1625 Donald CtGEO. SEDGWICK HTG. & AIR COND. CO.
- HOUSE HEATING TEST RECORD ? _ 9 7_07
ADDRESS 1(0?% .lg?`l?,v CAn., ? CITY
OCCUPANT OWNER
HEAT LOSS DATE HTG. I ST.
SOLD BY INSTALLED BY-
Electrical Work By Gas Line By
TYPE OF HEAT GA_ FA HW_ STEAM_ SPACE HTR._UNIT
GAS DESIGN
MAKE
Model
Serial
INPUT
THERMOSTAT
Valve
Limit
Limit Setting
Fan Setting _
Pilot Type -
Pilot Make -
Pilot Model
Pilot Timing.
L.W. Cut Off
MAKE OF BURNER
Model
_OTHER_
CONVERSION
Max. BTU Rating -
MAKE OF FURNACE
Model
CONTROLS
eat Plug Vent Size
KIND OF LINER SIZE NONE
Draft Hood Regulator
=s Filters Size Nu
Chimney Location Insid Outside
Chimney Construction C ,411
Pressure 41 Percent CO2
Input CFH QQp Percent 02
Stack Temp. Percent CO
Smoke Bomb Wiring
Draft Test Tag -
Door Pressure Lighting Inst.. 1;1
Date Tested
Company Testing
Name of Tester
Form 235
GEO. SEDGWICK HTG. & Al R COND. CO.
/ n p4 HOUSE HEATING TEST RECORD
ADDRESS 110Ml A-INXX CITY.
OCCUPANT-
HEAT LOSS
SOLD BY
electrical Work By
TYPE OF HEAT
t GA DESIGN
MAKE
Model
Serial
INPUT
CONTROLS
THERMOSTAT 7 Heat Plug
Valve
Limit
Limit Setting
Fan Setting
Pilot Type
Pilot Make
Pilot Model
Pilot Timing - A,6Z,2- '?
L.W. Cut Off'/ 7Pressure - Percent CO2 J..
Input CFHin Percent 02
Stack Temp. -z? Percent CO Pw" Q
MAKE OF BURNER _
Model
Max. BTU Rating -
MAKE OF FURNACE
Model
i•
Vent Size
KIND OF LINER SIZE NONE
Draft Hood Regulator
Filters Size Num
Chimney Location Inside Outside
Chimney Construction __g 4r?
,
Smoke Bomb Wiring
Draft. Test Tag
Door Pressure Lighting Inst.
Date Tested
Company Testing S
,
Name of Test
,
CONVERSION
Form 235
N2 5397
BUILDING PERMIT APPLICATION Receipt # /
` -
To be used for SH Duplex Est. value 38,000. Dote 9-10 , 19 79
Site Address 1625 Donald Court Erect KJ Occupancy R3
Lot 19 Block 1 Sec/Sub. Cameron Court Alter ? Zoning R2
Parcel # Repair ? Fire Zone 3
Enlarge E] Type of Const. V
W Name C8Si12TOI1 Development Move ? # Stories
3 Addr ggss 715 Raymond Ave. Demolish ? Front 24 ft.
o L.
CI d Phone 646-8643
Grade ?
Depth
40 ft.
p Name Same Approvah 1
Fees
ut13 Address
t ran,
Name _
Address
I hereby acknowledge that 1 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: CORlerori _ 10
all work sholl be done in adanc ith all-11'a licable State it
Building Official 2z_? >
CITY. OF EAGAN
3795 Pilaf Knob kaad Eagan, MN 55122
PHCNEf 4548100
Assessment -
Water & Sew.
Police
Fire
Eng.
Planner -
Council
Bldg. Off. _
APC
Permit y"..,.,
Surcharge 19.00
Plan check 55.25
SAC 525.00
Water Conn. 270.00
Water Metqr 60.00
Road Unit 75.00
Total 1,114.75
on the express condition that
Statutes and City of Eagan Ordinances.
CITY OF EAGAN
- 3795 Pilot Knob Read Eagan, MN 55122 - NO 5398
PHONE: 454-8100
BUILDING PERMIT APPLICATION Receipt #
To be used for Duplex Est. value 38,000. Date 9-10 19-7-9-
Site Address 3 1627 Donald Court Erect r] Occupancy R3
Lot 20 Block 1 Sec/Sub.Cc-arer°n Court Alter ? Zoning R2
Re
air ? Fire Zone 3 -
Parcel .# p
Enlarge ? _ Type of Const. V
W Name Cameron DeyelO7;Awnt CO. Move ? # Stories
Address 715 Raym ond Ave. Demolish ? Front 24 ft.
° C; St. Paul phone 646-8643 Grade ? Depth 40 ft.
o Nome SatCe Approvals Fees
Address
Name _
Address
I hereby acknowledge that I hove 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 acco
Building Official _
Cameron
Assessment _
Water & Sew.
Police
Fire
Eng.
Planner
Council
Bldg. Off. -
APC
Permit 11U.DV
Surcharge 19.00
Plan check 55.25
SAC 525.00
Water Conn. 270.00
Water Meter 60.00
Road Unit 75.00
Total 1,114 75
on the express condition that
Statutes and City of Eagan Ordinances.
CITY OF EAGANN C? Include 2 sets of plans,
1/ I BUILDING PERMIT APPLI TION 1 site plan w/elevations 6
1 set of energy calculations.
To be used for S; ?e Valuation ?, 6n!. Date
i,
Site Address / i2.S D., ald' 0411,,7 OFFICE USE ONLY
Lot __L12Block Sec./Sub. .,,ova., Lea?? Erect Li Occupancy
Parcel U Alter Zoning
Owner: 'Ov6 n F?erio.`t lJmQu 7'( "?
