1767 Gabbro Tr
City of Eagan
Cash Receipt
Receipt Date 6/20/2011
Receipt Number 170457
PATH MINNESOTA/CHK#103284
1767 GABBRO TR
1221.4216 50.00
DAYCARE INSP/1767 GABBRO TR
Total Receipt Amount 50.00
141961 8:18:20
i
CITY OF EAGAN AT
3830 Pilot Knob Road, P.O. Box 21•199, Eagan, MN 55121 lr ? 9133
PHONE: 454-8100 L-1?
BUILDING PERMIT
To be uwd for FOOL ?
Site Add e 17 E'7 ('AfiBRO TR
i
Lot I BlQf ?T03'$eC??"$. ?
Percel No.
c. 1
Receipt J 6,1
$1,900 ,,,_._ ,7UNE 5 1e 84
?
Name "'.•,a.?_?u. ., . r . uvwraia SAME Address 452-5 7 7
City Phone ,
Name
? Addre
u
?- City _
Neme _
Addresa
Cky -
Phone
I hereby acknowled9e that I haw read this applicotion and state that
the Information Is torrect and egree to comply wifh all epplicoble
State oi Minnesota Stetutes and City of Eagen Ordinonces.
Sipnnturo of Perrnittee
A Buildinq Pem+it Is Iuued ro:
oll work shall be dons in ocoordance
8u{Idinq Officfol
Erect ?
Alter ?
Repair p
Enlorya p
Move p
Demolish p
Grade n
Occupancy -
Zoniny
Fire Zone _
Type of Const.
# STOries _
Length
AsseSSmenf
Woter 8 $ew.
Pol ite
Firo
Enp.
Plcnner
Council
Bldfl. Off.
APC
PBrI1l1t Y J L-J V
Surchorpe 0
Plon check
SAC
Water Conn.
Water Meter
Road Unit
Total • 0
on the express tondition tficit
cnd City of Eapan Ordinonces.
Psrmit No. Pwmit Holdsr Mise. Pormit No. Holder
Plumbing
H.V.A.C.
wmr Wall
D"ap.
Snor
Electric 1 15ty 3 v 0
Irqpeetion Daft Insp. Othw
Footinpt
r
Foundation
Fnmin9
Rouqh Plb¢
Rouyh HVA
Insulstion
Final Plby.
Final HVAC
Finsl y
L=x
W?r Wscri6e L io :
VWII
Sevwr
Pr. D'qp.
cInr oF EAGAN
3795 Pllot Knob Rood Eagan, MN 55122 N2 6638
PHONE: 454-8100
BUILDING PERMIT ReceiPt #
To be wad foe Est. Value Date , 19
Slte Address Erect ? Occupancy
Lot Bixk Sec/Sub. 'C 7 Alter ? Zoning
Repair ? Fire Zone
parcel #
E
l T
f C
t
n
urge ? ype o
ons
.
Name Move ? # Stories
W
z Address Demolish ? Front _ ft.
C? p?? ?>'?:'--5 %?..
Grade ?
Depth
ft.
cc
o Name - ApProvob
,
uu Addfess Assessment
~ Ci Phone Woter & Sew.
?
11
1
Polite
FW N°"'e
-
2 Firo
?zAddress Enp.
Ci Pfane Planner
Counci I
Permit
5urcharge
Plan check
SAC
Water Conn.
Woter Meter
Road Unit
I hereby acknowledge that I have reod this oppiication and state that g?? Off.
the information is correct and agree to comply with all applicable APC Total
Stote of Minnesota Stotutes and City of Eagan Ordinances.
Slgnoture of Permittee
A Building Permit is lssued to: on the express condition that
all work sholl be done in cccordance with all applioable State of Minnesota Stotutes and Ciry of Eagan Ordinances.
Buildinp Officiol
PamM # paM Iwwd PKaMtw
Plumbing
Mechanicol
T'?si3 s? /
INSPECTIONS DATE INSP. Rouph-In Final
FOOtings Date Irap. Data lnap.
Foundat' Piumbing
Mechonical
Fino
Remarks: 1F.X 41 ,,?p-? AIK ?uqf???[4rsK? S-- -15/-??/
? ? ?? ? RECT-ORIY.
CITY OF EAGAN PERMIT TYPE:
3830 Pilot Knob Road Permit Number:
Eagan, Minnesota 55122-1897 Date Issued:
(612) 681-4675
, , ,..
SITEADDRESS: ? ?: ? ? . ??t r?? ?;
, . :,u tnl
1 t UAlt t.kt?Vi pc..
PERMIT SUBTYPE:
Al/1?tK';: r.HrMNl°Y/FI Ifr
1l11 F I 11 ! 14l/
N;,'4q A
4!S 1 ! ' !9R
? APPLICANT:
( ?.!, 1 ? t•fii.- e,.?tj?t
TYPE OF WORK:
T FiF ! N'. {'t r 1 f It RI !I ifif I frlVt I Ft i I N+i
F . ?
L J
-------------------------------
Permit Holder Date Telephone #
PLUMBING
HVAC
Inspection Date Insp. Comments
FOOTINGS
FOUND
FRAMING
ROOFING
ROUGH
PLUMBING
PLBG
AIR TEST
FOUGH
HEATING
GAS SVC
TEST
INSUL
GYP BOARD
FIREPLACE
Z
OC• $
FIREPLACE
AIR TEST
FINAL PLBG
FINAL HTG
ORSAT
TEST
BLDG FINAL
DOMESTIC
METER
IRRIGATION
METER
FLUSH
MAINS
CONDUCTNITY
TEST
HYDROSTATIC
TEST
BSMT R.I.
BSMT FINAL
DECK FTG
DECK FINAL
CITY OF EAGAN Remarks Sew & wtr permits and wtr conn. pd, on 11-27-b8
Addition Cedar Grove #6 Lot 15 Blk 8 parcel 10 16705 150 08
owne, Street 1767 Gabbro Tra3]. State EajzanaMN 55122
?
