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3810 Mill Run Ct3, lj • ? . . DAY /DATE : ADDRESS: 25 ?S I () ?-P jj-k . ` (Y. .. FTG ;AL L HTG. DECK FTG. PL FOUNDATION FINAL/C. . FRAMING ??} a FINAL/DECK ? O ROOFING ADDITION v INSULATION FIREPLACE R.I. HTG. POOL C' o /' R.I. PLBG. l?.H"yr?,? ? "GARAGE ? OTHER -,f'<<,C.L?`? ? ?Sy -a? I FOR PERMIT# ?- MECHANICAL PERMIT CITY OF EAGAN 383 PI RECEIPT # 0 LOT KNOB ROAD, EAGAN, MN 55122 l DATE: CONTRACT PRICE: 7/ PHONE: 454-8100 Site Address ? ` ? ? ?•'''' `??' ?' % ? BLDG. TYPE WORK DESCRIPTION Lot Block . ? / . ? Sec/ Sub ? ? ?, • , Res. New 1 n Mult Add-on ? ? ?c Name SIAN AR Address 410 VIEST N LC,t,E ^ lqFET Comm. Repair m c I' EAPO!!5, f Clty 1".I? '•? 55408 Other _?- 5 L Name l1Ja :?-;?. ,. c Address 0 City TYPE OF WORK Forced Air Boiler Unit Heater Air Cond. Vent. Gas Piping Oudets # Other M BTU M BTU M BTU ? M BTU CFM FEE S/C: TOTAL: FEES RES. HVAC 0-100 M BTU - $24.00 ADDITIONAL 50 M BTU - 6.00 (RES. HVAC INCLUDES A/C ON NEW CONSTRUCTION) GAS OUTLETS (MINIMUM - 1 PER PERMIT) - 1.50 EA. COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS. - COMM. RATE APPLIES TOWNHOUSE & CONDOS - RES. RATE APPLIES MINIMUM RESIDENTIAL FEE - ALL ADD-ON & REMODELS - 12.00 MINIMUM COMMERCIAL FEE - 20.00 STATE SURCHARGE PER PERMIT - .50 (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND $1,000) SIGNATURE OF PERMITTEE FOR: CITY OF EAGAN PERMIT # PLUMBING PERMIT RECEIPT q CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: ? nunur_ •a. s.ww $It@ Lot. ? Name ? L ? Address , c City ''?^• - Name !L 1t`LA4-? V ry? c,s ? c Address 'Pf G ti' ,Y%- O Ciry ?? - Phone FEES COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS - COMM RATE APPLIES TOWNHOUSE & CONDO - RES. RATE APPLIES MINIMUM - RESIDENTIAL FEE - $12.00 MINIMUM - COMM/IND FEE - $20.00 STATE SURCHARGE PER PERMIT - ,50 (ADD $.50 S/C IF PERMIT PRICE GQES PERMITTEE FOR: CITY OF EAGAN BLDG. TYPE WOfiK DESCRIPTION Res. New Mult. Add-on Comm. Repair Other RES. PLBG. ONLY - COMPLETE THE FOLLOWING: NO. FIXTUFiES TOTAL Water Closet - $3.00 $ Bath Tubs - $3.00 Lavatory - $3.00 Shower - $3.00 Kitchen Sink - $3.00 Urinal/Bidet - $3.00 Laundry Tray - $3.00 Floor Orains - $1.50 Water Heater - $1 50 Whirlpool - $140 Gas Piping Outlets - $1.50 ? (MINIMUM - 1 PER PERMIT) _ Softener - $5.00 Well - 510.00 Private Disp. - $10.00 Rough Openings - $1.50 FEE STATE S/C: GRAND TOTAL: PLUMBING PERMIT CITY OF EAGAN 3830 PIIOT KNOB ROAD, EAGAN, MN 55122 PHONE: 454-8100 Site Addres,s Sec/Sub BLDG.TYPE Res. ?- Mult. Comm. m Name ? Addre c Ciry '( ? Name 3 Addre 0 C'ry - Phone FEES COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS - COMM RATF, qPPLIES TOWNHOUSE 8 CONDO - RES. RATE APPLIES MINIMUM - RESIDENTIAL FEE - $12.00 MINIMUM - COMM/IND FEE - $20.OU STATE SURCHARGE PER PERMIT - .50 {ADD $.50 S1C IF PERMIT PRICE GOES FOR: CITY OF EAGAN PERMIT # RECEIPT # DATE: WOfiK DESCRIPTION New ?-- Add-on Repair Other -RES. PLBG. ONLY - COMPLETE THE FOLLOWING NO. FIXTURES -.Z,Water Closet - $3.00 TOTAL ?r__? • ? -,t_.Bath Tubs - $3.00 ..Z,Lavatory - $3.00 ?? • ' I Shower - $3.00 - -' _4_K0chen Sink - $3.00 -- Urinal/Bidet - $3.00 Laundry Tray - $3.00 ? FloOr Drains - $1.50 ?• '1 ?' Water Heater - $1.50 1 • - -- Whirlpool - $3.00 =Gas Piping Outlets - $1.50 (MINIMUM - 1 PER PERMIT) Softener - $5.00 Well - $10.00 Private Disp. - $10.00 :t_Rough Openings - $1.50 . t? FEE: STATE S/C: -`? GRAND TOTAL• •CITY OF EAGAN . . _ , . 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHON E: 454-8100 BUILDING PERMIT Receipt # To be used for Est Value ' Date ' ,19 Site Address ' • OFFICE USE ONLY LOt BIOCk ` SBC/SUb. On Site Sewage Occupancy - MWGC S siem Zoning A x Name LLI ; Addre a City _ rc =o O` U¢ ? Y On Site Well (Actual) Const City Water h (AllowaWe) PRV Required # of Stories Booster Pump Length ? Phone Depth ' N a m e S.F. Total Address Footprint S.F. City Phone Name 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. Signature of Permittee - A Building Permit is issued to: on the express condition that all work shall be done in