Loading...
1285 Wilderness Run Rd         øïï  ýüü  ûúþ úÿþþ     ùüü þÿ éüü     û ø ôî  çôæ     ýüö  ÿþýü  ûúù øõøþýü  ûøþýü ûúù ø÷ úù ü   øüö õ õ ôôðüý ó òø ñ  üøï  î î ø òø    øÿ øí ì øúúü ìøìø  ü ü íõìøìü ì øí õøÿë   øø ø òø ÿýú ìýî í  ñ éèéççíæ  ç íô çæ ôù  øîø  êéèéíæ å íåæ ê í  óò ö ñð üü ûúûøè øÿ øý î  ø îï Ù çæû ø  ÷ í ä÷ææ åä÷ææ àãæßáá ææá î ø ÿýú  î îï ø îüü îî ìøøø ø üýúîüüÿ    ìä   õýìðø í üüù ø  ø  ý ø ^ ~ -,T- ~ t 'cate o~ ~c~~anc~ 77eis Certiftcate ismsed prrsmant to tlee nqrdnments of the Uniform Building Code certifying tlmt at t6e t6we af issuance this stnrcmn wias in compliance with the various oidinances of dee Ciry itgWating buildisg conslnrcdae or wse. For the followutg: ~ 21388 u~ ~ ~ sm~ ra,~t No. ~r'~Y~ 7a.m nimd ~ry~ o~ or I~ ~M1Ii'S IlC ~ 7570 5 1~:, ~ ~ 1285-MEUMESS RW RD tACEEtv . , { r. /Orlu P05T M A CONSPICIJOl1S PLJ4CE ~ F.m,n No. wnnlt Hokl.r oet. Tel.pnone # SMI PLUMBING HVAC I ELECTRIC ELECTRIC Inspsctbn Deb Insp. Commmft Footinp6 I Foir?dation Freming RooHng Rough Plbg. Rou9h FIt9• i Isul. Fireplace Finel Htp• I Orsat Test Fnal Pbg. Plbp. Inspeclor - NoYr(y Plumber C.onst. AAeter ErgrJPlen Bldg. Final Declc Ftg. DeCk Final ~ /7~ss ~O•Z. 9s ~~J~„ wen ..u•e-~,Q~~. ~cec.~ y~i.k / •r9f/xZe Pr. Disp. - _ _ _ ~ a3lQ 5!0 ~ 0 a1 95-2 01 Re uest Da e Fre No Rou9 -In InSpxclWn Repmretl In G_f~ pection Olher Ttia ugh-ln (VOU must cell inspeao`r when ready) Reatly Now WiII Notity Inspeclor ~ ? Yas N. Da~e Read t I~'6censetl contractor ? owner hereby reqoest inspection of above elecirical work at Jab Atltlress (Sheel. Box or Roule No.) Ciry 4ud ~f',D G''A-Gr0~1 Section N0. To~vnship Name or No. . Range No. Covny Occupant(PRINT) Phona No ~E ':f~~~ ysZ 61 y Pawar Supplier qtltlress , ElecVical Conlraclor (COmpany Name) CpmrectoYS Licansa No ~ti° E,TA Ec~'~ RsC C/; o0lJ'J- Malllnq Atltlress (Conttaclor or 6w•ner Making Instaliatron) ~ -7711J'~/1/!/I ?E4 AuthonEeO SiqnaNr (COmradonOwnar ldakmg Installalion) Ppone Numser YvO=l1 z ~ MINNES TA STATE BOARO OF ELECTPICITY THIS MSPECTION REOUEST W ILL NOT Gtlggs- tlway BIEg. - Room 5-148 I II II I I II I I I I II I I( I II 9E ACGEPTED BV THE STATE 60FFD 1821 Unlversity Ave., St. PeW, MN 55104 UNLESS PROPER INSPECTION FEE IS Phono(614)fiA2-U800 ENCLOSED _ /1 q/~qJ/ REOUEST FOR ELECTRICAL INSPECTION es-ooooi-os O~(/~ vV p-` loo Sea Instructwns lor compteting this iarm on back ol yellow copy. "X" Below Work Covered by This Request Ne Adtl Rep. "Type of Building Applianees Wired Eqwpment Wired Home Range Temporary Service Du lex Water Heater Electric Heahn Apt. Building Dryer Load Management Comm./Industrial Furnace Other (Specify) Farm Air Conditioner Olher (spaciy) Conlredors Romarks: ffor 7a B Compute Inspecfion Fee Below: N Other Fee # Service Entranca S¢e Fee # Circuits/Feeders Fee Swimmin Pool 0 to 200 Amps 0 to 100 Amps Transiormers Above 200_Am s Above 100 -Am s Si ns Inspeclols Use Only: O 70TAL Irrigation Booms (.(C7 ~40 i S e cial Ins ection Alarm/Communication THIS INSTALLATION MAY BE ORDEAED DIVONNECTED IF NOT Other Fea COMPLETED WI 18 MOINTHS. I, ihe Electncal Inspecror, hereby Roupn-in ~ - Dete 1 certify that the above mspection has Fuial Dala - been made. _ OFFICE USE ONLV This raquest voitl 18 monlhs Irom ir.,7 ~7,7- , o ,~04 0-TZ" ReOU st Date Fue No Rough-in Inspection ~I - 93 Reqwretl7 ? Reatly Now ~ Wdl Notity Inspepor - Vas No When Ready? Iricensed conhactor p owner hereby request inspection of above electrical work at: Joo AoEress (SVeeL Bax or Routa Na,l ciry ' /~.n c1.FL Secuon No Townsnip Name or No. Fange No. Coumy Ocmpam IPRINJi POOne No. Powe upaier . Aadrass Eie<.r~ al Convaaor ICOmpnny Name) CoNraclor5 Licepse No. CA 0 ~ MdNng Atltlres5(COnl:aclor r Ownar Making Insianauon) / 3 s C_ Nf ~ Autnonzetl Sgna:ure ICOnvatlovOwnar Makm Installauant Phone Numper MINNESOTA STATE BOARO OF ELEC ITY THIS INSPECTION REOUEST WILL NOT Gngge-MlEway Bltlg. - floom 5473 BE ACCEPTED BY THE $TATE BOARO 1821 Unlvers0y Ava.. 56 Veul. MN 55104 UNLESS PROPER INSPEGTION FEE IS Phone(81t) 642-01100 ENCLOSED REQUEST FOR ELECTRICAL INSPECTION j``=;Jza~ eea00/0~1ae r~ ? See insVUClions lor completmg ihis brm on back ol yellow copy 4 3t"~ ~ G "X" Below Work Covered by This Request ew Atltl R Typeol8wlding AppbancesWiretl EpwpmentWiretl Home Range Temporary Serwce Duplex Waler Heater Elecinc Heatmg Apt 8mlding Dryer Other-(Specify) Comm./lndustrial ? Furnace ~ Farm V Air Conditioner Other(suanly) Contractor§ Remarks: Compufe Inspechon Fee Below: # ONer Fee # SernceEniranceSae Fee # Circuits/Feetlers Fee Swimming Pool 0 to 200 Amps 1,F .