3218 Red Oak Dr??.>.
?. ?
«+ ?
(ger#ifirate of Orrupanrg
titp of (Eagan
arparbtteni Lif ldwm iwprtinn
This Certifrcate issued pursuant to 1he requrrements of Section 3116 of the Uniform Building
Code certifying that a1 the time of issuance this strucuere ms in compliance with the varrous
ordinances of the City regulating building construction or use- For the following.•
ux a,,r.,,, SF DWG/GAR B,,,s. Pao,;,,,o. 14939
pceupa-y Type R3! rt I z.Mp,,,,, R I 7ym camt. VN
Owner of &rildi.sHARS3D .ro. Addreae 19M SMVM I-W R-M. NU MIGUM
e? nea,,. 3218 FMQAK DRIVE jom;ty TS, B4, B[TR QAK HI.TS
MARQi 21. 1989
Bwld V
POST IN A CONSPICUOUS PLACE
? . CITY OF EAGAN
, .3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
PHON E: 454•$100
BUILDING PERMIT
To be used for " Est. Value y'+O(X
Receipt #
Date
Site Address
Lot Block ' Sec/Sub. •? `
Parcel No.
a Name
W
z Address
3
o r.irv
¢ Name
,o
0 4 Address
r City Phone
City
I hereby acknowtedge 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.
Signature of Permittee
A Building Permit is issued to:. _-
on the express condition that all workshall be done in accordance with all
applicable State of Minnesota Statutes and City of Eagan Ordinances.
Building Official
$.h
OFFICE USE ONLY
?
On Site Sewage Occupency
MWCC System Zoning
on sire well (Actuaq const '
City Water (Allowable)
PRV Required # of Stories
Booster Pump Length ?
Depth
S.F. Total
Footprint S.F.
APPROVALS FEES
Engr./Assess. Permit '
Planner Surcharge
Council Plan Raview "
Bldg. Off. SAC. City i
Variance SAC, MWCC '
Water Conn. '
Water Meter
Road Unit
Treatment P1
Parks
TOTAL
? Pormit No. Psrmit Holder Dete Tslsphone it
PI mbing `
H.v.n.c.
ElBctric
Softener
Inspectlon Date Insp. Comments
Footings I ?
Footings II
Foundation
Framing ? ?
Roofing
Rough Plbg.
Rough Htg. yu,
Isul.
Fireplace a zt4
Final Htg. , A
Final Plbg. ?
Bldg. Final
Cert Occ.
Temp. LP
Deck Ftg.
Deck Final
WeU f
Pr. Disp. ? ?2 -?
INSPECTION RECORD
CITY OF EAGAN PERMIT TYPE:
3830 Pilot Knob Road Permit Number:
Eagan, Minnesota 55123 Date Issued:
(612) 681-4675
SITE ADDRESS: APPLICANT:
. I;. i.i ik kioIt Ilit III . Iii 11/1k H) 1 I , c c, i.? a?;.??rry
PERMIT SUBTYPE:
. . , ; tl i , I li j ,')
TYPE OF WORK:
lt111 1 Ii I Ni,
INSPECTION D` • D'
Illlll?i ? 11 i'i 1?.1 I fl:l ?
RFMARk";r ',E1'ARAlU VtkMl 1', AFtr HruifI Firu FOk ANY F'1 IIMi.iiMe- (iK FI 1 4 Iirlt AI W[rV1
? J
Permit No. Parmfl Holder Dete Telephone i
S/W
PLUMBING , /? / j • 907f
HVAC
ELECTRIC
ELECTRIC
Inapectlon Date Insp. CommerHs
Footings I
Foundation
Framing ?
Roofing
Rough Plbg.
Rough Htg.
Isul.
`
Fireplace
Finai Htg.
Orsat Test
Final Pibg. Plbg. Inspector - Notity Plumber
Const. Meter
Engr./Plan
40tlg. Final
Deck Ftg.
Deck Final
Well
Pr. Dfep.
Date: "•7- ??
C:IT'Y OF EAGAN Permit No:
3830'Pitot Knob Aoad B/P No: ? p8ie'
P.O. Plox 21199
Eagan, MN 55121 -
!
