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4575 Hay Lake Rd SCITY OF EAGAN Remarks Addition OVERHILL FARM 1ST ADDN Lat 10 e1k 2 Parcel 10-56150-100-02 %fte Street 4575 S. Hay Lake Road Stete Owner Improvement Date Annual Years Payment Receipt Qate ' STREETSURF. jQHj 15.54 20 233.09 0010215 4-1945 ' STREET RESTOR. 1954 466.23 5 1 . 0 C01021 4-1945 ' GRADING 1985 2 ' 1017.39 C01021 4-14-85 E SAN 5EW TRUNK 1981 17.96 20 269. 48 C01021 4-19-85 EWER LATERAL - 790.73 sw?m SEW TRK LAT BE?1 1984 - 17.8 15 1.$1 C010215 -1 -$ WATERMAIN WATER LATERAL 1981 172.42 8.62 0 129.32 C01021 7. g WATER AREA 1981 359.28 17.96 20 269.48 1 21 -1 --8 STORM SEW TRK 19$ 513-42 .2 15 .8 C010216 4-1945 STORM SEW LAT --rrjc 40 1984 92.23 6.15 15 79•95 c010216 4-19--85 )(1985 - CURB & GUTTER SIDEWALK 5TREET LIGHT WATER CONN. 500.00 i BUILDING PER. 9919 sAC 525, PAR K ? 1 LI11Y111 71 7l/jd MECHANICAL PERFIg RECEIPT # f 2 C1T/ OF CAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: Name ? Addre , c Ciry _ ? Name _ c Address a CitY - Phone ! TYPE OF WORK ? Forced Air M BTU Boiler M BTU ' Unit Heater M BTU Air•_Cond. M.BTU _ ' Vent CFM Gas Piping Outlets # Other FEE S/C: TOTAL: BLDG. TYPE WORK DESCRIPTION Res. ? New Mult. Add-on Al Comm. Repair Other FEES RES. HVAC 0-100 M BTU -$24.00 ADDITIONAL 50 M BTU - 6.00 (RES. HVAC INCLUDES A/C aN IVEW GONSTRUCTION) GAS OUTLETS (MINIMUM - 1 PER PERMIT) - 1.50 E/ COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS. - COMM. RATE APPLfES TOWNHOUSE & CONDOS - RES. RA7E APPLIES MINIMUM RESIDENTIAL FEE - ALL ADD-ON & REMODELS - 12.00 .50 j FbFI 1 EAGAN , - ? eUILDING kItMIT CITY OF EAGAN 3830 Pilot Krab Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 Receipt UwGJuAn Fa? 5 0, a It o "y-t?* 9919 Site Addrest ? ? ? ?' • Erect LJ Occupency ' -` ! ? Lot Block ? Sec/Sub Remodsl , , ; ? • . .! Zoning . Repair ? Type of Const. Parcel No. Enlarge ? No. Stories Move ? Length Name Demolish ? Depth ? Address Grade ? Sq. Ft. City Phone '{' 1. E' 6 A Install ? Name Addresa Name Add ress 1 hercby acknowledpa thot I how recd this opplicotion and stote thnt the informotion is correct ond ogree to comply with oll opplicable Stote of Minnesotc Stotute: ond City of Eogon Ordimnces. Slqnoturo of Pertnittea A Building Permit is issued to: all work sholl be done in occo?donte with all appliaoblt State of Mii Buildirq Offldal /lssessmtnt Water & Sew. Police Fin Enp. Planner Cowxil Bldg. Off. ' APC Var. Date ? - Permir J.l_J . +JV . J 0 SurcFwr? ?? Plan Review . ? ? ? rl S/1C G Watu C4nn. .? Q Woter Meter . U o Rood Unit 77• l' d:?, ... s.s.' .04i Total . . ')') on ths exprcfs condition Ihot ond Gty of Eopan Ordinonces. Pwmit No. Pwmk Holde? Dan Telephona # PlumbinY "M ,< H.VA.C: 5 /lX/?,oy 1.?r?c?? 3l o? ? 37 - d 1 Sy electria 3l r k ? o, o d t) -.3 ') Softwor Irqpeetion Dsta Insp. OthK Footinyt g7 3 ? ? oundation Framiny SSs ?fi ?Ll Roofing Rouqh PI6g 17- Rou9h HVAC Inwlation ? Final Plbp. Final HVAC Final CKt/Oa. Wmr D?se?ibe Loe tibn: ? ? ? wall l d.l` • C,??"" '- (l' T _ l ? - OJ Sevwr fil Pr. Disp. Receipt PLUMBING PERMIT CITY OF EAGAN Fee S/C Tot Permit No. Fill in numbered spacea Type ar Prini /egib/y 1. Date X? 2. Installation Cost 3. Job Address -A,ot Blk. _ 4. Owner 5. Contractor 6. Address , Tract r Phone "s'`. -• _ ` . _, 7. City Stete .?,Zip . 1, , 8. Building Type: Residential ? Commercial ? Institutional O 9. Work Description: New,CH, Add O Alter O Repair O 1 10. Describe 1 11. No. Fixtures Water Closet No. Fixtures Cesspool/Drainfield Bath tubs Septic Tank - Lavatory Sottner ' Shower Well Kitchen Sink Urinal/Bidet Other , Laundry Tray Floor Drains Drinking Ftn. Slap Sink Gas Piping Outlets 12. I hereby certify that the above information is true and correct, and ( agree to comply with alj ordinance;.and codes goY?rning this type of work. L Signed;-- ? ?for ' Rough Final Inspections: FDate Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-8100 Receipt MECHANICAL PERMIT Permit No. ? CITY OF EAGAN r ? F88 ??. FiII in numbered spaces S/C Type or Print legibty Tot. ,, - 1. Date o& r 2. Installation Cost L/ _?" ,_.%?;r, 3. Job Address 5'7Ry?j?r Lot ?- Blk. Tract f??+ ?) 4. Owner :`yGbi'Tis/57A? 5. Contractor 4)1';'OA1&41 ? f?FAT/.V6 Phonel?T 4gS'7 6. Address 7. City?vfN ???