IL
Address:
Phone #:
Contractor: (!??
Address: Ae, ,/
Phone #: /z1 - e4g3
Arch/Eng.:
Address:
Phone 0:
Repair Fire Zone
Enlarge Type of Const.
Move 9 Stories
Demolish _ Front ft.
Grade Depth =/n ft.
Approvals Fees
Assessment_
Water/Sewer
Police
Fire
Eng.
Planner
Council
Bldg. Off.
Permit //.
Surcharge
Plan Check
SAC
Water Conn. 70
Water Meter fs -
Road Unit 7.5'?
TOTAL I / 4'
r' Include 2 sets of plans,
CITY OF EAGANC)
1 site plan w/elevations &
BUILDING PERMIT APPLICATION 1 set of energy calculations.
To be used for S/` _ ?'s Valuation ' 3 nC%: Date -13
Site Address %6 '2 -
Lot Block /
Parcel S? 7 r Id Ota,.
Sec./Sub. (^ fn,?r?/?H Ceu.?
gC
e??v
Owner: ( ??s?P?aN. /
pro%or,ni
.71
Address:
Phone #:
/?
Contractor:
Address: BLS c? c1
/JCaa/[iv.d'hat-
Ne?A /? sv``a??
Phone U:
Arch/Eng.:
Address:
Phone #:
Erect
Alter
Repair
Enlarge
Move
Demolish _
Grade
OFFICE USE ONLY
Occupancy
Zoning
Fire Zone
Type of Const.
# Stories
Front ft.
Depth - - ft.
Approvals Fees
Assessment 7117 Permit /hD
Water/Sewer
Police Surcharge
Plan Check
t-=
Fire SAC !; -
Eng.
Planner
Council Water Conn.
Water Meter
Road Unit -
Bldg. Off.
APC
TOTAL I 1
This st void 18 months from L-t?=Ct -R
D a Date w this Request C ?e l z, 9-7 S 7334
1, as (Licensed Electrical Contractor ? Owner, do hereby request inspection of the above electri-
cal wiring installed at:
Street Address or Route No. A,? - A ? 7 &,q,4 -o 01;r-, rite 5 AGi*V
Section Township Range CountyK6 7W
Which is occupied by
l
Is a roughin inspection required on this job? No ? Yes I Ready Now ? Will Call'V
??ro ? /7l??CtIFGL, /t'O
Power Supplier S/9 ?)O Address ///I_?Lt r/ - SSO rS'
Electrical Contractor. ?Contractor's License No./_Y_2J 74
(Company Name)
Mailing Address.->ZO5 6 LVftr F?J; 1?14 a < SS / D C7
(El ttrical -Contactor or Owner Making This Installation)
Authorized Signature Phone No. 7?(
(EI trlcal Contractor or Owner Making This Installation)
n ?, ?D n [r' j 1`U This inspection request will not be accepted by the
;? G' u 'J L ?b J tiy1 J? `J State Board unless proper inspection fee is enclosed.
Minnesota State Board of Electricity
t' niversity Ave., St. Paul, Minn. 55$04-Phone 645-7703
aEQUEST FOR ELECTRICAL INSPECTION
CHECK BELOW WORK COVERED BY THIS REQUEST
?CO ac ? -
r `7334
Type of Building New Add. Rep. Check Appliances Wired For Check Equipment Wired For
Home ? ? Range Temporary Wiring ?
Duplex ? ? Water Heater Lighting Fixtures 19
Apt. Bldg. ? ? ? Dryer Electric Heating ?
Commercial Bldg. ? ? ? Furnace Silo Unloader ?
Industrial Bldg. ? ? ? Air Conditioner ? Bulk Milk Tank ?
Farm C] E] 0 ppList
hersl List
hersi
Other - O ? ? _,..
He
re He
re
COMPUTE INSPECTION FEE BELOWI)'
Service Entrance Size: # Fee Feeders&Subfeed Fee Circuits: # Fee
o 100 Amps. cK- / .00 0 to 30 A 0 to 30 Am eyes
101 to 200 Amps. 31 to 100 A 31 to 100 Amperes ,
Above 200 Amps. Above<) ps. Above 100 Amps.
Transformers Rem te- trol uc. Partial or other fee
Signs
Special Isis tion
Minunum fee $5.00
Remarks 'n//??
6 -li cHA/?'
TOTAL FE ' S=+
L
I, the Electrical Inspector, hereby cc at ffa? ve ion has been made.<G 30 7f?'
(Rough-in) (/cJ u/? Date 0 /d = ?
(Final) Date This request void 18 months from
CASH RECEIPT
CITY OF EAGAN
3795 PILOT KNOB ROAD
EAGAN, MINNESOTA 55122
DATE' - 19
RECEIVED
AMOUNT I
& -DOLLARS
loo
? CASH ? CHECK
FOR 1 ' YJ/// <+
C
FUND CODE YAMOUNT -
Thank You ms=s
BY-
White-Payers Copy
Yellow-Posting Copy
'.? ''? Pink-File Copy
CASH RECEIPT
CITY OF EAGAN
3795 PILOT KNOB ROAD
EAGAN, MINNESOTA 55122
DATE 19
RECEI V 6D •
FROM
AMOUNT $ I
gk DOLLARS
100
? CASH ? CHECK
FOR,`- ?,!! •Gr'? / ?/, ..
'
FUND CODE AMOUNT
Thank You
_ // BY -
V
U
?N
Sc)
i
7-47 f aj.I
White-Payers Copy
Yellow-Posting Copy
Pink-File Copy
0
yt?BUILDING PERMIT
CITY OF EAGAN
3795 Pilot Knob Rood Eogon, MN 55122
PHONE: 454-8100
Receipt #
38,000.
