4715 Hazeltine Lane
Use BLUE or BLACK Ink
%
IC
alt of E, Permit ~ ,
(9s
Permit Fee:
~
3830 Pilot Knob Road
Eagan MN 55122 j Date Received:
Phone: (651) 675-5675 i I
Fax: (651) 675-5694 1 Staff: I
I ,
V
2011 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address:
401e;, ~0f~F471-,0/c LA A455- unit
Narne: &WC CR~Lsc Phone tote - V49
.
RESIDENT /
OWNER Address i City / Zip: /
Caf~!✓~
Applicant is: Owner L Contractor
TYPE OF WORK Description of work: 'RCPt f4L,4a
Construction Cost: "FlIe /Y-r cx~ Multi-Family Building: (Yes / No
Company: 17 ~f &OqM L7-1 >460 Contact: St&LIE sr*eo y/Z ,N t;
CONTRACTOR Address: J_ /`P®~Bg~wJ~1.~~ City:
State: hA Zip: /079 Phone:
License Lead Certificate AMT- 'Z
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:
Sewer & Water Contractor: Phone:
NOTE :Plank end suppo~rtlr~g o10:u~lsnt~ 4t #4/~' o,;b publJc l ot'maoc RQr#lons:of
the lnfonnatlon ~ ~ s_ f J Mill 00Ath~ ^`ft
'/(~Ry"to
:>,ti• .a,;f~.R~i "'bh .~~NYM.'Tn.r'~' nV 8 +1 ,~t
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 464-0002 for protection against underground utility damage.
Call 48 hours before you intend to dig to receive locates of underground utilities, mmrv ctooherstateonecaii org
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; Mat I understand this is not a permit, out 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.
A52=:~
x
d x
x5rA
pplicant's Printed ame Applicant's Signature
Page 1 of 3
PERMIT
City of Eagan Permit Tppe: Building
Eagan. Permit Number: EA096767
Date Issued: 11/01/2010
OR Permit Categorp: ePermit
41~ it~ of E3
E
Site Address: 4715 Hazeltine Lane
Lot: 3 Block: I Addition: Fairway Hills 3rd
PID:10-25602-030-01
Use:
Description:
Sub Type: e-Windows iDoors Construction Type:
Work Type: Windows Doors-New ; Replacement
Description: House
Census Code: 434- Occupancy-:
Zonin,:
Square Feet: 0
Comments: Improvements to the home require smoke detectors in all bedrooms. If altering window openin,s, call for framing
inspection. Call for final inspection after installation.
Carbon monoxide detectors are required by law in ALL single family homes.
Fee Summary: BL - Base Fee S3K $88.50 0801.4085
Valuation: 6.211.00 Surcharge - Based on Valuation S3K $1.50 9001.2195
Total: $90.00
Contractor: - Applicant - Owner:
Pella Windows & Doors Turnkey Sales Gregory- S Carlson
1300 25th Ave N =100 471 Hazeltine Lane
Ply-mouth MN 55447 Eagan MN 55123
(763) 74-1400
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 Cite of Eagan Ordinances.
ApplicantiPermitee: Signature Issued Bv: Signature
CITY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
SPECTIO
RECORD
PERMIT TYPE:
Permit Number:
Date Issued:
f<ti .r i ta r ai
0,11 s1q
@4 l1 v % y6
SITE ADDRESS: 0 •'''" '' "''A 4
I r, I : c tcl,ii 11,
Ni i nNi:
I f A! t•:t.IpY 1411 I:!+!r
PERMIT SUBTYPE:
1,,, . , . , . , .> V
,I i,ti'i i r
' I f tMF1i
APPLICANT:
1 ??( c? 1 t, 1? ?"? - fC1 Il (
TYPE OF WORK:
i {:'AM 1 Nl.
; RF MAKV S s A";i F'ARA 1 1 F'I I:M t i t`, 11! 011 1 fcF 1t t??1i NNr i 1 1= c i it 1 i AI !-lijlrp
I. k r? ??
?IP I I I Il,,
Permit No. Permit Holder Date Telephone #
ELEGTRIC O'
PLUMBING ?
HVAC
Inspectlon Date Insp. Comments
FOOTINGS
FOUND
!
FRAMING
z?o
?J
ROOFING
ROUGH
PLUMBING
PLBG
AtR TEST
ROUGH
HEATING
GAS SVC
TEST
iNSUL
GYP BOARD •
FIREPLACE
FIREPLACE
AIR TEST
FINAL PLBG
F1NAL HTG
ORSAT
TEST
BLOG FINAL &
BSMT R.I.
BSMT FINAL
DECK FfG
DF_CK F1NAL
CITY OF EQGAN
3830 Pilot Knob Rd.
Eagan, MN 55122-1897
DATE ; `I. =; , 1991
?
OFFICE USE ONLY
METER # PERMIT DATE
CHIP # 69,07 3 Q'2 F PERMIT # 1? 1 15
METER SIZE h?g 5 B.P. RECEIPT # C 1432?'_
ISSUE DATE " Z3" Ft B.P. RECEIPT DATE 07 Ci3 91
- PRV -L- BOOSTER PUMP
SITE ADDRESS r. % t. ='' =.:i: LAi .
LOT-BLOCK I SEC/SUB T'AIR'+rE,i 14i1.I.,: 3JRJ
j APPLICANT:
? ADDRESS:_
CITY, STATE ZIP
PHONE:
PLUMBER; R C PLL1tt13IPiG
ADDRESS: 5910 CI'E ;Tt::?. AV1;
CITY, STATE NORTtiPZELD t1T! Zip 55:;57
PHONE: 461-2006
OWNER: SONS CONSTRUCTIOiv f'C!
ADDRESS: 4600 k'AII'.•JAY ItILLS I+R
CITY, STATE FAGAN ;% Zlp 551 21 3
PERMIT REQUESTED
X SEWER ? WATER _ TAPS
COMM/IND ? RESIDENTIAL
x NEW
EXISTING
Lawn Sprinkler Meters are to be Installed
Ahead of Domestic Meters on Water Line.
Credit WILL NOT be given for Deduct Meters.
COMPLY WITH CITY OF
TURE WHEN ME1"ER ISSUED
WORKING DAYS ?OR PROCESSING. CALL 454-5220 FOR INSPECTIONS. FOR STORM
TACT ENGINEERING DEPT.
CITY OF EAGAN
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
PHONE: 454-8100
BUILDING PERMIT Aeceipt #
To be used tor sr DYG/GAII Est Value $94000 Dat •1I1I•
. e --
?Lw 19 3 37
Site Address 4715 HAZEL?I1QR LM
Lot 3 BIoCk _I SeCJSub. FAIBYAY AII.LS
; Parcel No. RD
occuPancy R-3 OFFICE USE ONLY
M-1 FEES
W
Name ?? COl?3TR1JCTI0?1 Zoning
(Actual) Const ?
V-?
Bld
Permit
613?00
o AddfBSS 4? 1?AI1tIJAY ?iILIS (AUoWania) ? g. ?
47
City ?N Phone 432-5333 +r of stories
400 Surchar
9e
Pl
R
i ?
"8+?
Q
p $?
Name Length
th
De ?
43 an
ev
ew
S
C ?/? ?
Z p A
, City ._!?p[,1p?
c.) a AddfeSS S.F. Total _ 6?
¢
City Phone
S.F. Footprints
_ ??
s,ac, nncwcc
60•oo
?.
? W
W Name On Site Sewage
On Site well _ Water Conn 95.00
?
'
W
? ;
Address
MWCC System
? water nneter
?.
¢ W
4
City Phone
Ciry water
?
_
Acct. Deposit 110000
oo
?
^?+ 1n hereby acknowlege that I have read this application and state that the
? iformation is correct and agree to comply with all applicable State of
? Minnesota Statutes and City ot Eagan Ordina
9res. PRV Required
Booster Pump x .
S/W Permit
S/yy Surcharge ?sQ
Treatment PI 276•00
Signature of Permitee ApPROYAIS
Road Unit
370.00
A Building Permit is issued to: ?C=Tffl=10N
, on the express condition that all work shall be done in accordance wiih ail
applicable State of Minnesota Statutes and City of Eagan Ordinances.
Building Ofticial Pia^^ef
Council
gidg, pN.
Variance -
?
_
- Park Ded.
Copies
TOTAL
,264 .30
I
Permk No. PermR Holde? Date Tebphone #
WAiER
SEWER
PItUMBING
H.V.A.C.
ELECTRIC
h0d
Mspsction Date 1 Comments
Footings I
Foundation 2
Framing
Roofing
Rough Plbg. 7/ ? ?Y
Rough Htg. ..
Isul. K ?
FirePlace 9 ?
Fin81 Htg.
