1435 Wellington Way
PIROVIL)E AAID MAtNTRIN
Ii~LET P OTECTION UN'fIL
L
°iNATI'R RI 1SHED ( I
u ~
~ . Approximotelocatlm ;
Sonitory ond Wcter stub s8y•s3'34"E Certificate of Survey,
RLK Kuusisto plan
er
84.. 9.31 OF
3:9 Mamenum Slopea
IU 1435 WELLINGTON WAY
• ~ , - . i ~ ~ ~ ~ E~c~1aiNng Wsll ~Uitl! and 6 9a~`9-~ 0 I7.83' O as.so °yt' -eo ina9nt per pl tY Be ReQUIf9d
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1400 Corpotote Center_ Curve
LJ.93 33 ~ ~ 1- 989 +9 , i
~ Eogan, MN Zip 55121
(o~O 1 ~ , ~I~ 9g01 9~~ ~Egress windor
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d ~ ~"y ~ ~i . • drivewaY dI ^ i r v~aosea
g4 99 G 1 OI 9arage
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N EPIC'a G DEP"d:
LEGEND IEAt'nA~
~
FB HOUSe 9 SCALE IN FEET
Gora ri ht Iron monument found r= Droina e Direction
ge 9 0= Iron monument set cnd morked -&W- = Proposed 10' contours from groding plon BENCHMARK
Minimum IOw@Sf. fl00~ wiih license No. 23968. -842- = Proposed 2' contours from groding plan Top Nut Hydrant SW comer of Lot 2. Beorings shown ore ossumed
elevation = 980.1 a - Offset iron -840- = Existing 10' contours Bixk 3, Steeplechase of Eagan
a Son. Sewer Stub Eiev.= 975.2 -842- = Ezisting 2' contours Elevotion = 989.15 feet PROPOSED ELEVATt(7NS
„ n = Droinoge & Utility Eosement
y - = Existing sonitory sewer
~ eeao = Existing Elevotion -<< - = Existing storm sewer Goroge flow dev. = 987.7
a Proposed elevation From grode - I - = Existing woter PROPOSED AREAS Top of wall elev. = 967.8
v or development plon 0 = Sonitory manhole Lowest floor elev. = 980.1
a w = Gote valve Areo of l01 2. Block 3= 14,310 Sq. Ft.
~ Proposed House = 2,694 Sq. Ft.
' ~ O ` ~ B I O C~ ~ Percent of Lot Coverage= 18.8 %
~ Drowing File: 700\718-L2.83.DWG
~ 7 Project No. 2006-40$-L
~ STE E P L E C E I hereby certify thpt this survey, plan or report wos prepored by ron Bros. Code= ~ 2. CaRVER.
p me or under my direct supervision ond thot I om a duly Registered
< Land Surveyor under the iaws of the Stote of Minnesota.
~ Duluth, MN
= OF EAGAN z-,Z-os ~ HHibb g;~
Minnetonka, MN
~ Michoel E. annon, MN LiCense No. 40035 Date RT .K ' Oakdale,NIN
DAKOTA COUNTY, MINNESOTA INCoRPoR,=
~ Revised 2-12-68 Adjusted house Phone:9529330972
~ Subject t0 eosements of record, if OfIY. Revised 2-5-08 Cit commentsl Fasc: 9529331153
n Y ~ J www.rllbnc.com
o Revised 1-15-08 Added egress window coll
~ 6110 Blue Circle Drive • Suite 100 • Ivlinnetonka, MI3 55343
~
01/17/2008 14;23 6128252303 RAY N WELTER HEATING PAGE 94/84
Date: 1/17108 Revision Date: 1/17108 New Constn,ctlon
Sita Informalion
Addr6Bg 1; 1435 Wellington Way ProJectV. Steeplechase of Eagan
Address z; Lot: #OOa Block; #3
City: Eagan Couniy: Subdivision:
Application Information
gusiness Name: Ray N Welter HVAC MN Contractor License
Contact Person: JOE
OfflCe Ph: 612-8256867 Fax: Cell Ph:
Address 1: 4637 Chicago Ave, So,
City; AAPLS. State; MN. Zip Code: 55407
HouaQ Details
Square Fe2t: 4592 sq. ft. Avg_ Ceiling Ht: 12.8 Number oi Bedrooms: 4
ft.
