4134 Braddock TrCity of Eagan
3830 Pilot Knob Rd
Eagan, MN 55122
(651) 675 -5675
www.ci.eagan.mn.us
Site Address: 4134 Braddock Tr
Lot: 51 Block: 4 Addition:
PID:10- 72500 - 510 -04
Use:
Description:
Sub Type:
Work Type: Gas Fireplace (new)
Description:
Census Code: 434 - Occupancy:
Zoning:
Square Feet: 0
Comments:
Fee Summary:
Valuation: 2,000.00
Contractor:
Fireside Hearth & Home
20802 Kensington Blvd
Lakeville MN 55044
(952) 985 -6675
Stafford Place
PERMIT
Cit of Eaan
e- Fireplace Construction Type:
Chimney /flue must be inspected prior to concealing. Smoke detectors are requ ired in all sleeping rooms prior to final
inspection. When wall studs or ce iling joists are exposed, hard -wired detectors are required. Battery operate d types are
acceptable if the wall/ceiling finish (i.e. sheetrock) has to be removed to install a smoke detector.JOCINA 2700
FAIRVIEW AVENUE NOR TH ROSEVILLE, MN 55113 651- 638 -3309 hammerj@hearthnhome.com
Surcharge - Based on Valuation $2K
BL - Base Fee $2K
Total:
Applicant/Permitee: Signature
- Applicant -
$1.00
$69.00
$70.00
Owner:
Randy T Feld
4134 Braddock Tr
Eagan MN 55123
Permit Type:
Permit Number:
Date Issued:
Permit Category:
9001
0801
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.
Issued By: Signature
Building
EA075043
09/07/2006
ePermit
Parcel Files Cover Sheet
Unique ID: 2000
4134 Braddock Tr
107250051004
CASH RECEIPT
CITY OFEAGAN
3830 PLOT KNOB ROAD
EAGAN, MINNESOTA 55122 DATE V? `F-' 19,`
y' i r
?IFROM
AMOUNT $ °J (?
? CASH
CHECK
DOLLARS
too
J
Thank You
BY
White-Payers Copy
84114 Yellow-Postlng Copy
Pink-File Copy
? fi q
CITY OF EAGAN 1
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
PH ON E: 454-81 00
BUILDING PERMIT Receipt #
To be used for l `; f Est. Value 731,,('(' Date
Site Address 4134 rf: OFFICE USE ONLY
3 '" i f` i !-)A(
Lot Block it See/Sub On Site Sewage Occupancy
. MWCC System X Zoning
Parcel No.
On Site Well (Actual) Const
Name FO z 1_? 4?i `'t ?a ',;Vi' City Water (Allowable)
m
z q' r 3 J a E
Address PRV Required # of Stories
3
P t, "i
f ?. ,. Phone ?, 34- . 4 ,
City Booster Pump Length
- Depth
p Name S.F. Total
0u Address Footprint S.F.
P City Phone APPROVALS FEES
v
L
"
Name Engr./Assess. Permit Lifts •
w
W
z
Planner
Surcharge
3'{)
0
U Address
Council
Plan Review
X33 fits
CC w City Phone Bldg. Off. SAC, City t ?'O •t
I hereby acknowledge that I have read this application and state that the Variance SAC,MWCC 50, Uea
information is correct and agree to comply with ail applicable State of Water Conn.
3; • vi;
Minnesota Statutes and City of Eagan Ordinances.
Water Meter -.0,
SigpAture of Permittee Road Unit _3,:.:4..
A Building Permit is issued to: Treatment P1 + i • f}'
on the expless condition that all work shall be done in accordance with all
applicable State of Minnesota Statutes and City of Eagan Ordinances. Parks
h
2
1-
_ ?
Building Official
TOTAL
°
CITY OF EAGAN PermitNo:-T96-1?4-?-?z- Date: 5-27--88
3$30 ailot#(nrab Road Meter No: Z)03 J a a J Size: g rr o ./
P.Q. Box'21199 Reader No: 1Z ?{7? Date:
Eagan, MN 55121
Owner. Frontier Midwest
Site Address: 4134 Braddock Trail L51 B4 Stafford Place
Plumber Star Plumbing
Conn. Chg: 550.00 Zoning; R1
Acct. Dep:pd No. of Units:
Permit Fee: l0.OOPd
Surcharge: • 50pd I agree to comply with the City of Eagan
Tr. Plant 204.00pd Ordinances.
Meter: 67, O
Misc.: By
WATER SERVICE PERMIT
BLDG. PERMIT NO.
01-3422 Plan Check
01-3445 Surch./Adm.
01-3446 SAC/Adm.
01-2155 Surcharge
75-3860 Road Unit
20-2275 SAC
20-3865 Water Conn.
20-3868 Water Trmt. f
20-3716 Water Meter 42 2
20-2252 Acct. Dep.
20-3713 Water Permit
20-3743 Sewer Permit
79-3866 Sewer Conn.
28-3855 Park Ded.
j '? ,
TOTAL
W - . 4
TrrIifiraft of (! rruvanrg
ttitp of Cagan
i0 r#xntnt of vuithing innpmtwo
This Certificate issued pursuant to the requirements of Section 306 of the Uniform Building
Code certifying that at the time of issuance this structure was in compliance with the itarious
ordinances of the City regulating building construction or use. For the following
Use Classification ?W Bldg. Permit No. 15076
Occupancy Type _ R3 MI ` Zoning District R1 Type Const. T1f1
Owner of Bolding RM Address 3902 C AU DL, L"
Building Address 4134 `"? IBML Locality I.51, B4 a ffMM R" '
AT 5, 1988
Building oBici4
POST IN A CONSPICUOUS PLACE
CITY OF EA AN
r
3830 Pilot Knob Road, P.O. BOx 2 -199 E
ilitgAni MN 65121 r
PHONE: 454- 100 f j
BUILDING PERMIT Receipt #
To be used for Est Value $73 • ( Date MAY 2?
