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4650 Kingsbury DrCASH RECEIPT CITY OF EAGAN 3795 PILOT KNOB ROAD EAGAN, MINNESOTA 55122 DATE RECEIVED FROM 19 AMOUNT $ I & DOLLARS 1 oo ? CASH F-I CHECK FOR UND COOE AfAOUNT Thank You ? B V - ' White-Payers Copy Yellow-Poating Copy Pink-File Copy ? ----- _ ---------------- INSPECTION RECORD CITY OF EAGAN PERMIT TYPE: 3830 Pilot Knob Road Permit Number: I Eagan, Minnesota 55122-1897 Date Issued: ( (612) 681-4675 ? Pt ti? ?',i7E 4 ti ? t7' SITE ADDRESS: APPLICANT: ,,. if W ??N ?! ?! 1 t c, t.• , ,' stt ? t c?r,.? PERMIT SUBTYPE: th, I TYPE OF WORK: i: F t" r1 'f k F;t)la(`TN k0M 1 N .1, . Parmit No. Parmit Holder Dete Telephone M ELECTRIC PLUMBING HVAC Inspection Dats Insp. Commenta FOOTINGS FOUND FRAMING ROOFING ROUGH PLUMBING PLBG AIR TEST ROUGH HEATING GAS SVC TEST INSUL GYPBOARD FIREPLACE FIREPLACE AIR TEST FINAL PLBG FINAL HTG ORSAT TEST BLDG FINAL BSMT R.I. BSMT FINAL DECK FTG DECK FINAL Receipt ? PLUMBING PERMIT Permit No. CITY OF EAGAN Fee fill !n numbered spaces S/C Type or Print /egibty _ Tot. I 1. Date 2. Installation Cost ' 3. Job Address Lotv " Blk. Tract ? I 4. Owner i I 5. Contractor ' - Phone " 6. Address 7. City State Zip _ I 8. Building Type: Residential 0 Commercial ? Institutional ? 9. Work Description: New ? Add ? Alter ? Repair ? 10. Describe 11. No. Fixtures Water Closet No. Fixtures Ce l/Dr i field _ Bath tubs n sspoo a Se tic Tank Lavatory p Softner Shower Well _ Kitchen Sink Urinal/Bidet Othe _ Laundry Tray r Floor Drains Drinking Ftn. Slop Sink Gas Piping Outlets 12. I hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : for Rough Final Inspections: Date Insp. Date _ Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-8100 CITY OF EAGAN Remarks Addition BEACON HILL ADDITION Lot 8 plk 4 Parcel 10 13500 OSO 04 Owner.0 st,eet 4650 Kingsbury Drive state EaQan, MRd 55122 Improvement Date Amount Annual Years Payment Receipt Date STREETSURF. 1982 1806.93 200.77 9 1806.93 C007580 10-1-81 STREET RESTOR. GRADING 95 1982 526.46 58.50 9 526.46 C007580 10-1-81 SAN SEW TRUNK ' Q * SEWERLATERAL 1982 3116.46 346.27 9 311 .46 C007580 10-1- 1 WATERMAIN * WATER LATERAL I982 J WATER AREA 1982 198.01 22.00 9 198.01 C007580 10-1-81 * Stubs 1982 9 STORMSEW TRK (? Z 1982 359.82 39.98 9 359.82 C007580 10-1-81 * STORM SEW LAT 19$2 9 CURB & GUTTER SIDEWALK STREET LIGHT Ro WATER CONN. 19 BUILDING PER. 6716 sac 1981 PARK „ ?i'C?aR?d toM 4 .? . BUILDING PERMIT Te be used fer , (034 Ca+tibm tlWE Ar• LIt BS1 Bfacen 14 Us CITY OF EAGAN 3795 Pilot Knob Road Eagan, MN 55122 N2 6716 PHONE: 454-8100 Receipt .# 67_0$` -7 _ _ $ite Address tlb Sb tC ( i?e S l l,i p r• Lot g Block Sec/Sub. Parcel # lx Nome W ; Address ?' "1 ??82'riEl Iid. o - _ - • ;1 tcm o Nome _ Erect p Occupancy Alter ? Zoning Repnir ? Fire Zone Enlarge ? Type of Const. Move ? # Stories Dertrolish ? Front fr. Grade ? Depth fr. Aoorovals Fees OU Address Assessment Permit F C. Phone Water 8 Sew. Surchorge F Police Plan check WW Name Fire SAC ? ?? Address Eng. Water Conn. aW Ci Phone Plonner WaterMeter Council Rood Unit I hereby eckrrowledge that I have read this application ond state that gldg. Off. the informotion is correct ond agree to mmply with all applicoble - State of Minnesota Statutes and Ciry of Eagnn Ordinances. APC Total Signoture of Permittee A Building Permit is issued to: ` on the express condition thot all work sholl be done in eccordunce wiTh oll applicable State of Minnesota Statutes and City of Eogan Ordinances. Building Officicl P*nsit # - pab larW PawIIfM Plumbin9 2q3b a. Y.I\Z - ?2 0. f\, Mechonical A(p?U -£r? 4j) F ( r Tq8-7a g' tc- t INSPECTIONS DATE ibo(.1siVF_ INSP• Rough-In Final FoOtings - DaTe Ins . Date Irop. Foundation Plumbing t- 0 ? Frame / ins. .Qf Mechanica I _ Final - ? ? Remarks: Receipt PLUMBING PERMIT Permit No. .? 3 '*X- CITY OF EAGAN Fee Fill in numbered spaces S/C Type or Print /egib/y Tot. 1. Date 2. Installation Cost 4(usc, Kcrqsbur.*'b r, 3. Job Address Lot Blk. ?7 Tract 4. Owner 5. Contractor Phone 6. Address - ; ? 7. CitY ? State ?' ::?i: Zip `. 8. Building Type: Residential El, Commercial ? Institutional 0 9. Work Description: New,Q Add ? Alter ? flepair ? 