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4555 Acorn St , - ~~U N 73630 sate of this ReI4 stL_v I, asp ensed E trical ('ontraetor caner, do hereby request inspection of the above electrical Wfftig inst ed at: Street Address or Route No_ ysS `s A cc t-4 slt, City'So s E It by- Sectioownhip'x' / Range County Da. Ika Which is occupied by R y m C t1 d` C Na i-z pyt* a m (Name of Occupant) Is a roughin inspection' required on this job? No p Yes JK Ready Now, IR Will Cali ;p 8RI . t • i~` m fA Power Supplier t) 0. k O J-zk "F r QG Address Mi~►~l. Electrical Contractor' ®w~ Q_ e °.►f Kn o n C" &et f itA 6Dntractor's License No ( ompany Name) Mailing Address d Y` 0 f V , Nk (Electrical Co tractor or Owner Making This Installation) Authorized Signature t Phone'No:2 70-aakb (rare cal Contractor or Owner g This Installation) Minnesota StOw Board of Electricity ® S/ / 7 19S4.1)niversity Ave., St. Paul, Minn. 55104--Phone 645-7703 REQUEST FOR ELECTRICAL INtSftCTION N 73630 CHECK BELOW WORK COVERED BY THIS REQUEST Type of Building New 'Add. Repair Check Appliances Wire& For Check Equipment Wired For Horse 19 ❑ ❑ Range Temporary Wiring ❑ Duplex ❑ ❑ Water Heater Lighting Fixtures Apt. Bldg. - ❑ ❑ ❑ Dryer )lectric Heating ❑ Commercial Bldg. ❑ ❑ ❑ Furnace Silo Unloader ❑ Industrial Bldg. ❑ ❑ ❑ Air Co r Bulk Milk Tank ❑ 13 ❑ ❑ List List l Farm Other Other Others } ❑ ❑ ❑ Here Here Affm COMPUTE INSPECTION."FEE `BEL Service Entrance Size: # Fee Feeders & Subfeeders; # Fee Circuits: # Fee 6 to 60 Amperes 0 to 30 Amperes 0 to 30 Amperes JJ 61 to 100 Amperes 31 to 100 Amperes 31 to 100 Amperes 101 to 200 Amperes Above 00 m s Above 100 Am Above 200, m Remote Control Circuit; Signs Transformers Special Inspection Partial or other fee,<-• Remarks I TOTAL 3'1 i D 1, the Electrical Inspector, here ify #b'-ve i ection haol,een mitzl 7 (Rough-in)- (Final) "Date CITY OF EAGAN 3795 Pilot Knob Road Eagan, MN 55122 N2 4468 PHONE: 4514-8100 BUILDING PERMIT $45,000. Receipt # 7278 Date September 1, 19. _ 77, To be used for o nu~ F atn S?avl o 4 f:sr$ Site Address`! ern _ Erect [ Occupancy Lot - Block 3 Sec/Sub.South Oaks_Alter ❑ Zoning Parcel # L Repair ❑ Fire Zone Enlarge ❑ Type of Const. V_ Q~ Name - '--a ~nd C. ~i1L9L+~*»t Move ❑ # Stories Address 22101cEiidfge Ave. Alt 105Demolish E] Front 7~2_ ft. City 140. Paul Phone 770-2226 Grade ❑ Depth Swap- Capp Homes Approvals Fees -Nome Address Assessment - Permit --Au_ Water & Sew. Surcharge - ~ Cit Phone - Police Plan check ww Name Fire - SAC 415,00 a: Address Eng. - Water Conn. 'f Qw city Phone _ Planner Water Meter Council hereby acknowledge that I have read this application and state that Bldg. Off. the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. APC - Total 6ni_WT Signature of Permittee- 4 il'Mand C N tzmanu A Building Permit is issued to: C. on the express condition that all work shall be done in ac rdance with all applicable State of Minnesota Statutes and City of Eagan Ordinances. k Building Official T 1-.