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3672 Ashbury Rd Use BLUE or BLACK Ink For Office Use I Gt I Q J~~S I City ~1 ~LL ~Permit ~j I Permit Fee: Q- v 1 3830 Pilot Knob Road I I Eagan MN 55122 Ij U j Date Received: .,e~ Phone: (651) 675-5675 1 1 Fax: (651) 675-5694 1 Staff; 2010 2010 RESIDENTIAL BUILDING PERMIT APPLICATION ss~zz GIs a~~y /;/V Date: / 1 site Address: led 3 7 h Tenant: /4L a /n~e X? Z 7111" Suite RESIDENT / OWNER Name:.4 L n ald /l Z E' n Phone: Q V/ k Address / City / Zip:367Z 1 j/da/lN 1?d G 1,4AI &A! -515/221 Applicant is: Owner V- Contractor TYPE OF WORK Description of work:LtlzAldo uJ (j'"J~'~~`r l PA rld Flo®,[ 'Po vJdit t is ,l U Construction Cost: % Multi-Family Building: (Yes / No CONTRACTOR Name: Dense ST !Dull l 1~ Address: City. r' 9 3 db State. .n/ Zip: .f.T ~j'Z L Phone: rZ 3 o Contact: Se- or Ti /ruBJ Email: COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? Yes _No If yes, date and address of master plan: Licensed Plumber: Phone:, Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that the are trade secrets. CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.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' the case of work which requires a review and approval of plans. a x C o /'f V e/ X_ Applicants Printed Name Appli is ignature Page 1 of 2 CITY OF EAGAN I n T' 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 11705 PHONE: 454-8100 BUILDING PERMIT Receipt # To be used for SF DWG/GAR Est Value $110,000 Date APRIL 1 19 86 Site Address 3672 ASHBURY RD Erect C' Occupancy R3 Lot 5 Block 1 Sec/Sub. SLACKTIAW[; GLEN Remodel ❑ Zoning R1 Parcel No. 1ST Repair ❑ Type of Const V Addition ❑ No. Stories 48 Name LUNDGRFN BROS CONST Move ❑ Length 9 5 E [STAY ZATA BLVD Demolish ❑ Depth 16 o Address Int. Impr. (0 Sq. Ft City WAYZATkone 473-1231 Install ❑ = o Name SAME Approvals Fees 00 $ 458 Address Assessment Permit ' 00 cc 55 City Phone Water & Sew. Surcharge ' 00 1F W D F SIGN ETC Fir SPlan AC Review 00 'I W Name • a= AddresPLYhn j5 DUNKIRK 559j-2637 Eng. WaterConn.~'0 a W City WIne Planner Water Meter Council Road Unit ~ 00 I hereby acknowledge that I have read this application and state that the Bldg. Off. 4/1/86 Tr. PI. 156. 00 { information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. APC Parks Var. Date Copies Signature of Permittee * i Total 2 r 3P;. 50 A Building Permit is issued to: LUTaDGRtN RRO. COFST 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 Pwn* No. PsrmN Hallo Dab TNsphone 1 Plumbiny7 7 7 Elecdlc 1oa1 R7 1~ J ~ 50 Softener G ktCS t-- Cr C'l~~s J 15 Inspection Date Insp. Comments FootingsI Footings II Foundation Framing Rooting Rough Plbg. 1-241 Rough Htg. Insul. Fireplace Final Hill. Final Plbg. Bldg. Final Cert. Dec. Deck Flo. Deck Frmo. Well Pr. Disp. IL Cities Digital Quality Control The following image represents the best available image from the original page. Every effort was made to capture the content from the original page. PERMIT # _70 0 9 MECHANICAL PERMIT RECEIPT # CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55121 DATE: J ~oZ ' CONTRACT PRICE: PHONE: 4544100 Site Address BLDG. TYPE WORK DESCRIPTION Lot Block Sec/Sub ' i Res. New Name Mult Add-on _ eo Address Comm. Repair S City Phone Other Name FEES c Address RES. HVAC 0-100 M BTU _ $24.00 p City - -Phone ADDITIONAL 50 M BTU 6.00 ADD-ON AIR COND. 0-24 BTU - 12.00 TYPE OF WORK ADDITIONAL 6 M BTU - 6.00 GAS OUTLETS - 1.50 EA. Forced Air M BTU COMM/IND FEE - 1% OF CONTRACT FEE Boiler M BTU ;-,MINIMUM - RESIDENTIAL FEE - 10.00 Unit Heater M BTU MINIMUM - COMM/IND FEE - 20.00 Air Cond. M BTU STATE SURCHARGE PER PERMIT - .50 Vent CFM (ADD $50 S/C IF PERMIT PRICE GOES Gas Piping Outlets # BEYOND $1,000.00) Other FEE S/C: SIGNATURE OF PERMITTEE TOTAL: FOR: CITY OF EAGAN PERMIT # -CIO i PLUMBING PERMIT RECEIPT # CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55121 DATE CONTRACT PRICE PHONE: 454.8100 Site Address BLDG, TYPE WORK DESCRIPTION Lot Block Sec Sub es. New f m Name Mult Add-on I ~o Address Comm. Repair c City hone- i ~ - Other NO. FIXTURES TOTAL Name Water