10. Describe 11. No. Fixtures Water Closet No. Fixtures ool/Drainfield CesS _ Bath tubs p Septic Tank _ Lavatory Softner _ Shower Well Kitchen Sink Urinal/Bidet Other _ Laundry Tray Floor Drains Drinking Ftn. Slop Sink Gas Piping Outlets - ?. 12. I hereby certify that the aboye information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : for Rough Final • Inspections: Date Insp. Date Insp. . This is your permit when numbered and approved. ARproved CITY OF EAGAN 454-87 00 Receipt MECHANICAL PERMIT CITY OF EAGAN Fill in numbered spaces Type or Prini/egib/y 1. Date -1l,-$1 2. Insiallation Cost Permit No. Fee S/C Tot. 3. Job Address Lot Blk. Tract 4. Owner • 5. Contractor -? -?`i ?, . • Phone 6. Address «??37 Ck13C?;?7ci o. 7. City . State :!. Zip jri' 8. Building Type: Residential El 9. Work Description: New ? Commercial O Institutional ? Add ? Alter ? Repair ? 10. Describe ?. °ceci aiI' he, :t nLfuelType :Tat g,.: 11. No. ? Equioment 9TU - M. Ea. Forced Air No. Equipment CFM Ai H dli Mfg. r an ng: ? Boilers Mfg, - Mech. Exhaust Unit Heater Mfg. Other _ J_ Air Cond. Mfg. 1_ Gas, Piping Outlets 12. I hereby certify that the above information is true and correct, and 1 agree to , comply with ?Il ardinances and codes governing this type of work. Signed : for i f Rough Final IAspections: Date Insp. Date Insp. +• This is your permit when numbered and approved. tApproved CITY OF EAGAN 464-8100 ?- CITY OF EAGAN 9795 PNof Knob Roed Eegan, MN 55142 -.'r . _) e PHONEs 454-8100 BUILDING PERMIT ReceiPt # To be w.d hr DECK Ese_voiue $2,000 oatP June 20 1953 Siro Addreu 4650 t:inaabury Drive Lot 8- Biock _}_ $ea/Sub. Beacon Hill pa,ui # 10 13500 080 04 W Name -- llarold Htivden ; Add^ess 4650 Kin$sburv Drive ? Name Owtler Z o?u Address Nome _ Addresa I hereby acknowledge that 1 hove read this opplication and stote that the informotion is correct ond agree to comply with ull applicnbla State of Minnesoto Stotutes amd, City of Eagan Ordinonces. Sipnoture of Permittee P-f ? , ???r ' aro d Hay en Erect }M Occuponcy Alter ? Zoniny Repolr ? FIrc Zone Enlarpe ? Type of Const. Move ? ,{k Stories Demolish ? Length Grode ? Depth Sq. Ft.- AvVrorals Faes Assessment Permit 32.50 Water 8 Sew. Surcherge 1.00 Police Plan check Fire SAG Eny. Water Conn. Planner Woter Meter Council Road Unit Bldg Off . . APC Total A Building Permit Is issued to: on tha express cordition thai all work sholl be done in accordonce with all applicable Srote of Minnesoto Stmutes ond City of Eoqan Ordinances. Buildinp Official -- .<_ Parmit No. Permit Halder Mise. Psrmit No. Holder Mesa Plumbing H.V.A.C. Wall Wrtar Disp. Sawer Eketric InspeMion Date Insp. Other Footings -j7 w Foundetion Framinp Rouph Plbp. Rouph HVAC Inwlation Final Plb¢ Final HVAC Final ? Watar Deuri6e Location: Wel I Sewer Pr. Dbp. cirr :F EAGAN SEWER SERVICE PERMIT 3795 Pllat Knob Rood PERMIT NO.: Eagan, MN 55122 DATE: ZO^'^g: No. of Units: Owner: Address: Site Address: - Plumber. I aarea M ownon, wRh eM Cky of Eagon Connedion Charge: Ordiaanees. Account Deposit: Permit Fee: . Surcharge: By Misc. Chorges: Date of Insp.: Total: I'5p.: D t P id c e a : ' EAGAN 3: 05 Fsiot Knob Road Eagan, MN 5512Z - Zoning: Owner: Addtess: ..S'O Site Address: Plumber. Meter No.: Size: Reoder No.: I e9?ee to eomplr wkh !6a Gfy of Eagon Ordinaneos. By Dote of Insp.: WATER SERVICE PERMIT PERMIT NO.: DATE: _ No. of Unirs: 2 ? Connection Chorge: Account Deposit: Permit Fee: Surcharge: Mlsc. Chorges: Totol: Date Paid: ? ? WATER SERVICE PERMIT CITY OF EAGAN 3)55 PiIM Knob Road PERMIT NO.: Eagan, MN 55112 DATE: Zoning: No. of Units: Owner . - Address: Site Address: . r I? "l Ylt'aCLrI "111.1-` Plumber: --- Meter No.: Connection Charge: S Acwunt Deposit: ize: R N d Permit Fee: o.: ea er n Cit f E l i h h I Surcharge: y o aga y w a agree M eomp F ! Charges: Misc Ordinanees. . Total: Dote Paid: gy Date of Insp : Insp•: . CITY OF EAGAN SEVNER SERVICE PERMIT 8713 Pilaf Kno6 Road PERMIT NO.: Eagan, MN 55122 DATE: ZO^i^9: No. of Units: Owner: Address: Site Address: Plumber. 1 ogrea to oomply with iM Cify of Eagon Connection Chorge: Ordinaneet. Account Deposit: Permit Fee: Surcharge: BY Misc. CFwrges: Date of Insp.: Total; Ir15D.: . 1),.ha On:.l• CITY OF EAGAN Include 2 sets of plans, . ? ? 