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2085 Cliffview Dr' cirir oF EAG+N ?-.. 3745 Pilot Knob Reod Eagon, MN 53122 N2 6465 PHONE: 4548100 BUILDING PERMIT Receipt .# -_--_- Te be osed for Est. Value DoTe , 19 Site Address Erect 0 Occupancy Lot Block Sec/5ub. Alter p Zoninq Porcel # Repair ? Fire Zone Enlarga ? Type of Const. o C Nome Move p # Stories W z 3 Address Demolish ? Front ff. ? Ci Phone Grode ? Depth ft. ? Name pP v ,o Address Assessment Water & Sew. Ci phone ? Police Name ? W Fire ?? Address Eng. <W Ci Phone Plonner I hereby acknowledfle that I have recd this opplication ond stote that Council gldg. Off. the information is cor?ecc and agree to comply with all appliccbie Stote of Minnesota Statutes and City of Eogan Ordinances. ro oh e?-• A APC Pertnit Surcharge Plun check 5AC Water Conn. Water Meter Rood Unit Total _ Signature of Permittee I A Building PeRnit is issued to: on tha express condition that oll work sholl be done in cccordonce with all appliaable Stote of Minnesota Stotutes and City of Eogan Ordinances. Building Official •• 1 P*rmk # De% Fwwd ftnelftK Plumbing -/ Mechcnical / ? INSPECTIONS f DATE INSP. Rouflh-In Finol Footings ? Dote Insp. Dote Inip. Foundation Plumbing '61 Framelins. Meclwnical Finul Remorks: a _?-?? Qlrrtif'tra#r of (Orrupttnry a Cirp of eagan loPpal'wtPtt# of litilbmg 3itSpPtftittt Tf1tf CMf f1CAtG tJJNd p71lJflofll t0 lllt fAllflf[flttMtJ of SQC1fOM ,3OG of lIX Uf!lfom &eildiug Codc artifring tiaat at tix titue of it.arancc tbir anrctare wa.r in cmis pliana with tbc variow ordinaxcu o f tbr CuY ngxlAtimg bxildirig corutrWCtioa or xrc. For the f ollae7ng: SF TM/GAR 6465 ??•- -- .,._ ?...._ iiiif?OldeW o.a: 2-20-81 roW w w ooww? Puu No. CITY OF EAGAN 3795 Pilof Knob Road Eagon, Minnesota 55122 Phone: 454-8100 PERMIT Date: Site Address: 2085 C1if£view Lot Biock Sub/Sec. INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS Recelpt No.: $ingle , I Residential Multi Res., Comm./Ind. I Nome New/Alter./Repair. .. . t_ ? •l,? i • . ; Address ' Cost of Instollotion City Phone: Permit Fee Nome Surchorge . ? ? Address City Phone: Totol This Permit is issued on the express condition that ail work sholl be done in occordance with oil appliwble State of Minnesota Statutes ond City of Eogon Ordinonces. 8uildiny Officiol ? CITY OF EAGAN . 3795 Pilot Knob Rood 6ogaw, Minwesota 55122 No. Phona: 464.8100 PERMIT Date: Site Address: Lot 81ock Sub/Sec. I ! 7Y Name . °e Address ? City Phone: Nome ? ? Address City Phone: This Permit is issued on the express condifion thot oll work sholl be Minnesoto Stotutes and City of Eogon Ordinonces. INSPECTOR NOTIFICATION REQUIRED BY LAW FOR ALL INSPECTIONS Receipt No.: Single Residential Multi Res., Comm./Ind. I New/Alter./Repalr. Cost of Instollotion Permit Fee Surcharge i I Total done in nccordance with oll appliooble Stote of Building Officiol CITY OF EAGAN Remarks Addition Cadg,? ?j?f'Q Arl?iItin» _Lot 2 61k 3 Owner 1 Street-?085 C1iffV1eW DT1Ve State- Improvement Date Amount Annual Years Payment