1690 Oakbrooke WayAddress 1690 OAKBR66Y.E 41AY Zjp $$122
L.ot 17 Blk i Sub onxaROOxE 4Ta
THESE ITEMS WERE / WERE NOT COMPLETE AT THE T1ME OF THE FINAL INSPECTION.
Date:
fo/ Yes No Inspector. Z
Final grade (6" om siding)
Petmanent steps (garage)
Permanent steps (main enhy)
Permanent driveway
Permanent gas
Sod/Seeded grass
Trail/curb damage
Porch
Basement finish
Deck
Please verify with the builde[ lhe removal of root lest caps from the plumbing system and the shutoff of water supply to
the outside lawn faucet before freeze potential exists.
Contact engineering division at 681-4645 before working in rightof-way or installing underground sprinkler system. ?
White - City Copy Yellow - Resident Copy Pink - Contractor Copy
PERMIT # W-OH_
RECEIPTDATE: '? 24 -01
iiESIDENTIlkL PLUM$IAfi fERM1T APPLICATION
c11'Y og Eksm
3$30 PELOT KA08 iiD
£A6RA, !IA 55122
651-681-4675
Please complete for:
SITE ADDRESS:
? single family dwellings
? townhomes and condos when permits are required for each unit
? backflow preventer for irrigation system
OWNER NAME: : WU IO1 SGY lrTl fd L TELEPHONE #: `15'?1 ` FJ I Oy
(AREA ODE)
INSTALLER NAME: D1"Q?11?1 ?C'p ?lU VJf (1 TELEPHONE #: ?? ?-IVoq - L9qCl?
? J
STREET ADDRESS: (.' L1) yGT (AREA CODE)
N"10?__ ?W e-
cirv: LCx-? V ( I I P J sraTE: M'?n?nesc7?'o. ziP: 55DL114
Plaen a eMne4 marlr nnv4 4n fha narmit work tVOe
New residential dwelling unit under construction and not owner/occupied $ 90.00
Add-on, modification or alteration to existina dwelling unit, including: $ 50.00
• abandonment of septic system
• new installationlrepair/rebuild of RPZ
• lawn irrigation system
• water tumaround
t
k
?'tL?'l
Q?'
N
f
wor
: i
,
a
ure o
-'-v
Septic System, new/refurbished - $ 225.00
• includes County & Consuiting inspector fees
• requires MPC license
State Surcharge $ .50
Total $?4rD C)
Reminder. Be sure to schedule inspections of alterations, i.e. water heaters, water softeners, etc.
I herehy acknowledge that I have read fhis applicatlon, state fhat the intortnatlon is corred, and agree to complywith all applip6le City of Eagan ordinances. It
is the applicanfs responsibilily to natl(y the propeAy owner that the City of Eagan assumas no liability for any damages caused bythe City during its normal
operedonal and maintenance acflvitles to the facilitles constructed under this pertnit witliin City property/right-of-way/easement.c
SIGN'ATURE OF PERMITTEE
Updated 1/01
7
Site address: Ilald OG Wa-I Lot 0r Block A4
Subd. (3STD
On April 15, 2000 the Minnesota Energy Code, Category I Building Requirements for insuiation protection, air
tightness, and ventilation, was adopted. As a result, the City of Eagan is requiring that the following information be
submitted prior to issuance of a Certificate of Occupancy.
7 This sWCture: is wnstructed to meet minimum requiremenls of the Mn Energy Code, Chapter 7670
OR
_ This struclure: will be constructed to meet more restric6ve requirements of Chapters 7672 or 7674
APPLL4NCE GAS ELEC MANUFACTURER MOOEL BTU'S VENTING TYPE
Water Healer aS
Fumace
Dryer
EXHAUST SYSTEM
LOCATION
TYPE
MODEL
CFM's VENTED
YES No
Kitchen kitchen
Bathroom 1
Bathroom 2 y1f
/NVl4 c??.-?
