2056 Emerald LaneCITY OF EAGAN Remarks * CadaL' -mv Ar_rn+i si tinn
Addition CE)AR GROVE #1 Lot 9 Blk 6 Parcel 10 16700 090 06
Owner L' 1- ;Street 2056 02era? d T-%nE+ State Eaq$n, MN 55122
?-??- -
Improvement Date Amount Annual Years Payment Receipt Date
STREETSURF. ,j 1985 1266.95 84.46 15 1266.95 C009823 10-23-84
STREET RESTOR.
GRADING
5AN SEW TRUNK
* SEWERLATERAL 1972 1,304.00 52.16 25 '
WATERMAIN
# WATERLATERAL 1972
WATER AREA
STORM SEW TRK
STORM SEW LAT
CURB & GUTTER
SIDEWALK
? STREET LIGHT
WATER CONN.
' BUILDING PER.
SAC
PARK
IN
? ITY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
SITE ADDRESS: '
?
•1.A PIF
? IIi3t-? i!'r. (.1'J1 t E
PERMIT TYPE:
Permit Number:
Date Issued:
q -It APPLICANT:
f? t3 ? c, r ;
PERMIT SUBTYPE:
TYPE OF WORK:
frf ',C F: I I' 1 f(IN
f- riri 1 t N I ,
i t NAt
['Nf1FV ! Ni)
f???# I i D I N
0.4 i t;F,I
4! :if ofi/q
At? r R A T. T tt N
WT N U I i W.
.. . . . . . . .. ?i? ?1t',?? . . ? . . . . . .. . .. . ?..
. . " ? ? ?" .... . ? . .. .. ?
-------------------------------------
F-
Pertnit No. Permlt Holder Date Telephone #
ELECTRIC
PLUMBING
HVRC
Inspectfon Date Insp. Comments
FOOTINGS
FOUND
FRAMING
ROOFING
ROUGH
PLUMBING
PLBG
AIR TEST
ROUGH
HEATING
GAS SVC
TEST
INSUL
GYPBOARD
FIREPLACE
FIREPLACE
AIR TEST
FINAL PLBG
FINAL HTG
ORSAT
TEST
BLDG FINAL
BSMT R.I.
BSMT FINAL
DECK FfG
DECK FINAL
,; .
EAGAN TOWNSHIP
/ aUIL.D,1-AIG PERMIT
Addrees
Bvilder
Addxess
DESCRIPTION
N° 591
Eagan Towaship
Tawn Hall
DaYe ----?v
---- ' -"--'---._ ................
5tories To Be Used Fos Froni Depfh Heigh7 Esl. Cost Permit Fee Aemarks
//? LOCATSON f " /?? -?
Sireei, R d or olher DescriatioxV of LocaYion I Lot I 81eck I Addifian, or?raef
?4g?-
2? - ??iA??'.? I 9 I c????'???
?
This permit does not avlhoriae !he use of streeis, roads, alleys os sidewalks nos does it give !he owner or his agen!
2he right io exeale any siluaiion which is a nuisance or which presenYS a hezard Yo !He healih, safeip, eoavenience and
general welfare !o anyon in !he c mmuniip.
THIS PERMIT MUST B ON T RE IS HIL£ THE WORK IS IN PAOG/R?g?SS.
This is !o eerfify, 3 a . . ? . . ... .._._. _ _.... ._has permission e f a.?L?fL.%? _flr.._._. ....upon
!he above doscribe -? re sub'ec! Yo i ov' . f
' o !he Build' inance ?r Ea o ip p d April 11,
1955. A
Chairman of Town Soard
EAGAN TOWNSHIP
UlleDl
Ownex g,4?2
Address (pres
Builder .... ; l
Addresa .
Siories
of
?
Nc 420
Eagan Township .
Town Hall
>- ? -
Dat ...._??rJ...---....... C..__........
.
or
/
i
as permii does nol? authorise the use f slseeis, xoads,'alleys or s' ewalks nor does if give the owner or his agen!
the righffo create any sifuafion wrich is a nuisanee oz which preszn?s e hazard io the healih, safefy; convenience and
.qeneral welfare to anpone in She ommuaity.
LE THE WORK IS IN PAOGRE f
THIS PEAMIT MUST ?MI . ?i.? • ? t
j _ .o?/ . .
This is So erfifp, Yh .......... --_,.....:..___ ...8?' .... Pexmission !o ereci y
-!?£ .upon
? .. _....._........
the abov described px s 7e '!he rovisions of the Buildi.-g Otd'nance xor E^gan p adopTed April 11,
1955 . .: , .,.. . _ .
