674 Campton Ct,-INSPECTION RECORD [ Control N 1323
CITY OF EAGAN PERMIT TYPE: VV3'LOl i,
3830 Pilot Knob Road Permit Number: "4:09@0
Eagan, Minnesota 55123 Date Issued: $*fflf*
(612) 681-4675
SITE ADDRESS: LOTt IS eLOCKt & APPLICANT:
674 CMMTS$ CT KRECH CDITOM Ot_a0 tft
HILLS OF STOMEB41994E (612) 414-flU -
PERMIT SUBTYPE: MI9N TYPE OF WORK:
Txq
r
FRAMING
FINAL
RfP*RKSz RECEIPT N
Permit No. Permit Holder Date Telephone II
s/W
PLUMBING
HVAC
ELECTRIC
ELECTRIC
Inspection Date Insp. Comments
Footings I
Foundation
Framing
Roofing
Rough Plbg. a_ '4
Rough Htg.
Isul.
Fireplace 3 ?f O f
`AY s
Final Htg.
Orsat Test
Final Plbg. Plbg. Inspector - Notify Plumber
Const. Meter
Engr./Plan
Bldg. Final i y
Deck Fig.
Deck Final
Well
Pr. Disp.
?. . ? R
BLDG. PERMIT NO./ /
01
01-3422 Plan Check
01-3445 Surch./Adm.
01-3446 SAC/Adm.
01-2155 Surcharge
La-
?i?7-3$60 Road Unit
20-2275 SAC
20-3865 Water Conn. 0,
20-3868 Water Trmt. ?' C Q
20-3716 Water Meter
20-2252 Acct. Dep. Q 0
20-3713 Water Permit / 0 0
20-3743 Sewer Permit / V
79,-,3866
Sewer Conn.
- () r
3855 Park Ded.
TOTAL
CITY OF,EAGAN Permit No.
i'. Date:
3830 Pilot Knob Road B/PNo: Date: ?.
P.O. &x 2 199 Eagan, MN 55121 Site Address: 74
Court L
Plumber: Valley Plumbin,z
MWCC: 350.0Onc?
City Chg: lOO.Oi r.c
e, ore digging cal' 14?iI#i'I
Acct Dep.
Permit Fee: R g1Q19 `5C pIy with the City of Eagan
Surcharge. P'1 t 11 D C O ' ow
Misc.: By
SEWER SERVICE PERMIT
CITY OF EAGAN Permit No: of Date:
330 Pilot Knob Road Meter No: Size:
P.J. Box 21199 r Reader No: Date:
Eagan, MN 55121
Site Address: 74 Campton c'x nrt LT' P, ?TI is of C?t:arr-O,ridr°
Plumber. Valley ;?? um}+ tr , r
Conn. Chg: 550•OUpd Zoning: 11
Acct. Dep: 1 5.00n No. of Units:
Permit Fee: in, no:
Surcharge: I agree to comply with the City of Eagan
Tr. Plant ?±'tl++ _ t?,tt,: Ordinances.
Meter
Misc.: By
WATER SERVICE PERMIT
%'CITYt1 EAGAN Permit No: Date:
3830 Pifot Knob Road ,9/P No: Date:
AO. Box 21199 • ,b
Eagan, MN 55121
Owner. ,oar-d OaI:s
Site Address 674 Carnnto
Plumber: Valley
MWCC:
Zoning.
City Chg: No. of Units:
Acct. Dee: I agree to comply with the City of Eagan
Permit Fee:
Ordinances.
Surcharge:
Misc.: By
SEWER SERVICE PERMIT
-----------------
CITY OF EAGAN
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
PHONE: 454-8100
BUILDING PERMIT Receipt # > : f r s
To be used for Tlt'CI GAR Est. Value 134,tX" Date AY' IL 15 ,19 83
Site Address 674 CAMPTON CT
HILIZ OF
Lot tit Block 5 Sec/Sub. STOtJi 11UJ GF
Parcel No.
Name GRAND OAKS DEVELOPPIF:_'-.'T
3 Address 3988 STCONNEBRIDGE DR i
0 City EAGAN Phone 452-0747
o Name SANE
o a Address
P City Phone
f-?
Nafie
Address
r, a m City Phone
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 Permittee A Building Permit is issued to: GR i9t' 0A' £' 1.7 VELOFMrNT
+ 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 ____
OFFICE USE ONLY
On Site Sewage Occupancy R-3/kii -S
MWCC System X Zoning PI) R'1
On Site Well (Actual) Const Y^N
City Water (Allowable) V-N
PRV Required * of Stories
Booster Pump Length 75'
Depth 31,
S.F. Total
Footprint S.F.
APPROVALS FEES
Engr./Assess Permit 684.00
___
Planner Surcharge 077.00
Council Plan Review 342.00
Bldg. Off. SAC, City 100.00
Variance SAC, MWCC 50.00
Water Conn. 550-00
Water Meter 67.00
Road Unit 325r?.
Treatment P1 ___.f_
Parks
1 }
TOTAL
CITY OF EAGAN
3830 Pilot Knb Rdad, P.O. Box 21-199, Eagan, MN 55121
PHONE: 454-8100
BUILDING PERMIT Receipt#
To be used for Est- Value Date 19
Lot Block Sec/Sub.
Parcel No.
W Name
= Address eft N
o rit., :ACs O74;
OFFI CE USE ONLY
On Site Sewage Occupancy
MWCC System Zoning
On Site Well (Actual) Const
City Water .t, (Allowable)
PRV Required # of Stories
Booster Pump Length
Depth
S.F. Total
Footprint S.F.
