1500 Sherwood Way------------------
Eor office Use
j Permit #:
"
Pennit.Fee: 75
q?
? Date Received:
I Staff; v I
I
2008 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: / L 0 It(- 09 Site Address: I5 DO /` S lu r &10 b c[ Wa
Tenant:
Suite
RESIDENT/OWNER Name: KPk,v_ + $ Latta Hi_kx_+??y,, Phone: 691 -6$8 -2-1418
Address/City/Zip: 1500 30_t^Woo? WC ui?
Applicant is: Owner Contractor
TYPE OF WORK r
S n -1--Cif -C
Description of work:
/'
?? Multi-Family Building: (Yes / No
Construction Cost: T y 00 0 r
CONTRACTOR gg
Name: VZ tu& Ia r5 ) 61Af Icl.e1"5 License #: 2oro 30S o (o
Ln Gk +.
& 2
)2s 2
41
Z
Address:
City: APP l?Vd-Lt? State: MA) Zip: 5512(4
Phone: k- 2) 2 Contact Person: 201N10.n
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7672
_ Minnesota Rules 7670 Cateaorv 1
_
Energy Code • Residential Ventilation Category 1 Worksheet New Energy Code Worksheet
Category Submitted Submitted
(J submission type) • Energy Envelope Calculations Submitted
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: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: 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 the are trade secrets.
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 ap:M6??
x R01MOY" C?a6ah x
Applicant's Printed Name Applicant's t
Page 1 of 3
Address: 1500 Sherwood Way Zip: 55123
Lot: 13 Block: 2 Subdivision: Pinetree Pass 6th
THE FOLLOWING ITEMS WERE/WERE NOT COMPLETE AT FINAL INSPECTION ON 94.03
Yes No Comments
Final grade - 6" from siding
Permanent steps - garage
Permanent steps - main entry Ternp step
Permanent driveway
Permanent gas
Sod/Seeded lawn
Trail/curb damage
Porch
Lower level finish
Deck
Fireplace
• V erify with your builder that roof test caps from the plumbing system have been removed.
• Turn off water supply to the outside lawn faucets before freeze potential exists.
•Call the City's Engineering Department at 651-675-5646 prior to working in right-of-way or installing
irrigation system.
BUILDING INSPECTOR: Craig Novaczyk
CONTRACTOR:
Lundgren Brothers Construction
935 Wayzata Blvd E
MN 55391
p 2005 RESIDENTIAL BUILDING PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
New Construction Requirements RemodebReoalr Reeuirements Office. Use Ord
3 registered site surveys showing sq. ft of lot, sq. ft. of house; and all roofed areas 2 copies of plan Cad of Survey Reed _Y -N
(20% maximum lot coverage allowed) 1set of Energy Calculations for heated additions Tree Pies Plan.Reu4 Y N
2 copies of plan showing beam & window sizes; poured found design, etc. 1 site survey for additions & decks Tree Pres Required -Y -ti
1 set of Energy Calculations Addition • indicate i/oa-sile septic system On-site Septic System _ Y .- N
3 copies of Tree Preservation Plan "rf lot platted after M193
Rim Joist Detail Options selection sheet (buildings with 3 or less units)
Date a 4 / 2 $ / 05 Construction Cost 4 scloo . oo
Site Address 1500 5 Afkl,ua00 WAy Unit/Ste #
C-AI, W mij 5St'LL
Description of Work LOw64 ?? frNUµ - /J o Q 16
r
Multi-Family Bldg _ Y A N Fireplace(s) _ 0 1 _ 2
Property Owner Kba /LAVA ?}?IEf ICr! Telephone # ( (OSI) ok 7,10
c? -775 111 2, 956
Contractor SeLF
Address City
State
1 n p n r,
T ? ?
,,j L I
I Telephone #( )
APR 2 8 2005
COMPLETE
Energy Code Category . Residential Ventilation Category 1 Worksheet
(J submission type) Submitted
. Energy Envelope Calculations Submitted
Have you previously constructed a building in Eagan with a similar plan?
fee applies.
Licensed Plumber
Mechanical Contractor
Sewer/Water Contractor
Telephone #(
Telephone # (
Telephone # (
N If so, 25% plan review
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.
?fNN? M NdtTTf,.?
Applicant's Printed Name Applicant's a e
A NEW BUILDING
Minnesota Rules 7672
New Energy Code Worksheet
Submitted
OFFICE USE ONLY
Sub Types
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? 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 (screen/gazebo) ? 36 Multi Misc.
? 05 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
? 31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding
? 32 Addition ? 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 applicant
Valuation 1,9 l Occupancy MCES System
Census Code t j? Zoning City Water
SAC Units Stories Booster Pump
# of Units Sq. Ft. PRV
# of Bldgs Length Fire Sprinklered
Type of Const Width
- Footings (new bldg)
Footings (deck)
Footings (addition)
Foundation
_ Drain Tile
Roof _ Ice & Water _ Final
Framing
_ Fireplace - R.I. -Air Test -Final
X Insulation
Approved By:
Base Fee
Surcharge
Plan Review
MC/ES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
License Search
Copies
Other
Total
REQUIRED INSPECTIONS
Final/C.O.
Final/No C.O.
