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1904 Carnelian LaneCITY OF EAGAN 3795 Pilo! Knob Road Eagen, Minnesofo 55122 Phone: 454-8100 •LrAv,R 9CIVEMM Date: I2-Y-'S8 PERMIT $ite Address: 1904 Ca?? Tam ^ Lot Block 13 $ub/Sec. Cedar Geri-Va 5th _- I Name 3ary M. Nadvan -? c O 0 t 0 ? 0 V Th M Address 1904 emmn'1'1'an 7am Cify ?cian Phone: 894?2,001) Nome I'ri'?INW?- C cytk"IYTy Q°`'"'Q$P1 Address 1001 PtxiL" AvF31iI2 Cityx. lzt. 1'aul 55106 Phone: 459.-2241 is Permit is issued on the express condition that all work sholl be nnesoto Statutes ond City of Eagan Ordinances. No 296 7.2514 Receipt No.: Single Residentinl Multi Res., Comm./Ind. New/Alter./Repair Cost of Installotion Permit Fee Sed0 - .50 Surcharge _ Total 5.50 done in accordance with ull opplicable Stote of Building Official CITY OF EAGAN Remarks * Cedar Grove Acqyfsition adatioo-CEDAit GitovE #S Loc 2 eik ],$ Parcel 10 16704 020 13 Owner L-111D; L. t. "ui j41 st,eet 1904 Carnelian LdriE State Ea9an• MN 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK 1967 100.00 45.00 C003463 3-5-77 SEWER LATERAL 196EI WATERMAIN * WATER LATERAL 1972 6 ?.00 24.28 25 Z - 7 WATER AFEA STORMSEWTRK 3 19']]. ']?.?0 3.5 0 4$.$0 C003463 g-$- 7 STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. BUILDING PER. SAC 200.00 PARK RECORD OF COMPLAINT Date: 7/10/00 Type of Building: X Residential _ Aparhnent _ Other, Name: Brenda Christianson Address: 1904 Carnielian Lane Phone nuxnber: 952-891-4174 (h) 507-420-1382 Cell Complaint: Entire basement to 2%z feet to the top floor. Comment: Waste Management Action Taken By: Mandy Boudreau EAGAN TOWNSHIP N° 1667 BUILDING PERMIT Ownex ---.a....... 4:w??--..r...e-.?.sL:..-`-.. Address (Pzeseni) ._................... ......_ Buildex ............................. _............................... ._.................. -.... -' --? Address ......... ...... ................. _..-------------- ...... .... ..... ........ ----- -...__.. Eagan Township Town Hall /U Date ....... ?i.lL__I................. _.. SSoriesl To Be Used For Froni Dep1h Height Esi. Cosi Permi! Feel- ---Aemarks -------------- ----- I ---- -L--- - ?c' ?, -I - - - - --- ----- g LOCATION This permit does ao1 aulhorize the use of streefs, roads, alleys or sidemalks nor does it giva the owner oz his ageni the righi fo cxeale any situation which is a nvisance oz which presenfs a hazard fo the healih, safefy, eonvenience and generalwelfare !o anyone in the communiiy. THIS PERMIT MUST BE KEPT ON H£ PREMISE WHILE THE WORK IS IN PROGRESS. This is So eeriify, ihal... .C.t..°.-:eE''..:..... L ..'.'.'t°.... aspermission So eree! a....?. ....... ?c. '" ...... _upon the above descxibed premise subject lo the provisions of the Building Ordinance for Eagan wnship ado ed April 11, 1955 GF..-4 :.--.?a!.'.".`::.'.-s.. ?d-'?? ......_......... ........... ........_.l.} ''.. ?._...(j.?? -""--°---- Per .._ ._..__ V Chairm.f of Tn wn Bo?rd f Building Inspeclor? ?J CITY USE ONLY L BL I ? RECEIPT#: suso. C a CQ Q?Y .l-e_ Al 5 RECEIPT DATE: PERMIT# 2000 PLUMSING PERMIT (RESIDENTIAL) CITY OF EAGAN 3830 PILOT FINOB RD EAGAN, MN 55122 651-681-6675 ?? Please complete for: ? single family dwellings ? townhomes and condos when permits are required for each unit ? backflow preventer for underground sprinkler system ?v 1 cnrrnooc FOCH # TOTAL Alterations to existing dwelling - minimum fee Describe: $ 30.00 Bath tub $ 3.00 x = $ Floor drain 3.00 x = $ Gas pipin outlet ' minimum - i 3.00 x = $ Hot tub/spa 3.00 x = $ Kitchen sink 3.00 x = $ Laundry tray 3.00 x = $ Lavatory 3.00 x = $ Septic System newirefurt>isned • requires MPC Ile. 75.00 x = $ SeptiC System abandonment 30.00 x = $ RPZ new installatioNrepaidrebuild 30.00 X = $ Rough opening 1.50 x = $ Shower 3.00 x = $ Under round sprinkler ifdwelling is under consWCtion 3.00 x = $ Underground sprinkler if existing dwelling 30.00 x = $ Water cioset 3.00 x = $ Water heater 3.00 x = $ Water softener IT dwelling under constructlon 5.00 x = $ Water softener if existing dweltlng 30.00 X = $ Water tumaround 30.00 x $ State Surcharge 50 -> -> --> $ .50 TOtal --' Reminder. Call for inspections of alterations, i.e. water heaters, water softeners, etc. - ------------------------ I -- ha-ve --re--a-dthis ppl-----a----ica-t-ion, tat----s----e-that ----th--e ---------- is - wrt---e-d-, -and ----agree ----- to comply --- with - all -- - applicable Cily --- - ----- ---• - -- ----- - --- -- ------ I hereby acknowledge that iritortnation of Eagan oidinances. It is the applicant's responsibility to notiry the property owner that the City of Eagan assumes no liability for any damages caused by the City during its nortnal operational and maintenanca adivities to the facilities canstructed under this permit within City property/right-of-way/easement. SITE ADDRESS: OWNER NAME: : INSTALLER NAME: U'-1 L.O. v STREET ADDRESS: CITY: TELEPHONE #: (AREA CODE) STATE: ZIP: u.,V?-- O Vl TELEPHONE L,,S ( -?l-4 (AREA CODE) SIGNATURE OF PERMITTEE 2000 STORM DAMAGE PERMIT APPLICATION (RESIDENTIAL) 4A - CITY OF fAGAN ? e? ? 3830 PILOT KNOB RD - 55122 651•681-4675 Reaulrements ? 2 coples of plan DATE: 0 O CONSTRUCTION COST: DESCRIPTION OF WORK? 1? If rr?Iti-fami bldg., how many units? ?1,f5 ' /7Zt !n'I 4? INDICATE THE FOLLOWIIVG EQUIPNi M TO BE REPLACED AWD BY WHOAA: ?Plumbing ?iomeowner Q ContracTOr Name Mechanical -?omeowner gL Contractor Name "Note; if somebody other than the homeowner is pertorming plumbing or mechanical work, they must apply for appropriate permit. Only licensed piumbing conirqctor or homeowner may complete plumbing work. STREET ADDRESS: I % o4 SUBD.IP.I.D. #: LQT: ? BLOCK: PROPERT`f OWNER Name: 4??,eV Phone #: &V"2`7 / ^ Last Flrst a/'? / ctty state: / / /A1 zip: Sfreef Phone #: COMRACTOR (area code) Street Address: License N Exp. Glty Sfate: ZiP: 1-1 I r,UU I hereby acknowledge that I have read this application, state that 1he informafion is correct, and agree to compty wHh allapplicahle Sfate of Minnesota Stalutes and Cify of Epgan Ordinances. Signature of Applicant: ?Y?? ?-?'// !/?'°dr° "<5t? 1999 BUILDING PERMIT APPLICATION (RESIDENTIAL) ?$ 31 ? 3830 PILOT KNOB RD - 55122 I 651-681•4675 New Conshucifon Reauiremenls ? 3 registered sNe surveys showing aq. M. of loi, sq. tt. of house and Qp roo/ed areas (20% maximum lot coveraae allowed) D 2 coptes of plans (show beam d window sizes; powed fnd. dealgn; etc.) ? t sef of energy calculahons ? 3 copies ot hee preservafflon plan N{W plalled aXer 7/1193 DATE: f 1 J 1!," ) 1 ?"'! ?f- ? - !? /) DESCRIPTION OF WORK: STREET ADDRESS; ? LOT: ? BLOCK: COST: ???)r)o . ? PROPERTY Laat First ??( OWNER Street Address:`1 /1?? V n /? ?y, l.(.i.."? ln ? 1LLi" l j(,l j e.{ ?}.. ,,, n' ? ?? J ! City State: - ?f Zip: ?-1 Company.&a( Phone #: ? :2 Tf1 LT7U lJ r (area code) CONTRACTOR SheetAddress:?J? / ?? ? _?r?-J? J ' \? • Lieense ?