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3985 Pumice LaneCITY OF EAGAN Remarks * Ceddr GroVe ACqu1s3.tinF1 Addition . CEDAR GRfJVE #5,? Lot 19 Blk 6 Parcel 10 16704 190 06 owne,ljt? V-ez??!?o? 3985 Pumice Lane State_?9an• MN 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK Z 1967 100.00 5.00 20 P8].CZ SEWER LATERAL 53- 1967 555.00 27.7$ 20 Paid WATERMAIN * WATER LATERAL 1972 607.00 24.28 25 Paid WATER AREA STORM SEW TRK 1974 70.00 4.66 15 Paid STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. BUILDING PER. SAC 200.00 452 PARK Receipt MECHANICAL PERMIT Permit No. CITY OF EAGAN Fee Fill in numbered spaces S/C Type or Print legibly Tot. 1. Date 2. Installation Cost 3. Job Address?/?J??,''tt6E?.Q?o ? Bik. ' Tract -?- 4. Owner 5. Contractor Phone _ 6. Address 7. City State Zip 8. Building Type: Residential ? Commercial ? Institutional ? 9. Work Description: New ? Add O Alter O Repair ? 10. Describe 11. Fuel Type No. Equipment STU - M. Ea. Forced Air No. Equipment CFM Ai H dli Mfg. r an ng: Boilers Mfg. Mech. Exhaust Unit Heater Mfg. Other Air Cond. Mfg. Gas, Piping Outlets 12. I 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 INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: ''`? ? i?' ? M`' 3830 Pilot Knob Road Permit Number: Eagan, Minnesota 55122-1897 Date Issued: (612) 681-4675 SITE ADDRESS: APPLICANT: . , ; 1I14I1 '1 I AME !'.t tjAK tikltVl. !., f ?d ( 6l.:' ) PERMIT SUBTYPE: 11: rll it; H TYPE OF WORK: At it linI I rfrr INSPECTION .• . .. nt sI FtFMARx - tJr Nta IM b t_ Gk f?: '?0, Wl Mrl„t. I F ? ? a ? ?° ? L Permit No. Permit Holder Date Telephone # ELECTRIC PLUMBING HVAC Inspection Date Insp. Comments FOOTINGS FOUND FRAMING ROOFING flOUGH PLUMBING PLBG AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYP BOARD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL BSMT R.I. BSMT FINAL DECK FfG DFCK FINAL ? EACAN TOWN SI-I I P N° 1592 BUIL.DING IaERMIT Owner ....... •?f??G?-'E7?"? -••.._ . . ------ ............................ Eagan Township 7 ? Address (Present) ...... -??-•?--••---•.._..-•----• ........... Town Hall Builder ---------•-••----------------------------------------------------- --- ? 7 Date ...... -•-_..•-•--•--•-••--•--- -.............. Address -----•-•----...-----•--•-•-••-••-----•-•----•-••-•------•-•-•--•----••--•--------------------- DESCRIPTION 52ories To Be Used For Front Depth Height Est. Cosi Permit Fee Remarks 0-0 LOCATION SYreet, Road or other Descripiion of Locatioa I Lot I Block ? Addition or Traci 1 /l? ? 1 e- Ap -4-- s' This permit does not authorize the use of streets, roads, alleps or sidewalks nor does it give the owner or his agent 2he right to creafe any situation which is a nuisance or which presents a hazard to the health, safety, convenience and general welfare to anyone in the community. THIS PERMIT MUST BE PT ON THE PREMISE WHILE THE WORK IS IN PROGRESS. This is. to certify, that----?.-•.. ------•-•---•--•----•-••••-•••-•-•--•has permission to erect a............ ---- -••--•• -...... ................... upon !he above described premise subject Yo the provisions of the Building Ordinance for Esg Townsh adopted April 11, 1955. • ....................... ........... . ... - Awn !??-----. Per ..._.-••---• ''?'?`'-•-••-•airman Board Buildiny Inspector ? ''Q EAGAN TOWN S H I P BUILDING PERMIT ? owne! ....._14,G...?Lac??--?-cf''?! ...... C.-rQ-'t--:.-. 6, .................. Addr,ess (Preseni) •-.?c...... :.?