Veatllatlon : Balancad
Total Ventilation Capacity ; 253 cfm.
Minimum Con6nuous Ventilatlon :75cTm.
Intermittent ventilation: 178 cfln.
Combuation A lianee
Water Heeter. Power Vent Input BTUs: - 80,000 Independently Vented
Fumace/Boller. Direct Venf/Sealed Combustion Input BTUs: 120,000 Indepsndendy Vented
Other Combustion Apoliances
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 Eaulpment ~
Condnuous Exhaust Ventilatlon Capacity (cfm): NA Gofhes Oryer (c(m): 135
Exhaust Fan Ratlng (cfm); 400
Make-Uo Air No Mak"p Air Required by Code
Combusdon Air
Minimum Combustion Air Requireiments Met.
,
- - - _ ~
[Rlicent Neme (Print): 9ign2Eure/l7ate'
Code Official (print): ~VA signature/pat . s/ Z 7
_ -
= - -
- ~ 200d`Cenrerpoine En-igy Minnegesco, 2004 Mechanical Code puidmlines.
Page 1
b d SS59 'IN anoag a[d2W #a salEl Wd£0:£ 860Z 'Ll '1Ef
Address: 1435 Wellington Way Zip: 55123 p~ Permit: 81912
THE FOLLOWING ITEMS WERFJWERE NOT COMPLETE AT FINAL IN5PECTION ON :
Yes No Comments
Final rade - 6" from sidin ?
Permanent ste s- ara e
Permanent ste s- main ent
Permanent drivewa
Permanent as ?
Retainin Wall or 3:1 Max Slo e
Sod/Seeded lawn
Trail/curb dama e Y
Porch ?
Lower level finish ?
Deck
Fire lace • n CeR
• Verify with your builder that roof test caps from the plumbing system have been removed. '
• Turn off water 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
irrigation system.
V BUILDING INSPECTOR: /
G/Bldg Insp/FOrtns/2007/Checklists
' ~L 8! t13
~
/aA,-
Clty of Eapn Perznit# j
I permit Fee:
i
3830 Pilot Knob Road
Eagan MN 55122 ~ Date Received:
Phone: (651) 675-5675 I
' Fax: (651) 675-5694 i Staff: i
--r ~T~-71,-, ~
2008 RESIDENTIAL BUILDING PERMIT APPLfC~(0N ~fDate: SiteAddress: I I-ss W~~1Jt~(OJ W " .I /„~rJ ~ SS/tt
Tenant: Ti~~.+-~RS~Tu~,.NS T.-~ ~ 2 ~~-K' Suite
RESIDENTlOWNER Name: TO~.~ Fz;1u TUktiS Phone: Ivs1 '3(-S •'Obo I
Address / City / Zip: W" .T SA614'A. MN 5s-i't L
Applicant is: _ Owner -)L- Contractor
TYPE OF WORK Description of work: NF-~ ~4 ie4..~ r"'~"" FkM iv.I LlOµk-
oa
Construction Cost: Z..SS. 0 00 . Multi-Family Building: (Yes _ I No ~
CONTRACTOR Name: T u- &ZT4404- 9 Z a~ License 2-0 4 S3 l0lo Z
Address: M'~-S ,SSIZL..
City: r--A f` Ar--)~ State: M^r Zip: 9-f1 2 Z
Phone: (o 571 '3b,r OtooI ContactPerson:
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
~Minnesota Rules 7670 Cateqorv 1 Minnesota Rules 7672
Energy Code . Residential Ventilation Category 1 Worksheei • New Energy Code Worksheet
CatBgOry Submitted Submitted
(4 submission type) • Energy Envelope Calculations Submitted
In the last 12 montlis, has the City of Eagan issued a pertnit for a similar plan based on a master plan?