Site Address
Lot Block Sec/Sub.
Parcel #
C yx>rt-
t c
o Name L-11 ; 1-2`121111""L
W _
Address ?? l r? T
t ?al
O? Name _
0
0? Address
F' ni,
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.
N0- 5398
Erect (] Occupancy
Alter ? Zoning
Repair ? Fire Zone
Enlarge ? Type of Corot.
Move ? # Stories
Demolish ? Front ft.
Grade ? Depth ft.
Aaaeavals Fees
Assessment
Water & Sew.
Police
Fire
Eng.
Planner
Council
Bldg. Off.
APC
Permit ZIL
Surcharge
Plan check
SAC
Water Conn.
nr
Total
Signature of Permittee I
A Building Permit is issued to: on the express condition that
all work shall be done in accordance with all applicable State of Minnesota Statutes and City of Eagan Ordinances.
Building Official
.s
Permit # Deft lowed Pam""
Plumbing _ /.S( C
Mechanical
INSPECTIONS DATE INSP. Rough-In Final
Footings 9? 3 r?2DDZ Date Insp. Date Insp.
Foundation Plumbing /-]
Frame/ins. /- -? Mechanical
Final
Remarks: '?-/7- 7' .?ct t?l xj AO
r
7-;Po
?o?
i
BUILDING PERMIT
9
CITY OF EAGAN
3795 Pilo Knob Road Eagan, MN 55122
PHONE: 454-8100
Receipt #
38,00(
Site Address
Lot Block Sec/Sub.
Parcel #
e, Name
W „ we .
Z Address
s Name _
0
Address
city
W Nome _
H
2Z Address
1 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.
N? 5397
Erect ? Occupancy
Alter ? Zoning
Repair ? Fire Zone
Enlarge ? Type of Const.
Move ? # Stories
Demolish ? Front ft.
Grade ? Depth ft.
Aenraveh Fees
Assessment
Water & Sew.
Police
Fire
Eng.
Planner
Council
Bldg. Off.
APC
Permit
Surcharge
Plan check
SAC
Water Conn.
Water Meter
Total
Signature of Permittee I
A Building Permit is issued to: - on the express condition that
all work sholl be done in accordance with all applicable State of Minnesota Statutes and City of Eagan Ordinances.
Building Official
Pe It # Daft I=mW P*Mfttee
Plumbing /S/ 4
Mechanical /$g 3
INSPECTIONS DATE INSP. Rough In Final
Footings Date Insp. Date Insp.
Foundation - Plumbing
Frame/ins. Mechanical
Final
Remarks: / I7 / if
CITY OF EAGAN
379S Pilot Knob Road
Eagan, Minnesota 55122
Phone: 454-8100
TT7 A''TT
PERMIT
l I-F--74
Date:
125 1iio?ald ?srt
Site Address:
1^ 1 Cameron Ccnst
Lot Block Sub/Sec. _-
Cameron Deael?:t
Name
715 Raymanc r`-P-.
e Address
5t. Pahl ?4E- 864
City Phone:
(-+t sedgWick 11tx?. .AfC
Name
10"I "OC i.a Aw. S<vth
ddress
e
o _
City _ Phone:
This Permit is issued on the express condition that all work shall be
Minnesota Statutes and City of Eagan Ordinances.
OCT," r17M 1 AIR Rl TI
No.
1583
1625?
Receipt No.:
Single
Residential
Thlalex ?:
Multi Res., Comm./Ind.
New/Alter./Repair
Cost of Installation
2o. nn
Permit Fee
.5?
Surcharge
Total
done in accordance with all applicable State of
Building Official
CITY OF EAGAN
3795 Pilot Knob Rood
• Eagan, Minnesota 55122
Phone: 454-8100
?" - PERMIT
Dote: 1'x-79
li2? k ?1.' Ccoxt
Site Address:
,- 1
Lot Block
Sub/Sec.'
No. 17-14
Receipt No.:
Single
Residential
Multi Res., Comm./Ind.
Name .mr-rot: DPW-lG°
New/Alter./Repair. Address
Cost of Installation
City Phone: Permit Fee ?7t. Paul C. t?)ffrLarl
Name Surcharge
ddress
a
city Phone: TotoI
This Permit is issued on the express condition that all work shall be done in accordance with all applicable State of
Minnesota Statutes and City of Eagan Ordinances.
Building Official
CITY OF EAGAN
3795 Pilot Knob Rood
Eagan, Minnesota 55122
Phone: 454.8100
'`Fjter Softener PERMIT
Date:
Site Address:
Cron Ct.
Lot Block Sub/Sec. _-
Name
sa,:.,
e Address
City Phone:
No.
Receipt No.:
Single
Residential
Multi Res., Comm./Ind.
New/Alter./Repair
Cost of Installation
Permit Fee
50
Name Surcharge
Address
0
v
City Phone: Total
This Permit is issued on the express condition that all work shall be done in accordance with ail applicable State of
Minnesota Statutes and City of Eagan Ordinances.
Building
CITY OF EAGAN Remarks
Addition Lot 19 Blk I Parcel
Owner Street 1625 Ronald ('ours State Fagaii,
/90 -o/ )
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF. 1975 PAID UND ER P. 10 1 00 12 4 01
STREET RESTOR. J 71 1975 66.41 6.64 10 26-57 A009809 1
17
/80
GRADING .
1
.?
SAN SEW TRUNK yG' 1974 26.92 1.12 24 1 15.35 A008809 117180
* SEWER LATERAL, 1974 142.49 11.88 12
** Sew Lateral /? ? 1974 358.09 18.84 19 119 S9 A008809 1
17
180
** WATEW MA "Lat 16,1 1974 12 .
.