~ry - ti I lsnwll oww bard Po odow mechanical IWSPECTIOM DATE IMP. Roweb4n flow Footings ewe Inw. Do* how Foundation Frame/Ins. Final 5 J~v Remarks: J 7 t r A fi` /i I ti /~.~'ic> Gr 71 CITY OF EAGlkR k, 3795 Phut Knob Road, Eagan, mhmetotc SS123 Phone: 45444100 - SEPTIC TANK & bRAINFIELDPERMIT No. 1) Date: - Novnmher 18 r 1977 Receipt No.: 08165 _ Single Site Address: 4555 Acorn _ Residential Lot -2 Block 3 Sub/Sec. Multi Res., Comm./lhd. Name Raymond C. PNutzmann new - New/Alter/Repair, . Address Cost of Instaltation - ` C City Phone: 10.00' Permit Fee _ y Name Nutzmann (Killing) Surcharge' • 50 City Phone: Total 10.50 This Permit is issued on the express condition that all work shall 4done in accordance with all applicable Stag of Minnesota Statutes and City of Eagan Ordinances. Building Official CITY OF EAGAN 3795 Pilot Knob Road Eagan, Minnesota 55122 Phone: 454-8100 PI,Ui ,MING _ PERMIT No. 953 November 2, 1977 07974 Date: - _ Receipt No.: Single Site Address: _ 4555 Acorn Ave. Residential X- Lot 2 Block 3 Sub/Sec. _ Sou Oaks Multi Res., Comm./Ind. Name Raymond Nutzmann _ New/Alter./Repair new Address _ 2210 rldridge Apt. 105 _ Cost of Installation C City No. St. Paul Phone: Permit Fee _ 20.00 Name same _ Surcharge .50 0 u .a. dress - - c 0 City Phone: Total 20.50 This Permit is issued 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 i f { CITY OF EAGAN 379$ Tot Knob Rood ~ Eagan, MinoesoM $5122 Phone: 454-51110 WELL -PERMIT No. 300 Dote: February 27, 1978 Receipt No.: - 0 910 5 Single 1 Site Address: 4555 Acorn Residential l4 X 2 3 South Oaks Block Sub/Sec. _ Multi Res., Comm:/Ind. ,Lot Nutzman new Name New/Alter./Rear s Address Cost of installation - No• Cuts Paul Phone: Permit Fee i~ 10. 00 1!P Nome Corcoran's Hdwe. & Impl. Co. surcharge .50 Address2975 145th St. W. 0 Rosemount 55068 ,1,0.50 City Phone: Total - This Permit is issued on the. express condition that all work shall be "done ern. cacGonmnie 'iw * ddl applwcaable2 ` to of Minnesota Statutes and City of Eagan Ordinances. I Spildfng ciat CITY OF EAGAN ac t 3795 Pilot Knob Rood s Eagan, Minnstate 55132 , f" Phone: 154.ffi100 ~ HEATING 1098 i No. PERMIT f February 13, 1978 A9431 Date: Receipt a.: Single 4555 Acorn Residential Site Address: Multi R q;., Comm./Ind. Lot 2 Block 3 Sub/Sec.Sutn Oaks Ra Nutzmann new Name Ray WW/Al r./Repair m 2210 Eldridge Ave. #105' r _ Address Cost of Installation City No. St. Paul 55109 Phone Permit Fee 20.00 E .50 Name SaTrlt? Surcharge b Address - e City _ Phone: Total r, This Permit is issued on the express condition that all work shall be done in accordance with all'appiic 6t Staf "pf Minnesota Statutes and City of Eagan Ordinances. Building Official - - CITY OF EAGAN 8795 PRot Knob Road Eagan, _MN 55122 NQ 446 `PHONE: 434-8100 BUIL©114G PERMIT APPLICATION $45,000. Rec44gt # 7275 To be t fae 1601 X &_W'" Bate Se "!ftr 6_1? 