?
Improvement Date Amount Annual Years Payment Receipt Date
STREET SURF.
STREET RESTOR.
GRADING
SAN SEW TRUNK
# SEWER LATERAL 1970 1472.00 20 P31d
WATERMAIN
* WATER LATERAL 970 20
WATER AREA
j? STORM SEW TRK 970 20
STORM SEW LAT
CURB & GUTTER
SIDEWALK
STREET LIGHT
WATER CONN. 200.00 1094 12-2-68
BUILDING PER.
s,ac 200.00 10 12-2-68
PAR K
/s- E - (,--
TOWN OF EAGAN
3795 Pilot Knob Road
Eagan, Minnesota 55122
PERMIT N0. 181
The Board of Supervisors hereby grants to Deluxe He.atin(; & Air Condit3oning
of 1405 47est 97th Strest, Hloaningion 55431
1
a AIR COidil.
Permit for: (Owner) Ed Soli
at 1'767 Uabbro Trail, Eagan ;j'122 , pursuane to application daeed
Fee Paid: r'.''Dated this 6th day of 1f?'Ch
197? .
Building Inspector
EAGAN TOWNSHIP
BUILDING PERMIT
o,.ne= .... 02-4..a^"-le?l .---V.-/`'-„t,-,.-.-?d-.-`-'^"?.----`? ?.-----
Addre6s (Pr6senf)
Bvilder ................ ....'.......................................................... .............--
Addrees
DESCAIPTION
N° 1922
Eagen Township
Town Hall
Date ... 75-.._ ?./..../_? ?-?-----
Siorie To Se Used For Fron!
.?M? ?e. ? ? Dapth Heighf Esi. Cos! ermif Fee Remazks
? .??/.2 1_.-..:.1 _
LOCATION ? ? -
, Streef. noad or othex Uescraplion ot Loc}Sion I Lof I B{ock I Addifion or Trect
? s-i?-•w--'?r?do
v
This permit daes aot auihori:e the use of aireafs, roads, elieps or sidewalks n does ii qive the owner or his a9ent
!6a riqht !o crea?e enp sifuation whic6 is a nuisance or which presenls a haaard fo the healih, safetp, convenience and
geceril weliare !o anpone in the eommunity.
THiS PERMIT MUST SE E?P'T O`N TjiE PAEME WHILE THE WORK IS IN PROGAESS.
This is !o cerbiy. lhai._..... ' - --has permission !o ereci a-?t`.. -- - • .-_ ......... ....upon
............................ "- ....... ............
the above deaeribed pramise subjec! !o the provisions of the Building Ordinance fofr"?Eagan wnship.ad fed April 11,
1955. i
..... ?/?
?-c. . ?C.c.tiJ
.-..'._- .. .....---' -?'.Ty....--- ......
.i..? . ----------- .' Per --.............. ..//.c.7 ?'
°-_
- ....................
Chai °' -an ofCTnwn Board t ..... Huilding Inspeeior
, G B
?
?? CITY OF EAGAN Include ? sets of plans,
1 Gertificate of Survey'&
BUILDING PERMIT APPLICATION 1 set cf_ energy calculations.
To `Be Used For 7c, ( ,. Valuation Qd ei Date -7
Site Address / ')
MILL-
IAt /!5 BZoCk ? Sec./Stib. ?cc4? )h.J i.Parcel #: /O- (010 S 'IS O-
Oumer:
Address: J11C7 C»-a9 r3.2n ?lZ41(
City/ZiP Code: IErtGAN 2
Phone #:
Contractor: rr
Address:
City/Zip Code:
Phone # _
Arch./IIzg. :
Faddress:
City/Zip Code:
Phone #:
L CFJi?/ B - Of! -
?o
Re7olRMt?`? /f ?
OFFICE USE ONLY
Erect T? Occupancy ?-2J
Alter Zoning -1
Repair Fire Zone 1,1 A
En].aYge Zype of Const. Q
_
Move # Stories
I?amlish Fzront tt
Grade Depth ft
APPROVALS FEES
Assessments Pennit 2, so
TVater/Sewer Surcharge
Police Plan Check -
Fire SAC
Ehg. Water Conn. -
Plannar Wat2r MEter -
Council Road Unit --
Bldg. Off.
APC
TOTAL 3 3 • !s
CITY OF EAGAN
3830 Pilot Knob Road, P.O. Box 21•199, Eagan, MN 55121 *T
l?l ? 9133
PHONE: 454-8100 ? /
O b
BU ILDING PERMIT 3
Receipr # 7 ?
Te ba wad fer POOL Est. Volue +51,900 Dafe JUNE 5 19 84
SiteAddress 1767 GABBRD TR Erect [7 Occuponcy
lot 15 Block 8 SeclSub. CED GRV 6 Alter ? Zoning
rercei No, 10-16705-150-08 Repoir ? Fire Zone
Enlarge ? Type of Consf.
W Name WILLIAM J. F. DUGGAN Move p # Stories
; Address SAME _ Demolish ? Length_
b City Phone Gmde ? Depth Sq. Ft.-
g Name SAME Aporovalf Faes
}
ou
u
Address 2.5
Assessment Permit
1
0
? City Phone .
Wafer 8 Sew. SurcFwrge
Gw Polfce Plan check
?w Neme
Fire
SAC
Address Enp. Water Conn.
?W City Phone Plonnar WaterMeter
I hereby ackrwwledge thct I hove read ihis upplication ond stote that
the informotion is correct and ogree to comply wiih ull opplicoble
Stote of Minnewto Storutes and City of Eagon Ordinonces.
Council _
Bldg. Off. _
APC _
Road Unit-
0
rorol $ 33.50
Sipnoture of Permittee I
A Building Permir is issued ro: WjLLIAM J. F. DUGGAN on the exvress condiHOn thni
all wo.k shnll be dona in ocwrdonce wltFyEf?a?fpli?w?bfla1 ,S,tat of inne ot $tatutes and City of Eopan Ordinamea.