Receipt Date STREETSURF. ?jj 1982 1496.30 299.26 5 1496.39 C007317 0-1- 1 STREET RESTOR. GRADING 433.11 A010015 3-24-81 SAN SEW TRUNK 106.57 a04 42.26 32481 - - * SEWER LATERAL 5,/c 2 S-24-91 WATERMAI N * WATER LATERAL 1981 WATER AREA 940 603 3-24-81 STORM SEW TRK S 324.08 A010015 3-24-81 * STORM SEW LAT 1981 CURB & GUTTER SIDEWALK STREET LIGHT WATER CONN. BUILOING PER. 22461 SAC 595 00 22461 PARK WAtER SERVtCE PERMIT CiTlf OF E!?GAN PERMIT NO•: , 3795 p;lot Knob Road OATE: MN 55122 _ No. of Units: Eo9an. Zoning: p„rner. qddress: Site Address. . PlumbQr: ? Meter No.: Size: Reader No.: an agm@ to comVIY witfi lhe CitY °T Ea9 4 prdinaeces• gy ------ - Dote of insp.: ? Conneccion Char9e: Account DePosit: - Permit Fee: ? Surchar9e: r misc. Char9es: - Total: ? Dote Paid: ?- CITY QF EAGAN 3795 pilot Keob Road lagon, MN 55122 Zoning: ------- Qwner: ?r Address: .?---'- .,Site Address: -- be ? SERVICE PERMR pERPAIT NO: DATE: ! No. of Units: p{um • , .?- Connection Char9e: y a9ree to wmp?Y wi}h !fis Gtll ? Eo9p° Account DePosit: prdinaeces. Permit Fee' Surcharge: AAisc. Char9es: BY Totol: Date of Insp.: Dote Paid: I nsp.: r Minnesota 5tate Board of Electricity Griggs Midway Bldg. - Room N191 rsiry Ave., St. Paul, Minn. 55104 - pFane 297-2111 IEST FOR ELECTRICAL INSPECTION V WORK COVERED BY THiS RFniiFCT Home 61 ? ? Range Duplex ? ? ? Water Heates Apt. Bldg. ? ? ? Dryer Commercial Bldg. ? ? ? Fumace Industrial Bldg. ? ? ? A'v Conditior Fazm ? ? ? List j / ^ c) E13-00001-02 T 20140? Temporary Wiring ? Lighting Fixtures ? Electric Heating ? Silo Unloader ? Bulk Milk Tank ? COMPUTE INSPECTION FEE BELOW Service Entrance Size: # Fee Feeders&Subfeeders: # Fee Ci[cuits: ?k Fce D to 100 Am s. 0 to 30 Am res 0 to 30 Am eres 101 to 200 Amps. 31 to 100 Am res 31 to 100 Am res Above 200 Amps. Above 100 Amps. Above 100 Am s. Transformers Remote Control Circ. Partial or other fee Signs S cial lns ction Minimum fee Remarks ? TOTAL FE z2 00 I,the Elect (Rough-in) nc e (F;nal) This request void 18 months from This request void 3?,c,.?-? / 18 months from has been ma e. A0 -fr/ 7- ;L a-A-i Date ot chis Request 1-20-81 Fire No. T 20140 I, as ? Licensed Electrical Contractor O Owner, do hereby request inspection of the above electri- cal wiring installed at: Street Address or Route No. r:'""' r;fv Eagan Section Township Range County Dakota Which is occupied by Zachman Homes (Name of Occupant) Is a roughin inspection required on this job? No ? Yes EE] Ready Now D Will Call O Power 5upp(ier _ Dakota. Llec f:ric Electrical Contractor Sunrise Electric. Ine. Contractor's License No. 39778 (Company Name) Mailing Address 4120 03rd Ave No Mpls } MirLn. 55443 (Electrlcal Cantractor or Owner Making Thls Installatlon) Authorized Signature xei:th R Hesli Phone No. 566-8600 (Electrlcal Contractor o? Owner Makln9 Thls Installatlon) ????? ?o??D ?,o?Y This inspection request will not be accepted h State Board unless proper inspection fee is e CITY OF EAGAN ? 