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3180 Jurdy Ct N Use BLUE or BLACK Inl~~ F--------------- I For Office U I I CZLS ' Permit I ~~-----Itt City I of I Permit Fee: u 3830 Pilot Knob Road I I Date Received: I Eagan MN 55122 I I Phone (651) 675-5675 I I Fax: (651) 675-5694 1 Staff: I 2011 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: Unit Name: .~e n c t PhoneA/~,,J f RESIDENT / e OWNER Address / City / Zip: 31 Y-O -J& U rri v C t Applicant is: Owner x Contractor Description of work: r Gt TYPE OF WORK Construction Cost: Multi-Family B ilding: (Y sx_-_ / No ) r7c . oit ~rgY?c. LS b Company: SCk wl Contact: d k L- CONTRACTOR Address: Z 70 / fih City: 9, C.h~ State: Zip: Phone: l~ - dot f License Lead Certificate Does this project require Lead Remediation? ❑ Yes )2~kO (see Page 3 for additional information) If no, please explain: COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? _Yes _No If yes, date and address of master plan: Licensed Plumber: Phone: Mechanical Contractor: Phone: Sewer & Water Contractor: Phone: NOTE. Plans and supporting documents that you submit are considered to be public information. Portions of the information may be classified as non-public if you provide specific reasons that would permit the City to conclude that they are trade secrets. CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.aopherstateonecall.orct I hereby acknowledge that this information is complete and accurate; that the work will be in conf ance w h 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 wor ' not to st without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approva f plans. x -@ 1 C/` r C i c S Lr .s ea x Applicant's Printed Name Ap cant's Signature Page 1 of 3 CITY OF EAGAN Remarks Additivn Donnywaod Acidn. Lot 11 sik 1 Owner t?, ??' ??f •????V?t :: Street 3180 No. Jux'dy Ct. Improvement Date Amount Annual Years Payment Receipt Date ? STREETSURF. STREET RESTOR. 'J 1975 GRADING SAN SEW TRUNK ?2 5 1970 62.80 2,51 5-J-9_ SEYVER LATERAL 19 $ . 455.75 5 WATERMAIN ?- WATER LATERAL & StubS 1975 ??- WATER AREA 1975 * STORM SEW TRK 1975 ? S70RM SEW LAT 1975 CURB & GUTTER SIDEWALY. STREET LIGHT aa ni 75.00 13626 3-19-79 WATER CONN. 270.00 13626 3-19-79 BUILDING PER, sa,c 525.00 13626 PARK CITY OF EAGAN 8795 Pilef Knob Road Eagae, MN 55122 PHONE: 454a100 BUILDING PERIMIT Receipt #p nr+ -..i,_ I ?...Y..._.? n" nrNn Porcel # r °c Name ?o N2 5136 r_ ,%_,I n rrecc {i vccupanry ? Alter ? Zoning Repair ? Fire Zone T Enlarge ? j Type of Const. Move p # Stories Demolish p Front Grnde p Depth Approvah Fees Address . ` Assessment Permit dz,09 '?? ('1 , •,v t,- '^.Y yr", . r^, ' y • r : ) Water & Sew. Surchorge Ci Phone ?r Police Plon check Name Fire SAC Address Eng. Water Conn. [i ph? Planner WoterMeter ri?' ? Council T. ? ?. In 1 hereby acknowledge that I have read this application and state thut Bldg. Off. the information is correct and agree to comply with oll opplicnble APC Total State of Minnesota Stntutes and City of Eagan flrdinances. Sipnoture of Permittee A Building Permit is issued to: T``? on the express condition that cll work shall be done in accordance with oll