77 Site Address 4555 A" Erect Occupancy I Lot 2 Block 3 Sec/Sub. South Oaks` After Q Zoning Parcel # 1021200-820-03 Repair p Fire Zone Enlarge ❑ Type of Const. T ~ Name Ramood C. Nut s~sn Move n # Stories z Address 2210 8iridRe Ave.Pt 145 Demolish El Front 76 ft. No. St. Paul 770-2226 Grade n Depth 28 Same d Capp Homes APPravels Fees p Name _ 00 Address Assessment Permit 124.00 Water & Sew. Surcharge 22.50 Cit Phcme Police Plan check W Name Fire SAC 475,9_ ~z Address Eng. Water Corm. dui city Phone Planner Water Meter Council hereby acknowledge that i have read this application and state that Bldg. Off. the information is correct and agree to comply with ail applicable "5_ _ • State of Minnesota Statutes a City of Ea ncV. APC Total Signature of Permittee A Building Permit is issued to:. Rit ,111it Xnaull on the express condition.that all work shall be done in oc oppli ble Stote of M' es Statutes arid' City of Eagan Ordinances. Building Official V'! MXT APPLIC M Zxclude 2 sects *f plans, 1 site plan w/*leftti*R S&t Ot aet &VW A"O". To be used for Valuation Site Address a hat see - '10 71200 020 03 45SS Acorn _ Darner a n. za a T*Is Mk( Address Arch./Enq. ThIspbome Address - t s Alter Zoning Repair Fire Zee Balarge Type at txD"st. Mmve # of Stories 1 soh From Grade _ Depth ~ICE - i f~MY R iii tw rime Assessment Permit water! Surrge Police PI" G! Fire Eng. Water Mm. Planner wafter Meter CmMil Bldg. Off. A.PX9 TOTAL 5. hi`? CITY OF EAGAN Remarks Addition Sm,"b Oaks Lot alk ~3 Parcel 10 71200 020 93, Owner fyw Wh1VIa C Q1A. IQL _12_-Street 4555 'ACOxrt Stage ~:iR~+tlt t~ $5123 Improvement E%6te Amount Annual Years Payment Receipt bate STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK - 370.40 0008329 8-3-83 Ike 15 SEWER LATERAL WATERMAIN WATER LATERAL WATER AREA STORM SEW TRK 617.00 0008329 8-3-83- STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. SUILDING PER. SAC 4 5 . 727 8 PARK CITY of EAGM 3795 PBot Knob Rol Eagan, Woviesoft 33122 Phone: 4544100 WATER SOFTENER PERMIT Nay 214 June 12, 1978 10126r Date: r Receipt` No.: - Single I ~ • . Site Address Acorn $t Residential Lot CA Block Sub/Sec. S C _ Multi Res., Comm./Ind. E Nome Raymond Nutzmann alteration 1de~vlAMer. ffte~oir 3 Address 4555 Acorn St. Cost of installation O City Eagan Phone: Pennit Fee 5.00 Name Milbert Co. - Culligan Surcharge • 50 Address e 0 So. St. Paul 5.50 City Phone: Total r. This Permit is issued on the express` condition that all work shall be done irx accordmnte with 66 S- late of Minnesota Statutes and City of Eagan Ordinances. PERMIT CITY OF EACIo1N 3830 Pilot Knob Road PERMIT TYPE: e u L I ff pagan, Minnesota 5512271897 Permit Number: 0 3 32, ~ A I: . { je$2) 68f-44675 Date Issued: 4 / 8 I} SITE ADDRESS: ~a5"a AC011W ST LOT: 2 BLOCK 3 SOUTH OAKS ` P . I . N 10--71,200-0.20-03 f - I DESCRIPTION: REROOR/STORM DAMAGE; Bt4i.Idin.q Permit Type ST~61RM 0AfCAGE . 