3832 Country Creek Way
Use BLUE or BLACK Ink
I For Office Use I
I
1 l
I Permit a
I
City of Ea
tit r I I
I Permit Fee:
3830 Pilot Knob Road 1
Eagan MN 55122 I Date Received: j
Phone: (651) 675-5675 I I
1 Staff: I
Fax: (651) 675-5694 1 I
2011 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: Unit
Name: I 2evatWin/ Phone: &07- 4452
RESIDENT /
OWNER Address / City / Zip:
Applicant is: Owner Contractor
TYPE OF WORK Description of work: ! 1~/ 4- 77 0-fl/ 4Flo A-135?_1 -el _
Construction Cost: oZ tea Multi-Family Building: (Yes / No )
Company: 4 (--Z- Contact: \ 3 oe-
CONTRACTOR Address: /Sr1L.~ City:
State: Zip: 62~4 Phone: f< v ^~a P7
License W gd/4. i4 Lead Certificate
If the project is exempt from lead certification, please expl~aiin why: (see Page 3 for additional information)
Z!~a / 4- C/ /
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan?
_Yes _No If yes, date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: Phone:
NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of
the information may be classified as non-public if you provide specific reasons that would permit the City to
conclude that the are trade secrets.
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 4540002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.Qor)herstateonecall.org
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 thi ' 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 approv d p n in the case of work which requires a review and approval of plans.
Exterior wo authorize by ilding it ssued in accordance with the Minnesota State Building Code must be completed within 180
days tissuanc
Applican rinted lillame Applicant's Signature
Page 1 of 3
DO NOT WRITE BELOW THIJLINE
SUB TYPES
Foundation _ Fireplace _ Porch (3-Season) _ Storm Damage
_ Single Family _ Garage Porch (4-Season) _ Exterior Alteration (Single Family)
Multi _ Deck _ Porch (Screen/Gazebo/Pergola) _ Exterior Alteration (Multi)
_ 01 of Plex _ Lower Level _ Pool _ Miscellaneous
_ 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 Occupancy MCES System
Plan Review Code Edition j&Afj(Vfj 01r) SAC Units
(25%_ 100%Zoning City Water
Census Code Stories Booster Pump
# of Units Square Feet PRV
# of Buildings Length Fire Sprinklers
Type of Construction- Width
REQUIRED INSPECTIONS
Footings (New Building) Meter Size:
Footings (Deck) Final / C.O. Required
Footings (Addition) Final / No C.O. Required
Foundation HVAC _ Gas Service Test Gas Line Air Test
Drain Tile Other:
Roof: -Ice & Water -Final Pool: -Footings -Air/Gas Tests Final
~c Framing Siding: -Stucco Lath -Stone Lath Brick
T Fireplace: -Rough In -Air Test -Final Windows
Insulation Retaining Wall: _ Footings _ Backfill _ Final
Sheathing Radon Control
Sheetrock Erosion Control
Reviewed By:Building Inspector
RESIDENTIAL FEES
Base Fee
Surcharge
Plan Review 12l 92-2
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant Ole
Copies 2
Y 7
TOTALM '
/Page 2 of 3
l/I V I v v i v
CONCPFTF FOUNPAfiON P0,95 f3Y 5U55F1-
L_,l ~~-FCI ICAL (3Y OWWW
SUSSF'~ IS NOT P:F5''ON51P FOP: VAMAGF TO FXI5TWG 120VFWAY
LANr)5CA2ING AP.O'UNP FX15fIN6 UAPA,F ANP HOU5F FOP, I:FA50N
FINA, GOING, SLACK PII2T, Gt;OUNP COVFp, ANP 1NCLUPIWA THE
TOl" 50ii- 15 THE OWNFf?512F5PON51mITY
5U55FL TO IN5U11ATF A5 'iNPICATFP ON CI?055 5FCVON
ALL WINDOW ANP 0001; HFAJFP: AF:F (2) 2X!0'5 LINLF55 OTHFV
Al HFAP7 F,5 -O" ANC LONGED P,FQUIF? POUPI-~ MIMWPP5 AN
3 f pOVIVE FLA5HING Af ALL- WINDOW ANn POOP, OPFNING
3 I115TAL1 C3LOCKIN6 Ai AL-L WINDOW OPFNING5 FOP: WINDOW TEED
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CGUN PROVIDE 5MOKF DF1'FCTOP5 AND CAPI30N MONOXIDE DFTFCTOP"_
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TNFSF PLAN5 AMP FVNNT5 VZ MAIN THE FXCLU5IVF CONFIDENTIAL PWnI:TY OF 5U55FL, AND HOWOMM/ LANb`
MAY 13F 1-15FD 13Y OTHEP5 ONLY FOP? THE PUPWO5E 5PFCIFICALLY AUTHOPZIZFD f3Y SU55EL, TO PP2FVFNT M015TUP.F PI20f3LFM
UNAUTHOPZIZFD COPYING 012 P.FPWOUC11ON5 OF ANY POP?TION 15 FOPZ13IDDFN BELOW THE TOP OF THE FOUNDA
MURi6 AN 11 l (6876 HaEURINO mnn
sttwh tiffCavt 4 Atwricipal Sail Trefw4 a Land gwwy,.i • Lnd Picw a ' 'OI Clrt...~,•. - i sumsW4, Mntnescaa 55337
( Cortiffcate of Survey for S3
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y.i
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a
LOT I I BLvC CEDAIZ GROVE NO, It
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- - 1~22raoT¢5 c~raing9¢ r ufr~ty eageirle/IF
i hereby certify that this is a true and correct representation of a survey of the boundaries of the above
described land, and of the location of all buildings, thereon, and all visible encroachments, if any, from w on
said land. As Surveyed by me this day of i. A.0. 19~71. _
SUBUR13A w ENGINEERING, INC. .
