1490 Wellington Way
Address: 1490 Wellington Way Zip: 55122 ~ ermit: 76675
THE FOLLOWING ITEMS W'ERElWERE NOT COM1iPLETE AT FN1AL INSPECTION ON :o -7
Yes No Comments
Final grade - 6" from siding
Permanent ste s - garage Permanent ste s- main entry
Permanent driveway 1/' ~'ft'(L
Permanent gas
Retaining Wall or 3:1 Max Slo e ?
Sod/Seeded lawn
Trail/curb damage
Porch
Lower level finish ?
Deck
Fireplace
• Verify with your builder that roof test caps from the plumbing system have been removed.
• Tum offwater supply to the outside lawn faucets before freeze potential exists.
• Call the City's Engineering Department at 651-675-5646 prior to working in right-of-way or installing
irriga[ion system.
'J BUILD[NG INSPECTOA: ~GlBldg Insp/Fortns/2007/Checklists
01t`8/2007 13:23 6128252303 RAY N WELTER HEATING PAGE 03/03
Date: 1110107 Revision Oate: 1110107 New Construction
51te Information
Address 1: 1480 Wellington Way Project Steeplechase of Eagan
Address 2: . Lot: #22 Block:
' City: Eagan County: Subdivision:
Apalication Information
Business Name: Ray N Welter HVAC MN Contractor License
Contact Person: JOE
Oifice Ph: 612-8256867 Fax' Cell Ph:
-Address 1: 4637 Chicago Ave. So: - --J- - - - - T- - - - - - - -
City: MPLS. State: MN. Zip Code: 55407
House Details
Square Feet: 5413 sq, ft. Av8• Ceiling Ht: 10.9 Number of Bedrooms: 5
ft. .
Ventllation : Balanced
Total VentilaHon Capacity : 258 cfm.
Minimum Continuous Ventilation :90cim.
Intertnittent Ventilation: 168 cfm.
Combustion Aoollance
Water Heater. Power Vent Input BTUs: 80,000 Independently Verited
FurnaceBoiler. Direct VenUSealed CombUstion Input BTUs: 120,000 independently Vented
Other Combustion Appliances
Gas Fired Direct Vent Fireplace(s): Yes Gas Fired Power Vent Fireplace(s): No
Gas Fired Natural Draft Fireplace(s): No Solid Fuel Appliance(s): No
Exhaust Eauioment
Continuous Exhaust Ventilation Capacity (cfm): NA Clothes Dryer (cfm): 135
Exhaust Fan Rating (cfm):. 300
Make.UP-Air [E 0 [E 0 W E D
No Make-Up Air Required by Code ~ Ul
~ JAN 1 0 2007
Combustion Air
Round Rigid Required: 6 inches or Insulated Flex: 7 inches
Applicant Name (print):611,116- Ile 6a /iak SignaturelDate: ~fIt 0 ~
Code Official (print): SignaturelDate:
0 2004 CenterPoint Energy Minncga5co. 2004 Meche¢rieal Code Cruidelines. Page 1
I - 2006 RESIDENTIAL BUILDING PERMTT APPLICAT ON 90
I City OfEagan rf~,f- -7 7 40. 50
; 3830 Pilot Knob Road, Eagan MrI 55122
Telephone # 651-675-5675 FAX # 651-675-5694 CA,II~ -D-b 7
. New bnNnudion Reoviremenls RemodeVReoak Rmu72ments Ofiee Use OnH
3 ra9'teretl sqe surveys showhip sq. R ot lol, sq. R ot house; end aA mofed areas 2 copies of plen show4ig tootings, beams, jokts CaK M Survey Recd y~y
(201 mm" bt coverege e?wied) . 1 set of Fnergy CabWatvore fir heatad additions Tree Pms Plan Recd 1/2 coPls'M aMwMg 6eam 6 windmv shes; pomed tound design, efe. 1 s@e suNey tar additions 6 dedcs Tree Res Requhed - Y t/N
_ N
?1setFEn~g~yCaladations ~y Adddion•indirate6auFSdesep6cryslem OnslleSepticSystem _y _N
3 coRs o(Tree Pon'61znN Ip( p~ted aNer 711193
?Rirz+ ~kM DehU 0 sel Eel: b~"u?d' s wilit 3 or less untls
,iMiiuegasco mechsn~ ventilation fortn
'
~
Da4 4_/$'I L9.7 Construc6on Cost Z~ Z' 0C70, S'•'
SiteAddress ~ UniVSte {i 2Z
$ lac.Y~.S
DesriptionotWork
M!Iti-Family Bidg _ yX N Fireptace(s) _ 0.~ L _ Z
c6Sl) 7~o2-Z7 4 s~
rSS rty Owoe r Telephone #
actor ddress[• ~7(~ G IYdL'~ Ci[ate ZiP -eMZZ Te(ephone#(~j~) _
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
i
Energy Code Category - Minnesota Rules 7670 Cateeorv I p~`~.~ I_c '.I M nesota Rules 7672 •
! (4 submsslon type) • Residentia! VenLlation Category 1 heet ew Energy Code Woft¢heet
Submitled . ' ~ ubmitted
~ • EnergyEnvelopeCalwlations5ubm ed JA~V Z 4 Z007 '
~ In the last 12 months, has the CiTy of Eagan issued a pertnit for a simlar planaied on a master plan?
Y # N If yes, date and address of master plan:
i
LiCensed Plumber a yc~ 71 (,r,.,,,, Telephone ~ -6/Bp
i
Mechanical Contractor I'l d Telephone # (//L)~Z$'- ~ jp 3
Sewer/Water Contractor Telephone #((~'~j ~/~O
I hereby apply for a Residen6al Building Permit and acknowledge that the informarion is complete and accuratt
that the work wi11 be in cbnformance with the ordinances and codes of the City of Eagan and the State of M
Statutes; I understand this is not a permit, but only an application for a permit, and work is not to start without
permit; that the work will be in accordance with the approved plan in the case of work wluch requires a review az
approval of plans.