Site Address ?134 % r f ' Q( v, OFFICE USE ONLY
;TA X020 PLA ?
51 C;
Lot Block Sec/Sub
On Site Sewage
Occupancy -3 ,?1
. MWCC System A Zoning '"
Parcel No. O s
n Site Well (Actual)Con
t __
Name 7 fiOP?S COkP City Water (Allowable) 4
Address PRV Required * of Stories
{City Phone A 54-14433 Booster Pump Length 4O
Depth s
p Name" S.F. Total
0 d Address Footprint S.F.
-` City Phone APPROVALS FEES
F ¢
W W
Name Engr./Assess. Permit * OO
36
50
Ft
C' Address Planner Surcharge .
233 OG
sx , City Phone Council Plan Review
100 -
Bldg. Off. SAC, City
I hereby acknowledge that f have read this application and state that the Variance SAC, MWCC
_50
W
information is correct and agree to comply wi all applicable State of
M Water Conn. *
innesota Statutes and City of Eagan Ordinances,
Water Meter 67,00
Signature of Permittee Road Unit
325-
A Building Permit is issued to: ti -? Treatment F+1 - 304.
on the express condition that all work shall be done in accordance with all harks
applicable State of Minnesota Statutes and City of Eagan Ordinances. _-t
Building OtkiaL TOTAL
Pest ice. it
aV C. 4f r5
Eric ? /f
kvqkftbm cme p' P• C Ptll anta
Footings i .t7
Foo,fings 0
FoundWon
Framing
Rooting
Rough ?t?
Rough Htg
isul
Fkspk"
Final Htg.
Final Pgp
Sift Final
Cert Occ.
Temp. LP
Deck Ftg.
Dddt Fins!
well
Pr. Dim
PERMIT #
PLUMBING PERMIT RECEIPT CITY OF EAGAN
3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE:
CONTRACT PRICE: PHONE: 454-8100
Site Address /.3 .fs
Lot Block Sec/Sub
Name?'_
elb-
(a
r c. S~ f `- `
ess
C City Phone
Name
Address G
p City Phone
FEES
COMM/IND FEE - 1% OF CONTRACT FEE
APT. BLDGS - COMM RATE APPLIES
TOWNHOUSE & CONDO - RES. RATE APPLIES
MINIMUM - RESIDENTIAL FEE -$12.00
MINIMUM - COMM/IND FEE - $20.00
STATE SURCHARGE PER PERMIT - .50
(ADD $.50 S/C IF PERMIT PRICE GOES
BEYOND $1,000.00)
?
!
SIGNATURE OF PERMITT •
"
BLDG. TYPE WORK DESC?R4PTION
Res. New L/
Mult. Add-on
Comm. Repair
Other
RES. PLBG. ONLY - COMPLETE THE FOLLOWING-
NO. FIXTURES
'$4T t
Water Closet -' $3.0.00
Bath Tubs - $3:O0
Lavatory - $3.00
Shower - $3.00 , pd
Kitchen Sink - $3.00
Urinal /Bidet - $3.00
-Laundry Tray $3.00 3• ??_
-Floor Drains - $1.50
=Water Heater - $1.50
Whirlpool - $3.00
-Gas Piping Outlets - $1.50
(MINIMUM - 1 PER PERMIT)
Softener - $5.00
WeII - $10.00
Private Disp. - $10.00
Rough Openings - $1.50
FEE: . .3+400
STATE S/C: S
FOR: CITY OF EAGAN GRAND TOTAL:
PERMIT It 9 la
MECHANICAL PERMIT
3830 PIL RECEIPT #
CITY OF EAGAN
OT KNOB ROAD
EAGAN
MN 55122
CONTRACT PRICE: ,
,
DATE:
PHONE: 454-8100
site Address 4134 Braddock a
LotBlock
Sec/Sub BLDG PE WORK DESCRIPTION
Res. New 2X
Name T Q& A/C Mult Add on
ro 1955 Shawnee
Address Road Comm. Repair
City Eagan. Phone 452.1565 Other
Frontier Comp
Name anies FEES
Address 3908 Sibley rial
HWY. RES. HVAC 0-100 M BTU - $24.00
ADDITIONAL 50 M BTU - 6.00
O City. Eazan Phone 45404433 (RES. HVAC INCLUDES A/C ON NEW
CONSTRUCTION)
1
GAS OUTLETS (MINIMUM -
PER PERMIT) - 1.50 EA.
TYPE OF WORK COMM/IND FEE - 1% OF CONTRACT FEE
Forced Air 80,000 M BTU 24.00 APT. BLDGS. - COMM. RATE APPLIES
Boiler M BTU TOWNHOUSE & CONDOS - RES. RATE APPLIES
MINIMUM RESIDENTIAL FEE - ALL ADD-ON &
Unit Heater M BTU $ REMODELS - 12.00
Air Cond. M BTU $ MINIMUM COMMERCIAL FEE - 20.00
Vent. CFM $ STATE SURCHARGE PER PERMIT - .50
(ADD $.50 S/C IF PERMIT PRICE GOES
Gas Piping Outlets # $ 1,50 BEYOND $1,000)
Other $
FEE: 25.50
S/C: SIGNATURE OF P MITTEE
'426'
TOTAL:
FOR: CITY OF EAGAN
CITY OF EAGAN Permit No: 10760 Date: 5-27-88
3830 Pilo IAno Road B/P No: 8`+114 Date: 5-26-86
P.O. Bti'2f`f9 -
Eag; NIN 55121
Owner. ?Front iki Midwest
Site Address: 413+ `Braddock Trail L51 B4 Stafford Place
Plumber: Star Plumbing
MWCC: 550 a OODd Zoning` Ri
City Chg: 100.001 d No. of Units: 1
Acct. Dep: is f'CPci I agree to comply with the City of Eagan
Permit Fee: ? O - ( nrl
Surcharge: Cg Ordinances.