Owner. , aretau Com a:v•
;
1171R ked t?a?: rrive !.S B4 Rvrr ? ?. , . ..
5ite Address: _
Plumber:
n"
MWCG: Zaning.
City Chg: No. of Units; -
Acct. Dep: I agree io comply with the Clty o1 Eagan
: Permit Fee: Ordlnances.
Surcharge: r`
Misc.: By
SEWER SERVICE PERMIT
1
- Date: b--'L7-p•?
CSTY CF EAGAN Permii No: ' • / ? ? 9 S? O _ Size:
3830 pllot Knob Road Meter No:
Date:
P.O. Box 21199 Reader No:
Eagan, MN 55121
owner. "6 ° - -
e Drive LS B Burr UaK
Site Address: ,218 ?u?b•in?
Plumber.
R1
550 Zoning: 1
Conn. Chg:
Acct Dep: 15 0 No. of Units:
r?
Permit Fee: ?? ?
- _ I agree io comply with the City o Eagan
Surcharge: u5o°d
Tr. Plant ?04 Dd Ordinances. ?
Meter. Br ?
Misc : . f
VIfATER SERVICE PERMIT
CITY OF EAGAN NO 14 9 3 9
•, ' , 3830 Pilot Knob Roatl, P.O. 8ox 21-199, Eagan, MN 55121
BUILDING PERMIT PHO N E: 454-8100
Raceipt uE Is
?
Tobeusedfor SF DWG/GAR Est.Value $141,000 Date MAY 4 ,19 88
Site Address 3218 RED DAK DR
Lot 5 Block 4 Sec/Sub.BUR OAK HILLS
Parcel No.
rc Name HARSTAD CO
; Address 1900 SILVER LAKE RD
° CityNEW BRIGHTON Phone 636-3751
o Name SAME
?4 Address
: Ciry Phone
ra
ww Name_
?
Address
a w CitY _
I hereby acknowladge that I have
information is correct and ag'k ad ihis application and state that the
t`o comply wi all applicable State of
'
Minnesota S[atutes and City fV ?Qrdin
gan
s.
.
/
Signatuie of Permiltee j
C
A Building Permit is issued to: HARSTAD CD
on the express condition that all work shall 6e done in accordance with all
utesayn
d
City of Eagan Ordinances.
applicable State of Minnesota Stat
y
BuildingOf?icial ?( 1 i
[?l ?
p
1
1?I.
?1
, „
OFFICE USE ONLY
On Site Sewage _ Occupancy
MWCC System X Zoning
On Site Wen (ACtuap Conat
City Water X (Allowa6le)
PRV Required _ # of Stories
Booster Pump _ Length
Dep[h
S.F. 7otal
Footprint S.F.
APPROVALS
Engr./Asseas.
Planner
Council
81dg. Off.
Variance
FEES
Permit
Surcharge
Plan Review
SAC,City
SAC, MWCC
W ater Conn.
Water Meter
Road Unit
Treatment P7
Parks
TOTAI
R-3 M-1
R-1
V-N
V-N
641
42'
708.00
70.50
354.00
100.00
550.00
550.00
7'65.00
204.00
2,92$.50
n?413 REQUEST FOR ELECTRICAL INSPECTION
10- See instmctlons for mmplenng this form on back oi yellow copy.
G
-? _ "X" Below Work;,Covered by This Request
a?
ea?00001-09
?j.?3?? S
.. iM!..
e Add Re . - Type of Building Appliances Wired Equipment Wired
Home Range Temporary Service
Du lex Water Heater Electric Heatin
Apt. Building Dryer Load Mana ement
Comm./Industrial Fumace Other S eci )
Fartn Air Contlitioner
Othar (specity) Contrectars Remerks:
Compute Inspection Fee Below:
# Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps to 100 Am s
Transformers Above 200 Amps Above 100 -Am s -
Si ns iinsa«tors use onir: TOTAL ?
Irrigation Booms L
5 ecial Ins ection ??
Alarm/Communication THIS INS7ALLA1ION MAY BE 0 E DISCONNECTED IF NOT
Other Fee COMPLETED WITHiN ONT .