Apphcant's Printed Name Apphcant's Stgnature `
~
\
DO NOT WRITE BELOW THIS LINE . Sub Tvpes
? 01 Foundation ? 07 OS-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
)p 02 SF Dwelling ? OB 06-plez ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Multi
? 03 01 of _ plex ? 09 07-plez ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF
? 04 02-plex ? 10 OB-plex ? 18 Deck ? 23 Porch (screen/gazebolpergola) ? 36 Multi Misc.
? OS 03-plex O 11 10-plex ? 19 Lower Level ? 24 Storm Damage
? 06 04-plex ? 12 12-plex ? 25 Miscellaneous
Work T es
31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding
? 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair
? 33 Alteration ? 37 Demolish Building' ? 43 Reroof ? 46 WndowslDoors
? 34 Replacement 'Demolition (En[ire Bldg) - Give PCA handout to applicant
DBSCflptl0ll: WaterDamage_Yes
Valuation ~ ' Occupancy 3 MCES SYstem
Plan Review ~ 100% or _ 25%
Census Code 12) 1 Zoning p_ City Water
SAC Units Stories 2i Booster Pump
# of Units Sq. Ft. ZE6 -7 PRV
# of Bldgs a~ Length ~ Fire Sprinklered
Type of Const 'y_ Width _ v1 7
REQUIRED INSPECTIONS
_p Footings (new bldg) _ Sheetrock
Footings (deck) ~ FinaUC.O.
Footings (addition) _ Final/No C.O.
~ Foundation _ HVAC
Drain Tile Other
Roof Ice & Water 1? Final _ Pool Ftgs Air/Gas Tests Final
~a Framing _ Siding _ Stucco Lath ZO Stone Lath _Brick
_p Fireplace _Y R.I. _)Q Air Test ~ Final _ Windows
-\c Insulation _ Retaining Wall
Approved By: Building Inspector
- -•l4 i-----------------------------------------------------------------------
BaseFee 6z-vi GE 765- 53•/rJt35'-b
Surcharge /39 $ea-evll"(P;n;sheD) 2~`IS59•
PlanReview 1)'fd.'4 ZIcJb Sq - FT• x7~'1•2 8
MC/ESSAC anD 7Z S9•fr x'71
cicy snc S7 •t~r. • x ys o0
ns?~~
' Utility Connection Charge CD v e Fe D s Too{' 59
S&W Permit & Surcharge
Treatment Plant
II License Search f/17.
, Copies
Other
Total
I
' LOT SURVEY CHECKLIST FOR RESIDENTIAL
BUILDING PERMIT APPLICATION
PROPERTY LEGAL: $ S S C(:4aSe- O~
DATE OF SURVEY: IZ
LATEST REVISION: ZI R 107
m
a
c
m
L
U
v
O z ¢ DOCUMENT STANDARDS
,0 • Registered Land Surveyor signature and company
Jd ? ? • Building Permit Applicant
~ ? ? • Legal description
B ? ? • Address ? 0 • North arrow and scale
.0 . House type (rambler, walkout, split w/o, split entry, lookout, etc.)
p' . Directional drainage arrows with slope/gradient %
'0 ? 0 • Proposed/existing sewer and water services & invert elevation
'0 ? ? • Street name
~ ;R ? f~ • Driveway (grade & width - in RNJ and back of cur , 22' max. .
fG ? ? • Lot Square Footage
~ ? ~ • Lot Coverage~ ~ In~~C~,VEl~k2-~ i'/I a'/v'S
ELEVATIONS
Existinp
? ? • Property comers
~ '
. Top of curb at the driveway and property line eMensions
~?P • Elevations of any existing adjacent homes- Sl,ou/7op £L. Car £.c,'rf;n9 Ilcme, fo L?esf
H' • Adequate footing depth of structures due to adjacent utility trenches
? 2 ? • Watenvays (pond, stream, etc.)
Prooosed
)6 ? ? • Garage floor
H 0 ? • Basementfloor .
fd ? ? • Lowest exposed elevation (walkouUwindow)
? ? • Proerty corners
loj~ • ront nd rear of home at the foundation -
~VA d.d Jn BaeK.
PONDING AREA (if applicable)
? JZ ? • Easement line
? ,H ? • NWL
? Jd ? • HWL
? ~ ? • Pond # designation
? ~ ? • Emergency Overflow Elevation
? ,0 ? • Pond/Wetland buffer delineation
Y ~ . Shoreland Zoning Overlay Distrid
Y • Conservation Easements
DIMENSIONS
~ ? ? • Lot lineslBearings 8 di
0 yl • Right-of-way and treet width (to backof curb)
• Proposed home dimension~sTncTu~ any roposed decks, overhangs greater than 2', porches, etc.
(i.e. all structures requiring permanent footings)-b;in"ion
p
? • Show all easements of record and any City utilities within those easemen{s
,0 0? • Setbacks of proposed structure and s' yard setback of adjacent existing strudures
2 ? ? . Retaining wall requirements:
Reviewed By: Date /~Z9,0-7
. G:lFORMSBuilding Pertnil Application Rev. 11-26-04
RffirJwck SoRaare Ve[d¢on 3.6 Releaee 1
. . ~ PamitNumber DAT8:1220/Ofi .
' pRpIECT 7'f17.E: PepinModel
' RE3check Compliance CertiGcate ctieckeaBrrnue pldg. II
~ 2003IECC un I
RESchuk SoRwae Vecmm 3.6 &]eeee t I
DmafileoetnaK:IHNGINSIIRIIJGSHRVICESIE{VACDII"15_HnergyCalcdatioualAM1cep1ce6ueafEagen I Cqtlugr.