.....i.. .. ...__....... -
.... Per
-----.--. :..? .F? ??-. .. .. - -°-----
- ? ? . .__._._------...---._........._ .
' C a' - Building Inspec2or '
FaERMIT
J /
?=? ,??
o1--?
CITY of EAGAN
BUILDING PERMIT
` - 4-9-?.?
?. . ....e`c .-.-? ......... .. .... ..........`/..........-.-..
owne: ........
...... ....:..... .. . . .
Addsese (presenf) .... ". ..<
... .... ...... n ............
Suilder ...............? :?K-.:.................................................. _........_'
Addzaes ..............................................................................................
DESCAIPTION
. ;,
N2 3577
3795 Pilo! Knob Road
Eegan, Minnesofa 55122
454•8100
Dela .................... - 75-
6Sories
- To Be Uced For Fron2
- Depth I Height Est. Coaf Permi! Fse l Remarks
?
/
.?,??.vc GL?`Lr.?yv?,
rJ.eti-
?3?C ? /
(a A-o.o?o
oL. 171
/
.3. Sn
LOCATION .-'1' 7•-SZi
Sireei, aoed or oiner DBSCStpIlaa ot l.aaarion I Lo! I Sloek I Atldifion os Traet
This pe:mit doas not authorise the use of stree2s, roads, alleya or sidawalks aoe does f3 give the owaer os 6ia sgea!
the righf So creale anp silvalion which is a nuisanee os which presenSs a haaard !o the heallh, safetp, eoevenlencro aad
general weltere !o anpoae in the commuaiip.
THIS PERMIT MUST SE KEPT ON THE PREMISE WHILE THE WORK IS IN PAOGAESB. ?
Thia is !o eertifp, .......° -----.has ermissioa !o arec!
.4.2:t.4s} .... J'--....._..-°---. p ....................................... npoa
the above described premise subj?ci fo the provisions of all applicable Ordinances for the Ciiy of Eagan
............................ ..........
----°°-,) ........................... ...... Per ................................................. ............... .........
-......-°---.......---....
Mayor ? Sullding Iaapaefor
S
CITY USE ONLY
L n1 BL CP RECEIPT #:
SUBD. DATE:
1996 PLUMBING PERMIT (RESIDENTIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, MN 55122
(612) 681-4675
Please complete for: ? single family dwellings
? townhomes and condos when permits are required for each unit
FIXTURES EACH TOTAL
Shower 3.00 x =
Water Closet 3.00 x =
DaIh TUb 3S.VV X =
Lavatory 3.00 x =
Kitchen Sink 3.00 x =
Laundry Tray 3.00 x =
oYfie 3.00 x
Water Heate 3.00 x =
n 3.00 x =
Gas Piping Outlet ' minimum -1 3.00 x =
Rough Openings 1.50 x =
Water Softener 5.00 x =
Private Disposal ' Dakota Cty. license 50.00 =
(new and refurbished systems)
U.G. Sprinkler * home under const. 3.00 =
Alterations * to existing 20.00
Water Turn Around 20.00
STATE SURCHARGE .50
TOTAL
SITE ADDRESS: TOURTILLOTT
2056 EMERRLD LRNE
ERGFN , 55122
OWNER NAME: H ess-7szs w
Mfi4NRRD
INSTALLI
STREET
CITY:
PHONE #: ( )_
STATE: ZIP:
PERMIT
° CITY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
SITE ADDRESS:
PERMITTYPE: BuiLozNG
Permit Number: 031551
Date Issued: 0 3/ 0 6 J 9 8
2056 EMERALD LANE
I.OT: 9 BLOCK: 6
CEDAR GROVE 1ST
P.I.N.: 10-16700-090-06
DESCRIPTION:
- -?.? WINDQWS
,guild3ng-,Permit Type
`Building_Woar.k TYPe
Census Code ?
..,. . . . .. W,._:t
1
3
._,. ?'.. ` vr?=??r'?p'
.-
.,.
SF (MISC.)
ALTERATION
434 ALT. RESIDENTIAL
REMARKS:
FEE SUMMARY:
VALUA7ION
Base Fee
Surcharge
Total Fee
$124.75
$3.50
$128.25
$7,eee
CONTRACTOR: _ Applicant - ST. LzC.OWNER:
MN RUSCO INC 19359669 0002173 TOUR7TLLOTT MAYNARD
7911 WASHINGTON AVE S 2056 EMERALD LANE
EDINA MN 55439 EA6AN MN 55122
4(612) 935-9669 (612)668-7525
I hereby scknQUledge.that I have read=this applicati.on and.sta,te,.that the
' inforriist£on is correct and agree to? cizinply. witfi a11 app.3icab2e 'Stake a'P Mh.