Phone
City Phone
I hereby acknowledge that I have read this application and state that the
information is correct and agfee to comply with all applicable State of
Minnesota Statutes and City of Eagan Ordinances.
Signature of Permittee
A Building Permit is Issued to'
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
APPROVALS FEES
Engr./Assess. Permit
Planner Surcharge
Council Plan Review
Bldg. Off. SAC, City
Variance SAC, MWCC
Water Conn.
Water Meter
Road Unit
Treatment P1
Parks
TOTAL
Permit No. Permit Holder Date Telephone #
Plumbing
H.V.A.C.
Electric
Softener
Inspection Date Insp. Comments
Footings I
Footings II
Foundation y!7 ?,
Framing
Roofing
Rough Plbg.
Rough Htg.
Isul.
Fireplace 43 ? /
Final Htg. ,-r' J. ,
Final Plbg. v .61
Bldg. Final ?r. /n
Cert. Occ. 9 rQ _ i? a `?
Temp. LP
Deck Ftg.
Deck Final
Well
Pr. Disp.
CONTRACT PRICE:
PERMIT # PLUMBING PERMIT RECEIPT #
CITY OF EAGAN
.? s/err r•
3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE:
PHONE: 454-8100
Site Address --
Lot Block $ec(Sub
Name
Address
C City Phone
Name
a Address
3
p
City Phone
FEES
COMM/IND FEE - 1% OF CONTRACT FEE
APT, BLDGS - COMM RATE APPLIES
TOWNHOUSE & CONDO - RES. RATE APPLIES
MINIMUM - RESIDENTIAL FEE - $12.00
MINIMUM - COMM/IND FEE - $20.00
STATE SURCHARGE PER PERMIT - .50
(ADD $.50 S/C IF PERMIT PRICE GOES
BEYOND $1,000.00)
SIGNATURE & PERMITTEE
I
BLDG. TYPE WORK DESCRIPTIOP
Res. New
Mult. Add-on
Comm. Repair
Other
RES. PLBG. ONLY - COMP LETE THE FOLLOWI!
NO. FIXTURES TOTI
Twater Closet - $3.00 $--?-
_I__..Bath Tubs - $3.00
,-Lavatory - $3.00
I Shower - $3.00 _-.?-
1 Kitchen Sink - $3.00
Urinal/Bidet - $3.00
_ Laundry Tray - $3.00-
0
$ -
-Floor Drains -
1.5
1 Water Heater - $1.50 1 .
Whirlpool - $3.00
i_Gas Piping Outlets - $1. 50
(MINIMUM - 1 PER PERMIT)
Softener - $5.00
Well - $10.00
Private Disp. - $10.00
Rough Openings - $1.50
FEE:
OF EAGAN
. PERMIT #
MECHANICAL PERMIT RECEIPT #
CITY OF EAGAN
3
P MN
122
NTRACT PRICE
C 830
ILOT KNOB ROAD, EAGAN,
55
DATE:
:
O PHONE: 454-8100
Site Addr
ss C_' WORK DI
G
TY
F
f BLD
.
(?
Block
Lot Sec/Sub /?
r,
-
1'
? f r
;
?ti
?? Res. New
-
.
•
.
Name r, e'
; Mult Add-on -
D
Address Comm. Repair _
Other
City Phone a ?G-
FEES
Name
+
` RES. HVAC 0-100 M BTU
'. E '.
Address >I ?.,.. LA t' ADDITIONAL 50 M BTU
_
p City Phone (RES. HVAC INCLUDES A/C ON NEW
CONSTRUCTION)
GAS OUTLETS (MINIMUM - 1 PER PEkd
TYPE OF WORK COMM/IND FEE - 1% OF CONTRACT FE
RATE APPLIES
BLDGS
- COMM
APT
Forced Air 1 _? ! _ M BTU .
.
.
il
B
M BTU
$ TOWNHOUSE & CONDOS- RES` RATE
o
er -- MINIMUM RESIDENTIAL FEE - ALL AD[
Unit Heater M BTU $ REMOD
Air Cond. 22 M BTU s? , ' MINIMUM COMMERCIAL FEE
STATE SURCHARGE PER PERMIT
Vent. CFM $ (ADD $.50 S/C IF PERMIT PRICE GOES
Gas Piping Outlets # I i+ BEYOND $1,000)
Other
FEE: -I a
S/C: SIGNATURE OF PERMITTEE
TOTAL:
FOR: CITY OF EAGAN
CITY OF EAGAN
454-8100 '
DEPT. OF BUILDING INSPECTIONS
Correction Notice
Located at U,IG' u c-71
have this day inspected this structure and
When corrections have been made, please
call 454-8100 for inspection.
Date Inspector City of Eagan
DO NOT REMOVE THIS TAG
9185 1c _,'',o
CITY OF EAGAN Permit No. Date:
3830 Plot Knob Road deter No:.3S 5 6 'V Size: V - 9 , / o
P.O. Box 21199 - Reader No: t'Z??? 5247 Q? Date:
Eagan, MN 55121
Site
Conn. Chg: 511
Acct. Dep: 1
Permit Fee:
Surcharge:
Tr. Plant
Meter.
Misc.:
. flflnr? ' '1110 8hi hip- 1G.
Ita.
ree to comply with the City of Eagan
YISS Ordinances.
By
WATER SERVICE PER "I
This request voi n y
18 months from / F7
E 113 9 7,L f r 62x ?
R
Request Date
/
l"
'I Fire No. Rough-in Inspection
RequiretlT
Ready Now Q Will Notify Insp
ec-
/?
cr
5
I il fo yes ?NU 1? for When Ready
L icensed Electrical Contractor I hereby request inspection of above
Owner electrical work installed at:
Street Address, Box or Route No. City
m o G
Section No. Township Name or No. Range No. County
Occupant (PRINT) Phone No.
