3723 Blackhawk Lake Ct . °•~r 4-w--n. 771
~l'~".-~.x7L
{ 1E
tt
30
0 P1it Knob Road, P taxi `tty1~►3
PFi~t~! 4;r~9+t6ti
BUILDING FERN T f eeipt r {
To be used for BF ■.w.i 40 'Est. value l r 1
Situ Address
Lot 13 Block I Sec/Su ta OW Sao
Parcel No. Occupancy ~ 1 1
Zoning
¢ Nant® A 1A d CONSTIM Y (Acluaq Const Bldg. Permit E 10",
Address 4W r AVE S (Allowable) ii4r
Phone'! # of Stories Surcharge
Lengths Plan Review
' " a r Depth 7"t
SAC, Ctly
S.F. Total SAC, MCWCC
Phone S.F. Footprints
On Site Sewage Water Conn
r~e
On Site Well
Water Meter
MWCC System
City Water X Acct.oepetsil
PRV Required X S/W Permit
1 hereby ack ' that 1 have read this application and state that the Booster Pump • ~
S1W Surche~e,
ihttxmation is rest and agree to comply with all applicable Slate of
Minnesota Statutes and City of Eagan Ordinances. Treatment Pt.....
Signature of Permitee APPROVALS Road Unkt
A Building Permit is issued to: Planner Park fwd. • ~.r. .
on the express condition that all work shall be done in accordance with all Council
applicable State of Minnesota Statutes and City of Eagan'Ordinances. Bldg. Off, i Copies
70TA1
t
Building Officials Variance
PtxtN Ms. Dtlb Tdepl%M #t
WATER
S AR
PLUMBMO r
H.VJkC. I? 5
ELECTRIC
Deft ceowmft
FookhW 1
Faundafm 2- 3
Framing IB'3o S w, `sS a`' /'e s
is 2 t i t• s
Rough Pi6g.
Rough HN.
Rnpims
FlnDl MIEp.
On" Test
P". Plbg. Inspector - NoMy Plumber
ConsL L46 ter
EngrJPlan
B14 FmW
Deck Fig.
Deck FkW
Wd
Pr. Disp.
CITE' OF EAGAN - t; ~ ~ ~
3830 Pilot Knob Aoad permit t+ wber
6
Eagan, Minnesota 35122-1807
we isawd.
- ;
(612).681-4675
SITE ADDRESS: - APPLICANT:
tR)t' t. HLOfK
r~t.~,~;:tKt~~w~ t.nkx ~ r ~ M1'txHFi~~?f.
PERNUT SUBTYPE: TYPE OF WORK:
t <;t t t' w :tw tt ALTfrkkt'Y0#4
pokinFt 1#4 p1.0It _ t tN t.
k'MAttA t. PARA.IV PE PM UT IS 0f t;U10f-0 f01A ANY 411,kJAR•t0#6 OR IF t,E:'4.4-0I.c* 46I6IRK
l
42,
ftmilt No. P*=R lbtdw date Telephone #
a1P . .
FCIJND
FPAWW
Z-G-
R000
Ims Svc
MML
s
MALI
OR
TEST
BLDG FINAL
BSMT A.F.
BSMT FINAL
PECK FTG
DECK MAL
INSPECTIONRECORD
CITY OF EAGAN ~ PEROT
8836 Not Knob Road PermR Nurriber:
Eagan; Miniks.d a 55122-1897 Date I8 d:
(612) 681 Y4675~~ t+t A a s R
SITE ADDRESS: COT ~ 13 6 L OC I(_ 2 APPLICANT:
31 3 at ACKHAWK CAKE CT I UT7. MirNA~l
nt Ac HAW9 (It find 300 (612) 601-9046
PEF II1 SUBTYPE: TYPE OF WORK: Ntsa c
"q.
+r Fn ~-9 77-
«gp~ _ _ q T ~f ' i~ ~U
.f4
t s. T k J. ~Y! 1 , C
Panait No. Pe a* Hdidar Data Teftpmm #
SACTJW
top"Hon I ilow 1: COMMON
FWJN0
-ROW* 4
TOT
IN& L
BYP BC NtD
RR€PLAOM
FwkPL861
RNAL HTQ
ORSAT
TEST
BLDG FWAL
BSMT R.I.
BSMT FINAL
DECK FTG
DECK FINAL _ rJ ,
All ~ OF =SEONL This r st void 18 months validation date printed in s box
Illllllillllilllllllllillfllllllllllllllllllall Y 60
* D 4 1 6 1 5 2 7* PLEASE PRINT OR TYPE
Request Dpte R h4n in on r uired;! Yes
1 oug specri eq ❑ No Inspection Other Than Rougha~d]~ Now Will Call
t jL I ~ (You must call the inspector whe ready) Date Ready: 1.x011-1
I, ❑ licensed contractor P owner hereby request inspection of the above el rical vi etAi '06
Job Address (Street, Bo or Route No.) City 14P ode
Section No. Township Name or No. Range No. Fire No. County
Occupant Phone No.
Power Supplier Address
~11"C41 C-
Electr cal Con (Company Name) Contractor License No. Master Lic. No. (Plant Elect. Only)
9e -F
Mailing Address (Contractor or Owner Performing Installation)
Authorized SignatujjCan1,,,,dor or r rming Installation) Phone No.
