3923 Beryl RdRESIDENTIAL
?qrj 3(? g BUfL.DING PERMIT APgL1GAT10N
cmr oF EAGaN
saso PrLoT KNoB Ro - 55122
631-681-4675
1Cortdnuetlan Reaubmenb
• 3m4? ?ump kowin8 s1. R. of IK aQ. A. oi hom; and d moed aness . 2 topies ui ow
(10l6 rnwtirtNNn lot coverage aNoMred) • 1 aet t?f ?g?r C?nt ?Ort?ed ?dd?ons • ZcDPies of Pm Wv**D beem 8 whtdow aizes: Poured found deagn, etcj • i eb strM for e#etior addOmt & dedrs
• 1 sek of Energy Cakulatlons . Indkc01hart*eerved bY aepe "*m far ed0?ons
• 3 coQfes of Tree Pceawtallat Plan I lot ptaM after 711193
• Rim Joist Detai Optiam setection sNest (ddp w1tlh 3 or lm tauls)
DATE 09/24/01 VAIUATIfJN ,l,3, 2Q,Q:0_0 ?
JOB S1TE ADDRESS 3923 Beryl Road Eagan, M 55122
IF MULTI-FAMiLY BUILDtNG, HOW NIANY tlNtTS?
PROPERTIf QWNER Jasan Brubaker
TYPE QF Wt7RK Seamless Steel Siding, Roof pIREpLqCIE(S) - p- j T2
APPUGANT Exterior Innavatioons, Inc. PHQNEC952) 884-4814
ADDRESS 9635 Humboldt Ave. S., Bloomington, MN Ap CppE 55431
PAGER # CEI.L PHONE * PAX # (952) 884-57O :
: ..
Nt?1'RESIDENTIAL BUILD?INI G ONLY - FILL ?,IUT COMPLE'tELY
Energy Cocte Category MiNNFSOTA RL1M 7670 CAIWORY 1f?
(check one) r - Residential Vertdla#bn Categcry 1 Workshest Subm
- Ensrgy Envelope Caicuiations Subnitted
_ MINNF•SOTA RtTLE'S 7672.
New E„ergy coae worksneet subrtdtted ?
Plumbing Contractor. Phone #:
Plurnbing Systern Includes: ! Water Softener ., Lawn Sprinkler Fee: $94.00
Water Heater , No. of R.I. Baths
No. of Baihs
MechcMcoi Contrcctor: Phcsne #
Mechanical System Includes: «. Air Conditioning Fee. $70.00
_,_, Heat Recovery System
SawaE/Wvter Contractow Phone # -
_. . , ,, .
Alt above ir*rmation must'be submitted privr ta procefssing of application.
1 hereby aeknowiedge fihat I have read this dpplication, state that fhe inftemaition is carect raiitCgMe tt? cornplI
with all applicabie State of Minnesota Statufies and Ci#y of Eag ina es.
Signature ot dppNc n#
Csrtificates of Survey Received _ Tre+e Preservatian Pian Received ? Nat Required
t3pdow 1m9
OFFICE USE ONLY
O 01 Foundation
O 02 SF Dwelling
0 03 01 of _ plex
0 04 02-plex
0 05 03-plex
? 06 fl4-ptex
O 07 05-plex O 13 16-plw
O 08 08-piex 0 16 Fireplace
? 09 07-plex O 17 Garage
o 10 os-pieX o 18 Deck
? 11 10-plex ? 19 Lower Level
? 12 12-ptex Pibg,_Y or _ N
O 20 Pool
O 21 Porch (3-sea.)