_ Plumbing
HVAC
Other
Pool _ Ftgs _ Air/Gas Tests _ Final
Siding _ Stucco - Stone - Brick
Windows
Retaining Wall
Building Inspector
;r 00 _4?1
.r /-7c)
5 -7s-8-6p
RESIDENTIAL yV?p ,-1 (o 0 S?
BUIL61NG PERMIT APPLICTION
CITY OF EAGAN ?n A lJ P V --I (o 1 C) o .
3830 PILOT KNOB RD, EAGAN MN 55122
651-681-4675
New Construction Reauiremenb &C'" RemodelfRepair Requirements
• 3 registered site surveys showing sq. It. of lot, sq. R. of house; and all roofed areas • 2 copies of plan
(20% maximum lot coverage allowed) • 1 set of Energy Calculations for healed additions
• 2 copies of plan showing beam & window sizes; poured found design, etc.) • 1 site survey for exterior additions & decks - C} . Q3
• 1 set of Energy Calculations • Indicated home served by septic system for additions
• 3 copies of Tree Preservation Plan if lot platted after 711193
• Rim Joist Detail Options selection sheet (bidgs with 3 or less units)
DATE 0 VALUATIONE7'???
SITEADDRESS (J` L76 S/fE/(?9nn71 (?1?y MULTI-FAMILY BLDG _Y XN
TYPE OF WORK FIREPLACE(S) _ 0,K 1 _ 2
APPLICANT> JAAJD G-AC-0 Ako, 0_0/O5% A!&(__7-/0 )
STREET ADDRESS 5 ?'S -_C10Z)1 A) 7-40u10b CITYGUfiVZAT-h- STATE OZIP 553? 1
TELEPHONE # 52 -0 CELL PHONE # FAX #
9 '
PROPERTY OWNER
Energy Code Category
(J submission type)
COMPLETE FOR "NEW" RESIDENTIAL B
MINNESOTA RULCS 7670 CATEGORY I
• Residential Ventilation Category 1 Worksheet Submitted
• Energy Envelope Calculations Submitted
TELEPHONE #
_ INNFSOTA RULES 7672
New Energy Code Worksheet ubmitted
By 2-
Plumbing c
Plumbing Contractor: _?Lfi7J? /L_ jECaA-A)jCA? Phone # !3 ?l ?c7'(h"4 4!
Plumbing system includes: Water Softener Lawn Sprinkler Fee: $90.00
Water Heater No. of R.I. Baths
Mechanical Contractor. 45
No. of Baths
r
Z/ 1/ s 4& 9Z-
Mechanical system includes: Air Conditioning Fee: $70.00
Heat Recovery 5yste ? - '- ? , ? L 7
Sewer/Water Contractor: SAIL P4-W7?&t)G' ti - Phone 4k__ ? 411Z/9
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 Eagan Or inances.
Signature of Applicant
---------------
OFFICE USE ONLY
Certificates of Survey Received S? Tree Preservation Plan Received Not Required _
1U So;? -6 GCQ Updated 4102
OFFICE USE ONLY
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Access'orq Bldg,
A 02 SF Dwelling ? 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 Pibg-Y or _ N ? 25 Miscellaneous
X 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding
? 32 Addition ? 36 Move Bldg. ? 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 (7i'' 0 Occupancy 2,-a-L MC/ES System
Census Code /Lz) Zoning City Water
SAC Units L?! Stories Booster Pump
Nbr. of Units Sq. Ft. PRV
Nbr. of Bldgs Length Fire Sprinklered
Type of Const N) Width W?
REQUIRED INSPECTIONS
Footings (new bldg) Final/C.O.
_ Footings (deck) Final/No C.O.
_ Footings (addition) _
_ Plumbing
2C Foundation _ HVAC
Drain Tile Other
Roof _ Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests _ Final
Framing Siding
Stucco
Stone
+'
Fireplace -b R.I. X Air Test I _
_
_
Final Windows (new/replacement)
Insulation Retaining Wall
-------------------- Approved By Building Inspector
----------------
Base Fee
S ----------- ------------------------------------------
p ----
21)73
5
urcharge l
Pl
R
i R
`? _
?
S
an
ev
ew p !
MC/ES SAC
r?"'a J?`,'??•
G7?
(?o
City SAC
?
Water Supply & Storage y? (31-7 7(
! /
S&W Permit & Surcharge ,,: rio
Treatment Plant
Plumbing Permit err F ?p?'??
Mechanical Permit
License Search (???j4
Fn
Copies
Other
T
t
l
J ??/ !
o
a
R T
MNcheck COMPLIANCE REPORT
Minnesota Energy Code
MNcheck Software Version 3.0
Permit #
Checked by/Date
COUNTY: Dakota
STATE: Minnesota
ZONE: 2
CONSTRUCTION TYPE: Single Family
DATE: 12-9-2002
DATE OF PLANS: 12-9-02
TITLE: CHATHAM "B" INVENTORY HOME
PROJECT INFORMATION:
1500 SHERWOOD WAY
STONECLIFFE
COMPANY INFORMATION:
LUNDGREN BROS. CONSTRUCTION, INC.