/?C State /j1AI. Zip -;)'? 8. Building Type: Residential Er 9. Work Description: New B' 1 10. Describe 1 11• Commercial ? Institutional ? Add O Alter ? Repair ? FuelType,iyrr; No. ? Equioment STU - M. Ea. Forced Air No. Enuiament CFM Ai H dli : Mfg. r an ng Balers Mfg. Mech. Exhaust Unit Neater Mfg. ' Other Air Cond. Mfg. ? Gas, Piping Outlexs 12. { hereby certify that the above infiormation is true and correct, and 1 agree to comply withP ordinance;?nd codes governing this type of work. Signed: ?n.,f "! for Rough Final Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-8100 CITY OF EAGAN sEWER SERVICE PERMIT 3830 Pilot Knob Road P. O. 3ox 71199 PERMt7 NO.: Eagan, MN 55121 DATE: Zoning: `` ] No. of Units: Z Owner: :;ortfiytgr P.Ldrs Inc Jlddress: Site Addr Plumber: I eorae to oompy wkh !M Ciey ef Eegas Ordinaneet. By Dote of Insp.: Co„ec"o„ p,fl,pe; 425.00 nd Aooourut Deposit: ,. Pertnit Fee: ' Surcharpe: Mist. Gharges: Totol: Data Poid: L, A :Y C.0 . . . ki .d 4 3830 Pilot Knob Roed P. O. Bax 21185 HIfAYE1[ SERVIGE PERMIT NO.: PERIYIIT " ' - Eagan, MN 55121 DATE: Zonirg: - ' No. of Units: 1 ;cirC'`Star Eldra p , Tnc M ner: /lddrcss: . ? SiM Address. ( i7 5 So Hgv al-P "(-)acl rl^ 't7 r'nr .?r? Fnrm 1 Plumber. 'critar2 °lur:` AAeter No.: Conr,ection Chorfle: 500. 00 ? ? ' Size: Acoount Deposit: . n,- Reoder No.: Permit Fee: ,:. ? ., - 1 pw* te eanply wNh /ie Cfh ef Eayop Surchorge: Owdl"nc«. Misc. CF,orom I 37 . Ct) ? Total: i g Dote Poid: y ? Date of Insp.: Irop.: 3830 Pilot Knob Road [ . O. Box 21199 pERMIT h10.: egan,. MH 55121 DATE: 1 No. of Units: No.: "' . 'r fe aoinplp Wielr Nw Cky ef Eaqan ..?;. ,,;? ??.,r,o? D? . . . ?_ ? . . =_?.?;r:- .. i? .__. t. _ ??. t -• M1. + `a i ; '? ? r ?_ ? ? t ?? ' J ? ?? ? . ??? ?? ?`--'?_ . . _ - ' i CASH RECEIPT F ? CITY OF EAGAN ? P. 0. BOX 27-199 EAGAN, MINNESOTA 55121 , i r i ? R CFI ED ? ?i ? Ij I `r '_1 AMOUNT $ > &aOOLLARS ?o ? CASH ECK FUNG COOE AMOUNT o ' 1 .? / ! ? -?•?: ) v. 'l 7 .3711 ? . 7 C) T aYou ?? ; . - - - er" ? VJhite-Payers Copy VellOw-POSting Copy CITY OF EAGAN No 9919 T 3830 Pilot Knob Road, P.O. Box 27-799, Eagan, MN 55121 PHON E: 4548100 ??? ? BUILDING PERMIT / ReceiPt # To M wsd for SF DWG/GAR Esr. Value $60,000 pate FEBRUARY 2 , Iq_BA SiteAddrese 4575 SO HAY LAKE RD erece %] Ocn,Pancy R3 10 2 c OVERHILL FARM 1 Remodel ? Zoning Rl Lot Block ec/Su6. Repair ? TypeofConrt. V Percel Na. Enlarge ? No.Stories ? IN,m, NORTHSTAR BLDRS ? A?ress P.O. BOX 24487 p;ty APPLE VAL pnone _ 890-1661 o Name _ u? Address i- Cirv Name _ Address City - Phone Phone Move ? Length 39 Demolish ? Depth Q$ Grade ? Sq. Ft. Inscsu o .. -ApProrab ' faet.. Assessment _ Water 8 Sew. Police ? fire Enp. Planner - Councll Ihercbyacknowled tl?6pvarepdthisapplicotiona `thot Bldg.Off. ZIlS/SS fhs information '[orretl dnd ag e fo Com I if o ap ' ble APC Stata of Min ta Stotutea and ity of 9on Var. Date Sipnoturc of PertnillE? - Permit:? -j.L J 700 SurcFrorqs 30.00 Plan Review 156.50 SAC 525.00 WarerConn. 500.00 WoterMater 63.00 Road Unit 280.00 T.P. 132..00 ro:al $1 „999': 50 A Buildinq Permif Is issued to: NORTHSTAR BLDRS on the express caditbn Ihot nll work shall be done in acmrdance? o?ll apppl,?iwbl?\5?f? of Minnewto Statutea ond City of Eoyun Ordirwnces. Buildinp Offlciol w R£QUEST FOR ELECTINCAL IP14SPECTIOM EBmWI'04 Sea irmtruetions fo? eompbLinp Chia tmve an 6ect e!reliuw rnp?. 3// I?? 06 `l 3 8X" 8elow Work Covjered by Thrs Request ? kv4AAd flev. Type ot Buildinq Aooiiarrcea W?U Eau:pesnt Nired q F4 ServicsEntraneeSizs p Fee foadera?Sebtecders # iee Circuits 0 tn200 Amps 0 to30qm 0 M30 Asnilis Above 200 Anips 37 to 100 prrqrs 31 to 100 Air" Swimmi Pool Above tOD_ Above 100 Trarwsf?5 Irtigation Boars Partial•`Otlher Fee Signs Special IcrsPeetiort b? ? TOTe'/FEE'U Remarks S 0 'T t6 ? ? RouOh-in Date 1. the Elscb:ul ' ??P??-?Of? ?1lf66Y .... ?• , t ih Hrt tlr abova Final -? - ? .,o. ?. ?.n This reQUes[ wiE +a ,?o,,,ns r.? A 0 6 7 3 2-1 vA,2 o,r l.rr 3li1g5 tb,rll') Requesf Date ,l y^ ?J`? f D Fire No. Rouph-in itspecf:ot? flepv?retlJ r.ii@ady Nuw.Q Will Notity Inspeo W 1artllA fl DYes ?WO an eatlY ? Licensed Elec[rical Can[tactar ???? eaquey? inspecfim oi ebOY! ? Owner eieeb:eaf work irtiIDlMd ac Street AMress, Box w Raute No. Ci1Y ect?on Trnvm3hiv Name or No. Pfnege Ma. ' GwMy ???i'GT9 Ot IRtINT) r PFew?c No. A /r!