4343 Jennifer Ct.
CI-
? OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55123
(612) 681-4675
N RECORD
PERMIT TYPE:
Permit Number:
Date Issued:
HI, r! t? r Nr,
0.1.0, 1 (,
14 1:' %1I/'1 4
SITE ADDRESS: I „+ :
PERMIT SUBTYPE:
TYPE OF WORK:
INSPECTION .• . ..
IN .111 p. J F o;,i I I „? ? I Al ,
rif I ra li I
I i14 (i{
I 1 1 ra(t kKk: S L. 14 PLHi: f(+M NE/VN F1I.Ft6
APPLICANT:
:a";:j.ri . )Wr,,i
. tbt: ) 4 h2--!}3!
Permit No. Permit Holder Date Tetephone k
SNV
PLUMBING 7l OA(
HVAC .3'350"0.'
ELECT RL? z7D O'o
ELECTAIC
inepection Date Insp. GommerNa
Footings I 3 ? 110
FoundaTion
Framing
Y? T
RooBng
Rough Plhg. .??
Rough Htg.
IsuL
Firepiace
/P
Final Htg.
Orsat Test
Final Ptbg. ?? ?? Plbg. Inspector - NotiTy Plumber
Const. Meter
Engr./Plan
Bidg. Final ?
Deck Ftg.
Deck Final
Well
Pr. Disp.
C`"' ? ? ? N ?
AY/L T?-' Gi.?? 6rLvG,* Z,9 - 7,/??'?' /?
INSPECTI4NRECORD
CITY OF EAGAN PERMIT TYPE:
3830 Pilot Knob Road Permit Number:
Eagan, Minnesota 55122-1897 Date Issued:
(612) 681-4675
SITE ADDRESS: APPLICANT:
t .11 NN I f-i F: i: 1
IN(;inN s'r) 1NfF "+It1
PERMIT SUBTYPE:
! I - ' I I t4 l,
I F
y: ?. iYIV'• ? I??1
TYPE OF WORK:
} ( Ni}I
•S
? .. . ?? _ . . ?
. . . .. .. _. ? .. ? ?
-----------------------
Permit No. Pe?mlt Holder Date Talephone M
ELECTRIC
PLUMBING
HVAC
hropectlon Date 1nap. Commanb
FOOTINGS
FOUND
FRAMING
ROOFING
ROUGH
PLUMBING
PLBG
AIR TEST
ROUGH
HEanNG
GAS SVC
TEST
INSUL
GYP BOARD
FIREPLACE
FIREPLACE
AIR TEST
FINAL PLBG
FINAL HTG
ORSAT
TEST
BLD(3 FINAL
BSMT R.I.
BSMT FINAL
DEGK FfG
DECK FINAL /
3 ?v
INSPECTION REC4RD
CITY OF EAGAN PERMIT TYPE: ?:it 1 I li i N??
I 3830 Pilot Knob Road Permit Number.
I Eagan, Minnesota 55122-1897 Date Issued: '
? (612) 681-4675
? SITE ADDRESS: APPLICANT:
?
i11id E? 1.1 #. N 11. ?i I H !•? 1. ? '> yy i., y? {: i: rt .
PERMIT SUBTYPE:
, .F1
I I;:ri ie tN r•,
! I '+31l I N F' L1i9
TYPE OF WORK:
?it ffRAfiTf1N
iN',i1t :i i TItN
f IN
j txfMAlvk?: A -, fPRRA1C Pt- ttMIT T s 1t4rv11tHH17 FUR AtlY P!oMh7NA. o R r it=rrRI I'RI Wl#f
, ,
'
. ,. .: .
_
- ,.. ,... r. _., ,.._ . _ ?.
,
, ;.
,.
.
?
?
Permit No. Permit Holder Dsts Telephone #
ELECTRIC
PLUMBING a 9
HVAC
Inspectlon Dste Inep. Comments
FOOTINGS
FOUND
FRAMING
7 (/
ROOFING
ROUGH
PLUMBING
PLBG
AIR TEST
ROUGH
HEATING
( 0
GAS SVC
TEST
INSUL
GYP BOARD
FIREPLACE
FIREPLACE
A!R TEST
FINAL PLBG
r
FINAL IiTG (( ?
ORSAT
TEST
BLDG FINAL
BSMT R.I.
BSMT FINAL ? d
? o
DECK FTG
DECK FINAL
WeL'tifiCQte of cCCIipQIiC?
W" of Wagan
Zoartmcnt oF 13xiliiug ?u??ertion ,+
e Y
f
V
Tfeis Certiftcate issued pursuant to the requirements o}" the Uniform Bui[ding Code
certr, fying that at tlte tirrte of issuartce ihis stntcture was in eornpliance wirh the various
otzfinances of the City rrgulating building construction or use. For the following:
Use Classificalion: SF DW Bldg. Permit No. 23619
Occupancy'lype Mfrl1 2ating District PD Type Const. VN
Owner of B,,M4 SHkRm K FIM Addn? 4351 JMf.FER 0C1[1RT, F.AGAN
eujj6n'g nedress 4343 .TMZ4Il+'ER O01.1RT twwny Ll I, B2! LEnWIC+T POIINlE qM
Building Officia! [Wc,
,
POST IN A CONSPICUK)l1S PIACE
REQUEST FOR ELECTRICAL INSPECTION
? j Ow See ms[mctions far completrng this lorm on back of yellow copy
M 12385 -X° Belov,)*Work Covered by This Request
New Atld Rep. Type of Building AppliancesWrted EquipmentWired
Home Range Temporary Service
Duplez Water Heater Electnc Heatng
Apt. Building Dryer Load Managemant
Comm./Industrial Furnace Other (Specity)
Farm Air CondRioner ' f
Other (specdy) ontrecrorC RemaBs
Compute lnspeciion Fee Belaw:
# Other Fee # ServiceEntrance Srze Fee # Cvcutls/Feeders Fee
Swimming Pool 0 to 200 Amps CK_
SiV, ' U 0 to 100 Amps D-?
Transfortners Above 20U Amps .- A6ove tOQ Amps
Signs Inspector's Use Only III^^^---
? TOTAL
Irngahon Booms ???
I I/? ? Q, ?
Speciallnspechon ? ???
Alarm/Communicanon THIS WSTALLATION MAY E ORDER DISCONNECTED IF NOT
Other Fee COMPLETEO WITHIN 16
I, the Elecirical Inspector, hereby Rouqn-in
?
certif that the above ins ection has
y P
been made. Final ? Date
42
OFFICE USE ONLV ?
This request void 18 monihs imm
ee-ooooi-oe
a
?s Ga7 9y
8s5
?
Request Date
V Fire o. Rouqh-in Inspeclion
e uiretl? NOTICE: You Must Call Electncai Inspcctor
I! A Rough-In InSpechan
u ?
?
5' Ves ? Na Is Requrtetl
IK licensed contractor ? owner hereby request inspection of above electrical work at:
Job Atldreas (SUeet, Boz or Rou[e No j Ciry
3l! ,j2?cn.ifir'ri 41 r+7n_. -17-'?-3
Seclron No Township Name o? No Range No. County
Occupant (PRINT7 Phane No
3.;2,3
PowerSuppheHr ? ?
/ ?5 Adtlress
Elecmcal Comrador (COmpeny Name) Coniredor§ License No
G _ U ?
Maling Adtlress (COntrecmr ar Owner Making Instalianon)
SignaWre (COMract tlOwner Ma Installation) Phone NumEer
/ 4
ESOTq STATE BOARD OF ELECT i
THIS INSPECTION REQUEST WILL NOT
IggsMltlway Bltlg. - Noom 5-09 BE ACCEPTED BYTHE STATE BOARO
18T1 Univerelty Fve, S[. Paul, MN 10C UNLESS PROPER INSPECTION FEE IS
P?one (612) 642-0800 ENCLOSED.
Address 4343 I'nMFE[t mrmr Zip 5512 3
I.ot IH Blk 2 Sub LEKH13" PO= 9TH
THESE ITEMS WERE / WERE NOT COMPLETE AT THE TIME OF THE FINAL INSPECITON.
Date: ?h)W Yes No Inspector:
Final grade (6' from siding)
Permanent steps (garage)
Pennanent steps (main entry)
Permanent driveway
Permanent gas
Sod/See.ded grass
TraiUcurb damage
Porch
Basement finish
Deck
Please verify with the builder the removal of roof test caps from the plumbing system and the shut-off of water supply to
lhe outside lawn faucet before Freeze potential exists.
