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1386 Towerview RdCASH RECEIPT CITY OF EAGAN P. 0. BOX 21-199 EAGAN, MINNESOTA 55121 DATE 1! RCQlinvim -3FROM f !i AMOUNT $ v ?I xU -& _DOLLARS seo ? CASH Q-C"eCK row /?,,. FUND CODE AMOUNT 1 Thank You By White-Payers Copy Yellow-Posting Copy Pink-File Copy CITY OF EAGAN 9 7 5 0 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 BUILDING PERMIT Receipt TT'T' 4 Site Address 1386 TOWERVIEW ROAD Lot 02 Block 30 Sec/Sub. SECT. 10 Parcel No. 100' OF 10-01000-020-30 Name TOLLEFSON BLDRS. Address 1655 NORWOOD DRIVE City PAGAN phone 454-6873 Erect ?3 Occupancy R-3 Remodel ? Zoning R-1 Repair ? Type of Const. V Enlarge ? No. Stories Move ? Length 70 Demolish ? Depth 2 f Grade ? Sq. Ft. Name ?; AM E b` Approvals Fees Add Assessment Permit 340.00 ress u City Phone Water b Saw. Surcharge 34.50 Police Plan check 17 0 . 0 0 'W Name Fin SAC 525.00 U0 Address Eng. Water Conn. 470.00 <W City Phone Planner Water Meter G 3 . U U Council Rood Unit 260 - 00 I hereby acknowledge that 1 have road this application and state that Bldg. Offl 1 2 7 8 4 Parks the information is correct and agree to comply with all applicable APC T t l 1 862 5 o a , - 0 State of Minnesota Statutes and City of Eagan Ordinances t V D ar. a e Signature of Pertnittee A Building Permit is issued to: TOLLEFSON BLDRS. on the express condition that all work shall be done in accordance with all ovOicable State of Minnesota Statutes and City of Eagan Ordinances. Building Official // Permit No. Permit Holder Dab Plumwno 2 Id I a Q g ?( `{ -( y H. V A.C. 6,- Electric softener Inspection Date Insp. Other Footings Zt? (? Foundation Framing Rough Plbg. ?. Rough HVA A> ? 5- S Insulation Final Plbg. Final HVAC Final l Cert/Occ. Water Describe Location: Mll Sewer Pr. Disp. Receipt f PLUMBING PERMIT • Permit No. CITY OF EAGAN Fee Fill in numbered spaces S/C Type or Print legibly Ti, o 1. Date 2. Installation Cost ~ Y k T 3 J L B ob Address ot l . . ract 4. Owner <:- 5. Contractor -,v Ph one - ` 6. Address `r .° • / _ _ i 7. City State ,v Zip 8. Building Type: Residential © Commercial ? Institutional ? 9. Work Description: New ED- Add ? Alter ? Repair O TO. Describe 1,4. No. Fixtures No. Fixtures Water Closet Cesspool/Drainfield Bath tubs Septic Tank Lavatory Softner Shower Well Kitchen Sink Urinal/Bidet Othe Laundry Tray r ; uA A . Floor Drains l Drinking Ftn. ? Slop Sink Gas Piping Outlets 12. 1 hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : ; for Rough Final In$pections. Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-8100 Receipt 1. Date f L- 2. Installation Cost 3. Job Address Lot 4. Owner ?•?s-?? t =? ?