EB-0000141 1 8/96 crevF Penn rntav _ crr tucrtattr nnuc nu nary nr vct t nw mov
REQUEST FOR ELECTRICAL INSPECTION& 7
416-152 71 1^821 University Ave.,r Rmof Electri
. S-128 St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service (r
'X' above the work covered by this request. Enter remarks in this space and on the back of the white copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Amps Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Outline Ltg. Xfmr. n
Alarm/Remote Control
Swimming Pool
I hereby cart that I ins i s I herein on The d
Irrigation Boom Rough-in Date
Special Inspection
Date
Investigative Fee fh~G~
THIS INSTALLATInN MAY BE nRDFRFD DISCnNNFCTFD IF NOT COMPLETED WITHIN 18 MONTHS.
roar yr v
J 147 5 0
Request Date Fire No. Rough-in Inspection
Required? C eady Now n Will Notify Inspector
G Yes I. When Ready?
I icensed contractor D owner hereby request inspection of above electrical work at:
Job Address (Street, Box or oute No) City
2;;9 3 - od 'e!~.-46:A-
Section No Towns Tip Name or No. Range No. Goun
Occup PRINT) Phone No.
Power S keC,~ Addre
I
Ele ncal Contractor (Company Name) ~/~A ~
~ Contractor's License No.
-s 3
Abf -4 Made ddress (Conlr or Owner Making InstaHati
Autho ignature (Contra V w along Insta tion) Pho Number
MINNESOTA STATE BOAR OF ELECTRIC( THIS INSPECTION REQUEST WILL NOT
Griggs-Midway Bldg. - Room S-173 BE ACCEPTED BY THE STATE BOARD
1821 University Ave.. St. Paul, MN 55104 UNLESS PROPER INSPECTION FEE IS
Phone (612) 642.0800 ENCLOSED.
/l(e f9 REQUEST FOR ELECTRICAL INSPECTION T!_%;w I=a- oo,-oa
1 ► See instructions for completing this form on hack of yellow copy.
J X" Below Woik Covered by This Reques
New Add ReP-~' YPeofBuildin9 APPIiancesWired E9uiPmentWired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Other (Specify)
Comm./Industrial Furnace
Farm Air Conditioner
Other (specify) Contractor's Remarks:
Compute Inspection Fee Below:
# Other -T Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Swimming Pool 0 to 200 Amps 0 to 100 Amps
Transformers Above 200 Amps Above 100 Amps
Signs Inspector's use Only: TOTAL
Irrigation Booms
Special Inspection
Alarm/Communication THIS INSTALLATION MAY BE ORD D DISCONNECTED IF NOT
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby Rough-in u / Date
certify that the above inspection has Final ate
been made.
OFFICE USE ONLY
This request void 18 months from
SEWER & WATER PERMIT OF CE USE ONLY `
CITY OF EAGAN METER.# yr( /d 9 PERMIT DATE 12 /Q3/9'i
3830 Pilot Knob Rd.
Eagan, MN 55122-1897 CHIP # g) e24 k 4 PERMIT #
METER SIZE ; B.P. RECEIPT # l I q,
ISSUE DATE cam- i i 14 9I
NOV 13, 1991 B.P. RECEIPT PATE . / /
DATE
PRV BOOSTER PUMP
SITE ADDRESS 3723 BLACKRAWK LADE CT PERMIT REQUESTED
LOT 13 BLOCK 2 SEC/SUB BLACKHAWK GLEN 3RD
X SEWER %-WATER -TAPS.
APPLICANT:
ADDRESS: - COMM/IND _X__ RESIDENTIAL.
CITY, STATE ZIP X NEW - EXISTING-
PHONE:
VV Lawn Sprinkler Meters are. to be Installed
.
PLUMBER: d BRUCE NELSON PLUMBING Ahead of Domestic Meters on )fqaterLine
'ADDRESS: 1272 S PT DOUGLAS RD Credit WILL NOT be giv fo D d .cc Meter ,r
CITY, STATE ST PAUL MN ZIP 55119
PHONE: 738-9354
AGREE TO COMPLY WITH CITY OF
OWNER: D M R CONSTRUCTION INC EAGAN ORDINANCES
ADDRESS: 8505 JEFFERY AVE S
CITY, STATE COTTAGE GHOyE mN ZIP %5016 WW EN 459-9327 SIGNATURE WHEN METER ISSUED
PL L LL 454.5220 FOR INSPECTIONS. FOR STORM
SEWER , CONTACT ENGINEERING DEPT.
Wrtiftratt of Mrruvanry-
Citp of Cagan -
arvatumt of luaim Jmw"twu
This Certff We issued pursuant to the requirements of Section 306 of the Uniform Building
Code certifying that at the time of issuance this structure mm in comp&uwe with the mririous
ordinances of the City reguladng building conowcdon or use For the following:
the C -W DGf m ew8. Pa=c TIm 19872
O=Upa-TTA- Ed 1l l z.-i's Dkwa R Typo c,- uN
o-otaawm Lm cm=xn T 00 AM= 8505 AM= Am S, COE= 4mm
372 TJAZ M TaMoar T L..uq T.11, R9,19AMIM IMEN 3M
tGcal
POST IN A CONSPICUOUS PLACE
Address: 3723 BLACKH&y LAKE r_T Lot 13 Blk 2 Sec/Sub BLA,KHAW GLEN 3RD
These items were/were not complete at the time of the final inspection.
t : 2/P9192 Yes No Tnqpprtor;
Final grade (6" from siding)
Permanent steps - garage
Permanent steps - main entry
Permanent driveway
Permanent gas
Sod/seeded grass
Trail/curb damage
Porch
Basement finish
Deck
Please verify with the builder the removal of roof test caps from the plumbing
system and the shut-off of water supply to the outside lawn faucet before
freeze potential exists.
