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1128 Westbury Cir ÿ ÿþ ýüü ûúùÿú ùù øüüùù ïü õûüöùö å ýüõ ýüûúùøõöÞö õöúùøß öøõöÞö ãöýÝãöúùøãüêüööýößüîûöàîßüîûöýÝ ù÷ù ü àßï Þè ýú þãß åäá çìåìåá ôø ýüööÿ÷éçìäìä óÿÿò õñð øø êÛ ãùæù àøíåõûüöùòö ý ÿãß ôóåäá öûù ÿ íöøøêöîööÿöîøù øøûý êãýüòùê ÿïöì øøë üùýÿüö , • CiTY OF EAGAN 10890 3830 Pilot Knob Rosd, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 eUILDING PERMIT Receipt # T* M And fw Esf. Vol ue Dote Site Addre:: ~ 1 • ~'~L1.r~Y L i~' Erect Q; Occupancy l.ot Blcek Remodel ? Zoning Sec/Su6. Percel No. Repair ? Type of Conat. ~ Additlon ? No. Stories ~ • ~ , - Mave ? Length • ~ Name W Demolish ? Depth . ; Address i•'-,' ;~Vt; Int Impc ? Sq. Ft. b City Phone ? 1 Install ? Approrals fe" Name - !1 i: v~ A~~ Asussment Permit r - City Phone Woter 6 Sew. Surcharge •3 Police Plan Revfew Name Fin SAC Address Eny. Water Conn. < W City Phone Plonner Water Meter o Council Road Unit • o'~ 1 iurcby ccknowfedfle thct I hove reod this opplicotion and stote thot gldg. Off. Tc PI. the inlormotion is conect or?d og?ee to comply with oll oppliccble APC Stdto of lvtiinnesota Stctutes and City of Eagan Ordinonces. Parks Var. Date Copies Siqnoture of Pemuttee , . . - . . . Total A Bulldiny Permit Is issued fo: . on the express condltlon tha+ oll work shotl be done in occordonca with oll opplicoble Stote of Mlnnesofa Statutes and City of Eopon Ordinonces. Buildinp Officfol ~ •ds~a '~d ~~MOg ^ IIoM d ~ ^J Y wclavoul aquac.a ~aWM `sg,..15 /--f/ 'dqld IvuId i L?~ •insul p •BZH yanoa ~ ~:1D 'Bqld 46~l1 euuooa 6ulwei.4 ~ uo~yapuno~ ~~s8upood I s6uls~d Aayip •dsu~ a4ap uol~odsul ~w~lyog C °z' 9~ ~ /a a ~ o'~''°~ C I ~ •~•v,n•H bu14WnId ~t 6uoydolal qea AOPIOH *d 'oN zlWwd ~ CITY OF EAGAN 1• 3830 Pilot Knob Road, P.O. Box 21-189, Eagan, MN 55121 BUILDING PERMIT PHONE: 454•8100 Receipt *-95 O ~J[~ To be used for Est. Value Date ,19 Site Address ~ OFFICE USE ONLY Lot Block SeC/Sub. , r. 't Riv`+' V') On Ske Sewaqe Occupancy MWQC System Zoning Parcel No. On Ske Well (Actual) Const a Name City Water (Allowable) z Address PRV Required ~ of Stories ; t ~ Booatar Pump Length 0 Ciry Phone - Depth , p Name r S.F. Total ~ 4 Address Footprint S.F. ~ City Phone APPROVALS FEES ~ a Engr./Assess. Permit W uyW Name ~ Planner Surcharge ~ ~ Address ~ W City Phone Council Plan Review Bldg. Off. SAC, City I hereby acknowledge that I have read this applicetion and state that the Variance SAC, MWCC information is correct and agree to comply with all applicable State of Water Conn. Minnesota Statutes and Ciry of Eagan Ordinances. Water Meter Signature of Permittee Road Unit A Building Permit is issued to: Treatment P1 on the express condition that all work shall be done in accordance with all Parks applicable State of Minnesota Statutes and City of Eagan Ordinances. Building Official 70TAL ' Permit No. Psrmit Holder Dats TslspAons it Plumbing r 2•c~: , H.V.A.C. Electric 5oftener Inspectlon Date Insp. Comments Footings I Footings II Foundation Framing Roofing Rough Pibg. Rough Htg. &J oz~ yQ Isul. FireplaCe Final Htg. Ffnal Plbg. Bldg. Final -2-p/ ~S Cert. Occ. Temp. LP Deck Ftg. Deck Final Well Pr. Disp. ~c f ; ' • PERMIT # PLUMBING PERMIT CITY OF EAGAN RECEIPT tk 3630 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: 7~ SE3 CONTRACT PRICE: PHONE: 454-8100 5ite Address ' BLDG. TYPE WORK DESCRIPTION Lot Block Sec/Sub w Res. New 7 Mult. Add-on ~ Name Comm. Repair ~ Address Other c City Phon - RES. PLBCa. ONLY - COMPLETE THE FOLLOWING: , : -r - - NO FIXTURES TOTAL Name J~ . Water Closet - $3.00 $ Bath Tubs - $3.00 3 Address - ~Lavatory - $3.00 p Ciry Phone Shower - 53.00 Ki!chen Sink - $3.00 FEES Urinal/Bidet - $3.00 :.OMM/IND FEE - 1% OF CONTRACT FEE Laundry Tray -$3.00 4PT. BLDGS - COMM RATE APPLIES Floor Drains -$1.50 rOWNHOUSE & CONDO - RES. RATE APPLIES Water Heater -$1.50 VIINIMUM - RESIDENTIAL FEE - $12.00 Whirlpool - $3.00 1AINIMUM - COMM/IND FEE -$20.00 Gas Piping Outlets -$1.50 3TATE SURCHARGE PER PERMIT - .50 (MINIMUM - 1 PER PERMIn ADD $.50 S/C IF PERMIT PRICE GOES Softener -$5.00 9EYOND $1,000.00) Well - $10.00 Private Disp. - $10.00 Rough Openings - $1.50 - - 31GNATURE OF PERMITTEE FEE: srare s/c: r ~ FOR: CITY OF EAGAN GRAND TOTAL: 1'? ~ CITY OF EAGAN .,.4 16422 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 . BUILDING PERMIT Receipt # To be used for pECk Est. Value w j, C00 Date •'sAY S . 