[V S 5. Contractor K 6. A 7. City A State i 8. Building Type: Residential Commercial 11 9. Work Description: New) Add ? Alter 10. Describe Fi 1 11. Tract / _ Zip -'•-?l tutional ? Repair ? Type No. Equipment BTU - M. Ea. Forced Air No. Equipment CFM Air Handli : Mfg. ng Boilers Mfg. Mech. Exhaust Unit Heater Mfg. Other Air Cond. Mfg. ! Gas, Piping Outlets / 12. I hereby certify"that the above i or n is true and correct, and I agree to comply with all ordinances an overnin9, his type of work. Signed : ` for o Final Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-8100 MECHANICAL PERMIT ?ermit No. 1 SpY CITY OF EAGAN Fes Fill in numbered spaces S/C Type or Print legibly Tot.. s ITY OF EAGAN 0 Pilot Knob Road P. O. Box 21199 Eagan, MN 55121 I Zoning: col Owner: Address. Re Address: - Sa Plumber: `Z WATER SERVICE PERMIT PERMIT NO.: 1 _ DATE: 1 _ No. of Units: IV c7 7 4 on Charge: Meter No.: i pci 15. 00 7 D by Deposit: 'Rea No.: 62 g b 30 Permit Fee: .50 pd agree to a mpliy w" the City of swim Surcharge: 63 0t1 nd meT F, t?ayaaes . Misc. C;horges: . Total: Date Paid: By e of Insp.: _ Insp.: TER SERVICE PERMIT CITY OF EAGAN WA 3830 Pilot Knob Road 9 '- PbRMIT NO.: 9 P. O. Boz 21 Eagan, MN 55121, DATE: 1 I No. of Units: Zoning: Tol l of son i3u ild er s Owner: Address 1396 Tawerview : Tor L02 B30 Sec Sih Address {;CilZ T'.yan 00 d 470 Plumber. : wr No M . Connection Charge: 15 09 ? . a ? Account Deposits i,i0 Size: Reader No.: Permit Fee: c ?} cl . r 1 alms to empk rhill 111110 COY of laws Surcharge: 63.00 d ret c' Misc. Charges. Total: Dote Paid: BY trap., nsp.: Date of IMP.: CITY OF EAGAN SEWER SERVICE PERMIT 3830 Pilot Knob Road PERMIT NO.: P. O. Box 21199 DATE: Eagan, MN 55121 1 No. of Units: Zoning: l d Owner: ss. 386 Towerview m ? C 1. Address: Si te Benz ltyan p Plumber 1 42 . 1 some to eewrMlp wNM tb CRf? ? BeNa Connection Charge: - Account DePoeW 0"Onea w permit Fee: ---- Surcharge ------ Misc. Charges: By Total: Dote of I nsp : Dote Paid: ?_ RESIDENTIAL BUILDING PERMIT APPLICATION u b 5? CITY OF EAGAN 3830 PILOT KNOB B RD RD - 55122 651-681-46757, rib New Construction Requirements RomodellReoelr Requirements (/ • 3 registered site surveys showing sq. ft. of bt, sq. IL of house; and L11 roofed areas • 2 copies of plan (20% maximum IN coverage allowed) • l set of Energy Calculations for heated additions • 2 copies of plan showing bears & window saes; poured found design, etc.) • 1 site survey for exterior additions & decks • l set of Energy CalaAations • indicate if horse served by septic system for addNions • 3 copies of Tree Preservation Plan if lot platted after 711193 • Rim Joist Detail Oplons selection sheet(bldgs with 3 or less units) DATE Zl31leol ? VALUATION Zd SbLw Zr X120 0 JOB SITE ADDRESS IF MULTI-FAMILY BUILDING, HOW MANY UNITS? PROPERTY OWNER Zi'- '///le' n Zt> eOJe_° /.lri1 TYPE OF WORK-Roo rli-jg FIREPLACE(S) _ 0 _ 1 _ 2 APPLICANT /tJi !1 ti Z/__ llOL- PHONE# 1,41,< -/- Z20y ADDRESS Sti -vr'r ZIPCODE S??zl PAGER # FAX # NIEW RESIDENTIAL BUILDING ONLY - FILL OUT COMPLETELY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY I (check one) - Residential Ventilation Category 1 Worksheet Submitted - Energy Envelope Calculations Submitted MINNESOTA RULES 7672 New Energy Code Worksheet Submitted Plumbing Contractor: _ Plumbing System Includes: Mechanical Contractor: _ Mechanical System Includes: Sewer/Water Contractor: Air Conditioning Heat Recovery System Fee: $90.00 Phone # Fee: $70.00 Phone # All above information must be submitted prior to processing of application. 