~jp 20 0 to 100 Amps p Translormers Above 200 _ Amps Above 100 _ Amps Signs Inspecror§ Use Only: TOTAL Irngation Booms ~-6 U~ I Special Inspection y J Alarm/Communication THIS INSTALLATION MAV BE OflDERED DIS ONNECTED IF NOT Other Fee COMPLETED WITHIN 18 MONi41S. p 5'S.J'7J I, the Electrical Inspector, hereby Aough-in //n a~x oa certifY that the above insPection has 1 F~~ai ~ oeie been made. 2 i OFFICE USE ]NLV This request Witl 18 monlhs IrOm C 4~4 3s6 ' ReQUest Oa~e Fire No. Roug~-In Inpsoction Redwr E Inspec40n Other Than Rougn-ln r.~ ~ (vou must cell inapedor wM1en reaCy) ~ Reetly Now~~Al NoLly Inspector ~ ? Ves N. Date FeaE IX, icensed contrector p owner hereby request inspection ol above electrical work aC JoG Atltlrass IStreet Box or Rome No.) n piy ~1l?SS ,.1.~/ l~c~. ~~i~N Secuon No Townsnip Name or No. Range No Counry 7.<F kaTf,~ occuog ~~~PR~NT~ pnone No ~.ee G'o/ Pawer Supolrer qtltlrass -DAk,9I fI' Electncal Convac;or ICOmpany Namel Convactar5 License No. e or'4&i^s ,E%aG y'i c e n Maihng qaare ss IG tr cto~ o~ Oaner rdakin9 InstellaLOn) 3s` C'eG~1r de So /s' 5 S o7 AuIDOnzetl Wre 1COm ton r MaKi stallauo pnone Numoer ~ 7a 1 a6 MINNESOTA STATE B04R0 OF ELECTRICITY THIS INSPECTION REOUEST WILL NOT Griggs-MiEwey BIOg. - Room 5473 BE ACGEPTED BY THE STNTE 60AR0 1821 Umvenlly Av¢. 51. Paul. MN 55104 UNLESS PROPER INSPECTION FEE IS Vhone(612) 641-0900 ENCLOSED 7G RE0~T FOR ELECTRICAL INSPECTION s=""t'~~g EB~00001-OB " ? See n clions lor complelinq Ihis lorm on Ca[k ol yellow wpy. C~ 44356 . ' "X" Below Work Covered by This Request ew Add Rep TypeofBuiltlmg ApphancesWirad EquipmentWiretl Home Range Temporery Service Duplex Water Heater Electric Hea[ing Apt. Building Dryer Load Manegement Comm.nntlustrial Furnace Other (Specify) Farm Air Condrtioner Omer (syxiyl Comraclors Femarks: ' ~e4:k6ecA Servi- ei-tier Compute Inspechon Fee Belaw: t 0 Exl 5 4-IN6 5-e1^ V/GG -(!vr Dri? # Other Fee # ServiceEntranceSrze Fee # CircuitsiFeeders Fee 0 to 100 Amps Swimming Pool 0 to 200 Amps / 45 Transformers Above 200 _ Amps ~ AOOVe 100 _ Amps Signs I inspemor§ use Onry. TOTpL Irrigation Booms - M T~~ Speciallnspection JF~ a , Alarm/Communication THIS INSTALLATION MAY BE DRD'~ERED DISCONNECTED IF NOT Other Fee COMPLETED WITHIN 18 MONTHS. I, the Electrical Inspector, hereby Rougn-m oate certifythatiheaboveinspectwnhas F,,,ai aie been made. OFFICE USE ONLY ~ ThiS request wio IB momhs trom Address 1285 wn.oERn~'ss xuiv ROnD Zip 5512 3 L.ot ~ 20 ~ Blk 3 Sub wn.nERNEss [ujN arH THESE ITEMS WERE / WERE NOT COMPLETE AT THE TIME OF THE FINAL INSPECI70N. Date: Yes No Inspector. S Final grade (6" from siding) Permanent steps (garage) Permanent steps (main entry) Pertnanent driveway Permanent gas Sod/Seeded grass TraiUcurb damage ? Porch ? Basement finish ? Deck Please verify with the builder Ihe removal of roof test caps from the plumbing system and the shut-off of warer supply to the outside lawn faucet before freeze potential exists. Contact enginecring division at 681-4645 bcfore working in rightof-way or installing underground sprinkler system. ~ White - Ciry Copy Yellow - Resident Copy Pink - Contractor Copy PERMIT ~ GITY OF EAGAN 3830PiIotKnobRoad PERMITTYPE: euiLDrNG Eagan, Minnesota 55123 Permit Number: 021389 (612) 681-4675 Date Issued: 0 7/ 0 8/ 9 3 SITE ADDRESS: 1285 WILDERNES3 RI1N RD LOT: 20 BLOCK: 3 WILDERNESS RUN 4TH P.I.N.: 10-84353-200-03 DESCRIPTION: Buildi g--_Permit Type SF OWG Building lJork Type NEW rUBC Occupancy\,,' R-3 M-1 Construction Type V-N Zoning ~ R-1 