Building Offlcial ?""? ?'?-""
CITY OF EAGAN Include 2 sets of plans.
1 site plan w/elevations &
BUILDING PE13MIIT APPLICATION 1 set of energy calculations.
r AJO acaz 4nacJKA &?(qE Q -
'ib Be Used For &10412 r E3?usrNr G424c,k Valuation /?? p0 0 Date
I.vro FAu (Lt?
Site Pddress 17(07 (O&I.1n 7?Ri1, t OFFICE USE ONLY
Iot /'?F slock S sec./sub. Fsect _X occupancY ?3
Parcei #: lo 16 76S ?so oi?
Ovmer: (,?rliiAtu I. ?UCoto,4n/ -
Acldress: /7 7 cv4c?ilP6 7%JAr?
City/Zip Cale: k?4c,.d44 N41. -Q?i?2
Phone #: yr.? - C 77[?
Contractor: 1t'c'1(2r_°r2 ZiivbC.v
Ptidress:
City/Zip Code:
Phone #: Y7,e- GD'JD
Arcn./Eny.: &r.l?,?
Address:
City/Zip Code:
Phone #:
Alter Zonin9
l?epair Fire Zone
gz7,arqe ,? Type of Const. I/
N1ove # Stories
Danolish Front ft.
Grade Depth ? a.. ft.
APPROVAiB FEES
Assessnents Pexini.t a /
T.qater/Sewer Surcharqe ?
-
Police Plan Check /
Fire SAC
gnq, Wates Conn.
Planner Water Meter
Council Road Unit
Bldg. Off.
P,PC
TarAL tf3 5'
/? 0,76 ..4-` e0va-'0-V
cITr oF eacaN
3795 Pilot Knob Reod Eagan, MN 55112
PHONE: 454-8100
BUILDING PERMIT APPLICATION
N4 6638
Receipt # cv!?` a7
To be used for GARAGE Est. Volue 6,000 Date 5-4 , 1981-
Site Address 1767 GBbbY'O TY' _ Erect FE] Occupancy R3
Lot 15 Bbtk 8 Set/Sub. Ciedar GTOVe 6 Alter ? Zoning RI
10 16705 150 08 Repair ? Fire Zone NA
Porcel #
E
l of Const
V
T
n
arge ? .
ype
w Name Wi 1 l i avn .T. fTiyg 27P Move ? # Stories
z Address Demolish ? Front - 20 fr.
° 55122 452-5775 Grode ? Depth 22 ft.
Ci Phone
? ?er Lln?1211 AVVr?'als Feas •
Name
0
? Address Assessment
? Water & Sew.
? CI Phone 47$-6070
Police
w
F Nome
Fire
Address Eng.
L Cl Phone Planner
Council
I hereby ackrawledge that I have read this application ond state that Bldg. Off.
the information is correct and ogree to wmply with all applicable
Stote of Minnesota Stotutes and City of Eagon Ordirronces. AP?
16??1-ot coy_
Petmit 21.00
SurtFwrge• 3.00
Plan check 10.50
SAC
Water Conn.
Water Meter
Road Unit
Totul 34 _ 50
Signature of Permittee I
A Building Permit is issued to: Wlll.]:ffiri DUC{c(3ri on the express condition thot
oll work shall be done in accordance ith all applic le St of Minnesota Statutes and City o£ Eogan Ordinonces.
Building Official
?a
??.
City of EapIl
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 6755694
__________
I I
; Pertnit #: 7J 2S O g ;
I Permit Fee: 96)
?
? I
? Date Received: 1' 30 ?
i
; scan: L f ' Jv i
? ___________J
2008 RESIDENTIAL BUILDING PERMIT APPLICATION
oete: 0 ?
Tenant:
RESIDENT / OWNER
TYPE OF WORK
Site Address: / 7lv 7?vQ-44tO 1/k?
,
r
Name:/))Q.f.?'lLA?
Address / Gity / Zip:
Applicant is: _ Owner _X_ Contractor
Description of work: ? - 6?eh
Construction Cast: ? , zo MuI'
Sulte #:
Phone:??S'u?o? - 5944?1
;,?,. l? ?''• 55/? a
Building: (Yes No ?
CONTRACTOR Nam- - ,L47 A'Lt11?1.21J License #: / % 12°71
Address: 7
City: //NA (? State:/"h• Zip: s ?
Phone.&S 7p -?Z444 Contac[ Person:
COMPLETE THIS AREA ONLY IF CONSTRUCTING EW BUILDING
Minnesota Rules 7670 Cateaorv 1 Minnesota Rules 7672
Energy Code . Resldentlal Ventllation Category 1 Worksheet • New Energy Code Worksheet
Category Submitted suanined
(J submission rype) • Energy Envelope Calculffilons Submitted
In the last 12 months, has the CRy of Eagan Issued a permit for a similar plan based an a master plan?
_Yes _No If yes, date and address of master plan:
Licensed Piumber: Phone:
Mechanical Contractor:
Sewer & Water Cantractar.
Phone:
Phone:
I hereby acknowledge that ihis tnformatian Is complete and accurate; ihat ihe work will be in coniormance vAth [he ordlnanc and codes of Ihe City of
Eagan; that I underMand this is not a pertnit, but only an application lor a permR, and work Is not lo start wlthout a pe it; that the ?work will 6e in
accordance with the appro,v?y plan in the case ol work which requires a review and approval of lans.
X Ji?u f??l1 L,?? X
AppllcanYs Printhd Name " ApplicanlySlignatur-WO/I
Page 1 of 3
??\3)
?