/S7`o%R - rd- _ Ar-f Pow¢r $upplia pddn¢s,t D a 9 .- L?c.,? ee ? F?,¢? ?? ro,.?• Eleclripl ConM1actw (Compa'ry Narre) Cmuxtar's lice'ece No_ O,? Qr T? •L,??r?r/L O . . Mail ino .4ddress (COnhactw m Ow?e? 67aking; Insui Wtion) 1?1.3.sd Gf,?i.Q/JFia 0?4e L.s=/1?'lir.?a?o? AuMorized i0nstura lCo n trac lm/O wner Abkinp Iristalfationf Phome NuM¢r / J ? ? ?/Sa^Ti?- . 6 ? C . MINNESpTA STATE'BOAXD OF ELECTRtCISY TNfS IPLSPECTIOM REQUEST NILL NOT Grippa-Midwar 81dg. - Room N-791 aE ACCEPTED Br 7HE STA7E BOA11D 7821 Univeraih Aw-, St. Paul, WV 55104 ONLESS PpOPE6 IMSiEGitON FEE IS Pinro 16121 2872111 ENClOSED. ?U3a3 I?QUeeie?strucEST FOR ELECTRICAL INSPECTION EB1'OO0°'A0 ' Stions iw coavleting?(Fis forcon beek of vellow cuPV. 628377 '"X" Be/ow Work Covered by This Request ? d I o? aaa xeo. ryue of Bu:lajnu Appliaaces wirae Eq.inmanc wi.ed Home J?o Range Temporary Service Duplex Water Heater Ligh[ing Fixtures Apt Building Dryer Electric Heatfn Cortmercial Bldg_ Furnace Sflo Unloader Indiistrial Bldg. Air Corditioner Bulk Milk Tank Fartn otnn Deo y other ISnecirrl t r SucciW Other Othe:r ompute lnspectron Fee Below - M Fee ServiceEntrameSiza N Fee fanders/5ubteeders ? Fe:e Circuits E ,?• D Amps UO 0w30qms 2.SO 0to30Am Above 200 qm 37 to 700 qmps •l, O 31 to 700 AFTw Swimming Pool A6ove 100_Amps Atwve 100-A? Transtormers Irrigation Boo'r.s 5' Partial.'Other Fee L I ISigns ISpeciailnspec!ion \ Remarks ' $33. v o TO AL FEE ? Mecu ac,,m *-? 3,? -.r o Rowe-i. r ne Ere?+?a ?.?,. rtiry [Aat tM abora Final ( (J inspectimhns4een z P d ,,.ae. Thilre9ue5t vOid 503?3 ?'fi l L-i- c; A a cj??k. m ( 3a • s ? pe0uest Uate ?' G fn6? I Fire No. Fbugh-in Inspec'ion 11ea ? ?atlY Now Q Will No?ify Inspec- Z / d Yes ?NO tor When ' ElLicensed Electrical GonVac[or 1 hemby request inspection of ebove ? Owner e1etlriw1 work irelalled aC SVeet Address. Bor or flome No. - L / City ? s ?s A cy g ecuon Townsriw N or No. Range No. Co Ocwpant (PRINTI Phone No. . 68,49 rowe' SuDOlier ?i l aea.ess C, oO /.7A ka 1`-11 L e" EIhical Contra tor ICOnWany Namel ? Conhartui s Licen No. ? /r cfr,e: (..vp ? ?3 Oo0 S MailinB Address (Conimctor w Ovnrer AAakine ?retaiWfion) ?L '4+?? u r!/ E. M'V s ?p nva todOwner MakinB Installatianl 1 Authof Si0non0 Phone Nwnber ? / Li? laY. YINN OTA STpTE BpppD F ELECIRICITY THIS INSPECTION REAUFST INILL NOT Griggs-YidwaY Bldg. - Room N-191 BE ACCEiIED BY THE STA7E 60ABD 1827 University Ave_. St. Paui. YN 55106 UNLESS PNOPEX INSPECTION FEE 6 Pbm 1612) 297-211111 ENCIOSED. RESIDENTIAL BUILDING PERMIT APPLICATION CITY OF EAGAN 3830 PILOT KNOB RD, EAGAN MN 55122 651-681-4675 New Conetructlon Beaulremante • 3 regislered site survays showing sq. M. of bt, sq. tt. of house; end It roofed areas (209'o meximum bt coverage albwed) • 2 copies of plan showing beam & wmtlow sizes; pouretl found despn, atc.) • lsetafEnergyCakulatbns • 3 copies ol Tree Preservatbn Plan ii bt platled aner 711/99 • Rim Joist Detall Oplions seledbn sheet (bk19s wiN 3 or less unils) lP DATE l! U? NemodeVReosir Beaulrements . 2 copies of plan • 1 set W Energy Catulatbns for heated a0dltbns . 1 silesurreytoreMefioraddRronsBdecks . IMlcate N hane sarve0 by septlc syslem for add0bns VALUATION SITE ADDRESS S 14<4 LK /69- ed MULTI-FAMILY BLDG _ Y TYPE OF WORK 0 <= (' FIREPLACE(S) _ 0_ 1 APPLICANT ? ?X?.e rj C) rs -?\ N _ 2 STREET ADDRESS 7 & ?5`fTrn CITY Eckrt 6AL6w STAiE /1'tKU ZIP 5_0 3 yel TELEPHONE # 95'Z'?P-fZ31 CELL PHONE # FAX # PROPERN OWNER " "? df- TELEPHONE # 6 61 Vo S - COMPLETE THIS SECTION FOR uNEWN RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 MINNESOTA RULES 7672 (4 submission lype) • Residentlal Ventilation Category 1 Worksheet Submitled • New Energy Code Worksheet Submitted • Errergy Envelope Celculations Submitted Plumbing Conhacfor: Plumbing system includes: Mechanical Conhactor. _ Mechanical system includes: Sewer/Water Conhacfor. _ Air Condirioning _ Heat Recovery System Fee: $90.00 Phone N ? 4c n JUN 1 1 2002 I hereby acknowledge that I have read this application, state That ihe Information i T, and agree to comply with all appllcable State of Minnesota Statutes and City of Eagan i ance : Signafure of Applicant i ? k ........... -............ ..._......... _............... OFFICE USE ONLY _ Water Softener _ Water Heater _ No. of Baths Phone # Lawn Sprinkler No. of R.I. Baths Certiflcates of Survey Received - Tree Preservation Plan Received _ Not Required _ Updated 4102 OFFICE USE ONLY O 01 Foundatbn ? 07 Orplex ? 73 76-plex ? 20 Pool 0 30 Accessory Bidg ? 02 SF Dwelling ? 08 OCrplex ? 16 Fireplace ? 21 Porch (3-sea.) 0 31 Ext. Ak- Multi ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 PorchlAddn. (4sea.) ? 33 Ext. Alt - SF ? 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (screened) ? 38 Multi ? 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04plex ? 12 12-plex Plhg_Yor_ N ? 25 Miscellaneous ? 31 New O 35 Int Improvement 0 38 Demolish (Interior) ? 44 Siding ? 32 Addition ? 36 Move Bldg. ? 42 Demolish (FOUndation) ? 45 Fi2 Repair O 33 Atteration ? 37 Demolish (Bldg)' ? 43 Reroof ? 46 Windows/Doors ? 34 Replacement •Demolition (Entire Bldg only) - Give PCA handout to applicaM Valuation Occupancy MC/ES System Census Code Zoning City Water SAC Units Stories Booster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs Length Fire Sprinklered Type of Const W idth REQUIRED INSPECTIONS _ Footings(new bldg) _ FinallC.O. _ Footings (deck) _ FinaUNo C.O. _ Footings (addition) _ Plumbing Foundation HVAC Drain Tile Other Roof _ Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests _ Final _ Framing _ Siding Stucco Swne _ Fireplace _ R.I. _ Air Test _ Final _ Windows (new/replacement) _ Insulation _ Retaining Wall Approved By Base Fee Surcharge Plan Review MC/ES SAC City SAC W ater Supply & Storege S&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total Building Inspector 1 (r i J j ITY OF EAGAN 2/84 APPLZCATION EOR PERP4IT SEWE R AND/OR WATER CONNECTZODi • '(PLEASE PRIHT) 1) P.-,TY)PERTY ACDRESS: rFr711I, DE..iP'?'IC;1: c (Lot/Block/S ubdivisicn or Tat rarcei I.D_ N=cer) ST?S;CP=, Dait. 0_° ORT_GuLa.i, :iiI==:G ISSI:;\G.: PCFCLT ••r.;?;?.?0°O5? L'S'-': JVR-1 Si;GL°. cP`•ffLY ? R-? pLPI= (?'.:? Ui?ITS ) ? ?-3 1Cit?-uCJSE (Tc= + L^:Z.S) UN7Z^_S) ? n-4 ti:.:i'?`TM'`:T/CC:?C:•S?Ii.?f ( GZiITSi p CCiAMERC L-S?/RE.'_"AII?G'r"-'ICr. Q :NmliSi:?_-Lu ? INSTITi,TION'?,L/GG==-VT Z) A?PPT_; ` `.,i (7LLAS't 'rRIi1T) N'hr "•LF': ADDRESS: CI^_"I, ST?ITE, ZIP: • PHONE: 3) FLL:=2 • kP EdSE PRIYiJ y ?^, FOR CITY USE 04LY ADCRESS: PLII!!BEAS LICEYSE: Active CITY, ST.'1TE, ZIP: ?f/'iA?r /JiQ?? ?iN11-,) ?S ??Z (? /- 7x?i:n ? PHO?IE: LUMBEN p LICENSE # ? E:pired Q Not o Rec rd ? ar' ln1^131 4) 0..'C;,?Pu?1T/CI. ir:II2 NAf+1E: ADDRESS: CITY, STATE, ZIP: PHO:VE: 5) IfJDIG,T'E :JfiICH PERtiLiT IS BEI\C Rf.'OUES'P"..D: 0LL''LNT1ECi'IO^I 'IYl CIT`! SEViER ? COi7[QEX.TIC:] 'Io CITY WATE? C] =UER (PLEr'ZE DFSCRIBE) b) L:uic:;=" c.-: ? PM_?SE I?OID APPP,pM) PERMIT FOR PICi:-lir BY ONE OF A6GVE ? PLEiSc .?'AIL APP??OVm PEF.:•IiT TrJ 1, 2. 3, 4 AfiOVE 7 ? (Circle one) r/?.: 7) DATE: ! ROIala1Vf?si? ? ra E?gar.? ? s nes?aFa?a a? s??cs?:?a ?c re?caaw?a ? a r?ss??aa ? F 0 R PEDUIT '-` ISSUED C I T Y U S E ON;,Y gvES : $ i D .v"lo $ $ $ 5 $ _ i , e-a $ $ $ $ S $ $ S C?":??'-.D Pv!J\17m (T„CT...;.,.. ",?2.• JU7`:•••l - _ 1 :cL) WaTER PEM1TT (IilCi.uDE SiiRC.`iARGE) WATER METER/COPPERHORN/OUTSIDE READER WATER TAP (INCLUDE CORPORATZON STOP) S ::iE4 ; .Ap ACCCUNT DFPOSIT - 41ATER WnC SAC T3li:•IK WATER ASSc55A?E2:T TRu:1K SEWER '.SSESS.•1ENT Li;Tc,RAL SE:IEFIT/TRUNK SE?•:ER LATE:L-lL BENEs IT/TRU`K S•7ATER OT?iER TOTAL AMOL'..T PAZD/RECET?'?' 1, DOES UTILITY CONNECTION REQUZRE EXCaVATION IN PUBLIC RIGHT OF WAY? YES IF YES, THEPI n"PERMIT FOR 'r70RK L4ITHIN ? PUBLIC ROADWAY" MUST BE ISSUED BY THE NO ENGINEERING DIVISION. LIST AS A CONDI- TION_ SliB.7ECT TO TEiE FOLLOWING CONDITIONS: APPROVED BY: TI.LE: DATr: o•* 313•00+ 30•00+ 156•50+ 525•00+ 500 • 00 + 63•00+ 280 • 00 + 132•00+ 1J 999•50* . ? ? ? 1985 BUILDING PERNIT APPLZ ON - CITY OF EAGAN NOTE: ALL CONTRACTORS NUST BE LICENSED 1{ITH TAE CITY OF EAGAN INCLUDE 2 SETS OF PLANS 3 CERTIFICATES OF SURVEY n 1 SET OF ENERGY CALCULATIONS So Be Used For: ??