4276 Dunrovin LaneCITY OF EAGAN Remarks
Addition WILDERNESS RUN 6TH ADDITION Lot 20 Blk 5 Parcel 10 84355 200 05
Owner 1 ". j Street 4276 Dunrovin Lane State Eagan, Minnesota 55123
/0 rla z
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF.
STREET RESTOR.
GRADING
SAN SEW TRUNK 1973 161.21 8.04 20 - 112-8-5 _
SEWER LATERAL
WATERMAIN
WATER LATERAL
WATER AREA 1977 162.14 15 140-54 Ann 9 r?QAL- 9-3 7-7g
-
STORM SEW TRK qoL 1979 277-61 1$ , 5U 15 277.61 0003482 9-12-77
STORM SEW LAT _
CURB & GUTTER
SIDEWALK
STREET LIGHT
WATER CONN. 230.00 8057 11_10-77
BUILDING PER. #41561 9057 11-10-77
SAC A75 ()() 8057 11-10-77
PARK
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. CASH RECEIPT 0
CITY OF EAGAN
3795 PILOT KNOB ROAD
EAGAN, MINNESOTA 55122
DATE
RECEIVED
19
AMOUNT $
CASH [-? CHECK
DOLLARS
loo
FOR
NUMERICAL FILE COPY
??` BY
CITY OF EAGAN
3795 Pilot Knob Rood Eagan, MN 55122 N4 4563
PHONE: 4548100
BUILDING PERMIT Receipt #
r
To be used for A^ Date 19
Site Address Erect ? Occupancy
Lot Block Sec/Sub. Alter ? Zoning
Parcel # Repair ? Fire Zone _
Enlarge ? Type of Const.
Name - Move ? # Stories
Z Address Demolish ? Front ft.
0
Grade ?
Depth ft.
City Phone
1 Aoorovals Fees
cc
0
=V
r
Name _
Address
Name _
Address
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:
all work shall be done in accordance with all applicable State of
Building Official -
Assessment
Water & Sew.
Police
Fire Permit 42-00
Surcharge
Plan check
SAC 4
Eng. Water Conn.
Planner
Council Water Meter
Bldg. Off.
APC Total
on the express condition that
sota Statutes and City of Eagan Ordinances.
PeneM # Data homed Penalftee
Plumbing
Mechanical
INSPECTIONS DATE INSP.
Rough-In
Final
Footing s Date Insp. Date Insp.
Foundation_ r Plumbing
Frame/ins. I Mechanical
Final 1 • f • ? ?'
Remarks:
CITY OF EAGAN
3795 Pilot Knob Reed
Eagan, Minnesota 55122
Phone: 454-8100
PERMIT
Date: ,
Site Address:
Lot Block Sub/Sec.
Name
3 Address Ylellin a ;
G City 3u 1 ri 5 ] ' Phone:
Name = i.. Peter Cc!
Address
e
0
V
City Phone:
This P it is issued on the express condition that all work shall be
i esota Statutes and City of Eagan Ordinances.
Receipt No
Single
Residential
No.
Multi Res., Comm./Ind.
New/Alter./Repair
Cost of Installation
Permit Fee
Surcharge
Total
done in accordance with all applicable State of
Building Official
CITY OF EAGAN
" 37" Pilot Knob Rand
Eagan, Minnesota 55122
Phone: 454-8100
PERMIT
Date: ` rch 10 , 19 Recelpt No.:
Single
Site Address: Residential
Lot Block Sub/Sec.
Name L S e ll 140LIe. S I n n.
Address Yl .i
city ` • a l-I Phone:
Name
Address 1. T!utIer E,
City _ Phone:
This Perm" is issued on the express condition that oil work shall be
Minne Statutes and City of Eagan Ordinances.
No.