2005 RESIDENTIAL BUILDING PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone 4 651-675-5675 FAX # 651-675-5694
-7a,oo
New Conslruction Renuirements RemodeVReoair Reouirements Otfice Use Onlv
3 registered sde surveys showing sq. ft. of lol, sq. R. of house; and all roofed areas 2 copies of plan CeR of Survey Reoi Y N
(20% maximum lot coverage allowed) 1 set af Energy Calculations for heated addNons Tree Pres Plan Recd _ Y _ N,
2 copies oF plan showmg heam & window sizes; poured found design, etc. 1 site survey far addidons & decks Tree Pres Required ' _ Y _ N
1selofEneMyCalculations Addkion - Indicateif on-site septic system On-site Septic System _Y _N
3 copies of Tree Preservalion Plan N lot platled atter 711/93
Rim Jolst Delail OpAOns selection sheet (buildings with 3 or less units)
Date /^ d,
1 / ? ?
Canstruction Cost
Site Address 1 -1 (n ` C-;6l b h?o 11(?-?? ? n? Unit/Ste #
Description of Work ?a i'V lAC ??? s Nl
Y
Multi-FamilyBldg _ Y_YN Fireplace(s) _ 0 1 _ 2
PropertyOwner M axi(` ui5 Da,?Ls Telephone #(?6l )S?JZ 9 N4
Contractor e-?" ? ? l D}'S
Address
_
City ElouminnikA
State Zip Telephone #
COMPLETE THIS AREA ONLY IF
A NEW BUILDING
- Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672
Energy Code Category . Residential Ventilation Category t Worksheet • New Energy Code Worksheet
(dsubmissionlype) Su6mitted Submitted
. Energy Envelope Calculations Submitted
Have you previously constructed a building in Eagan with a similar plan?
fee applies.
Licensed Plumber
Mechanical Contractor
Sewer/Water Contractor
Y_ N If so, 25% plan review
Telephone #( )
Telephone # (
Telephone # (
I hereby apply far a Residential Building Permit and acknowledge that the information is complete and accurate;
that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN
Statutes; I understand this is not a permit, but only an application for a permit, and work is not to start without a
permit; that the work will be in accordance with the approved plan in the case of work which requires a review and
approval of plans. ? n
Cr???. 1M?.?Y
Applicant's Printed Name
ApplicanYs Signature
CI 1? (?I?11f?LC
A .,,- - -
„ - . __? -1
2004 RESIDENITAL BUII.DING PERMIT APPLICATION
City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX # 651-675-5694
? l "l l .T1 S
New CoreWction Reauiremenfs RemodeVReoair Reauirementa
3 registered sde surveys showing sq. ft of lot, sq. fL M house; and all rooted ereas 2 copies of plan
(20%mazimumblcoverageallowed) lsetotEnergyCalculationstorheatededditons
2 copies of plan sfwwfng beam & window shes; poured fouM design, etc. 1 stte survey for additions & decks -
1 set o( Enetgy Cakulations Addihon • indicate if onatife septic system _ -?
3 copies of Tree Preservatkin Plan'rf bt platted after 711193
Run Jo61 Dela?l Options selection sheet (bldgs wHh 3 or less unik
Date ConstrucHon Cost
?
Site Address _ (`7(p 7 [v8[;Q c) TRO)L Unit/Ste #
DescriptionofR'ork 3 Sfr/YS?&(r' x&D S/f4StlW1` ??( ff
Multi-Family Bldg _ Y X N Fyreplace(s) _ 0 _ 1 _ 2
Property Owner 4jAA/}[-1-S1VLS ij? M42C.V <? d AI/I S Telephone #(?l ) J'5 2' 99 y`7
Contractor /s9 k{} L J'{PMlf lM?d? /fw['d'cz,?; . LLC
Address Z f
7
7 ?r/lA,Vl1 l}(/[s n
City
"
?
State /?! V Zip Telephone #(6lj 1)
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
- Tvlinnesob Rules 7670 Cateporv 1 Minnesota Rules 7672
Energy Code Category . Residential Ventilation Calegory 1 Wwksheet • New Energy Code Worksheet
(J submission type) Submitted Su6mitted
• Energy Envelope Calculations Submitted
Have you previously constructed a building in Eagan with a similar p1an2 _ Y _ N If so, 25% pian review
fee applies.
Licensed Plumber
Mechanical Contractor
Sewer/Water Contractor
Telephone #(
Telephone #( )
Telephone # (
I hereby apply for a Residential Building Pemut and aclmowledge that the information is complete and accurate;
that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN
Statutes; I understand tlus is not a pemut, 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.
6ws-arv Mo*A &5CC ? -
ApplicanYs Printed Name Applicant's Signature
OFFICE USE ONLY
, ,.
Sub Types '
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bidg
? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace X 21 Porch (3-sea.) ? 31 Ext. Alt - Multi
? 03 01 of_ plex ? 09 07-plex ? 17 Garage ? 22 Poroh/Addn. (4-sea.) O 33 Ext. Alt- SF
? 04 02-plex ? 10 08-plex ? 78 Deck ? 23 Porch (screen/gazebo) ? 36 Multi Misc.
? 05 03-plex ? 11 10.plex ? 19 Lower Level ? 24 Stonn Damage
? 06 04-plex ? 12 12-plex Plbg_Y or_ N 0 25 Miscellaneous
Work Types
? 31 New O 35 Int Improvement O 38 Demolish interior ? 44 Siding
,X 32 Addition ? 36 Move Building ? 42 Demolish Founda6on ? 45 Fire Repair
? 33 Alteration O 37 Demolish Building' ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement 'DemoliUon (Entire Bldg) - Give PCA handout to applicant
Valuation ? Occupancy MCES System
Census Code h'3y Zoning /2- r City Water -
SAC Units Stories - Booster Pump -
# of Units - Sq. Ft. ? PRV
# of Bidgs ? Length ? Fire Sprinklered
Type of Const ? Width ?
REQUIRED INSPECTIONS
Footings (new bldg) FinaVC.O.
