The URL can be used to link to this page

1250 Deerwood DrPERMIT City of Eagan Permit Type:Building Permit Number:EA128371 Date Issued:11/07/2014 Permit Category:ePermit Site Address: 1250 Deerwood Dr Lot:1 Block: 1 Addition: Langstraat PID:10-44475-01-010 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:Two or More Windows/Doors Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow windows, call for framing inspection. Call for final inspection after installation. Carbon monoxide detectors are required by law in ALL single family homes . Valuation: 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 - Ronald C Hansen 1250 Deerwood Dr Eagan MN 55123 Renewal Andersen 1920 County Road C West Roseville MN 55113 (130) 651-2644 X777 Applicant/Permitee: Signature Issued By: Signature City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 1250 Deerwood Dr Lot: 1 Block: 1 Addition: Langstraat PID:10- 44475- 010 -01 Use: Description: Sub Type: Work Type: Description: Census Code: 434 - Zoning: Square Feet: 0 Comments: Fee Summary: Valuation: 3,000.00 Contractor: Fireside Hearth & Home 20802 Kensington Blvd Lakeville MN 55044 (952) 985 -6675 e- Fireplace Gas Fireplace (new) Improvements to the home may requ concealing. Carbon monoxide detectors are required by law in ALL single family homes. BL - Base Fee $3K Surcharge - Based on Valuation $3K Total: I hereby acknowledge that I have read this application and state that the informa of Minnesota Statutes and City of Eagan Ordinances. on is correct and agree to comply h all applicable State Applicant/Permitee: Signature PERMIT City of Eaan - Applicant - Construction Type: Occupancy: e smoke detectors in all bedrooms. Chimney / flue must be inspected prior to $88.50 0801.4085 $1.50 9001.2195 $90.00 Owner: Ronald C Hansen 1250 Deerwood Dr Eagan MN 55123 Permit Type: Permit Number: Date Issued: Permit Category: Issued By: Signature Building EA088464 03/16/2009 ePermit _LAon sv}2 PLQ-?I (, K w? ) c ? ?? ? tnciude z sets of plans, . 1 site plan w/elevations & ?? BITI7D?NG pF?1IT APPLICATION 1 set of energy calculations. Be Used For ??'Valuation?d () nate ?5--?'1-- site Address ? 2 S D &-r.rriro o d A::?P Lot (?? I l Block-? Sec./Sub. 5FC, Z-L- Paroel #: 1 ?^ D Z 2 0 ? p?? Owner: ?92Y? _ P,ddress: ? City/Zip Code: Phone #: OFFICE USE ONLY Erect ^7<, Occupanc3! Alter Zoning ? Repair Fire Zone Ehlarge _ Type of Const. .? ? Nbve # Stories Danolish Fmnt D £t. Grade Depth. S/ ft. Contractor: 4Qz2„/o.QO,PS ?o?sT Address: ,City/Zip Code: r .P Phone #: . Arch./Ehg•: Address: ?4ater/Seaer Police _ Perntit Surcharge Plan Check Fire SAC Eng, Watex Conn. Planner ater Meter Council Unit 4' Bldg. Off. ? -' APC City/Zip Code: Pnone #: t.pjs J n 0? ?a le w',4 ek A41tvJGe Vn s! 1-+r at6lro I??? ? Sd 7l7PAL S- b/.e?.cite? L? rE.? ? r IZ;?n Q 0 te ? Uo0nloo I ? . ? cirr oF Er?r,,nN N°. 7335 3795 PUM Knob Reod Eagen, MN 55121 - PHONE: 45;6100 BUILDING PERMIT , Receipt Value $128, 000 Te 6a ond fer SP DWG/GAR Est Date JU rie 10 _, 19 8? . Site Address 1250 DeeT'ilood D=iVe Erect [H Occupancy R-3 Lot Oll Blxk 86 Sec/Sub. S6Cti0A 22 Alter ? Zonin9 A 10 02200 Oll 86 air ? Re Fire Zone VA Purcel # p Enlarge ? Tyce of Const. V rc Name Ron BOyle Move ? Stories ; Addreu Demolish ? Length 90 b Grade ? Depth 51 Sq. Ft.- ci phoret ? Develoner' a Conatruction apvovota Fees p Name ?? Address 1101 Cliff Road ? ?...w?rnaville --- 890-6194 Name Asussment Water 8 $ew. Police Fire Eng. Plonner Council I hereby acknowledge that I have reod this applicotion ond stota that Bldg. Off. the inlormofion is correct and agree to comply with ull opplicabla APC - State of Minnewta Statutes and City of Eagon Ordinances. Permil ow.uv Surcharge 64.00 Plan check 251.50 5AC 525.00 Water Conn. Watei Meter-NA- Rood Unit 240.00 Totol a5 I 83-50 $ignoture of Pertnittee I A Building Peimil Is Issued to: DBVelOD¢VI9 aDRBtTtIC'ti0fl on the express condltion thai all work sholl 6e done in occordance with ell appliwble Sfnjcpf Minnesafo tutes ond City of Eayan Ordinonces. Buildinp Offfcial CITY OF EAGAN 3795 Pilot Kneb Rood Eoqoe, MN 55122 • , PHONE: 454-8100 BUILDING PERMIT Recelpt # Te be used fa Est. Valua Date , 19 Site Nddress Er t O ec Q ccupancy Lot Block Sec/Sub. Niter ? Zoning parcel # Repoir p Firo Zone T Enlorgs p ype of Consf. W Name Mo ri # St ve O o es Z ? Addross Demolish p Length Ci phone Grode ? Depth Sq. Ft. °C Nome Approvab Faes ??0 Address ra,, n?....._ Nome _ AddreSS I hereby ocknowledge tFwt I have read this opplicotion and stnre that the information is correcf and agree to comply with oll opplicable Stote of Minnesota Stotutes and City of Eoflon Ordinances. Assessment Water 8 Sew. Police firo Enp. Planner Counci I Bldy. Off. APC Permit Surchorge Plon check SAG Woter Conn. Water Meter Road Unit Totol Sipnoturo of Permittee I /1 Buildiny Pertnit Is issued to: on the express tor+dition that oll work sholl be done in atcordante with oll opplicable State of Minnesota Statutes and City of Eoflon Ordinontes. Bu{Idinp Officiol ? t ? ? 3 ? M : a 6 Z . I . 0 t = a 2 ? t-- N f L? al O s, • . _ r ? 2, ? w, J? ?' L ? {t ?7 6 y" " 1e ? N E . ?.. ? , C $ d C? a 'x' o ? x ; d a 0 ? q N Y «C ij W O t ? ? ? C g LL O 4 L O C LL d ? fL ? = ? ? C O M a C ? d ? LL Q 9 S < LL < LL ; 3 - ? ? •? ?7 a .a ° ? Recaipt MECHANICAL PERMIT Permit No. ' CITY OF EAGAN Fee FA1 in numbered spaces S!C Type or Print /egib/y Tpt 1. Date 2. Installation Cost n ' 3. Job Address Lot 011 Blk. Tract ? 4. Owner =et ! l _ , `',• . ?_, 5. CoMractor Phone ? 6. Address .' ??' l ' ? 7. City State Zip 8. 6uilding Type: Residential O Commercial ? Institutional ? 9. Work Description: New O Add ? Alter ? Repair ? 10. Describe Fuel Type 11. No. Eauioment STU - M. Ea. Forced Air No. Equipment CFM Ai H dli Mfg. r an ng: Boilers Mfg. Mech. Exhaust Unit Heater Mfg. Other Air Cond. Mfg. Gas, Piping Outlets 12. I hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : for Rough Final Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-8100 { .. Receipt . PLUMBING PERMIT Permit No. ? CITY OF EAGAN Fee Fil1 in numbered spaces S/C TYPe or Prini /egibly T ot. 1. Date 2. Installation Cost 3 Job Address Bik T t`~ . . rac n._ 4. Owner ? 5. Contractor • ?r .? ; Phone 6. Address ? 7. City State Zip 8. Building Type: Residential Q Commercial ? Institutional ? 9. Work Description: New 0 Add ? Alter ? Repair 0 10. Describe 11. No. Fixtures Water Closet No, Fixtures Cess ool/Drainfield Bath tubs p $e ti T nk Lavatory p c a Softner Shower Wel I lCitchen Sink Urinal/Bidet Othe Laundry Tray r Floor Drains Drinking Ftn. Slop Sink Gas Piping Outlets 12. I hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : Rough Inspections: Date Insp, for Ffnal Date Insp. This is your permit when numbered and approved. Approved _ CITY OF EAGAN 454-8100 Receipt PLUMBING PERMIT CITY aF EAGAN Fill in nuntbered spaces Type or Print /egibly Permit No. Fee S/C Tot. 1. Date 2. Installation Cost 3. Job Address Lot Bik. R?Tract 4. Owner / , _ - ; - 5. Contractor Phone 6. Address • ' ' 7. City State Zip ' 8. Building Type: Residential m Commercial ? Institutional ? 9. Work Description: New El Add O Alter ? Repair ? I 10. Describe 1 11• No. Fixtures Water Closet No. Fixtures Cesspool/Drainfield Bath tubs $epticTank Lavatory Softner 5hower Well Kitchen Sink Urinal/Bidet Other Laundry Tray Floor Drains Drinking Ftn. Slop 5ink Gas Piping Outleu 12. I hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : for Rough Final Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-8100 I ;? ? C a !`4 Receipt PI.UMBING PERMIT Permit No. CITY OF EAGAN Fee U Fill in numbered spaces S/C Typa or Print /egib/y Tat , 1. Date - ?? `- 2, Installation Cost 3. Job Address'_' Lot n?( Blk. gb 4. Owner - - ' ? 5. Contractor Tract•.-' ,-Rhone ' ? " • 6. Address ? 7. City State Zip 8. Building Type: Residential Commercial O Institutional O 9. Work Description: New C3. Add ? Alter O Repair ? ? 10. Describe I 11• No. Fixtures Water Closet No. /V Fixtures Cesspool/Drainfield Bath tubs Septic Tank Lavatory Sofiner Shower Well Kitchen Sink Urinal/Bidet Other Laundry Tray Flaor Drains Drinking Ftn. Slop Sink Gas Piping Outlets 12. I hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : for Rough Finel Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-6100 CtTY OF EAGAN ' Remarks Addition' SectiOn 22 Lot Blk Owner -'? reet C e ?? ? . lC.?' a v ?Y19 . 7 _ A Q ii s., -I'7. /- .rJ' , 10 02200 010 86 Improvement (t7ate Amount ual Years Payment Rece' Date STREET SURF, STREET RESTOR. GRADING SAN SEW TRUNK SEWER LATERAL WATERMAIN WATER LATEFiAL WATER AREA STdRM SEW TRK STaRM SEW LAT ? CURB & GUTTER SIDEWALK STREET LIGHT / WATER CONN ; BUILDIN ER, ' SAC RK ?I CITY OF EAGAN Remarks Addition SF(?'??8? `22 Lot O11 Blk 86 Parcel 10 02200 O11 86 Owner ?1L1L?ldt,??? ??V??L'tr?1 ?:OA ( F . Street ? ?5 ?/ _ _ 11,0,ri1'-wow State Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. STREET RESTOR. GRADING SAN SEW TRUNK q3 1985 3781.00 252-07 15 SEWER LATERAL WATERMAIN WATER LATERAL WATER AREA STORM SEW TRK STORM SEW LAT CURB & GUTTER SIDEWALK STREET LIGHT ROAD UNIT 240.00 # 484 6-11-82 CONN. BUILDING PER. 73 SAC PARK INSPECTTON RF.r.Oun CITY OF EAGAN 3830 Pilot Knob Road , Eagan, Minnesota 55122-1897 ? (612) 681-4675 SITE ADDRESS: ? • ;t i,? I , i PERMIT SUBTYPE: krM ARKS: IyttiI HE; ?.r?r r i r rA°,f rA 14 111 rrra?. E ... ?. ?;.: t ? .. fj,, APPLICANT: it.i.ly u??? ?