JL/ ?}
r
Bathroom 3
Bathroom 4
Other
FIREPLACE S
LOCATION
GAS
WOOD
MANUFACTURER
MODEL
BTU'S VENTING
DIRECT ATMOS
J f,
MAKE-UP AIR MODEL TYPE CFM's
U
I hereby acknowledge that the above information is correct and agree to comply with the Minnesota Energy Code and City of Eagan
W??')o- (
Dat
' This fortn is Ihe responsibility of the General Contractor.
CITY USE ONLY
PERMIT #: RECEIPT DATE:
USIDEPTIlEL MECE"CAL PEfiMIT APPLICATION
crrY oP EAsnx
3830 Pu.oT Kxos gu
r.ALsax Mx 551$$
651-681-4675
Please complete for: ? single family dwellings
townhomes and condos when permits are required for each unit
Date: ?- 6 "?A
SITE ADDRESS:
V
OWNER NAME: ? 1};? ?YLLS?S TELEPHONE #: CBfSZ q6a'?'a0c?'
? (AREA CODE)
INSTALLER NAME: rYt??? . C- TELEPHONE #: 9sa 'I'DOO?_
(AREA CODE)
STREET ADDRESS: ,AltAi \ IL{'lOlL IS?GI-?1(y- Av - S-
CITY: Sa_.0QQ ?
STATE: " N ZIP:
Place a check mark next to the ermit work t e
New residential dwelling unit under constructionand not owner/occupied $ 70.00
Add-on, modification or alteration to existinq dwelling unit $ 50.00
• furnace replacement
• air exchanger
• air conditioner
• other
Nature of work:
State Surchar e $ .50
Total $ 26`E v
Reminder: Call for inspectians.
i •
SIGNATURE OF PERMITTEE
Updated 1/Ol
CITY USE ONLY
PERMIT #: RECEIPT DATE:
APPROVED BY:_ INSPECTOR
COMMERCIAL MECHANICAL PERM1T ?PPLICATION
CITY OF EA&AN
S$SO PILOT KNOB ftD
E4fiAN, IdN 55122
651-6$1-4675
Please complete for: all commercial/industrial buildings
multi-family buildings when separate permits are not required for each dwelling unit
DATE:
SITE ADDRESS:
OWNER NAME: PHONE #: -
(AREA CODE)
TENANT NAME (IMPROVEMENTS ONLY):
WAS THERE A PREVIOUS TENANT IN THIS SPACE? Y N. NAME:
INSTALLER:
ADDRESS:
CITY:
PHONE #: -
(ARbA CODB)
STATE: ZIP:
WORK TYPE: New construction Install U.G. Tank
_ Interior Improvement Remove U.G. Tank
_ Processed Piping
SpecifyNature ofWork: -
When insta[ling/removing underground tank, call 651-681-4675 for inspection by Fire Marshal and
Plumbing Iinspector.
Fees: 1% of contract price OR $50.00 minimum fee, whichever is geater.
Underground tank removal/installation = mivimum fee
Conuactprice: $ x 1%= $ (Base Fee)
State surcharge calculate at $.50 for each $1,000 Base Fee
TOTAL $
SIGNATURE OF PERMITTEE
Updated 1/Ol
CITY USE ONLY
L Bl I RECEIPT#:
SUao. Oakbroo ke, 'I 1, RECEIPTDATE:
PERMIT # II ? Lq 7
2000 PLUMBING PERMIT (RESIDENTIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, MN 55122
651-681-4675
Please complete for: ? single family dwellings
? townhomes and condos when permits are required for each unif
i// r ? J ?Il /ho ? backflow preventer for underground sprinkler system
FIXTURES
EACH #
TOTAL
Alterations to existing dwelling - minimum fee
Describe: $ 30.00
Bath tub $ ? 3.00 x = $ -
Floor drain 3.00 x $ ?