545 INDIAN MOUND EAST
WAYZATA, MN
NOTES:
8' FOUNDATION
SIDE LOOKOUT
COMPLIANCE: PASSES
Required UA = 622
Your Home = 504
19.0% Better Than Code
Area or Cavity Cont. Glazing/Door
Perimeter R-Value R-Value U-Value UA
---------------- -_'----__-------
CEILINGS --'--
1647 _------
44.0 _
0.
0
44
WALLS: Wood Frame, 16" O.C. 182 15.0 2. 0 10
WALLS: Wood Frame, 16" O.C. 83 19.0 2. 0 5
WALLS: Wood Frame, 16" O.C. 185 19.0 2. 0 10
WALLS: Wood Frame, 16" O.C. 1304 19.0 2. 0 73
WALLS: Wood Frame, 16" O.C. 1241 19.0 2. 0 69
BSMT: Conc. 8.0' ht/7,5' bg/8.0' insul 1321 10.0 0. 0 83
GLAZING: Windows or Doors, Above Grade 52 - 0.350 18
GLAZING: Windows or Doors, Above Grade 321 0.350- 112
GLAZING: Windows or Doors, Above Grade 167 0.350 58
DOORS 38 0.350 13
FLOORS: Over Unconditioned Space 197 30.0 0. 0 7
FLOORS: Over Outside Air 62 30.0 0. 0 2
HVAC EQUIPMENT: Furnace, 90.0 AFUE
------
-------
----------------
-----
--------------------------------------------
COMPLIANCE STATEMENT: The proposed building -
design descri bed here is
consistent with the building plans, specifications, and other calculations
submitted with the permit application. The propose d building has been
designed to meet the requirements of th e Min nesota Energy Code.
Builder/Designer /?}}
Date ( 0' Da
-
e
OFFI??? ?lCf a-TI
,
(SEE ATTACHMENTS)
Development TZ.cE 6S's 61' 6n
Lot Number l? Block Number Z
Address tS? 5E1?2 ?t1? -L-, IA ?(
Builder LtANt? ,Ci 1y TSt?CS CLt?S i 1 tvC
Tree Protection Requirements:
x
Replacement Trees:
Attachments:
Additional Notes:
Tree Fencing ?00-t.A-NbE SALT Pt t?1Cc?
Oak Tree Pruning (Immediately seal wounds during April 1 to July 31)
Therapeutic Pruning
Retaining Wall ?t 2djY iNr OI- SL ?\
Other: l
Not Required
As Follows:
EAGAM Fg?aESFFIY ?6l?9S{O?
Yes
No
opt
H:\ghove\2000FlIe\treepres\Tree Preservation Plan Summary-2000
i
_y SH
A EMSTNG HOUSE 14
I `Y TOP GAR. EON. <
on .3
0
Oo
J `
( 4
On
rn 1
L
V1 e
N '
E?sl5'ttN(,- 6RprN6?SU.t !^Et`?C? .?
TR??
FFh?
HARDCOVER
LOTAREA= 16,361SF.
HOUSE AREA= 2,149SF.
COVERAGE= 17.39%
7
WOO
WA Y ?
° cc ? C
29.7
979. e
14 C 0
4 sS 4.
/
So
3s 22'
r .D S
F
R..
O `38
`
e7t.D ? 6g
981,
.
13
._
I 5 C
?T
. _ ?m
I ? _
II
? r?N s??. i H
(983.8) 986.0 L ' r A '?
F
?1 Tsi00P 13.66 ,^P 30.34 r:12:
V
A
n o 23 ° GARAGE
(984.0)
m
I °^,
PROPOSED LOOKOUT one
R 1500 SHFAwOOO WAY c V 11
Y
X
X983.1 %991.6
DRAINAGE k UTILITY
5L- - EASEMENT
I I
4
1LG
09? rJT
j NNH"'
6B .GYyq??t? ,
?'i19'?N LN (:
W *U'
17.7 999 3
77.7) S89022'24°W 99.25 (999
?1\II 1-/-LI V\I vT(T ITV VI.IIVIV A/AF?`????
TREE SUMMARY
EXISTINGTREES=O
TREES REMOVED =9
SO 15 0 15 39 SO
SCALE IN FEET
LEGEND
Q$ DENOTES SANITARY MANHOLE
DENOTES HYDRANT
DENOTEs CATCH BASIN
$ DENOTES SANITARY SEWER
W DENOTES WATERAWN
ST DENOTES STORM SEWER
® DENOTES STORM MANHOLE
n DENOTES STORM APRON
SETBACKS
MIN. FRONT YARD SETBACK - W
MIN. SIDE YARD SETBACK - S (GARAGE), to (HOUSE?
MW. REAR YARD SETBACK =15
PROPOSED TOP OF FOUNDATION ELEVATION= 994.34
PROPOSED GARAGE FLOOR ELEVATION- 981.9
PROPOSED LOWEST FLOOR ELEVATION= 976.34
LOOKOUT BLOCK ELEVATION= 979.64
ALL OFFSET IRONS ARE MEASURED TO HUNDREDTHS
OF A FOOT AND CAN BE USED AS BENCHMARKS.