0 22 PorctUAddn. (4-sea.)
o aa Porcr, (screenea)
O 24 Storm Damage
O 25 MisceHaneous
a 30 AwMawy eWg
D 31 E)#. Alt w %A
[] 33 Ext. Att - SF
C] 38 hluffl
? 31 New 0 35 Int improvement O 38 Dernolish (irrterior) D 44 Siding
O 32 Addi#ion ? 36 Move Bldg. 0 42 Dertrolish (Foundation) 0 45 Fire Repair
0 33 Alteration 0 37 Demolish (Bidg)• ? 43 Reroof 0 46 WGxfows/C?oors
? 34 Repiaeement ''Qemoiition (Entiro Bldg only) - Giw PCA handout to appllcant
Valualion Occuoancy MClES System
Census Code Zoning City Water
SAC Units Stortes Baoster Purrip
Nbr. of Units Sq. Ft. PRV
Nbr. of Bk1gs Length Fire Sprinklared
Type of Const Width
REQUIRED INSPECTIONS
Footings (new bMg)
Footings (deck)
Foatings (addition) P
Foundation HVAC
Drain Tile
Roof Ice & Water Final Other
Framing` _ Pool _ Ftgs _ Air/'Gas Tests ? Fina2
Fiteplace _ RI. ,r Air Test _ Final _ Siding Stucco Stone
Insulation _ Windows (new/replaccmtut)
APProved By ; Bt?dkng inspector
Base Fee
Surcharge
PI$n Review
MC/ES SAC
City SAC
Water 3apply 8? Storage
S8W Permit & Surcharge
Treatment Rlant
Piumbing P?mit
Mechanical Permit
Lfcense Search
Gopies
Other
Total
FinaUG.O.
? FinaUN4 C.O.
_ ??
CITY USE ONLY
LOT Cot?- BL / RECEIPT #:
SUBD. RECEIPT DATE:
199$MECHANICAL ?ERMIT (RESIDENTIAL)
CITY OF EAfiAN
3$30 f'tLOT KNOB RD
£A6i4N MN $5188
Date: (618) 6$1-4675
Complete this section only if you are installing HVAC in single family, townhomes or condos under
construction and not owner /occupied '
• HVAC: 0-100 M B T U $ 24.00
ADDITIONAL 50 M BTU 6.00
• Gas outlets (minimum of one required @$3.00 ea.)
• State Surcharge: .50
• TOTAL:
Complete this section onlv if you are remodeling, adding to, or repairing existing single family dwellings,
townhomes, or condos. Note: Mechanical permit is not reauired for alteration/add-on to ductwork in
existing residential units; but is required for the following:
X Install furnace Install air conditioning
Install air exchanger, i.e. Vanee system, etc. Other
Minimum fee applies to all remodel or add-ons of existing residences $ 20.00
State Surcharge C2.5?/
Total: SITE ADDRESS:
O WNER NAME: ?r? C,?--t??t,•i I L-f"?? f'l``? PHONE #:
?
iNSTALLER NAME_ PHONE #:
STREET ADDRESS: Ef' 1'Zrt C' c < 4u{' •
CITY: STATE: ZIP:
SIGNATURE OF PERMITTEE
JS/FORMS BLD/MECH PERMIT (RES) - 1998
L BL
SUBD.
APPROVED BY:
INSPECTOR
199$ MECHANICAL PERMIT (COMMEftCIAL)
CITY OF E4fiAN
8$80 PILOT KNO$ ftD
EAfiAN, MN 55122
(612) 6$1-4675
Please complete for: all commercial/industrial buildings
multi-family buildings when separate permits are not required for each dweliing unit
DATE: CONTRACT PRICE:
WORK TYPE: NEW CONSTRUCTION INTERIOR IMPROVEMENT
DESCRIPTION OF WORK:
FEES: 1% of contract price OR $25.00 minimum fee, whichever is greater.
Processed piping - $25.00
CONTRACT PRICE x 1 %
PROCESSED PIPING
PERMIT FEE
STATE SURCHARGE
TOTAL
SITE ADDRESS:
($.50 per $1,000 of permit fee due on all permits.)