RECYCLED "A
White - City copy Yellow - Resident copy Pink - Contractor copy
! CITY OF EAGAN NOM .19877
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
'
BUILDING PERMIT PHONE: 454-8100 (L o i
Receipt # l.• ! /
To be used for SF DWG/GAR Est. Value $161,000 Date NOV 13 tg 91
Site Address 3723 BLACKHAWK LAKE CT
Lot 13 Block 2 Sec/SubBLACKHAWK GLEN 3R OFFICE USE ONLY
Parcel No. occupancy R-3 M--1 FEES
Zoning .R.1
W Name D M H CONSTRUCTION INC (Actual) Const V_N Bldg. Permit 853.00
c Address 8505 JEFFERY AVE S (Allowable) Surcharge 80.50
City COTTAGE GROVE Phone 459-9327 # of Slories -
Length 66' Plan Review 554.00
41 sac, city 100.00
=o Name SAME Depth r
u¢ Address S.F. Total SAC, Mcwcc 650.00
City Phone S.F. Footprints -
On Site Sewage Water Conn 660.00
W Name On Site well 95.00
W W X Water Meter
M' Address MWCC System 30.00
<6 City Phone City Water X Acct. Deposit
PRV Required X S/W Permit 30.00
I hereby acknowlege that I have read this application and ate that the Booster Pump S/W Surcharge .5o
information is correct and agree to comply with all ap State of
Minnesota Statutes and Cit of Eagan Ordinances. Treatment PI 276.00
Signature of Permitee + APPROVALS Road Unit 370.00
A Building Permit is issued to: D M H CONST INC Planner Park Ded.
on the express condition that all work shall be done in accordance with all Council -
applicable State of Minnesota Statutes and City of Eagan Ordinances. Bldg. Off. Copies
I y~,,
Building Official Variance TOTAL 3,699.0
1991 BUI AP CATIt1N
CITY OF SAGAN
SALE FAMILY INGS XMIPLE, LLINGS
2 SETS OF PLANS 2 SETS OF PLAN'S I, S OF AWWUPTURAL
3 REGISTERED SITE SURVEYS REGISTERED SITE SURVEYS ST=CTtWW*1-,PUm-:..
1 SET OF ENERGY CALCULATIONS (CHECK WITH BLDG. DEPT.) $9T OF MnM 'ATION'S
1 SET OF ENE C, IJOULATTI S 1 SFFP `r No. 'CALLS
# OF RENTAL UNITS
# OF FOR SALE, UNITS
PENALTY APPLIES WREN: TYPING OF PERMIT IS REMStTED, BUT NOTPIQ= `u ,EY`11AT' D ING. DAY,
OF MONTH IN WHICH REQMT IS MADE.
LOT CHANGE IS REQUESTED' ONCE.. P2MT IR IES
NOTE: ADDRESSES FOR CORNER LOTS . CONTRACTOR/ROMEOWMAUST I a IS
DESIRED. NO CHANGES _WILL. BE ALWM O=F, BUILUI S_ 2=76 TS. IF.fl►.
PROCESSING TIME FOR SEWER & WATER PERMITS IS TWO DAYS .ONCE;A P T
PERMIT MUST SHOW A LICENSED PLUMBER.
To Be Used For: '~11+1G1.,E ~AKIUY JIA&Valuation: •,1 te; {
Site Address ~wa,1CNAWK •
3-77.5 LArAE 0-r. OOV Optics `QSE
Lot Block _
Occupancy` Sldg. P
Zoning
Parcel/Sub &mY.AAWK G&&a - Actual Const ~loitn RAW r
Allowable Y~ +1! a i
Owner (MICE L u T Z # of storie* ow, MWCC
Length Vater-C A Q0
Address 322 A L. t) F- tJ PiajdJ04. Depth x
S. F. Total ~;_t Dolt
Cfty/Zip Code L1GAatFootprint S.F._
Phone On site sewage_ Troatmoft
On site well "a'd jjjj~
zN
Contractor D-M, 14. QVftT*JA&M Zg%, MWCC System Park Deed.
City water "]W
.r
Address 9150-5 a'e, F P-Y que.03!„;..,..,..,.~ PR9 ~ ~'e~i+st
. 16 Booster Pump
City/Zip Code QTP` G,p My. Phone A~ Pe~al,ty . ;
45ef- 93 ~7 Planner Lot
Council
Arch./Engr. Rift.
Off.S
Variance
Address
City/Zip Code
Phone #
1". 3"t1._ ~ PA.f+d►. agrees that all work. shall be done to co a with.
(Signature of Contractor)
all applicable State of Minnesota Statutes and City of. Eagan 'ftdimoa.
Li A, 4
logo IA
6FARA&e
~y.6'? x35-= X63
14,11 y (113)
735
1,33 x z = 3~'
~267~ y2 ~ 532
VzYM3= Z~3
3,`7 X 1233 u S
1305 I sT
13os 53 = bq J 6 5
2Np ~Dri .