19 Site Address :128 WF5TBUFcY L'Zli Lot ~ Block L Sec/Sub_ WESTEilR': IRn OFFICE USE ONLY Parcel No. occupancy - Fees Zoning - W Name naN Fit~:r ?`.A fActuaq Consl - Bldg. Permit 26. c;v 3 Address i I w`r S r~1URY G I P. (Allowable) - Surcharge • 0 City Phone # of stories LQngth 131 Plan Review ~ 16• Name ~ oWm s,ac, aiy Address S.F. Total - gAC, Mcwcc ~ City Phone S.F. Footprints - On Site Sewage _ Water Conn W W Name On Site Well - Water Meter ~z MWCCS stem OZ Address Y - Acct. Deposit a W City Phone City water - PRV Required - S/W Permit i hereby acknowlege that I have read this application and state that the Booster Pump - S/W Surcharge information is correct and agree to comply with all applicable State of Minnesota Statutes and Ciry of Eagan Ordinances. Treatment Pi Signature of Pertnitee ~ APPROVALS Road Unit A Building Permit is issued to: L!W4 t'll' LrIr' FRXEMM Planner - park Ded. on the express condition that all work shall be done in accordance with all Council - applicable State of Minnesota Statutes and Ciry of Eagan Ordinances. g~. pry. _ Copies Building Otficial Varianoe - TOTAL Z~•~ Permit No. Permit Holder Date Telephone # WATER SEWER PLUMBING H.V.A.C. ELECTRIC Inapection Date Insp. Comments Footings I Foundalion Framing Roofing Rough Plbg. Hough Htg. Isul. Fireplace Final Htg. Final Plbg. Const. Meter Plbg. Inspector - Notify Plumber Engr./Plan Bidg. Final Deck Ft9. srle LJ Deck Final Well Pr. Disp. Re7ipt PLUMBING PERMIT Permit No. I 7 3 CITY OF EAGAN Fee fi!l in numbered spaces S/C Type or Print /egibly Tot I 1. Date ' 2. Installation Cost 1 3. Job Address ~Lot Blk. Tract ~ 4. Owner i' 5. Contractor ' Phone ~ 6. Address 7. City_ State Zip 8. Building Type: Residential Cl Commercial O Institutional ? 9. Work Description: New 0 Add ? Alter 0 Repair O 10. Describe 11. No. Fixtures No. Fixtures Water Closet Cesspool/Orainfield Bath tubs Septic Tank Lavatory Softner Shower Well Kitchen Sink Urinal/Bidet Other Laundry Tray Floor Drains 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 Inspectians: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 45"700 CITY OF EAGAN Remarks Addition WESTBURY THIRD ADDN. Lot 5 Blk z Pa,ce, lo 83652 050 02 112 Westbury Circle State Eagan, MN 55123 Owner Street Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK ~ 17.00 pD SEWER LATERAL watermain 1 4 ''"W. ~ 3.33 15 WATERMAIN 19 4 & WATER LATERAL WATER AREA 69. 3 • 3 15 414. 7 water area 1984 8.95 1 , STORM SEW TRK 1986 368.28 73.66 .2 STORM SEW LAT 1C~8~j 491 , 0 98.20 5 D CUFi6 & GUTTER SIDEWALK STREET LIGHT WATER CONN, n n BUILDING PER. loR9O SAC 525.00 PARK Receipt , I. PLUMBING PERMIT Permit No. ~ CI7Y OF EAGAN Fse Fil/ in numbered spaces S/C . ~ Type or Prin[ legib/y Ta_ 1. Date 2. Installation Cosi 3. Job Address Lot Blk. Tract 4. Owner 5. Contractor Phone 6. Address 7. City State ZiP 8. Building Type: Residential ? Commercial O Institutional ? 9. Work Description: New O Add 11 Alter ? Repair ? 10. Describe 11. No. Fixtures No. Fixtures Water Closet Cesspool/Drainfietd ~ Bath tubs $eptic Tank Lavatory 5oftner Shower Well Kitchen Sink Urinal/Bidet Other Laundry Tray Floor Drains Drinking Ftn. Slop Sink Gas Piping Outlets 12. I 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 Inspections: Date Insp. Date tnsp. This is your permit when numbered and approved. Approved CITY OF EAGAN 464-8100 Roaipt MECHANICAL PERMIT Permit No. ~ J CITY OF EAI3AN FN Fill in numbered wscet S/C ~ TyPe or PrinC lepiWy Tot X 1. Date t . 2. Installetion Coat 3. Job Addrest 'Lot Blk. Trect . ~ 4. OWllef N \ 6. Contrsctor Phone'.- 8. Addren 7, City _ State. Zip 8. Buiiding Type: Residential O- Commercial ? In=titutional O 9. Work Description: New 13 Add 0 Alter ? Repair ? 