1681 Walnut Lane
YILLAOE OF EAGAN WATER SERVICE PERMIT
375+5 Pilot hnob Road PERMIT NO.: 1472
Eogan, MN 55122 DATE: 5/29/4
Zoning: R-1 No. of Units: 1
Owner: Naw me
Address: D -
Sice Address: 16$1 Walnut_ Lane
Plumber: Than~sOri Pltnttbing._CO.
Meter N Connection Charge:130.00 pd 3/18
Size: Account Deposit:
Reader No.i-.~~ ,e 24<_!4-"' Permit Fee: 10.00 billed 5/29/4
1 oOrN to eoinpir with tM VUbyo of Eagan Surchazge: .50 billed 5/29/4
Ordjnances• Misc. Charges:lie.~~
~ Total:
BY ~ Date Paid: ~
Date of lnap.: insp.:
YILLIOE OF EAfiAM SEWER SERVI aE PERMIT
3799 Pibt Knob Road PERMIT NO.: 5 J~7 -
Eogan, MN 55122 DATE;
Zoning: 8 1 No. of Units: 1
Owner: New Hnri 7on Hoewa
Address:
Site Address: 1681 Wa nLt L3ne
Plumber. rpbnmpsnn PlumbinG Co
I oqroe to eemplY with HN Vilkye oi Eagan Connection Charge:400.00 pd 3/11
Ordinanus. Account Depos110.Od b e
Permit Fee: . 1 e ~
Surcharge:
gy; Misc. Charges: -
Date of Insp.: Total: -
Insp.: Date Paid: I
,.......Y.w..an- I
I
I
~
CITY OF EAGAN Remarks
Addition Woodqate lst Addition Loc 6 eik 5 Parcel 10 84600 060 05
Owner~+'• - Street 1681 Walnut LIl. State Eagan, MN 55122
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF.
STREE7RESTOR.pAVINCaL33 1974 $115.45 $23.09 5 PAID
GRADING
PAvING 1976 $992.92 $330.97 3 PAID
SAN SEW TRUNK 7- qi 1974 $93. 54 $6.24 15 PAID
* SEWERLATERAL 1975 15
WATERMAIN
* WATER I.ATERAL 1975 15
* WATER AREA 1975 15
* STORM SEW TRK 1975
* STORMSEWLAT 1975 $2036.55 $135.77 15 PAID
CURB & GUTTER
SJDEWALK
STREET LIGHT
WATER CONN. $130.00 10204 3-18-74
BUILDING PER. 2 4-19-76
5AC $400.00 10 4 3-18-74
PARK
INSPECTIUN RECORD
CITY OF EAGAN PERMIT TYPE:
3830 Pilot Knob Road PeRnit Number.
Eagan, Minnesota 55123 Date Issued: .
(612) 681-4675
SITE ADDRESS: APPLICANT:
llrllFJir]
PERMIT SUBTYPE: TYPE OF WORK:
~ r~ i.~ ~ i•~i i
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( f'irltt~l{ I N 1M,
1
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NI., MAt l'. t 1`1011',1 „ItAF0l1il I
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( Portnlt No. ParmK Hokler Date Telephons N
I S/W
I PLUMBING
I
HVAC
ELECTRIC
ELECTRIC
insp.etion oea anp. commsna
FootMW I
FourWation
Framhng
Roo(ing
I Rough Plbp•
fi0ugh Mp•
Isul.
I FlreplaCe
I
I Final Htg-
I
I Otaat Test
I Final Plbg. Plbp. Inspector - Notily Plumber I
( Const. Meter I
EnqrJPlan
I I
I Bldp. Final
I
Dedc Ftg. I
Dedc Final
Well
Pr. Oisp.
~ - CITY of EAGAN ?v~ 3223
_ ? BUILDING PERMIT ~
3795 Pilof Knob Road
Owne: Eagan. Minnesota 55127
Addzeu (preseni) _L a:.}'.°........7.%~c..~^^tc.r..~.5....~....
~ S~3 K3 454-8100
Bufldar / -
Dsfe
Addrsu
DESCRIPTION
7crios To Bs Usad For Front Deplh Hsigh! Esl. Cos! Piermi! Fee Aemuks
7 3 9
LOCATION 3"0 ~So
Stree2, Roed as ofhas Deaeriplinn ot Loealion I Lo! Bloelc I Addiffoa oz Tnc!
