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4926 Rusten Rd ~ INSPECTION RECORD . - ~ ~ ~ ~ ~ ~ w ? C~T1~ OF~ EAQAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number: '-•''`'r'~ Eagan, Minnesota 55122-1897 Date Issued: " (612) 681-4675 SITEADDRESS: ~ , ~ ` ' + APPLICANT: ~ ~~~.1'F r~ lt~r ~ ` ~i, • , , ~ ~ ? PERMIT SUBTYPE: , TYPE OF WORK: ~ . ~ r . • , . ; , , ~ , . ~ ~ ~ . , ~r• . ~ . , . ,i; z s ; . , , ~ ~ ~1/il • ' ~ ~ : ~ „ . , , r..' . ` ° , „ , ~ ~ ~ : ' ~ - , d : = ~ . . ~ ~ , ~ _ ; . " ; , . , . ~ Permit No. Permit Holder Date Telephone N ~ R ELECTRIC /~~grf~(,~ /p ~ ~ ~ PLUMBING ~D !{~,j ~~SL HVAC - 97 ~ ~/S~ Inspection Det Ins . Comments FOOTINGS ~ ~ 7 ~ FOUND ? ~ FRAMING n iv ROOFING ROUGH PLUMBING 9 PLBG AIR TEST _ .s ROUGH ~ ~-1-~' ~ HEATING ~ -9 GAS SVC TEST ~ ~ INSUL ~j~ly7 ~i GYP 80ARD ' FIREPIACE ~ FIREPLACE . AIR TEST 9 FINAL PLBG J~~ t7 'f/°0 FINAL HTG l/ ORSAT TEST BLDG F~NAL ~ BSMT R.I. BSFAT FINAL DECK FTG DECK FINAL ~ • ~ ~ _ _ . s + ~ ~ . ~ : . ~ ` ~ ' r ~ ~ , i ~e~#i~icate o~ ~ccu~a~tc~ ~it~} a~ ~agan ~~epartmeut of ~~itbixg ~a~cctioa , This Cerfiftcate issutd pursuant to tlre ~+equiremenrs of the Uniform Building Code certijying rhat at t/r~ ti~ne of issuance lhis stnrcture was in compliance wi~h the various ordinances of the Ciry regulating br~ilding corutructrort or erse. For the following: Ux Classifica~ion: BId6. Pemii~ No. ZqS~7O occ„v.ncr ~Yr~ R3~IJ I Zaaing aSU;a R I Type crn,u. ~`1 Owmer of Buil~na , ~S . AdA'cst J ~lll/ ~aS ew~a;~s nam~ 4926 RUSIEN RL1AD T~?1+, B2. ~.R k~I(~TTS ~ / , , ' s~m~ ar~ POST IN A CONSPICUOUS PLACE ~ ^ ~ . ' . , 1 . . _ . RESIDENTIAL BUILDING PERMIT APPLICATION ~ ~O G91 CITY OF EAGAN ~ ~D ~ ~5 U 3830 PILO7 KNOB RD - 55122 • ~ 651-681-4675 ~u~~t~ ~~~0`~~ New Conatructlon Reauirements RemodellReoair Reaulrements ~ • 3 registered site surveys showiig sq. 8. of lo}, sq. R. of hause; and all,oo(ed areas • 2 capies of plan (20% maximum kt coverage allowed) . 7 set of Energy Calculatlons (or healed addi0ans A 2 copies of plen showing 6eam & wi~CVa Sfzes; poured found design, etc.) . 1 site survey for exterior additia~ & decks U • 7 set of Energy Calculations • Indicate H home served 6y septic rystem (ar additions . 3 copies of T2e Preservation Flan if lot platted after 711/93 • Rim Joist Delall OpGons selection sheet (bldgs wifh 3 or less units) DATE ~OI U I J~, VALUATION JOB SITE ADDRESS ~~-l0 ~LtS'tC-VI ~O~ IF MULTI-FAMILY BUIJ~DING, OW MANY UNITS? ~ PROPERTY OWNER TYPE OF WORK , P_~ ` FIREPLACE(S) _ 0_ 1_ 2 APPLICANT ~G~~~~c~ S~'P-~G~V~ , PHONE#~~ ADDRESS LI-~2 fi~ l.f_ ~f7/,i ZIPCODE ~IZZ PAGER # CELL PHONE #~J~~~~S I~SL'J~J~ PAX # NEW RESIDENTIAL BUILDING ONLY - FILL OUT COMPLETELY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 (check one) - Residential Ventilation Category 1 Worksheet Submitted - Energy Envelope Calculations Submitted _ MINNESOTA RULFS 7672 - New Energy Code Worksheet Submitted Plumbing Contractor: Phone Plumbing System Includes: Water Sofrener _ Lawn Sprinkler Fee: $90.00 Water Hcater _ No. of R.I. Baths No. of Baths Mechanical Contractor. Phone # Mechanical System Includes: Air Condirioning Fee: $70.00 Heat Recovery System Sewer/Water Conhactor: Pho ~ ~ All above iMormation must be submitted prior to processing of application. ~~e , j I hereby acknowledge that I have read this application, state that th 'nformat n is correct, and a o comply with all applicable State of Minnesota Statutes and City of Eagan r nances By _ Signature of Applfcanf Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 1l01 OFFICE USE ONLY ? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Actcessory Bldg ? 02 SF Dwelling O OS 08-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 ERl!!~It - F~lulti ? 03 01 of _ plex O 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF ? 