(.,z? Valuation; Date: Site Address: 16' 75- , OFFICE USE ONLY Lot: Block Sect/Sub ??rect X Occupancy R-3 Parcel Ii Remodel _ Zoning R-I Repair _ Type oF Const S Enlarge # of Stories Owner Move _ Length ?? Demolish Depth 45 Address Grade _ Sq Ft City/Zip Code Contractor Address ??70 City/2ip Code ;y??,/ v Phone # ?? ? o - Arch./Engr Address Phone N APPROVALS Assessments Permit -3 1 3 '• Water/Sewer Surcharge 30.e Police Plan Review I 57. 5= Fire SAC 25, "' Engr Water Conn ?,C.??, °' Planner Water Meter (D-; Council Road Unit ? LEO.°- Bldg OffILOP Parks APC Treatment Pl 132. ? Variance SOrAI. c? c 44° l2n I? - 2o4-x S4- - I I o??, 22? 2q- " SZg K?? " S?oB k ?z"a, W c? ?M1 f' , . C?2o SBE) ? ?. .?? 3 ? e° d .` ? tt ii ?I ?I s? i I?0,b" =7 0 .9_0 Q N9% ?" d1 2 . to .?i A , ,. .r1. i; . 1499°47' to"E I eI'D • 00 in EF ?T 93 ' y3v.a >?-rt 'Ml " ?4n f o / ? - - ,•, •••••t u? 24,o E?ST 93t,b V• .?/ i 0 EX?yt °13°' a N - - - 1 ? ! O 93°?.ti n?i ? ? ! ° Z d?? • _ ?Q . .?ti ? , ?. II J ? ?.o-. I ? ? ? ?- - _ _ E?--?- 9Jdg 3b,.o . . ?w}T 9318 d?- --%. ? ?? 934.o d h Q ? ? 140.97 ?' ., ? W 0 •V? NN ? o h .o y' 5 f ? yz DE4cR(PTtou L.oT t o i gf..oc.o- 9: , avEQ.%lieA- FAR.AW F?v..ST ADDCTtotsj DAIG.o-m couUTY, Iv?Io.t P1.lE4oTA I hereby certify that this survey was prepared by me or under my direct supervision and that Z am a duly Registered Land Surveyor under the laws of the State of Minnesota. Date: Fz?,.u.,, 0??/9?s ,t l-? /%•?-l ? Le oy H. Bohlen Registered Land Surveyor No. 10795 NDLRI{ O6AP.E 6A1= 3a' A4.L eeaaru" off uMEo o DEAOTE4 IRoN MPPIUIAEeIT va.n?.vr ' w 1116611FV I 1?111 teau w. 145m suow --<Appl6 VJley, MN 65120 EXTERIOR ENVELOPE AVERAGE "U" COMPl7TATI0N - OWNER SITE ADDRESS Tota1 Total Total Total Totdl Total Total CONTRACtOR ,?oRTH5T4R Su?I.DERS pATE 2-13-85 PNONE Determine working square footage of each. 1. Total exposed wall area ..... 18t48.1 la sq. ft. x •1l ? 2. Total roof/ceiling area ...... I o ZD sq, ft. x •o21i- ToYal expased wall area above floor = 15 37.10 a. b. c. d: e. f. 9- Determine "U" value of each wall segment. ' a• 13y ?y X liu,l , S = "7.2 h._ 3N_ x"u° 13 = 5.Z8 • c. B8 x liu„ , d• y8 X ,ou„ ,31p = ZS e._ I11.q2 xItU13 ; o lDb = 919 8 f• ? IDIe ?28 xllu" . 03ln =. 39.8Z. 9. IqO X "u" , 03 = ,Z h. - g ituli i._ 6"10?S1o X ??U" Io$Z = ,13?98 3 ......................? Total ......... ZD .Z If item #3 is the same as, or less than item #1, you have meC the intent of 56C 6006(c)2. ? .? . .. wa11 window area ........................... door area ................................. s]iding glass door area .................... fireplace wall area ........................ wall framing area (average 10%)...:........ net wall area above floor ................. rim joist area ............................ Total exposed foundation area = 1708 510 h. Tota1 foundation window area ..................... ?- i. Toat net foundation area abpve grade ............ l7 0?510 -.-?....? , Total exposed roof/ceiling area = ? b 20 Total gross roof/celling area = 10 ZO , j. Tota1 skylight area ........................ `--' k. Total roof/ceiling framing area ............ IOZ #O 1. Total net insulated roof/ceiling area....... q 1 g Determine "U" value for each roof/ceiling segment. j, x ltuit k. I o-c. Xllu„ ? ozq = 2, 9 S I. 9t8 x .,u„ ?03?= 7-2 ?95 a ................. l.4zR..........Totai = Z . If total of #4 is the same as, or less than fl2, you have met the intent of SBC 6006{c};. To utilized the total envelope system method, the values established 6y the sum of items #3 and N4 shall not be greater than the sum.of itens #1 and k2. 3. + 2. + 4. MATERIALS Therm. Resiatance "RIN Exterior Air ,1 Siding.Material -45 Sheathing 5 I 5 Inaulation iy Sheetrock _ .4 5 Interior Air Lalb Studs L„ 5q Rim. 1, AS . Conc. Blks. i , L , . CITY OF EAGAN UTILITIES DEPARTMENT INCIDENT REPORT - 4575 SOUTH HAY LAKE ROAD RESIDENT NAME: ANTHONY IRELAND DESCRIPTION OF INCIDENT: sEWER SERViCE BACKUP DATE OF REPORT: MARCH 17, 1994 SYNOPSIS: ThursBav, March 10 I received a call regarding a sewer backup at 4575 South Hay Lake Road and dispatched a crew to investigate. The sewer cleaning service said that they ran into problems at approximately 70 feet, which put them into our service stub. I contacted the resident and told him that I would be able to get a televising crew in on Tuesday morning March 15. The resident was accepting of this arrangement since the problem was infrequent. Tuesflav, March 15 Televising indicated severe deflection of approximately 20 feet of PVC pipe starting at 51 feet from the house. At 56 feet, there was a breech at 4 o'clock in the line. At 70 feet, there was a blockage and the camera was unable to continue. Since the house is for sale, Excavation was scheduled for the following day. Thursdav, March 17 Excavation commenced at 8:00am following Wednesday's street cutting and frost breaking. 