2X 2~, Z
-WZ ~ ~oyZ~ 8L 1
8 5 yC !ao = 1-7 0
^x
~l57 XS3=~~_
1 ,
1
3123 W
CERTfF CAT Q SURVEY for' D.M. Rae 7'10N
100.00 N 0°19'19"W -
5 5 C505 _~;OP~ST~E.tCTION
1
r
C3- it3s AC33 Gvraye
L-~ a
~ ~rajoaSeo/ t
23.6
W Aaez e O
d' ?2. Ac
co a I t 1 -I
L_</ I
OD
z 07 t
0 1 C_
O 1 Ki
a• OD' F 0 R B N
e'
N .*~!';N! LOT 13 'PERNT ONLY
5
~ ORAffifAGE 8 tlT1Lf 1'Y
rAsEmENr PER- PLAr`"
IOf?.OD rAY
9766 W/. 33 9c9Poib
g2d !29
'nms,
100.00 S O 'D 19'19 F -
• DENOTES PROPOSED SURFACE DRAINAGE
O DENOTES IRON MONUMENT SET SCALE: 1 INCH 30 FEET
• DENOTES IRON MONUMENT FOUND PROPOSED GARAGE FLOOR 939.3 FEET
X000.0 DENOTES EXISTING ELEVATION . PROPOSED LOWEST FLOOR - 930.G FEET
(000.0) DENOTES PROPOSED ELEVATION PROPOSED TOP OF BLOC --Cff raw
o DeneAS . we0a/ ha, oIt"rcX
t o B/act Bl A~'kyAYV Gl1`N 3
SCALE: 1 Inch= 3d Feet o Denotes Iron Bearings shown are assumed. Jop No. Bk.Pg.
We hereby certify that this is a true and correct representation of a survey of the E.G. 1 ~~4► SONS, INC.
.
boundaries of the above described land and of the location of all buildings, if any, thereon, and all visible encroachments, if any, from or on said land.
LAND SSURVMRS
TE. G. RUC} Bl SONS, INC: 9180ieAngton Avenue N.
Dated this ~ day of 0v 19-. by~~ Circle Pines, 6.555 ota,55014
Telephone: 7886.5556
Minn. Reg. No. 9BO8
D.fd.". CONSTRuenON
OPTIONAL DESIGN METHOD 8505 JEFFERY A`F_ SO.
( OOKBOOK APPROACH) COTTAGE GROVE. MN `r 16
OWNER/n11L LLaz .JOB ADDRESS?;_1 'A &LA' 4KWAWV. Lr1AWjre.T.
CALCULATIONS DONE BY LAQ.ni t4,nLTj PHONE 455-4$47DATE
TYPE OF BUILDING 7_51-Y
ACTUAL VALUES MINIMUM R AUIREM NTS
ROOF/CEILING ASSEMBLY AS DESIGNED LF bTATE ERGY LODE
R ONE & IWO FAMILY
CEILING AREA: ~ SA. FT. ELLINGS
-
SKYLIGHT AREA SA. FT.
R-VALUE OF CEILING INSULATION: R-38 (MIN)
R-VALUE OF SKYLIGHT:
WALL ASSEMBLY (ABOVE GRADE EXT. WALLS)
WALL AREA: _ p$A, FT,
R-VALUE OF WALL INSULATION: / 97 R-ZO (MIN)
FLOOR ASSEMBLY (FLOORS OVER UNHEATED SPACES)
FLOOR AREA: 1110,-4 45' $A. FT.
R-VALUE OF FLOOR INSULATION: R-20 (MIN)
NOTE: FLOORS OVER EXTER OR SPACES SHALL BE INSULATED
THE SAME AS ROOMEILING ASSEMBLY.
WINDOW & GLASS DOOR (PATIO DOORS) ASSEMBLY
WINDOWS ONLY (BUILDING HAS NO SLIDING
(GLASS DOORS--MUST BE AT LEAST DOUBLE
I LAZED WINDOWS)
TOTAL WINDOW AREA: n hALC
- IS. $A. FT.
PERCENT OF WALL AREA IN WINDOWS: 12Z (MAX)
WINDOWS & GLASS SLIDING DOORS (BUILDING HAS
BOTH WINDOWS & GLASS SLIDING DOORS--MUST
BE AT LEAST DOUBLE GLAZE
TOTAL WINDOW AND DOOR AREA _341.0SQ. FT.
PERCENT OF WALL AREA IN WINDOWS
AND GLASS SLIDING DOORS: 10% (MAX)
DOOR ASSEMBLY (METAL INSULATED OR WOOD
WITH STORM DOOR)
DOOR AREA:_ ~5..57' SA. FT.
R-VALUE OF DOORS: J R-3 (MIN)
NOTE: ATTACH DOOR & WINDOW SCHEDULE.
(SUCH AS PAGE OF ENERGY
CONSERVATION tVALUATION.)
FOUNDATION ASSEMBLY
R-VALU OF FOUNDATION INSULATION: 4_ R-5 (MIN)
(FULL ASEMENT WITH IN ULATION
OVER COMPLETE HEIGHT OF WALL.)
R-VALU OF FOUNDATION INSULATION: R-10 (MIN)
(FULL EASEMENT WjTH INSULATION
ONLY DOWN TO "b" BF9LOW FIN1 H
GRADE, SPLIT LNTRY UR CRAWL PACE.)
IHIS OPTIONAL DESIGN METHOD MAY BE USED INSTEAD OF THE STANDARD ENERGY CONS RVATION
VALUATION.
AREUNOT,METCHTHE STANDARDEENERGYUCONSERVATIONTEVALUATBIONMMUST BE COMPLETED
TO DETERMINE IF THE TOTAL BUILDING ENVELOPE MEETS THE MINIMUM REQUIREMENTS OF THE
MINNESOTA ENERGY CODE.
