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1931 Berkshire Dr
CITY OF EAGAN WATER SERVICE PERMIT 3830 Pilot Knob Road P. O. Box 21199 PERMIT NO.: - Eagan, MN 55121? . Zoning a No. of nits: Owner: Address: TE' . ^ i bite Address: inn : ~iv~ L1 ~tPlumber. gixro ~ i b SD Meter No.: 17 A Connection Charge: Account Deposit: 1. 5.0ut~~i Sim: 10.OOnd r No.: / L.2 Y7 3- 7 Permit Fee: . 50pd 1 to amply whim the City of apes Surcharge: ~ oNisarae. Misc. Charges: 00 D t:,Y Total: BY Date Paid: Date of Insp.: ~i7 6 S Insp.; CITY OF EAGAN SEWER SERVICE PERMIT 3830 Pilot Knob Road 7 31 P. O. Box 21199 PERMIT NO.: Eagan, MN 55121 DATE: Zoning: No. of Units: 1 Owner: To ^ e ? s _ i j _ Address: Site Address: 1931 Berkshire Drive L 3 >er shire Ponds Plumber Plymouth : aim. in't" 7r P793 5' :r" SX 1 agree to campy with the City of Eagan Connection Charge: 425.00 pd oraioamose. Account Deposit: 15.00vd Permit Fee: Surcharge: _ r{` By Misc. charges: Date of I nsp.: Total: Insp.: Dote Paid: ! CITY OF EAGAN WATER SERVICE PERMIT 3830 Pilot Knob Road 4 P. O. Box 21199 PERMIT NCB.: Eagan, MN 55121 DATE: 1 Zoning: 1 No. of Units: Owner: Address: Perk lire Drive L1 31 i,Qr?:shire Ponds Site Address: Plumber. n 1 uml., in g' Meter No.: Connection Charge: Pu Size: Account Deposit: 15,00pd Reader No.: Permit Fee: 10.00pd 1 agree to comply with the City of Eagan Surcharge: ° pd ordimanae. Misc. Chorges: 132.00) pd Total: x'3.00 pd Eeter By Dote Paid: Date of Insp.: Insp.: h6/B1 -,-REACTIVATED FOR DECK SAUMALY XAYXANAVONGPHET CITY OF EAGAN 4 5 2 - 8 5 7 6 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454.8100 BUILDING PERMIT Receipt # ire be wed far Est. Valor Date 19 Site Address Erect ❑ Occupancy Lot Black /Sub. ReModet C3 Zoning - Sec Parcel No Repair 11 Type of Const. No. Enlarge ❑ No. Stories Move ❑ Length Namti1 Demolish ❑ Depth Addresi Grade ❑ Sq. Ft. City Phone Install ❑ Approvals Fees Name Assessment Permit Address Water b Sew. Surcharge City Phone Police Plan Review Name Fire SAC 19 Address Eng. Water Conn. <W City Phone Planner Water Meter Council Road Unit I hereby acknowledge that I have rood this application and state that Bldg. Off. the information is correct and agree to comply with all applicable APC Total State of Minnesota Statutes and City of Eagan Ordinances. Var. Date Signature of Pe"ni tes A Building Permit Is Issued to: on the express condition that all work shall be done in accordance with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Building Official Permit No. Parmh Holder Dane Tsls hone it Plumbing H.VA.C. ~L: C~ h~ r~\i I ` 5 7 ~C ,~p22 Electric 54SL2,5-1,Lb. Softener Inspection Date Insp. Other Footings Foundation Framing ~D iY5 Ao Roofing Rough Plbg. Rough HVAC Insulation Final Pibg. _ Final HVAC Final COVOoc. p' ItJ~ Water Describe Location: Mllsll Sewer Pr. Disp. CITY OF EAGAN Remarks - Addition BERKSHIRE PONDS Lot 1 Blk 1 Parcel 10 13750 010 01 Owner ► L' ' Street 1931 Berkshire Drive state 55J,~ 3 Improvement Date Amount Annual Years 8 Payment Receipt Date STREET SURF. arI 1982 238.93 23.89 10 143-37 A015792 -1 -8 STREET RESTOR. iggg 123-81f) 9-25 IS 115-55 GRADING ~r rr SAN SEW TRUNK 1982 176.28. 11.75 15 129.12 SEWER LATERAL 1982 3.83 15 2.00 ~r rr rr n * 42Z-.88 28.5$~5 399.36 WATERMAIN 105 1982 46.43 3.10 33.81 * WATER LATERAL 1985 WATER AREA 1982 176.28 11.75 15 129.12 STORM SEW TRK 198 i8r)-m 25-67 359-37 'r rr STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. rr rr BUILDING PER. SAC 595 no PARK Cities Di , ital Quality Control The following image represents the best available image from the original page. Every effort was made to capture the content from the original page. Receipt PLUMBING PERMIT Permit No.~ CITY OF EAGAN Fee f a \ Fill in numbered spaces S/C Type or Print legibly Tot. 1. Date 2. Installation Cost 3. Job Address Lot Blk. Tract-- 4. Owner 5. Contractor Phone 6. Address 7. City State Zip 8. Building Type: Residential ❑ Commercial ❑ Institutional ❑ 9. Work Description: New ❑ Add ❑ Alter ❑ Repair ❑ 10. Describe 11. No. Fixtures No. Fixtures Water Closet Cesspool/Drainfield Bath tubs Septic Tank Lavatory Softner Shower Well Kitchen Sink Urinal/Bidet Other Laundry Tray Floor Drains Drinking Ftn. Slop Sink Gas Piping Outlets 12. 