Powe
ppher Address
er
// C?? irc. r t/Yi
El7t jJical Contractor (Com any Namel Contrarto' License No.
Mailing A dress )Contractor or Owner Making Inst
G 7S allation)
/ 3
Author ed Sigma ure LCgntractor/Owner Ma ing installation) Phone Numb
MINNESOTA 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
Ph,.,.e 'R»% aa, nnnn ENCLOSED.
/jq/ REQUEST FOR ELECTRICAL INSPECTION E13-00001-06
q 1 See instructions for completing this form on back of Yellow copV. gge '-G
E r11-39,7 "X" Below Work Covered by This Request
Neivi 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 Other peel y Other iSoor.i fyi
1 er Speci y Other other
Compute Inspection Fee Below
R Fee Service Entrance Size a Fee Fenders/Subleeders
q
Fee Circuits
OL 0 to 200 Am s 0 to 30 Amps
Ole 30 Am s
Above 200 Amps 31 to 100 Amps 31 to 100 Amps
Swimming Pool Above 100_Am s Aba a 100_Amps
Transformers Irrigation Booms Partial Other Fee
I I I Signs (Special Inspection ] $ Remarks _ ! -
rtily that the above
Final ate I9. inspection has been
)!1 // made.
K34827
j V
Request Date Fire No Rough-in Inspection
Required'
0 Ready Now ill Notify Inspector
R
h
d
?
(r- Ves E No en
ea
y
l $Jicensed contractor Downer hereby request inspection of above electrical work at:
Job Addres
s/(Sire Box or Route No I Cey^
ss
Section No, Township Name or No Range No Co ty
I
Occupant MINT) Phone No.
LOL
?l -flSZ?
Power Supplier Address
Elect c Contractor Corn any mel /` A a Conirectork License No
?g?(l?dd?reas (,Contractor or ner Making Installation
?/ l5 J//
Authonze S oniradodown r Maki Installanani Phone Number L ^U 6
MI N SOTA STAFF BOARD OFELECTRICITY + THIS INSPECTION REQUEST WILL NOT
Grlggs-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) 5424000 ENCLOSED
K 34827
REQUEST FOR ELECTRICAL INSPECTION
? See instructions for completing this form on back of yellow copy.
JX" Below Work Covered by This Request
% A ES-00001-0e
i /fl 7,4>
ew Add Rep Type of Building AppliancesWired EquipmentWired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt. Building Dryer Other-(Specify)
Comm./Industrial Furnace
Farm Air Conditioner
Other (specify) Contractors Remarks
Compute Inspection Fee Below:
# Other Fee # Service Entrance Size Fee # Cimuits/Feeders Fee
Swimming Pool 0 to 200 Amps D to 100 Amps
Transformers Above 200 _ Amps Above 100 Amps
Signs Inspectors Use Only: 2 AL ..r
Irrigation Booms
.2
?-
Inspection
Special
Alarm/Communication THIS INSTALLATION MAY BE ORDERED SCONNECTED IF NOT
Other Fee COMPLETED WITHIN 18 HS. p
1, the Electrical Inspector, hereby
certify that the above inspection has
been made. Rough-m to p
Final Date
OFFICE USE ONLY
This request void 16 months from
13 gel 2 RESIDENTIAL
BUILDING PERMIT APPLICATION bd2
CITY OF EAGAN
3830 PILOT KNOB RD, EAGAN MN 55122
651-681-4675
New Construction Requirements
• 3 registered site surveys showing sq. ft. of lot, sq ft of house: and all roofed areas
(20% maximum lot coverage allowed)
• 2 copies of plan showing beam & window sizes, poured found design, etc.)
• 1 set of Energy Calculations
• 3 copies of Tree Preservation Plan if lot platted after 711/93
• Rim Joist Detail Options selection sheet (bldgs with 3 or less units)
DATE ?_ I'1 `0
SITE ADC
TYPE OF
APPLICANT L.
STREET ADDRESS
TELEPHONE # Wi
52.1 PROPERTYOWNER R®4111 SA Cole tee TELEPHONE# 0 ??-?5q- 3?/V
--------------------------------------------- - -----------------------------------------------
COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY
Energy Code Category MINNESOTA RULES 7670 CATEGORY 1 _ MI.NNES ildl??Eff;?7 I
(ieI7 ynl
(J submission type) • Residential Ventilation Category I Worksheet Submitted • New En de-VJorstlAetutigt
• Energy Envelope Calculations Submitted I If
JUN 14 CUUZ
Plumbing Contractor: Phone # B
Plumbing system includes: _ Water Softener _ Lawn Sprinkler hear $90:00""'
_ Water Heater _ No. ofR.I. Baths
No. of Baths
Mechanical Contractor:
Mechanical system includes:
Sewer/Water Contractor:
Air Conditioning
Heat Recovery System
ULTI-FAMILY BLDG _Y N
FIREPLACE(S) - 0 - 1 - 2
Phone #
Fee: $70.00
Phone #
--------------------------------------------------------------------------------------------------------------------------
I hereby acknowledge that I have read this application, state that the information is correct, and agree to comply
with all applicable State of Minnesota Statutes and City of Eagan Ordingrpc W
Signature of Applicant OFFICE USE ONLY
RemodellReoair Requirements
• 2 copies of plan
• 1 set of Energy Calculations for heated additions
• 1 site survey for exterior additions & decks
• Indicate if home served by septic system for additions
VALUATION ?I ?(/?o?
