4497 Slater Rd
~ j~ CASH RECEIPT
,
CITY OF EAGAN
1 3795 PILOT KNOB ROAD
EAGAN, MINNESOTA 55122
DATE 19
R<CBIY~D
FROM
AMOUNT $ 1
4 DOLLARS
~ao
? CASH ? CHECK
IOR ~
~Tf'
FUND COOE AMOUNT
Thank You
C~C~- ~ ~ B v
White-Payers CoDY
Yellow-Posting Copy
Pink-File Copy
~t
C~~ ~F EACs/1N ~ r : , .
379! ?ilof Keob Rood Eoyen, MN S'i122
- • ~ ~HONE:IS4-a100
BUILDING PERMIT Receipt #
To b~ w~d fo~ Esf. Value Date 19
Site Add?ess Erect ? Occuponcy
Lot Blotk Sec/5ub. ~;c' Alter p Zoniny
Paroel # i Repoir ? Ftre Zone
Enlorge ? Type of Const.
W Name ,;1C . MOVe 0 # Stories
~ Addross ~ Demolish p Length
C; - p~~ G.ade p Depth Sq. Ft.
Name ApProval~ F~es
~fe~ Assessment Pennit
~ Cit p~~ Water b Sew. Surchorqe
F Police Plon check
~ Nome
F Z Fin 5AC
l~ddrcss Enp. Water Conn.
~ W C+ p~ Planner Water Meter
Council Rood Unit
I hereby ockrawledge thot I have reod this application o~d state that Bidp. Off.
the intormntion is correct and ogree to comply with oll uppliCOble
State of Minnewto Statutes and City of Engon Ordinonces. APC Totol ~
Sipnoture of Permittee
A Building Permif ts iuued to: on the ezpress oonditlon thn~
oll wo~k shall be done in acw~dance with oll opplioobls Stote of Minnesoto Stotutes ond Cify of Eopon Ordinontes.
Buildinp Offlciol '
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`,,,,S~ ~r~pttr#m~ti ~f ~~ilding ,~ns}~Pr~~nn = \
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` ~ T6~ Ce~tifirate issatd prrrtaa~rt so tbe requiremc~rs o f Sation 306 of tix U~ri
fonn Bieildis8
1, ~ Code arti
f
yi~ag that at tix tinie ef irmranu thii unuture suar in coin
pliaruc with tbe vuriwes ~ \
~ ~
. E~;~ ordiAa~uc.t o
f the Citr ngulr+ting bxilcliag conttruction or ux. For thr followi~g: ,
i, ~ ,
~ ;i` u~.cr~+wo SF DWG/GAR s~as.r.,nuNo. 7309 `~f
:I R3 '~,p. caru~c~w. V Fr. T NA zo~i„~ o~.,,ict ~
~ Oeo~lr¢7'~'P~
~~~..,.j.~ Zachman Homes. Inc.,we~,.7760 Mitchell Rd.. Eden Prai. 3~
~ 4497 S ater Rnad ~,~,n,~t 1,Block 1,Cinnamon Ridge~
lridY~ Ad4r r
2nd ,~q 1~
. ~i~ , '
~ ~ ap: Novenber 23. 1982 f~! ~-1~.~
r.-~B ~,,:I ~ ,B~ ;s~
rwr ir • oo,wncrwn w.?ca - - ~
''I Y~ 'C~ a 1.~.. r~V~~ 9 ~
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Receipt MECHANICAL PERMIT Permit No.
CITY OF EAGAN
Fee
Fill in numbered spaces S/C
Type or Print /egib/y Tot '
1. Date ~ 2. Installation Cost ~ ~ ~
3. Job Address ' - ' ' Lot ~ Blk. ~ Tract
4. Owner ~ '
5. Contractor • ~ • Phone ~
6. Address -
7. City ' State ' Zip
8. Building Type: Residential ~ Commercial ? Institutional ?
9. Work Description: New ~ Add ? Alter O Repair O
10. Des~ribe 1= -v1=~_~ Fuel Type ~
11. No. Eauinment BTU - M. Ea. No. Ectuipment CFM
Forced Air ~~r -
Air Handling:
Mfg,
Boilers Mech. Exhaust
Mfg.