0 DENOTESIRON
MONUMENT
X 000.0 DENOTES EXISTING
ELEVATION
(OOO.O) DENOTES PROPOSED
ELEVATION
DENOTES DIRECTION
OFSURFACEDMINAGE
971.0 DENOTES SANITARY
SEWER SERVICE ELEVATION
A TRUE OPINION WAS NOT FURNISHED TO THE SURVEYOR
NOR WAS A SPECIFIC TITLE SEARCH FOR TIE EASTENCE OR
NONEXISTENCE OF RECORDED OR UNRECORDED
EASEMENTS CONWCTED BY THE SURVEYDR AS PART OF
THIS SURVEY.
F
x
I hereby certify that this is a true and o urecl representation
of a survey of the boundaries of
LOT 13, BLOCK 2, PINETREE PASS STH ADDITION
DAKOTA COUNTY, MINNESOTA
And the location of all buildings, if any, thereon, and all ViSIb16
encroachments, If any, from or on said land. As surveyed by
me this 19th day of November, 2002.
Gary R. Gamwnd
Licensed Land Surveyor, Minn. Lic. No. 24764
REYIS DNB
(y331
M
rb {1
s
re R
",-7-
o G GJ
N
?oPaO?
l1 4
Oat -
rc
Fw- a
_Uu?Q
? ZQ
a
DRAWN
RS
CHECKED
GRG
DATE
11r2=
SCALE
ASSHOWN
JOB NO.
5402-851
LOT SURVEY CHECKLIST FOR RESIDENTIAL
BUILDING PERMIT APPLICATION
PROPERTY LEGAL: °t /3 15-lo,?k 2 /, ,ec ?q?t C
DATE OF SURVEY: -/ Y-D
LATEST REVISION: /- 03
m
m
c
m
t
U
O z 9
Q
DOCUMENT STANDARDS
a/[] ? • Registered Land Surveyor signature and company
@ /I ? ? • Building Permit Applicant
v ? ? • Legal description
Add
Y ?
? ? • ress
l
? ? • e
North arrow and sca
/
fiY Y ? ? • House type (rambler, walkout, split w/o, split entry, lookout, etc.)
6/ ? ? • Directional drainage arrows with slope/gradient %
q/ ? ? • Proposed/existing sewer and water services & invert elevation
Iu/ ? ? • Street name
? ? • Driveway
? ? • Lot Square Footage
g ? ? • Lot Coverage
ELEVATIONS
/ Existing
11'/ 0 ? • Sewer service (or Proposed)
(}/ ? CI • Property comers
Cl ? • Top of curb at the driveway and property line extensions
? ? • Elevations of any existing adjacent homes
? W? /? • Adequate footing depth of structures due to adjacent utility trenches
? L'? ? • Waterways (pond, stream, etc.)
Proposed
V)) F1 ? • Garage floor
Ca ? ? • Basement floor
g ? ? • Lowest exposed elevation (walkout/window)
311 ? • Property comers
? ? • Front and rear of home at the foundation
PONDING AREA (if applicable)
? ? • Easement line
? d ? • NWL
? ? • HWL
? ? • Pond # designation
? f9?, ? • Emergency Overflow Elevation
? C?/ ? • Pond/Wetland buffer delineation
DIMENSIONS
M/ CI ?
D/ ? ?
CY/ ? ?
fid/ ? ?
d? ?
• Lot lines/Bearings & dimensions
• Right-of-way and street width (to back of curb)
• Proposed home dimensions including any proposed decks, overhangs greater than 2', porches, etc.
(i.e. all structures requiring permanent footings)
• Show all easements of record and any City utilities within those easements
• Setbacks of proposed structure and sideyard setback of adjacent existing structures
Retaining wall requirements, if an
Reviewed:
G:/FORMS/Building Permit Application
i
- ? SHERWOOD
,? WAY
N89°22'24"E ?,L1
974.0 29.77 979. v \S
C\ `SC90
974.9 6S 1g.
(974.9) ° R\6S0 it
22 F
w NP
?$i0 ' I 71.0 \ 6..O ?O
{dleximu
Cr Racaining 9i .,
3
Ftequired
982.1
".,t I t NGAR.FMIg. rn (984.3) BOULDER O (981
TOP I RETAINING W
977.3 0 i WALL K.,t! Q
`\ N
W ?
TN M1L S n I O/? \ \ it
OO 4 X(984.8) X 986.0
O rn STOOP ~ 13.66 m 20.34P w u'
12
?r
-4 23 GARAGE o
1 W A t o (985.0) v rn
0) 7- a t" T p? 0) m PROPOSED LOOKOUT 19
M 00 a, 1500 SHERWOOD WAY 985.4X
"y ;x ? ? I v b m
N 1.98 33 CANT. 4rn? I I
17
-_-_
IV^' O o
d 984.3( ) X 99-5'f-
0 (984.6 84.6) ?- X(985.6)
t ?'' V 6? 985.9 9?
.J X 982.1 \2. I
f ?f 1 Fr I EXISTING BOULDER-
-.p? I X 983.1 RETAINING WALL X 991.6 I
DRAINAGE & UTILITY
5L EASEMENT` ?_ -
:..,.:.... ;_ (971.7) S89°22'24"W 99.25
30 15 0 15 30 60
\ SCALE IN FEET
LEGEND
A
I I
l?^
Q DENOTES SANITARY MANHOLE
DENOTES HYDRANT
JW DENOTES CATCH BASIN
S DENOTES SANITARY SEWER
W DENOTES WATERMAIN
ST DENOTES STORM SEWER
® DENOTES STORM MANHOLE
DENOTES STORM APRON
SETBACKS
MIN. FRONT YARD SETBACK= 30'
MIN. SIDE YARD SETBACK = 5' (GARAGE), 10' (HOUSE)
MIN. REAR YARD SETBACK = 15'
S9) SfN G
n I
O ,
W I
(3
01
r 9?0
9
N ?
