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983 Stony Point Rd ~ << ~ CITY OF EAGAN ' ~ ~ 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PH O N E: 454-8100 BUILDING PERMIT Receipt# To be used for ~ Est. Value '~t ~ Date `='lY' c• ~9 , Site Address OFFICE USE ONLY c. i i~ ~ i• i; On Site Sewage Occupancy s Lot BloCk Sec/Sub. ; 1 MWCCSystem Zoning Parcel No. 'rn On Site Well (Actual) Const .i),ti'~'! : C'G7. i. City Water ~ ~itt s Name (Allowable) W PRV Required # of Stories 3 Address o ~ _ ~ ; Booster Pump Length ~'`a Ciry Phone Depth °C Ngme S.F. Total ~O O~ Address FootprintS.F. City 'Phone APPROVALS FEES Engr./Assess. Permit y k~ ~ W W Name ~$p ~ Z Planner Surcharge ~ ~ Address ; , ; , L~ Council Plan Review a W City Phone Bidg. Off. SAC, City Variance SAC, MWCC " I hereby acknowledge that I have read this application and state that the `4 i S.~ information is correct and agree to comply with all applicable State of Water Conn. Minnesota Statutes and City of Eagan Ordinances. ~ U~, V(j Water Meter Signature of Permittee ~ Road Unit i~ A Building Permit is issued to:_ " ~ ' ' 1 Treatment P1 on the express condition that all work shall be done in accordance with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Parks Building Official TOTAL Permit No. Permit Holdsr Date Telephone # Piumbing ~ ~ j; ~ ~ ~J ~ ~ I'S.V.AC. ' : ~ ~ !G,~J J~h rl ' y,' - ~ u_ ~14 .c /;C%Jr_< Ii~. . Electric "'•1,1 f' i li rj `'Y'.;F' 1 ~ -y'~~ ~ C'. .+.$.-iC _ ~ ~ .~7~ Softener Inspection Dats Insp. Comments Footings I '~~/3 ~ Footings II Foundation Framing Roofing Rough Plbg. `f,3 ~ Rough Htg. ~ s ~ Isul. ~a i Fireplace Final Htg. ~ Final Plbg. ~ f Bidg. Final Cert.Oca % Temp. LP Deck Ftg. Deck Final Well Pr. Disp. . : , , . PERMIT # C~ ~1 `-1 : PLUMBING PERMIT RECEIPT q CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: 7 CONTRACT PRICE: PHONE: 454-8100 Site Address f ~ ! c-• ~ BLDG. TYPE - WORK DESCRIP710N Lot Black Sec/Sub Res. ~~Y~ New - MuIL Add-on ~ Name Comm. Repair ~ Address - ~ Other c City Phone '4 RES. PLBG. ONLY - COMPIETE THE FOLLOWING: NO FIXTURES TOTAL ~ ~ f' ~Water Closet - $3.00 ~ ~ Name ~ga~h Tubs - $3.00 3 Address G t ~tavatory - $3.00 -p City 1~~ i-r i ~i ~/i ~ . Phone i Ji~ ~ - -~Shower = $3.00 . - - Kitchen Smk - 53.00 FEES Urinal/Bidet - 5300 , COMMlIND FEE - 1% OF GONTRACT FEE -LLaundry Tray -$3.00 APT. BLDGS - COMM RATE APPLIES ~Floor Drains -$1.50 TOWNHOUSE 8 CONDO - RES. RATE APPLIES ~_Water Heater - 3~.50 MINIMUM - RESIDENTIAL FEE - $12.00 Whirlpool - ~3.00 MINIMUM - COMM/IND FEE - $20.00 -LGas Piping Outlets - $1.50 , ' ~ STATE SURCHARGE PER PERMIT - .50 (MINIMUM - 1 PER PERMI~ (ADD $.50 S/C IF PERMIT PRICE GOES Softener -$5.00 BEY9t~lC~$1,000.00) ~ Well -$10.00 ~ > ~Private Disp. - 510.40 j~.