acwrdin,g to the reeorded plarthereof subject w}he tams and eoaditions stated bejow. NOW, TEWREFORE, based oa the foreBoinB faeffi aud, orher good and vatuable consideiation, rhe receipt ead s?fficiency of which are hereby ackaowledged, the Landowner aad City do hexoby agcee as follows: 1• The City is kerebY granced.au option to acquire a Petmaqent right-of-waY, `?. d[8tt18V and UrlI1LY Q85CII1CAL OYR, under and across OuUot A, YYmetee Fvrest Addiaoi0. ? Dakota Couniy, Minaesata, for tlu sum of One aad uo/100 Dollatis ($1.00). 'Th Opii ? may be exaeised bY delivery aaFa writtar Notice of fntmt to ?ercise to the is on owners at the foIlowing addresa: U C! 0 0 ? ;: 022,03199 08:19 F.4X 8518389020 Li\P TITLE I\C ZU03 R(7Y81 Q$1($ RCglyr I11C• 4196 LexiagWn Avenue Shoreview, MIV 55126 Upon receiyt-o£-said Notice, the Laadowner shali deliver to the City et: City of Eagan Atta: ThoFnav A. Colbery Directnr of Public Wodcs 3830 Yilot Knob Roa3 Eagan, Miv 55122 With a Copy W: Severson,;Sheldon, Dougherty & Moleuda, Attn: Michael G. Dougherty, City Amomcy 7300 West 147th Sh'eet, SuiEe 600 Apple Valley, hN 55124 A unencnmbered ftsement ovcr, under aad across Outlot A, Pinetree Foresi Addition for riglrt,ef-waY, dtainage'aad aliiity Purposes. Landovmer sball provide the City with evidence or nnencnmbexed tirle to said 4udat A. Such aasetaent shall be delivered to the City witfrio thirry (30) days aRer reeaipt by thc Lmidowau of such Natice of Intaat to Exercise. This easeme,nt ia being given to the City as a requirement under Minn. Stat. §462.358 sad the uadersigaed recogrizes thst no sdditional considerarion wll be received for the granting of the eesemeat 2. .48er tlus .Option is exacised, the City ttttznds to build aad construet rigfit of-way, drainsge amd ytility improvements over and across Outiot A, Pinetree Forest Addition and 3o instail ; snch ather improvements in crnonection tJaarcwith that rhe City Aaay deem necessary,'iacluding but norliaaited tio, sipage> sxdewalka, smetligbits, sewer and watw mffins, and other utilities (hdreinafter tcfared to as the "Publie Tmprovements"). 3, All costs aad improvements incurred by che"?ity, its agaats, servaat5 aud contractas regarding the conatcucrion of the Public Luprovemarts shall be charged, assessed aad levied agaiasr the lots wizhm tLe Pinetee Forest subdivisioa. The Landowner agrees to apcept the wsts and expeases for the conshuction af the PubIic Improvements coasauctqd over, upon and across said Outlot A,, Pinetree Fvrest Addition. As a bencf?t W ixs respective FroPerties, Pmvided said assessmems are detrrmined ia accordance with the standard praclices and policies of she City. 0:,'o3?95 08:19 F.0.Y 85189880:0 , LdND TIrLE !NC r . - -Z OOJ 4. The Leudawaer bereby waives notice of anY, Publie heaflng unrler M'wm. Stat. g429 and 'm connection with azry public improvecneak aud/or assessment Peclainft to the wnsunaflon of the Public Improvemezts, over, vmier snd acioss said Ontlot A. 5. Tbe Lan&wacr waives its r7gtit to objax and appeal the adoption of the Au.scm..,t for the construction of the Fublic Imgrovemdats aa set-forth in Mian- Stat §429.OSx. b. The