Gas piping outlet " minimum -1 3.00 x $,3?
Hot tub/spa 3.00 x = $
Kitchen sink 3.00 x = $
Laundry tray 3.00 x = $
Lavatory 3.00 x = $
Septic System new/refufiisned ' requires MPC lic. 75.00 x $
Septic System abandonment 30.00 x = $
RPZ new installatioNrepaidrebuild 30.00 X = $
Rough opening 1.50 . x = $
Shower 3.00 x = ?
Underground sprinkler if dwelling is under construction 3.00 x = $
Underground sprinkler if existing dwelling 30.00 x = $
Water closet 3.00 x = $
Water heater 3.00 x
Water softener If dwelling under construction 5.00 x = $
Water softener if existlng dwelling 30.00 X = $
Water turnaround 30.00 x $
State Surcharge .50 -> -> --> $ .50
TOt81 _> -> °-> ----> 1 $
Reminder: Call for inspections of alterations, i.e. water heaters, water softeners, etc.
-----------------------------------------------------------------------------------------------------------••--•-----------------------
I hereby acknowledge that I have read this application, state that the infortnatlon is correct, and agree to comply wdh all appliwble City of Eagan ordinances.
It is the applicant's responsibility to notify the property owner that the Ciry of Eagan assumes no liability for any damages caused by the City during its
normal operational and maintenance activities to the facilities constructed under this pertnit within Ciry property/right-of-way/easement.
SITE ADDRESS:
OWNER NAME: :
INSTALLER NAME:
STREET ADDRESS:
CITY:
TELEPHONE #:
(AREA CODE)
TELEPHONE #:
(AREA CODE)
4 "C,dl? V ZIPr _
SIGNATURE OF PERMITTEE
S_ A-w 4 '4 3 L53
, . _ 2000 BUILDING PERMIT APPLICATION (RESIDENTIAL)
• ctrr or eAcnir lI
3830 PILOT KNOB RD - 55122 `? L? , 14`1
851-881-4874
D 3 roplfleratl sIfe wrvays showlnp 94 R of bt, 84 R. d tfouM
mtl 21 roofed arow @OX maximum bf coveraoe ailowadl
D 2 coplas of Waru (Yww baam R wirWOw sixe+: Doured fnd tleggn; afc.)
D 1 wt ol anerpy edeulaMant
D J caplei d frea profanatlon plan H lof qalpd aRw 7/1 /93
0U
Remodel/Reoait ReaWremeMs
2 caplet of plan
1 set o1 enerOY cdadaHOru lor Neafed additlorq
i slTa nuveY for exeAa addlMau 8 tWCb
DATE: I J I3 ? Da CONSIRUCTION COST:
DESCRIPTION OF WORK: r?'Ev? ?onls'?'tz??cam nl ??d? P;P,%?ua
51REET ADDRESS:
LOT: I-7 BLOCK: _I SUBD./P.I.D.1:
Name: Phone i:
PROPERTY lau flnt
OWNER
Sheet
citY
State:
Lp:
Company._FB?,* Hwa> E4 &.\ Phone#: 6l'a- ?vto`C-atr??
(area code)
CONTRACTOR ?????
Sheef Address: lav,??" iY1F?11 ?A- /,l?t'6oF-f l? P? Llcense /?ExP• ?/rld!
cny ?4k6!Mza ?r.c-,AQ> stare: MN Lp: SSI
ARCHIiECT/
ENGINEER Company: Ncme:
Talephone C (
Sireet Addreas: Regishatbn Ik:
CNy
State:
LP:
3ewer/water licensed plumCer (H Installina aewerMralar): -7' phone P. (9c?P 1? 102 - oZ j oZ`
1 herebY acknowledye Mwf I have read Ihk appllcafbn, atate ihaf tlw InMmwlbn k oorteoi? and ayree b crompy wilh a1 appYcable Stade
of Minneaota Staiutea and Cdy of Eapan Ordinaneaa
Sipnalure of Appficant ?-??? C.???'