? Footings (deck) 2f FinaVNo C.O.
_ Footings (addition) _ Plumbing
Foundation HVAC
Drain Tile Other
?t- Ice & Water
Roof ? Final Pool _ Ftgs Air/Gas Tests Final
_
? Framing _
_ Siding _ Stucco _ Stone _ Brick
Fireplace _ R.I. _ Air Test _ Final _ Windows
? Insulation _ Retaining Wall
Approved By:
------------ - --- ------ , Building Inspector
-------------'------
------__-.-----------------•------------
Base Fee v ?
Surcharge
Plan Review
MC/E3 SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
License Search
Copies
Other
Total
11 ? t-Y- 2 /G 4v ? y0
J-f.4?O
1'TI -l?
'7'O '
9529284964
09/07/2004 13:69 9529264964
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GUS HANSON PAGE 01
Jw4j-.Tc*-f l.J1k2uT/L s 0 19*1
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`???
PERMIT
ClTY OF EAGAN
3830 Pilot Knob Road
Eagan, Minnesota 55122-1897
(612) 681-4675
PERMITTYPE: euzLozNG
Permit Number: 0 3 2 9 4 3
Date Issued: 0 8/ 17 / 9 8
SITE ADDRESS:
P.I.N.: 10-16705-150-88
1767 fiABBRO TR
LOTa 15 BLpCK: 8
CEDAR GROVE #6
DESCRIPTION:
Bul3d*in-
g,Permit Type
B'uilding W"ork Type
:GensusCade '
?-.
r
FIREPLACE
NEW
434 ALT. RESZDENTIAL
^r)
z S. _
REMR%?? v/FLuE MUST BE INSPECTED BEFORE CONCEALING.
FEE SUMMARY:
Base Fee $50.00
Surcharge ? .50
Totel Fee $50.50
CONTRACTOR:
?
r
OWNER: -
6IE5ELMAN
1767 GA
EAGAN
(651)686-6384
Applicant -
NEAL
BBRp TR
MN 55122
Z hereby acknowledge that I h.ave read this
information'is corrset ancf'agtee"ta cdimply
Statutes and City`qfi Eagan Ordinances.
L
APPLICANT/PERMITEE SIGNATURE
application and 5tate that the
w'ith alI 8pplicable 5tate ofi Mn.
(-)ISSUED BV: SIGNATURE I
,
CITY OF EAGAN
3830 PILOT KNOB RD - 55122
1998 FIREPLACE PERNIIT APPLICATION
681-4675
DA1'E: ?I 17 I `f b
DESCRIPTION OF WORK: X Construct new fireplace
_ Install eas insert onlv
Other
g-?--1 -9 k
PERMIT FEE: $50.50
_ Alterations W existing
_ Install gas lioe onlv
JOB ADDRESS: 1-76 "7 64 5 b rv J??? 4v1 /)N a s 1 z Z
LOT: BLOCK: LS SUBDIVISION/P.I.D. #: -4??
APPLICANT (circle one only): OWNER CONTRACTOR
I hereby acknowledge that I have read this application and state that the information is conect
and agree to comply with all applicable State of Minnesota Statutes and City of Eagan
Ordinances.
Nazne: ?o(rre?r.?uh N-ev/ Phone#:
PROPERTY Last ? / $'ust
OWNER
Signature:
Street Address f7(° -7 G u b b
FIItEPLACE
INSTALLER
city E4
I rU,- /
State: Zip: Z
Phone #:
Street Address: License #
City
State:
Zip:
Company: Phone #:
GAS LINE
INSTALLER Sip,nature:
Street
EAGfiN TOWNSHIP
3795 Pilot Knob Road
$t. Paul, Minnesota 55111
Telephone 454-5242
PERMIT I'OR SFb1ER SERVICE CONNECTiON
DATE• 11/27/68
OWNEP.;Cedsr Grove Const. Co.
PLUMBER Stein Inc.
mUMsEx 306 _
Addreas 15mM 1767 (}8bbro Trail :
TYPE OF PIPE Cast Iron
DESCRIPTION OF BUIID ING
Industriall CotmnercialI Residential I Multiple Dwelling I No, of units
I I % I 1 1
Location of Connections:
Conaectioa Charge 200.00
Permit Pee 7•50
Street Repairs
Total
Inspected hy:
Date
Remarks•
By. Chief Inspector
In consideration of the issue and delivery to me of the above pexmit, I
hereby agree to do the propoaed work in accordance with the rules and
regulaCioas of 8agan Totmship, Dakota County, Minneaota
gy. St n Inc.
?..i-?,?.?. i
Please notifq when ready for inspection and connection aad before any portion
of the work is covered.
EAGFN TOWNSHIP
3795 Pilot Knob Road
St. Paul, Minnesota 55111
Telephone 454-5242
PER1-1IT POR WATER SERVICE CONNECTION
Date: 11/27/68
Billing Alame•
Owner: Cedar Groce Const. Co.
PLumbeY: Stein Inc.
Number: 197
Site Address: 15-8.6 1767 Gabbro Trail
Billing Address
of Connection Meter Size Connection Chg. 200.00
Meter No. Pexmit Fee 7•50
Meter Reading Meter Dep.
Meter Sealed: Yes Add'1 Chg.
NO Total Chg.
Inspected by
Building is a;
DaCe
Remarks:
Residence 1
Multfple 1t'0, Units
Commercial
Industrial
Other
Hp:
Chief Inspector
In conaideration of the issue and delivery to me of the above permit, I
hereby agree to do ne proposed work in accordance with the rules and
regalations of Eagan Township, Dakota County, Minnesota.
gy; Stein Inc.
..efV? / A?/',o ?
Please notify the above office when ready for inspection and connection.