Building Length ~ 64 Building Width 32 i r F REMARKS: S & W PLBR - FEE SUMMARY: VALUATION $87,000 Base Fee $581.00 MISCELLANEOUS $1.744.50 Plan Review $377.65 Total Fee $3,496.65 Surcharge $43.50 SAC $750.00 SAC 8 100 SAC Units 1 Subtotal $1,752.15 CONTRACTOR: - Applicant - OWNER: KIRBERGER COMPANIES INC 17842604 KIRBERGER COMPANIES INC 7570 HWY 65 NE 7570 HWY 65 NE BLAINE MN 65432 BLAINE MN 55432 (612) 784-2609 (612)784-2604 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 Mn. Statutes and City of Eagan Ordinances. - ~4/P ~ P I CANT/PERMITEE SIGNATURE ISSUE BY: SIG URE INSPECTION RECORD CITYOFEAGAN PERMITTYPE: BuiLDiNs 3830 Pilot Knob Road Permit Number: 021388 Eagan, Minnesota 55123 Date Issued: 07 /08 /93 (612) 681-4675 SITEADDRESS: Lor: 20 BLOCK: 3 APPLICANT: 1285 WILDERNESS RUN RD KIRBERC,ER COMPANIES ZNC WILDERNESS RUN 4TH (612) 789-2609 PERMIT SUBTYPE: TYPE OF WORK: SF DWG NEW INSPECTION . .A FOOTING FRAMING INSULATION FINAL FIREPLACE REMARKS: S & W PLBR - L ~ J REALTIVATE _ I ~~~~~VED CITY OF EAGAN PERMI,T 1893 BUILDING PERMITAPPLICATION 1993681-4675 SINGLE & MULTI-FAMILY esets of plans,,3registered site surveys,~Ycopy of energy calcs. COMMERCIAL 2 sets of architectural 8 structural plans, 1 set of specifications, 1 copy of energy calcs. Penalty applies: 1) when permit is typed, but not picked up by last working day of month- in which request is made, 2) address is changed or 3) lot change is requested once permit is issued. Date Yaluation of work 9Site Address: l~gS w;~cPeRtie&S OPU•V OW SiREET ' SUITE Y Tenant Name: (commercial only) IAT A0 BIACK 3 SUBD. QP.I.D. M Descri tion of work: a_zsrp i L. The applicant is: ? Owner E?(ontractor ? Other (Deaeribe) Name GOl'c !1!5 Phone Property LAST FINST Owner Address STREET STE IF City State Zip ~ Company Phone 79y&Z6y COI1tt'BCtOf Address 75~J~ , License N~~ Exp. " City ~fi~l.d,1E State Zip 55113 Company Phone "757' 200 Architect/ Engineer Name Registration N Address //y7~v I'lT427'I,0 ST2T,~ZZ'_ City c~t~-U~IDS State Z i p Sewer & water licensed plumber . Processing time for sewer & water permits is two days once area has been approved. 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. Signature of Applicant: OFFICE USE ONLY Y .w• ~ BUILDING PERMIT TYPE O 01 Foundation , ? 06 Duplex ? 11 Apt./Lodging •O 16 Basemen"f finish 002 SF Dwg. ? 07 4-Plex O 12 Multi. Misc. ? 17 Swim Pool ? 03 SF Addition ? OB 8-Plex 0 13 Garage/Accessory ? 18 Comn./Ind. ? 04 SF Dorch ? 09 12-Plex 0 14 Fireplace ? 19 Comm./Ind. Misc. E3 05 SF Misc. ? 10 Multi. Add'1. ? 15 Deck O 20 Public facility O 21 Miscellaneous WORK TYPE 0 31 New ? 33 Alterations ? 35 Tenant Finish O 37 Demolish ? 32 Addition 0 34 Repair ? 36 Move GENERAL INFORMATION Const. (Actual) Y_N Basement sq. ft. NWCC System YcS (Allowable) v-N lst F1. sq. ft. City Mater UBC Occupancy p2--,; M-j 2nd F1. sq. ft. PRV Required Zoning R_i Sq. Ft. total Booster Pump of Stories Footprint Sq. ft. Fire Sprinkler Length On-site well Census Code Depth 32, On-site sewage SAC Code APPROVALS j Planning Building Assessments Engineering Variance REQUIRED INSPECTIONS p Site ? Footing ? Framing O Insulation ? Wallboard 0 Final ? Draintile ? Fireplace Permit Fee vtwc;a+= S 0060r Surcharge G AGc; Plan Rev abk26= 676K 1l0 8/6 iew 63MT; ~ License a6x4o= lOYo MWCC SAC Lity SAC Water Conn. Water Meter ILFLo0, Acct. Deposit S/W Permit 656I'r 5/W Surcharge IYZX7= /0 Treatment Pl. Road Unit IIloKS3% 56630 Park Ded. Trails Ded. Copies Other Total: SAC % 100 SAC Units = , " Established in 1962 LOT SURVEYS COMPANY INCo INVOICE NO. 34240 ~ F. B. NO. SS'i-fifi_fi7 LAND $UJtVEY0It8 SCALE I" = ZQ' o Denotee Iron Monument REGISTERED UNDER I.AW9 OF STATE OF MINNESOTA o Deno}es Wood Nub Set 7601- 79rd Avenue North 560-8093 For Excavation Only Minneapolis, Minnesoq 55428 x000.0 Denotes Ezistinq Elevation O Denotea Proposed Elevation omtgaro E~ Denotes Surface Drainaqe KIRBIItGIIt COPlSTRIJCT'IIN 9 I5.1 Proposed Top of Block Proposed grades are subject to '314•6 PraDosed GoraQe Floor depth of existing utilities 90 proposed Lowest Floor in easements. Type of Buildinq - M ~ ~I~ r,aLGH7E~9 ~aic~Jr O / . - - - - _85.21---- _ fENUF_ ~ ~ ; N 9° Pi 0 ~A <V ~ c~ iel W~j % - a99 0/ SqS~ , ~ G4%U„ r4 I ~ n1' ~ / RzvPoSE-D t(` ~ I I ~ ~ ~ ~€51 CUEk~IC~ ~ ~ y ~ / ~n~Rou o i % %38'-0 89~, g ~0 - r 516.53 ~ 9oz,4 l0' o 2S 15LV- .9o U1't LITY (0- POWf-~ - / ~ //f- f - - DA90'fA' eI.EG, a Ef+5Er1~NT , , - , ~ 11 % J ; 1 I ~ / ' ' ,9~ ~ \ W i j _ l~, , - . - ~ _ , • : P A ~ TLI - oJr qsb,ro 0 g0,~r&G~ zzitxa ~,UlI.