This permit doas not suihorise the use of airea2a, roads, alleps or sidewnlica nor dom it giva the owaer or hL nqeat
the righl So create anp situalion which is a nuisanes or which psesanic a hesard !o the healih, sefetp, convealoan aed
gsneral welfare !o anpone in the eommunilp,
THIS PEAMIT MUST SE KEPT ON TIiE PREMISE WHILE THE WORK IS SN PAOGRESS.
idis is to eerlifp. !hal--~~-~u~Y~~..........basparmLslon !o erect a..... .,°.~L..'.`;~............_up~
the above described premise subjec! fo the provisions of all applicable Ordinanees for the CiEegan.
:~J..........V.......... Pe!
Ma r BuIIdinq I~up~ator
~
. ` ~ ia ~f~ln~o oloo os
CITY OF EAGaIQ
: 3795 Pilot Knob Road
Eagan, btinnesota 55122
PLFuti1T N0. : 4,12
~ The City of Eagan hereby grants to 4'homPaor. P1urihin- Co.
of 12201 kttnaetonka p1vA.
a p7rIKrnI*?G Permit for: (Oi,mer) fTew xorizon Fomms y;oo8nate Addn. 1
at see attached l.ist ~ pursuant to application dated 4/19/7.'
Pee Paid: $1.Q60.00 dated this ^4rh day of AFrxl 1 19 74
49.00 s/c
Building Inspector
Mechanical Permits:
Bid Total:
\
EAGAN TOWNSHIP DALE S. PETERSON
Budding & Urdiry /nspector
PUBLIC WORKS DEPT. wiLunM H. aRnNCH
3795 PILOT KNOB ROAD Supermrendento/PubhcWarks
EAGAN, MINNESOTA 55122
PHONE 454-8100
nnt"irit :70. 441 _ 11/2d/74
Covers foLlo.vinn units an(~ ;iomcs:
!'',2fl,1~-32, 153r., 164'i. 1F44, 16;n, 1554, 1F58. 1662, 1;70, 1674, 1.67°, 1FP2,
1G92, 1r-.94 , 1.696, 1r", 1 7nr; b;alnut I,anc and 3 F35. ]655. 1rr1, 76r5, 15F,.9. 1f73, 1577, lL~.l
]CR5, 1689, 1593, 1507, 17n1 taalnut I,ane
1r;31-'n-27-25 Hicl:ory fllll, ]«E-F8/tl.ic}:ory [iill & 1567-ES flickor.p Lanc, 1665,~,7-r,n-77 ,
Hict;-,r, p!ill, 16r,3-r-.1-59-57 !iickory Ilill, 1F-R7=II3=85=R7 3!3.ckory Hi11 plus lart eleven.,
(Il.) to:,rnhrjti•,e huildincgs -do not have correct house numhers ati vet.
. - - , , r~
VILLAGE OF EAGAN
3795 Pilot Knob Road
Eagan~ Minnesota 55122
PERMIT NO.: 516
The Village of Eagan hereby grants to Geo, 5edawick xeatina
of 1001 Xenia Ave. So.
a_uEnTrxa Permit £or: (Owner) New xorizon - Woodgata .
at iri5 ti ~~lwalnLt Tane , pursuant to application dated 5/e/74 ,
Fee Paid: sqp_oQ dated this 31st day of rfay ~ 1974
1.00
Building Inspector
iJechanical Permits: ,
Bid Total:
HOUSE HEATING TEST RECORD D-21119
ADDRE55 1681 Walnut Lane APT. LOOR CITY SUBURB Eagan
oCCUPnN7 Darrel F. Tomp ins OWNER lfea
HEAT LOSS DATE HTG. INST. GAS C0. METER BADGE QdgwiCk Htg.
SOLD BY INSTALLED BY
Elecirical Work By Gos Line By a u
TYPE OF HEAT GA _ FA X HW -STEAM -SPACE HTR. UNIT HTR. OTHER
GAS DESIGN CONVERSION
MAKE W11112m9011 MAKE OF BURNER
Model 1117-10-5 Model
Seriol 7420095 Maz. BTU Rating
INPUT 100,000 ~1 HT, MAKE OF FURNACE
Model
CONTROLS
THERMOSTAT Cm 260 Heat Plu-$~Vent Si:e 5„
Volre M.H. VFSOOC KIND OF LINER AlIIm, SIZE s„ NONE
Limit Robshaw RFL 750n Droft Hood Vertical Raguloror
LimitSetting Z00of Filters Size 16« g 25° Numbarl
Fan Setting 90°f & 120°f Chimney Location Inside Ye8 Outsida
Pilor 7ype Couple Chimney Construction Metalbeetos
Pilot Make
Pilot Model $moke Bomb Wiring
Pilot Timing 56 Seconde Dwft OK Tesf Tag Ye8
L.W. Cue OFf ~ Door Pressure Lighting Inst. Ye9
Pressure 4,4~~W'C. PerceniCO 2 $'~'5 Date Tested 10/ `g1/74
100 ~ Com ti n Speci lties
Input CFH 0 Percenf OZ ~ ' ~ Company Testing ~
Stack Temp. 550 f percent CO Name of Testar
Form 235
CITY of EAGAN N2 3898
BUILDING PERMIT
/T / 3795 Pilo1 Knob Aoad
Ownar ~til .