Sigoaaves1022u'epin-Provinciel-D7Zack [ 1 I 1. PletCeiliog:FletCaliagor5ciaeo[
~ Comanb:
PRO]EL`T11TLE:Pepin Mode1 1 2 WallCeilmg:P]atCdlingorSciew
~ Cummmta:
CI7'Y:Minnapolia [ ] ~ 3. SlapadCaliog:FletCwlingmScie
srA'rs:Minnesora I camma
IIDD:7981 I
fANS1RUCfiON 7'YPE: Single Aemtly Above.Gnde WeW:
' WP7DOW / WALL RATIO: 0.15 [ 1 ~ 1. (iuege waR: Wood Pnme, 16" o.a
~ Cummeats:
DA1E: I2f2NQ6 ( 1 I 1. Knee Well: WoodFnmG 16" a.c.,
OAT60APLAN5:1711N2U06 I Commenffi:
I 1 I 3. Beod ]oiet Waod Fmme,16" o.c.,'.
PROIECf D85CRIP'170N: I ~~mtg:
Slceplecheaeol'Eegm-Cmdegee . [ 1 I 4. EveriorWd16":WoodFnm0.24'
4876Steeplocht+eWryIqt= ~ Cammente.
Eagm,MN 53122
. I
1 ~ HuemmtWeW:
I ) ~ l. BaeemautWall 1:3olidCa¢aele0
~ R-11.0contiwmisineuletlan
DFSIGNER/CONIRAC7'OR: ~ Commb:
To?Brotherelnc. ~ Extuio~ioeWetianmuathavearig
PAOJECI'N07ES: ~ covmtlneapaed(ebmo-gede)i
Elevafioo: Pmriucial ~
Optlams:Ul7.023,025,151,IB7,190~67,9002012, I Windo~:
900270I4,90022015,90022D7 [ J ~ 1. Window2:ViuylNmme:Dau6leP
~ Fmvriudowewit6mrtleWedU-fa
FreokDmeo, P.E. ~ #Penes_FtemeType-
Tesk 36226 ~ Ca~rnls
[ 1 ~ 2. Wiaduw 3: Ymyl Nm=:Dauhle P
CAMPI]ANCH:Pam ~ Farwindowewit6outlsbeledU-fl
MeximumUA=906 ~ #Panw Fteme7pPe-
YmaHOmeUA=fi60 ~ Comments:
IB.I°bHetterThmCade(OA) Qlazi% ~
A[eeox Cev'dy Cmt. m?oar ~ Skyllghh:
Paimeter R-VelueR-ValueU-Facmr UA I 1 I 1. Skpligh[ 1: Vinyl F~ame:Doohle E
Pocskylig6tiwiWrndhbeledU-11
UP
AletCeiling:AletCeiliogot3cieeorTives 1726 44.0 0.0 47 ~ ms_Rcame7~pa
WallCeiibgFletCeilingm5ciawrTnus 32 44.0 OA t ~
glopodCei]ing;FlalCeil'mgot5aeeoi Trues 704 44.0 0.0 19 I
~ Doon:
SkyGg}n 1: Viuyl Frame-Doublo Peoe wit6 Low-6 8 0.400 3 1, Dooc 5: Solid, U•feclur: 0.200
6etege wal1: Wood Fremq I6" o.c, 727 19.0 0.0 19 I Ccamicab:
Dooc 5: So]iJ 17 0.200 3 [ 1 ~ 2. Door 7: Solid, U-facroc 9.7AD
Knce Well: Woad Fmne,16" o.a 795 13.0 0.0 65 I commenta;
Baod]oiet:WoodFiame,l6"a.a 271 19.0 0,0 16 ~ 3. Dow 9:Glsis,U-feclor.0350
V'PxtaimWe116":WaadFwme,74"o.a 3014 19.0 0.0 140 ~ ~,~mp:
Wmdaw 2: Ymyl Fnme:Double Pme with Law-E 610 03fi0 270 I
Doax 7: So1id 40 0.100 B ~ Flaon:
BasemmlWal]L'SolidCantTetearMavomy 1742 0.0 11.0 95 L I 1 1. F7ompverGamgp;pll-Waodlo
WeRheight8.0' ' 1 R-30.0 cavity iosulatim
Depthbalawgisde:7.S ~ Coovrn6:
InaJanw depth T.S ~
Wmdow3:VioylFiame:Donb]ePmewiWI.ow-E 11 0.360 4
Dom g; p~9e 42 0350 15
Moot We Crenge: A14WoodJoiaV1'nue:OraUaondifianedSpece 139 30.0 OA 5
Fumece L• Amoed Hat Aic, 42 AN[1H
Aa Cooditionec 1; Hlectrie Centtd A'v,13 SEER '
CAMPLIANC9 STAT@rENT: 'Ne pmpossd build'mg design deecnbed 6ero ie coneieteotwith 1ha buiidia8 Pium,
specificafiw&ando4ercelculeti~esubmiuedwiththepe~mitapplirafioa 7Leproposedbuildinghaa6em
decigned ro meetWe 2007IHCC ceqinnemeou m RE3cherk Vaeio¢ 9.6 Relwee 1(fmmedylR:Ccheck) end W
comylywithlLemstedaroryroquine nblietedintheRrSche pectianCBsHirt.
Builda/Deeiygueer Dffie~/ C~ /
~ RE101S E ; -
Certificate of Survey
~ ~ ~ D~Gt7CS[~4 O n 5O9 OF
1490 WELLINGTON WAY
WELLINGTON
w Q_ 24'4 ~ 9
<I ~0
i~ I° /I R'1 955~ TOLL BROTHERS
1400 Corpotate Center Curve
1 • ~ ~I ~`~s,~o Eagan, MN Zip 55121
A98. 6 0 ~ c~ cs cQ ~
- ql 5 OL
r 99~ ~ `_O 1 ~ ~ ~f s $ 0,~g9'1.
