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1972 Glenfield Ct C oot6l~ Use BLUE or BLACK Ink ForOffice Us «r ~ I 1 n n I Permit#. y Ub11 City of Ea I ~ Permit Fee: 14 7, Jt I 3830 Pilot Knob Road I I Eagan IVIN 55122 I Date Received: I Phone: (651) 675-5675 I Fax: (651) 675-5694 Staff: I y L--------.------- 2010 RESIDENTIAL BUILDING PERMIT APPLICATION CI -.W., 0 &-z 4) Date: t0 ZD 0 Site Address: 5('&. 6$ 70.2&-74 ] 78 Q 82 94, 88 64VA? j" Tenant: Suite RESIDENT / OWNER Name: ~V &QPaZy [!,cl c !NG Phone: 651 - SS4~- gp4~9 Address / City / Zip: 2 0. DVX 2125 1010, 6awr 11n&rfrs, /VAN ,SSO 76 Applicant is: Owner Contractor TYPE OF WORK Description of work: KEMOVE AA1,0 Qr-ncIfIE 9y'uV6WV Qoof Construction Cost: 4 .2 '30 pp 0 Multi-Family Building: (Yes / No ) CONTRACTOR Name: _3El EkTET-(OiL MA-1 N7; COkP. License 24Oo2111131 ter /Address: ~05 VV. (~tl STRCer City: 1QcAfA(&-AP(JGIJ State: / nN Zip: S-SLII 9 Phone: Grp 12 - 6 2 3 _ Contact: P-kf- _ Email: lylfa OeliCM. con-1 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) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.goopherstateonecall.orci 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. X 6'f1 el-r it/~c~IJ X Applicant's Printed Name Applicant's Signature Page 1 of 2 I For Office Use 'Ab Permit (-a 70 I non City of Ea~d I Permit Fee: o I 3830 Pilot Knob Road I e q I Eagan MN 55122 Date Received: APR, V 3 2009 Phone: (651) 675-5675 I ' I Fax: (651) 675-5694 i Staff: 2009 RESIDENTIAL BUILDING PERMIT APPLICATION GCd,d ~~7 ~ J~~ Date: Site Address: 1 d° e Tenant: Suite RESIDENT / OWNER Name: - Phone: Address / City / Zi 1 1 Applicant is: Owner Contractor TYPE OF WORK Description of work: L Construction Cost: r Multi-Family Building: (Yes ! No CONTRACTOR Name: ti o License Address: 13-3s-3 City:' State: Zip: Phone: 6 3 kj 0 Contact Person: ` COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 Category 1 Minnesota Rules 7672 Energy Code . Residential Ventilation Category 1 Worksheet New Energy Code Worksheet Category Submitted Submitted submission type) • Energy Envelope Calculations Submitted 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. 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. Applicant's Printed Name Applicant's Signature Page 1 of 3 DO NOT WRITE BELOW THIS LINE SUB TYPES - Foundation _ Fireplace Porch (3-Season) _ Storm Damage 4- 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 -X Fire Repair Windows _ Demolish Foundation Replace _ Repair Egress Window Water Damage *Demolition of entire building - give PCA handout to applicant DESCRIPTION Valuations Occupancy MCES System Plan Review - Code Edition ; 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) Sheetrock Footings (Deck) Final / C.O. Required Footings (Addition) Final / No C.O. Required Foundation HVAC Drain Tile Other: Roof: -Ice & Water -Final Pool: -Footings -Air/Gas Tests -Final Framing Siding: -Stucco Lath -Stone Lath -Brick Fireplace: -Rough In -Air Test -Final x' Windows 'Jc Insulation Retaining Wall Meter Size: Erosion Control Reviewed By: , Building Inspector RESIDENTIAL FEES Base Fee Surcharge Plan Review' MCES SAC 1 v r City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies TOTAL Giertsen Company Restoration Specialists Since 1918 Recap by Category O&P Items Total Dollars % APPLIANCES 111.02 0.38% CLEANING 1,999.82 6.85% CONTENT MANIPULATION 615.04 2.11% GENERAL DEMOLITION 2,954.62 10.11% DOORS 1,438.32 4.92% DRYWALL 2,285.45 7.82% ELECTRICAL 1,142.56 3.91% PERMITS AND FEES 540.00 1.85% FINISH CARPENTRY / TRIMWORK 1,723.51 5.90% FINISH HARDWARE 152.52 0.52% HEAT, VENT & AIR CONDITIONING 354.38 1.21% INSULATION 733.97 2.51% LIGHT FIXTURES 809.68 2.77% PLUMBING 1,406.77 4.82% PAINTING 5,145.47 17.61% SIDING 210.00 0.72% WINDOWS - VINYL 884.08 3.03% WINDOWS - WOOD 114.40 0.39% Subtotal 22,621.61 77.44% Base Service Charges 1,171.44 4.01% Matl Sales Tax Reimb @ 6.750% 409.88 1.40% Overhead @ 10.0% 2,420.29 8.29% Profit @ 10.0% 2,420.29 8.29% O&P Items Subtotal 29,043.51 99.42% Cleaning Sales Tax @ 6.750% 168.73 0.58% Total 29,212.24 100.00% DIFFLEYCOMMONS_1972 4/2/2009 Page: 19 SEWER & WATER PERMIT OFFICE USE ONLY CITY OF EAGAN METER # PERMIT DATE 12/04/91 3830 Pilot Knob Rd. 12419 Eagan, MN 55122-1.897 CHIP PERMIT # METER SIZE B.P. RECEIPT # C 016048 DATE 10-25-91 ISSUE DATE B.P. RECEIPT DATE 11 /04/91 PRV - BOOSTER PUMP 1%6, 1%8, 1970, 1972, 1974, 1976 1978 SITE ADDRESS 1980, 1982, 1984, 1986, ' 58 LENMD Cr PERMIT REQUESTED LOT 5 BLOCK _ 2 SEC/SUB n if f 1 ay Commons X -SEWER X WATER -TAPS APPLICANT: The Rottlunc3 rn Inc- ADDRESS: 5201 E. River Road -COMM/IND (KRESIDENTIA CITY, STATE Fridley, Mn. ZIP 55421 X NEW EXISTING PHONE: 571-0304 Lawn Sprinkler Meters are to be Installed PLUMBER: Valley P1 timobing Ah of Domestic Meters on Water Line. ADDRESS: 610 C r P ek Lane Cr LL NOT be:gi n for Deduct Meters. CITY, STATE Jordan, Mn, ZIP 55359 PHONE: 492-2121 AGRE - O OMP -Y WITH CIT OF OWNER: The Ratt1und Co,-Ine. EAGAN ORDI ANTES ADDRESS: 52Q1 E.}t~a>^ R„a CITY, STATE Fri leT, Mn ZIP 55423 PHO 1371-0 ~Q SIGNATURE WHEN METER ISSUED PL O WO K AY5 FO PRO E~SSIA CALL 454-5220 FOR INSPECTIONS. FOR STORM SEWER PERMITS, CONTACT NGINEERING DEPT, r iv 06/17t2014 15:05 Les Jones Roofing,Inc. �AJI�528817009 P.006/020 Use BLUE or BLACK(nk �----------------- � For OHlce Uce � � j Permtt#: 6 �� j C�ty of Ea�a� � � � �� � � PermN Fee: � 3830 pilot Knob Road Eagan MN 66122 � Dala Racelved: � Phone:(661)6765675 I I Fax:(661)875�5694 . j S��• 1 �������������.�.�.�_J 2014 RESID�NTIAL BUILDIIVG PERMIY ApPLICATION �9G*6- /9b� /9�0-/97.2-/97� /9'7����'I8' �ate: / SlteAddress:198o-/��2-/98y-�98�-/9�� l�En.F�Ez,o C��Q u�it�: �li.': /�'�.:: :1 .�`.�::A.+�; ` !13..•;.'�:.`;t:�c'.�rJ� . : �,:;:.;;,:.,...,,;;,�:;�;:<;�::,�;:�:� Name: ya P�oPa2rY c�a-�� 6/�c.. Phone: �v�!