-? . Z "aM City diij ellState: Yip: ARCHITECT/ ENGINEER Telephone #: area code ( RemotlellReoah Reauhements 2 copies of ptan 7 seT W energy calculoTfons tor healetl addXlons 1 s8e survey for exferior addNions R decks Name: Sfreet Address: Registratfon #: City State: Sewer R water Iicensed plumber (reauired for new conshuction onlvl: Zip: Penalty applles when address change and bt change is requeriod once permH Is Issued. Ihereby acknowledge that I have read this applicaHOn, state that the informatlon is con f, and a ee to cdmply w all applicabl 5iafe of Mtnnesota StatuTes and Cify of Eagan Ordinances. SlgnaSure ot Applkant OFFICE USE ONLY Certificates of Survey Received _ Yes _ No Tree Preservation Plan Received _ Yes _ No _ Not Required ? OFFICE USE ONLY BUILDING PERMIT TYPE 01 Foundation ? 06 4-plex ? 11 10-piex ? 16 Fireplace ? 21 Porch (3-sea.) ? 02 SF Dweliing ? 07 5-plex ? 12 12-plex ? 17 Garage ? 22 Porch/Addn. (4sea. ? 03 1 of _ plex ? 08 6-plex ? 13 16-plex ? 18 Deck ? 23 Porch (screened) ? 04 2-plex ? 09 7-plex ? 14 ApaRments ? 19 Lower Level ? 24 Storm Damage ? 05 3-plex ? 10 8-plex ? 15 Lodging 0 20 Pool O 25 Misceilaneous WORK TYPE ? 31 New ? 35 Tenant Impr ? 39 Gas Line Only . ? 43 Siding/Soffits/Fascia ? 32 Addition ? 36 Move Bldg. ? 40 Gas Insert ? 44 Windows/Doors ? 33 Alteration ? 37 Demolish Bldg.' ? 41 Wood Stove ? 45 Fire Repair El 34 Repair ? 38 Demolish (Interier) /15--->42 Reroof "` Give PCA handout to applicant for demolition permit GEIdE^AL INFORiUIkTlOt: Const. (Actual) Basement sq. ft. (Allowable) Main level sq. ft. UBC Occupancy sq. ft. Zoning sq. ft. # of Stories sq. ft. Length sq. ft. Width Footprint sq. ft. APPROVALS Planning Building Permit Fee Surcharge Plan Review License MC/ES SAC Gity 5AC Water Conn. Water Meter Acct. Deposit S/W Permit S/VN Surcharge Treatment PI. Park Ded. Trails Ded. Other Copies Total: Engineering ? ? ?)) rG? Valuation: Census Code. SAC Code No, of Units No, of Bldgs MC/ES System City Water Booster Pump PRV Fire Sprinklered Variance SAC Units % SAC _ city of eagan MEMO TO: DIANE DOWNS, UTILITY BILLING CLERK FROM: ED KIRSCHT, SR. ENGINEERING TECHNICIAN DATE: AUGUST 23, 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 yg 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 p Block 10, Lots 1-23 23 Block 11, Lots 1-14 14 Block 12, Lots 1-9 g Block 13, Lots 1-75 15 208 The City is currently being billed by Dakota Electric for streetlighting in the above listed subdivision. Edward J. irscht Sr. Engineering Technician Cc: Mike Foertsch EJK/je EAG#iN TOtJNSHIP 3795 Pilot Knob Road St. Paul, Minnesota 55I11 Telephone 454-5242 PERMIT FaR SES7ER SERVICE CONNECT30N DATE• necgnher 1,01967 OWNER:s;pdar Grove Const_ 00 _ PLUMBER Steins ". NUMBER 8q Address Lot 2 Blk 19 C.G. 5 TYPE OF PIPE Cast Iron _ DESCRIPTION OF BUILDING IndusYriall Commerciad Residential Multiple Dwelling No. of unies Location of Connections: Connection Charge 9200.00 Pd. Permit Fee $7.50 Pd. Street Repairs ToCal Inspected by: DaCe Remarks• By. Chief Inspector In consideration of the issue and delivery to me of the above permit, I hereby agree to do the proposed work in accordance with the rules and regulations of Eagan Tounship, Dat:ota County, Minnesota By. Please r.otif.y uhen ready for inspection aad connectton and before any porCion oi Cha wcrk is covexed. Dennis W. Curtis SPECIAL IMPROVEMENT$ TWi.n City Pederal 1904 Carnel.ina Lane 801 MarquetCe Avenue Eagan, M 55122 on Attention: Beth Wegleitner 370-7163 a All that tract or parcel of land lying and being in$?? County, Minnesota, described as fol'lows, to-wii \01 I a Int 20 H7ock 130 Cedar Grove Number 5 io 16704 ozo is 1904 Carnelian Lane This is to certify that I hove examined the records in the office of the City Clerk, City of Ea?an Da.kota County, Minnesota, ond find 1hoT the obave described Tract or parcel of land has the following improvemenis as indicnted by CHECK MARKS: ? Water-f.Imn?Ai Sidewalk _ Street Paving _f Main Trunk Sewer _ Curb & Gutter Ailey Paving ?I_aterial Sewer _ StreeT Grading _ Garbage Collection Storm Sewer _ Alley Gradin9 _ Tarring Street I further certify that according to tlte records of said ofFice, the Following assessmenis appear unpaid: Total Amount Unpaid Original Suhsequent to Kind of Improvr.ment Runs Beginning Amount -C.irrent Year sw trk/lat 20 1967 1.00:00 45.00 sewer lat 20 1968 515.00 257.50 sm sw trk 20 1971 70.00 45.50 water lat 25 1972 607.00 461.32 I further certify fhat occording to the records of soid af{ice, the following improvements are contempiated ?r pending nfter having br.en opproved, and nre now in ihe process or plonning or completion: Qpprozimate dpte of Approximate Cost of Kind of Improvement ' Completion Improvement _ $Treet $prinkling NONE Dated rhis 27 77 day of MaY , 19 Ann Goers, Assessment Clerk xxxxxxx Gry of Eagan Charge of $5.00 PAID FGFM458 iIFV. I,1-72 ` CITY of EAGAN N4 4002 UILDING PERMIT Owae: ... ? ? 3795 Pilof Knob Road ..'. ....../p4-..... . . . ......... ..... ...... ' Eagan, Minaesota 55122 Addrese (psecen!) ..,C.L .P,...??......... ?••? 454-8100 Huilder .????F?!?'?I-.••• ..............4111?fF.. ....?........... ....... /J 9p- ?y Dale ?L[r/?C.-_a.S.A r.f?•.-.??7 Addreae .?.?lJ........ Z?...? ...............r9.'.•.??kXk?.F ? , DESCA2PTION Siosies To Be Uced For Front Daplh Heigh! Eai. Cos! Perm!! F?a Rams:ks 2q zl I?o'pe- l I LOCATION ,9D ? or Thia permit does not av2horize the use of sireels, roads, alleys or sidewalks nos does it give !h4 oweei or his agaa! the righ!!o ereate any eiluafion whieh is a auisanca or which presenls a hazard !o the heallh, safelq, oonvanisnes and general welfare !o enpone in the eommuniiy. THIS PEAMIT MUST BE PT E PREMISE WHILE THE WORR IS IN PAOGRESS???/? ns• This ie !o cerlifY• ................. hasPermiesion !o arect a/1...... 44???t'.ni? the above de/scr/ibed premi u'ec4 the rovisions of all applicab es for the Ci! a sr•-- -g .'•'•"......... ....... ._ .:C....... upoa .""--....................... p0r'L-i?L<a"r-"'••••--D???''???? ... ................................. . ..........IvI r.,...,k, . Huildinpsefos ' . . Eagan Township ' Dakota Counlp, Minxesoia ApplicatioA fot Bnilding Petmi# Tppe of building or wosk conlemplaied. Circle eorreoi deseripfions. . . Aesidential Commercial Indusirial Olhes----------- ........._.-...._...._ .........:.... ;?;? Euil Enlarge Alier Repaie Inslall Move Wreck 03her Dimennions.... : -4-q ......... Cosl...?.f..zNZ - -----'----' Details os eemarks ................... ..°- --._...--°--.. ------- ------- ...... .---------------- ----------- .. Loeation '& PERM T NO. ..:?7.Y.. DaSeZ?........ ....... Numbex Siree2 Bxiween what cross streels Size Est. Valuaiion Lo! 8loclc ddition Rearrangemeni ox Traci ? Owner _- /?? ? '?.?:^.._ .."----"--'.......... Address - ' --'-----------'-- ..'--' ""-"' -"...._-'° - -"._. . ?..._. ............................ "- _- ---"--'-° -' ---'-- .......... '.j?!.L6 ........... .---------- ...'_........... "" Coniraclor ...... tt AV? .. .......... ....... .. ..... _`............................. .... Address '--._......`.j0.---'---' ---'----' The undessigned he=eby makes applicetion fox a permit to $ do work as herein speeified, agreeiag to do all woxk in sirici Toial fee collecied. 8ccordanee wiih Yhe huilding ordinance adop2ed April 11, 1955 bp She Eagat? ip B=dvisors. Permit fees are no! . refundable. ?---.---'---...._ _........ _'-"-""-""-.--' .................°-----...