Laadoovner aclarowledges and agees that Yhs provisions of Sris P.greement beneftto' du tofs contained within the Pineuee Farest subdivisaon and sha]1 rnn wrirh eacfi of said lats aad s$all be binding upon and iznn'e to the bemefit of all parii.es hav;ng any rigyt, title or subsequent iaterest in os to all or any pazfion fl£-seid lots or any ofthem, their respective heirs, admicnistaivn, saecessozs vruas.signs. ROYAT. OAKS REAL'fY,1NC., a QTY OF EACsAl+t, a Micuxesota Minnesota coxperation. municipal corpatatiom /J?aia By . areel Eibe 'me; y: as A: Egatt Its: Pregident Tt4: Mayor L ? W ity clerk STATE t5F M54NE50'i'A ) ) sg. COCJNTY OP AAKO7'A ) On this aS'6day of sa'- 1997, befo,rc m;a I34ti?Y Pub&c within amd for said 'County, Ixrs' aUY qpeared MARLBL• •.?EN5TEINER to me personally lmown, who beamg by me duty swora, did saY th?t he is tha President of Rnyal Oalcs Rea1tY, Inc, 9ie ooiponmion nena.ed in du faaegoing inshviaeny and tLat said 'm.str=ent was signcd oa beW of snid corporado,u by suthoriry of its Board of-D'¢xtors and said Pcemide;at seknowiedged said 'msawnent to be tbe &ce ad and deed of dte carpomtion. DWm M.IePAC+F MO1+?tnwAo-wwNfSp71? [qY 11 N L 4v .. ) ftblic 02- 03:99 08:20 F.a% 8518383020 L:uND TITLE IVC Z ous sTnxs og MINNE.soTa ) ?. CAUNTY rIF DAKOTA ) r Oa this ' day a 1997, befot'e me a Notary Pabfie wi#hin atud fox said ?Connty oaallY BPPemed THOMAS A. EGAN and E.J. VanOVERBEKE to me pasonally Imown, who being eaoh by me dnt,y swora, each did say that they are rospectively tho Mayor end Clerk of the City of Eagan, the mimicipaliry named in the Eorego'mg iasmanen; and tbat the seal affixed on behaif of-said municiPaht3' b3' audwrih' of its Ciry Council and said Mayor and Clerk ac,lmawledged said iltsbrument Yo be. tbe frce aat aad deed of said nuunicipatity. THIS 1NSTRUMFNT WAS DRAFIBD BY; SEVERSON, SFffiLDON, DOU41MRTY & N10LENDA, P.A. 7300 West 147th Street, Sbits 600 Appla VaIIcy. MN 55124 (612) 432-3136 1lBB/wkt 206-14569 ??i ?R?1 aY?o°F81NfG ., _--? ?.?, _ ? ,...?.,.. P iuSt?Erm FoRESt SEcoND ADDi t i oN r _ - II --_--_.?--__-? I f i ? ? L O T I ? BLOCK I ? € I I - ? I IL _ _ _ ---- _ _ _ _ _ _ _ _ _ J I .. SB9Y?'SSI 198.11 ?^ I ; p CP n I i I X mI «I ? 10Ya]'S W FLB(IS ..?.. ?-J H . E. G. RUD t SONS, ING. Land &lveyore I I , .. . . ' .. GMY?ue " ' x ? «, `a .. Y fF ?M' s • .. ? _ w?SSji: s ms ?n.. _ am ei __, i. '.?? mv., w..r. ?r?... Wn 7p'f? .,, -aa. i u ? nti m V . .. ? ip?a l WL A I owuri ?n Le?m YID 6? ?m?w?o Sn?.u? ?nia oei w ehn ewe+1 mn _ v? a____ n_ ? ? r . . e n ...r?. - m? a ?va e9.?tlen? KKU N ?m Y N? 4. . . I ?? _ .. o - _ae o Y r ? n. n ..... secu? W. rw.M 27. na. xa o.Aa. cowy. ux GkAV111C SCALF - - ?p ?-:? ? ,; , ?y I Pinetree Forest -?p? ?' ?p? ?9ks ?::?I .. '?p ? LOCATED IN SOUTHEAST EAGAN *?p i??'i -? 'sT x? ?: i i ' - - !i--- ?+ _ k s9:.a GUN CLUB ROAD _?-'- a.,.o, x ?°°'--', 0?'? bI.U - ?`.. ?? ?9].>i ?I?? ?5}M ? ' f ? ` 'o$i ?.i\ ? \ I ? ? :_. -?e$ ?. 8oe.? \ ? In ln ::: v?? V?g q '-' ?? ? ? "? _ ? ? '"8 M 4 :" ' : , - i. i4 :; s ? kR::: . 4"xi? ? . / I C?'LUj L, ? ?'J . _ _ ?? ? ` ?R r'Y '?,? ? ??a?` aq i[i ° i/ ? 4? ?\ 1?96B??W ?:.:? r ? ?? 