6V ~sl~
~9BSn,y-~lr ~TO I. - ~ aW°`~
10 ~ a fie4ainirsg Wall NR
- s ~1- _s,.s J__ ~ e~.a, ~ 86 Requ~red
N 6.6. T~1.68 '
iop I.P T8'i ~ q Sy~,p St~Oa i. /
994.23 I 95~ ~999'i.~w O\i ~ 99 8 87. y~ ~ oi 9~ S\ gq 2~~t
94 MID
~y6 ~J J~ ~ N 12.0
i
Or„ S B 1.5~. i'a 98. ~ ~ NORTg
yB
4.3 I X q 6 a
9901 nx9 996, ~ Pr pase ~ O ~
- - i 9o9 ~
N ~ L 7
g9p5pfOP052d hOU58X9g0.1 1120 9y1,a iQ' x 9 poured wall 99~ p
9~ ~ ~ SB walkout basement N i i~ ~
~ ~ ~~e SCALE IN FEET
~ @g8 14.9 p O ter cti
20 0_ N12.9 7_3 9--~ ~ 99x ~
J O^ 17.92 x 34.t5 99.
/9ea ~ I ' ~892 % y0 ~991.j 9py~. / /
- If
986 ~2
\ ~894
~ -b'q-" - - l-~'?
\ \oe_ x9B -~98e_.__--i•~`05 e~~ O
PROPOSED ELEVATIONS
~lPb n'6/ • ` ~
tr=-"z- - / Garaqe floor elev. = 998.1
Top of wall elev. = 998.5
10 Lowest floor elev. = 989.8
~ ~ , , 3
PROPOSED AREAS
BENCHMARK Area of Lot 8, Block 5= 17,529 Sq. Ft.
Top Nut Hydrant Lots 6 and 7, Block 3, Propoaed Houae = 3,126 Sq. Ft.
~ Steeplechase of Eagan Percent of Lot Coverage= 18%
Elevation = 989.61 feet (NAVD 1986)
San. Sewer Stub Elev.= 986.6
LEGEND
WO House
Garage left Iron monument found = Drainage Dlrectlon
Minimum lowest floor O= Iron monument set and marked -840-= proposed 10' contours from grading plan
eleVatlon = 989.8 wlth Ilcense No. 23968. -842- = proposed 2' contours from grading plan
~ ' ~ n ~ a = Offset iron -840- = Existing 10' contours
~ \V \V ~ = Dralnage & Utllfty Easement - $4z- ° Exfsting 2' contours
- < - = Existing sanitary sewer
BY eoo.ox = Exlsting Elevation = Existing storm sewer
~/~Z~~ Proposed elevation from grade - I - = Existing water
Date or development plan p = Sanitary manhole
EA(}A!1 I$RIGU4EEMCi DEff. Woter Curb Stop m = Gate valve
C I TY O F EAGAN Bearings =t t~-_
Lot 8, Block 5 50f: 31
S T E E P L E C HAS E ~ABUILDIPECYM~
O F EAGAN Drawing File: 700\708-LI8.B5.dwg
Project No. 2006-408-L
D A K 0 TA C 0 U N TY, M I N N E S 0 TA Toll Bros. Code= # 4, SPR ({HSE-PLAN-N0.
Subject to easements of record, if any.
I hereby certify that this survey, plan or report was prepared by ^ Duluth, MN.
me or under my direct supervision and that I am a duly Registered Hibbing, MN.
Land Surveyor under the laws of the State of Minnesota. RJ.K Ham Lake, MN.
Minnetonka, MN.
Z~ January 19, 2007 K~SE37V LTD Phone: (952) 933-0972
Mich el E. C nnon, MN License No. 40035 Date Fax: (952) 933-1153
w
Rav: 2/5/07-City comments, feld info ~ ww.rlk-kuuSisto.COm
Rav. 2/28/07-Changed to 9' ba98ment 6'I'10 Blue Circle Dr. •Suite #100 •Minnetonka. MN. 55343
Feb 28. 2007 7:42om
T:\TOII Brolhe.s\2006-408-L\dwg\700\718-LB,65.dwg
~ oll Architecture 10
February 16, 2007
Chad Carroll
Steeplechase of Eagan Signatures
4876 Steeplechase Way
Eagan, MN 55122
RE: Pepin - TBI Lot #022
1490 Wellington Way
Dear Chad,
For TBI Lot #022, I have reviewed the construction documents for structural integrity.
I find no exceptions to the roof framing, floor framing, and foundations including °tall
wall" assemblies and garage portal stability. Note that dhe stud framing shown on the
consVuction documents have a maximum deflection criteria of span/240 for the Foyer
wall and span/180 for all other °tall walls" under wind loading per ASCE 7-98.
If you have any questions or concems, please do not hesitate to call.
Sincerely,
Toll Brothers, Inc.
I htreby ccT.ify lh3i Shis gtan, W-~&
fi:atiun, ar rtport wus ¢repared by
me crr unde,r my di.*eci supeivisian
and dtiat ( am a duly Licased
Pruf*asinnal Er,ginecr under tha
laws oi thc SWte of Ad'umesnta.
Priat Name: I SA M. GROSSE
Slpature:
Dete 2/6 ~7 Lic Ii44835
Lisa M. Grosse, P.E.