Certificates of Survey Received - Tree Preservation Plan Received - Not Required _
Updated 4102
CITY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55123
(612) 681-4675
SITE ADDRESS:
PERMIT Control No. 13 2 3
PERMIT TYPE: BUILDING
Permit Number: 0 01 8 2 B
Date Issued: 11120192
674 CAMPTON Cl
LOT: 1'- BLOCK: 5
HILLS OF STONEBRIOGE
DESCRIPTION:
f' uildt Permit' Type BASEMENT FINISH
&aiIdIrrj`,Work Type ALTERATION
UBC Ocupat y R-3
v t'.
{,-.** gam, ^-
101
REMARKS:
RECEIPT # Co ?f 3a /
FEE SUMMARY:
Base Fee $35.00
Surcharge __$?50
Total Fee C35.S0
CONTRACTOR: - Applicant -- ST. L. cOWNER:
KRECH CUSTOM BLDRS INC 14543036 0003322 COON ROBERT
620 ERIE CT 674 CAMPTON
EAGAN MN 55123 EAGAN MN 55123
(612) 454-3036 (612)452-5784
I hereby acknowledge that I hive read this application, and state that the
information Is oorreet and agree to comply with. all applicable State of Atrt.
Statutes and City of Eagrn Ordinances.
L
APPLICANT/PERMI E SIGNATURE ISSUE BY. SIG MATURE
INSPECTION RECORD Control No. 1323
CITY OF EAGAN PERMIT TYPE: BUII DING
3830 Pilot Knob Road Permit Number: 0 01.8 2 8
Eagan, Minnesota 55123 Date Issued: 11 / 2 0 / 9 2
(612) 681-4675
SITE ADDRESS: LOT.- 13 BLOCK : 5 APPLICANT:
674 CAMPTON Cl KRECH CUSTOM BLDRS INC
HILLS OF STONEBRIDGE (612) 454-3035
PERMIT SUBTYPE: TYPE OF WORK:
BASEMENT FINISH ALTERATION
REMARKS: RECEIPT it
P
PERMIT f
REACTIVATE
ilti
CITY OF EAGAN
1992 BUILDING PERMIT
681-0675
APPLICATION'S
'U9,411-14
NOV' i a
RECO
SINGLE & MULTI-FAMILY 2 sets of plans, 3 registered site surveys, I copy of energy
talcs.
COMMERCIAL 2 sets of architectural & structural plans, 1 set of
specifications, I copy of energy talcs.
Penalty applies when typing of permit is requested, but not picked up by last working day
of month in which re guest is made or lot change is re guested once ermit is issued.
Date Valuation of work
Site Address: &711 /Am o.C i ,ati £a e+ v W-Xj
STREET SUITE S
Tenant Name: (commercial only)
LOT BLOCK SUED. J /, c ,P I ky? I ?
U F.I.D. it
zoos
Description of work: l'ni t5/t UAS?M?{iT
The applicant is: ? Owner Contractor ? Other (Describe)
Name _Coo /Po 3d?2"r w A n? Phoiie V - 3 78'
Property LAST FIRST
Owner Address 107 / (7AmP%o
STREET STE S
City _;r/4 all A/ State nlZip
Company ECN ay3ronl ?aaPfes 1Lc Phone ya `? 3o3
Contractor Address Z0 4e/tom C? License 04,09322 Exp. f- SJ M
City State Al Zip -4_37/Z-3
Company Phone
Architect/
Engineer Name Registration 8
Address
City State Zip
Sewer & water licensed plumber . Processing time for
sewer & water permits is two days once area has been approved.
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:
J!'• s•
BJLL9IN(PERMIT TYPE
0 01 Foundation
? 02 SF Dwg.
? 03 SF Addition
0 04 SF Porch
? 05 SF Misc.
WORK TYPE
31 New
110d32 Addition
OFFICE USE ONLY
? 06 Duplex
? 07 4-Plex
? 08 8-Plex
? 09 12-Plex
? 10 Multi. Add'l.
? 33 Alterations
? 34 Repair
GENERAL INFORMATION
? 11 Apt./Lodging
0 12 Multi. Misc.
0313 Garage/Accessory
? 14 Fireplace
? 15 Deck
? 35 Tenant Finish
? 36 Move
36-BCment Finish
117 Swim Pool
? 18 Comm./Ind.
? 19 Comm./Ind. Misc.
? 20 Public Facility
? 21 Miscellaneous
? 37 Demolish
Const. (Actual) Basement sq. ft. MWCC System
(Allowable) 1st Fl. sq. ft. City Water
UBC Occupancy 5:
JE_ 2nd Fl. sq. ft. PRV Required
Zoning
i of Stories Sq. Ft. total
Footprint Sq. ft. Booster Pump
Fire Sprinkler
Length On-site well Census Code y9y
On-site sewage SAC Code
APPROVALS AC,
DG
bus wp,r ___
Planning Building Assessments
Engineering Variance
REQUIRED INSPECTION S
? Site ? Footing ? Framing ? Insulation
? Wallboard ? Final ? Draintile ? Fireplace
Permit Fee 3;. uo valuation: $
Surcharge g_-
Plan Review
License
MWCC SAC
City SAC
Water Conn.
Water Meter
Acct. Deposit
S/W Permit
S/W Surcharge
Treatment Pl.
Road Unit
Park Ded.
Trails Ded.
Copies
Other
Total:
SAC %
SAC Units
CITY OF EAGAN N_ 14 8 41
3830 Pilot Knob Rodd, P..Tl.' Box 21-199, Eagan, MN 55121
/Y? rya
BUILDING PERMIT PHONE:454.8100 Receipt # d d 7
To be used for SF DWG/GAR Est Value $134,000 Date APRIL 15 ,19
Site Address 674 CAMPTON CT
HILLS OF
Lot 13 Block 5 Sec/Sub. STONF.BRTDGR
Parcel No.