OWNER NAME: PHONE #:
TENANT NAME (IMPROVEMENTS ONLY):
INSTALLER:
ADDRESS: PHONE #:
CITY: STATE:
CITY USE ONLY
RECEIPT #:
RECEIPT DATE:
ZIP:
SIGNATURE OF PERMITTEE
CITY USE ONLY
LOT BL PERMIT
SUBD. RECEIPT #: 317
. RECEIPT DATE: c, " C'U
2000 MECHANICAL PERMIT (RESIDENTIAL)
Date: p ? 1 -?> -0 6
Complete this section onlv if you are ir_stalling HVAC in a sing!e fa.mily dwelding, townhome or condo urder
construction and not owner/occupied.
• HVAC: 0-100 M B T U
ADDITIONAL 50 M BTU
• Gas outlets (minimum of one required @$3.00 ea.)
State Surcharge
Total
$ 30.00
6.00
.50
$
Complete this section only if you aze remodeling, addiniz -to, or re aip rin? an existing single-family dwelling,
townhome, or eondo. Please indicate if it is a new item, alteration, or repair.
New _ Alteration
Furnace
Air exchanger
Reminder: Call jor inspections
, Repair _ Other
? Air conditioning
Other
Fee $ 30.00
State Surcharge
Total 30.50
7? ? v
SITE ADDRESS: 1 ??--
OWNER NAME: C) ^.),
C (-- ? PHONE #:
(AREA CODE)
INSTALLERNAME:??????.? Ca a,Ak2.PHONE #: ?k 2- Z'r"i.`
(AREA CODE)
STREET ADDRESS: S(-) ?'-X`(-_ r?`
CITY: m . ("?` ".' t= _ STATE: -M P'j_ ZIP:
CITY OF EAGAN
3830 PZLOT IQNOB RD
EAGAN I•IIt 55122
651-681-4675
SIGNATURE OF PERMITTEE
CITY USE ONLY
L BL PERMfT
SUBD. RECEIPT#:
APPROVED BY: , INSPECTOR RECEIPT DATE:
2000 MECHANICAL PERMIT (CObMRCIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, 1rIlN 55122
651-681-4675
Please complete for: all commerciaUindustriai buildings
multi-family buildings when separate permits are not required for each dwelling unit
DATE:
WORK TYPE: New construction Install U.G. Tank
Interior Improvement Remove U.G. Tank
Processed Piping
When installing/removing underground tank, call 651-681-4675 jor inspection by fire marshal and
plumbing inspector.
Description of work:
Fees: 1% of contract price OR $30.00 minimum fee, whichever is greater.
Underground tank removaUinstallation = minimum fee
Contract price: $ x 1%_$ (Base Fee)
State surcharge calculate at $.SQ for each $1,000 Base Fee
TOTAL $
SITE ADDRESS:
OWNER NAME: PHONE #:
(AREA CODB)
TENANT NAME (IMPROVEMENTS ONLY):
WAS THERE A PREVIOUS TENANT IN THIS SPACE? _ Y,_ N. NAME:
INSTALLER:
ADDRESS:
PHONE #: -
(AREA CODE)
CITY: STATE: ZIP:
SIGNATURE OF PERMITTEE
0_ 29 6
9S
? ? &tL
8? ?c
Request ate
2 7 Fire No. ugh•In I spection Required
(You must call inspector when ready)
? inspection Other Th n ugh-In
? Ready Now Will No[ify Inspector
? Yes
No Date Ready
I licensed contractor ? owner hereby request inspection of above electrical work at:
Jo. ?AJdtlress (Street, Box o Route No.)
.?...! ?
? 12?..i' City
?
Section No. Township Name or o . Range No. County
o F'(PRINT) Phon No.
Power Supplier Address
Ele ic ?Conlraclor ( ompan Name) /?' ?
i j CN License N??N"°'_..! Y°/
c
Maili dress (CQ ctor or Owner Makin Insta ation
,
th ized gnature (C ractor/Owne tallation)
&044V%2__\.i Phone Number
7"r _ --
?
?g?gUM'zs y B?$?SRoPmS-M128E'?I ?III?IIIIIIIIIIII?III(IIIIlill?illlllllrll(IIIIIII ? ENC OSEDOPER WSPECTIONBOEE 3T
`EQUEST FOR ELE 9TRICAL INSPECTION EB_000909
See instructions for completin this form on back of eilow copy. ?- x1 7f?? ?