//.-~f~ Eagan, Mianesofa 55122
Address (Present) 1(~.1 Z,~-- ' . 454-6100
$u3,da= xc.Z.< De:....'Y..:.1..1...-..>..Sl...............
Addrece
DESCRIPTION
5tories Ta Be Uaed Fos Fron! Deplh Heigh! ~E-el. -Cos-! Permi! FeeI Ramaslcs
/ ~D~ V o
I
LOCATION
Siree2. Aoad ar alher Deseripiion ot Loeation I Lo! Block Addiiion os Traet
16
This permif does aot suthorize the use of sireels, zoads, alleys or sidewalks nor does it giva 1191 owner or hts egen!
the righf !o create any situation which is a nuisance or which presents a hesard !0 the healSh, safely, eonvenienes and
general weltare !o anpone in the communily.
THIS PERMIT MUST B~ EPT O~yg PA£M E WHILE THE WORK IS IN PROG ~S.
This is !o eeriifp. !hal.~`.~O.iutQY...... . hesparmbsian !o erect """'upon
the above descri6ed premise subjeci io the p visions of all appliaable Ordinances for the CiYy of Eagan
r
-V'- ' - . Per .~~...~'e---?.
Mayor Haildinq ImpecloEn~tl
MASTER CARD
LOCATION Gp~v(/00440Z
OWNER
STRUCTURE AND
LAND USED AS
Issued To
Permit No. Issued Coniracror Owner
L ` g4
BUILDING 3Rq !y
w
PLUMBING
CESSPOOL - SEPTIC TANK
WELL
ELECTRICAL
HEATING
GAS INSTALLING
SANITARY SEWER
OTHER
OTHER
Appraved
, Items (Initial) Date Remarks Distance From Well
FOOTING SEPTIC
FOUNDATION CESSPOOL
FRAMING TILE FIELD FT.
FINAL
ELECTRICAL DEPTH
HE.4TING OF WELL
GAS INSTALLATION
SEPTIC TANK
CESSPOOL
DRAINFIELD
PLUMBING
WELI
SANITARY SEWER
Violations Noted
on Back
COMMENTS:
INSPECTION RECORD
CITY OF EAGAN PERMITTYPE: euzLozNc
3830 Pilot Knob Road Permit Number: 023813
Eagan, Minnesota 55123 Date Issued: 0 6/ 0 7/ 9 4
(612) 681-4675
SITE ADDRESS: APPLICANT:
LOT: 6 BLOCK: 5
1681 WALNUT IANE SELA ROOFING & REMODELING
WOODGATE (612) 823-8046
PERMIT SUBTYPE: TYPE OF WORK:
SF (MI$C.) REPAIR
DESCRIPTION (ROOFING)
INSPECTION .
FRAMING ROUGH IN PLBG
ROUGH IN HTG FINAL
REMARKS: (HOUSE & GARAGE)
I ~
L J
PERMIT C 2, ILW
'CITY OF EAGAN
3830 Pilot Knob Road PERMIT TYPE: B U I L D I N G
Eagan, Minnesota 55123 Permit Number: 023813
(612) 681-4675 Date Issued: 0 6/ 0 7/ 9 4
SITE ADDRESS:
1681 WALNUT LANE
LOT: 6 BLOCK: S
WOODGATE
P.I.N.: 10-84600-060-05
DESCRIPTION:
(ROOFING)
Building,Permit Type SF (MISC.)
IBuilding Wo_r\Type REPAIR
~
~
i ~
>
~
REMARKS:
(HOUSE S GARAGE)
FEE SUMMARY:
VALUATION $5,000
Base Fee $72.00
Surcharge $2.50
Total Fee $74.50
CONTRACTOR: - Applicant - ST. LIC. OWNER:
SELA ROOFING & REMODELING 18238046 0001050 BOEMKE JEFF
4100 EXCELSIOR BLVD 1681 WALNUT LN
ST LOUIS PARK MN 55416 EAGAN MN 55122
(612) 823-8046 (612)452-8653
I hereby acknowledge that I have read this application and state that the
information is correct and agree to comply with all applicable State of Mn.