Name GRAND OAKS DEVELOPMENT
= Address 3988 STONEBRIDGE DR N
City EAGAN Phone 452-0747
Name SAME
0
u Address
`
r- City Phone
Name
Address
City Phone
Building Official Athit, OFFICE USE ONLY
I hereby acknowledge that I have read this application and state that the
information is correct and agree to com k -w all applicable State of
Minnesota Statutes and City of Eagan Ordinance *
pj At
Signature of Permittee
A Building Permit is issued to: GRAND OAKS DEVELOPMENT
on the express condition that all work shall be done in accordance with all
applicable State of Minnesota Statutes and City of Eagan Ordinances
On Site Sewage _ Occupancy R-3/M-1
MWCC System X Zoning PD R-1
On Site Well (Actual) Const V-N
City Water X (Allowable) V-N
PRV Required * of Stories
Booster Pump Length 751
Depth 311
S.F. Total
Footprint S.F.
APPROVALS FEES
Engr./Assess. Permit 684.00
Planner Surcharge 67.00
Council Plan Review 342.00
Bldg. Off SAC, City 100.00
Variance SAC, MWCC 550.00
Water Conn. _5__50100
Water Meter 67OO_
Road Unit 325.00
Treatment P1 204.00
Parks
88 .00
2
TOTAL ,
1988 BUILIING 1ERMIT APPLICATION - CITY OF EAGAN
-#I4,LfI
SINGLE FAMILY DWELLINGS
INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS
NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS
IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED.
MULTIPLE DWELLINGS RENTAL UNITS FOR SALE UNITS __I__ # OF UNITS
INCLUDE 2 SETS OF PLANS, CERTIFICATE OF SURVEY - CHECK WITH BLDG. DEPT.,
1 SET OF ENERGY CALCULATIONS
COMMERCIAL I-! l
INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS, 1
1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS
r' BCD APR 13
To Be Used For: i Valuation: 1-3!y, ODD Date:
Site Address 0 7" (am 1- n Cu
Lot 12) Block
Parcel/Sub
Owner r
Address
City/Zip Code
Phone T'f!
Contractor
Address .\\?j
(
l
City/Zip Codee?v"
Phone /
Arch./Engr.
Address
City/Zip Code
r'I
On site sewage_ Occupancy R-3`_.-
MWCC system ? Zoning PD+ t-I
On site well _ Actual Const V-id
City water Allowable V- N
PRV required _ # of stories
Booster Pump Length _T
Depth
S.F. Total
Footprint S.F.
'APPROVALS FEES
Engr/Assess Permit &a4-' 00,
Planner Surcharge .-6A;ob
Council Plan Review :3!.? raa
Bldg. Off. 6j47(5 SAC, City 100,00
Variance SAC, MWCC 550,00
Water Conn 550.00
Water Meter (22,00
Road Unit 325, 00
Treatment Pl Z04 0
Parks
Copies
TOTAL
Phone #
V'ALU.A- lON
GARAGE
3zkz1 = Gr?.L
1 X 13 13
&85 $ 14 . g59d
1NouSE ?5sm tss Fwu?G?
ZisX 44 = 1144
-7 (w x6z r?.z 912
aAy - z x ? _ N n y9 . 6 g ?, -
ZN„ rL0OZ
I (o k ?S .= .z'4 o
z'x L6 = 'ls4
`6KU= 32
I1?32X4q=
Sv5 GS
13375
.
CITY OF EAGAN
EXTERIOR ENVELOPE AVERAGE 'U' COMPUTATION
OWNER: GRAND OAKS DEVELOPMENT CO.
HILLS
SITE ADDRESS: (.,o 1 (3 !_7(G??C J HILLS CF STONci3R1'h6?
CONTRACTOR: GRAND OAKS DEVELOPMENT DATE: PHONE: 452-8167
Determine working square footage of each: 40 LONG
1. Total exposed wall area ... 2448 sq. ft. x .11 = 2AQ.2a
2. Total roof/ceiling area ... 992 sq. ft. x .026 = 25,7o
Total exposed wall area above floor = 2131
a. Total wall window area ........................... 175
b. Total door area ................................... 40
c; Total sliding glass area 42
d.' Total-fireplace wall area ......... ........... 12
e. Total wall framing area (average 101) 186
f. Total net wall area above floor ................... 1676
g. Total rim joist area .............................. 249
Total exposed foundation area = 68
h. Total foundation window area ...................... 8 88
_
i. Total net foundation area above grade .............. 65.34
Determine 'U' value of each wall segment:
a. 175 x
b. 40 x
C. 42 x
d. 12 x
e. 186 x
f, 1676 x
g. 249 x
h. 8.88 x
i. 65.34 x
'U' .414 = 72.45
'U' .07700 3.08
'U' .460 - 19.32
'U' .2500 3.00
'U' .06998 13.02
'U' .03716 = 62.28
'U' .03528 8.78
'U' .4800 4.26
'U' .06609 432
.. Tota _ 190.51
If item f/3 is the same as or less than item 111, you have met the intent of SBC
6006(c)2.
Total exposed roof/ceiling area = 997.
j. Total skylight area ............................... _--
??99
k. Total roof/ceiling framing area (average 10%) .....