10. Describe Fuel Type • ' 11. No, EquipmSIIi STU • M. Ea. No. Enuiament CFM Forced Air ; Air Handling: AAfg, Boilera Mech. Exhaust Mfg. Unit Heater Mfg, Other Air Cond. Mfg. Gas, Piping Outlets 12. I hereby certify that the above information is true and correct, and I agree to comply with ell ordinances and codes governing this type of work. Signed : - ~ ~ for Rough Final Inspections: Date Inap. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 464-6100 ~ CITY OF EAGAN NQ 16422 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55721 PHONE: 454-8100 BUILDING PERMIT Receipt # < J To be used for DECK Est Value $1 , 000 Date Mt1Y 5 , 19 89 Site Address 1128 WESTBURY CIR Lot 5 Block z Sec/Sub. ~STBURY 3RD OFFICE USE ONLY Parcel No. occuPancy - Fees zoning - e NBme DEAN & LYNN FREEMAN (Ac1ua1)Const _ BIdg.Permit 26.00 w ; Address 1128 WESTBURY CIR (Allowable) - Surcharge .50 0 Cit EAGAN Phone :r ot stoues - Y Length 13, Plan Review , o Name SAME Depth 16 snc, cuy 0Q Address S.F.TOtal - gqC,MCWCC ~ City Phone S.F. Pootprints - On Site Sewage _ Water Conn Name On Site Well - Water Meter AddfeSS MwCC System - qcd. Deposit City PhOf10 CiryWaler _ rPRV Required _ S/W Permit I hereby acknowlege that I have reatl ihis applicaiion and state ihat the Booster Pump - SM/ Sumharge infortnation is correci and agree to_,pomply with all applicable State ol Minnesol25latutes and CiW of Eag6yfOrdinanceys Treatment PI Signatufe of Pefmitee~_--~'APPAOVALS Roatl Unit A Building Permit is issued to: DEAN OR,T.YNN FRRFMAN Planner - park Ded. on the express condition ihat all work Shall be done in accordance with all Council - 1.00 applicable State oi Minnesota Statutes and City of Eagan Ordinances. Bld9Off. _ Copies Building Otficial 'Afltll4 .L~lll ' !CJ Variance - TO7AL 27.50 CITY OF EAGAN (y2 15 2 6 3 3830 Pilot Knob Road, P.O. Box 21•199, Eagan, MN 55121 C~46ro "7~ BUILDING PERMIT PHONE:454-8700 Receipt # ?S l To be used for BASEMENT Est. Value $1500 Date .TUNE 24 lg 88 Site Address 1128 WESTBURY CIRCLE OFFICE USE ONLY Lot 5 Block 2 Sec/Sub. WESTBURY 3RD OnSiteSewage _ Occupancy MWCCSyetem _ Zoning Parcel No. On Site Well _ (Actuap Const a Name DEAN R FREEMAN Ciry Water _ (Allowable) PRV Required _ # of Stories 3 i Address gAME 0 City phone 452-6123 eooster Pump _ Length Depth , o nlame SAME 332-7717 (w) s.F.7otai ~ Q Address Footprint S.F. , City Phone pppqpVALS FEES Engr./nssess. Permit ~34.00 Ww Name 1.00 ~ Z Planner Surcharge z - Address a W City Phone Council Plan Review Bldg. Off. SAC, City I hereby acknowledge that I have read this application and state that the Veriance SAC, MWCC informa[lon is correct and agree to comply with all a icable State of Water Conn. Minnesota StaWtes and Ciry of Eagan Oidin Water Meter Signature of Permittee ~1 Road Unit A Building Permit is issued t6'E R~RE ~MAN Trea~ment P1 on the ezpress contlition that all work shall be done in accordance with all parks applicable State of Minneso Sta[utes and G1ty,of~ Ordinances. Building ONicial ~ TOTAL :9.~ 11 S CITY OF EAGAN N°_ 'I O H 9 O 3630 Pilot Knob Road, P.O. Box 21-799, Eagan, MN 55121 i - PNONE: 4548100 , BUIIfD1NG PERMIT Receipt ~t i Te~j~ ~ y~ SF DWG/GAR Est.Value ~62~000 ~~e SEPTEMBE 4 ~q 85 1128 WESTBURY CIR Erect ~C occu ancy R Site Addre~ P 4ot 5 elock 2 Sec/S~b. WESTBURY 3RD Remodel ? 2o~ing Rl Percel No. RePalr ? 7ype af Const. V Additlon ? No. Stwia JOE MILLER CONST MOVB ~ ~.e"eth ~ Name Damolis~ ? Depih 35 Z Address 18133 CEDAR AVE SO Int Impr. ? s~. Ft. ~ City FARMINGTON pho~e 431-2001 Insta~~ ? SAME Approralf Fae~ g Name Addreu Assessmenf Pelmit 1.~~ • City Phone Worer & Sew. 5urcherge 31. 00 Police PlanReview ~~5~ Gw Name Firs SAC 525.00 Address Enfl• WaterConn. ~~.~0 ~W City Phone Plonrwr WaterMeter ~~0~ ~ Council Roed Unit 280 _ 00 I hereby acknowledge thot I have reod this application ond stare thaf gldg. Off. $ 2( $S 7c PL 7.32 _ 0~ the Inlormation is corrett nd ogree to wmply with oll opp~icoble A~ Stete of Minnewro Statu ond C' y of Eagan Or ironces. Pef~'e ~~J Var. Daxe Copies S~pnoturc of Permittes $2~009.50 JOE MILL R CONST rota~ A Building Permit Is issuad ro: on the exprosf wrditbn tho~ oll work shall be done in accordance wifh all ap~ blapS~fa~~,~-,~~/qM.