•+b.? TYPE OF WORK: PERMIT TYPE: ? ll D r 14' Permit Number: 1 T q!' Date Issued: `' ` ` I F? /t)t Permit No. Parmk Holder dete TNephone 11 EIECTRIC PLUMBING HVAC Inspectlon Date Insp. Comments FOOTINGS FOUND FRAMING ROOFING ROUGH PLUMBING PLBG AIR TEST ROUGH HEATING OAS SVC TEST INSUL GYPBDARD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLOG FINAL BSMT R.I. BSMT FINAL DECK FfG DECK FlNAL r-I I IN CITY OF EAGAN 3830 Pilot Knob Road Eaqan, Minnesota 55122-1897 I SITE ADDRESS: ' ' i c? c 7 , ! 1 K?.11"1ClIl 4)F PERMIT SUBTYPE: II , I taN t,r,I I ''°4APK':: I'I RN RF4'f1-1,111 ft IiY MTKF- fillP a ON PERMIT TYPE: I I n r Nca Permit Number: ' . E `P'o Date Issued: f 17 /941 .-»a ynIt) r, r• K? APPLICANT: TYPE OF WORK: ..?? f I NAi m V ? ? ?? Permit No. Permit Holde? Date Telephone f ELECTRIC PLUMBING HVAC Inspection Date insp. Comments FOOTINGS FOUND FRAMING ROOFING ROUGH PLUMBING PLB(3 AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYPBOAHD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL BSMT R.I. BSMT FINAL DECK FTG / ? DECK FINAI ! ? INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number: Eagan, Minnesota 55123, Date Issued: t;I I I t 0 i nrr, 0 .• 3 I i Fy 0 3 I:" <.?lcra SITE ADDRESS: ; „ j PERMIT SUBTYPE: ? ? y 4;?i? K, ,, APPLICANT: TYPE OF WORK: <<? I•,?? i a< ?? f; ? It I ?<:Pd i1?uUFllYr:i) INSPECTION DA • DA Permii No. Permft Holder Date Telephone # S/W PLUMBING HVAC ELECTRIC ELECTRIC Inspection Date tnsp, Comments Footings I Foundation Framing Roofing Rough Plbg. Rough Htg. Isul. Freplace ? Final Htg. Orsat Test Final Pibg. PI6g. Inspector - Notify Plumber Const. Meter EngrJPlan Bidg. Final Deck Ftg. Deck Final Well Pr. Disp. ^ REQUEST FOR ELECTRICAL INSPECTION ? 7 `,? 9 1 3' See insttuccions tor comnletinq this form on bar.k of yellow copv. ""Xi"-? Vv'ork Covered by This Request E13-00001-03 3d7 ?-( N Atltl Rqp. - Tyue ot Building Appliances Wired Equinment Wired Home Range Temlwr2ry Service ?uplex Water Heater Lighting Fixtures Apt. Building Dryer Electric Heatin Commercial Bldy. Furnar.e Silo Unloader IndustrialBldg. AirConditloner BulkMill<Tanl< Farm OrhnrtSpeolv Oinur?SUOr,lfyl the, (Spneify Othor Oihor U0/!IDLIC@ (ASDEC170R fFP. HP.IOW K Fee ServiceEnVanceSize # Fee F?eders?SUbteeders ?? Fee Circuits 0 to 100 q?n os 0 to 30 Am)s U?? D to 30 Am)s Zi00 101 m 200 qmps 31 io 100 F?mps aZ JO , OQ 31 ta 100 Am s A6ove 200 Amps Above 1?0-Amps Above 100_Amps Transiormers RemoteControl Circ. C.. 1 50 Partial?'Oth; Stgns Speciallnspection 5 /' ?SC ? T Remarks OTAL E Noog1 L11c`:} 6i id the Electrical spectoq hereh?y ertitv tnat tne , nove Flna $ j??? / ? ??] i / ?""Y?`?[i6-? Datn(? [n ??spection has heen de. irus rcquest void 18 months fram Thls request void ?? h C 1a moncns rrom ? oC.J 79913 tfs /6 O?Zb c, n l 1 5(10 / 3 0 `7 .2`Z < <{ s, o0 Request U'te Firc Nu. Rou -ii InsGCr.tlon ? P f 2 R q ired? K m Rc.idY Now Will NnGfv fnspec- hr Wh n R d j vos F . e oa Y Licensetl Electncal Gonvactur I hereby request inspection of 2bove ? Owmu elecRlcal wnrk insteiled at: Streat Atldress, Bo or Route No. CI ?• C) t? _ ection o. Township Namo or No. Ranga No. Gounty OccuGaM (PRINT) 4 ` A)+ Phonc No. Powe Sup ler Add EI nnt a r(Gompa me) Conv } 's Llc?e No. , Y Mailing Address.ICoMlacto or Owner Makiny Instailation) AuNonz 1p' Ignowre IC Vac Owner Making InsY gIatluN h /7ry'umber 5 .5 J MINraE50TA STATE BOAR?IOF EIkCTRIGTY - THIS INSPECTION.REQUEST WRL NOT Griggs-Midwav eldg. - Hoom N-1?'I BE ACCEPTED BV THE STATE BOAFD 1821 Universily Ave., St. Paul. MN 55104 UNLESS PROPEF INSPECTION FEE IS Phone 16121 29]2'l11 ENCLOSED. 2005 RESIDENTIAL BUILDING PERMIT APPLICATION City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 FAX # 651-675-5694 New ConsWCtion ReouiremenGs RemodeVReoair Reauiremen4s Office Use Onlv 3 2giste2d sita surveys showing sq, ft. of lat, sq. f4 of house; and all mofed areas 2 wples of plan Cert of Survey Rerd Y. N (20%manimumlotcover.geallowed) lsetofEnergyCalculatbnsforheatedadditions TreePresPlanRecd _Y _N. 2 copies of plan showing beam & window sizes; paured found design, etc. 1 site survey for additions & decks Tree Pres Requfred _ Y_ N isetofEneyyCalculations Addi6on-indicataAon-sifesepticsystem On-siteSepticSystem _Y _N 3 copies of Tree Preservation Plan H lot platted after 711193 Rim Joist Detail Op6ons selection sheet (buildings wAh 3 or less uniGs) Constnction Cost J 91 T(g) ? Date -a_ /itm- / a S ? Site Address (,-??0 / /.,-eA UniUSte # Description ot Work 'iK`pi C.e 36 l.Ut C\6LOW Cs W j , Y? --C ; S'sLQn Q pY1!nCy? • Multi-Family Bldg _ Y_ N Fireplace(s) _ 0_ 1 _ 2 PropertyOwner lj2\O`n Telephone#(LDSy) L4 SI-I _u'9$(O Renewal By Andersen Coutractor _1920 County Rd. "C" West Address _ Roseville, MN 55113 City State 651-264-4777 Telephone # ( ) License # 20130983 COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING - Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672 Energy Code CategOry • Rasidential Ventilation Category 1 Worksheet • New Energy Code WoAcsheel (dsubmissiontype) Su6mitted Submitted • Energy Envelope Calculalions Submitted Have you previously constructed a building in Eagan with a similar plan? _ Y _ N If so, 25% plan review fee applies. Licensed Plumber Mechanical Contractor Sewer/Water Contractor Telephone # ( Telephone #( ) Telephone #( I hereby apply for a Residential Building Permit and acknowledge that the information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN Statutes; I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved lan in the case of work w'ch?requiFes- - d appr val of plans. ?a rSOV? d J N 0 6 2005 J pplicanYs Printed Name Applicant's Signature ••?r°s•m••••'. +uu tL:ao i?t2d tod D(1'4460 t(t,'P!l:11hL?1°&!YU$[(.7fFf! • . ?e a.? ?. - . . : . sune t zoal ?of Ba?gan. : - 3836 PiIaf ffttob Itoad . EaM MN 55122 . To Whom k May Goncern; . IIder.Tones is authorized to pttII buikUng Peralits forResmvval by Andezsea ptease atIow Eidcr Jones to Provide this servi?c for ua in Ea?an. 7itis authotizetian is velid f?vr assy . ? bcyond 6J6/01: untiI a?`auewa! bY . tA the Cyry Andersaa mana?r ?IY revakes it in wiiHag I rcquest th'rs awiiox7Adon be ac.ccpted'??ottsly ' -. - ,- our baild"mS Ponmitz aay furtfiar. Picnac caA mc if tha? arc nnot n ?8y in the Prpersaitig oP ? contacted at ?63-502r47A6_ Y 4?tona._ I'cen l?e _ ?. Xour itnmSdfatc attcntiotl ta this mattcr is aL?6arn11 + . . sinoeialy, yritandR Rau tistallation M,anag?r Rcnowal by Andcrscn CoMotafion Karn-F.fder 7onem . aH d? ??? s ur cam,aaon - - ??n,uns V f :- wU V Received_Time Jun. 7. 1'07Pfd' I?,GJC?Q 0 2005 RESIDENTIAL MECHAIVICAL PERMIT APPLICATION City OfEagan 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 Please complete for: single family dwellings & townhomes/condos when permits are required £or each uni[ Date (o Site Address Unit # P t O -PX A? hone #kQ4 Z) Tele wner roper y ) p Contractar BURNSVILLE HEATING & AIC, INC. 3451 W. umsvi e a way Street Address SUItB 120 City S umsw e, Zi l` ?.,?y? Tele hone# ?S ?? ? ?-1.? tate p - p U Bond #: LA IS ' eZ d? IC)? Expires: The Applicant is _ Owner X Contractor _ Other Add-on or alteration to existing dwelling unit $ 30.00 furnace _Additional _Replacement ' air exchanger )< ' air conditioner _New -YReplacement other State Surcharge $ .50 T l ota 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; 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 appr ved plan in the case of work which requires a review and approval of plan ??I????1. 1 ( ApplicanYs Printed Name Applicant's Signature i a 2005 , ? L -_ Q Indi r t -dt?(f r .tA/. g x nv Uance InspE riduaC Sewa :j Ge rs{,., ? 7 ----- I ? Person Cequpsq?g'I?sQ?Ction,"'. Site Add ,c,. . Fire No / Parcel.Na Legal.De;crlption Local RegulatoryAu?ority --?A Date sysbem constructed' Proteclion;Area: yes no System servinj Shoreland or.WeUhead „ ;.:Beverege or for n, 2/25/02 Water/vtastewater-IST5431 ??? 1 4 o Form for; Existing ' ?? ? Minnesola PcUution ! ??t111@11t?S?S'tgills Controi Agency SeP? . ?' .'. ` . _ ._<e,.d .an?QrAta R aL 7080 (rsss). Piease reter ... . .:4:. ' '?. 2 &9 /a/ la ,;Telephone 7 Tele,phone.(... ) „? ? ? ?nI A,.? Zfp Code?.-1-3-?3 Akd7?.4.:' TownshiP =27- 7 System in Shoreiand Area: yes no System in Welihead a MDH licensed faciUtys Yes nQ,Local Permit # (if any) iU2d Gt Sy50e(i15.lOCdkCd,f11$horeW(10 4r-Weuneaa rrU« a Foqd. Areas, or $ervfng a Food, Beverage 9r ?91ng , Estabqshrpent, or systems BuiR after _ ML ? ? ?, - o? safetv7 (aYesaasweris an l7PHSsyslem) ' yES pluharge ot seerage m tne ground svrface? ves No ?S7 YES; ? -Discharge of .,,. to draiMiie or surface wabers? YES NO ?_?. ea...i.wltlnn7 • YES NO - Seyyage tiaclap into tlweping7 . - , . T = m? ' yyt? tlie pqtienNal m lmiriOdfaEelY and' - ??? ?r •..- --•---- - - SfWaHori wlth tW potentlal bo tmmedfatelY and yd?rerspJy fmpact or threaten pubUc heakh or.; , fm ortfireaten Wblk health or a?'? ? YES NO SafetY7 YES_ ? 5afety? (a yes answeiis a faiGng systern).: ; Is the'?*pm faillria7 *< rhe ""t'fflm fallina7 (a )4s answer is a fa1/Ing syslem) _ - Less.than 7WQ feet of verdcal separatlon: between. F - Less than THREE feet of vertlcal separatlon between YES NO botWm an{isatsuated-soil or?bed[odc7 ., t ES Sy? pqt?°m-and saWrated sdl or bedfodc7, - dM?!eJl, or leahfi9 f?7 Y?. - A?'-Pa9? P?. ;Ys em A?Pa9e ?4 e???