1. Total net insulated roof/ceiling area .............. 893
OVER
Determine 'U' value for each roof/ceiling segment:
J• x 'U' .53
k. .99 x 'U' .02894 - 2.87
1. 893 x 'U' .02205 - 19.69
4 . ...................................................... Total =(- 22. 56
If total of A4 is the same as or less than 112, you have met the in of SBC
6006(c)1.
Alternate Building Envelope Design
To utilize the total envelope system method, the values established by the sum
of Items 113 and f14 shall not be greater than the sum of Items 111 and 112.
1. + 2.
3. + 4. -
'I -
2
•e
SINGLE & DOUBLE FAMILY HOMES
1984 ENERGY CODE REQUIREMENTS
On or about March 1, 1984, the following energy code requirements
should be calculated and included with a building permit application.
1. Roof - ceiling assemblies - R-38 U = 0.025 Average
2. Exterior walls & rim joists - R-20 U = 0.11 Average
3. Floors over unheated spaces - R-20 U = 0.05 Average
4. Exterior overhangs will be considered as exterior wall.
5. Foundations (all exterior walls) - Minimum of R-5 insulation.
6. All insulated areas must be separated from the heated space
by a well-lapped or sealed vapor barrier with a minimum perm
rating of 0.1. A 4 mil. polyethlene sheet or equivalent meets
this requirement.
A Kraft face R-19 type insulation will be accepted in the rim joist
areas. Air chute baffles are to be placed in every rafter space.
l.iii Ut 1'.AUAPI
MINIMUM "U" VALUE ANDI, R-FACTOR AT ROOF, WALL, RIM LuND CONCRETE BLOCK
'rovidc insulation baffles in every*
Root CEILf NC,
.after 5pacc. - (Y) VAL
Q: tI?TE?tott A1!- FH
513" GYP. ED. - sG
QQ INSUtA?IoN ?1y °G..
O EX fC & Off AlR FILE 1 /7
u_.vz?os (,STILL)
10 C2)
'`UII = I/tz = ozs TOTAL (R)= yy
WALL
(T-) \/AL(;
w IN Ic(=1O[' Ali- FILM 66
BD.,
O : It
INSULATION Sizt? / q: 0 C
o ?G 51D1N(x 6 /
tt ET==i 10 Alit FILN\
U =11 rz , ?f: I-OTA?
IZIM
107
,t II1TEi''loK- .?j1C` FILL fig.
I? S'/ I ;(1LA [IDI ?i, ric
CIO
'2! FIF- Plf'l CIS r
5 ZSM ?ftir? ?lA. .OC
C) jr4
- O . -XTnIOF- AT- FILM ` • / 7.:
& C'3 r-2
fo;Jt?DATioi l
(tz) VALU.
13 iN TCVlolt Altc FILM - 6
(? 3r/s ? sub, /.7 0C
on-
O f6?f=?`F` th?6
O EXTE-(c1ot AIR FILM . /7
u=.a God
«Uu = l/(Z= , j', WtAL (Cc)_/S/.3
Floors over unheated spaces must have minimum R-factor of R-20 (tuck-under garages).
Floors over outdoor air (overhangs) must liavc a minimum F,-factor of R-33.
L BL CITY OF .EAGAN
PLUMBING PERMIT
SUBD. (612) 681-4675
RESIDENTIAL
PLEASE COMPLETE UPPER PORTION ONLY FOR SINGLE FAMILY DWELLINGS
WHEN PERMITS ARE REQUIRED FOR EACH UNIT.
CITY USE ONLY
RECEIPT # L __ _ _o
DATE-
ALSO, FOR TOWNHOMES AND CONDOS
WORK DESCRIPTION
NEW CONST _
ADD ON C_
REPAIR
OWNER NAME:
SITE ADDRESS: 674' ep z*. 724" Cot-hei
INSTALLER: d = ' r l m c'wa 4 v"'1 /3 fl' 6 -
A D D R E S S : - / 2 S S o y! -Ac-- ,5 44'
CITY: g° • S %/r,' ZIP:
COMPLETE THE FOLLOWING:
NO. FIXTURES EA. TOTAL
REPAIR/ADD ON 15.00
SHOWER 3.00 3.00
WATER CLOSET 3.00 3.av
_ BATH TUB 3.00
L LAVATORY 3.00 5.00
KITCHEN SINK 3.00
_ LAUNDRY TRAY 3.00
_ HOT TUB/SPA 3.00
_ WATER HEATER 3".00
FLOOR DRAIN 3.00 3.oO
GAS PIPING OUT.
(MINIMUM - 1) 3.00
_ ROUGH OPENINGS 1.50
_ OTHER _
_ WATER SOFTENER 5.00
_ PRIVATE DISP. 15.00
U.G. SPRINKLER 3.00
W. TURNAROUND 15.00
5c>
¢
STATE SURCHARGE .50
15
TOTAL: s
PLEASE COMPLETE THIS PORTION FOR ALL COMMERCIAL/INDUSTRIAL BUILDINGS. ALSO FOR MULTI-FAMILY
BUILDINGS WHEN SEPARATE PERMITS ARE NOT REQUIRED FOR EACH DWELLING UNIT.
WORK DESCRIPTION:
OWNER NAME:
SITE ADDRESS: _
TENANT NAME:
SUITE #:
INSTALLER:
ADDRESS:
CITY:
PHONE
FOR:
CITY OF EAGAN
ZIP:
CONTRACT PRICE:
1% OF CONTRACT FEE.
STATE SURCHARGE - $.50 FOR
EACH $1,000 OF PERMIT FEE.
$25.00 MINIMUM FEE.