~~Ri~~S~ R Lot 20, Block 3, WILDE[2NNFSS RUJ 4TH ADDITIIN n,e ony om«n.nn .Nown am rran plata or roc«id w tnt«mnion piovWwed by dw,L ~ ~ 1Me hsreby cMNy thN thls ba tnis arW cortsct ropsasntatlon ol a aurvey of tM boundwln W tM above doseflbed land and ths locetlon o( tll buiWirps and vir IbN oncrwchrrNnU, if a* lrom a on aald land. siped surwywbywmi. 1$th diyof Mav 19 93 Qymond A. Prasch Minn. Req. No. 6743 . . LOT BORVEY CHECRLIST FOR RESIDET;'PZAL SUILDING RMIT APPLI ATION pROPERTY LEGAL: V m Dnte of Survey: DOCUMENT STANDARDS 0 0 • Registered Land Surveyor signature and company 0 • Building Permit Applicant ? ? • Legal description 0 g--'13 • Address fY 00 • North arrow and bar scale C~0 0 • House type (rambler, walkout, split w/o, split entry, / lookout, etc.) FY 0~~ • Directional drainage arrows with slope/gradient ? • Proposed/existing sewer and water services .f~ 0 • Street name ~ ? • Driveway ELEVATIONS , Existinq D Cr'll • Sewer service 9~ ? ? • Lot corners 0 • Top of curb at the driveway ? 0? • Elevations of any existing adjacent homes prooosed Id' ~ ? • Garage floor @~0 D • First floor 0 • Lowest exposed elevation (walkout/window) 0 • Property corners ~ O? • Front and rear of home at the foundation PONDINl3 AREAS (if applicable) 0 ~ ? • Easement line ~ ? • NWL ? • HWL ~ ? • Pond # designation D~ 0 • Emergency overflow Elevation DIMEN8ION8 ~ ? ? • Lot lines ? 0 • Right-of-way and street width (to back of curb) 0' 0 ? • Proposed home dimensions including any proposed decks, overhangs greater than 21, porches, etc. (i.e. all struc*_ures requirinq permanent footings) ff'?? • Show all easements,of record ar.d any City utilities within those easements Cy- 0 0 • Setbacks of proposed structure and setback of adjacent existing homes ? 9/Q • Retaining w *i/ts, if any ~ Reviewed• Nam / D e October 1992 Cities Di ital ualitv Control The following image represents the best available image from the original page. Every effort was made to capture the content from the original page. . t7f~tRIOR [M~[L0~[ A11EIIqOt "U• COIOUTAT1011 • - • . . ~ ~ ~ ~ t5 - Gc=-~-, q- ~*e~rNt ~rw ~a~c ?wMC or , *s?ft c" CU, wkL Mca. ISZ 1 RoariaruMO .•u- ---"Nee • I~~. ~ M[A~ ~1 i. lOm .[k/me MWm;~=mNmmmmNq ff. i•U' ~E~ • ~U. ~ ~ ~Ll111A1lON~~ . 00 16641 ~spenM wll '.w •..re n... 141 °I ~ ~l 1~1 ~y11 ~l~yw N. It. N• f!. ¦ •U` -r LA [ •l~~~ ~I~eM - • tMal doo* N. tf. ¦ •Y• ~ N• •y„ ~~i f~ T~l ~i~~~M ~~N~ ~ ~~G •.~Y`1... ~h~~ • t.wi.~ ~~.w 35. g N• f~. a •Y• Je1 ?IM/1~ M11 N. ~Y• AANNN a - fiall I?at N. I~. ~My fAwragelOY~ N• I!. ~ 'U' _e~L • ~O.?`~ MN IN11 ~~w ~Mw ~r tlaor tln~al~tN) "7.'7-~ .t. . w• -amen. - 4 4, i q ±~1 1k~1 Rl• ~els! ~h~ ~~1 ~.~Z ~~~r q. It. ¦ 'll'eeggUene • -7.g5 • t.~.i r~.~~.,~ N. f!. ¦ 'll• NNAi" ~ - •~w.. ~+.r. ~ Z . . . q . I 4 -NNNe_ N. ft. . u Nnaafi. . . „ TOTAL Mh lI I~ Z.~14 If IpN p Is !M su~ a~, or 1N~ l~~s !fw ~1• Im Aaw sN ~M I~t~t •4 B.D.C. Y~cllo~ im Icl ' 4. TOTAL ExVOBED ROOf/CEILINO CALCULATf0"gl ToW •iposed roof/calling area ~r sq i! J1 TolOl •krlight •re& - . . .a rc . «u" , - k1 Tota! Poo//crtliny fr• an •~9• (awrap lOf) ~I ' .4q /t ¦ ~_oas z, ~ ~ 3/ Tot~l not insulatod "of/cotlny •rw& ~~GV /t ¦ z 5 TOTAL j) thru 1) ZS D~ l/ totAl 0/ N4 is the safte as, t4v l or l~~s tAan N29 You have N ~Sont o/ 6.P,C. 6Octaon L006 fc! ! 70 ALTERMpTE OUTLDINO ENVELppE pE0I0N ~fillt• 'Pstaol»hed !h0 total snvelops •rsl~ br tAe au¦ o/ iterr r NlAod, tAe tA&" tA• sur o/ ilars valu~s M1 •nd 02. N3 •ntl M? %hall not be yreabr J. ~z . '2• Z~ . ZZ t-7 , -r, 4 ~ C E k T( F I C A T I 0 N rsrl'Iy that I Aaw calculated th• •'U•- fietols •nd •nd that CA• butldiny her• described h• 6t*t• oI Ilannesot• EnergY Conserv&tton Acl. OT N~~f / / ~ • I4@notur@1 CHAkLE L. ERO fDatal ~ r''• • y 7('6 4ALL YITH 2ii , . • . -..u1~1T1C ~r:.. .,..riG ' [ons!