I_ Statukes and CitY,ofi,Eaga?i. Orcl3nsnc0s.,
, , . e.• . ' ?- °_.._ _ _. . _ . . _ _ . _
SiGN
APPLICANT/PERMITEE SIGNATURE - ISSUED BY: ATURE
-? 1998 BUILDING PERMIT APPLICATION (RESIDENTIAL) ? CITY S 3830 P ? $ ? 85122 15
\ 681-4675
New ConeWdion ReauiremeMa
? S regiatered site suneys
• 2 copies of plans (indude beam & window stzes; poured tnd. design; etc.)
? 1 energy calaletlons
• 3 copies of treo presenation plan H lot pletted after 7N193
required: _ Yes _ No
DATE: rl 04- 4 g
DESCRIPTION OF W
STREET AODRESS:
LOT: ? BLOCK:
RemodeVReoair Reauirements
? 2 eopies of plan
? 2 site surveys (exterior additions 3 decks)
? 1 energy celculafions (or heated addkions
CONSTRUCTION COST; 4 6 i5 (?(-)
SUBD./P.I.D.#: 41,- I
Name ?bi? rLj 1)J?? fy-?Vi t 1(1Q'C cl Phone #: 662- 7Sc-LS
PROPERTY L%st FT
OWNER
Street Address: p` ( n c
C TYLQJIaoCA 4?Z/1 x'i ?
City _EA n an State: 11'? ( l Zip: 5
113
Company: -L f]<_. Phone#: Q3S'Qt0(0 C1
CONTRACTOR ?
Street Address: ?Q? I ?171p4Q1?l?A ;J Jf` 1 U? License #
Crty - 1 Y1 Y19? State: (? n Zip: c
ARCHITECT/
ENGINEER Company: Phone #:
Regis7ation #:
Street Address:
City
5ewer 8 water IicensQd plumber (new construction onty):
and lot change is requested once permit is issued.
State:
I hereby acknowiedge that I have read this appiication and state that the infortnation
State of Minnesota Statutes and City of Eagan Ordinances. _^/,
Signature of Applicant
OFFICE USE ONLY
Certificates of Survey Received _ Yes _ No
Tree Preservation Plan Received Yes No Not
Zip:
Penally applies when address chang
and agree to comply with all applicabl
?40 Ir4 6
MASTER CARD
LOCATION ?? yyyyjQ (/'a /((.
OWNER
?c -
$TRUCTURE AND
`
LAND USED A$ 1-3
Permit I
No.
Issued Issued To
Coniractor Ownef
BUILDING ?677
-?
4?
`
PLUMBING
CESSPOOL - SEPTIC TANK
WELL
ELECTRICAL
HEATING
GAS INSTAILING
SANI7ARY SEWER I
OTHER I
OTHER I
Items Approved
(Initial)
Date
Remarks
Distance From Well
FOOTING ? d.. ? SEPTIC
FOUNDATION CESSPOOL
FRAMING TILE FIELD FT.
FINAL
ELECTRICAL
Hc'ATING DEPTH
OF WELL
GAS INSTALLATION
SEPTIC TANK
CESSPOOL I
DRAINFIELD
PLUMBING
WELL
SANITARY SEWER
Violations Noted
on Back
COMMENTS:
VEC M?.riYYY
MAYOw
?
TNOMAS EGAN
MARN PARRANTO
JAMES A. SMITM
TMEOOOHE WACNTER
COVNCIL MEMBEN9
May 2, 1979
.KP
?
FtnutSOn Mbrtgage & Financial Corp.
Suite 208
310 h@st Burnsville Pazkway
Burnsville, -MIlV 55337
ATrErPIZON: SUE ERIQCSQd
Re: 40-&ilver_Be11.Road
20
56 IIrerald?I,ane
e730 Ta55ftite=Tr?iil
Flood Hazard Areas
Dear Ms. EYickson:
Zhe August 11, 1978 Flood Insurance Rate Map, 270103 0001 B, places
the above addresses in Zone C.(Minimal Flood Hazard).
Sincerely,
) CC ?4?