3795 Pilot Knob Road Eegan, MN 55123 ?PHONE: 444-8100 BUILDING PERMIT APPLICATION 2eceipt # To ba used for SF DWG/GAR Est. Value 37, s;.a Add„« 2085 Cliffview Lor 2 Bmck_3 Sec/sub. Cedar Cliff 1 Porcel # 10 16600 020 03 W INome Zachman Homes Inc. z Address 7760 Mitchell Rd. 8 Eden Prairie.Mn 9- 0 p Name _ ?? Address fif.. Nome _ Address I hereby acknowledge that I have read this application and state thet the in4ormation is correct and ogree to mmply with all applicable State of Minnewta Statutes and City of Eagan Ordirqnces. Signature of Permittee - A Building Permit is issued to: aIl xrork shali be done in ncca Buildirg Officiol N4 6465 Erect U OcCUpanCy R3 Alrer ? Zoning Rz Repair ? fire Zone 3 Enlarge ? Type of Const. V Move ? # Stories Demolish ? Front 42 ft. Grode ? Depth 38 ft. Aonrorah Feea Water & Sew Police Fire Eng. Planner - Council _ Bldg. Oft. - APC - Permif 1uo.vv Surcharge 18.50 Plan check 54,00 SAC 525_00 Woter Conn. 305. 00 WaterMeter 60"00 Road Unit 185 . On Toral 1,255.50 Z3Chman Homes Iric, on tha expreu wndition that with,all appJiGable?State of Minnesota Stututes and City of Eagon Ordirmnces. ./ .? ??X5 Zb Be Ilsed crry oF FAGAN_ BUIIDING PERMI'P APPLICATION = -- - Include 2 sets of plans, 1 site plan w/elevations s 1 set of ereryy calculatiOns• For S\ J?._ valuation .3 2 • 0'O v.. D?te_ Site Adciress: ?oAS ? .{.. ' 1SELec.?t Lot Z- -; Bloclc aJ Sec- / Alter - Paroel #: d RePair rV _ . _ n. .. Enlar3e Owner: Address ? P City/Zip Code? Prone 1: 93`?-?sZ a Contractor: Pddress: Cit;y/Zip Code: Phone #: Arch-/fln9. : Pddress- (Yty/Zip Code: Phone A: OFFICE USE OA7LY pccupancy ------------ - Zoninq R 2 Fire Zone 3 lype of Const. ? - u Fjove Q Stories ft. nolish Front D y ? e ft Grade ?P? 3E-- . --- APPRCNAIS FEES ? 6 eF pssessrents . . Pel?nit _ f0. a o water/Sewer Surrhange / 8. so Police Plan Check ,S'Y.O d Fize SAC 52s o0 U109, Water Conn. 30.i,00 Plarnes Wates Meter Ga ad Councyl goad Unit oO Bldg. Off. APC 7VTTAL ? .?.?-S• S? 'c H. HEDLUND seoe oiroro Avenue soure ALVIN Bloominqton,Mlnnsaota 55431 Land Survayor Civfl Enqinesr Phone :889-2080 Swnewrifs G'ertlf "teate JOB N0. "35 SURVEY FOR: Zachman Hxnes DESGRIBED AS: Lot 2, ffiock 3, CEDAR CLIFF, City of Eagan, I!a]cota County, A4innesota, and reserving easementa of record. 695.8 78.00 899.0 - - -, r - - - I I ? Top aP Fokedatton •901.9 ( ? I Liasement Floo. = 898.1 Garagc Floor= 901.5 I i ? I Propo:ed Elevaiiona J 1_" Exis+i?y Elev.ttton: _ O 1 qoL 10 I penotrs Draina9e ?-? pen }es Lof Gorner O - ? o . . ? Z??M1- Zs's" IN ` North I OAKWapD?O ? I IO?SOstakes is „?? N ? l?} N GAR s ? I 10?p stakes , ' p ,N M j foJer I 1 1 LV_? ? ? ? ? ?? ? ? ? l ? r• n l. v i I lr l_ ( • `? ? 901.2 9oi. ? _ ? ? I I AR?VE ?_??------? I i 898_I I ? 