Orstat Test
Final Plbg. Plbg.Inspeclor-No6tyPlumber
Const. Meter
EngrJPlan
81dg. Final 7?4 !Z LJ
Dedc Ftg.
Dedc Rnal
Wall
Pr. Disp.
. ?+
lb -••• '?
(Itrti#ira#t uf Mrru?anxy
titp of (tagan
iorpwftrnt n# Nuilaatg imwrrtioa
M Cenffuate fssued pursuaxt to Me requirernents ojSeclion 306 of 1he Unijorns Building
Cade catil!'M8 thal at the &e of lssuanae rhis strucwne w= tn conrpliaxce wilh tJie various
ordinmrcrs ojrhe Cr1y negula&g building cnxs&ucfion or rrse For tlre following:
uk a.umcwoo. `'? DWG/gar st. Pa uo. 19367
O-wxr TY" R37M 1 Z,;,g nidr? R? TM. c?? VN
owm d saft SONS ORN5TRICTIUN Addtm 4600 FAIIddAY fuIIIS, EAGAN
??? 4715 HA7FZ,TIM LANE L3, B!, FAIRWAY HIIIS 3!2D
i
7/16/c)2
POST IN A CONSPICUOUS PLACE
MOUSE HEATING TEST RECORD
/ "A
,
41 F
M
ADDRE55 61p,
• APT._-FIOOR
1 -CITY_,
_p"UBURB
1
OCGUPANT Curlso OWNER ,
HEAT LOSS DATE HTG. I NST. 11-w -yw ,
SOLD BY fw? i 4 -L?l G_ . INSTALLED BY --?'• '? L,
EI•crrieal Wwk 8r 51- Go• lin• Br ?i. i`
TYPE Of HEAT GA _ FA _ MW ?STEAM __. SPACE HTR. _UNIT MTR. -OTNER
G?S DESIGN CONVERSION
?IAKE ? A MAKE OP BURMER
Moe.i Gx Pr mos.l _
Swiol MpY. g711 Q 1
INPUT 10i0A4 _-MAKE QF FUQUI['F ?
Mod.l _
CONTROLS
THERMOSTAT H.nt Plup V•nt Si:.
Y
limil .___?P1'Q
rr KIND OF LINER SIZE NONE
, Droh Moed -? VRepulamr
7
?p
Limit $eMiny 1 ?V" ? ._ Fi11HS Siso ?? - NV ?r
Fan $ettin9 O+lmMy LoeaNen (nsid? Ou1side
?n M M
Pitee Typo atrudion
Chi
e
C
_ mn
y
on
Pilar Mob _ ??O:?Y •
Piler Modd _
Smoke Bomb . ?? /
Wiriny U°
Pilot Timin9 -=;0 ! 7,?C" Drah ? Tesf Top
L.W. Cw Ofl Dew Preasuro Liyht
ny Imt.
l
Porcen1 C0 Daf. TesIod ?
(
2
Input CFM.. 70
- Pere?ne OZ (?Lr . Compeny Teati g
?e? IIIC°
Sbck Temp. ''? Pxe??f CO d Name, of T*siN
BUILDING PERMIT
To be used for SF DWG/GAR
Est
Site Address 4715 HAZELTINE i N
Lot 3 Block 1 Sec/Sub. FAIRWAY H7r T S
Parcel No. 3RD
w Name SONS CONSTRUCTION
? Address 4600 FAIRWAY HILLS
° City EAGAN Phone 452-5355
F Name S?
i
a
0 Address
,
? City Phone
?w Name
t?W
7c ;
Address
<W Ciry Phone
I hereby acknowlege thal I have read Ihis application and stale Ihat the
inlormation is correct and agree t comply with all applicable State of
Minnesola Slatutes and City ot E?na es.
Signature of Permitee ?( ??n
A Building Permif is issued lo: SON4 CONSTRIICTION
on Ihe express wntlilion that all work shall be done in accordance with all
applicable State of Minneso"la {S?tatut?es antl City of Eagan Ordinances.
BuiltlingOfficial ??(?,?q.vllAlTl?
i `
CITY OF EAGAN
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
PHONE: 454-8700
94,000
Receipt #
Id° 19367
OFFICE USE ONLY
Occupancy R- 3 -M-1 FEES
Zoning R-1
. (Aduaq Const Bldg. Permit 613.00
(Alloweble) ?N Surcharge 47.00
Y otStories
length 40' PlanReview 398.00
Dapih 43 ? SAq City 1 00 - 0
0
S.P.Tolal - SAC,MCWCC 650.00
S.F. Footprint5 -
on site sewage _ water conn 660.00
OnSiteWell WaterMater 95.00
MWCC System X
X
Acct. Deposit
3?. ??
City Waler
PRV Requiretl - S/W Permit 30.00
Booster Pump ?- S/W Surcharqe _ SO
TreatmeniPl 9 7 r+_nn
APPROVALS qoad Unit 'A 70 _ nn
Plenner - park D80.
Council
BIAg.Off. _ CoPies
Variance - TOTAL 3. 269. ??
Address:'4715 HAZELTINE LANE Lot g Blk I Sec/Sub FAIRWAY HILS.S 3RD
These items were/were not complete at the time of the final inspection.
p Yes No TnspPrrnr*
Final grade (6" from siding)
Petmanent steps - garage ?
Permanent stepa - main entry i/
Permanent driveway ?
Permanent gas
Sod/seeded grass V
Trail/curb damage l?
Porch j?
Sasement finish ?
Deck ?
Please verify vith the builder the removal of roof test aaps from the plvmbing
system and the shut-off of water supply to the outside lawn faucet bafota
freeze potential exists. ?
??..?.
White - City copy Yellow - Resident copy Pink.- Contractor copy
II I II ?II 1111111111 RE?U soTa EST FOR ELECTRICAL INSPECTION d3?*; ?
Minne State Board of Electricity
1821 University Ave., Rm. 42 , St. Paul, MN 55104 I- ??
?k 0 2 7 3 2 3 4 5 *- Phone (612) sa2-0eoo,?/g 9(r
Home up e: Apt. Bldg. Other: New Addn
Commerciol Indusfrial Fartn Remod Re air
Air Cond. Hig. Equip. Wafer Hfr. Load Mgmt. Other.
D er Ran e Elec. Heof Tem . Service
"R' above the work covered by this request Enter remorks in this space ond on ihe back oi the white copy only.
Calcufafe Inspeciion Fee - 7his Inspection Requesf will not be accepted without fhe mrrect fee:
Other Fee # $ervice Erdmnce Size Fee aF Circuits/Feeders F.
Mobile Home Park Sfoll 0 to 200 Amps 0 to 100 Amps
Sheet Ltg./Troffic Sig. Above 20D Amps Above 100 Amps
Tronsformer/Generofor INSPECTOR'S USE ONLY
1 TAL
7
$ign/Oufline Lig. Xfmr. ao
O •
Alarm/Remote Con}rol f
Swimming Pool
lednml insl hercin on tha dvles s ted
nif thm I i
s Po
I h
reb
Irrigafion Boom e
ce
n
e e
Rough-In Da1e41
Special Inspedion
Invesiigotive Fee Finol ?%i Dax
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
2 1 J- 2 3 4 0 ?? E USE ONLY This request void 1 B monlhs hom validoMan dok pnnled in ihiz hox
.55?649
PLEASE PRINT OR PE
Request Dare ? -k n
???
? Roughin inspxlion quired2 N.
(Yaa mus? call Ihe inspedor wfim ready) In:petlion OMar Than Ro.gh-Im 0 Reody Now IR'Will Call
Oore 0.eody:
I, C] licensed confracfor Gyl-?-rer hereby request inspection of the above electrical work at:
Job Pddrtss ?Streel, Box, or Rouk No.? Ciry 2ip Code
-
?s ? '
Z
Secfion No. Township Name ar No. Range No. Firc No. County
DA?o
Oaupant Phone No. ?
Power Suppiler Pddrcss
Elednml Conwcror (Company Name) Gonhmnar timnse No. Mmter Lic No. (Planf Eletl. Only)
Mailing Pddmss (Commcbr or Owner Perfarming InnMllation)
Auihod 5ignanm (Connoeor o er P orming Insmllanon) Phone No.
EB-OWOINK 6/95 / STIITEBOMUCOPY-SEEINSTRUCiIONSONWCKOF9ELLOWCOPY
O 70 5??
" 3 `?
Request aie Fire No. Ro Inspection
qeq i'+
?eatly Now GWIII Notiry Inspedor
>
wh
R
d
? as ? en
ea
y
I icensed contrector ? owner hereby request inspection of above electrical work at:
Job qtldress ($lreal. Boxy ?r Route No.t /
i `f /? /7'AL
/ 'T ,(? !