accordanee with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Building Official APPROVALS FEES Engr./Assess. Permit Planner Surcharge Council Plan Review Bldg. Off. SAC, City ? ` • ?? Variance SAC, MWCC Water Conn. Water Meter Road Unit ? Treatment Pt ? Parks TOTAL ' Permit No. Permit Holder Dste TeIsphone Rlumbing Electric Softener Inspectlon Date Insp. Comments Footings 1 Footings II Foundation Framing ? ,00?, Roofing Rough Plbg. Rough Htg. lgul. Fireplace Final Htg. Final Pibg. Bldg. Final I .,? Cert Occ. Temp. LP Deck Ftg. Deck Final Well Pr. Disp. . ?? ? • * PERMiT # _ MECHANICAL PERMIT RECEIPT # CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: Site Address ';I11 Run Cou.r. t BLDG. TYPE WORK DESCRIPTION Lot "• Block Sec/Sub " Res. New -? ult Add-on L o Name - ='=- Heatincl- & Air Condition ~13075 Pionec:Y Trail Address ;?? omm. Repair ? City ?den Prairie phone 941-4211 Other Cornorate Name Constructio!i FEES RES, HVAC 0-100 M BTU -$24.00 c Address 4466 Yded ewcod ADDITIONAL 50 M 8TU - 6.00 p Ciiy `"??`??-?? Phone 454-0644 (RES. HVAC INCLUDES A/C ON NEW CONSTRUCTION) GAS OUTLETS MINIMUM 1 PER PERMIT 50 EA 1 ( - ) - . . TYPE OF WORK COMM/IND FEE - 1% OF CONTRACT FEE Forced Air ?.) r`?tiC? ;,_•;,nox M BTU 24.00 APT. BLDGS. - COMM. RATE APPLIES TOWNHOUSE & CONDOS - RES. RATE APPLIES Boiler M BTU MINIMUM RESIDENTIAL FEE - ALL ADD-ON & Unit Heater M BTU REMODELS - 12.00 Air Cond. M BTU $ MINIMUM COMMERCIAL FEE - 20.00 Vent. 3 hath * aMFM, STATE SURCHARGE PER PERMIT - DD $ C IF PERMIT PAICE OES 5 S .50 Gas Piping Outlets # LI= , ?•1 i,r . ?.5 ?ye ~ -- (A . 0 ! G BEYOND $1,000) Other FEE: •'J ? j/ , ? ? ?' S/C: SIGNATURE OF PERMITTEE TOTAL• --'`` • `" `? FOR: CITY OF EAGAN ? - r =. F eryr . ' (Itrfi#iratP uf Orrupttnry titp of Cagan RppartmM o# 'Eugbng jtwrrtintc This Certificate issued pursuanl to 1he nequiremenu of Section 306 of the Uniform Building Code cenifying tirat at the time of rssuance this structure was in compliance with the varivus ordrnances of the City regulatrng buelding constructron ar use. Far the foilawing.• U. Ctatifiration :?F DIX/G1R s,ag. Permit ro. I4305 occ„p.),y r,? R3 z«mng o;,tr;G i ry. C..L Vrx owm ot euaaiol'x'RPIOIiA1E CONSTUM r(-V Add= 4466 WIDrJOCY yDii, F?'S,t+c?, B„1d;,S Add. 31 1(! M?7l. PIW uaM I3. B I I. BRiDi.E R.'L[JGE ' a,e: OECD= 16, 1987 auuUng otrid.l ? POST IN A CONSPICUOUS PLACE ? . b 19_ r AMOUNT $ _..;? •'? i .7 & DOLLARS ioo ? CASH C] CHECK FOq ? ?. BY CASH RECEIPT CITY OF EAGAN 3830 PILOT KNOB POqD EAGAN, MINNESOTA 55122 DATE ? White-Payers Copy Yellow-Posting Copy Pink-File Copy Thank You . .? ? BLDG. PERMIT N0. 01-3210 Bldg. Permit 01-3422 Plan Check 7.5- 01-3445 Surch./Adm. 7lp 01-3446 SAC/Adm. 01-2155 Surcharge J ', ^ `17-3860 Road Unit ?'f ?,?J Cr Lr) 20-2275 SAC ?' y r 'rl 20-3865 Water Conn. i: 20-3868 Water Trmt. 20-3716 Water Meter 20-2252 Acct. Dep. ?.i e? nE ? 24-3713 Water Permit 20-3743 Sewer Permit 79-3866 Sewer Conn. j! { 11-3855 Park Ded. TOTAL CITY OF EAGAN Permit Na Date: 38W PIIQt Knob Road Meter No: 3f-5 5 7s Size: ?? c.? P.O. Box 21199 Reader No: U A P? 7?T Date: /a -?FZ Eagan, MN 55121 Owner. _ Gopporate Const. Site Address:_ _3,> 10 M.ill Run C'os»-'_ ", 311 Bridle ? Plumber Tla Haea :'1umt->:n Conn. Chg: 5 2S . COpd nin Acct Dep: -?-5 _ ??Ondt--- ?? Permit Fee: ,L)?- " E?jitlU •Gas C. Surcharge: ?a ta?cl?wlth ths City of Eagan Tr. Ptant c Meter. 4T.??: ?PERM M isc.: WATER SERVI IT qTY OF EAGAN 3830 P9iot Knob Road P.O. 8ox 21199 Eagan„MN 55121 Owner4 ? T.?o Permit No: "1,i Date: 1 I-1' -` 7 B/P No: 732?=4 Date: ZO t- e-` Site Address: I ' lu •"`•11!. tcun t;o,:r !: . ...? : r :.,'le Klgge Plumber. 17 liaeg `'ILmbir- MWCC: <, •, - 5• 00 ,• ,? , Zoning• City Chg: `? ? i??.?.0 'i . -,S No. of Units: " Acct Oep: . 1 I sgree to comply with the City ot Eagan Permit Fee: T,d Ordinances. Surcharge: SEWER SERVICE PERMIT CITY OF EAGAN (v°_ 14 3 0 5 3830 Pilot Knob Road, P.O. Box 21 •199, Eagan, MN 55121 ?/ pa ? 