New/Alter. /Repair
Cost of Installation
Permit Fee
Surcharge
Total
done in accordance with oil applicable State of
Building Official
CITY OF EAGAN
3745 Pilot Knob Road
Eagan, MN 55122
Zoning:
Owner: to
Address:
Site Address:
Plumber:
SEWER SERVICE PERMIT
PERMIT NO.:
DATE:
No, of Units:
1 agree to comply with the City of Eagan Connection Charge: - ``
Ordinances. Account Deposit:
Permit Fee:
Surcharge: _
By Misc. Charges:
Date of Insp.: -_ Total:
Insp.: Dote Paid:
CIT-- OF EAGAN WATER SERVICE PERMIT
3714 Pilot Knob Road PERMIT NO.:
Sagan, MN 55122 DATE:
Zoning: No. of Units:
Owner:
Address:
Site Address:
Plumber:
Meter No.: Connection Charge:
Size: Account De
osit:
p
Reader No.: Permit Fee:
agree to comply with the City of Eagan Surcharge:
Ordinances. Misc. Charges:
Total:
BY Date Paid:
Date of Insp.: Insp.:
CITY OF EAGAN
3795 Pilot Knob Road Eagan, MN 55122 N? 4563
PHONE: 454.8100
BUILDING PERMIT APPLICATION Receipt # 8057
$51,000.
To be used for Sing. Fam 1)w1g• d Garg. Date Nov. 10, 19 77
Site Address 4276 Dunrovin Ln Erect ff Occupancy I
Lot 20 Block 5 Sec/Sub. WR 6th_ Alter ? Zoning R1
air ?
Re Fire Zone 3
Parcel # p _
Enlarge ? Type of Const. V
z Name Tilsen Homes, Inc. Move ? # Stories
3 Address .627 So. Snelling Ave. _ Demolish ? Front 62 ft.
City St. Paul Phone _ 454-47R4 Grade ? Depth 28 ft.
0
0
zu
u
Name _
Address
Name _
Address
I hereby acknowledge that I have read this application and state that
the information is correct and agree to comply with all applicable
State of Minnesota Statutes and City of Eagan Ordinances.
Signature of Permittee
A Building Permit is issued to: Tils
all work shot[ be done in occorcldnce with all
Assessment
Water & Sew
Police -
Fire
Eng.
Planner
Council -
Bldg. Off. -
APC
Fees
Permit 14L. W--
Surcharge 25.50
Plan check
SAC 875.00
Water Conn. 230.00
Water Meter 60.00
9732.50
Total
nc• on the express condition that
of Minnesota V.&utes and City of Eagan Ordinances.
Building Official
w B 7 --17Uo 10
T?,4quest void 18 months from
D$/-7-3
Date of this Request 11-7-77 P 36809
I, as i Licensed Electrical Contractor ? Owner, do hereby request inspection of the above electri-
cal wiring installed at:
Street Address Route No 42 6 Dunn vikn Lane City r gan
?s?02o ?S
Section Township Range County Dakota.
Which is occupied by Tilsen
(Name or Occupant)
Is a roughin inspection required on this job? No O Yesa Ready Now ? Will Calf
Power Supplier Dakota Cty. Address Farmington
Electrical Contractor O.B. Thompoon Electric Co. Contractor's License No&.13735
(Company Name)
Mailing Address 12201 I4tka Blvd., titka 553,43
(Electrical Cpntractor?o.?°w r Making This Installation)
Authorized Signature s 17? Phone No. 433.2521
(Electrical Con ra tw or Owner Making This Installation)
Safi M SOLD CO
Minnesota State Board of Electricity
#T954 University Ave., St. Paul, Minn. 55104-Phone 645-7703
REQUEST FOR ELECTRICAL INSPECTION
CHECK-BELO* WORK COVERED BY THIS REQUEST
0,9 1 73
P 36809
Type of Building New Add. Rep. Check Appliances Wired For Check Equipment Wired For
Home :E= ? ? Range 13 Temporary Wiring ?
Duplex ? ? ? Water Heater ? Lighting Fixtures 40
Apt. Bldg. ? ? ? Dryer ? Electric Heating ?
Commercial Bldg. ? ? ? Furnace :a Silo Unloader ?
Industrial Bldg. ? ? ? Air Conditioner ? Bulk ht' k Tank ?
Farm ? ? ? List _ lash
Other __ 0 ? ? HeyersI e s
COMPUTE INSPECTION FEE BELOW C rJ i I ?? ??
Service Entrance Size: # Fee FeedersASubfeeders: I#' Fee J Circuits: # Fee
0 to 100 Amps. 0 to 30 Amperes , l 0 to 30 Amperes
101 to 200 Am Q0 TJG 31 to 100 Amperes 31 to 100 Amperes
Above 200 Amps. Above 100 Amps. Above lO(L_Amps.