Contact enginee[ing division at 6814645 before working in righPOf-way or installing underground sprinkler system.
White - Ciry Copy Yellow - Resident Copy Pink - Contractor Copy w
?-
?/?ql /
2007RESIDENTIAL BUILDING PERMiT nrrLrcnTioN
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
New ComWction Reauiremenls
3 registered site wrveys showing sq. ft d la, sq. ft af Muse; aiW aU rooted areas
(20%matimum loteoveraga allaved)
1 Sopa Report if proposed bWlding is to be placed on disWrbed sdl
2 coples d plan shaxing beem 8 xindav sizes; poured land design, etc.
1 setMEnergyCalalatlons
3 wpies MTree Preurvauon Plan if IU platted after 711193
Pom Joist Detall Options sdection sheel (Guildirgs wIN 3 a less unib)
frSnnegasco medianical venh7ation fam
?i 9e- o o
RemodeVReoair Reaulrmnenb Me Wsa OnN
2 wpies ol plan showin9 fooBoAs, beams, pist% CeR of SuNey Recd _Y _ N
t set M Eneryy Caialations fa heated additlons Stlls Repal _ Y_ N
1 sile survey for additians d decks Tree Pres'iNenRecd _Y _ N,
Adafltion-lndicafeilonsi(eseptlcsystem TreePre3?R§qWred _Y _N
On•sdeSepdcSySlBm _Y _N
UDIIC InTOfR18i1011 UI11BS5 VOU SLBiB LI1BY 8f@ LCBQ@ S@CCBL Bllq Il12
?
Date ? Construction Cost ?1 ! lv 67o
Site Address 434?J " :r&v? r? i=7eti . ???,rf Unit/$te #
Description of Work
Multi-Family Bldg _ Y _Y N v Fireplace(s) _ 0 _ 1 _ 2
Property Owner m . llC e Q- Telephone # (
LAKEWOODS REMODELING, INC.
Contractar = i 9001 E. Bloomington Freeway
Address Su'? 144
Bloanington, MN 55420
State_ ?------- ----
Telephone k(C/,/ 3) 8e?' SSS O
COI'dPLETE THIS AREA OPii.Y IF
Energy Code Category "- MinnesoW Rules 7670 Categorv 1
(J submission type) Residential VentilaUon Category 1 Worksheet
SubrnlqBd
• Energy Ernelope Calculations Submitled
A NEW BUILDING
Minnesota Rules 7672
• New Energy Code Worksheel
Submitted
In the Iast 12 months, has The City of Eagan Issued a permiT for a slmllpr plan based on a master planB
_ Y _ N If yes, date and address of master plan:
Licensed Plumber
Mechanical Contractor
Sewer/Water Coniractor
Telephone #(
Telephone #( )
Telephone #(
I hereby apply for a Residential Building Permit and acknowledge that the information is compiete 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 of plans. )
ApplicanPs Printed Name Appiicant's Signature
City
04/30/1997 23:29 6514569963 ILLINGWORTH COMM INC PAGE 02
REBBCCA 4343 Jennifer Court
IQM Eagan, Mdnneeota
ILI,iNGWORTH 56123
Doug Reid
Ckuef Building Officiat
City o£EaSan
3830 Pilot Knob Road
Eagan, MN 55122
Dear poug Reid:
I am respondiiog to yaur letter in which you ifformed me that the openingThole on my deck
dces not mcet Iv1in»esota Uniform Buiiding Code.
T will be rectifying this violarion by building stepe along the TTorth side of my deck. In
addition?, all the boards that were cut-out in order tv create this hole will be replaced.
Therefore, the opening itself wi11 no longer exist. Considering there arc no city codes
prohibiting me from building thesc stcps along side my deak, Z will assume this is an
acceptable form of resolving this matter.
Although T appreciate your recommendation to expand the run along side my deck,
neighborhood covenants will not permit this to happen. In order to abide by these
covezAams, the only solutiou I have is to build thcst sttps.
I also wam to thank you for waiving a fine. As I explained to you, this opemi.ng was
created under ihe recommendation of tha Walnut Ridgo Homeowpers Association Board
of Birectors. Although Z do not believe this recommendat'son was made out of negligence,
I do believe it was made wiihout proper research and knowledge of city codes.
Considering our neighborhood is atready in substamial debt due to a recent lawsuit, I will
assume responsibility o£ all necessary costs that will be incurced in order to rectify this
violation. Although this is an expense that I did not anrieipate, I will do so ouc of respect
fbr my neighbors.
Please let me know if this sofution is not satisfactory. Otherwise, per your request, I will
comact you for veri6cation once the proper corrections have been nuade. Once again,
thank yw for your leniency.
Res y, ?,, r?
?
Rebecca Kim I1Gngwo
cc: Walnut Ridge Homeownexs Associatioa Board of Airectors
Te1: 651-456-0693 P= 661-466-0963
e-mail: Illingworth@worldnet.aft.net
6514560963 => CiTY Of EAGAN ,TEL=6516814612 03/15'01 15:55
city oF eagan
PATRICIA E. AWADA
Mayor
December 6
2000 PAUL BAKKEN
, BEA BLOM9UIST
PEGGV A. CARLSON
SANDRA A. MASIN
CounalMembers
MS REBECCA ILLINGWORTH THOMAS HEDGES
Ciry ndmirnstwtor
4343 JENNIFER COURT
EAGAN MN 55123
RE: LOT 11, BLOCK 3, LEXINGTON POINTE 9TH
Dear Ms. Illingworth:
In response to a telephone call on December Sth from Richard Ronning, we met you at your
home to inspect your deck for safety. Mr. Ronning was uneasy about a 2' x 3' hole in your deck
with a 36" high railing around it. You mentioned that this opening was created for your dog to
get into the kennel azea.
I would suggest that you expand your kennel on the north end of the deck (similar to what you
presently have on the west side), but somewhat narrower, to allow your dog to go down the deck
stairs to access the kennel.
Minnesota's Uniform Building Code requires installation of a guazdrail azound any opening to
prevent small children from falling through. Please make these changes and call me at 681-4697
to verify that proper conections have been made.
Thank you.
Sinc re
Oly,
-?e?
? ?
Doug Reid
Chief Building Official
DR/j s
MUNICIPAL CENiER
3830 PILOT KNOB ROAD
ENGAN. MINNESOTA 55122-1897
CMONE: (651) 681-4600
FAX (651)681-4612
TDD: (651) 0.54-8535
THE LONE OAK TREE
THE SYMBOL OF STRENGTH ANO GRON?H IN OUR COMMUNIN
Equal Opportunity Employer
www.ciryofeagan.com
MAINTENANCE FAdLIiY
3501 COACHMAN POINT
EAGAN. MINNESOTA 55122
PHONE. (651)68Id300
FAX:(651)681-4360
TDD: (651) 454$535
PERMIT
•? CGY OF EAGAN
3830 T Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
PERMIT TYPE:
Permit Number:
Date Issued:
BUZLDING
031106
11/26/97
SITE ADDRESS:
4343 JENNTFER CT
LOT: 11 BLOCK: 2
LEXIN6TON POIN7E 9TH
P.I.N.: 10-45093-110-02
DESCRIPTION:
(NO BEDROOMS)
Oruilding _d?ermit Type
;86ildiqg 1d'6'rk Type
' Census Code 439
I
F i}
Zt $ » P i
BASEMENT FINISH
ALTERATION
pLT. RESIDENTIAL
g?0 '0 R%i f
. .?: U:^'? i? CS\.\`•;.ro z..?...1 .
REMARKS:
A SEPARATE PERMIT IS REQUIREp FOR ANY PLUM9ING OR ELECTRTCAL WORK
FEE SUMMARY:
Base Fee $50.00
Surcharge $.50
7ota1 Fee $50.50
?
t
CONTRACTOR: OWNER: - Applicant -
ORFAN KEVIN
4343 JENNIFER CT
EAGAN MN 55123
(612)995-0608
?
I he?i?by acknowledge that ?;.,have raad-.;ti?ie ???ppli?tia? 'Antl r;tate that tl?a
info"ri[iatfisf? is ?d,rreot and agr?ee ?n epr?p2Y:'{??ith'??:l,ap?tlicab??e SC4?e bf=.Mn. `.
Statutes an.d City of Eegan tirdinances.