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 Ordinances. Signature of Applicant W o? CELL PHONE # _ Water Softener - Water Heater _ No. of Baths _ Phone #: Lawn Sprinkler No. of R.I. Baths Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 1101 OFFICE USE ONLY ? 01 Foundation ? 02 SF Dwelling ? 03 01 of _ plex ? 04 02-plex ? 05 03-plex ? 06 04-plex ? 07 05-plex ? 13 16-plex ? 08 06-plex ? 16 Fireplace ? 09 07-plex ? 17 Garage ? 10 08-plex ? 18 Deck ? 11 10-plex ? 19 Lower Level ? 12 12-plex Plbg_Y or _, N ? 20 Pool ? 21 Porch (3-sea.) ? 22 Porch/Addn. (4-sea.) ? 23 Porch (screened) ? 24 Storm Damage ? 25 Miscellaneous ? 30 Accessory Bldg ? 31 Ext. Alt - Multi ? 33 Ext. Alt - SF ? 36 Multi ? 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 Census Code SAC Units Nbr. of Units Nbr. of Bldgs Type of Const Footings (new bldg) Footings (deck) Footings (addition) Foundation Drain Tile Roof _ Ice & Water _ Final Framing Fireplace - R.I. -Air Test -Final Insulation Occupancy MC/ES System Zoning City Water Stories Booster Pump Sq. Ft. PRV Length Fire Sprinklered Width REQUIRED INSPECTIONS Final/C.O. Final/No C.O. Plumbing AVAC _ Other Pool _ Ftgs _ Air/Gas Tests - Final Siding _ Stucco _ Stone Windows (new/replacement) Approved By Base Fee Surcharge Plan Review MC/ES SAC City SAC Water Supply & Storage S&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total Building Inspector This request void 1 S q O rronths b/?m ° Yl 1 8 7 It o 1-I r74 5 y9.5'0 Request Dale Fire No. Rough"n Inspection Regwredl ?Ready Now Will N0Uty Inspec- Yes ?No or When Ready ,Licensed Elece++eEl Contractor 1 hereby request inspection of above ?Owner electrical work installed at: Street Address, Box or Route No. City etion No. Township Name or No. Range No. County Occupant (PRINT) Phone No q ,Ll - 0;873 Power Supplier Address Elec ncaI Contractor (Company Nnme) / S C 6,9RZ R I C Z ii c.. Contractors License No. bu 15 8 5 3 MaihnB Address (Contract or Owner Making insta ila ti I ? ? ry) 1s5,? i <::,,l AuMorized Signature ontra Owner Maki Installatmnl Phone Number (4 q-- (530 THIS INSPECTION REQUEST WILL NOT MINNESOTA STATE BOARD OF ELECTRICITY 821 UMidway Bldg. Room RE ACCEPTED RV THE STATE BOARD 1 UNLESS LESS PROPER INSPECTION FEE IS 1821 University Ave., , St. Paul, MIN MN 55104 ENCLOSED. 16121 7979111 REQUEST FOR ELECTRICAL INSPECTION E- _ v1 'See instructions for complei me 1lisfrnm on bock of yellow copy. 0 6187' "X" Below Work Covered by This Request MM" Add Rep- Type of Building Appliance. Wired Equipment Wired Home Range Temporary Service Duplex ' Water Heater Lighting Fixtures Apt. Building Dryer Electric Heating Commercial Bldg. Furnace Silo Unloader Industn al Bldg. Air Conditioner Bulk Milk Tank Farm Other peu v Dire, Ispedtyl thor Specify Other OthuF Compute Inspection Fee Below 0 Fee Service Entra nce Srze n Fee Feeders/Subteeders g Fee Cucuits 0 to 200 Am 2s 0 to 30 Amps 3 3J•? 