CONTRACT PRICE x 1% $
STATE SURCHARGE $
TOTAL:
(SIGNATURE)
PHONE #: -1s7-/13 37
APPLICATION FOR PERMIT
SEWER AND/OR WATER CONNECTION
aty of eagan
1) PROPERTY ADDRESS: (07
LEGAL DESCRIPTION:
: NOTE: PA\flNT OP FEE AT TIME OF
APPLICATION DOES NOT CON- ,`.
smITUTE APPROVAL OF PERMIT. :
: INSPECTION OF SENER AND/OR WATER
INSTALLATIONS WILL NOT BE S®ULED
: L'N IL PERMIT HAS BEEN APPROVED.
IF EXISTING STRUCTURE, DATE OF ORIGINAL BUILDING PERMIT ISSUANCE:
(Month/Year)
PRESENT ZONING/PROPOSED USE:
Q COMMERCIAL/RETAIL/OFFICE
INDUSTRIAL
INSTITUTIONAL/GOVERNMENT
2) NAME:
ADDRESS:
CITY, STATE, ZIP:
PHONE:
3) ?• NAME: y a
ADDRESS: o
CITY, STATE, ZIP: .n r
PHONE: 1-IQ ',
a eu.a•®
4) 1116757
NAME:
ADDRESS:
CITY, STATE, ZIP:
PHONE:
5) s a
® CONNECTION TO CITY SEWER El CONNECTION TO CITY WATER a OTHER
I?( Active
Expired
Not recorded
St Initi
6)
****************************************************************************************************
*
* THE GOLD COPY OF THE PERMIT WILL BE SENT DIRECTLY TO PUBLIC WORKS TO FACILITATE METER PICK-UP.
PLEASE ALLOW TWO WORKING DAYS FOR PROCESSING. SOt4BDNE FROM THE CITY WILL CONTACT YOU IF THERE
* ARE ANY PROBLEMS.
I,j R-1 SINGLE FAMILY
El R-2 DUPLEX (Two Units)
El R-3 TOWNHOUSE (Three + Units) ( Units)
Q R-4 APARTMENT/CONtOMINIUM ( Units)
MASTER LICENSE # sU ) 1 1 "
.FOR CITY USE ONLY
PERMIT # ISSUED
2/8 5
Pd w/Bldg. Permit FEES:
$ /D $ SEWER PERMIT (INCLUDE SURCHARGE)
$ /0. " $ WATER PERMIT (INCLUDE SURCHARGE)
$ id , O $ WATER METER/COPPERHORN/OUTSIDE READER
$ $ WATER TAP (INCLUDE CORPORATION STOP)
$ $ SEWER TAP
$ / 5 'c2'a $ ACCOUNT DEPOSIT - SEWER
$ /5-a o $ ACCOUNT DEPOSIT - WATER
$ 5-5U _ G'am' $ WAC
$ ?P fc. o o $ S
C
A
$ $ TRUNK WATER ASSESSMENT
$ $ TRUNK SEWER ASSESSMENT
$ $ LATERAL BENEFIT/TRUNK SEWER
$ $ LATERAL BENEFIT/TRUNK WATER
$ c2(? T C? C $
WATER TREATMENT PLANT SURCHARGE
$ $ OTHER:
$ /52- Z'0O $ TOTAL
- 2- 97
RECEIPT RECEIPT
DOES UTILITY CONNECTION REQUIRE EXCA VATION IN PUBLIC RIGHT OF WAY?
ED YES IF YES, THEN A " PERMIT FOR WORK WITHIN PUBLIC
NO
Q ROADWAY" MUST BE
DIVISION
LIST ISSUED BY THE ENGINEERING
AS
O
. A C
NDITION.
SUBJECT TO THE FOLLOWING CONDITIONS:
APPROVED BY:
TITLE:
DATE:
Y//? /?c
SURVEYOR'S CERTIFICATE GRAND OAKS DEVELOPMENT CO.
do DENOTES PROPOSED SURFACE DRAINAGE
O DENOTES IRON MONUMENT SET SCALE: 1 INCH - 30 FEET
• DENOTES IRON MONUMENT FOUND PROPOSED GARAGE FLOOR - cio.e FEET
X000.0 DENOTES EXISTING ELEVATION PROPOSED LOWEST FLOOR - 9o2.9 FEET
(000.0) DENOTES PROPOSED ELEVATION PROPOSED TOP OF BLOCK= Qii•o FEET
WE HEREBY CERTIFY TO GRAND OAKS DEVELOPMENT CO. THAT THIS IS A TRUE AND CORRECT
REPRESENTATION OF A SURVEY OF THE BOUNDARIES OF:
Lot 13, Block 5 , HILLS OF STONEBRIDGE , according to the recorded
plot thereof, Dakota County, Minnesota.
IT DOES NOT PURPORT TO SHOW IMPROVEMENTS OR ENCROACHMENTS, EXCEPT AS SHOWN. AS
SURVEYED BY ME OR UNDER MY DIRECT SUPERVISION THIS 13 TH DAY OF APRIL '1988.
PROPOSED ELEVATIONS SIIOWN WERE
TAKEII FROM THE DEVELOPMENT PLAN
FOR HILLS OF STONEBRIDGE, PRE-
PARED BY PIONEER ENGINEERING AND
LAST DATED II-5-87
SIGNED: J ILL, INC.
l ..
BY:
HAROLD C. PETERSON, LAND SURVEYOR
MINNESOTA LICENSE NUMBER 12294
0 0 m ?
Hill
inc.
James R
F ,
.
c) m o W PLANNERS ENGINEERS SURVEYORS
> Cn
m OD z 9401 JAMES AVE. S. • BLOOMINGTON, MN. 55431 • 612-884-3029
SURVEYOR'S CERTIFICATE GRAND OAKS DEVELOPMENT CO.