'?"`?"" Be%w Work Covered bv This Reauesf ?
Buiiding Appiiances Wired Equipment Wired
Home Range Temporary Service
'Duplex Water Heater Electric Heating
Apt. g Dryer Load Management
ustriai Furnace Other (Specify)
Farm Air CondiYioner
ContraQtPr's Rem)arks: 74c? /5$_
?
ee(ow: +G?
# Other Fee # Service Entrance Size Fe # CircuitslFeeders F e
Swimming Pool 0 to 200 Amps 0 to 100 Amps
Transformers Above 200 Amps Above =1,Q0 Amps
SigtiS Inspector's Use Onry: ? TOTAL
Irrigation Booms ?
Speciai Inspection
AlarmtCommunication THiS INSTALLATION MAY BE OR DISCONNECTED IF NOT
Other Fee COAAPLETED WiTHIN 18 MONTHS.
i, the Electrical inspector, hereby
tif
th
t th
i
b
ti
h Rough-in Oate
y
cer
a
e a
ove
nspec
on
as
been made. F;nai oate
OFFICE USE QNLY
This request void 18 montbs from -
CITY OF EAGAN Remarks * C@dar G3:OV@ Acqu3sition
Addition CEI3AR GROVE #5 Lot 22 Bik 1 Parcel 10 16704 220 Ol
Owner ?Street 3923 Berv] RDti3d State Fa??1T'1, MN 55122
' Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF.
STREET RESTOR.
GRADING
SAN SEW TRUNK 7, 1967 100.00 5.00 20 Paid
SEWER LATERAL I961 540.00 27.00 20 P3].
WATERMAIN
* WATERLATERAL 1972 607.00 24,28 25 PS(ld
WATER AREA
1
STORM SEW TRK V'7 197¢ 70.00 4.66 15 P11d
STORM SEW LAT
CURB & GUTTER
, SIDEWALK
STREET UGHT
WATER CONN.
BUILDING PER.
sAC zov. oo soz 11--14-67
PAR K
EAGAN TOWNSHIP
BUILDING PERMtT
Owner ._....-5?:?:??_`..'••-???'L:?.r?:....??'?,-.?Z'`::_.._.?_c?!.,-•----..
Address (present)
...?.`----?:....?r. =?::?..,............... --,• ----
Builder .._.._....-•---•-•-• ....................•--•-----
.......................•---••---------..._. -•-
Address .......................................... ---..._----------- _..._............. ...------•------
DESCRIPTION
N° 168'7
Esgan Township
Town Hall
Date ._.-•?.t_.?`7?`.??-•...__..._............
Siories To Be Used For - -Fronf Uepih Heighf Est. Cost Permit Fee Remarks
if --
I I LOCATION
s2reet, Hoad or otrier DescripYion ot Locaiion ' Lo3 Biock ? Addii3on or Tract
This permit does not suihorize the use of streets, roads, alIeps or sidewaiks nor does if give the owner or his agent
the right to cxeaie any siiuation which is a nuisance or which presents a hazard io !he heaith, safeiy, convenience and
generai weifare to anyone in 2he community.
THIS PERMIT MUST BE ?K+EPT ON THE P?tEMI5E WHILE THE WORK IS IN PROGFiSSS.
• • - - - - ------• - -
This is to certify, that___.5..?.__.2?. -:??"....... e .? .............. has permission to erect a__.,.d.f1 __ ------------------ upon
ihe above described premise subject to the provisions of the Building Ord"snance for Eag Townshi adopied Aprii II.
1955.
................ Chairman --._..__._.. Per -------- ...... •-----•- ? /. ?? ?-?-?.'+?-z., ........
.--•._...._... . .. _.. ..._ . _ .....-?.=--:-..._....._ _. ..... , .._.. . --
........------
r af Tnwn Bosrd ! Buiiding Inspecfor
t?? ? ?.