1 hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed: for Rough Final Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OREAGAN 454,8100 Receipt MECHANICAL PERMIT Permit No. _ CITY OF EAGAN Fes J 1( Fill in numbered spaces S/C Type or Print legibly Tot. 1. Date 2. Installation Cost 3. Job Address _ ; ~r't 1Jr I ~,Wt:_Blk. _L- Tract 4. Owner > , r i~ 5. Contractor Phone ; 6. Address U 1 . ; k , 7. City t- State zip 8. Building Type: Residential ❑ Commercial ❑ Institutional ❑ 9. Work Description: New ❑ Add ❑ Alter ❑ Repair ❑ 10. Describe Fuel Type 11. No. EQuipment BTU - M. Ea. No. Eauiament CFM Forced Air Air Handling: Mfg Boilers Mfg. Mech. Exhaust ' Unit Heater Mfg. Other Air Cond. Mfg. Gas, Piping Outlets 12. 1 hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : - for Rough Final Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 464-8100 Receipt PLUMBING PERMIT Permit No. CITY OF EAGAN Fee Fill in numbered spaces S/C Type or Print legibly Tot. 1. Date 2. Installation Cost 3. Job Address % Lot Blk.' Tract 4. Owner J r 1. 5. Contractor Phone 6. Address 7. City State Zip B. Building Type: Residential ❑ Commercial ❑ Institutional ❑ 9. Work Description: New El Add ❑ Alter ❑ Repair ❑ 10. Describe 11. No. Fixtures No. Fixtures Water Closet Cesspool/Drainfield Bath tubs Septic Tank Lavatory Softner Shower Well Kitchen Sink Urinal/Bidet Other Laundry Tray Floor Drains Drinking Ftn. Slop Sink Gas Piping Outlets 12. 1 hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : for Rough Final Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 4548100 REQUEST FOR ELECTRICAL INSPECTION EB-OOWI-04 ' See ie_sto=tions for corrmleting this form on back of Yellow copy. f~ ":R" Below Work Covered by This Request Add Rep. Type of il0ing Aaefm.. Wired Eaeipnwnt Wired Home Range Temporary Service Duplex Water Heater Lighting Fixtures Apt. Building Dryer Electric Heating Commercial Bldg. Furnatl Silo Unloader Industrial Bldg- Air Conditioner Bulk Milk Tank Farm Other mr.1 Iher ISaeofyl t r Soccify Other Other Compute Inspection Fee Below N Pea Service Entmrtce Size a Fee Feeders/suhfeeders H Fee Circe:[. j in 0 to 200A s Oto 30 Amps o`Z Oto 30 Am Above 200 Amps 31 to 100 Amps y' 31 to 100 q Swimming Pool Above 100_A - Above 100_Anys Transformers Irrigation Boors Partiab'Other Fee Signs Special Inspection S 4/0, tr~TOTAL FEE flem~rks Rough-m Dale the ElectrAv 'F /0 8S Irrapactor" hceDify ,M, Final vllirttc ion ha/ 1Marepuest vaitl l8 mongs from - This request void 18 months fr= ` Request Date Fire No. Rough-in Inspection aired? ]Ready Now WdI Notify. Inspec- Yes ❑NO for When Ready Licensed Electncal Contractor 1 hereby request inspection of above 190iome, electrical work installed at: Street Address, Box or Rou3~33eNo. 9 3J . Git 0'%. 4e A64n ecu On O. Township Name or No. Barge No. C yj~ OCcc nt (PRINT) Ph N Po SupDller Addressp Electncal Contractor (Company Name) Conlractor•s License No. ailing Address ontractor or Owner M.Okirg Irtstailation) z Auth ¢ed Signa r (Co tractor ner Making r s nation) Pbone Number sa -~~U MINNESOTA STATE BOARD r, ELECTRICITY BE THIS ACCEPTED By INSPECTION THE REQUEST STATE HOARD N-tSl 1821 WILL NOT Griggs-Midway Bldg. , Room , UN UNLESS PROPER INSPECTION FEE IS Pnonn (6121297.2111 sAve., St. Paul, MN 551 W ENCLOSED. f CITY OF EAGAN N2 10 0 9 7 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 4548100 BUILDING PERMIT Receipt # SF DWG/GAR list.Value $68,000 Date APRIL 15 L985_ Te be and Fee Site Address 1931 BERKSHIRE Erect ® Occupancy R3 Lot 1 Block -1 Ses:/Sub. BERKSHIRE PONDSRemodel ❑ Zoning R1 Repair ❑ Type of Cont. V Parcel No. Enlarge ❑ No. Stories JOE MILLER CONST Move ❑ Length 40 W Name Demolish ❑ Depth 46 z Address 18133 CEDAR AVE Grade 11 Sq. Ft. City FARMINGTOD~hone 431-2001 Install O o SAME Approvals Fees Name Z~ Address Assessment Permit ^00 City Phone Water R Sew. Surcharge 34.50 Police Plan Review 168.50 .t= Name Fire SAC 921-00 16 Address Eng. Water Conn. 10.0....00 <W City Phone Planner Water Meter n0 Council Road Unit 9 R n n 0 1 hereby acknowledge that I haw read this application and state that Bldg. Off. 4/15/85 T. P . 132.00 the information is correct and agree to comply with all applicable APC Total $9 _ ndn nn State of Minnesota Statutes a ity of Eagan Ordinances. -r- ~ Var. Date Signature of Penmit ww ~G A Building Permit Is issued to: JOE M LLER CONS ' an the express condition that all work shall be done in accordance with all a bla St o In ato„ Statutes rd City of Eagan Ordinances. Building Official ` e 2/84 CITY OF EAGAN (llu APPLICATION FOR PERMIT SEWER AND/OR WATER CONNECTION (PLEASE PRINT) 1) PROP= ADDRESS: zvl3/ /✓C~j1// c LEG.