I, the Electrical Inspector, hereby R°ugh-In ? oate z
certify that the above inspection has
been made. Finai
OFFICE USE ONLY
This rBquest void 18 momhs irom
!(?0 i?13 s
Request Dete •
p i r 9 Flr N. Rough-in nsp ion?equlretl
(YOU mus1 Inspecror when roaGy) Inspecfion Other Than Fou
? Reatly Now ill NMity Inspedor
es ? No oate Reed
I? licensed contractor ? owner hereby request inspection of above electrical work at:
Job AtlEress (Street, Box or Route/
/
?
7 Ciry ?
/
-
J s
aG l S
?.?i ('[ z
" ,
'd
Secfion No. Township Name or No. Ranga No. County
.0.a
Occupant (PRINT) 7t-- PhoneNo./`?
Power Supplier Address
Eieclrical Conhe uo Compan Name) ? ConVadofs License No.
Meiling A ress (C ctor or Owner Makin Wllaftn)
/
G?o
'L
t/'-?Of?
IC
V V
?
r
6
Au[honzetl ' ur (COnI od ner Maki 1 tellanon Phone Number
?
MI ST TE BO D O?E?GI?( THIS INSPECTION REOUEST WILI NOT
Grl S-128 BE ACCEPTEO BY THE STATE BOARD
ggs-Mltlw Bldg. - oom
1821 Univera ty Ava. L Paul, MN 55100 UNLESS PROPER INSPECTION FEE IS
Phone (612) 692-0800 ENCLOSEO.
1988 BUILDING PERMIT APPLICATION - CITY OF EAGr.N
-tr 14q? q
SINGLE FAMILY DWELLING3
INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS
NOTE: ADDRE3SES FOR COftNER LOT5 - C6NTRACTORJHOMEOWNER MIJST DESIGNATE WIiICH ADDRESS
IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE HIIILDING PERMIT IS ISSUED.
MULTIPLE DWELLINGS RENTAL QNITS FOR SALE UNITS # OF UNITS
INCLUDE Z SETS OF PLANS, CERTIFICATE OF SURVEY - CHECK WITH BLDG. DEPT.,
1 SET OF ENERGY CALCULATIONS
CONAfERCIAL
INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS,
1 SET OF SPECTFICATIONS AND 1 SET, OF ENERGY CALCULATIONS
?N?yY z ?8
?
To Be Used For:s,)ti4 L/%Valuation:Date: IV',
Site Address ? ZI p REa'pqK- ('V-
Lot Block V
Pareel/Sub 6,V2 C'AK /-iLLS
Owner AtCS4/ ??'rk,?/bc?ic?5
Address l/OU S/GVGv- LAK?- 'C'D 0
City/Zip Code
Phone
Contractor
Addres
City/2
Phone
Arch./
Addres
City/Z
Phone u
IWIOJV-
3
On site sewage_ Occupancy -i
2
MWCC system ? Zoning R-1
On site well Actual Const V?N
City water ? Allowable V-N
PRV required S of stories
Booster Pump
Length D
_ Depth 41 ? --?iF
S.F. Total
Footprint S.F.
APPAOVALS FEES
Engr/Assess Permit I? O$. 00
Planner Surcharge 70.50
Council Plan Review 5tl ?, DO
Bldg. Off. L SAC, City /OU. DO
Variance SAC, MWCC 5ri0.00
Water Conn
O
550.0
Water Meter 69. 00
Road Unit 37-5, 00
Treatment Pl 204
Parks
Copies
TOTAL
0
VA L.LA AT io?
G? ?2 A-?t:,
--`1-
2o?c zq 7 S6L)
12 ?c f 6p -- 312
Y, 13''i = L$ Y?
98'f K 1?i ? roq??
Z l4 K ? ?I --
S
?dX3t =
?3??tiK6?/z = gY
13zo x i3 < <?l?d
?t
73smj )32a
?-
?3?`s X4?i?. ?s3?6
Z±o LO0r ,
3ox32- yROyo
I?1o542
N
CERTIFICATE OF SURVEY
_ ?A?P.f'T.9D C0?19?.qN/E.I'
Scale: I' n 30'
c Denotes Iroa Mon.