J
J /
m
? l
m J
1 l-_
J
r-.^11TTA IN 1\/ uTl I A r•\r'11T1l1?1
L??\I 1 IA1v 1 v 1 fl ADui I IVIV
HARDCOVER
LOT AREA = 12,354 S.F.
HOUSE AREA= 2,149 S.F.
COVERAGE = 17.39%
TREE SUMMARY
EXISTING TREES = 0
TREES REMOVED = 0
PROPOSED TOP OF FOUNDATION ELEVATION= 985.34
PROPOSED GARAGE FLOOR ELEVATION= 985.0
PROPOSED LOWEST FLOOR ELEVATION= 977.34
LOOKOUT BLOCK ELEVATION= 980.54
ALL OFFSET IRONS ARE MEASURED TO HUNDREDTHS
OF A FOOT AND CAN BE USED AS BENCHMARKS.
O DENOTESIRON
MONUMENT
X 000.0 DENOTES EXISTING
ELEVATION
(000.0) DENOTES PROPOSED
ELEVATION
f- DENOTES DIRECTION
OF SURFACE DRAINAGE
971 O DENOTES SANITARY
SEWER SERVICE ELEVATION
A TITLE OPINION WAS NOT FURNISHED TO THE SURVEYOR
NOR WAS A SPECIFIC TITLE SEARCH FOR THE EXISTENCE OR
NON-EXISTENCE OF RECORDED OR UNRECORDED
EASEMENTS CONDUCTED BY THE SURVEYOR AS PART OF
THIS SURVEY.
I hereby certify that this is a true and correct representation
of a survey of the boundaries of:
LOT 13, BLOCK 2, PINETREE PASS 6TH ADDITION
DAKOTA COUNTY, MINNESOTA
And the location of all buildings, if any, thereon, and all visible
encroachments, if any, from or on said land. As surveyed by
me this 19th day of November, 2002.
F
0
x
i
ads ?a
N?,? of
?Ao
LLJ
0
? V
0
0
LL ?
00
W
W <
V of
z
U
W ra
U
DRAWN
RS
CHECKED
GRG
DATE
11/20/02
SCALE
AS SHOWN
JOB NO.
5402-851
Gary R. Germond
Licensed Land Surveyor, Minn. Lic. No. 24764
?3.Sa
2005 RESIDENTIAL BUILDING PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
New Construction Requirements
3 registered site surveys showing sq. ft. of lot, sq. R of house; and all roofed areas
(20% maximum lot coverage allowed)
2 copies of plan showing beam & window saes; poured found design, etc.
1 set of Energy Calculations
3 copies of Tree Preservation Plan if lot platted after VIM
Rim Joist betail Options selection sheet (buildings with 3 or less units)
Remodel/Repair Requirements Office Use Only
2 copies of plan Ced of Survey Reod _Y _N
I set of Energy Calculations for heated additions Tree Pros Plan Recd _Y _N
1 site survey for additions & decks Tree Pres Required _Y _N
Addition - indicate if on-site septic system On-site Septic System _Y _N
Date 'Z if /
Site Address SG6C? a-o Construction Cost 4 /, o do,
(y( (/?.(/ Unit/Ste #
Description of Work 0-V 1' [ rr" ?" `- L
Multi-Family Bldg Y Y_ N Fireplace(s) _ 0 _ 1 - 2
Property Owner uQ 11-v rJ I/i°Fi? Telephone # ( )
Contractor 1 2 - Y ly4 ' C y?
5
Address ? oo fv,
State nn
?"?U, City ( 45Tj1V(os
Zip ??O '73 Telephone # (r4 5- () ! s O 9
COMPLETE THIS AREA ONLY IF
Energy Code Category - Minnesota Rules 7670 Cateeorv 1 _
Residential Ventilation Category 1 Worksheet
(J submission type) Submitted
Energy Envelope Calculations Submitted
Have you previously constructed a building in Eagan with a similar plan? _ Y
fee applies.
Licensed Plumber
Mechanical Contractor
Sewer/Water Contractor
Telephone # (
Telephone #(
Telephone #(
N If so, 25% plan review
? Ill FF@ h551
I hereby apply for a Residential Building Permit and acknowledge that the information is complete an 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.
L`=d V1A1A)A(/'1AK9
Applicant's Printed Name
(T_?at_
Applicant's Signature
A NEW BUILDING
Minnesota Rules 7672
New Energy Code Worksheet
Submitted
OFFICE USE ONLY
Sub Types
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
) 02 SF Dwelling ? 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 (screen/gazebo) ? 36 Multi Misc.