* WATER LATERAL/ 1974 19
WATER AREA 1973 PAID UN ER ORIGINAL ARCS
** Storm Sew Lat/ ri 1974 19
* STORM SEW TRK 1,5el 1974 12
STORMSEWtAV# Trunk, 1974 35.15 2.51 14 16.43 A008809 117180
1149.79 A008809 1/7/80
CURB & GUTTER
SIDEWALK
STREET LIGHT
Road Unit 71; nn 0/10
179
WATER CONN. 971) ()Q ,
of
BUILDING PER. -
If
S25-00 15837 10110/7-9
PARK
U 7,
CITY OF EAGAN Remarks
Addition CAMERON COURT Lot 20 Blk I Parcel 930 t Al
Owner? W- -? -f - Street 1627 Donald Court State Eagan.
as / -? Aao -, it
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF. 1975 PAID UND ER P 10 413 00 12 0
STREET RESTOR. 1975 66.41 6.64 10 26.57 A008810 117180
GRADING
STREET S
SAN SEW TRUNK {d 1974 26.92 1.12 24 24-9-2 ""55 1 8
* SEWER LATERAL 1974 142.49 11.88 12 85 5 3 A008910 117180
** Sew Lateral 1974 358.09 18.84 19 119 3q A008810 117180
** WATEI#N AOW#Lat 1j -y 1974 12
* WATER LATERAL ,2q 1974 19
WATER AREA 1973 PAID UNDE R ORIGINAL F ARCEL
** Storm Sew Lat i 1974 19
* STORM SEW TRK f 1974 12
STORM SEW # A1f# Trk % 1974 35.15 2.51 14 16.43 A008810 1 7/80
CURB & G ER
SIDEWALK
STREET LIGHT
Road Unit 75.00 15838 10/10/79
WATER CONN. 270.00 1 n
BUILDING PER. +t
SAC 2-1; - Q0 ++
PARK
sA"N WATER SERVICE PERMIT
A Knob Road PERMIT NO.:
IH 55122 DATE:
No. of Units:
Address:
Site Address:
Plumber:
Meter No.: Connection Charge:
Size: Account Deposit:
Reader No.: Permit Fee:
1 agree to Comply with the City of Eagan Surcharge:
Ordinances. Misc. Charges:
Total:
By Date Paid:
SEWER SERVICE PERMIT
Knob Road PERMIT NO.: r:
55122 DATE:
- No. of Units:
t Donald Court, - "-
Address: agree to comply with the City of Eagan
of Insp.:
Connection Charge:
Account Deposit: _
Permit Fee:
Surcharge:
Misc. Charges:
Total:
Date Paid:
M
OF EA"H WATER SERVICE PERMIT
ig6 Pilot Knob Road PERMIT NO.:
Eagan, MH 55122 DATE:
Zoning: No. of Units:
:Owner:
;'Address:
Site Address:
Plumber:
Meter No.: Connection Charge:
Size: _ Account Deposit:
Reader No.: Permit Fee:
I agree to comply with the City of Eagan Surcharge:
Ordinances. Misc. Charges:
Total:
By D
t
P
id
a
e
a
:
Date of Insp.: I ns
:
p.
OF EAGAN SEWER SERVICE PERMIT
JS Pilot Knob Road PERMIT NO.: 7
Eagan, MN 55122 DATE:
Zoning: - No. of Units:
Owner: --
Address:
Site Address:
Plumber-
I agree to comply with the City of Eagan
Ordinances.
P„
Date of Insp.:
Connection Charge: o'? --
Account Deposit:
Permit Fee:
Surcharge:
Misc. Charges:
Total:
Date Paid:
. .?..,;,. :^. a >i„..aa-? K '_::i:'?.. .:x.+,...:ak ? ..w.. ,:,.v:•:.w?+..r? ., .-srr-.cFrat:?.c?. :.ac ?.+etia.
R E 9 G L U T I 0 N
CITY OF EAGA7
WHEREAS, a public hearing pursuant to notice was held at a regular
meeting of the Eagan Advisory Planning Commission on November 27, 1979
concerning the application of Cameron Dev. Co.
for waiver of subdivision requirements under Eagan Ordinance No. 10 covering the
following described premises: lots 19 20 B ock 1 Cameron Court
WHEREAS, a majority vote of the members of the Advisory Planning Comission,
with a quorum being present at the hearing, voted in favor of recommending approval
of, such application, and, as attached
MHEREAS, a regular meeting of the Eagan City Council, Dakota County,
Minnesota, was held on December 4, 1979 at the City Hall at 6:30 P,V!.
all members being present except: none
NO41 THEREFORE, upon motion of Parranto seconded by,
Egan all Council members voting in favor except: none
it was RESOLVED that said application for waiver of subdivision requirements covering'
the above described premises be, and it hereby is, approved.
DATED: December 4, 1979
CITY COUNCIL - CITY OF EAGA7
EXEVTT FP.ON STAVE By;
DEED TAX STAVE'S Its Mayor
C E R T I F I C A T I O N
I, Alyce Bolke , Clerk of the City of Eagan, Dakota County,
Minnesota, do hereby certify that the foregoing is a true and correct copy of a
RESOLUTION adopted by the City Council of the City of Eagan, Dakota County, Minnesota
on December 4, 1979
DRAFTED BY : - `. `-
GIT7 OF EAGAVI City Clerk
3795 Pilot Knob Road City of Eagan
Eagan, Minnesota 55122 (SEAL)
CITY USE ONLY
LOT 0a BL I RECEIPT /yTo 6-
SUBD?? RECEIPT DATE: 1997 MECHANICAL PERMIT (RESIDENTIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN MN 55122
(612) 681-4675
Date: (o - 3 - °17
Complete this section only if you are installing HVAC in single family, townhome, or condos that are
under construction and are not owner /occupied.