••--Cf'e??:?:::•-................. -• Builder ......... ------•---;I........................................... .... - --• Address ......... ....................................................... --------•-•---•., ' DESCRIPTION N° 1529 Eagan Township Town Hall Dafe ../--a---, 5tories To Be Used For Froni Depth Height Esi. Cosi Permit Fee Remarks (1 U -- LOCATION Street, Road or o2her Descripfion of Localion. I Lo Block ' Addifion or Trac! -?- ? , i •- G , L • - . . I q y- I ? n `?_ This permit does not suihorize the use of streets, roads, alleys or sidewalks nor does i! give the owner or his aqen! the righ! Yo creale anp silualion which is a nuisatsce or which presents a hazard to the heal2h, safely, convenience "and general welfare !o anyone in the communiiy. THIS PERMIT MUST BE KEPT OIJj ?THE PREMISE WHILE THE WORK IS IN PROGRESS. This is to cerlify, iha!__.?.?....................................... has permission !o ereci a...... ' ?'-: :_ ??,c__..?-i:- -t?, .................. upon the above dESCribed premise subject io the provisions of the Building Ordinance for Eagan q`ownship adopied April 11, 1955. . /? ? _ ..:...:.....................??::..:?- -'... ---•• .........•••-••. Per ----•-•.......--•• -.............. ....... t -r . ................. •---•-.? r?_?z •---•-? Chaiiman of T?wn Board........ Building Inspector " ?' k?- .1/45*0 416-140 .- ' REQUEST FOR ELECTRICAL INSPECTION Minnesota State Board of Electricity 1821 University Ave., Rm. S-128, St. Paul, MN 55104 ,;-Phone ?fi12) 642-0800 Home Duplex Apt. Bldg. Other: New Addn Commercial Industrial farm Remod Re air Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other: Dryer Range Elec. Heat Temp. Service "X" above the work covered by this request. Enter remarks in this space and on the back of the white copy only. Calculate Inspection Fee - This Inspeciion Request will not be accepted without the correct fee: Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps Street Ltg./Traffic Sig. Above 200 Amps Amps Transformer/Generator INSPECTOIRr'S USE ONLY TOTAL ? Sign/Outline Ltg. Xfmr. Alarm/Remote Confrol Swimming Pooi th f t f I h Y i l i ll fi d ib d h i d d b Irrigation Boom ere n on ere cer e ech nsfa a on escr e ca n es s a e a e Date Special lnspection Investigative Fee Final _ THIS INSTALLATI6N MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MON HS. OFFlCE USE ONLY This requesf void 18 months (rom validation date printed in this box. of {P ? ???'/ 11111111111111111111111 111111111 I 11 ? ? 1 1 1 11111111 IIII ?/ iu"?u+t A-) * 13 4 L 6 1 4 0 2* PLEASE PRINT OR TYPE 40 Request Dafe ?.. g? - TK Rou h-in ins tion r uired$ Yes g pec eq ?You musf call the inspecfor when ready) ? No Inspection Other Thar.'Rough-In: ? Ready Now Will Call Dafe Ready: I, ? licensed confractor N owner hereby request inspection of the above electrical work at: Job Address (Sheet, Box, or Route No.) City ip Code 913 5 - ?'U c?- ?. ??t 5 S p Section No. Township Name or No. Range No. Fire No. ounty 0 ? . Occupant Phone No. CrQ Power Supplier ? Address lechicai Conkador (Company Name) Contrador License No. Master Lic. No. (Plant Elecf. Only) Se Mailing Address (Conhacfor or Owner Performing Installation) Aufhorized Signature (Conhacfor or Own rfor ng Installation) Phone No. a? 6LI--al ? I ??