04 02-plex ? 10 08-plex ~.18 Deck ? 23 Parch (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 Miscetlaneous b. 31 New ? 35 Int Improvement ? 38 Demolish (Interior) O 44 Siding ~ 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair 33 AI[eration ? 37 Demolish (Bldg)" ? 43 Reroof ? 46 Windows/Doors Q 34 Replacament •Demolitlon (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 Width REQUIRED INSPECTIONS Footings (new bldg) FinaUC.O. ~ Footings (deck) ~ FinallNo C.O. _ Footings (addition) _ Plumbing Foundation HVAC Drain Tile Roof Ice & Water Final Other _ Framing _ Pool _ Ftgs _ Air/Gas Tests _ Fina1 _ Fireplace _ R.I. _ Air Test _ Final _ Siding Stucco Stone , Insularion _ Windows (new/replacement) Approved By ~ 2 , Building Inspector Base Fee Surcharge ~/J , ~C ~ ~7rC/ 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 Address 4926 RUSTIN ?tOAD Zip 5512 2 - I.ot 24 Blk 2 5ub ~oax xelca~rs THESE ITEMS WERE / WERE NOT COMPLETE AT THE TIME OF THE FINAL INSPECTION. Date: ~ f 9 7 Yes No Inspector: ' Final grade (6" from siding) Permanent steps (garage) ~ Permanent steps (main entry) Pecmanent driveway Permanent gas Sod/Seeded grass TraiUcurb damage ? Porch Basement finish Deck Please verify with the builder the removal of roof test caps from the plumbing system and ihe shutoff of water supply to the outside lawn faucet before freeze potential e~cists. Contact engineering division at 681-4645 before working in right-of-way or installing underground sprinkler sys[em. White - City Copy Yellow - Resident Copy Pink - Contractor Copy ~ r O CE USE ONLY This requesl wid 18 monlhs Bom validafion dale prinfed in ILis 6ox. g k'~~'a -o/t,a, ~ 7~g III~IIIIIIIII I~IIIIIIIIIIIIIIIIIII~II~/o~ ~j~aP~SEPR~R~ P~OS~O R~1Bg~ RougMin ~mpeciion required? ? No Inspeclim Olfier TMn RougFln: ? Rmdy Now all q~ ~Vw musl mll the Inspeclor ready~ Oa1a I, icensed conhactor ? owner hereby request inspection of the obove elechiwl ~ ,ob naa.~,> Is~,~ , a eome Ny..~ ~ n n ry F, . o~ ~/XLX /~t~ ~ f ' Secnon No. Tawnship Noma or No. Ra~ga No. Fire No. Cau Ocw Ph / t C_~ Pawer p e Addr e co ~e~ y r~me~ c Li Mosxr ~c No. ~Plvm Ekn. OnMI `T/~ " ig A ess Kanh Perlorming Insbllafion~ / ~ ~ ~T ~ 06~ Aui Nre ( er Perfarml Inskllanon~ ~('y~ ) ~C/A~U c_x~~--- EBDOOD 11 /96 reTC nnnon cnov _¢ve wemucnnue nu wecv ru ve~ ~ nw rnw q~j~~/9 / RE~UEST FOR ELECTRICAL INSPECTION !O~ Y 1- ~ 7_4 6~~ 8121 Univers~ry ABearRm. S- 28, St. Paul, MN 55104 Phorre (fi11642-0800 ~ Home Duplex Apt. Bld . Other: New Addn Commercial Indushial Farm Remod Re ir Air Cond. Hfg. E uip. Waler Hh. Load Mgmf. Oiher: Dryer Range Elec. Heof Temp. Senice "X" above the wo~~fhis request. Enler remarks in fFis space and on ~he back of ~he whik copy only. 2~~~ ` ~i~ ~U° ''c/ ,Z ~ . ~ ( ~ P - ~ Ce~cu r~Ce~,~~~`'~~ ~ ~s ~ I ~ Calculafe Inspecfion Fee - Tlris Inspecfion Requesf will nof be accep ifhouf fhe corrxf fee: / Other Fee # Service Entrance Size Fee # Circuils/Feeders Fee Mobile Home Park Stall 0 Io 200 Amps 0 to 100 Amps Sheet Lig./Traffic Sig. Above 200_Am s ove Amps Transfofiner/Generafor INSPECTOR•S u5E oNLY ~ Sign/Oudine Ug. Xfmr. ~ Alarm/Remole Control I Swimming Pool - I hne ceni ~hm I ms ml jn' i6ed'lrerecn on ihe dales elo Irrigaiion Boom Ro~gM~ G ~ $pecial Inspection Invesligotive Fee F~nal / ~ Dwe THIS INSTALLATION MAY 6E ORDEHED DISCONNECTED IF NOT COMPIETED WPTHIN 78 MONTHS. _ . ~ - ~ ~ PLOT PLAN FOR RYLAND HOMES • h//S /S N07 A BOUYDARY SURVEY - Koo~JEfFE~RSO~ta S~ N.EI~~ ~ i rei~r ~nn nur niis aar n~x ves ~n~ er ~ COlLMBlA FEIOFiTS. IN. 9S~2i , w uoer w oixen avervi:ia _ nur ~ia w~ ~2r : CWi TE RK8@rt OF A NeOPOS~ BU~ ~ wp PROPOSED OATE 2- I Z- 1 ~ 9~ 16111 7Ea-8769 fAX <612 ) 7l6-7802 ~ - re~~ oErai~ uo tw~T i w~ oLLr uc GRADES iroa~ ne wrs sr ~i I RON MOMIMEN7 ~ BEARINGS ARE PER PLAT 0 30 ~ ananae s~ne - 99-C O SPIKE SET ti • EXISTINC ELEVATION ~ a - 111MlESOTA LICE E N . ~ 1 3 ~P OF BLOG7C - q~~L 3 pROPOSED ELEV, SCALE IN FEET a BA59~T FLOOR •~89'~0 E- ° DRAINAGE ARROV j /~,S ~ TAC~.TO W IMOP/JS ~ 9''3 ~ 1 Q ~°~5~ ¢ ~ q.5) a.DO¢.