• d+Y?. x leachEng ?ik7 YES NO . . .. ,. . comolfant? non Is rt,R system - Is 1he system regulaled under a monitorqig plan or :.; YES 10 Eg the Ns* m non-comolian ,: Is' the system regulated.-under.,.a monitoring P NO to P88e 2) YES operating permil? ?'drw, go . opera?Ung Qermft? , Uf no. 9a to page 2) . . .? , ; = Has'rr tlhe required monROrtng taken plai:e? " YES NO ffyes, - Has the required monitoring taken place? YES NO (ll no, the system k non-complYln9) (!f no, rhe system fs non-comPWn9) = Does the morotoring indicate fhat the system mee4s' ?' • `= Does the monitoring indicate that the system meets yES._NO : performance expectaYrons?- - ` perfortnance expectatlons? YES NO (!/ra-ifiasystem.tsnwrrcomplY .k!81 p/no..Nesyater?Ts.?++Ph'?+9).. . , _ JUN 19 2002 :.. , _ Page 1 of 2 wq-wwists43 Prope?ty System Comnonents (P/ease desa/be the system .._.,.?. _ _.. .,. .. n I,:. „ 1. Probed tank" bottom o Observed low Ifquid level , Examined const. records c3 Examined emPtY (Pumped) tank ? Probed outside tank for "bladc soii° ? . Pressure/vacvum check .• ;..,,. .. , o ? Othe? . Fire No./ Parcel No. and attach s/le sketch showing systeln locationJ: ?? Z ly iv .? - detarminatlons for the comnlianre Insoedlont (Note: No standard profocal erlsts. quenUal order nor ii+dlcales whkh mmbinations may necessary [o make a determinationJ Hydraullc Functioning Vertical Separation Distance /J?a R/ L ?. Searched for surface oudet ? Conducted soil borings ?C 0 Perf,ormed hydraul(c test Depth to IimlGng layer . 7d ? Searched for seeping In yard ? Checked for 6ack-up in home 0. Excessfve ponding in soll sy5tem/U-6oxes ? Homeowner testimony a Examtned for surginy In tank Depth to system bottom _ ? Examined records o LGU Umitlng Layer Verffiwtlon cl Otlier ? ? "Black wil" above soll system O Other `. ...:.:.' .: Status of the svstem ` Based on the tomplfance criterla; the system status is: (check one) ? failing (to protect groundwater) ? an imminent threat to publlc health or safety (1TPH5), O non-compliant (monitoririg issue) O compliant (none of the 3 previouS. conditions).:Therefore,.this document ls a: XCertiFl,sake of Compliance 0 Nodce of Noncompiiance Is this system an EPA Class V In ect3on Well? ? ye3 n Certification ,,: . ' I hereby certlfy as a stafe of Mlnnesota Ucensed Inspector and/or Designer I or. Qualified Empioyee Inspector and/or Qualified EmploYee Designer I that I conducted an investigatlon that acarately determiried the compliance status of this system and tha[ my recorded observatlons are accurate as of this date. No determinatlon of future hydraulic performance has been nor can be made due to unknown conditlons durfng system construction, abuse of the system, inadequate maintenance, or future water usage. " Inspectors name (prlnt),?'??? ?i7?W _ Phone /?S/ ^ 6?3 7 Lfcense and/or Re915tratlon Number _7 !2 _!W Address.? Employed b pAddress ? v ST•.?$ Stanahira"' ' ?l? Date A ' UparadeReauirements IduivedtromMinnewtasrarutesytlsss) An ITPHSmustbe upgradet; replaced, or/ts usr d/sconG'nuer/ withln ten monfhs ofrecelpt of thls nofice ol, within.a shorterperiod if requ/red bylocal adinance. If the system fails to provide sulrluentgraundwater protecG'on, then the system musC be upgraded, rep/aced, or/C; use discondnued wlthln the lime requiredby ru/e or the /ocv/ ordinance, lf an exlsting system /s nat fvi//ng as defned/n law, and has af laast lwo feel of deslgn so!lseparat/on, then the system need not be upgraded, repalred, replaced, or its use dlsmndnuec? nohvlUutanding any /aalor+??nance thatls more s[dct. Thls does not app/y lo systenns !n shoreland arevs, wellhead protcrUon area3; athose usedln ronnect/on with food,'beveruge, and lodging establishmen[s as derlned /n law. Suaaested Attachments : ;1) Site sketch could aLsolnclude: weA, well setback W system, dweltlng or other bufldings, tank(s),reserved soil treatrnent area, surface water and wil boring laatlons: :Indude arbullt drawing If available.. 2) 'Sotl bodng logs; showtng each horizon. Indicate the texture, color, redoximorphic features depth to bedrock, standing water and whether:the material Is fill. 3) A list of any and all requirements of the:local ordinance that are different from the state requirernents referred to on this form. 4) A homeowner survey of system performance, signed by the homeowner as bein9 factual. 5) Monitoting data as appropriate. Page 2 of 2 .S ?-'-_ 'P,¢y e- 3 '-?- w.4 / 8? 16RM,?:,;'d/MV hED PROD DIV', ? 5»3> DELMAR H. SCHWANZ L-MOfV.VEYOm Ny4ww oww L. H iM $1N. el y.011 30t1 _ ?q}h 9TREET W. -!DY y puMpyM. WMymullA Mas SuPVEYOR'6 CENTIFICIITE M ro M T M 7 N N N F" N? N( ID N3 ?? •? V? in _o ? Q \ IlowTr? L ?We o? SE?A}? F_ /?. N0.9B6 P.3 lMOME 9f1 41Ytmp ? Ha n p I J11 ?p i o 1461 V . `Jyp vp? y6 v o Y'. ?pa 1:La Il.YI 24 14.0 3.11 2YA7 ? p N VE'TN\L, ,/ o -- M ? tl ? rW +? d? Q ? s p • ° -+' in ??- F ? ?• o ? J? 0 ? F b 1A / -33o.v9 N 99° 55, VO E?• SourN uue o? ?o2fiq G60.0 I ? .}? wL,a,sE??4,sEC. Zz Sca? ?. QQi e ? 1i?,?h =1 ' `e0y t:ertlty t}yt tT11s ie fi LaUQ gpd colTect TeplM6entation of a ?Y of the hounparlee oP ttte North 6b(1.00 faet oP tne Weat C?uarier ie Southeaat @uarter af Seation 22, 7brnehtp 27, Rsnge 23, gxCEpr aat 33;,..? Ceet therept, Dakotn Cuvncy, Apinneeota, at"ing the looakion or a proposed twuaa ae stakaA, rveyed by me thla /3 deyr of /n9y/ 1992. 1dh Cllil, j • / j MNM4604 R[ {TnATION No W ? , Date: . '• . :. ? ., i. Customer Name .5t)'A 'q'T StreetAddress City, State; Zip .'J::"_8 V ?-??S l z 3 Phone Number: , ' " ' .... l?y, ' COh9PANYiDISCLAIMER . ,b1.. .' Based on what we were able to observe and on our experience with on•site wastewater technology,.we submit this Onsite Sewage Treatment System inspection Report based on the present condition of,,thi; onsite sew,aQa disposal system. Bob Freiarmuth has not been retained to warrant, guarantee, or certify the proper functioning of ther system forany period of time in the future. • Because of the numerous factors (usage, so.il characteristics, previous failures, etc.) which may affect the proper operation of a septic system, as well as the inability of our company to supervise or monitor the use or maintenai7ce of the system, this report shall not be construed as a ,•: warranty by our company that the system will function properly for any particular buyer, BobFreiermuth hereby DISCLAIMS,ANY WARRANTY, either expressed or implied, arlsing irom the inspection of the septic.system or this report? We are also not ascertaining any affect the system is having on the groundwater. ` Inspecting Company Phone? 651 437•9605 ::Bob Freiermuth License No. %98 I have studied tha Information contained herein and certify that my assessment is honest, thorougri;'and to the best of my ability, correct, ^ v S Nar A I I L RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB RD, EAGAN MN 55122 651-681-4675 New Constructlon Renuirements • 3 registered sile surveys showing sq, fl. of lot, sq. ft of house; and all mafed areas (20% mauimum lot coverage allowed) • 2 copies of plan showing 6eam & window sizes; poured found design, etc.) • i sel of Energy CalculaUOre . 3 copies of Tree P2servation Plan H bt plaqed after 717193 . Rim Joisl Detail Options seledion sheet (bldgs wAh 3 or less units) DATE _SV Y/ a2- RemodeUReoair Reauirementa • 2 copies of plan . 1 set of Energy Calculations for heated additions . 1 site survey for extedor additions & decks • Indicate'rfhomeurvedbyuptlcsyslemforaddNons d? VALUATION Z? 9'34) SITE ADDRESS 12- 5 0 0 c.? .- w?a d MULTI-FAMILY BLDG _ Y ? TYPE OF WORK ??'1r or? f. u? C Rd? ? FIREPLACE(S) _ 0 ?1 _ 2 APPLICANT STREET ADDRESS I Z?- HJ ira ? L e-7- All" CITY "_?'-STA? ZIP 5512 3 TELEPHONE #SZ7??- Ioq SS CELL PHONE # FAX OfZ ? ?'?-qSZr .s67 ' PROPERTYOWNER N/t- TELEPHONE# Z 6 `I - /(1 1 (e COMPLETE THIS SECTION FOR °NEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNrSOTA RULFS 7670 CATEGORY 1 MINNESO'1'A RiJLES 7672 (J submisslon type) . Residential Ventllation Category 1 Worksheet Submitted • New Energy Code Niorksheel Submitted • Energy Envelope Calculations Submitted Plumbing Contractor: Plumbing sysLem includes: Mechanical Contractor. Mechar:ical system includes: Sewer/W ater Confractor: Water Softcner _ _ Water Heatcr _ No. of Baths Air Conditioning Heat Rccovery Syslem Phone # MAr o z 2002 L 5 /j Fee: $70.00 --------°----------°--------------------------------°°---------------°-----------------------°---------------------- 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 Ordinances. Signature of Appllcant gd-z? °-------°°----'-°°°----------------°°---°------------------------------°-°-------------------------------------°----------------°-°°------°---- OFFICE USE ONLY Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4102 _ Phone # Lawn Sprinkler No. of R.I. Baths Phone # L[qGl -70 RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB RD, EAGAN MN 55122 651-681-4675 New Construcfion Reaufrementa • 3 registered sile surveys showing sq. ft. of lot, sq. ft. of house; and all roofed areas (20Yo maximum lot coverage allowed) • 2 copies of plan showirg beam & window s¢es; poured found design, etc.) • 1 set of Emrgy Calculations • 3 copies of Tree Preservation Plan if lot platted after 711193 • Rim Joist Detail Options selecGon sheet (bldgs wilh 3 or less unifs) DATE SI LIA+ L RemodallRaoair Reauiremenis . 