Misc.: By
SEWER SERVICE PERMIT
CITY OF FAGAN
3830 kilpt1(neb Road
P.O. Box 21199
Eaggn MN 55121
Permit No:_
Meter No: -
Reader No:
Date: 5-27-88
Size:
Date:
I
Owner. Frontier Midwest
Site Address: 4134 Braddock Trail L51 B4 Stafford Place
Plumber. Star Plumbing
Conn. Chg: 550.00pd Zoning: Rl
Acct. Dep: P- No. of Units:
Permit Fee:
Surcharge: I agree to comply with the City of Eagan
Tr. Plant Ordinances.
Meter. 67.OOpd
Misc.: By
WATER SERVICE PERMIT
9614
This request void
18 months from
E 28446 A-41 Reques Date Frre No. Rough-in Inspection
Require ? ?Ready Now @g-W'111 Notify InsPec-
60 es ?No for When Ready
Vicensed Electrical Contractor I hereby request inspection of above
? Owner electrical work installed at:
Street Ad ress, B or Ro No. City
4
Sen se or No.
r Range No. County
Occ nt ( T) ^
74 -A
k)
Phone No. -?
Pow
plier
A
Address
Electrical Contractor (Company Name) ontractor' License No.
K
c
F
R
M
?
'arttrfi'?L
ing Instailation)
o wn
14540 PENNOCK LANE
AuthP$MV
MEY/C7?v]M??gg lation)
Phone Number
THIS INSPECTION REQUEST WILL NOT
,MINNESOTA STATE BOARD OF ELECTRICITY BE ACCEPTED BY THE STATE BOARD
Griggs Midway Bldg. - Room N.191
UNLESS PROPER
MN 59104" INSPECTION FEE IS
'?2'T?"f)rSrve"r`§rty Ave;; sf.?'8'ul, " `° "
Phone (612) 642-0800 ENCLOSED.
REQUEST FOR ELECTRICAL INSPECTION .. EB-00001-06 Ii, See instructions for completing this form on back of yellow copy. .? >
E 2 8 4 4 ""X'" Be/ow Work Covered by This Request
Now A d Rep. Type of Building Appliances Wired Equipment Wired
Home Range Te rary Service
Duplex Water Heater ightiny Fixtures
Apt. Building er Electric Heating
Commercial Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
Farm Other (Specify) Other (Snocify)
Other (Specify) Other Other
ompute Inspection Fee Below
p Fee Service Entrance Size tt Fee Feeders/Subfeeders Circuits
Ll 16U Oto200Amps Oto30Am s to30Am s
Above 200 Amps 31 to 100 Amps 31
to 100 A s
Swimming Pool Above 100Am S bove 100_Amps
Transformers Irrigation Booms artial-Other Fee
Signs Special Inspection OT
Remarks , i- )
Rough-in n?t?_ 1, a Ele al
?(f Inspec or, hereby
certify that the above Final Y-141" to inspection has been
made.
This request void 18 months from
d V RESIDENTIAL BUILDING
Permit Application
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
New Construction Requirements Remodel/Repair Requirements Office Use Only
3 registered site surveys showing sq. ft. of lot, sq. ft of house; and all roofed areas 2 copies of plan Cart of Survey Rem -Y -N
(20% maximum lot coverage allowed) 1 set of Energy Calculations for heated additions Tree Pres Plan Recd -Y -N
2 copies of plan showing beam & window sizes; poured found design, etc. I site survey for additions & decks Tree Pres Not Reqd -Y -N
1 set of Energy Calculations Addition indicate if on-site septic system On-site Septic System -Y -N
3 copies of Tree Preservation Plan if lot platted after 7/1/93
Rim Joist Detail Options selection sheet (bldgs with 3 or less units
Date Construction Cost ?i4:00 •
Site Address i5 2.7 Y ?,.a. /h c L 7•• ,• ( Unit/Ste #
Description of Work 7c--?- 6.4' x C -
Multi-Family Bldg _ Y ?1q Fireplace(s)
0 - 1 - 2
Property Owner / Ar- i e. (4 Telephone # (6?f) 6f "' ,'?
Contractor 7a Add ?.'•. _.G•, .
Address ?4' 9 3 4 re -' tv?: '''???
State Zip S" S: 3c Y' City f o%We y a-
Telephone # ( 76'3) ? 7 -OD Or d'
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
- Minnesota Rules 7670 Category _ Minnesota Rules 7672
Energy Code Category Residential Ventilation Category I Worksheet • New Energy Code Worksheet
(/ submission type) Submitted Submitted
Energy Envelope Calculations Submitted
Have you previously constructed a building in Eagan with a similar plan? Y , N If so, 25% plan review
fee applies.
Licensed Plumber
Mechanical Contractor
Sewer/Water Contractor
Telephone #(
Telephone #
Telephone # (
I hereby 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
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
OFFICE USE ONLY
Sub Types
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Multi
? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF
? 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (screen/gazebo) ? 36 Multi Misc.