Fvo
Soy
In ,
S
(802 ?? ?
1
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er.s)1
CAMPTON
COURT
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(D n m
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/ n fG
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01
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I
James R. Hill, inc.
PLANNERS / ENGINEERS / SURVEYORS
9401 JAMES AVE. S. • BLOOMINGTON, MN. 55431 • 612-884-3029
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA130846
Date Issued:05/18/2015
Permit Category:ePermit
Site Address: 674 Campton Ct
Lot:13 Block: 5 Addition: Hills Of Stonebridge
PID:10-32990-05-130
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 -
Mahin Schroeder
674 Campton Ct
Eagan MN 55123
Hearth and Home Technologies
2700 N. Fairview Ave
Roseville MN 55113
(651) 638-3309
Applicant/Permitee: Signature Issued By: Signature
' . � �`v\j ( ��� Use BLUE or BLACK Ink
�.l -llx- �------------- --,
�(��� � For Office Use �
�l�, n v � �
��H-� �]� � Permit#: i
� �11 i! �
� � (� /''�/��
1
3830 Pil v �
ot Knob R
oad Perm'
�� �� � it Fee: � • I,JV �
Eagan MN 55122 �
� I
Phone:(651)675-5675 � Date Received: "ao�� I
Fax:(657)675-5694 JUL 2 2 ZU15 � �. � � I
� Staff:i-,�) �
I
��, �����������������J
2015 MECHANICAL PERMIT APPLICATION
❑ Please submit two(2)sets of plans with ail commercial applications.
Date: Site Address:
Tenant: Suite#:
_ Name:�li�l�� U'��U Q,U�/V 2 . I ,, '
: � Phone: V�
_ �C
a5 5 �
- ?� ��5�
� Address/City/Zip: ��� '� �� � �
' Name: ��Q �� �Y � � �"�� �`l� License#: � �� � U �� S
Address f��� ��� �' � ( !� ��City: -�
State:�Zip:�� Phone: _ �����' `T�7 - �� � J
,
Contact: Email:���Jl(�.1rCX�(/l� �Yl�-l/It�LLG'GL(V�,�C1VG-t
_New �Replacement _Additional _Alteration Demolition
Description of work:
RESIDENTIAL COMMERCIAL
� Fumace _New Construction _Interior Improvement
r Air Conditioner _Install Piping _Processed
_Air Exchanger _Gas _Exterior HVAC Unit
_,Heat Pump _Under/Above ground Tank �Install/_Remove)
Other
RES/DENTIAL FEES I
$60.00 Minimum Add or alteration to an existing unit(includes$5.00 State Surcharge) '
$100.00 Residential New(includes$5.00 State Surcharge) _$���_TOTAL FEE
COMMERCIAL FEES
Contract Value$ x.01 I
$55.00 Permit Fee Minimum
$70.00 Underground tank installation/removal =$ Permit Fee �
*If contract value is LESS than$10,010,Surcharge=$5.00
**If contract value is GREATER than$10,010,Surcharge=Contract Value x$0.0005 -� Surcharge*
***If the project valuation is over$1 miliion,please call for Surcharge
_$ TOTA!FEE
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(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 wiil be in accordance
with the approved plan in the case of work which requires a review and approval of p�ans.
x �� t L � ��/�.� X ~
Applic nYs Printed Name .
Applicant s Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA149376
Date Issued:05/18/2018
Permit Category:ePermit
Site Address: 674 Campton Ct
Lot:13 Block: 5 Addition: Hills Of Stonebridge
PID:10-32990-05-130
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:Does not include skylight(s)
Census Code:434 - Residential Additions, Alterations
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 within 10 feet of all sleeping room openings in residential homes (Minnesota State
Building Code).
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 -
Mahin Schroeder
674 Campton Ct
Eagan MN 55123
Liberte Construction Llc
1406 West Lake St, Suite 202
Minneapolis MN 55408
(612) 999-7663
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA158215
Date Issued:10/01/2019
Permit Category:ePermit
Site Address: 674 Campton Ct
Lot:13 Block: 5 Addition: Hills Of Stonebridge
PID:10-32990-05-130
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
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 -
Mahin Schroeder
674 Campton Ct
Eagan MN 55123
Renewal Andersen
1920 County Road C West
Roseville MN 55113
(651) 264-4777
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA172440
Date Issued:09/30/2021
Permit Category:ePermit
Site Address: 674 Campton Ct
Lot:13 Block: 5 Addition: Hills Of Stonebridge
PID:10-32990-05-130
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:Includes Skylight
Census Code:434 - Residential Additions, Alterations
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please print pictures of ice and water protection and leave on site.
If water damage is encountered, please call (651) 675-5675 to schedule a site visit to verify the extent of the damage. Any
repairs must be inspected prior to covering. The inspector will determine if an additional permit will be required to repair the
water damage.
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 -
Mahin Amini Schroeder
674 Campton Ct
Eagan MN 55123
(952) 356-7987
Built Strong Exteriors Llc
2215 Quebec Ave S
Lakeland MN 55043
(651) 702-1300
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA177006
Date Issued:06/10/2022
Permit Category:ePermit
Site Address: 674 Campton Ct
Lot:13 Block: 5 Addition: Hills Of Stonebridge
PID:10-32990-05-130
Use:
Description:
Sub Type:Single Fam
Work Type:Replace
Description:
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 $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 -
Mahin Amini Schroeder
674 Campton Ct
Eagan MN 55123
One Hour Heating & Air
15191 Boulder Ct
Rosemount MN 55068
(651) 437-4177
Applicant/Permitee: Signature Issued By: Signature