1 site plan w/el,evations & BUILDING PERNILT APPLICATION 1 set of energy calculations. Zb Be Used For ?le c Valuation `;q(??OO Date c,rl C o7d /Y-9 3 51t2 Addr2SS: !{Gi .5 n K inu S LJdV [/?iJP Lot $ Block ? Sec./Sub"y\, 4A( Parcel #: (D d Owner: ioto r a li /A vW1. N Address: v City/Zip Code: ?a s ? Z Z Pnone #: Contractor: ,? ?E?? Address: ? Gity/Zip Code: Phone #: ?j Arch./B7ig. : Address: City/Zip Code: Phone #: OFFIGE USE ONLY Erect ? Occupancy _ Alter Zoning Repair Fire Zone Enlarge 'Iype of Const. Nbve # Stories Demolish Front ft. Grade Depth ft. APPROVAI,S FEES Assessments ' PeYnut Water/Seaer Surcharge / -- Police Plan Check T Fire SAC Eng, water Conn. Planner Water Meter CounCil Road Unit Bldg. Off. APC ? - TarAL mmnesVaa aia[n noara or uecancIry Griggs Midway Bldg. - Room N191 E? 00 ? 2_f? . 582f University Ave., St. Paul, Minn. 55104 - Phone 297-2111 ?_Ee REQUEST FOR ELECTRICAL INSPECTION CHECK BELnNLWORK COVERED BY THIS REOUEST T 49728 Type of Building Ne Add. Rep. Check Appliances Wired Foc Check Equipment Wired For Home ? ? Range poi Temporary Wiring ? Duplex ? ? Water Heater Lighting Fixtures ? . Bldg. ? ? ? Dryer Electric Heating . "U imetcial Bldg. ? ? ? Furnace Silo Unloader ? ndustrial Bldg. ? ? ? Ait Conditionec Bulk Milk Tank ? Farm ? ? ? List List Other ? ? ? o Heiers? Hehe=S? COMPUTE INSPECTION FEE BELOW ao 'a0 Service Entrance Size: # Fee Feedera&Subfeeders: # Fee Circuita: # Fee 0 to 100 Am s. 10 0 to 30 Am eres 0 to 30 Am eres 101 to 200 Amps. 1 31 to 100 Amperes 31 to 1 Amperes Above 200 A Amps. 4 Above 1mps. Tcansformers 1 RemoteControlCi:c. Partialofee Signs Special Ins ection Minimum fee $5.00 Remarks ?' 1 TOTALFEE y? 0 1, the E1 Q"" trica7'Inspector, hereby cer ' •at e iqspection has beeg.ma ? (Rougha'?r Date ? (Final) Date This request void 18 months from This request"void°? LB', 3V, BFc?ai i v q7 c o d 18 months from ? Date of this Request ? 1 JSC ? Fire No. ?48728 I, a}?Licensed Electrical Contractor ? Owner, do hereby request inspection of the above electri- cal a•ln?g installed at: Street Address or Route No, ?tY E?.? ? *on Township R?ge County ? Which is occupied by (Name of Occupant) !s a roughin inspection required on this job? No O Ye.0( Ready Now O Will Cal}04 Power 3upplier kh Address W-h io 4 Tzy Electrical Contractor C- _ Contractor's License NADI-T ` (Company Name) Mailing Address n [uw- AaAA < <?a? ncracto or Owner Making This Installatlon) Authorized Signature ` ° ?q P Phone Nu. LS j,D` S?vJ iiacuicar?onvactor or Owner Making This Installatlon) ---'-? 20??O CU" ??Y This inspectian request will not he accepted by the w fn1L1U State Board unless proper inspection fee is enclosed. iUr#iftrttt.e? nf wrrupttnrij Citp, of (Eagan ' " .. : - . . . , _. , EP}iMTftltPttt ii# Bltilat2tg lIw#iPl't[11ti . , -- - . .. _ . ; sjy:? .?? Thir Ce+ti ficate u.rucd ?rrruant to tbt,rcquisrmenu of 3uaon .306 0/ tlx Uniform Building Codc arti f ying ihat at thc timr o f i.anana tbi.c tlruituri wai in cmnplianci with the variour ordinanas of thcCity rrgrdating bnilding connruction or ux Foi thr follounng: -' g ;. - -SF'DWG/GARtxY4r}5'??g?>???? 6l16 IHe Cymffkayao &de. Permit No 00-warTYoe R3 Tywc?uw v FiroZone NA ' u" n;.mn Rl a,= of?„. Centes Homes •,;,d,? 8601 Darnel Rd., Eden Prai B,,,,;,gA,,,m 4650 Kingsbury Dr. ?ty Lot B,Block 4,Beacon Hill by _ eWMingofficial Dau September 28, 19$1 , . . , ? . . . . , s; .. 1': ' rosi w w ew?ncuou? wwci . ooeea ?e, -- --- -- urno?x u.vn. G?. ?? ?1L l.? Y lP(? w /? ?.Y 1 Z OF F-AaV'P ? BLTILDING PE:RMIT APPLICATION To Be Used For Addres valuation n L3-19?t $F0,c611- Include 2 sets of plans, 1 site plan w/elevations & 1 set of energy calculations. _ Date ?? /?? OFFICE USE OAILY Sl? S. ?r.z?-. y . .... . . -?.. ` T n Ipt ? Block ? Sec.fSub. a_x Erect` X ???1' Q / ? Q ??r Zoning ??- 1 ? J? s C7 O pair Fire Zone Parcel #: v Enlarge `iype of Const. Owner: Nbve # Stories Address: Dennlish _ Front ° fft. t. Grade Depth _ y?- City/Zip Code: yf? Pr,one #: 9y1-106& ' APpFOvALs FEES Contractor: ?al2n? Address: CityJZip Code: Phone #: Arch. /?'ig. : _ -_!5z?" C Adciress: Assessments peam-t 'Z?? ? Water/Sewer Surcharge o? S Police Plan Check / 0 7 Fire SAC ?sTJ Eng. Water Conn. 33s planner . Water Meter ` ?