Unit Heater
Mfg. Other
Air Cond.
Mfg,
Gas, Piping Outlets
12. I hereby certify that the above information is true and correct, and I agree to
comply with all ordinances and codes governing this type of work.
Signed : for
Rough Finel
Inspections: Date Insp. Date Insp.
This is your permit when numbered and approved.
Approved CITY OF EAGAN 464-8900
Receipt ~ PLUMBING PERMIT Permit No..~C ~ i~
CITY OF EAGAN .
Fee -
FiII in numbered spaces S/C n
Typs or Prinf legibly ~ r, r::
a
Tot.
1. Date ~~~~F~2 2. Installation Cost
('j~~n:1.^.^sn
3. Job Address `~7 ~1~fi~"' z:~'•Lot ? Bik. I Tract~'=~:"'
4. Owner c"n~ n i?amP s
5. Contractor .".arcu~ Pl~u~~i;i;,'; Phone ~
6. Address I c~.reen "vF . `ao .
7. City ,~till~ ~?~cr State Zip
8. Building Type: Residential L•~ Commercial ? Institutional ?
9. Work Description: New ~ Add ? Alter ? Repair ?
1D. Describe
11. No. Fixtures No. Fixtures
~ Water Closet ~SpoQ~/Drainfield
_ / Bath tubs Septic Tank
Lavatory Softner
Shower Wel I
Kitchen Sink
Urina?/Bidet Other
Laundry Tray
Floor Drains
Drinking Ftn.
Slop Sink
Gas Piping Outlets
12. I hereby certify that the above information is true and correct, and I agree to
comply with all ordinances and codes governing this type of work.
Signed : for
Rough Final
Inspections: Date Insp. Date Insp.
This is your permit when numbered and approved.
Approved CITY OF EAGAN 454~51~0
CITY OF EAGAN Remarks t~.cc_c.e~i~l</~y9- /~'`8'/
Addition CINNAMQN RIDGE 2ND ~ot 1 R~k 1 Parce~ 10-1740~ 010-01
Owner ~ Street 4497 SLATER ROAD 5tate
~~l i r? `fl~ i' fJ{
Improvement Date Amount Annual Years Payment Receipt Date
STREETSURF, j 26 93 1~$.3g $ 26. CO~~~# ~
STREET RESTOR.
GRADING Q 1984 268.44 53.69 5 2b8.44 C00$~+ 4 --8
SAN SEW TRUNK q 1973 85 38 5 69
* SEWERLATERAL 1 2330.32 46b.06 $ 2 0. 2 eoo8~+ o --8
~ WATERMAIN 1984 5
WATER LATERAL
WATER AREA ZD 1973 109. 78 7. 32 15
* 1 8 5~
STORM SEW TRK Q 1979 8. 8a 15.9.4 Zd
* STORM 5EW LAT ~ g g 4 5
CUR6 & GUTTER '
SIDEWALK
STREET LIGHT
24Q. #3 328 -2-82
WATER CONN. 4ZO.OO TT t~
BUILDING PER. 7349
SAC a
PARK
SEWER SERVICE.
P~~1
CITY OF EA64N
L79S Pilot Knob Reed PERMIT NO.: c;.'': -
MN 5b 1~Z DATE: 1
Eagon, ~yo, of Units:
Zoninfl: ,
;c'
Qwner:
Address: ~ . - ^.id e II
Site Address: GG97 °latel
~ttt C . i ~ .<<'S
Plumber.
, . : ~ ~ ~ , t~~l •.f -
l e~~ ta e~VM ~ tM Cih' e~ F~9°• C~+nedion CFwr9e: '
AccourK Deposit:
Ordinanas. perrnit Fee:
Surcharpe:
Misc. CFarOes.
By Totai:
Dote of Insp.: pote Poid:
I nsp.:
~
WATER SERVICE ERM~T/ ~
CIT1f OF EAGA!'
PERMIT NO.:
g~;y pilot Knob Roed p^TE:
~yo~, MN S51 Z2 •
No, of Units:
Zoning: . _Z -
. .BC~ ~l:~i.
^ddr°ss' 449' S18ter rCa<' s l iz_. T~
S~tg /~dfe55: ~ ~ L y 1
~~i. Y3U.. ~ _ • ~
Plumber: Connection Charge: !