~inn-ewta Sfatutea ond Ciry o4 Eaqon Ordirwnces. Buildinp OfHcfal •'~1~w[n-rtv~ l ~ PERMIT # ls-lwds RECEIPT DATE: 2002 g£SIDENTIlFL PLUMBIN6E PEFiM1T ~PPLICATIOR crrY oF EAsAv 3$30 Pt1.OT KROB i{D SA6AA. I+IN $51EE 651-691-4678 Please complete for: single family dwellings, townhomes and condos when permits are required for each unit, backflow preventer for irrigation system SITE ADDRESS: nZ b V V eS 1~U~I 016C. OWNERNAME:: Ifl~(~ ~1_T(',Y1 TELEPHONE#: JI" -q331 (AREA CODE) INSTALLERNAME: hra-w Tlm-NAYnb 1-) TELEPHONE#: qlU"l-[o-Iqq STREET ADDRESS: ~ y I'1~ ~f ( Olyl U1 e W ttU - (AREA CODE) CITY: l11AV ( I~Q STATE: ZIP: ~'JD _ SEPTIC SYSTEM, new/refurbished (requires two sets of plans and MPC license) $ 100.00 includes $40.00 County fee Note: Adtlitional consultant fees may apply • MODIFICATIONIALTERATION TO EXISTING DWELLING UNIT, INCLUDING: _ Adding fintures to lower levels or room additions, excluding water softeners and water heaters. $ 50.00 _ Abandonment of septic systam. _ Water turnaround - existing dwelling unit 5/8" meter if needed -$118) Other: _ RPZ: new installation/repair/rebuild 30.00 _ laern irriyation system i r=; 1^ 9n~~ ~ i ReplacemenUadditional: _ water softener ~ water heater 15.00 -9 State Surcharge $ .50 rotal $ ~ I hereby acknowledge that I have read this application, st2te thatthe information is covect, and agree to complywith II applica6le City of agan ordinances. It h itydng its normal sed by t is the applicanPs responsibility to notify the property owner that the City of Eagan assumes liabilit for any egn operational and maintenance activities to the facilities constructed under this permi wi ty p ei . / U SIGNATURE OF PERMI 11102 RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN N MN 55122 / oj G~ ~SJ 3830 PILOT g51g681~4675 ' J o< 0 New Constructlon Reauiraments RemodeVRewir Reauirements • 3 registered site surveys showing sq. ft. of lot. sq. tl. ot house; and all roofed areas • 2 copies ot plan (20%macimum lot coverage allowed) • 1 5et ol Energy Calculations for heated addifions • 2 copies of plan shomng 6eam & windax s¢es; poured found design, etc.) • 1 site survey for ezterior additions & decks • 1 set of Energy CalculaGore . Indicate if home served 6y septic system for additions • 3 copies of Tree Preservation Plan ii Wt platted after 7!1193 • Rim Joist Detail Options selecUon sheet (Wdgs with 3 or less units) DATE VALUATION SITE ADDRESS MULTI-FAMILY BLDG _Y~ 1/ N TYPE OF WORK FIREPLACE(S) _ 0~/ 1_ 2 APPLICANT STREETADDRESS CITY~STATE A4IP TELEPHONE CELL PH.NE # FAX # fW- PROPERTYOWNER rPd TELEPHONE# COMPLETE THIS SECTION FOR KNEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESOTA RULES 7670 CATF:GORY t MINNESOTA RULES 7672 (J submission type) . Residen6al Ventilation Category i Worksheet Submitted • New Energy Code Worksheet Submitted . Energy Envelope Calculations Submitted Plumbing Contraetor: _ Phone _ Plumbing system includes: Water Softener _ Iawn Spri ~ Fee: 90.00 Water Heater _ No. of R.I. ths 2 Q ZD~Z No. of Baths Mechanical Conhactor. Ph # Nlechanicil sysfem includes': :\ir Conditioning Fee: $70.00 Heat Recovery 5ystem Sewer/Water Contractor: Phone # I hereby acknowledge that I have read this appiication, state that the infor at on is correct, and a ree to comply with all applicable State of Minnesota Statutes and City of Eagan Ord' nc . /f Signature of Apptfcanf ,~t OFFICE U5E ONLY Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4/02 OFFICE USE ONLY ? 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 (screened) O 36 Multi ? 05 03-plex O 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-pfex 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 ? 33 Alteration ? 37 Demolish (Bldg)" ? 43 Reroof ? 46 Windows/Doors ? 