? 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage
? 06 04-plex ? 12 12-plex Plbg_Y or _ N ? 25 Miscellaneous
Work Types
? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding
? 32 Addition ? 36 Move Bldg. ? 42, Demolish (Foundation) ? 45 Fire Repair
? 33 Alteration ? 37 Demolish (Bldg)* ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement *Demolition (Entire Bldg) - Give PCA handout to applicant
Valuation Occupancy MCIES System
Census Code Zoning City Water
SAC Units Stories Booster Pump
Nbr. of Units Sq. Ft. PRV
Nbr. of Bldgs Length Fire Sprinklered
Type of Const
Footings (new bldg)
Footings (deck)
Footings (addition)
_ Foundation
Drain Tile
Roof - Ice & Water _ Final
_ Framing
_ Fireplace _ R.I. -Air Test -Final
Insulation
Width
REQUIRED INSPECTIONS
Final/C.O.
Final/No C.O.
Plumbing
HVAC
Other
Pool _ Ftgs _ Air/Gas Tests -Final
Siding _ Stucco Stone
Windows (new/replacement)
Retaining Wall
Approved By , Building Inspector
Base Fee
Surcharge
Plan Review
MC/ES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
License Search
Copies
Other
Total
CITY OF EAGAN NO 15076
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
PHONE: 454-8100 BUILDING PERMIT Receipt # n14
To be used for SF DWG/GAR Est. Value $73,000 Date MAY 26 ,19 88
Site Address 4134 BRADDOCK TR OFFICE USE ONLY
Lot 51 Block 4 Sec/Sub. STAFFORD PLACE On Site Sewage Occupancy R-3 M-1
MWCC System
X Zoning R-1
Parcel No. On Site Well (Actual) Const V-N
x Name FRONTIER MIDWEST HOMES CORP City Water X (Allowable) V-N
LM
Address 3902 CEDARVALE DR
PRV Required
# of Stories
-
City EAGAN Phone 454-9433 Booster Pump Length 401
Depth 48'
p Name SAME S.F. Total
z o Q Address Footprint S.F.
U4
City Phone
APPROVALS
FEES
u uJ
W
W Name Engr./Assess. Permit 466.00
_
Address Planner Surcharge 36.50
Z
W City Phone Council Plan Review 233.00
Bldg. Off. SAC
City 100.00
I hereby acknowledge that I have read this application and state that the Variance ,
SAC, MWCC 550.00
information is correct and agree to c ly wi I applicable State of Water Conn. 550.00
Minnesota Statutes and City f gan e
Water Meter
67.0
Signature of Permittee Road Unit 395-0
A Building Permit is issued to: FRONTIER MIDWEST HOMES Treatment P1 204.00
on the express condition that all work shall be done in accordance with all
applicable State of Minnesota Statutes and City of Eagan Ordinances.
I Parks
2
531.50
Building Official
l
-, IX
,Q11ti .jAj?
TOTAL
,
1988 BUILDING PERMIT APPLICATION - CITY OF EAGAN
SINGLE FAMILY DWELLINGS
INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS
NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS
IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED.
MULTIPLE DWELLINGS RENTAL UNITS FOR SALE UNITS # OF UNITS
INCLUDE 2 SETS OF PLANS, CERTIFICATE OF SURVEY - CHECK WITH BLDG. DEPT.,
1 SET OF ENERGY CALCULATIONS
COMMERCIAL
INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS,
1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS
To Be Used For: New Construction Valuation: $ 9'QD Date: May 4, 1988
Site Address 4134 Braddock Trail
Lot 51 Block 4
Parcel/Sub Stafford Place
Owner Stephen Kremer & Alma Zyvoloski
Addr13 Guthrie Way
City/Zip Code Apple Valley, MN 55124
Phon632-5438 or 831-1176
Contractor Frontier Midwest Homes Corp.
Address 3902 Cedarvale Drive
City/Zip Code Eagan, Minnesota 55122
Phone 454-9433
Arch./Engr. Phillips Plan Service
Address Apple Valley, MN 55124
14530 Pennock Ave.
-e
Phone #
432-2044
?«?po OFFICE USE ONLY
On site sewage Occupancy
MWCC system Zoning R -I
On site well Actual Const V-N
City water Allowable
PRV required # of stories
Booster Pump Length Ny
Depth y S
S.F. Total
Footprint S.F.
APPROVALS FEES
Engr/Assess Permit y 6 0
Planner Surcharge so
Council Plan Review Z3 3, 0o
Bldg. Off. 5/lo SAC, City o. o
Variance SAC, MWCC SSO.00
Water Conn s so,
Water Meter 69 , 00
Road Unit 3Z5,00
Treatment P1 DO
Parks
Copies
TOTAL ,3 .
GAMBR,t* MOO L-
R' /VlE'2/ZaOLO-SK/
Hedlund Engineering Services 9201 East Bloomington Freeway
Bloomington, Minnesota 55420
Land Surveyors Civil Engineers Land Planners Phone: 888-0289
Sit ores Certificate
BOOK PAGE
JOB NO. 88R- 163
SURVEY FOR: Frontier Midwest Homes Corporation
DESCRIBED AS:Lot 51, Block 4, STAFFORD PLACE, City of Eagan, Dakota County,
Minnesota and reserving easements of record.
ti
33 ?
-Ij
10 .*
1 o O
O
A°f'
n ?rwK 895.1
-
v I.asrew
891..E
33
46,33 i
FZ :5.33
/ j -
`? 117
/71
?.y 8°Io-' 4 O
K i ? $91,5 ?
997, ? s9 ? P.ep?d
14 Spht- ?
EnY.v1 O
to ---- ---- - - in15
/Y 89 °45' E g9t.v
TOP OF FOUNDATION
GARAGE FLOOR
BASEMENT FLOOR
SEWER SERVICE ELEV.