7 BUILDING PERMIT PHONE: 454-8100 Receipt # ? a. p,`! To be used for SF DWG/GAR Est. Value $76, 000 Date OCTOBER 14 19 87 Site Atldress 3810 MILL RUN CT OFFICE USE ONLY 3 11 BRIDLE RIDGE Lot Block Sec/Sub on Site Sewage Occupancy R3 . MWCCSyatem X Zoning Rl Parcel No. V On Site Well (Actuap Const T1 a Name CORPORATE CONST INC Ciry Water X (Allowable) Vn ; Address 4466 WE?GWOOD DR PRV Required _ # of Stories 47 ° Ciry EAGAN phone 454-0644 eooster Pump _ Length ? Depth , p Name SAME S.F.Total ?a Addre55 FootprintS.F. P City phone APPROVALS FEES w W Name Engr./ASSess. Permit 419.50 38 00 ?i Planner Surcharge . i. Address Council Plan Review 209.75 a W City Phone Bidg. ON. SAQ City 100.00 I hereby acknowledge that I have read this application and state that ihe Variance SAC, M WCC 525.00 information is wrrect and agree to comply with all applicable State of Water Conn. 525.00 Minnesota Statutes and City o g rdinances. ? WaterMeter 67.00 SignaNre of Permittee - Road Unit 1Q5....00 A Building Permit is issued to: CORPORATE CONST INC Treatment P7 180.00 on the express condition 1 hat all work shall be done in accordance with all applicable Sfate of Minneso s?Statutes antl Ci ? of Eagan Ordinances. parks 369 : 25 ?z Building Ofiicial TOTAL ? K This reques[ vold 18 nwnths trom //f D 694 2 /.3 7 / Reau`ire[I7..?•?....V..? IE]Pe9A4 Nuw ilTNoii(v InsPec'I r-n '? [L]'?s ?N [or When fl Ay ?y.v.?ensetl ElecVical Contractor I herebV reQUast inspection of abova ? Owner eleclrical work instelled at St Address, Box nr R uta No. - Cityr ^ l C-1 ecUOn o. Towns Ip Name or No. Range No. Lounty ? Oc ant IPflINT }M?j D ? 5 7- ? Phonc No. D Fower p lier Atldress Elec[rical Contrar.lor ICOmpany Nemel Conhac or's License No. KENDRICIi ELECT??IC ?a ailationl j \J ti1 'lA4 Amh m e /A a i nVt a atjon) Phone Nmnber MINNESOTq STATE BOAND OF ELECTNICITY TMIS INSPECTION qEQUEST WILL NOT Griggy.Midwey Blde. - Aoom N•191 BE ACCEPTED 6Y THE STATE BOAHD 1821 Universitv Ave.. St. Peul. MN 56104 UNLESS PflOPEH INSPECTION FEE IS Phona (612) 642-0800 ENC L05ED. REQUEST FOR ELECTRICAL INSPECTlON es.ooooi-os Il, See instructions br completing this torm on back ot vellow cooY. D. . 69462 "X" Below Work Covered by 7his Nequest Elsay .4dt1 fle0. TVPB 01 Bulltlinp ApOtiancef WireC EquiVmBnt Wir¢A > Home Range 7emporary Service DuplFx Water Heater ghtiny Fixtures Apt. Buildinc? Dryer Electnc Heahn Commercial Bldy. umaCe Silo Unloader Industrial 91dg. Air Conditioner Bulk Milk Tenk FBfm Oth, (SPer.i v OIher ISnenify) L P.! SVCCI y OlhCf 0Ifll_f nsoection Fee Below p Fee Service Entrence5ize b Fee Faxders/SUbieedars IX Fe? Circui[s 0 to200qms 0 to30Ams Oto30An s Above 200 Amps. 37 to 100 Amps I Q [IAIO 31 ta 100 A s Swimming Pool Above 100_P.mps Above 700_Am s Transiormers Irrigatlon Booms Partial-Other F ' I I Signs I I iSpecial Inspection ? J TOTAL P ? ?I Remirks LI+, Final 1? the Ele tncal (nspectoq re certify thnt tne abov insoeccian has been vold 18 mantlre trom SU;R V E YO R' S CE=RTI F ICAT E CORPORATE CONST. ? 0 ? M ? ?-- Z EC ?qENE ROAD S ?8°/T?4n W ? 1 P _- r ? 1 ? _L LLJ I I ? ` I (G 00 ? MN ' - / ' I i NKj -T--- ? 19 - - ?1 pct 360 ? ,o/ ? !iJ ? ' a PROPOSED N HOUSE M 0 rn (V .. a 11.0 I f 0 I N M N I a co 40 7 QA/ R. 6T'. ? 12.83 (/? . ? 19_00•. 22.67 6 N ? ?? ? r ? , --?=- -? .. , O 8 r _ J ?? O ) , f' 32.11 -A. d? / F?=65.00 " ' a=280I8 09 Rr8 s O 0 06 y ds-q?3 9c 2. 3? / 6 ?O n N MILL RUN COURT - ,. o p W rt1 ? 0 inc Hill Jaames R ? Or I- ?l (li O G `'p ? D a , . . N m R o m ? Q T > u Z .D • m i6 ? « Z PLANNERS / ENGINEERS / SURVEYORS o T M O m , { , . .. '... 9401 JAMES AVE. S. • BLOOMINGTON, MN. 55431,+ 812•884-3029 ti SURV E YO R' S C ERTIF`I C°ATE CORPORATE coNSr. ?- DENOTES PROPOSED SURFACE DRAINAGE O DENOTES IRON MONUMENT SEf SCALE: 1 INCH - 30 FEET • DENOTES IRON MONUMENT FOUND PROPOSED GARAGE FLQOR - q0 7• 4' FEET X000.0 DENOTES EXtSTING ELEVATION PROPOSED LOWEST FLOOR - 900 • 3 FEEf (000.0) DENOTES PROPOSED ELEVATION PROPOSED TOP OF BLOCK - `/a 7• 7 FEET WE HEREBY CERTIFY TO CORPORATE CONST. THAT THIS IS A TRUE AND CORRECT REPRESENTATION OF A SURVEY OF THE BOUNDARIES OF: Lot 3,81ock II , BRIDLE RIDGE IST ADDITION, according fo ihe recorded plat thereof, Dakota County, Minnesota. IT DOES NOT PURPOfiT TO SHOW IMPROVEMENTS OR ENCROACHMENTS, EXCEPT AS SHOWN. AS SURVEYED BY ME OR UNDER MY DIRECT SUPERViStON THIS ! 