@SSl'{9zto R~n-rCf+ aoo.~ v i i ~ ~S' ~ - oa~a¢w4V A~A 'rioWK : 9S03c• ~ i. . ~1 'o , G /y 500 4CCA 7HouN ; ~iOSOs4. ; Jy,~ o . ° ~ sc ~ ~ e~ .S i ~ ,o o % SB ` ~ 990•'~~ ~~V%L^ ~ A 3Rt/ X~~\ 8:G 1 _r P~ ~ ~ , h ~ ~ .Z~ °s .F i ~0 ~ EAG ~ a ~ , 99 • o~ ~ ,9 h ' ti zg ~6 ~~s~~~ , 49 3 ~ REVIE ED ~ . ~ P 'o ~2,~ o o ` 3~~ ~ BY i C ~sg~ ~ ~.P~ a°@~,~ ~ ~ ~ DATE z-zs- 7 ~ ` oo. Y ° ~~o',+~ ~ ~ BUILDING INSPECTI NS ~EPT. ~ 'y~rQ' ~i o ~ i ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ / ~S ~ ~ t C ~s/. \ / pO~ ~ ~ o' 0 2- r`' h ~ 98.9 N\ ~ ~.~ry F±:' _ e~ i , l 9ie ; ~J~`vy~ , ~~.:'1C.:._:~ i....;:.;.~~-~~-" f1;::t~,,.-~ J9~'' /~~~oh~` LOT 24 BLOCK 2. ~ ~ SA CEDAR HEIGHTS, ~ ~ C°''`a 9,~ DAKOTA CO MN . ' ial~fl~2T 4 -1'~t~~uW4D2V'lv.y~o~ I ~S ~ ~ ~ ~ i ~ ' ' i'P.b I n p~ " ri . , , , , Sep 19 Z007 1:19PM HP LRSERJET FRX p.2 `I~B~~' ~~~3 zom RESIDENTIAL SUILDING ~xHnT nrriscnTio~ O.O~ City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 C~ Gr Telep6one # 651-675-5675 FAX # 651-675-5694 C~~ 1 f ~ ` C~ s~ee~~a ~m rve~s ~e sa s of ioe, ~ n. or &+a at~oorm ~ 2~ av~ anowr~ r~ow~a. n~e, id.m ~ (2096rnazunu IotcweteBaeBawad) 76atafEna9YCekulefonetorheateEaddilims . - _ 68 ~ 1 Saile RepM il tpoeed 6ulding ia l0 6e M~ on ~sLabed soi 1 silesie~sY Tor eddtions 8 Oetlta 2caplesofWan beem&rindoxeizes:Paaedfoundd~i8~.etc. Adtlitlm-7nd'ic~eifans!lesePYcsysfem ~ 1 see of Ene~py 3 cwpiee atTroB ervali0n PI~ fl bl WaMed eMer 7/1183 Rim Jo'st De~ill aele~tim eheet (6uadings wiB~ 3 a iess u~) MimreOaaco ~~zlvantilatlaitorm ~ Plans a considered ublie informatiorr unless ou state if~e are trade secret and the reason. I~/ Q r Constractbo Cost /A9 . 4~° 5ite Add s}4~a Ki~Q~ Unit/Sto H Descriptio of Work ~c~/ Gif'T" G~it~/ri~~d~lC l~'~ ~ Ma111-Fam B1de _ Y~ N FSreplaee(s) _ 0 _ 1 _ 2 ~-7 28' Property er l~'ii~.f 6.A _ Telophone ~ . Coutracto /T~ ~~~~i2a Add '~ai ~iRSY:~F ~Q"'r ~ S`+Ai 2.00 (-~tY ~~ir~..t _ ~ s~~e ziP SS'y3S` Telephone #(ej$7.1 ~i~~ /vS'~Z rI . C~MPLETE THIS AItEA ONLY IF CONSTRUCTINI~i A NEW BUILDING - Minnesota Rules 7670 Cateernv 1 _ Riiles 7672 Ef1e~gY odB~Cete~rY . {~sldential Ve~p9a8on Ca9epory 7 WMkeheet . Neri Ener9Y ~o~ W°Acshe~ (J sub isslon type) Subrtdtted ~ Submiqed ~ • EnergyEnvelope Celnletlons Submiltetl ~ In The last 2 monThs, has the Gty of Eagan issued a permB far a similar plan based on a master plan8 _ _ N If yes, date and address of masfer plan: Licensed lumber Telephone ~ Mechani al Contractor Telephone ) Sewef/W terConiractor Telephone#( ~ I hereby pply for a Residential Building Permit and acknowledge that the information is complete and accurat that the ork wilt be in conformance with the ordinances arid codes of the City of Eagan and the State of M Statutes; understand this is not a permit, but only an application for a pennit, and work is not to start without permit; the work wil] be in accordance with the approved plan in the ease of work which reyuires a review a~ approval f plans. c i/~~ Applican s Printed Name Appl cant's Signature ' 1 PERMIT ~ CITY OF EAGAN 3s30 Piiot Knob Road , PERMIT TYPE: g u 1 ~ o r N ~ Eagan, Minnesota 55122-1897 Permit Number: p 2 9 5 6 0 (612) 681-4675 Date Issued: 0 3/@ 3/ 9 7 SITE ADDRESS: q926 RUSTEN RD LOTs 24 BLOCK: 2 CEOAR HEIGNTS p.T.N.: 19-16725-240-02 DESCRIPTION: ~~~~l~.n~ermit Type SF OW6 ,~~iildznq ~~k Type NEW :a~~k~G ~~aCUpr~iTGf~','~' R3/U1 ~ Coh~~rlrCtti~n ~'y~e VN ~ ~ ' ~43r[ar~g ; t~~a~ R1 ° ' €~U3.5.°~1~~9 I.~"rfg~h A6 " : BU ~~~1~ kl~~t~h 40 ~B+u ~`7~~d ar i e s s~. 