34 Replacement 'Demolition (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) _ FinallC.O. _ Footings (deck) FinallNo C.O. _ Foorings (addition) _ Plumbing Foundation HVAC Drain Tile Other Roof _ Ice & Water _ Final _ Pool _ Ftgs _ AidGas Tests _ Final _ Framing _ Siding Stucco Stone _ F'seplace _ 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 5&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total • ^ ~ U , ~ D ~ ~ 1985 BUILDING PERNIT APPLICATION - CZTY OF EAGAN NOYE: ALL COHTRACTORS NUST BE LICENSED IiITH THE CITY OF EAGAN INCLUDE 2 SETS OF PLANS 3 CERTIFICATES OF SURVEY 1 SET OF ENERGY CALCULATIONS • (p2,ooo n i7 To Be Used For: (~9dG~!7`~_.. Valuation: Date: Site Address: ~oW OFFICE USE ONI.Y Lot: ~ Block dC Sect/SiL`~ ~Erect X Occupancy rC-3 i Remodel Zoning 2-~ Parcel Repair _ Type of Const 'IL Addition Ik of Stories Owner Move i Length 50 Demolish Depth 35" Address Int.Impr, Sq Ft Install ~ Ci t y/ Z i p Cod e Phone APPROVALS FEES Contractor Assessments Permit Water/Sewer Surcharge 31 Address /~.3 ~pJt C,(,!/.Q -'~p , Police Plan Review 1 Sq ,=o 1Fire SAC 52S p0 City/Zip Code ?G%~j)7~~ S50~c~ Engr Water Conn Sco.°= 1131 Planner Water Meter 7-7-3 Phone oQ l Council Road Unit ZSo. ° Bldg Off 72- 5Treatment Pl ~ 32. A-Z Arch./Engr. APC Parks Variance Copies Address TOTAL City/Zip Code Phone 11 T RI- LANQ C0. SU RV,fYIN G S~f ~ N L!, ,i SERVI CES ~ N33°47' ~~ST eURY ~I ~lE 33"W a C, 8 oo \ f3 2 SCALE' I"=30' LEGAL DESCRIPTIOW ~.i i • S ~ LOT 51 9 LO H{RO • I a'cAR~„E ` WESTBURV / NousE ADDITION n iY I ~N~I . N ~ i CS/ x ~ ~ / I ~ I ~ 5 I KEY: / IpOitOp OEN(1rES fX15TING SPOT ELEVqTIDN (IDO.OO) DCNdiES PROPOSED SPOT ELEVATION L-- DEN07E5 DRAINaGE PiREC7ioN Sl861.e0 PRDPOSEO GARA6E FLOOR El-EVAti PROPOSED LiHSEMENT FLOOR ELEVqnoN L------- 87.17 M PROPOSEO ctRST FLUOR ELEVAriON 9o S 50° 17'33" E NOTE• UERIFY ALL FL.OOR HEt6HTS W ITN A1?ni'( t3 F.j FINAL HOUSF_ PlANS i~terevy CC'Y'"G.' i y "LiidL 'Gi115 [)'.8f1 repori. i.!as preuaroc; uy rae or unci-r CIiY[?Ci: SUuOr'd~iS:i0I1 d.!le Ciidti 1 d:] d J. ..ensnn iin. !:ey. :!o. ~.i,y i;'615iP_Y'eG Land 5ur~,eyor undei° I:u~ ~ ;1'>n' SG9IAC LatIS Oi' th2 $tdi.E oi' riinneso'r.a. - 1988 BUILDING PERMIT APPLICATION - CITY OF EAGAN ~ SINGLE FAMILY DWELLING3 450 63 INCLUDE 2 SETS OF PLANSo 3 CERTIFICATES OF SURVEYo 1 SET OF ENERGY C6LCULATIONS ~ NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRES;--,~-- IS DESIRED. / NO CHANGES WILL BE ALLOWED ONCE HOILDING PERMTT IS ISSUED. / MULTIPLE DWELLIN RENTAL ONIT5 FOR SALE UNITS # OF UNITS INCLUDE 2 SETS 0 PLANS, CERTIFICATE OF SURVEY - CHECK WITH BLDG. DEPT.p 1 SET OF ENERGY C LCULATIONS COt~AtERCIAL INCLUDE 2 SETS 0 ARCHITECTURAL & STRUCTURAL PLANS; 1 SET OF SPECIFI(~ATIONS AND 1 SET OF ENERGY CALCULATIONS _ To Be Used For: Valuation: ~ Date: C~ Site Address OFFICE USE ONLY Lot ~ Hloek ~ On site sewage_ Oecupancy MWCC system _ Zoning Pareel/S b On site well Aetual Const ) City water Allowable Owner/::_'56<--) PRV required of stories Booster Pump _ Length Address Depth S.F. Total City/Zip Code1~<~ <31/Z Eootprint S.F. Phone ,~/Z -~/tz 6/ z3 APPAOVALS FEES Contractor Engr/Assess Permit 3 Planner Surcharge Address Council Plan Review Bldg. Off. SAC, City City/Zip Code Variance SAC, MWCC Water Conn Phone Water Meter Road Unit Areh./Engr. Treatment P1 Parks Address Copies I TOTAL ~S=Oa City/Zip Code ~ Phone 1t ~ 1989 BDILDING P&liMIT 9PPLIC9TION - CTTY OF EAGAN SINGLE FAMILY DWELLING3 ~ \D 4 T INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS NOTE: ADDRE4SES FDB CORNER LOTS - COIQTRACTOR/HOMEOWNER MOST DESIGNATE WEi2CH ADDR&SS IS DFSIRED. NO CHANGFS WILL BE ALLOWED ONCE BIIILDING PERMIT IS I3SUED. MQLTIPLE DWELLING3 RENT9L DNITS FOH SALS UNITS t OF UHITS INCLIIDE 2 SETS OF PLANS, CERTIFICATE OF SDRVEY - CHECK WITH BLDG. DEPT.v 1 SET OF ENERGY CALCULATIONS COMMERCIAL INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS, 1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS To Be Used For: Valuation: ~ Date: ~1 f'9 Site Address `000OFFICE IISE ONi.Y Lot ~ Block ~ Occupancy FE6S Zoning Parcel/Sub Actual Const Bldg. Permit Allowable Sureharge .So Owner ? of stories Plan Review Length 13 SAC, City Address //Z~i C~°sr~~/•~/ G'!l~ Depth SAC, MWCC S.F. Total Water Conn City/Zip Code Footprint S.F. Water Meter ~ Acet. Deposit Phone On site seWage_ S/W Permit On site well S/W Surcharge Contractor MWCC System _ Treatment P1. City water _ Road Unit Address PRV required _ Park Ded. Booster Pump _ Copies /00 City/Zip Code TOTAL ar) ,5a APPROYAIS Phone Planner _ Council Areh./Engr. Bldg. Off. Varianee Address City/Zip Code Phone # NOTE: Sewer & Water Permit fees and aecount deposit fees vill be included in the building permit fee. Processing time for aewer sud raater permits is two daqs once a licenaed plumber has applied Por a permit at City Hall. I .i LAND CO a -SURV~gYING s i 'f E P L ,4 SE RVI C E S ~ N33°47'33" wf SrevRY CI CLE j,V ~ S~ g oo \ d•9• 2 1/ ~ ` 39 !8' ~ e SCALE' I"=30' _q I.EGAL DESCRfPTtoN' s LOT 5 , 8 LotK 2 - r+ARpC,f ~ WESTBURY THIRD NoUSF I ADDITION N A/ =Y (V ~ tl 13, ,,9 / f M N / / 5 ~ KEY / IOpzOp DENarES EX15TIiv4 SPOT ELEVqTiOH / J (IDO-OO) Denuxras PRODOSED SPoT ELEVATION 5 ~ DENOTES DRAINnGE PiREC7ioN Bbl.oO PROPGSED GPRA6E FLoOR EIEVAil pRpppSeD 6ASEMENT FLOOR EL.EVAneN PROPOSEO FtRST FIUOR ELEUaTION - 87-37 90 5 500 17'33" E '•~'C~ ~ i:i:l ~Zv' ~ Ii<<>i NOTE. UERIFY ALL FLAOR HE16HT5 WITN HDDi-ri0h1 FINAL HousE PLaNs i-iere;y cer4iry ciiar. sur-.;ey, pian 'c,Pori: ,ras pr(-i)ai°(,d uy i;ie o'r unc~-r I; direc`L supervisaon and ttiac I a:.i a -y J. _.enson ihn. i:ey. .!o. 1623:; i)y Nr~~ic;;ered Land Surveyor undei° La!!s or tiie State o4` i•iinnesoca. ~ z ~sa ~ CITY OF EAGAN i ~ ( AP°LICATION FOR PERPIIT SEWER AN?/OR WATER CONNECTIODi (PLEASE PRINT) 1) PP.OPERPY ADDRESS_ Aa f~ (,t/t.s-/Eauhv ~~~cIC r.FrAr DESGRIPTICV: (Lot/Slock/Subcuvisicn or T Parcel I. . r) S?'RL'CP.`:(E, Dr1TE 0_" ORT_Gl^.Ai, uiI:.DL`:G :.i_•ST ISSi;AyG: P°ES~T --.^`7I2T./P?--!OPQS-"~.~' L'•S: 0 R-1 Si=- FPY-TLY . ? R-2 CUP= ('ITrn u,\7ITS) ? R-3 ZC:t~-uC'USE ('!Pp.:'~ + L~]ITS) ( Wi Z^'S) ? R-4 P.PFiRTT~,'T/CC_3XJ'sNnj.'j ~ UVZ`T_~S) ? CO`~L IE.:CLM/RE:AIL,/OFF'ICs: Q ~.'CliST2Z?.L Q LVSTI'S!,'TIOJIAL/GGV~~:`:~~'T 2) APPLSC;dT (PLEASE PRlNi) ADDPEss: JR 133 (feOa- auc. crr°r, sraTE, zzP: _jr-aN„?3 uc4n,..) ?NAJ S4 0.2 Phove: 4r31 -~.mol 3) pj.v,iBEn.N~~. (PLEASE PRIHTJ FOR CITY USE 04LY ~ ~A lp/ M ; y PLUXBERS L 64SE: , anDPEss: /5I~,2 8 2.31" .4.~ AY' Lj ce1v CITY, STATE, ZIP• ~mw~ ~?'f~ Sscrle// . x'red ,s'~ H]iCn t of ecord PH0NE: 9-34 7S PLUMBER LICENSE q arr ic3a 4) OCcGPADIT/CSPPIER DIFINIE (PLEASE PRINi) : ADDRESS: CITY, STATE, ZIP• c SiqM c. qs, ,Z ) PHO^IE: 5) INpSG",TE S41-IICH PERMIT IS HEING RF~2UESTID: ER'CONNECI'ION 'IO CITY SaiER, Q7NNFI'S'ION 'IC) CITY SVATER ? dif;ER (PITIISE DESCf2IBE) 61 L":DIG,:: C.+F.: - . 2/PLE,%SE E?OLD r1PPFlUVED PETLMIT FOR PSCIi-GP BY ONE OF AHOVE ? PLEi1SE b~'.aIL APPRpVEp PII'W lIT 'PJ 1, 2. 3, 4 ABWE (Circle one) _ 7) szcaIL7tE: (.U.rzu&iO DAzE: ~lROI:Rail}P.aoli~Y~salsJSftalsr+e~e~s~aa~~i~~sa:~a~fall.+~,•~--- ` • . F0 R C I T Y U 5 E ON;,Y PERMIT ISSUED F°L5: $ ~d ~LSz':`:Lb nr.RMrm (I`_]C?.[:DE SU°C=?RGc) $ SJATER PEi2DlZ: (Ii7CL'uDE SiiRCF:ARGc.) $ WATER METER/CDPPERHORN/OUTSZ'JE REi,DER $ WATER TAP (INCLUDE CORPORATION STOP) S S:::GER TA? $ S•<' G ACCOiJbIT DE°C}S IT - P7AT°_.^t wac SP.C ~ TRliVK S9ATER ASSE55:?E.dT $ TRLi:1;C SEG'7ER y55ES5:iEPiT $ LA„ERAL BEivEFIT/TRU:IK SE;dER $ LATE:tlL BEVEFIT/TRU2:K SVAT°R $ WATER TREATMENT PLANT SURCHARGE $ OTHER; $ TOT?L $ f ~ ~U AMOL';:T PrIID/REC°IPT DOES UTILITY CONNECTION REQUIRE EXCAVATZON I,1 PUBLIC RIGiIT OF LJAY? 7-7 YES IF YES, THEN i: "PERMIT FOR 'r10R?C WITHIN P[IBLIC ROADWAY" MUST BE ISSUE? BY THE 7_7 NO ENGINEERING DIV:SION_ LIST AS A CONDI- TION. SUBJECT TO THE FOLLOLVING CONDZTIONS: • APPROVED gy; TZ:LE: - DATE: _ i i Clt~ of EaaaIl , Perri i Permit Fee: 3830 Pilot Knob Road Eagan MN 55122 j Date ReceivecJ1 it t7 2009 j Phone:(651)675-5675 Fdx: (651) 6755694 I Staff: I 2009 RESIDENTIAL BUILDfNG PERMIT APPLtCATION t2ae&d Date: 71a7/01 Site Address: J I at Tenant: Suite RESIDENT/OWNER Name: /0O1! . Phone: Address / City / Zip: o~ b'~ ~.VVT,,{~ Applicant is: _ Owner _X Contractor TYPE OF WORK Description ofwork: gdittv &_jC Construction CostAg. I-(qo'a- Mulli-Family Building: (Yes No4-) r p ~ CONTRACTOR Name: l~la5oh c.r: (cC 2cS .