cpplicable Stote of Minnesota Stotutes und City of Eagan Ordinonces. Bulldinp Official - - .. PomM # OeN Iawd PuwMlM Plumbing Mechanicol 11-470 - 1 -1 - 7 / ? ' S v INSPECTIONS DATE INSP. Rough-I n find Footings ? Date Insp. Oote Imp. Foundation Plumbing 4 7?1 - 0 Frome/ins. ? Mechonical -;l - Final 0-0- 1 Remarks: 1? /? SEWER SERVICE PERMIT nnr oc Er?"N 3795 Pilot Knob Roed PERMIT NO.: Eagan, MN 55122 DATE: 2oning: No. of Units: Owner. r'_ Address: - Site Address: . . •_ , . , Plumber: , . . ? I agree to eomplr with the City of Eagan Connection Chorge: ? Ordinoneas. Account Deposit: Permit Fee: ry ? ? Surchorge: BY _ Misc. Charges: Dote of Insp.: Total: Insp.: Dute Paid: No.: to oomply wilh Hhe Cify of Eogon Connection Chorge: Acmunt Deposit: _ Permit Fee: Surcharge: Misc. Charges: - Total: Dote Paid: cirr oF eaGAN 3795 Pilot Kno6 Road Eagan, MN 55722 N2 5136 PHONls 434-8100 BUILDING PERMIT APPLICATION ReceiPt # - rs k„ ..a fo. SF Dwlg & Garage en. voi.e 47,000. Date 3-19 _, 1y 79 _ Slte Address ".. ?""• """'y """" Lot 11 Block 1 Sec/Sub. ??yWood Addn Parcel # 10 20960 110 01 w Name "y "' Addma 1866 Tioga Blvd. ° -' - . . . _. ?p J Name Pdt K1YWdri o? Addr ss7319 Cleve Ave. E. Inver Grove Htfhone 455-1180 Name _ Address I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with aIl applicable State of Minnewta Smtutes and City of Eagan Ordinances. Signature of Permittee A Building Permit Is issued to: P Kirwin oll work shall be done in uewrdaw' h al1,?}opy?1 cq le Stote of Bulldtrg Officlal ?'I 2"-O? R3 Erect $] Occupancy Alt ? Zoning PD er Repair ? Fire Zone Enlarge ? Type ot Const. V Move ? #'Stories Demolish ? Front 55 ft• Grade ? DePt+ 40 N. ppPrpvols Fees Assessment Woter & Sew. Police Fire Eng. Planner Council Bldg. Off. APC Permit _ Surcherge - Plan check _ SAC WMer Conn. Water Meter Total 1,153.00 on the express condition that Stotutes and City of Eagon Ordiimnces. Minnesota State Board of Electricity T854 University Ave., St. Paul, Minn. 55104-Phone 645-7703 ' REQUEST FOR ELECTRICAL INSPECTION C,HECK BELOW WORK COVEREB BY THIS REQUEST 'R 12768 Type of Budding New Add. Rep. Check Appliances Wi=ed Foc Check Fquipment Wired For Home ? ? ? Range El Tempotary Wiring ? Duplex ? ? ? Water Heater ? LightingFixtures ? Apt. Bldg. ? ? ? Dxyei ? Elec[ric Heating ? Commercial Bldg. ? ? ? Pumace ? Silo Unloader ? Industrial Bldg. ? ? ? Air Condi ' nex ? 8ulk M0k Tank ? Faxm ? ? ? List List ) Othh ? ? ? 2thei ? er 2 Others} Hexe 1 COMPUTE INSPECTION FEE SELOW eZIR Serv' e Entrance Size: # Fee 1 1 Feeders& rs: Fee Cirwits: ik Fee , 0[0 1D0 Am s. 0 to 30 Am s 0 to 30 Am eres i 101 m 200 Amps. 31 to 100 Ampe `- 31 to 100 Am eres Above 200_Amps. Above IOD Am ' Above 100 Amps. Transformets RemoteControlCire. Panialoco[herfee - Signs 1 1 Special lns ution Minimum fee $5.00 Remazks TOTAL FEE I, the Electrical Inspector, hereby certify (Final) This reyuest void has been X?