2 copies of plan • 1 set of Energy Calculations for heated additions • lsitesurveyfore#erioradditions&decks . Indicate'rf home served by seplic system for additbm c' VALUATION V Y& ? SITE ADDRESS I LS ??? w l?.d? ? ?J" MULTI-FAMILY BLDG _ Y ''FI TYPE OF WOR K FIREPLACE(S) _ 0_ 1_ 2 ^ Y0 APPLICANT? /?^<-? c- T?ciC,•- STREET ADDRESS 12 Z L-1_7 ClT1r /3r•^-sv "- STATE /n` ZIP SS) ZJ TELEPHON # -767'Lo1f`?`I CELLPHONE# FAX#`ISL- 7°7?j57? 5%"?? PROPERTYOWNER La?--- ?-R'?9 S I r?I JN / TELEPHONE# 2? t- ----------------------------------------°-----------------------------------°---------------- COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ Iv1INNESOTA RULES 7670 CATLGORY 1 _ MIN ?. QA&1]E5 F'&72 (J submission type) • ResidenGal Ventilation Category 1 Worksheet Submitted • Ne er8y,podq??N(prk?qg,e{ S I IPIHT U ( LUUL • Energy Envelope Calculations Submitted Plumbing Confractor: Phone By # _________ ___ Plumbing system includes: _ Waler Softener _ L.awn Sprinkler Fee: $90.00 WaCer Heater N0. of R.I. BaChs No. of Baths Mechanical Contractor: Mcchanica] systcm includes: Sewer/Water Contractor: _ Air Conditioning Heat Rccovery System Phone # Phone # Fee: $70.00 ----------------------- ° --- -- --- ------------------ ° --- °--- ° ----- ---- ° ----- ----- ° -- -- ° -- -- ° ---------- ----°-------- I hereby acknowledge that i have read this application, state that ihe information is correct, and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. /r> ??? ,/? Signature of Applicant s.L??i OFFICE USE ONLY Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4/02 Apri129,2002 Hazlan Langstraat Dorothy Langstraat 3744 Wright Rd Southwest Rochester, MN 55902 RE: 1250 Deerwood Drive- 10-02200-011-86 Deaz Hazlan: In response to your request, I pmvide the following: The City of Eagan will not impose connection charges as a condition for the approval of a subdivision of your property. This condition is limited to the following: l. There is no connection to the City's utility system. When the existing residence is connected to the utility system connection charges will be levied. 2. Two lots will be created by the subdivision. Sincerely, Gerald R. Wobschall CC: Parcel File PHUPtHIY UAIA SY51tM OWNER NAME AND ADDRESS INQUIRY CURR 302 PROPERTY ID Owner Change Date NEXT _ 10-02200-011-86 01/18/2002 1250 DEERWOOD DR LAST NAME FIRST M CORP TAXPAY ADDR Owner: LANGSTRAAT HARLAN J N Y N Addr1: 3744 WRIGHT RD SW Addr2: ROCHESTER, MN 55902 Addr3: Addr4: Owner: LANGSTRATT DOROTHY N Y N Addr1: Addr2: Addr3: Addr4: Owner: Addri: Addr2: Addr3: Addr4: Owner: AddM: Addr2: Addr3: Addr4: Tvoe PID: oress ENTER: or F1 F2 F5 F8 SE.114 SEC.22 T.02 7 L.ot C? 1 Block S'(o PID # Sewer /water permit # Plat J f' C-?A O V\ ?' ?-- Date Receipt # CITY OF EAGAN 2000 SEWER AND WATER CONNECT?ON AND AVAILABILITY CHARGES EXISTING RESIDENTIAL PROPERTY Sewer Lateral charge @ $2230/ff $ Trunk @ $900/connection City SAC 100.00 Base SAC 1,100.00 Date paid Receipt # Account depos' 15.00 Septic aban nment 30.00 Sewer p it & surcharge 50.50 Subt 1 $ $ Water Lateral chazge @ $22.55/ff Trunk @ $940/connection Water supply & storage / Date paid Receipt # Treatment plant Water meter •'Ins ions req'd prior to issuing Account dep6sit Water pep(nit & surchazge Total Sewer and Water permit & surcharge 840.00 492.00 114.00 15.00 50.50 ? 30.50 S Sewer lateral charge @ $2230/ff Water lateral charge @ $22.55/ff - ? Sewer trunk @ $900/connection Water trunk @ $940/connection °° City SAC 100.00 Base SAC 1,100.00 Date paid Receipt # Water supply & storage 840.00 Date paid Receipt # Treatment plant 492.00 Water meter *"Inspections teq'd prior to issuing 114.00 Account deposit 30.00 Septic abandonment 30.00 Sewer and water permit & surcharge 100.50 Subtotal $ Plumbing pennit & surcharge 30.50 Total $ Property owner Address Phone number v:?- I - <S<?? a - I H *? / _ Plumber T-VIJ ?6 ?IG7Y0 ?1• ? 'I3//d-000 OFFICE USE ONLY PRV required: ?? R-O-W Permit: City'SCounty ?D Unpaid $ Permit Fees: City financed: cc: Cazolyn Krech, Finance Department ? -CiTY OF EAGAN 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 PERMIT PERMIT TYPE: Permit Number: Date Issued: BUILDING 031990 05/12/98 SITE ADDRESS: 1250 DEERW000 DR LO7: il BLOCK: 86 SECTION 22 P.I.N.: 10-02200-011-86 DESCRIPTION: @uil<sling,?Permit Type Bp3dding Wa?r,,k Type ? Census= Code , ,f`r: . ' .. ?-,'•h? t ? ":.?_ ?? ; ? -? .,:d? ?a;,?,,?d?' •?t . .i REMARKS: DECK NEW 434 ALT. RESIDENTIAL i" 'jj f ;j i° 00 COPIES (5) 50 Total Fee 50 __..._ ;. 1.F?SI-I:f'c!'t:: ,7^ ? ... . '.i?dr-_ p•!i:'!;; ? ?::.?.? ? i (i?1P::? tl ; . . ' ? :i:';°i?.. _ , • ,-y. NflP•5.?-:; p1N Vl!-d1'I... ':?`r':;7':[i'.?:i ?:t.p;:' . .. ?,.i.t.ii'. !..:1.';i't i'i`?,'? Y`') )0 11 1 1,]f.) 1? ? t ?I.-'.I..fl.! ?•.I ,. ?.i._.. ? , .,, ? ? Tr?" . • ... :.. ?,I.i?9:!• ?;? 7111 Jtlid '(: $1.25 $51.75 ST. LIC OWNER: 05 2010247 LANG3TRAAT HARLAN 1250 DEERWOOp DR EAGAN MN (612)452-2790 ? ave read, tHis apP3.icaCfon` and st-ati:' that t'he' res t9 eomply. yJ.tb atl, aPpiic,able state. af Mtt. 3inartoes. i ISSUED BY: SIGNATURE 1998 BUILDING PERMIT APPLICATION (RESIDENTIAL)?/ 3830 PII.OT I{NOB RD 55122 ? 681-4675 New Construdion Reauirements RemodeVReoair Reauirements ? 3 registered site surveys ? 2 copies of plans (include beam 8 window sizes; poured tnd. design; etc.) ? 1 energy calculatlons ? 3 wpies of tree preservation plan 'rf lot platted after 711l93 required: _ Yes _ No DATE: q -W 9B DESCRIPTION OF WORK: ? 2 copies of plan ? 2 site suneys (eMerior add'Rions 8 decks) • 7 energy wlwlations for heated additions CONSTRUCTION COST; STREET ADDRESS: I a50 ?2P.rl.a`!(Yar? Dr ? LOT: ? 0 BLOCK: SUBD./P.I.D. #: P Name_ L'B,YIq "?io._? a4' Y' ?CW'1 Phone #: 752 -o27n7C? PROPERTY L Fiat OWNER SveetAddress: 15150 'Xpeir-(j-)oml -J)r. City tgw'l State: zip: 55ia-3 Company: IU,tY1rlew&-,2 O? nG l tAl.u/vlinlt/!'1 Phone CONTRACTOR Street Address: )0?71' .?.Q S? Pil ?C? License # 2-0 l() 2 N 73 City State: Zip: ff3 79 ARCHITECT/ ENGINEER Company: Phone 1t: Name: Registration #: Street Address: City State: Zip: t .i. .. Sewer & water licensed plumber (new construction onty): . Penalty applies when address chang and lot change is requested once permit is issued. I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with ail applicabl State of Minnesota Statutes and City of Eagan Ordinances. ;?;, '?, Signature of Applicant: OFFICE USE ONLY V Certificates of Survey Received _ Yes _ No Tree Preservation Plan Received _ Yes _ No _ Not Required BUILDING PERMIT TYPE ? 01 Foundation 0 06 Duplex ? 02 SF Dwelling ? 07 4-plex ? 03 SF Addition ? 08 8-plex ? 04 SF Porch ? 09 12-plex O 05 SF Misc. ? 10 _-plex WORK TYPE X31 New ? 33 Alterations ? 32 Addition ? 34 Repair GENERAL INFORMATION Const. (Actual) (Allowable) UBC Occupancy Zoning # of Stories Length Depth APPROVALS Pfanning OFFICE USE ONLY ? 11 Apt./Lodging ? ? 12 Multi Repair/Rem. ? ? 13 Garage/Accessory ? ? 14 Fireplace ? ,?ff 15 Deck ? 36 Move ? 37 Demolition Basement sq. ft. Main level sq. ft. sq.ft. sq.ft. sq. ft. sq. ft. Footprint sq, ft. Building Engineering Variance o/ ! D , Permit Fee Valuation: Surcharge Plan Review Zicense MCNVS SAC City SAC Water Conn. Water Meter Acct. Deposit S!W Permit S/W Surcharge Treatment PI. Park Ded. Trails Ded. CS)(p •zs ,,Total: _ $ 16 Basement Finish 17 Swim Pool 20 Public Facility 21 Miscellaneous MC/WS System City Water Fire Sprinklered PRV Booster Pump Census Code. SAC Code Census Bldg Census Unit f :%SAC _ PERMIT CITY OF EAGAN _ 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 PERMIT TYPE Permit Number: Date Issued: COL2L BUILDING 031795 04/16/98 SITE ADDRESS: 1250 DEERWOOD DR LOT: 11 BLOCK: 86 SECTION 22 P.Z.N.: 10-02200-011-86 DESCRIPTION: Permit Type Wo,rk Type p, .. -.? 4 , c . .. jf C.:: ?., ?.. . ?y ? a.?toc.???. z .? B u i l fBuilding, Census Go < t SF (MISC.} REPAIR 434 Y1LT. RESIDENTIAL Y t t G? y "v. Q^_3s?:f ,b...?'??re?7?????f'?c`° REMARKS: SIDING FEE SUMMARY: Base Fee Surcharge 7ota1 Fee SOFFST FASCIA GUTTERS VALUATItlN $237.25 $B.@0 $245.25 $16,000 GONTRACTOR: - Applicant - s-r. Lxc.OWNER: GREAT LAKES WIN•DOW & SIDE 18913400 20060427 LAN63TRAAT HARLAN 6098 LOWER 161ST ST 1250 DEERW000 DR ROSEMOUNT MN 55068 EAGAN MN 55123 (612) 891-3400 (612)452-2790 ( i hereby acknowledge`that I have read this app23cati`on and s`-tate that`the I informatkan is correet an.6 a(jree to cutnply-uA tl7 el,1 appla.dah.le?'_State.crfi Kn. Statutes and City ofi Eagare Ordinaqces, ? APPLICANT/PERMITEESIGNATUFE rF'S ED Y:S NATUREM ??? 1998 BUILDING PERMIT APPLICATION (RESIDENTIAL) CITY OF EAGAN 3830 PILOT KNOB RD - 65122 681-4675 New Construction Reauirements • 3 registered sde survays ? 2 copies of plans (inGude beam 8 window sizes; poured tnd, design; atc.) ? 1 energy calwlations ? 3 copies of tree preservation plan if lot platted after 7/7193 required: _ Yes _ No DATE: `1-13 - I r DESCRIPTION OF WORK: STREET ADDRESS: ? V-? LOT: ? l ! BLOCK: RemodeVReoair Reauirements ? 2 copies of plan ? 2 site surveys (eMerior addkions & tlecks) ? 1 anergy calcuiations for heated adOitions CONSTRUCTION COST; 8 ? SUBD./P.I.D. #: ?r?-- Name:_ //QA/'G/,S/? /?j¢,Cc,dk,/ Phone#: 7`So'L-0L7'-7 0 PROPERTY Lq First OWNER \ Street Address: /oA-.$Z? ?C,I-a-"e% ? City State: 19?tM Zip: Company:.J.1-G? r}-z.(ny y/?c..lli,kJ Phone #: - C! CONTRACTOR O/c StreetAddress: ?'