20 feet of pipe was replaced, and the cause of the backups was directed to the PVC/cast iron connection at 71 feet from the house. The excavation and backfilling was completed at 1:00pm. Supexwisor•s commenta The 20 feet of PVC pipe was poorly backifilled in the original installation, causing deflection and dimpling from rocks. The connection of the PVC pipe to the cast iron riser was totally unacceptable, the contractor having modified the incorrect PVC fitting to make the angle required. The contractor cut a 90 deqree-bed fitting by hand cutting it to the desired angle and retrofitting it to the cast iron riser with a rubber "Fernco-type" coupling. This modification eliminates the hub on the fitting, as in this case, eventually allowing the pipe to slip out of the coupling and misalign, causing the blockage. (See attachad photos) Respectfully Submitted, Kelley M. Janes Utility Supervisor City of Eagan t ?, 2000 FIREPLACE PERMIT APPLICATION i ?'?O ?? ?? CITY OF EAGAN 3830 PILOT KNOB ROAD - 55122 651 681-4675 Date: /0 / -6O Description of Work: _ Construct new fireplace _Gas _Masonry _ Alterations to existing C? Install 2as inser[ only Install ras line onlv Other 7ob address: d - 2?" Lot: 10 Block: a Subdivision/P.I.D. Applicant (circle one only): Owner Contractor Permit Fee: 560.50 v VG?-d-C.J PROPERTY OWNER FIREPLACE INSTALLER Street GAS LINE INSTALLER Street City I hereby acknowledge that I have read this comply with all applicable State of Minne? Phone #: W_-_?/4&SM? Phone #: (area code) Zip: and state that the infornnation is conect and agree to ?City Ordinances. ' scll?/' !n -G)-!t -? ' ---=""___--- ? , State: City State: 02bi Zip: Company: P6one (area code) u Street CiTy !-3 state: /?? A) zip: SJ 33 / ComQany: ?,-YA? Last First OFFICE USE ONLY BUILDING PERMIT TYPE ? 16 Fireplace W ORK TYPE ? 31 New ? 33 Altemtions ? 39 Gas Line ? 41 Wood Stove ? 32 Addition ? 34 Repair ? 40 Gas Insert GENERALINFORMATION Census Code 434 SAC Code 01 REMARKS Chimney/flue must be inspected before wncealing. r_________-..______- For Office Use Permit City of EaRd~ Iti 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: r O Site Address: 0al Tenant: G."i~G~s 2 Suite RESIDENT/ OWNER Name: L%~ Phone: G/.? 716 /3 a 3 _A6~~ Address / City / Zip: S-7 -.Po .S"r-/a 3 Applicant is: Owner Contractor r F TYPE OF WORK Description of work: Construction Cost: /c2j arw Multi-Family Building: (Yes / No License CONTRACTOR Name: S D Address: City: State:" Zip: Phone: 9 S-( 6U/ Y'9 S^Z Contact Person: / COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW 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: NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that 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 4/2,t, (0 GJ R c-1-1 x Applicant's Printed Name Applicant's Signature Page 1 of 3 Use BLUE or BLACK Ink r - - - - - - - - - - - - - - - - - I For Office Use I Permit 5w City of Ea~dIl 26 Permit Fee: ~1 ` 3830 Pilot Knob Road I a~ l I Eagan MN 55122 Date Received: ! 1 a 13 Phone: (651) 675-5675 I I Fax: (651) 675-5694 I Staff: /118 _ I I I ~i 2013 ,RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: "..AC4 Unit I Name: Phone: 65-1 7 96 ~ ~6 G j Resident/ Owner Address/ City /Zip: Applicant is: Owner Contractor Type of Work Description of work: /~?itrrrr) Construction Cost: 500 Multi-Family Building: (Yes / No y W . t Company: Contact: 4LVet Contractor Address: l~ SU City:- State:2!?' Zip: -5 Phone: ` 5_7 r- 1~~ S License V,766 Lead Certificate If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING 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: I Sewer & Water Contractor: Phone: -m ~ R, _ m NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of ; the information may be classified as non-public if you provide specific reasons that would permit the City to I 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 completed within 180 days of permit issuance. x~ra 1 ~~1~h< x-~~2,.