0 to 30 Am s Above 200 Amts 31 to 100 Amps E3.o 31 to 100 Ai Swinmi ng Pool Above 100-Amps Above 100 Amps Transformers Irrigation Booms S Partial.'Other Fee Signs Special Inspection ? r $ ??---? Renerks g N, TOTAL-FtE / rl li -. , t r /f Rough-in D_tte the lE'"eical/ Inspector, hereb certify that the above Firtal D;l a inspectr on has been LL 3 Lr made. ?n.. -a.nldfR.,ahnfrom ALL CONTRACTORS MUST BE LICENSED WITH THE CITY OF EAGAN INCLUDE © SETS OF PLANS, (? © CERTIFICATES OF SURVEY n 6 ?{ Q SET OF ENERGY CALCULATION I l ? To Be Used For: Valuation: (?2 OBI Date: Site Ad d r ees - /.J 7? • • ? / p L ot: --Xoc /Sub: Erect: X Occupancy: Parcel #:IyesT-/DO a1 /D-o/oa9=Rl Remodel: 2n Repair: Zoning: Type Of Const: Enlarge: # Stories: Owner:, Move: Length: -70 Address: Demolish: Depth: 2(n City/Zip Code: Grade: Sq. Ft.: Phone #: Contractor: -ol4am, &Vjzz z Address: L? NovWaa? I??J City/Zip Code: _ Phone #=AEM4 3 _,... Ar c h..,/,,E ng,: Address:' City/Zip Code: Phone#: Assessments: Water/Sewer: Police: Fire: Engr.: Planner: Council- Bldg. Off.: APC: Variance: Permit: Surcharge: Plan Rev.: 1-10.= SAC: 251= Water Conn: 4-10.= Water Meter (v 3. Road Unit: 2GO.°-` Parks: 0-30. 1 9&2.50 CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454.8100 BUILDING PERMIT Receipt # N° 9750 To bo used for Site Address 1386 TOWERVIEW ROAD Lot 02 Block 30 sec/Sub. SECT. 10 Parcel No. W- 100' OF 10-01000-020-30 Erect ?3• Occupancy R-3 Remodel ? Zoning R-1 Repair ? Type of Const. V Enlarge ? No. Stories Move ? Length '_ Demolish ? Depth - :? 6- Grade ? Sq. Ft. Approvals Fees $ Name TOLLEFSON BLDRS. zz Address 1655 NORWOOD DRIVE. City EAGAN Phone 454-6873 0 o Name _ u Address Assessment Permit 340-00 U City Phone Water 8 Sew. Surcharge 34 - S 0 Police Plan check 1 70 . 00 W ?w Name Fire SAC S 7 S_ 0 0 ?? Address Eng. Water Conn. 47n _ fl 0 <W City Phone Planner Water Meter 63 00 - Council Road Unit 960 00 I hereby acknowledge that I .ve read this applicati on and state that Bldg. Off1 1, 7 84 ' Parks the information is correct State of Minnesota Statu s agree to comply w ity o1 Eagan _ h oll opplic ble PC rdinarr es. Total A? Var. Date Signature of Permittee A Building Permit Is issued to: TOLL N BLDRS on the express condition that all work shall be done in accgfdbnce with all cAWicoble State of Minnesota Statutes and City of Eagan Ordinances Building Official, CITY OF EAGAN Remarks Addition LUNKA ADDITION Lot 7- Blk 1 Parcel 10 4 300 010 01 Owner '),", , ?V <arce; st;eet 1386 Tower-view Road scare Eagan, NN 55121 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK ,9-1 1970 all asses menu id der ri nal el 030 • SEWER LATERAL 919' 1975 WATERMAIN • WATER LATERAL 1975 WATER AREA STORM SEW TRK %8 1984 STORM SEW LAT o _1984 CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. BUILDING PER. SAC PARK Tollefson Builders Inc. fnr Lnnka JACKSON - SURVEYORS Scale: 1H 301 REGISTERED UNDER LAWS OF STATE OF MINNESOTA • Denotes Iron 3616 EAST 55th STREET, MINNEAPOLIS, MN 55417 727-3484 =Drainage Existing Elevations *urht*'% Certificatt Oe.11577 188-14 ? I J J I I ` I / - fi` __ L ?y ?? r r '` y \ / 13' 1 I N Proposed Garage Floor Elev. 98.0 ?