/?6 ,LOl.,t'iC ?GI - 3 Licen? #?aD6O 5xe27 6VV City State: f224r.._ Zip: 5-57J6dp-` ARCHITECT/ ENGINEER Company: Phone #: Name: Regishation #: Street Address: City State: Zip: Sewer 8 water licensed plumber (new cons6vction only): and lot change is requested once permit is issued. Penalty applies when address chang I hereby acknowledge that I have read this application and state that the infortnation is correct and agree to comply with all applicabl STate of Minnesota Statutes and City of Eagan Ordinances. Signature of Applicant: OFFICE USE ONLY Certificates of Survey Received _ Yes _ No Tree Preservation Plan Received - Yes - No - Not Required ? CITY OF EAGAN 3830 Pilot Knob Road Eagan, Minnesota 55123 (612) 681-4675 PERMIT PERMIT TYPE Permit Number: Date Issued: all ar q6 ?3?ci?? uzL N 023176 03f29/94 SITE ADDRESS: P.I.N.: 10-02200-011-86 DESCRIPTION: 1250 DEERW00D DR LOTe 11 BLOCK: 86 SECTION 22 (ROOFING) BuildingLPermit Type Building Wa.rk Type ,, \ 1 . `?\ •/l `. SF (MISC.) REPASR i ? ? ? .1'?? REMARKS: FEE SUMMARY: VALUATION $13,000 Base Fee $144.00 Surcharge $6.50 Total Fee $150.50 CONTRACTOR: - Applicant - ST. ?zC. OWNER: SELA ROOFING & REMODELSNG 18238046 0001050 LANGSTRAAT HARLAN 3233 HENNEPIN AVE S 1250 DEERWOOD DR MINNEAPOLSS MN 55404 EAGAN MN (612) 823-8046 (612)452-2790 I hereby acknowledge that I have read this informat orrect ahd agree to comply Stat es a d Ci y of Eagan Ordinances. I ! ?? ? applieatiun and state that the with all applicatrle 5tate of Mn. -i ? 1 -' ISSUED W. S NATU E 1511C CITY OF EAGAN 1994 BUILDING PERMIT APPLICATION 681-4675 $ I-6 0. ffD SINGLE & MULTI-FAMILY 2 sets of plans, 3 registered site surveys, 1 copy of energy calcs. COMMERCIAL 2 sets of architectural & structural plans, 1 set of specifications, 1 copy of energy calcs. en alty applies: 1) when permit is typed, but not picked up by last working day of month F n which request is made, 2) address is changed or 3) lot change is requested once permit s issued. Date Valuation of work l2, ?7T 1.? Site Address: STREEi SUITE # Tenant Name: (commercial only) q.,-"s,-,A 0' k LOT ?L BLOCK ? SQBD. P.I.D. # ? Descri tion of work: The applicant is: O Owner &Gontractor ? Other <oesor;be> Name fz_''N-V- H , Phone Property LAST FIRST Owner pddress I' `?? ?;? __ ,_w• ?? 7^, STREET STE # City 1\ v-i r-- State r"?? Zip Company Phone Contractor ? Address y l?'? ? K?• z?.? ?.?_ Li cense Exp3-1 5 City State Zip Company Phone Architect/ Engineer Name Registration # 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 1 applicable State of Minnesota Statutes and City of i Eagan Ordinances. / ? ?' ?? Signature of Applicant: • ` ` z / PLEASE COMPLETE FOR SINGLE FAMILY DWELLINGS. AISO, FOR TOWNHOMES AND CONDOS WHEN PERMITS ARE REQUIltED FOR EACH UNiT. NO. FIXTURES SHOWER WATER CLOSET BATH TUB LAVATORY KITCHEN SINK LAUNDRY TRAY HOT TUB/SPA J_ WATER HEATER FLOOR DRAIN GAS PIPING OUTLET • minimum - ROUGH OPENINGS WATER SOFTENER PRIVATE DISP. • neILcty. uc. U.G. SPRINKLER • home under consi. ALTERATIONS • to austing WATER TURN AROUND STATE SURCHARGE TOTAL: r SITE ADDRESS: LpnosrRRaT 1 1250 DEEPWOQD DRIVE OWNER NAME:_ EHGflN , 55123 H 432-2790 W 688-0699 EACH 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 1.50 5.00 15.00 3.00 15.00 15.00 TOTAL .50 ? INSTALLER: ?/ ' ?? lJL L ADDRESS: 2905 GAR:'i7-0 1aVEAQJE SOUTH . M, CITY: 927-4033 ? 829-71AfiE: ZIP CODE: PHONE #: ( ) HFRLFN SIGNATURE OF PERMITTEE 1993 PLUMBING PERNIIT (RESIDENTIAL) CITY OF EAGAN 3830 PII,OT KNOB RD EAGAN MN 55122 (612) 681-4675 i - • ' ?i ? I nr----- ---- ? R-4 ?? q h,' r? I? ; ?;.;?-- ; ---il PILOT oe R t'14 -- i , '`CSC' ij w---? CENT R\\.,, i?- ? PI ? . IsT -,.. ,,. ?.. CARRIAGE. ?- ?? A HILLS , GOLF 3 COURSE CAR ? wooo P F RaiLs R _4 ? , - - r /'??/?1 V . .4' R_I R-I i ; ; .. cirY HaL pF Q i ES OT qp / K PF A •.1 1 ??; . . `rR? ,l:. '. . ? K f A D -- R-I . •? • ---',,,f_-` ? `?., µ . i. PD ? '•. ?? . ? ?-?, ? ?-- 74 - I 4 •,??., ? ? t,_,s;-^?"?_ ?i, /? ? $ ? /?•? „-:' t' !?'i f?_" ; i '^ y? `? ? . T ?7?!i, R'! / ,y• l ?,fA?Y?. ? L? ?/G I . ? ff 2 ?J Ci / ^? m r+ O ? z ?c A ; s ?" P ?i .? t,4•? ?r.'? I'1 ? .{.??rv.• y? ? ??V•t,.4' a, ????4'L ?r'???r I, ? y ? .. ? ? ? r? ? 4? 1 .LF. •.?' 'ri i r i. F ..... , ;...,_ , MIIiNSSOTA STATS EIIILDIIiC CBDE DIVISION IDCPERIOR ENVEIAPE AiIERAGE "D" COlP10lATIOTI I Otitiffit ?? -? ?f1 !z .C'?e SITE ADDRESS " CONTRACTOR DATE .a. d z.- PHONE 42±-- Determine vorking equare footage of each. 1. Total axpoaed vall area ..... 3,170 aq. ft. x.17 m 538.9 2. Total roof/ceiling area ...... 2,535.5 . aq. ft. x.OS m 126.78 Sotal expoaed wall asea above floor 2,730 a. Total wall window area ................................... 445 b. Total door area .......................................... 55 c. Total sliding glasa door area ............................. 40 d. Total fireplace vall area ................................. -0- e. Total vall framing area (8verage lOX) ..................... 193.5 f. Total net wall area above floor ........................... 1,741.5 g.? .Total rim joist area ..................................... 255 Total exposed foundatiori area - 440 h. Total foundation vindow area ............................. 29 i. Total aet foundacion area above grade .................... ? Determine "U" value of each wall eegment. a. 445 X"U" 0.56 a 254.8 b. 55 X"U" , 0.32 m 17.6 c. 40 R"U" 0.56 ? 22.4 d. -0- % •oUu -0- ? r0- e, 193.5 7( "p" 0.21 ? 40.64 g, 1,741.5 % "U" 0.047 m 81.85 B. 255 X"U" 0.10 m 25.5 b, 29 R"U" 0.56 a 16.24 1, 411 R"U" 0.11 m 45.21 3 . .................................. TOTAI. a 504.24 If itm /3 ir tde sase as, or less than ites /1. yon hsve set Lhe incent of 5EC 6006(c)2. • . R l • f iotal eiposed roof/ceiling area a 2,535.5 a J. Total skylight area .................................. 17.•' k. Total roof/ceiling framing area (average lOx)..... ... 1. Total net ineulated roof/ceiling area ................ ,?- Deteraine "II" value for each roof/ceiling segment. J. 17 g "U" 0.60 . 10.2 k. -0- % "U" -0- . -0- 1. 2,518.5 g"u" 0.025 . 69.96 4 . .................................. TOTAL . 80.16 If total of /4 is the same ae, or lee6 than /2, qou have mst tbe intent of SSC 6006(c)1. Alternate Building Envelope Design To utilize the toal envelope syatem method, the values extablished by the eum of itqme i3 and 04 ehall not be gre8ter than the aum of itema I1 end Y2. 1. 538.9 + 2, 126.78 n 665.68 3. 504.24 + 4. 80.16 a 584.40 ? SAC 1/16/86 D. PROSECT 411, BIRCH PARK ADDITION/PATRICK EAGAN PARK - TRUNK STORM SEWER 4. Ron Boyle (10-02200-011-86) BACKGROUND INFORMATION At the September 17, 1985 final assessment hearing for the above-referenced project held before the City Council, Mr. Ronald Boyle submitted a written objection to the trunk area stor? sewer assessments for his parcel. Enclosed on page ?_ is the written objection submitted by Mr. Boyle. Enclosed on page(s) 74 ' 7a' are maps showing the loca.tion of the property in relationshi to the proposed improvements. Also enclosed on page(s) ]I is the proposed final assessment roll with the related calcu ations. As the Committee may recall, similar type objections were reviewed by the Special Assessment Corunittee at the October 9, 1984, meeting as it pertains to neighboring property owned by Thomas Bergin, Thomas Rooney and Anthony Caponi. As a result of these neighborinq objections and the relationship .of the property to the storm sewer improvements installed under Project 411, the City Council subsequently deleted these properties from the final assessment roll with the understanding they would be included with any future storm sewer project directly benefitting their property. STAFF RECOMMENDATION Based on the action taken by the Special Assessment Committee and City Council pertaining to similar objections of neighboring property owners under this same project, it is the staff's recom- mendation that the assessment against this parcel be deferred until some future project directly benefitting the property. COMMITTEE RECOMMENDATION/COMMENTS ? ?..,.. ._ I /z n c'J D S" y,JJK.1 September 17, 1985 Mayor and City Council of the City of Eagan 3830 Pilot Kaob Road Eagan, Minnesota 55122 P h-? S Re: Parcel #10-02200-011-*S-(O Dear Sira: Li // My abjections are on the grounda that the assessment unfairly, illegally, and arbitrarilp assesses my property which will receive no benefits from the improvements proposed to be assessed. I object in addition to the anticipation of revenue from the assessment of an amount of approximately $100,000.00 above the anticipated coat and the failure to include land located in [he southwest quarter of Section 22 and Hilltop Estates as assessed for this project. I have an additional objection that the parks areas located within the area intended to be drained have not been included for assessment purpases. oura truly, `.'?/? n I RoNALD ?•?QLLT I 2- S O?Le?L W DOZ) b2, . 7'S .?( H ; :,.::: ..II ? ? ,.._. _.._ ? `-1, ? ? . . . ... ??. N 0 R T H L.-" - . --.?-"-- _. ..... .._ . _ . . _-- .? - . . . . ? . .?..._._.. .. _?_ _.. . ? ._.._.._. .. _. . .. .?. __? 0 1000 2000 SCALE IN FEET PATRICK EAGAN PARK / BONESTROO, ROSENE, ANDERLIK & ASSOCIATES, INC. BIRCH PARK ADDITION Conaulting Enpinaere STORM SEW.ER LAYOUT 74 St. Paul, Minn. Date: JUNE, 1984 PROJECT POND ,;P-6, 7. 8, 9, 10, 11, 38, 47, & 49 Comm. 497! 1 N0.41 1 r-Jr ci a: m O 2 Y t ,- ? r ? ?• , , ? s ,. 17 FI?S /i" •.. , ? Q,??`? " EX. UFT STA.14 ' k ? • ?• ; , JP-47 ; ? . ?J `1. JP-I I ? ...