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833 Govern Cir PERMIT City of Eagan Permit Type: Building 3830 Pilot Knob Rd Permit Number: EA080202 Eagan, MN 55122 . Date Issued: 10/03/2007 (651) 675-5675~~~ EPermit Category: ePermit www.ci.eagan.mn.us lflflUl tflflLLL Site Address: 833 Govern Cir Lot: 11 Block: 5 Addition: Gardenwood Ponds PID 10-28800-110-05 Use Description: Sub Type: e-Reroof Construction Type: Work Type: Repair Description: House & Garage Census Code: 434- Occupancy: Zoning: Square Feet: 0 Comments: If there is no ice protection inspection prior to final, you must meet inspector with ladder and flat bar. Pictures are not acceptable in lieu of inspections. Fee Summary: BL - Base Fee $3K $88.50 0801.4085 Surcharge - Based on Valuation $3K $1.50 9001.2195 Valuation: 3,000.00 Total: $90.00 Contractor: -Applicant - Owner: Horizon Home Improvement Vicki I Ishman 13205 Sheffield Ct 833 Govern Cir Burnsville MN 55337 Eagan MN 55123 (612) 816-9809 I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Applicant/Permitee: Signature Issued By: Signature ? ?..? ... T INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number: ' '? •' ?? ? Ea an, Minnesota 55122-1897 9 Date issued: ? ' (612) 681-4675 , SITE ADDRESS: ? APPLICANT: . r;. R33 C, nvrp I fi11!"+I1rNWt30f.t h'f}M1iC3!ti PERMIT SUBTYPE: ?1 ufe?4-1 H 11Vi ItF wa. u r ( ti E:') A'r Q R ti F. 3 TYPE OF WORK: hi I tJ INSPECTION D• • D• i I Nl1I itFMaaifSt 5$iJ P1.114$FR- M& W W1111-:11 ANCl 5EC#kit 1'iaN. kF'llti4t'll FIY MIi:f NARt'k Permk No. PermR Holder Date Telephone A ELECTRIC PLUMBING yoM3 HVAC Inepecdon Dete Insp. Comments FOOTINGS ? jQQ O FOUND ? 1 `r Y ? 5? Z L-g p M.g UIG FRAMING ?v ROOFING ROUGH PLUMBING 41 / PLBG AIR TEST ? Q RQUGH HEATING -,? GA5 SVC TEST INSUL v GYP BOARD FIREPLACE FIREPIACE AIR TEST /t !{ FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL BSMT R.I. 85MT FINAL DECK FTG DECK FINAL ;)- I Address '933 GUvM CLR Zip 5512 3 Lot l i Blk 5 3ub caxnE2%oou PorIDs THESE ITEMS WERE / WERE NOT COMf'LETE AT THE TIME OF THE FINAL INSPECTION. Date: & 9 Yes No Inspector: Final grade (6" from siding) Permanent steps (gazage) ? Permanent steps (main entry) Permanent driveway Petmanent gas v Sod/Seeded grass Trail/curb damage ? Porch Basement finish i/ - Deck l? Please verify with the builder the removal of roof test caps from the plumbing system and the shutoff of water supply to tAe outside lawn faucet before freeze potential exisis. Contact engineering division at 681-4645 before working in rightof-way ot installing underground sprinkler system. ? White - City Copy Yellow - Resident Copy Pink • Contractor Copy xxFxFxxxzY***************************** CITY OF EAGAN CASHIER: JS TERMINAL N0: 014 DATE: 04/12/00 TIME: 10:47:22 ID: NAME: VICKI J OR CRAIG ISHMAN 3210 9001 833 GOVERN CIR 60.00 2155 9001 833 GOVERN CIR 0.50 Total Receipt Amount: 60.50 CR125990 USER ID: JAN 2000 BUILDING PERMIT APPLICATION (RESIDENTIAL) CITY OF EACAN ? 3830 PILOT KNOB RD - 55122 851-881-4675 Remoael/Reoair ReatlremaMa 9 6o, iro ? 3 r6pisisred qfa wrveri showlrp p. R Of W. aQ. fl. at house 2 captea OI Pkm ma gH roorec cww r20% mcnamum Wi eoremae anowem I set m aneryy cacwonons ror nearea adanona D 2 caplea ot Plarx (dww beam a window si:ea: PWred Intl. deslgrr etc.) i sifa wrveY tor exteAOr atldi8ons d dacks D 1 tet d enefyy caicWaHana > S coples d hee preserva8on plpn H lof ptatted aRer 7/1 /9J DATE: y 110 100 CONSiRUCTION COST: b 00 DESCRIPfION OF WORK: 13..-Jj nz, SIREET ADDRESS: ?3 3 G a?le.f?L LOT: I I BLOCR: ? SUBD./P.I.D. A: PROPERTY OWNER COMRACTOR ARCHITECT/ ENGINEER 93.3 r6tle!'.. C(,\r- 2w00 m:) b9 =? rVx-A 00 3Vck,' w,one:: 6?l-Ysy-szz(o Name: wer Flrat SheAt CNy L °?? ?, n State: Sheet CNy Telephone Y: ( mee+ CNy ) State: a? ?? LP. ?si z3 Phone A: (area code) License # Exp. ` Zip; State: Zlp: Sewer/water licensed plumber (H installina sewarlwaterl: Jv IA Phone 1 hereby acknowledpe that 1 have read tha applicaNon, atate ttwt fhe In(omwfion M a compry wil of Minnesota Sialutea and CNy ot Eapan Ordinances. i Siynafure of Applicant OFFI USE ONLY Certficates of Survey Received _ Yes _ No ' ?,•'? 1 0 Tree Preservation Plan Received Yes _ No ? Not Required M: aA appficable State OFFICE USE ONLY t ? BUILDiNG PERMIT SUBTYPES D 01 Foundatlon O 07 05-piex ? 