- s.s�/- 9q'y�/ . ..�,,,j;�,,5t;�'�.,.,,..�.. �.:�.<, 'I,;,�r.. , �•,1•;..y_,,..:.�:-.� .:'�:;;;�;��,$�(�.Qllt/-,;;:<:;';;;; ,/ ;, ,'�, NvEJ�t.C�72o �S f,/TS: /L1sl� �.� '��e `'''�;';:��/��j�r't:;•":'`: Address/City I Zip: �o. BO k 2i 2 5 / +�� /� 1;;<�... ��� ";'.,:., ,';:,;,:�` ;.�;y::, ��'r��; :-i.; ,,�, �'�'`:'","I,�`�;:�;`��'"���''' ApPlicant is: Owner x ConVector Y l . ':.i:. �.�.-; ',.,;;>..�;:".:�., ,�.,.y:�....,. ,..,..,,:t�� �::.. �.,.i �.',.:`.::r1:�. .� �r'.F:;,�r,: .,,��r,.i:. ,.�.)'. C� ,;,;:;'s ;J�,;:.r If �e D�Nb-. �'i�:L�_ .�Y .0"'1'-'j.i��^'�;tr',;!�,;.� Descripdon of wo�k:_ly�/l/l0�/� .�� [L�iQ � S/ ;:•��������f aW,��'{�'.,":; � ' �:;;-;=;;"''""�."''��`-�'�`�` Constructlon Cost: � 2�v D D� ? 4 X '�1'�X''�:�'��• ;'`1���+:Rti MUItI-Family Building:(Yas /No� n'(•"��; .�A',:: . i.�f�/,.�t.,,ti����.T:.:�:i:�i����`1.��'�r.��:'�: :{' .' �f����.�r�1�`W�:� ��',,.-I / �'�`- ������,"';,�:�z°�"";;�`>'; Company: �E'S �ToNE3' RADFfi✓G- /NG , r� �Q�-ivor�2so�/ ;,s',f\:'�.. :...:::......:_ Confsck G .e�s �i::�i';?'''�`<r,';�,.;`; ��';�,':S;i,>(;:>��: : . . ';� .. •�'; �;'��"%`�M�'F�:�::,:�'��r`�'a!�s:���,� Addrass: 9K 1 W. 8'D� .f7�2�L'7" City: ��.a.u6i►'ai✓ :,,, .� ,;r ,�:; ;�ari'�ra;�t�'r���;;:: � :<�;r-'�;��,;:'•%' �:�� :�`<'',� State:�zip: ,�,��E�D Pho�e: �5�- yrc 7-�8/9 t:' ,,:;,S;.;J:.c, ,:;'. '+° '.ji;.tli. :����„�' ��:����� �''�1'��:� •::iit.'.- � ,��'� , � '".•' �`.it. ':'�r'�'__'. �"�' ''� �'''`` '°` ��cenae#: �S�roO �ead�ert�flcate#: �;a::'� ,;R�, ;';�,.; .vA�� �f o 3 9.?-/ ';�:.. .�... If 1he project is exempt fram lead certlficatlon, piease explein why: (see Page 3 ior addiE(onal information) COMPI,ETE THIS AREA ONI.Y IF CONSTRUCTING A NEW BUILDING In the last 12 months,has the Clty of�agan Issued a pennit for a simllar plan based on a maater plan? Yes _No ff yes,dete end eddrae8 of master plan: Llcen9ed Plumber: Phone: Mechanical Contractor. Phone: Sewer 8�Water Contractor: Phone: 'i� .�.. _ - q::. „c..��w: ��.�� .�p.��,w.s.0 ,q• .,n oa�,:,,{.�:�- ,';i ;w,��'KOTL�,i..I�ris�an`-�' <'��!. 'rid'�ie�"ryj '�tli"f�' ur�ii ;�a�� ,.cb s 'e'�' �'°'�� ''� I � t o'" a o <, .,�.Q.,.,;��:�, ��,;.,�'P�,;.,1�ri�►f ,.�� �l!��s, ,�t,,..Y.qr,,,.. .;�►ta r'� .,n ;T�I.,�r�4�:t°����!�1,��., r�#.���„,�, n ��"�;�i n�, �,��,; *�i `r �y- {�" '�"S, ' t / A' i, a 1 � I / �+, � n.�„ J�,%.y��'„ ��j ; � � s�p� �i '��r�°f�e;l�io�atl�1�? 8�/���4C�a�5`,��?f�,d.�S�'l�.Qhir,jl����f ��j�1)'p�/�:����!'�'���e��'+' Q , �,Sr .�,�51;{r��IF7:� ��St�a „�F .�b�rJ'i � j� , ,H � r, V�� . 2�. aA'.l u�s•,4..0� � �,7 a �P'.:s(':"b•��� � �•,;�i. ^t�. �,7�� ��� „r;.,e:,,%�� ,�;s�.i l. ;.� ��,t.�i r ���y^� !.a Yv � J.'ti� s �� r Q �i� � iK,�..-t'x,y.r�j� i .. . � . .c, . � , • �.. ....� , y ... �,.. �..,en�......!n:t. ��i�., ..^�i,�o�n.:,`'. Q.u..�.5 ��t Q. ;7�. a.. .�iS ���!- `F SrL°;!�'� 4...,�.� :_i�'y�� .�,�'� J.