-- Council _ Road Unit / ? ? Bldg. Off. APC City/Zip Code: Phone #,. ? - - CITY OF EAGAN ?J /?? k?? 3795 Pilot Knob Rood Eagan, MN 55122 55,6? ?PHONE: 4548100 `7 BUILDING PERMIT APPLICATION Receipt To 6e uaed f? .Sr' M'r/GAR Est. Volue $100.000 Date _ Site Address Lot Block Sec/Sub. BeBCOII Hill8 Parcel # l(1 1,3500 Q10 05 s Name .C2Slt?]LflOmr+R 3 Address 8601 Darnel Rd. ? _ _ _ _. Ai t GLT W. Name ?1nLT - ? ?? Address f !':+.. DMnnn Nome Address I hereby acknowledge that I hove read this application and state that the information is correct and ugree to comply with all applicable Stote of Minnesota Statutes and City of Eagan Ordinances. N° 6716 # ar5? ? ? Erect ol Occupancy Alter ? Zoning RI - Repair ? Fire Zone NA Enlarge ? Type of Const. Y Move ? # Stories - Demolish ? Front 60 ff. Grade ? Depth 42 ft. Aoorovols Fees Assessment _ Water & Sew Police Fire Eng. Plonner - Council - Bldg. Off. _ APC Permit 1 Surcharge 50.00 Plan checlc107.7L 5AC 525.00 Water Conn. 335-00 n WaterMeter 60_0 Road Unit 185 _ 00 Total $1478_25 Signature of Pertnittee I A Building Permit is issued to: C@At2% HOID@8 on the express condition that oll work shall be done in occordance with all applicable Stprq of Minnesota St tes and City of Eagon Ordinances. Building Official ? ' CITY OF EAGAN N• ? $166 3795 Pilof Knob Raod Eogon, MN 53122 " PHONE: 454-8100 BUILDING PERMIT Receipt # Te bs ased ior DECK Est. Value $2,000 Date June 20 1 q 83 Sire Address 4650 Kingsbury Drive Erect XN OccuPOncy Lot $ Block 4 Sec/Sub. $eaCOn H711 Alter ? Zoning porcel # 10 13500 080 04 Repoir ? Fire Zone W Name Darold Hayden 9 z Addreu 4650 Kingsbury Drive rl...Eaizan 55122 06..__ p Name Owner r ?? Address ~ Cit Phone u? W Name FW ?? Address <'Z" Ciri Phone I hereby acknowledge that 1 hove read this application and state that the informotion is correct ond ogree to comply with all opplicoble State of Minnesota Smtutes City f ogag ?OLrdisonces. / fs ? Signafure of Permittee A Building Permif is issued t aro ay en o: all work sholl be done in accordonce with ell oppliwble 8uilding Offfciol Enlarge Q Type of Const. Move p # Stories Demolish ? Length Grode ? Depth Sq. Ft.- Approvals Fees Assessment _ Water & Sew. Police Fire Eng. Planner - Council _ Bldg. Off. _ APC Permit 'J°'-"v Surchorge 1.00 Plan check SAC Water Conn. Water Meter Rood Unit Total $3-1-5n Minnewta on the express condition thn+ and City of Eagan Ordinontea. jo?Yi?f7?i.'.',i:??:4iCi.•`,:}?Si(?)?O??.?iY.!i?...?n..uGY?Il?:s:?!;1:.?..J`}?`?;f.iU)?C.B???:Fi:?C)i:')?i C:f.'r4' Of-- EAGF:N ('! a?ne ..a ?"n,i:?_I'i'?::1?`u T ..:-,...:?,..,_.t. .: ?::??1,N.!.IVi1I... ii:J,? ;,1. T„ti j??:r. ? :'::11:J:ii `7ir, ?T ?i'i:'. _ f .?1: , ; ;t?j r .. i. .IP-.V.... ,?..... _?...?.??r., \h',i ;iC.. '. `'if? ?' ;::.?•i ?:'??.'I?_?f. ..1\la F `:}•.i?j(l :,^(jj'}•i ?.(:.r.:?j.} i;.j.r??..r?.????_? t.. \ea:}AFI.?'... ?f (?. ??•.,(? . . . ........ .??...._: ..r._...) jl.ic:?cr 9001 r.i.F??.`7[1 ?'l'\?n? ,?i ??...1?:.?-%Ijt.i?.. `?? i.50 _.i..._..l ... _ r?l';?;1.?. ,..'(:PC?"i •}cr _ ?..? .k:? ?: (-?,4;;'i?_''^:'?; ? „ i _ .i..,.c....? !. , C!'t(7@:,''::;'i:ir+ . U`_;!::.R I.Y.tr, ;'.Ji`t7';i:;Y .,...../....?s.•dq.;t:?ry:.p4{.p.?fth^.?I`?j.:;.:?.ef.n,,..:.P-?1?`.?.iitii.:;:?rqz ?'.?A}?.M1)(4(?I+ ,_ PERIVIIT -?'CITY OF EAGAN 3830 Pilot Knob Road PERMIT TYPE: B U I L D I N G Eagan, Minnesota 55122-1897 Perinit Number: 029027 (612) 681-4675 Date Issued: 10/ 10 J 9 6 SITE ADDRESS: 4650 KINGSBURY DR IQT: 8 BLOCKc 4 BEACON HILL P.I.N.a 10-13500-080-04 DESCRIPTION: (RQQFIN6) Permit Type 0Vqrk Type eT?? S 5F (MSSC.) REPATR 434 ALTe RESIDENTTAL RENlARKS: FEE SUMMARY: vaLuaTxoN $3,000 Base Fee Surcharge Total Fee c COIVTRACTOR: - Applicant - 5T. LIG OWNER: SATHER RQOFING 17381062 0005254 WOLTER sILL 457 GROVNER AVE N 4656 KINGSBURY DR OAKDALE MN 55128 EAGAN MN (612) 788-1062 (612)452-4157 t , APPLICANT/PERMITEE SIGNATURE $74.75 $1.59 $76.25 -?I nED B Y. SI J TU E? CITY OF EAGAN 3830 PILOT KNOB RD - 55122 lq-0211996 BUILDING PERMIT APPLICATION (RESIDENTIAL) 681-4675 New Canstrudion Reauirements ? 3 registered site surveys ? 2 copies of plans (include beam R window sizes; poured fid. design; etc.) ? 1 energy calculations ? 3 copies of hee preservation pian iF bt pletled atter 711/93 Y Remodel/Renair Reauirements ? 