& n ade J ? ? &ate': v"/ - > S° 1'his request void 18 months from N t.J /O 1-e7l 1y - n-? ?o0``?,'O`? R 12768 Dke of this Request I, as'l Licensed Electrical Contractor ? Owner, do hereby request inspection of ihe above electri- cal winng installed at: Street Address or Route No. aZ)1T 8 d-gwl A?l C"r City Section Township p.) Range County C? Which is ocwpied by (Name of OccuDant) Is a roughin inspection required on this job? No ? Yes W Ready Now $ Will Call ? Power Supplier L0.Knd-?, 0-0_L,Vc r c_. Address ?M l IL'??"?rJ Electrical Contractor . 76AVAp\,p ia=r Contractoi s LicenseL Mailing Address o10175 IN 4? Authorized (tiec[ncal contraGior or owm SWQVE 2OQG°3D Qapl Nol3l- !ELI This inspection request will not 6e accepted by the State Board unless proper inspection fee is endosed. ? Minnesota State Board of Electricity 1954 University Ave., St. Paul, Minn. 55104-Phone 645J703 * REQUEST FOR ELECTRICAL INSPECTION CHECK BtLOW WORK COVERED BY THIS REOUEST Type o[ BuaQing New Add. Rep. Check Appliances Wired Foc Check Fquipment Wved Foc Home, ? ? ? Range ? Tempoiary Wiring ? Duplex ? El Water Heater 11 Lighting Fixtures 13 Apt. Bldg. ? ? ? Dryer ? Electric Heating ? Commercial Bldg. ? ? ? Fumace ? Silo UNoadei ? Industriai Bldg. ? 0 ? Air Conditioner ? Bulk Milk Tank ? Farm ? ? ? List - List Other ? ? ? ?eh ; ?ehers ? COMPUTE INSPECTION FEE BELOIV AM5%§" Secvice Entiance Size: # Fce Feeders&Subfceders: # ee C'¢cuits: # Fee 0 to 100 Am s. 0 to 30 Am eres 0 to 30 Am eres c o 101 to 200 Amps. 31 to 100 Am res 31 [o ]00 Am eres `vL Above 200 Ampa Above ]00 Amps. Above lO?Amps. Transfottneis Remote Contcol Circ. Paztialor othei fee Si s S ecial Ins ec[ion Minimum fe Remazks !•',?? T TOTAL F E,7). 0-0 I, the Electrical Inspector, hereby ce rtif'?t?iat t13e pbqv? inspec ' n has been ma e. ?o (Rough-in) ??z? Date ? - /? (Final) /? Date ?.?4 2-?? This request void 18 months from o i/ This request void 18 months from Date of this Request 0- 7-196 g_ 17505 I, as [?l Licensed Electrical Contractor 0 Owner, do hereby request inspection of the above electri- cal wi'ring installed at: C::r,// "'7 l v??.,/?, -?_ Street Address or Route No. 340 HeITI ? Section Township Range County nal2c;r-: Which is occupied by A& . (Name o} Occupant) Is a roughin inspection required on this job? No Q<L Yes ? Ready Now Q? Will Call O Power Supplier Address Electrical Contractor Mailing Address Authorized Contractor's License No;?M7 Phone No. yo13^/?V31 This iMpection request will not he aceepted by the State Baard unlesspraper inspection fee is endosed. (grr#ifirtt#r u# (orrixpttnry (Eitp of (eagan igcpttrtmenf uf +?uiliting 3nsprrtimt Thir Certi ftCRtt iJJG!!I !M[rrrutnt to tix rrqursemtnu of Sectron 306 0/ the Uniform Building Cods mti fying thqt at t/x time a f iirtianct tbrt ttrutturr wat in tomPliunn with 1!n variout ordirinruer of tix Cuy rtgulating bniJding casrtrratiars or ure. For the fo[louung: u:ci.m?um SF rwig/r,arage__Bldg:hmutNo. 5136 (k-wd.r'ha R3 IYPC?? V Fm 7n„ III . z?a PD NllWB.y Bldi'8.. ... l R55 Ti nvn _ Mcm Rri oh+n?. Lll Bl Doxu?yuvood Addt. Dale S. Peterson June 16, 1980 ,.. ?,we,,. ...?. o?,.,.a -- - CITY OF EAGAN 3795 Pilo! Knob Road Eogon, Minnesota 55122 Phone: 454-8700 P&UL-7H3C7G pERMIT rnp 4, 1979 Date: Site Address: 3150 VLA. 3uY'd9 CervoC Lot +Y Bbck g _ Sub/Sec DG-`nV?'