_ crION A VAiUE. , . WALL, FqAMIMG SECTION: ' _ 1 I terior alr fllm Z 3 nches so t wooA y '~T,•' " . . 'STQINC" ~ ~ Exter or a r m T... ~ . 0TA . U • I/U ' ?MLL SECTION (IMSULATEp) . / . I Interlo? alr /lla - 2 ' n.FA 7 y F Exter or • r m 0ALfl• u ~ I/n . .043.. ' RIM JOIST SECTIII?1: I Interlnr alr /Ilm 2 n.RA ~ 3 2X " 4 ~ F Ext~~~ a i, m ~0 , ~ • ' Y n .014, . A•; FOUNDATION SECTIOM: '•A. ? . . I Intorlor alr-/I'Im' _ ' , s'• ~t' 'A~ G ` 2" CONCkhTh Exter or a r ~ . Q' 0•' ~ .a ` A ' . ' 2• 6TYh OTAI R~ 9 l3 . ~ ~ • ~ • • . 1, STYitO~l/it ' S1A11 ON GqApE 2 t 4 wltb A33 •.06~ r a~ , :Q•• , `;4c'4:,.Q~ ~ : ~ '~v~ •~q ~l•::q~•d P A . . : . • . ; . ~ ~ ..t , a ~ ; . . fA . . 9', ~ A i • ~ V•~~• ~ ~ / • ' ~ ~ p 1 4•.. a~ • . . • .,~1t • ~4• • y' 1 I • ~I ~ • f/ ! • : • ~al • ~ ~4 ; ~ ~ . . ~9 . •47 , f , . . ~.Q•u q ..,~Q,~ ~ . • ' : . 40 :Q 0 ~Q 4~~: q ; ~ • 4. o" .1~~,.` fl . • A W/ CETI.IM6 IN.`iUUTt.. ' [011s, . . CEILIMfi S[CTIQM (91, 1 Int rlor aly ' 3 4 ~ aterlor alr ~ U ~ I/It . .A22 2 5 CEIlI46 FMNIMG SECTION: , 1 Interlor •Ir /llw AIR VENTEO FLOW . . 4 ~t~r or a r m st • S ncnes so e ..o~ DAl a QMUM . • ' . 11 • 1/R •,0w2+ [[ILlqli S[CTIfk1 (IMSULATED): ~ I' Intarloi atr.fllA ~.RI 1 SULATIUN ~ f.xt~r or a r, m st n, OTA~ . ~ U ~ 1/e . .032 2 3 q 5 ' CEILINR rRwinr, secrion: ' •VENTEG ' 1• Interlo~° ~i r.Il iw ' ~.~1 2 7 • xta? or 4 r w st . S mchi• w t wood • . • OTµ . • , ..,r,~ • ' 3 ' 4 . 5 1 lnsta. .tr rilw n.Rl 2 ~ 2 A.17 OTAL R • ' IJ • 1/It • . ~ PERMIT 'o 45S' ~ CIT•Y 00 EAGAN 11~~fG 3830 Pilot Knob Road PERMIT TYPE: B U I E D I N G Eagan, Minnesota 55123 Permit Number: 0 2 4 3 9 6 (612) 681-4675 Date Issued: 0 8/ 11 / 9 4 SITE ADDRESS: 1285 WZLDERNESS RUN RD LOT: 20 BLOCK: 3 WILDERNES3 RUN 4TH P.I.N.: 10-84353-200-03 DESCRIPTION: % Building-Permit Type DECK Building Wor \ Type NEW 1 /-••i l-~\ ~r~, REMARKS: FEE SUMMARY: ` Base Fee $30.00 Surcharge $.50 Total Fee $30.50 CONTRACTOR: OWNER: - Applicant - COLE LEE 1285 WILDERNESS RUN RD EA6AN MN 55123 (612)452-0654 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 Mn. L Statutes and City ofi Eagan Ordinances. J ,~aun. R ` ~ PPLIC T/PERMITEESIGNATURE ISSUEDB SIG TURE INSPECTION RECORD CITY OF EAGAN PERMITTYPE: au2LozNe 3830 Pilot Knob Road Permit Number: 0 2 4 3 4 6 Eagan, Minnesota 55123 Date Issued: 08 J11 J94 (612) 681-4675 SITEADDRESS: LoT: ze BLOCK: 3 APPLICANT: 1285 WILDERNESS RUN RD COLE LEE WILOERNESS RUN 4TH (612) 452-0654 PERMIT SUBTYPE: TYPE OF WORK: DECK NEW INSPECTION . FOOTINGS FINAL F L ~ CITY OF EAGAN 1434C 1994 BUILDING PERMIT APPLICATION 681-4675 CR i gw SINGLE & MULTI-FAMILY 2 sets of plans, 3 registered site su AgGuedpn rgy calcs. AUG 0 B 1994 COMMERCIAL 2 sets of architectural & structural lans, 1 set of specifications, 1 copy of energy calc Penalty applies: 1) when permit is typed, but not picked up by last working day of month in which request is made, 2) address is changed or 3) lot change is requested once permit is issued. Date ` Valuation of work Z- 9 o v - Site Address: STREET SUITE # Tenant Name: (commercial only) LOT BLOCK 7 SUBD. P.I.D. # l,ll .,~'lt~r~ i ~ Descri tion of work: ILIi~3 C`IiC._ The applicant is: ? Owner ? Contractor ? Other (Describe) Name ~~e_ LQ2_ Phone YS2-O~Sy Property IAST FIRST Owner Address L2~S W.tdlmtilA.44 (u.+-. Coact STREET STE tf City 'F lA-4;r l'fv-J State ~q '\J Zip SS/23 Company Phone Co ntractor Address License # Exp. City State Zip Architect/ Company Phone Engineer Name Registration # Address " City State Zip Sewer & water licensed plumber Processing time for sewer & water permits is two days once area has been approved. 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. Signature of Applicant: OFFICE USE ONLY BUILDING PERMIT TYPE ~ . ? 01 Foundation ? 06 Duplex ? 11 Apt./Lodging ? 16 Basement Finish ? 02 SF Dwg. ? 