78.0? ? I 899.3 _ b o m M ?S CLIFFVIEW pRIVE I 899.0 CERTIFICATE OF SURVEY I hereby certify ihaf on 11- 14-a0 2 surveyed the property described oGove and ihot the obove plot ia a correct representution of said survey. (' Colvin H. Hedlund, Minn. Req. Na 5942 9/OO 1100 r------- AkL_ `Qrca#ies Clse ' City 0 Permit f Eaan Permit Fee: 3830 Pilot Knob Road Eagan MN 55122 Date Received: Phone: (651) 675-5675 /7 Fax: (651) 675-5694 Staff: - - - - - - - - - - - - - - - 2008 RESIDENTIAL BUILDING PERM T APPLICATION Date: A5-1457-499 Site Address 93 Tenant: Suite RESIDENT/ OWNER Name: ~1 Phone: f:4~ l ' - 7 'c Address / C / Zip:016 g 5- M n. 6_7 a a~3 Applicant is: Owner Contractor TYPE OF WORK Description of work: 06 Construction Cost: '?4 dr~ • Multi-Family Building: (Yes No CONTRACTOR Name: License i q 0 Address: 7 L4 city: State: zip: 570 1 Phone: Contact Person: COMPLETE THIS AREA ONLY IF CONSTRUCTING A EW BUILDING - Minnesota Rules 7670 Category 1 Minnesota Rules 7672 Energy Code • Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet Category Submitted Submitted submission type) • Energy Envelope Calculations Submitted In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? Yes _No If yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NO E: PI ns and supporting.dpcumQnts thatyou.submit ,f;ahsider i to be publl Information °Portions of the information may be classified as nor puki7c f you pr :specific reasorfs that would per lt':the City to carilcrtl~ thafi t de secret I hereby acknowledge that this information is complete and accurate; that the work will be in conf rmance 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 of to start without ape it; that the work will be in accordance with the approved an in the case of work which requires a review and approval of plates. x U x Applicant's Printed blkme Applicant' ignature Page 1 of 3 PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA107699 Date Issued:10/23/2012 Permit Category:ePermit Site Address: 2085 Cliffview Dr Lot:2 Block: 3 Addition: Cedar Cliff PID:10-16600-03-020 Use: Description: Sub Type:e - Furnace Work Type:Replace Description:Furnace Comments:Questions regarding electrical permit requirements should be directed to Mark Anderson , State Electrical Inspector, 952-445-2840 Andrea Preusse 4145 Sibley Memorial Hwy Fee Summary:ME - Permit Fee (Replacements)$55.00 0801.4088 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 - James C Larson 2085 Cliffview Dr Eagan MN 55122 Wenzel Heating & Air Conditioning 4145 Sibley Memorial Hwy Eagan MN 55122 (651) 894-9898 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA112814 Date Issued:08/23/2013 Permit Category:ePermit Site Address: 2085 Cliffview Dr Lot:2 Block: 3 Addition: Cedar Cliff PID:10-16600-03-020 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are not acceptable in lieu of inspections. Carbon monoxide detectors are required by law in ALL single family homes . Nicole Flattum Valuation: 4,000.00 Fee Summary:BL - Base Fee $4K $103.25 0801.4085 Surcharge - Based on Valuation $4K $2.00 9001.2195 $105.25 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - James C Larson 2085 Cliffview Dr Eagan MN 55122 (651) 454-7828 Storm Guard Restoration 1355 Geneva Avenue North, Suite 201 Oakdale MN 55128 (651) 738-1698 Applicant/Permitee: Signature Issued By: Signature 651 783 9a50 