MEMO
T0: DIANE DOWNS, UTILITY BILLING CLERK
FROM: ED KIRSCHT, SR. ENGINEERING TECH
DATE: AUGUST 25, 1993
SUBJECT: STREETLIGHT ENERGY COSTS
CEDAR GROVE NO. 6(141 LOTS)
This memo is to inform your department to begin to invoice the energy costs at the singie
family rate effective August 1, 1993 to the property owners in Cedar Grove No. 6 Addition
as listed below:
Block 1, Lots 1 1
BloCk 2, Lots 1-8 8
BloCk 3, Lots 1-18 18
BloCk 4, Lots 1-11 11
Block 5, Lots 1-9 9
Block 6, Lots 1-53 53
(Lots 54 through 61, Block 6, should not
be billed at this time)
Block 7, Lots 1-12 12
Block 8, Lots 1-18 18
Block 9, Lots 1-11 11
TOTAL 141
The City is currently being billed by Dakota Elsciric tor streetlighting in the above listed
subdivision.
?'c4,-?•7. Li ?-
Ed Kirscht Sr. Engineering Tech
cc: Mike Foertsch, Asst. City Eng.
EK(je
/
?
s
'A
Gy-alar lcrouqP P06-- lo
MUNICIPALITY OF: Egan Township
RE: ?t10, Block 8$ Cedar Grove No. 6(1777 Ga6bro Trail)
Lot 15, Block 8, e ar Grove No. _(1767 Gabbro Treil) ?
MX 3795 Pilot Knob Raad
Egan Township, minnesote 55111
1,472.00 ?
Enclosed please find check in the amount of 1,472.00 , for i
payment of special assessments on the property described above. !
Please refer to our file No.7e55 & 8429 when returning receipt. I
Thank you,
MIDWEST TITLE GUARANTEE C 7NY
60 E. 4th Street
St. Pau1, Minnesota 55101
7 $
?
This request void e?n' 6 ? ? ? ?L ?
18 months from 15134
Date of this Request LW 7d/ Fire No. T I, as O Licensed Electdcal C ntracror II.Owner, do hereby request inspection of the above electri-
cal wiring installed at:
Street Address or Route No. City?
Section Township
Range Counry
Which is occupied by (r ell,
Is a roughin inspection required on this job? No ? Yes ? Ready Now ? Will Call P4
y, ? r
PowerSupplier 1yfh'35t? Address
Electrical Contractor /1"1,r rvt-P/S? Contractor's License No. _
(COmpany Name)
Mailing Address /7 j ??isFiS'?'/'? ?? !fi'/'?C/? /?/r/??'? .?ro? %
( leclri fCOntractor or Owner Making Tnls Installatlon)
Authorized Signature?f' Phone No.
f3 (Electrlcal contractor or er aking Thls nstallatlon)
?(?/?`j?? o ??{?? ((?? This inspection request will not 6e accepted hy the
t'J lfil Pl WU ly Stete 8aard unless praper inapection he is enclosed.
Minnesote 5[ate Boartl of Elechicity
Griggs Midway Bldg. - Room N191
1827 University? Ave., St. Paul, Minn. 55104 - Phone 297-2171
ST FOR ELECTRICAL INSPECTION
CHECK BELOW WORK COVERED BY TH1S REQUEST
G
T 151-34
Type of Building New Add. Rep. Check Applisnces Wired For Check Equipment Wired For
Home ? ? Range ? Temporary Wiring ?
Duplex ? ? ? Watei Heate[ ? Lighting Fix[utes ?
Apt. Bldg. ? ? ? Dryer ? Electric Heating ?
Commemial Bldg. ? ? ? Fumace ? Silo Unloade[ ?
Industrial Bldg. ? ? ? Air Conditioner ? Bulk Milk Tank ?
Fazm ? ? ? L'm t List
Other ? ? 1-1 Hehers# Oehecs?
H
COMPUTE INSPECTION FEE BELOW
Smice En[rance Size: # Fec Feeders&Subfeeders: # Fee C'ucuits: # Fee
0 to ] 00 Am s. 0 to 30 Am eres 0 to 30 Am e[es . 0 ?
SOl to 200 Amps. 31 to ]00 Amperes 31 to 100 Am eres
Above 200_Amps. Above 100 Amps. Above 100 Am s.
Transformers RemoteControlCirc. Partial or other fee
Signs 1 1 Special lns eclion Minimum fee $5.00
Remazks TOTALFE ?,00
I, the Electrical Inspector, hereby cerufy that the above inspection has been mVe
.5
(Final)
This request void
18 months from
Date
5)ate ,S-/3-3/
., If 30
A n7 5 i7 u0 & S C.o-k by?-?
? c?tz.5-tly
3 0. av
Repuest Date
^ Ffre. No. Requi?¢dj nsVection ?qeaAy Nuw [:] Will Notify, InyOec-
('J ? ??es ?No - tur When Ready
C] Li"nsed Electrical Contrector 1 hereby requast inspeciion o1 above
PQ Owner electrical work installed at
SVeot AdtlreSS, Bax or flaute No. Citv
17 ?r7 ? ?i,xze&1 ?/ • ?
ecbon o. Township Name or No. Ran9e No. Co?('1ty
Occuo?m (PpINT) Phone No.
l ?j T• ,4f & S/ - S`77
P wer Supulier Address
IT ?"-
Elecirical Convactm lCompany Namel C.ntrxctols license No.
Mailing Atldress ICOnVac[m or Owner Makinp Installationl
Authoriz d Si 2[ure IC -I76c[or/Owner MnkinO l??stallationl Phono Number
6f tfS :?-i ' ?
MINNESOTA STATE BOARD m ECTRIGTY ' THIS INSPECTION qEQUEST WILL NOT
Griggs•Mitlway Bldg. - Room N-791 BE ACCEPTED BY THE STATE BOAPU
1821 University Ave., SL Paul, MN 55104 UNLESS PPOPE0. INSPECTION FEE IS
???? ENCLOSED.