--- ? . : ?•:.. • ; - __:_ . . _ _ CITY HALL tii niu?L ? a --? JP-II ?i-; -, ;•' ?C--' '? ? $K s?DC,i FF AD? 49 ? N0. 2, C /^l - 1 / _.?,\.•) JP- -• _.. _.... . , T ? ? : •? . r , ?-': Y, . `?1 ? `?..... ____ _- ? ; -- _J` D .. .. ? ?•; •-I-- '- -_„--:-- - , i I; •?`?; ('''-i4'?i - ? JP-7 >.,. ..• .?? "'-. . ----•- ?? -? _,?? . '.. ? \ - --- 40 t F':.; cii?.K ? wl-86 , o ?r Jp_g r• _..--- (?\ ? +LLTO?HIQFpP? _ PLA=ZA ,?EAGr.rt ? • tl ??-V • '•v ? ? H F / . --- -?'--?? _ SINGLE FAMILY RATE PATRICK EAGAN PARK / BIRCH PARK ADDITION • TRUNK AREA STORM SEWER 77 EAGAN, MINNESOTIA I'TH o iooD 2000 SCALE IN FEET BONESTROO, ROSENE, ANDERLIK 8 ASSOClATES, INC. Consulting Englneera St. Paul, Minn. Dale: JUNE, 1984 PRO.IECT r ? " A-V Td? Z-la- , , .. . . , .? ! .. ?-. : . TRUNK STORK SEVER oUTLET REVISED FINAL 9SSFS3lSENT ROLL - PROJECT 411 CONTINUED, SEPTIIMBER 11, 1985 Parcel Area Credit Assessable Rate Total Description (aq.ft.) (sq.ft.) Area(sq.ft.) (per sq.ft.) Assessment sE ?/4, ssCx2ox 22 013-75 289,674 St R/W(20%) 57,935 231,739 $0.045 $10,428.26. 015-75 206,910 Large Lot (1) 82,500(5) 0.045 3,712.50 020-75 124,146 Large Lot (1) 49,500(5) 0.045 2,227.50 011-76 116.930 Lar e Lat (1) 49,500(5) 0.045 2,227.50 012-76 209,088 - - - 209,088 0.045 9,408.96 031-76 228,291 St R/w(20%) 182,633 0.045 8,218.49 0'IO-77 295,691 ,o7 St R/W(20%) 59,138 236,553 0.045 10,644.89 010-80 412,230 St R/W(20%) 82,446 329,784 0.045 14,840.28 010-84 412,393 St R/W(20%) 82,479 329,914 0.045 14,846.13 012-86 451,423 St R/W(20%) 90,285 361,138 $0.045 $16,251.21 011-85 207,035 Large Lot (1) 82,500 (5) 0.045 3,712.50 ? 011-86 206,916 Large Lot (1) 82,500 (5) 0.045 3,712.504 L SUB TOTAL ................ $100,230.72 ? -_ :-:??-- _ A. SCfMIDT ADDITION Lot 1 2¢,310 Large Lot (1) 16,500 (5) $0.045 $742•50 Lot 2 124,052 Large Lot (1) 49,500 (5) 0.045 2.227.50 SUB TOTAL ................ $2,970.00 TOTAI. (SE 1/4, SECTION 22) ...................................... $103r200.72 (1) Large lot credit xas applied and assessed at 16,500 aq, ft. per acre. F . . ?? ? . .. ? ci . tVoE e0q0n 31130 PILOT KNOB ROAD. P.O. BOX 21199' • • BEp BlOy+an51 EAGAN. MINNESOTA 55121 . W? PHONE (612) 454$100 7iqMAS EGaN JpMES 0. SMITN JERRV TY.pMFS DATE: January 28, 1986 . iKooor.evIneHren . cc„K' t?, • iMC.MA$ /rDGES ' . Cuv A?.snara EWENE VAN OVERBEF I?PECI.aI. ASSESS?fEVT SF-4,RCH Gnce.• Stewart Tit1e ? Co of MN RF= Section 22 • Suite 107 10-02200-011-86 101 West Burnsville Parkway i? - 1250 D2ex4AOd DYiV2 '' • Burnsville MN 55337 Enclosed herein is the search which you requesced made on the ahove described propert Kind of Innrove^.:enc vPa- Beeinnins Orisinal ?.mount Salance Due San Sew Tnuilc 15 1985 $3781.00 $3276.88 ??? .. I further certify that according to the records of said office, the following improve ments are concemplated or pending after having been approved and are now in the proce of planning or completion. Rind of Imnrovenient. Aooroxinate Date of ComDletion Aonroximate Cost Sewer Trunk Project #361' ???? $995..00 per acre Trunk Storm Sewer Project #411 .. Sprir}g of 1986 _ $3529.00 WAIVER: . . . ' _ heither the City of Eagan nor.its employees guarantees the aecuracy of the above in£o mation vhich was requested by-the nerson or persons indicated. Nor does the City or employees assume any liahility for the correctness thereof. In consideration for ihe supplying of the indicated information in the above foim and for all other considerat of any nature wha[soever, any claim against the City or its employees rising therefro is herehy expressly waived, Levied assessments to be paid to the CITY OF EAGaN, 3830 Pilot 1Cnob Road, P. 0. Box 21149, Eagan, MN 55121. • .Very,truly yours, • ' - ' ??-su??,?-s?? ... ? -- - . ... • SPECIAL ASSESS*SENT DIVISION - ? 1HE LONE OAK iREE...THE SYMHOL OF SiRENGTH AND GROWTN IN OUR COMMUNITY • • 0 2ZOO o ?L ?Co f? p{j?*;IE50"CADtP????`?T OF H-ALTH sectionof Ar:alytical Services ? y7 Dela:?aze 5t/ 5.-., ?nneaoolis. Minnesota 55640 7 COR SANITARUALITY ?PORT OF ACIZILYSIS =.'? I @ ,4PN ?` ? isms/100 ml ? ? - ' ??? Licer.se 110-- Coliform Organ Licen ee Business mg/1 YItiNE50TA UNIQUE F4ELL NO. Nitrate Nitro4en IL ?../ sanitarY fluality. ., ? ,.-• I?- S 3t15fdctol'y ?' t3F% Nitzate (Colifozm < 2.2 M p N Or Laboratory No•? not )ver 1.5 mg/1) Q c`?. We 11 should be RTY Toliform or4ar'is05 found• le. E R OF PROPE: / ? L; 9? p 1.?., Je.?-?itrd?f?C ? disinfected again. ResamP R e c e c k a.7 N ss: ' iiicant nitrate concentration. ? dicate contam- pddre Sign ?? ??E_- ?.' may in annually ? nitrate r local ?5 le Collected/ l ?? ?- ination. Please con t a c:t You Date Sas'iP ? agency. • NitYate o?r 10 ng/1• Tnis Water MUS'=oT_ Hour: fee3ing. er Sn`?rmation, <all. (6121` 6-5301 or ? be uSed £Or infant For EUCt? vrice to t4e :?innesoca Depact+?nc o'- ?teal • to o zz.o 0 o LC 8?o -• ' REPORT OF INSPECTION - INDIVIDUAL SEWAGE•DISPOSAL SYSTEM PRIMARY TREATMENT consists of ?Septic tank OCesspool °Septic Tank: ' Distance from well,/ feet. Material, ?&A L Number of compartments Total Iiquid capacity, 7.) gallons. Capacity iniet compartm gallons. Inside length, feet. Inside width, feet. Liquid depth, feet. Cesspool: Distance from well, feet; foundation, feet; nearest lot line at ? front ? side ? rear feet. Inside diameter, feet Depth, feet. Liquid capacity, gallons. Lining materiai . SEGONDARYTREATMENTconsistsof 0 Tiledispo;al.field.. ?Seepagepits ?Other(Specijy) ... .. .... . ......... < , . . ., . _ ` y Tile Disposal Field: . `. _..? h . . ... .. ?.. `.. Distance from well, feet; foundation, 3 ? feet; nearest lot line at ? front Alside ? rea a, 70 feet. Total length of tile lines, v feet. Number ot lines, 6 . Distance between lines, feet. Trench width, inches. Total effective absorption area in bottom of trenches, square feet. Length of each line, _ :1 U feet. Depth, top of tile to finish grade, i c es. Type of filter material: ?Gravbl ?Broken stone U?Other(Specify)!? j I P?DS y?aJ o v? . Depth of filter material beneath tile, ? 4 inches. Depth of filter material over tile, e5 inches. Seepage Pits: Number of pits, . Outside diameter, feet. Depth, feet. Lining material Distance from well,_feet; building foundation feet; nearest lot line at ?front ?side ?rear feet. Inspection made by: ?State ?County ? Local Health Authority . - , - Inspected by Date of inspection 19 _ ? REPORT OF INSPECTION - INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, feet. Size of main, inches. Individual wells Are ?are not customary in neighborhood. . Give most recent record of failure of weils in immediate vicinity to furnish adequate supply of water Properties in neighborhood ? r ? are not being developed with both individual water•supply and sewage•disposal systems. Lot size:- 7 Q feet wide, feet deep. Dwelling set back from front property line, -"-feet. .-.Individual water supply from: V Drilled well ? Driven well ? Dug weil ? Bored we1L ."" Distance of well from: . _ Building foundation, -4!?- feet; nearest lot line at Afront ? side El rear feet; cast iron sewer, feet; tile sewer, feet; septic tank, feet; disposal fieid, ?feet; seepage pit, feet; cesspool, feet; other sources of possible pollution, feet. Well constructian: . Diameter, inches. Total depth, feet. Type of casing, . Depth of casing, . Approximate depth to pumping level of water in well, feet. Approximate yield, gallons per minute. feet. Sealed watertight to depth of feet. Exterior space around casing sealed with: ?Cement grout ?Puddled clay ?Ordinary backfill. - Well cover: ? Concrete .? Wood ? Metal. Openings in well cover watertight: ? Yes ? No. Pump: O Shallow well ? Deep well. Length of drop pipe, feet. Pump capacity,_gallons per minute. Located in: ? Basement ?Pumproom off basement ? Pumphouse above ground ?Pump pit. Pumproom properly drained: ? Yes ? No. Pump mounting wateriight: ? Yes ? No. Type of storage: ? Pressure ? Gravity. Capacity, gallons. Has bacteriological examination of water been mad'e? f81 Yes ? No. If answer is "Yes," give date ?Z -/-3_ , 19 Ai? T? Quality of watar Igis ? is not satisfactory for human consumption. Installation ? does ? dces not comply with approved exhibits, if any. . Inspection made by: ? State ? County ? Local Health Authority. Inspected by Date of inspection - '19 . . . . ?. (' - (TFtle/ . .\` aV.S.GOVEFNMENTPi11NTING OFFICE:iB9t-]61-488/JX 1 ? ? Form ApqovM VETERANS ADMINISTRATIONN.S. DEPARTMHNT OF NOUSINO AND URBAN DHYRIOVMENT XEALTX AUTXORITY APPpOVAL INDIVIDUALWATER SUPPLYANO HUD/FHA pR Vq CASE NO. - SEWAOE-DISPOgAL8Y8TEM HUD/FMAOflVAOFFICE IMPORTANT-This form ahould be wmplemA and fi1M u requ'vc0 by exuting Ww 78 U.S.C. 1804 and I SIO. PAflT I-TO BE COMPLETED BV HUDlFHA OR VA MORTGP.GEENAMEANDAOORE55(lndudeZlPCede) - • • MORTGNGOqpR5i0N50fl .