1 Ciry
6
e
/ n t 1 G 4 A rl
Senion No. Township Name or No. Rarge No. Coun Q /_o 44
%
OccupentlPRIMt
Gve ? a ? lS o Pppne No.
?" 7f
PowerSUpd'
of
4- AGdre
,
ElecCincal onlr pa
ecto ICOmny?Jame)/ ?+
?
/
1
?
ConVaqaS License No.
3
??
C Cc
vt Ca / 7 ec? T/?S
a
vIC d-2G
C
Mailing Aatlress IConVactor or Owner Meking stallatqni
Aum ed ignaWrelCon cmr?0
_ PnoneNUmber
?, - (b 1- Cor
MINNESOTR STpTE BOAND OF ELECTRICITY THIS INSPECTION REOUEST WILL NOT
Griggs-MlCway BIEp. - floom 5173 BE AGCEPTED BV THE STATE BOAqD
1821 Unlvwsity Ave., SL Paul. MN 55100 UNLESS PHOPER INSPECTION FEE IS _
Ppone (612) 662-0800 ENCLOSED.
/a /? f,2 REQUEST FOR ELECTRICAL INSPECTION
K„ 17 311 , See instmctions 1Dr completing t0is brm on beck ot yellow copy.
. "X" Below Work Covered by This Request
ar"" ee.00001-0e
y.^?! /O 7D 40
9, ?yg
ew Add R p. Typeoi8uilding AppliancesWiretl EquipmentWiretl
Home Range Temporary Service
Duplex Water Heater Eleciric Heating
Apt. Building Dryer Other.(Specity)
Comm./Industrial Furnace
Farm Air Contlitioner
01?er ?syxify) Gontmctor5 Re arks:
Compute Inspection Fee Below: "//e wA/C
# Other Fee # ServiceEmranceSize Fee X Circuhs/Feetlers Fee
Swimminq Pool 0 to 200 Amps ? 0 to 100 Amps Y.o
Transiormers Above 200 _ Amps Above 100 _ Amps
ns
Si inspectors use ony: TOT(?
9
trri ation eooms ? ?
Special InspeC[ion
Alarm/Communication THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT .
Other Fee COMPLETED WITHIN 18 MONTHS.
I, the Electrical Inspector, hereby
f Rouqh-in Date
certi
y that the above inspection has
been made. F;,,ei
? a
oa?
OFFICE USE ONLY
This requast voiE 18 monMS bom
;'
2005 RESIDENTIAL BUILDING PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
,? 7a.=
New ConsWcfion Reauiremenis Remodelhieoair Reauiremenb Offce:UseAnlv
3 2gistered site surveys showing sq. ft. oF l06 sq. fl. of house; and all roofed areas 2 wpies of plan CeR of Survey Recd _ Y _ N
(20% maximum lot coverege allowed) 1 set of Energy Calculations for healed additions Tree Pres Plaa Recd Y _ N
2 copies o( plan showing beam 8 window s¢es; poured found design, etc. 7 site survey for addrtwns 8 decks 7ree Pres Required _ Y _ N
lsetofEnergyCalculaGons Addilion-IrMicateifonsdesepUCSystem O"ReSepticSystem _Y _N
3 copies of Tree Preservatbn Plan if lot plaked aRer 711N3
Rim Joist Delail Optbns selectbn sheet (buildings with 3 or less uniGC)
Date I I /?/ dS O?
Construction Cost ?,0W
Site Address 5 IJA -Gl?'1 YYC sD.r...¢.. Uniuste #
Description of Work ?FlrtQk0. C-e. GJ W`?(?pC.uS W?i(v Xi5'71a!'.? 09-fYN;Y.YJ•
Multi-Family Bldg _ Y_ N Fireplace(s) _ 0 _ 1 _ 2
Property Owner C G.0S O Yt ayy., Telephone #((05" I)? 8lp -?-4 (0 3
PELLA WINDOWS & DOORS
Contractor 15300-25TH AVE. N. STE. 4100
nddress pLYMOUTH, MN 55447 City
State 763-745-1400 telephone # ( )
LICENSE420165884
COMPLETE THIS AREA ONLY IF
A NEW BUI
- Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672
Enefgy Code Category • Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet
(J submission type) Submiried Submitted
• Energy Envelope Calculations Submitted
Have you previously constructed a building in Eagan with a similar planB
fee applies.
Licensed Plumber
Mechanical Contractor
Sewer/Water Contractor
Telephone # (
Telephone # (
Telephone # (
N If so, 25% plan review
I hereby apply for a Residential Building Permit and acknowledge that the information is complete and accurate;
that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN
Statutes; I understand this is not a permit, but only an application for a permit, and work is_no1 to start without a
permit; that the work will be in accordance with the approved plan in the case of work wfiich'requires a?- r€u icwFa_jnd
approval of plans. I, III 'II
I?v1AY 13 2005 U
A0.C0? Sor1
Applicant's Printed Name App icanYs Signature IE;;, _
OFFICE USE ONLY
Sub Types
? 01 Foundation ? 07 05-plex O 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? 08 08-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - MuIG
? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF
? 04 02-plex ? 10 OS-plex ? 18 Deck ? 23 Porch (screen/gazebo) ? 36 Multi Misc.
? 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage
? 06 04-pIOx ? 12 12-plex Plbg_Y or_ N ? 25 Miscellaneous
Work Types
? 31 New ? 35 Int Improvement O 38 Demolish Interior ? 44 Siding
? 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair
? 33 Alteration ? 37 Demolish Building' ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement `DemollUon (Entire Bldg) - Give PCA handout to applicant
Valuation Occupancy MCES System
Census Code Zoning City Water
SAC Units Stories Booster Pump
# of Units Sq. Ft. PRV
# of Bldgs Length Fire Sprinklered
Type of Const Width
_ Footings (new bldg)
_ Footings(deck)
_ Footings (addition)
Foundation
Drain Tile
Roof Ice & Water Final
_ Framing
_ Fireplace _ R.I. _ Air Test _ Final
Insulation
Approved By:
Base Fee
Surcharge
Plan Review
MC/ES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
License Search
Copies
Other
Total
REQUIRED INSPECTIONS
Final/C.O.
FinaVNo C.O.
_ Plumbing
HVAC
Other
Pool _ Ftgs _ Air/Gas Tests Final
_ Siding _ Stucco _ Stone _ Brick
W indows
Retaining Wall
Building Inspector
PeF1a Wiadows & Doors - Twin Cities, Inc.
?
?o
Wd9E:1 '.g •unp amil paniaaaa
1530015TH AVE. N. STB. #lOQ
PLYMQLJTIi, MN 55447
76sn4s-iaoo
PTATS 1-800-462-5359
FAx 763f145-1401
7une 8, 2001
Ciry of Sagan
3836 Pilot Knob Road
Eagan, MN 55122
I3ear Jan:
Elder Jones Corporation is authorized to pull huilding permits for Pella Windows &
Doors -'Itvin Ciries, Inc. Please allow their representative to provide fhat service for us
in Eagan. This authorization shall be valid until such time as the dzvision manager
expressly revokes it, in writing to'the City.
I request thai this authorizadon be accepted expeditiously, so as to not delay the
processing of our building permits any further. Please call me if there are any questions,
I canbe contaeted at 763-745-1432.
Your ircunediate attention to this matter is appreciated.
' cerely, ?
Y ``' ? ?11NEF1E ?
Hryan . May.
Replacement Saies Manager
?yaorem?rqnFttwa4a9b?G06
cc: Kaza-E1dcr7ones
Denna ICzafty - ReplacetnenY Sales Process Coordinator ?-?
Wiadows, I}oors,
& Skylights
7nn Ffi
carrrn Urur TIA.7 aixr exi 7ru vw.r JT:CT rus Tnionion
RESIDENTIAL
BUILDING PERMIT APPLICATION
CITY OF EACAN
3830 PILOT KNOB RD, EAGAN MN 55122
651-681-4675
New Construction Reauirements
• 3 r=gisterea srte surveys showing sq. fl. ol lol, sq. ft. of house; and all roofed areas
(20 o maximum Int coverage allowed)
•? cccies of plan showing Oeam 3 windcw sizes; poured found desfgn, etc.)
• 1 set of Eneqy Calculations
• 7 copies of T!ee Preservation Plan if lot platted after 711193
• Rim Joist Oelad ODtions selecGon sheet (61dgs with 3 oi less units)
DATE q,- 3 - oa
J?
RemodellReoair Reauiraments
• 2 co0ies o( plan
. 1 set of Energy Calculatians for heated addiUons
• 1 site survey tor exterior additions 8 decks
• Indicale if home served 6y sep[ic system for addifions
?