13 16-plex p 21 Porch (3-sea.) ? 31 Ext Alt - Mutti ? 02 SF Dweiling O OS 06-piex ? 17 Garage ? 22 Poroh/Addn. (4sea.) O 33 Ext: Alt - SF ? 03 01 of _ plex ? 08 07-plex ? 18 Deck O 23 Porch (saeened) ? 38 MuMi ? 04 02-plex ? 10 OB-plex 19 Lower Level p 24 Storm Damage 0 05 03-plex ? 11 10-plex Plbg _Y or_ N O 25 Miscenaneous ? 06 04-plex ? 12 12-plex O 20 Pool O 30 Accessory BId9• . WORK TYPE ^ ? 31 New ? 36 Move Bldg. O 43 Reroof ;9 32 Addition ? 37 Demolish (Bldg)" 0 44 Siding ? 33 Alteration ? 38 Demolish (Interior) 0 45 Fire Repair ? 34 Repair ? 42 Demolish (Foundation) O 46 Windows/Doors * Give PCA handcut to applicant for demolitic+n pertnit GENERAL INFORMATION SAC Code # of Stories sq. ft. No. of Units Length sq. ft. No. of Buildings Const. (Actual) V?- Width Basement sq. ft. Footprint sq. ft. Census Code ? (Ailowable) Main level sq. ft. MC/ES System ? UBC Occupancy , f, sq. ft. City Water Zoning sq. ft. Booster Pump PRV Fire Sprinklered MISCELlANEOUS INSPECTIONS 0 Stucco/Stone APPROVALS Planning Building Tigq Engineering Variance ? Permit Fee Surcharge Pfan Review License MC/ES SAC City SAC Water Conn. Water Meter Acct. Deposit S/W Permit S/W Surcharge Treatment PI. Park Ded. Trails Ded. Other Copies Valuation: $? ? o,5-04 Total: SAC Units % SAC ?J ? ? ?•l?- ?- C^ I ? ? - ?? . ? \ N F O N I ' i ?411 . Drainu9`1it? t eosem6n . W 51 ? 02?.. ??`??------_148907130rE 1 ? ( 1 / ? yz J ? d,b a r°w I y g0 ? I oQ°?? ? rb?'8-4.3 Q 05F ? ,8 ? L- ? 0 `-__ ?? ? .. -----/ Is __ CERI1FlCAlE OF SURVEY ror ,--dpE MILI.ER HOMES 1 .! N w? s?-J9,v ? 118.87 S82'28'S9"E 00 M32-1720-9E , ? ?b 97 ? ` °- y" Op ' A ?I ? ? M^ r • - ?`:? ' '- ? .1?I i _ ?L? \ U . L U ((.) 0 a Scale: 1" = 30' Top curb to Gar slab = 386 Top block = 994.33 Lowest bsmt flr = 1A•62 833 Govern Circle DESCRIP110N ,..r.?Y„'niY(,',?7,i:,J,i?, :;,<:•:r,??;$':'•,?;YOm::!)YnOi4; ?m.::7ki:,,. l;:I.iY OF li:Ad:;(ai! i'At;HIERe S tt-r'tMLNAL Ni1g ,'1:a DA71r:n 05/i.9/92 T[t.'..: I.:>.46;;4`; 1D !; NG1111_; D R 1-I0i:'i(']F1 ):NU. i.'.E".::6 9041:: P;'s 3 f;J'/CTiiV f'LR 47;3;32, i':I. iA Ti„t?"I. Pr<ct,ip$ AiriC,1t:`° t.yk53i'.i1. rFt:O92044 USER Mr N•iP#L'V CPTY OF EAGAN 3830 Pilot Knob Road Eagan, Minnesota 55122-1897 (612) 681-4675 PERMIT PERMIT TYPE: Permit Number: Date Issued: BUILDIN6 032023 05/19/98 SITE ADDRESS: P.S.N.: 10-28800-110-95 DESCRIPTION: 833 GOVERN CSR LOT: 110 BLOCK: 5 GARDENWOOD PONDS e rmit 7ype Lk 7Ype $F AWG NEW ft-3, U-1 VN R-1 65 47 2 2,33@ 101 1 - FAM. DETACH ??? ? ?? ,? ?, ti ? _ ^? ? 9r?'? „ ?;' ? - ? n ? E REMARKS: 5&W PLUMBER: M& W WATER ANp SEWER PLANS REVZWED BY MTKE BARCK FEE SUMMARY: Base Fee plan Review Surcharge SAC SAC % SAC Units Subtotal VALUATION $1,302.25 $846.46 Q? $9/?/?1.5@ `P1g/}?GGV.00 100 1 $3,240.21 $153,000 MISC. FEES $1,592.80 Total Fee $4,832.71 CONTRACTOR: - Applicant - sT. LIC.OWNER: HbRTON INC OF MN, D R 14544663 2000565 JOE MILLER HOME5 34,59 WASHINGTON OR 204 3459 WASHING70N DR EAGAN MN 55122 EAGAN MN 55122 (612) 454-4663 (612)454-4663 , . 3 ???? ......__ 204 ' / V I ISSUEO BY SIGNATUFE • ? ? 1998 BUILDING PERMIT APPLICATION (RESIDENTIAL&p'JZ ,--l ( , crrsr oF Enanx ??1??( `? 3830 PII.OT KNOS RD - 55122 ? 681-4675 New Conatrudion Reaui2ments RemodeUReoalr Requirements ? 3 regiatered site surveys ? 2 copies of plans (inGude beam & window sizea; poured fid. desipn; etc.) ? 7 energy ealwlations • 3 wpies of tree preservation plan H lot platted aRer 7/7l93 requiretl: _ Yes k_ No ? 2 copies of plan ? 2 sRe surveys (exterior adtlRions & dedcs) ? 1 energy celculetions for heated addkions DATE: CONSTRUCTION COST; /Sy lqS DESCRIPTION OF WORK: c,/ 7OTfETADDRESS: ?.33 GovP.?n Civc.IC. : // BLOCK: li?_ SUBD.lP.I.D. #: G[?rL', Wccj Ancl5 4?_eax Name: Phone #: PROPERTY Last evst OWNER City State: Zip: Company: b.1Q. ({e,ViuH P-mA/ dIb/? T e/ylill?ltauPhone #: 4S? S??oG 3 P?!I /?9 CONTRACTOR ' / r \ StreetAddress: W?SN,h??iH Lhrt/e _5k.a5? License# a600s6,57 City ???y?'h State: IYlrtI Zip: ARCHITECT/ ENGINEER Company: Phone #: Name: Registration #: Street City State: Zip: Sewer & water licensed plumber (new construcdon ony): JY?d-U? GtlafG.