~ Statutes and City ofi Eagan Ordinances. ~
APPLICANT/PERMITEE SIGNATUFE SSUED Br. SI ATURE-~~
REACTIVATE _ CITY OF EAGANO"'
PEttAIT 'i ' 1933 BUILDING PERMIT APPLICATION ~
" ~ 681-4675 3 g~ 3° rN,ZD
SINGLE & LTI-FAMILY 2 sets of plans, 3 registered site surveys, 1 copy of energy
calcs.
COMMERCIAL I 2 sets of architectural & structural plans, 1 set of
specifications, 1 copy of energy calcs.
Penalty applies: 1) when permit is typed, but not picked up by last working day of month
in which request is made, 2) address is changed or 3) lot change is requested ance permit
is issued.
Date Valuation of work ~ 0 U
Site Address: lJO$ l G!4-LN07- Lddir
STREET SUITE N
Tenant Name: (commercial only) T-E-FF l30 -`/tjK_t~
P.I.D. N
IAT (D_ BIACK _.6- SUBD. I,i/
Descri tion of work: flfteojF E-QdoF USC-- 1Wf}bt'
The applicant is: ? Owner EA-Contractor ? Other (Deccribe)
Name 0bEnnKt :rEF T Phone V 5'2- -b"6S3
Property LAsr vIasr
Owner ~
Address .168,1 wPrL~~t ~~E
SiREET sTe x
City N State 111 NA) Zip Sl l~
Company Phone 5 Z3'~'o7~6
SELA ROOFING 8 REMODELING, INC.
Contractor Address a,nn G rr~j cnp BLVB License # Exp.
ST, LOUIS PARK, MINNESOTA 5541gtate ZiP
Ci tY # „M.,.S„
Company Phone
Architect/
Engineer Name Registration III
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
carrect and agree to comply with all applicable 5tate of Minnesota Statutes and City of
Eagan Ordinances.
Signature of Applicant:
I
CityofEaaan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
r
Use BLUE or BLACK Ink
For Office Use
Permit #: / 0 2
Permit Fee: /0 5 -
Date Received:
Staff:
2012 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: 41/—a-)
/ / --a1 " 2 - Site Address: /6 '/ tA4., 1 rr u- L �� Unit #:
J
Name: k %Ung l l e c>�� � Phone:
Address / City / Zip: fi r3 l .U/°•• , L-1/1 ice% eA. ty��ti
Applicant is: Owner Contractor
ki
Description of work:
Construction Cost:
Multi -Family Building: (Yes / No )
Company: 1 /'d ✓ Lo L Jtt,:Contact: 1 cam,' '>> 412.--i.
j j
Address: / . 6 22.. ra-5 4 �� �. Nr. City: a� <� L . L.
State: / Zip: 3 5 2 2 Phone: f://217--) b 9 O
License #:
Lead Certificate #:
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
9 7 j 5
COMPLETE THIS AREA Y IF CONSTRUCTING A NEW ILDING
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:
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.orq
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180
day permit issuance.
Applicant Printed Name
Page 1 of 3
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PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA111699
Date Issued:07/08/2013
Permit Category:ePermit
Site Address: 1681 Walnut Lane
Lot:006 Block: 005 Addition: Woodgate 1st
PID:10-84600-05-060
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Water Heater
Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size
Comments:Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Kris Oien
3670 Dodd Rd
Eagan, MN 55123
Fee Summary:PL - Permit Fee (WS &/or WH)$55.00 0801.4087
Surcharge-Fixed $5.00 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 -
Waldean B Wall
1681 Walnut Lane
Eagan MN 55122
Champion Plumbing
3670 Dodd Rd., #100
Eagan MN 55123
(651) 365-1340
Applicant/Permitee: Signature Issued By: Signature
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Use BLUE or BLACK Ink
r For Office Use el(4))//66(' .