_Yes k No If yes, date and address of master plan:
Licensed Plumber: N`1 MdxH ~L~t~1S1J b Phone: -+bZi -qct b - (O I 0 lo
MechanicalContractor:l'~A,`I N. WEa.Tt.n.. LlN/art- Phone: 10/ 2-qZS- (ogb7-
-~3rs
Sewer&WaterContrector. bSiJI •LXcAVM'tCJ Y Phone: (ps!- y80
NOTE: P,lans and s`upporting documents,that you'submit "are;consider'ed to be public informabon: ~ Portions of
`',tfie'informapon may be classifi,ed as non=pub6c if you proviile specific reasonsrthat wou(d perm~t the C~ty to : , , ,
s: coMClude thaf;lhe 'are,i[atle,'sbcr,els I hereby acknowledge that this information is complete and~acwrate; that the work will be in confortnance wiih the ordinancesland codesof theCiry 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; thal the work will be in
accordance wi[h the approved plan in the case of work which requires a review and approval of plans. X R.tc.Ha-u.b Ki X
ApplicanYs Printed Name ApplicanYs Signature
. - - --Page1-of 3------
1
" DO NOT WRITE BELOW THIS LINE
SUB TYPES
? Foundation ? 05-plex ? 16-plex O Accessory Building ? Pool
)6-Single Family ? 06•plex ? Fireplace ? Porch (3-season) ? Ext. Alt. - Multi
? 01 of _ Plex ? 07-plex ? Gara9e ? Porch (4-season) ? Ext. Alt. - SF
? 02-Plex O 08-plex ? Deck ? Porch (screervgazebo/pergola) ? Multi Misc.
? 03-Plex ? 10-plex ? Lower Level ? Storm Damage
? 04-Plex ? 12•plex ? Mlscellaneous
WORK TYPES
I'L New ? Interiar Improvement ? Siding ? Demolish Building*
? Addition ? Move Building ? Reroaf ? Demolish Interior
? Alteration ? Flre Repair ? Windows ? Demolish Foundation
? Replacement ? Egress Window ? Water Damage
' Demolition (entire building) - give PCA handout to applicant
DESCRIPTION:r~
' Valuation Occupancy LAIC- 1- MCES System
Plan Review Code Edition 0(,t SAC Units
(25%_ 100% Zoning City Water /
Census Code Storles Booster Pump
# of Units ~ Square Feet PRV
# of Buildings ~ Length ( 07 ~ Fire Sprinklers
Type of Const. Width
REQUIRED INSPECTIONS
V Footings (new bldg) ~ Sheetrock GfIA-C-0 ' "'s
_f Footings (deck) ~ FinallC.O.
Footings (addition) Final/No C.O.
~ Foundation _ HVAC
Drain Tile Other:
Roof: _Ice & Water _Final Pool: _Footings Air/Gas Tests _Final
~ Frsming _ Siding: _Stucco Lath _Stone Lath _Brick
Fireplace:+R.l. AirTest *Final Windows
-*fInsutation ~ Retaining Wall ~ Reviewed By: Building Inspector
-
RE5IDENTIAL FEES: ~
Base Fee 05- K J ! ~r 5~ ~ 2'~
~
Surcharge 77a'D - D7~j 9 Q
Plan Review
MGES SAC
City SAC
Utility ConnecUon Charge
t ~
S&W Permit & Surcharge
Treatment Plant ~~,r,
cop~e5 J
Total ~
Page 2 of 3
~j (~`~~D~I~
• 7
N~oll Architecture ~
January 10, 2008
Chad Carroll
Steeplechase of Eagen - Signatures
4876 Steeplechase Way
Eagan, MN 55122
RE: Carver - TBI Lot#002
1435 Wellington Way
Dear Chad
For the Carver TBI Lot #002, 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 lateral stability. Note that the stud framing shown
on the construcYion documents have a maximum deflection criteria of span/180 far the
Foyer based on loading conditions per ASCE 7-05.
If you have any questions or concems, please do not hesitate to call.
Sincerely,
Toll Brothers, Inc. "_~rhy certit'p ;lrzt il~.is plan, speci-
fication, or rcport was prcpazed by
me cr uoder rny direct supervision
aod t6at I arn z duly Licensed
Professional tingine-'r under the
laws of the Stata ef Minnesota
fd d"
Print Name: L AM. GROSSE
Signature: h'~?1 Q~
Date I lo oQ~ Licens tW4835
Lisa M. Grosse, P.E.