-=d Name °:':-Lbal DM$Ic3;-:S6_-_ P.34. ICG'SC7ait o Address O City Phone: Name E ° Address 5500 3a* :c 1ac. t'ssu: c 0 City Phone: This Permit is issued on ihe express candition thot a!I work sholl be Minnewto Stotutes ond City of Eagan Ordinonces. No. 1338 804335 Receipt No.; Single Residentiol FS Multi Res.,;Comm./Ind. New/Alter./Repair rtQw Cost of Installation Permit Fee 20•()0 Surcharge •50 Total ?r.. ?,0 done in occordance wit h atl applicoble State of Building Official CITY OF EAGAN 3795 Pilot Knob Road Eogon, MinnnWa 55122 Phone: 454-8100 FM Ari?+n Dote: Site Address: Lot 3:30 7. JIELYa'V C:tY'iL2't Block Sub/Sec. Nome P84 F,1i^--'zb1 c 1;i?F" Address . ?'`'• _^?'°??" . ._' 3 - - O City i'7!:° Phone• ' - p Name ° Address c City - " _ Phane: This Permit is issued on the express condition thot all work sholl be Minnesota $tatutes and City of Eagan Ordinances. PERMIT ?L-.l3/JJ.l1V!'J 'tl?R 7.1:C!L'1j`'jJ No. 1470 1<1592 Receipt No.: Single X Residential Multi Res., Gomm./Ind. I New/Alter./Repair Cost of Instollation I, 795 . OG Permit Fee -- Vn Surchorge Total done in atcordance with all opplicable State of Building Official RESIDENTIAL 53 - 1$C BUILDING PERMIT APPLICATION °? CITY OF EAGAN 3830 PILOT KNOB RD, EAGAN MN 55122 651•681-4675 J New Cons W ction Reauiremenh • 3 registered site surveys showing sq. fl. of lot, sq. ft. of house; and all raofed areas (20°k maximum lot caverage allowed) • 2 copies of plan showing 6eam & window sizes; poured found design, etc.) . 1 sef of Eneryy Calculatians • 3 copies of Tree Preservation Plan if lol platted after 711I93 . Rim Joist Defsil Options selection sheet (bldgs with 3 or less unAS) oATE_7-17-0 a SITE ADDRESS TYPE OF WORKP0 APPLICANT_, STREET ADDRESS TELEPHONE # (D/, ?ULTI-FAMILY BLDG _Y FIREPLACE(S) Z,P rs`JVz3 PROPERTYOWNER JIIG+?-?'F- U-s I TELEPHONE# ??,J'??Ia'? rI?,3 ----------------------------------------------°-----------------------°---------------------- COMPLETE THIS SECTION FOR KNEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESOTA RtiLES 7670 CATEGORY 1 MINiVt:SOTA RULES 7675 (d submission type) . Resideniial Ven[ila6on Category 1 Worksheet Submitted • New Energy Code Worksheet Submittetl • Energy Envelope Calculations Su6mitted Plumbing CoMractor: Plumbing system incIudes Mechanical Contractor: Vtechanical system includes: Sewer/Water Conhactor: Air Conditiaiing Heat Recovcry System P'ee: $90.00 ? ,IUI 17 2002 -------------°--°°---•---°------°--°°----°°°----°-------°°--°°--°-°°iBy----°°---...°°---- - - - I hereby acknowledge that I have read this application, state that the information is c?+rrecf, an agree o comply with all applicable State of Minnesota Statutes and City of Eagan Ordi 57gnafure of Applicarttr? OFFICE U3E ONLY Certificates of Survey Received _ Tree Preservation Plan Rece+ved _ Not Required _ Water 5oftener _ Water Heater _ No. oF $aths RemodeUReoair Reauiremeots . 2 copies W Oan • t sel of Eneqy CalcNatlons for heated additions . 1 sde survey fir ezterior additions & decks • Indicate'rf Mme served by septic system for add0ions VALUATION o 7 3, o d _ Phone # Lawn Sprinkler No. of R.I. Baths Phone # Updated 4l02 DATE BUIi,DItiG PERMIT APPLICATION Include 2 sets of plans, 1 site plan w/elevations and 1 set of energy caicuations. To be used Eor -?31A) 6?1- C-- Valuation Site Add ress: , re ?