Meter No.: q~~unt Deposit:
Size: Pennit Fee: ~ ,
Reader No.: Eagan Surcharge: .
1 ogroe to eompir witl~ t6~ City -
Misc. Choroes:
O?dinan~es. Total:
Dcte Poid:
By InsD.:
Date of Insp.:
CITY OF EAGAN - -
t 979! Pllet Knob Road Eagan, MN SS1I2 N~ . 7 J ~ 9
PHONE: 451-6100
BUILDINCa PERMIT Reuiv~ #
Te be wad ier SF DWG/GAR Est. Vulue $48~000 ~ote June 2 , ~q 82
Site Address 4497 Slate= Road Erect gg Occupancy- ~3
Lot 1 Block 1 Sec/Sub. ~'~8~a R~Bqe 2l1d Alter ? Zoning R-1
Parcel # 10 17401 O10 Ol Repatr ? Fire Zone ~
Enlarge ? Type of Const. V
s Name ~~s I7lC Move ? # Srories
Z Addrass 7760 M1tChe11 RDad. pemolish p Length 56
~ Eden Pt81z'ie pho~ 937-9520 Grode ? Depth 26 Sq. Ft._
~ Name ApO~ovals Fee~
Address Assessment Permit ZZ4.0~
~ Woter 8 Sew. SurcFwrga
Cit PFwne 137.00
Police Plon check
~w Nama Fire SAC $25.00
4~ Address Enp. Wafer Conn42~.00
<W Ci Phone Plonner WoterMeter 60.00
Council Road Unit 240.00
I hereby ackrwwledge that 1 hava read this apDlicotion and stare that gldg. Off.
the information is corred and agree to comply with oll opplicoble APC Totol S1Q~_AO_f1f1
Stata of Minnesota $tolutea ond City of Eagon Ordirwnces.
Sipnafure of PermiMee
A Building Pertnit is issued to: ~CY~Sn HOfieH~ IXIC. on the express cordition thnr
all work shall be done in occordante wlth oll opplicable St Mlnnesoto Ja s of Eapan Ordinoncea.
Buildinp OHlciol
?
T s,a4~es~ ~o~~ Z`?~ L~ S I C.~ n ri ~0~7 37
~n~~ 1t31~59 ~ , - ~sb
Raquest Ilate Pire No. Rouph-in InsvecGon
2q FequueA? ? ~ReaAy Now~IWill NntifY Inspec-
.-n~J U nl~ ~`Z ;~YOS No tor When Peady
~Licensod ElrcVical ConVactor I hereby reqonst inspac~ion of nbove
? Owner electricel work ina~alled at:
Svee~ Atldress. Box or Route No. ~ Ci~ -
, S G, l
i;ction o. Tpwnship Name or No. Range No. Calyty
% %
V
O ant IPRINTI P one N~~.
c ,v } ~l 1'3 -9S Z
Power upplier ~ Address
o C`d e~c
El~al ConVactor ICOmDan Name) Conlractor's Licr3nse No.
uWCs ~ ~ Q 6'~ -
M lin Address ICgntrer.to~ ar Owner Makmy i taila~ionl
~~3~ KNv4~ v~~ 2 N~ 6~-i ~S s
sy 3
Auth ed Signature IC trect wner Making ~nstallation) Phone Numbar~
MINNESOTp S TE BOARD OF ELECTflICITY THIS INSPECTION NEQUEST WILL NOT
GrieAS-Midwey Bldg. - 0.oom N•t91 BE ACCEPTED BV THE STATE BOARD
7821 Vniversi~y Ava., St. Paul, MN 557~4 ' UNLESS PROPEH INSPECTION FEE IS
o~.....e IF'191 J9~.911'I ENCLOSED.
~ ~ REQUEST FOR ELECTRICAL INSPECTION ' .r« -
' See inslructions for complating this form on hFlCk at yellaw copy.