REQUEST FOR ELECTRICAL INSPECTION ee-ooooi-cw
J$ee iostruclions for completin; this twm en back aT Veilow coCV.
A' nM7 ""1('" Below Work Covered by This Request
AAtl pep. ' TyOe o} Builtling Appliencee Wired Equipment Wired
Home Fange Temporary Service
DuUlex Water Heater Lightiny Fixtures
Apt. Building Dryet Electric Heatin
Commercial Bldy. Fumace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
F2rm Other Speci y ther ISUCCifv)
t er Sueci(y Other Other
Comnute Inspection Fee Be/ow
k Fea Service Enhance5ize M Fee Feetlars/Subfeetlers Circuits
OtoDOqms Oto 30Ams 30Ams
Above 200_qm ps 31 [0 10U qmps 100 qm
Swimming Pool Above 100_Amps e 100_Am -
Transform Irrigation Boorr?,s al-'Other Fee
Signs Speciallnspection
L FEE
Z
Hemarks
0•
Nough-in .
ctor, hereby
Y ?he[ the above
F'naf f ction has been
y4p.cti..
.
Tblere0uestvoitll8monlh6lrom - ??° '"P-"IN
PERMIT
City of Eagan Permit Type: Building
Eagan. Permit Number: EA103473
Date Issued: 03/27/2012
OR Permit Category: ePermit
41 it~ of E3
E
Site Address: 1767 Gabbro Tr
Lot: 15 Block: 8 Addition: Cedar Grove 6th
PID: 10-16705-08-150
Use:
Description:
Sub Type: e-Windows iDoors Construction Type:
Work Type: Windows Doors-New ; Replacement
Description: House
Census Code: 434- Occupancy :
Zonin,:
Square Feet: 0
Comments: Improvements to the home require smoke detectors in all bedrooms. If altering window openin,s, call for framing
inspection. Call for final inspection after installation.
Carbon monoxide detectors are required by law in ALL single family homes.
Fee Summary: BL - Base Fee S4K $103.25 0801.4085
Valuation: 4.000.00 Surcharge - Based on Valuation S4K $2.00 9001.2195
Total: $105.25
Contractor: - Applicant - Owner:
Home Depot At Home Services Nlaricuis Davis
656 Nlendelssolm Ave. N 1767 Gabbro Tr
Golden Valley NIN 55427 Eagan NIN 55122
(763) 42-8826
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 Cite of Eagan Ordinances.
ApplicantiPermitee: Signature Issued Bv: Signature
PERMIT
City of Eagan Permit Type: Building
Permit Number: EA107553
Date Issued: 10/16/2012
of 3 a R Permit Category: ePermit
Site Address: 1767 Gabbro Tr
Lot: 15 Block: 8 Addition: Cedar Grove 6th
PID: 10-16705-08-150
Use:
Description:
Sub Type: e-Reroof Construction Type:
Work Type: Reroof
Description: House
Census Code: 434- Occupancy:
Zoning:
Square Feet: 0
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.
Fee Summary: BL - Base Fee $4K $103.25 0801.4085
Valuation: 4,000.00 Surcharge - Based on Valuation $4K $2.00 9001.2195
Total: $105.25
Contractor: - Applicant - Owner:
Legacy Restoration LLC Maricuis Davis
10650 Cty Rd 81, Unit 101 1767 Gabbro Tr
Maple Grove MN 55369 Eagan MN 55122
(763) 354-7660
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.
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA117119
Date Issued:10/15/2013
Permit Category:ePermit
Site Address: 1767 Gabbro Tr
Lot:15 Block: 8 Addition: Cedar Grove 6th
PID:10-16705-08-150
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 .
Jeff Greenlun
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 -
Maricuis Davis
1767 Gabbro Tr
Eagan MN 55122
Perfect Exteriors of MN Inc
321 1/2 Walnut St, POB 297
Monticello MN 55362
(763) 271-8700
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA147628
Date Issued:01/22/2018
Permit Category:ePermit
Site Address: 1767 Gabbro Tr
Lot:15 Block: 8 Addition: Cedar Grove 6th
PID:10-16705-08-150
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:One Window/Door
Census Code:434 - Residential Additions, Alterations
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow
windows, call for framing inspection. Call for final inspection after installation.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Valuation: 1,500.00
Fee Summary:BL - Base Fee $1500 $62.50 0801.4085
Surcharge - Based on Valuation $1500 $0.75 9001.2195
$63.25 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 -
Maricuis Davis
1767 Gabbro Tr
Eagan MN 55122
(651) 552-8944
Custom Remodelers
474 Apollo Dr
Lino Lakes MN 55014
(651) 784-2646
Applicant/Permitee: Signature Issued By: Signature
EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 I TDD: (651) 454-8535 I FAX: (651) 675-5694
buildinainsoectionsecitvofeacian,com BY
ECEIVEll
JUL 01 1020
r For Office Use
Permit #: /, 9
Permit Fee: /?? ' I ' - /
Date Received: :`/ -
Staff:
2020 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: (.P • 'a( () Site Address: 11 L l G- abbro • r Unit #:
esidents
Qwner
Name: 1 rCAAS o1 nThOISOO tile teW tS Phone: 1051' 5 g/4o844
Address / City / Zip: f (51 baJobro `1`rl et.nrn Q 5 5 31-1 LI
( ,
Applicant is: Owner �fJ Contractor A ( 6 412 Aar r �Lo . Co
,:.:.:.......... ............,.........
T jpe of Wor
- tit
Description of work: C I t -M 4� 1A)/ LOW KI t1 '
p ,ire- b Surround
mot, II__
Construction Cost: 65 4e 1 Cp oO Multi -Family Building: (Yes / No )
ontractor..:.