11 NQ y \ `, R': ? ;^ °9 ?P 'F ? '? ? k?. 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M.Po-?l00N ? 1, ? ;x SYCAMORE x DRIVE xi .o?.??o-a ? n? a._.._,?-co7?-?' . i m• an : ?. ??lrz?o?s?r-?w-? eo-?reew-ir- oo ?r- w-?r-esao-ir-e>o?-ir-??w-?r i? ii ik ? ii i ii ii ii r i r iiF ii ii ii co i r i r i8 '[7 ?a '/ ? ? I F I b I ? I?? I ? I W I4 r I F I? J ? ? k iK ?dki?1'` c ? ?+ ?L? ? O ??N?o aCF- ? rn= ? .m ? ?( ? ? ? ??+ ??_ n ?? n ..1 . ? NL C wC 0 G ? o G ??e, ?? ? $ ?'.ic?V tn ? `i(.i i? iG ?i4i iC• i? ?CJii i? i? ? ii ? ii? i ?/ I . :'1 ???_'_2zL??_____JL_?e.uo??_ea?_Jl_s??_JL_eaao_JL_esoa_J?_PSa+_?L32oe-_JL esPP_JL_as.m_JL_eP6_??_CSro_??_aP,?_? ?. .. ' N00'!8'08"W '. I 13f6.73 EV??, ?. ??R 1 ?-- ??[ [.s? ?mc nr TM[ swn??ns? wwe*ca a TMc I?C ?? ?. I sWTMC?s a•ut[n n s[cna? 1b. rzx nv b ?n ? ? ?SSVU(U ??invF. ? L?Mix4 C! r??YG'CC w ?^ Au ?d? ??r??, ?, .? Cantract No: Project No: 7-_Z-_Y_-) Submittal Date: ??/zo 7 CITY OF EAGAN SEWER 6 WATER PERMIT RELEASE FORM PROJECT DESCRIPTION: Substantial Completion of Sewer & Water o1*2 Dar,d of ccurrence STEP I: PERMISSION TO HOOK UP SANITARY SEWER STATER MAIN ? I:ines Lamped aad Acceptable t/ Proparly Chlorinated & Flushed Deflection Mandrel Test Passed ? Entire Systam Pressure Tested ? Manhole Structures Properly ? Entire System Conductivity Tested Constructed (cstg. 6 cover, rings, ? All Valve Boxes Accessible, cone, 1 ft. sections, final rim straight 6 keyed setting, & build aad imrert) ? All Valves Opened or-Closed as Approp. ? Infiltration Test y/ Bacteria test completed BERVICES ? All Wya Locations confirmed ? All Curb Boxes Exposed, Set to Proper Grade & Marked w/Fence Post -L/_ Required Sez?ice Risers Telev sed cottet?rs: ?,K, ?2 CC/P 7-r "?-/. ?- STEP II: ESII,L USE PERMIT (OCCiTPANCY) STORM SEWER _ Lines Lampad 8 Acceptable _ CB Structures Properly Constructed (cstg 8 cover, rings, 1 ft. . aection, iirvert, final cstg. setting 6 build, DL-DR correctly set rings & cstg. set in full bed of mortar) _ Aprona, Dissipators & Rip Rap ptoperly.installed COMMENTS• RECOt4lE2UDATION: I herein verify that the tests and inspections indicated above have been auccessfully completed. Aay deviations or eaceptions are dascribed in my comments. With this coneidered I recommend.that permission to hook up or DgMisaiop-f?or occupancy be granted as appropriate to the above indications. C__ Proj ect Confirmed by: STREETS Material Tests Checked & Passed (Conc. compressive strength 6 Air Content, Bitum. Extact & gradation, gravel base gradation). _ Utility Structures & Linea Clear & Free of Debris & Gravel (Gate Valves keyed) " Public Works Address: 4977 Pine Lane zip: 55123 Lot: 1 Block: 1 Subdivision: Pinetree Forest 2ad Addition TIIE FOLLOWING ITEMS WERE/WERE N(YP COMPLETE AT FINAL INSPLCTION ON I Yes No Comments Final grade - 6" from sidin Permanent ste s- ara e Permanent ste s- main ent Permanent driveway Permanent as Retainin Wall or 3:1 Maac Slo e Sod/Seeded lawn Trail/curb dama e Porch Lower level finish Deck Fire lace • Verify with your builder that roof lest caps from the plumbing system have been removed. • Turn ofF water supply to the outside lawn faucets before freeze potenrial eausts. • Call the City's Engineering Departrtient at 651-675-5646 prior to working in right-of-way or installing irrigation system. J BUILDINC INSPECTOA: I? CONTRACTOR: Huttner Cons[ruction 4945 Pine Lane Eagan, MN 55123 401' City of Eaau Date: 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Use BLUE or BLACK Ink 1 For Office Use Permit #: 110154, Permit Fee: (oma Date Received: 4 /? 