Assistant Director of Engineering
MN License #44835
CC: Kurt Jensen
LMG/sy
SESG_1tr0030
EASTERN DIV[S[ON
250 Gibrattar Road n HorshTm, PA L9044 o (315) 293-5300 n FAX: (215) 293-5313
PIiILA]>ELPHIA m ORLANUO o SCOI"CSDALE o DALLAS o DENVLR o LOS ANGELES
A `Zoli`Bmthers CoMPA,vy
LOT SURVEY CHECKLIST FOR RESIDENTIAL
BUILDING PERMIT APPLICATION
PROPERTY LEGAL:
DATE OF SURVEY: I 0
LATESTREVISION: ~IS~OB
m
~
t
m
L
C.>
~
p Z a DOCUMENT STANDARDS
. Registered Land Surveyor signature and company
~ ? ? • Building Permit Applicant ~
B? 0 • Legal descrip5on ~p( SA+n • SWr~
ca ? o • Address a~VW
~`I~ C~,@,~ ~nJ ~IW • s S'IYYK Y' 984.O
,e ? ? • North arrow and scale ~{„~,(t $I'Ab q(pu,n~ •
,g • House type (rambler, walkout, split w/o, split entry, lookout, etc.) ~ Sp,i,~,Ck.
sk- . Directional drainage arrows with slope/gradient %
" ? A • Proposed/existing sewer and water services & invert elevatio ,vp&: $a.,,, ~IErI. !p &,u,~„{Mf 4'f~.,
)a ? ? . sveet name $cos}er pN,,n b¢. Ry
,g . Driveway (grade & width - in RNV and back of curb, 22' max.) ~ 1+1 ~ kifls~.
~ z ? ? • Lot Square Footage
o,d . LotCoverege-bo,4-m0MJe cI';,Itw*~ ca,la,AaI"-., -avs+ l,sx.se, 4A4 cwAra1z S{,m,.ld be /8.B%
ELEVATIONS
Existina
,g ? ? . PropeRy corners
~9 D O • Top of curb at the driveway and propeRy line extensions
p;r ? . Elevations of any existing adjacent homes
g? ? • Adequate footing depth of strudures due to adjacent utility trenches
? ,d O • Watenvays (pond, stream, etc.)
Prooosed ~ ? ? . Garege floor
jy ? ? . Basement floor
,gr ? ? • Lowest exposed elevation (walkouUwindow)
D O . Property comers
4*4 ? .0 . Front and rear of home at the foundation SAovi Qfopol¢.d LiEU. W+ o F~o~"t
PONDING AREA (if apqlicable)
? J11 ? • Easement line .
? ~ ? • NWL
? ~y ? . HWL
? ;3 ? • Pond # designation
? yJ ? . Emergency Overflow Elevation
? 6 O • Pond/Wetland buffer delineation
y . Shoreland Zoning Overlay District
y 1 • Conservation Easements
DIMENSIONS
•B' ? ? • Lot Iines/Bearings & dimensions
S' • Right-of-way and street width (io back of curb)
. Proposed home dimensions including any proposed decks, overhangs greater than 2', porches, etc.
(i.e. all structures requiring permanent footings) ~Awc '30' 9A 6cC~ nG ckJ
. Show all easemPnts of record and any City utilities within t;ose easements ~m~. ~ y~qe aF
? 9 • Setbacks of pro osed structure and side ard setback of ad'acent existin9 structures
~ ? ? . Retaining wall requirements: ~3 ~f``T'~ ~
Reviewed By:~j~y 1~ ' Date 1~~I~S
z./~/o8
G:/FORMSBuilding Permit Applicalion Rev. 11-26-04
I
f el REScheck Software Version 4.0.1
Compliance Certificate
,
RE6 E~~
Project Title: Carver Model
Report Date: 09109108
Data filename: K:5_ENGINEERING SERVICES\_HVAC DEPT1_Energy CalculationslMNlSleeple e agan - g re
SESG\0021CanervClassio-002.rck DAM ~
Energy Code: 2000 Minnesota Energy Code ~~~~iNG IN$PE(+TIONS a~~. ON ~ Location: Dakota County, Minnesota Constructivn Type: Single Family
Glazing Area Percentage: 14%
Climale Zone: 2
D Construction Site: OwnerlAgent: DesignerlContractor:
,.1 Steeplechase at Eagan - Signatures Toll Brothers Inc. Toll Brothere Inc.