SKYLIGHT, WINDOW AND DOOR ASSEMBLIES
+ -Value
ht Manufacture I Manufacture No. No. Used Total Sash Area (A) R-Value U=1/R U x A
Totals Enter Pace 1 XX XXX X XXX X XX X
- a ue
Windows Manufacture Manufacture No. No. Used Total Sash Area (A) R-Value U=1/R U x A
CRIMUM QeAZ-240 Z.2 3 :Z-77-
C)
0-0-Al- 2AAn_ •4. -
r~
&C A2 -1 A15 18.10
cc z - o
60,A 1 -2-440 Zz 4A.64
ACA L2440 7,
44, A 26601
Totals Enter Pace 1 vXXXXI X
Foundation - a ue
'Wall Window I Manufacture Manufacture No, No. Used Total Sash Area (A) R-Value U=1/R U x A
I
Totals r_nter age
- aue - aue
R-Value Storm Door Door U-Value
Dcors Manufacture Size No, Used Total Door Area UU Door (If Used) Assembly U=1/R UxA
Let
E (o° { Z.~-T
2 g ` 1 1-7,16
1
26 1
f
i otais ztiter ace XRMX,xx 1- I
7
PERMIT
CITY OF EAGAN
3830 Pilot Knob Road PERMIT TYPE: B U I L D I N G
Eagan, Minnesota 55122-1897 Permit Number: 0 2 9 3 2 5
(612) 681-4675 Date Issued: 12/17/96
SITE ADDRESS:
3723 BLACKHAWK LAKE CT
LOT: 13 BLOCK: 2
BLACKHAWK GLEN 3RD
P . I . N 10--14362-130-02
DESCRIPTION:
B'r. ilding :Permit Type BASEMENT FINISH
€3uilding Work Type ALTERATION
Census Code 434 ALT. RESIDENTIAL
REMARKS:
A SEPARATE PERMIT IS REQUIRED FOR ANY PLUMBING OR ELECTRICAL WORK
FEE SUMMARY:
Base Fee $50.00
Surcharge $.60
Total Fee $50.50
CONTRACTOR: OWNER: - Applicant -
LUTZ MICHAEL
3723 BLACKHAWK LAKE CT
EAGAN MN 55122
(612)681-9046
'I hereby acknowledge that I have read this appliwat"ion acid state that the
information is correct and agree Co 'comply with all, applicable State of Mn.
St,~tutcs and City of L,agan Ordinances.
APPLICANTIPERMITEE SIGNATURE ISSUED F1' NA OPE
CITY OF EAGAN
14316 3830 PILOT KNOB RD - 56122.
1996 BUILDING PERMIT APPLICATION (RESIDENTIAL) `J 1
681-4675
RomodetfRaeait HNUJ ementa
♦ 3 registered site surveys ♦ 2 copies of plan
2 copies of plans (trrduds beam d window sites; poured And. design; etc.) 4 2 site surveys (exterior additions & decks)
4 1 energy calculations ♦ 1 energy calculations for heated additions
♦ 3 copies of tree preservation plan M lot platted after 711193
required: _Yes _ No
DATE: CONSTRUCTION COST:
DESCRIPTION OF WORK: ~~sPU-+,~,,..`~ ~l ~c • r+S
STREET ADDRESS: 5 S` l Z2
LOT BLOCK SUBD.IP.I.D. JIM b-f'L
PROPERTY Name: V V L t c ~l c~ Phone ("R OWNER y
Street Address- R 1c,A ha-k,',
City: T-a.C' cy State: A4 K) Zip- 12 2
CONTRACTOR. Company: Sc Phone
Street Address: License
City: State: Zip.
ARCHITECT/ Company: Phone
ENGINEER
Name: Registration
Street Address-
City: State: Zip.
Sewer 8 water licensed plumber: Penalty applies when address change and lot
change are requested once pem-dt is issued.
I hereby acknowledge that I have read lltiis application and state that the Information is correct and agree to comply with all
applicable State of Minnesota Statutes and City of Eagan Ordinances.
Signature of Applicant: " L
OFFICE USE ONLY
Certificates of Survey Received Yes No 1
DEC 0 4 1996
Tree Preservation Plan Received Yes y No 1 B
OFFICE USE ONLY
BUILDING PERMIT TYPE
❑ 01 Foundation ❑ 06 Duplex ❑ 11 Apt./Lodging 16 Basement Finish
❑ 02 SF Dwelling ❑ 07 4-plex ❑ 12 Multi Repair/Rem. ❑ 17 Swim Pool
n 03 SF Addition ❑ 08 8-plex ❑ 13 Garage/Accessory ❑ 20 Public Facility
a 04 SF Porch ❑ 09 12-plex ❑ 14 Fireplace ❑ 21 Miscellaneous
a 05 SF Misc. ❑ 10 ___:.plex ❑ 15 Deck
WORK TYPE
❑ 31 New 33 Alterations ❑ 36 Move
❑ 32 Addition ❑ 34 Repair ❑ 37 Demolition
GENERAL INFORMATION
Const. (Actual) ytti Basement sq. ft. MCMS System
(Allowable) L Main level sq. ft. _ City Water
UBC Occupancy 3 ~F-7P sq. ft. Fire Sprinkiered
Zoning sq. ft. PRV
# of Stories sq. ft.Booster Pump
Length sq. ft. Census Code.
Depth u' Footprint sq. ft. SAC Code 0(
Census Bldg
Census Unit
APPROVALS
Planning Building Engineering Variance
Permit Fee Valuation: $
Surcharge
Plan Review
License
MCNVS SAC
City SAC
Water Conn.
Water Meter
Acct. Deposit
S/W Permit
S!W Surcharge
Treatment Pi.
Road Unit
Park Ded.
Trails Ded.