EAGAN T7+?t1S"THIP
3795 Pilot K:iob P,oad
St. Paul, Minnesuta 5'a111
Telephone 454-5242
PERMIT FOR SEWER SERVICE GONNECTiON
DATE:_ _ November 10, 1967
OWNER: Cedar Grove Const. Co.
PLUMBER -Stein, Inc.
NUMBER Z, 'o
r -
Addxess 3923 Beryl Road
TYPE OF PIPE Cast Iron
A ESCRIPTION OF BUILDING
Iiuiustrial CommerciaI Residential Multiple Dwelling No. Qf units
X 1
Location of Coni:ections:
Connection Charge 200 00 Permit Fee 7.50
SCreet Repairs
Tota 1 ?2 G °7-
Tnspected by:
Date
Remarks:
sy _
Chi?:f Trwpector
In consideratfon of t2?.a issu.P and delivery to me of the abc±ve pemit, T
hereby agree Co do the proposed work in accordance Eri.th the rules aad
regulations of Eagan Towrship, Dakota County, Minnesor_a
Stein, Inc. -•
By )r- .? c
Please notif.y vihen ready for insPection aad coinection and before any portion
of the work is covered.
?IN???;yl 016
1
MEMO
- city of eagan
TO: DIANE DOWNS, UTILITY BILLING CLERK
FROM: ED KIRSCHT, SR. ENGINEERING TECHNICIAN
DATE: AUGUST 239 1993
SUBJECT: STREETLIGHT ENERGY COSTS-CEDAR GROVE NO. 5(208 LOTS)
This memo is to inform your department to begin to invoice the energy costs at the single
family rate effective August 1, 1993 to the property owners in Cedar Grove No. 5 Addition.
Block 1, Lots 1-22 22
Block 2, Lots 1-19 19
Block 3, Lots 1-11 11
Block 4, Lots 1-16 16
Block 5, Lots 1-25 25
Block 6, Lots 1-22 22
Block 7, Lots 1-25 25
Block 8, Lots 1-5 5
Block 9, Lots 1-2 2
Block 10, Lots 1-23 23
Block 11, Lots 1-14 14
Block 12, Lots 1-9 g
Block 13, Lots 1-15 15
208
The City is currently being billed by Dakota Electric for streetlighting in the above listed
subdivision.
9, r/u ?/'Q' &12-? i Z
Edward J. irsc t
Sr. Engineering Technician
cc: Mike Foertsch
EJK/je
EAGAN TC]WNSHIP
BUILDING PERMIT
...`-...-'
Owner ...... A,,.°.?-..._..........:?G.
Address (psesent) ..:.?.} a? .........??._....••-•--•---•.__._......
Builder ..... ..................... .........
??..??..-":".?......... -.._..,..................
.......
Address '
....................... 21- ....................................................
DESCRIPTION
Na 2320
Eagan Township
Town HaIl
Date ......d >d
......................................
...,.
Stories To Be Used For Front Depth Height Est. Coa2 'P.rmit Fse Remarks
-- o,ltg
LOCATION
Strset, Road os othez Descrip3ion of Location ( Lo3 Black Addiiion os Trac!
This permit does not authozise the use of streets, zoads, alieys or sidewalks nos does it give the ownes or hia agent
the sight io cresie anp situsiion which is a auisance or which presents a hasard to the healih, safeiy, convenience aad
general welfare !o anyone in !he community.
THIS PERMIT MUST BE K PT ON THE PREMISE WHILE THE WORK IS IN PROGRE5S.
This is !o cerlify, tha3 ......1
.............................. -' ' haspermission to ezect a....,?-?-;:....?...
............ ........ ...... .......... ...... upon I
the above desczibed premise subject to the rovisions of !he Building Ordinance for Eagan Towaship adopt April il.
1955,
.........p ... . .........................................................
...........?.l.-?.-? :.................... Per .........._.......`' ?l-s---?