Dale S. Peterson
Building Inspector
D6P:tlp
?°9 '?5 ?e -dc°a--? J? 6r /
CITY OF EAGAN
9796 PILOT NNOB ROAO
EAGAN. MINNESOTA
55122
/MONE IE/.GIOO
CIT ?Or?N??iq?T01?
ALYCE 90LNi
CIT CL[PK
?
THE LONE OAK TREE ... THE SYMBOL OF STRENGTH AND GROWTH IN OUR COMMUNITV.
pn Mortgage &
,encial Corporatipn -- - _ , _
? ;. ?
- - - •--- -----_ - __---- -
-- __----_---
--
_
Suite 208
First Burnsville State Bank Bldg. .. ,
301 West Burnsville Parkway
Bumsville, MN 55337
Office:(612) 890-5800
April 25, 1979 ?-
Eagan City Hall
3795 Pilot Knob Road
Eagan, MN
Attention: Dale Peterson
Dear Mr. Peterson:
As per our phone converstion, I am sending descriptions of the properties
in question. Please indicate to us whether they are in the flood areas.
1.) Strom- buyer
1940 Silver Bell Road
Eagan, hIN
Lot 3, Block 1, Langhaven Addition, Dakota Co.
2.) Stock- buyer
2056 Emerald Ln.
Eagan, MN
Lot 9, Block 6, Cedar Grove #1
Plat 16700
3.) Ray- buyer
1730 Taconite Trail
Eagan, MN
See attached legal description
Thank ,
V
Sue Erickson '?=?J
qp,? 2 ;??n
y1`92
9
- --- ---- ?
i?
PERNIIT #:
CITY USE ONLY
?qdb ff RECEIPT DATE:
2002 R£SIDEVTIAL MECHA1VICAL PERMI1' APPLICATION
CITYOF EA6AN
S$SO PILOT KNOB RD
EtsAN UN 551 sa
651-681-4675
Please complete for: ? single family dwellings
townhomes and condos when permits are required for each unit
Date: Q ?
SITE ADDRESS:
OWNERNAME: ??^( /f TELEPHONE#: ?,, P R ?? 5-"
INSTALLERNAME: ?iJ/ro??k/ ?i?' TELEPHONE#: :?LlQ_ ?19?a
t°
STREETADDRESS: C79/1_)/(} 6rfn2) 90
CITY: ?kn7 STATE: ,t) i ZIP:
Place a check mark next to the permit work type
Add-on, modification or alteration to existin dwelling unit $ 30.00
• furnace replacement s
• air exchanger
? ir conditioner
• other
Nature of work: `
A r
MAR 0 8 2 ?2
State Surchar e $ 50
Total ey
?_z L?,T4?
IGNATURE OF ERMITTEE
vo2
2004 RESIDENTIAL PLUMBING PERMIT APPLICATION
CITY OF EAGAN
3830 PILOT KNOB ROAD, EAGAN MN 55122
651-675-5675
Please complete for modifications to existing residential dwellings.
^? ,
Date ? Z I J I f O3 i = -- -- ,
TOUTILLOTT, MAYNARD
- - 2056 EMERALD LANE
SltB StfB@t ACICII'@SS _ EAGAN, MN 55122 UnIt #
(651) 688-7525 -
Property Owner Telephone # ( )
(612)827-4033 •
Contractor Telephone # (
M )
Address .
. City_ _ State_ Zip _
r
The Applicant is: _ Owner ?Contractor _Other
Alterations to existing dwelling $ 50.00
_Add fixtures to rooms, exciudin g water softener and water heater
Septic System Abandonmen!
_Water Turnaround (add $121.00 if a 5/8" meter is required)
; _Other:
_ Water Softener J? Water Heater $ 15.00
? replacement _ additional j
Lawn Irrigation System RPZ_ new _ repair _rebuild $ 30.00
' S.r.ate Surcharge
?
- $ .SQ
Total $ lrj-7
I hereby apply for a Residential Piumbing 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 plumk>ing ccdes; that I understand this is not a permit, but only an application for a
permit, work is not to start wifhout.a permit and work will be in accordance with the approved plan in
the event a plan is required to be reviewed and approved.
-e ttA
ApplicanYs Printed Name p'? s ignature
gY .? -I
3830 Pilot Knob Road
Eagan MN 55722
Phone: (651) 675-5675
Fax: (651) 675-5694
----------,
? Permit #:
? Permit Fee:
? Date Received:
j Staff: I
I
2008 RESIDENTIAL BUILDING PERnniT aPPUCarioN
Date: Site Address: a65(, 5-me Yn. r1 lIAJ
Tenant:
Suite #:
RESIDENT I OWNER Name: 1?1?7`0,4 ?jir 17'-' Phone: /oSt-,g?s
Address 1 City / Zip:
Applicant is: _ Owner _ Contractor
TYPE OF WORK Description of work:
Construction Cost: 45-060 . C9 l1 Multi-Family Building: (Yes _! No A?
