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961 Stanwix Rd ClTY QF EqGA'~ Permit No: r, -~8 Date: 3830 PGot Knob Road Meter No: 'yo ~~a a ~ g1Ze; ' mc P,O, Box 21198 Reader No: ~3 S Yd Eagan, MN 55i21 Date: " 5- ~ Owner. ''~~Lro Cu~~tor,~ Homes SiteAddress: Stanwix RoaC T?P P? Lexingtan Sq t1~ Plumber. DreGh r i?v /~7~--~ier~ Conn. Chg: 55i'. ~;Op~ Zoning: P.I Acct Dep:- ZS , Ot)pd No. oi Units: Permit Fee: 1'~~ ~ ~~Pd Surcharge: - • S~ad I agree to comply with #he Cify of Eagan Tr. Plant L~4 • ~~~n~ Ordlnances. Meter. ~ 7 ~~~z~4 Misc.: gy ~7 , ~ . ,,J WATER SERVICE PERMIT ~ ' ~ - - - _ p~~r~/s ~ 5_~4-•~, Date: , ~ , , CITY ~~..~?GAN Permit No: Date: 3830 F~~4t'~~ Road B/P No: P.O. Boql 71199 i Ea~a,~~ WIN 55121 ~ etsa C Etorri L.ce~s ~ ?tr ~ M u Owner. F~ou~ 1,.,~ .exi'= . ' i ~i - SiteAddress: `i~ehe1 ExcJ~l-~e~' T~ I I 5' Plumber: ' , 5(t . :?!''`_'d Zoning' , MWCC: s,~~ No. of Units: ; C~ty Chg: , _ I agree to comP~Y wi~ ~e C~ oE Eagan .i Acct Dep: , ~ OrdinancBS• Permit Fee: . Surcharge: gy Misc.: SEWER SERVie~ PERMIT _ , ~ - _ - - . : 5-24-88 ~ . , q 6~7 Dat~ CITY OF EAGA'V Permit No: Siza 3830 Pilot f~nob Road Meter No: Date: p p, gpx 21199 Reader No: Eagan; MN 55121 j ';etro '=usto:: ?Fomes t ~ Owner. cy~l 5tanwix Faa~ L2~ ~a ~xinz,ton Sq Site Address Plumber. Dresher ; X~ ~l ~~er' ~1 55~? . ~~~P~ Zoning: Conn. Chg: ~ a~ No. of Units: Acct Dep: , ~Opd Permit Fee: ~ a8~~ ta comP~lt M?~h ~e C~~ ~ Eagan ' Surcharge: 2 . ~ p~ Ordinances. Tr. Plant Meter. gy Misc.~ WATER SERVICE PERMIT -r- ~ - E ~ CASH RECEIPT ` ~ ~ . ~'r~~ CIT~(•~F EAGAN ~ , 3830 PILOT KNQB ROAO • EAGAN, MINNESOTA 55122 - DATE ~ ~ ~ 19 i nECErvEn ~ ~ d 1 ~,u' z. ~.~r~f~ AMOUNT $ ~ ` ~ ~ ~ ~ v' & DOLLARS ,oo ? CASH ~CHECK / ~1 ~ , ~ ~~7 L? `I ~ ;M1 I ~ ' ~ ~ . / ~ ~ ~ ~ ~ ! ~ 4 " j ~ FUN BJECT L AMOUNT : Thank You sv.~~~;1 L~G~l~_- White-Payera Copy ~ i~ c,~, ; ~ i ~ Yeuow-Postln9 ~PY Pink-File CoPY ~ BLDG. PERMIT NO. ~J~ / (G'~ U ~ 01-3210 Id . er t ~ ~ ~ 01-3422 Plan Check ~ 01-3445 Surch./Adm. ~ 01-3446 SAC/Adm. d~ Oi1-2155 Surcharge ~ ~ ~ 7'S-3860 Road Unit ~a ~ ~ 20-2275 SAC ~"7'" ~ ~ 20-3865 Water Conn. ~ ~ 2~-3868 Water Trmt. ~ 20-3716 Water Meter 20-2252 Acct. Dep. 20-3713 Water Permit 20-3743 Sewer Permit 79-3866 Sewer Conn. ~ ~ ~ ~ 28-3855 Park Ded. TOTAL ~ D D CITY OF EAGAN : ~z ~ ~ ~ 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE:454-8100 ` / f~' BUILDING PERMIT Aeceipt# To be used for 5F UNt:/GAR Est. Value ~82,U4U Date tiAY 24 ,19~_ SiteAddress g~l ~'fANI~IX x<~ OFFICEUSEONLY 38 3 ~ LEXI OICTU~i SQ 7TN s~te Sewage occuPancy ~-3 M-1 Lot Block 5ec/Sub. MWCC System Y Zoning p~ ParCel No. On Site Well (Actual) Const V"~ ~ Name METItO CL~S'f01~S ttJ.'~FS Citywater x (Allowable) v~~ = Address U Bt?X 1049 PRV Required # of Stories o City B!