- 7PO? i F+- i i a/ro /VATE BOARD COPY - SEE INSTRUCTIONS ON BACK OF YELLOW COPY RESIDENTIAL BUILDING PERMIT APPLICATION qq CITY OF EAGAN 3830 PILOT KNOB RD, EAGAN MN 55122 651-681-4675 New Construction Reauirements • 3 registered site surveys showing sq. ft. of lot, sq. ft. of house; and all roofed areas (20% maximum lot coverage allowed) • 2 copies of plan showing beam & window sizes; poured found design, etc.) • 1 set of Energy Calculations • 3 copies of Tree Preservation Plan if lot platted after 7l1/93 • Rim Joist Detail Options selection sheet (61dgs with 3 or less units) DATE ) ;L S7.D-S' RemodellReaair Requirements • 2 copies of plan • 1 set of Energy Calculations for heated additions • 1 site survey for exterior additions & decks . Indicate if home served by septic system for additions VALUATION SITE ADDRESS MULTI-FAMILY BLDG _ Y "SN TYPE OF WORK -L9f&NF??-4cLA- FIREPLACE(S)?_ _ 1_ 2 APPLICANT STREET ADDRESS 2489?2iGe & SuitP 70 CITY Roseville STATE__MZIP55112- TELEPHONE # 655 _ 1-734-9433 CELL PHONE # FAX # 651?Y021g_ PROPERTYOWNER TELEPHONE# COMPLETE FOR "NEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 MINNESOTA RUI.ES 7672 (4 submission type) • Residential Ventilation Category 1 Worksheet Submitted • New Energy Code Worksheet Submitted • Energy Envelope Calculations Submitted Plumbing Contractor: __ Phone # -------------------- Plumbing system includes: Water Softener Lawn Sprinkler Fee: $90.00 Water Heater No. of R.I. Baths No. of Baths Mechanical Contractor: _ Mechanical system includes: Air Conditioning Heat Recovery System Phone # Fee: $70.00 Sewer/Water Contractor: Phone # ;? I j 1? I hereby acknowledge that I have read this application, state that the information is correct, and agree to comply: with all applicable State of Minnesota Statutes and City of Ea Ord' Signature of Applica C ? OFFICE USE ONL Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4/02 OFFICE USE ONLY ? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg ? 02 SF Dwelling 0 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Multi ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF ? 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (screened) ? 36 Multi ? 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-plex Plbg_Y or _ N ? 25 Miscellaneous ? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding ? 32 Addition ? 36 Move Bldg. O 42 Demolish (Foundation) ? 45 Fire Repair ? 33 Alteration ? 37 Demolish (Bldg)* ? 43 Reroof ? 46 Windows/Doors ? 34 Replacement *Demolition (Entire Bldg only) - Give PCA handout to applicant Valuation Occupancy MC/ES System Census Code Zoning City Water SAC Units Stories Booster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs Length ' Fire Sprinklered Type of Const W idth REQUIRED INSPECTIONS _ Footings (new bldg) FinaUC.O. _ Footings (deck) FinaUNo C.O. _ Footings (addition) _ Plumbing Foundation HVAC Drain Tile Other Roof _ Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests _ Final _ Framing _ Siding Stucco Stone _ Fireplace _ R.I. _ Air Test _ Final _ Windows (newheplacement) _ Insulation _ Retaining Wall Approved By , Building Inspector Base Fee Surcharge Plan Review MC/ES SAC City SAC Water Supply & Storage S&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total ,.?.?.:..?..?.?,.._a,.?.,?...u..,,n?...r,_....,.?.M... , w.?,.w? : -140 Lmv'a 1`l'`??xN 9 • f ? IcIYl ,r?7 ?jr A 0M Aw"4"' ? '"'a ? ?? G. ? N EM ?? I N G * I N C ? . . .?t; . Loa????"s Sw *???? far 9A??9 L, l'???F-i-JF. 98S J?0?Ii i C,E LA?I?. ? . ....°..`„?...,3. ?... ?....>?.? . _.,?.,,.? .,? ..f ? ? ?..... ?..?..?YS? ??.?:.. ??? . . - ??P?swx.v+.aw-.oticw' .+av4 ? ?. _•?'3 r'...ca? . ! ; ' ., ?F ? A 'S ° 'S ?- e ? ? ? i t ? ...... ? ....,._.:.., ?....__._ ?._...«:_.._., .,...,?......•....,?. .<,. . : . ., . : c ? . _ _., . ? .,. _ ......?a......?..... -.r?' ............. ?,.m.,...... ? ..4..?;2?,` . ,.» .,,+ . . ? .. iT i ? ? . e +tlr _.._.?. S..d 9? ?,'" a T.rtx t °`? ,?3?'