Other
Copies
Total;
% SAC
SAC Units
PERMIT
~"PUTY OF EAGAN
3830 Pilot Knob Road PERMIT TYPE: B U I L D I N G
Permit Number: 030521
Eagan, Minnesota 55122-1897
(612) 681-4675 Date Issued: 07/28/97
SITE ADDRESS:
3723 BLACKHAWK LAKE CT
LOT: 13 BLOCK: 2
BLACKHAWK GLEN 3RD
P.I.N.: 10-14352-130-02
DESCRIPTION:
Building Permit Type DECK
Building Work Type NEW
'Census Code 434 ALT. RESIDENTIAL
REMARKS:
FEE SUMMARY:
Base Fee $50.00 COPIES (3) x.75
Surcharge $.50 Total Fee $51.25
Subtotal $50.50
CONTRACTOR: OWNER: - Applicant -
LUTZ MICHAEL
' 3723 BLACKHAWK LAKE CT
EAGAN MN
(612)681-9046
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 Mn.
Statutes and City of Eagan Ordinances.
GC 1
P LICANT E ITEE SIGNATURE ISSUED BY: SIGNAT E
1997 BUILDING PERMIT APPLICATION (RESIDENTIAL~~
p S a I CITY OF EAGAN
3830 PILOT KNOB RD - 55122
681-4675
Now Construction Reaulrements Remodel/Repair Reauirements
# 3 registered site surveys # 2 copies of plan
# 2 copies of plans (include beam & window sizes; poured find. design; etc.) # 2 site surveys (exterior additions & deciw)
# 1 energy calculations # 1 energy calculations for heated additions
# 3 copies of tree preservation plan if lot platted after 711/93
required: Yes _ No
DATE: 7 - 9 CONSTRUCTION COST: fOd
DESCRIPTION OF WORK: oy' /,cot
STREET ADDRESS:
LOT BLOCK_ SUBD./P.I.D. 3
PROPERTY Name: 41 t a 4, Phone
OWNER LW
Street Address:
City: _ c a 4~ State: M A/,_ zip: _t1/-
CONTRACTOR Com Ry: Phone
Street Address: License M
City:. State: Zip:
ARCHITECT/ Company: Phone
ENGINEER
Name: R
Street Address:
City: State: Zip:
Sewer & water licerned plumber (new construction only): Penalty applies when address change
and lot change are requested once permit is issued.
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.
{
Signature of Applicant:
OFFICE USE ONLY EIVED
2 4
1°97
Certificates of Survey Received Yes No JUL
Tree Preservation Plan Received Yes No Not Requi'
OFFICE USE ONLY ,
BUILDING PERMIT TYPE
❑ 01 Foundation o 06 Duplex o 11 Apt./Lodging o 16 Basement Finish
❑ 02 SF Dwelling ❑ 07 4-plex o 12 Multi Repair/Rem. 0 17 Swim Pool
❑ 03 SF Addition o 08 8-plex a 13 Garage/Accessory o 20 Public Facility
o 04 SF Porch ❑ 09 12-plex o 14 Fireplace ❑ 21 Miscellaneous
❑ 05 SF Misc. 0 10 _ plex ,W 15 Deck
WORK TYPE
,ef 31 New o 33 Alterations ❑ 36 Move
o 32 Addition o 34 Repair ❑ 37 Demolition
GENERAL INFORMATION
Const. (Actual) Basement sq. ft. MC/WS System
(Allowable) Main level sq. ft. City Water /
UBC Occupancy sq. ft. Fire Sprinklered
Zoning sq. ft. PRV
# of Stories sq. ft. Booster Pump
Length sq. ft. Census Code. A13 4
Depth Footprint sq. ft. SAC Code
Census Bldg
Census Unit a_
APPROVALS
Planning Building Engineering Variance
Permit Fee Valuation: $
Surcharge
Plan Review
License
MC/WS SAC
City SAC
Water Conn.
Water Meter
Acct. Deposit
S/W Permit
S/W Surcharge
Treatment PI.
Road Unit
Park Ded.
Trails Ded.
Other _
Copies 3 ; . 7 S
Total:
% SAC
SAC Units
37 2 3 $kNck .
I
VE
RTIFICAT OF SURVEY • H. A CONSTRUCT
4
BL,4L'~YN~Wif~ L,4 E L'DIJ~T .
100.00 N 0°19'19"W -
` 0 2
5 8505 JEFFFR SO.
COi'T~-,3r CI.-)•
o--- b73
- ~ z3 .z
4159. - ck bz I
a-- 1233 %R33 Goraye b -/4
~ Pra~oseo! 3 _
23
_ W
f/QUSe b ~d'w
/9.33 N ?2. L6
1.
CU L_ L`l
ao - to
z i ~a s-f 0 112
0 lO
o • ao
CV
Of
OD FOR M6.~
ILY I
LOT 13 P E R M T
5
DRAINAGE 8 UTJLlTY 5
EASEMENT PER, PLAr~
100.00 _ ~ ~~D
8 Qf p 0 `
8?•L6 4l.33. 9~fPoio' p v• s s 5~ _ '0
E D
._._X : M•
"Iciel
100.00 S 0019,191, E
4 2GAN~ EERI DEPT
DENOTES PROPOSED SURFACE DRAINAGE _
O DENOTES IRON MONUMENT SET SCALE: 1 INCH - 30 FEET
DENOTES IRON MONUMENT FOUND PROPOSED GARAGE FLOOR - 9SR-3 FEET
X000.0 DENOTES EXISTING ELEVATION • PROPOSED LOWEST FLOOR --Bad_C FEET
(000.0) DENOTES- PROPOSED ELEVATION PRO?QS 17 TOP OF BLOC
O Pe voAr woos/ fiat ow ol>se.l, E s
lof 8/oc~ ,Z ACAW,4WA * 67. N
3 ~~•~lf'/~~', ~o:~o v Coan~~yl, M~.~rr~
SCALE:1 Inch= -3O Feet o Denotes Iron Bearings shown are assumed. Job No.-Z&-&A--r- Bk. Pg.