J Eagan, M~N 551 Hoo hamaIPA19044 HorehamalPAR9044
Permit # 002
Permit Date: 09/04l2008
D.
Floor Over Garage: All-Wood JoisUTruss:Over Unconditioned 684 30.0 0.0 23
Space:
Flat Ceiling: Flat Ceiling or Scissor 7russ: 1456 44.0 0.0 39
Sloped Ceiling: Cathedral Ceiling (no attic): 39 44.0 0.0 1
Garage wall: Wood Frame, 16" o.c.: 442 19.0 0.0 25
Door 1: Solid: 17 0200 3
Knee Wall: Wood Frame, 16" o.c.: 164 19.0 0.0 10
Band Joist: Wood Frame, 16" o.c.: 327 79.0 0.0 19
Exterior Wall 6": Exterior Wall 6": 2501 79.0 0.0 120
Window 1: Above-Grade:Vinyl Frame:Double Pane wilh Low-E: 412 0.350 144
Door 2: Solid: 20 0200 4
Door 3: Glass: 40 0.340 14
Basement Wall 1: Solid Concrele or Masonry: 835 0.0 5.0 70
Wall height: 8.0'
Depth below grade: 7.5' -
Insulation depth: 7.5'
Window 2: Basement > 5.6 k2:Vinyl Frame:Double Pane with 16 0.350 6
Low-E:
Furnace 1: Forced Hot Air: 92 AFUE
Air Conditioner 1: Electnc Cenlral Air: 13 SEER
Compliance Statement: The proposed building design described here is consistent with the building plans, specifications, and ofher
calculations submitted wilh lhe permit application. The proposed building has been designed to meet the 2000 Minnesota Energy Code
requirements in REScAeck Version 4.0.1 and to comply with the mandatory requirements listed in the REScheck Insp ction Checklist.
PcuA+-ce
Name - Title Signature Da e
Praject Notes:
Elevation: Classic
Options: 023
Nehal Patel
Carver Model Page 1 o( 4
REScheck Software Version 4.0.1
REScheck Inspection Checklist
Date: 09/09/08
Plan Review and Inspection Issues
This list of items may be helpful for Plan Reviewers and Building Inspectors to use as a guide for enforcing the Minnesota Energy Code.
The items appty to Group R, Division 3 Occupancies, one- and hvo-family residential dwellings. The items marked with' apply only lo
detached one- and two-tamily residential dwellings.
Plan Review Issues
Foundation Inspection:
El Foundation wall insulation R-5 minimum.
ci Foundation insulation extends from top ot wall down lo rop of the footing.
~ Exterior foundation insulation is covered by a protective coaling finish.
Concrete Slab or Under-Slab Inspection:
~ Slab on grade perimeter insulation R-5 minimum.
~ SIa6 insulation extends from top of slab to design frost line or top of footing.
~ Floors over unheated space R30 minimum.
Windows I Doors I Skylights:
n Average U-value is 0.37 maximum for windows and glass doors (excludes foundation windows).
~ Window U-values consistent with building plan and RESchack Certificate.
~ Window and door areas consistent with building plan and REScheck Certificate.
Mechanical Ventilation Issues:
Fl Residential mechanical ventilation system provides adequate ventilation per code requiremenis`.
F-I Furnace effciency is consisient with REScheck Certificate or building plan.
E] Protection against excessive depressurization is installed per code requirements'.
Envelope Insulation for Plan Review:
El Interior basemenf insulation R-5 minimum (if no exterior insulation).
Fl Ceilings with a[[ics R-38 minimum or consistent with building plan and REScheck Certificate.
F-I Wall iraming and insulation level is consistent with building design and REScheck Certificate.
Inspection Issues
Concealed Insulation
Framing and Sheathing:
Cl Wind wash barrier installed at attic ed9e.
Fl Exterior wall corners tremed so that insulation can be installed aiter exterior sheathing is installed.
F-I Intersections of interior paAition walls and exterior walls framed so that insulation ran be installed behveen the partition and
exterior sheathing after exterior shealhing is installed.