? e?<af.??' # §Fd ? `?'c ? o ? ?t ? q ? ?,? . ?? ?? ? ?.,?? ? ? ? ???9, ??x:a:? ? ? ? H ?? ?? E M o$ ??? ? ? 1"A C?? ?LINTY .. ?' rgv on+ ?:a? rt?-VsJ? A"?? ?v es'w' r,D= omed emv, o dmn . .a')Q''?s t Z? . . ? ? . , ? ,?... 2. ? ?lJ # wt ?.,a ? ? us ,,.. « ..a?:. ....?...-??., , a#uf PERMIT ._ t CITY OF EAGAN 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 SITE ADDRESS: ' 3985 PUMICE LANE , Lp7: 19 BLC1CKs 6 GEDAfi GROVE 5TH P.I.N.: 10-16704-190-06 PERMIT TYPE: e u zLDx NG Permit Number: 028157 Date Issued: 07 f05/ 9 6 DESCRIPTION: BAs??EN-r FxNIsH ALTEFtATIQN 434 ALT. RESIDEN'fIAL £, :a .? kr A REMARKS: WINpOW & ECRESS WTiVDpW FEE SUMMARY: Base Fee $5e.00 5urcharge .50 Tatal Fee $50.50 a L?VIV 1 1'fNlr 1 VI'f: VVVIVCI'f: ` riNp?L.t[:cari w - WEBER JQHN 3985 PUMICE LIV EAGAN MN 55 (612)452-7908 fv a I A I IQ&) fWih IAPPLI NT/PERMITEE IGNATURE I SUED BY: SIG TURE ?? ;j?;? , C{TY OF EAGAN ??. ° 3830 PILOT KNOB RD - 55122 1996 BUILDING PERMIT APPLICATION (RESIDENTIAL) 681-4675 New Construction Reauirements Remodel/Re aiFLr Req,uirements ? 3 registered site surveys ? 2 copies of pian ? 2 copies of plans (include beam 8 window sizes; poured fnd. design; etc.) ? 2 site surveys (exterior additions & decfcs) ? 1 energy catculations ? 1 energy ca4culations for heated addit9ons ? 3 copies of tree preservation plan if lot platted after 7/1/93 required: _ Yes _ No DATE: CONSTRUCTION COST: "toaU `6U DESCRIPTION OF WORF STREET ADDRESS: LOT ? BLOCK ? SUBDJP.I.D. #: - PROPERTY Name: Phone #: 4,52^ EDE' owNER ?T FIRST Street Address: ?t?n-w f (A, i"lc., City: State: (V.a`? Zip: 55 )??- CONTRACTOR Company: Phone #: Street Address: License #: City; State: Zip: ARCHITECT/ Company: Phone #: ENGINEER Name: Registration #: Street Address- City: State: Zip: Sewer & water licensed plumber: . Penalty applies when address change and loi change are requested once permit is issued. 1 hereby acknowiedge that I have read this application and state that the iIL is correct and agree to comply with all applicable State of Minnesota Statutes and City vf Eagan Ordinances. ? / Signature of Applicant: '2 &?-2 OFFICE USE ONLY ? RE PMEDD . Certificates of Survey Received Yes No J u N 2 1 Mb Tree Preservation Ptan Received Yes No - - - - - - - - - - - - - - - OFFICE USE ONLY BUILDING PERMIT TYPE ? 01 Foundation o 06 Duplex ? 02 SF Dwelling ? 07 4-plex ? 03 SF Addition ? 08 8-plex a 04 SF Porch ? 09 12-plex ? 05 SF Misc. ? 10 = plex WORK TYPE ? 31 New 33 Alterations 0 32 Addition ? 34 Repair GENERAL INFORMATION ? 11 Apt./Lodging -gptl't" 16 Basement Finish ? ? 12 Multi Repair/Rem. ? 17 Swim Pool ? 13 Garage/Accessory o 20 Public Facility ? 14 Fireplace ? 21 Miscellaneous ? 15 Deck ? 36 Move ? 37 Demolition Const. (Actual) Basement sq. ft. MC/WS System (Allowable) Main level sq. ft. City Water UBC Occupancy sq. ft. Fire Sprinklered Zoning sq. ft. PRV # of Stories a Length sq. ft. sq. ft. Booster Pump Census Code. ?f3f? Depth Footprint sq. ft. SAC Code Census Bldg ? Census Unit APPROVALS Planning Building Engineering Variance Permit Fee Valuation: $ Surcharge Plan Review License MCNVS SAC City SAC Water Conn. Water Meter Acct. Deposit S/W Permit S/W Surcharge Treatment PI. Road Unit Park Ded. Trails Ded. Other . Copies - s Total: % SAC SAC Units ? ,.., ? MEMO city of eagan TO: DIANE DOWNS, UTILITY BILLING CLERK FROM: ED KIRSCHT, SR. ENGINEERING TECHNICIAN DATE: AUGUST 23, 1993 SUBJECT: STREETLIGHT ENERGY COSTS-CEDAR GROVE NO. 5(208 LOTS) This memo is to inform your department