Transformers Remote Control Circ. Partial or other fee .50
Signs
ns ection
Special]
Minimum fee
Remarks -
Hall TOTAL r YO •00
{.0.50
I, the Electrical Inspector, hereby that above insp?ec?tion has been m
(Rough-in) • ??4? Date & 1'?-';'7 (Final) Date
This request void lg months from
PERMIT #:
CITY USE ONLY
RECEIPT DATE:
2002 RESIDENTIAL MECHANICAL PERMIT APPLICATION
CITY OF EAGAN
3630 PILOT KNOB RD
EAGAN MN 55128
651-681-4675
Please complete for. ? single family dwellings
townhomes and condos when permits are required for each unit
Date: 'q / "q SITE ADDRESS: ! t-) -7
OWNER NAME: It TELEPHONE `f%' jrr ^
INSTALLER NAME: a /L./ TELEPHONE #:
STREET ADDRESS: ) t / vs ?J e6klLf w?
CITY: e6 t--r a ax'- STATE: /KK_ ZIP: S-S-06
Place a check mark next to the permit work type
// ??/? - n
er
Add-on, modification or alteration to existing dwelling unit 1 Q
$ x30.00
0
• furnace replacement 0 1
• air exchanger
• air conditioner
• other ?? i + 1n u /?
Nature of work: L ?/ UR S?LU
State Surcharge $ .50
t
l 1SL
? "
$
To
a -
s
Ja-
CSI__,?O 'A
1/02
------------------
For Office Use
(x
permit #.
Permit Fee:
Date Received j
I Staff. _; ' I
I
2008 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: l ?" ?Oe Site Address: 4'12 7 b YU'y, ?
Tenant:
Suite #:
RESIDENT/OWNER Name: .9 V4 ? ( $ tn
/411?1
Phone: 6?rf
Address/ City/ Zip: L( 276 /?cJ ?7 ?ol?i ?'?n2"
Applicant is: Owner X_ Contractor
TYPE OF WORK
Description of work: ?J
Construction Cost: Y/. 3rJd Multi-Family Building: (Yes No 2?n)
CONTRACTOR Name:&?Ly'GST CC9'? P rt'r5 License #: ?o I J--Z Ll ! 3
Address: /
(5 /t9HL
City: Wre
State: ?ip: ?
-LIL
Phone: 6)2--7?Yli ? / Contact Person: r/7 m
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
_ Minnesota Rules 7670 Category 1 Minnesota Rules 7672
Energy Code • Residential Ventilation Category 1 Worksheet
Category Submitted
(J submission type) • Energy Envelope Calculations Submitted _
New Energy Code Worksheel
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 nor a permit, but only an application for a permit, and work is,ag 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 olgil 34
Applicant's Printed Name
Page 1 of 3
7!-?I
LO P4?5-(??
Date: /0 -/'v /12
BUILDI11G PERMIT APPLICATION
LOT AO BLOCK ADDITIO:i? (O
PARCEL & SECTION 1ARIBER IF U17PLATTED
ADDRESS OF PARCEL ?? ?( ?? ••? r iJ ir/ h
_._OCCUPANCY USE 61 R ZY
ESTLMATED I COST: / ??
OT?TIER 7C.-G? I . ? TELEPHONE NO. /n?•/L3
ADDRESS
.10.
Idote% Include site plan, building plans, and energy calculations with this
application
OFFICE USE
VALUATIOi??
? _
?
77 7 r?
SAC 7
S'YAER CO TEC_I .'! ?D
MWER METER
?7
BUILDING PERMIT FEE m
2
SURCHARGE FEF
PLt1II C:=ECK FEE ?? -
PARK DEDICPMMT FEE
OTHER
TOTF:L*
APPROVALS.
ASSESSi4E7T CLERIC ?/. BUILDING DEPT.V - POLICE DEPT.
t1ATER & SEWER DEPT. FIRE DEPT. PARK DEPT.
? IV i?lo3 ?, ?