Assistant Director of Engineering
MN License #44835
CC: Jerry Lamina
LMG/11
SESG 1tr0021
Task #43022 A09730
EASTF.RN D[VISION
250 Gibraltur Roud 0 Horsham, PA 19044 m (215) 293-5300 0 FAa: (215) 293-5313
PIIILADELPIIIA m ORLANDO 0 SCOTTSDALE a DALLAS s DEWER n LOS ANGELHS
d `r011 `BrothBtS COiL11'ANY
REScheek Softwme Vamon 3.6 Rckase 1
PavdNumber DATFi 17110106
PAOlECI"III1E: Pryin Model
REScheck Compliance Certificate Cnecked BylDete B»e• I
2003IECC D`P` I
Uu ~
RESclwA SoBware Vcrsion 3.6 Relceee l ~
Dala6lename:K:\SNGINEQtINGSERVICESI_HVACDEPT_EnergyCe~darionsV~4hSle~lecLveofEappn I Ceirmgl:
- SigoaAVa1072~Pepia-Piminciel-022.~ck I 1 I 1. ['let Cdliug Plef Caling ar Sdse
~ Conammb:
PROJECf 17TLE: PeQm Mode] 1. Well Czilmg:l7ec Cciliog m Sae
~ Carmarnh:
Cl'1'Y:Mimeapolis I 1 1 3. S(opedCei4t7etCei1ingmSi
SfAT& bfmesota ~ Ca~rnb:
HDD: 7981 . ~
CANSIRUC'CfONTYPE:Si¢glePemily ~ A6o.e-GredeWelh:
WAlDOW / WALL RATIO: 0.15 ~ I. Guege wa0: Wood Preme, 16" o
Co
DATE:l1!!0l06 ~ ~mm:
~
~ I I ZKna Well: Wood Fmme,16° ac
DATEOFPLAN5:11R0.2006 ~ commmti:
PROJECT DFSCRIPTION: [ I I 3. Bmd Joist Wood Fremq 16 ac
Smelec6a~e of~• Catri ee I
P B~ 8B [ ] ~ 4. A.xteriorWe1l6°:WoodFamq2
4876 Steeplw6avo Way Lott1022 I Conarn
Eagno, MN 55122 ~
~ H.>mmtWeOe:
[ J ~ 1. Beeemmt Wall L• Solid Caaps
DESIGNER/CON[7tACiDR: I R-I1.0 amtmomuinnJetion
ToOBrotheialnc. I Commrnm:
PROIECE N07E5: I ~~M mu+t huve a ri
Elevatioo:Pmrmcial I cmastheexpoced(ebovcgrede)
Optioav:017.023,025,151,187.190,367,9002012, I
9qY22014,90022015, 9002207 ~ ~mdoWs:
I 1 ~ 1. Windnw2:V'mylPmmc:Dauble
FmntDmw.P.E. ~ EwwimlawewilLoutlebeledU-f
Tesk 36226 ~ #Penee_ Fmanc TyPc_
~ Carnmeu6:
CAMPI.IANCS. Pema ~ Z Wiudnw 3: Ymyl Prame:DaubLe
Maximm UA=806 ~ FarwindowtwkboutlabeledLLf
Y=AomoUA=66D ~ #Peaa-FtemeType-
~
IB.IYa DcUcrlLau Code (UA)
Gross Olezing Cuanuents:
~ SkyRghh:
Ma m Gvity CoN. m Door
Pckcter R-Ya1ucA•VelueU-Facror UA ~ I I i. Skytight 1: Viuyl Pceme:Double
~ PaekYliglWwitLautlebeledU-1
AlelCciling: Alel Cciling ot 3ciesa Ttuss 1726 44.0 0.0 47 I # Pgos_ Frama Type
Wa11Cei1mg:FlatCeilingm5cioeorTnus 32 44.0 DA l ~ C0~mis:
5loped Cciliog FIt1 Ceilmg m Saawc7'rwe 704 44.0 0.0 19 ~
S1yGgSrt l: Vmyl FmmeDau6h Pane with Low-& 8 0.400 3 ~Doen:
Gmege well: Wood Feeme,16' o.c. 327 19.0 0.0 19 I 1 I 1• Dooe 5: Solid U-tacror: 0200
DoocS:Solid 17 0100 3 ~ Comments:
RacWaIL•WoodFme,16•o.0. 795 13.0 0.0 es I Z• Door7:5olid,U-tacror.0.200
Baodlaist Wood Flame,l6' o.e. 271 19A 0.0 16 I Commmts:
Ex[aim Wa116": Wood Freme, 24" o.a 3024 19.0 0.0 140 3. Door9: Glass, UfeeM: Q350
Wmdov+2:VmyiFmme:Daoh]ePmewithLow-E 610 0360 220 I c'0turnC°ti:
Dom 7: Solid 40 0.200 B ~
Baremeol Wal] L Solid Cancrete mMmomy 1742 0.0 13.0 95 ~ Nloon:
Well 6eightB.P [ ~ I 1. F1oorOvcrGaraBe:Alf-WoodJo
DepIL below gak: 7.S ~ R-30.0 uvity innilefim
Iawlntim depthT.S I Commrnh:
Wmdow 3: Vmyl Frame:Dvoble Pme adW Laa-E 11 0960 4 1
Dom 9: Glass 42 0350 15
P1oorOver Gazage:
A14WoodJoisuTws:OverUocwdi6anedSpaa 139 30.0 0.0 5
Fumaa l: Fmml Hol Au, 92 AFOH
A'v Conditiona L Elxrtic Centrel A'v,13 SEER
COMPI,IANCC STATDMQJ'I: 7Le propased building design descnbed hero ie cooeisteulvriilh tha build'wg plms,
epecificaGoo;eadothacs1w1a6mswbminedwithtLepmmitsppliiatioa Thepopasedbuildingheaban
de*ed m meet the 2003 IECC reqirimmeote m RFSekd Vavo¢ 7.6 &kast 1(fmmety M1tiCchecle) md W
wmply wi~h tl~e mmdalory requue ef IiGed in 16e REScAerk impectiao Cbceklist.
~ ~E~.. %'A'`` Z -Z o;,
IN ~"oll Architecture JV
December 28, 2006
Chad Carroll
Steeplechase of Eagan - Signatures
4876 Steeplechase Way
Eagan, NfN 55122
RE: Pepin - TBI Lot #022
1490 Wellington Way
Dear Chad,
For TBI Lot #022, I have reviewed the construction documents for structural integrity. I
find no exceptions to the roof framing, floor framing, and foundations including "tall
wall" assemblies and garage portal stability. Note that the stud framing shown on the
construction documents have a maximum deflection criteria of span/180 for all "tall
walls" under wind loading per ASCE 7-98.