ingineors 1.` J Surveygrs .
New Construction Energy Code Compliance Certificate
Per N1101.8 Building Certificate. A building certificate shall be posted in a permanently visible location inside th Date Certificate Posted
building. The certificate shall be completed by the builder and shall list information and values of components /N7=E.tabitshed iA i9ls MN ic, 1934
listed in Table N1101.8.
Mailing Address of the ])welling or Dwelling Unit Cih SUSSEL BUILDERS
3~ icy/1i rT 8S4T:maiezRoad 861.643.0331
Name of Residential Contractor MN [,itesse Number 3t.Pavl, Wmnasota 33114 Fax 831.848.8971
5U 7 5
THERMAL ENVELOPE RAD N SYSTEM
Type: Check All That Apply assive (No Fan)
w
o y
atllcr.rystem
Active Milh lam and ntonouteter or
C
T v
rnonitnrtnsdevi(e)
P
o a o V o .o
p m a
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Insulation Location z ro _U p w
o ca ea
o N o ~ a ~ ~ c "en iio
~ a z w u w° w° w cZ Other Please Describe Here
Below Entire Slab
Foundation lVall Type in location interior exterior or integral
Perimeter of Slab on Grade
Rini Joist (Foundation) Type in location: interior exteno.- or Integral
Rim Joist (I" Floor+) Type in location: Interior extenoror integral
Wall
Ceiling, flat
Ceiling, vaulted
Q-
Rnnn
Describe other insulated areas
Windows & Doors Heating or Cooling Ducts Outside Conditioned Spaces
Average U-Factor (excludes skvlights and one door) U: ♦ Not applicable, all ducts located in conditioned space
Solar Heat Gain Coefficient (SHGC): s R-value
MECHANICAL SYSTEMS Make-up Air Select a Type
Appliances Heating System Domestic Water Heater Cooling System Not required per mech. code
Fuel Typed Passive
Manufacturer t Powered
Interlocked with exhaust device.
Model K f/7(/ Describe:
input in Capacity in output in Other, describe: _
Rating or Size BTUS:, Gallons: Tons:
Heat Loss: Heat Gain. Location of duct or system:
Structure's Calculated
AFUE or SEER:
HSPF% ^
alculated
Efficiency a ♦ cooling load: Cfm's
" round duct OR
Mechanical Ventilation System " metal duct
Describe any additional or combined heating or cooling systems if installed: (e.g. two furnaces or air Con 13ustion Air Select a Type
source heat pump with gas back-up furnace): Not required per mech. code
Select Type Passive
Heat Recover Ventilator (HRV) Capacity in cfms: Low: High: Older, describe:
Energy Recover Ventilator (ERV) Capacity in cfms: Low: High: Location of duct or system:
Continuous exhausting fan(s) rated capacity in cfins:
Location of fan(s), describe: Cfin's
Capacity continuous ventilation rate in cfms: " round duct OR
Total ventilation (intermittent + continuous) rate in cfms: " metal duct
Created by BAM version 052009
Use BLUE or BLACK Ink
I For Office Use/~ I
Permit /
City of EaVan ~
Permit Fee.