OFPICE USE ONLY
Certifiptes of Survey Received Yes _ No RECEIVED
Tree Preservetion Plan Received _ Yes _ No 146t Required
IBY:?
OFFtCE USE WNLY
BUILDING PERMIT SUBTYPES
O 01 FoundaUOn O 07 05-plex
lp 02 SF Dwelling ? 08 06-plgx
O 03 01 of _ plex ? 09 07-piex
O 04 02-plex O 10 08-plex
O OS 03plex O .11 10-plex
O 06 04-plex 0 12 12-plex
WORK TYPE
LA7 31 New
32 Addition
0 33 Alteration
0 34 Repair
O 13 16plex O 21 Porch (3-sea.) O 31 Ext Ait - Multl
O 17 Garage p 22 Porch/Addn. (4sea.) O 33 Ext Alt - SF
O 18 Deck ? 23 Porch (screened) O 36 Muld
0 19 Lower Level O 24 Stortn Damage
Pft Yw_N 0 25 Miscellaneous
O 20 Pool ?' 30 Accessory Bldg. O 36 Move Bidg. p 43 Reroof
C3 37 Demolish (Bldg)• O 44 Siding
O 38 Demolish (Interior) O 45 Fire Repair
0 42 Demolish (Foundation) p 46 Windows/Doors
• Give PCA handout to applicant for demolition permit
GENERAL INFORMATION
SAC Code ?Q L
No. of Units ?
No. of Buiidings #S---
UBC Const. (Actual) (Allowable) Occupancy
Zoning
# of Stories
Length
Width
Basement sq. ft.
Main level sq. ft.
G4"6 s9.ft.
sq.ft.
MISCELLANEOUS INSPECTIONS
0 Stucco/Stone
APPROVALS
Planning _
Permit Fee
Surcharge
Plan Review
License
MC/ES SAC
City SAC
Water Conn.
Water Meter '
Acct. Deposit
S/W Permit
S/W Surcharge
Treatment PI.
Perk Ded.
Trails Ded.
Other
Copies
Totai:
8AC Units
% SAC
Building
-SD C?
.?S
Y4ll?
sq.ft.
sq. ft.
Footprint sq. ft.
Census Code
MC/ES System
City Water
Booster Pump
PRV
Fire Sprinklered
,?°I
/O/
?J Engineering Variance
?J
Valuation: $ `? 19?G
G710 ,?? ?-
Y4'ox !,6
0
'-4 H 7 5.?{3 I?OxS? ` S?tYG ?
PI!1 r-1?- 29:.Y_i 14 ! 03
h?Ncheck CqMPLIADICE REPORT
Minr.escta Energy Co3e
[wN^_heck Software Version 3.0
CCUNTY: Dakota
STATE; MinnesOtH
ZONE: 2
CorrSTRUCTION TYPE: Single Family
bATE: 5-12-2000
DAiE OF PLAN$: 5/12/00
'['IT1,Rr r_RYBTAL 9LAH w; PoRCH EL.1
FF?f'_tE,^.'P INFOF.MATION:
C)T.ti RR.!?Qj(E
("")r1FI,LnNC6: PAS8E3
r°q+ti.zg?d CLA = 503
Y!^nT Hnme - 399
20.6w PetY.t±r. Than Ce+de
? . 9G= 0 3
? Permit ? `
C ecke by/L?ar_.'e
Area or C.avity Cont. Glazzng/L!nor,
peYimeteY R-Va1ue R-VAlue U-ValuA
-- -------------------------------------------...------------- ---
CF7t,Ifl.r,g 1713 44.0 0,Li
S4hi,L5: Wood Frame, 16" o_C. 1784 19.0 2.0
cin.Z.LNG: Windowe or poora, Above Orade 299 0.350 ?