If you have any questions or concems, please do not hesitate to call.
Sincerely,
Toll Brothers, Inc.
I h^reby crtify tha: tltis Plan, spcci-
fication, or r•eport was pxepared by
me or ur.dcr my direct supervision
and that 1 sni x duly Licrnsed
Professionai EnginccK under tha
• L^,ws of th:: Su:te of Phionesata.
Print Nazne: ISA A9. GROSSB
,
Sigoattue: - ~N
Data 12 2b 4h L,i e#44835
Lisa M. Grosse, P.E.
Senior Structural Engineer
MN License #44835
CC: Jerry Lamina
LMG/Il
SESG 1tr0013
Task #37363 A08626
EASTERn D[V15IOY
250 Gibcnitar Road 0 Horsham; PA 19044 s (315) 293-5300 o FAX: (215) 293-5313
PHILADELPHIA a OKLANDO m SCOTTSD/+LE m DALLAS o DENVLR m LOS ANGFLrS
4 `r011 `BlbthCTS CODIPr(rb'Y
INSULATION INSPECTION CHECKLIST FOR RESIDENTIAL
BUILDING PERMITS
PROPERTY LEGAL: JSkrste_ S7
PROPERTYADDRESS.
INSPECTOR:
INSPECTION DATE: ^U 1
~ o ¢
Z SITE GRADING
~0 ? All slopes 3:1 or flatter?
??~f/ Slopes steeper than 3:1 require retaining wall. Are retaining walls present?
p~0 ? Does grading conform to As-Built Grading Plan 1 foot approximately)?
Q~l0 ? Does perimeter grading tie in well with adjacent properties/undisturbed land?
C~Y Is there proper grading and/or drainage around Lookout or Egress Windows?
EROSION CONTROL
b/ Is Silt Fence (or approved equal) installed and in good working order?
? ? Is Sod/Fiber Blanket installed behind curb?
O?? Is the Rock Construction Entrance/Driveway installed and in good working order (proper
~ type/size of aggregate, clean-not covered with soil, etc.)?
? 0~ ? Is temporary vegetative cover w/ mulch present?
? IM ? Is permanent vegetatroe cover w/ or wlo mulch present?
(circle one)
CITY EASEMENTS AND UT1LiTIES
B?? Are all easements clear-no part of any building/deck/porch/retaining wall/etc.
` encroaching in easement?
? Gf 11 Are catch basins present within the property or in the street in front of the property, if so
/ are they clean, do they have the proper erosion control in and/or around them?
0 Does the property have an Emergency Over Flow (EOF)? This can be found on the
Certificate of Survey. If so, is it present and has it been graded properly?
MISCELLANEOUS ITEMS
~ p ? Is there tracking present on Public Right-of-Way/Street from construction site?
/
L~~O ? Is the driveway at the proper width at ROW line? (22 ft. max.)(Curb stop is at ROW line)
? Is the site clean, no trash and/or construction debris lying around?
00 0 Was the proper type of building constructed according to the approved grading plans?
, ' (LO, WO, FB, R, etc.)
INSULATION INSPECTION CHECKLIST FOR RESIDENTIAL
BUILDING PERMITS
PROPERTY LEGAL: U~IAG K
PROPERTYADDRESS: (~~tn CJe((,/?e~T~Oq/ U~Cq~/
INSPECTOR _ 22mN w e,~ta,ud
INSPECTION DATE: q"3-0 '7
ai o ¢
y
} Z Z SITE GRADING
All slopes 3:1 or flatter?
Slopes steeper than 3:1 require retaining wall. Are retaining walls present?
Does grading conform to As-Built Grading Plan 1 foot approximately)?
Does perimeter grading tie in well with adjacent propertieslundisturbed land?
0 4g 0 fs there proper grading andlor drainage around Lookout or Egress Windows?
EROSION CONTROL
lmIs Silt Fence (or approved equal) installed and in good working order?
0Is Sod/Fiber Blanket installed behind curb?
~0 11 Is the Rock Construction Entrance/Driveway installed and in good working order (proper
type/size of aggregate, clean-not covered with soil, etc.)?
IN 0 0 Is temporary vegetative cover w/ mulch present?
IF 11 0 Is permanent vegetative cover w/ or w/o mulch present?
(circle one)
CITY EASEMENTS AND UTILITIES
Are all easements clear-no part of any building/deck/porch/retaining wall/etc.
encroaching in easement?
0 lig El Are catch basins present within the property or in the street in front of the property, if so
are they clean, do they have the proper erosion control in and/or around them?
0 0 0 Does the property have an Emergency Over Flow (EOF)? This can be found on the
Certificate of Survey. If so, is it present and has it been graded properly?
MISCELLANEOUS ITEMS
Is there trecking present on Public Right-of-Way/Street from construction site?
a 0 D Is the driveway at the proper width at ROW line? (22 ft. max.)(Curb stop is at ROW line)
0 93 D Is fhe sife clean, no trash and/or construction debris lying around?
iE D 0 Was the proper type of building constructed according to the approved grading plans?
(LO, WO, FB, R, etc )
2007 RESIDENTIAL BUILDING PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
New Construction Reauiremen5 RemodeVRewu Reouirements Office Use OnN
3 registered site surveys sharring sq. ft. of lot, sq. R of hau; and all roofed areaz 2 mpies M pWn shovnng footings, beams, joists Cert of Survey Recd _ Y_ N
(20%maximum lot covera9e allaxed) 1 sel of Energy Calcula6ais fw heated additans Shcs Report _ Y_ N
1 Soils Report if proposed bultling is to he placed on disWrbed soil 1 sde survey for addibons d decks Tree Pres Plan Recd _ Y_ N
2 wpies of plan showing beam 8 window sizes; poureE found design, etc. Addtlon - mdicafe d on-srte sepfic sysfem Tree Pres Required , _ V_ N
1 setotEnergyCakula6ms On-slte5epticSyslem _Y _N
3 copies ot Tree Preservafion Plan if lol platte0 aRer 711193
Rim Joist Detail OpGons selecM1On sheel (6uildings vnth 3 or less units)
Mmnegasco mechanipl ventllaM1On fortn
Plans are considered ublic information unless ou state the are trad e sec ef and th re8son.