? 05 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
? 31: New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding
? 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair
A 33 Alteration ? 37 Demolish Building' ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement *Demolition (Entire Bldg) - Give PCA handout to applicant
Valuation //r;?°l Occupancy R-3 MCES System -
Census Code 113y Zoning City Water
SAC Units Stories Booster Pump
# of Units - Sq. Ft. -' PRV
# of Bldgs Length - Fire Sprinklered
Type of Const Width
REQUIRED INSPECTIONS
- Footings (new bldg) _ Final/C.O.
- Footings (deck) j Final/No C.O.
- Footings (addition) _ Plumbing
_ Foundation _ HVAC
_ Drain Tile Other
Roof - Ice & Water _ F inal
Pool
Ftgs
Air/Gas Tests Final
??
A Framing _
_
_
_ Siding _ Stucco
Stone
Br _
ick
Fireplace _ R.I. _ Air Test - _
_
Final
Windows
- Insulation _
_ Retaining Wall
Approved By: _
Base Fee
Surcharge
Plan Review
MC/ES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
License Search
Copies
Other
Total
Building Inspector
2_20f_
1924 (P RESIDENTIAL PLUMBING
Permit Application
City Of Eagan
3830 Pilot Knob Road, Eagan Mn 55122
Telephone # 651-675-5675
Please complete for: Single Family Dwellings
Townhomes and Condos when permits are required for each unit
a# 3Us-?°
Date J2
/ ) / / 0 3
_
`
Site Address )?? SrL Jd O? LJ `t?
Unit #
Property Owner /lPrt Telephone # (6O 1) 6 69 -21 y5?
?)
k #eg7'1"
/ Q el
Contractor
`
W f
^ R ??J///C
Cit
_
Address y
State Zip _ 61 Telephone# ?3`?l??z
The Applicant is Owner Contractor - Other
Septic System _ New _ Refurbished Submit 2 sets of plans and MPC license $ 100.00
Includes County fee. Additional consultant fees may apply.
Alterations to existing dwelling $ 50.00
_ Add fixtures to lower levels or room additions, excluding water softener and water heater
Abandonment of septic system
- Water turnaround (+ 5/8" meter if needed - $121.00)
Other:
_ RPZ !" tt??. _ new - repair -rebuild $ 30.00
Lawn irrigation system
Water softener - Water heater $ 15.00
replacement _ additional
.50
$
State Surcharge
s 30'5D
Total
I hereby apply for a Residential Plumbing Permit and acknowledge that the mtormation is compiete and accurate; mac me wurx WILL
be in conformance with the ordinances and codes of the City of Eagan and with the Plumbing Codes; that I understand this is not a
permit, but only an application for a permit, and work is not to start without a permit; hat th ork will be in accordance with the
approved plan in the case of w which requires a review and approval of plans ?
?J n S7`/t`G ?Gcc??
Applicant's Printed Name
Address: 1500 Sherwood Way
Lot: 13 Block: 2 Subdivision: Pinetree Pass 6th
Zip: 55122
'FILE FOLLOWING ITEMS WERE/WERE NOT COMPLETE AT FINAL INSPECTION ON f. /-,03
Yes No Comments
Final grade - 6" from siding
Permanent steps - garage
Permanent steps - main entry 7?MP 5"=p
Permanent driveway
Permanent gas
Sod/Seeded lawn
Trail/curb damage
4
Porch 17 ,
Lower level finish
Deck
Fireplace
Verify with your builder that roof test caps from the plumbing system have been removed.
Turn off water supply to the outside lawn faucets before freeze potential exists.
Call the City's Engineering Department at 651-681-4645 prior to working in right-of-way or installing
irrigation system.
BUILDING INSPECI'O l? y
/bldginsp/forms/2002/final inspection checklist
EA057619-0I
CERTIFICATE OF OCCUPANCY
City of Eagan
Department of Rliildiro Inspection
This certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code certifying that at the tame of
issuance this structure was in compliance with the various ordinances of the City regulated building construction or use. For the
following:
Business Name Permit Number
Occupancy Groups I'-' U-1 Construction Type
Owner Address
Building Owner Lundgren Bros. Construction Zoning
Building Address 1500 Sherwood Way
4 ,
Building Official.
EA057619
`v -N
935 Wayzata Blvd E
Wayzata MN 55391
Sinele Familv (Res)
9 - -/ • 03
Issued Dare
rq,
0
0
ro
0
0
ro
Site address: Lot Block _2 Subd. (1;2C4L (.6 P7155
On April 15, 2000 the Minnesota Energy Code, Category I Building Requirements for insulation protection, air
tightness, and ventilation, was adopted. As a result, the City of Eagan is requiring that the following information be
submitted prior to issuance of a Certificate of Occupancy.
This structure: is constructed to meet minimum requirements of the Mn Energy Code, Chapter 7670
V OR
This structure: will be constructed to meet more restrictive requirements of Chapters 7672 or 7674
APPLIANCE GAS ELEC MANUFACTURER MODEL BTU'S VENTING TYPE
Water Heater D S/n 5D '{0 -0 DO P V (il
Furnace X `
M VOfv01 0
d o, d vo
P V C.,j
Dryer
VENTED
EXHAUST SYSTEM LOCATION TYPE MODEL CFM's YES No
Kitchen kitchen
Bathroom 1 Dcc9DE2
5a
X
Bathroom 2
Sr£
n1
J`D X
Bathroom 3 Crkl S 5 D X
Bathroom 4
I
Other A 6a-6'+0 C FM ?? 5 (? X EE
FIREPLACES
LOCATION
GAS
WOOD
MANUFACTURER
MODEL
BTU'S VENTING
DIRECT ATMOS
m X EST c 'D V 3 (v0 op0o
MAKE-UP AIR MODEL TYPE CFM's
I hereby acknowledge that the above information is correct and agree to comply with the Minnesota Energy Code and City of Eagan
requirements.