• HVAC: 0-100 M B T U S 24.00
ADDITIONAL 50 M BTU 6.00
• Gas outlets (minimum of one required @ $3.00 ea.)
• State Surcharge: .50
• TOTAL:
Complete this section only if you are remodeling, adding to, or repairing existing single family
dwellings, townhomes, or condos. L ?J
?4ce
furnace fvidmn air conditioning
Add-on air exchanger, i.e. Vanee system, etc. Other
Minimum fee applies to all remodel or add-ons_of existing residences S 20.00
State Surcharge .50
Total: $ 20.50
SITE ADDRESS: .I (P a S D D h a ?d Cf -
OWNERNAME: _GOKCIOh ri ehdl ti° h PHONE #: 4-54--"33+
''II
INSTALLER NAME: W4f ? ?, I-eVS SDIA'-k I k_, d+9 d P f G lhGPHONE #: A 31- 7099
STREET ADDRESS: 14-232, PLLLOck- Ay-- -.
CITY:
STATE: Mk' ZIP: S57 J,;4
l?nll ?? SIGNATURE OF PEPWITTEE
N?
??• ' Gordon K. Hendren
•? 1625 Donald Ct
MV, A7N 55121-1709
RESIDENTIAL
BUILDING PERMIT APPLICATION
CITY OF EAGAN
3830 PILOT KNOB RD, EAGAN MN 55122 c?
651-681-4675 f U
New Construction Requirements
• 3 registered site surveys showing sq. ft, of lot, sq. R. of house; and all roofed areas
(20% maximum lot coverage allowed)
• 2 copies of plan showing beam & window saes; poured found design, etc.)
• 1 set of Energy calculations
• 3 copies of Tree Preservation Plan if lot platted after 711193
• Rim Joist Detail Options selection sheet (bldgs with 3 or less units)
DATE oZ6d ?- -
67
SITE ADDRESS
TYPE OF
APPLICANT
STREET ADDRESS .
TELEPHONE #437- °/5Y
E
C
RemodetiRegair Requirements
• 2copies of plan
• 1 set of Energy Calculations for heated additions
• 1 site survey for exterior additions & decks
• Indicate d home served by septic system for additions /
\,.?5 UY
VALUATION /J
iro-o
LTI-FAMILY BLDG YY - N
FIREPLACE(S) 0 -1 -2
ATEMAAP .5 f
`FAX #
PROPERTY OWNER ?r'clo/? !-t",vdr-C,/V TELEPHONE# A57 Zo; -Y333y
------------------------------------------ ----------------------------------------------------
COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY
Energy Code Category _ MINNESOTA RULES 7670 CATEGORY I _ MINNESOTA RULES 7672
(J submission type) • Residential Ventilation Category 1 Worksheet Submitted New Energy Code Worksheet Submitted
• Energy Envelope Calculations Submitted
Plumbing Contractor:
Plumbing system includes.
Mechanical Contractor:
Mechanical system includes
Sewer/Water Contractor:
Water Softener _
_ Water Heater _
No. of Baths
Air Conditioning
Heat Recovery .System
Fee: $90.00
I? ?? • t. "F&-, ' $70.00
AUG 0 7 2002 '•L-;
------------------------------------------------------------ ------------------------------------------------------
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.
+? 71.- lld?
Signature of Applicant
OFFICE USE ONLY
Phone #
Lawn Sprinkler
No. of R.I. Baths
Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _
Updated 4102
OFFICE USE ONLY
? 01 Foundation
? 02 SF Dwelling
? 03 01 of _ plex
? 04 02-plex
? 05 03-plex
? 06 04-plex
? 07 05-plex ? 13 16-plex
? 08 06-plex ? 16 Fireplace
? 09 07-plex ? 17 Garage
? 10 08-plex K18 Deck
? 11 10-plex ? 19 Lower Level
? 12 12-plex Plbg_Y or _ N
? 20 Pool
? 21 Porch (3-sea.)
? 22 Porch/Addn.(4-sea.)
? 23 Porch (screened)
? 24 Storm Damage
? 25 Miscellaneous
? 30 Accessory Bldg
? 31 Ext. Alt - Multi
? 33 Ext. Alt - SF
? 36 Multi
X° 31 New
? 32 Addition
? 33 Alteration
? 34 Replacement
? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding
? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair
? 37 Demolish (Bldg)' ? 43 Reroof ? 46 Windows/Doors
'Demolition (Entire Bldg only) - Give PCA handout to applicant
Valuation ?? UU Occupancy R. 3 MC/ES System _
Census Code Zoning City Water
SAC Units Ci Stories Booster Pump
Nbr. of Units U Sq. Ft. PRV
Nbr. of Bldgs Length Fire Sprinklered _
Type of Const J ' Width
REQUIRED INSPECTIONS
Footings (new bldg) _ Final/C.O.
Footings (deck) _ FinalfNo C.O.
_ Footings (addition) _ Plumbing
_ Foundation _ HVAC
_ Drain Tile Other
Roof - Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests _ Final
- Framing _ Siding _ Stucco _ Stone
- Fireplace - R.I. -Air Test -Final Windows (new/replacement)
Insulation _
_ Retaining Wall
Approved By l 4*9-_ ' , Building Inspector
Base Fee
Surcharge
Plan Review
MC/ES SAC
City SAC
Water Supply & Storage
S&W Permit & Surcharge
Treatment Plant
Plumbing Permit
Mechanical Permit
License Search
Copies
Other
Total
RESIDENTIAL
BUILDING PERMIT APPLICATION
CITY OF EAGAN
3830 PILOT KNOB RD, EAGAN MN 55122
3 3 651.681-4675
New Construction Requirement$
• 3 registered site surveys showing sq. ft. of lot, sq. ft. of house; and all roofed areas
(20% maximum lot coverage allowed)
• 2 copies of plan showing beam & window saes; poured found design, etc.)