07 4-Plex ? 12 Multi. Misc. ? 17 Swim Pool ? 03 SF Addition ? 08 8-Plex ? 13 Garage/Accessory ? 18 Comm./Ind. ? 04 SF Porch ? 09 12-Plex ? 14 Fireplace ? 19 Comm./Ind. Misc. ? 05 SF Misc. ? 10 Multi. Add'1. ,E1'15 Deck ? 20 Public Facility ? 21 Miscellaneous WORK TYPE /a 31 New ? 33 Alterations ? 35 Tenant Finish ? 37 Demolish ? 32 Addition ? 34 Repair ? 36 Move GENERAL INFORMATION Const. (Actual) Basement sq. ft. MWCC System (Allowable) lst F1. sq. ft. City Water UBC Occupancy 2nd F1. sq. ft. PRY Required Zoning Sq. Ft. total Booster Pump N of Stories Footprint Sq. ft. Fire Sprinkler Length On-site well Census Code 3 y Depth On-site sewage SAC Code o1 Census Bldg APPROVALS Census Unit i- Planning Building Assessments Engineering Variance REOUIRED INSPECTIONS ?.Site O Footing D Framing ? Insulation 13 Wallboard O`Final ? Draintile ? Fireplace Permit Fee veiuac;on: S Surcharge Plan Review License MWCC SAC City SAC Water Conn. Water Meter Acct. Deposit S/W Permit S/W Surcharge Treatment Pl. Road Unit Park Ded. Trails Ded. Copies Other Total: SAC % SAC Units - ' Estoblished in 1962 LOT SURVEYS COMPANY, INCo F. BONO. N~ 553-6fi467 INVICE LAND SURVEYOR4 SCALE I" = 20' o Denotae Iron Monument REGIBTERED UNDER LAWB OF STATE OF MINNESOTA o Denofes Wood Hub Set 7801 - 78rd Avenue North 680-8093 For E atavation Only MinneapolL, Minnaota 66428 z000.0 Denotea Exlsflnp Elevation O Denotes Propoaed Elevation ATY1112gOTo E~ Denofen Surface Drainaqe ' KIRDERGII2 CON51'RUCTIQJ 915.1 Proposed Top of Block Proposed grades are subject to 914.110 Proposed Garaqe Floor depUi af existing utilities 907 f Proposed Loweet Floor in easenents. Type ot Buildinp - , i % r4 (D W ~ ~ o N 9 ° y` 90., /O (A. s lA IJ' n ~ RZ Pc~SED ~ • ._`y.•. I ~ N / RESI DE~CFf rl ~ / =9 1 v uvivaN i38U~ ~ 8.85.,r9/65 -i 591."~ O902.4 I ~7 9ob, J •9~4,d I 8~K / / '1 L I"iY ;7' 1~4 : gOjA- el.Eq Gwr / / %i L~~. 1-7 ~V Ij , ~ : ....s. . ; LTS a , < . » ,Y:.; '*•Y`~ • ' ~ BL. . . . , . : . . . ....:~f](GY . . . . . . . ..~°.........~..~::~'~~':If°: ~:i:L.i#o.`1..::~.~(• T'~.y ..:•:'..A:~:.:.• ` ' a t . . ~ . . . ~1 ~ : : . . . : ~ • . . . . ~ . - . . .,.o....:... ~:"At.,.:k`i. f..`:~ . . . .'1I. . A. ~.~:~r~'~tG~c~''. ..v _ . .,.~,.~...z , . 1993 PLUMBING PERMIT (RESIDEIVT7AL) CTIY OF FAGAN 3830 PII.OT KNOB RD EAGAN MN 55122 (612) 681-4675 PLEASE COMPLETE FOR SINGLE FAMII.Y DWELLINGS. AISO, FOR TOWNHOMES AND CONDOS WHEN PERMITS ARE REQUIF2ED FOR EACH UNIT. - - - - NO. FIXTURES EACH ZbT~ SHOWER 3.00 ! WATER CLOSET 3.00 BATH TUB 3.00 / LAVATORY 3•00 3 ^T KITCHEN SINK 3.00 3 ~ LAUNDRY TRAY 3.00. HOT TUB/SPA 3.00 - ~ WATER HEATER 3.00 2 FLOOR DRAIN 3.00 b-~ _.7- GAS PIPING OLTTLET • minimum -1 3.00 ro 3 ROUGH OPENINGS 1.50 y.so WATER SOFTENER 5.00 PRIVATE DISP. • Da1c.Cry.lit. 15.00 U.G. SPRINKI,ER • eome unaer mmi. 3.00 ALTERATIONS ' to edsting 15.00 WATER TURN AROUND 15.00 STATE SURCHARGE .50 TOTAL: SITE ADDRESS: OWNER NAME: ~ir b2v-q2~-' l_w»oa ie5 INSTALLER: /7Z, -ewt ~ ADDRESS: -L.! 2(a CTTY: ~nd~a STATE: ZIP CODE: ~3a3 PHONE ( ) Zf2-7 -Z3Z/ SIGNATURE OF PERMI7TEE ~ PlXMSEONLY: , . , .BL _ , . , , . t, . > . . . : . . . - :...r..,.,.:..~< _ . , . . ; : ~ . . . . ..:..,.x.... . _ _ . . _ . . _ . . . ; a.<. . ~....,..........~,:.<..;:_.<~: : : I? ...,,.~r.~..:.... a . <>~,r~~;~~:N~:::::< . A.,. .~<D - •.,~:._:~..?1,TE:;~~:=~>z~>~<,w;;.w,: w,. . . . . 1993 PLUMBING PERMIT (COMMERCIAL) • CITY OF FAGAN 3830 PIIAT KNOB RD EAGAN MN 55122 (612) 6814675 PLEASE COMPLETE FOR ALL COMAMRCL4UINDUSTRIAL BUILDINGS. ALSO FOR MULTI- FAMILY BUP DINGS WHEN SEPARATE PERMTTS ARE NOT REQUIRED FOR EACH DWELLING U;;:T. _ NEW CONSTRUCI70N ADD ON REPAI R WORK DESCRIP'I'ION: CONTRACT PRICE: $ FEE: 1% OF CON'I'RACT FEE. ~ STATE SURCIW2GE: S•SO FOR FACH $1,000 OF p£RMYF FEE MINIMUM FEE: $ 25.00 CONTRACT PRICE X 1% $ STATE SURCHARGE $ TOTAL $ SITE ADDRESS: TENANT NAA'IE: STE. # OWItER IVA111E: INSTALLER: ADDRESS: CITY: STATE: ZIP CODE: pHONE FOR: ' CIT1' OF EAGAN APPLICANT F? 'IY USE ONLY ~yyy1 ; =ff~ ~L ~ , ~ f ,f' i F iWV'°~F r Y Y, ''k"i~~°!,"~~~1=1~• ~~~~a ' i ' i , < f 3 a _ .:x.