=S. DESCRIP'PICV: _ I (LCt/Block/Suncivi.sicn or Tat Parcei I.D. Nurzer) IF W:IS='.:v c^o ^;o DA's OF OZ zGI`IA -.iiILr, .,I: T ) d:C'??,..., rw :.,r.., p=-'-11T PFIEM. ' 2 TX /P?OFOS US : ❑ R-1 M-. F'PyIILV ❑ R-2 DTJJPT . (IS:-0 L^'ITS ) ❑ R, 3 'I - CU7SE (T=- L~iTS) ( TT42=-2) E3 ?~4 UN IT ❑ CCi•1•~:CL~.L/RLTAIL~CFF'ICE ❑ 1'DUSi?T1L ❑ INSTI'^,'_^IC AL/GG'=RNN >z 7 2) APPLI -,m ~Jy PLEASE PN I:ii) NAP-T:7tlG ADDRESS: LR133 (°c~•a< CIT`_', MATE, ZIP: j 141p yrSo,2 Sl PHONE: 1131- 200/ 3) PLL?T.T~'? (PLEASE PNINT) _ FOR CITY USE ONLY NIME: A-.0wo"V /)4l'"/ii ✓ PLUMBERS LICENSE: ADDRESS: /'l. 2.8 a3 RD ,Qum .y Active CITY, STATE, ZIP: 14215 /yjy SYY/ Q Expired Twair. C Not of Record PHONE. Sk7-3675 PLUMBcER LICENSE N ,~2p65 *Y arr nicia 4) OCC.UT..A=/Cr:TIER NAME: (PLEASE PRINT) : ADDRESS. S4w• .45 cz;~ CITY, STATE, ZIP- PHONE- 5) INDICATE WHICH PERMIT IS BEING REQUESTED: CC:NELTION TJ CITY SEWER ❑ CONNECTION TO CITY WATER ❑ OMER (PLEASE DESCRIBE) 6) 13DiG, - G'Z: U!LPLE.-,SE HOLD APPROVED PERMIT FOR-PICK-UP BY ONE OF AECUT - ❑ PLE SE MAIL APPROVE?) PER'-LIT TO 1, 2, 3, 4 ABOVE (Circle one) 7) SIC..A7,RE: -~c+~i~~oteQi~ DATE: ~ waae..w~a:,ssa eaE~gata: s~v:~:aat~ s sss~~a:..e :w~.~s~~+~ r ~~i`aec¢~~ F O R C I T Y U S E O N L Y PERMIT ISSUED FEES: $ /49. ~G SE:"ER PERMIT (I_`?CL':)E SURC: '1RCE . ) $ /~O•~ WATER PERUtT_T (INCLUDE SURCHARGE) $ ot~ WATER METER/COPPERHORN/OUTSIDE READER $ WATER TAP (INCLUDE CORPORATION STOP) $ SE;vER TAP $ / u ACCOUNT DEPOSIT - WATER $ WAC $ Sas vv SAC $ TRUNK WATER ASSESS:IE'7T $ TRUNK SEWER ASSESS:IENTI $ LATERAL BENEFIT/TRUNK SEl"ER $ LATERAL BENEFIT/TRUNK WATER $ / j z) OTHER $ TOTAL $ °U AMOUNT PAID/RECEIPT DOES UTILITY CONNECTION REQUIRE EXCAVATION IN PUBLIC RIGHT OF WAY? C] YES IF YES, THEN A "PERMIT FOR WORK WITHIN PUBLIC ROADWAY" MUST BE ISSUED BY THE / - NO ENGINEERING DIVISION. LIST AS A CONDI- TION. SUBJECT TO THE FOLLOWING CONDITIONS: APPROVED BY: TITLE: DATE: ~j ~sw~w.~wrE~wwww~w~alwwR+~+~w~~wwwaw~wW"R~Pam" fwwm 77 x 1985 BUILDING PERMIT APPLICATION - CITY OF EAGAN NOTE: ALL CONTRACTORS MUST BE LICENSED WITH THE CITY OF EAGAN INCLUDE 2 SETS OF PLANS 3 CERTIFICATES OF SURVEY 1 SET OF ENERGY CALCULATIONS To Be Used For: Valuation: l Date: ~/D 9S Site Address: AW 601ele -'L& OFFICE USE ONLY Lot: Block Sect/SuQ~&Ee4g X Occupancy R-3 Remodel Zoning Q-I Parcel # Repair Type of Const S[ Enlarge # of Stories Owner Move Length 40 Demolish Depth 44- Address Grade Sq Ft City/Zip Code Phone APPROVALS Contracto Qj Assessments Permit Water/Sewer Surcharge 50 Address Police Plan Review 1; Fire SAC 5Z5. City/Zip Code Engr Water Conn 5GY3.°- /Planner Water Meter (03. m Phone Council Road Unit ZOO-= Bldg Of ,sue arks Arch./Engr. APC Treatment Pl 13Z•°° Variance Address TOTAL City/Zip Code Phone # 0-* 337-+ 34-5+ 168.5+ 525-+ 500• + 63-+ 280* + 132,+ 2>040• * • / ROBE CONSULTING ENGINEEAS ENGINEERING PLANNERS and LAND iURMORS COMPRNY, INC. 1000 EAST 146M STREET, BURNSVILLE. MINNESOTA 35337 PH 4323000 cer"'FZf Z CCZ~ d'~~ Z.ev4l .0eocrIggion: L07 1, BLOCK 1, BERKSHIRE PONDS, OAKOTA COUNTY, MINNESOTA r DRAINAGE AND - 30 FRONT BUILDING (4p UTILITY EASEMENT SETPACK LINE \ \ W O 9 z~5) N 84° 40 42 "W 930 2 ~z5 3z. ' 84.85"~ NORT1 i ~2 Zi ~n u, h 0 SCALE I"= 50' D D `I r~ 10 I 'V - n !g3o,o~ DE?,IOTES EXISTING Ip,? I LOT ELEVAT\ON F1 _ N - / (930.0) DEVOTES PROPOSED aW 45 ~3 0SE~o i~j ELEVATION N ppa 40o ( 3 = S p htoPDSeil O --w- 11 O INDICATES DIRECTION OF I ~1 m House SURFACE DRAINAGE m m I- "w~cNESSa" m I- O n ---I I ~.0 11 FUSHEC GARAGE FLWR I 4.aa v1 __I 1253 /4• /a ~+~6E a ELEVATION = `t ~c} 33 -I d :4.o.o .~31.w z3.34 - 434.0 10 5 3151 (~{3Z.5) 84.09 N 89° 40' 4e W 9 q3! I~~ BERK5HIRE DRIVE I o VON I hereby certify that this is a true and correct representation of a tract of land as shoxn'and described hereon." As prepared by me on this 17T9 day of Q.o+ , 19 85 . Ninn. Reg. No. le-o CITY USE ONLY a L BL/J nL RECEIPT#: SUBD. L~[.IQr'C^'~ r~.