8uiIdlni '-Work Type RE IR ~ p r~ us Cgdp 434 ALT. RESZOENTIAL a - t x REMARKS: <5 .fi. fo y : a FEE SUMMARI N t ~ 1 Ct~~AC'tOR: Applicant ST LIC. OVVNER: A1TffC',,,R00FING _ 18954040 20139140 N'UTIMAR kAy ~ b r 11683 RUPP ,R 0. 4555 ACORN ST BURNsviLLE: ~iN +S53V EABAW MN 55123 . (612} 695-0040 6151 j X54-5,795 F T~ --hereby ac*nowi-Lh.6, -1 have r°et h f S'. apP'1-€=4lAVon' :a.1 5t4't~' ~41i*b' u: intormatiorr 5- correct .#rrd agree to damply w*itri all a pTickb t i°fi 1Ms .t tatutesan d;City ff F'a'un ardinarTCC h; Al-a- APPLEARITlPE MftiSE SIGNATURE I SPEZ 110N RECORD CITY OF EAGAN PERMIT TYPE: t> I 3 f 3830 Pilot Knob Road Permit Number: el'; ~ 4 Eagan, Minnesota 55122-1897 Date Issued: (612) 681-4675 SITE DRESS: ` _ r, t ; t k sn APPLICANT; fit,' s"V)R11 ,1 A` I, I t'. R"')IJIN14 •~t911(#i fort~;`r; ~~yt;+} ~°~~i_.(F(~4?I hr ~ PERMMT SUBTYPE: TYPE OF WORK op W 4' INSPECTON DA -,F M ~_r i n T,. p PhbrmPt HoI¢or Date T # PLUMBING HVAC Inspection Date kps CerttmtYs FOOTINGS FOUND FRAMING ROOFING ROUGH PLUMBING PLBG - AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYP BOARD FIREPLACE FREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL DOMESTIC METER IRRIGATION METER FLUSH MAINS CONDUCTIVITY TEST HYDROSTATIC TEST BSMT R.I. BSMT FINAL DECK FTG DECK FINAL i l I rs BUILD r t -two I* CITY OF EA!IMN 3930 PU.OT X NOR lV - SS122 4 "1-4675 New C'enswon Roguirernents f medelsl is rill ♦ 3 registered site surveys ♦ 2 copies af#lan ♦ 2 copies of plans (include beam & window sues; poured Md. design: etc.) ♦ 2 ado surv s ~ r a~dditidns ~ t~ecics)' ♦ t energy calculations ♦ 1 enerW aft"04a heated a$Mons ♦ 3 copies of tree preservation plan if lot platted alter 711f93 required:..._. Yes _ No DATE: CcNSTR Tio~:TA`~ rti i ORK: ~ DESCR=RESS: STREE c on P-T ~S-T , BLOCK: SUED./P.I.D. Iqk: C? LOT;,,_ Name:,__ LV ` a `14 Phone S - LS:,1-- 1 PROPERTY Last Fi t OWNER Street Address: 6-657 'A-CO City . State. Zip: Q Q-22 company: Phone CONTRACTOR 4" C, C 1(-K ~ Street Address: 1^h License # City 1- ~rt•J~U 1~Q State: r _ Zip: r ARCHITECT/ ENGINEER Company: Phone Name: Registration Street Address: City State: Zip: Sewer & water licensed plumber (new construction only): Penalty ap;*d When Dress and lot change is requested once permit is issued. I hereby acknowledge that i have read this application and state that the information is dorred and agree ta, y with all applica State of Minnesota Statutes and City of Eagan Ordinances. Signature of Applicant: OFFICE USE ONLY Certificates of Survey Received Yes No Tree Preservation Plan Received , Yes No Not Required CITY OF EAGAN Remarks Addition Sonf-h [k=IGS Lot Rik 2 Parcel 10 71200 020 03 Owner Street 4555 Acorn ~ State Eagan.MN 55123 i Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK 370 .00 0008329: 8-3-93-Jlo,..