VALUATION
SITE ADDRESS 41 'S ' ` 4 '? ' ? V 'c?,"? MULTI-FAMILY BLDG Y N
TYPE OF WORK__ JA - L° c--- FIREPLACE(S) _ 0_ 1_ 2
APPLICANT
STREET ADDREJ,S ?R -lar 0-?? "aaD 1 CI?STA? z?5 ) a I
TELEPHONE??o51 19a'a'CELL PHONE # '-" F,?#to??t-?a. y 6a3
PROPERTYOWNER (U.2SQGI TELEPHO IE#(oS1 l00-
---------------------?' --------------------------------------------------------
COMPLETE THIS SECTION FOR "NEW^ RESIDENTIAL BUILDINGS ONLY
Energy Code Category _ M IV NE50'1':\ RCLES 7670 C:\TI:GONY ! MI\NL• SO'l':\ Ri'L1:5 7672
(J submission rype) . Residential Ventllatlon Cate9ory 1 Worksheet Submitted • New Energy Code Worksheet Submittetl
• Energy Envelope Calculations Submitted
Plumbing Contractor:
Plumbing systcm includes:
Mechanical Conhactor:
Ndcch:uiic.il s%stcm includcs
Sewer/Water Conhactor:
Air Condiuoning
-- Hcat Rccovcn 5ystcm
Fee: $90.00
? o T'T ??? °
?
# SEP 0 3 2002
D
e
... - ----....----
------------------------------------°---------------------------ngimz!
I hereby acknowledge fhat I have read this application,
statog e to comply
with oll applicable State of Minnesota Statufes and City of E Signature of Appli
'---- - ------------------------------------------- ---___..---------------------- ------------- -°---_ .-°----------•----??..
OFFICE USE ONLY
Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _
Updaled 4l02
_ Water SoFtencr
Water Heater _
No. of Baths
_ Phone ik
Laim Spnnl:ler
No. of R.I. Baths
OFFICE USE ONLY
? Ot Foundation ? 07 OS-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? 08 06-plex ? 16 fireplace ? 21 Porch (3-sea.) ? 31 Ext. AIt - Multi
? 03 01 of _ plex p 09 07-plex ? 17 Garage ? 22 Porch/Addn.(4-sea.) ? 33 Eut. Alt- SF
? 04 02-plex ? 70 08-plex ? 18 Deck ? 23 Parch (screened) ? 36 Multi
? OS 03-plex ? 11 tp-plex ? 19 Lower Level ? 24 Storm Damage
? 06 04-plex ? 12 12.plex Plbg_Y or _ N ? 25 Miscellaneous
? 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 (Bldg)' ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement •Demolition (Entlre Bldg anly) - Give PCA handout to applicant
Valuation Occupancy MClES 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) FinaVC.O.
_ Footings (deck) FinaLNo C.O.
_ Footings (addition) _ Plumbing
Foundadon INAC
Drain Tile Other
Roof _ Icz & Water _ F inal _ Pool _ Ftgs _ AiriGas Tzsts _ Final
_ Framing _ Siding Smcco Stone
_ Fireplace _ R.I. _ Air rest _ Final _ Windows (new/replacement)
_ Insutation _ Retaining Wall
Approved By
Base Fee
Surcharge
Plan Review
MC/ES SAC
Ciry SAC
Water Supply & Storage
S8W Permit 8 Surcharge
Treatment Plant
Plumbing Permit
Mechanical Permit
License Search
Copies
Other
Total
Building Inspector
Sa c RESIDENTIAL
BUILDINC PERMIT APPLICATION
CITY OF EAGAN
3830 PILOT KNOB RD, EAGAN MN 55122
651-681-4675
New Canatrudion Renuiramanta
• J reg¢tered site surveys slrowing sq. fl. of lot, sq. ft. of house; and all roo(ed areas
120% maximum bl coverage allaxed)
• 2 copies of plan shoxring Ceam 8 window saes: poured found design, etc.)
• 1 set of Energy Calculations
• 3 capies of Tree Preservatian Plan i( lot platted after 71193
• Rim Joist Detail Options selection sheet (61dgs with 3 or less units)
DATE 1S-A?Oa
aIs -?S
RemodaVReoair Reauirements
. 2 co0iN of Olan
. 7 set of Energy Calculauons for heated additions
• 1 site survey `or extenor additions 8 tlecks
. Intlicare if home served hy septic system for aCditions
VALUAiION 11. '5103 ?z
?
SITE ADDRESS MULTI-FAMILY BLDG _Y fC?q
_ . ... . . ,
TYPE OF
APPLICANT
STREET ADDRESS
TELEPHONE#ISA3,_+?LS•ILUX') CELI
Pella Windows & Doors
15300-25th Ave. N. Ste. #100
Plymouth, MN 55447
fiREPLACE(5) _ 0 _ 1 _ 2
_STATE _ ZIP
i#
PROPERTYOWNER C,fM?Spt?1 Z 1•1eASAK0rr,n TELEPHONE#IaSl+to$(c•JI(0A
--------------------------------------------------------°-------------------------------------
COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY
Energy Code Category _ MIYVLSOTA RCLES 7670 CATEGORI' I MI:YNESO'CA RULL•'S 7672
(d submission type) . Residential Ventilation Category 1 Worksheet Submitted • New Energy Code Worksheet Submitted
• Energy Envelope Calculations Submitted
Plumbing Contractor:
Plumbing system includes:
Mechanical Conhactor.
Mcc}?lnical sys[cm includes:
Sewer/Water Confractor:
-- Air Conditioniu;
Hcat Rccoven Systcm
Phone #
Fee: $90.00
s7o.oo
---------------------•-----.......-------------------------•----------°°---..•,.-_...-•-°-------------....--------•-----
I hereby acknowledge that I have read this application, state that the in rmation is correct, and agree to comply
with all applicable State of Minnesota Statutes and City of Eagan Or ' ances.
SlgnatureofAppl(canf „?/?`/? Denjs,
OFFICE USE OvLY
Water Softener
Water Heater
No. of Baths
_ Phone #
L1rni Sprinkler
No. of R.I. Baths
,;; AU6 2 ? 2?02
Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _
Updated 4J02
. ,
OFFICE USE ONLY
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? OS 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) O 31 Ext. AIf - Multi
? 03 01 of _ piex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 E#. Alt - SF
0 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (screened) ? 36 Multi
? OS 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage
? 06 04-plex ? 12 12-plex Ping_Y or _ N ? 25 Miscellaneous
? 31 New ? 35 Int Improvement ? 38 Demoiish (Interior) ? 44 Siding
? 32 Addition • ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair
? 33 Alteration Ci37 Demolish (Bldg)' ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement `Demolitlon (Entire Bldg only) - Give PCA handout to applicant
Valuation Occupancy
r . MC/ES System
A 1
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 Width
. . ," . REQUIRED INSPECTIONS -
_ Footings(new bldg) _ FinaVC.O.
_ Footings(deck) _ FinaWo C.O.
_ Footings (addirion) _ Plumbing
Foundation HVAC
Drain Tile Other
Roof _ Ice & Warer _ Final _ Pool _ Ftgs _ AiriGas Tests _ Final
_ Framing _ Siding Stucco S[one
_ Fireplace _ R.I. _ Air Test _ Final _ Windows (new/repiacement)
_ Insula[ion _ Retaining Wall
Approved By
Base Fee
Surcharge
Plan Review
MClES SAC
City SAC
Water Supply & Storage
5&W Permit & Surcharge
Treatment Plant
Plumbing Permit
Mechanical Permit
License Search
Copies
Other
Total
Building Inspector
RESIDENTIAL
BUILDING PERMIT APPLICATION
CITY OF EAGAN
3830 PILOT KNOB RD, EACAN MN 55122
651-681-4675
New Canstmclion Reauiremen[s
• 3 registered site surveys showiig sq. tt. of lot, sq. A. of house; and all roofed areas
(20 % maximum lot coverage allowed)
• 2 copies of plan showing beam 8 winaow sizes; poured found design, etc.)
• 1 set of Energy Calculations
• 3 copies of Tree Preserva6on Plan if lol piatted afler 711193
. Rim Joist Detail Options selec(ion sheet (bidgs with 3 or less units)
DATE o ?
SITE ADDRES
TYPE OF WO
APPLICANT
ULTI-FAMILYBLDG _Y Y_ N
FIREPLACE(S) _ 0 ?( 1 _ 2
STREET ADDRESS ???'I 576Z 7INL CITY STATE N%V ZIP
TELEPHONE #Go;7'k6 - 216CELL PHONE # G?GS^(- ?06 -0 I q 4' FAX # ?,f2 -
PROPERTY OWNER S, C?L.LSUV TELEPHONE# ??I' IW?_7%?67
------------------------------------- ----------------------------------------------------------
COMPLETE THIS SECTION fOR KNEW" RESIDENTIAL BUILDINGS ONLY
Energy Code Category _ \[I\NLSO'I'A KUI.1:5 7670 CATliGOItY l \IINNLSOT:\ RULHS 7672
(J submission rype) . Residential Ventilatlon Category 1 Worksheet 5ubmitted • New Energy Code Worksheet Submilted
• Energy Envelope Calculations Submitted
Plumbing Contractor: ____
Plumbing systcm includcs:
Mechanical Contractor:
Vlcckianical syslcm includcs:
Sewer/Water Contractor:
Phone #
Phone #
I'ce: $90.00
P'cc: $70.00
-------------------°--------------------------°-°-------------------°...----------...---------------------------------
i hereby acknowledge that I have read this application, state ihat the information is correct, and agree to comply
with all applicable State of Minnesota Statutes and City of Eagan Or ances.