AS
m o ' ° -?2
D
?
? ? V1
,f?rs^.
/_ O
?? r I
70
A
C N I
n? -
m
g9?° 60
?? ? ? 'D
By ?_.??
Da±e
EAGA.Td ?.i+TGiiT:21UNa AEi'T.
59.29' N.@7°0629°E• ?i1
? 2B 73,4B ?- -lio
q M
-- m N?
? 411Vye ?y if. .
ro
-r ;
I
??1 ? • , ?s?.?
411a4.l,1 /1mvJ? 1?.
?? ?
?? k
'5?sxm
o\"
\
l ?
' o
1
laggfwd \
Lor
*b2lu---?WWZ-,I VJNW
148.77' 5.88°58"52"E.
6&T.t7__Tryp o? l?asr?rsa'????io/'
c?o 3
N 1^l
3 0
y O
l
?
0
?
5110
geP 0
LEGAL DESCRIPTION
Lot 5 Block 4
BOR OAK HILLS
Dnkntn Countv. Minnesota
MERILA & ASSOCIATES, INC.
ENGINEERS, SURVEYORS, SITE PLANNERS
7216 Boone Arsnus North • Suite E 63
Brooklyn Pcrk, Minnasota 55428
ToIephone+ (612) 533-7595
We hereby certify that this is a true and correct representation of a survey of
the boundaries of the abovedescribed land and of the location of all buildings,
if any, thereon, and all visible encroachments ii any, from or on said land.
As wrveye thi -z-z- day of• WRTZ/L , 19 e8.
Land Surveyor ? Minn. Rp. No./ZZ r
bb No. P-7-07,?P 9ook - Peys
WNER ?
I
l'XTLHIOR ENVELOPL AVfiHAGL "U" COMPUTATTON '
Ra
321
K Uj
'
?? AK ?LGS
80 O
SITE ADDR 0
ESS
V/
?
i .
CONTRqC2O R T-I?}'?O GD. DATEy-G0-60 PHONE47 0-77SI
Determine vorking square footage of each.
1. Total exposed vall area ... 2587?2 sq. ft. x 0'
2. Total roof/ceiling area ... sq. ft. x 0•02Ce
3. Tote1 floor/cant. area ... sq. ft. x 551'05,
Total exoosed wz11 area above floor = " .
a. Total wail window area . . . . . . . .
b. Total door area . . . . . . . . . . . . (a??31
c. Total sli,ding glass door. area .... . 54:47.
d. Toial fireplace Wa11 area ... . . Z4
e. Tota1 wall framing area(average 10%1 . . 20 15.
f. Total net wall area above floor .... $52-3
g. Total ri.m joist area . . . . . . . . . 235•2
Total exoosed foundation area = 1-70
h. Total foundation windoa area . . . . . . ?a ' i
i. Total net foundation area above grade. . 15Z .,
Determine "L"' val.ue of each wall segment.
g. ICai,55 X?lu" o.4ie = l4,?I
b- C?8 • 31 x 'lUll 0, 13? = 9, 4-7_
c. 34.97 x "U" a 4-(? _ lS.--!7 $
d- Z4 x 'lUll p, ? = 2.4
e. ZoS. 1 x "U" 0•08q = f8.3f
r. t8 2•3? X I'Ul. 0.,04'? - -79.L5
?• Z35, 2 x "u" o. o4-t = 9. 05-
h. ! 8 x ?lU,l p, 4?o = g• ZS
i. x „ull O?14 = z?•z8
SUBTOTAL =
_. ?
TOTAL i 2-_4I r_ L?-
O AC--
4. If item #4 is the same as, or less than ite¢n H1, you have met the
intent of SBC 6006 (c) 2.
..?• ?+ ?r `?
-
.. : , ?1? ?