--- App'riicant s Printed Name App icanVs Signature Page 1 of 3 �v�� °�yo�� Use BLUE or BLACK Ink �---------- --� �/") � For OfFice Us � . �� i l'�fC� I t ]� ' ` � � Permit#: 1 l I ��t�� U��11 � � I �'"` ��i � Permit Fee: � � 3830 Pilot Knob Road � ,i� • s � r • I Eagan MN 55122 � � Phone:(651)675-5675 � Date Received: I Fax:(651)675-5694 I � � Staff: I ��J 2015 MECHANICAL PERMIT APPLICATION ❑ Please submit two(2)sets of plans with all commercial applications. Date: Site Address: �t �j��j � (--}� ,� �'�l �n(� Tenant: �l.L'� Suite#: s . � Name:_�l�Gtl�( `�' ��5 S�r0� 1`�"'�"l�� Y CS Phone: �.C��Z' / I lY"�q)� Address/City/Zip: _ G' � Name: Q t"f� r � "f' � License#:_ � � � U b txr '�j '�j Address: � � T City. State: � i � i �-1 �Zip:�,'�j��j Phone: �Oc�il� `1�� / - �� Contact: Email:�Scjl(�.'►ra�(� Qj�e,[ilf�l�(.l�'G�.f►r,�Cll�bi New �Replacement _Additional Alteration Demolition Description of work: � � � �� , . � �a „ RES/DENT/AL COMMERC/AL �Fumace _New Construction _Interior Improvement _Air Conditioner _Install Piping _Processed _Air Exchanger _Gas _Exterior HVAC Unit _Heat Pump _Under/Above ground Tank (_Install/_Remove) Other RES/DENTIAL FEES $60.00 Minimum Add or alteration to an existing unit(includes$5.00 State Surcharge) $100.00 Residentiai New(includes$5.00 State Surcharge) _$ U U TOTAL FEE COMMERCIAL FEES Contract Value$ x.01 $55.00 Permit Fee Minimum $70.00 Underground tank installation/removal =$ 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$1 million, please call for Surcharge _$ TOTAL FEE I hereby acknowledge that this information is complete and accurate;that the work will be in confortnance 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 X Applicant's Printed Name Applicant's Signature RECEI v D For Office Use s r e� ,� * MAYS 6 2418 :::t:e: 171 J /2 367 5-jaro V Date Received: dC, �f 0 3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810 r (651)675-5675 I TDD: (651)454-8535 I FAX: (651)675-5694 Staff: 47 (/ buildinginspectionsCa�citvofeagan.com L 2018 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: Unit#: L Name: TL7M �- T & -, A) Phone: 6 S i -c,/ca -IA/.1 Resident/ 4f 5 7 5 S P", l� LAAt �c1 Owner Address/City i Zip: v u a y Applicant is: Owner contractor Description of work: �-e., c._'. Type of Work p . Construction Cost: 6 vim` GJ Multi-Family BuildipgI No ) Company: 56 L S ref Contact: U 5 � - 1 0 55 _3 S 91I Contractor Address: I() !Y i-5 Ca,. ` • S 4 G A City: C./M .i5 State/MO/Zip: 5S C.14/ Phone: Email: A.1 i, `'or •� License#: t Lead Certificate#: - o ('vi ` (,2.r4 If the project is exempt from lead certification, please explain why: , c 6 COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING 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: I Phone: Mechanical Contractor: Phone: i i Sewer&Water Contractor: Phone: Fire Suppression Contractor: Phone: NOTE:Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-•ublic if ou •rovide •ecific reasons that would •ermit the Cl to conclude that the are trade secrets. You maysubscribe to receive an electronic notification from the City of proposed ordinances by e signing up for an email update on the City's website at www.citvofeagan.com/subscribe. Exterior work authorized by a building permit issued in accordance with the Minnesota State Bui •' , o•e mus •• completed within 180 days of permit issuance. CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection -inst underground utility dama. Call 48 hours before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.orq I hereby acknowledge that this information is complete and accurate; that the wor will be in conformance with the • :inances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a pe- it, and work is not to start wi -.ut a permit; that the work will be in accordance with the approves an in the case of work which requires a review-nd approval of plans. x- S-st.) kA rU,LI x Applicant's Printed Name Apr ' r Signature DO NOT WRITE BELOW THIS LINE 5/S7,1 /va- Z -4 /C) S SUB TYPES Foundation Fireplace Porch(3-Season) _ Exterior Alteration(Single Family) Single Family Garage Porch (4-Season) Exterior Alteration (Multi) Multi k.. Deck — Porch(Screen/Gazebo/Pergola) _ Miscellaneous 01 of_Plex Lower Level Pool Accessory Building WORK TYPES e.