Closet - $3.00 $ 7 3 Address Bath Tubs - $3.00 p City Phone Lavatory - $3.00 r' Shower - $3.00 FEES Kitchen Sink - $3.00 COMM/IND FEE - 1% OF CONTRACT FEE Urinal/Bidet - $3.00 MINIMUM - RESIDENTIAL FEE -$10.00 ' Laundry Tray - $3.00 MINIMUM - COMM/IND FEE - 20.00 ~Flaor Drains - $1.50 STATE SURCHARGE PER PERMIT - .50 Water Heater - $1.50 Whirlpool - $3.00 (ADD $.50 S/C IF PERMIT PRICE GOES -WGas hirlpool Piping Outlets - $1.50 BEYOND $1,000.00) Softener - $5.00 Well - $10.00 I f Private Disp. - $10.00 t~tv Rough Openings - $1.50 SI(a' JATURE OF PERMITTEE FEE STATE SIC: r FOR: CITY OF EAGAN GRAND TOTAL- CITY OF EAGAN WATER SERVICE PERMIT 3830 Pilo( Knob Road P. t. Box 21189 PERMIT NO.: 7 3 Z~~ Eagan, MN 55121 DATE: Zoning: No. of Units: Owner; Address: Site Address: 3677 Ash*:ury i . 1 Plumber. Lundcran Meter No.: Connection Charge: Stu: Account Deposit: Reader No.: Permit Fee: 1 Gyres to esr Ph with the Clop of Eye■ Surcharge: ordlownass. Misc. Charges: Total: By Date Paid: Date of Insp.: Insp.: CITY OF JEAGAN SEWER SERVICE PERMIT 3$30 Pilot Knob Road P. O. Box 21199 PERMIT NO.: Eagan, MN 55121 DATE: Zoning: - - No. of Units: T .l In ' Owner ` r Address: Site Address: 1.? Plumber. r'~ n+,£n~, °3.14an~4n~ I epee to Ph VAA On ply of go/e■ Connection Charge: ordhosee& Account Deposit: Permit Fee: Surcharge: By Misc. Charges: Dote of Insp.: Total: Insp.: Date Paid: CITY OF EAGAN Remarks -D I V qpL- ~(o 9 Addition Blaekhawk Glen ist: Lot S Blk Parcel 10-14350-050-01 Owner Street 3672 Ashbury Road State Eagan MN 55122 Improvement Date Amount Annual Years Payment Receipt Date STREET SURF, 50.70 5 1076 253.48 STREET RESTOR. GRADING SAN SEW TRUNK 1970 167.44 6.70 25 Pd prior to division SEWER LATERAL 112.09 22.42 5 WATERMAIN Bn 1075 1986 92.80 18.56 5 WATER LATERAL WATER AREA 1072 1986 309.40 61.88 5 Storm Sew Trk 1073 1986 110.91 22.18 5 STORM SEW TRK 732 1983 32.57 15 STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. BUILDING PER. SAC PARK CITY OF EAGAN WATER SERVICE PERM 3830 Pilo1<.Kaob Road P. 0.13ox 21199 PERMIT NO.: 7,32 _ Eagan, MN 55121 DATE: ` 7 E Zoning: pi No. of Units: 1. Owner. Lundgren Bros. Addrom Site Address: 3672 Ashbur y Po:i(! ' ^ckhaw.. Plumber: Lundgren p _ Meter No.:.3 6 7.5_S/. 00111 500. 0 oml Size: << Rac 0514 local 15.00pd Reads No.~~ 10.00 d I Myer to eessry wMfi tie gQAEp . SOnd O►dbaaem V~[ LVN►rsc.,Charpes: 1 ,6.-_1Ond TP total: Sp,,? f•ter ey Dote Paid: of Insp.: Insp.: g-2.9-IF G r This request void y' nths from 7 ~J 099627 )-5" Request Oate., I I Fire No. RRZ.gh ed Inspection Ready Now ❑ Will Notify. Inspec- ❑Yes o Ipr When Ready Licensed Electrical Contractor I hereby request inspection of above 5 Q Owner electrical work installed at: Street Address, Box or Route No. City /-!1 ,2 J~ e ion o. Township ame or o. ge No. C /ATt Occu nt (PRINT( Phone No. wer upplier w . n Address Elec bal Contractor (Compan ame) LeF Co ,actor's Licen/se No . O C 1 I V-- :2 Ma ung Address (Contractor or OwnernMaking Instailation) V Auth i ed Signatu~eking Installation) PI]Qne Number Y Ill MIN ESOTA STATE BOARD OF ELECTRICITY THIS INSPECTION REQUEST WILL NOT Griggs-Midway Bldg. - Room N-191 BE ACCEPTED BY THE STATE BOARD 1821 University Ave., St. Paul. MN 55104 UNLESS PROPER INSPECTION FEE IS Phone 16121 297-2111 ENCLOSED. REQUEST FOR ELECTRICAL INSPECTION EB-00001-04 Y , Sae instructions for complgtiag this form on back of yellow copy. 041S.3 n X" Below Work Covered by This Request t~! 74 S AdtlRep. Type of Building Appliances Wired EFgq.ipdmteont Wired Home Range Temporary Service Duplex Water Heater Lighting Fixtures Apt. Building Dryer Electric Heatin Commercial Bldg. Furnace Silo Unloader Industrial Bldg. Air Conditioner Bulk Milk Tank Farm Other p1,6 v Iher (Specify) Other (Svoi,ify) Other Compute Inspection Fee Below q Fee Service Entrance Size n Fee Foeders/Subteeders k Fee Circuits 0 to 200 Amps 0 to 30 Amps 0 to 30 Am s Above 200 Amps 31 to-100 Amps 31 to 100 Am s Swimming Pool Above 100_Amp; Above 100 Amps Transtormers Irrigation Booms Partia 'Other Fee Signs Special Inspection s~ ~ TOTAL FEE fl¢marks