2 ~5~~4,~';~ °`'~~c~~'~ 1 0 512 ~ Ce°rc},si~~~Ct~'~e'~ 1@1 1- FAM. DETACH ~ u~ ~ ~ .r' &~~~~`~`~~„.~~g~~w~, ~ ~'~z~€u~~~~: 3 ~ ~ ~~R ~ REMARKS: S& W PLUMB~R: STAR PLUMBING FEE SUMMARY: ~ VALUATION $1_36,0~0 Base Fee $1,067.25 MISCELLANEOUS $1,979.50 Plan Review $693.71 Total Fee $4,758.46 Surcharge $68.00 SAC $950.00 SAC ~ 100 SAC Units L 5ubtotal $2,778.96 C(I:~ITRACTOR: - Applicant - sr. ~rc OWNER: R~YLAN? HOMES 18546363 2~03544 ftYLAND HOMES ,d~0 E 79TH ST 101 9@m E 79TH 5T 101 BLOOMING70N MN 55420 MPLS MN 55420 (612) 854-6363 ~(612)854-6363 . . . , . : : ; . . . ~ B f,~ ~ ~ r~. ~ r „ ~ ~ _ ~ ~ . . " y' . hara~ a~~kre~au~e~g'~ ~a~~~ ha~~ rea4P.~'~~~s ~„P€~~a~at~~n._~rv~ s~~~ tha~ ttue trr ~ b~ or~~e~ ae~ree~ tQ ~i~{sl~ ~t~.~r a~~, appS~.~~bS2 -St~~~ o~~ ~7rs. _ ~ ~ ~ af ~aga~r a~=~ii~~rr~o~ ~ . x _ , r,:. e . m.b ~,n :ix. .-.t . . _ _ _ . a ~ ~ _ ~ ~ ° ~ ° - APPL T/P RMITE NATURE , ISSUED B E . C :'~'~C};'w~. y uyr~w~:l• ~D°v`ky,i,.,~.~~e ~~~.;%i^k~(1N',h,~'M(*~,yiYd)~t - , r.zrv o~ :.~icF~ ' ~L.`4, r~i: 5 " _ . _.~~~'i ~h1~ I~..'..^ '~L~ ~-i!'x`'- -`{1:3/:i:~/.5" --r--n',. ~ '.'`.:Fn.9.i . . ~~.'~y~.r.. }'~5N O~r'; ;spib '7L'~:, 45'c I'~ i,,.~C,~ ~r•, n,.,?~f~.~t; r R:~:r.~i;r` qr~~s~r • ~ . 3.4~5 ~i:~~i"-::•r43 ,;5~-~., rn.. .:Ay ~.a,a..., r. '~"~ift... ~.~'~'.iY~)n:-.'<'n"6'{ :L ..:.7.:.CS. :.~:..d:i.,`~'7~.h. ~ ~ . , CITY OF EAGAN ~~7~-S~ 3830 PILOT KNOB RD - 55122 ~2/a~l , • • 1996 BUILDING PERMIT APPLICATION (RESIDENTIAL) ~ ~eo~( 681-4675 ~ New Construdion Reauirements RemodeUReoair Reauiremenis ? 3 registered aMe surveys ? 2 copies ot pian O 2 copies of plans (include beam & window sizes; poured (nd. design; ete.) ? 2 site surveys (exterior adddions 8 decks) ? 7 energy caleulalions ? 1 energy calculatlons tor heated additions ? 3 eopies of tree preservation plan H lot platted after 7H/93 required: _ Yes _ No DATE: c~. - c~. ~ ~ ~ CONSTRUCTION COST: ~ ~ ~ QoU DESCRIPTION OF WORK: ~S1 ro~f ~'1 i I J~l Ofl'1 C STREET ADDRESS: ~ _I «~n ~ LOT ~ BLOCK Q~, SUBD./P.I.D. ~e 0~(X.r Nf',IQ~~ PROPERTY Name: ~ i~µorhPS Phone ~~~^1~~~ OWNER Street Address: ~ F. ~q th ~~~e • ~ 0 ~ City: ~115. State: ~ Zip: 5~'~~~- coNTwacroR Company: ~ ca~',~.(Yu (~.A (~0 Vl Phone Street Address: License a~~~~~,~ City: State: Zip: ARCHITECT! Company: ~ ~n.rnc (;.A (~Q Phone ENGINEER Name: Registration Street Address: City: State: Zip: Sewer & water licensed plumber: ~~Q~' p~ ~i - ~ Penalty applies when address change and lot change are requested once permit is issued. I hereby acknowledge that I have read this application and state that the infe~mation is correct and agree to comply with all applicabie State of Minnesota Statutes and City of Eagan Ordinances. ~ Signature of Applicant: ~ , OFFICE USE ONLY ~tECEIVED Certificates of Survey Received _ Yes _ No ~ 4 97 Tree Preservation Plan Received _ Yes ~No~ ~ ~ ~ , OFFICE USE ONLY ~ r ~ ° „ BUILDING PERMIT TYPE 0 01 Foundation o O6 Dupiex ? 11 Apt./Lodging ? 16 Basement Finish e~ 02 SF Dwelling o 07 4-plex ? 12 Multi Repair/Rem. ? 17 Swim Pool ? 03 SF Addition ? 08 8-piex ? 13 Garage/Accessory o 20 Public Facility 0 04 SF Porch ? 09 12-plex ? 14 Fireplace ? 21 Miscellaneous 0 05 SF Misc. ? 10 _-plex ? 15 Deck WORK TYPE ~31 New ? 33 Alterations ? 36 Move ? 32 Addition ? 34 Repair ? 37 Demolition GENERAL INFORMATION Const. (Actual) V- n1 Basement sq. ft. 3~ MC/WS System ~ (Ailowable) J- N Main level sq. ft. ~ 0 3~ City Water ~ UBC Occupancy R- 3, u- i sq. ft. i D 3 I Fire Sprinklered Zoning I ~i o~a<P sq. ft. ~t 81 PRV # of Stories 2 ~L' sq. ft. Booster Pump Length y~ sq. ft. Census Code. ~ o i Depth ~~O ' Footprint sq. ft. ~ 5 i z SAC Code o i Census Bldg I Census Unit I APPROVALS Planning Building r^~ Engineering Variance Permit Fee Valuatio~: $ ~ a~~_"- Surcharge 3 a~,e,,.,,~,~F- Plan Review ~J License ~y" y~ ~s~.~`~ MC/WS SAC 3 z, z g.r ~ ~ G 3. S City 5AC ~Y • z S x~ q.