- New _ Interior Improvement _ Siding _ Demolish Building* Addition _ Move Building _ Reroof _ Demolish Interior Alteration _ Fire Repair _ Windows _ Demolish Foundation _ Replace _ Repair Egress Window Water Damage Retaining Wall *Demolition of entire building—give PCA handout to applicant DESCRIPTION Valuation 113, Z `�a . Occupancy i ~t MCES System Plan Review Code Edition M A 20 i. ' SAC Units (25% 100% Zoning J,-\ City Water Census Code Stories Booster Pump #of Units Square Feet PRV #of Buildings Length / I Fire Suppression Required Type of Construction V gj Width / y REQUIRED INSPECTIONS Footings (New Building) Meter Size: C=. Footings (Deck) Final/C.O. Required Footings (Addition) ?G Final/No C.O. Required Foundation Foundation Before Backfill HVAC_Gas Service Test Gas Line Air Test Roof:_Ice &Water _Final Pool:_Footings Air/Gas Tests _Final Framing 30 Minutes 1 Hour Drain Tile Fireplace: _Rough In Air Test _Final Siding:_Stucco Lath Stone Lath _Brick_EFIS Insulation Windows Sheathing Retaining Wall: _Footings_Backfill_Final Sheetrock Radon Control Fire Walls Fire Suppression: _Rough In_Final Braced Walls Erosion Control Shower Pan Other: Reviewed By: l `' ►'-" M; k h A , Building Inspector RESIDENTIAL FEES Base Fee -1) P c�`' 19 C) S9. �t Surcharge 5%/47?-- Z .> Sci . FY- Plan Reviewer J /S^ D v Sp • /17- MCES SAC City SAC Utility Connection Charge S&W Permit& Surcharge Treatment Plant Copies TOTAL Page 2 of 3 . _ . . ., . Lis"7c i(A-J i-dx-' a s 410 s- N. Or ‘ v ...(117-4'‘ . o# Ye' o '' . 0 ;. v 0 / A/rie ,,„,p 04, sz 4, 7 k 4, 4, 7 / /' /4' e 44 �. 1I i ,�� ->�I'.., )489047' tow E. I 3 , 0)36"° r 140.00 86% 930.0. toy �� . (IlkC' E 7 9311, it �s )7 93 24.0 0 / lb ,4u% 24.0 e,4hS' 930a Wat 1,1 i 111 4_0 a , 9 3,.E , �h�4 % o Lt! O r lip it,... oQ ti �; , d • r4 6° 3d ii,a ‘2.0 2 0o � q 'Z's j m i 11 ,� 0 70 0 ,� �0 meq - � �� c — ,,. 'A N +� r .,-r y�.o 1_....... 7,_310,�7. \ I'I34 ! y..rb I "i` ,0 d f- 4 el J In Il sr -tik (10$ 1 19)( 1!,,, ,),E 41' '• M• a Ew l., '� `� (,,_1 6.02! ,0 � 5 ii I al)) 1 ., 1 OE4C RIPTt°)4 hlomor k Lor to , 5LoC.oc. % , #4ALE Ins'3D' D 4E&tAI LL F &M ALL 11EARI1tGS OI UME0 G oLosn. A 0 D mots 1 o DEADTE$ Mai MPNUMEbtT Dkg.0 TA. CoUW `'r M10•1114E4cork I hereby certify that this survey was prepared by me or under my direct supervision and that I am a duly Registered Land Surveyor under the laws of the State of Minnesota. Date: &L11 o f c s 1,,e( .---�.____ Le oy H . Bohlen Registered Land Surveyor No. 10795 PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA165532 Date Issued:11/05/2020 Permit Category:ePermit Site Address: 4575 Hay Lake Rd S Lot:10 Block: 2 Addition: Overhill Farm 1st PID:10-56150-02-100 Use: Description: Sub Type:Residential Work Type:Replace Description:Water Softener Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size Comments:Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Building Code). Please call Building Inspections at (651) 675-5675 to schedule a final inspection. Fee Summary:PL - Permit Fee (WS &/or WH)$59.00 0801.4087 Surcharge-Fixed $1.00 9001.2195 $60.00 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Ryan & Jessica M Atkins 4575 Haylake Rd S Saint Paul MN 55123 (612) 716-1323 Milbert Company (culligan) 1801 50th St E Inver Grove Heights MN 55077 (651) 451-2241 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Mechanical Permit Number:EA172435 Date Issued:09/30/2021 Permit Category:ePermit Site Address: 4575 Hay Lake Rd S Lot:10 Block: 2 Addition: Overhill Farm 1st PID:10-56150-02-100 Use: Description: Sub Type:Residential Work Type:Replace Description:Air Conditioner Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Pete DeGrood at (507) 210-0754. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088 Surcharge-Fixed $1.00 9001.2195 $60.00 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Ryan & Jessica M Atkins 4575 Haylake Rd S Saint Paul MN 55123 (612) 716-1323 One Hour Heating & Air 11825 Point Douglas Rd S Hastings MN 55033 (651) 437-4177 Applicant/Permitee: Signature Issued By: Signature