APPLICANT/ MITEE SIGNATURE ISSUL-D BY: SI URE
7BUILDING PERMIT APPLICATION (RESIDENTIAL) 4?O.J p
an oF ?r?GaN
3830 PILOT KNOB RD - 55122
31 lot
681-4675
New Construction Reawrements RemodellRecair Reouirements
? 3 registered sRe surveys ? 2 copies W plan
? 2 copies of plans (inctutle beam & window sizes; poured fnd. design; etc.) ? 2 site surveys (extenor add@ions 8 Cecks)
? 1 energy calculatians ? 1 energy calwlations for heated additions
? 3 wpies ot tree preservation plan iT lot platted after 711193 ?
required: _ Yas _ No
DATE: CONSTRUCTION COST:
DESCRIPTION OF WORK:
STREET ADDRESS: ? y?V3 j-?r? n9idar- eaa,- T eEse?...?
LOT ? BLOCK 1- SUBD./P.I.D.#: ZeXi,47?0? 'EI&AZ g? WIIJ
PROPERTY
OWNER
CONTRACTOR
Name: /Q-AZ,.t 1-4I evF", Phone #: _ 4os-o?o8'
IA6i PRei
Street Address: y 3?f ? T rI.s rlewr- ma.,.. ??
City: IZ" ?`..._.. State: MW Zip: S?! z3
Company: S??Q Phone #:
Street Address:
City: State:
License #:
ARCHITECTf Company:
ENGINEER
Name:_
Phone
Zip:
Registration #:
Street Address:
City:
Sewer & water licerr.ed plumber (new construction only):
and lot change are iequested once permit is issued.
State:
I hereby acknowledge that I have read this application and state that the information is correct
State of Minnesota Statutes and City of Eagan Ordinances.
OFFICE USE ONLY
Certificates of Survey Received
Tree Preservation Plan Received
Signature of Applicant: _
_ Yes _ No
_ Yes _ No _ Not
Zip:
Penaity appiies when address chance
agree to
w,7 - aM
? CITY O'" EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
SITE ADDRESS:
PERMIT
4343 JENNIfER CT
LOT: 11 BLOCK: 2
LEXINGTON POINTE 9TH
P.S.N.: 10-95093-110-02
PERMIT TYPE:
Permit Number:
Date Issued:
c? ?-5 4 3
BUILDINB
025803
06/14/95
DESCRIPTION:
"i1,d€rig_Permit Type DECK
i:idingType NEW
aa?
?
.-
-?;?'?_
%y`4 a?s
??? ??? ? ?Z?
n?
a;ES?
G ek °
_rt?FA"
w.. ?
?ikLa
REMARKS:
FEE SUMMARY:
Base Fee
Surcharge
Su6Cota1
$30.00 CQPTES
$.50 Total Fee
$30.50
$1.00
$31.50
CONTRACTOR: - Applicant - sr. LTC. OWNER:
P K CONSTRUCTTON 12573926 0008800 CURTIS ART
15875 260TH ST N 4343 JENNTFER CT
LINDSTROM MN 55045 EAGAN MN 55122
(612) 257-3926 (612)686-2996
?
•° , ° •_ ,,,..
,I he,reb y- acknowle?tkge` th'at" Ihave cead..this-,ap`plic6 tio n and-_stata tha.t the° ?
inf'tirinatiort I is; corrsat-arad,: agr-ee 'tv` cofliply witri. al3 a_ppY3?dable S'tdte`df*n=.,,.
Statutes=anii C3.C'y of_Eagab::Orrdlnances.
APPLICANT/PERMITEE SIGNATURE ISSU D 6. IGf U
1NSYL(:'1'IUN RECURD
CITY OF EAGAN PERMIT TYPE:
3830 Pilot Knob Road Permit Number:
Eagan, Minnesota 55122-1897 Date Issued:
(612) 681-4675
SITEADDRESS: P•I.N.: 1e-45e93--11e-02 APPtICANT:
LOTs 11 BLOCK: 2
4343 JENNIFER CT p K CON5TRUCTION
LEXINGTqN POINTE 9TH (612) 257-3926
PERMIT SUBTYPE:
DECK
FT.
? .w . '
TYPE OF WORK;
NEW
suaLozNG
625803
06J14/95
?.
.N
z CITY OF EAGAN .i?
3830 PILOT KNOB RD - 55122
1995 BUILDING PERMIT APPLICATION (RESIDENTIAL)
681 -4675
? 3 registered sile aurveys ? 2 copies of plan
? 2 copies of plens (include beam 8 window stzes; poured fid. design; etc.) ? 2 site surveys (exteriu atlditions 8 decks)
? 7 energy celwlationa ? 7 energy eatculationa for heffied edditlons
? 3 copies of tree proaervation plan if lot plettad after 7l1I93
iequfred: _ Ves _ No
DATE: CONSTRUCTION COST: 93' O°o' °?
DESCRIPTION OF WORK:
STREET ADDRESS:
LOT BLOCK C°^ s4`" ` °'S A
--I e n ^,f-r,,
SUBD./P.I.D.#: / g' r,
tGt 4 J%o d`°` /C?
/k „ , SS/ aq ?
PROPERTY Name: CU,,k s ? k? M L-4?
' Phone #: 6gd -°? qry d
OWNER Street Address, -j1P "^J?w C N
Ciry: C'? yX-. State: M.. Zip;
CONTRACTOR Company: u`?, (f% y S/- Phone #: 95 7' 3
Street Address: /SuS -OL'2 License #, 99 0D
City: Z,?^°IS4r?'"^ state: l4 -q zi`+s
ARCHITECT/ Company: Phone #•
ENGINEER
Name: Registration #
Street Address,
City: State: Zip:
Sewer & water licensed plumber:
change are requested once permit is issued.
Penalry applies when address change and lot
I hereby acknowiedge that I have read this application and state that the in tio rrect and gIgIree to comply with all
applicable State of Minnesota StaWtes and City of Eagan Ordinances.
Signature of Applicant:
OFFICE USE ONLY
Certficates of Survey Received _ Yes _ No
Tree PreservaGon Plan Received _ Yes _ No _ _ _ _ , m , z -„ -e -
? CITY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55123
(612) 681-4675
PERMIT OV, a V7? ?
PERMITTYPE: BUl ILpING'
Permit Number: 023619
Date Issued: 0 5/ 17 / 9 4
SITE ADDRESS:
4343 JENNIFER CT
LOT: 11 BLOCK: 2
LEXINGTON POINTE 97H
p.I.N.: 10-45093-110-02
DESCRIPTION:
Bailding-Perm3t Type SF DWG
Building Wor_k Type NEW
UBC Occupancyl R-3 M-1
Construction Type V-N
, Zoning PD
Building Length ? 55
? Building Width ; 51
Building stories -? 2
?
?-
?i% `"? ?./ Q-1 I\JL i L! i i
REMARKS:
S& W PLBR - TQM HESSIAN PLBG
FEE SUMMARY:
VALUATION
Base Fee
Plan Review
5urcharge
SAC
5AC %
SAC Units
Subtotal
$884.50
$574.93
$85.00
$800.00
100
1
$2,344.43
$170,000
MISCELLANEOUS $1p828.50
7ota1 Fee $4,172.93
CONTRACTOR:
SHARON K HOMES
4351 JENNIFER
EAGAN MN
(612) 452-7850
- Hpplicant - 5T. LIC
14527850 0007826
CT
55123
OWNER:
SHARON K HOMES
4351 JENNIFER CT
EAGAN MN 55123
(612)452-7850
I hereby acknowledge that I have read this
information is porrect and agree to comply
Statutes and City ofi Eagan Ordinances.
L
?
PLICANT/PEFMITF_E SIGNATURE
application and state that the
with all applicable State of Mn.
??ED B V : S'-?N'Y?d ?d?`RC w1?
J
INSPECTION RECORD
CITY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55123
(612) 681-4675
SITE ADDRESS:
LOT: 11 BLOCK:
4343 JENNIFER CT
LEXINGTON POINTE 9TH
PERMIT SUBTYPE:
SF pWG
PERMITTYPE: eurLozNG
Permit Number: 023619
Date Issued: 0 5/ 17 / 9 4
2 APPLICANT:
SHARON K HOMES
(612) 452-7859
TYPE OF WORK:
NEW
INSPECTION
FOOTINGS .. .
FOUNDATION ..
FRAMING ROOFING
INSULATION FIREPLACE
ROUGN IN PLBG ROUGH IN HTG
FINAL PLBG FINAL
REMARKS: S& W PLBR - TOM HESSIAN PLBG
F-
?
L ?
,:, , . . „ . .