~•.. RECEIPT DATE: 1998 PLUMBING PERMIT (RESIDENTIAL) CITY OF KAGAN 3830 PILOT KNOB RD EAGAN, MIN 55122 (612) 681-4675 Please complete for: ➢ single family dwellings ➢ townhomes and condos when permits are required for each unit ➢ backflow preventer for underground sprinkler system All, FIXTURES EACH # TOTAL Shower 3.00 X = Water Closet 3.00 x = Bath Tub 3.00 x = Lavatory 3.00 x = Kitchen Sink 3.00 X = Laundry Tray 3.00 X = Hot Tub/Spa 3.00 x = V. te7-Heater 3.00 x -L- _ Floor Drain 3 00 x = Gas Piping Outlet * minimum -1 3.00 x = Rough Openings 1.50 X, _ Water Softener * for dwellings under construction 5.00 X = Water Softener * for existing dwelling 20.00 X = U.G. Sprinkler * for dwelling under const. 3.00 = U.G. Sprinkler * for existing dwelling 20.00 = Alterations * to existing residence 20.00 = Water Turn Around 20.00 = Private Disposal System * MPC lic. 75.00 = (new and refurbished systems) Private Disposal Systems * Abandonment 20.00 = RPZ (new installation only) 20.00 = STATE SURCHARGE .50 TOTAL C>eu - - I hereby aGcnowledge that I have read this application, state that the information is correct, and agree to comply with all applicable City of Eagan ordinances It is the applicant's responsibility to notify the property owner that the City of Eagan assumes no liability for any damages caused by the City during its normal operational and maintenance activities to the facilities constructed under this permit within City property/right-of-way/easement. SITE ADDRESS: /9Uj 6~cxta,41,, -'z D~iy< OWNER NAME: 6c`Ht! ~7tn ¢7W INSTALLER NAME: A7,e-w TELEPHONE eS -Jr- STREET ADDRESS:.Vdl) L'fih~®~s✓ a/1 ~/u~ n` ~6 CITY STATE: IP: SIGNATURE F PERMI CD/PERMIT FORMS/RPLBG PERMIT (RES) - 1998 u ity of eagan 3830 PILOT KNOB ROAD. P.0 BOX 21199 BEA BLOMQUIST EAGAN. MINNESOTA 55121 - Magw PHONE. (612) 454-8100 THOMAS EGAN JAMES A SMITH MC ELUSON THEODORE WACHTER Council Members THOMAS HEDGES ary ar~,n~mm« EUGENE VAN OVERBEKE aN ae CERTIFIED MAIL - RETURN RECEIPT REQUESTED April 29, 1987 MS SAUMALY XAYXANAVONGPHET 1931 BERKSHIRE DR EAGAN, MN 55122 RE: DECK PERMIT FOR 1931 BERKSHIRE DR EAGAN, MN 55122 LOT 1, BLOCK 1, BERKSHIRE PONDS Dear Ms Xayxanavongphet: On April 28, 1987, a final inspection of the above referenced deck was performed, wherein we found several violations of the City building codes. It was noted that an inspection was made on 9/10/86, a correction notice was left with you, and to date none of the violations from this correction notice have been corrected. This is to notify you that the deck is not structurally safe and should not be used until the corrections are made and you have notified our department so we can reinspect. A list of code violations and a copy of the City of Eagan's requirements on deck construction are enclosed. If you have any questions concerning the necessary corrections, please feel free to call me at 454-8100. Sincerely, Ernie Aden Building Inspector EA/js THE LONE OAK TREE... THE SYMBOL OF STRENGTH AND GROWTH IN OUR COMMUNITY CODE VIOLATIONS FOR DECK AT 1931 BERKSHIRE DR. 1. Joist spacing shall not exceed 24" on center, existing joists are spaced anywhere from 42"-50" on center. 2. Beams carrying joists from both directions shall be doubled. (2 - 2x8.) 3. Joist hangers shall be nailed (in all holes) with joist hanger nails. 4. Rim joist needed against house and shall be lag screwed to house. 5. Cantilevered upper deck needs support on corner. 6. Each step of stairways shall be the same height (maximum - 8".) 7. The tread or step of stairways shall be not less than 9" - presently only 5 112". 8. One joist spliced, by lapping two short pieces shall be replaced. 9. Joist butted together using truss plates shall have a letter of approval (from truss plate manufacturer.) 10. Spacing of vertical parts of guardrail shall not exceed 6". 11. Stairways, if over 30" in height above grade shall have handrails. RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB B RD RD - 55122 651-681.4675 lew Construction Requirements RemodellReoair Requirements 3 registered site surveys showing sq. ft. of lot, sq. ft 0 house; and all roofed areas • 2 copies of plan (20% maximum lot coverage allowed) • 1 set of Energy Calculations for heated additions 2 copies of plan showing beam & window sizes; poured found design, etc.) • 1 site survey for extenor additions & decks 1 set of Energy Calculations • Indicate if home served by septic system for additions 3 copies of Tree Preservation Plan if lot platted after 711/93 Rim Joist Detail options selection sheet (bldg(s with 3 or less units) )ATE (ll 1 VALUATION 1600-010 IOB SITE ADDRESS !l` A ~~~KSkIi~E 112 MW~X 4Z F MULTI-FAMILY BUILDING, HOW MANY UNITS? V Ie 