5113 Staff: 2013 RESIDENTIAL PLUMBING PERMIT/APPLICATION Site Address: 4 / 77 Pin Pi �a, ed Tenant: Suite #: Resident/Owner Name: _]De. fA)2r5 Phone: / - a7� '"30730 -- Address / City,�/ Zip: Contractor ` -1 p Name: 0074 y�/Uyr i ? JyS 117, -S, -VIC License #: Phi D� ?c O 5" Address: 02:297 &y S R/ City: Ags inoLin '- State: 4/I/ Zip: ..5:64g Phone: 9Sr--) _ 029.2 -0.7/ Contact: jNe:�C. Email: Type of Work New Replacement Repair Rebuild Modify Space Work in R.O.W. — _ _ _ _ Description of work: Permit Type RESIDENTIAL Water Heater Water Softener Lawn Irrigation ( RPZ /_ PVB) X Add Plumbing Fixtures ( Main / X Lower Level) Septic System Water Turnaround New r Abandonment RESIDENTIAL FEES: $60.00 Water Heater, $60.00 Lawn Irrigation $60.00 Add Plumbing 'Water Turnaround $105.00 Septic System Water Softener, or Water Heater and Softener (includes $5.00 State Surcharge) Turnaround* (includes $5.00 State Surcharge) and $5.00 State Surcharge) TOTAL FEES $ (includes $5.00 minimum State Surcharge) Fixtures, Septic System Abandonment, Water (add $200.00 if a 5/8" meter is required) New ($10.00 per as built) (includes County fee 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.gopherstateonecall.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 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 plats. x /q/C,4 Yd /y Applicant's Printed Name x AppliLant's Signature FOR OFFICE USE Reviewed By: Date: Required Inspections: _Under Ground _Rough -In _; Air Test +Ga s Test ___„Final PERMIT City of Eagan Permit Type:Building Permit Number:EA127345 Date Issued:09/29/2014 Permit Category:ePermit Site Address: 4977 Pine Lane Lot:1 Block: 1 Addition: Pinetree Forest 2nd PID:10-57651-01-010 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 - Brian J Nevanen 4977 Pine Lane Eagan MN 55123 Krech Exteriors Inc 5866 Blackshire Path Inver Grove Heights MN 55076 (651) 688-6368 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA149505 Date Issued:05/24/2018 Permit Category:ePermit Site Address: 4977 Pine Lane Lot:1 Block: 1 Addition: Pinetree Forest 2nd PID:10-57651-01-010 Use: Description: Sub Type:Residential Work Type:Replace Description:Water Heater Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size Comments:Please call Building Inspections at (651) 675-5675 to schedule a final inspection. Allow an 18" minimum radius clearance to the water meter from all appliances (i.e. furnace, water heater, water softener). Fee Summary:PL - Permit Fee (WS &/or WH)$59.00 0801.4087 Surcharge-Fixed $1.00 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 - Brian J Nevanen 4977 Pine Lane Eagan MN 55123 (651) 330-9708 Oc Installs Llc 1061 Hwy 23, Suite 101 Foley MN 56329 (320) 201-7009 Applicant/Permitee: Signature Issued By: Signature