~ : Rough Openings - $1.50 y ` -~~,'d`ti-." , -~l-! ".;rjr. ~ ~IGNATURE OF PERMITTEE FEE: ~ ' ~ STATE S/C: FOR: CITY OF EAGAN GRAND TOTAI: - , , PERMIT # f ` MECHANICAL PERMIT RECEIPT # ~ r ~ CITY OF EAGAN , ~J ~ ` ` 3630 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: - CONTRACT PRICE: , PHONE: 454•8100 Site Address ` k=~ BLDG. TYPE WORK DESCRIPTION Lot Block ' Se~ ~ b Res. New ~ , Name ~Z Mult Add-on ~ - Comm. Repair ~ Address ~ ~ ' c City ~ + 1 >.ti ` • Phone ~ ~ Other 1~ FEES Name LU~~ RES. HVAC 0-100 M BTU -$24.00 c Address k~'~' ~ T ~ r ADDITIONAL 50 M BTU - 6.00 p Ciry ~ Phone ' CO STRUCTION) DES A/C ON NEW GAS OUTLETS (MINIMUM - 1 PER PEHMIn - 1.50 EA. TYPE OF WORK COMM/IND FEE - 196 OF CONTRACT FEE Forced Air M BTU - r APT. BLDGS. - COMM. RATE APPLIES TOWNHOUSE & CONDOS - RES. RATE APPLIES Boiler M BTU MINIMUM RESIDENTIAL FEE - ALL ADD-ON 8 Unit Heater M 8TU REMODELS - 12_00 Air Cond. M BTU MINIMUM COMMERCIAL FEE - 20.00 STATE SURCHARGE PER PERMIT - .50 Vent CFM (ADD $.50 S/C IF PERMIT PRICE GOES Gas Piping OuUets # ' BEYOND $1,000) Other FEE ~~•V ~ } SlC: ' SIGNATURE OF PERMITTEE TOTAL: ' FOR: CITY OF EAGAN -y. . ~ ~ f~~ertif ir~tP ,af (~rr~~ttnr~ 4~itp of ~aga~t ~c~rtatrn# nf ~iu~[d'atg ,~ns~Prt~nn This Certificate issued pursuant to the requirements of Section 3Q6 of the Uniform Bui/ding Code certifying thar at the time of issuance this structure wus in canp/iance with the various ordinances oj[he Ciry regulatirrg building constructron or use. For the fo!lowing: [hc cLssifiauon %%+'~~-t = - - Eids. Ptrmic No. ' ~P~Y ~'P~ P' ZoninB Diuria f' ~ Type Cn~ntr ownnatan~~-':,i.F'f~?.1CLT`i ~h'S~ _ ~ A~ n970 1515~ :r ~ p,,;lA;~„ . ~ ;l ~ I'.' :7(~~i-y~'r(' :~5,.'41~; ~ 1/'F 17'~ i.islllA~41f 1.. ; / ! I~~l' ~~17 .....~..,b A~fE66 ~ ~ 7 } pa0e; i i!.! ~~i~.}C ~ ~ ~ ~ POST IN A CONSPICUOUS PLACE . ~ ^ - ~---r--:--.,-T-~--v-_..~ INSPECTION RECORD CITY OF EAGAN PERIVIIT TYPE: 3830 Pilot Knob Road PeRnit Number: Eagan, Minnesota 55123 Date Issued: 'i t` ~i (612) 681-4675 SITE ADDRESS: ; „ ~ . ~ ; APPLICANT: . ~ „i`! i~t?7M1 ki1 ; ; ~~~i•. i t; t rl~, J~~~1 ~~~i;,~ : 1 tl r I. I'•. s~, ' PERMIT SUBTYPE: TYPE OF WORK: ~ ' ~ rit . I I r~,, i~ trf,r ~ ~ ~ ~ i Permit Na. Permit Holder Date Telephone ~1 S/1N I PWMBING I I HVAC I ELECTRIC I ELECTRIC I Inspectlon Date insp. Commenta ~ Footings I I I I Foundation I Framfng Roofing Rough Pibg. Rough Htg. Isul. Rreplace Flnal Htg. Orsat Test Flnal Plbg. Plbg. Inspector- Notify Plumber Const. Meter Engr./Ptan Bldg. Fnal Deck Ftg. -1 Z Deck Final ~ Well Pr. Disp. ~is requesl void /G/~y /_/p~j /J' ~'S~. ~ 18 IYqnlhS IrOm Jc D/ D 3328~ - ; ~`,~o Rnquest D~IC~~- ~ Fi No. flough-In suection p Require~' ~ReaAy Niow~ Will Notity InsDec- ~Q -~3 - p 7 ,~Ves ?NO tor When FeaOy Licensed Elechical Conlrac[or I hereby requesl inspection af eEove ? Owner elecbical work ins~alled ec Street Address, Boa or Noute No. GtY 9~'3 S~oNe ,?~d E.s ~+n~ ectwn a. Township N me or No. RanBP Na~ County .r/~v/,B Occvuan~ WflINT) ' Phone No. C~ /~e G C% !rdNS'T Pawer $up0lier Adtlress .~~,~aT ~"<<~~. ~,orz~~~ Ty i~~ Elechical Conhac[or ICOmpany Name) Lontrur.tor's License No. ~i'i/.~~.7"a ~e' f_-~~t ,e, ~ Oy33Q0- Mailing ACdress (COnvactor or Owner Making Instaila~ionl /~J'1~ ~'Yv-t /ldi~ i.r/~~t.z.i~%~ /!f!