3 DAY GF (SGrc 962 , 1987 SIGNED: J . HILL, INC. BY: AROLD C. PETERSON, LAND SURVEYOR MINNESOTA LICENSE NUMBER 12294 ~ u, m ? ? ? 0° s Q ? o ? Om y O O < O ?D p y m az 0 mzQ ?? D v Z °° aM N ? p m ? v & < James R. Hill, inc. PLANNERS / ENGINEERS / SURVEYORS 9401 JAMES AVE. S. • BLOOMINGTON, MN. 55431 • 672-884-3029 ; /430S Q , 7987 BDILDING PEAMI? APPLICATION - CITY OF EAGAN SINGLE FAMILY DWELLINGS INCLDDS 2 SETS OF PL9PS, 3 CERTIFICATBS OF SIIRVEY, 1 SET OF ENERGY CALCULATIOAS NOTE: ADDRESSES FOB CORNER LOTS - CODiTRACTOR/HOMEOSiNER MOST DESIGNATfi W$ICH ADDRESS IS DFSIRED. NO CHANGES WILL BE ALLOFiED ONCE BDILDII3G PERMIT IS ISSIIED. MULTIPLE DWELLINGS - RBSIDENTIAL REdTAL ONITS FOR SALE iJNITS INCLUDE 2 SETS OF PLANS, CERTIFICATE OF SDRVEY - CHECB WITH BLDG. DEPT., 1 SET OF ENERGY CALCULATIONS C.OMMRRCTAi. INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS, 7 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS, $2,000 LANDSCAPE BOND SINC,LE FRMILy VW6LLING r? To Be Used For: ?Jk? Valuation• ((a 0O C) ? Date: J?}. Q' 16? Site Addresa 35?fU f"`ill 0, C-4 Lot ? Block Lk Parcel/Sub Owner rQrOo?Wt Address (/J?t.?v'J 0- City/Zip Code ?Lt, VA/ S11 Phone ''Ciq' 06qq Contractor Address City/Zip Code Phone Arch./Engr. Address City/Zip Code Phone ll On Site Sewage Occupancy R-3 MWCC System ? Zoning R-1 On Site Well Type of Const City Water ? (Actual) V-N (Allowable) V_N ll of Stories Length Depth 33 S.F. Total Footprint S.F. APPROVALS FEES Assessments Permit 9•50 Water/Sewer Surcharge ,00 Police Plan Review 209.75 Fire SAC, City O O, Engr SAC, MWCC 5 Z5,OD Planner Water Conn 5 Z5. ? Cauncil Water Meter (.10?0 Bldg Off Road Unit D 0510 APC Treatment P1 0.00 Varianee Parks Copies TOTAL ? . ? ?? . ? .. ? k •? ? ? n , Z3x22" 506X l2?- 6 6 72 ? 'ZLI X12 = 28$ 2 y x 3? = g6y lls.2x ?Y= 16129' H ousr IIX?? = 8X I?i = zS,136= ?i?z X Z = 6 ?C Z = 2 C66 12 go0 ( 9) (2 IZdI X`f4= 5? ? 5 o?-?'i t r[f/YFY ?A6?Vi S' .?,?.._,,._._ _ L 1 Yrt t0 ? 1?i ' `? ` Pfqne ^ato V rltt AdOress ?4AN3 C-T T :ontractor Oc`o???__?c?s'?!V`JC_?:c?l? ahoni ? imitding C1 uatt4cstion: Type A1 (Stngle Fa:nily 6 Duplex) ?'Type A2 (Residentfal) : -(3 storiesorTesf3.-;(OLfitT) (Oaer 3 stories) i„gNERAL INFORlNtION E: Bu1lCtng Ptriwoter l'Q-A ft. ;. Mall hetgh! (groqnd W eave) ? p S ft. 2 3. t. X 2. (atiow) gross wa.il 4rg04\C)Ea fc. i. Building dimenslons (L) 4?o x(u) L? •??O ?7 ft 4: Sqwre tcot 4i•a;} ot rim 3otst - Ftoor ,}oi:c stxe (2 x\o? } (? x Derimeler = Rim o st area ? '?I. 3o0rs - A?N TA1C n?ss?? a actor Typt qt?truC p? t?\ C"s ?--?rrft. ManuhcWrer Ca _ e 7. ?otal door's perimtttr ?Z-• z`Z-, ft Wlndor?t: Mieutactursr 1?.,? f? nc r State approved_ V fiCLOM' .50 TYPE Sf1E AREA (f:.2) NUMBER OF TOTAI FEET 2 EACH UNTTS ? 5040 14.-I 4 S -7 3.'10 3&3 • o Z ... 4oC) . b' . . . - . . . . 7?. y, totai ft.2 61ass 106 FtrepiaCe area: Midth x heiaht ¦ -c="? x E-?_-_' ?-?-- FL•z 11. Exposed foundatlon: Melght x?erimeter ,O?j z '-A `b ' AC FL•Z 4:7MPi,.£TIQN Of THI$ fplM 15 REQUIRED FOR ALL NEW CQtiSTRUCTION, MAJQit REMODEIINfi AMO BUILDt'IGS ?IN toEO wHE? Et?k6r, OTHEA THA?i YNE MIN[MAL COOE ALLONANCE. IS USEfl. `'°f! , , •:;;: ?Y .a_ _ _ .. . • _. . ' . . ._ .. . ? i? 2F'S SS ) S???i ?? ??.? ? ? ` O ? ,'* • i W ndow area A z, zo .-I 5 f t. Z i: M I t1EpMQ • . s o U x A• \1 .3 Rim foiit area A _• \\0\. Q? ft.Z U rim joist • , p U x q poor arN A -7 ft.' 7 door area • . \?3 U x p Flreplace area A ?-- f:.2 !J rireplace ¦ -?_ U x a• ?- Exposed foundetiort A _4?? ft.? . J foundation ? .\\ U x A• Framing area A Z\O. $ it.` J`raning area •• oq U x A- 1%_q, ?aat wati area A l4t (o`? • 'T`b fc. u wall = - . 043 u x A • G.,3.Z _ (t?o -,-,L . . . . . . . . . . U x A ?.? ?; . !. 6ross wall area x 0.11 (A-1 single family S J4?.^A • allowablt U.c A1Code ,r (13. above) . x 0.23 0-2 other resiGentia x .23 !Other Duilding,` . x .2E (Ovev• 3 star;e.) /? a ? ?j TUH Must b e larger'thin . lJ x ?: CCdI? Cl. 138 . ? ? `, ?iWve ' 6. Cailing framing area A a uais 100; af ? f) 4 ---?or the -r ? ea same as ) : 6A. Gross ceilin area 9 • (l) ?