_ i
Z
0
?opo.oY
LINE
I-
4a`
a
'A?EIM- AkoPERTY LINE
Z 0' ._---1
I
L%Nt
LOT Moe -K
rROntT_?R?i?F_rZTY., Li_NG
-PLOT -4 LAN
OD 2006 RESIDENTIAL MECHANICAL PERMIT APPLICATION DF 1-0
City Of Eagan '/
111 3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675
Please complete for: single family dwellings & townhomes/condos when permits are required for each unit
Date / a / /
;)_ / 0
/
6
Site Address '7` ? -7 lo ?/ /
lGl /I ?'O J / 4--) l (J L F?
Unit #
Property Owner Telephone # ( r) ?? - U 0to
BURNSVILLE. NF_ATING &A](', INC.
Contractor 34G' 1^!. Btir?sville Parkway
Suite 120
Street Address Burllsviiic,'24 5x337 City
State Zip Telephone # ( )
c'-
Bond Expires: 7 - 0
The Applicant is Owner _/X_ Contractor Other
Add-on or alteration to existing dwelling unit $ 30.00
furnace -Additional YReplacement - New
_ air exchanger
air conditioner
heat pump
other
State Surcharge $ .50 Pr
Total $
I hereby apply for a Residential Mechanical 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 with the Mechanical Codes; at I understand this is not a
permit, but only an application for a permit, and work is not to start without?-pertni; that the work dl a in accordance with the
approved plan in the case of wo hich requires a review and approval of pla s.
Applicant's Printed Name App icl ant's Signature
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Every effort was made to capture the content
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ERYERIOR EN"LOPE SPACE "U" COMMATIM
-y •? (To be ao.;,mitted with building permit application)
an; or two family dwtellin4.2 Z JitnroUbw\LOwnet
4,11 other 20 - w , e, Co ' h -- _ - - ?. ......:?.-
Site Address
:ontrector ?? _ .c ;< <> > Date Phone
` _
.VIRAL FT. OF
OIFOSED WALL +t 1+{_? +? J?7 +?, _+ i_+ ± xa_?j ft. above gs'ade? 1 Z 1C:, ! L r
4
TOTAL EXPOSED WALL AREA SQ. FT. ,
)FAQUE WALL CONSTRUCTION: "U" value R area
,l z2
q.
..
ft,
(A)
t-IGhR ,i t 1 P?-? "U" •?"? x sq. ft. t p,i• t % 1. (11) (A)
itail reference
_ '+U" x sq. ft. (U) (A)
from ;. TN
_ f f_c__ _?_wn a esq. ft. 1 CU) (A)
:cached sheets ". x sq. ft. M (A)
,ryU1„ x sq. ft. (U) (A)
"U" x s q. q• (U) (A)
IIKDOWS: "U" VALUE X Area u \+t._ -.u'?-_ l?b?;c• 1z?c??c,
t Cd "a., 1",Y 40,
r. la ._ it 2Aw"14--
I _ >,-, ? 4a- _
? 'a_I Lic gr -_
! t 44
1,1
ke 6 type u_
"ryU" x sq.
11 t 3' tt?' 4" x sq.
IU If sq.
It Is, If
OORS: "U" value X area t)cc+'_., C•' p =_.,
lake 6 type
? q.
r „
x sq.
eq.
u --
OTAL (U) (A) VALUES _;0
IVIDED BY TOTAL WALL AREA,, AVG. "v"
WERAGE "U" .17 or less for 16 2 family dwellings
.22 or less tor all other buildings
OOF/CEILING:
7TAL AREA:
3tail reference
from _
I'Ittached sheets
scribe openings
roof
)TAL (U) (A) VALUES
TIDED BY TOTAL. ROOF/
!ILING AREA
-sq. ft I
I'll _x sq.
" ,.
U 414_2_x sq,
.lull x sq.
---x sq.
I 1'__? x sq.
t:-` +11'6 w
t L. L sq.ft.
sq. ft.
ctn. sq. ft.
f , . 7 sq. ft.
14 "to sq.ft.
sq. ft.
sq.ft.
3 ?'7 5.1. F'r •
ft. (U) (A
ft. 1 ! 7 . Y L: 2 . (U) (A)
ft. (U) (A)
ft. 3. 7 2•..0 (U) (A)
ft. ")•C4c 2.Cn M (A)
ft. -7 1 .. 2--(U) (A)
ft. U yc??p M (A)
TOTALS a2, 2` , I sq. ft. ??021 15 (U) (A
ft. (U) (A)
fc. 1 7 R -2- -7. / (U) (A)
ft. (U) (A)
ft. (U) (A)
ft. (U) (A)
1 `J. f F-------?TOTALS 'L sq. ft. 22.1 (U) (A)
i -79
%ME "U"' .05 for ventialated roofs
.10 for all other construction
OF/CEILING: R- value
1• _C?? T SI n - Ak 1'l
3." ?YP<vpn 4?