+'/o JN7'dt/ / `/ - tot Block Sec./Sub. Parcel 9umter M a?y6O / ? Owner ,r?7 /v tc L?3 /,r J y /C./e• ;- ; .?_ Telephone E7U/ /.? Address Contractor ,?f?T ?s? 4/,y??• Telephone Address 47 ?'L l7TK ? Arch/Eng. Telephone Address OFFICE USE ONLY Erect Occupancy ]S - ? Alter Zoning Repair Fire Zone Enlarge Type of Const. Move # of Stories Demolish Fron[ .? ? Grade Depth Date of A rova a Initial Fees Assessment 116 Permit 00 0 Water/Sewer Surcharge 2 3 4' Police Plan Check ? Fire SAC ?;L5 a Engineer Wa[er Connection Planner Council ? Bldg. Off. ? A.P.C. Water Meter J 1C?1 LLJ!!? i?.j , G!? TOTAL ? ? J ^ ` ?k r + e \ ? IJ o ? ;?? .. ? j? `t.?.?...?-.?.-? \J '...v . .. . .. . . I ,. ? i : t.' .. ? . . _ • ? _ _._ ... _ __ ._ _._ . . , ..'_ ' '__ .. _... _ ? . ? . \ . ! . ? ?? ? . ? ,. . . ` ? ? . ,. '9 -- ? ?,• ? 1?`, i ? i ??' ? i i i ?j 1? ?, .?i' 3_..-3 . ?_ . . I ?_ . ?.. I ?? :•? ? ? ?.. t , ? . \ : - ? -, : i __•n ?-, ?_-y ? _ ? ?. ? . ; ' ' ' I ? ? ? ? : 4 '? ? ? ? ! ?? 1 ? i 1 1 ? ? +:.? • ? ? I ? L- ?9 , , -(? - , xY _ ..'= 0. t(' '. '__ ' ? ' ? ?i ? i i 7 -- - ,.s2 • . ? yj ? i _ ? j _.. . . .+ , _ ?- ? ? . i ? . . ? . . . ? . . ? ?. _ ?_. . .;. p :._. ? . . O . . ? _. , . . ?1 ? -?--; -. .,-,i.-'.;'"=d QNIV 0 y C Uun?.r ,i r ? ? . . Y ..,< _„ EXTERIOR ENVEL"OPE AVERAGE "U" COMPUTATIOH OkNER %-4 -r- ? S(TE ADORE55 3/5 3 A) ? r ? k J?''" ? CONTRACTOR ?,'A 7 L 19 r.v AAi DA i E PNONE 4 ?-z"-ULd Determine working square footage of each. 1. Total exposed wall area .,.,. Z 3 4 7_vd sq. ft. x .17 = -? ? 2. Tota1 roof/ceiliag area .,... (Z5-7) sq. ft. x ,05' •? Total exposed a:all area ebove ftoor • 2270-00 a. Total wa11 window area,,,,,,,,,,,,,,,,,,,,,,,,,,, [S't/U6 b, Total door area ,,, ,,,,,,,,,,,,,,,,, 3 7- e,,,' c. Total sliding glass door area ................... q o.n L d. Total fireplace wall area,..,.., .,,,,,,,,,, - e. Total wall framing area (average 10%),,.,...,..., 'Z3 4.7_0 _ ? f, Total net wall area above floor ,I /G,•-"? y g. Total rim joist area ........................... /??.2 c? Total exposed foundation area =. -]-00 h. Total foundation window area..................... - I. Toal net foundation area above graue ...,..,..... --77.0 0 Determine "U" value of each :iatl segment. a, /5w.(I C x n, z^u° -%7 • 4 1 c. 40-07- z•u" • S? • z.Za( d. - x ^up • ?i e. 234-70 X nun f._ lG7r/,L?/ % "U" -07 : 9._ /23 2v x Du„.0G • ?__ .3? h. - X "U° rT? • "_ 1• --) ?.VL1 x nUA ? t /Wi // c ? 3. ..,.......Z.347: `........ ...........Totai ' ? If item 13 Ss the same as, or tess than item it, you have r4et tF?2 tntent of SBC 6006(c)2. . Total exposed roof/ceilinq area - /2 31• eU j. Total skytiqht area............................. k. Total rooficeiling framinq area (average 10%)... l. Total net insulated roof/ceiling area........... ( L; (. 