~s Water Conn. 3. s r z. 3~/ y Water Meter ~ ~ o~ S= , 5 v~s. - Acct. DepoSif SIW Permit s~„n.~ SIW Surcharge ~~3i r~ ~1 s~l = ss, - Treatment Pi. z Road Unit ~ Park Ded. ~~x z8 ~ 0 3 i d7 ~ sd = 55, c. ~ y, Trails Ded. Other ~,u.~ Copies ~a.s,~ c. gi ~o,t ~ 9. S Total: a. „ u 2. 3y ~G O . -y. ~ r~ 76y~ SAC Units ~ 4 ~ ~ ~ ~ r ~ ~ I 2oV ' i 3S, 7D~.~ - - - - - - . - > FOR RYLAND HOMES P L OT P LAN f((~T}i SURYEYING, IMC. ~ ' TNIS 1S N07 A BOldJD~RY SURVEY ' ~00I JEFFERSON ST. N.E. ~ i rsi~r ceircFr nuT niis etar n.w vas vs~,v~ er ~ COLU.~IA i$IGFRS. W. 55~1I ~ a vm~ ur orRa~ u~nsia . nuT ir+ia rvn ca~car pROPOSED OATE Z- ~ ZI ~ 9Z ~6i11 70E-9768 PAX f6l21 lal-7602 awc nF r~"csea °v """°°s~ eui n~ u'° GRADES _ ~ew oesa~i~ xo nwT 1 NI A PlY LIC O• IRON MONUMINT uoee ne uua sr ~ aF BEARINGS ARE PER PLAT 0 30 ~ 99Z~0 • = SPIKE SET ~~I ~ enrenae s~~e - e~ .~(I STINC ELEVATION ~ ~--1 6 . ?41 tdJES07A LI CE E N . 1(o 3 ron aF e~ocx - °192 ~ 3 pROPOSED ELEV . ScA~E IN FEET 6 BASB/SN~ FLOOH •'~89'~O F' = DRAINACE ARROV >aa:.ce.w~..uo.,.~s ~93.~ Q ' (~8a ~ a I "~~S) A002L•~iS: ~I92M QJSTCIi ena~ P r ~ 1 ,S, ~l oe~~ew4V o¢~A 7upwµ:950sc. ¢ j ~ ~ So0 vCeA 7HOw'3 ; "70SOSf• I ~l`~ a ~ ~ ; c' ~ysC r ~ .S ' ~7 0 p p y 0 ~ Sg ~ q~ / ~J rO ^ ;a~ ' X~`~ ~Bgo k ~ . ~ ~r 2/~(~ ~ c~%p ro . C~ a ~ ~ ~ ~ / ~ . \~ti , ~ rn LSG"-.11~:1 ° I ~v ` ~tl , /~Or < / 9Z.. f '9, 9 ~ Id [.1 ~ D ~ ~{~~(/I/_ O%~ \ a- Le 6 J!9 '4 I ~ / Yr~-\ N Q / ~ } 1/~ - i ~a~ \ r2'~I N 3~~ ~i By / _ ~ . ° ~G~ o ~ a~ ~ ~ 1r~' ~ DATE Z - a S- 7 ~ ~-`~~8, e~ , s aa~~ ~°=9~' BUILDING INSPECTI NS ~EPT. R o, o > 41 = ,yd ~NOj Yo a" Q9 / _ \ +.9 F C 1S ~ ~ I ~ ~ ~ S ~ ~d'~ h ' ~ , / . / o' O / ~r `y I 9d ' \ ' .i 9~L ~i ° ~ _ 4B l~ ' ` / J~~~. T t'~--[-F-~------ / ~ 9SD ~ ~t y~ s"`+~.J.._.i.i ~.iV~r ..~r:i.~1JlI~i1'.1'~~.. J9'r \ ~'~T~~oh~ LOT 2 4. BLOCK 2, R ~ S CEDAR HEIGHTS. ~ ~,o~~`0 9~` DAKOTA C0 . . MN . ' Lsfl-4V~LLT 4 - I'~t-L~~AA14D4LV "L-0•~~DC lOT SURVEY CHECKLIST FOR RESIDENTIAL ' ILD~NG PERMIT APPLICATION ~ PROPERTY LEGAL: %t ~ ~ DA OF SURVEY: 2 ~ ~ ~ LATEST RE1/ISION: m ~ S ~ DOCUMENTSTANDARDS t~o ? • Registered Land Surveyor signature and company ? • Building Permit Applicant 1r ~ ? • Legaldescription ~ ? ? • Address ~0 ? • North arrow and scale ? • h4ouse type (rembler, walkout, split w/o, spl'd entry, tookout, etc.) ? • Directional drainage arrows with slope/gradient % e~ ? ? • Proposed/epsting sewer and water services & invert elevation ~ ? . ? • Street name ~ ? ? • Driveway ELEVATIONS 6~asstin ~/~p_ ? • Sewer service (ar Proposed} ~ ~ ? • Property comers C~a ? • Top of curb at the dtiveway ~ • Elevations af any existing adjaoent homes Prooosed t~ ? ? • Garage floor Rr ? ? • First floar , C~ ? ? • Lowest exposed elevatron (walkout/window) ? ~ Properly comers ? • Front and rear of home at the faundatf~n PONDING AREA frt aonlicablel ? C~'/ ~ • Easement line ? ~d' ? . NWL ? ~ • HWL ? • Pond # desgnalion ? ? • . Emergency Overtlow Elevation i QIMENSIONS - ~ ~ • Lot Iines/Bearings & dimensions ~ ? • Right-of-way and street width (to back of curb) O ? • Proposed home dimensions including any proposed decks, ovefiangs greater fhan 2', porches, etc. (.e. all strudures requiring permanent footirigs) ~ • Shaw all easemenffi of record and any City uoilities within those easements ~ g~ • Set6acks of proposed structure and sideyard seffiack of adjacent erisGng structures ? B~0 • Retaining wall requiremenis, if any Re~~,~: _ 9 7 Name / D Jara~ry 1996 qiA1679BBiBLOGPRMT.FM w JUL-06-1995 F18~33 FF.CJ~i RYLf71~D rl!D4iEST REGION TO M1NN P.004/N0~ ' + CABO MEC 92 CQ~!PLI.ANCE * Builder RYLAND HOMES Svbmitted dy R.I~. TRACEY Model GILBERT Date 4/5/95 Lot/Plan/Address OPT. 295 Degrea Day Sase BoCO Minneapolis Type Single Family House Volumz 41400 Filename GILBERT Control