4061 Halite LaneCITY OF EAGAN Remarks
Addition CEDAR GROVE #7 Lot 3 Rlk 10 Parcel 11 16600 030 10
Owner !-te 2s
- ?Yi(?"tSOy ] Street 4061 Halite Iane State Eagdn• M 55122
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF.
STREET RESTOR.
GRADING
SAN SEW TRUNK 1970 58.16 2.08 28 Pdld
* SEWER LATERAL 1971 ZO
WATERMAIN
* WATER LATERAL 1971 1,615.00 80.7rj ZD Pa d
WATER AREA
* STORM SEW TRK (j 1971 20
STORM SEW LAT
CURB & GUTTEA
SIDEWALK
STREET LIGHT
WATER CONN. 280.00 5478 3-16-72
BUILDING PER.
sAC 240.00 5478 - -
PARK
T - - -
CITY OF EAGAN
3795 Pilot Knob Rood Eogan, MN 55122 N2 4512
PHONE: 45481 U0
BUILDING PERMIT ReceiPt #
Te be uted for Date , 19
Site Address - Ered ? Occuponcy 1
Lot Block Sec/5ub. Alter 0 Zoning
Porce1 # Repair ? Fire Zone '
E
l e of Const
T
n
orge ? .
yp
? Nome ' Move ? #?' Stories
3 Address Demolish ? Front ft.
? Grade ? Depth ft.
City Phone
- ' Nam e APProvala Fees
0
Zv
°u?
r-
Address
Nome _
Address
I hereby acknowledge that I have reod this aF
the information is correct and agree to cort
State of Minnesoto Statutes and City of Ea
Signature of Permittee
A Building Permit is issued to: "
oll work shall be done in accordance with oll
ond state thot
Oil ODDIiCpbIQ
Assessment Permit 12
• ? ? ? _
Water & 5ew. Surchorge -' %
Police Plon check
Fire SAC
Eng. Woter Conn.
Plonner Water Meter
Council
_
Bldg. Off
.
APC Totai -
on the express condition that
of Minnes-,ta Statutes and City of Eacan Ordinonces.
Building Official
PumM # pah IseN/ Pwm!!M
Plumbing
Mechanicul
INSPECTIONS DATE INSP. Rouph-In Final
Footings Dote Inap. Date Inap.
Foundotion Plumbing
Frame/ins. Mechonital
Finnl
Remorks: 7e A" / rDf r«J'
r
.ft.g
l
- `
EA.?'a,AN TOWNSHIP
BUILDING PERMIT
Ownex "... ??..?. :P::ti...-°--?'?
p ....-- ------.'-...............................................
Addrau (Presenl) ....GlO.........:...Jl...6:..tie? ...........................
Butider .............................................................. ....... ...
Address
DESCRIPTiON
N° 2661
Eapan Township
Town Hall
Dete
Sios-us Ta Hs Used For Fron! Dapth Hatgh! Esf. Cos!
rJ/, yd--U Pssml! FeaI
Ag=?" Romuko
?
J 0
This permif does aot aulhorisa the use of sireeffi, roada, alleys os sidewalke nor does it qive the omnsr or his agen!
the righi 2o creale anp silualion whieh is a nuisanee or which psesenla a hazerd !o the heal2h, safelp, eonvenienee aad
general walfare !o anpone in the eommunily.
THIS PERMIT MUST BE KEPT ON THE PAEMISE WHILE TIiE WORK IS IN PROGAESS.0
T6b ia to earfiiy, lhat...6.<.d-au. ..?!r.?.<.:Z.....has permission fo eree! d_:`?--_}?`'-" "•_"?''':... oq
""'--'--'-uP
the a6ova deacri6ed psemise eubjee! !o the psovisioxu o3 the Sui7ding Ordinenae for Eagan Township adopled April 11.
1955
.
r1 / `
..
..
.................. ...... !.....--:- ... .... ..?.?...-... Pe: _........_._-"'....I+S4"."_.......SC..........""..."""''_-.".......................
.?. Soard.. .........
Chai:m n ot Town.--.?r. :.