`it~'lSVI LLE phone 454-9~83 eoaster Pump Length ~7 ~ Depth ~ ~ o Name S.F. Total ~ ~ ,4'ddress Footprint S.F. ~ Ci~y Phone APPROVALS FEES ~ ¢ ~ Engr./Assess. Permit • ~ ~W Name ~ 41.40 _ ~ Address Planner Surcharge City PhOne Council PIa~Revlew ~sl•~ sW Bldg. Off. SAC, City ~ • ~ I hereby acknowledge that 1 have read this application and state that the Variance _ SAC, MWCC information is corroct and agree to cpmply with aU. appticable State of Water Conn. S5O.00 Mifinesota Statuses and City c+t Fagari Ordina~aea.~ - ~ Water Meter 67.OO S~nature of Permitte~.,- _ - Road Unit ~25.~f1 A By~ilding Permit is issued to: ~f'~~ ~V~T~`S ~Q~~ _ Treatment P1 ~a4.(~ on the express condition that al I work shall be done in accordance with all Parks ~ applica6le State of Minnesota Statutes and City of Eagan Ordina~ces. TOTAL _ Building Official _ ~ - CITY OF EAGAN i~ r~ ~ 3830 Pllot Knob Road, P.O. Box 21-189, Eagan, MN 55121 PH O N E: 454-8100 BUILDING PERMIT Receipt # To be used for ~ Est. Value ~ Date ,19 Site Address OFFICE USE ONLY Lot Block Sec/Sub.:. .^~.1 ~ ~Iv 5l"; i"T' ; On Site Sewaqe Oxupancy ~ MWCC Syatem Zoning ' . ( Parcel No. . On 51te Well (ACtual) Conat • ; ~kyp~~g CltyWater ~ (Allowable) a NaRFe ' 3 Addre~9s ~ PRV Required ~ of Stories ~ City ` PhOne ~ ~ ~ ~ Ba~ter Pump Length ~ ~ Depth ' , p Name S.F. Total ~ ` Address Footprint S.F. ~ City Phone APPROVALS FEES ~ ~ Engr./Assess. Permit L~~ • ' Name ~ Z Planner Surcharge ' ~ • ~ ~ Address 4 W City Phone Council Plan Review Bldg. Off. SAC, City I her by acknowledge that I have read this application and state that the Variance SAC, MWCC informalio~ is correct and agree to comply with ali applicable State of WaterConn. Minnesota Statutes and City of Eagan Ordinances. Water Meter Signature of Permktee Road Unit A Bu" "ng Permit is issued to: Treatment Pt on tt .:xpress condition that all work shall be done in accordance with all Parks appl ~:able State of Minnesota Statutes and City of Eagan Ordinances. Buil< ~g Official TOTAL Permit No. Permit Holdsr Date Tslephone ~t Plumbing ~ - . G~ "ttw.- ~ H.~~.~. 993 'fa ~ Electric ' ~ ' / - ~ , ~ 4'~~ ,y ,~o~ 8 Softener Inspactlon Date Insp. Comments Footings I ~ Footings II Foundation Framin9 _-ze~ ~~w~ - iu. c~s~ 6 ~'~S''~1' Roofing Rough Plbg. .~6~ Rough Htg. p Isul. ~ 2~~ ` ~ Fireplace Final Htg. V Final Plbg. p,/~.t6 Bldg. Final Cert.OCC. 0 - O, NC~ /L~ Temp. LP ~ j~ ! ~so~ ~t- S / Deck Ftg. ~p~~~, 0 Deck Final Well Pr. Disp. ~ • _ _ _ _ ~ ,.-.~a ~ y r•~ f~~rftfir~f.e u# (~rru~ttnr~ ~Gitp o~ ~a~an ~p~ptci n# ~iuiiding .~naper~inn This Certificate issued pursuant to the requiremenu of Section 306 of the Uniform Building Code cemfying that at the time of issuance ihis structure was in compliance wttlt the varrous ordinances of the City regulating buildrng constrtection or use. For the foUowrng.• t3x Cluo6adon ii i; 1. gldg. Pami~ No. ` 4..?~?..~ ~ : 'v:~; Oocupaoty Type Zoning District Type Co~ o~r~re~ua~ :.:IR~? C~.SI'Ct'i t~t~r= i'.0. B(SY f°. "~~r; , r ~ : 5?'n~ ~.,r~ ~](yI3 :~28, B3 f :.t~ ~'~'icS~ :1~?Z:: : ~ , e~ oa~ POST IN A CONSPICUOUS PLACE !Pr'4~~+Lp:~.