No. ~~~8 Uo Totals ~ Proposed ~ Required ' Component Area Uo Total Uo Total {Jalls 2611 .i03 269 .110 285 Ceilinas 1148 .026 29 .026 30 FJ.oors 162 .D47 8 .OSC 8 Floors (Open) 0 .035 0 .026 0 Hamt h'all(i]) _I195_.080___96~_'097._ 109 This House Qualifi.es With Total Total ~ 401 ~ ~ 432~ U-Value Calculatione SLJ~cifiCdL10RS UO C31cUlaC10I16 -------~---p--~-------___----------------- Walls Size O.C. Insul. Sheac. Com onent Area u-Val Total A Frame 3.5 16 13 i.06 Frame Wall A B Frame 5.5 16 19 2.06 ~Fr&me Wall B 1666 .052 87.7 C Frame:-Gar. 3.5 16 13 ,95 Frame-Gar.C 286 .082 23.4 D Masor.ary 8 N/A 11 N/A I t4asonary D w . 080 E t+lascna-ry N/A N/A Masonary E * Ring Joist '_5 24 13 4.0 IRing Joiat 350 .C56 19.6 - Window A 268 .&8 1?8. IDoors Panel Glass ' S,C. Window B I A Meta1 .19 .62 .89 Window C ( B IWOOd .46 .62 .88 Dcor A-Panel 38 .19 ~.22 C ~Other I Door A-GLass 3 .62 1.86 Door H-Panel Ceilings O.C. Ineu1. Sheat. Door B-Glas~ A W/AtCic 24 38 N/A Door C-Panel S No Attic 16 19 .b3 Door C-Glaes C ~Other Totals 2611 268.6 - - Uo=iUt/Ae) .103 I Floors I O.C. Ineul_ Cover A Non Con3. 16 19 1,2~ Ceiling A 1148 .025 29.2 B Overhang I 16 30 1.23 Ceiling A C Other N/A 5 Ceiling C - Skyighc A Windows U-Val S.C. Skylight A A Alum T.B. .48 .88 Skyli_qht C B Wood .52 .88 Totals I 11d8 ~9.3 C Vinyl/FG .36 .88 Uo=Ut/At ~Skylighta V-Val S.C. * BasementTwalls ~ 50~ below qrade A Standard .60 .88 B High Perf. .32 .5 NOTICE: Users of this software are responeible C Other Yor the specifications and dimensional data used to generate thi~ repo.rt. The developers of HvAC Equip Rating the software are in no way reepansible for the ~ Gas AFUE .76 misYepesentaC.ion of any build3.ng due to errore, Hp HSPF 6.8 omissions, or any other mieuse of the so£tware. RC/HP SEER 1D ~ JLL-06-1995 ~~~3a FROM R1titiND MIllWE5T REGI~J TO Mll~h! P.005~0~5 , Page 2 of 3 Builder 12YLAND HOt4ES Submitted By R.H. T1tACEY Model GILBERT Date 9/5/95 Lot/Plan/Address OPT. 295 Degrae Day Base 8000 Minneapolis Tyge Single Family Houee Volume 41400 Filename GILHERT COritx01 NO. 7748 e=eac'=~co " ==-cceac='==ev~--°===oa~v~'aavc'~ca=~vns--~~v~cae'=~vem~ec-c~--e=_a 7imensiona " ;P~ails ~ Frame A ~ r^rame B ~ ~Gar.Com.C~ ~ Mason.D~ Maaon.E ' Basem~nt ' ~ Bsmt. Above Gr 608 lst Floor , 912 lat Floor 304 Helow Gr 608 2nd Floor 1024 Crawl. 3rd Flcor Misc. Misc. MisC. Misc. Misa. Ring Areal 350 - ----------------z?'-------"-- - Iwindows I I i?~luminum I 247 I I ~ Wood Viny1/FG Doors (G-Glase Area O-O ~~ue Area) Metal G 3 O 20 :8 Wood G O Other G O ~ Ceilinas With Attlc No Attic I Oth~r i I 1148 I iStd.Skylitasl I I ~xP Skylitea ` I Other Floors Nan Cond. Overhang I Slab --I---16z------I------------'_'--------^- windews~Qty. Desoription Qty. Description Qty. Description I I.1 I6068 GLASS DOOR I 12 I3250 I 2 I3030 Doors Qty. Deecription Qty. Deacription I4tY.l nesoription I I 1 IGAR. WALL DOOR ( 1 IENTRY DOOR ~__aa_~~~___~~ ___~~~=ae==sva=----c_~~maea'~.~c~avv~~~aC-as_~-- T~7TAL P.0~5 ~ a;,.: -r• . ta ~ro., > d . ~.~w.,~ I 3 P4-W Y i~ ,~t r.~ vo-:,-u, n 9ne a.cee.~ r.a m.~a 2 la ~Ra ~rt ~1 ~h tlW0 eccv' Mt~n~ Pu~~. w ..a e.: .i mar. I i II ( ~ ~ i i~- {~r i' r I u i I r ~ I w~t..?v x u `w'.'~'~ ~ • w,""r i i~ .n . M.: :.-ro ~ I xpMlNµliFO Rooa ixnn:M,'~ ScM[?uE LVq„~ W~ Cti OCSCRIVIICN M111N4LEAL.M 1 1 + 9 1/2' Vert>-N~n 98 Il0'~ 2 ~ 9 1/<" BCI/a5 6' J 3 'f v2' BCI/~5 2:' 4 ] 9 I/3' YCI/~0 15' ] 9 9 1/2' B[V~] 6 ] 91/2' OCV~3 ]T ~ 10 9 I/2' GCVU 29' 8 2 9 I/2' DCIHJ ~T 9 1 9 1/2' BCI/~] :0 2 9 1/2' BCI/~] k 11 ~ 9 1/2' BCI/~I 10• . ' 12 l J 1/2' ~ II )/B' var[o{nn B' ? t 3~ 1 JH' H ll )/B' Verao-lan 21' 9 1/2' BCV<5 2 19.2' O.C. SPACING •MT-<~f. 46W.~iS . . 16 pc. LYL-I1mi MAIN LEVEL FL?OR FRAMING PLAN • SC0.E. V~• . I'-C . . , F~ Y I_ A N D Lyrtun WmCxCempenY I ~ '~"'r "y.