(o z ?? ,,? L? Z b`I ft.2 B! Joist area (Af) ¦ 10^, Ceiling area p_"7 ft.2 C. Net cetlina area (AC) (15A - 1 U teiling x A co U framing x A f= , O Z?o4 D. rotaL u x a ................... . Ceiling area (15A) x 0.026 (A-1 -^-y-- x O.C33 (A-2 5B) '---__-_?-r-?.'?±(c• 30 tt•2 - x----?--'? ` x .................... sinyle •`amilj S Cuplex - code aTloNable U x A otAer reside7:iel) x 0.06 (Other) A(15A) ??I Q'I xIL (S44gLs C) Z BaUN Must be larger Chan 15D (above) f (or the Samejas) HOTE: Use U and a values obtained f-om )ps l, 3 and 4. ,su. O °° ? ? SiJtng ?L-6u,-kL . 7? air Eilm .17 •r ?-'-"^'-? ? - ----.? . . . Q roTAL ? O ;tk ' f.M instde atr film .oA STU ; v?c, tnc.: f or +ii t . 4? SIMTIOM _ 4"s cud R= (g ? 1 (Framing) U . . ? I ?Qe?thin6 ?L:.b6. . Siding • J Outsld• air itln .17 ocN ?•? ? "'OTAL )rl4 .? ,. ?..,,•- _ ?:;.;, Instae air film R• .68 . 2ND VALL Intertor wail .'45 S[CTI?li ineulstion (Wat1 Sheathing Z .06 _ Exterlor vA11 .ovvrins , !,!"? i Exeerloc air tllic "n +.1 i R T07'A4 Interiur air (iiT ?=.63 Jots; IL ir,cA so[t •ruud 4*l.pa (Rim U¦? ? ? r h ahhn Joist,a g "kit?' ?or watl cuvertng . (e1 , 1 8xterlar air f[tm W' .17 , B TOTAL -- / l.(,_ 0 4 Inc.riur air t:ta u s.o lnsula:lor. ?e.o0 ?i acFouoJatlun -0???C rb Z?t o. (Fdn.) U • ?A. •:"; I ` y xteCloT air ftln Re_ 1.7 . ; ` 4F TOtAL ?- -=? ? I Expofad 31uck ""_'_"' • ? ?? r,reCe i, ;. , ° R"s'.?- -.?"_ '.1':r:?yF.w_ v..-in+'r• rwA?iir.r ' ... ....; ... ::. . , ...: .. '_'?p^'!?. `.-f,'w.wi'F? r ?.+ .n-.-.:?. 4_. ? ------ ------ , ? ? ?? .-I.?, tRtut"stion 44 Q Jo1st .? Coi t tng 5 ? ? . O.E1 Air film 0.61 3-7 .9 3 lotat a 03,? 4 - I u F:AF ROOf QR CAtHEQS:LcIi6ZtIG IrT4 ue f R;.MINfi Inside air fi Ceiiing Joist (stu Insulatlon Air ;pace ? Root Qe;king Intulatton 8ytit+aiep rca! Qut;1??' efr f FoLaI. R k*U R YALUE CfiFI I?1G , 0.61 infiltrdticn .5 cfnVlineal fpot of crack ttel door tnfiltration 0.5 cfm/square foo: or dcor and mininuc code regulrertKnt idential door infiltratfon 11.0 cfm/lineal `oct of crack - 12" concr•ete btock no insu9,atton =,47 R 2.1 12" toncrete bleck insulAted cores =.26 d 3.8 12" 11 ghtsoi.gltt :blqtk .32 R 3.1 12" lightw6t9ht bi0¢k irisulated cores - .12 Q 3.3 ngle qlass + 133; r1!th stom windovr .54 uets 41l?s • ??r ?pi! glitf • :4i 11 exttrlor wall,s and tNlings must have a vapor barrier (C.10 perm msx.),. ?por barrier *Ax bo pq the,in;tde (heated side) of watl. ;?or esrrtars pAlyetl) oiue tM n f i l m have no R va l ue . " .' a. . ?.: CIT----f OF EAGAN APPLICATION FOR PERMIT SEWER AND/OR WATER CONNECTION N01E: PAYMFTTP OF FEE AT TIME pg APPUCAMON mES MT CONSTrff= APPROVAL OF PERI+IIT. INSPDC.`rZON OF SMffi2 MID/CHt FIATFR Tr1STAT7ATTONS WII.L 1Vt7P BE $CFgD- UI.ID UNfII, PERNffT AAS B?1 APPROVID. P ease Print 1) PROPERTY ADDRESS: 3,??? ?. ??y??? (7??-- •. LEGAL DESCRIPTION: " Lot Block Subdivision or Tax Parce ID ) IF E7QSTING STRLY.Z[7RE, DATE OF ORIGINAL BiJILDING pERMIT ISSL'ANCE: - . PRFSENP ZONING/PROPOSID USE: (Mon Year ? CM`JERCIAi./REfAIL/OFFICE Q IDIDOSTRIAL ? INSTITIPfIONAL/GOVER1ZEN1.' ?R-1 SINGLE FAMILY " Q R-2 DL'PLEX (7t,o Onits) R-3 TOWN30LiSE (Three + Units) ( Units) q x-a apaxTmErrr/corroorurrnM c onits) 2) ? ADDRFSS: CITY, STATE, 2IP: PHONE: 3) (VRME: ADDRESS: CITY. STATE. ZIP: PHONE: I MASTER LIC.ENSE# ? ActiVe FScpired Not recorded Sta In1t1a1 4) •• L?..i.i?• NarE: ADDRFSS: QTY, STATE, ZIP: PHONE: .g) ,? M.. • ?• : ? a? - a? ?NI?TION 1n CITY SEWER CONNDCrION TO CITY WATEE2 ? OTHER ' 6) °• •? Q PLEASE HOLD APPROVID PII2MiT FOR PICK-C?P BY ONE OF ABdVE 'EASE MAIL APPROVID PERMIT ZU 1, 2,f? 4, ABOVE n ? ; (Cir? one) _ . ? ._. : FOR CITY USE ONLY PERMIT # ISSUED ZZ? Pd w/Bldq. Permit FEES: $ $ $ SEWER PERMIT (INCLUDE SURCHARGE) WATER PERMIT (INCLUDE SURCHARGE) $ IG ?'