, . ,? ? .. . , . „
....,?
, , ?
REACTIVATE _
PEMI7 5` . . ?
nLIG
CITY OF EAGAN ??
1990 BUILDING PERMIT APPL
'U¢ 681-4675 r7?` tl ? 1944
.G ?, ? °?? • ??' -
SINGLE 8 MULTI-FAMILY 2 sets of plans, 3 registered site surveys, 1 copy of energy
calcs.
COMMERCIAL 2 sets of architectural 8 structural plans, 1 set of
specifications, 1 copy of energy calcs.
Penalty applies: i) when permit is typed, but not picked up by last working day of month-
in which request is made, 2) address is changed or 3) lat change 1.s requested once permit
is issued.
Date 9'/ Yaluation of work ? ??jcor?
Site Address: Znn1kC ?!vLr,r?7- f ffl(12 i'l
Si0.EET fU17E Y
Tenant Name: (commercial only)
IAT ? BIACK SUBD.L??'?hq
?
P.T.D.
Descri tion of work: Z71' l(f FQ'mI & kfzyiC__" ,
The applicant is: ? Owner 04ontractor 0 Other CDescribe)
Name <?,'?: /-/n h:j?: S Phcne
Property «ST fIRSi '
Owner
Address
STREET fTE r .
City State Zip _
Company Phone Z{5?--7??7
Contractor Address -?,?- e-J- _ license NQ(»Rab Exp.
City FfYC]h State l_ Zip .?_
Campany Phone
Architect/
Engineer Name Registratlon
Address
City State Zip
Sewer & water licensed plumber Zh'1 1??S7CX?h . Processing time for
sewer & water permits is two days once area has been approved.
I hereby acknowledge that I have read this aPplication and state that the information is
f
correct and agree to camp h all appl able State of Minnesota 5tatutes and City o
Eagan Ordinances.
Signature of Applicant
OFFICE USE ONLY
t
BUILDING PERMIT TYPE
? Oi Foundation ? 06 Duplex 0 ll Apt./Lodging 01 16, 0asement Finjsh
PD02 SF Dwg. ? 07 4-Plex ? 12 Multi. Misc. 0 U Swim Pool
0 03 SF Addition ? 08 8-Plex ? 13 6arage/Atcessory O 18 Comn./Ind.
? 04 5F Porch ? 09 12-Plex 0 14 Fireplace ? 19 Coiom./Ind. Misc.
? 05 SF Misc. ? 10 Multi. Add'1. ? 15 Deck ? 20 Public facillty
0 21 Miscellaneous
WORK TYPE
P) 31 New O 33 Alterations O 35 Tenant Finish 13 37 Demolish
? 32 Addition ? 34 Repair ? 36 Move
GENERAL INFORMATION
tonst. (Actual) ? Basement sq. ft. 13/2 MWCC 5ystem
Allowable) _ lst F1. sq. ft. y319 City Water
S
UBC ccupancy /
?t 2od F7, sq. ft. ?2,?3 PRV Required
2oning ! Sq. Ft. total Booster Pump
?Y of Stories z Footprint Sq. ft. Fire Sprinkler
Length ? s On-site we11 Census Code
Oepth 51 On-site sewage SAC Code
APPROVALS
Planning Building Assessments
Engineering Variance
FiEQUIRED INSPECTIONS
? Site
? Wallboard
JZ Footing
JR Final
/O,r. 3
,0 framing
0 Draintlle
Permit Fee
Surcharge
Dlan Review
License
Mktt SAC
City SAC
Water Gonn.
Water Meter
Acct. Deposit
S/W Permit
5/W Surcharge
Treatment P1.
Road Unit
Park Ded.
Trails Ded.
CoPies
Other
Total:
SAC %
SAC Units
75/
0/
/
/
)I Insulation
? Fireplace
co6-/'.
ZS, 60 1ra 2 --
(o.t-'?,(v7 o z-
3
5,7?z/c
z-A
?oX30
; foo
a-s : lZ
? s,ria ' ya
?zk6 - ?2
n?z Yxsy= ?9
2?(_1
? aQa
r??•?,?ss = &9
2'Z sl2y.9C/
1 z,? 12.3 ? /Y741
U LOT SIIRVEY CHECRLIST FOR RESIDENTIAL
w
, m ??w, BUILDING PERMIT APPLICATION
W ? ¢ PROPERTY LEGAL:
w
W < ? Date of Survey:
m pOCLTMENT STANDARDS
?l ?.?T ?
? D ? • Registered Land Surveyor signature and cdman? q
cr- 0 0 • Building Permit Applicant
Br ? 0 • Legal description
0?-? p • Address
p? 0 ? • North arrow and krzn.-scale
?? 0 • House type (rambler, walkout, split w/o, split entry,
lookout, etc.)
C3? 00 • Directional drainage arrows with slope/gradient %.
B? 0 I} • Proposed/existing sewer and water services
p'? ? ? • Street name
B' 0 ? • Driveway
ELEVATIONS
Existina
G--17 ? • sewer service
0? 0 0 • Lot corners
?? ?] • Top of curb at the driveway
C? p? ? • Elevations of any existing adjacent homes
Prouosed
V? ? • Garage floor
V ? ? • First floor
? 0 ? • Lowest exposed elevation (walkout/window)
0 0 • Property corners
0'?-?? • Front and rear of home at the foundation
ONDING AREAS fif avUliCable
? C}'?o • Easement line
? Q' 0 • NWL
0 v ? • HWL
? 8' 0 • Pond # designation
p 9---0 • Emergency Overflow Elevation
DIMENSIONS
PJ?O ? • Lot lines
D? 0 0 • Right-of-way and street width (to back of curh)
? 0 ? • Proposed home dimensions including any proposed decks,
overhanqs greater than 21, porches, etc. (i.e. all
structures requiring permanent footings)
Q' ? o • Show all easements of record and any City utilities within
those easements
8" ? 0 • Setbacks of proposed structure and setback of adjacent
existing homes
p 0-"0 • Retaining wall requirements, if any
Reviewed:
October 1992
- coI (rXIS I. nr?.
-
- W'- EXISTING 10'PVC SANITARY SEWER ?--
- - =X. MH.
?ONCRETE THRUST 9LOCKING
?3 NNEi.T 70 3STUB - EXIST. STUB SEE STA. PLATE ttl2Q ?-
,v vATE '?ALVE IF NEC. QDa BEN? E?-- -? _
E
??ko1o? ?0° 9EiW ?=DGE OF
:X. IO" ?VC If !G' EASEMtf+?T ? TREES '-
8 10" P'.-UG ------- ? 20' EASEMENT
CONCRETE THRUST BLOCKING' ?
SEE STA. °j_ATt #I20 ? O I ? STA I+7E
i N=993.OG
STA 2+29 s-aa4.?o
W- 993.0? I ? I
S- 984.80 ;
STA 2+35
w- 993.02
;- 984,80 r?^
STA 2+40
TF?F-Gf i YOF Et1GFaN DOES P OTGUAR,4NTF497.50
TFiE ACCJRACY OF UTILITY LOCATIQW?)ga,C _
At.DiorELEVATIONS. THIS DATA IS FOR
1N.=OReLWtiQN PURPOSES OiNLY AND
F'Ea?SC.':?l' Li;lNG IT SHQ!!LD TI;c
ONTK:-'iTf7,. STA 2+24
'vU=993.40
c_ aP 1,8 i
9
8
/2°
3 t•iC
6".ti' ?EE
S LF 6" DIP CL °2
ioHYDRANT
?? II ;? ?7
?
i ?
7
6
STA 1+85
W- 99254
5-984.48
TA 0-+98
r?9 2.5 0
-983. %13
i?)
STA I•I I
N=992.97
s-Qa7.ae
?
? STF
>
? Mf7,.-
STA 0
VJ-9
5-Q83.
4
- i"- 10' VERTICAL (
1"=50' HORIZONTAL J E N N I F
MH 7
STA 5+68.5
TC=993.63
?.5' MtR'
;
w? ?
INV 98.3.00
250 LF 8" PVC 5DR 35 @ 0.8%
a I 7.5 MW. COVER
wi
Q
pl ?.
?
EL ! . ?p
? i
Q ? h 6-;'v ?'."E 1" OF EAGAPJ DOC-.S N
........ ........... .. .......... _......::::;?:.....,_,.,.:.r G?710?0
. ' . : - t f-Jt? e ?.9GunAGY ? OF. ..l?T1L ....... ..... .