DO'?R9 38 0.350
SL7+P FLOORS: Vnheaf_ed, 42.0" inaUl, 196 3.0.0 1
HVAC SQUSPMFNT: Furnnce, 92.0 AFL7E
- _...__---- --._--------- - ---------^-------_.-.-----------------------
C(1MFL'IANCE 3TATEMENTi The propoAed buildil7g deaiga describrc4 tiere is
consietent with the building plans, specifications, and other calculationg
sl+bmirted with the permit applicetion. The proposed building has k',esn
d=_eigned tn meet the requiremenCe of the Minnesota Energy Code.
Builder(ne6ignar ?L?-??? Date ! ?/?v
LOT SURVEY CHECKLIST FOR RESIOENTIAL
BUILDING PERMITAPPLICATION
L PROPERTYLEGAL: /O% 1-7 gLOGIL I
N DATE QF SURVEY: ?a,3/ Ou
?y LATEST REVISION:
?
?
0 DOCUMENTSTANDARDS
? 2
O z
? p ? Registered Land Surveyor signature and company
y?
'frl ? :
BuildingPermdApplicant
/ ? • Legaldescnption
d ? ? • Address
? ? • North arrow and scale
sl ? ? • House type (rambler, walkout, split w/o, split entry, lookout, etc.)
? ? • Directional dreinage arrows with slope/gradient °h
LI? ? ? • Proposed/existing sewer and water services & invert elevadon
M/?
v ? • Street name
D
i
o
c ? •
r
veway
? ? ? • Lot Square Foatage
?? ? • LotCoverege
ELEVATIONS
Existina
d ? ? • Sewer service (or Proposed)
Va ? • Properry cornere
c-"? ? • Top of curb at the drrveway
--"? ? • Elevations of any exdsting adjacent homes
-u 0/ ? Adequate footing depth of structures due to adjacent utlliry Venches
Prooosed
g/ ? ? Garage floor
? ? •
Firstfloor
rra? ? c • Lowest exposed elevation (walkouUwindow)
E ¢"? ? • Property corners
? c ? • Front and rear of home atthe foundation
PONOING AREA (if apWicaWe)
? ?? • Easementline
? a? ?
a m-/ ? • NN/L
. HWL
? ra?/ ?
' • Pond # designation
ti
Ei
O
fi
o m o eva
on
ow
• Emergency
ve
DIMENSIONS
zi ? Lot lineslBearings & dimensions
? ? Right-of-way and street width (to back of curb)
etc
porches
reater than 2'
h
? .
,
,
angs g
• Proposed home dmensions including any proposed decks, aver
(i.e. all sVuctures requiring permanent foatings)
e?o Show all easements of record and any Ciry utilibes within those easements
c? ? ? :
Setbacks of propased structure and sideyard setback of adjacent exdsting strudures
? 2r ? • Retaining wall requirements, Aany
d GlG ? f/ ' ?0
Reviewe
Name f Datd
March 1998
CMIC3IBLOGPRMf.FM
-` Surveyor's Certificate
SURVEY FOR :PULrE
DESCRIBED AS : Lat », Block 1, OAKBROOKE 4TH AODITION, City of Eagan, Dokota County, Minnsota and
reserving easements of record.
x qq2.o
N7?• - ?
29.,w 82.
? ;: 992.8 O
492'n 16.gz ? 0
PWOPOaed
SIpy6ler N
CroCe
x 44 / C0fp9e
944.0 71d A lo° 00
?`
S77 '4S'zs_•e?82. p6944.0
, ----
,
J EkiS?
TpB' H9me `i
5.4 i
r
i
LOT SQ. FDOTAGE = 3,6081 HSE. SQ. FOOTAGE = 20196
LOT COVERAGE = 66%
1
/
Q '
? / .
ai
/ .