CONTRACTOR Name:47r5'41??lle,?, s z'hr. License#:.r!['L31797.5
Address: g?c?c( S- p/G60CA E)r
City L[t,6 ui ? p state: u/ zip: .SS?D y?
Phone: Srej?- 2`I0 O Contaci Person: 1?Se,0k ?S- rr I
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Cateaorv 1 Minnesota Rules 7672
Energy Code . Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet
Category Submitted Submitted
Submisslon type) • Energy Envelope Calculations Suhmitted
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 Plum6er: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: Phone:
-'NOTE: Plaris and sapporfing olocumenfs that you'submit are consider ed to be public.info[mation„ ? Portions of -
0: fhe rnformation may be classified as non public if you provrde specific reasons that would permk the Crty
;'. }Y:. = •, • .h aCi . • . •,:n. JF sr [
) { {.?y y j?.
r. k5. 'i S F'.4 'ir.onriludpi f .L/lP. y afe I {?YP.: 1P.ri?iW . t. st R 4k .
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, hut only an application for a permit, and work is not to start without a pertnR; that the work will 6e in
accordance with the approved plan in the case of work which requires a review and approval of plans.
X Ci 1S? x?? - --,
ApplicanPs Printed Name qpplic t's Signature
Page 1 of 3
34
23
•
32
21
20
18
77
16
15
14
73
11
10
9
8
7
6
5
9
3
1
u
---L-?2 " 3 4 5 6 7 8 9 10 il 11 13 14 15 16 ` V 1$
z G. S`c' ?
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA112024
Date Issued:07/24/2013
Permit Category:ePermit
Site Address: 2056 Emerald Lane
Lot:9 Block: 6 Addition: Cedar Grove 1st
PID:10-16700-06-090
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Water Heater
Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size
Comments:Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Tony Boerner
2090 County Road 42 W
Burnsville, MN 55337
Fee Summary:PL - Permit Fee (WS &/or WH)$55.00 0801.4087
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 -
Maynard P Tourtillott
2056 Emerald Lane
Eagan MN 55122
Tony's Appliance
2090 County Road 42 West
Burnsville MN 55337
(952) 435-2442
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA116097
Date Issued:10/03/2013
Permit Category:ePermit
Site Address: 2056 Emerald Lane
Lot:9 Block: 6 Addition: Cedar Grove 1st
PID:10-16700-06-090
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 .
Elizabeth Hess
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 -
Maynard P Tourtillott
2056 Emerald Lane
Eagan MN 55122
Sela Roofing Remodeling
4100 Excelsior Blvd
St. Louis Park MN 55416
(612) 823-8046
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA172219
Date Issued:09/21/2021
Permit Category:ePermit
Site Address: 2056 Emerald Lane
Lot:9 Block: 6 Addition: Cedar Grove 1st
PID:10-16700-06-090
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Water Softener
Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size
Comments:Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Building Code).
Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Fee Summary:PL - Permit Fee (WS &/or WH)$59.00 0801.4087
Surcharge-Fixed $1.00 9001.2195
$60.00 Total:
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Contractor:Owner:- Applicant -
Maynard P & Mary T Tourtillott
2056 Emerald Ln
Saint Paul MN 55122--281
(651) 688-7525
Milbert Company (culligan)
1801 50th St E
Inver Grove Heights MN 55077
(651) 451-2241
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA175635
Date Issued:04/11/2022
Permit Category:ePermit
Site Address: 2056 Emerald Lane
Lot:9 Block: 6 Addition: Cedar Grove 1st
PID:10-16700-06-090
Use:
Description:
Sub Type:Water Heater
Work Type:Replace
Description:Standard Water Heater
Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size
Comments:Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Building Code).
Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Fee Summary:PL - Permit Fee (WS &/or WH)$59.00 0801.4087
Surcharge-Fixed $1.00 9001.2195
$60.00 Total:
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Contractor:Owner:- Applicant -
Maynard P & Mary T Tourtillott
2056 Emerald Ln
Saint Paul MN 55122--281
Tony's Appliance Inc.
2090 County Road 42 West
Burnsville MN 55337
(952) 435-2442
Applicant/Permitee: Signature Issued By: Signature