~ne__ -License#: ~0q5'baQ Address: ~ City: L„ /<ev State: 8 r ro Phone: 15 -j-' d~ i- Fs7 3~ Contact Person rtzi COMPtETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 Cateaorv 1 Minnesota Rules 7672 Energy Code . Residerrtial Ventilation Category 1 Worksheet • New Energy Code Woricsheet Category Sunmiuea submined N submission type) • Energy Envelope Calculffiions Submitted In the last 12 months, has the City of Eagan issued a pertnit for a similar plan based on a master plan? _Yes _No If yes, date and address of master plan: Licensed Plumder: Phone: Mechanical Contractor: Phone: Sewer 8 Water Contractor: Phone: NOTE: Plans and supporting documents ihaf you submit,are considered to 6e public i0oimadoh: Pnrtions ot ' = Uae rnforma6on may be cfassi~eii as non-pulilic' if yov provide specr/ic reasoiis that would perin'rt the Cify ~a, • concfude_thattlie are_tradesecze3s. I hereby acknowledge that this information is complete and accurate; that the work will be in confortnance vrith the ordinances and cotles of the City of Eagan; thal I understand this is not a permit, 6ut only an application for a permit, antl work is not to staA without a permR; that lhe work will be in accordance with lhe approved plan in the case of work which requires a review and approval of pians. XB(F l fD rAK CS 0 n x~~,~--- ApplicanYs Printed ame ApplicanYs ignature Page 1 of 3 Q&4butzy 0;4 DO NOT WRITE BELOW TH15 LINE SUB TYPES - ? Foundation ? 05-plex ? 16-plex ? Accessory Building ? Pooi ? Single Family ? 06-plex ? Fireplace ? Porch (3-season) ? Eact. Alt. --Mu1ti ? 01 of _ Plex ? 07-plex ? Garage ? Porch (4-season) ? 6ct. Ait - SF ? 02-Plex ? 98-plex x Deck ? Porch (screeNgazebo/pergola) ? Multi Misc. ? 03-Plex ? 10-plex ? Lower Level ? Storm Damage ? 04-Plex O 12-plex 0 Miscellaneous WORK TYPES ? New ? Interior Improvement ? Siding ' ? Demolish Building' ? Addition ? Move Building ? Reroof ? Demolish Interior ? Alteration ? Fire Repair ? Windows ? Demolish Foundation ~ Replacement ? Egress Window ? Water Oamage . ' Demolition (entire building) - give PCA handout to appliwnt DESCRIPTION: _ Valuation .304rV Occupancy MCES System Plan Review Code Edition SAC Units - (25%_ 100%~ Zoning City Water Census Code H3k Stories ~ Booster Pump # of Units Square Feet PRV # of Buildings ^ Length Fire Sprinklers Type of Canst Width REQUIRED INSPECTIONS Footings (new 61dg) Sheetrock . Footings (deck) - Final/C.O. Footings (addition) ~ Final/No C.O. Foundation . HVAC Drain Tile Other: Roaf: _Ice & Water _Final Pool: _Footings _Air/Gas Tests _Final Framing Siding: _Slucco Lath _Stone Lath _Brick Fireplace:_R.I. _AirTest _Final Windows ' Insulation Retaining Wall Reviewed By: Building InspecYor RESlDENTIAL FEES: ~ Base Fee / 21 Surcharge ~ Plan Review fl MClES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies Total Page 2 of 3 ,-t L AN D C 0. C,` ° • SU RV,gYIN G 5 i TE N L,1,j SERVI CES ~ 1 ST8 U R ~ N33°V7'33"w Y Cf C~E %A 8'0 51.i3 \ 4.yo r3 S r ~ ~ _ 39 ~8' Z SCALE, I"=30` LEGAL DESCRIPTION ~ LoT 5, BLOCK 2 _ I ~6ARHc,E ~ WESTBURY TH{RD ADptT ION ZV ~ I EAGA / y 7~epl4~v~ eK;sF,1 RIE~f I E k 9 °AyE~ - ioNs Da~seoN I Bl.1LDING IN~PF KEY: IOp;(3p ()EN6TE5 EXlSTING SPOT ELEVqTiON _ I 00000) DENOTES PROPOSED 4W7 ELEVATION - 51 ! 1-,- OENOTES DRNNnGE PiREC7IoN 861.o0 PROPDSED GARA6E FLOok EX-EVAtia PRpPOSED OASEMENT FLOOR ELEVArioN tn 87' PROPOSED FtRST FLUOR ELEVATIDN 90 ~ 0 S 50° I1'33" E 8 . '~,i~5Tu:1rt~' i1l?C ) V"' 4 i ~ •J NOTE'. UERIFY FlL FLAOR HE16NT5 W ITH ~ ~ FINAL HOUSF_ PLANS i 'i2Y'.°_!?y cer°miy 'cijai. iWis Slli"+'d,!, i)l.dl'1 ' reporc r!as preoarr6 uy i:ie or uncj^r direrL supe,°, ~~s~on ,nd i~~ac i a:.~ a .radipy J. ..enson i1n. i:ey. :!o. t:i'L3~ i.i,y i;eyis'cnred Land Surveyor under iWin Laiis or the State oi' iiinnesoi:a. F F - orOffic--- e-U-se ~'U I City of EU Ll~ Permit Permit Fee: 3830 Pilot Knob Road Eagan MN 55122 Date Receivedill-11 27 2009 Phone: (651) 675-5675 I Fax: (651) 675-5694 Staff: 2009 RESIDENTIAL BUILDING PERMIT APPLICATION e"d 27/2,1 Date: V!