?' G $ WATER METER/COPPERHORN/OOTSIDE READER $ $ WATER TAP (INCLUDE CORPORATION STOP) $ $ SEWER TAP $ ? $- /?? • L??' ACCOUNT DEPOSIT - SEWER $ ACCODNT DEPOSIT - WATER S WAC $ SAC $ $ TRUNK WATER ASSESSMENT $ $ TRUNK SEWER ASSESSMENT $ $ LATERAL BENEFIT/TRONK SEWER $ $ LATERAL BENEFIT/TRLNK WATER $ ?d'C?'C•? $ WATER TREATMENT PLANT SURCHARGE $ .. i, $ OTHER : $ TOTAL r? RECEIPT RE CEIPT DOES UTILITY CONNECTION REQUIRE EXCAVATION IN POBLIC RIGHT OF WAY? F__j YES IF YES, THEN A"PERMIT FOR WORK WITHIN PUBLIC Q NO ROADWAY" MOST BE ISSUED BY THE ENGINEERING DIVISION LIST . AS A CONDITION. SUBJECT TO THE FOLLOWING CONDITIONS: APPROVED BY: TITLE: DATE: _ / RECORD OF COMPLAINT DATE: _ 1,7 _ ,g? 0 + COMPLAINT TAKEN HY: NAME: ADDAESS: 3o`CZ ia, e-1'-. PHONE NO.: COMPLAINT:_ I --- ----- ? ---- ACTZON_TAKEN s _ %. 3 --` -? -0? ?- - TYPE O --- NGe...?--------...._. - --E B -UIL ---DI LEG9L DESCRIPTION: ------ - - - -------_?GLteC! P'z.- _ .I?. ------- • - ? ?--- - SIGNED:_--- WNAfENTS: --- ------ --- -- -,??«)?P RESIDENTIAL BUII.DING PermitAppGcation City Of Eagan 3830 Pilot Knob Road, Eagan MN 55122 Telephone # 651-675-5675 FAX # 651-675-5694 New CansWCtion Reouirements ?RemodeVReoair ReouiremenGS Office Use Onlv 3 registered site suneys showing sq. ft o( lot sq. ft. of house; and all roofed areas ?p copies of plan Ced W 5urvey Recd Y_ N (20%maximum lot coverage allowed) 1 set of Energy Calculations for heated additions Tree Pres Plan Recd _Y _ N 2 wpies of plan showing beam & window sizes; poured taund design, etc. 1 site survey for addiUons & decks Tree Pres Not Reqd _ Y_ N isetofEnergyCalculations AddAion - irMicateifon,sitesepticsystem On-stteSeptic5ystem _Y _N 3 copies af Tree Preservation Plan 'rf lot platted aker 711193 Rim Joisl Defail Options seledion sheet (bldgs with 3 or less unfts f ? Construction Cost Date Qv l-Z??-l 03 Site Address 3500 t'l r f[ I` lj?j ri_ i Unit/Ste # Description of Work f? N jc?V n'1 64 I?, f}N a j2y._:- 6 $.oo rv\ Multi-Family Bldg _ Y&N Fireplace(s) _ 0 x 1 _ 2 Property Owner ri-QA-Z.Z. IN+ yA njD /7k: j L-1425cin1 Telephone #(657) a S' 3- 3 Iq? Contractor ? Address 3$ 1 O h'1 ??? Rti N e-y- State )" /V Zip 5-S1a 3 City EffAllpirX3 Telephone #( ---) COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING - Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672 Energy Code CategOry . Residentiai Ventilation Category 1 Worksheet • New Energy Code Worksheet (dsubmissionType) Submitted Submitted • Energy Envelope Calculations Submitted s`?] o , oc7 c?ec??l g/l 3103 Have you previously constructed a building in Eagan with a similar plan2 _ Y _ N If so, 25% plan review fee applies. Licensed Plumber ? N14hone #( Mechanical Contractor Sewer/Water Contractor #( #( I hereby apply for a Residential Building Permit and acknowledge that the information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN Statutes; I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. P0 l, wiRs01v Applicant's Printed Name ? Applicant's Signature OFFICE USE ONLY Sub Types ? 01 Foundation ? 07 05-plex O 13 16-plex ? 20 Pool ? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 PorchlAddn. (4sea.) ? 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (screen/gaze6o) ? 05 03-plex ? 11 10-plex 121( 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-plex Plbg_Y or _ N ? 25 Miscellaneous Work Types ? 31 New 91"'?35 Int Improvement ? 38 Demolish (Interior) ? 44 ? 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 ? 33 Alteration ? 37 Demolish (Bldg)" ? 43 Reroof ? 46 ? 34 Replacement •Demolition (Entire Bldg) - Give PCA handout to applicant Valuation ?0 ea'" Occupancy MC/ES System _ Census Code q36} Zoning City Water _ SAC Units Stories Booster Pump _ Nbr. of Units ? Sq. Ft. PRV _ Nbr. of Bldgs I Length Fire Sprinklered _ Type of Const g Width _ Footings (new bldg) _ Footings(deck) _ Footings(addition) _ Foundation _ Drain Tile Roof Ice & Water Final ? Framing ? Ficeplace R.I. ?irTest ?Final ? Insularion ? 30 AccessoryBldg ? 31 Ext. Alt - Multi ? 33 Ext. Alt - SF ? 