PROPOSED ELEVATIONS
EXISTING ELEVATIONS
DRAINAGE DIRECTIONS
DENOTES LOT CORNERS
= 898.2
=891.8
= ggs.o
=8a1.9-
:o
DENOTE 0 TdT • o
0
VEL)
?aiE? a
75 A3 o
1yL' r-RTNC: rl
SS -7
M0
W
894.
2z t...3
M JR.
891.5 ?? ? ? to
8N'.4 I O
N
CERTIFICATE OF SURVEY,
I hereby certify that this survey, plan or report was prepared by me or under my direct
supervision and that I am a duly Registered Land Surveyor under the laws of the
State of Minnesota.
Date: 4 / 11, / 3b
ren, License Nd. 14376
AAvnl?t?
EXTERIOR ENVELOPE AVERAGE "U" COMPUTATION KNe -wl Z X (o
OWNER Stephen Kremer & Alma Zyvoloski
SITE ADDRESS -41111 Rrar1dr,rk Trail. Fagan. MN
CONTRACTOR DATE i5-4-88 PHONE 454-0433
Determine working square footage of each.
1. Total exposed wall area ...... 2 Z $g.(oly sq. ft. x .1 1 1 "'55 1. S
2. Total roof/ceiling area ..... 1 U$ _ sq. ft. -x
Total exposed wall area above floor
e. Total wall framing area (average 1OA)...:........ _a a S. J310
f. Total net-mall area above floor ................. . _____
g. Total rim Joist area ............................ v48
a. Total wall window area ........................... a5•___
b. Total door area ................................. c. Total sliding glass door area .................... _zi&
_
d. Total fireplace wall area....... ........... d49
Total exposed foundation area = '1 .3 3
h. Total foundation window area...... .............
i. Taal net foundation area above grade ............ Z ,33
Determine "U" value of each wall segment.
a. 1 a5,7S X flu„ 35 = ?S
b. 3g.(oaZ X "U"
C y;a X „u„
d. y$ X "U" . Mo t-1.?8
e. e3 X-19 _ &, x "u»
?f • L (e J(c; $3 X "U" 03
g• I y $ X Bull eO (a = 5,35
h. X "U" _
i. -15.33 X fluff . t L4 _ S
3 .............. .....................Total =
If item #3 is the same as, or less than item #1, you have met the intent
of SBC 6006(c)2.
Total exposed roof/ceiling area JOSS
Total gross roof/ceiling area =
j. Total skylight area ................
k. Total roof/ceiling framing area .... lo. 'd.. .
1. Total net insulated roof/ceiling area.......
Determine "U" value for each roof/ceiling segment.
j. - X "lull
1 i2. Z?
k.- I X "U" 0 Z.
1. X "U .019 = 1 S . (
4 ..................................Total = 2
If total of 714 is the same as, or less than #2, you have met the intent of
SBC G006(c)l.
To utilized the total envelope system method, the values-established by the
sum of items #3 and #4 shall not be greater than the sum of items #1 and 722.
i. A5 i,7.c + 2. 27,ZR = 2'30'0T
3.-X Ck \' o3 + 4. 2= _..t1 t3
MATEaIALS Therm. Resistance "a"
Ext eriar Air - (1
Siding Mat erial .4 el
Sheathing 3/4"
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Interior Air . t
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7r--a C? ?TG. #? r Tntericr a i= film
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• 1 :Enter,-or a;--- film 0 63
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-
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lrtkir*** tatWflWtr:ttWXWtWt1tWWW*nxw+ararl *.Wss
APPLICATION FOR PERMIT : PAYMMT C M AT TIM of
APPLICMM WT COW ,*.
srritn'E APMVAL oE' PMWT. ,'?,
SEWER AND/OR WATER CONNECTION ± t Qa IF s mw Aen/c whm
*k INSTALLa wim wr m scmmm
t rIL M OUT MS BE 4 APPRat+E9.
qty of cagan
(P PRINT)
1) PROPERTY ADDRESS: .4134.Bra'ddock Trail, Eagan, MN
LEGAL DESCRIPTION: Lot.51,.Block 4, Stafford Place
.Lot B oc S vision or Tax Parcel ID
IF EXISTING STRUCTURE, DATE OF ORIGINAL BUILDING PERMIT ISSUANCE:
Mon ...Year
PRESENT ZONING/PROPOSED USE:
Q COMMERCIAL/RETAIL/OFFICE JJ R-1 SINGLE FAMILY
INDUSTRIAL [J R-2 DUPLEX ('t'wo Units)
Q. INSTITUTIONAL/GOVERNMENT El R-3 TOWNHOUSE (Three +.Units) ( Units)
R-4 APARTMENT/CONDOMINIUM ( Units)
2) a• IU NAME: Frontier Midwest Homes Corporation
ADDRESS: . 3902 Cedarvale Drive
CITY, STATE, ZIP: ..Eagan,.MN_ 55122
PHONE: 454-0433
For City Use
3) NAME: Saar Plumbing Plu-TEers License:
ADDRESS: .1018Mound Springs-Terrace Active
Expired
CITY, STATE, ZIP: . Bloomington, MN 55420 Notrecorded
PHONE: -884-4149 MASTER LICENSE # 3329
Init a
4)I ?aa'l'Si:
NAME: Stephen Kremer .& Alma Zyvoloski
ADDRESS: 14413 Guthrie Way
MN 55124
CITY, STATE, ZIP: Apple Valley,
PHONE: 432-5438 or 831-1176
5) , w s n r
CONNECTION TO CITY SEWER . CONNECTION TO CITY WATER OTHER
6) ?w (Soq?