W AIt,L- PtRG A :
1 -1 0 8 = 1-er C? (4
t24 la ? 1.'L
To-rt.?. = 250?, 2
9(so 0
24 ?. ! 4- = 3'?(0
?o-5x r3.5 = 3 1
,'15
Ta?.? I 3 n 3,75
kcw'? 5co = B, l8 x?, = 24,54.
kc w 45(, = 8,? 3 X 4. = 32.'? Z
KCw336
?w°iSG = 9-IS X'? _' 2 4,54.
I?cx 25 = 9,?s x Z ? I 4. 34
To T€?? - f(o t. 55
POO 2-
RM -loV7T.
Zg4 Xo,b =23SZ
Gr4tis-C p??b
3ZX2 = C,?i- _.
?'???Y ? 3?x?a + 2s,c. = ZI ,t2q, G =50 •c,
GA??c? Z 8 X a a = I 7, Z 1
??31
Q'rp-i uM Doo2
I `?'X6b -3"•' j
? Z
?
>
?
Total exposed roof/ceiling ar
i -?>$3,-7 s ,
j. Total sltylight area . . . . . . . . . .. . . .
k. Total flat roof/ceiling framing area ....
1. Total r.et insulated flat roof/ceiling area .
M. Total vault roof/ceiling framing area ....
n_ Total net insulated vault roof/ceiling area .
3-7.
/ ? 4-5 • 3s
Determine "U" calue for each roof/ceiling segment.
5
i X "Up,
x. 138.37 x rIUl, 3,73
1. _[ Z45. 3b x "U" O, 0 22 = 27, 3R
M. x "U" _
n. X ?,Ull
. . . . . . . . . . . . . . . . . . . . . . . Tot al
If total of #5 is the same as, or less than 112, you have met the
intent of SBC 6006(c) 1.
Total exposed floor/cant. area (p4C
o. Total floor/cant. framing area(average .10% ... 61.?
p. Total net iasulated floor/Cant. area
Determine "U" value for each floor/cant. segment
o. 4-_X ,lU„ o, 3
P- 5 7• Cg X"U`l O. 0 24 =
5. . . . . . . . . . . . . . . . . . . . . . . . Total-.
, -
If totai of N6 is the same as, or less than.#3, you have met the .
intent of SBC 6006 (c) 3•
ALTERNATE BUILDING ENVEZOPE DESIGN
To utilize the total envelope system method, the values established
by the sum of items t14, N5, and A6 shall not be greater than the sum
of items d+.l, N2, and ll3•
i,
4.
2.
5:
6
^?.o .? -,*-, .?j:
3- _
-? CITY QF EAGAN
383b Pilot Knob Road
Eagan, Minnesota 55123
(612) 681-4675
BASEMENT FINISH
AITERA7I0N
SITE ADDRESS:
P.T.N.: 10-15500-050-04
DESCRIPTION:
,Li`5?f
PERMIT cu3 0b
PERMITTYPE: surLorNG
Permit Number. 0 2 4 7 3 6
Date Issued: 10 / 18 / 9 4
3218 RED OAK DR
LOT: 5 BLOCK: 4
BUR OAK HILLS
130fi1 ding-Permit Type
Building Wo.rk 7ype
r
\
REMARKS:
SEPARA7E PERMITS ARE REQUIRED FOR ANY PLUMBING OR ELECTRICAL WORK
FEE SUMMARY:
Base Fee
Surcharge
Lic. Search
Total Fee
$35.00
$.50
Fee $5.00
$40.50
CONTRACTOR:
OL-BERG CONST
6400 131ST
APPLE VALLEY
(612) 432-9079
- Applicant - ST. LIC
14329079 0004518
ST CT
MN 55124
OWNER:
T000 FRANK
3218 RED OAK DR
EAGAN MN
(612)454-6096
I hereby acknowledge that I have read this
infiormation zs correct and agree to comply
Statutes and City of Eagan Ordinances.
L
?
, PPL AM/P TEE 51 ATURE
application and stats that the
with sll applicable State of Mn.
-j
11f?U ?.I,f?.? I IIJd
ISS ED e SIG TURE -?