- f?er. . Penalty applies when address chang and lot change is requested once permit is issued. I hereby acknowledge that I have read this apptication and state that the information is Correct and agree to comply wRh all applicabl State of Minnesota Statutes and City of Eagan Ordinances. Signature ofApplicank OFFtCE USE ONLY Certificates of Survey Received v Yes _ No /Not Tree Preservation Plan Received Yes No OFFICE USE ONLY BUILDING PERMIT TYPE ? 01 Foundation ? 06 Duplex M 02 SF Dweliing ? 07 4-plex ? 03 SF Addition ? 08 8-plex ? 04 SF Porch ? 09 12-plex O 05 SFMisc. 0 10 =plex WORK TYPE t 31 New O 33 Alterations ? 32 Addition ? 34 Repair GENERAL INFORMATION Const. (Actual) (Allowable) UBC Occupancy Zoning # of Stories Length Depth APPROVALS Planning ? 11 Apt./Lodging ? ? 12 Multi RepaidRem. ? 13 13 Garage/Accessory ? ? 14 Fireplace ? ? 15 Deck ? 36 Move ? 37 Demolition 04 Basement sq. ft. n_ Main level sq. ft. 2-3,o-1 ZMt- sq. ft. 21- I 442 sq. ft. y sq. ft. C-5 ' sq. ft. : Footprint sq. ft 16 Basement Finish 17 Swim Pooi 20 Public Facility 21 Miscellaneous ?? 33 MC/WS System City Water 'n ? Fire Sprinklered ?, G L PRV Booster Pump Census Code, iai 23 SAC Code Census Bldg i Census Unit ? Building nW3 Engineering Variance Valuation: $ 183,avo. ? . r?.?s?F•-n-_- Permit Fee Surcharge Plan Review License MC/WS 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 !SAC Units- sy X is. s ?3.s,r 3 1Z.5'y a, ? xc. /i 5.4.u? PL ? S Z,?y Z Y L . S _ . , Z_- `" _.r...?1 3'IK 31 ?? ?•sxq.s f7,_,z,?E ?i.s K 3z zi y Z t3-77 4o,s , c?. zs IB 2,?at. ? r 3 7. S' ??33•2 s ?6 d 16 = 2y49$.?r I `33 . 1S ,g ? 14 `y . 2 S r?'t s?/ = 84 ???k • S? 1os4 iy,ar? 1 oGB. 2 s rb ?sy' S7i C-8 s_ s (e2?/ . , . Y ? 1& 2 Family Acsidential "Cookbook" ttlclhoa S(CE ADDRESS ?OV ?? I Gty i oU1LDER JoE MlL-C.E1L 1117I"?ec, I Dale I 1 MInimum Crileria: Rim Joirt: R•19 insulauon Foundaion wodows: Insulucd glass, 112" a'u space, w'ood or vinyl frame Ennv doors: t'Ji inch solid wood tivith storm or better I STEP 1 Window & Door Area STEP 2 Calculate ama as a percenl o[ µ•all I Total Window & Door Area in Sq. Fcct WnIlNDOPlS (iaclu?',ing fcuoda:icn windows): Dimcnsions Qoty. Arca Zi CD'X 5-d' ?I+?I 75 Zx51-o11 0 'LX41-d' II ' I Z1-Con xT on f!f IIII q L? Z, 1_(a'' z 41 '-ol' X5'-a' ? ?LD zi-o'i x5?? f?il (00 X 3'_h II ? Z X z x DOORS: X(? ° 1 -10 l?x (' ' z Z- Total Area of Window & Doors ? A Total Wal] Area io Sq. FL Wa11Total Pcrimctcr Hcigh[ Area I n-7, (.?,3 l lo Total Arca .r.,,,ii -? ) ? . ?I .. J B- IIox A(window & door ana) dividcd by Boz B(cotal wall zrea) times 100 cquxls tbc window z^d door uca as a perccnt of wal] area (Boz C). soxa xioo= noXg ?-L^I c STEP3 Design Feahires ASSEMBLY oMov Fi2AME WALL: STANDARD FRAI.4NG ? ADVANCED 1=RArffNG CAVITYINSULA7ION R- Z-J S1IEATEIING: LESS TIIAN R-5 ? R-S OR hSORE WINDOWS (ezccpt foundaiion windows): U-PACTOR U-, ?j(p Prom the table, dctcrminc the maximum pcrccnt wiudow & dooc arca for thc design options scicctcd and cnicr thc value in box D bclow: LU i Boz C must be Icss ihan or equal lo Box D ! 1 _ y P. Tlie building must nol exceed lhe mai:imum window and door area as a percentage of overall exposed wall area listed below for the combination of framing technique, R-value oE insulation wilhin the insulated ca\,ity, sheathing R-value, and tvindow [I-factor. Other components must meet Ihe requirements of this subpart. MaxinTUnI SVINpoW aNn Doon Arcr:.a AS A Pf: RCtiNT OF OVGRAI.L rXPOS[D WA1.I. Cavitp WinAav U-Pactor _ Framing • fnsulalior. ' Shcaihing_ __0;49 • 06 031 p.2i ST'ANDARp R-13 ?IZ-7 13.46/6 17.8°0 21.3% 2•1.30% STANDARD R-15 2R-5 12.99a 17.1°/ 20.1 23.9% STANDARD R-18 . <R-5 , 11.1% ; 16.040 22.006 STANDARD R-18 2R•5 13.59a 18.6°6 21.89e 25.3';L AOVANC[D T2-18 <It-5 11.I0"a 17.1% 20.1°6 23.9;L ADVANCED 1i-18 2R-5 13 5°. 19.2% 22 50. 26.111 0 STANDARD Ii-21 <12-5 11.801, ; 17A01, 19.90,6 23.10,1u STANDARD It-31 zf<_5 14 00". 19.3",' 0 22.5"? 2G.196 ADVANCED R-21 .:k-5 11.8°? 16.1% 21.2/ 21.61' ADVANCI:D It-21 2ft-5 . 11.001, 19.90"6 23256 26.9°;, Subp. 3. Performance crileria. The combined lhermal transmiitance (Uo) factors for walls, rooF/ceilings, anel floors over nnheated spaces musl Ue less lhan or equal to: A. 0.110 13tu/h ftz °P for walls; B. 0.026 13lu/h f12 °F for roof/ceilings; and C. 0.04 Dtu/h ftz °P fnr floors. STATAlI7'1I: A1S§116C.19 FtIST: 78 SR ?361 7670.0480 12epenleA, ]8 SR 2361 p tl4inn. Hules Chaplcr 7670 26 ???lu: 1991 LOT SURVEY CHECKLIST FOR RESIDENTIAL BUILDING PERMIT APPLICATION , > m a i ? 