• 1 set of Energy Calculations
• 3 copies of Tree Preservation Plan it lot platted after 111193
• Rim Joist Detail Options selection sheet (bldgs with 3 or less units)
DATE F - r7 - O,-a
T
-s '-10, o 0
Remodel/Repair Requirements s4Y- 1'"?v
2 copies of plan
• 1 set of Energy Calculations for heated additions
• 1 site survey for exterior additions & decks
• Indicate if home served by septic system for additions
VALUATION
SITE ADDRESS ILDQrl Dtgrtca..LA Cj-- MULTI-FAMILY BLDNY
TYPE OF WORK K\ %O_t 0 C?oc I? FIREPLACE(S 0
APPLICANT
- N
-2
STREET ADDRESS I L?a r1 ,, ,,tCC? C CITYSTATEtfrly ZIP 55
TELEPHONE # b5I-Z1SCn-GA&4//CELL PHONE # FAX #
PROPERTY OWNER OA4?g L k 21 n 1 TELEPHONE # -
-----------------------------------------------------------------------------------------------
COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY
Energy Code Category _ MINNESOTA RULES 7670 CATEGORY I _ MINNESOTA RULES 7672
(J submission type) • Residential Ventilation Category 1 Worksheet Submitted • New Energy Code Worksheet Submitted
• Energy Envelope Calculations Submitted
Plumbing Contractor:
Plumbing system includes:
Mechanical Contractor. _
Mechanical svsten3 includes:
Sewer/Water Contractor:
Air Conditioning
Heat Recovery System
D 15 v
Aug
Pee: $90.00
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 Applicant `(?1 t 4 1 yYlY'??A 1_'?
OFFICE USE ONLY
Water Softener _
Water Heater _
No. of Baths
Phone #
Lawn Sprinkler
No. of R.I. Baths
Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _
Updated 4102
OFFICE USE ONLY
? 01 Foundation
? 02 SF Dwelling
? 03 01 of _ plex
? 04 02-plex
? 05 03-plex
? 06 04-plex
? 07 05-plex ? 13 16-plex
? 08 06-plex ? 16 Fireplace
? 09 07-plex ? 17 Garage
13 10 08-plex AN 18 Deck
? 11 10-plex ? 19 Lower Level
? 12 12-plex Plbg_Y or- N
? 20 Pool
? 21 Porch (3-sea.)
? 22 Porch/Addn. (4-sea.)
? 23 Porch (screened)
? 24 Storm Damage
? 25 Miscellaneous
? 30 Accessory Bldg
? 31 Ext. Alt - Multi
? 33 EM. Alt - SF
? 36 Multi
/, 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding
? 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair
? 33 Alteration ? 37 Demolish (Bldgr ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement 'Demolition (Entire Bldg only) - Give PCA handout to applicant
Valuation Occupancy 0) MC/ES System
Census Code Zoning City Water
SAC Units U Stories Booster Pump
Nbr. of Units C7 Sq. Ft. PRV
Nbr. of Bldgs Length Fire Sprinklered
Type of Const V-10 Width
REQUIRED INSPECTIONS
Footings (new bldg) _ Final/C.O.
_ Footings (deck) _ Final/No C.O.
Footings (addition) _ Plumbing
_ Foundation _ HVAC
_ Drain Tile Other
Roof - Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests _ Final
Framing _ Siding _ Stucco _ Stone
_ Fireplace - R.I. _ Air Test - Final _ Windows (new/replacement)
Insulation _ Retaining Wall
Approved By
Building Inspector
Base Fee
Surcharge
Plan Review
MC/ES SAC
City SAC
Water Supply & Storage
S&W Permit & Surcharge
Treatment Plant
Plumbing Permit
Mechanical Permit
License Search
Copies
Other
Total
A
Block 1, CAMERON COURT according .o the plat Minnesotan file and of record
ffice of the Cour.y Recor:er, Dakota County,
t of Lot 20, Bl:xk 1 of :ai.: CA":?OW COURT whi.-h 1 ie$ East -rly of a line
d as follows: be,:innit; at a point ?n the r-fh'sai: Lot 20; thence0
0.50 feet Westerly frog the ,Nortnea--t cor::e
y to a point on the South line of said Lot :' Jistan` 32 feet 'Westerly,
Southeast Berner of sai-- Lot 20 and said li e there terr^•inating.
3
Block 1, CAMERON rO'UR.T, accordina to the olat ther-c,f ?n file and of record
ffice of the County RecDrder, Dakota Cou.1ty, 'i.nesota. Excrnt that part
which lies East-rly )f a li'te descri,.ed as `o 11;:is: b^_:;inninq at a point
orth line of said Lut 20, distant thcraoutholinePo{ eroheaL0` 90 ,hence Southerly f said Lot 20; e+ 2
0.32 feet Westerly, from the Southeast corner of said Lot 20 and said rite
rminating.
tr:s is a tr.:e and correct lecresental-on of a survey or the tocndanes o' the land at O:e tlescribed and
ocatiDn of all buildings d any thereon. and all vsmre 2nroacnrnenis if any. irpm or on said !and This survey Is s " ma a. e
o the hoi-er of
Bcoy on Cernecltidy on that
h a mortgage loan now be'tne eason of sucnFm p?yaaen' Scunde'tst ooe and agreed eP `nmonumen'; nave
-Dr(gage or any other rr-lerest acquired oy me and -fQT -"-
-aced for the nIIrDOSe of esta Dlishing9 lot ,n es or boundary careers 45 Surveyed by/ this
77 V lea
M.....P,liln LrU: ?•: dli...f N.r 13057 .