'ROPERTYOWNER LGuc-A BA +}6fiNG YPE OF WORK RCCF FIREPLACE(S) _0 X1 _2 _3 kPPLICANT Loucn RA 44(pAIJG PHONE # 6S4 GRG ZO-q- %DDRESS 4934 BJEP 49-14',F-E- DR ZIPCODE 'AGER # CELL PHONE # FAX # NEW RESIDENTIAL BUILDING ONLY - FILL OUT COMPLETELY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 (check one) - Residential Ventilation Category 1 Worksheet Submitted - Energy Envelope Calculations Submitted MINNESOTA RULES 7672 - New Energy Code Worksheet Submitted Plumbing Contractor: Phone Plumbing System Includes: Water Softener Lawn Sprinkler Fee: $90.00 Water Heater No. of R.I. Baths No. of Baths Mechanical Contractor: Phone # Mechanical System Includes: Air Conditioning Fee: $70.00 Heat Recovery System Sewer/Water Contractor: Phone # 111 above information must be submitted prior to processing of application. hereby acknowledge that I have read this application, state that the information is correct, and agree to comply with 711 applicable State of Minnesota Statutes and City of Eagan Ordinances. Signature of Applica^t'~- :ertificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 1101 OFFICE USE ONLY 7 01 Foundation ❑ 07 05-plex ❑ 13 16-plex ❑ 20 Pool ❑ 30 Accessory Bldg 3 02 SF Dwelling ❑ 08 06-plex ❑ 16 Fireplace ❑ 21 Porch (3-sea.) ❑ 31 Ext. Alt - Multi 3 03 01 of _ plex ❑ 09 07-plex ❑ 17 Garage ❑ 22 Porch/Addn. (4-sea.) ❑ 33 Ext. Alt - SF 7 04 02-plex ❑ 10 08-plex ❑ 18 Deck ❑ 23 Porch (screened) ❑ 36 Multi ] 05 03-plex ❑ 11 10-plex ❑ 19 Lower Level ❑ 24 Storm Damage 3 06 04-plex ❑ 12 12-plex Plbg_Y or- N ❑ 25 Miscellaneous 7 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 7 34 Replacement *Demolition (Entire Bldg only) - Give PCA handout to applicant /aluation Occupancy MC/ES System ;ensus Code Zoning City Water 3AC Units Stories Booster Pump Jbr. of Units Sq. Ft. PRV Jbr. of Bldgs Length Fire Sprinklered -ype of Const Width REQUIRED INSPECTIONS - Footings (new bldg) _ Final/C.O. - Footings (deck) Final/No C.O. - Footings (addition) _ Plumbing Foundation _ HVAC _ Drain Tile Roof Ice & Water Final _ Other Framing - Pool _ Figs _ Air/Gas Tests _ Final Fireplace _ R.I. -Air Test -Final - Siding _ Stucco _ Stone Insulation Windows (new/replacement) Approved By , Building Inspector - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 3ase Fee surcharge 3lan Review AC/ES SAC ;sty SAC Hater Supply & Storage >&W Permit & Surcharge -reatment Plant Numbing Permit Aechanical Permit Jcense Search ;opies ether i otal rraa y RESIDENTIAL U6~5 I BUILDING PERMIT APPLICATION 1 CITY OF EAGAN 3830 PILOT KNOB -55122 I r~✓ New Construction Requirements RemodetfReoair Reouiremen s • 3 registered site surveys showing sq. ft. of lot sq. f4 of house; and all roofed areas 2 copies of plan (20% maximum lot coverage allowed) • 1 set of Energy calculations for heated addhons • 2 copies of plan showing beam & window sizes; poured found design, etc.) 1 site survey for exterior addihons & decks 1 set of Energy Calculations • Indicate if home served by septic system for additions • 3 copies of Tree Preservation Plan If lot platted after 711193 • Rim Joist Detail options selection sheet (bldgs with 3 or less units) DATE 23- 13-0 J VALUATION 4'q515199 JOB SITE ADDRESS 3) be-_'S b\' ~ 'DC IF MULTI-FAMILY BUILDING, HOW MANY UNITS? PROPERTY OWNER_ Cz1r C,~Z~`~~ TYPE OF WORK ~2K C~U~r FIREPLACE(S) X 0 _ 1 2 APPLICANT Re^CO& {gVY1ErICQ CbC~~~UfiL6Y1 _ PHON0953 eM5490 ADDRESS 95M Ljn"e Irv S ZIPCODE 55uao PAGER # CELL PHONE # C0\,(~- 2I&_7gSo FAX #qsa 91in S NIEW RESIDENTIAL BUILDING ONLY - FILL OUT COMPLETELY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY I (check one) Residential Ventilation Category 1 Worksheet Submitted Energy Envelope Calculations Submitted _ MINNESOTA RULES 7672 New Energy Code Worksheet Submitted Plumbing Contractor: Phone Plumbing System Includes: Water Softener _ Lawn Sprinkler Fee: $90.00 _ Water Heater _ No. of R.I. Baths No. of Baths Mechanical Contractor: Phone # Mechanical System Includes: _ Air Conditioning Fee: $70.00 _ Heat Recovery System ~ ~ ~ n nn Sewer/Water Contractor: Phone a All above information must be submitted prior to processing of application. ~RY I hereby acknowledge that I have read this application, state that the inf rmation is correct, and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordi nces. Signature of Appli ant Certificates of Survey Received _ Tree Preservation Plan