.. SulldiaQ Insyselo:
_e
cirr oF EacnN
. ? 9795 Pito! Knob Rood Eagan, MN 55142 N? 4 5 ? a
` PHONE: 4548100
BUILDING PERMIT APPLICATION Receipr # 4512
$3,000.
To be usod fer e.i.l..
re.ege Date October 12. ,1 9-77
Site Address 4061 Halite - Ered ? Occuponcy i
Lot.3_- Block 1(). Sec/Sub. ?G --7- Alter Zoning
Parce1 # Repoir ? Fire Zone e 3 _
Enl
r
e ? T
e of Const
V
g
o yp
.
rc Name Atlthony Kushlan Move ? # Stories
z Address 4061 Halite oemonsn ? Front 13 _ ft.
o .
Eegan
454-2393 _
Grade ? Depth ZZ ft.
C
Phone
t
? APDrovals _ Fees _
0
Zu
°u4?
r
Name _
Address
Name _
Address
1 hereby acknowledge that I have read this application ond state that
the information is correct and agree to comply with all applicable
$tate of Minnesoto Statutes end City,pf Eagan Ordinances.
Signature of Pertnitt
A Building Pertnit is is
oll work shall be done
Assessment _
Water & Sew.
Police -
Ffre
Eng.
Planner -
Council _
Bldg. Off. _
APC
Permit 1Z.UU _
Surcharge 1.50
Pian check
SAC
Water Conn.
Water Meter
Totol 13.50
Kushlan on the express condition that
)$tat;.ot Minnewta Statutes and City ot Eogan Ordinances.
Building Official -0
. - 3• ?D
TOWN OF EAGAN
PERMLT NC).
The Board of Supervisors hereby grants to Cedas Grcve Construc'bion Co.
of 7310 Coneoid Slr3. 'E., :ioutFi 36U. I'au7. :S+JIa
K"A`??`?G Ceda: Grove Couctructicn Qc.
e Permit for: (Owqer),
m^ e? 1) Citl:iab?;.r., uC.`i5 :i.::1 u c• „y-5-7, ,3?-/-7, ?-/n-7 -uod at 177? t=.coni?,e?
, pursuant to application dated
Fee Paid: Dated this day of ?'c11
, 197
T'Building Inspector
3795 Pilot Knob Road
Eagan, Minnesota 55122
3
.
TOWN OF EAGAN
3795 Pilot Knob Road
Eagan, Minnesota 55122
?', ?• 7
3 '? v
PERMIT M. i6ti.
The Board of Supervisors hereby granes to _cedar GraTe Construction Ga.
of 73!3 uoncorcl E.I ;out:i :Jt. Pau2 ?'()75'
e Ii,iJ;?'.:3i'dG pe,rmit for: (Owner) Ced.a C-rc-:s Cottsi:xuetlon Co.
4 e) ,Gg
at pursuant to application dated
:•ac'? 101 1972
Fee Paid:
Dated this 16th day of iiaich , 1972 ,
. s e "'-
Building Inspector
J
e
.. '
BUILDI[SG ?8WIT APPLICATIOd
PATE
include 2 sets of p],ms, 1 cite plau w/elevations and 2 aet oP energy calculatfons.
To be usea for .,0 r "?
i
S1te Address : 1/ 66 / 14-66 -C-^
Lot Block 5ec./Sub.
3 i0 GU7
owner 4,., / /, e.. . -T e, ,
°,,:. .
axes6 yny- I, l,p ?
dontractor e
Address
Arch. /Enq • -- ? a •., .c
Address
?
/?-? 4`
vsluation Li316d 6
Parcel Number
Talephone 7 J`? "y A 3 Q-3
Telephone
'!b lephone
OFFICE USE
Erect
Alter
Repair
Enlarge
Move
Demolish
crade
OFP'ICE USE
Date of Approval & 7aitial
Assessment
water/sewer
Police
Fire
Eng.
Planner ,
Oouncil
Bldg. Off.
A.P.C. _
Occupancy ?
Zoning
Fire Zone
Type of Const.
$ of Stosies _
Front
Depth
FELS
?- ?