0?0 0 ??0 ? ? o '??? ? ? ? a? ? 13 I9' ? ? PROPERTY LEGAL: DATE OF SURVtY: LATEST REVISION: QOCUMENT STANDARDS • Registered Land Surveyor signature and company • Building Permit Applicant • Legaldescription • Address • North arrow and scale • House type (rambler, walkaut, split w/o, spik entry, lookout, etc) • Directional drainage arrows with siope/gradient % • Proposed/exissting sewer and water services & invert elevation • Street name • Driveway 'sdn e-'[ ? • Sewer senrice (or Proposed) ? • Property corners 0 ? • Top of curb at the driveway ? &-'o • Elevations of any eristing adjacent homes Pror)osed / C7? ? ? ?' • Garege floor 0 l ? • First floor ? • Lowest exposed elevatian (walkouUwindow) ? ? • Property comers ? o • Front and rear of home at the foundation PONDING AREA Cif aoolicable) ? • Easement line ? ? • NWL ?o ? • HWL ? ? ? • Pond # designation ? • Emergency Overflaw Elevation DIMENSIONS ? ? • Lot IinesBearings & dimensions 0 ? • Right-of-way and sVeet wldth (to back of curb) 0"? 0 ? • Praposed home dimensions including any proposed decks, overhangs greater than 2', / porches, etc. (.e. all structures requiring pertnanent footings) ? 10 ? ? • Show all easements of record and any Criy utilities within those easements ? • Setbacks of proposed sVucture and sideyard setback of adjacent exdsting structures ? • Retaining wall requirements ,,if any ? Reviewed: i January 1996 CRAN31008rB1.OGPRMi FM C[TY USE ONLY + I LOT BL S RECEIPT #: SUBD. RECEIPT DATE: 1998 MECHANICAL PERMIT (RESIDENTIAL) cixY os EncAx 3830 PIIAT I4d08 RD EaGAN MIIN 55122 (612) 681-4675 Date• O? Complete this section onlv if you aze installing HVAC in single family, townhomes or condos under construction and not owner /occupied • HVAC: 0-100 M B T U $ 24.00 ADDITIONAL 50 M BTU 6.00 • Gas outleu ( minimum of one required @$3.00 ea.) t•oD • State Surchazge: .50 • TOTAL: a. SC? Complete this section onlv if you aze remodeling, adding to, or repairing eatisting single family dwellings, townhomes, or condos. Note: Mechanical permit is not reauired for alteration/add-on to ducrivork in existing residential units; but is required for the following: Install furnace _ Install air exchanger, i.e. Vanee system, etc. Minimum fee applies to all remodel or add-ons of existing residences 5tate Surcharge SITE ADDRESS: 'r OWNER NAME:- -s INSTALLER NAME: S'fREET ADDRESS: CIT'Y: 15/FORMS BLD/MECH PBRMIT (RES) - 1999 Install air conditioning Other $ 20.00 .50 Total: $ 20.50 PHONE#: '?5?74(0L'1 PHONE _ STATE: ?w ZIP: SSd ? T IG ATURE OF PERMITTEE vl? r CITY USE ONLY ?y L 1L 8L J RECEIPT#: 62.:z 8 l SUBD. RECEIPT DATE: 1998 PLUMBING PERMIT (RESIDENTIAI,) CITY OF EAGAN 3830 PILOT IINOB RD EACAN, 2M7 55122 (612) 681-4675 Please complete for: ? single family dwellings ? townhomes and condos when permRs are required for each unit D backflow preventer for underground sprinkler system FIXTURES. EACH # - TO Shower 3.00 x ? _ Water Closet 3.00 x Bath Tub 3.00 x Lavatory 3.00 x Kitchen Sink 3.00 x Laundry Tray 100 x Hot Tub/Spa 3.00 x = Water Heater 3.00 x Floor Drain 3.00 x Gas Piping Outlet " minimum - t 3.00 x Rough Openings 1.50 x Water Softener 'tor dweilings under construc[ion 5.00 X = Water Softener ' for existing dwelling 20.00 x = U.G. Sprinkler ' for dwelling under const. 3.00 = U.G. Sprinkier ' for existing dwelling 20.00 = Alterations ' to existing residence 20.00 = Water Turn Around 20.00 = Private Disposal System ' MPC iic. 75.00 = (new and refurbished systems) . Private Disposal Systems' Abandonment 20.00 = STATE SURCHARGE .50 TOTAL 01?7 60 -----------------------• ---------------- • •--------------------------------------- ------------.....---------- • ---- •- --------- • -------- I hereby adcnowledge that I have read this appliptlon, state that the infortnation is cortect, and agree to comply witli all appliceble Cily of Eagan ordinances. It is the applicanl's responsibilily to notify the properry owner that the City of Eagan assumes na liabiliry for eny damages caused by the City during Rs nortnal operational and maintenance activities to the facilities construded under this pertnit wilhin City property/right-of-way/easement. SITE ADDRESS: OWNER NAME: INSTALLER NAM STREETADDRE' CITY: /t op-Pm OGCnl- STATE: / / /N ZIP: i155U JSlFORMS BLDGlPLBG PERMIT (RESIDENTIAL) 1998 # ` ?