~ 24-67 15 1 , SEWER LATERAL w_ WATERMAIN WATER LATERAL WATER AREA STORM SEW TRK 617.00 0008329 8-3-83 STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. BUILDING PER. 144623 - SAC 475.00) 2 8 PARK *4 ra j i• fir= SEWER CONNECTION CHARC ES: SAC 650.00 ACCOUNT DEPOSIT 15.00 _ SEWER PERMIT J ' --LO-- 50 TOTAL FOR SEWER H_tJP _ WATER CONNECTION CHAR+OES s ` 14ATER CONNECTION 550.00 METER 67.00 TREATMENT SURCHARCE 204.00 ACCOUNT DEPOSIT 15.00 14ATER PERMIT 10.50 PLUMBING PERXIT 12.50 TOTAL FOR jATER BOOK-UP 859.00 TOTAL FOR SEWER & WATER HOOK-Up t9INI14tiM PLUMBING MARCE FOR COMMERCIALS • 2-3~ 'Its: BILL BRANCH, SUPERIN EMENt OF STREETS AND EQUMr , F?W: THC S A. COLBERT, DIPBCIMR OF PUSLIC WORKS DATE: s 3BBR 22, 1982 (MAVEL, FUM WASH OUT I have received a call from Mr. Ray Nutwenn at the above rofer (454--5795) requesting raintenaance on the gravel rc dram ditch it fvrmt~. i of his house. Please review the situation, and if reoessaxy, contact Mr. Nutmrann to get further clarification pertaining to the c 1a nt: and, take the appropriate actim necessary. TAC/jack i o° 20BUILDING PERMIT APPLICATION (RESIDENTIAL) ~ CITY oIS encaN ~o ~ov~s9 vpo 5 3830 PILOT Kf Q6 RD - 55122 651-MI.4675 W / A r3 t4 of tot, sq ft of houso 2 copious Of OW W4 9 MOW afeaaa (01 MQft= WA 9=mm t X64 of 1~nery~ i > 2 cis Of pkm Wow bo nn i wkidow d ws. poumd fhd. design; etc.) i site yfiDt' td0 o > I sN of anwgy cateLkAkra > 3 cOes of be* prasriro Ow V lotpiatted aftu 7/1193 DATE: CONSTRUCTION C08r MSCWWN OF WORM . mss oYh sTrr Asa. LOT. BLOCK: SURD./P.I.D. Ja Q i PM IA* I+lA d Sk"Addw hCD~-n Stals• ry' S CRY CONTRACTOR Ale. ~ ~ coy Skft. ARCHITECT/ Strew AddreW Regftoffort C :z CBy StCtte' S "d plumber . I t tjt acknowle fte I how mad its opp#w*m, *ft W irie irrlfon nOWn is wff6d, tc+ e of fU motes and C ► CSI fog= Oft4nonc" Slgnok" of Appkont: OFFICE USE ONLY Cer& of Survey Received Yes No Try ation Plan Rscsived Yes No Not Requlred lq# t ;tit r N. ~ ~T ~ t: n . a. CIL" ; AA-iL -74 Lo N r Q ~ , 'Fri t ~ x,'. I-A c~ E F _ F~s ttli t' QAI 14 w. .3 not `ytpyi:: ~ `Rrya~ yt .X%7 e y~ 2wpiwd sh^~ X71 ; 747N1~~ yaWiJ HaNI Su3 1 Y~ ~i t W of Effigy t;ir ns • 3 copies CATMe For a Poi # 1Dfffi814d M103 RimJoist OWOpfmoetw'i ,jW: ~ Moj U*" DATE fi:h,-W~00 VALUMON f. ti -if MUi. t4AMKY i UWNG, W. ;i;14tAW.VNITS? i'ROPERTY OW z i r TYPE OF WORK 4#'Y » APPLICANT 11 44 A M.. 2,:4 d. Energy Code Calory MINNESOTA RUB' 70 CA1,P.G (check one) Rss~'ftstit~'- wab, e# Energy i*r ps Oft"" §wftlpfod, WNNES I' RUB 767 New En*W Code Wo*0UwtSubrnMW Plumbing Contractor: Plumbing Systcm Indudes. 'air Softm" Lkvm 0kler P+ s$ 4 _ w r Heater c41tL S s Nb. of Baths Mechanical Contractor Mechanical System Includes: „ A C0Dditi Heai, Recovery System. Sewer/water Contrac tc above inforrnrion owst be sui tted p r * p +g of melon. hereby acknowledge that t ham read this application stag the #k~~~ i~~~> xs~c r+ x and to comply with all applicable State of Mir~nesoto Statutes and C.Ity of Eagan ?rct+ 0M. Certificates of Survey Received Tree Preserve t Plan'ROCONW! ! Qt*4d Ilp ated Vol cl It $1, ice . 