2 copies oF plan ? 2 site surveys (exterior additions & decks) ? 7 energy ealculations for healed additions requved. ss No ? _ ? DATE: c l?Z CONSTRUCTION COST: ?? DESCRIPTION OF WORF STREET ADDRESS: LOT 91 BLOCK I SUBDJP.I.D. #: I-? ?? ? r4ill, PROPERTY OWNER GONTRACTOR ARCHITECTf ENGINEER Name: R i I Phone #: ucr , swsr , , A?, Street Add V City: q ti State: Zip: Company: ??,v' Ph?on #: Street Address: V? c? ?`/ vE( ?,/ Lice Cit???,4 ? State: ?. ? ? Zi?•?J ?°?- ? Company: _ Name: 5treet Address: City: Sewer 8 water licensed plumber: change are requested once permit is issued. State: Zip: Penalty applies when address change and lot I hereby acknowledge that I have read this application and state that the in ation is correct and agree to compiy with all applicabfe State of Minnesota Statutes and City of Eagan Ordinances. ?1--p Signature of Applicant: OFF{CE USE ONLY Certificates of Survey Received _ Yes _ No Phone #: Registration #: Tree Preservation Plan Received Yes No OFFICE USE ONLY . . ft a •.? . ; 4,rt3, ... ? . BUILDING PERMIT TYPE ? 01 Foundation ? 06 Duplex ? 02 SF Dwelling o 07 4-plex 0 03 SF Addition ? 08 8-plex 0 04 SF Porch ? 09 12-plex n 05 SF Misc. ? 10 = plex WORK TYPE ? 31 New o 33 Alterations D 32 Addition ? 34 Repair GENERAL INFORMATION Const. (Actual) (Allowable) UBC Occupancy Zoning # of Stories length Depth APPROVALS Planning ? 11 Apt./Lodging o 16 Basement Finish ? 12 Multi Repair/Rem. ? 17 Swim Pooi ? 13 Garage/Accessory ? 20 Public Facility ? 14 Fireplace ? 21 Miscellaneous a 15 Deck 0 36 Move ? 37 Demolition Basement sq. ft. Main level sq. ft. sq. ft. sq. ft. sq. ft. sq. ft. Footprint sq. ft. Building Permit Fee Surcharge Plan Review License MC/WS SAC City SAC Water Conn. Water Meter Acct. Deposit S/W Permit S/VN 5urcharge Treatment PI. Road Unit Park Ded. Trails Ded. Other Copies Total: Engineering Valuation: $ MCIWS System City Water Fire Sprinklered PRV Booster Pump Census Code. SAC Code Census Bldg Census Unit Variance % SAC SAC Units Ce`rtiPicate for: Centex Aanss lRidwest Inc. 8601 Darnell Road Bden Prsirie, Mln. 55344 ?? . ? .? Top le,"'8: ?sse0l?t Mook g, tioms" , 1 Pebl'u9" DELMAR H. SCHWANZ LANDSURVEVOR RpfstoW UnMr l+wf Of TM State of Mfnmwta 11!? {49TM lTREET W. - BOX M R MINNBSOTA QlOd! ? SURVEY ?h ClRTIftCATE O N 'I..._ At tl W, L40.00 _ 5 890 15W *;?` 0 o e ?r v ?. i ^ 33 1 1789 pMONEr 0 m . ,? 1 ?, ??? I o o a . ? ? o -se-- I - I . - JS 4t7,oc) 890,5a\3z" F_ ?Danotee proposed elevatian Garage F1ooT that tKie ia a true and corre4t AILL9, according to the reaorded a. 1981 Benchmsrk s CenRerlins centerliae Hill Road $levation - 944.00 ft. ohm prwPcaed house dune 3. 1981 ;. , . Y_ S I a? ? 3D "1?? : tr. smntation of Lot 1, , thereof, Dakota Road and Beaarnn ' Ce??ti ficate for : ., Cetstex Romss MidNest Inc. $601 Daretell Road Bden Prairie, Mhs. 55344 AM ? ? ? . ? . ? ? 30 DELMAR H. SCHWANZ l,ANO SUiiV EVOR Rpiftered UndM laws of Tht Slott OI MieeMOti "TM sTNEET W. - BOX M R ? MINN680TA l1Ob! SURVEY ?? CERTIFICATE EN T 0 W t-. At f?l L4/soo S B9° Ist3 sz" er ,es proposed elevation s??? N o.ov 'S 69° 3E?' lbz" W? ' czo? ?¢Z•33 0 ? 4 0? -? 3 ° t m -1°'? _ ? 12,3 o . a WOE- o a ? tv o ? 30 13 .?--- ? Top af B1ock _ Bamemmt n9or Garage Floor ?'?•+''0?4z3' 0 m I'`here11y osltlty /that thie is a true and eorreot re 7 Moak i, BMW ,HILL.4, according to the reaorded plao, ftuvo3, mimwsexa. i aabruel* 30 lool Bencheuice Csaterlirte ceaterli" Hill Roed Blevatioa - 944•00 ft. / Asvised to efiow groPoeed house June 3r 1981 j ?. ?. #.: ?' . . " . . .. sestation oP Iat 1,, thereof, Dakota Road aakd Beatson r ?7 MINNE50TA E iSTHATION N0.88Z6 .+ .. pfi'.. ..' F r . j-- i ?T ?-- ? ? . '? ?; I ii , __ _ S• ? ? ? ? ? ?I?- ?? I? I ' i ? ? ? i ? ? I , I . ?-. ??. '? 1 ' ?? I I ? i ? ?• - I ; ; ?i----;;- ??-+l----? I I I I i ?? , . ` V'?.T?I i-- J I l 40 I I I ? I T --?-?-- r-='?---I , , ,. ' , - I , I? , ---- _ - - ? Certificate Por: ri?S-o ??11C?Sb? L?'t t?EL 3*?n f-?c`(CS Centex Homes Midwest Inc. `C (\ 8601 Darnell Road Eden Prairie, Mn. 55344 ??(IN DELMAR H. SCHWANZ LANOSURVEVOR 30 RpisterW UndOf Laws O! TM Sbte of Minnesota 8- 146TH STREET W. - BOX M ROBEMOUNT, MINNESOTA 55088 PHONE 813 C?