We hereby certify that this is .o true and correct representation of a survey of the 1, RUD & SONS INC.
boundaries of the above described land end of the location of all buildings, it any,
thereon, and loll Vie" encroachments, if any, from or on said land. - LAND SURVEYORS
,E. G. RUD & SONS, INC. 9180Lexington Avenue N.
Dated Chia I day of °V 19-& Circle Pines, Minnesota,55014
by
Telephone: 786-5556
SURD. f,
Pin!
M.'MIA
2. _
4.
o' 61 Shmmr x~
Water C &00
"
.3E" ' .a
Bath Tub 3.00
z- 4
too
Kitchen Gh*
Leundr?y.T( a".»...~
T~~4 44 _
Hot Tuwspa .t a ~
Water'Heater 100
Floor ter 100
.A..I.~.
Gay Pier tartlet' mwmwn - 3; ,
Rough Opp 160 ; x k.
(new, and refudbhod '.r
U. G. Sprinrk#er * h ►r ems. 3.00
~
Alte vtions t o)" .t'l0
Water 'urn Around 2D.00
ON MV CHAM9
TOTAL
SITE ADDRESS:
OMER NAME
i6o
INSTALLER PlAI?lE` 5e! r-7 t La c
s ,
STREET ADORM,
CITY: ST'.: ,
t~
- r!
PHONE
t ~
_ v
- - SU`rte
M t #
PUN
t
Mot
- ,
t
#W' lbr
Pke"voto
VON
e
-t kT,
WAMFLOW,
I E ~
FA LUW.'M.
Fes: M~yme' m
WA#E a
6 MF 4 i 7
( 4-
Rio
NOW
OVOMR
7 7
six-- i r~ r. S Y ib= -
1r ~ t
- _ ~i Ir.lll 6 N--~rir-rr1iG -rwrr..~~. iY.i~1..~.4.rn NIS 1iG111pF -
-
'r '
2005 RESIDENTIAL BUILDING PERMIT APPLICATION
City Of Eagan
3530 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
New Construction Requirements RemodelfReoair Requirements Office Use Only
3 registered site surveys showing sq. ft. of lot, sq. I of house; and all roofed areas 2 copies of plan Cad of Survey Recd _Y _N
(20% maximum lot coverage allowed) 1 set of Energy Calculations for heated additions Tree Pres. Plan Real 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 Add&n - indicate if on4e 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)
Date Construction Cost A/9 dej C) , ex)
Site Address ~ L3 &4441
(jrr, Zjgek- e, Unit/Ste #
Description of Work 0 74' Z& 11 lei
Multi-Family Bldg _ Y X N Fireplace(s) _ 0 _ 1 _ 2
4e
Property Owner /f/It f✓ i } t.J ~,/'fZ Telephone # ( 4#6 / O
Contractor Pea
'a lb ~+~tl1~S . ~fC.
Address , -172 1!9Z J ~G e City
State J tj&,50DR Zip ,551,IL/ Telephone # (4W)
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7674 Category 1 _ Minnesota Rules 7672
Energy Code Category • Residential Ventilation Category 1 Worksheet New Energy Code Worksheet
(4 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 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' rName Applicant's Sign e
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
C.1 32 Addition ❑ 36 Move Building ❑ 42 Demolish Foundation ❑ 45 Fire Repair
❑ 33 Alteration ❑ 37 Demolish Building* ❑ 43 Reroof ❑ 46 Windows/Doors
❑ 34 Replacement "Demolition (Entire Bldg) - Give PCA handout to applicant
Valuation Occupancy MCES System
Plan Review 100% or 25%
Census Code Zoning City Water
SAC Units Stories Booster Pump
# of Units Sq. Ft. PRV
# of Bldgs Length Fire Sprinldered
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 Other
Roof - Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests -Final
Framing _ Siding _ Stucco - Stone _ Brick
Fireplace _ R.I. -Air Test -Final Windows
Insulation 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
-7
Monday, November 07, 2005
VIA E-mail - tmiklyaCajcityofeagan.com
Mr. Tom Miklya
Buildign Inspector
Department of Building & Safety
3830 Pilot Knob Road
Eagan MN 55122
Ref: Metro Roof Panel side-wall detail, installation at 3723 Black Hawk Lake Court.
Dear Mr Miklya,
This letter is provided on behalf of the Metro contractor on the above roofing project,
Elite Exteriors (Jason Vogen) and specifically addresses Metro's side-wall detail
recommendations.
This Metro installation used two different techniques for flashing and weatherproofing
the side-wall areas of the roof. One of which is acceptable (Front of house) and the
other (Back of house), while providing adequate weather protection does not meet
Metro's long-term weathering standards.
SIDE-WALL Front of house:
The siding on the front of the house (as requested by the home owner) was removed
and the Metro panels bent up against the base wall sheathing. The siding material
was then brought down over the bent-up panels to provide a counter-flashing detail.
This is an acceptable method by Metro.
SIDE-WALL Back of house:
This portion needs to be re-done by removing the 3-1/2" stone-coated Counter-
flashing and cut the siding to allow insertion of a'Z-bar' up under the siding. This'Z-
bar' is then dressed down over the previously installed and bent-up Metro panels
providing a long-term weathertight finish. The Metro trainer - Daniel Detamore will
organize this repair with the local Metro rep - Dan Henkel schedule permitting over
the next two months.