G'~ 1315 9 _
"X"_B~~ w Work Cavered by This Request ~ 7 3~
Ne Add Nop. Typn nf Buiiding Appliunces W~red Equipmant Wiretl
Home Range Temporary Service
Duplex Water Heater Liyhting fixtures
Apt. Building Dryer Electric Heatin
Commerciai Bldg. Furnace - Silo Unloader
Industrial 81dc~. Air Conditioner Buik Milk Tank _
Fyfm Oihor per.i y [her ISneci!yl
~har peci(y Othcr Oth¢r
Compute lnspectioi~ Fee Below ~
# Fee S¢rviceEnt~ancaSiza # Pov Feedors~SUbfoeders M Fae Cimuits
0 to 700 qm - 0 to 30 Am s 0 ta 30 Am s
101 ta `Am 31 to 700 qmps / 31 to lU0 Am -
~b , z A. Above 100_Amps Above 700_Am 5
~ T- iysx6 5 Remote Control Circ. Partial%Ot
~~~j S s Special Ins~Cti~ S oo OTA FEE '37 ~Q~
Aemarks w~
.J~
Rough-in I, thn Electrical
~ ~ ~spector, hereby
C8ft1~Y lflfll thB FlbOVB
Fin,el ( Da~e inspeciion has bean
This rc~ueet voitl
18 months fiom ~
_ . . .
_ - . _ . ._p_ . '
- ~~'~~1~°~
CITY OF EAC~N Inciude 2 sets of lans
1 site plan w/elevaticns &
BUILDING PERMIT APPLICATION 1 set oi energy calculazicns_
To Be Used For ~
alua ' n Date ~
Site r~C.'dress: ~ ti OFFICE USE ONL
Lot ~ Block Sec./Sub, ect Occugar:cy i~~
Parcel : l ~ ( o ( C~ p ( ter Zoning
Rep3ir Fire Zone
O~mer: Enlarge _ Rype of Const.
Nbve tt Stories
Pddress: _ Derolish Front S!o ft.
City/Zip Code: ~ Grade Deoth ~(e ft.
Pn~~ 93~~95o~.C~ APPF~UAIS F'EFS
Contractor: ~ AssessTrents Pecm.it ~7y °-O
~ Water/Se.a~r _ Surcnarge ~y?~
Pddress: Police Plan Check ~ j j~
City/Zip Codec Fire SAC ° ,g~~
Phone r: ~9• Water Conn. $O
. Planner Water Meter (DQ
Arch./E.11g. : Council ad Unit ~~ap .
Bldg. Off. ~
Pddress : p,p~
Citrf/2ip Cade:
Phone ~pi, ~ ~~j~~ DC~
I/~ . ,
CALVIN H. HEDL D ~726 MORGAN AVE. so.
MINNEAPOLIS, MINN. 55423
Lanu Surwyer Grl~ Enqin~a PHONE N0. 866-2523
~urverror~~ G~rt~f
"~cate
JOB N0. 7L B2-f5
352
SURVEY FOR~i'~Zachman Homea
DESGRIBED A5~ ~t 1, Block l, CINNA1dON RIDGE 2ND ADDITION, City of Eagan,
Dakota County,'Minneeota, and reaerving easements of record.
q37.o
938•5 i
83-~ ~ 7 ~n
, ~S~ ~~ti 30
~
- - - -
- I _
~ e4' Nor~l~ern Nef. ~ '
' TtnT ( ~
Gas Ce. Eax `e a ~ I $
I ~ r~' ~ . W
- ~
. ~ 1 T '
~ .
• - ~ ~ _ .lo~~ ~ 4O$ ~ . ^ Tpp os Fou~daicon= ~94t..5
~ ~ ~ ~ .B65Gn+anf F~aor = 933.9
- ;c~~ ~ ~ Q
' NI~ /y~ " yo, ~ O c.arege Ftoor = 941.I
00
~ l;,,Ty~r ; o[
~ - Proposed Ek~s?ions ~
i ExiS~iny EkvetSOns
, ~ W ` brain~ye Direction
~ ~ 'l . . I ' ~ ~I6netGS ~.Oo- CO~Rtr Q
~ ~ I C~AR 4 S~
t_..) ~ I y ~
.s 24 a4o~e ~ g V1
~ i
.I ~ ~ .~p
~
~ ; \ Q~ ~
~P. 6~ 'o~ I a
FS p - -
30
939.0 ~P:lo
6 8 31.77 997.0
- x
H ~ ~
S L A'TE Q ROA D _ 936.~3
931.6 ~
I herebY serfify that on 5/~~~82 ; surveyed fhe property de~cribed obove o~d ihot
Ihe above plot Is a w~recf rtpns~ntofion of sold survey.