~ Gaps between framing less than one-half inch are eliminated by securing (raming together or are insulated at the time of assembly
C] All penelralions belween conditioned and unconditioned spaces made priorto framing inspection are sealed'.
Interior Air 8arrier:
Carver Model Page 3 of 4
f-1 All fire stops are air sealed.
Lj Pipes, ducts, wires, equipment and flues and chimneys throu9h the in[erior air barrier are sealed.
~ A sealed continuous interior air barrier is installed on the warm side of the building envelope at ceilings, walls, and floor rim joist
areas'.
F-1 Air barrier behind tub and shower is sealed and protected. -
n Recessed IigM fixtures are sealed.
Envelope Insulatfon:
F-i Basement insulation R-5 minimum.
~ Wind wash barrier on wall separating house and garage is sealed.
~ Loose fll insulation is prevented from entering the eaves.
Lj Insulation on skylight shafls and walls exposed in attics is supporled on the unconditioned side.
Attic Insulation:
Fl Attic access panel insulated to R38 for ceiling panel and R-19 for wall panel.
F] A[[ic card attached to framing near access opening.
Fl Notifcation of attic R-value and date of installation posled near building permit inspection card.
This is a summary only. Other requirements may apply. See the Minnesota Energy Code. Queslions? Call the Departmenf of Public
Service Information Cenler al 651-296-5175 or 1-800-657-3710.
Carver Model ~ Page 4 of 4
Use BLUE or BLACK Ink
-------------,
� For Office use 1
' � d' b� 1
C�t af �a �n � Permit#: !
� /� _ �� i
� � Permit Fee: C.9� f
3830 Pilot Knob Road � �
Eagan MN 55122 I Date Received: �
Phone:{651)675-5675 j �
Fax: (651� 675-5694 �S��_____
, �,-��������J
2014 RESIDENTIAL PLUMBING PERMIT APPLICATION
Date: � °�� �`� � /y Site Addressc S t...� 1 ; n � �
Tenant: Sulte#:
�� � � �� Name: � f�a ���� �Q,�..'f' S ft,^'\ Phone: % v �' � � �^ ���
R�SiCt�r�#/Q�n/Fter' ��
Address/City/Zip: � 3 S (i�;� 1 i� � C.�J'ej ...5 �I' >2�
' Name: ���Q.,_S',.�' t� ���� License#: � �°- �* � � �~� ��
�t1t1#t'i�C�flf Address: �� C� u `�� a a � �� City: �- `z-�a'`'`
State: I ' `J� Zip: -�S` o oZ 2 Phone: �f l (�, r} 1 � Z S Z
`
Contact: r' Email:
.C�������� _New _ eplacement _Repair _Rebuild _Modiry Space _Work in R.O.W.
` Description of work:
RESIDEN L
�ater
Water Softener
Lawn Irrigation(_RPZ/ PVB)
P������ ' Add Plumbing Fixtures�Main!_Lower Level)
Septic System
New Water Tumaround
Abandonment
RESIDENTIAL FEES:
$60.00 Water Heater, Water Softener, or Water Heater and Softener(includes$5.00 state Surcharge)
$60.00 Lawn Irrigation (includes$5.00 minimum State Surcharge}
$60.00 Add Plumbing Fixtures, Septic Svstem Abandonment, Water Turnaround"(includes$5.00 State Surcharge)
*Water Tumaround(add$200.00 if a 5/8"meter is required)
$'115.00 Septic Svstem New($10.00 per as built)(includes County fee and$5.00 State Surcharge)
TOTAL FEES$ � U• Uv
CALL BEFORE YOU DIG. Calf Ciopher State One Call at(651)454-0002 for protection against underground utility damage.
Ca1148 hours before you intend to dig to receive locates of underground utilities. www.aopherstateonecall.orq
i hereby acknowledge that this information is complete and accurate;that the v�rork 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; tl�at the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
X � ., �,( /� � �
1 �`-'2_.. V c:,�+ / � �. X
Applicant's Printed Name ppli nt's Signature
�t�R�FFICE USE Reviewed�y: 'i��:�'
Requir�ed Inspect�ons: tJnder Grouncf ' Rougt��in Air Tes�' ! Gas�'est Fir�1
A�teter Rel�ted l�ems: Me#ee�ize� Radio Fteatl - �t�ff: '