--. ? ? ? ? CERTIFICATE OF SURVEY for /--dOE MILl.ER HOMES ?I ? ? N7 04•5g» ?4.. ?g W ?- Sf? ? ?' ? ?-,-,,o ?WL Draino9e & u1wIt epsement t r ? I F f /I (-) I /_ Lot 11, Block 5, GARDWNWQOD PONOS Dakota County, Minnesota Plat bearings shown o Denotes iron monument "I Existing? Proposed BRAIdDT ENGINEERING & SURVEYING 1600 West 143rd Street, Burnsville, MN 55306 (612) 435-1966 Suite 206 01 : cu . ?, , ?CD :z n I o` M32-1720-98 N I O N I Z , 56?. 1I ? W 5? s9 o2j F • ? ? 0 0 „?(O ------ 90.7 S?d0r10 T ? ??'?! ???'? .o J ?, j ? w • ??a ??b oy ? I oQ w, ?? I r? ? Q Qjy? I , olq ? ?,(gq/ 3 ?m 0` ,,. I =M Ic? 11 V.87 S82 28'5g••E M32-1720-99 ? 397i 14' ? ? v; r? so Q) \ .? V ? nL? ?L.J ? 0 ? / 01 ? S??I Q o ? Scale: 1" = 30' Top curb to Gar slab Top block = g94?3?_ Lowest bsmt flr = $iUL , ? 833 Govern Circle - DESCRIP710N I hereby certify that this survey, plan, or report wos prepared by me or under my direct supervision and that I om a duly Registered Land Surveyor under the Laws of the State of Minnesota. Date (J 329 19YR. f99,? Reg. No. 8140 ? W ? / ry ? _1^ ( V ? Y! ? z Use BLUE or BLACK Ink RECEIVED Permit O c/S City of Eajan 6 Ion I I 3830 Pilot Knob Road ,AN i Permit Fee: Eagan MN 55122 1 Date Received: i Phone: (631) 675.5675 Fax: (951) 675-5694 Staff. 2011 RESIDENTIAL PLUMBING PERMIT APPLICATION Date: Z Site Address: fldt~ r1 ~ Tenant: S,ruite ales RgSIDENT / OWNER Name: Phone: r ' Address i City / Zip: CONTRACTOR Name: MILBERT COMP C.dba CULLIGAN WATER Address: 1801 50THST EAST City: DMR GROVE HGIS State:' MN Zip: 55.077, phone: 651'-.'451-2241 Contact: BILL.MILBEIkf, . Email: TYPE OF WORK _ New replacement _Repair _Rebuild _Modify Space Work in,R.O.W. Descrl tion of work:.. PERMIT TYPE REtIDENTIAL Water Heater Water Softener Lawn Irrigation RPZ PVB) Add Plumbing Fbdures Main Lower Level) Septic System Water Turnaround _ New Abandonment RESIDENTIAL FEES: ` $55.00 Minimum Water Heater, Water Softener, or Water Heater and Softener (includes $5.00 State Surcharge) $35.001-2-mn irrigation'(Inch des $5.00 State Surcharge) $55.00 Add Plumbing Fixtures, Septic System band nment, Water Turnaround* (includes $5.00 State.Surcharge) "Water Turnaround (add $166.00 if a 5/8" meter is required) $105.00 Septic System New ($10.00 per as bullt) (includes County fee and $5.00 State Surcharge) $95.00 Fire Repair (replace burned out appliances, ductwork, etc.) (includes $5.00 State Surcharge) TOTAL FEES $ 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.gol)herstateonecall.om 1 hereby acknowledge that this lrn$rrnation is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that 1 understand this is riot 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 t s approved pia' in the case of work which requires a review and approval of ple X-- x Applicant's Prin ed Name Applican ghAtUte ~FOR70FFICE',USE `fiaa~ kwRev owed By 2 x Date. 1~'irfri h~.t+m~~a i f 7 d~tt'~Y~,'...... r-^•,.k; 4 111 Reuiredelnspe,ils,„dEi~! a • f Use BLUE or BLACK Ink r For Office Use I I Permit ~ ,lot, I City of Ea~a~ I Permit Fee: 3830 Pilot Knob Road I y.-~ I Eagan MN 55122 Date Received:` )3 Phone: (651) 675-5675 Fax: (651) 675-5694~`~ { I Staff: I I 47 2013 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: 3 C z> v Unit Name: C. ✓ c r 2 v r~~ Phone: Resident/ Owner Address / City / Zip: Applicant is: Owner Contractor Type of Work Description of work: 6 r.- -s Construction Cost: C;7. Multi-Family Building: (Yes / No C, J Company: Contact: Address: ( -So s-t -7 City: Contractor Zip: Phone: S L - License VIC 3 2 S Lead Certificate 2- If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) t, 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: 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. 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.