Date OB / 2C) e / O 7 Constructioo Cost ~ Z~' -
Si[e Address /~i-`1O "Ij in 14a'A Un UniUSte #
Descrip[ion of Work e, A 'a 2-(0 o
- Multi-Family Bldg _ Y v~ Fireplace(s) _ 0 _ 1 _ 2
Property Owner Telephoneit((oSl t-, D 1~-
Contractor~9
Address City (1.4rl-
State Wf. Zip S S 1 l$ Telephone #((oS 1) 4 5 S- S S~~
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING ,
- Minnesota Rules 7670 Cateeorv 1 _ Minnesota Rules 7672
Energy Code Category . Residential Ventiiation Category 7 Worksheet • New Energy Cotle Worksheet
(J submission type) Submitted Submitted
. Energy Envelope Caiculations Submiried
In fhe last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan2
_ Y _ N If yes, date and address of master plan:
LicensedPlumber 2 fl. 'Telephone ~
~ .
Mechanical Coniractor Telephone #
. , , AUG "
Sewer/WaterConiractor Telephone#( )
a
I here6y 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
perrrtit; that the work will be in accordance with the approved plan in the case of work which requires a review and
approval of plans.
t~r- x • ~A
55
Applicant's Printed Name Ap ' s Sig e
DO NOT WRITE BELOW THIS LINE
Sub TYpes
? 01 Foundation ? 07 OS-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (&sea.) ? 31 Ext. Alt - Multi
? 03 01 of _ plex ? 09 07-plex ? 17 Garege ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF
? 04 02-plex ? 10 08-plex X 18 Deck fi< 23 Porch (screen/gazebo/pergola) ? 36 Multi Misc.
? OS 03-plex ? 11 10-plex O 19 Lower Level ? 24 Storm Damage
? 06 04-plex ? 12 12-plex ? 25 Miscellaneous
Work Tvpes
? 37 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding
X 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair
? 33 Alte2tion ? 37 Demalish Building' ? 43 Reroof ? 46 Windows/Doors
? 34 ReplaCemenl 'Demolitlon (Enlire Bldg) - Glve PCA handout to appliwnt _
DCSCrIptlOn: WaterDamage_Yes
C~O ' Occu anc -3 MCES System
Valuation P Y
Plan Review 100% or 25%
Census Code, y 3y Zoning )D.D Ciry Water
SAC Units Stories / Bodster Pump ~
# of Units ~ Sq. Ft. PRV ~
# of Bldgs Length • Fire Sprinklered ~
Type of Const ~ Wdth ~T • ' '
REQUII2ED INSPECTIONS
Footings (new bldg) _ Sheetrock
~ Fooangs(deck) Final/C.O.
Footings (addition) h-, Final/No C.O.
Foundation _ HVAC '
Drain Tile Other
Roo( !ce&Water Final _ Pool Ftgs AidGasTests Final
yL~- Framing _ Siding _ Stucco La[h _ Stone Lath _Brick
Fireplace R.I. AirTest Final Windows
Insulation _ Retaining Wall
Approved By: Building Inspector
BaseFee 177'L 1aj/ fjf p,jGh 3a~~
Surcharge r /1
Plan Review 7S G- ~ y0 246J°
MClES SAC r,
City SAC C'f ZqOo o„~ f
Y ^
Utility Connedion Charge
S&W Permit 8 Surcharge
Treatment Plant
License Search
Copies - ~ . .
Other
Total
~ REH ISE\Y I
Certificate of Survey
QI~~4l~ldd [~f~OO ~DOO C~1 OF
~ ~3~~ICg~4 Ot~ ~OOD
1490 WELLINGTON WAY
WELLINGTO N ko<'
- < <I
i~ I° l ; R=1B0 TOLL BROTHERS
55r
I~ ~ 7 ~/99j5po~o 1400 Corpotate Center Curve
• q ~I' ~~`~~~~o Eagan, MN Zip 55121
BBB. 6^o ~ g 9 s cQ ^
J ~ D ~ `r
I g91 '<U ~'E
91 5 .t 6
~ ~etback ~ V g~~~eweeswQ~
~tlIWN~~ Wr~' V1rM°v
/ 9 9q6 Eq lif18 -i ( T P
/ff~ O 6 "YF,~~f 9~B
~ = I 6~etalnirsg WaU WI~
<.5 BeFiequlred
1~_ -'6.6 T~+_ _ _ _ _ _ _ 9' ~ -
Top I P= TS"4 tc~o n 11.C~ f ~
~
a e~'t,e 97.
994.23 m
i
~y6B 20.0 12 0
9_ ax-` 3 1.57 J~
4 3 1.4 98. 68 NO=
x xg96.4 ~
07 yg6~ i proposed ~ -
n garage rv /o~~
N N L-------- 99ospropased housex9901 112.0 99 a%~ • /
~ x 9 9poured woll 9N 9~ p ' Q 30
walkout bosement i~
x°'l
-a~gu c ngg.. SCALE IN FEET
I O Bq8 14.9 0 89• ~ p~ (me~r ec~tigr+
I.yb~'~ A~ Lot O 2U.U N V1 7.3 TAp ly-
~ 12.9 9'66 - I ~
O^ 7.92 BB. yg9 ~9 \l9 S-J 4 8
J~98~ ~ I nq09. x~g9.0 I \ y\. g4}~. / ~ / .