_ P: e/
Ity of Eaaal ,-7/ 0 E7,
3830 Pilot Knob Road MAR 1 U 2011
Eagan MN 55122 Date Received: 3,x'17
Phone:(651)675-5675
Fax: (651)675-5694 Staff:
2017 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: 3 a Site Address: (/, S 1 �L1,I riA �-Y"��'I. Unit#:
Name: \--10-( citeoTh, 4. Phone:<06�� tD6lll I l 756
Resident/
Owner Address/City/Zip: I lD p,i gJn u �7 L a r}P
Applicant is: Owner '✓-Contractor
i
Type o,Work Description of work i,� �_ 'IA, 111* v jI-46 q
Construction Cost:,`, bio( Lj e e Multi-Family Building: (Yes /No
1 Company: __ ir@ a. �r_ .� ,/" r/d Contact: G kryn Pr, r
Contractor Address: 11113D14, -4611p c- City: k,y�/fie.
II
1 i State: M110 Zip: C- 01-4)--It Phone:(f�1'6).�( -(-1141i Email:&C1.r S m dP./I S @ ya,hP•o-Lary-,
1 i
n I .41, 7/ l993(,5J I
License#:�CcF�����1 Lead Certificate#� J
I If the project is exempt from lead certification, please explain why:
1.,_ ___ _
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
I In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan?
1
1 Yes No If yes,date and address of master plan:
1 Licensed Plumber: Phone:
I
1 Mechanical Contractor: Phone:
Sewer&Water Contractor: Phone:
Fire Suppression 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 th- are trade secrets.
CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.qopherstateonecall.orq
I hereby acknowledge that this information is complete and accurate;that the work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180
days of permitissuance.
x G l-Ml J 4' ?,( x _......—.........--- .:..-.-._.
Applicant's Printed Name App icant's ;'ture
Page 1 of 3
/&(( (A)A. (II A ty . DO NOT WRITE BELOW THIS LINE j -/1 7
.. ..4
SUB TYPES k`
Foundation _ Fireplace Porch (3-Season) Exterior Alteration (Single Family)
Single Family Garage Porch(4-Season) — Exterior Alteration(Multi)
Multi Deck X, Porch (Screen/Gazebo/Pergola) Miscellaneous
01 of_Plex Lower Level Pool Accessory Building
WORK TYPES
New Interior Improvement Siding Demolish Building*
Addition Move Building Reroof Demolish Interior
Alteration Fire Repair Windows Demolish Foundation
Replace Repair _ Egress Window Water Damage
Retaining Wall *Demolition of entire building-give PCA handout to applicant
DESCRIPTION
Valuation /1, 2.do .-- Occupancy j)24– I MCES System
Plan Review Code Edition al rJ z®r5 SAC Units
(25%_ 100% g)) Zoning ? D City Water
Census Code Stories Booster Pump
#of Units Square Feet PRV
#of Buildings Length /V Fire Suppression Required
Type of Construction (/13 Width /.(0
REQUIRED INSPECTIONS
Footings (New Building) Meter Size:
Footings (Deck) Final/C.O. Required
X Footings (Addition) X Final/No C.O. Required
Foundation Foundation Before Backfill HVAC_Gas Service Test Gas Line Air Test
Roof:_Ice &Water _Final Pool: _Footings _Air/Gas Tests _Final
x, Framing 30 Minutes 1 Hour Drain Tile
Fireplace: _Rough In _Air Test _Final Siding: _Stucco Lath _Stone Lath _Brick EFIS
Insulation Windows
Sheathing Retaining Wall: _Footings—Backfill_Final
Sheetrock Radon Control
Fire Walls Fire Suppression:_Rough In_Final
Braced Walls Erosion Control
Shower Pan Other:
Reviewed By: '7 /44 /79 k/7 , Building Inspector
RESIDENTIAL FEES 5 eft eeh ptR.CYI 5-0• 00 sq, /f-,
Base Fee
Surcharge /9X/
Plan Review l0 _ 2 Z y
MCES SAC X Ste.
City SAC
Utility Connection Charge 41/ z oe,
/
S&W Permit& Surcharge
Treatment Plant
,----
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TOTAL
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PERMIT
City of Eagan Permit Type:Building
Permit Number:EA164701
Date Issued:10/06/2020
Permit Category:ePermit
Site Address: 1681 Walnut Lane
Lot:006 Block: 005 Addition: Woodgate 1st
PID:10-84600-05-060
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:Does not include skylight(s)
Census Code:434 - Residential Additions, Alterations
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please print pictures of ice and water protection and leave on site.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Building Code).
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 -
Waldean B & Sheila K Wall
1681 Walnut Ln
Eagan MN 55122--253
(651) 247-8013
Austad Construction
182 A Ryan Ln
Little Canada MN 55117
(651) 482-0070
Applicant/Permitee: Signature Issued By: Signature