Signature of Applicant ???
OFFICE USE ONLY
W,ucr So[tcncr
Walcr EIcatcr
No. oC l3atfis
?q4--73
,I
.II II 0 5 7007
II J
RemodeVReoair Reauirements IBy J? J,
. 2 copies of plan
• 1 set of Energy Calculalions for heated additions C,
. 1 site survey for extenor additions & decks
. Indicate if home served by septic system Por addiGons a
7-1? ?S
VALUATION
Phonc #
I.awn Sprinkler
No. oF R.I. 13aths
-- Air Canditioning
-- Heal Rccovcry Systctn
Certificates of Survey Received _ Tree Preservation Pian Received _ Not Required _
Updated 4102
CA 4ac0 e_LY S . CA-,,'-L5;&7V
OFFICE USE ONLY
? 01 Foundation
? 02 SF Dwelling
? 03 01 of _ plex
? 04 02-plex
? 05 03-plex
? 06 04-plex
? 07 OS-plex ? 73 16-plex
? OS 06-plex ? 16 Fireplace
? 09 07-plex ? 17 Garage
? 10 OS-plex ? 18 Deck
? 11 10-plex ? 19 Lower Level
? 12 12-plex Plbg_Y or_ N
? 20 Pool
-lif 21 Porch (3-sea.)
? 22 Porch/Addn. (4-sea.)
? 23 Porch (screened)
? 24 Storm Damage
? 25 Miscellaneous
? 30 Accessory Bldg
? 31 Eut. Alt - Multi
? 33 Ext. Alt - SF
? 36 Multi
? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding
X 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair
? 33 Alteration ? 37 Demolish (Bidg)* ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement 'Demolition (Entire B ldg only) - Give PCA handout to applicant
Valuation LeeU Occupancy ' 3 MC/ES System l
Census Code Zoning 1-i City Water ?
SAC Units ? Stories / Booster Pump r
Nbr. of Units ? Sq. Ft. IG? PRV ?
Nbr. of Bldgs ? Length j If Fire Sprinklered ?
Type of Const W idth f;_
REQUIRED IN SPECTIONS
Footings (new bldg) FinaL'C.O.
? Footings (deck) ? Final/Na C.O.
_ Footings (addition) Plumbing
_ Foundation ?- HVAC
Drain Tile O[her
Roof ? Ice & Warer ? Final Pool Ftgs AiriGas Tests _ Final
? Framing Stone
Sidin,
Stucco
_
Eireplace ? R.I. _,KAir Test ;&Final _
_
W indows (newheplacement)
?
Insulation - Re[aining Wall
Approved By
Base Fee
Surcharge
Plan Review
MClES SAC
City SAC
Water Supply & Storage
S&W Permit & Surcharge
Treatment Plant
Plumbing Permit
Mechanical Permit
License Search
Copies
Other
Tatal
3
Building Inspector
/G ? ll5 9 t`° = ?'?zo
Cbvsr,PU?7?a?1
?
. N\P49 VS 365
flOt36 CoN1U i a gNaIHEE11f ENGlN??fllNG pIAH???t anJ ANp CaMpFlNY, INC.
IUUU EAST 118fi 6iflEHT, dURH6YILI.Co HINNEi01A PN Certificate of?uruey
Legal Descr t?.ion:GOT3. B[OCK /, FA/RW9Y H14 L6 -4w AW/T/ON,
R4KOTA COVN7Y, M/NNESoTiI.
(%o2--2.a) DENOTES EXISTINQ ELEYATION '
(/030. o) DENOTEB PROPOSED ELEVATION
SCALE t 1' - 30'
m?
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Vi
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INDICATE6 DIRECTION OP' 6UPFACE DRAINAGE
a3? o, 33 ma FINlSHED {iARAQE FLOOFi ELEVATION
02 , = BASEMENT FLOOR ELEVATION
pl .3o.bbm TUP OR BLOCK ELEVA710N
DRAlNr76E An/D
IJrlclrY EkSWENr
`2
N 89•
?21,'?% /?jl•ZD
,30 fT. FkoNT BUILDJN6.
SET446K L/NE
''J ?`_•? w
W,s al ?obo?? 24a0 loia?
o?` ? .r+
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?J ? y? ? 64NA6F
?. J ? 39,00
`A J ?l,oL"f?3;
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BOOSTER PUMp 2 ? .
REG?UIRED i heroby aes111y Utal this 1s e irue and oonQOt tspl41s41nl5llmi ol 0 tioal ol IanJ 66 dlown
Z.TMday ol
aitd deaocibad h•rwa. As poepued by'me ou 11de '
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PERMIT 0"5S5L99
. CITY OF EAGAN
3830 Pilot Knob Road PERMIT TYPE: a u z Lo z rv G
Eagan, Minnesota 55122-1897 Permit Number: 027314
(612) 681-4675 Date Issued: 0 4/ 19 / 9 6
SITE ADDRESS:
4715 WAZELTINE LANE
LOT: 3 BLOCK: 1
FAIRWAY HIILS 3RD ,
P.I.N.: 10-25602-030-01
DESCRIPTION:
Building-?Permit Type
Buildin9 W'42!?k TYPe
Cer?;sus code
GARAGE/ACCESSORY
ADDI7ION
438 ALT. GARAGE
i ?
z
?,-
? F
/
' a` k
REMARKS: A SEPARATE PERMIT IS REQUIRED FqR ANY ELECTRICAL WORK
FEE SUMMARY:
VALUA7ION $6,000
Base Fee $112.25
Surcharge $3.00
Total Fee $115.25
CONTRACTOR: OWNER: - Applicant -
CARLSOM GREG
4715 HAZELTINE LN
EAGAN MN 55123
(612)686-7963
I
I 15ereby acknawledge that X have read!` tfiis application arttl state that the
information is correct and agree to comply with a11 applicable State of'Mn.
? Statutes and City pf Eayan Ord3,nances.
a oa .? `C11.
APPLI ANT/PERMITEE IGNATURE I _ BY:ta.n
SI,NA E
•-1
143' CITY OF EAGAN
? 3830 PILOT KNOB RD - 55122
1995 BUILDING PERMIT APPUCATION (RESIDENTIAL)
681 -4675
New Conshudion Raouirements RemodeUReoefr Reaukements
? 3 iagisterod tite wrveys ? 2 copks of ptan
? 2 copies of plans (indude beam 8 window a¢es; pouied fid. design: ete.) ? 2 ske surveys (enterior addidons 8 decks)
* I enerOY calWlafim ? 1 energy plwlations for heated addkions
? 3 copks o} tree preaenation plan 'rf lot pla@ed eRer 7/1l93
mqufred: _ es No
DATE: ? ,6 kT lp l? O O, o"D
CONSTRUCTION COST: ?
DESCRIPTION OF WORK:
STREET ADDRESS:
- 67/;7??'c// l i A/0'40'// /51;k)
`f 41116?
I.OT 3 BLOCK / SUBD./P.I.D. #: 69 - 4??-r66 Z? d 3d - 6
PROPERTY Name: Phone . Z?b
OWNER
Street Address-
City: state: zip• 5?S/Z 3
CONTRACTOR Company: Phone #:
Street Address: License #:
City:
State:
ARCHITECT! Company:
ENGINEER '
Name:
Zip:
Phone #•
Registration #•
Street Address•
City:
State:
Zip:
Sewer 6 water licensed plumber: Penalty applies when address change and lot
change are requested once permit is issued.
1 hereby acknowiedge that I have read this application and shate that the information is coRect and agree to comply with all
applicable State of MinnesoNa Statutes and City of Eagan Ordinances.
Signature of Applicant:
OFFICE USE ONLY 7A (?,r?'( ??
Certificates of Survey Received _ Yes _ No R 7$ j9g6
Tree Preservation Plan Received _ Yes _ No _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
BUILDING PERMIT TYPE
? 01 Foundation o 06 Duplex
0 02 SF Dwelling o 07 4-plex
a 03 SF Addition ? 08 8-plex
a 04 SF Porch ? 09 12-plex
0 05 SF Misc. 0 10 = plex
WORK TYPE
0 31 New
v,-?2 Addition
0 33 Alterations
0 34 Repair
GENERAL INFORMATION
OFFICE USE ONLY
0 11 Apt./Lodging o
0 12 Multi RepaidRem. o
3 Garage/Accessory o
0 14 Fireplace ?