36 Multi Misc. Siding Fire Repair Windows/DOOrs REQUIRED INSPECTIONS _ FinaUC.O. Final/No C.O. ? Plumbing ? HVAC Other _ Pool Ftgs Au/Gas Tests _ Final _ Siding Stucco Stone _ Windows (new/replacement) _ Retaining Wall Approved By 041!4"Lw-? , Building Inspector Base Fee Surcharge Plan Review MC/ES SAC City SAC Utility Connection Charge S&W Permif & Surcharge Treatment Plant License Search Copies Other Total PLUMBING (RESIDENTIAL) Permit Application City OfEagan 3830 Pilot Knob Road, Eagan Mn 55122 Telephone # 651-675-5675 FAX 4 651-675-5694 Please complete for: Single Family Dwellings Townhomes and Condos when permits aze required For each unit Date O-V I I,;L l D 3 Site Address 1\ 4 N C--F- Unit # Property Owner P?.. •? Lt¢fLSn /J RW OA-4 6?2/47-Z%N r Telephone #(6S7) PR'3' 3 fqY Contractor Address U /-'t Lt -j cl T City ? ejr'J State /&-I /`-' Zip 5-?149 3 Telephoue # The Appticant is ? Owner _ Contractor _ Other Septic System New _ Refurbished Submit 2 sefs of plans and MPC license $ 100.00 Indudes County fee. Additional consultant fees may apply. Alterations To Existing Dwelling Unit, Including $ 50.00 Adding fxtures to lower levels or room additions, excluding water soften er and water heater _ Abandonment of septic system _ Water turnaround (+ 5/8" meter if needed -$121.00) Other: _ RPZ _ new installation _ repair _ rebuild $ 30.00 _ Lawn irriga[ion system _ Water sof[ener _ Water heater $ 15.00 _ replacemenl _ additional ? State Surcharge A UG 1 3 2003 $ '50 Total L ' $ y - I hereby apply for a Residential Plumbing Pemut and aclnowledge 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 with the Plumbing Codes; that I understand this is not a pemut, but only an applicarion for a pernvt, 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 wlilch requires a review and approval oFplans. ft? i L-R,tscz? CEx ApplicanYs Printed Name Applicant's Signature I ?'S\3 2006 RESIDENTIAL PLUMBING PeRMiTaPPUCaTio 3830 PILOT KNOB ROAD, EAGAN N?'??? 1? D 651 675 5675 Q `-` ?..z .???.`?_.,?.e. . .?. mplete for modifications to existing residential dwellings. t,5.s0 Date_46?0_! [??? n) n Site Street Address Unit# Properly Owner p dc1lX,ylap l?C?I l? Telephone #( M.P. PIPEWQRlCS Contractor $670 DODD ROAD Telephone # ( ) Address ?GAN, MN 55123 City State Zip The Applicant is: _ Owner Contractor _Other Septic System _ New _ Refurbished Submit 2 sets of plans and MPC license Includes County fee $ 100.00 Per as-built $ 10.00 Alterations to existing dwelling $ 50.00 _ Add plumbing fixtures. This fee includes installation of a water softener and/or water heater at the same time. !f you are installing onlv a water softener anaVor water heater, do not complete this section; move to the next section and check the appliance(s) you are installing. _Septic System Abandonment _ Water Turnaround (add $130.00 if a 5/8" meter is required) Other: _ Water Softener ? Water Heater $ 15.00 _ new replacement Lawn Irrigation _RPZ _PVB _new _repair _rebuild $ 30.00 State Surcharge $ .50 FTotal $_L? , - - I hereby apply for a Residential Plumbing Permit and acknowledge that the information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan and the plumbing codes; that I understand this is not a permit, but only an application for a permit, work is not to start without a permit and work will be in ,apcordance wi?h tfhe approved plan in the event a plan is req??to pf r,er"d an$Cpprpved. ppTicanYs Printed Name Appli nY§ 'SigfaEn?e ?s?o,? City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 3810 Mill Run Ct Lot: 3 Block: 11 Addition: Bridle Ridge 1st PID:10- 14996 - 030 -11 Use: Description: Sub Type: e- Reroof Work Type: Replace Description: House & Garage Census Code: 434 - Zoning: Square Feet: 0 Comments: If there is no ice protection inspec acceptable in lieu of inspections. Fee Summary: Valuation: 3,000.00 Contractor: Seta Roofing Remodeling 4100 Excelsior Blvd St. Louis Park MN 55416 (612) 823 -8046 BL - Base Fee $3K Surcharge - Based on Valuation $3K Total: Applicant/Permitee: Signature PERMIT City of Eaan - Applicant - Construction Type: Occupancy: on prior to final, you must meet inspector with ladder and flat bar. Pictures are not $88.50 0801.4085 $1.50 9001.2195 $90.00 Owner: Nathaniel E Bork 3810 Mill Run Ct Eagan MN 55123 Permit Type: Permit Number: Date Issued: Permit Category: Issued By: Signature Building EA081138 11/16/2007 ePermit I hereby acknowledge that I have read this application and state that the informa of Minnesota Statutes and City of Eagan Ordinances. on is correct and agree to comply h all applicable State Bork City of Eaafl 3830 Pilot Knob Road MAR 1 9 2014 Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Staff: ` v 2R SIDENTIAL BUILDING PERMIT APPLICATION RECEIVED 651 365-1445 p.l Use BLUE or BLACK Ink For Office Use Permit #: Permit Fee: Date Received: Date: ' % / 7 / / c-! Site Address: 32/ 0 /vi / / /2 r!