Hough-in _ Date I, the Electrical Inspector, hereby certify that the above Final r inspection has been made. This request void 16 months tram " quest void 18 months /tom J J C+i / 15608 Request Date Fire No. Rough-in Inspection Requiretl? C]ReadY NUwfll Notify, InsDec- es QNO for When fleatlv Licensed Electrical Contractor 1 hereby request inspection of above ❑ Owner electrical work installed at: Street Address. Box or Route No. Ci 2 ~ 5 :36 ecuon No. Township ame or No. anBe o. Co y Occu nt (PRINT) Phone No. Y Po r S tier Address Elec .l Contractor IC nY Name) tractor's License No. Mailing Address (Con rector or caner Making Instailationl CT!(! Q 44 Aut or zed Signature (Co acto Owner Making Installatio Phone Number MINNESOTA STATE OARD OF ELECTRICITY THIS INSPECTION REQUES WI L NOT Griggs-Midway Bldg. - Room N-191 BE ACCEPTED BY THE STATE BOARD 1821 University Ave., St. Paul. MN 66104 UNLESS PROPER INSPECTION FEE IS Phnn. 16121 297-2111 ENCLOSED. o V REQUEST FOR ELECTRICAL INSPECTION //EB.00001-04 See instructions for completing this form on back of yellow copy. . -15608 V Below Work Coveied by This Request Add Rep. Type of Building Appliances Wired Equipment Wired Home Range Temporary Service Duplex Water Heater Lighting Fixtures Apt. Building Dryer Electric Heating Commercial Bldg. Furnace Silo Unloader. Industrial Bldg. Air Conditioner Bulk Milk Tank Farm Cher pert y Other (Specify) t nr ucufY Other Other ompute Inspection Fee Below k Fee Service Entrance Size ft Fee Feeders/Subleaders k Fee Circuits 13 v-cl U to 200 Am S 0 to 30 Amps 0 to 30 Am Above 200 Amps, 31 to 100 Amps 31 to 100 Amps Swimming Pool Above 100_Am s Above I00_Amp Transtormers Irn anon Booms Partial,'Other Fee emarks / Signs Special Inspection s TOTAL 5 E__~ -UU! 7 Rough-in ~ {/p DCate I, th , e lect[icel/' "1" ✓~/fp ~`f` Inspec tor. hereby certify that the above Final pate inspection has been mile. This requeffi void ie months from RESIDENTIAL BUILDING Permit Application City Of Eagan 7 S Q 9 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 FAX # 651-675-5694 New Construction Reouirements Remodel/Repair Recuirements Office Use Only 3 registered site surveys sharing sq, tL of lot sq. ft of house; and all roofed areas 2 copies of plan Cart of Survey Recd _Y _N (20% maximum lot coverage allowed) 1 set of Energy Calculations for heated additions Tree Pres Plan Recd _Y _N 2 copies of plan showing beam & window sizes; poured found design, etc. 1 site survey for additions & decks Tree Pres Not Reqd _Y _N l set of Energy Calculations Addtion - indicate if on-site 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 (bldgs with 3 or less units / Date-I(_ I D Construction Cost ~t~ ]I_4_J I C) Site Address V 1 Unit/Ste # Description of Work tit ) Multi-Family Bldg Y N Fireplace(s) - 0 - 1 - 2 to Property Owner1 Y Y s V_C~/ 7 1 -`p~. Telephone # ~ I' 052) Contractor / n I~ S Address Q City State Zip Telephone COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 Category I _ Minnesota Rules 7672 Energy Code Category • Residential ventilation Category 1 Worksheet • New Energy Code Worksheet (J submission type) Submitted Submitted • Energy Envelope Calculations Submitted Have you previously constructed a building in Eagan with a similar plan? _ Y _ N If so, 25% plan review fee applies. Licensed Plumber n r~ ~ oM U K1111 Telephone ) ij~j Mechanical Contractor AUG 2 2 2003 III Telephone ) V Sewer/Water Contractor Liu Telephone ) y--U f 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. ELL "As V' y l L Applicant's Printed Name Appr's Signature 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 E 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-Yor-N ❑ 25 Miscellaneous Work Types ❑ 31 New ❑ 35 Int Improvement ❑ 38 Demolish (Interior) ❑ 44 Siding ❑ 32 Addition ❑ 36 Move Bldg. ❑ 42 Demolish (Foundation) ❑ 45 Fire Repair ❑ 33 Alteration ❑ 37 Demolish (Bldg)' ❑ 43 Reroof ❑ 46 Windows/Doors 134 Replacement 'Demolition (Entire Bldg) - Give PCA handout to applicant c~ Valuation Sb0 Occupancy MC/ES System - Census Code '{fig Zoning City Water - SAC Units Stories Booster Pump - Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs r Length Fire Sprinklered Type of Const Width REQUIRED INSPECTIONS Footings (new bldg) ✓ Final/C.O. Footings (deck) _ Final/No C.O. _ ootings (addition) _ Plumbing Foundation - HVAC _ Drain Tile Other Roof _ Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests _ Final Framing _ Siding _ Stucco _ Stone Fireplace - R.I. -Air Test -Final - Windows (new/replacement) Insulation _ Retaining Wall ~p l Approved By I rVt {_c-.te'PLC4Building Inspector - - Base Fee 153. aS Surcharge q, o~ Plan Review MC/ES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant License Search Copies , Other Total Jr CITY OF EAGAN N -0 117 2 5 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 ~/p BUILDING PERMIT ReceiptA To be used for SF DWG/GAR Est. Value $110,000 Date APRIL 1 1986 Site Address 3672 ASHBURY RD Erect R3 EJ Occupancy Rl Lot 5 Block 1 Sec/Sub. BLACKHAWK GLEN Remodel ❑ Zoning Parcel No. 1ST Repair ❑ Type of Const. V Addition ❑ No. Stories Name LUNDGREN BROS CONST Move ❑ Length 3 Address 935 E-WAYZATA BLVD Demolish ❑ Depth 36 ° WAYZATA - Intall ❑ Sq. Ft Ciry 'Phone Install ❑ c Name SAME Approvals Fees 0 4 Address Assessment Permit - 00 Ciry Phone Water & Sew. Surcharge~5' 00 W Name DESIGN ETC Police PlanRevieww~.0000 =5 Address 5735 DUNKIRK I.N Fire SAC 500.00 u Z Eng. Water Conn. W Ciry PLYMOUne 559-2637 Planner Water Meter 63.50 Council Road Unit 290.00 I hereby acknowledge that ,avereadthis application and state that the Bldg.Off. 4/1/86 Tr. PI. 156.00 information is correct and gree to mply ith all licable State of Minnesota Statutes and t Eaga rdi ances. APC Parks - Signature of Permittee Var. Date Copies Total $2.326.50 A~Building Permit is issued to: LUNDGREN BRO CONST on the express condition that all. work shall be done in accordance with all applica a State of nn Styattu-tes and Ciry of Eagan Ordinances. Building Official y(,L~ a-,r..~ 12 1985 BUILDING PERMIT APPLICATION - CITY OF EAGAN NOTE: ALL CONTRACTORS MUST BE LICENSED WITH THE CITY OF EAGAN INCLUDE 2 SETS OF PLANS 3 CERTIFICATES OF SURVEY 1 SEY OF ENERGY CALCULATIONS To Be Used For: Va uation: ~ Date: Site Address: 3C a S d OFFICE USE ONLY ' I Lot: 15' Block Sect/Sub ,r Erect X Occupancy R•3 Remodel Zoning 12, 1 Parcel # S Repair Type of Const Enlarge # of Stories Owner~~ A,4 L/-/&2Lae Cove Length 48 Demolish Depth Address_ q grade Sq Ft City/Zip Code 5J Phone APPROVALS Contractor Assessments Permit Water/Sewer Surcharge 5 5. Address Police Plan Review Fire SAC rrzJ~ City/Zip Code Engr Water Conn ,Sop. Planner Water Meter ('3 Phone Council Road Unit 'Lqp Bldg Off Parks Arch./Engr. APC Treatment Pl IS6. Variance Address TOTAL a 3 a b 5 0 01 City)'Zip CodV03~~i1~ Phone 0 3 52 T" Q 2~ K Z~ ~ 72~ x. ~ - 4222¢ 1 ~ ~ ~ 2 14 JJ~ ~ t / 0 4~2 X 12 s~14 2(,~ 22 28~ 2~ ?2~~46 ~4 K2v _ 28c~ K 44 ` 125z(f) O 2 -SURVEYOR'S. CERTIFICATE SIENNA CORPORATION . N ! I _ I _ S 73051 '59" E 8270 30 8272% ".32.83 36.00 165.34 1 9269 ¢ y m U 831.13 i X830.5 U 831.5% D n' ^IO ; -13.50 13.50., 1 1 ~ eat ^e 26.33 tnn o (n V ; w inD 1 r_ ~n s V I O a\ A\ O 831.8 O M -1m 1 V Le N ♦b Fa I O W O PRO :,3 831.7% X CO O I~ t 1 V I ezes DRIVEWA~ D 30 e3i.ex 36.0 %e31.a y 10 0% , •>13.39 13.39. 1 030,2 # ` N 933.83 630.9x 2B.eo 36.00 155.02 , ym~ 30 m N 73°51 '59,, w 1m L_ I lj I I 1 IA I - DENOTES PROPOSED SURFACE DRAINAGE SCALE: 1 INCH = 30 FEET p DENOTES IRON MONUMENT SET PROPOSED GARAGE FLOOR = 832.3 FEET • DENOTES IRON MONUMENT FOUND PROPOSED LOWEST FLOOR = S z4,(~ FEET X000.0 DENOTES EXISTING ELEVATION (000.0) DENOTES PROPOSED ELEVATION PROPOSED TOP OF BLOCK = 837,1 FEET WE HEREBY CERTIFY TO SIENNA CORPORATION THAT THIS IS A TRUE AND CORRECT REPRESENTATION OF A SURVEY OF THE BOUNDARIES OF: Lot 5,Block I, BLACKHAWK GLEN 15'1 ADDITION, according to the recorded plat thereof, Dakota County, Minnesota. IT DOES NOT PURPORT TO SHOW IMPROVEMENTS OR ENCROACHMENTS, IF ANY. S SURVEYED BY ME OR UNDER MY DIRECT SUPERVISION THIS 13TH DAY OF NO V. SIGNED: JAMES— 11LL, INC. REVISED 3-19-86 TO SHOW PROPOSED HOUSE BY LUNDGREN BROS. CONST„INC. BY: HAROLD C. PETERSON, LAND SURVEYOR MINNESOTA LICENSE NUMBER 12294 PROJECT 110, FKK// JAMESR. HILL, INC. 85618 ( 86445i'fanners /Engineers /Surveyors FILE NO. 0200 Humboldt Avenue South FOLDER Bloomington, Mn. 65431 012-004-3029 ~CON51 RUCl IOIJ-- . INC. 1 473-1231 (6BOULEVARD " V:HYZ!