~;.. 1993 MECHANICAL PERMIT (RESIDENTIAL) CITY OF EAGAN 3830 PILOT KNOB RD EAGAN MN 55122 (612) 6814675 PLEASE COMPLETE FOR SINGLE FAMILY DWELLINGS. ALSO, FOR TOWNHOMES AND CONDOS WHEN PERMITS ARE REQUIRED FOR EACH UNTf. ~ NEW CONSTRUCTION ADD-ON A/C ADD-ON FURNACE DATE g-~~-93 FEES HVAC: 0-100 M BTU 24.0 ADDI'T10NAL 50 M BTU 6.00 GAS OUTLETS (M W IMUM 1 C$3.00 EACH) J7,oo ADD-ON/REMODEL (ExISTING CoNSrRUCTtoN) $ 15.00 STATE SURCHARGE .50 TOTAL Vapor- 7 ~ ~c- . SITE ADDRESS: h e 55 ~u ~pao-d OWNER NAME: TE,LEPHONE INSTALLER: 1T4474'n, a ~ /~'+i£ ADDRESS: Z~ Z b- Z`'°~ /~ve , CTI'Y: STATE: ZIP CODE: -T TELEPHONE SIGNATURE OF PERh4ITTEE C°IY:-USE'O1VLY . . . ' . : .....:.......w.......~.M.~..:,;,--..~~.;, .._...w.~~ , .......,...n.. .,ih~.)~} : ...:+~Y .3i La_+~.1~~j' . . . ~ ..::.:......:..~,:_;!<,r:.o~...~;~.~.:.:;.C;''.~::a . x•z::...i6i.':7';:r::~.::;,., . . . : . . . . . . ,..t. . . i . . _ ..y xp.•..:. ..:3.:.. c ...s... . . ~ . . . . . . . - . . :..._.~..r...>:r,:... .wgV°' :'.r`<%.:&:>.'."..:i;:.. <..<_:;..I~a;a";:, . . . . _ .¢...,...~:::>n......<.;.;, ..::.<;r..,.. . ..:i,~....^ ~ .....:r.s... ::£.::tL;%:J..r....:.:c:E"':}'. . . . :.i°_.FS,;: ~a . . ...........,..:~.x.. r......,:.i:,::i'r~'~~r~ . <u......... . , . . . .,...,.........,..:a, a >....y;".;'`e ..._i.......:....~... n: ...d........~ . ~ ...s.: `3'F'M',:.'i£.:~ l.3fJo":. D. •.~y:: 3,,..~ ~~AT'!£;:`~:`~- _...:,_..f....... . , , .r .,x::..~:,.:-::,....<.:. ...H_.......,................._. . 1993 MECHANICAL PERMTT (CONII?ERCIAI,) CTTY OF EAGAN 3830 PILOT KNOB RD EAGAN MN 55122 (612) 6814675 PLEASE COMPLETE FOR ALL COMMERCIAI/INDUSTRIAL BUILDINGS. ALSO COMPLETE FOR APARTMENT BUILDINGS OR OTHER MULTI-FAMIl.Y BUII.DINGS WHEN SEPARATE PERMITS ARE NOT REQUIRED FOR EACH DWELLING UNTT. - - - - - - - - DATE: CON'TKACT PRICE: $ NEW BUILDING INTERIOR IMPROVEMENT WORK DESCRIPTION: FEES 1% OF CON7'Rr1CT FEE $ PROCESSED PIPING: $25.00 MINIh9UM FEE: $25.00 STATE SURCHARGE $.50 FOR EACH $1,000 OF I'FRMIT FEE. T07"AL $ STTE ADDRESS: OWNbR NAME: TELEPHONE TENANr NAR4E: (IMPROVEMEM'S ONLY) INSTALLER: ADDRESS: CI7-y; STATE: ZIP CODE: TELEPHONE SIGNATUP.r OF PERMITTEE ~TTY INSPECTOR ~7 -7 76/ 2007 RESIDENTIAL BUILDING rERMIT arPLicaTioN ~?o -b O City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 Telephone 0 651-675-5675 FAX # 651-675-5694 New ConsWCtion Reouiremenis RemodeVReoair Reauirements ORce Use Oniv 3 re9iste2d srte surveys showing sq. ft. of lot, sq, ft of house; and all roofed areas 2 mpies of plan showing loohngs, beams, joists Cetl of Survey Recd Y_ N (20%mazimum lot coverage allowed) 7 sel of Energy Calculations (or heated additions Soils Repod _ Y_ N 1 Soils Report d proposed building is to be placed on disturbed soil 1 sile survey for additions & decks Tree Pres Plan Recd Y N 2 copies of plan showing beam & window sizes; poured found desgn, etc. Addition - indicafe i/ on-sde sepfic system Tree Pres Required _ Y_ N 1 set of Energy Calculatons On-site Septic System _ Y_ N 3 copies of Tree Preservahon Plan il lot platted after 711193 Rim Joist Detail Ophons selecGon sheet (buiidings with 3 or less uniLs) Minnegasm mechanipl venGlafion form Plans are considered ublic information unless ou state the are trade secret and the reason. ygs ~a Date ,S / ko 2 Construction Cost ~ Site Address 1:).s5 W+1 ~Qprne `S S 2.,n ZA UnitlSte # v~ 1M.. v~ Y~a S al' ~ Description of Nork T~b 1.c~ Y Oc7 ~ Multi-Family Bldg _ Y~ N Fireplace(s) _ 0 _ 1 _ 2 ~ Property Owner V arn i e vi Telephone #(&X7 )V5 y/62~ Contractor ov&t2- T" f G e Awc-P,,~) ~ L..tG , 2DC)7 20 Z-5" Address 50-P ~a-r2cc? q,i,e .