~""~ I ~ I ? }y ryY xll 4C1~ ufrV Ii0 12' ac ar :W a< C p[. fu~r ]/f ? YWU r~a uy[nYl I I I YAwa~ A ] NN V -B~ 9Y luR V W N lO ~n s~CI J~ Jon[~ ~rWO OC(v pA~~~ J]tlil P-br+a ~m W s~ b~w f ' ' _ - u ru~a rzw ~ ~ k'~ v ~u'~r. I w.iri w:~w.u`~a~ I f u ~u~ ~ ~I ~ ICnUMlRC9 ROCH PPUIIxG SCXE:0.[ nRR 01Y OESfAIOp[H WMINAL ICNGiN ~ 1 I I' v f tR' veno-9n 98 IN•. E x s ve• ItV.o x~ . ] 2 9 IR' ?[1/U 1~' B 9 iR' !CI/~] ~1' 5 i0 9 VB' YCV6 20~ . ] ] 1/2' ECI/IS 8" S 9 V2' IGIi~] 16' 1 9 1/2' K:/~] 1 9 1/2' 1CVU 12• 0 t ] I 3H• e 19' v...o-L.n 20' 1 1 J I J/1' w) V2' Verfu'Lnn 01. . 9 V2' HCI/43 B 19.2' D.C. SPRCING )ou` ?N-09W UPPER LEVEL FLO~R FRAMING PLAN 1 SC~IL I/~•• 3•~P F~ Y L- A I~I ZZ~ '.I ~ • artlui c , I ~yT11M ~AIfl16ll CM1~i11~' ~~rn 1 ' ' ~ CITY USE ONLY . ' ry L ~ BL RECEIPT#:. SUBD.~,euc ~,Jii~~_ RECEIFTDATE. ~~~7'~'I 1`997 PLUMBING PERMIT (RESIDENTIAL)- ` : CITY OF EAGAN 3830 PILOT KNOB RD EAGAN, MN 55122 (612) 687 ~675 Please complete for. . single family dwellings - • townhomes and condos when permits a~e required for each unit . backflow preventer for underground sprinklersystem FIXTURES EACH ~ . TO7AL, , Shower 3.00 x = _ Water Closet 3.du" x = Bath Tub 3.00 x Lavatory 3.00 x - Kitchen Sink 3.00 x Laundry Tray 3.00 x , _ ;r ' Hot Tub/Spa 3.00 x = Water Heater 3.00 x ' / ~ ' Floor Drain 3.00 x 7 = Gas Piping Qutlet • minimum - t 3.00 x ~ : Rough Openings ~ . 1r50 x Water Softener ' for dwellings under construdion - 5.00 x- _ Water Softener ' Tor existing dwelling 20;OQ x' _ U.G.Sp~inkl2r `tordwellingunderconst. 3:00 ~ U.G.Sprinkler `forrxistingdwelling 20:00 = ARBrdtiOns ' to existing resitlence 20.00 Water Tum Around 2D.00 Private Disposal System • ~ae cry iic. 65.00 (new~andrefurbishedsystems) ~ , ~ , . ~ Private Disposal Systems ~ A6andonment 20.00 = STATE SURCHARGE .50~/~y- T4TAL ?v I hereby aGcnowiedge.that I have read this epplicatlon, state that the i~ormatlon ~a correct and agree to,comp~ytwrthiallvspplicafile:Clty„ ~ of Eagan ortlinances: k is the applicant's responsibility to notiy the property owner;ttiat Ne City of;Eagan'essumes no~liatiiliry kr~any~ . damages caused by Ne Cily during tts nortnal operetional and maintenance activities:to.lhe~:faaliGes:conshucted onder this~pertpit witfiin~ - Ciry property/right-of-way/easement. ~ ~ ' ~ . SITEADDRESS: ! /v~ n ~~1~,,~x~[ ~ OWNER NAME: ~~Q/~~ T/U/?~~ ~ . INSTALLER NAME: GENZ=RYAN PLiA!'IBING TELEPMONE ~~23-1.J.44 STREET ADDRESS: 14745 So Robert Trl _ _ CITY: Rosemount STATE: -ZIP: 'S5068 _ _ ~ ~ SIGNAT : E OF.;PERMITTEE' OFFICE USE ONLY ' . ~ ~ ~ ~ / l?~ - L~ BL CITY USE ONLY RECEIPT 7~y~-S SUBD. l~a.n- ~s~~ RECEIPTDATE: 9 1997 MECHANICAL PERMIT (RESIDENTIAL) CiTY OP EAGAN 3830 PILOT KNOB RD EAGAN, MN 65122 (6S2J 681rt675 Please complete for. ? single family dweilings • townhomes and condos when pertnits are required for each unit New construction Add-on fumace Add-an air conditionina Acic~-on air exclianger: i.P. ![ar~e~ €~~stPm; ptc. Date: ~.JJ~~/~ / FEES ? Minimum Fee: Add-on/Remodel (existing residence oniy) $ 20.00 ? HVAC: 0-100 M BTU 24.00 Additional 50 M BTU 6.00 . Gas Outlets (minimum of 1 requised ~$3.00 each} ~ ? State 5urcharge .50 TOTAL ~ JO,_ SITE ADDRESS: ~ I./S~ !i( OWNER NAME: rC /~I~/Yl~S PHONE#' INSTALLER NAME: GENZ-RYAN HEATING PHONE#. 