******************* **********************************,*************************************
THE GOLD COPY OF THE PERMIT WILL BE SENT DIRECTLY TO PUBLIC ACS TO FACILITATE METER PICK-UP.
PLEASE ALLOW TWO WORKING DAYS FOR PROCESSING. SOMEONE FROM Tim CITY WILL CONTACT YOU IF THERE
* ARE ANY PROBLEMS.
FOR CITY USE ONLY
PERMIT # ISSUED
Pd w/Bldg. Permit FEES:
,--D $ SEWER PERMIT (INCLUDE SURCHARGE)
$ /t) S $ WATER PERMIT (INCLUDE SURCHARGE)
$ 7 o e $ WATER METER/COPPERHORN/OUTSIDE READER
$ $ WATER TAP (INCLUDE CORPORATION STOP)
$ $ SEWER TAP
$ f_ L?Z? $ ACCOUNT DEPOSIT - SEWER
$ ACCOUNT DEPOSIT - WATER
$ S $ WAC
$ (r?? C9 $ SAC
$ $ TRUNK WATER ASSESSMENT
$ $ TRUNK SEWER ASSESSMENT
$ $ LATERAL BENEFIT/TRUNK SEWER
$ $ LATERAL BENEFIT/TRUNK WATER
$_ ' ?/€ b n $ WATER TREATMENT PLANT SURCHARGE
$ $ OTHER:
$: Z • C"> $ TOTAL
RECEIPT # RECEIPT
DOES UTILITY CONNECTION REQUIRE EXCAVATION IN PUBLIC RIGHT OF WAY?
YES IF YES, THEN A " PERMIT FOR WORK WITHIN PUBLIC
NO ROADWAY" MUST BE ISSUED BY THE ENGINEERING
DIVISION
LIST
S
O
O
. NDITI
A
A C
N.
SUBJECT TO THE FOLLOWING CONDITIONS:
APPROVED BY:
TITLE:
DATE : // S7,
uf?
f 3 1tet t G.. `, fi'I?.v ???.. l- /..tt 'WENLEL MECHANICAL
Ntmt
wK ?? ^R 3600 Kennebec Drive
dress t C..lAMT- a) Eagan, MN b5122
HEAT LOSS CALCULATIONS DEPARTMENT OF INSPECTION`'
Wcatbcrstripa A
Guide Construction No. linsulation
isnflows Doors Reference Out. Wan lat. Wall Ceiling LRoof Floor Kind Now Applied
e1?o ( es- 0 19_
F] -I Room Length Width 1 He' ht FI.1 4 Rom Lsngth Width HaigM 8."
Windows and Doorsrack Be and Area Ln t'tath Net9 M No of Linul ft. Ana
W.-A-- a r racka`e and Area
•e. of p•ne of WM IIgM• of crack • fl.
Coef. Btu
nGltratioQ ? k O
:lau Z t.+...
ap. wall 's Z
lit cap. wall 21 ?D 3
nt. wall . 7 9
clung 1
lour 0
otal Btu.
,equired sq. ft. E.D.R. or sq. ini. W.A. Leader area ?a 4
Fl I Room Length ! Width 12- Height
Windows and Door --Crack aBe and Area
W1411 Height No. at Lineal it, Area
o. of pans of pane lights of crack
2 aq. rt.
1 /S
12.
Coef. Btu 11 thou p l 0 a
.lass
ap. wall
t4O
-et ra.p. wall
VOW
°'!io? !80 q 0 Q
loor
otol Btu.
equired sq. ft. E.D.R. or sq. ins. W.A. Leader area $ '-1
Fl Room I Length Width 8 Height
Windows and Doors-Cracka`e and Area
tau Nssght No. of Lineal h. Ana
of aan. of. ans u. w..
I_?
Coef.
ifiltration
Jass
sp. wail
let exp. wail
L. wall
tiling
loot
L_-
v
No. W14911%
of popope Haight
of na N. a1
11oht-o Iasal ft.
of crack Ar"
0.99.
Coef. Btu
Infiltration
Glass
Exp. wall
Net exp. wall
Int. wall
Ceiling (6 3 3
Floor
1 otal btu.
Required sq. ft. E.D.R. or sq
Fl.i yScI Room I L
Windows and Doors-Cra
width Holght H
No. or pan. of Dana huh
1 .?.%- C? v rxltl
Infiltration .
Glass
Exp. wall
WA. Leader area 3
Width Height
1 and Area
daoal rt. Ana
of crack sq. ft.
m-) 17,9 8 t3
19.3 2.0
lcftf. Btu
Ka ?5ti
17co . _
N.f .xp. wall
Int. wall
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ifis. WA. Leader area ' (o G
1 Fl. l_ i V Rom I Length I W Width l' s Height `30
Windows and Doom.-•Cracltage and Area
No. Width
of pate Haight
of pans, No. of
lights Llaa?1 16
of crack Ana
•a. It.
fv.
Coef. Btu
Infiltration Ny. O r1
Glass ?? !7
Exp. wall 2!0
Net exp. wan
lat. wan Lae ?
Ceiling
Floor . Z a
1i ..Was LOOM.
aq. it. E.D.R. Of sq. ins. W.A. Laadu area
Required sq, it. E I).R or sq. in, WA. Leader area
aft"t Z Of 2... {
Nstmn s
*34 dddretoa t
HEAT LOSS CALCULATIONS DEPARTMENT OF INSPECTION
Weatherstrips Guide Construction No.