Permit
Surcharge ? s
Plan Check
SAC
vlater Conn.
S•later Meter
ToTAr, ? l 3 Of C-
r?
3-/0- 7
EAGPN 1UWNSHIP
3795 Pilot Knob Rosd
St. Paul, Minnesota 55111
Telephone 454-5242
PERMIT FOR WAT1iR SERVICE CONNECTTON
Date:
Number• 788
Billing Name: ?GGYLk,?rJ ?rr,?r.cei L?0/LD? Site Address: 5?10/
v //
Owner: `-D2,14LI Bi113ng Addreas
Plumber:
of
NO i1bta1 Chg.
Building is a:
Residence xx
t3ultiple No, Units
Commercial
Industxial
Other
3X6/72
Meter No. iMeter Permit Fee 10.00?pd 3/1 3/16/72
72
Meter Reading Dep.
Meter Sealed: Yes` lAdd'1 Chg.
Inspected by
Date
Remarks:
y.L%.1. ?._..il,i.Jl.ti•? I?L.? I?l?.?
Pu"; _RU i-NS1ALLEU ,???ETrRse
By:
Chief Inspector
In consideration of the issue actd delivery to me of the above permit, I
hereby agree to do ttm pxoposed work in accordance with the rules and
regulations of &agan Towstship, Dakota County, Mianesota.
B}r:
i ?GCI/fZpZ?i ? GLL/v-'
Please notify the above oftice when ready for its.spection and connection.
i
3-10-7
EAGAN TOWNSHIP
3795 Pilot Knob Road
St. Paul, Minne-,ota 55111
Telephone 454-5242
PERMIT FOR SAWER SERVICE CONNECTION
DATE:
AESCRIPTION OF BUILDING
OWNER: &&2&/ Addresa 17'061 PLUMBER TSCPS OF PIPE L'? ?5,?yt.
Industriail Commerciall Reaidentiel 4 Multiple Dwelling i No, of units
1 1 xx 1 1 -
Locatioa of Connections:
NtMEa 949
$y
Chief Inspector
In consideration of the issue and delivery to me of the above pexmit, I
hereby agree Co do the proposed work in accordance with the ruies and
regulations of Eagan Tocanship, Dakota County, Minnesota
By ?2Gc???i ,r"%?.?-a?-G? (`,C??Z?L`O
,C?aGO2G ? ? _.C?C!6?G+'7
Connection Charge 240.00 pd 3/16/72
Permit Fee 10,00 pd 3/16/72
/72
Street Repairs
ToCal
Inspected by:
DaCe
Remarks:
Please notify wheu ready for inspection aad connection and before any portion
of the work is covered.
MASTER CARD
LJ
- in .
OWNER
STRUCTURE AND
LAND USED AS
•
•
Permit
No.
Issued Issued To
Coniractor Owner
BUILDING
PLUM8ING
- ? -?-
CESSPOOL - SEPTIC TANK
WELL
ELECTRICAL
HEATING
GAS INSiALLING
?-R=
SANITARY SEWER
J
OTHER ? ?JClJ C •G' .
OTHER I
Items Approved
(Initial)
Date
Remarks
Disiance From Well
FOOTING SEPTIC
FOUNDATION y CESSPOOL
FRAMING ? , l, ? ? TILE FIELD FT.
FINAL
ELECTRICAL
HEATING
? DEPTH
OF WELL
GAS INSTALLATION
SEPTIC TANK
CESSPOOL
DRAINFIELD
PLUMBING .+;L?
wEU 39 '
SANITARY SEWER ?-
-- All
,
Violations Noted
on Back
COMMENTS:
COMPLIANCE INSPECTION REPORTS
TO BE USED ONLY IN EVENT OF OBSERVED VIOLATIONS
0
PERMIT IJO,
CONDITIONS OF CONSTRUCTION AT THIS INSPECTION
? NO EVIDENCE OF NON-COMPLIANCE
OBSERVED.
11 ACCEPTABLE SUBSTITUTIONS OR
DEVIATIONS.
DATE OF INSPECTION
? NON-COMPLIANCE. BUILDER WILL COMPLY
WITHOl1T DELAY.