-7769 ? Zi-?-, SURVEYOR'S CERTIFICATE nN_ ii y ?. r \9 ? 4arage floor Top of Block ? a \; Qoh?hb \ , ?-- .• Hasement floor 0 SCALE: 1 inch = 30 feet QDenotse proposed elevation y ? z? , ? Drainage & utility ,, easement 6 ` Benchmark: Centerline centerline C11Pf Rd. and Heacon Hill Rd. Elevation- 944.00 ft. ? I ' , ? /q48o ? "i /?ro ??. I hereby certlfy that this ia a true and correct representation oP Lot 8, Block 4, BEACON HILL, aceording to the recorde8 plat thereof,- Dakota County, Minnesota. Dated: January 28, 1980 Revised to show proposed houa• July 16, 1981 I ^f, ' ? ?i?.C/f I /'? 1 ?IJ /,??1, ?',+/ !.?" _{ i? MINNESOTA REGISTRATION N0.8625 ' (.. 2004 RESIDENTIAL BUII.DING PERMIT APPLICATION City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 FAX # 651-675-5694 ? S-? 0 .C) d New ConsWction Reouiremenfs RemodellReoair Reauirements 3 registered sde surveys showing sq. ft o( lot, sq. ft oi house; and all roofed areas 2 copies of plan '???' (200/o maximum bt coverage allowed) 1 set of Energy Calculatlons for heated additions Tree Pfes PtanReK?r 7 2 wpies oi plan showing beam & window sizes; poured found design, etc. 1 site survey for additions & decks ""?4:?' lsetofEnergyCalculaUons Add'rfion-indicateilon-sitesepticsystem Qns?t,¢Setp.tic"System,,,.,? ??Ni 3 copies of Tree Preservation Plan'rf lot platted after 711193 Rim Joist Detail OpBons selection sheet (bldgs with 3 or less units Date Construction Cost L Site Address UniUSte # Description of Work , Multi-Family Bldg _ Y_ N Fireplace(s) _ 0_ 1 _ 2 O Telephone # (6SI ) wner Property Contractor ?2&? Address fh State Cit3' Zip ? Telephone #('X3 );Wf.s l COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Energy Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672 Code Category ? . Residential Ventilation Category 1 Worksheet New Ener9Y Code Worksheet (4 submission type) Submitted Submitted . Energy Envelope Calculations Submitted Have you previously constructed a building in Eagan with a similar plan2 _ Y _ N If so, 25% plan review fee applies. Licensed Plumber Mechanical Contractor Sewer/Water Contractor 11_'? elephone # ( ? i ij elephone # ( L) T?elephone # ( I hereby apply for a Residential Building Pernut 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 pernut, 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. ? ?Zx ? S Applicant's Printed Name Ap icant's Signature OFFICE USE ONLY 5ub Types ? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool 0 30 Accessory Bidg ? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Multi ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) O 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-plex ? 12 12-plex Plbg_Y or_ N ? 25 MiscellaneouS Work Types ? 31 New ? 35 Int Improvement ? 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 *Demolition (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) Foundarion 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 FinaUC.O. Final/No C.O. _ Plumbing HVAC Other _ Pool _ Ftgs _ Air/Gas Tests Final _ Siding _ Stucco _ Sione _ Brick Windows _ Retaining Wall Building Inspector 2009 RESIDENTIAL BUILDING PERMIT APPLICATION v.? ? ?v ???/Z 2 Date: Site Address: Tenant: Suite #: Phone: ''7?l Z RESIDENT / OWNER Name: Address / City / Zip: Applicant is: &Owner _ Contractor TYPE OF WORK Description of work: Construction Cost: 11117, dVU _ Multi-Family Building: (Yes No ? CONTRACTOR Name: License #: Address: City: State: Zip: Phone: Contact Person: COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 CateqoN 1 Minnesota Rules 7672 Energy Code • Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet Category Submitted Submitted (4 submission type) • Energy Envelope Calculations Submitted In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? Yes _fJo If yes, date and address of master ptan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: ?iY NoTE: ,Plansi and,'supporfing docirmsrtts thaf you s'ubmrt are considered to be pub9c, rnf?rmatlon Portions of ?y ? the information'irrey;[ie c?assiired as`iiori pabl?c rf you??rovrde:,specific rea`soi?s tt`+at woui?pQrm?##he'C?ty LLconcludethatthe' ?