3830 Pilot Knob Road I I
Eagan MN 55122 ; Date Received: ;
Phone: (651) 675-5675
Fax: (651) 675-5694 Staff:
J
2011 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: _ Site Address, 3,6 3~ (oun7i C A5Z: 4 CCORt) Unit
Name: F/~7`- ) /fi~U Ill Phone: _1( v~l cf 7Q ` Lq
RESIDENT I ,fir
OWNER Address / City / Zip: 3W R, awyr V eR.&eK_ Lde F'r4cow
.Sl~►-~
Applicant is: Owner V_ Contractor
Description of work:
CT F n~
TYPE OF WORK
Construction Cost: 3- &-0 Multi-Family Bt~iIding: (Yes /No
Company: -~l.~i/J &A # 10e:: tri!i04ontact: I!Z It ~'7I'~OF /''Ltl bbl
CONTRACTOR Address: 54,6E DQal~E`= twe City:
State: AA Zip: J`rJ'~Tp~ Phone: r 095
License Lye) -~~DG oZ Lead Certificate /1/Q 7-- -7,& 73 --1
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
In the last 12 months, has the City of Eagan issued a permit fora similar plan based on a master plan?
Yes _No If yes, date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: Phone:
NOTE. Plans and supporting documents that you submit are considered to be public information. Portions of
the information may be classified as non-public If you provide specific reasons that would permit the City to
conclude that the 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.aopherstateonecall.org
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 permit issuance.
x ~~E lO£ 5/Y!{4j/ ~/Z x
Applicant's Printed Name Applicant's Signature
Page 1 of 3
PERMIT
City of Eagan Permit Type: Building
Permit Number: EA106614
Date Issued: 08/30/2012
Permit Category: ePermit
Site Address: 3832 Country Creek ~Vay
Lot: 12 Block: 1 Addition: Cedar Grove 1 lth
PID: 10-16711-O1-120
Use:
Description:
Sub Type: e-Reroof Construction Type:
Work Type: Replace Description: House & Garage
Census Code: 434 - Occupancy:
Zoning:
Square Feet: 0
Comments: If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are
not acceptable in lieu of inspections.
Carbon monoxide detectors are required by law in ALL single family homes.
Fee Summary: BL -Base Fee $4K $103.25 0801.4085 Surcharge - Based on Valuation $4K $2.00 9001.2195
Valuation: 4,000.00 Total: $105.25
Contractor: -Applicant - Owner:
Gullickson Homes Kent J Pederson Revocable Tst 5131/07 12701 Co. Rd. 9 3832 Country Creek Way
Goodhue MN 55027 Eagan MN 55122
(651) 208-2602
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.
ApplicanvFermltee: Nignature issued tiy: NIgnature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA118385
Date Issued:10/31/2013
Permit Category:ePermit
Site Address: 3832 Country Creek Way
Lot:12 Block: 1 Addition: Cedar Grove 11th
PID:10-16711-01-120
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:
Census Code:434 -
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 by law in ALL single family homes .
Eric Gullickson
Valuation: 4,000.00
Fee Summary:BL - Base Fee $4K $103.25 0801.4085
Surcharge - Based on Valuation $4K $2.00 9001.2195
$105.25 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 -
Kent J Pederson Revocable Tst 5/31/07
3832 Country Creek Way
Eagan MN 55122
(651) 470-0322
Gullickson Homes
12701 Co. Rd. 9
Goodhue MN 55027
(651) 208-2602
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA146751
Date Issued:11/13/2017
Permit Category:ePermit
Site Address: 3832 Country Creek Way
Lot:12 Block: 1 Addition: Cedar Grove 11th
PID:10-16711-01-120
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Furnace & Air Conditioner
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
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 -
Kent J Pederson Revocable Tst 5/31/07
3832 Country Creek Way
Eagan MN 55122
Robert Boldt Hvac
4310 Trenton Tr
Eagan MN 55123
(651) 454-7760
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA168494
Date Issued:04/22/2021
Permit Category:ePermit
Site Address: 3832 Country Creek Way
Lot:12 Block: 1 Addition: Cedar Grove 11th
PID:10-16711-01-120
Use:
Description:
Sub Type:Windows/Doors
Work Type:Overhead Garage Door
Description:
Census Code:434 - Residential Additions, Alterations
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings, call for framing
inspection. Call for final inspection after installation.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Valuation: 1,500.00
Fee Summary:BL - Base Fee $1500 $62.50 0801.4085
Surcharge - Based on Valuation $1500 $0.75 9001.2195
$63.25 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 -
Kent J Pederson Revocable Tst 5/31/07
3832 Country Creek Way
Eagan MN 55122
(651) 470-0322
Twin City Garage Door Co
5601 Boone Avenue North
Minneapolis MN 55428
(763) 533-3838
Applicant/Permitee: Signature Issued By: Signature