\ ZG' S ? 0 3 0 ' m t, \ 41 C 2G' I \ I I I ?? Ih \ I V I N I HER Y CERTIFY THAT THE A8OVE IS A TRUE AND CORRECT PLAT OF A SURVET OF I 1 /. n G ai: o f S W, ?.?t e f N W, ?-y, I r I The East 100.0 feet of the West 328,2 feet of the North 199.63 feet of the Southwest 1/4 of the Northwest 1/4 of Section 10,Township 27, Range 23,containing 0.458 acres,reserving therefrom the North 33.0 feet for a road easement. All in Dakota County and State of Minnesota. AS SURVEYED SY ME THIS-_24th. DAY 10-27-23 Nov. A D 1984 QED F. C. JACKSON. REGISTRATION, NO. 3600 CITY OF _ BUILDING DEPARTMENT EXTERIOR ENVELOPE AVERAGE 'lull C014PUTATION (To be submitted with building permit application) One or Two Family Dwelling 4- Owner All Other Site Address Contractor TO(.tEsotJ ?VIG 2S iNe. RAlu # 4-szcp LINEAL FEET OF ? 1) 11 L EXPOSED WALL Ei: lt'oeK 7d6MT ft• 0?AQUE WLLL COP'STRUCTION: "u" Value x Area Date Phone above grade = 1 ? PjSZ• 00 TOTAL EXPOSED WALL AREA SQ. FT. 1 ;R,gWE flUfl .043 x SQ. De tail 6VA'O+' "U" 098 x Sq. reference Rim SoISr "U" . a4D x SQ. from nun x SQ. attached Ilpn x SQ. sheets nU" x SQ. WINDOWS: "U" Value x Area FT. / D .O . (00, (U) (A) FT. /e4.5z= o,z (U)(A) FT. IZ4.49= 5_474U)(A) FT. _ (u)($) FT. _ (U) (A) FT. _ (U) (A) Make 8& Type iw94• ded-r "u" x SQ. FT. 2. O = S$. (U) (A) It " "U" x SQ. FT. _ (U) (A) It to nufl x SQ. FT. _ (U )(A) n u fluff x SQ. FT. _ (U)(A) DOORS: "u" Value x Area :[ate & Type kEac /AISVL• "U" .14 x SQ. u If PATIO nun , 48 x SQ. it u flue x SQ. n n nun x SQ. TOTALS 185Z.00 SQ. AVERAGE "U" TOTAL (U)(A) VALUES M- 07 = . OB(o DIVIDED BY TOTAL WALL AREA AVERAGE "U" ,11 r less for 1&2 family dwellings ROOF/CEILING: TOTAL AREA: _ 13Z3.0a FT. 47, (U) (A) FT. 42,00= (U) (A) FT. - (U) (A) FT. - (U) (A) FT. /(vl•O7 (U) (A) Detail reference "U" •OZI x SQ. FT. 1323 7•7 M(A) from nun x SQ.-FT. . (U)(A) attached sheets. fluff x SQ. FT. ZZ (U)(A) Describe openings "U" x SQ. FT, _ (U)(A) in roof. fluff x SQ. FT. _ (U) (A) TOTAL (U)(A) VALUES DIVIDED BY Z7.7F? TThI.47 1373, 07.7$ (L)T> TOTAL ROOF/Cg dG AREA 13 Z Tj AVERAGE "U ,025 for ventilated roofs. II f,?v?K ?7?E?T d G? ?X PcSCD w4u- 9• Sd x (48 +48 t 30-t 30) = _ 9•oc x ( z4 f"24 + Z(O) 1482. o0 ' 370.00 IgSZ. oo ?- Cone, . 4o7X (+Ft'4.81- 3o t 3v? 104-. sz • g3 X (48t48t 3oi-3?? _ /Z9-¢8 ?-'_ . WIWAVwCi WxB&= 4.o x a Zvx -3 = S•o X 4 = ZA-X g, = , 6, v x Z. ZoX (oo = 8• x 4 =- ;4x48 = S.o x (o = B.oo 0D on. lZ • ao ; . . ?3.ZV /z/• zo-?E- . ?oop- ri C,TC. W/S,L, - ZS•ov Z 57m• sEn. = Zl•o0 (off pi?'fr0 = 4Z,oo ; . ?E? EXP?yD W/1GC_ E-?tvfK.S ??`? ?A?- /SS2.OP9 G?sS Gouc, /o¢,sz ?? Rr? n c?ArS /29.48 izr. zo -49Z 0(0 8? od? z1xz(o _ ZgX Z8 - !07 z (?.s X Z = 27 1, 3z3.oo?