£.?t?Dj`?)F ELEVATIONS. THIS DATA lS FOf1
<IST. e" 5TU6 ?:pTVOP? PURPOSES oFLY=y AH?
P
?lGIT SHOULD
Tuc c.ITF
PLEASE COMPLETE FOR SINGLE FAMII.,Y DWELLINGS. ALSO, 'FOR TOVVOH_O '1VE,S AND
CONDOS WHEN PERMiTS ARE REQUIRED FOR EACH UNTf.
- ------------------ - --------------- - -----
NO. FIXT[JRES
1 SHOWER
VVATER CLOSET
LO
BATH TUB
LAVATORY
- KTTCHEN SINK
? LAUNDRY TRAY
HOT TUB/SPA
? WATER HEATER
FLOOR DRAIN
? GAS PIPING OUTLET • m?n?mm -
ROUGH OPENINGS
WATER SOFTENER
PRIVATE DISP. • neray. uc.
U.G. SPRINKI.ER • ? uncier omsc.
ALTERATIONS • a austing
WATER TURN AROUND
STATE SURCHARGE
TOTAL:
EACH TUTAI.
3.00
3.00
3.00
3.00
3.00
3.00
3.00
3.00
3.00
3.00
1.50
5.00
20.00
3.00
20.W
20.00
-?
.5,0_
_.& wro
SIGNA E OF ? Iv1 _ 1994 PLUMBING PERMIT (RE$IDENI7AL)
SITE ADDRESS: 1/3 X3 j 1:ri?...l.-w ?? 1 /0
OWNER NAME: SA-2? "%[ ."
INSTALLER: TPA4 uUanN Q ...mN.. ., i r-
' 121 REDWOOD URIVE . ?
ADDRESS: APPL ? E VALLEY MN 555124 CTTY: STATE: r;?ZI;P;;CODE: .
PHONE #:
C1TY OF EAGAN
3830 PII.OT KNOB RD . EAGAN MN 55122
(612) 681-4675
PLEASE COMPLETE FOR SINGLE FAMILY DWELLINGS. ALSO, FOR TOWNHOMES AND
CONDOS WHEN PERMITS ARE REQUIRED FOR EACH UNTI'.
? NEW CONSTRUCTION
_ ADD-ON A/C
ADD-ON FURNACE
FIREPLACE INSERT
DATE S/ Z ?
FEES
HVAC: 0-100 M BTU $ 24.00
ADDITIONAL 50 M BTU 6.00
D
GAS OLJTLETS (MINIMUM 1@$3.00 EACH) G- ?
ADD-ON/REMODEL (Exis'['uvG CoNSTRUCI'ION) $ 20.00
STATE SURCHARGE .50
sa
TOTAL
SIT'E ADDRESS: l_/3'-13 c T
OWNER NAME: fO,u lAl0/^ eS TELEPHONE #: 7F$ d
ADDRESS:
CTI'Y:_ ?0? ? I?d ??7' STATE: 1771t) ZIP CODE: -?"S_N 9e
?
TELEPHONE #: l/ 2- 3- 3.ft) `L
S-rGWAT E O ERMITTEE
1994 MECHANICAL PERMIT (RESIDENTTAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN MN 55122
(612) 6814675
v L / BL ? CITY USE ONLY
?
SUBD. ?.C?SG• ??. ? ?
RECEIPT#:
RECEIPT DATE:
1997 PLUM$INH PEftMIT ($£SIDEN1'1AL)
CITY OF $AfiAN
9$30 fILOT KAOB iiD
$A6AN, b1N 5518E
(61E)691-4675
Please complete for: ? single family dwellings
D townhomes and condos when permits are required for each unit
? backflow preventer for underground sprinkler system
FIXTURES
Shower
Water Closet
Bath Tub
Lavatory
Kitchen Sink
Laundry Tray
Hot Tub/Spa
Water Heater
Floor Drain
Ges Piping Outlet ` minimum • 1
Rough Openings
Water Softener ' for dwellings under construdion
Water Softener ' tor exis6ng dwelting
U.G. SpfinklBr ' for dwelling under const.
U.G. Sprinkler ' for exisling dwelling
Alterations ` to existing residence
Water Turn Around
Private Disposal System ' Dak Cry lic.
(new and refur6ished systems)
Private Disposal Systems ; Abendonment
STATE SURCHARGE .50
TOTAL ?
------------ ?- ---------------------------• --- --------------• ------------------------ • •-- •-------------------------------------------------
I Frereby adcnowledge that I have read this application, state that the infortnation is coned, and agree to amply with all applicable City of Eagan ordinances.
It is the applicanPs responsibility to notity the property owner that the City of Eagan assumes no Ilability for any damages caused by the City dunng ks
notmal operational and maintenance activdies to the facilities conslructed under this permd within Cily propertylright-of-wayleasement.
SITE ADDRESS: yJ ?/? ?n n s,Lpr-
/ u
OWNER NAME: J?1 ?i1S1, )C?1- e4?v?
INSTALLER NAME: /S e2 r I?PJ`f 4?`. TELEPHONE#: 90S-4Q60e'
STREET ADDRESS:
ciTV:
EACH # TOTAL
3.00 x =
3.00 x
3.00 x
3.00 x
3.00 x =
3.00 x =
3.00 x =
3.00 x =
3.00 x =
3.00 x =
1.50 x =
5.00 x =
20.00 x =
3.00 =
20.00 =
20.00
20.00 =
75.00 =
20.00
SIGNATURE
CDIFORMSIPLBG PERMIT (RESIDENTIAL) 1997
73SSI
2006 RESIDENTIAL MECHANICAL PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675
Plcase complete for. single family dwelLngs & townhomes/condos when pertnits are requved for each unit
Date ? l / 3 / o b
Sitc Address 13 L/ 3 ?/ P?1?7.? ?(`t?? ?
CJ Uni[ #
Property Owner i / if Telephane # ((?,j( ) a0 ? 7 0 3 U
Contractor BURNMI11
1
r
-
-
- .
3451 W. Burnsville Parkway
Street Address ci
4'
State Bumsville, MN 55337 Zip Tetephone# (9ya)d(;?5 /0005
Bond #: 0 5_`f Exp(res: 7_do `v 6
The Applicant is _ Owner ? Contractor _ Other
Add-on or alteration to existing dwelling uni[ $ 30.00
? furnace _Additional AReplacement _ New
D
air exchanger
air conditioner
heat pump
ather
State Surcharge $ 50
Total $ 0•
I herehy apply for a Residen[ial Mechanical Permit and acknowledge [ha[ the infovnation is complete and accurnte; tha[ [he work will
be in conformance with the ordinances and codes of [he City of Eagan and wrth the Mechanical Codes; tha derstand this is not a
ork wi e in accordance with the
the w
pernvt, but only an application for a permit, and work is not to start without a pe 7-1
approved lan in [he case k which requires a review and approval of plans.
?Q ? ?..
Applicant's Printed Name Applicant's Signature
? -4-5 Z 4 30 . Sa
2006 RESIDENTIAL MECHANICAL PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675
Please complete for. smgle family dwellings & townhomeslcondos when petmrts are required for each unit
Datc
Site Address h Unit #
y?
Property Owner / ,y? ' ?
? <-e
Telephone # ( 1 )
Contractor RI IRNSwI I F HEATIAIG R /+LC
INC
r
.
Street Address 3451 W. Burnsville Parkway
2J.-4te 120
CitS'
State Bumsville; MN 553?p Telephone #( J-r,-) C??%S?OGY7S`
Bond #: Expires: ' 21 ? D 7
The Applican[ is _ Owner ? Contractor _ Other
Add-on or alteration to existing dwelling unit $ 30.00
fumace _Additional _Replacement _ New
air exchanger
air conditioner
heat pump other 1 ?-u-v
State Surcharge
p
[ (C I ?, Il ??% ? ?: $ 50 R
Total NOV 0 1 2006 $ O•
I hereby apply for a Residen[ial Mechanical Permi[ and acknowledge [hat the information is complete and accurate; that the work will
be in confoanance with [he ordinances and codes of the City of Eagan and with the Mechanical Codes; that I understand [his is no[ a
cordance with the
permit, but only an application for a permit, and work is not to start without a pe ','Lhat the work w7__-?Xt
approv n in the case k which requires a review and approval of plans. ?
CA,.5a,?Q it.t o l 12-P App tcant's Printed Name I Applicant's Signature
F -For- O-fti--Us-e - - - - - - - - - - - ?