� �I CALL BEFORE YOU DIG. Call Gophar Stato Ono Call at(661)464-0002 for protectlon agaln5t underground utlllly damage, Ce1148 hours before you Intend to dfg to receive locates of underground ulllltlea. www.gopherstateonecall.ora I hereby aeknowledBe ihef thls informallon Ia camplete and accurete;thst the work wlli be In co�ortnance with the ordlnancea and codes of the Gly af Eegan;thet 1 understand thls Is not a pertnit, but anly an applicallan far a pertnit,and work Is nol to Start uAthout a permlt;thet lhe work wlll ba In accardance wilh Ihe approved plan In lhe case of work which req�res a revlew and approval ot p1an8- Exterior work authorized by a bullding parmit Issued In accordancs with the Mlnnesota Stata Building Code mual be completed wllAln 160 days of permlt Issuance. X Gµk�s �4�rDE�sa,�/ x ��� G��� Appllcant's Printed Name Applicant's Slgnature Page 1 of 3 02119/2014 12:33 Les Jones Roofing, Inc. �AK�528817009 P.0061020 � Use BLUE or BLACK I�k �----------------- ��C������ � For Offlce Uso � � ' FEB 1 9 71114 � pa"„��'�: ���� ; C�ty of �a�a� � ��� � Permlt Fee: � 3830 Pilot Knob Rosd Eagan MN 6b122 j Date Recelv�ed; j Phone:(661)675-6875 j S��_ I Fax:(661)67G-569a . � I ���.__�----------�a 2014 RESIDENTIAL BUILDING PERMIT APPLICATION �f �4��, �q�s,�9�0, �9�a, i 9�y i9�� Date: 2 �9 � SlteAddrees: 1478 /98 /9�1 1985/ ♦ � �Unit#: .. ,�,,.�.,; ....,.,,C A._..,,..,�..,,�. :�_ i: , `�;��})';�.�r� a,� `ti��u`.�'''''�',' Name: yo P�20P�Ty GA-�'E �NG. Phone: �vs/� 5'S�/- p9�1� " �.i�•r -r,�; -;:.:I::� ; �S �'R .� � . w � � ?.�;��� ^ :t�. � •>��'�;° - ,�p•;'r;•�.'�M1 Address/City/Zp: �O. �30� 2►2 � /NaElL�,o✓d �'S� ��o .�. <;r. ; ��^¢'Y.•:.�:..� �S��M>;��• �%�� � �`���'�`��� X Contractor G�.•���:�� ,�y��'�,p,.�b.���;+� ApPllcent le: Owner � ,n::. ..-' .:. ,:�' ..,,x����, ,,�;;�. � ', ,,.;� s ;;.,, ` �2 p �1� „.��, ;�f'+ �;: Descriptlon ofwork:��D�E A�/VD d"TCPLlff.S //a»P �� ���2-�4�'i�r �� �`�Y��';Of 11V,Q�±IC:�; . "� � �' ""� "� "a �`= 1''� Canstructlon Cost: � / � 7� Mul6-Family Building:(Yes X 1 No� �;. .�3�6,.:,? r,�:;,:�i?„ .....�'r,•.�Y ..F'- ..:y..�M,� ••T: r.,.,�_;Y.".�.�I�� .���Y�.: ; :�,.� ;,�;. .�:� ;a���:�,;lr'"?���;�v�-;� Compeny: �E5 �7'oN�S RaiDfs�/b- /•vG contact:c'�•e+s A-,vn�.son� i � ;� ., ,;r��.,:• � ;�;�C;.' Y :I�, x .:�di• -/ .;r,..�..;�.:��y��,.�( �.,....•'•i� ' /� ,���,.�.» �GYlGCA�TTYaN dp:,".�,h;....��,�.ri�s�.. ���i �d(8S$. '7�� w �d� �/�G i Cil�l: :�;�L,qr�4r��t�,i?�, o '_' -�...��.,�;��'1,x..r`:,.,;n��;; State:�zip: ,�,t'k�2o Phone: 9'SA— 7�7- a?8/7 N1�''�✓'� ���1C�(.�J;;.�°I, ..^�V.� . ' � '�;,r`a:M La^:.T'�'�' � '• �J�D � ��a":A �v�cy ��,fi,, ^��' Llcenee#: Lead CertNlcate#: �l/,4� � � ��—( .::'�:.:_ .krf... ',�..e�.... If the project is exempt from lead certlflcatlon, pleese expfein why: (see page 3 for additional information) C�MPLETE THIS AREA ONL.Y IF CONSTRUCTING A NEW BUILDING In the lest 12 months,has the Clty of Eagan Issued a permk for a slmllar plan based on a master plan? ,_,Yes �No If yes,dete and addrees of mastar plan: Llcensed Plumber: Phone: Mechanlcal Contractor: phone: Sewer&Water Contractor: Phone: i:' � t.'