07/2012009 09:03 CUSTOM REMODLERSINC (FAx)651 783 9050 P.0011001 00 qa. . . r----------------- 1 ~ - f Pertnlt Of JJ LL~~ t~ 3830 Pliot Knob Road ~ I Permit Fee:~ Eegan MN 55122 ~ Date Racelved: Phone:(651) 675-5675 ~ Fax: (651) 67S5694 i Steff= 04!:;, r ~ 200$ RESIDENTIAL BUILDWG PERM T AcPPUGATION~' Data: ~J • Q~ Site Address: 73 ~Jf Tenant; Suite RESIDENTlOWNER' Name: Phone:(G~~ 4.s'Lf-7D 8' ` ndares5 i c i ap: o g S' Sk a os AppllcaM is: _ Owner Y_ ConVacior . . " TYPE OF 4VORK " Description of wark: - od . ~ Constructlon Cast: _ -7, dco• MuIU-Famfly Building: (Yes No CpNTRAGTOR Name: LJcense Address: Z . Clg': State:mn Zlp:. 57g?p 4. Qhona: CoMact Person: CdNlP,LETE THIS AREA ONLY IF CONSTRUCTI G A EVIf 6UILDING Minnesota Rules 7670 CateaorV 9 Minnesota Rulas 7672 Energy Code . Resfdemlal Ventllayon Cetegory 1 Workshaet • New Energy Code YVodssheet Category submined . suhmitted ' . ' (^I submisslop iype) • Energy Envelope Catculatlons SuWnrited In the lest 12 months, has tha Cfty of Eagan issued a perntft for e sfmilar plan b on a master plan? _Yes Np 11 yes, data and address of master plan: L+censed Plumber: Phone: Mechanical CqntraCior; ~ Phone: Sewer & Water Coqtractpr: Phnna: I hereby aeknowletlge Ihefthlg 1iAortneNon 18 Completa and ecCUrate; ll»at ihe xroAc wlll ba In con%rmanca wllh the ordlnenees end codes of the Clty W Eagan; that I understand ffiIs Is not a perml4 hut oNy an appllceUonfur a pqrmit, aritl work is ot W'sten withoul =itthat war k will 6e In accordanca wlth the approveE p an In tha case ot work which requires a revtew arW epprovel ot pla is. . ' x U~. ~ x ApplicanYs Prlnted 16me Applfcarrt' gnature - Page S of 3 Use BLUE or BLACK Ink r-----�--- --------� I For Office Use, � C�� O}'L1� �n � Permit#: �� 1J � � y � �, � �� ' � o�� � 3830 Pilot Knob Road I Permit Fee: � Eagan MN 55122 � I Phone: (651)675-5675 � Date Received: � Fax: (651)675-5694 I � � Staff: � �-----------------� 201 MECHANICAL PERMIT APPLICATION ❑ Please submit two(2)sets o plans with all commercial applications. Date: � lS� SiteAdd ess: ����� � ���� ��' pr��e � Tenant: Suite#: '. iu Ik � �'������ ',G� M� C, L�L°� an G��_ '�`'�.���� �� u"�Ij Name: S Phone: ��� �' ��e ��� � � �. ,� d��j �I� .`f ��:������,,��i�u!� Address/ ity/Zip: �'G��� �. ������w �Y'V N. a�y � pio����� ` zF,I� u � a��� �`�� � :� Name: � License#: =�� '°�� � ��` ������� Address: City: ��lE1'�1'��t��:- , -_ ��"'���I��� ` State: Zip: Phone: � � ��3�����������W����� � _a�,� : ������N� N: Contact: Email: ��,� _��� � � � m �' New Replacement Additional Alteration Demolition T�#pe� - r�!'�'! Descrip ion of work: I� ' ��� '`� � �,�' x E:R f � i ., r+aunc�ri�c�un�ed rr���h�n►c�r-� '�!� �r�c##e�b���re�nn�d i� ����d �����!���� �,r'�"ti..�i� � � .i ��� Y � �?