? 15 Deck
0 37 Demolition ^.
0 36 Move
?
16 Basement Finish
17 Swim Pool
ZO Public Facility
21 Miscellaneous
Const. (Actual) Basement sq. ft. MCIWS System
(Allowable) Main level sq. ft. City Water
UBC Occupancy sq. ft. Fire Sprinklered
Zoning sq. ft. PRV
# of Stories sq. ft. Booster Pump
Length sq. ft. Census Code. ?/37
Depth Footprint sq. ft. SAC Code ?
Census Bldg /
Census Unit ?
APPROVALS
Planning Building Engineering Variance
Permit Fee Valuation: $ 6 i vaD ^ •
Surcharge
Pian Review
License
MCNVS SAC
City SAC
Water Conn.
WaterMeter 2
f/x 2- 7 S/XlG
Acct. Deposft
S/W Permit
S/W Surcharge
Treatment PI.
Road UnR
Park Ded.
Trails Ded.
Other
Copies
Total:
..?:
:? .
% SAC
SAC Units
,
-ZS?o 2 a 36 ° / `? .
Lot Survey for.
GREG CARLSON
I L 0 r onsnNC ' 2 I
I HOUSE
,.- N89°13'41"E 741.20
?'' Q i n Pvim aMUld Eosemanb...... __ °l
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HOUSE
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S89°1341'W 147.20 ..
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LEGAL DESCRIP710N
? I Lot 3, B(ock 7, FAlRWAY HILLS 3R0 ADDITION, ottording
to the recorded plat thereol, Dokoto County, Minnesota.
I Ar<o = 72.002 squorc leet (0.276 ocre)
I
Scale: 1 inch = 20 feet
N
O Denotes Iron Monument Set
I ? • Denote5 Iton Monument Found
I
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I
Li' I hercby certify thot this is a lme ond corred represenlation
. I of a survey of the boundaries ol the bnd abwe describe0 and
? of the locotion ot all buildings on said lond.
? 1 DateO this 22ntl day of March, 7996.
1 REHDER & ASSOCWTES. INC.
60 AMn R. Rehder, l,onE Surveyor
Minnesoto Registrotion No. 13295
Rehder and Associates, Inc. I
GVrt ExWMEEI+S AND lANO SURvEY0F5
a..e r?.a o:.. sw zw . r,y.? w?m . rm. (na) ua-sos?
?
Lot Survey for:
GREG CARLSON
2
L O T EXISTfNG %
HOUSE ?
N89013'41 "E 141.20
Q :• l v? •_.Drainage and Utility EasemenA.-........,
i - - - - - - - - - - - - -
, r - - - - - - - - - - - - - - - - - I 10
? 10 ? I
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EXISTING
? I HOUSE
< < . :-..
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;. ; .: -•.. ............................ ....
.......
30.16
O -T rc<
? S l.l O a ? : I
I : o Fireplace t ?..?
J C6 6 - i
? 10 i W.o? ----? ,a
4 L -- ----------------- ?
?--"
--- S89°13'41 "W 141.20
EXISTING ?
? Q T NOUSE ';.
P
4 1991 BUILDI A ? In.n??
' LICATION
CITY OF EAGAN
SINGLE FAMILY DWELLZNGS
2 SETS OF PIANS
3 REGISTERED SITE SURVEYS
1 SET OF ENERGY CALCULATIONS
19ULTIPLE DWELLINGS
COMMERCIAL
2 SETS OF PLANS 2 SETS OF ARCHITECTURAL
REGISTERED SITE SURVEYS - & STRUCTURAL PLANS
(CHECK WITH BLDG. DEPT.) 1 SET OF SPECIFICATIONS
1 SET OF ENERGY CALCULATIONS 1 SET OF ENERGY CALCS
# OF RENTAL UNITS
# OF FOR SALE UNITS
PENALTY APPLIES WHEN: TYPING OF PERMIT IS REQUESTED, BUT NOT PICKED UP BY LAST WORKING DAY
OF MONTH IN WHICH REQUEST IS MADE.
IAT CHANGE IS REQUESTED ONCE PERMIT IS ISSUED.
NOTE: ADDRESSES FOR CORNER IATS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS
DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED.
PROCESSING TIME FOR SEWER & WATER PERMITS IS TWO DAYS ONCE A PERMIT HAS BEEN COMPLETED.
PERMIT MUST SHOW A LICENSED PLUMBER.
f?UL ? ' ° "A
To Be Used For: /aMF ' Valuation: ? Date: 7-/ "?i/
Site Address
Loc 3 alock L
{????I
Parcel/Sub FAigujA4
Owner SO/i/ j l?p}?S1'RlLC7f70N
Address 00
City/Zip Code grG'cu, '0,l
Phone
Contractor S d,US C6N1jMU_(+`n00
Address 4-(pO PAI2vw 4,LLf b2
City/Zip Code 9-{&AIS'JA?
Phone
Arch./Engr. ?;?l^)kd /}ST/"j 6-
9y/ Ju J? OFFICE USE ONLY
Dccupancy R-3M-I
Zoning R'1
Actual Const V-N
Allowable V-N
# of stories
Length ?ld
Depth ?
S.F. Total
Footprint S.F.
On site sewage_
On site well
MWCC System
City water
PRV -
Booster Pump ?
APPROVALS
Planner _
Council
Bldg. Dff. =9/
Variance
FEES
Bldg. Permit G13100
Surcharge 4 ,0O
Plan Review 398,00
SAC, City 0 O?DO
SAC, MWCC 650000
Water Conn. 100,00
Water Meter 9S Oc)
Acct. Deposit 301ce
S/w Permit 3a, W
S/W Surcharge i50
Treatment P1. 296,00
Road Unit nD,OD
Park Ded.
Trail Ded.
Copies
SUBTOTAL
Penalty
I.ot Change
TOTAL SMILT. (
agrees that all work shall be done in accordance with
all applicable State of Minnesota Statutes and City of Eagan Ordinances.
Address ,6OU PAI2l/1AUi&s 6r
City/Zip Code
.. wo, . . 1 ' sy t :
VALUATIt3N?` .?
Ga aG
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ENG1NCEfllNG PlflNN6RS and LAND ?URViY0N3 p
COMPANY, INC.
L??,I?OU LABT 148fi BIAfiBT? 9UflN6VILl.L, MINNE80TA 50331 PM 432'1000
Certificate ofi Su_ rmy -
Lgal Descr ttt ion 9 LOT 3, BGOCK 1, FA/RWAY N/LLS .?D /?LPIr/On!
pQKDYA 40Y/N7Y, M/NN00TII.
(T2,?.o) DENOTES EXISTINQ ELEVATION '
(I030. o) DENOTEB PROPOSED ELBVATION
?. - INDICATES DIRECTION OF 6URFACE DRAINAGE
1630.3 p FINISHEq GARAQE FLOOH ELEVATION
102 , = BASEMENT FLOOR ELEVATION
oL3o,bbm TOP OF BLOCK E1.EVATION
SCALE t i' + 30'
pRA/N46E AND
(/T/LITY EA.SE'MENT
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1 hareby oarl{ly Iliat Ilils Is a true and aoneot "p'"all1aUon ol o Irool ol land as shown
TM
and deaarlbsJ Mrwn. As peapated by'me on 11ds'? daY o( ?l)u.NE -'19
/?"_" _ Mha?, Rey. No. ??° ?._- d?--',?--?
S4X6 ri Y
' E1(TERIOR EMYELOPE AVERAGE "U" COMPUTATION
i.
OuF1ER: Sons Consturction
- ADQRE55: Lot 3 Block 1 Fairway Hills 3rd Addition
CONTRACTOR: Sons Construction Co. DATE: 7/2/91 PHONE: 452-5355 ,
DETERMfNE NORKINf SOUARE FOOTAGE OF EACH:
;. TOTAL E%POSEO UAIL AREA228-7
sq ft x"U" .11 .
•••••• 251,5-)
t. TOTAL ROOF/CEILING AREA,,,,,,,, __ sq ft x"U" .026 ¦--???
2,}2
1. TOTAL EXPOSEO NALL AREA CALCULATIONS:
Total exposed wal)
aroa.above fioor,,,,,,,, sq ft •
a) Tota1 wall window ares: ?T-
glazed...... _ 122 sq ft x"U" ,5°I • ?i.qg
-r_ qla2ed...... !q f[ x "Ull ?
b) Total door area ,,,,,,,. ?D sq ft x"U" 2,g0
c) Total slidTng glass door area:
d)
?_9I azed...... sq ft x'oUn 23.20 _
giazed...... sq ft x "U" .