/'?--/ /- 0 2-
Signature Date
Company Name
This form is the responsibility of the General Contractor.
City of Eaan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
r
Use BLUE or BLACK Ink
For Office Use
o-Szs—f
5.94.
Permit #:
Permit Fee:
Date Received:
,(9'�
Staff:
2012 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: ll/ 12 0 / 12i Site Address:
1 SH woo0
Unit #:
RESIDENT 1
OWNER
Name: tfit.E11-8IJ Phone:
Address / City / Zip: IGOO-1'1512,1/t--0•010
Applicant is: Owner Contractor
TYPE OF WORT
Description of work:
Construction Cost: �� Multi -Family Building: (Yes / No _,
CONTRACTOR
Company: (-4 (-'1%a (.,E 12:7 ,i Vtn elic5 Contact: .1t2 .-7%1ry 4-73
Address: IS -k0 Co ll( i Ir-{ 1.- City: O(` -)-i 2610-14--t a -t `-x.-
State: MO Zip: .SS --431--(1-1 Phone: 4:3S-2 ')L( _ S -VO2
License #: -.....4,0.3-1 ZZCs. Lead Certificate #:
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
T jfiolvt � w Y+s to A s 10-1 R 1 vlo Pi? ,g ' r iii 0 3
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: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: 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
concludethatthey 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.org
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.
x 44.0A
x �,
Applica 's Signature
Applicant's Printed Name
Page 1 of 3
DO NOT WRITE BELOW THIS LINE
SUB TYPES
Foundation
— Single Family
Multi
01 of Plex
Accessory Building
WORK TYPES
New
Addition
Alteration
Replace
Retaining Wall
DESCRIPTION
Valuation
Plan Review
(25%_ 100%_✓)
Census Code
# of Units
# of Buildings
Type of Construction .43
Fireplace
Garage
Deck
Lower Level
Interior Improvement
Move Building
Fire Repair
Repair
4'34
i
J
Porch (3 -Season)
Porch (4 -Season)
Porch (Screen/Gazebo/Pergola)
Pool
Siding
Reroof
Windows
Egress Window
J5 w
Storm Damage
Exterior Alteration (Single Family)
Exterior Alteration (Multi)
Miscellaneous
Demolish Building*
Demolish Interior
Demolish Foundation
Water Damage
*Demolition of entire building — give PCA handout to applicant
Occupancy
Code Edition
Zoning
Stories
Square Feet
Length
Width
REQUIRED INSPECTIONS
Footings (New Building)
Footings (Deck)
Footings (Addition)
Foundation
Drain Tile
Roof: Ice & Water Final
Framing
Fireplace: ,$-Rough In Air Test „Final
Insulation
Sheathing
Sheetrock
Reviewed By:
RESIDENTIAL FEES
Base Fee
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
Copies
TOTAL
3517 ®O
.z36'=
1
MCES System
SAC Units
City Water
Booster Pump
PRV
Fire Sprinklers
Meter Size:
Final / C.O. Required
Final / No C.O. Required
y HVAC _ Gas Service Test Gas Line Air Test
Other:
Pool: _Footings _Air/Gas Tests _Final
Siding: _Stucco Lath _Stone Lath _Brick
Windows
Retaining Wall: _ Footings _ Backfill _ Final
Radon Control
Erosion Control
, Building Inspector
Tome/0
Page 2 of 3
JUL/09/2012/!ON 01:54 PM City of Eagan
4,11' City of Eaall
Date:
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Tenant:
FAX F1e.851-975-5694
r
P. 001/KI
Use BLUE or BLACK Ink
For Office Use 7
Permit* L3)
3'17
Permit Fee:
Date Received:
Stall:
2012 RESIDENTIAL PLUMBINGPERMIT APPLICATION
�.- Site Address: ISOO Stle-rWoDr+` WAc�
Suite*:
RESIDENT I OWNER
CONTRACTOR
came: 14" 4. L&/)A. Rme -Hon Phone:
Address / City / Zip: IS -OD S% �7A^� CAi•�✓
-
Name: PreC1S'i on ?ItAarlini 14(,x' ine ..1 -pie . License #:
4
Address: 1)//0 j%%'.,�!/IUe r NC City: S. milJA4
State: /i%/(/ Zip: .5 5-37(, Phone: 70-L417- 748
Contact: mi ka Tor CM Email: r feCtSion til rrit 2C e_A4j
j/L'Ote
TYPE OF WORK
x New Repta
_ Repair
Workment
Rebuild _Modify Space Work
R.O.W.
_
Description of work:
_
PERMIT TYPE
RESIDENTIAL
Water Heater
1 PVB)
Water Softener
Lower Level)
Lawn Irrigation (_ RPZ
I Add Plumbing Fixtures (_ Main 1 !