• i PROVERTYADDRESS ' SUBDIVISION/LOT NO. TOTAL NUMBER IS THERE A BASE- MENTI ISTHISANEW INSTqL1.ATIONt CNN THE ATTIC OF OTHER AREA BE MADE INTO AOUITIONAL6EDROOM51 / ? "Y 'h LIVINGUNITS 9EOROOMS BATHS ( owmany a• ) I , E] VES ?NO EIYES ?NO ?VES ?NO WATEREUPPLY BY: ? ? SVSTEM DESIGNED FDfl PUBLICSVSTEM COMMUNITYSYSTEM ?INOIVIpUAI NO.OFBEORODMS -' GAPBAGEDISPOSAI SEWAGE-0ISPOSAL 9Y: ?PUBLICSVSTEM ?COMMIINITVSYSTEM ?INDIVIDUAI ?y ES []NQ PAflT II-TO BE COMPLETED BY HEALTH DEPARTMENT OR COMPLIANCE INSPECTOR INSPECTOP'S SKETCH (TO REAORTAS.BUILT 0£VIATIONS FROMAPPROVED PLAN/ It u the opinion of the ? State ? County ? Local Department of Health thet this iudividual watm-supply system)p is Q irr4 satisfactory asja domestic water-supply for the subjxt property. It is the opWon of the ? State U County ? Lacal DepaRmrnt of Health that this individual sewagedisposal system with proper maintenance [ry Can be expected to function sa4sfactorily, and'u not Wuly to create msanitary condiUOns ? Cannot be expechd to Ponction utisfactorily. OP.TE z-zv-- Z $IGN E TITLE NOTE: The health authority should complere the appropriate opinion statement abave and a(flx date, vgnature and tiQe in the spaca provided. NOTE: Use of the rcvttu of this Corm is at the oplion of the health au[horiTy. PART III-FOR USE OF FIELD OFFICE I have reviewed the foregoing and ffie pertinent Compliance Inspec[ion Report and recommend Ihat the individual water-supply sys[em be considered ?accepiable [] not acceptable and that the sewage-disposal be considered El acceptablc 0 not ncceptable . DATE . SIGNwTUFE TITLE ? XVO ARCHrtECTURAL SECTION CHI EF OR pEPUTV CHIEF ? VA CHI EF pPPRA15AL SECTION OB DESIGNEE vA FORM 06E395, APq 1982 SUPERSEOES VH FORM 26S395.OCT 1976, "HUDFOpN.VY5]3 WHICHwiLLNOTBEUSED. ' HEALY LABORATORIES, IIVC. Food,Water, m A Subsidiary of Environmentai Reseazch Group, Inc. Dairy & Feed Analyses 135 State Street • St. Paul, MN 55107 Sample Su6mitted 12/13/82 (612) 227-4637 Lab Report // 6942 76is is lo cer}?{Y fho} there was tesled under Ihe supervision of Healy Laborafories, fnc., a somple represenled os follows: SAMPLE IDENTIFICATION COLIFORM/IOOML NITRATE MG/L WATER ANALYSIS (1 n 0.2 RON BOYLE IZSO DEERWOOD DR, EAGAN. MN, 55123 HEALY LABORATORIES,INC. Professronal Laboratory Service Since 1932 gY ....-._....---- - - - - - - ' --- - - - - . __?_....-. ._ -'-- " -. .`---__ _.....__,..._______--'--- ----'_ _ _ - - - - - - - ^ - - ' - Remarks: The Standard Plate Count is the total number of organisms capable of growth at 35°C. This test may provide supporting data of ihe results of the coliform test levels. The Coliform group of organisms are found in the intes;ines of human4 and ali other warm 6looded animals as well as surface soil. A positive test for coliforms is indicative of contamination by sewage or surface water. Drinking water supplies, which contain coliform organisms in excess of'1 coliform per 100 ml. of water, are contaminated and corrective measures should be taken. Thus a result of <t is acceptable. Nitrate-Nitrogen, is considered excessive over 10 Mg/liter. If excessive the water can be harmful to small infants and young livestock and should not be consumed by them. Any number less than 10 is considered an acceptable level. Note: When existing well defiencies have been corrected, disinfection by approved methods may resutt in improved bacterial quaiity. After disinfection the well should be re-sampled foilowing a waitMr;MJVQ.AWAgtM&Vk. ST TE T p Commenu [`9 This water is acceptable by FHA or VA Standards. O6 -- ,.- -- L ? ??ST?C' 227r637 1J ? .. . ,. . . .' _ _ (612) - ?. . . ... .. . .. .. ., _ ...., .. .-- .:...... . -. . ... .: .. .. .- ' . , .,.; .., , ..-. . . .?. ? -Y .. ..:;, .....:_. J.- ;:-.:.? ,?..:_. ',,?.<_ . ' .. :.._:?.:: '.-. ._ .... .... ..... . ... _.... /'?3j S? ?p y' 2004 RESIDENTIAL MECHANICAL PERMIT APPLICATION City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 . Telephone # 651-675-5675 Please complete foc single family dwellings & townhomes/condos when pemnts are required for each unit Date 5 l C)!J / 0 '7 Site Address / °f50 '"'UA"U-Wd /ol/ , • Unit # Property Owner Tetephone # (rQS? )yij?' `YO d ? Contractor Street Atldress Burnsviile Heating & AlC, LLC State 12481 Rhode Island Ave. So. zip Savage, MN? 575378-1122 Bond #: Expires: City Telephone #(??- ?j ?/ ?T ?V T The Applicant is Owner X Contractor O ? _ Add-on or alterarion to existing dwelting unit ? fumace _Additional ?Replacement air exchanger ? airconditioner _New ?Replacement other By _ _,._.. $ 30.00 State SurcLarge $ .50 Total $ 0"m I hereby apply for a Residential Mechanical Pernrit 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; that I understand'this is not a permit, but only an application for a pernut, and work is not to start without a permit; that the work will be in accordance with the approv ,Xd plan in the case of work which requires a review and approval of plans. /f ., .-? Ap icant's Printe Name App?anYs Signature City of Eapn Pat Geagan MAYOR Peggy Carlson Cyndee Fields Mike Maguire Meg Tilley COUNCIL MEMBEHS Thomas Hedges CITV ADMINISTRATOR MUNICIPAL CENTEN 3830 Pilot Knob Road Eagan, MN 55122-1810 651.675.5000 phone 657.675.5012 fax 657.454.8535 TDD MAINTENANCE FACILRY 3501 Coachman Point Eagan, MN 55722 651.675.5300 phone 651.675.5360 fax 651.454.8535 TDD www.cityafeagan.com THE LONE OAK TREE The symbol of strength and growth in our community. December 7. 2005 Ronald & Shelly Hansen 1250 Deerwood Drive Eagan, MNT 55122 Re: Windcrest/ Deerwood Drive/ Denmark Avenue - Street Improvement City Praject 972 Dear Mr. & Mrs. Hansen: This letter is in response to a request made by your neighbor, Mr. Thor Raarup (1240 Deerwood Drive) to thz City Council at their December 5, 2005 listening session to reconsider the special assessment ]evied to his property for the street overlay improvements under the above-referenced project completed this past summer. His objections to the assessment were also stated in a letter to the City. Mr. Raarup believes that since his property did not directly adjoin any of the improved portions of Deerwood Drive; his property should not have been assessed for the street improvement project. As you may recall from your notification from the City, the levied assessment is $421. The assessment was based on the City's Special Assessment Policy in that properties are assessed for improvements to public streets where driveway access is taken, in this case onto the improved portion of Deerwood Drive. As was explained to Mr. Raarup at the Council listening session, che City met all applicable stamtes in notifying and conducting public hearings for assessed proper[y owners, and that the opportunity for o6jection to the assessment expired after the public hearing October 18, 2005. Mr. Raarup was also informed of the untavorable precedent that reconsideration oF levied assessments after the public hearing would present to the City. Mr. Raarup understood and requested that, in ]ieu of immediate reconsideration of the assessment, the City provide documentation that the assessment levied under City Project 912 ($421) may be considered by the future City Council as a credit to possible future street upgrade improvement assessments, in the event an improvement and associated assessment were to tahe place within the existing City Deerwood Drive right-of-way adjacent to his property. City staff feels chat the same documentation should be provided to you and your neighbor (1244 Deerwood). In addition to your assessment notice sent to you in October, please consider this letter as such documentation. While allowing such a credit on future assessmen[s will be entirely at the discretion of the City Council at the time of the assessment, City staff believes it is reasonable that such a credit be considered. A copy of this letter will be kept in the Ciry's parcel files for future reference. If you have any questions or concems, please feel free to contact me at 651-675-5645 or jgorder(cD c itvo feaean. com. Sincerely, o?, co?aer Assistant City Engineer C: Tom Hedges, City Administrator Tom Colbert, Director of Public Works Russ Matthys, City Engineer Adhbk- Clty 0? ?apIl 3830 Pilot Knob Road Eagan MN 55122 Phone:(651) 675-5675 Fax: (657) 675-5694 - ----------- I For O,ffice Use ? I ? Permit#: s F-?? (3 i ? ?-Z?_ ? I Pertnit Fee: 6Z) i ? ? Date Received: i ? I ? I Staff: p L _________________? 2009 RESIDENTIAL PLUM`BING PERMIT APPLICATION Date: Site Address: 10;Z15`?-??C?cJC9op Tenant: Suite #: RESIDENT / OWNER Name: ?GtL? Phone: Address / City / Zip: CONTRACTOR NamQ -s, License #: Address: /O,> /, ) ?/u,?? ?/l0U/' .S''r`E • , City: State:4Zl-VI Zip: <?S//2 Phone: Contact Person: TYPE OF WORK "L?_New )?_Replacement _ Repair _ Rebuild _ Modify Space _ Work in R.O.W. Descri tion of work: PERMIT TYPE RESlDENTIAL , Water Heater _ Water Softener Lawn Irrigation Add Plumbing Fixtures (_ RPZ /_ PVB) ? Main _ Lower Level) Septic System _ Water Turnaround New Abandonment RESIDENTlAL FEES: $50.50 Minimum Water Heater, Water Softener, or Water Heater and Softener (includes $.50 State Surcharge) $30.50 Lawn Irrigation (includes $.50 State Surcharge) $50.50 Add Plumbing Fixtures, Septic System Abandonment, Water Turnaround' (includes $.50 State Surcharge) *Water Turnaround (add $165.00 if a 5/8" meter is required) $100.50 Septic System New ($10.00 per as built) (includes County fee and $.50 State Surcharge) $90.50 Fire Repair (replace burned out appliances, ductwork, etc.) (includes $.50 State Surcharge) TOTAL FEES $ 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 1 understand this is not a permit, but only an application for a permit, and work is not to start without a permR; that the work will be in a=,- ith the approved plan in the case of work which requires a review and approval /o/fJ?lans. x /l'???rl 2 , 14 - Applicant's Printed Name -Ij Applicanf Sigi ature FOR OFFICE USE- Reviewed By: Date: Required Inspections: Under Ground _Rough-In =Air Test _Gas Test _Final" ------------------ ? For Office Use ? I ? j Permit ? j ? Permit Fee: . n 2 5 ? Date Received?o I I ? I Stafl:- ? 