Total fireplace well area sq ft x"U"
.
e) Total wall framing area
(Average IOR)............... _ 2?S aq ft x"U"
f) Total net wal) area above
.ID .. . ZZ,&O
floor (Insulated)........ Ilo9'7 sq ft x"U" ,a?- . co?
9) Total rim Jolst area...... I2-(40 ' sq ft x"U" _
Total foundatlon
area (Exposed)........., s ft
q
h) Total foundatlon •
wlndow area ............. aq ft x?fUll
'
i) Tota) net foundatlon
area above qrade........ S? sq ft x"U"
?
,0'7 ?
TOTAL a) thru i)
f Item 03 is the same as, or less
2
tICpR 1.16008 A and 0. than Item ?1.
you have met the intent of
, .. Page 1
• '. .4., TOTAL EXPOSEG ROOF/CEILING CALCUlAT10NS:
Total exposed -
rooi/cetling area ........ I sq ft .
J) Total skylight area........ sq ft x"U" ?
k) Total roof/ceilinq framinq `
area (Averaae 1f1R)....., 1Z'? sq ft x"U" •02'Ilo • 3.L45
1) Total net tnsulpted
roof/ceilinq area....... ll 22 sq ft,x "U" -0 2• '
4. , TOTAI 1) thrw ) 30.
If total of 04 Is the same as, or less tkan 02, rou haw met'tla Intent of
2 MCAA 1.16008 A end 0.
, ` .
ALTERNATE BUILDING ENVELOPE DESIGN
To utlltze the total envelope system method, the values eftabllshed by the tua
of ttems 93 and p4 shall not be greater than tM sum af.itaas 11 and 02.
1. + 2. •
3. + 4. ?
CERTIFICATION
I hereby certify that I have calculated the "U" faetors and "R"
values Aerein and that the bulldlnq here descrlbed aeett or exceeds the Stats
of Minnesota Energy Conservatton Act. gnature
(Data)
, Page 2
czrv aF .r:.FlrnN
rA5hI7:fR: JS t'L.:RMINAI_ Nn? Of)?
DATE; 07f15/99 T'IMI"^ i0:29.58
ID:
NAMENQME FNHANCERS :I:MC,
3210 9001 4 i l.°i HA7EI_TINE 60.00
2155 9001. 4715 HA7EI..1'INE D..`.;Q
,
1
.
To+,a7. Peceipt Artioun+„ 60.50
Ck113435
115Efi SLi: .JAN
1999 Bl11LDING PERMIT APPLICATION (RESIDENTIAL)
CITY OF EAGAN ?irb ?
E830 PILOT KNOB RD - 55122 q651-681-4675 r, _ n p l1 6o', q q
c.:??.ensi !
Remodel/Reoalr Reaulremen}s
Non ReauUem
D 3 registered sNe surveys showing sq. tl. o( tof, :q. H. W house
and Q rooled areas (2096 maximum lof coveraae apowed)
D 4 eopies of plans (ihow beam i wlndow ilzes; poured ind. design; etc.)
D 1 set of energy calculaNons
D 3 copies o} hee presenalbn plan B loT plalfed aMer 7/1 /93
DATE:
DESCRIPTION Of WORK:
STREET ADDRESS:
LOT: ?J BLOCK: ? SUBD./P.I.D. N: 1::?0.?. A, W 0._, t?l ? l S ?J Y'k)
Name: Ll's r/S C3,IJ 9 Phone #: ?l-' ?,?'?• 7?/G 3
PROPERTY ? F??
OWNER y7??
Sheet Address: dl.Zc
City Fzt:!7 06-h, State: ??. Zip:
Company: rL aa-?tC&?S ?GLG Phone #: /? . ??
(area code)--?
CONTRACTOR /? .?E
Sheet Address: ?d ?e. /VUCS aO ? License #Exp? }
Ciiy State: 1/±t1.- Zip:
ARCHITECT/
ENGINEER Company: Name:
Telephone #: area code ( )
Sheet Address: Regishation IR:
City State: Zip:
Sewer 3 water Iicensed plumber (reauired for new conshucHon onHl: .
Penaly applles when address change and lot change Is requested once permN ia issued.
,
I hereby acknowledge that I have read ihis appBcaHon, sfate that the informatl is cortect, and agree to comply wNh all applicabl
?ate of Minnesofa StWufes and CNy of Eagan Ordtnances. /?
. ? /
Signafure of Applicant: ..?i+.. -?o ?
r----/,?
OFFICE USE ONLY f ? rV ?
Certificates of Survey Received _ Yes _ No 2 igc)9
Tree Preservation Plan Received _ Yes _ No _ NotRequired I??L
2 copia of plan
1 sef of energy cakulaHOns la heated addlNOns
1 sMe survey far exterlor addHions 6 decks
CONSTRUCTION COST:
?? ?
4:7- -1 e
OFFICE USE ONLY
BUILDING PERMIT TYPE
? 01 Foundation ? 06 4-plex 0 11 10-plex 13 16 Fireplace ? 21 Porch (3-sea.)
? 02 SF Dwelling ? 07 5-plex ? 12 12-plex ? 17 Garage ? 22 Porch/Addn. (4sea.
? 03 1 of _ plex ? 08 6-plex 0 13 16-plex ? 18 Deck ? 23 ' Porch (screened)
? 04 2-plex ? 09 7-plex ? 14 Apartments ? 19 Lower Levei ? 24 Storm Damage
? 05 3-piex 0 10 8-plex ? 15 Lodging O 20 Pool ? 25 Miscellaneous
WORK TYPE
? 31 New ? 35 Tenant Impr q 39 Gas Line Only ? 43 Siding/Soffits/Fascia
? 32 Addition ? 36 Move Bldg. ? 40 Gas Insert ? 44 Windows/Doors
? 33 Atteration ? 37 Demolish Bldg' ? 41 Wood Stove ? 45 Fire Repair
? 34 Repair ? 38 Demolish (Interior) ? 42 Reroof
` Give PCA handout to appiicant for demolition permit
GENERAL INFORMATION
,
Const. (Actual)
(Allowable)
UBC Occupancy
Zoning
# of Stories
Length
Width
APPROVALS
Planning
Basement sq. ft.
Main level sq. ft.
sq. ft.
sq. ft.
sq. ft.
sq. ft.
Footprint sq. ft.
Building 13W
Census Code
SAC Code &/_
No. of Units G
No. of Bldgs ?
MC/ES System
City Water
Booster Pump
PRV
Fire Sprinklered
Engineering Variance
Permit Fee
Surcharge
Plan Review
License
MClES SAC
City SAC
Water Conn.
Water Meter
Acct. Deposit
S/W Permit
S/W Surcharge
Treatment PI.
Park Ded.
Trails Ded.
Other
Copies
Total:
SAC Units
Valuation: $ /2?
1
.
% SAC
CTTY USE OtiLY
LOT _?_ BL RECEIPT #: 11033
SUBD. f:jVY W fla.? H`?S ?
RECEIPT DATE:
MECHANICAL PERMIT
1999 MEcHANICAL PERMtT (REsinErrrIAW
CIi'Y OF £AfiHN
SSSO PILOT KFOB RD
gA6AP MN 5S1 £E
(651)681-4675
.
Date•
Complete this section on if you are installing HVAC in a single family dwelling, townhome or condo under
• FiVAC: 0-100 B T U $ 30.00
ADDI NAL 50 M BTU 6.00
• Gas outlets (minimum of one re uired @$3.00 ea.)
State Surchazge .50
Total $
Complete this section aelv if you are remodel g, adding to, or repairing an existing single family dwelling,
townhome, or condo. Please indicate iFit is a new it , alterafion, or repair.
_ New Alteration Repair V' Other
Reminder.• Ca11681- (75 for inspections.
Fumace
_ Air exchanger
BSRf 64M%sk, d'a e'Z1W'0J(e.Fmsl
Gc???° ? vU?t
OPAJ? ?Pe ?e
SITE ADDRESS
OWNER NAME: _
INSTALLER NAME:
STREET ADDRESS:
CITY: FZt
Air conditioning
? Other
V140q $ 30.00
State urchazge
Minimu?Total Due $ 30.50
PHONE #: Xt4; f -/Ows- 7w
(A?E)
_ PHONE
(AREA CODE)
STATE: P7
ZIP:25iW
_. • .