Received _ of Required _ Updated 1/01 OFFICE USE ONLY ❑ 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 0 10 08-plex ❑ 18 Deck ❑ 23 Porch (screened) ❑ 36 Multi ❑ 05 03-plex ❑ 11 10-plex ❑ 19 Lower Level ❑ 24 Storm Damage ❑ 06 04-plex ❑ 12 12-plex Plbg_Y or - N ❑ 25 Miscellaneous ❑ 31 New ❑ 35 Int Improvement ❑ 36 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 only) - Give PCA handout to applicant Valuation Occupancy MC/ES 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 Width REQUIRED INSPECTIONS - Footings (new bldg) _ Final/C.O. - Footings (deck) _ Final/No C.O. - Footings (addition) _ Plumbing _ Foundation _ HVAC _ Drain Tile Roof _ Ice & Water _ Final _ Other Framing _ Pool _ Ftgs _ Air/Gas Tests _ Final Fireplace _ R.I. - Air Test - Final _ Siding _ Stucco _ Stone Insulation _ Windows (new/replacement) Approved By Building Inspector Base Fee Surcharge Plan Review MC/ES SAC City SAC Water Supply & Storage S&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total Use BLUE or BLACK Ink r For Office Use l Permit ROD City of EaRd I Permit Fee: 3830 Pilot Knob Road I I Eagan MN 55122 Date Received: Phone: (651) 675-5675 wt-s I I Fax: (651) 675-5694 I Staff: I JUN U 5 2011 2012 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: Unit Name: wl l U-MXA 1,54ww, Aw Phone: RESIDENT / OWNER Address/City/Zip: 1ch)l I<t ten, A1 -DI-21 Applicant is: Owner X,_ Contractor TYPE OF WORK Description of work: 1~0 last... QctiU Iwo Construction Cost: 12-04 404 Multi-Family Building: (Yes / No ) Company: C lrbnvvi Z Contact:.x7i!.&M CONTRACTOR Address: ' Z C) u,<r City: 5 - State: A- Zip: Phone: 2 9 Z ` `f License #:-20W 5-(~(,? Lead Certificate AIA-T ---ng to 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 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 they 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.gopherstateonecall.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. I Applicant's Printed Name Applicant's Signature Page 1 of 3 DO NOT WRITE BELOW THIS LINE SUB TYPES ~~~1 fz2~s~l</ 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 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 Framing Siding: -Stucco Lath -Stone Lath -Brick 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 MCES SAC A City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies TOTAL Page 2 of 3 Use BLUE or BLACK Ink For Office Use i tan I f Ent, I Permit : alt y o Permit Fee: I ZZ' 3830 Pilot Knob Road S l Eagan MN 55122 RECEIVED ~ Date Received: I f I Phone: (651) 675-5675 Fax: (651) 675-5694 JUN U 5 2012 staff 2012 RESIDENTIAL BUILDING PERMIT APPLICATION 'v A~ Date: Site Address: Unit 16 Name: IBM V OW'11 ~ /.uG/ ~►art Phone: RESIDENT / OWNER Address/ City / Zip: 'L Applicant is: Owner Contractor TYPE OF WORK Description of work: ®&M. ~t~~-frame r49.,00- e,,A- ~tl Ng.662 c;U k-13 Construction Cost: Multi-Family Building: (Yes / No ) Company: A11 JmkrA ` rZe:f 2 Contact: CONTRACTOR Address: g1Ca -Y'CSW~'r C2Rity: ~ 9 Z State: AQJ Zip: Phone: Q License 106 26 Lead Certificate If the project is exempt from lead certification, please explain y: (see Page 3 for additional information) L ( 4,1, 6~ / q CN 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.ciopherstateonecall.org a I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and odes 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 an'I SCI I /1 `m ~yyL x Applicant's Printed Name App cant's Signature Page 1 of 3 DO NOT WRITE BELOW THIS LINE /DIU SUB TYPES /93) U-zrk,s), Dr _ Foundation _ Fireplace ` Porch (3-Season) _ Storm Damage _ Single Family _ Garage _ Porch (4-Season) _ Exterior Alteration (Single Family) Multi L* 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 T Water Damage Retaining Wall *Demolition of entire building - give PCA handout to applicant DESCRIPTION Valuation AeW (,al;) Occupancy ;Cke, - MCES System Plan Review / Code Edition ;L_2 SAC Units (25%_ 100%--!!,-) Zoning City Water Census Code '-13Y Stories Booster Pump # of Units J Square Feet :Z l PRV # of Buildings Length 3 Fire Sprinklers Type of Construction Width 17 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 Framing Siding: iStucco Lath Stone Lath -Brick Fireplace: -Rough In -Air Test -Final Windows Insulation Retaining Wail: _ Footings Backfill _ Final Sheathing Radon Control Sheetrock _ Erosion Control Reviewed By: Building Inspector RESIDENTIAL