'K... , {rtt'i' v+ : iwt ~3? t ti ej .i3 'i.yt ,'►'t a Ilk lp- 45 V Addition 42 0WOW JP 43 7ft~*f ~k. l~l'. "~irbt~t ~t'~ ~ ~ ~ i# 4:a~~ ~ a~gf~i►nt , . VOU"djon y Nbr. of Unl qtr. of Bitl~ecf T)" Of C491m, _V103 roofings { b } ` Footings Omk) Fim" c.o. ~o HVAC b~ttt'T'ile ~ ,Y Roof ► 1piml Framing Pct ! A&Gs Tesu _ final Fireplace R.I. :Ait Tact ~ Vital *uiart itchwa`en} AP prwtd, B F$e ' yetr ktir'bY-.. ~~i'-lwnr~•' Pilo ftvIew JAM MC Oftjt SAC 1 -41 Wfvw supply ! $W Remit Stir 1 Tmtm"t Pwt I birV PWMft - AFi_h PERMIT City of Eagan Permit Type:Building Permit Number:EA117589 Date Issued:10/21/2013 Permit Category:ePermit Site Address: 4555 Acorn St Lot:2 Block: 3 Addition: South Oaks PID:10-71200-03-020 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 . Matt Pietruszewski 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 - Raymond C Nutzmann 4555 Acorn St Eagan MN 55123 Rybak Brothers Construction Llc 2206 East 117th Street Burnsville MN 55337 (952) 405-8871 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA120267 Date Issued:01/29/2014 Permit Category:ePermit Site Address: 4555 Acorn St Lot:2 Block: 3 Addition: South Oaks PID:10-71200-03-020 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 - Raymond C Nutzmann 4555 Acorn St Eagan MN 55123 Rybak Brothers Construction Llc 2206 East 117th Street Burnsville MN 55337 (952) 405-8871 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA122213 Date Issued:04/29/2014 Permit Category:ePermit Site Address: 4555 Acorn St Lot:2 Block: 3 Addition: South Oaks PID:10-71200-03-020 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 or installing Bay or Bow windows, call for framing inspection. Call for final inspection after installation. Carbon monoxide detectors are required by law in ALL single family homes . Valuation: 500.00 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 - Raymond C Nutzmann 4555 Acorn St Eagan MN 55123 (651) 454-5798 Home Depot At Home Services 656 Mendelssohn Ave N Golden Valley MN 55427 (763) 542-8826 Applicant/Permitee: Signature Issued By: Signature Use BLUE or BLACK Ink r----------------i I For Office Use � I � C1 � Permit#: /� ��✓� I lU� Ol ����11 I I � p�'�C��� I � Permit Fee: � 3830 Pilot Knob Road ,l � Eagan MN 55122 � � �,, ,, u ,,,/,�y) N'Y�•(,'��%1 � Date Received: j Phone: (651) 675-5675 '�1Z �C�'���"'V � (� I Fax: (651) 675-5694 � �� �/��^-� I Staff: � �,� 0 �-----------------� 2014 RESIDENTIAL PLUMBING PERMIT APPLICATION Date: �� �-/`�'�y Site Address: �s� �o�/� �T, Tenant: Suite#: , , �., Re�ide�`tlQwne� ����; Name: n � Pnor,e:�ir= 1��'�" �.3�f�' ` , sy7 0 Address/City/Zip:��Z 3 Z 8Y8�y'T'/ '�f�i v�t �Lo�.t� GJl�S c �� �-f- �4-� ,7,3� `,�`, Name: _ / �� License#: C�S�SG o 9 jr'�� K4 � Address: /�O"3 �� City: �./'f✓�N1�A4�ih