ITEMIZFD AND DESCRIBED AS POLLOWS:
? NON-COMPLIANCE. BUILDER DOES NOT
INTEND TO COMPLY
? COMPLETION Of CERTAIN IMPROVEMENTS
WILL BE DELAYED BY CONDITIONS BEYOND
CONTROL.
? REINSPECTION REQUIRED
REINSPECTION REVEALED
DATE OF REINSPECTION
CERTI FICATION -1 certify that I have carefully inspected the above in which I have no interest present or prospective, and that I have reported herein
all significant conditions otserved to de at variance with ordinances of the Town of Eagan, approved plans and specifications, and any specific require-
ments for off-site imprwements relating to the prOperty inspected.
? ALL IMPROVEMENTS ACCEPTABLY COMPLETED
BUILDING INSPECTOR
•
e
?? rza
2000 BUILDING PERMIT APPLICATIO 9001.498s 84,7s
CITY OF EACAN LEE 7 ERICkSGN
?f / 3830 PILOT KNOB RD - 55121
q3076 651-681-4675
New Cauhuctlon ReaWremeMS E
m s reyigerea rre wnetin srwWing sy. n a iw, sq. e. a nousa a
and 9H raofed areas (10% maxlmum bl covemsye allowetl) 1
? Z coples of plaru (ahow baam 8 wintlpw tlzea; poured fid. Healgn; etc.) 1
D 1 t91 O! 6neryy cdculaHOna
? 3 coples of hae preianoHOn plan M lol plaMetl aRer 7/1/93
pqTE: Z CONSTRUCTI
DESCRIPTION OF WORK: kF"Mo?? /Q---844caf 5?f-l,t-1(ot
SfREET ADDRESS:
LOT ? BLOCK: ?Q SUBD./P.I.D. M• l CjGIY UYOY? ? ToL31 R?C.YSFF ??ounx is4.7?
- Lser ti ;t:l-•KGH
PROPERTY
OWNER
GOMRACTOR
ARCHITECTI
ENGINEER
Name: Lt5,a?- ! Ptwne #: 651 ?i 52
IqSf ? FIrSt
Street Address: 46?/ lA/7J? Lxl
city ??e4VC4 state: /YInJ zip: S S i z Z
Company: Phone #:
(area code)
Sfi'eet Address: Uce? ? ExP•
City
Stafe:
Company: Name:
Telephone 41: (
Sheat Address: Registrarion
.
Cly ,
State:
Sewer/water licensed plumber qf instalflna sewer/water): Phone #:
Zip:
Lp:
1 herebY xknowledge fhat I have read this applkatbn, slate thaF 1he infomxtion is ccrrect, and ogree to Compy wNh on appfloable State
of Minnesota Sfatutes and Cily ol Eagan Ordinances. Signature ot ApplicanY.
OFFICE USE ONLY
Certificates of Survey Received
_ Yes _ No
Tree Preservation Plan Received _ Yes - No - Not Required
??CF,TVED
ocr o z zooo
BY:?
OFFICE USE ONLY
BUILDING PERMIT SUBTYPES
0 01 Foundation o 07 05-pleX
? 02 SF Dwelling ? 08 06-plex
? 03 01 of _ plex ? 09 07-piex
O 04 02-plex ? 10 08-plex
? 05 03-piex O 11 10-piex
O 06 04-plex ? 12 12-plex
? 13 16-plex ?
? 17 Garage ?
O 18 Deck O
? 19 Lower Level ?
Plbg Yor_N ?
? 20 Pool ?
21 Poroh (3-sea.) ? 31 Ext. Alt - Mufti
22 Poroh/Addn. (4-sea.) ? 33 Ext. AM - SF
23 Porch (screened) ? 36 Muki
24 Storm Damage
25 Miscellaneous
30 Accessory Bidg.
WORK TYPE
O 31 New ? 36 Move Bidg. ? 43 Reroof
? 32 Addition ? 37 Demolish (Bldg)• ? 44 Siding
? 33 Alteration ? 38 Demolish (Interior) ? 45 Fire Repair
O 34 Repair ? 42 Demollsh (Foundation) ? 46 Windows/Doors
* Give PCA handout to applicant for demolition permit
GENERAL INFORMATION
SAC Code
No, of Units
No, of Buildings
Const. (Actual)
(Allowable)
UBC Occupancy
Zoning
# of Stories
Length
W idth
Basement sq. ft.