Installation details as described above are acceptable to Metro and a Metro warranty
certificate for the product will be issued upon correction of the back side-wall flashing
detail as noted above and the attached drawing. '
If you have any questions on the above please do not hesitate to call our office.
Yours Sincerely,
;V• 4 &e#
P. A. Croft
Metro Roof Products V.P. Sales & Marketing
3093'A' Industry Street
Oceanside CA 92054 Encl. PDF of Side-Wall Flashing detail
Toll Free: Cc: Dan Henkel - Metro MN - e-mail: dhenkel123 a().yahoo.com
PH: Daniel Detamore - Metro Technical Training danield anmetroroofs.com
(760) 435METRO-9988-42
PH: (
Order FX: (760) 435-1162 Jason Vogen - Elite Exteriors - FX (651) 688-7817
General FX: (760) 435-9412
www.metroroofs.com
EtiteEW10-13-05v2 Rev. 11171051:02 PM
(760) 435-9842 Tel. GD 3093'A' Industry Street 13 Oct., 2005
www.metroroofs.com Oceanside CA 92054 SIDE-WALL -Siding Flashing Detail pg.1-00
kAr RWU for S=d Fowl#
(5)
(4)
(3)
(2)
(1)
- - - - - - - - - - - - - - - - - - - - - -
(6)
(7) (8)
TECHNICAL DETAILS
1 Metro panel bent-up against siding min-1 Winches 6 Panel batten (1X4 or 2X2)
2 Selant bead applied at top of bent-up Metro panel 7 Existing Asphalt Shingle roof
3 'Z-Bar' fitted up, underbehind siding as shown. Cut a slotislit in the 8 Existing 'L' Flashing as shown
siding to allow insertion of the 'Z-Bar.
4 Existing siding
5 2X4 Wall framing
PERMIT
City of Eagan Permit Type: Mechanical
Eaaan. Permit Number: EA095046
Date Issued: 07/21/2010
OR Permit Category: ePermit
41 it~ of E3
E
Site Address: 3723 Blackhawk Lake Ct
Lot: 13 Block: 2 Addition: Blackhawk Glen 3rd
PID:10-14352-130-02
Use:
Description:
Sub Type: e - Furnace & Air Conditioner
Work Type: New
Description: Furnace & Air Conditioner
Comments: Quesetions regarding electrical permit requirements should be directed to Mark Anderson. State Electrical Inspector. (952)
445-2840
Fee Summary: ME - Permit Fee (Replacements) $50.00 0801.4088
Surcharge-Fixed $5.00 9001.2195
Total: $55.00
Contractor: - Applicant - Owner:
Apple Lake Heating & Air Conditioning lolichael Lutz
207 150th Street West 3723 Blacldiawk Lake Ct
Apple Vallev NIN 55124 Eagan MN 55122
(952) 431-4328
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 Cite of Eaaan Ordinances.
ApplicantiPermitee: Signature Issued Bv: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA111005
Date Issued:06/07/2013
Permit Category:ePermit
Site Address: 3723 Blackhawk Lake Ct
Lot:13 Block: 2 Addition: Blackhawk Glen 3rd
PID:10-14352-02-130
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:One Window/Door
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings, call for framing
inspection. Call for final inspection after installation.
Window or Door:1 windows
Tim Schenk
Fee Summary:BL - Base Fee $500 $40.00 0801.4085
Surcharge - Based on Valuation $500 $0.50 9001.2195
$40.50 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 -
Michael Lutz
3723 Blackhawk Lake Ct
Eagan MN 55122
(651) 681-9046
Home Depot At Home Services
656 Mendelssohn Ave N
Golden Valley MN 55427
(763) 542-8826
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA119601
Date Issued:12/09/2013
Permit Category:ePermit
Site Address: 3723 Blackhawk Lake Ct
Lot:13 Block: 2 Addition: Blackhawk Glen 3rd
PID:10-14352-02-130
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:Two or More Windows/Doors
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings, call for framing
inspection. Call for final inspection after installation.
Carbon monoxide detectors are required by law in ALL single family homes .
Fee Summary:BL - Base Fee $4K $103.25 0801.4085
Surcharge - Based on Valuation $4K $2.00 9001.2195
$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 -
Michael Lutz
3723 Blackhawk Lake Ct
Eagan MN 55122
New Life Contracting Inc.
814 Grand Avenue
St. Paul MN 55105
(651) 224-3442
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA126864
Date Issued:09/15/2014
Permit Category:ePermit
Site Address: 3723 Blackhawk Lake Ct
Lot:13 Block: 2 Addition: Blackhawk Glen 3rd
PID:10-14352-02-130
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 .
Susie Case
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 -
Michael Lutz
3723 Blackhawk Lake Ct
Eagan MN 55122
(651) 283-5104
New Century Exteriors
P.O. Box 261
Big Lake MN 55309
(763) 262-2378
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA128787
Date Issued:12/05/2014
Permit Category:ePermit
Site Address: 3723 Blackhawk Lake Ct
Lot:13 Block: 2 Addition: Blackhawk Glen 3rd
PID:10-14352-02-130
Use:
Description:
Sub Type:Siding
Work Type:Replace
Description:
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please leave printed pictures of house wrap on site for the final inspection.
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: 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 -
Michael Lutz
3723 Blackhawk Lake Ct
Eagan MN 55122
(651) 283-5104
Craftsmans Choice Inc
26219 Fremont Drive
Zimmerman MN 55398
(763) 633-1390
Applicant/Permitee: Signature Issued By: Signature