•.TA. IAIIJF:ESC)T/- 55391 " i2 935 EAST VJHYZHTA EY.TEP.IOR E6'VELOPE A.VEP.AGE U COmPUTATIONr _ Lot -'5'Bl ock--L Site Address~~~~~~~` ,3 707 R U R &act°rs .058 opaque Walls .117 Wall Framing Areas 023 Ceiling insulation Area .027 Ceiling Framing Area - 04 Rim Joist 14 I'asonry Wall 26 1•Jindows Double Hung 46 Casements .18 Doors 46 Patio Doors 47 Sidelites 1) Lower Level (Basement) Total exposed wall area 8 ~~x ( U) . 058 = Opaque Wall Area 1712X (U) .117 = Wood Frame Area - x (U) .04 = Rim Joist. _ ~x (U) -14 Exposed block as x (U) .46 = 1~2-= - Window Area Casement x (U) 26 = Double Hung _ Q sliding Glass Door ~x (U) .18 = Door Area ~G 6 Total } 0 (CCONSI RUC1101J ~JG IIJC. S EAST VJAYZATL. BOULEVARD VJAYZATA. I✓INIJESOTH 5539} (E}2) 473 }231 °3 2) lst or main floor Total exposed wall area (U) 058 - -51 -5 9x Opaque Wfall area lx ( U ) .117 = --Z21 0.5 Wood frame area x (U) -04 = y~26 Rim joist Casements =X (U) .46 = 1•lindow Area $Q x (U) 26 = Double Hung x (U) -46 Sliding Glass Door 8 x (U) .18 = Door area 2x (U) -47 = - si del i tes a0. ? Total 3) 2nd floor if 2 story Total exposed wall area ~~o9x (U) .058 = CoJ Opaque wall area /fix (U) .117 = ! - Wood frame area _ Window area Casements -'X ~U~ .26 = a~ 2 Double Hung -x (U) .46 = Sliding glass door x (U) -18 Door area a Total /ODD 4) Total ceiling area /DL.x ( U ) .02 7 = Wood frame area q ? x (U) -023 = - Opaque ceiling area - - x (U) .55 - SkylightJ s Total CCONSI RUCI ION 473 935 EAST WAYZNTN BOULEVNP,D VJAYZNTk. IAIIJIJESOTA 55351 (612) -1231 X 15inn. U Factors Total exposed wall area 3_ D 5 7 _ a_~Q~-Y .026 = o?~, a Itinn. U Factors Total exposed ceiling are - (A) Total + Item 4 Item ls(o.(a + Item 2/o?D. + Item 31p .a If total of Items 1 - G is less than Item (A), building complies with SBC 6006 (C)s C CITY O F E A G A iV * tWE: PAYMFM OF FEE AT TIME OF * APPLICATION DOES NOT CONSTITUTE *1 APPROVAL OF PERMIT. C APPLICATION FOR PERMIT * INSPECTION OF SEWER AND/OR WATER y* INsrAL=oNs WILL NOT BE sCHED- SEWER AND/OR WATER CONNECTION I'm UNTIL PST HAS BEEN * APPROVED. • t (Please Print) 1) PROPERTY ADDRESS: Z~j]1 .4C4 btyl.~ 17-d. LEGAL DESCRIPTION: Gp~L Lot Block Subdivision or Tax Parcel ID ) IF EXISTING STRUCTURE, DATE OF ORIGINAL BUILDING PERMIT ISSUANCE: PRESENT ZONING/PROPOSED USE: (Mon Year C0.MMERCIAL/RETAIL/0FFICE r {y R-1 SINGLE FAMILY INDUSTRIAL R-2 DUPLEX (Ttm Units) (l INSTITUTIONAL/GOVERNMENT R-3 TOWNHOUSE (Three + Units) ( Units) Q R-4 APARTMIIU/CONDOMINIUM ( Units) 2)vv NAME:- ADDRESS: CITY, STATE, ZIP: PHONE: - G 7.T` - 3L 88 r 3) y NAME• For City Use Plumbers License: ADDRESS: g3s~ CG, 4t-yfq z&44 yQyv Active Expired i CITY, STATE, ZIP:_ 6&yy zafw jw(Alf Not recorded PHONE: I/ 7f - / Z 3 / MASTER LICENSE# 7 /Vt- Sta Initial 4) •a• e4 TU • ia• /J / - NAME: Z;;Ie. ADDRESS: 93S w/ifKrL.t)+~► BG++•~~ CITY, STATE, ZIP: 4/4"*w4 L(g,,, . -,ni;f PHONE: L747 3 -/7-3 / CONNECTION TO CITY SEWER 9( CONNECTION TO CITY WATER OTHER ' 6) U • r PLEASE HOLD APPROVED PERMIT FOR PICK-UP BY ONE OF ABOVE ` PLEASE MAIL APPROVED PERMIT TO 1, 2, 3, 4, ABOVE (Circle one) 7) Acc ' • Y: • r' •I: • • • U • I' a• • a i:e•7 .00 i1 Y:I• • ~I• 1 %1 kna • 5 a• • 11 TOR CITY USE ONLY PERMIT # ISSUED 7)7~ 11X71%1, ",3 a. 9' Pd w/Bldg. Permit FEES: $ $ SEWER PERMIT (INCLUDE SURCHARGE) $ $ WATER PERMIT (INCLUDE SURCHARGE) $ lJ J S D $ WATER METER/COPPERHORN/OUTSIDE READER $ $ WATER TAP (INCLUDE CORPORATION STOP) $ $ SEWER TAP $ $ ACCOUNT DEPOSIT - SEWER $ $ / J 'n e~) ACCOUNT DEPOSIT - WATER $ d • 0 U $ WAC $ 5 7S D-D $ SAC $ $ TRUNK WATER ASSESSMENT $ $ TRUNK SEWER ASSESSMENT $ $ LATERAL BENEFIT/TRUNK SEWER $ $ LATERAL BENEFIT/TRUNK WATER $ $ WATER TREATMENT PLANT SURCHARGE $ $ OTHER: $ $ d 7) TOTAL G//o 3 RECEIPT RECEIPT DOES UTILITY CONNECTION REQUIRE EXCAVATION IN PUBLIC