FEES ` 'rf /q ur/,r/r Base Fee 7.3 7- Surcharge Plan Review Jif MCES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies TOTAL Page 2 of 3 b ROSE fm G INGINE NGINGGRING E PLANNEAS an d LAND S9URMOAS COMPRNY INC. ~1202 it EAST 14611 STREET. BURNSVILLE, MINNESOTA 53337 PH 4323000 Cer-1z' z Cgz 1131 Legal C rL , LOT 1, BLOCK 1, BERKSHIRE PONDS, DAKOTA coUNZY~ MINNESOTA ~r W to ~C-4 W to . DRAINAE AND - 3o FRONT Bul DING 14P - UTILITY EASEMENT SET%'0'CK LiN>t \ W 0 Z q z N 944 42 VY o.a 5 i. 84.65• r u~ 0R! ~ P I ^J DF- .JOTES EXISTING LOT I ELEVAT 10 N _ C ) DEMOTES PROPOSED A 4- 5 Ewa ELEVATION N oa 14 ~31lo4o.a = o 0 co o?oSEA $ pr: ~ - too INDICATE-S DIRECTION OF I _ o" _ WIT CHESS a" m I 0 `P r_. SURFACE DRAINNGE k ¢ in r~ n - - - -I o r~, FMSI-tiED GARgp-E FLOOR EArA&E a r233 1 -t C3. ¢ z~. 54 DEG 4 3+ f.a R E iA' Ir' H- V E BY (g3Z.fi~ 84.09 N 89' 40' 4eW r ~q ""UIONS DIVISION 6ERK5HIRF- DR%vF- ~sJ hereby certify that this is a true and correct representation of a tract of land as shown'and described hereon.. As prepared by me on this '?TV day of lla~.:~ 19 r5 . ~ inn. Reg. No.~_ R0BC 2w Fm NGINCERING PLANNEAS o d LAND SiuaV9YOfiS 20~~ COMPRNY, I NC. .1000 EAST 141h STREET, BURNSVILLE, MINNESOTA 55337 PH 432-30 ccrl- Z' t eeca~ 1131 dow fog z . LOT 1, BLOCK t, BERKSHI PONDS DAKOTA COUN"CY, MINNESOTA • r ~r hi to DRAINAGE AND • 30 FRONT BUIL-DIt` r i ' . lTY EASEMENT SETZACK LINE c 4 14,99-0 44`42"W q z_,s) o,a2 . NORTH I-IONS DIVISION- ~5 z . $4.85 SCALE I"= 30' ~ Z Z, 10 10 '4,00P rt DEMOTES EXISTING, ( LOT I ELEVATION -.q (93oc) FT ip DEMOTES PRUP4SED Tp X q- 45 3 o S~v~o g3iaj ELEVATION N oa o.o 3 ~f tip."r # z $ rrt ow1a pp 90 INDICATES DIRECTION OF 70 tai I ~ Dusc+~~s5 a" m I d r_ , SURFACE DRAINAGE 10'gr? k cn FFi N ISHF-0 GARArcC FLOOR c v► err a ~r2s~ Yx3~. ELEVATION= 9%A,33 x..4.0 . ~33.b 23.34 - 43+t•a D"k EAGAN 1.- J R E V I =WED BY 84.09 a3Z.~~ N 89° 40' 42"W r- 0- aTIONS DIVISION ' BERK5H1R DF WF- Isa~~ I hereby certify that this is a true and correct representation of a tract of land as shown'and described hereon.. As prepared by Fe on this gTiday of f 19 rs . _Ninn. us. No.~85 .-m... PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA117964 Date Issued:10/25/2013 Permit Category:ePermit Site Address: 1931 Berkshire Dr Lot:1 Block: 1 Addition: Berkshire Ponds PID:10-13750-01-010 Use: Description: Sub Type:Residential Work Type:Replace Description:Furnace Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952) 445-2840. Brian Nerison 430 E. County Road D Fee Summary:ME - Permit Fee (Replacements)$55.00 0801.4088 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 - Nasir I Haji 1931 Berkshire Dr Eagan MN 55122 Kb Service Company 430 E. County Rd. D Little Canada MN 55117 (651) 748-4933 Applicant/Permitee: Signature Issued By: Signature Use BLUE or BLACK Ink For Office Use------_-- I Permit ; City of Eap ; 0 as Permit Fee. 3830 Pilot Knob Road I I Eagan MN 55122 ; Date Received: j Phone: (651) 675-5675 I I Fax: (651) 675-5694 1 Staff: I 2013 RESIDENTIAL BUILDING PERMIT APPLICATION Date: /l ©W Site Address: &4011-e f . ah Unit Name: A14;1- LTr[1 Phone: (,!w) a-~ ^ w7a Resident/ Owner Address / City / Zip: q3/ i5~ "%^t? 1Ir, 4wa" Applicant is: OwnerContractor lh!f 1/111"( Type of Work Description of work: p- c.A / a v1~ V14.1 cep' ~atq ~T Construction Cost: 9 a-y An Multi-Family Building: (Yes / No Company: 16V J-.-n1K'/rbly Contact: pjyt Sep? Contractor Address: Po ac y5-y City: L-pg wtle State: /A Zip: 337 Phone: ~R ya't- ~S16 License ~33 d7 Lead Certificate _ qYV 33 - / 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: 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 issuanccfee. Applicant's Printed Name Applicant's Signature Page 1 of 3 PERMIT City of Eagan Permit Type:Building Permit Number:EA129056 Date Issued:01/05/2015 Permit Category:ePermit Site Address: 1931 Berkshire Dr Lot:1 Block: 1 Addition: Berkshire Ponds PID:10-13750-01-010 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 . Description:Re-roof home. Removal of existing 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 - Nasir I Haji 1931 Berkshire Dr Eagan MN 55122 (612) 490-7682 Home Depot At Home Services 656 Mendelssohn Ave N Golden Valley MN 55427 (763) 542-8826 Applicant/Permitee: Signature Issued By: Signature Addendum to Registration Form Housing With Services (HWS) Establishment Applicants