CITY USE ONLY
L BL RECEIPT#:
SUBD. RECEIPT DATE:
APPROVED BY: . INSPECTOR MECHANICAL PERMIT #:
1999 MEctAviCAl. PERMrr (coMME[tClAL)
cm'of' EAeAx
3$30 PILOT KNOB ftD
EA6AN, hIN 55122
(651) s81-4s95
Please complete for: all commerciai/industrial buildings
multi-family buildings when separate permits are not required for each dwelling unit
DATE: CONTRACT PRICE:
WORK Tl'PE: New construction Install U.G. Tank
_ Interior Improvement Remove U.G. Tank (Minimum Fee)
_ Processed Piping (Minimum Fee)
"*NOTE: When installing/removing underground tank, ca11 65 1-681-4675 for inspection by fire mazshal
and plumbing inspector.
DESCRIPTION OF WORK:
FEES: 1% of contract price OR $30.00 minimum fee, wluchever is greater.
CONTRACT PRICE x 1°/a
PERMIT FEE
STATESURCHARGE
TOTAL
SITE ADDRESS:
OWNER NAME:
TENANT NAME (IIvfPROVEMENTS ONL7):
INSTALLER:
ADDRESS:
` CITY:
($.50 per $1,000 of permit fee due on all pe:miu.)
PHONE #:
(AREA CODE)
PHUNE #: -
(AREA CODE)
STATE: ZIP:
SIGNATURE OF PERMITIEE
CLA1M VOUCHER- REFUND REQUEST
CITY OF EACAN
MAKE CHECK PAYABLE TO: Centraire Heating & A/C Inc.
ADDRESS: 7402 Washington Ave
Eden Prairie, MN 55344
LOCATION: 4715 Hazeltine Lane P.LD./LEGAL: Lt 3, BI 1, Fairway Hills 3rd
RECEIPT #/DATE: 114833/8-4-99 VALUATIOfY:
REASON FOR REFUND: Permit Not Needed PERMIT #: 37129
TYPE OF REFUND:
Elechical Permit 3211-9001 $
Plumbing Permit 3212-9001 $
Mechanical Permi[ 3213-9001 $ 30.00
Building Permit Fee 3210-9001 $
Plan Review Fee 3422-9001 $
SAC (MC/WS) 2275-9220 $
SAC (Ciry) 3866-9379 $
SAC (Admin) 3446-9001 $
Water Connection 3865-9220 $
Sewer Permit 3743-9220 S
Water Permit 3713-9220 $
Account Deposit 2252-9220 $
Water Meter 3716-9220 $
Water Treatment 3868-9220 s
Surchazge 2155-9001 $ .50
Utility Acct Overpayment 2250-9220 S
Curb Box Deposit Refund 2253-9220 $
Construction Meter Dep Refund 2254-9220 S
Water Usage Chazge 3711-9220 $
Other $
TOTAL $ 30.50
I declare under the penalties of law that this account, claim, or demand isjust and that no part of it has been paid.
DATE
QV,NATURE
S-f
L BL CITY USE ONLY RECEIPT #: J?P_154P
d
SUBD. DATE: 4A 9
Please complete for: ? single family dwellings
? townhomes and condos when permits are required for each unit
_ New construction 1,"?'Add-on furnaee-
Add-on air conditioning Add-on air exchanger, i.e. Vanee system, etc.
Date:
? Minimum Fee: Add-on/Remodel (existing residence only) $ 20.00
? HVAC: 0-100 M BTU 24.00
Additional 50 M BTU 6.00
? Gas Outlets (minimum of 1 required @$3.00 each)
? State Surcharge .50
sIV
TOTAL a0
1996 MECHANICAL PERMIT (RESIDENTIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, MN 55122
(612) 681-4675
FEES
SITE ADDRESS: :17/5- /?zeNke4ue
OWNER
PHONE #: 6?103
INSTALLER NAM
STREET
CITY: 15Em' kwffe STATE:1-11(r ZIP:
PHONE #: (?,/Z) q¢? lD?
1:-z-12- 5 7
14
1
CITY USE ONLY
L BL
Sl1BD.
RECEIPT #:
DATE:
1996 MECHANICAL PERMIT (COMMERCIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, MN 55122
(612) 681-4675
Please complete for: ? all commercial/industrial buildings.
? multi-family buildings when separate permits are = required
for each dwelling unit.
DATE: CONTRACT PRICE:
WORK TYPE: _ NEW CONSTRUCTION
DESCRIPTION OF WORK:
FEES: ?$25.00 minimum fee 4C 1% of contract price, whichever is greater.
? Pracessed piping - $25.00
? State surcharge of $.50 per $1,000 of r i fee due on all permits.
CQNTRACT PRIGE x 1%
PROCESSED PIPING
STATE SURCHARGE
TOTAL
INTERIOR IMPROVEMENT
SITE ADDRESS:
OWNER NAME:
TENANT NAME: (IMPROVEMENTS ONLY)
INSTALLER:
ADDRESS: _
CITY:
PHONE #:
SIGNATURE:
SIGNATURE OF PERMITTEE
TELEPHONE #:
STATE: ZIP:
CITY INSPECTOR
40" City of Eapn
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
? [;??Ti ?L'
OCT 14 2008
?. J
------------
? FoF;??,tl? '
??3 ?
I Permit #:
'
I Pertnit Fee:
i ?D v i
? Date Received: ?
I ?
? Staff:
-------- ---------J
, 2008 MECHANICAL PERMIT APPLICATION
Date: 1R V? Site Address: u'12
?
Tenant: Suite #:
RESIDENT / OWNER Name: Phone: (D `S i, -
Address / City / Zip:
CONTRACTOR Name: ?License #:
Address:
mu ?' IV ? `? i C? L4'
Q
City: .;?' t,4' State:1A?v?j_Zip: ?--?7
Phone: ntact Person:
TYPE OF WORK - New -Neplacement _ Additional _ Altera'on D molition
Descrlption of work:
i"A
NOTE: Both roof mounted and gr und mounfed mechanfcal equfpment is requlred fa -
be screened by City Code, Please contact the MechaniCal Inspecfor oY one oi the
Planners for information on- ermitted screenin`.methads:? ; -
PERMIT TYPE RESIDENTIAL COMMERCIAL
F Interior Improvement
New Consfruction
?
umace _
_
Air Conditioner _ Jnstall Piping _ Processed
Air Exchanger _ Gas _ Erzterior HVAC Unit
?leat Pum ` HVAC units must be screened
p Under / Above ground Tank (_ Install / Remove)
Other " When installing/removing tank(s), call for inspection by Fre
Marshal and Plumbin Ins ector
RESIDENTIAL FEES:
$50.50 Minimum Add-on or alteration to an existing unit (includes $.50 State Surcharge)
$90.50 Flre r8pdir (replace burned out appliances, ductwork, etc.) (inCludes $.50 State Surcharge)
$-? TOTAL FEE
COMMERCIAL FEES:
$70.50 Underground tank installation/removal OR Contract Value $ x 1%
$50.50 Minimum (includes State Surcharge)
_$ Permit Fee
- If Permit g is less than $1,000, surcharge is $.50.
- If Permit Fee is > $1,000, surcharge increases by $.50 for each =$ State Surcharge
$1,000 Permit Fee (i.e. a$1,001-$2,000 Permit Fee requires a$1.00 surcharge).
$ TOTAL FEE
i nereoy acKnowieqge ihat this iniorrnation is complete and accurate; that the work will be in corNormance wifh the ordinances and codes of the City of Eagan; tha[
I understand ihis is not a permd, but only an application for a permit, and work is not to start wilhout a permit; that ihe work will. e i?tlance with the approved
plan in the case of work which requir@S a review and approval ot plans.
X l ?
Applic?ant's rio ° Name ? Aoo?tiCa" 's i re
FOR OPFICE USE
Required inspections: _Under Ground _ Rough In -Air Test Gas Service Test
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA147808
Date Issued:02/06/2018
Permit Category:ePermit
Site Address: 4715 Hazeltine Lane
Lot:3 Block: 1 Addition: Fairway Hills 3rd
PID:10-25602-01-030
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Furnace
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088
Surcharge-Fixed $1.00 9001.2195
$60.00 Total:
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Contractor:Owner:- Applicant -
Nicholas Leatherman
4715 Hazeltine Lane
Eagan MN 55123
(906) 370-1385
Centraire Heating & Air Conditioning
7402 Washington Ave
Eden Prairie MN 55344
(952) 941-1044
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA178307
Date Issued:08/10/2022
Permit Category:ePermit
Site Address: 4715 Hazeltine Lane
Lot:3 Block: 1 Addition: Fairway Hills 3rd
PID:10-25602-01-030
Use:
Description:
Sub Type:Furnace
Work Type:Replace
Description:
Comments:Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Building Code).
Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Pete DeGrood at (507)
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 -
Nicolas & Emily Leatherman
4715 Hazeltine Ln
Eagan MN 55123
S & R Appliance Repair
4118 Hoffman Road
White Bear Lake MN 55110
(651) 429-0001
Applicant/Permitee: Signature Issued By: Signature