REVISIONS I DESIGNED Bl'
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} bl\ 11uKn av1 Gordon Nerl? ren
ulla5 DoroAac+_
T-_cx?a,lmtd sst:.l
sslaIt
MnRTGAGE SURVEY
A
3lock 1, caMERON COURT according to the plat thereof on file and of record
ffice of the Couc,y Recor'c,r, Dakota County, "innesota.
t of Lot 20, Bl:xk 1 of -ai- 'NFt RON COURT vhi-h lies East r'.Y of a line
d as follows: beainnii; at a point nn th•: North sali, , of Lot i: Lot 20; thence0
C.50 feet 'Westerly fron the Northea-t corn' 2r 3isn 32 feet 'Westerly,
y to a point on the South line of said Lot
Southeast corner of sai-, Lot 20 3nd said li e there terminating.
52.00
3
the olat thrr•.nf m file
and of record -- - 2550
!FEW C i 20'?? a
3lock 1, MMERON COURT, acccr+inq to
Exce
Dakota Cou ty, •'i"nesot
pt that part c
.
ffice of the County Reorder,
descri: ed as full ::fs: ee ;lnnir,
l i q at a poi t
24.0.
e
:fhich lies Easterly 3f a
distant 0.50 feet b!esterl; from the
t 20
L
Northeast
t 20 Io
;
l
,
o
pith tine of said
id Lot 20; :hence Southerly to a 4'-oint on the South line
t 20
id L
f of sail Lo
and said 1 le •
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o
sa
from the Southeast coif r of sa
t Westerly,
32 fee
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.
rminating. p ,
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o'
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t' Ex r s rwG B vrconvr.
and
eoy certify that tr•is is a true and correct iepresental:on of a sur+ev of :he to Wtdanos of the land aTh,s sdL.ervscey a noed maa.,r
ocanGn of all buildings d any thereon. end all %sro,e emoachments it any, from or on said land Tins
connection W,!h a mortgage roan now being placed' on ;he properly and no IrabiI?lY is assumed axcePt 10 the odder of
•ortgage o: any other interest acquired oy the reason of such mortgage It is unde,s;ooe an 5 agf a dQTd( nwmer.'s nave
laced for!ne purpose of es!aol,shmig ot79 s or boundary Corners AS surveved try _Qcmaiew . ---
13057
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5E.00
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llaa`1 -?t?Ct. Ecv?an,MtJ SstD.
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55 1.1 l
RECISIONS DESIGNED BI'
' MnRTGAGE SURVEY
For Office Us,.;
yam}
Clt of Ea Ull Permit
40D
el I Permit Fee:
3830 Pilot Knob Road
Eagan MN 55122 Date Received:
Phone: (651) 675-5675
Fax: (651) 675-5694 staff:
2009 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: 6-,26 Site Address: J t /BAa,1 C
Tenant: 6O r%4 ~`/t? e/! Suite
RESIDENT / OWNER Name: rt Ile K Je Phone:
35r1.
Address/City/Zip: /(E12-5 L2o1t~/1 ('I_ X~e4lrt'
Applicant is: Owner -Y Contractor
TYPE OF WORK Description of work: /W a.c/c 9 W T 1J
Construction Cost: `_/_507_ Multi-Family Building: (Yes / No )
CONTRACTOR Name: s L~ ~ - i ~LC License o265 fV-2-W
Address: g-/o7 4- rl / rcc„_e
City: S l h °u- State: llt Zip: 33_ /
Phone: 915~2-V7_ M2 Contact Person: C' , 0.,-/
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
_ Minnesota Rules 7670 Category I Minnesota Rules 7672
Energy Code • Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet
Category Submitted Submitted
submission type) • Energy Envelope Calculations Submitted
In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan?
_Yes No If yes, date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: Phone:
NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of
the information maybe classified as non-public if you provide specific reasons that would permit the City to
conclude that they are trade secrets.
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
x di, r 4CL ~ ~la. G,eK x JL;~=
Applicants Printed Name Applicant$ Signature
Page 1 of 3
Use BLUE or BLACK Ink
I For Office Use I
RECEIVED
Permit
City o Eapn MAR 0 3 .016
/ Permit Fee. (X~
3830 Pilot Knob Road I I
Eagan MN 55122 Date Received:
Phone: (651) 675-5675 I ` I
Fax: (651) 675-5694 I Staff:
r
2Le-V
014 RESIDENTIAL BUILDING PERMIT APPLICATION ~j
Date: 1 Site Address: 16"o 6a~ Unit ~ 3/•°''
Name: Phone:
Resident/
Owner Address / City / Zip: /\Ak 4-
Applicant is: Owner Contractor f
Type of Work Description of work: J~L 0 t~ f'' S ~ r~ GI ✓~7' )4 ~otG L~ ~Z l~-
& 0
Construction Cost: ty 0 Multi-Family Building: (Yes / No
Company: Contact:
r~ i2~[ti
Contractor Address: /'~'e4t4 City: t t3~
State: Zip: ~.>d (o Phone: Cl _ O`.~ D l~y-us
License Lead Certificate
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
ay-l;- r /,,;p -7 9 ~'7,
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
I
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:
-P-lans-and-supportin",ocumentss i nit a be-pub n.-Portions e#
the information may be classified as non-public if you provide specific reasons that would permit the City to
t conclude that they are trade secrets.
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.ora
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be corn d within 180
days of permit issuance.