_
Septic System
— Water Turnaround
New
Abandonment
RESIDENTIAL FEES:
$50.00 Minimum Water
$60.00 Lawn Irrigation
$60.00 Add Plumb ng
'Wetter Tumaround
$105.00 Septic System
Heater, Water Softener,
(includes $5.00 State Surchlrge)
Fixtures, Septic System Abandonment,
or Water Heater
Water
is required)
crudes County fee
and Softener (includes $5.00 State Surcharge)
Turnaround' (includes 55.00 State Surcharge)
and $5.00 State Surcharge)
TOTAL FEES $
(add $189.00 if a 5/8" meter
New ($10.00 per as built) (i
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground Ally damage.
Call 48 hours before you intend to dig to receive locatds of underground utif&es, www.gopherstateon ce i .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 permll, out only an ipplicaiion tor a penult. and work is not to start without a permit; that lite work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
x Y11 l kG ) OWe41
Applicant's Printed NameJ
x ' `��
App ' ant's Signature
FOR OFFICE USE
Reviewed By: Date:
Required Inspections: _Under Ground Rough -in Air Test _Gas Test Final
Z'd Z5OLL6b£9L
6uigwnld uoisioaid d80:£0 ZI. Ol Inr
PERMIT
Permit Type: Building
City of Eagan
Permit Number: EA105279
Date Issued: 07/06/2012
Permit Category: ePermit
Site Address: 1500 Sherwood Way
Lot: 13 Block: 2 Addition: Pinetree Pass 6th
PID: 10-57665-02-130
Use:
Description:
Sub Type: e-Fireplace
Construction Type:
Work Type: Gas Fireplace (new)
Description:
Census Code: 434 -
Occupancy:
Zoning:
Square Feet: 0
Improvements to the home may require smoke detectors in all bedrooms. Chimney / flue must be inspected prior to concealing.
Comments:
Carbon monoxide detectors are required by law in ALL single family homes.
BL - Base Fee $3K $88.50 0801.4085
Fee Summary:
Surcharge - Based on Valuation $3K $1.50 9001.2195
Valuation: 3,000.00
Total:
$90.00
Contractor: Owner:
- Applicant -
Twin City Fireplace Kenneth M Huetten
6916 Washburn Ave S 1500 Sherwood Way
Richfield MN 55423 Eagan MN 55122
(612) 282-2684
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.
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA122882
Date Issued:05/21/2014
Permit Category:ePermit
Site Address: 1500 Sherwood Way
Lot:13 Block: 2 Addition: Pinetree Pass 6th
PID:10-57665-02-130
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:One Window/Door
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 by law in ALL single family homes .
Valuation: 500.00
Fee Summary:BL - Base Fee $500 $40.00 0801.4085
Surcharge - Based on Valuation $500 $0.50 9001.2195
$40.50 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 -
Kenneth M Huetten
1500 Sherwood Way
Eagan MN 55122
(651) 447-3292
Pella Northland
15300 25th Ave N #100
Plymouth MN 55447
(763) 355-1300
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA167611
Date Issued:03/23/2021
Permit Category:ePermit
Site Address: 1500 Sherwood Way
Lot:13 Block: 2 Addition: Pinetree Pass 6th
PID:10-57665-02-130
Use:
Description:
Sub Type:Residential
Work Type:Alteration
Description:Fixtures
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.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Building Code).
Fee Summary:PL - Permit Fee (miscellaneous)$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 -
Kenneth M & Lana M P Huetten
1500 Sherwood Way
Eagan MN 55122
Boevaag Plumbing
P.O. Box 1257
Prior Lake MN 55372
(952) 292-1511
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA167952
Date Issued:04/05/2021
Permit Category:ePermit
Site Address: 1500 Sherwood Way
Lot:13 Block: 2 Addition: Pinetree Pass 6th
PID:10-57665-02-130
Use:
Description:
Sub Type:Residential
Work Type:Alteration
Description:Stove
Comments:Please call for a Rough In and Air Test, prior to the Final Inspection.
Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Pete DeGrood at (507)
210-0754.
Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088
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 -
Kenneth M & Lana M P Huetten
1500 Sherwood Way
Eagan MN 55122
Sundown Heating And Ac Llc
26187 Busch Drive
Belle Plaine MN 56011
(952) 412-1446
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA177213
Date Issued:06/21/2022
Permit Category:ePermit
Site Address: 1500 Sherwood Way
Lot:13 Block: 2 Addition: Pinetree Pass 6th
PID:10-57665-02-130
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:Does not include skylight(s)
Census Code:434 - Residential Additions, Alterations
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please print pictures of ice and water protection and leave on site.
If water damage is encountered, please call (651) 675-5675 to schedule a site visit to verify the extent of the damage. Any
repairs must be inspected prior to covering. The inspector will determine if an additional permit will be required to repair the
water damage.
Valuation: 5,000.00
Fee Summary:BL - Base Fee $5K $118.00 0801.4085
Surcharge - Based on Valuation $5K $2.50 9001.2195
$120.50 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 -
Kenneth M & Lana M P Huetten
1500 Sherwood Way
Eagan MN 55122
NMC Exteriors & Remodeling
14505 21st Ave N, Suite 226
Plymouth MN 55447
(763) 244-2961
Applicant/Permitee: Signature Issued By: Signature