4.
5.
6. . Z.
NSTRUCTION FRAMING:: R- value
1.
2.
3.
4.
5
1'E.43
6. CL -
X4, 9q .off
If average "U" values as calculated above do not meet the Energy Code requirements.
the "Alternate Envelope Design" as outlined in SBC 6006 (g) may be used. Additional
sheets may be used to show calculations.
0
City of Eagan
3830 Pilot Knob Rd
Eagan, MN 55122
(651) 675 -5675
www.ci.eagan.mn.us
Site Address: 4276 Dunrovin Lane
Lot: 020 Block: 005 Addition: Wildemess Run 6th
PID:10- 84355- 200 -05
Use:
Description:
Sub Type: e- Windows/Doors
Work Type: Windows/Doors - New/Replacement
Description: House
Census Code: 434 -
Zoning:
Square Feet: 0
Comments:
Fee Summary:
Valuation: 3,000.00
Contractor:
Beissel Window Siding
1635 Oakdale Ave
W St Paul MN 55118
(651) 451 -6835
PERMIT
City of Eaan
BL - Base Fee $3K
Surcharge - Based on Valuation $3K
Applicant/Permitee: Signature
- Applicant -
Construction Type:
Occupancy:
Carbon monoxide detectors are required by law in ALL single family homes.
$88.50
$1.50
Total: $90.00
Owner:
Steven M Wall
4276 Dunrovin Lane
Eagan MN 55123
Permit Type:
Permit Number:
Date Issued:
Permit Category:
Improvements to the home require smoke detectors in all bedrooms. If altering window openings, call for framing
inspection. Call for final inspection after installation.
0801
9001
Building
EA088984
05/01/2009
ePermit
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply
of Minnesota Statutes and City of Eagan Ordinances.
h all applicable State
Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA118437
Date Issued:10/31/2013
Permit Category:ePermit
Site Address: 4276 Dunrovin Lane
Lot:020 Block: 005 Addition: Wilderness Run 6th
PID:10-84355-05-200
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please print pictures of ice and water protection and leave on site.
Carbon monoxide detectors are required by law in ALL single family homes .
Jayme Meyers
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 -
Steven M Wall
4276 Dunrovin Lane
Eagan MN 55123
Bayport Roofing and Siding LLC
10 South 5th St, Suite 700
Minnepolis MN 55402
(612) 235-7663
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA152282
Date Issued:10/08/2018
Permit Category:ePermit
Site Address: 4276 Dunrovin Lane
Lot:020 Block: 005 Addition: Wilderness Run 6th
PID:10-84355-05-200
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Furnace
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088
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 M Wall
4276 Dunrovin Lane
Eagan MN 55123
(651) 303-3399
Bonfe's Plumbing & Heating
455 Hardman Ave
South St. Paul MN 55075
(651) 228-7140
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA157746
Date Issued:09/05/2019
Permit Category:ePermit
Site Address: 4276 Dunrovin Lane
Lot:020 Block: 005 Addition: Wilderness Run 6th
PID:10-84355-05-200
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 -
Steven M Wall
4276 Dunrovin Lane
Eagan MN 55123
(612) 327-6102
Beissel Window & Siding Co
1635 Oakdale Ave
W St Paul MN 55118
(651) 451-6835
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA160623
Date Issued:03/30/2020
Permit Category:ePermit
Site Address: 4276 Dunrovin Lane
Lot:020 Block: 005 Addition: Wilderness Run 6th
PID:10-84355-05-200
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Standard Water Heater
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.
Allow an 18" minimum radius clearance to the water meter from all appliances (i.e. furnace, water heater, water softener).
Fee Summary:PL - Permit Fee (WS &/or WH)$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 M Wall
4276 Dunrovin Lane
Eagan MN 55123
(651) 303-3399
Bonfe's Plumbing & Heating
455 Hardman Ave
South St. Paul MN 55075
(651) 228-7140
Applicant/Permitee: Signature Issued By: Signature