- -t WALL SECTIO -- Determining "U" values at Roof, Wall, Rim, and Conc. Block ROOF/CEILING 1.) Interior Air r'ilm 2.) 5/8,, Gyp. Bd. 3.) Insulation 4.) 5.) Exterior Air Film (STILL) (R) VALUE 0.61 .56 44 CFO .61 "U" = I /R= • OZ I iOTAL (R)= 49.7$ WALL 6.) Interior Air Film 7.) 1" Gyp. Bd. 8.) Insulation 9.) Z54Z!l Sw(S ?' 10.) Masonite Siding 11.) Exterior Air Film (R) VALUE o.68 .45 /?.00 Z•O4 .60 .17 °U° = 1/R= .0¢3 TOTAL (R)=Z3.o1 RIM 12.) Interior Air Film 13.) Insulation 14.) 211 Fir Rim Joist 15.) ZS/.'Z!l sv1tT-9i17; 16.) Masonite Siding 170 Exterior Air Film (R) VALUE 0.68 19•oO 1.88 Z•04 .67 .17 nUn = 1/R= ,bcJO TOTAL (R)=0411 FOUNDATION 18.) Interior Air Film 19.) 20.) 21.) 12" Concrete Block 22. ) 91G1b /A*4,.11-• 23.) Exterior Air Film (R) VALUE o.68 1.28 $•v0 .17 ?iUn = 1/R= .07$ TOTAL (R)= fO.?? 1 )w j 2/84 (Jc) ?J CITY OF EAGAN iCl?. wit APPLICATION FOR PERMIT SEWER AND/OR WATER CONNECTION (PLEASE PRINT) 1) PROP= ADDRESS: 4)c / LEG.=,L DESC.RIPTICN: .,OT a, : / 36 -5 /O (Lot/Block/Su civisien or Tax Parcel I.D. Nu.ner) IF ST'=URE , DA= OF ORIG-=AL EUI'. nrXS :-: IT ISSN:::C: P.° SLT _^II:?/n?OPOS? USE: ?-1 SL•:GL FP}tIr - - _?. ? R-2 CL'P='.1 MID UNITS) ? R-3 TC?`:tiz rrtc^ (T ? = L =TS) T L?7? S) [I F?4 ? CCir"•SE:CI?T./:ZF^_"uL?CFFICE ? ---\DusT-R 1 ? I\'STI ^ TICC` ALiGC'v T 2) A PiIC .`T PLEASE Pn'lti i ) ADDRESS: / (e CI':Y, STATE, ZIP: PHONE: y5y 873 3) P=-Isp--, NAIME: LEASE PRINT) C A) z_ FOR CITY USE ONLY ADDRESS: /y71P, d0077f'?3AMPeT /1pw1L PLUERS LICENSE: Active CITY, STATE, ZIP: PHONE: sc7fi0 VT h7it? S?a(g ?Ifu?E. ya23-//yy PLUMi tBER LICENSE it / 8yym C Expired Q Not.Qyf Record C/X<< R arr Inttla +/ 16A..1, k'PDlL/l_,':fCltdt Irccex rnull) NAME: ADDRESS: CITY, STATE, ZIP: PHONE: 5) INDICATE WHICH PERIIT S BEING REQUESTED: TNECfION TO CITY SEWER VC1-11 ICN TO CITY :•)ATER ? OT1!ER (PI.ZASE DESCRIBE) ?l =r SE I!OLD APPROVED PERMIT FOR PICK-UP BY ONE OF AW%T Er=:,SE :TAIL APPROVED PERMIT TO 1, 2,G) 4 ABOVE _(Circle one) 7) SIG?TURE _1??????J?/(? DATE: ol(. ?! ?! 01:? X11 /ep y? i D ! ?:Ofll? f1 ? IR t:s s?.s ?/ s 1?/ iss:a :a s ! !lJ?:f? ss? s S ? ? S OCiJSY F' FOP. C I T Y US E ON LY PERMIT - ISSUED FEES: $ CO --ard SE::ER PER`?IT (I`?CL O SURCEARGE) $ /D. WATER PERMIT (I:iCL DE SURCHARGE) $ (1... F WATER METER/COPPERHORN/OUTSIDE READER $ WATER TAP (INCLUDE CORPORATION STOP) $ SE',iER TAP S ?S • ?-° ACCOUN T DEPOSIT W.ZT_== $ 70 ~? WAC S <?? ? -? rJ Si:C $ TRUNK :MATER ASS--SS:!=-.':T S TRU:iK SEi'iER ASSESS:-iE?;T $ LATERA L BENEFIT/TRUNK SEidER $ LATERA L BENEFIT/TRUNK WATER $ OTHER $ TOTAL $ A iOL.:T PAID "RECEIPT DOES UTILITY CONNECTION REQUIRE EXCAVATION IN PUBLIC RIGHT OF WAY? YES IF YES, THEN A "PERMIT FOR WORK WITHIN PUBLIC ROADWAY" MUST BE ISSUED BY THE NO ENGINEERING DIVISION. LIST AS A CONDI- TION. SUBJECT TO THE FOLLOWING CONDITIONS: APPROVED BY: TITLE: DATE : f ?.'5 ?is?wfm wMa m"w ntmw ww wwwwwfJ{ Won WkmRa wm:# 4ofs Rm wl w w5r wa www SAwm