to begin to invoice the energy costs at the single family rate effective August 1,1993 to the property owners in Cedar Grove No. 5 Addition. Block 1, Lots 1•22 22 Block 2, Lots 1-19 19 Block 3, Lots 1 •11 11 Block 4, Lots 1-16 16 Block 5, Lots 1-25 25 Block 6, Lots 1-22 22 Block 7, Lots 1-25 25 Block 8, Lots 1-5 5 Block 9, Lots 7-2 2 Block 10, Lots 1-23 23 Block 11, Lots 1-14 14 Block 12, Lots 1-9 9 Block 13, Lots 1-15 15 208 The City is currently being billed by Dakota Electric for streetlighting in the above listed subdivision. 9,(1%11?Q" .? ?/ Edward J. rsc t Sr. Engineering Technician cc: Mike Foertsch EJK/je 2004 RESIDENTIAL PLUMBING PERMIT APPLICATION CITY OF EAGAN ? 3830 PILOT KNOB ROAD, EAGAN MN 55122 651-675-5675 Please complete for modifications to existing residential dwellings. 5 / s- / ? Date _. Site Street Address Unit # Property Own?,T_?L Telephone # (pJL) `ID8? Contractk? Telephone # (lt-?-) o-R ` tU Ar_icleess Ci#y _ _ State 'A Zipf]j LLL The Applicant is: _ Owner ? Contractor _Other Alterations to existing dwelling $ 50.00 _Add fixtures to rooms, excluding water softener and water heater lSeptic System Abandonment _Water Turnaround (add $121.00 if a 5/8" meter is required) Other: ? Water Softener _ Water Heater $ 15.00 Y, replacement _ additional Lawn Irrigation System RPZ_ new _ repair _rebuild - $ 30.00 S:ate Sssa-ch,:: ge Q .5r1 Total I hereby 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 l understand this is not a permit, but only an application for a permit, work is not to start without a permit and work will be in accordance with the approved plan in the event a plan is required to be reviewed and approved. /I Applicant's Printed Name PERMIT City of Eagan Permit Type:Building Permit Number:EA113796 Date Issued:09/09/2013 Permit Category:ePermit Site Address: 3985 Pumice Lane Lot:19 Block: 6 Addition: Cedar Grove 5th PID:10-16704-06-190 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are not acceptable in lieu of inspections. Carbon monoxide detectors are required by law in ALL single family homes . Robert Gramling 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 Weber 3985 Pumice Lane Eagan MN 55122 Clear Choice Restoration 487 Owasso Hills Dr Roseville MN 55113 (612) 226-7170 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA131951 Date Issued:07/15/2015 Permit Category:ePermit Site Address: 3985 Pumice Lane Lot:19 Block: 6 Addition: Cedar Grove 5th PID:10-16704-06-190 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:Two or More Windows/Doors Census Code:434 - 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: 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 - John Weber 3985 Pumice Lane Eagan MN 55122 Clear Choice Restoration 2722 Hwy. 694, Suite 100 St. Paul MN 55112 (612) 259-7177 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA138057 Date Issued:08/05/2016 Permit Category:ePermit Site Address: 3985 Pumice Lane Lot:19 Block: 6 Addition: Cedar Grove 5th PID:10-16704-06-190 Use: Description: Sub Type:Siding & Windows/Doors Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please print pictures of house wrap and leave on site for 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: 8,000.00 Fee Summary:BL - Base Fee $8K $162.25 0801.4085 Surcharge - Based on Valuation $8K $4.00 9001.2195 $166.25 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 Weber 3985 Pumice Lane Eagan MN 55122 Clear Choice Restoration 2722 Hwy. 694, Suite 100 St. Paul MN 55112 (612) 259-7177 Applicant/Permitee: Signature Issued By: Signature