--"'--'---""-_ ....................... Signed 4 SUSSEL GAAAGES "s?sS'E'L"o°;>:.: Permit by Legal Des Lot_ Blk_ Add'n _ Type Const. SLAB: tggy SUSSEI. ? By Owner Approz. ?In POJf1TS 2-STARTINGS ONLY . S.P.L. S. S. P. L. R.P.L. AI ley 2- C f6-0 House F. Stree Other ? Squa re W ith . ?SodRem.-ByvliSSC'-C ? ? 5-Bag Mix ' .19 6; Bag Mix ? Tamping, No Tamy?g u5 c? 0 A.B.UL?•P X(DGrade Point ? Conduit ? BloCks ?ByOwnerE] OySussel pMaintain 8' Total Wall Height including Blocks ?Maintain 8' Wall Height on Top of Blocks ?otner Dr Offset Location L] Att Gar Roof Tie-in Drawn on attached"pictures Existing garage: N ?Detached ?Attached Yes Size of existing:-x - Existing garage will be: ? Left as is ? Converted to L.S. - sv owner ? Removed By: Owner? Sussel ? Junk Must Be Removed By Owner DOOR SWING: LH OUTSIDE E INSIDE RH 6 ?r. • IY ' V / bd" ? Specity removals by Sussel or owner - trees, 6ushes, etc. O Show approx. dist. garage to house and all prop. IinesQN Stakes visible - >(Yes C7 No - Survey availabie - ? Yes ? No ? Special instructions from PURCHASER'S INITIALS: WORK ORDER ?7? -. HOME PHONE: NAME D ENN/ S 4f v 27-1 S BUS..PHONE:: JOBADDRESS BLDG CODE AREA ? C? -4 SALESMAN /1 0CONTRACT DATE SIZE 2e Z/ FOR OFFICE USE ONLY A CONTRACTOR Sre>011EV4 / E , Jpg.# S+Y`S ?, . . . ; . ;_ .. . . . .. V ?.?. : ?_, . .. ?.. . , ION:._: MASTER CARD STRUCTURE AND IAND USED AS Permit No. Issued Issued To Conirac}or Owner BUILDING PLUMBING CESSPOOL - SEPTIC TANK V?ELL ELECTRICAL HEATING GAS INSTALLWG SANITARY SEWER I O7HER I OTHER I Items Approved (Initial) Date Remarks Distance From Well FOOTING r !L SEPTIC FOUNDATION CESSPOOL FRAMING TILE FIELD FT. FINAL ELECTRICAL HEATING DEPTH OF WELL GAS INSTALLATION I SEPTIC TANK CESSPOOL DRAINFIELD PLUMBING WELL SANI7ARY SEWER Violations Noted on Back COMMENTS: PERMIT City of Eagan Permit Type:Building Permit Number:EA115325 Date Issued:09/25/2013 Permit Category:ePermit Site Address: 1904 Carnelian Lane Lot:2 Block: 13 Addition: Cedar Grove 5th PID:10-16704-13-020 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are not acceptable in lieu of inspections. Carbon monoxide detectors are required by law in ALL single family homes . Jeff Pelant 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 - Lance L Robinson 1904 Carnelian Lane Eagan MN 55122 (763) 439-3949 Legacy Restoration Llc 14000 25th Ave N Suite 110 Plymouth MN 55447 (763) 354-7660 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA120485 Date Issued:02/14/2014 Permit Category:ePermit Site Address: 1904 Carnelian Lane Lot:2 Block: 13 Addition: Cedar Grove 5th PID:10-16704-13-020 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 - Lance L Robinson 1904 Carnelian Lane Eagan MN 55122 (763) 349-3949 Legacy Restoration LLC 14000 25th Ave N Suite 110 Plymouth MN 55447 (763) 354-7660 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA162511 Date Issued:07/16/2020 Permit Category:ePermit Site Address: 1904 Carnelian Lane Lot:2 Block: 13 Addition: Cedar Grove 5th PID:10-16704-13-020 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:Two or More Windows/Doors Census Code:434 - Residential Additions, Alterations 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 within 10 feet of all sleeping room openings in residential homes (Minnesota State Valuation: 5,000.00 Fee Summary:BL - Base Fee $5K $118.00 0801.4085 Surcharge - Based on Valuation $5K $2.50 9001.2195 $120.50 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 - Lance L Robinson 1904 Carnelian Lane Eagan MN 55122 Renewal Andersen 1920 County Road C West Roseville MN 55113 (651) 264-4777 Applicant/Permitee: Signature Issued By: Signature