2009 RESIDENTIAL BUILDING PERMIT APPLICATION t-IM, Date: Site Address: v2e? Tenan[: Suite #: RESIDENT / OWNER Name: ROKA k &tL-1-b'? IAAI`IZEA Phone: LRSI -'-A?-q -qB't3lsa Address / City / Zip: Applicant is: _ Owner ?.Contractor TYPE OF WORK Description o( work 41tA4E+- }gemY?1 Construction CoJ 2 5t 000 Multi-Family Building: (Yes No Y__j CONTRACTOR Name: ?'=M(T?-"Lr 1(a J?lNl=--tl$1Dh1$ License #: 2cc?4bL4cbc15 Address:5 12EXr_?1p?_ F?L,Uc?. City: JT LW1S PAeK.... state: 1AJ _ zip: 5'SL41LQ ? c?HULTZ-??2-71D-4ld5 952•92p.SS5? C n t tP KtVY Ph : on ac erso . one: COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 Cateqorv 1 Minnesota Rules 7672 Energy Code . Residenfial Ventilation Category i Worksheel • New Energy Code Worksheet Category Submined Submined (4 Submis5lon type) • Energy Envelope Calculations Submittetl 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 pubNc iniormation. Portions of the lnformafion may be classilied as non-public it you provide specific reasons thai would permit the City to condude that the are trade secrets. I hereby acknowledge Ihat ihis iniormation is complete and accurate; that ihe work will be in contormance with the ordinances and codes oi the City oF Eagan; that I undersland Ihis is not a permiL but only an application for a permit, and work is not to start without a permit; thal ihe work will be in accordance with the approved plan in ihe case oi work which requires a review and approval oi plans. x l`?-?IIP( 6wL'TZ- x - Applicant's Printed Name A licant's Sig ature Page t of 3 / DO NOT WRITE BELOW THIS LINE SUB TYPES _ Foundation ? Single Family _ Multi : .. .. _ 01 of _ Plex Accessory Building WORK TYPES _ New Addition ? Alteration _ Replace Valuation Plan Review (25%_ 1D0%? Census Code # af Units # of Buildings Type of Construction _ Fireplace _ Porch (3-Season) _ Storm Damage _ Garage _ Porch (4-Season) _ Exterlor Alteration (Single Family) _ Deck _ Porch (ScreenlGazebo/Pergola) _ Exterior Alteration (Multi) Lower Level Pool Miscellaneous _ Interior Improvement Move Building _ Fire Repair . _ Repair Siding _ Demolish Building' Reroof Demolish Interior Windows Demolish Foundafion Egress Window _ Water Damage 'Demolition of entire building -give PCA handout to applicant J U"C? Occupancy Code Edition Zoning Stories Square Feet Length Width REQUIRED INSPECTIONS Footings (New Building) Footings (Deck)' Footings (Addition) Foundation Drain Tile Roof: _Ice & Water _Final X Framing ? Fireplace: __?Rough In ___?Air Test VFinal Insulation Meter Size: MCES System yytN '?r.?o7 SAC Units City Water Booster Pump PRV Fire Sprinklers _ Sheetrock Final 1 C.O. Required ? Final / No C.O. Required ? HVAC Other: Pool: _Footings _Air/Gas Tests _Final Siding: _Stucco Laih _Stone Lath _Brick Windows Retaining Wall Reviewed By: I (i , Building Inspector RESIDENTIAL FEES Base Fee Surcharge Plan Review MCES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies TOTAL K';t71-7W Z,l9ba?rt`?If?`'u °a?l n,.??t rryl 644- /rGa"V1 I Iin T &rmvr vr?r ;??;a cz v blty 0f EapIl 3830 Pllot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax:(651)675-5694 ---------------, r-M... j PermM fl: v"?'?' ! I ? ? PermilFee: ? Date Received: 3 I I ? ? Staff:_--J 2008 MECHANICAL PERMIT APPLICATION oete: q//1/t? f sne nadregs: ! fi ° Tenant: 7*,r15e1:n , !`ld+-k Suite #: RESIDENT / OWNER Name: /? r7D bce-cc... L-ti'l/u'f p'/' Phone: Address / Ciry / Zip: "v / CONTRACTOR Name: M+z-cA _ License x: Address: ° State: City: Phone: CoMact Person: TYPE OF WORK - New _ Replacement _ Additional , Alteration _ Demolition Description of work: ?.D? ? . ?? ? ?? ? -Ze- NOTE Both rool moun;ed antl groerndLLmounted mechantcaJ eqb3pment 1s requlred; to.. ; . chan/cat,lnspector or;one orthe : Cfty-Cvde , Please contaci the"A4O tie scresiied by , .:Plariners lor`lnformat/ori on PWMNW screenin methotla : RES/DENTIAL COMMERC/AL PERMIT TYPE New Conmuction _ Interior Improvement Fumace - Install Piping _ Processed AirCondBiorrer _ EMerior HVAC Unit Gas Air Exchanger _ - ' HVAC unifs must 6e screened Heat Pump -ac Other Under / Above grourM Tank (_ Install /_ Remove) " When installing/removing tank(s), caN for inspeclion by Fire - Marshal and Plumbin In or RES/DENT/AL FEES: $50.50 Minimum Add-on or alteration to an existing unit (includes $.50 SWte Surcharge) $90.50 Fire tepeir (replaca bumed out appliances, ductwork, etc.) (InGudes $.50 State Surcharge) r ( S/ TOTAL FEE $ COMMERClAL FEES: $70.50 Underground tank installation/removal OR Contract Value $ x 1°,6 $50.50 Minfmum (includes State Surcharge) Permit Fee - If Permk F_sg is less Man $7,000, surcharga is $.50. - If Pe i Fgg is> $1,000, surcharge increases by $.50 far each =$ StBte SufCharg6 $1,000 Permil Fee (I.e. a$1,001•$2,000 Permit Fee requires a$1.00 surcharge). $ TOTALFEE I hereby advrowledge that ihis inlortnetlon is complate anC accvraze; tnat me wonc vnn oa m comormance wim ure araimucae w" uww ?? ?. Z ...v .. ? =na, •-, I understand this is not a partnd, but aNy an applicatlon for a permR, and wOrk is not ro start vAttiout a , that Me tivoric wili be in accordence with the app?roved plan in ttre case W work xfiich requlres a review end approval W plans. AppllcanYs Prlnted Name pllcanYs Signature FOR OFFICE USE . %' Revlewed By: date Requlred fnspecUons:'' Undei Ground •_ flough lrt' AIr Test Gas Service Test _fn filor Heat "Fnal - r .i ., _•?? fflo I I -saz ? .2 ?VM s SUBJECTJ ; PARCEL 5N, •.??? ? ?.\? . , ?,. ?ii I , ° A , r??? .ou p y? oI i?r ? e l?1\P .i:?= 0 t , °r a ? ,.. , I• I ,. • `: . t? . , ., ? ?7 ?'??•.. . ?? ? ?"?EX. LIFT STA. 14 ?-. . ..._ ? JP I ? JP-B f •'.",; °- N 0 R T H ? ? .. .. . ...) ?. _. _ i._. _ .. _.-"--... ,.. . .. . ... .?.._.__... __.... ._._...__..... . .,, _'- 0 1000 2000 SCALE IN FEET PATRICK EAGAN PARK / nvnts t Hvv, HpSENE, nnoERIIK 3 ASSOCIATES, INC. B)RCH PARK ADDlTlON Coneultlnp Enpineers STORM SEWER LAYOUT ]L St. Paul, Mlnn. Date: JUNE, 1984 pROJECT POND ,iP-6, 7, 8, 9, 10, 11. 38, 47, & 49 Comm, 49311 N0.411 • :, ,, . . ?V • ? r i j_y_- F ?til•?•a.??...? ..?_.?. . - SINGLE FAMILY RATE PATRICK EAGAN PARK / BIRCH PARK ADDITION • TRUNK AREA STORM SEWER 77 EAGAN, MINNESOTA N 0 R T N 0 1000 2000 SCALE IN FEET BONES7R00, ROSENE, ANDERL{K 5 ASSOCIATES, INC. Coneulting Enqlneere St. Peul, Minn. Date: JUNE, 1984 pROJECT Comm,_49311 N0.411 .,..a.._ .,.,??.-.. ?.. ...?,....._.?___._. ._. T...__ Certificate ror: fD O zzoo oi ( S?o BK 53?25 Devslopera Construction Inc. ?1101 Cliff Road Burnsville, Minnesota = r 55337 22 DELMAR H. SCHWANZ -_- LANDSURVEVOA RaqistarM V naor Laws of The Sbb o/ M innosob 2978 - 146TN STREET W. - 80X M ROBEMOUNT, MINNESOTA 68088 PMONE 672 423-1789 SURVEVOR'S CERTIFICATE nr02TK L ?q? oT SE,'TI S?C.. ?.Z. 45 ?o E K. _ ?EE.1ZW00? 33o.01 - _ M DR?OE ? ? 000 ?p ?X?- N lbA? ? D q N\ ? 11f ou _ S . N _ a? I 5.3i ? _ I 4,0 ? , o s 17.67 i. 24 0 3, ? jr1 c-,m ?Q 'a : aa 0 \- ? r 0 _?? 0 d F. o b?-r??L 0 •? y O ry` ? ? 1 • ui ? o 0 oY? J ?9 x ` 2 ul?d" a o ?? • U °c ?Q ? ?r -330.Z.9 N 890 55'16 E_-" 1007 So??a l..?uE o? NoIZT?? (pfoO.p ?QQ/1 =?? ? SC i hereby certify that this is a true and correct repreaentation of a survey,of the boundaries of tne North 660.00 fse-z of tne West Quarzer of the Southeast Quarter of Seetion 22, 'lbwnehip 27, Range 23, EXCEPT the east 33^„20 feet thereoP, Dakota County, Minnesota. Also showing the location of a propoaed house as ataked. As surveyed by me this /3 day of M? y 1982, MINNESOTA RE STHATION N0.862 ? ,May-01-98 04:36P Harlan Langstraat P.01 , De.vr-lopera Constructlon, Inc. /v U ` - L„ ' ,_,t k 4 7 1101 C11Cf Road Burnsville, I4innesota 55337 DELMAR H. SGHWANZ - LANOSVRVEVOR RpitibeE UnCor Uws of The Sble Of MinaOta<s 2978 - 1AGTH STREET W. - BOX M ROBEMWNT, MINNE50TA 66066 PMONE 612 423-1769 SURV EYOR'S CERTIFICAYE m m ? I N ' ? ? i N NX N V' S \? V W. IN) V0 0 0 o ? Z --4- 0 ? O J ? ? U 3 tSoRfir? LiuL o} SF, 1?1 - N ?')° S5 o E, - _ D??czwoot) 330.0, ? DR10 E ? ?-- ?000c}? J-- a_t.o -' ,1 I / X? , ,i • ? ' \TA ? ., .? (? w t 1*aIl Wc \ ..' a ? ? i.3) q.o ?r p 30,?7 4.0 .r? '' oJ ?7 b i o \?K Y 14.0 i+' f 1.41 ? ?y ''? fCir 7?4. 'a 3J5 Z4 ?l ? 0 ?C V Q x` . ? c ,., C \ i 3 N? MN : ?+ u N 60 1 O tu O d ?' - z ut.d" Q J? ?-4- ? t) F--r-A 1L.. ; -330. ?9 N 89° 55' 1p" E?f ,?+ .?eQ/t ee?? ? W??Q?S?`/q ?Sac. S I hereby certi£y that this le a true and correct repreeentation of a survey of the oou:adar?es o_*' tha Plorth 660.00 feet oP the Ylest Quarte^ oC the Southeast Quarter of Seotion 22, Rbwnahip 27, Range 23, EXCEPT the e3st 33'.111 feet thereof, llakota County, Minneeota. Also shoxing the location vf a propoeed houge as ataked. Aa surveyed by me thls /3 day o£ NJ4y 1982. MINNESOTA RE TRATION N0.861? PERMIT City of Eagan Permit Type:Building Permit Number:EA126737 Date Issued:09/09/2014 Permit Category:ePermit Site Address: 1250 Deerwood Dr Lot:1 Block: 1 Addition: Langstraat PID:10-44475-01-010 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 . Luanne Yang 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 - Ronald C Hansen 1250 Deerwood Dr Eagan MN 55123 (651) 454-4886 New Life Contracting Inc. 814 Grand Avenue St. Paul MN 55105 (651) 224-3442 Applicant/Permitee: Signature Issued By: Signature