$o City m ` kAc Gw~ State ni Lre elesvk Zip SSoI ~ Telephone #(65 2-3 g'Q113 Y COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING - Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672 Energy Code Category . Residential Venlila4on Category 1 Worksheet • New Energy Code Worksheel (q submissiontype) Submitted Submitted , • Energy Envelope Calculations Submitted In the lasf 12 months, has fhe Cify of Eagan issued a permit for a similar plan based on a master plan? _ Y _ N If yes, date and address of master plan: Licensed Plumber Telephone # ( ) Mechanical Contractor Telephone ) Sewer/Water Contractor Telephone ) 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 e case of work which requires a review and permit; that the work will be in accordance with the approve lan :Signature approval of plans. ~ J~ Applicant's Printed Nanie ppl cant's DO NOT WRITE BELOR' THIS LINE Sub Tvpes ? 01 Foundation ? 07 OS-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg ? 02 SF Dwelling ? OS 06-plex ? 16 Fireplace O 21 Porch (3-sea.) ? 31 EM. All - Multi ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF ? 04 02-plex O 10 08-plex ? 18 Deck ? 23 Porch (screen/gazebo/pergola) ? 36 Multi Misc. O 05 03-plex O 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex O 12 12-plex ? 25 Misceilaneous Work Tvpes ? 31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding ? 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair ? 33 Altera6on ? 37 Demolish Building' ? 43 Reroof O 46 Windows/DOOrs ? 34 ReplaCement 'Demolition (Entire Bldg) - Give PCA handout to applicant DESCfiption: WaterDamage_Yes Valuation Occupancy MCES System Plan Review 100% or 25% Code Edition Census Code Zoning City Water SAC Units Stories Booster Pump # of Units Sq. Ft. PRV # of Bldgs Length Fire Sprinklered Type of Const Width REQU[RED INSPECTIONS _ Footings(new bldg) _ Sheetrock _ Footings (deck) _ Fina]/C.O. _ Footings (addi[ion) _ FinaUNo C.O. Foundation H V AC Drain Tile O[her Roof _ Ice & Wa[er _ Final _ Pool Ftgs Air/Gas Tests Final _ Framing _ Siding _ Stucco Lath _ Stone Lath _Brick _ Fireplace _ R.I. _ Air Tes[ _ Fina] _ Windows Insula[ion _ Re[aining Wall Approved By: , Building Inspector Base Fee Surcharge Pfan Review MC/ES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant License Search Copies Other Total CITY OF EAGAN Remarks Addition Wilderness Run 4th Addition Lot 20 Rlk 3 Parcel 10 84353 200 03 Owner street 1285 Wilderness Run - State Ea an MN 55123 R SS ` Improvement Date Amount Annual Years Payment Receipt Date STREETSURF. 8 1977 1032.06 103.20 10 1032.06 C002370 10-4-76 STREET RESTOR. GRADING SANSEW TRUNK 1973 $163.26 $B.lEi 20 SEWER LATERAL WATERMAIN WATERLATERAL 1972 $584.91 38.99 1 WATER AREA -11// 1977 160.00 10.66 15 STORM SEW TRK STORM SEW LAT CUFB & GUTTER SIDEWALK STREET LiGHT WATER CONN. 6UILDING PER. SAC PARK INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number. Eagan, Minnesota 55123 Date Issued: i011-11 1 11114 (612) 681-4675 N c-~ SITE ADDRESS: APPLICANT: I +i7' I~I !•M7 , , ~I;I ; i. ~ i~l 1 : r PERMIT SUBTYPE: TYPE OF WORK: INSPECTION • L~ J .-.r__~__ , . _ • . INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number: ~ Eagan, Minnesota 55123 Date Issued: (612) 681-4675 . SITE ADDRESS: APPLICANT: , ! r ~ ~ I~~ ~ tJf kl~~ • tri~ t i i, ~ ~.~ri; . i r~~ ! ~ ~ i i~s 1 !it . . ilVt ~I t !1 ~ , , . ~ •1 :'F.H~I i PERMITi SUBTYPE: TYPE OF WORK: , INSPECTION 1 ft'.itl F1) ! illl i I ~•1i11 f I 1~ f 7' ( p1 ~ i PWmit No. PwmN Hoklsr DeN Telaphone 1f . S/W PLUMBING . HVAC O 9~ aj7= ELEcrRic ~ • , 93 9J`~ ELECTRIC mspwnon Dd. Map. Commwrs Footings I ! Fa,ndatlon - uxrti~'- G Framing •%i $3 Ro0fIn9 tJ4 Rau9h PIb9. Rough "tg. is,i. Rmplaoe Rna' "ig. Z?- ,4 Orsat Test Fnel Plbg. Plbg. Inspedor - NdNy Plumber Const. Meter , Engr.IPlan &dp. Finel 53 Deck Ft9. Deck Fnal O weli Pr. Disp. ~ PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA173627 Date Issued:11/22/2021 Permit Category:ePermit Site Address: 1285 Wilderness Run Rd Lot:020 Block: 003 Addition: Wilderness Run 4th PID:10-84353-03-200 Use: Description: Sub Type:Residential Work Type:Replace Description:Furnace 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, Pete DeGrood at (507) 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 - Christopher M Schumacher 1285 Wilderness Run Rd Eagan MN 55123 Bonfe's Plumbing & Heating 455 Hardman Ave South St. Paul MN 55075 (651) 228-7140 Applicant/Permitee: Signature Issued By: Signature