CITY OF EAGAN
? 1994 BUILDING PERMIT APPLICATION
681-4675
4ll
IE
SINGLE & MULTI-FAMILY s
2 sets of plans, 3 registered sit
nergy
'po e
L
L
calcs. 994
COMMERCIAL 2 sets of architectural & structu set of
specificati ons, 1 copy of energy - --
Penalty applies: 1) when permit is typed, but not picked up by last working day of month
in which request is made, 2) address is changed or 3) lot change is requested once permit
is issued.
Date G C.? /?_ /Valuation of work
Site Address: JZ-Is C)o?,k A-){ _
STREEi SUITE ?t
Tenant Name: (commercial only)
LOT SIACK SUBD. Dd? ^11I.i
.YJia? P.I.D. #
Descri tion of work:
The applicant is: ? Owner JM Contractor ? Other (Describe)
Name T066 Er0„11A, Phone,4l54-GOqfo
Property LAST ?,RST
owner Address 3Z-f$ Re.C? oak b y'
STREET STE #
City State Mv", 2ip
Company S`Zge.? Cr?h? Phone 'otit??3??4c?7995
Contractor Address 4i?M t 31S} C.t L9cense #Exp. q6
City T1TOO'e- Vc?-\\¢,Y State M,\V\r Zip 55IZ
Company Phone
Architect/
Engineer Name Registration #
Address '
City State Zip
Sewer & water licensed plumber Processing time for
sewer & water permits is two days once area has been approved.
I hereby acknowledge t t I have read this application and state that the information is
correct and agree to c m ly with all ap icable State of Minnesota Statutes and City of
Eagan Ordinances.
Signature of Applicant:
OFFICE USE ONLY
BUILDING PERMIT TYPE
? 01 Foundation ? 06 Duplex ? 11 Apt./Lodging
? 02 SF Dwg. ? 07 4-Plex ? 12 Multi. Misc.
? 03 SF Addition ? 08 8-Plex ? 13 Garage/Accessory
? 04 SF Porch ? 09 12-Plex O 14 Fireplace
? 05 SF Misc. ? 10 Multi. Add'1. 0 15 Deck
WORK TYPE
0 31 New 0 33 Alterations ? 35 Tenant Finish
O 32 Addition ? 34 Repair ? 36 Move
GENERAL INFORMATION
Const. (Actual)
(Allowable)
UBC Occupancy
Zaning
# of 5tories
Length
Depth
APPROVALS
Planning
Engineering
REQUIRED INSPECTIONS
? Site
? Wallboard
Basement sq. ft.
lst F1. sq. ft.
2nd F1. sq. ft.
Sq. ft. total
Footprint Sq. ft.
On-site well
On-site sewage
Building
Variance
,2?,Footing
Zi_ Final
? Framing
? Draintile
yey
oi
?
0
4 Insulation
? Fireplace
Permit Fee
Surcharge
Plan Review
License
MWCC SAC
City SAC
Water Conn.
Water Meter
Acct. Deposit
S/W Permit
S/W Surcharge
Treatment P1.
Road Unit
Park Ded.
Trails Ded.
Copies
Other
Total:
vaiuecsm: $
117
`? - ?
•,
.+..?z?
?16`'Bdsement Finish
? 17 Swim Pool
? 18 Comm./Ind.
? 19 Camm./Ind. Misc.
? 20 Public Facility
? 21 Miscellaneous
O 37 Demolish
MWCC System
City Water
PRV Required
Booster Pump
Fire Sprinkler
Census Code
SAC Code
Census Bldg
Census Unit
Assessments
SAC %
SAC Units
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA106944
Date Issued:09/18/2012
Permit Category:ePermit
Site Address: 3218 Red Oak Dr
Lot:5 Block: 4 Addition: Bur Oak Hills
PID:10-15500-04-050
Use:
Description:
Sub Type:e-Windows/Doors
Work Type:Windows/Doors-New/Replacement
Description:House
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, call for framing
inspection. Call for final inspection after installation.
Carbon monoxide detectors are required by law in ALL single family homes .
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 -
Robert Wieden
3218 Red Oak Dr
Eagan MN 55121
DSS Exteriors
816 - 9th St SE
Minneapolis MN 55414
(612) 767-4660
Applicant/Permitee: Signature Issued By: Signature