Chaixman of Tnwn Board ? Building Inspaclor
? ?3 C?-o
,
??.
?
/,Y ?.
,c3 e l 'f'? g
?.
L o t- z? 23 L/
? LOCATION
I OWNER
MASTER CARD
V"'
STRUCTURE AND
LAND USED AS
Permit
No.
Issued Issued To
Contractor Owner
BUILDING ?!/
PLUMBING ??rf /` V • / ' / N1'Yl ?dJ? N d C. ? ? ??
CESSPOOL - SEPTIC TANK
WELL
ELECTRICAL
HEATING
GAS INSTALLING
SAN{TARY SEWER
OTHER
O7HER
0 Items
u
FOOTING
FdUNDATION
FRAMING
FINAL
ELECTRICAL _
HEATING
GAS INSTALLATION
SEPTIC TANK
CESSPOOL
DRAINFIELD
PLUMBING
WELL
SANITARY SEWER
COMMENTS:
Approved
(Initial) Date Remarks Distance From Well
SEPTIC
CESSPOOL
AO ?ILE FIELD FT.
DEH
OF WELL
J#
Violations Noted
on Back
1!
a ?
COMPLIANCE INSPECTION REPORTS TO BE USED ONLY IN EVENT OF OBSERVED VfOLATfONS
•
PERMIT NO. DATE OF IfVSPECTION
CONDITIONS OF CONSTRUCTION AT THIS INSPECTION
? NO EVlDENCE OF NON-COMPLIANCE
OBSERVED.
? ACCEPTABLE SUBSTITUTIONS OR
DEVIATIONS.
? NON-COMPLIANCE. BUILDER WILL COMPLY
WITHOUT DELAY.
ITEMIZED AND DESCRIBED AS FOLLOWS:
F-I NON-COMPLIANCE. BUILDER DOES NOT
INTEND TO COMPLY.
? COMPLETION OF CERTAIN IMPROVEMENTS
WILL BE DELAYED 8Y CONDITIONS BEYOND
CONTROL.
? REINSPEC710N REQUIRED
REINSPECTION REVEALED
DATE OF RE(NSPECT(ON
CERTI FICATION - I certify that I have carefuliy inspected the above in which I have no interest present or prospective, and that I have reported herein
all significant conditions observed to be at variance with ordinances of the Town of Eagan, approved plans and specifications, and any specific require-
ments for off-site improvements relating to the property inspected.
? ALL IMPROVEMENTS ACCEPTABtY COMPLETED
COMMENTS:
BUILDtNG WSPECTOR
DATE
?
E
ct!? 2 3
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA116243
Date Issued:10/04/2013
Permit Category:ePermit
Site Address: 3923 Beryl Rd
Lot:22 Block: 1 Addition: Cedar Grove 5th
PID:10-16704-01-220
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Water Heater
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.
Renae Frienwald
2200 Hwy 13 W
Burnsville, MN 55337
Fee Summary:PL - Permit Fee (WS &/or WH)$55.00 0801.4087
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 -
Paul Schott
3923 Beryl Rd
Eagan MN 55122
Genz Ryan Plumbing & Heating
2200 West Highway 13
Burnsville MN 55337
(952) 767-1000
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA117853
Date Issued:10/24/2013
Permit Category:ePermit
Site Address: 3923 Beryl Rd
Lot:22 Block: 1 Addition: Cedar Grove 5th
PID:10-16704-01-220
Use:
Description:
Sub Type:Reroof & Siding
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.
When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to
ensure maximum ventilation to attic. Call for final inspection after installation.