..I, r����' „1'�', -a�,�.��.1�1,'t�ftiia�-t',Q�'' �b��+� �:�'��°�l�f�.H'Cryz tbe°"ubll"in'�:Q�" �'E�{:i,S;h-�`IxQ;��"�i►s�,offt„ .,�'`��� •�.,^ '�a1:i�t :� �'' a� 1.';�`.y,Y'�4� �" ;�"°.' r .1 �� �?,�.W-�cc �� �.� �(:.,lr.. .��t ha+ �r • �a.�'n ��rr�,�, �yy'i�n�r.t�� ,�b��-b�s� s��``��' �e Q� �i�l.. �t', /��r�ra+�,��� o�fi � ����+.�. ��a:�p, r,�►�:'t��o��p< }��...>�g a..� '�`�` !Y� J' .�X � � i! � �:7 r�. �,� � �..'� ff�� �. 3 r. � � r^+•�lf�',.w 1. ..,M�y�y�� 7,.1.7 ;4.�. . h,� '�.r �k'• w �� �.,IM� �.� �: vr� �,d - L �5:�.:dt.:.. '�? , ,f... Q�. � , �j g�, ,� , . . xN H t1fu..,i:��l,...�,:,,«�.b.�t'�,.�i?;. ..;.u�t. .:,,. : "�•i �...... .(�.::.�:a;...:G.(�.IC.��+.�m�1��91 [����.r.:?fr.",x. f:..�....� gi .ii.a�� ...F;: i�..c�C�; :� 'M iCl,.�r: r_'it�`� u .� ��: ..Y. CALL BEFORE YOU DIG. Call Oopher 9tata One Call 6�t(661)464-OOOZ for protecflon agalnat underground uUllly demage. Call 48 hou►s before you Intend to dlg to recelve locatee of underaround utllltles. www.aonher9taleoneca��.nrn 1 hereby ackno+Medge that thle Info►matlon Is complete and eccurate;that lhe work wlll be In canformence wlth the o�dlnancee and codee of the Clty of Eegan;thet I underetand thla le not a permlt, but only an appllcatlon for a permlt, and work le not to stert wilhout e permlk that lhe work w111 be In eccortlence wllh the epnroved plen In the caae of worK wntch requlree a revlew end approval of ptens, Exterlor work authorized by a bullding permlt lesued In accordance wlth the Mlnnesota State Bu1lding Code mu9t be complated wlthln 180 days of parmlt laeuanca. x Gµ,@tS �4AlDEl2,�o^/ ��lr�� .G�s�s��' x AppllcanYs P�Inted Narne Appllcant's 3lgnature Page 1 013 PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA172723 Date Issued:10/13/2021 Permit Category:ePermit Site Address: 1972 Glenfield Ct Lot:042 Block: 04 Addition: Diffley Commons PID:10-20450-04-042 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 - Bruno Pareja Lozano 1972 Glenfield Ct Eagan MN 55122 (952) 594-4937 Majestic Custom Construction Inc 8800 Royal Ct NW Anoka MN 55303 (612) 419-2173 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA175476 Date Issued:04/05/2022 Permit Category:ePermit Site Address: 1972 Glenfield Ct Lot:042 Block: 04 Addition: Diffley Commons PID:10-20450-04-042 Use: Description: Sub Type:Air Conditioner Work Type:Replace Description: Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Pete DeGrood at (507) 210-0754. 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 - Bruno Pareja Lozano 1972 Glenfield Ct Eagan MN 55122 (952) 594-4937 Majestic Custom Construction Inc 8800 Royal Ct NW Anoka MN 55303 (612) 419-2173 Applicant/Permitee: Signature Issued By: Signature