GO�tt`'a�tQr,� � �- �� � `°�1 � ��� Sfiate:�Zip:��'—'�2 Y Phone:�r/ �G3��.3� ,� , � Contact: �Gl� Email: �f/� ��, t�,�O� . W I �New _Replacement _Repair ^Rebuild _Modify Space Work in R.O.W. Tylp4'��Wf?Ck, — � ' " ' Description of work:_�7�'s /�no+�siai� RESIDENTIAL Water Heater Water Softener Lawn Irrigation �RPZ/_PVB) ��r�����p� Add Plumbing Fixtures�Main/_Lower Level) Septic System � New �Water Turnaround �Abandonment RESIDENTIAL FEES: $60.00 Water Heater, Water Softener, or Water Heater and Softener(includes$5.0o State Surcharge) $60.00 Lawn Irrigation (includes$5.00 minimum State Surcharge) $60.00 Add Plumbing Fixtures, Septic System Abandonment, Water Turnaround*(includes$5.00 State Surcharge) "Water Turnaround(add$200.00 if a 5/8"meter is required) {f � �i�, /-1�U�I $115.00 Septic SVStem New($10.00 per as built) (includes County fee and$5.00 State Surcharge) � � �2 TOTAL FEES $ CO�� CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility darrra e � 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. x � ��+-°l'��/��t,�3e� Applicant's rinted Name pplic s Signature � �� : FOF��'?�FIC�US� ' Rr�vi�w�s� B�: aat�:i '�� Requ�red�lnspectia�ns: t.�i�d�ar�r�t�r�d������ ; Re�u���-f� }�€rTest ! Gas�Te�t � ��:Fkn�l �: i Meter Related It�rtts• Meter��z��_.�.. �Radic�,F���cf Mar��.m���r Staff: . Use BLUE or BLACK Ink --------- � For Office Use j • � j�a���i ; (���Tr �� ����� I Permit#: � J � � �f(D�. ° i � Permit Fee: � 3830 Pilot Knob Road � I Eagan MN 55122 Phone: (651)675-5675 � Date Received: � Fax: (651)675-5694 I I � Staff: � `_____�__�___�___J 2014 SEWER AND WATER CONNECTION AND AVAILABILITY CHARGES EXISTING RESIDENTIAL PROPERTY Address: "7-�/C� ���.�'1_ �� F�?R�F�I�E;USE t?Nt�Y ' Property Owner: � � �PRV r�quire�l ��� (p S�� ' 7 Cf S ,�-. A �, Cit�t R-�-VMf Permit Phone: Contact Name:_�C�� 1V vI:�L�'Ylf��� r�t - �t�S.- 'i t� _ 3��y' Gvunty R-t7-W Permit Plumber: ��Ptu�rttbin� Re�i�rn�t '' SEWER ' '1�CAT�R Sewer Service 'Q� .. , ��,;3�, Water Service p..� _�;. Sewer lateral charge �° Water lateral charge �• Sewer trunk �.�� �• Water trunk ��� �` City SAC @$100/unit ���' `���,`,,� Water Sampling Fee �` �`�v MCES SAC @$2,485/unit ' Water supply storage Recei t#:'�'� 'L'1`� �+� p �_, Date: ` '�TI Receipt#: , Date: Permit Fee $60.00 Treatment Plant @$828/unit 5��;�g .v� State Surcharge $5.00 Permit Fee $60.00 TOTAL: ��,�: State Surcharge $5.00 "Plumbing Permit Required-water meter to be aeq,uired with building permit TOTAL: �3,.� ��i;� ��E���`��TE� Sewer Service ' Water Service Sewer lateral charge �, - Water lateral charge Sewer trunk � , Water trunk �'dtfa�,er Sampling Fee � City S�i��.,.,�o... .. MCES SAC "'� Receipt# ������Date Water supply�8�...stri�age `"'"� .,.,°M1, Re�ipf"��# , Date .Txca`tment plant �� Permit Fee $72 . State Surcharge $5.00 .