RIGHT OF WAY? YES IF YES, THEN A "PERMIT FOR WORK WITHIN PUBLIC Q ROADWAY" MUST BE ISSUED BY THE ENGINEERING NO DIVISION. LIST AS A CONDITION. SUBJECT TO THE FOLLOWING &NDITIONS: APPROVED BY:~Cri TITLE: DATE: NEAT LOSS CALCULATION -U_° TEMP. DIFF.. CtatmmerWnla Rrot:. Tv"cwvuaflnn 1lolrwb%Ar1 - Cfty - Windows Storm Bath Dwiw Naffs. Walt . Ina. Bhrat GBpp one. City Flom 13 FI.I Flown IL Z- Width I t I F1.1p RomoffinlLemith -5- Width 1 Windows and Dome-Craekap and Ana Windows and Dome-Gadu and Ana Ne w.N. we. N LIMN N, Me. wwa N.. N LIMN h. n. N In!11tratiun _LbCp;~ Infiltration V t) 12- Btu Coaf. Btu aim L 2-100 Gear U 0 Emp. wall 35 'K 8t7 Exp. wall . S f7to f 3 (o Nat amp. Waal 23 5 2.- NO amp. will Int. well Int. wall Coiling 21 7,14 2 8 Calling S r Z recta Flom Z 3 FFS~ Floor 13 Z 2(0(0 Total Btu. lO I L Total Btu. (c (3FI.IA%t Room ILvg0Z7. Width Z%tlb t %sTFI.IK%±da Room Lan h O Width alai t Windows and Dome-CrsOsp and Ara Windows and Doors-Gadcpa and Aran wNM NManI Ms. N LIMN N. Nl Wlw~ Nw N LIMN h. ~N~. we p. M N w L II Ne. 0 tr I Z -1 a 2 30 3 Z d Coal. Btu Coat. Btu Infiltration Jig L/ FrO InfillrHion 1(0 LYO Gas S-0 Glace Exp. wall 2LL Exp. wall 1 O X ~sIJ No exp. wall p Not amp. wall int. wall IM. WON C.iling a7. s, X I CaNig 16 x r4 110 Z o tlonr 3 O Flow I Z ZSU Total Btu. Total Btu. rI II FI. I Roonw Width 14 mim 15TFlWidows , Inman 1 L&WA I Z WIN I t Wmlkrwc add Dome-d and Aran and Aran Mn ~w.Ne M .IM IiN. N N. Ns. w~11~ IM. N LIMN h. AN~. 2. 2 v t + bdov 101 Coaf. Btu Icam. Btu Infiltration _ Infiltration Z Glaze 21 Glas av W- Expo wall AV7 Emp. wall Nat exp. wall jq0 Not amp. well ? Int. wan let. WWI C&IINg l(n 5 K I Coding / Yc I &a Z ~i 41 0 2, Flora Fbar 6g Total Btu. Taal Btu. 4 mod- - - P HEAT LOSS CALCULATION 960 TEMP. DIFF.. Customr Nam ~r0 Typo Cordoli ntatlen Oar, b4 r-a D None. Windows Start m Sash Street Walt . Ins. City Callhp Ins. Floor I FI.I L'Iv . n Room I Len 'h Width 12r Nei t FLI s Roan I Lan 'h . S WINn I L4 IH11111111111111 Win}fows i6Q Doors-Craduoe and Ma Windows and Doors -Cradce and Ana wo Wi°'" wY~~ No. e1 m w. er .n. . el wH. No. wNM No. a &I 2 Z S[ 1► 2 I Z~ • 3G z Cad. Btu Coat. ON Infiltration O Infiltration Z Glass CIO 7 G00 Glass I L Exp. wall x Exp. wall S X 8 Net exp. wall I bf homes amp. WWI L4 110 Int. wall _ Int. well Coiling c( I b Ceiling I k O 4 Floor Floor ZO O Total Btu. ~j !Ml Btu. I S FLI Room I L 13 , S wroth I Z S 1.1 z 13 Roan I Larmooth 13, Width II. S- How" Windows and Doort-Cradugaand Anar~ Windows and Doors-Crack rod Arm No oa .Net i.. of of t a h. tl. Na. roils N. 1 No. 00 ~INIa 1. of r ~ to V 2 Z I ie 2 IL U l f Wood. also Cod. Btu Infiltration 3 5 Infiltration _qp Glass r! GIM ( 00 Emp. wall Z S k6 o Exp. wall 45 x Net amp. wall 140 6(c F. Net amp. wall one. wall lost. wall Ceiling I I 1(02- Z Ceiling 14 k,-11 !o dour 1 y y Flea wo r Total Btu. { T tal Btu. 3 Z Fl.l RIM R m1Lan h 0 VA-ld 1 t a Fl.l Larob 2- Width 1• TIMW- Wirminws a M Doort-Crm*a and Arair.. Windows and Does and Aran H.,h, Ne. ~1 1 h. N Me. wrn. MoNo. IM. oI Nn..l h. e G 7-Li 40 L Z ~2 2B cDWA Btu Btu Infiltration U b Infiltration O Guys ! p _ GMs 28 1 0 o Exp. wall T q- ><8 Emp. Wall (e, ZI - - Not amp. wall Aj= Li a 00 Not amp. well Int. wall - IM. Walt . Ceiling 20 c ( `FO Calling (2. x IL/, -I ra 2. Floor 2 O COO Floor z Total Btu. TOW Btu. I H Lt 1-( to [ _ or MEAT LOSS CALCULATION 50-0 YEMP. DIM /cu$«MNM* Lt~d~, nbn TV"ConerumNn Dah b/Yt4 City Windawa st4m smh Daalar NGma . Waft . Ina. Strom comm hr City - Flow 2 I.Ia1R"1/Room I Length I„ Width N p FI.I Roan I Lagth Width INI Windows and Doon-Craduga and Aran Windows and Dews-Cradcpa and Anp wo wWrn N~rpt Ne. el L~ to. ~1 - M onto or o.r L N of r Na. W AM Na. M LNrwl N. All. 