? I
City of Eap? ? Pg?°* ,
I Permit Fee:
3830 Pflot Knob Road
Eagan MN 55122 ? Date Received; ? ?
Phone: (651) 675-5675
Faz: (651) 675-5694 j Stw. j
2009 RESIDENTIAL BUILDING PeRaniT aPPUCATioNLCflki?
?
Dare: lnc,cc4. 7?',oaooasrteaaamsg: 143143 2-,nnLy- Cotir- ' _ ?r
Tenant
Suite #:
RESIDENT / OWNER Name: m L' ? i3 S (,`t' mAP 1 rn Y1 Pv Phone: Sp ? I .31 5', ??IJ S-I
?
AddresSlCity /Zip: t-43143 yav? fFrr Caor-7- Faofnr? I YMlIJ )-,S ) ?1.1
Applicant is: X ne ? Contrac[or
TYPE OF WORK Description ofwork: 1?pp?r.,cF r?c?s"rh•: w??+r?ow ? br?, c??Y W in ?o?.J ?flD1atP
S koy
Construc6on Cost: Mulfi-Famlly Building: (Yes _ f No X}
CONTRACTOR Name: ?17av % d Sc?, wC ? c, h C rn-?C"r. -I??'r . License #: .102G> DI C 2q
,address: a 1 ] iG Ka n-r- ;c,k 14 v P,
city: 4-a k Q vjl'? state: 0? tt) zip: .1 S DI'/ y
Phone: g) c, WGq 3aad; Contad PeSOn: {'?'?qr 1 1lt32V1.S
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Cateaorv 1 Minnesota Rules 7672
En9rgy Code . Residential Ven6lation Category 1 Workshcet T• New Emrgy Cotle Wo'kaheel
Category Submitted Submitted
(4 submission t)pe? • Energy Emelope Calculations 5ubmitted
In the last 12 moMhs, has the City of Eagan issued a pemiitfor a similar plan lased on a master pWn?
_Yss _No If yes, date and address of master plan:
Liceased Plumber: Phone:
MechanicalContractor: Phone:
Sewer & Water ContracWr: Phone:
NOTE: Plans and supparting documents that you submit are considered ro be puWfc lnformafion. Portions of
fhe informaiforr may be classified as non•pu6fic if you provfds speciffc reasons that would permit the City fo
conclude that the are frade secreb.
I hereby adcnowledge that this Infortnetion is complete and aCCUrate; that the wak will be in confortnance with the adinances arM cod% Of ihe Cily of
Eagan; that 1 understand this is not a permit, 6ut onfy an appfication tor a perm'rt, arM work !s trot to sfart without a permit, that the work wlll be in
accordance with lhe approved plan in the case of work which requires a reyiew and approval of pians.
ApplicaM's Printed Nama AppllcanYS SignaWre
Page 1 of 3
DO NOT WRITE BELOW THIS LINE
SUB TYPES
Foundation
i° Single Famity
Mufti
01 of Plex
_ Accessory Building
WORK TYPES
_ New
Addition
? Alteration
` RepWce
Valuation
Plan Review
(25°k_ 100°h )
Gensus Code
# of Units
# of Buildings
Type of ConsVuction
_ Flreplace _ Porch (3Season) _ Stortn Damage
_ Garage _ Porch (4Season) _ Exterior Akeration (Single Family)
i Deck _ Porch (ScreenlGazebo/Pergola) _ Exterior AltereUon (Multi)
_ Lower Level u Pool ? Miscellaneous
? Interior ImprovemaM
? Move Building
_ Fim Repair
_ Repair
Siding
Reroof
JO Windows
_ Egress Window
Demoiish Building"
Demolieh Interior
Demolish Foundadon
_ Water Damage
•Dertwlilion MeMire builtling-gWePCAhandout W applicant
Occupancy
Code Edition Alrl 2pc 7
Zoning ?
? 8toFies
Square Feet
Length
Width
REQUIRED INSPECTIONS
Footings (New Building)
Footings (Deck)
Footings (Addition)
Foundation
? Drain Tile
Roof: _Ice & Water lFinal
1O Ftaming
Fireplace: _ROUgh In _Air Test _Final
? insulation
AAeter Size:
Reviewed By:
MCES System
SAC Units
City Water
Booster Pump
PRV
Ffre Sprinklers
Sheetrock
? Final / C.O. Required
Final / No C.O. Required
HVAC
Other:
? Pool: _Footings _AidGas Tests _Final
? Siding: _Stucco Lath _Stone Lath _Brick
?Q Windows
Retaining Wali
? Eroaion Control
Building Inspector
RESIDENTIAL FEES
Base Fae
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S&W Pertnk & Surcharge
Treatment Plarn
Copies
TOTAL
3. Doa? ??
?. Z>a0 , -o'a
S ? 00 . o C)
J
TRI_Cm,>AN4/ COo
--L.L V URVEG Y NMd'
SERVICES
S I T E PLAN FOR ShA?Q+v K, HornU
LEGAL DESCRIPTIOiV: LoT_l.l_,BLOCK3._,1.?K?IoN towtc
ACCORDIN TO THE RECORDED PLAT
THEREOF ?COUNTY, MINNESOTA
ADDRESS: ySy1 J1u?DFfk CT.
f
4000,
a?
?
n ?
^ r ?
? A
-- ? -- ?'?p
LEGEtip
o pENOTES IRQPi Mv?dUPkE"i i
4 DENOiES WOOD HUB SET
°llan DENOTES EXf:,TING SPOT
ELEVATIQN
N" OENOTES PROPOSED SPOT
ELE VAT I OR7
e- DENOTES DkAINAGE DIRECTION
i h'rat?g cortify thal S1is gurviq,plon or
report aas preparad by :nc or un6or my
Girect suparviaion ond qheq 1 am a duly
R9q1610f0a Land Survep•or undar 4he
LGwa of 4he STaTe o} Minne&oPrt.
u
ravuruN mIVC'L?vr;L•'ziI1VGDEPT.
IVVERT Ft_EVATION AT SERViCE EXTEivSIpN=4? Q
PROPOSEp Gi?RAGE PLOOR ELEYA710Y =
PROPOSED FliiST FLOOR ELEVATlON =
PROPOSED DdkBEPAEiV'i FLC]OR =
E LE VA 71 ON
2-S'FoR? Wl?Iko?fi
NOTE VERIFY ALL PLOOR HEIGHTS WITH
FINAL HOUSE Pi.ANS
,
Brod?iey J. anaon, W9n. Roq. No. 15235
&
Dots • S
S li6/
r Ss?....
. ? TRI-LAND C0.
L? SURVEYING -
?
SERVICES
S IT E PLAN FOR :SNARON K. HomU
LEGAL DESCRIPTION: LoT-L_, BLOCK",'-, LfxING-[aN Po14110 'v`
ACCORDIN TO THE RECORDED PLAT
THEREOF COUNTY, MINNESOTA
ADDRESS: q3'+1 -TFNr/Jf-? S-1•
`W3P
N
.-
?
i
s
?
,
?•f""?`%. b ?
....,. -
? ....... ?
(Q'9E!) I ?? 2.d7' ?`l94 S'f'
ji'M
I '
as' n?oN`
l ? ?4 •.' I
I
? ( o L LOT1 " - -i
"' ? ? 78.11
LEGEND
o DENOTES IRON MONUMENT
a DENOTES WOOD HUB SET
°18a DENOTES EXISTING SPOT
ELEVATION
MWX DENOTES PROPOSEO SPOT
ELEVATION
? DENOTES DRAINAGE DIRECTION
I Mnby certify fhat ihis surwy,plan or
rspori wos prepored by me or undor my
dirsct suparvision ond ihat I om a duly
ReqisTSrad Land Surveyor unM? fhe
Laws of the Stute of Minnesoto.
ED
FAGAN ErNGINEERING DEFZ: ?
INVERT ELEVATION AT SERVICE EXTENSION-98 O
PROPOSED GARACaE FLOOR ELEVATION=
PROPOSED FIRST FLOOR ELEVATION =
PROPOSED BASEMENT FLOOR -
ELEVATION
2-stoa? w?tko?t
NOTE VERIFY ALL FLOOR HEIGHTS W17H
FINAL HOUSE PLANS
Brodley J. (Zinson, Mn. Rep. No. 15235
Date- Slg/q'y
?
o ,,•
IC
.:?
?
? ???
S?
I E Auh?v
' REVIEWE[7
I ar ?S
( -,
y
?