// ~6aY~3 Au[horized Signature lESntr ctor/Ow aki ~*Installati~N ' Phone Num~er ~ 3~L-~s`7 .s~~ i'~ MINNESOTA STATE BOARD OF ELECTqIC~ THIS INSPECTION REQUEST WILL NOT Grie9s•Midwey BIdB~ - poom N•191 ~ gE ACCEPTED eY THE STATE BOARD 1821 Universitv Ave., St Peul. MN 104 UNIESS PROPEN INSPECTION FEE IS Phone (612) 642-OBOO ENCLOSED. REQUEST FOR ELECTRICAL INSPECTION ea-ooooi-os 1 Sae inshuctions lor como~eting this form on back of yellow cooY. y / h ~ ~~~W ~Q ~"R~' Below Work Covered by lhis Request ntlJ Fep. TVpe ot BuilGing Apoliancea Wired Equipment WireA Home fiange Teniporary Service Duplex Water Heater liyhtiny Fixtures Apt. Buildinc~ Dryer Electric HeaLn Cominercial Bldy. Pumace Silo Unloader Industrial BIAg. Air Conditioner Bulk Milk Tank farm otnei oec~ v _inm ISnenlyl ~ er SuccilV iher p~h~.:~ ampute lnspection Fee Below M iee SarviceEnVenceSine ~ Fea Feeders~5ubfeeders N Fen Circui~s ~ to 200 qm s 0 to 30 Am s 0 m 30 Am s Above 200 qmps 31 to 100 Amps 31 to 100 Am s Swimming Pool Above 100_Am s Above 100_Am~s Transiormers Irrigation Booms i Partial•"Other Fee Si~s Special Inspec[ion ~ TOTA Pemerks p V Noueh-in .P~te f ~ ~ ~ ` ~y Inspecloq heieby - rtify that tha above Fina~ ~A~ insoection has been ...5~ metla. T~k repuest vo1G 7B montM trom REStDENTIAL I~ ~ BUILDING PERMIT APPLICATION c.,/ ~ ~ CITY OF EAGAN 3830 PILOT KNOB RD, EAGAN MN 55122 651-681-4675 New Canstruction Reauirements RemodellReoair ReauiremeMs • 3 registered site surveys showing sq. R of lot sq. ft. oF house; and all roofed areas . 2 copies of plan (20% maximum lot crnerege allowed) . 1 set ot Ene~gy Calalations tor heated additlons . 2 copies a(plan slwwi~ beam & window s¢es; poured found desgn, etcJ . 1 site survey (ar extenor additimis & decks . 1 set ot Ener9y Calculatlans . Indirate if home served hy septic system (or addifions • 3 copies of Tree Preservatlon Poan if IM piatled a@er 111l93 - . Rim Joist Oetail Options selec6on sheet (hldgs with 3 or less un~s) ~ DATE ~/~~1~d' VALUATION 95~a/. a~- /d%G-aS SITE ADDRE55 /~LJMULTI-FAMILY BLDG Y ~ TYPE Of WORK ~ ~/?D .~E .POZ~- FIREPLACE(5) _ 0~ 1_ 2 APPLICANT ~zy~l~~! l ~`ct~C~~tlC~`(~ STREETADDRESS 3~~ LU'cY~1P ~VP S. ~1C~2 CITY _~i STATE~( ZIPS~_ TELEPHONE #~2'~56~• CELL PHONE # yOa~ FAX # Io~Z • `~d 22 • `(apU PROPERTYOWNER~/ ~/Y~B TELEPHONE# COMPLETE 7HIS SECTION FOR °~NEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESOTA RLZES 7690 CATEGORY 1 MIVNCSOTA RUI,I;S 7672 (J submission type) • Residential Ventilation Category 1 Worksheet Submitted • New Energy Cade Worksheet Submitted • Energy Envefnpe Catculations Submitted Plumbing Contractor: _ Phone # Plumbing system includes: _ Water Softener _ Iawn Sprinkler Tce: R90.00 _ Water Heater _ No. of R.I. Baths _ No. of Baths Mechanical Conhactor. Phone # ~ Mechanical system includes: _ Air Conditioning ~F' c: ` 0 _ Hcat Recovery 3ys[em D~~, Q,~~p2 ~ J Sewer/Water CoMractor: Phone pUG U°----- I hereby acknowledge that I have read this application, state that the information is cor~ c~d agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordina es. - Signature of Applicant ~ TdC~ ~ ~ OFP'ICr, USE ONLY Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4102 OFFICE l1SE ONLY ? 01 Foundation ? 07 05-plex ? 13 16-plez ? 20 Pool ? 3D Accessory Bldg ? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (&sea.) ? 31 Eut. Alt - Multi ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF ? 04 02-plex ? 10 0&plex ? 18 Deck ? 23 Porch (screened) ? 36 Multi ? 05 03-plex ? 71 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. ? 42 Demolish (Fo~ndation) ? 45 Fire Repair ? 33 Alteration ? 37 Demol+sh (Bldg)' ? 43 Reroof ? 46 Wi~dowslDoors ? 