I /
rop P.= .,ty,//i~\.
986 ~2
~ ~saa e8 -984-_ -PQ'
i
\ya,~ 98z--- ~ ~-~o e ~ j o ~k• ~ i
~ ~ ~ ge4~'w~/ 12~ -r?"- ' ~ r / PROPOSED ELEVATIONS
Garage floor elev. = 998.1
Top of wall elev. = 998.5
~oE Lowest floor elev. = 989.6
<(„'O` ?J ~ ~r ~ v-
~-~F- F- ~J6g 5
PROPOSED AREAS
!Y~\~: 9• /
BENCHMARK Area of Lot 6, Block 5= 17,529 Sq. Ft.
Top Nut Hydrant Lots 6 and 7, Block 3, Propoaed House = 3,126 Sq. Ft.
~ Steeplechase of Eagan Percant of Lot Coverage= 189:
Elevatlon = 989.61 feet (NAVD 1988)
San. Sewer Stub Elev.= 986.6
LEGEND
WO House
Garage left Iron monument found Droinage Directlon
Minimuril lowest floor p= Iron monument aet and marked -840- = proposed 10' contoura from grading plan
elevation = 989.8 wlth Ilcense No. 23968. -842- = Proposed 2' contours from grading plan
a = Offset Iron -840- = Exlsting 10' contours
MIEVVE D = Dralnage & Utility Easement 84Z- = Existing 2' contours
< = Existing sanitary sewer
eoo.ox = Existing Elewtion = Existing storm sewer
~y Proposed elevotion from grade - I-= Existing water
or development plan Q = Sanltory manhole
EAOPeN EAlGLNEERWG DEP1: ff= Water Curb Stop m = Gata valve
C ITY O F EAGAN Bearfngs 9hoWn are assumad
EAGAN a,t- cw~
Lot 8, Block 5 FnnEVo~~~~
av. g =
STEEPLECHASE DATE.
O F EAGAN BU"°'Notrawing File: 30~~' sP ~~T'- ~,`08-1~~~5adwg
Project No. 2006-408-L
D A K 0 TA C 0 U N TY, M I N N E S 0 TA Toll 8ros. Code= 4, SPR #hiSE-PLAN-N0.
Subject to easements of record, if any.
I hereby certify that this survey, plan or report was prepared by ^ Duluth, MN.
me or under my direct supervision and that I am a duly Registered / \ Hibbing, MN.
Lond Surveyor under the laws of the State of Minnesota. ~ Ham Lake, MN.
Minnetonka, MN.
January 19, 2007 KIIJIUMMSTO LTD Phone: (952) 933-0972
Mich el E. C nnon, MN License No. 40035 Date Fax: (952) 933-1153
www.rlk-kuusisto.com
Rev. 2/5/07-City comments, fleld Info
Rev. 2/28/07-Changed to 9~ bO38rt1BfIt 6110 Blue Circle Dr • Suite #'I00 • Minnetonka, MN. 55343
Feb 28. 2007 ] 42am
i \ioll Brothers\2006-408-L\awq\700\7t8-LB.95 dwg
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA124847
Date Issued:07/11/2014
Permit Category:ePermit
Site Address: 1490 Wellington Way
Lot:8 Block: 5 Addition: Steeplechase Of Eagan
PID:10-72540-05-080
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.
Jennie Wood
1424 3rd St N
Minneapolis, MN 55411
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 -
John E Orner
1490 Wellington Way
Eagan MN 55122
Benjamin Franklin Plumbing
1424 N 3rd St.
Minneapolis MN 55411
(612) 604-4285 X61
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA164544
Date Issued:10/01/2020
Permit Category:ePermit
Site Address: 1490 Wellington Way
Lot:8 Block: 5 Addition: Steeplechase Of Eagan
PID:10-72540-05-080
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Air Conditioner
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
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 -
Jeffery A Jr & Katherine M Kohler
1490 Wellington Way
Eagan MN 55122
(402) 206-1118
Blue Ox Heating & Air Llc
5720 International Pkwy
New Hope MN 55428
(612) 238-9709
Applicant/Permitee: Signature Issued By: Signature
ItOIA
�- �ERIME'�ER Co
tmoL
L6 t;`�i,
()�( -. 2L
By:
Dater
Building
s Division
By s
-- Date
EAGAN ENGIN
..,AEI down* n��lu�i�ni��negr�M.._�e.tr.�s.-.00-rt I 1-.! J - 400M.M--IMrMM�. Asp &O....m 4w 400M A
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA173241
Date Issued:11/04/2021
Permit Category:ePermit
Site Address: 1490 Wellington Way
Lot:8 Block: 5 Addition: Steeplechase Of Eagan
PID:10-72540-05-080
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:Includes Skylight
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.
If water damage is encountered, please call (651) 675-5675 to schedule a site visit to verify the extent of the damage. Any
repairs must be inspected prior to covering. The inspector will determine if an additional permit will be required to repair the
water damage.
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 -
Jeffery A Jr & Katherine M Kohler
1490 Wellington Way
Eagan MN 55122
(402) 206-1118
Greenway Solar
3018 E 28th St
Minneapolis MN 55406
(612) 314-6369
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA179697
Date Issued:10/18/2022
Permit Category:ePermit
Site Address: 1490 Wellington Way
Lot:8 Block: 5 Addition: Steeplechase Of Eagan
PID:10-72540-05-080
Use:
Description:
Sub Type:Furnace
Work Type:Replace
Description:
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:
This permit shall be null and void if work does not start within 180 days of issuance, or if work is suspended for 180 days or more after
started.
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 -
Jeffery A Jr & Katherine M Kohler
1490 Wellington Way
Eagan MN 55122
(402) 206-1118
Blue Ox Heating & Air Llc
5720 International Pkwy
New Hope MN 55428
(612) 238-9709
Applicant/Permitee: Signature Issued By: Signature