10
S l161
93/98/69 20.35 6127313284 RELIABLE HOMES, INC PACE 01 ,
' . '
fi7CT8RI0A SPiVSLQPS AVBRAGS °U' COMRTYCATION
PLAN q
C
CON • SHARON K LIC. NO. 826
311'8 ADDRFSS:
1. Tael expoeed wall uea 22?299r-;o sq.R x.l l t:;=
r we... 2. Toqtl sipoeed mof/dling sq.8. x.026
1Ve11 oaiCUisabn
Totai wbmlow araa i.. aq. R. =.35 --
Tael door etaa t eq.R a.OT 1
"1`otel glaee dooi area eq.R x.35
Totsl fuaPlm uea *xq.AL ?vl:? , Toal wa11 flBming ata8 .R x.09
Net inmlated wall area .R. x.043
Tdal tim.1? em .d. x.04
Total ? area x .14 '
Tolrl fuundifia wicdow x,33 -- ?
3. Tom1 ,
IL it4m 3 is the aame as, or las thm item 1, you hava mat a?e imene oP2MCAS1.16008 A aad O
RooF/ceiliug almdrtiom '
Total aicYligLt am -"" sq.8. x 35
Tatal:oof/ceilinB 5aqWpB aq. R x.026 ?.t D
?i? mwleeed toof era 9q. ft. .022
4. Tatai ?•„?,
IF item 4 it tLe ome av, a las theu 2. Yw md tdo ineeae ot2 A4CAR L1b008 A aud O
A16eaasoe 6uild'Ing mvelope daeigq
TO utliiae the taal envelope ayalmn mefhad ft iwh of itema 1 sad x " b6 peow lhao rhe swn of
ibma 3 md 4.
I ImbY cartity that the huldmg hm deecribed meap a exaey? ?he
Caaeavation Act.. / ?
1 For C 0
• 1 ~ 1
I Permit*: C~ c~ 5 ~
City of Eajan
Permit Fee.
3830 Pilot Knob Road I 1
Eagan MN 55122 ; Date Received: Qaq;
9
Phone: (651) 675-5675 I
I
Fax: (651) 675-5694 ;staff:
2009 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: mo' O vA SiteAddress: q -3 LL3 Tin n h r cowy
Tenant: Suite
RESIDENT / OWNER Name: M e L5 s ct + M r /,e-rmtf Phone: 0-1 Address/City/Zip: LJ3q3 i5-KJhr Coor'r. Ecaf4to , iJ 1013
Applicant is: ~ ne ~ Contractor
TYPE OF WORK Description of work: - n rr ow w b i Y W L'3 keolp'ce
r ShoConstruction Cost: Multi-Family Building: (Yes / No -~L)
CONTRACTOR Name: v*i d w u C h Cans"'. , C,yjr License 20~2GaC, -,a_
Address: I 1(p Kf n C; C, L A y f,
City: L.C"k-Q v ► I 1 \e State: Zip: so ~i_
Phone: q J o~ ~1(n I 3 JL jj Contact Person: i ar 1 ,
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
(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 _„_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 odes 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.
xx ~r-► x
Applicants Printed Name App icants Signature
Page 1 of 3
DO NOT WRITE BELOW THIS LINE
SUB TYPES
_ Foundation Fireplace _ Porch (3-Season) _ Stone Damage
Single Family ` Garage i Porch (4-Season) - Exterior Alteration (Single Family)
_ Multi _ Deck _ Porch (Screen/GazeboiPergola) Exterior Alteration (Multi)
_ 01 of _ Plex Lower Level Pool Miscellaneous
_ Accessory Building
WORK TYPES
_ Now Interior Improvement Siding ` Demolish Building*
_ Addition r Move Building Reroof Demolish Interior
Alteration _ Fire Repair J Windows _ Demolish Foundation
Replace _ Repair - Egress Window Water Damage
*Demolition of entire building - give PCA handout to applicant
DESCRIPTION
Valuation J , at •`D C, Occupancy J%12G- ( MCES System
Plan Review Code Edition Ail aoo "t SAC Units
(25%-100%,_) Zoning _ City Water
Census Code •-t Stories Boaster Pump
# of Units Square Feet PRV
# of Buildings Length Fire Sprinklers
Type of Construction Width
REQUIRED INSPECTIONS
Footings (New Building) Sheetrock
Footings (Deck) Final / C.O. Required
Footings (Addition) Final / No C.O. Required
Foundation HVAC
Drain Tile Other
Roof: -Ice & Water Final Pool: Footings Air/Gas Tests Final
10 Framing Siding: _„_Stucco Lath -Stone Lath _„_,Brick
Fireplace: -Rough In Air Test ,-Final Windows
insulation Retaining Wall
Meter Size: Erosion Control
Reviewed By, Building Inspector
RESIDENTIAL FEES
Base Fee 3
Surcharge
Plan Review / ) p~ , •p a
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
Copies
TOTAL
----------------I
~ For Office Use I
City of Eajan I Permit Permit Fee: 12
I
3830 Pilot Knob Road
j
Eagan MN 55122 Date Received:
20
Phone: (651) 675-5675 1 I
Fax: (651) 675-5694 Staff:
4r-------------- 4-
/I
2009 RESIDENTIAL BUILDING PERMIT APPLICATION kJ
Date: Mcn -CC , 101ac fl Site Address: 14-3 ~i3 sir r, ~t` Y- Coy,, El
-r-
Tenant: Suite
l~ S-1
RESIDENT / OWNER Name: ' I i .5 4- u + M r (e. 1 rst n ey Phone: a f 1 .31
Address / City / Zip: L4 3 IJ3 zEnEe r Go to y f , C-en!A o r, ni t J J-5-1 133
Applicant is: x ne contractor
TYPE OFWORK Descripbon of work: RtOIL'c ,S rR4 V->)rN Ouo ('Jz ~ Y tU)lri)riLO ~ac'
1_/ I t J S kowe
Construction Cost: . ` ' Aw Multi-Family Building: (Yes / No X
CONTRACTOR Name: bmv', a S-.)w-Q., k (,cNtS 'j, _1~!I[ License v c. ?a
Address: -Z i ,r^ rG )41/ ,
City: t-CA k-Q v + i i State: 01, P') Zip: "i20 Y
Phone: q r I 3 ~ Contact Person: rb r i /
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Category 1 Minnesota Rules 7672
Energy Code • Residential Ventilation Category 1 Worksheet T 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 the 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 1 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.
Applicanrs Printed Name Applicanrs Signature
Page 1 of 3
Use BLUE or BLACK Ink
~ FaF~:~f~e'_t 1
I Permit ,
I
01 ~
l 0C..l1
4y of Eajan I Permit F F ee: I
3830 Pilot Knob Road I
RECEIVED
Eagan MN 55122 1 Date Received:
Phone: (651) 675-5675 1
Fax: (651) 675-5694 MAY 2 1 2011 staff
2011 RESIDENTIAL PLUMBING PERMIT APPLICATION
~r (J 11 ~
Date: ~ I 4 ` I Site Address: "tIN (I l.fp t C'4-
Tenant: lJk Suite
RESIDENT/OWNER Name: `IC.hol p I a L Phone: 30
Address / City / Zip:
CONTRACTOR Name: pliance G Ctl ,.5 n License
1313
Address: City:
State: Zip: Ph040:
Contact: -Email:
TYPE OF WORK -New Replacement _Repair -Rebuild - Modify Space - Work in R.O.W.
Description of work:
PERMIT TYPE RESIDENTIAL
Water Softener
Water Heater
Lawn Irrigation RPZ PV13) Add Plumbing Fixtures 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)
$35.00 Lawn Irrigation (includes $5.00 State Surcharge)
$55.00 Add Plumbing Fixtures, Septic System Abandonment, 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 built) (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.goi)herstateonecall.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 he case of work which requires a review and approval f llans..J
x x "r 0
Applicant's Printed am Applica is Signature
FOR OFFICE
`tJSE r. Reviewed By: Date:
Required fnspeGtions: Undef Ground ' Rough-In Air Test Gas Test Fina{
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA113830
Date Issued:09/09/2013
Permit Category:ePermit
Site Address: 4343 Jennifer Ct
Lot:11 Block: 2 Addition: Lexington Pointe 9th
PID:10-45093-02-110
Use:
Description:
Sub Type:Reroof
Work Type:Replace
Description:
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar.
Pictures are not acceptable in lieu of inspections.
Carbon monoxide detectors are required by law in ALL single family homes .