Main level sq. ft.
sq.ft.
sq, ft.
MISCELLANEOUS INSPECTIONS
O Stucco/Stone
sq.ft.
sq. ft.
Footprint sq. ft.
Census Code
MC/ES System
City Water
Booster Pump
PRV
Fire Sprinklered
APPROVALS
Planning Building Engineering Variance
Permit Fee Valuation: $
Suroharge
Plan Review
License
MC/ES SAC
City SAC
Water Conn.
Water Meter
Acct. Deposit
5/W Permit
S!W Surcharge
Treatment PI.
Park Ded.
Trails Ded.
Other
Copies
Total:
SAC Units
% SAC
2006 RESIDENTIAL BUILDING rExnuT .arrLrcaTioN
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephoue # 651-675-5675 FAX # 651-675-5694
New Construction Reavirements
3 regisiered site surveys showirg sq. ft of lot, sq. fL of house; and all rooted areas
(20% macimum lot coverage allaxed)
1 Soils Report if proposed building is to be placed on disWrbed soil
2 copies of plan showing beam & window sizes; poured found design, etc.
1 set of Energy CalcuWtions
3 copies of Tree Preservation Plan if lot platlad after 711/93
Rim Joist Delail Oplions selection sheet (buildings wilh 3 or less units)
Minnegasco mechanical ventilation form
RemodeVReoair Reouirements
2 copies of plan showing footings, beams, joisfs
1 sef of Energy Calcula6ons for heated add"Aions
1 site survey tor additions & decks
Add'Rion - indicate ilon-sde sepNc system
RAR$rzaa47
;' ?5-;??
Office'U's'e'OnN
CeilpfSurve'y,Recd???"`?_Y ?'=N
iree Prtms Plaii
"rt,u51' P N.
Date 3_ /%,3` l
SiteAddress 4?Yo/ D 1
fqA le Ln Ec,q Constructian Cost
w,n UniUSte #
Description of Work S,,ti o. Re /!x!C W?"AL-l
Multi-FamilyBldg _ Y_k N Fireplace(s) _ 0 2
Property Owner iL¢ e 0 E r ic l?'i,i Telephone #( 65! )4/Sc2 - bo /G
Contractor 1'?1lnneSak Exlrnbrs
Address Ffdcjb
State 11'1/?1 Sc?erv-,h Nw? City 055to
Zip ;5"5"3i;J Telephone#( 7cg) 341-62508
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
- Minnesota Rules 7670 Cateeorv 1 _ Minnesota Rules 7672
Energy Code Category . Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet
(4 submission rype) Submitted Submitted
• 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 plan6
_ Y _ N If yes, date and address of master plan:
Licensed Plumber
Mechanicai Contractor
Sewer/Water Contractor
Telephone # (
Telephone #(
Telephone # (
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 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 ofplans.
Te ?N?S
Applicant's Printed Name
Ap icant' Signature
DO NOT WRITE BELOW THIS LINE
Sub Tvpes
0 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pooi ? 30 AccessoryBidg
? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt - Multi
? 03 01 of _ plex ? 09 07-plex 0 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 EM. Alt - SF
? 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (screen/gazebo/perola) ? 36 Multi Misc.
? 05 03-plex ? 11 10-plex ? 19 LowerLevel ? 24 Storm Damage
? 06 04-piex ? 12 12-plex O 25 Miscellaneous
Work Tvpes
? 31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding
? 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair
? 33 Aiteration ? 37 Demolish Building` ? 43 Reroof ? 46 WindowslDoors
? 34 Replacement 'Demolition (Entire 81dg) - Give PCA handout to applieant
D¢SCI'IptlOtl: Water Damage _ Yes
Valuation Occupancy MCES System
Plan Review 100% or 25%
Census Code Zoning City Water
SAC Units Stories Booster Pump
# of Units Sq. Ft. PRV
# of Bldgs Length Fire Sprinklered
Type of Const Width
REQUIRED INSPECTIONS
_ Footings (new bldg) _ Sheetrock
_ Footings (deck) FinaUC.O.