°• ^°"�j "Plumbing Permit Required-water meter to be ""' �-�" acquired with building permit TOTAL: Number of SAC units is determined by the Metropolitan Council Environmental Services (651) 602-1000. 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.qopherstateonecall.orq Cc: City of Eagan Finance Department Minnesota Pollution Control Agency 520 Lafayette Road North 5t. Paul, MN 55155-4194 Instructions RECEIVED SSTS Abandonment JUL 2 0014 Reporting Form Subsurface Sewage Treatment Systems (SSTS) Program) This fort is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Stat. § 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned SSTS. The use of this form is not mandatory; however the information on this form must be submitted to the local government unit (LGU) within 90 days after the abandonment. This form may be completed by a certified SSTS practitioner or by an individual who has direct knowledge of how the system was abandoned. Property information / ,/' Date of abandonment: �6 —ZO1 Y Reason for abandonment: Csli d{rj/0,1 — J_ecX L t Property owner name(s): Property owner's address: City: --d L lr-L�)e _ _ State: &A>` C • Zip: Site address (if different): rf� r� d�• City: State: 2-i"- Zip:.S� Compliance Information 1. All solids and liquids removed from all tanks? Wes ❑ No 14 Disposal Site: T/c,�iK�w 2. All electrical devices and devices containing mercury removed? ❑ Yes ❑ No ,-4IW- Disposal Site: 3. All underground sewage tanks crushed and filled with soil or rock material? Was ❑ No or Removed and disposed off site? ❑ Yes KNO Disposal Site: 4. Contaminated materials* removed and disposed off site? ❑ Yes Wo Disposal Site: 5. All underground cavities" crushed and filled with soil or rock material? WYes ❑ No or: Removed and disposed off site? ❑ Yes �60 Disposal Site: 6. Future discharge to system permanently denied? �nes ❑ No Methods) used: S'L "Contaminated materials = Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile fabriclrosin paperlstraw, tanks, contaminated soil around leaking tanks, any soil that received sewage from a surface failure (7080.2500 subp.3). —Underground cavities = Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers (7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution boxes. www.pca.state.mn.us • 651-2%-630p . 800-657-3864 TTY 651-282-5332 or 8q0-657-3864 • Available in alternative formats wq-wwksts4.03 • 11/21/08 Page f of 2 Map Include location of building sewer, septic tank(s), soil dispersal system, cesspools, seepage pits, and other pits. Also include a permanent reference point(s) and dimensions. T North �~�{ 1(e Certification I hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any iocai requirements. Name (please print): ��� i �/ Title: p6,jA e Address: CS) City: State: ��i{/ Zip= 41. T/ 514Phone: � Liciflicable): #./� — Date: 7-14— *.a/ fi www.pca.state.mn.us • wq-ww1sts4-03 • 11121108 651-296-6300 800-657-3864 TTY 651-282-5332 or 800.657-3864 • Available in alternative formats Page 2 of 2