04) Determine "U" value for each roof/ceiling segment. J X „Ull ? k. Jf "U" = 1. l 23 X°U° - G/-5-"7 4 ............... ??,3.?.ca........... Tota1 = tG/-? s7? If total of 14 15 the same as, or less than A2, you have met the intenj of SBC 6006(c)1. Alternate Building Envelope Design To utilize the total envelope system method, the values established by-the sum of items 03 and 94 shall rtot be greater than the sum of items #1 and !2. t. + 2. G/57 - 4'GG,ST? 3._ 30l. z1 + a. G/.S7 = 362- 96 1804 Malody l" Bumsville, Minneso[a 8963063 WEPJA CO. PL.4N SERVICE ED ANOERSON ARCHITECTUWI OES?GNING 4Np PL4NNMp WCl: 1129 C1iH RoaO Bumsvil7e, MlnnesoG DffKe: 89P4636 ?? PLUMBING (RESIDENTIAL) sn Permit Application City Of Eagan 3830 Pilot Knob Road, Eagan Mn 55122 Telephone # 651-675-5675 FAX # 651-675-5674 Please complete for: Single Family Dwellings Townhomes and Condos when permiu are required for each unit Date Site Address ? ?? ? JLW44 (OIt/j14 N -0-t-Y 1 U nit # Property Owner IVh?7f ?,? f'?( j{ Ct Telephone #(WI )9Z` IP*7J3 Contractor H . P ( M Address City L(( GV L{/Vl State Zip TelePhone # [340 The Applicant is _ Owner u Conffactor _ Other Septic System New _ Refurbished Submit 2 sets of plans and MPC license $ 100.00 InGudes County fee. Additional consultafk fees may apply. Alterations To Existing Dwelling Unit, Including $ 50 00 _ Adding fiMures to lower levels or room additions, exclu ding water softener and water heater . _ Abandonment of septic system _ Water tumaround (+ 5/8" meter if needed -$121.00) Other: _ RPZ _ new installa8on _ repair _ rebuild $ 30.00 _ Lawn irrigation system ? _ Water sof[ener Water heater $ 15.00 ? replacement additional 4 2003 RFFEBO State Surcharge B y $ .50 Total $ IS ' s-D 1 uereby apply Tor a Residential Plwnbing Pernut and acknowledge tLat the informarion is wmplete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan and with the Plumbing Codes; that I understand this is not a pernut, but only an application for a pemrit, and work is not to start without a peimit; that the work will be in accordance with rhe approved plan in the case oFwork which requues a review and approval ofplUO' ?!k8b?-t% ApplicanYs Printed Name lic nt's Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA178895 Date Issued:09/08/2022 Permit Category:ePermit Site Address: 3180 Jurdy Ct N Lot:11 Block: 1 Addition: Donnywood PID:10-20960-01-110 Use: Description: Sub Type:Reroof Work Type:Replace Description:Does not include skylight(s) Census Code:434 - Residential Additions, Alterations Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Please print pictures of ice and water protection and leave on site. If water damage is encountered, please call (651) 675-5675 to schedule a site visit to verify the extent of the damage. Any repairs must be inspected prior to covering. The inspector will determine if an additional permit will be required to repair the water damage. Valuation: 5,000.00 Fee Summary:BL - Base Fee $5K $118.00 0801.4085 Surcharge - Based on Valuation $5K $2.50 9001.2195 $120.50 Total: This permit shall be null and void if work does not start within 180 days of issuance, or if work is suspended for 180 days or more after started. 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 - Robert L Rust 3180 Jurdy Ct Eagan MN 55121 (612) 581-6733 Viking Contractors Llc 7760 France Ave S Edina MN 55435 (612) 567-5522 Applicant/Permitee: Signature Issued By: Signature