'L~ Cod. Btu Caf. B/Y Infiltration Q Inflhfelbn Gbu 2 GNr Exp. wall :2$'t•pt 22 Exp. wall Not exp. wall 141 id 14 1 '78 No Gap. will Int. wall IM. well Coiling 17-- calling Floor 1112, L, $ Floor Total Btu. Total Btu. FI.I Room ILan h WWII Now" FI.I Roolnllarglh Width !me!. Windows and Doors-Cradtap and AraG Winton Land pooh-Cr@I* and Ana No X w lh Me."t Ne. N LN1 N. of = NNarrl N. Coal. Btu Cod. Btu Infiltration Inf iltration Glaze GIGS E■p. wan Exp. well We exp. wall Me Gxp, wall Int. wall Int. well Ceiling Coiling Floor Floor Total Btu. Total Btu. FI.I RoomfLwgth Wfdlh "1 111110111 FI.I ROOMILW40 Widtlt FNIILtt_ Windows and Doors-CrGdla a and Ana Wiltdowa and Omn-Grads and Arm wn w wr nl~~w♦ `s. ~ LrrrW N. wrwtr Nwlrt Na. M LNrIN n. M 1. Btu Cud. Btu Infiltration Infiltration Glaze aim Exp. wall Exp. well No exp. well No mo. welt Int. wall Int. wall Coiling cai1Mg FIotN Fbm Total Btu. Total Btu. 103, '735- CdkKe S L..+e I o vR1 ?24'er), 4;1,- q i,Wygkf 818'J`t T ;-k% k Ike-4+ (ov SS 1'2'7 City of E a jaIl ; Permit#: Permit Fee: 3830 Pilot Knob Road 1 Eagan MN 55122 j Date Received: j Phone: (651) 675-5675 I I Fax: (651) 675-5694 i Staff: b..----------- --rJ 2009 RESIDENTIAL BUILDING PERMIT APPLICATION Date: I " D Site Address: ~b 7 c Tenant: Suite RESIDENT / OWNER Name: JQ rn 2.s kerze_ Phone: 6 Sf " Address / City / Zip: _R 2j ~C Applicant is: Owner ' Contractor TYPE OF WORK Description of work: Ale /-1901 Construction Cost: Multi-Family Building:: (Yes 1 No ) CONTRACTOR Name: ~p +f License r2 a (n oZ 9y Address: l✓e Y1.~1~,`!~e~~ 7 City: -~a"C n State: Zip: Phone: yl J 0 Contact Person: COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 Category 1 Minnesota Rules 7672 Energy Code • Residential Ventilation Category 1 Worksheet New Energy Code Worksheet Category Submitted Submitted submission type) • 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? _Yes _No If yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that the are trade secrets. 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. xL - <Gt ~/S x Applic nt's Printed Name Ap icant's Srgnature Page 1 of 3 PERMIT City of Eagan Permit Type: Mechanical Eagan. Permit Number: EA096405 Date Issued: 10/12/2010 OR Permit Category: ePermit 41 it~ of E3 E Site Address: 3672 Ashbury Rd Lot: 5 Block: I Addition: Blackhawk Glen PID:10-14350-050-01 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: Angell Aire James herze 1223 Nicollet Ave S 3672 Ashburn Rd Burnsville NIN 55337 Eagan MN 55122 (952) 746-200 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 Eagan Ordinances. ApplicantiPermitee: Signature Issued Bv: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA131801 Date Issued:07/08/2015 Permit Category:ePermit Site Address: 3672 Ashbury Rd Lot:5 Block: 1 Addition: Blackhawk Glen PID:10-14350-01-050 Use: Description: Sub Type:Fireplace Work Type:Gas Insert Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home may require smoke detectors in all bedrooms. Chimney / flue must be inspected prior to concealing. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Valuation: 3,000.00 Fee Summary:BL - Base Fee $3K $88.50 0801.4085 Surcharge - Based on Valuation $3K $1.50 9001.2195 $90.00 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 - James Kerze 3672 Ashbury Rd Eagan MN 55122 (651) 600-6209 Hearth And Home Technologies 2700 N. Fairview Ave Roseville MN 55113 (651) 638-3309 Applicant/Permitee: Signature Issued By: Signature Use BLUE or BLACK Ink r For Office Use ` I/11\k-0 L7 City of Eapil Permit#: /Ili I'7 go Permit Fee: ._..6- 0 3830 Pilot Knob Road Date Received7- Eagan MN 55122 RECEIVED Phone: (651)675-5675 Ii F Fax: (651)675-5694 Staff: ar* FEB 272017 2017 RESIDENTIAL BUILDING PERMIT APPLICATION Date: . 2 -l7- Site Address: 56 7-.2 - /144 Ar Re'? Unit#: Name: 61 eve ¢ 2-41.,(4. PeeleVsGv. Phone: LPs-/—66GG-6 ZG`t l Resident/ 1 y` OWner I Address/City/Zip: 3? 72. 4-5413c1 J2 / f 73 ,.., ,, Applicant is: Owner ?r Contractor t 1 �' / i Description of work: /30. l--:K ifI " ReP6 i , ' � riwL� ' Type of Work I Construction Cost: fr 3 C Multi-Family Building: (Yes /No ) E I Company: �Ld/}R 52)4'& �, Fic ,4Sfrc,cti1,• „ ( Contact: J/15c--`' t�/ 64014-.0 1 i l' Contractor Address: i6,4116, 1.---.31." ,4„..„... City: 4—�kr.-,/(r/ mss!