'r
1
,61/7/vp
Plan # 17941
PROPOSED ELEVATIONS
BENCHMARK, rNH@ a3,24/1
Top of Foundation = 943,5 q3b.13
Garage Floor =R42,3
Bosement Floor = n/n
Aprox. Sewer Service =927•3t
Proposed Elev. = 0 MIN. SETBACK REQUIREMENTS
Existing Elev. = Front -25 House Side -
Drainage Directions =
-0enotes Offset Stake = • scn?: I inch - 30 feat Rear - Garage Side-
J08 N0:
HE????? I HEREBY CERTIFY THAT THIS IS A T?UE AND CORRECi REPRESENTATION OOR-532
OF THE BOUNDARIES OF 7HE A804E DESCRIBED PROPERN AS SURVEYED
BY ME OR UNOER MY DIRECT SUPERVISION AND DOES NOT PURPORT TO BOOK: PAGE:
PLANN/NG 6NGINSSRlNG SURVEYINC SHOW IMPROVEMENTS OR ENCROACHMENTS, E%CEPT AS SHOWN.
2005 Ptn Oak Drive Eugan, MN 55122 pnTE _io/ 3L/ oo cno FILE:
Phone: (651) 405-6600 0WVJEFFt& Y D. LINDCREN, LAN SURVEYOR OAKBROOKE
Fax: (651) 405-6606 f.? .? MINNESOTA LICENSE NUMBER 14376
94 A
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PERMIT
City of Eagan Permit Type:Building
Permit Number:EA126549
Date Issued:08/29/2014
Permit Category:ePermit
Site Address: 1690 Oakbrooke Way
Lot:17 Block: 1 Addition: Oakbrooke 4th
PID:10-53763-01-170
Use:
Description:
Sub Type:Siding
Work Type:Replace
Description:
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Please leave printed pictures of house wrap on site for the final inspection.
When installing ventilated soffit material, remove existing material (i.e. debris that could block vents) and take steps to
ensure maximum ventilation to attic. Call for final inspection after installation.
Valuation: 4,000.00
Fee Summary:BL - Base Fee $4K $103.25 0801.4085
Surcharge - Based on Valuation $4K $2.00 9001.2195
$105.25 Total:
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Contractor:Owner:- Applicant -
Janel S Prehall
3705 Blackhawk Rd
Eagan MN 55122
Property Claim Solutions Llc
2005 Pin Oak Dr
Eagan MN 55122
(651) 994-2028
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA127802
Date Issued:10/15/2014
Permit Category:ePermit
Site Address: 1690 Oakbrooke Way
Lot:17 Block: 1 Addition: Oakbrooke 4th
PID:10-53763-01-170
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 .
Lisa Nyberg
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 -
Janel S Prehall
3705 Blackhawk Rd
Eagan MN 55122
Property Claim Solutions Llc
2005 Pin Oak Dr
Eagan MN 55122
(651) 994-2028
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA140693
Date Issued:01/13/2017
Permit Category:ePermit
Site Address: 1690 Oakbrooke Way
Lot:17 Block: 1 Addition: Oakbrooke 4th
PID:10-53763-01-170
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Furnace
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088
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 -
Janel S Prehall
3705 Blackhawk Rd
Eagan MN 55122
(651) 777-7365
Joel Smith Heating & Ac
13915 Lincoln Street NE
Suite E
Ham Lake MN 55304
(763) 792-1066
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA170563
Date Issued:07/09/2021
Permit Category:ePermit
Site Address: 1690 Oakbrooke Way
Lot:17 Block: 1 Addition: Oakbrooke 4th
PID:10-53763-01-170
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Air Conditioner
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Pete DeGrood at (507)
210-0754.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088
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 -
Janel S Tste Prehall
3705 Blackhawk Rd
Eagan MN 55122
(612) 807-3351
Joel Smith Heating & Ac
13915 Lincoln Street NE
Suite E
Ham Lake MN 55304
(763) 792-1066
Applicant/Permitee: Signature Issued By: Signature