JViadows Doors Reference Out. Wall Int. Wall Ceiling Roof Floor
e es- o 19_
j_F1. rya) Room Length 11 Width t:? Heistht II FI_I
Windows sad Doors-Crackage and Area I(,3
%a %Vldth
of pane Height
of pans Na. of
llghis Llnoal ft.
of crack Aria
sq. it.
d .a, 32 a {t Le
Coef. Btu
Infiltration 3 Z CIO ? .. $ p
Glass
T
l a o 0 0
wall
Esp. i
-
Net cap. wall I $
Int. wall
Ceiling 2.4
Floor
I olat J31 u.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area ? -? L'
j.I k LTLR O%kRoom Length 11 Width Height
Windows and Doors-Crackage and Area lie
No. Wide
of pone Height
of pans No. of
lights Llnsal ft.
of crack Arse
p. ft.
Coef. Btu
infiltration oZ t (ad _u o (p
Glass ( (- (o o
EAp. wall 88
Net gap. wall
Int. wall
Ceiling Z7
Floor
total tstu. I
Required sq. it. E.D.R. or sq. ins. W.A. Leader area D- c. a, 3
Fi. Room ILength 2(o Width d./ 0 Height
Windows and Doors-Crackage and Area
tYtdth Holght No. of Lineal It. Area
No. or pane of pane 111111141 of crack an, It.
2iq 11 • 8.0 26 410
Zito
Coef. Btu
Infiltratior? '1o
5 a.
Cl... __
76 v 3 9 a o
Esp. waU p$
Net sap. wall (o
tat. watt
Ceiling
floor -Al 04401 5 a.. o
Total Btu.
Required sq. it. E.D.R. or sq. ins. VA. Leader area 1 "I , 3 3 So
'WENLEL MECHANICAL
3600 Kennebec Drive
55122 ..
Eagan, ON
lnitilatian
Kiad How Applied
Room ( Length Width Height
wlnaows aao uoor?-a.racu ne atw wrea
No. Width
of pane Height
of pans No. at
11 hta Laos/ tt.
of crack Area
00. tt.
Coef. Btu
Infiltration
Gls
Esp. wall
Net exp. will
lat. wall
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq.ins. W.A. Leader area
FI.I Room I Length Width Hci ht
winnows aao Boors--e.racu ge aim r+rea
No. Width
of as HHght
of pone No. of
11 fit* Lineal tt.
Of Brack AHa
tt
coof. Btu
Infiltration
Glass
Esp. wall
Net tap. wall
lat. wall
Ceiling
Floor
Total Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
F1.1 Roost I Length Width
Windows and Doors- Crackage and Area
Coef
Infiltration
Glass .
Esp. wall
Net exp. wall
lat. wall
s ARA 1
Total Btu. f
Required sq. ft. E.D.R. or sq. ins. VA. Leader area
I Sss3
2006 RESIDENTIAL BUILDING PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
o69?
New Construction Requirements RemodeVReoair Requirements Office Use Only
3 registered site surveys showing sq. ft. of lot, sq. ft. of house; and all roofed areas 2 copies of plan showing footings, beams, joists Cet of Survey Recd - Y N
(20% maximum lot coverage allowed) 1 set of Energy Calculations for heated additions Tree Pres Plan Recd - Y N
2 copies of plan showing beam & window sizes; poured found design, etc. 1 site survey for additions & decks Tree Pres Required _ Y N
1 set of Energy Calculations Addition - indicate if on-site septic system On-site Septic System - Y _ N
3 copies of Tree Preservation Plan if lot platted after 711193
Rim Joist Detail options selection sheet (buildings with 3 or less units)
Minnegasco mechanical ventilation form
Date /y 116 /
Site Address (741
A-?? Construction Cost tr- I I -2 U3
f3 2 4_10 PO - k t' ci . ( Unit/Ste #
rh YJ S- r Z 3
Description of Work Cl ! d Q 03 /t- (?X o 4 C Q.i - C- k:24 2. +v /' c -r 5 cy
Multi-Family Bldg _ Y !-'N Fireplace(s) - 0 - 2
Property Owner
G ., el IF S,- g- S S 8 k
z ..? d Telephone # (`I TL)
Contractor r r, 4L
Address I
State vIa City
Zip Telephone # ( )
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Category I _ Minnesota Rules 7672
Energy Code Category . Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet
(/ submission type) Submitted Submitted
• 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?
Y - N If yes, date and address of master plan:
Licensed Plumber Telephone #
Mechanical Contractor Telephone # ( )
Sewer/Water Contractor Telephone # ( )
I hereby 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. es f the City of Eagan and the State of MN
Statutes; I understand this is not a permit, but only an application f a permit, and work is not to start without a
permit; that the work will be in accordance with the approv' pla in th requ res a review and
approval of plans.
Applicant's Printed Name Applicant's Signa ure
City of Eaall
Fax: (651) 675-5694 ------------------
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Permit #: y 17
Permit Fee:
?t?
FEB 2 6 20091
Date Received:
Staff:
- - - --------------
2009 MECHANICAL PERMIT APPLICATION
Date: Z I Z t'? L U " I ' Site Address: L4I S I 6 6_ e - ? C 1 O C" (- - V - ( n 1 I
Tenant:
Suite #:
Name: Phone: C05I - Z 1O - 2515
RESIDENT / OWNER
Address / City / Zip:
CONTRACTOR Name, Cc? YYyf ('} License
Address:t-'10OC) (-3l?f1a2?1?G? Je N 410
City: N .P,c_.) State: Zip: /Z
Phone.'VS-3' 9 5 1 0 Contact Person: G L) \S+'
TYPE OF WORK New 4 Replacement Additional Alteration Demolition
Description of work: \?1 Y f s ?) '(( _.-
NOTE: Both roof mounted and ground mounted mechanical equipment is required to
be screened by City Code. Please contact the Mechanical Inspector or one of the
Planners for information on permitted screenin ,methods...