Scott Rise
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 -
Michael J Taney
4343 Jennifer Ct
Eagan MN 55123
Lakewoods Remodeling
9001 E Bloomington Freeway #144
Bloomington MN 55420
(952) 888-5550
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA121399
Date Issued:03/28/2014
Permit Category:ePermit
Site Address: 4343 Jennifer Ct
Lot:11 Block: 2 Addition: Lexington Pointe 9th
PID:10-45093-02-110
Use:
Description:
Sub Type:Siding
Work Type:Replace
Description:
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please leave printed pictures of house wrap on site for the final inspection.
When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to
ensure maximum ventilation to attic. Call for final inspection after installation.
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 -
Michael J Taney
4343 Jennifer Ct
Eagan MN 55123
Lakewoods Remodeling
9001 E Bloomington Freeway #144
Bloomington MN 55420
(952) 888-5550
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA123132
Date Issued:05/30/2014
Permit Category:ePermit
Site Address: 4343 Jennifer Ct
Lot:11 Block: 2 Addition: Lexington Pointe 9th
PID:10-45093-02-110
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Air Conditioner
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Stephanie Vought
3451 W Burnsville Parkway Suite 120
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 -
Michael J Taney
4343 Jennifer Ct
Eagan MN 55123
Burnsville Heating & Air Conditioning
3451 West Burnsville Parkway, Ste. 120
Burnsville MN 55337
(952) 894-0005
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA152069
Date Issued:09/26/2018
Permit Category:ePermit
Site Address: 4343 Jennifer Ct
Lot:11 Block: 2 Addition: Lexington Pointe 9th
PID:10-45093-02-110
Use:
Description:
Sub Type:Siding & Windows/Doors
Work Type:Replace
Description:
Census Code:434 - Residential Additions, Alterations
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please print pictures of house wrap and leave on site for final inspection.
When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to
ensure maximum ventilation to attic. Call for final inspection after installation.
Valuation: 8,000.00
Fee Summary:BL - Base Fee $8K $162.25 0801.4085
Surcharge - Based on Valuation $8K $4.00 9001.2195
$166.25 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 -
Michael J Taney
4343 Jennifer Ct
Eagan MN 55123
(651) 248-8221
Smith Cole Stucco And Stone
3916 Dight Avenue South
Minneapolis MN 55406
(612) 709-4980
Applicant/Permitee: Signature Issued By: Signature
stZIL Y"4141 VT101",17 -17- /1 f-06 01
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 TDD: (651) 454-85351 FAX: (651) 675-5694
buildinginspections(aD-cityofeagan.com
- - - - - - - - - - - - - - - -
I For Office Use I t
I I
I Permit #: I
I Permit Fee: c;7/,7/ I
OCT 08Ma
Date Received:
I I
Staff: <7I
L---------- ---- �
2018 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: 00 Site Address: -43A3 e4X tel Unit #:
7— T-
Name: Phone:IP✓ I. 2AS. J W
Resident/
Owner
Address / City / Zip: ^f
Applicant is: Owner Contractor
Type of Work
Description of work:
Construction Cost: + Multi -Family Building: (Yes / No )
C'f
ompany ITI A !FPSO&P 44&6AAI� Contact:
Address: 15414W s' % City: 4A
Contractor
Statel aM Zip: 'd` Phone s .7M-a0mail: tit %)e49D
License #: n6aaLead Certificate #: .r.• —Vr 154
If the project is exempt from lead certification, please explain why:
COMPLETE THI EA ONLY IF CONSTRUCTING A NEW BUILDING
In the last 12 months, has the City agan issued a permit for a similar plan base n a master plan?
Yes No If yes, d and address of master plan:
Licensed Plumber: Phone:
Mechanica ontractor: Phone:
Sewer & Water Contractor: Phone:
Fire Suppression Contractor: Phone:
NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of the information may be
classified as non-public if you provide specific reasons that would permit the City to conclude that they are trade secrets.
You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update on the City's
website at www.citvofeagan.com/subscribe.
Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180
days of permit issuance.
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
hereby acknowledge that this information is complete and accurate; that the work will conformance wit e o finances an cod sof the City of
Eagan; that I understand this is not a permit, but only an application for a permit, nd work is not to start wit out permit; th t t work will be in
accordance with the appr ved plan in the case of work which requires a review and roval of plans.
x %e x
Applicant's Printed Name Applicant s ignatur
;1
DO NOT WRITE BELOW THIS LINE
SUB TYPES
Siding Demolish Building*
Foundation
Fireplace
Single Family
Garage
Multi
Deck
01 of Plex
Lower Level
Porch (3 -Season) Exterior Alteration (Single Family)
Porch (4 -Season) Exterior Alteration (Multi)
Porch (Screen/Gazebo/Pergola) Miscellaneous
Pool Accessory Building
New
Interior Improvement
Siding Demolish Building*
Addition
Move Building
Reroof Demolish Interior
Alteration
Fire Repair
l` Windows Demolish Foundation
Replace _
Repair
Egress Window Water Damage
Retaining Wall
*Demolition of entire building — give PCA handout to applicant
DESCRIPTION
Valuation /
Occupancy
4-r2<' MCES System
Plan Review
Code Edition
SAC Units
Ivi
(25% 100%)
Zoning
City Water
Census Code
Stories
Booster Pump
# of Units
Square Feet
PRV
# of Buildings
Length
Fire Suppression Required
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 Foundation Before Backfill
HVAC Service Test Gas Line Air Test Hood
Roof: Ice & Water
Final
Pool: Footings Air/Gas Tests Final
Framing 30 Minutes
1 Hour
Drain Tile
Fireplace: Rough In
Air Test
Final
Siding: t4 Stucco Lath Stone Lath Brick EFTS
Insulation ? Windows
Sheathing Retaining Wall: Footings Backfill Fina
Sheetrock Radon Control
- Fire Walls _ Fire Suppression: Rough In Final
Braced Walls Erosion Control
Shower Pan Other:
F
Reviewed By: ; 7 J , Building Inspector
I
RESIDENTIAL FEES
Base Fee
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
Copies
TOTAL
Page 2 of 3
SMITH COLE
MN LIC# BC — 693563
STUCCO c STONE
SCOPE OF WORK
Proposal Submitted to:
Phone:
Date:
Mike Taney
651.248.8221
05.21.2018
Address:
Job Name:
4343 Jennifer Court
CMT Moisture Report Repairs
City, State And Zip Code:
Job Location:
Eagan, MN, 55123
Same
Estimated Project Start:
Estimated Project Completion:
ASAP
ASAP
All References are based on the CMT Report Dated May 17, 2018 and Visual Inspection:
o Mobilize Scaffolding as required, Protect adjacent materials, Pull required Permits
o Cut & Remove Stucco & Wood Trim in the following locations:
® Page 2 test # 6-7 (Around 2 Windows)
• Page 4 test # 5-6 (Around 2 Windows)
® At 5 Roof Terminations (install Kick out Flashings)
® All Wood Trim on Front of Home
o Inspect areas of Removed Stucco, Report findings to Owner
o Based on findings Remove and Repair all Damaged Framing / Sheathing and Insulation
o If Required Remove and Reinstall 4 Windows with the Proper Flashing Details Per Code
o Install 5 Kick Out Flashing at Roof Terminations
o Remove all Decorative Wood Trim on Front of Home
o Apply D Type Weather Barrier, Galvanized Metal Lath to all Removed areas Only
o Apply New Portland Cement Coat to Removed areas Only
o Install New Decorative Stucco Trim Work where Wood Trim was Removed
o Apply Primus Base Coat to all Stucco Surfaces on Front of Home for Proper Blending of Patch Work
o Apply New Acrylic Trowel Texture Finish to all Stucco Surfaces on Front of Home
o Color and Texture approved by Owner — Smith Cole will Provide Owner with Color Chart
o Conduct thorough cleanup, close out permits and exit site
"Bull ing The Future — Restoring The Past"
3916 Dight Avenue South Minneapolis, MN 55406 612.709.4980
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA170242
Date Issued:06/24/2021
Permit Category:ePermit
Site Address: 4343 Jennifer Ct
Lot:11 Block: 2 Addition: Lexington Pointe 9th
PID:10-45093-02-110
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. We encourage you to retain an electronic copy of
photos until the project passes a final inspection.
If water damage is encountered, please call (651) 675-5675 to schedule a site visit to verify the extent of the damage. Any
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 -
Michael J Taney
4343 Jennifer Ct
Eagan MN 55123
Applicant/Permitee: Signature Issued By: Signature