-'1 Resident/ Owner Type of Work Contractor L'f':, Lr�t;#1 A) :'/,�.3Unit#: Name: A.1.:..J-/-10 , e_ / !3<- . ;— Address / City / Zip: 333/0 /4% l I /: 04C: , F ay' h Applicant is: -^ Owner Contractor - Description of work: frillL c �to;2-k Construction Cost: j/OvOC, C'O Multi -Family Building: (Yes / No !� ) Company: A /A Contact: Address: City: Phone: 6_57 - „c ( j - 8 7toR l:z.? State: Zip: Phone: License #: Lead Certificate #: If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) T3 e b.,. fcl / i [% wr.c.sc c -6 t. � / / (i,/ ,,r l 9 7g - l 1987 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. Cali 48 hours before you intend to dig to receive locates of underground utilities. wwgopherstateonecall.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. Exterior work authorized by a building permit Issued In accordance with the Minnesota Stale Building Code must be completed within 180 days of permit issuance. X »AA�l ) ct-/1cti'IrC ! �� /��>r'K x Applicant's Printed Name Applicant's Signature Pagel of 3 Bork 651 365-1445 p.2 3$10 Nall,.h L� DO NOT WRITE BELOW THIS LINE SUB TYPES oundation Single Family Multi 01 of Plex Accessory Building WORK TYPES New Addition If Alteration Replace Retaining Wall DESCRIPTION Valuation Plan Review (25%___ 100% 1 ) Census Code # of Units # of Buildings Type of Construction Fireplace Garage Deck 4t Lower Level _ Interior Improvement _ Move Building Fire Repair Repair 3e7 REQUIRED INSPECTIONS Footings (New Building) Footings (Deck) Footings (Addition) Foundation Drain Tile Roof: _Ice & Water Final Framing Fireplace: _Rough In __Air Test Insulation Sheathing Sheetrock Reviewed By: RESIDENTIAL FEES Base Fee Surcharge Plan Review MCES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant Copies Porch (3 -Season) Porch (4 -Season) Porch (Screen/Gazebo/Pergola) Pool Occupancy Code Edition Zoning Stories Square Feet Length Width Final TOTAL et 2- 5`7 Siding Reroof Windows _ Storm Damage Exterior Alteration (Single Family) Exterior Alteration (Multi) Miscellaneous _ Demolish Building` _ Demolish Interior Demolish Foundation — Egress Window _ Water Damage 'Demolition of entire building — give PCA handout to applicant .12e MCES System SAC Units City Water Booster Pump PRV Fire Sprinklers Meter Size: Final / C.O. Required Final / No C.O. Required HVAC _ Gas Service Test Gas Line Air Test Other: Pool: _Footings _Air/Gas Tests _ Siding: Stucco Lath Stone Lath Windows Retaining Wall: _ Footings _ Backfill _ Final Radon Control Erosion Control Final Brick Building Inspector ii? AegAd 34/0 Page 2 of 3 PERMIT City of Eagan Permit Type:Building Permit Number:EA168046 Date Issued:04/07/2021 Permit Category:ePermit Site Address: 3810 Mill Run Ct Lot:3 Block: 11 Addition: Bridle Ridge 1st PID:10-14996-11-030 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. *Roof permits issued between December and March will be inspected in the spring or when weather warms up. 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 - Nathaniel E Bork 3810 Mill Run Ct Eagan MN 55123 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:EA174763 Date Issued:02/18/2022 Permit Category:ePermit Site Address: 3810 Mill Run Ct Lot:3 Block: 11 Addition: Bridle Ridge 1st PID:10-14996-11-030 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 - Nathaniel E Bork 3810 Mill Run Ct Eagan MN 55123 Champion Plumbing Llc 3670 Dodd Rd., #100 Eagan MN 55123 (651) 365-1340 Applicant/Permitee: Signature Issued By: Signature