Valuation: 8,000.00
Fee Summary:BL - Base Fee $8K $162.25 0801.4085
Surcharge - Based on Valuation $8K $4.00 9001.2195
$166.25 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 -
Paul Schott
3923 Beryl Rd
Eagan MN 55122
(612) 723-6345
Gates General Contractors, Inc
3500 Vicksburg Lane North, Suite 400-351
Plymouth MN 55447
(763) 550-0043
Applicant/Permitee: Signature Issued By: Signature
AUG 05,2014 13:04 7154265209 page 1
Use BLU�or BLACK Ink
� Fo�Office Use^�r i
�l 0��� � , ' /������
� (� {�� .� I � � Permil tl� . I
y a�a � S �, . � . i , s�-�
� U� i N e r i»i t�d d.____�� � i
3830 Plloc Knob Road � .�'j t y
Ea gan MN 55122 1 � � O a t o R e c e i v e d:.� � �
Phone;(651)675-5675 �� ) � �,,,Q �
Fax:(6 5 1)6 7 S•5 6 9 4 j S I a H:__... /�'^"7---- �
2o�a RESIDENTIA� BuILDING P�RMiT APPUCaTioN
a
Data• � Site Address• ���� �('N �_ ��0.-��. Unit�!:
n -
,__
Name'���`�-_`- sJ ? o_ _. „Phone:
Resident! � ( . .. ..— _ �...._
�WII@r �� Address/City/Zi�:_� G�� '�Q��.YI-`""".'/ � !'1/�.... 7��7i� _ ....__.
�T"
; Applicant is: __,.,, Owne1 �Contractor
Type pf WOt'k Description of work: _ � .. , �LC�vi.. l�� �b C �G�S
� ��, '�
� Construction Cusl: - '�� ' Multi•Family Building:(Yes �1 No
...
, .,.............. .. - , )
, � �. , /v .
_..
: Company;�1!�r S - '. _ ""� .. ...—Con ct_ _ U�� _ ���1� ,.
l
..... . ...
� C011tl'BCtOf. , Address:--6��� � CIIY. � 1r`""f' �(�-�A��_
State;,�Zi ��D�-Phone: . __ � •�"'�
p�. tmail:.�����
License#: 6Cy ��
CR. 11�. ..__.__Lead Cartificato#: __1�I�7 ' �
_ .. .--
. ,
If the project is exempt from lead certification, please oxplain why: (see Paye 3 for additional information)
.. __. . .. -•-•-
COMpLETE THIS AREA ONLY IF CONS7RUCTING A NEW BUILDING
In the last 12 montha,has the City of Eagan Issued a pertrNt for a similar plan based on a master plan7
.,__Yes _ No If yes,date and address of master plan:
lice�sed Plumber: . _ Phone:
Methdnical ContrdCtor: Phone:
Sewor 8 Water Contractor. Phone_
_
. .. .
NOTE:P/ans and supportinq docurnents fhat you submif are consielered,to be publlc.lnformation. Portions of
the Informadon may be c/as��fied as non-publlc if you provide specific reasons that would permit the Clfy to
... .............. ... .. .. ,., _,_ conclude thaf they are trade secrets, '
......... ........_ . „ , .
CALL BEFORE YOU DIG. Call Gopher 9tat0 One Cell at(851)�54-0002 for prot��liun againsl undergrounU ulility d3nlayo. Csli 48 hours �
beforu you intenQ lo dig lo recelva Ioce�eF of widerground ulilitiea. w�vr.;;uNhrr�;t,i��,�iinr�yp i�,,.�
...•-_
i hernby acknowlcdye d�et tMS inFom,aliun is complele and accurate;lhal thg w�rk will be in confqmt�nce wilh(hd nrdina�lCus and r.ptlCS of the Cily of
Eagan;that I understend thl::is no��perrnil,bul only an appllC�lion fof a permit, 3ntl work ig nOl lo st»rt wi0iout e permit; thel Ihe work w111 be in
accordana,wilh the 2pproved pl3n in the r.sse of work whiCl�requireg e raview anp approva�of pla�s.
Exte►lor work euthorized by a bullding pQryn�(iseued In accordance with ths Mlnne� • S1ate 8ullding Code rnust be tomplet9d wlthln 180
dt1y3 of pe mlt Isauance,
x ° b �� ' ,�/
Appllcant's Printe Name "— x— ��• Y
Appllc t's 8lgnature �
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