����in��� ��ai. a����,�:��" t��u�,H�: �a�� onta`�= ������l�r�n�+��tt��in��fa����f��i� ,�r� e��t��t^��r�r����1��ti�is � � ���.. _ '�� �,�. � ��'����'"������ � � � ��i RESIDENT/AL COMMERC/AL � �� ��� ad � ������� _Furna New Construction Interior Improvement ��N � '�i `� ��'�� ` �"���`.. �`� � _AirConditioner Install Piping Processed �_ � ���� ��� ��` Air Ex hanger Gas Exterior HVAC Unit �i�� ���� � � �� ��, i���� _Heat um� �ci,���c� � _Under/Above ground Tank (_Install/_Remove) `�ti����� ���j������dtu���"r �::-�I�i` Other �w� �tY RESIDENT/AL FEES $60.00 Minimum Add or alteration to n existing unit(includes$5.00 State Surcharge) $100.00 Residential New(includes$5 00 State Surcharge) _$ TOTAL FEE COMMERCIAL FEES Contract Value$ x.01 $55.00 Permit Fee Minimum $70.00 Underground tank installatio /removal =$ Permit Fee *If contract value is LESS than$10,010, Surcharge=$5.00 =$ Surcharge" "*If contract value is GREATER than 10,010, Surcharge=Contract Value x$0.0005 "*"If the project valuation is over$1 mill on, please call for Surcharge =$ TOTAL FEE I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan;that 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 hich requires a review and approval of plans. x �u►n�5 �, �wr�o� X � ��' Applicant's Printed Name Appl' ant's Signature � t�(���1� � f � � � �b �i�d�l T �� � ; ' �.� � �snteci B � �� I� Y t�rit�er' ' �� .��d ���`:�c�u�� � ' rTest �-� �s��nr���° ��� _; � Ir�#�o�r H��t ��n�l � r creer���;� � ���� �- ; �� PERMIT City of Eagan Permit Type:Building Permit Number:EA135699 Date Issued:03/30/2016 Permit Category:ePermit Site Address: 2085 Cliffview Dr Lot:2 Block: 3 Addition: Cedar Cliff PID:10-16600-03-020 Use: Description: Sub Type:Siding Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please leave printed pictures of house wrap on site for the final inspection. When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to ensure maximum ventilation to attic. Call for final inspection after installation. 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 - James C Larson 2085 Cliffview Dr Eagan MN 55122 (651) 587-1254 Custom Remodelers 474 Apollo Dr Lino Lakes MN 55014 (651) 784-2646 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA178482 Date Issued:08/19/2022 Permit Category:ePermit Site Address: 2085 Cliffview Dr Lot:2 Block: 3 Addition: Cedar Cliff PID:10-16600-03-020 Use: Description: Sub Type:Reroof Work Type:Replace Description:Does not include skylight(s) Census Code:434 - Residential Additions, Alterations Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please print pictures of ice and water protection and leave on site. If water damage is encountered, please call (651) 675-5675 to schedule a site visit to verify the extent of the damage. Any repairs must be inspected prior to covering. The inspector will determine if an additional permit will be required to repair the water damage. Valuation: 5,000.00 Fee Summary:BL - Base Fee $5K $118.00 0801.4085 Surcharge - Based on Valuation $5K $2.50 9001.2195 $120.50 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - James C & Carol Lynn Larson 2085 Cliffview Dr Eagan MN 55122--237 (612) 697-2650 The Roof Guys 7630 145th Street, Suite 110 Apple Valley MN 55124 (952) 997-4777 Applicant/Permitee: Signature Issued By: Signature