_ Footings (addition) FinaUNo C.O.
Foundarion HVAC
Drain Tile Other
Roof _ Ice & Water _ Final _ Pool Ftgs Au/Gas Tests Final
_ Framing _ Siding _ Stucco Lath _ Stone Lath _Brick
_ Fireplace _ R.I. _ Air Test _ Final _ Windows
_ Insulation _ Retaining Wal:
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
Building Inspector
Cities Di i? tal Qualitv Control
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PERMIT
City of Eagan Permit Type:Building
Permit Number:EA121435
Date Issued:04/01/2014
Permit Category:ePermit
Site Address: 4061 Halite Lane
Lot:3 Block: 10 Addition: Cedar Grove 7th
PID:10-16706-10-030
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:
Census Code:434 -
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 by law in ALL single family homes .
Jarrod Stenzel
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 -
Lee J Erickson
4061 Halite Lane
Eagan MN 55122
Schmidt Roofing Inc
3509 West Highway 13
Burnsville MN 55337
(952) 888-4889
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA121436
Date Issued:04/01/2014
Permit Category:ePermit
Site Address: 4061 Halite Lane
Lot:3 Block: 10 Addition: Cedar Grove 7th
PID:10-16706-10-030
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:
Census Code:434 -
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 by law in ALL single family homes .
Jarrod Stenzel
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 -
Lee J Erickson
4061 Halite Lane
Eagan MN 55122
Schmidt Roofing Inc
3509 West Highway 13
Burnsville MN 55337
(952) 888-4889
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA129259
Date Issued:01/26/2015
Permit Category:ePermit
Site Address: 4061 Halite Lane
Lot:3 Block: 10 Addition: Cedar Grove 7th
PID:10-16706-10-030
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.
Applicant: Holly Flood
1408 Northland Dr #310
Fee Summary:ME - Permit Fee (Replacements)$55.00 0801.4088
Surcharge-Fixed $5.00 9001.2195
$60.00 Total:
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Contractor:Owner:- Applicant -
Lee J Erickson
4061 Halite Lane
Eagan MN 55122
Sedgwick Heating & Air Conditioning
1408 Northland Drive, Suite 310
Mendota Heights MN 55120
(952) 881-9000
Applicant/Permitee: Signature Issued By: Signature
SEDGWICK HEATING & AIR CONDITIONING CO. HEATING �os tvo.N ZS '�J� 3�°
1408 NORTHLAND DRIVE,SUITE 310 • MENDOTA HEIGHTS,MN 55120 • (952)881-9000 TEST RECORD
ADDRESS 'v�� ��� �� CITY �tJ' " ''
OCCUPANT OWNER `�•`���—" -
SOID BY INSTALLED BY
r AKE �� MODEL v' `1��� b� �d>N
�RIAL NO. l�I�I �� r � INPUT �+/�
� � ' 1
'HERMOSTAT VENT SIZE
/ALVE � ✓''u 1' ti-- �{JC�--�-�� TYPE OF LINER ` U L'
�I � � �
'_IMIT ���� cN t S c� LINER SIZE
LIMIT SETTING � � � FILTERS: SIZE ��x�� � / NUMBER
FAN SEITING I l/ !d� WIRING � ��^
PILOT TYPE TEST TA�
IGNITION MODEL � � LIGHTINCa INST. —
PII.OT TIMING t ^- ��.o � (J
� DATE TESTED
PRESSURE ��S PERCENT CO2�`�_ � II
INPUT CFH �a ��J� PERCENT Oz �O�rI
COMPANY TESTING « �''�� L
STACK TEMP. !��� PERCENT CO ��- NAME OF TESTER ��°'"
FORM 235(REV.10/10) FORM DISTRIBUTION: WHITE COPV-JOB FILE YELLOW COPY�CITY