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; 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'-', lJ~'ec x K-L4-7- Applicant's Printed Name Applicant's Signature Page 1 of 3 g3 C-7L-Ale/tl I rv DO NOT WRITE BELOW THIS LINE SUB TYPES _ Foundation _ Fireplace Porch (3-Season) _ Exterior Alteration (Single Family) Single Family _ Garage _ Porch (4-Season) _ Exterior Alteration (Multi) Multi _ Deck _ Porch (Screen/Gazebo/Pergola) _ Miscellaneous 01 of Plex Lower Level Pool Accessory Building WORK TYPES New _ Interior Improvement _ Siding _ Demolish Building* Addition _ Move Building _ Reroof _ Demolish Interior i 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 3 CW0 Occupancy S&- 2 MCES System Plan Review Code Edition w? SAC Units (25%_ 100%_) Zoning City Water Census Code y 3y Stories Booster Pump # of Units / Square Feet PRV # of Buildings Length Fire Sprinklers Type of Construction Width REQUIRED INSPECTIONS Footings (New Building) Meter Size: Footings (Deck) Final / C.O. Required Footings (Addition) Final/ No C.O. Required Foundation HVAC _ Gas Service Test Gas Line Air Test Drain Tile Other: Roof: -Ice & Water -Final Pool: -Footings -Air/Gas Tests -Final Framing Siding: -Stucco Lath -Stone Lath -Brick Fireplace:, Rough In Air Test Final Windows A- Insulation Retaining Wall: _ Footings _ Backfill _ Final Sheathing Radon Control Sheetrock Erosion Control Reviewed By: , Building Inspector RESIDENTIAL FEES fI37 Base Fee ~.i / r~ ~ ~Q Qr > O Surcharge Plan Review 3 MCES SAC 3~3 W l/YOo Vj 000 City SAC / Utility Connection Charge 9 S&W Permit & Surcharge Treatment Plant Copies TOTAL Page 2 of 3 ~3 yovi2~/ G i~1 inr THE 20071ir»r I $'rATE BUILDING CODE A 1.3,) 3 I Co R*e "Am Combustion appIlim foforrrtaf;on. Fumacaftibr. Draft Mood - Fan Assisted _ Direct Vent (Net fan assisted) 4 Power Vent Input I water Heater: , /51n _ Draft Hood 1!'Assisted Ind - Direct Vol (Not tan Iit+stSted) d Power Vent j Calculate the volume of the Combustion Appliance Space (CAS) containing combustion appi(anrx;s. I I The CAS includes all spaces connected to one another by code compliant, CAS volumeoaoftI " Determine AN Changes Per Hour (ACH)' ' ~ Default ACH values have been incorporated into Table E-1 for use with Method 4b (KAIR Method). if the year of construction of ACH is not known, use method 4a (gtanoard Me11I ' i Determine Required v mum for Combustion Air. r 4a. Standard Method Total Otultu input of all combustion aoolian es (DO NOT COUNT DIRECT VENT APPLIANCES) Input gtu ft Use Standard Method Column in Table E-1 to rind Total Requrced Volume (TRV) TRV: If CAS Volume (from Step 2) i4 g reater than TRV then no WOW OW N$ are needed If CA$ VDII (frorm Seep 2) Is less than TRV then go to STEP 3, 44, Known Air Infiltration Rate (KAIR) Method Total Btullu input of all fan-assisted and power vent apoliances (DO NOT COUNT DIRECT VENTAPPLLANCES) j G~"I + Input.. ~BtuI Use Fan-Assisted Appliances wlueln in Table E-1 to find Required Volume Fan Assisted (RVFA) RVFA: Total But1hr input of ell non-fan-assisted apdiances .rte _gt r Use Nor -Far-Assisted Appliances Wurnn in Table E-I to find Input., Required Volume Non-Pan-Assisted (RVNFA) RVNFA; Tptai Required Volume (TRV) _ RVFA + RVNFA TRV _ N- O + _ { q A if CAS Volume (from Step 2) Is greater than TP,V then no outdoor openings are needed. If CAS Volume (from Step 2) is less than TRV then go to STEP S. i sy Calculate the ratio of avaiL3ble Interior volume tC the total required volume. Ratio = CAS Volume (from Step 2) divided by TRV (from Step da or $fea 4b) Ratio 0` f l t CalCUtate ReduCbom Fa for (AF). r r RF =1 minus Ratio RF = t - --A ?9 Calculate single outdoor I opening as if all combustion air is from outside, Total Sturhr input of all Combustion Appliances in the Same GAS (EXCEPT DIRECT VENT) Input I l Combustion Air Opening Area (CAOA)_ Total $tulhr divided by 30DO Whir per h2 CAQA /S+¢ J 300 &Ufhr - per ins ~S4ini c' CatCUtate Minimum t~AQA, Minimum CAOA it CAOA multiplied by RF Minimum CAOA a 5 x -it : ie s . Calculate ustion Air p ning Dame r (CAOD) CAOD = 1.13 multiplied by the square root of imam CAOA CAOD = 1,13 x Mi4j;. q nimum CAQA=f-- " 'if desired, ACH can be determined using AS4RAE calculation or t>to _ ) ores m ~y - 382 ~~br. j h 4 ' '* City of Eaaall 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 r Use BLUE or BLACK Ink For Office Use Permit #: Permit Fee: b('' Date Received: Staff: L 2013 RESIDENTIAL PLUMBING PERMIT APPLICATION Date: 1 (t1-c (c 3 Site Address: S / 3,3 v 'O v c'_ �i�- C (fvG Tenant: Suite #: Resident/Owner Name: Address / City / Zip: Name: Qin Q c. fC L () 6-- License #: 1J -c ' Lc4 (` 16 41 Address: C/ c) PL.. City: AA -v- A (- �S State: kAlik Zip: S- P-0 Contact: C, A New Replacement Description of work: Phone: 4 ( `-!) `l Z c -- ) Email: Repair RESIDENTIAL Water Heater Lawn Irrigation ( RPZ / PVB) Septic System New Abandonment Rebuild _ Modify Space Work in R.O.W. Water Softener Add Plumbing Fixtures ( / /----r6wer Level) Water Turnaround RESIDENTIAL FEES: $60.00 Water Heater, Water Softener, or Water Heater and Softener (includes $5.00 State Surcharge) $60.00 Lawn Irrigation (includes $5.00 minimum State Surcharge) $60.00 Add Plumbing Fixtures, Septic System Abandonment, Water Turnaround* (includes $5.00 State Surcharge) *Water Turnaround (add $200.00 if a 5/8" meter is required) $105.00 Septic System New ($10.00 per as built) (includes County fee and $5.00 State Surcharge) TOTAL FEES $ 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.orq 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 wit . -,.•proved plan in the case of work which requires a review and approval of plan 1)4A,b (3-4. x Applicant's d Name FOR OFFICE. USE x Applicant's S', Required Inspection: Under PERMIT City of Eagan Permit Type:Building Permit Number:EA112056 Date Issued:07/25/2013 Permit Category:ePermit Site Address: 833 Govern Cir Lot:11 Block: 5 Addition: Gardenwood Ponds PID:10-28800-05-110 Use: Description: Sub Type:Fireplace Work Type:Gas Fireplace (new) Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home may require smoke detectors in all bedrooms. Chimney / flue must be inspected prior to concealing. Carbon monoxide detectors are required by law in ALL single family homes . Mallory Miller Valuation: 3,000.00 Fee Summary:BL - Base Fee $3K $88.50 0801.4085 Surcharge - Based on Valuation $3K $1.50 9001.2195 $90.00 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 - Vicki J Ishman 833 Govern Cir Eagan MN 55123 Hearth and Home Technologies 2700 N. Fairview Ave Roseville MN 55113 (651) 638-3309 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA126528 Date Issued:08/28/2014 Permit Category:ePermit Site Address: 833 Govern Cir Lot:11 Block: 5 Addition: Gardenwood Ponds PID:10-28800-05-110 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:One Window/Door Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow windows, call for framing inspection. Call for final inspection after installation. Carbon monoxide detectors are required by law in ALL single family homes . Valuation: 500.00 Fee Summary:BL - Base Fee $500 $40.00 0801.4085 Surcharge - Based on Valuation $500 $0.50 9001.2195 $40.50 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Vicki J Ishman 833 Govern Cir Eagan MN 55123 Krech Exteriors Inc 5866 Blackshire Path Inver Grove Heights MN 55076 (651) 688-6368 Applicant/Permitee: Signature Issued By: Signature Date: City of Etall 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Tenant: RECEIVED JAN 082016 Use BLUE or BLACK Ink For Office Use Permit #: ' 77 LI to "I 5 Permit Fee: 1p0 . 00 Date Received: L S L Staff: `') 2016 MECHANICAL PERMIT APPLICATION ❑ Please submit two (2) sets of plans with all commercial applications. Site Address: � &bVv V1a r - / /S_uiite #: I / Name:�1FCt.? �V I Shy Phone: ISl /- ! —70 1 �T Address / City / Zip: &S 3 (v€ v V1. CI vela ra` y1, 1/1/6 S J Name: Snelling Company License #: Address: 1400 Concordia Ave. City: Saint Paul Zip: 55104 Phone: 651-646-7381 State: MN Contact: Jody Pflipsen Email: Jody@snellingcompany.com J New R Iacement Additional Alteration Demolition Description of work: r��F/ Q I L IACt-e-Q- RESIDENTIAL Fumace XAir Conditioner Air Exchanger Heat Pump Other COMMERCIAL New Construction Interior Improvement Install Piping Processed Gas Exterior HVAC Unit Under/Above ground Tank ( Install /_ Remove) RESIDENTIAL FEES $60.00 Minimum Add or alteration to an existing unit, includes State Surcharge $100.00 Residential New, includes State Surcharge COMMERCIAL FEES $60.00 Permit Fee Minimum $70.00 Underground tank installation/removal Surcharge = Contract Value x $0.0005 If the project valuation is over $1 million, please call for Surcharge l0 0.0 0 TOTAL FEE Contract Value $ x .01 = $ Permit Fee _ $ 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 which requires a review and approval of plans. x Philip Krinkie