- 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 f lans. x ?UiCt??c. /?t G?oll?5" X ? ApplicanYs Printed Name App canYs Signature Page 1 of 3 - - - - - - - - - - - - - - - - i I For Office Use 72 3 Permit City of EaQall _0, I Permit Fee: 3830 Pilot Knob Road Eagan MN 55122 Date Received: ~J Phone: (651) 675-5675 I Staff: Fax: (651) 675-5694 2009 RESIDENTIAL BUILDING PERMIT APPLICATION i S)92 2 Date: ~l ~5-J Site Address: Ki~GS J Suite Tenant: l l te 4f ! / Z/S 7 RESIDENT / OWNER Name: Phone: Z 2- Address / City / Zip: Applicant is: ,Owner Contractor TYPE OF WORK Description of work: Construction Cost: /9 yVU Multi-Family Building: (Yes / No XI) CONTRACTOR Name: License Address: City: State: Zip: Phone: Contact Person: COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 Category 1 Minnesota Rules 7672 Energy Code • Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet Category Submitted Submitted (J submission type) • Energy Envelope Calculations Submitted In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? Yes _No If yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that they are trade secrets. I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval fr plans. CGi/~ Gfiv/TES X Applicant's Printed Name App cant's Signature Page 1 of 3 City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 4650 Kingsbury Dr Lot: 8 Block: 4 Addition: Beacon Hill PID:10- 13500- 080 -04 Use: Description: Sub Type: e - Furnace & Air Conditioner Work Type: Replacement Description: Fumace & Air Conditioner Comments: Questions regarding electrical perm 952- 445 -2840. Fee Summary: Contractor: Standard Heating & Air Conditioning 130 Plymouth Ave. N Minneapolis MN 55411 (612) 824 -2656 ME - Permit Fee (Replacements) Surcharge -Fixed Total: Applicant/Permitee: Signature PERMIT City of Eaan - Applicant - equirements should be directed to Mark Anderson, State Electrical Inspector, $50.00 0801.4088 Owner: William Wolters 4650 Kingsbury Dr Eagan MN 55122 $50.50 Permit Type: Permit Number: Date Issued: Permit Category: $0.50 9001.2195 I hereby acknowledge that I have read this application and state that the informa of Minnesota Statutes and City of Eagan Ordinances. on is correct and agree to comply h all applicable State Issued By: Signature Mechanical EA079619 09/05/2007 ePermit City of Evan 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 RECEIVED MAR 142016 For Office Use L�j11/ Permit #: 43 /5 I Q Permit Fee: /25.%q Date Received: 3- (� Li 1 (-P Staff: 2016 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: Unit #: J Resident/ Owner Name: zZZ Y, P i) ,Z 5 Phone: �'9- 5 /X9.10 / Address / City / Zip: O- 0 k dq , �"ji/E- Applicant is: Owner /'r Contractor Type of Work 3 1/47/, _ Description of work: !l /1•, /i, _ ///, ;!� n �//` � . 1.±- itriJ. � Construction Cost: .,?:11.‘27)°Multi-Family Building: (Yes / No ) Contractor Company: j t,12 l 'j1,1L) .e3rie b Contact: itej�,,ed Address: /595- t'j1 5 .l, City: f StaterZip: 30, Phone:7J/1' 'I �? Email: _ f�t/QL:M ,cAdzLitsie-4011 License #: 1E6.. 390/6/ Lead Certificate #: -. If the project is exempt from lead certification, please explain why: ''k)D In the last 12 months, Yes No COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING has the City of Eagan issued a permit for a similar plan based on a master plan? If yes, date and address of master plan: Licensed Plumber: Mechanical Contractor: Sewer & Water Contractor: Fire Suppression Contractor: Phone: Phone: Phone: 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.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 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. Applicant's Printed Name x App t !_ `'can 's Signature Page 1 of 3 1 DO NOT WRITE BELOW THIS LINE SUB TYPES Foundation Porch (3 -Season) Single Family _Porch (4 -Season) Multi _ Porch (Screen/Gazebo/Pergola) 01 of _ Plex Pool WORK TYPES _ New Siding Addition _ Reroof Alteration Windows Replace _ Egress Window Retaining Wall Move Building Fire Repair Fireplace Garage Deck Lower Level Interior Improvement Repair DESCRIPTION Valuation A map Plan Review (25%_ 100% Census Code 4/311 # of Units # of Buildings Type of Construction Occupancy Code Edition Zoning Stories Square Feet Length Width REQUIRED INSPECTIONS Footings (New Building) Footings (Deck) Footings (Addition) Foundation Roof: _Ice & Water _Final Framing Fireplace: _Rough In Air Test _Final Insulation Sheathing Sheetrock Fire Walls Braced Walls Shower Pan - - Reviewed By: Exterior Alteration (Single Family) Exterior Alteration (Multi) Miscellaneous Accessory Building _ Demolish Building* Demolish Interior Demolish Foundation Water Damage *Demolition of entire building - give PCA handout to applicant C `" / MCES System ZD/ j SAC Units PJB City Water Booster Pump PRV Fire Suppression Required Meter Size: Final / C.O. Required Final / No C.O. Required HVAC _ Gas Service Test Gas Line Air Test Pool: _Footings Air/Gas Tests _Final Drain Tile Siding: _Stucco Lath _Stone Lath _Brick Windows Retaining Wall: _ Footings _ Backfill _ Final Radon Control Fire Suppression: _Rough In _Final Erosion Control Other: , Building Inspector RESIDENTIAL FEES Base Fee 73 (- Surcharge Plan Review 1.17 MCES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies yQ 0.5 / TOTAL 0/4 Page 2 of 3 City of kali 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 MAR 252015 Use BLUE or BLACK Ink For Office Use Permit #: Permit Fee: Date Received: Staff: I 3<60- 2016 RESIDENTIAL PLUMBING PERMIT APPLICATION Date: 3/22/2016 Site Address: 4650 Kingsbury Drive Tenant: 1 Name: Bill and Mary Wolters Phone: Suite #: Address / City / Zip: Name: Steinkraus Plumbing Inc License #: 058655 Address: 112 E 5th Street Suite 101 City: Chaska State: MN Zip: 55318 Phone: 952-361-0128 Contact: Dis McDevitt Email: Dis@steinkrausplumbing.com New ✓ Replacement _ Repair _ Rebuild _ Modify Space _ Work in R.O.W. Description of work: (3) bathrooms new fixtures on existing locations RESIDENTIAL Water Heater Lawn Irrigation ( RPZ / _ PVB) Septic System New Abandonment Water Softener IAdd Plumbing Fixtures (1 Main / ✓ Lower Level) Water Turnaround 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) 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.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 i t to start without a that the work will be in accordance with the approved plan in the case of work which requires a review and approval - pL s. x Dismas McDevitt Applicant's Printed Name x Applicant's Signature PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA146746 Date Issued:11/13/2017 Permit Category:ePermit Site Address: 4650 Kingsbury Dr Lot:8 Block: 4 Addition: Beacon Hill PID:10-13500-04-080 Use: Description: Sub Type:Residential Work Type:Replace Description:Water Heater Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size Comments:Please call Building Inspections at (651) 675-5675 to schedule a final inspection. Allow an 18" minimum radius clearance to the water meter from all appliances (i.e. furnace, water heater, water softener). Fee Summary:PL - Permit Fee (WS &/or WH)$59.00 0801.4087 Surcharge-Fixed $1.00 9001.2195 $60.00 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - William Wolters 4650 Kingsbury Dr Eagan MN 55122 Blaylock Plumbing 7731 4th Ave S Richfield MN 55423 (612) 869-7531 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA157972 Date Issued:09/18/2019 Permit Category:ePermit Site Address: 4650 Kingsbury Dr Lot:8 Block: 4 Addition: Beacon Hill PID:10-13500-04-080 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. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Building Code). 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 - William Wolters 4650 Kingsbury Dr Eagan MN 55122 Kaufman Sheet Metal Roofing 2521 24th Ave S Minneapolis MN 55406 (612) 722-0965 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA166942 Date Issued:02/16/2021 Permit Category:ePermit Site Address: 4650 Kingsbury Dr Lot:8 Block: 4 Addition: Beacon Hill PID:10-13500-04-080 Use: Description: Sub Type:Fireplace Work Type:Gas Insert Description: Census Code:434 - Residential Additions, Alterations 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 within 10 feet of all sleeping room openings in residential homes (Minnesota State 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 - William & Mary Wolters 4650 Kingsbury Dr Saint Paul MN 55122--271 Fireside Hearth & Home 2700 Fairview Ave N Roseville MN 55113 (651) 633-2561 Applicant/Permitee: Signature Issued By: Signature