34 Replacement "Demalition (Entire Bldg only) - Give PCA handaut~to appllcant Valuation Occupancy MC/ES System Census Code Zoning City Water SAC Units Stories Baoster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bidgs Length Fire Sprinklered Type of Const Width REQUIRED INSPECTIONS Footings (new bldg) _ FinaUC.O. _ Footings (deck) _ FinaVNo C.O. Footings (addition) _ Plumbing Foundation _ ~A~ Drain Tile Roof Ice & Water Final _ Pool _ Ftgs _ AidGas Tests _ Final Framing _ Siding _ Stucco Stone _ Fireplace _ R.I. _ Air Test _ Fina] _ Wi~dows (new/replacement) Insulation _ Retaining Wali Approved By , Building Inspector Base Fee ~ Surcharge _ Plan Review MC/ES SAC City SAC Water Supply & Storage SB,W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total ~~S ~ RESIDENTIAL a~s ~ BUILDING PERMIT APPLICATION CITY OF EACAN 3830 PILOT NNOB RD, EAGAN MN 55122 ` a~~ 651-681•4675 New Construction Requirements RemodeVReoair Reauiremand • 3 registerea ;ite surveys snowing sq. ft. of IoL sq. ft. of house; and all roofetl areas • 2 copies of plan (20 % maximum Io1 coverage allowed) • 7 set of E~ryy Calculafions for heated aOCi~ions . 2 copies of plan s~owing 6eam 3 winCOw;izes; poured found tlesgn, etc.) . 1 site survey for eztenor additions & decks • 1 set uf Energy Calculations • Indicale i( home served by septic system for addi6ons • 3 copies of Tree Presarvation Plan if lot platted aRer 771l93 ~ . Rim Joist ~etail Optlons selection sheet (Eldgs with 3 or less unAS) DATE ~o~+~ ( O'1~ VALUATION A~~~~L-(/~ _ ~ SITE ADDRESS f D3 S O~N !L MULTI-PAMILY BLDG _Y V N TYPE OF WORKT 5 F9REt'LACE(S) _ 0_ 1_ 2 APPLICANT~`~1~~~ C'OCTI~'C~Or L(1(1 STREETADDRE55 D ~ CITY IlltinnC>~~STATE~N ZIP ~~O TELEPHONE # FJ~-. CELL PHONE # FAX #l~~~L~ ~LZ, rIDOL~ PROPERTYOWNER Lk~M~~~Q-~. TELEPFiONE# T-~~"'~!~'1~ COMPLETE FOR ~NEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ ~IIV\k:SO'f.\ RUI.ES i6i0 C:1"I'1~~GORY 1 ~1I~NESO"C:1 RULI:S 767`? (J su6mission type) • Residen[ial Ventilation Cate9ory 1 Worksheet Submitied • New Energy Cotle Worksheet Submitted • Energy Envelope Calculations Submitted Plumbing Contractor: Phonc # _ Plumhing syste~n includcs: Walcr Softcner I.a~m Sprinl:ler e2,`~~ 00 _ Water Heater iVo. of~ R.I. B ~~~2 ~ ~S 1~1~t No. oF Batkis Q-~~~ 3 ~ ZQp2 ~ Mechanical Contractor: Phone V[cch.uiic.il sy'sLcm includcs: Air Condilionitig Pcc:~:b~f~. - I-[cat Rccovcry S}•stc~n gy' ^ Sewer/Water Contractor: Phone # I hereby acknowledge that I have read this application, state that the in(ormation is correct, and agree to comply with all applicoble State of Minnesota Statutes and City of Eaga O~ir~ nces. Signature of Applica OFFICE USE ONLY Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4/02 OFFICE USE ONLY ? 01 Foundation ? 07 05-plex O 13 18-piex ? 20 Pool 0 30 Accessory Bldg ? 02 SF Dwelling ? 08 06-plex ? i6 Fireplace ? 21 Porch (3-sea.) ? 31 E~. Alt- Multi ? 03 Ot of _ plex ? 09 07-plex ? 17 Garage ? 22 PorchlAddn. (4-sea.) ? 33 EM. Alt - SF ? 04 02-plex ? 10, 08-plex ? 18 Deck O 23 Porch (screened) ? 36 Multi ? 05 03•plex ? 71 70-plex ? 19 Lower Level ? 24 Stortn Damage ? O6 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. ? 42 Demolish (Foundation) ? 45 Fire Repair ? 