~9Q~f+~ ~ +7~
Golvln M. Nedlund~ Minn. Rp No. 9942
'/I ,
.
CALVIN H. HEDLU 7726 MORGAN AVE. 50.
MINNEAPOLIS, MINN. 55423
~ane Surreyer Wri~ Eny~n~a PHONE NO. 866-2523
s111~1e1/O!'`8 C~lflCa~e
;
J08 N0.'TL 8t-IS
i
I ! 352
SURVEY FOR~ Zachman Hanes
OESGRIBED AS~~t 1, ffiock 1, CINNAMON RIDGE 2ND ADDITION, City of Eagan,
Ddkota County, Minneaota, and reaerving eas~nents of record.
q'il.o
938-5
g3.0o ~ ~ ~y
~ 7
~ - ~ '
; ` ~ ; S~ _ /ro: 3p
, / 1 0
~ ef No.ther~ Na+- „ ~ -
i Gas Co. Ease~nent I _e~ M a0 .
/
i. i T~ t,~^ . b
- ,s,;.r - 1 - - - -
, I 408 Q Top ef Fou..dsrion = 941.~
~ ~ ' « ' .gBbGrwen~ Floer : ~j3.9
/'~''~~~F , I o ~~g~ F~ • ~t41.!
~ ! y~ ~ °C
- . . j_~f. ~ / - Propwsd Ekrsfions O
/ ~ i p,/ ~xis+iny Ekvafions
- - _b ~ ~ W,
, Dra~n~ye Direction
~ ' _ ~ . ~7AR Q flGno}GS ~.W' COrntr
L.~ L~ 1 r~ ' J
.s 24 a4o,8 ~ $ N
~ ~ I
• R~J~ .~0
940.1 ~ ti \ ~
~?,6' \ -o ~ w
FS p `----J
30
939.0 ~P:i ~6 s 31.77 937.0
-x o -
o ~ ,c'r .
N
SLATER ~ZDAD . _ 93b.43
937.6 \
I hereby c~rtify thot en 5/~~~BZ I su~v~yed 1he poperty described oDove o~d that
the oDove Olot Is a urr~ct r~pr~s~ntofio~ of satd surv~y.
~ ~ ~ Lr:-- ~ ,~Y~
Galvin H. Medlund, Minn.Req. No. 58.42 ~
'1'-~`~ a'
~ 15
Zoos RESIDENTIAL PLUMBING PeRnntr apPUCArioM
ClTY OF EAGAN
3830 PILOT KNOB ROAD, EAGANLMN 55122
651-&75~675
; ' 1
i ; ~i
Please complete for modificafions to existing residenUal dweltings. ~ ~
,
'i i t.~3a~~Q, ,
0,;
Date O 8 Z~~
~ f l, !
L ~
JOHNSON. DAVID -
S1Y2 Str29t Add('@SS ~ 4497 SLATTER ROAD ~ ~ UIil1
' EAGAN, MN 55122
(651) 890-3626 .
Prope~ty Owner lephone # ( )
ContracYor ~DY~IGYYI p(,L(,{rYLbt ~t G TeleQhone# ((a~z) ~'i7-~oa~~
Address 2QD5 £-t2r-fi~2(.d ~Fv. cv acy ~D ts st~ce fYi N z;P ~-l D8
The Appiicant is: _ Owner Y Contractor _Other
Septic System _ New _ Re4urbished Submit 2 sets of pians and MPC license Inciudes County fee
S 100.00
~ Per as-buiit $ 10.00
Alterations to existing dwelling $ 50.00
, Add piumbing fixtures. This fee inciudes installation of a water softener and/or water
heater at the same time. If you are installing onrv a water sofYener and/or ~vater
heater, do not complete this section; move to the next section and check the
applianca(s) you are instalfing.
_Septic System Abandonment ~
^ Water Tumaround (add $130.00 if a 5/8" meter is required) ~
Other.