/ I I State: /v Zip: �S_UN�j Phone: (DS) -(J4/7-OL/5 mail: ASG ? Ge��V'evnC- e,Ceist,1 License#: 6,366,c-5— Lead Certificate#: to If the project is exempt from lead certification, please explain why: 7y f COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? I t Yes No If yes, date and address of master plan: 4 I Licensed Plumber: Phone: Mechanical Contractor: Phone: t Sewer&Water Contractor: Phone: Fire Suppression Contractor: Phone: i NOTE:Plans and supporting documents that you submit are considered to be public information. Portions of the information maybe classified as non-public if you provide specific reasons that would permit the City to 1 , ,,a_ conclude that their are trade secrets,_______ x_ ,__,_ CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.orq 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 iri the case of work which requires a review and approval of plans. Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180 days of permit issuance. x .mss 1 A✓A) ✓ lefite, t), tD x _ Applicant's Printed Name Appli, - - K- Page 1 of 3 7� 4_-- /.1)61/2_,Cid DO NOT WRITE BELOW THIS LINE / - 7- SUBTYPES Foundation Fireplace Porch (3-Season) Exterior Alteration(Single Family) Single Family Garage Porch (4-Season) Exterior Alteration (Multi) Multi Deck Porch (Screen/Gazebo/Pergola) Miscellaneous 01 of_Plex ?Lower Level Pool Accessory Building WORK TYPES New Interior Improvement _ Siding Demolish Building* Addition Move Building Reroof Demolish Interior )4, Alteration Fire Repair _ Windows Demolish Foundation Replace Repair Egress Window Water Damage Retaining Wall *Demolition of entire building—give PCA handout to applicant DESCRIPTION Valuation 1 7/ 4 °i ' ') Occupancy pett, tL MCES System Plan Review Code Edition 0,14 D i s' SAC Units (25%_ 100% X) Zoning City Water Census Code Stories Booster Pump #of Units Square Feet PRV #of Buildings Length Fire Suppression Required Type of Construction 1/6, Width REQUIRED INSPECTIONS Footings (New Building) Meter Size: Footings (Deck) Final/C.O. Required Footings (Addition) s' Final/ No C.O. Required Foundation Foundation Before Backfill HVAC_Gas Service Test Gas Line Air Test Roof:_Ice &Water _Final Pool: Footings Air/Gas Tests _Final Framing 30 Minutes 1 Hour Drain Tile Fireplace:_Rough In _Air Test Final Siding:_Stucco Lath Stone Lath Brick_EFIS Insulation Windows66-1‘.6,45, a r.9\491, Sheathing Retaining Wall:_ Footings_ Backfill_Final Sheetrock Radon Control Fire Walls Fire Suppression: _Rough In_Final Braced Walls Erosion Control Shower Pan Other: Reviewed By: ii-V , Building Inspector RESIDENTIAL FEES Base Fee ( .> Surcharge , ii az, Plan Review tit/12.vell x- AA MCES SAC _ 412 City SAC 1:;a4S /' — ) / UtilityConnection Charge S&W Permit& Surcharge Treatment Plant il'7;'• ,1/ - e2SO Copies F 1 �J �.�,.--- TOTAL e k7 i r t ' *_____-----4-6-77— o 1Page2of3 7 PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA141697 Date Issued:03/27/2017 Permit Category:ePermit Site Address: 3672 Ashbury Rd Lot:5 Block: 1 Addition: Blackhawk Glen PID:10-14350-01-050 Use: Description: Sub Type:Residential Work Type:Alteration Description:Basement Fixtures 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. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Building Code). Fee Summary:PL - Permit Fee (miscellaneous)$59.00 0801.4087 Surcharge-Fixed $1.00 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 - Steven J Petersen 3672 Ashbury Rd Eagan MN 55122 Hessian Plumbing Services Box 22172 Eagan MN 55122 (651) 681-8252 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA150649 Date Issued:07/18/2018 Permit Category:ePermit Site Address: 3672 Ashbury Rd Lot:5 Block: 1 Addition: Blackhawk Glen PID:10-14350-01-050 Use: Description: Sub Type:Residential Work Type:Underground Sprinkler System Description:PVB 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. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Building Code). Fee Summary:PL - RPZ/PVB/Lawn Irrigation $59.00 0801.4087 Surcharge-Fixed $1.00 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 - Steven J Petersen 3672 Ashbury Rd Eagan MN 55122 Jay's Plumbing 25 South Sutton Lake Blvd. Jordan MN 55352 (612) 868-4102 Applicant/Permitee: Signature Issued By: Signature