for a HWS registration certificate issued by the Minnesota Department of Health under Minnesota Statutes,Chapter 144D,are responsible for contacting the municipality where the establishment will be located to inquire about applicable local requirements(M.S.144D.06). The applicant is responsible for taking all necessary actions as directed by the municipality to comply with local ordinance requirements (M.S.144D.06). Please document the following regarding your contact with the local municipality: Name of City/Municipality: Date of Contact: C;1 04- A:2-3// Name and Title of Official: Official's Contact Information—Phone and Email: ?ci.w,616,Dactz.2,c,k `4.rvn t?r ((051 ' 56'io _po�t i Z Q eA j etan.Cowl Name of HWS Establishment: ph OVA-1 C‘o-f hbMex LLC Address: ' l3 2VkS City/Zip: RajCt M i\C k 2 2 Name and Title of Person Responsible for Completion of this Page: -hiSbt A-14 W,f( 1:)%r4P k-fttv Name(Type •r Print) (Title) Tr-41PE2LIF' 2- k--13(9. (Signature) (Date) Make a copy of this form for your records and send the completed form with your HWS Registration Form to: Minnesota Department of Health Licensing and Certification Program P.O. Box 64900 St. Paul, MN 55164-0900 FAILURE TO SUBMIT A COMPLETE APPLICATION MAY RESULT IN DENIAL OF THE REGISTRATION CERTIFICATE. 5/16/17 To obtain this information in a different format,call:651-201-4101. 1 M (0 (-;) Qo (.;) (0 ;-) ,;') i) la W (;-) (0 IN 4 1 1. = 411. O1 O cn --,.. 0.4m ,_ Cr•I ,..____" illit N N . _____. W 4 i o. = a. •• 4. 0 C 4 1 M. pro a0 o . " V 0 = 0 a ...."--- ./(:). ____., co w 4 H r; Til��IIT'LT�IT ,: /"(AO*. , ___..., /'N,)>+ tn , •. 7;, ,..___. --. W til 4„<;>, .• _ \1,, ,, . ik,„,..„,--„. ilrl Uy ,�, W I---Ii.1, eff ',,S id • v1 .11. .-.4'11.1:141111114/1/: La10( . 'ilftiC r:IPrii ; •�- 111 �- 01 .1. E 01 p • la r •• �1 irj O ,--k 10:•\ '- '-----J,',i`,:-.!:1%-r;- ... Z'-'-'' id ,......._ -----s•1... Ail Pi' , 1 .,1.,, 4 .....__ .... Th. W 4 ,, . / �1► H W .s, . � V) fit► -----, 1:21 a z o ` 4.. Eno • m ga — N N r4 Qat J , Vri ----, HH I tO O Id a a o id u .,. O O I-I U O ....____ H H M aa Ch a '�' �, W g 1 o $+ .�. ____.... 4C w w m o o CO as w ° H14 ..... 4 . m o W a CO p is V CO . .I '0 El •rl C .8. A o 0 0 Zo411 (t) (_" (.1 (•1 .(:l (.l 0) ( _(:) (:) 0) (-) 0) ,,O 1111DEPARTMENT OF HEALTH Protecting, Maintaining and Improving the Health of All Minnesotans November 26, 2019 ECEIVE City of Eagan—Planning Commission DEC 0 2 2019 3830 Pilot Knob Rd. Eagan, MN 55122 BY: City of Eagan: The Minnesota Department of Health in consultation with the League of Minnesota Cities and the Minnesota Association of Townships, has agreed to notify local government officials when a Housing with Services Establishment subject to Minnesota Statutes 144D has been registered by the Minnesota Department of Health. This notice is to inform you that the establishment listed below has been registered in your community. Priority Care Homes LLC 1931 Berkshire Drive Eagan,MN 55122 612-481-8517 This notice does not require any action by your local unit of government, nor does it create a right of the local unit to intervene in the registration process of the establishment. It is being provided as a courtesy only. Because the above named establishment may provide services to residents who would need special assistance in the event of an emergency,you may wish to notify the emergency service providers for your city or town that this establishment is now located in your community. A list of currently registered Housing with Services Establishments may be accessed on the Minnesota Department of Health website,through the following link: http://www.health.state.mn.us/divs/fpc/directory/providerselect.cfm Additional information about Housing with Services registration may be accessed through the following link: http://www.health.state.mn.us/divs/fpc/profinfo/lic/lichws.htm If you have any questions about this notice,please contact 651-201-4101. Other questions should be directed to your local government association or legal advisor. Thank you for your attention to this matter. Melissa Poepping, Health Program Representative Senior Program Assurance I Licensing and Certification Minnesota Department of Health P.O. Box 64970 Saint Paul, Minnesota 55164-0970 Phone:651-201-4117 Email: melissa.poepping@state.mn.us CC: Licensing and Certification File An equal opportunity employer.