423-1144 STREET ADDRESS: 14745 So Robert Trl CITY: Rosemount STATE: ~ ZIP: 55068 ' a~ AT E OF PERMITTEE CITY USE ONLY ~ B~ _ ftECEIPT#: SUBD. RECEIPT ~ATE: 1997 MECHANICAL PERMIT (COMMERCIAL) - Ci'fY OF EAGAN 3830 PILOT KNQB RD EAGAN, MN 55122 (612) 681~6T6 Please complete tor. ~ all commerciaVindustriai buildings. ? multi-tamily 6uildings when separate pertnils are ng( required for each dwelling unit. DATE: CONTRACT PRICE: WORK TYPE: NEW CONSTRUCTION INTERIOR IMPROVEMENT DESCRIPTION OF WORK: FEES: . $25.00 minimum fee Q 1% of contract price, whichever is greater. ~ Processed piping - $25.00 ~ State surcharge of $.50 per $1,000 of pg~p~d fee due on all permits. CONTRACT PRICE x 1 % " - PROCESSED PIPING STATE SURCHARGE TOTAL ~i i E HDDRE~S: OWNER NAME: TELEPHONE#: TENANT NAME: pnnPROVEnnENrs oN~v~ INSTALLER: ADDRESS: C1TY: 5TATE: ZIP: PHONE SIGNATURE: SIGNATURE OF PERMITTEE CITY 1NSPECTOR _ CITY U3E ONLY RECEIPT 5`' L ~ BL ~i SUBD: LX-~K,c/c- ~.v`^'~ RECEIPT DATE; : ~/g ~ , 1997 PLUMBING PERMIT (RESIDENTIAL) CITY OF EAGAN 3830 PILOT KNOB Rp ~ EAGAN, MN 55122 (812) 681~675 Please complete foc . single familydwellings ~ townhomes and condos when permits are required forzeach::unR . backflow preventer for underground sprinkler system _ . FIXTURES .~A HC t(,Q, I9:TALi Shower 3.00 x = Water Closet 3.00 x = Bath Tub 3.00 x = Lavatory 3.00 x ` _ Kitchert Sink 3:00 x = - Laundry Tray 3.00 x = Hot Tub/Spa 3.Q0 x = Water Heater 3:00 x - Floor Drain 3.~0 x = Gas Piping Outlet " minimum -1 • 3:00 x = Rough Openings 1.50 x = Water Softener `to~ dwen~~es under consm,aion 5.00 x- . ~~"'Y , Water Softener ' for existing dwelling 20.OQ x_ _ U:G: Sprinkler 'fordwellingunderconsk 3.U0 . " - U.G. Sprinkler 'forexistingdwel~ing - 20:00_ - ~ Alte~ations " to ezistlng residence 20.0~ " = Water Tum Around 20.00 - _ Private Disposal System ` ~ak Cry iic. 75.00 = ~ (new end refurbished systems) ~ ~ ~ ~ - ~ . . . Private Disposal Systems' Abandonment 20.00 = STATE SURCHARGE .50: TOTAL ~ I hereby adcnowledge that I have read fhis.appliation, state that the infortnadon is.eorreG, and~agree to compty ~wlth a~l applicable City, ~ ~ W Eegan ordinances. tt~ Is~the applipnCs. responaibility fo nMify the property owner that the City'oryEagan essumes no IiehJity for any ' r- demages pused by the,City tluring ks nortnal. operationai and maintenance aGivities~to the.tacil~es mnstructed~.:urrcler this peiink+wrthin . ~ City propertylriglit-of-wayleasement. _ _ ~ , SITE ADDRESS: ~t ~"S~L` T~G~'n"~ , ONMER NAME: ~t°!~ I~~ S INSTALLERNAME ~ " P~~~ TELEPHONE#: ~~~I~3'~i~~, ~ ~ STREE7'ADDRESSs' !"-'Pv+'Fr~. /4-"~'Cv1?2 W`~' - cirY: %?'t~~n.~I~f STATE: t'~'1~? ZIP:;. - SIGNATURE OF PERMITTEE' L~/ _ B oZ. ' . , SUSD l~-~Q~ ~.,J NEW RECEIPT # ~97q9 RECEIPT DATE g/ 9 DATE To _ J ~e c- ~1~e2 /~s sv~ Jos ~`'/Z6 2~rS~`"Pr~ /~o~ OWNER ~y~4h~/ ~G~ cS . PLEASE BE ADVISED THAT THERE IS A FEE SHORTAGE ON THE ABOVS ELECTRICAL INSTALLATION IN THE AMOIINT OF $ Z~ ~ RF!MnRTfs` . . Z J 0- 30 AI~P CIRCUITS = Jo5 ~ 31 - 100 AMP CIRCUITS = 7 0 - 100 At~ SERVICE _ / 101 - 200 AMP SERVICE = 2 O TOTAL FEE DUE = J 3 2 - v LESS FEE RECEIVED / O S TOTAL FEE SHORTAGE DUE = 2- ~ PERMIT # ~ y•~ ORIG RECEIPT # 7O "r/O ~ RECEIPT DATE ~~/O~ T- PLEASE RETURN A COPY OF THIS FORM WITH YOUR REMITTANCE. THANK YOU -~995 west.oou ~.o~es - E Se.vices. ina ~ ~n~ T.. I`/'~`^ V/vpTCNirvG Of STREEL frl COkrvECT TO EX. MH BT ~ ~r n ~ql :8 Hwrs ~elure tl q S' / ~ COHE DRILL~CON~R[i[ SA'N 1~r ~~,I}~~~+ ANO E%. ORIYEWAY ~7 'S~L~ k aDJUST RW i0 uATCH E% ~ INPOENTA~ i0 WAiER , GOPHF,R ~STATE• ONE CALL ` gE R.P. Y609 U L ? \r ,r~~}, 7 GFnDE. \~v MniN rp~~SiRUCiiON. ~..n Ciry Area 656-0002 ~ ` \ (fICLO ~ERIFY LOCP?ON y , i fOR SERNCE TES k E~EVnii~n ~ Ma ~ou Fee t-eCU-252-1~66 % . 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CQNSTRUCTI~N SHEET G J y 6t~ 815-~99~ tlT' PRO.ECT / 9~0 PLA1~ 3 OF 7 CONiRACTOR: AR~ON CONST. CJ. R.P. _60? U "ti"`-~~`"~ ~ PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA153650 Date Issued:01/09/2019 Permit Category:ePermit Site Address: 4926 Rusten Rd Lot:24 Block: 2 Addition: Cedar Heights PID:10-16725-02-240 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 - Guy R Athey 4926 Rusten Rd Eagan MN 55122 (651) 500-6427 Champion Plumbing 3670 Dodd Rd., #100 Eagan MN 55123 (651) 365-1340 Applicant/Permitee: Signature Issued By: Signature