RESIDENTIAL COMMERCIAL
PERMIT TYPE Furnace New Construction Interior Improvement
Air Conditioner Install Piping Processed
Air Exchanger Gas Exterior HVAC Unit
Heat Pump Under /Above ground Tank C_ Install / _ Remove)
** When installing/removing tank(s), call for inspection by Fire
Other Marshal and Plumbing Inspector
RESIDENTIAL FEES:
$50.50 Minimum Add-on or alteration to an existing unit (includes $.50 State Surcharge)
50 State Surcharge) 60
k
includes $
50 Fir
r
ir
l
t
li
d
t
t
b
d
$90
wor
, e
.
(rep
urne
app
ances,
uc
c.) (
e
epa
ace
ou
.
O TOTAL FEE
COMMERCIAL FEES:
$70.50 Underground tank installation/removal OR Contract Value $ x 1%
$50.50 Minimum (includes State Surcharge)
=$ Permit Fee
- If Permit Fee is less than $1,000, surcharge is $.50.
If Permit Fee is > $1,000, surcharge increases by $.50 for each =$ State Surcharge
$1,000 Permit Fee (i.e. a $1,001-$2,000 Permit Fee requires a $1.00 surcharge).
$ TOTAL FEE
I hereby acknowledge that this information is complete and accurate; that the work will be in contormance win me ordinances ane cones u Ulu idly u Cagai., alai
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 (12?6zu c6ti?
Applicant's Printed Name Applicant's signature
FOR OFFICE USE
Reviewed By: Date:
Required Inspections: Under Ground Rough In _ Air Test Gas Service Test _ In=floor Heat _Final,
Exterior HVAC Screening, Inspection
Use BLUE or BLACK Ink
r-----------------+
I For Office Use �
' � Permit#: � ,)�� �`� j
Clty of ����� _ -� —
� �
� Permit Fee: � ���� �
3830 Pilot Knob Road � �
Eagan MN 55122 � Date Received: �
Phone: (651)675-5675 I I
Fax: (651)675-5694 I Staff: �
I I
2015 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: Unit#:
� Name: Y t(I Y(� �C'�l��'ICl ((,Z Phone:_C��'� � — L/�j y-7.3� 5
Address/City/Zip: ���z'( (�YQ �t� c7��1 7'ti"�t� �CA�'j�.� /�� ����
Applicant is: Owner Contractor
Description of work: � U C7 �!/v o1
�
Construction Cost: `�J ��� Multi-Family Building: (Yes /No�
Company: Contact:
:� :
,.�
� Address: City:
x�= Q
�� - � ,_
,� ° State: Zip: Phone: Email:
$. License#: Lead Certificate#:
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 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:
` 1 _- , : : . �
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.qoqherstateonecall.ora
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 �v��v v� ��� ��G7 �� � � X t���°�3 ���
Applicant's Printed Name Applicant's Signature
Page 1 of 3
Use BLUE or BLACK Ink
r—————————————————+
i For Office Use �/��� I
C�� O� �1� n� � Permit#: v ,
� �' �d ' b�� �
� Perrnit Fee:
3830 Pilot Knob Road I I
Eagan MN 55122 � Date Received: �
Phone: (651)675-5675 I I
Fax: (651)675-5694 I Staff: I
I I
2015 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: Unit#:
�
� F
k Name: "'�s Phone:
������
����� � �: Address/City/Zip: L��3�/ ���%�`� �/�'d�41� ����
� � :
� �� Applicant is: Owner l/ Contractor
F �� � '" Description of work: �`�.� �Ld iy�'�
�'�'p���1�c�'�C�� �
r: Construction Cost: �� Multi-Family Building: (Yes /NcS-'"� I
„�� � Company ���� 1��'1CK�� �Y��Contact: ���1"'�
� � :
�� ; �i �� n+v ; �,p /�,,d� '�
� �:. � � ` Address: �� �'�?P,i1�9� �cc�, ��City: �'�✓il���a��,
�1'1��"+��#!?�'
� � �� State:�Zip:�„�;�I� Phone: �-���� Email: �����y�K,�y3� ` 'Grsy�,�
r� � � �
` �� License#: �G �.3%��� Lead Certificate#:
i
If the project is exempt from lead certi�cation, please explain why:
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 8�Water Contractor: Phone:
Fire Suppression Contractor: Phone:
` !�?����' �������!'�f`�I�c�r�th�f,yc���'���f�� ��� � �����'8���f�'r
�t�rt'��+����������aat�pt��#�����r���+�c���ea� �`��� ��
'' �„�., ,.,, _.. ,.. „��« �. ''. . �.,, '`:;�������., � ����'��'S��'@��, � ,''4���,...�,?
: ��
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.ora
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 Rermit, 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 iss nce.
x ��../ �`/�"�� X _.
Ap ic nt's Pri ted Name Applicant s �gnature
Page 1 of 3
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA151010
Date Issued:08/03/2018
Permit Category:ePermit
Site Address: 4134 Braddock Tr
Lot:51 Block: 4 Addition: Stafford Place
PID:10-72500-04-510
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Water Softener
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.
Allow an 18" minimum radius clearance to the water meter from all appliances (i.e. furnace, water heater, water softener).
Fee Summary:PL - Permit Fee (WS &/or WH)$59.00 0801.4087
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 -
Randy T Feld
4134 Braddock Tr
Eagan MN 55123
(651) 270-5994
Bruckmueller Plumbing Inc
3992 Pennsylvania Ave
Eagan MN 55123
(651) 686-6696
Applicant/Permitee: Signature Issued By: Signature