X ~ t, kt
Applicant's Printed Name Applicant's gnat
Page 1 of 3
/(c~~j 'Ovl~atjq~ c--/-
DO NOT WRITE BELOW THIS LINE 3) (9
SUB TYPES
Foundation _ Fireplace _ Porch (3-Season) _ Exterior Alteration (Single Family)
Single Family _ Garage _ Porch (4-Season) _ Exterior Alteration (Multi)
Multi _ Deck _ Porch (Screen/Gazebo/Pergola) _ Miscellaneous
f 01 of I-Plex _ Lower Level _ Pool _ Accessory Building
WORK TYPES
New _ Interior Improvement _ Siding _ Demolish Building*
Addition Move Building _ Reroof _ Demolish Interior
Y Alteration Fire Repair Windows Demolish Foundation
Replace _ Repair _ Egress Window Water Damage
Retaining Wall *Demolition of entire building - give PCA handout to applicant
DESCRIPTION A^v 00
Valuation PAW- Occupancy t MCES System
Plan Review Code Edition - AM7 SAC Units
(25%_ 100%_z Zoning i~ City Water
Census Code Stories Booster Pump
# of Units f Square Feet PRV
# of Buildings / Length Fire Sprinklers
Type of Construction Width
REQUIRED INSPECTIONS
Footings (New Building) Meter Size:
Footings (Deck) Final / C.O. Required
Footings (Addition) Final / No C.O. Required
Foundation 4 HVAC _ Gas Service Test Gas Line Air Test
Roof: -Ice & Water Final Pool: -Footings -Air/Gas Tests -Final
Framing Drain Tile
Fireplace: -Rough In -Air Test -Final Siding: -Stucco Lath -Stone Lath -Brick
J Insulation Windows
Sheathing Retaining Wall: _ Footings _ Backfill _ Final
Sheetrock Radon Control
Fire Walls Erosion Control
Braced Walls Other:
Reviewed By: , Building Inspector
-44 It h^
RESIDENTIAL FEES
*is
ase ee
Surcharge
Plan Review Y7
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
Copies
TOTAL
Page 2 of 3
Date
C!ty of Evan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651).675-5694
Use BLUE or BLACK Ink
For Office Use
Permit #:
Permit Fee:
Date Received:
Staff:
2014 RESIDENTIAL PLUMBING PERMIT APPLICATION
Site Address:
Tenant:
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage.
Call 48 hours before you intend to dig to receive locates of underground utilities. www.Qopherstateonecall.orq
1 hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will. be In
accordance with the approved plan in the case of work which requires a review and approval of pI- s.
x 1 'I
x i it 0/ ftlihte-ACt---
/ -
Applicant's Printed Name
Applicant's Signature
�1'
,-ii-' Phone:
Name: uvuc 1. �itrxe -'+
Resic�en
e
Qwne
1 Address l City / Zip: " . aa�.t-A l
Milbert Company Inc dba Cullign Watel"
Name: ucense #: WC643176
�r; Cif
Address: 1801 50th Street East City: Inver Grove Hgts.
Contra
for
55077 651-451-2241
State: NI N Zip: Phone:
Contact: William R Milbert Email:
New /�/ Replacement Repair Rebuild Modify Space Work in R.O.W.
_ _ _
rTY a 0 r /— _
Description of work:
RESIDENTIAL
Water Heater
Water Softener
Lawn Irrigation (_ RPZ / PVB)
Add Plumbing Fixtures ( Main / Lower Level)
_
Permit'T p Aw
Septic System
Water Turnaround
_ New
N:• Abandonment
RESIDENTIAL FEES:
$60.00 Water Heater, Water Softener, or WaterHeaterand Softener
(includes $5.00 State Surcharge)
Turnaround* (includes $5.00 State Surcharge)
and $5.00 State Surcharge)
TOTAL FEES $
$60.00 Lawn Irrigation (includes $5.00 minimum State Surcharge)
$60.00 Add Plumbing Fixtures, Septic System Abandonment, Water
"Water Turnaround (add $200.00 if a 5/8" meter is required)
$115.00 Septic System New ($10.00 per as built) (includes County fee
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage.
Call 48 hours before you intend to dig to receive locates of underground utilities. www.Qopherstateonecall.orq
1 hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will. be In
accordance with the approved plan in the case of work which requires a review and approval of pI- s.
x 1 'I
x i it 0/ ftlihte-ACt---
/ -
Applicant's Printed Name
Applicant's Signature
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA121003
Date Issued:03/10/2014
Permit Category:ePermit
Site Address: 1625 Donald Ct
Lot:202 Block: 01 Addition: Cameron Court
PID:10-16300-01-202
Use:
Description:
Sub Type:Residential
Work Type:Alteration
Description:Fixtures
Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size
Comments:Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Fixtures:replace tub,tub faucet and drain.
Alex Barna
Po Box 188
Fee Summary:PL - Permit Fee (miscellaneous)$55.00 0801.4087
Surcharge-Fixed $5.00 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 -
Us Bank National Assoc
200 - 6th St S
Minneapolis MN 55402-1403
(612) 802-1865
Sowada And Barna Plumbing
PO Box 188
Cedar MN 55011
(763) 444-0292
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA123327
Date Issued:06/04/2014
Permit Category:ePermit
Site Address: 1625 Donald Ct
Lot:202 Block: 01 Addition: Cameron Court
PID:10-16300-01-202
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:One Window/Door
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: 500.00
Fee Summary:BL - Base Fee $500 $40.00 0801.4085
Surcharge - Based on Valuation $500 $0.50 9001.2195
$40.50 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 -
Heidi M Masanz
1625 Donald Ct
Eagan MN 55121
(612) 802-1865
Crew2 Inc
2650 Minnehaha Ave
Suite 100
Minneapolis MN 55406
(612) 276-1680
Applicant/Permitee: Signature Issued By: Signature