33tiAlteration ? 37 Demolish (Bldg)* ? 43 Reroof ? 46 Windows/Doors ? 34 Replacement '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 W idth REQUIRED INSPECTIONS _ Footings (new bldg) _ FinaUC.O. _ Footings (deck) Final/D1o C.O. _ Footings (addirion) _ Plumbing _ Foundarion HVAC Drain Tile Other Roof _ Ice & Water _ Final _ Pool _ Ftgs _ A'u/Gas Tesa _ Final _ Framing _ Siding Stucco Stone _ Fireplace _ R.I. _ Air Test _ Final _ Windows (new/replacement) _ Insulation _ Retaining Wall Approved By , Building Inspector Base Fee Surcharge Plan Review MClES SAC City SAC Water Supply & Storage S&W Permit 8 Surcharge Treatment Plant Plumbing Permit . Mechanical Permit ~icense Search Copies Other Total r $' CITY OFXAGAN Permit No El ` Date ' 10:-.30 - -87 38 _ o = , • b Road Meter No: Size P O B 99; Reader No " , r Date ; 1 E M N 551 . Owner - . Co13.0Ae, titq waist. Site Address: 483 Stoiv "Point ' L4 E4 ! lAitxhigtoti Sq 7th Piumber Star Praia Conn Chg. -5.40pd " ' - Zoning. r`;= RI Acct Dep: 15.0 pd No. of Units: 1 Perrnit Fee: _ 30.O8pd [ Surcharge: .5f1ix 1 agree to comply with the City of Eagan Tr. Plant ` 180. QOpd Ordinances Meter. 67. Opd Misc.: By `1 ) 1 WATER SERVICE PERMIT 6 --- 1 CITY OF EAGAN Permit N 13 D ate : 1 C ' ` I 3330,P oad B/ I No. -,k 7 287 " - Dat ` es. i 199 _ ''--' r i -''''1-''-‘1' C. C, Eagan, MN 5512 _ Owner. lege-`City Coast. Site Address: 983 Stony Point Road I R4 Laxintoa Sq 7t1. Plumber: Stag Piurib lug MWCC:. (1114 Zoning. -1 O- d 1 1 City Chg: g" No. of Units: l 1 .8 d Acct. Dep: . UO _ 3 Z t 1 agree to com with the it of Eagan PPrntit ree: i i'u Ordinances. Surchar a >:' '� �p \ SEWER SERVI t om: = 1` Nit PERMIT City of Eagan Permit Type:Building Permit Number:EA172214 Date Issued:09/21/2021 Permit Category:ePermit Site Address: 983 Stony Point Rd Lot:4 Block: 4 Addition: Lexington Square 7th PID:10-45081-04-040 Use: Description: Sub Type:Reroof & Siding Work Type:Replace Description: 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. We encourage you to retain an electronic copy of photos until the project passes a final inspection. When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to Valuation: 10,000.00 Fee Summary:BL - Base Fee $10K $191.75 0801.4085 Surcharge - Based on Valuation $10K $5.00 9001.2195 $196.75 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 - Larry A & Laura Lamb 983 Stony Pt Rd Saint Paul MN 55123--156 Taylor Brock Corp PO Box 1704 Minnetonka MN 55345 (952) 888-2000 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA175289 Date Issued:03/25/2022 Permit Category:ePermit Site Address: 983 Stony Point Rd Lot:4 Block: 4 Addition: Lexington Square 7th PID:10-45081-04-040 Use: Description: Sub Type:Siding Work Type:Replace Description:SEE COMMENTS Census Code:434 - Residential Additions, Alterations Zoning: Square Feet:0 Occupancy: Construction Type: Comments:3/28/22 - Permit refunded. Duplicate. - sc Please leave printed pictures of house wrap on site for the final inspection. 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 - Larry A & Laura Lamb 983 Stony Pt Rd Saint Paul MN 55123--156 (612) 328-5148 Taylor Brock Corp PO Box 1704 Minnetonka MN 55345 (952) 888-2000 Applicant/Permitee: Signature Issued By: Signature