~7 Lo Site Address: [ I c f W'S+h f v l r Tenant: Suite RESIDENT / OWNER Name: Iyntk Phone: Address / City / Zip: I I of Ff tA' ,f hc~,~y Applicant is: Owner _ Contractor TYPE OF WORK Description of work: W"-e- la=j< (LiS tl iq cx, nc j ~3 gas Construction Cos ~(7l) arJ Multi-Family Building: (Yes /No CONTRACTOR Name: ri 4c,, u ~cC 2C 5 e License _ Address: KA'~ _~ea a¢ 7 City: i<ev,t C rl e, State: AJ Zip: S 0 yGl Phone: q5-) o~ r s - S7 3 ) Contact Person: T> ra kr o COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING - Minnesota Rules 7670 Category 1 Minnesota Rules 7672 Energy Code • Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet Category Submitted Submitted ('I 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 they 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 approval of plans. x Do oraZ_ C5o X_ Applicant's Printed Name Applicant's Signature Page 1 of 3 DO NOT WRITE BELOW THIS LINE 90 q -3 3 SUB TYPES ? foundation ? 05-plex ? 16-plex ? Accessory Building ? Pool ? Single Family ? 06-plex ? Fireplace ? Porch (3-season) ? Ext. Alt. -•Multi ? 01 of - Plex ? 07-plex ? Garage ? Porch (4-season) ? Ext. Alt - SF ? 02-Flex ? 08-plex Pd Deck ? Porch (screen/gazebo/pergola) ? Multi Misc. ? 03-Plex ? 10-plex ? Lower Level ? Storm Damage ? 04-Plex ? 12-plex ? Miscellaneous WORK TYPES ? New ? Interior Improvement ? Siding ? Demolish Building* ? Addition ? Move Building ? Reroof ? Demolish Interior ? Alteration ? Fire Repair ? Windows ? Demolish Foundation Replacement ? Egress Window ? Water Damage Demolition (entire building) - give PCA handout to applicant DESCRIPTION: Valuation Occupancy T_ 4 j. MCES System Plan Review --_t"-- Code Edition ®O? SAC Units (25% 100% Zoning City Water Census Code 4'3L1 Stories Booster Pump # of Units Square Feet PRV # of Buildings Length Fire Sprinklers Type of Const Width REQUIRED INSPECTIONS Footings (new bldg) Sheetrock Footings (deck) Final/C.O. Footings (addition) FinallNo C.O. Foundation HVAC Drain Tile Other: Roof: -Ice & Water _Final Pool: -Footings Air/Gas Tests ___Final Framing Siding: _Stucco Lath Stone Lath -Brick Fireplace:_R.l. _Air Test -Final Windows Insulation Retaining Wall Reviewed By: Building Inspector RESIDENTIAL FEES: Base Fee 30 Surcharge Plan Review MC/ES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies Total Page 2 of 3 Al- LAND CO. SU RV,YIN G S I C N L li SERVICES N33° TBURY C/ Y7 33 W C~ E 800 ° 51.13 f3 2 r~ 4 SCALE 1`%= 3 0' xy LEGAL DESCRIPTION LOT 5, BLOCK 2 f I M GARA&E WESTBURY THIRD HOUSE I ADDITION ._1 i C3/ ,9 EAGA h~ % f / a 1Ze~14~~ exs~a~9 RE/I E ED BY: DATE: BUILDING IONS DIVISION KEY 15 / I IOOx00 DEt'orES EX1ST,NG SPOT ELEVATION / (IOO.O0) DENOTES PROPOSED SPOT ELEVATION S/, k- DENOTES DRAINAGE DIRECTION 861.0O PROPO5ED GARAGE FLOOR E\.EVArIa _ J r PROPOSED BASEMENT FLOOR ELEVATION 87-37 PROPOSED FIRST FLOOR ELEVATION 9o S 50° 17'33" E 9 , 0 /`+i~Dt"t'i l I.j NOTE.. VERIFY ALL FLOOR HEIGHTS W (TH FINAL HOU5F_ PLANS iere'!)f cer-4'ly triad. -Wis surwr?1, i>.arl .4 dl (,port rlas prepare; oy r;re or u!;cl~, direct supervision and ttia-c T a:.i a rad .ey J. ..enson M n. Ivey. :!o. 1:62h } y I;r i stored Land Surveyor under La~!s or the State of I ii nnesota . - r ,..+s ! 4. ' q m K b . 6699: = ta ., r L e y { ' 4 +« k : 17i 58121 . r 4 ' J o 1 ietr� c t u g ':v - 1 r : ¢. uS (W � • ef.. �` *�^ M ! 4 I �§ � ' d4 0.� ' v�,{pi� ai k�; Ata� 1 4 't e n ' '4 tr A „: ., .. _____ it:;...,_,........________47404401* Dat. 'In.p.: / f z , ,r . _ = . . 2110 7 851-21 f lak s r. , g' �'!(yC A M 1 of boo* R i 9-11-85 55294 # r i lierwitt Fs. +( IA, T , PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA165250 Date Issued:10/26/2020 Permit Category:ePermit Site Address: 1128 Westbury Cir Lot:005 Block: 002 Addition: Westbury 3rd PID:10-83652-02-050 Use: Description: Sub Type:Residential Work Type:Replace Description:Furnace & Air Conditioner Comments:Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Building Code). Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952) 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 - Molly K Lynch 1128 Westbury Cir Eagan MN 55123--146 Genz Ryan Plumbing & Heating 2200 West Highway 13 Burnsville MN 55337 (952) 767-1000 Applicant/Permitee: Signature Issued By: Signature