Water Sottener / ~Watar Heater $ 15.00
_ new ? replacement
Lawn irrigation _F2PZ _PVB _new _repair _rehuild $ 30.00
State Suroharge $ .50
Total $ ~~.`5d
I hereby apply for a Residentiai Plumhing Permit and acknowledge that the information Is camplete and accurate; that the
work wiil be in conformance with the ordinances and codes of the City' of Eagan and the piumbing codes; that I
undersiand this is not a permit, but only an appiication for a permit, work is n t to start without a permit and work wiit be in
accordance wfth the approved plan in the event a plan is requireed'To be vi ed acRi approved.
~e~r~c~ No r~low~, ~ y ~ .
.~;.l, : ~r~-~---._-
AppiicanYs Prin d^lame AppliCanYs Signature
v
CiLyof Eaau
3830 Pilot Knob Road
Eagan MN 55122
Phone: (851) 875-5875
Fax: (651) 675-5694
Use BLUE or BLACK Ink
Permit #:
Permit Fee: (910c1
i
L
Date Received:
Staff
2011 RESIDENTIAL PLUMBING PERMIT APPLICATION
Date:4"' 1a Site Address: R
Tenant: )1`AtAO1/4— 3\Atr5oA Suite t:
65
RESIDENT IOWNER Name:..`t;/IAA,p• Gt Spr Per: lei Flo
Address / City /Zip: •- l 1 3 .r A� X31 3 Y l a
" _
CONtRACTOR Nar ie: MILBERT COMPANY INC.dba CULLIGAN 1OATER •
Address: 1801 50Th ST EASTcity. .. INVER GROVES IG'TS•
State:' MN Zip: 55.07.7' ' 65.1 ;:451;-2241 •
Contact BILL.MILBEi `j
Phone:
Email:
TYPE OF WORK _ New _j(liteptacement Repair _ Rebuild Modify Space Work Ih.R,O.W.
Deacription of llwoorli:,
PERMIT TYPE
RESIDENTIAL
.Water Heater
'Water Softener
Lawn Irrlgadpn (_ RPZ /_ PVBj Add Plumbing Fixtures (_.•_ Main /.__ Lower Level)
Septic System•' ' Water Turnaround
• New
•_Abandonment
RESIDENTIAL FEES:
$35.00 Minimum Water Heater, Water Softener, or Water Heater Ell Softener (Includes $5.00 State Surcharge) •
335.00 Lawn Irrigation pnclJdes *5.00 State Surcharge)
$55.00 Add Plumbing Fixtufes, Septic System Abandonment, Water Turnaround' (Includes *5.00 State Surcharge)
'Water Tumaround (add $186.00 Ka 5/8" meter is required) •
;105.00 Septic System N (510.00 per as built) (Includes County fee end $5.00 State Surcharge)
$95.00 Fire Repair (replace bumed out appliances, ductwork, etc.) (Includes $5.00 State Surcharge)
l "
TOTAL FEES $
CALL BEFORE YOU DIG. Call Gopher State One Call at (551) 454-0002 for protection against underground utility damage.
CaII 48 hours before you intend to dig to recelve locates of underground utilities.. yvww.000heratateonecan.or2
I hereby acknowledge that this infiprmetion Is complete and accurate: that the work w11 be In conform ncs with the ordinaries and coda of the City of
Eagan; that I understand this N nota permit, but °nylon application' fora permit, and work is . to eta • without a permit: that the work will be in
/ /if AV
accordance wl the c( which approved pian In the case work whrequires a,review and approval • <'
x u/,1j rt- t
'Applicant's � ams
P Printed Name
"s'
Igna
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA156910
Date Issued:07/24/2019
Permit Category:ePermit
Site Address: 4497 Slater Rd
Lot:1 Block: 1 Addition: Cinnamon Ridge 2nd
PID:10-17401-01-010
Use:
Description:
Sub Type:Siding
Work Type:Replace
Description:
Census Code:434 - Residential Additions, Alterations
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: 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 -
David O Johnson
4497 Slater Rd
Eagan MN 55122
(612) 240-0657
Minnesota Rusco
5010 Hwy 169 N
Brooklyn Park MN 55428
(952) 935-9669
Applicant/Permitee: Signature Issued By: Signature