Applicant's Printed Name x Appli Date: City of Eakall 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 JAN 1 5 2016 Use BLUE or BLACK Ink For Office Use Permit #:, 3/"*`'J i l LI Permit Fee: VO • 0 0 Date Received: I 15 - 1 19 Staff: Sb 2016 RESIDENTIAL PLUMBING PERMIT APPLICATION 1.12.2016 Site Address: 833 Govern Circle Tenant: Craig & Vicki Ishman J Name: Craig & Vicki Ishman Address / City / Zip: 833 Govern Circle Phone: Suite #: Eagan, MN 55123 Name: St Paul Pipeworks Address: 2325 Buford Ave State: MN Zip: 55108 Contact: Charlie Avoles Phone: License #: PC644728 City: St Paul 651-644-9400 Email: charlieavoles@comcast.net New X Replacement _ Repair _ Rebuild _ Modify Space _ Work in R.O.W. Description of work: RESIDENTIAL X Water Heater RESIDENTIAL FEES: $60.00 Water Heater, Water Softener, or Water Heater and Softener (includes State Surcharge) $60.00 Lawn Irrigation (includes State Surcharge) $60.00 Add Plumbing Fixtures, Septic System Abandonment, Water Turnaround* (includes State Surcharge) *Water Turnaround (add $280.00 if a 3/4" meter is required) $115.00 Septic System New (includes County fee and State Surcharge) Lawn Irrigation ( RPZ / _ PVB) Septic System New Abandonment Water Softener Add Plumbing Fixtures ( Main / _ Lower Level) Water Turnaround TOTAL FEES $ 60.00 CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.qopherstateonecall.orq I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that 1 understand this is not a permit, but only an application for a permit, and work is not to start without a per it; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of play,. x Charlie Avoles Applicant's Printed Name x Applicant's Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA142133 Date Issued:04/14/2017 Permit Category:ePermit Site Address: 833 Govern Cir Lot:11 Block: 5 Addition: Gardenwood Ponds PID:10-28800-05-110 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:Two or More Windows/Doors Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow windows, call for framing inspection. Call for final inspection after installation. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State 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 - Vicki J Ishman 833 Govern Cir Eagan MN 55123 Krech Exteriors Inc 5866 Blackshire Path Inver Grove Heights MN 55076 (651) 688-6368 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA148027 Date Issued:02/28/2018 Permit Category:ePermit Site Address: 833 Govern Cir Lot:11 Block: 5 Addition: Gardenwood Ponds PID:10-28800-05-110 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:Two or More Windows/Doors Census Code:434 - Residential Additions, Alterations Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow windows, call for framing inspection. Call for final inspection after installation. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State 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 - Vicki J Ishman 833 Govern Cir Eagan MN 55123 (651) 271-7014 Krech Exteriors Inc 5866 Blackshire Path Inver Grove Heights MN 55076 (651) 688-6368 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA150263 Date Issued:06/27/2018 Permit Category:ePermit Site Address: 833 Govern Cir Lot:11 Block: 5 Addition: Gardenwood Ponds PID:10-28800-05-110 Use: Description: Sub Type:Windows/Doors Work Type:Replace Description:Two or More Windows/Doors Census Code:434 - Residential Additions, Alterations Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow windows, call for framing inspection. Call for final inspection after installation. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State 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 - Vicki J Ishman 833 Govern Cir Eagan MN 55123 (651) 271-7014 Krech Exteriors Inc 5866 Blackshire Path Inver Grove Heights MN 55076 (651) 688-6368 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA170764 Date Issued:07/15/2021 Permit Category:ePermit Site Address: 833 Govern Cir Lot:11 Block: 5 Addition: Gardenwood Ponds PID:10-28800-05-110 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 - Craig G & Vicki J Tstes Ishman 833 Govern Cir Eagan MN 55123 (651) 687-1117 Krech Exteriors Inc 5866 Blackshire Path Inver Grove Heights MN 55076 (651) 688-6368 Applicant/Permitee: Signature Issued By: Signature