Company: U S ?c. . 0 Si Si-tM S Contact: 4r i 'e kQpptrt C+l
Address: (�lI Wt�Shli/1 feu . S . City: Eder Prod r i e
State:f Y'J Zip: 55314Li Phone: g5d'14(il-/0laEmail: agiapper IdPUsbc hsv le .
urn
License #: i97t,:..LO1.0y %i Lead Certificate #: NAT- Fl 111-653- a
If the project Is exempt from lead certification, please explain why:
In the last 12 months,
Yes No
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
has the City of Eagan issued a permit for a similar plan based on a master plan?
If yes, date and address of master plan:
Licensed Plumber:
Mechanical Contractor:
Sewer & Water Contractor:
Fire Suppression Contractor:
Phone:
Phone:
Phone:
Phone:
NOTE: Piens ends pporting documents that you submit ere considered to be public information. 'Portions of the /nformatloti
classified as non-public If you provide specific reasons that would permit the City to conclude thatthey 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.citvofeaaan.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 (681) 454-0002 for protection against underground utility damage. Call 48 hours before you
intend to dig to receive locates of underground utilities. www,aopherstaleonecell,orq
I hereby acknowledge that this information Is complete and accurate; that the work will be In conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work Is not to start without a permit; that the work will be In
accordance with the approved plan in the case of work which requires a review and approval of plans.
x Pi m e 1(1 a per CtC X4Ja2aJt
Applica s Printed Milne Applicant's nature
DO NOT WRITE BELOW THIS LINE
SUB TYPES
Foundation
Single Family
Multi
01 of _ Plex
•
WORK TYPES
New
Addition
Alteration
_ Replace
Retaining Wall
DESCRIPTION
Valuation 000 Occupancy
Plan Review Code Edition
(25%_ 100% ) Zoning
Census Code Stories
# of Units Square Feet
# of Buildings Length
Type of Construction V / Width
Fireplace
Garage
Deck
Lower Level
_ Porch (3-Season) Exterior Alteration (Single Family)
Porch (4-Season) _ Exterior Alteration (Multi)
_ Porch (Screen/Gazebo/Pergola) Miscellaneous
_ Pool _ Accessory Building
Interior improvement
Move Building
_ Fire Repair
Repair
REQUIRED INSPECTIONS
_ Footings (New Building)
Footings (Deck)
_ Footings (Addition)
_ Foundation Foundation Before Backfill
— Roof: _Ice & Water _Final
Framing 30 Minutes 1 Hour
Fireplace: _Rough In Air Test `Final
Insulation
Sheathing
Sheetrock
Fire Walls
Braced Walls
Shower Pan
Reviewed By:
RESIDENTIAL FEES
Base Fee
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
Radio Meter Read
Copies
TOTAL
_ Siding
Reroof
Windows
Egress Window
_ Demolish Building*
Demolish Interior
Demolish Foundation
Water Damage
'Demolition of entire building - give PCA handout to applicant
MCES System
SAC Units
City Water
Booster Pump
PRV
Fire Suppression Required
Meter Size:
Final ! C.O. Required
Final ! No C.O. Required
HVAC — Service Test Gas Line Air Test Hood
Pool: Footings Air/Gas Tests Final
Drain Tile
Siding: _Stucco Lath Stone Lath „Brick _ EFIS
Windows
Retaining Wall: _ Footings _ Backfill _ Final
Radon Control
Fire Suppression: Rough In _Final
Erosion Control
Other:
, Building Inspector
vii*,41'6A/
Page 2of3
EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 I TOD: (651) 454-8535 I FAX: (651) 675-5694
buildinginspections(5.cityofeanan.com
r For Office Use
Permit #:
Permit Fee: 61b b ()
Date Received:
Staff:
2020 RESIDENTIAL PLUMBING PERMIT APPLICATION
Date: (@" , WO Site Address: 1147 G (A bbro lira.;1
'a«U». / 1 IA.r rim w I I II/4LJI.iLY I7C %AA",eJ Suite #:
ResFd011 wrier::.
Name: 1 t >ut,r(',.Lls -I 1 r >fAoakne 4icW is Phone: Gas ! - 5S1-1.04U
Address / City / Zip: n L l (.atbbro Tr 1 N 5 61 a a
a or
Name: US 9Cal 0 cD y 6-1tmS License #: a1ds a Up
Address:130D WOLS 1 fi'1C Vr t i, S, City: eclen 1=6 r i f
State: MN Zip: 653Lt0 Phone: 95D - u in - &lb'
Contact: An3 i e Y.1appert LK Email: itiUOPper i 0(E USbcx hsy S, cow).
Tape. ot` IVork
— New 4 Replacement Repair Rebuild Modify Space In R.O.W.
_ _work
Description of work:
Description
Tankless Water Heater
Lawn Irrigation ( RPZ I PVB)
_
Standard Water Heater
Add Plumbing Fixtures (_ Main / Lower Level)
_
Water Softener In_
Description: St.ptQ 9 41.430 k)tkh
Septic System
New Connection to City Water from Well
Abandonment
RESIDENTIAL FEES
$60.00 Water Heater,
$60.00 Lawn Irrigation
$60.00 New fixtures,
$60.00 Septic System
$100,00 New Residential
$115.00 New Septic System
$60.00 Connecting to
*Sewer & Water
Water Softener, or Water Heater and Softener (includes State Surcharge)
(includes State Surcharge)
adding or removing piping (includes State Surcharge)
Abandonment
(fee collected with Building Permit)
(includes County fee and State Surcharge)
City Water from Well* + $290 for Meter and $200 for Radio Read = $550
Permit also required for connection charges
TOTAL FEES $
CALL BEFORE YOU DIG. Call
Gopher State One Call al (651) 464-0002 for protection against underground utility damage. Call 48 hours before you
of underoround utaing Imams, nnnhamraie,.,.a..au ...,.
Intend to dia to receive locates
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.citvofeattan.com/subscribe.
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 wit be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Anoi {' upper i G<
Applic 's Printed Name
x it ► CLppAA,I,
App ca 4• - ignature
Page 1 of 2