~-~+-vs:.., _ y~: - -'a;. ^ , . . . . /f PERMIT # ~ ~3'~` ' " t , MECHANICAL PERMIT RECEIPT # ~ ~ ~ ~ " CITY OF EAGAN ~ 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: ln CONTRACT PRICE PHONE: 454•8100 Site Address ` ' ` BLDG. TYP WORK D RIPTION Lot P~ Block ~ Sec/Sub , • ~ Res. New ~ Neri1B ~ - 'r ! , ' , Mult Add-on Address ~ ~ ' Comm. Repair c Ciry Phone ~ ' ~h~ FEES Name ~ ~ ~ ~ RES. HVAC 0-100 M BTU -$24. c AddresS ' ` ADDITIONAL 50 M BTU - 6. O City .L~ Phone 7' (RES. HVAC INCLUDES A/C ON NEW CONSTRUCTION) GAS OUTLETS (MINIMUM - 1 PER PERMI~ - 1.5 EA. TYPE OF WORK ~ COMM/IND FEE - 196 OF CONTRACT FEE Forced Air ~ M BTU o!' ' APT. BLDGS. - COMM. RATE APPLIES TOWNHOUSE 8~ CONDOS - RES. RATE APPLJES &3iter = ~ ` IVf BTU MINIMUM RESIOENTIAL FEE - ALL ADD-ON 8 Unit Heater - M BTU REMODELS -~2.00 Ai~ Cond. M BTU g MINIMUM COMMERCIAL FEE ~ 20.00 STATE SURCHARGE PER PERMIT ' / .50 Vent ~FM (ADD $.50 S/C IF PERMIT PRICE GOES Gas Piping OuUets # ~ ~ ~ ' BEYOND $1,000) Other ~ ~ ` i.. 1 , FEE: ' ' % , ~ s~c: 5~i SIGNATURE OF PERMI EE ' r. - TOTAL• ~ FOR: CITY OF EAGAN ~ . • PERMIT # y'~ ~ ~ ' ~ PWMBING PERMIT RECEIPT # ~~I i~ CITY OF EAGAN _ 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: G~ CONTRACT PRICE: PHONE: 454-8100 Site Addre,S,s BLDG. TYPE WORK DESCRIPTION Lot Block 1r~Sub Res. New = ~ ~ f' Mult. Add-on m Name ~ ~ ' ~ ~4 ` r Comm. Repair ~o Address ~ j ' ' Other c City ; F!~~~~,r~.7' Phone ti' RES. PLBG. ONLY - C~MPLETE THE FOLLOWING: 1~0, FIXTURES TOTAL Name ~ ~ - -~~Water Closet - $3.00 S . m Bath Tubs - $3.00 3 Address " ~Lavatory - $3.00 ~ p Ciry Phon~t`r- ;i~ ~_Shower - $3.~0 ' Kitchen Sink - $3.00 ~ FEES Urinal/Bidet - ~3.00 COMM/IND FEE - 146 OF CONTRACT FEE ' Laundry Tray -$3.00 APT. BLDGS - COMM RATE APPLIES i Floor Drains -$1.50 TOWNHOUSE 8 CONDO - RES. RATE APPLIES ~-Water Heater -$t.50 MINIMUM - RESIDENTIAL FEE -$12.00 Whirlpool -~3 00 MINIMUM - COMM/IND FEE - $20.00 ~_Gas Piping Outlets - $1.50 ' - ? STATE SURCHARGE PER PERMIT - .50 (MINIMUM - 1 PER PEFiMI'~ (ADD $.50 S/C IF PERMIT PRICE GOES Softener -$5.00 BEYOND $1,000.00) Well - $10.00 ~ , Private Disp. - $10.00 ~ r`..;;,,..~ ~-Rough Openings - $1.50 ~ - ` ~ SIGNATURE OF PEFiMITTEE ~ FEE: 'y ~ " ~ STATE S/C: FOR CITY OF EAGAN GRAND TOTAL: ~f~' ~ PaRTA1VT MES':fAGE ~ FO ~ATE ~ TIME ~ •O~ . . ' ~ OF PHONE AREA CODE NUMBER EXTENBION TELEPHONE~ PLEASE CAIL CAME TO SEE YOU ; WIU. CALL AGAIN WANTS TQ SEE YOU RUSH AETURNED YOUR CAil. SPECIAL ATTEN'ftDN MES GE ~ ~ SIGNED LITHO IN U.SA TOPS ~ FORM 30025 . ~ O ~ m ~ . ~ , i. . . . . ':i~~'~?°~'~~ . ~ . . :?'~r ~Rc. ° . ""r~~"' ~ „ r?~4s+!T.w . . . _ . . . w;:_ -"Y?:... ~ CtTY OF EAGAN ; ~ ~ ~Q6O 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 454-8100 ~r"~ BUILDING PERMIT Receipt # ~ ~i`~ To be used for A~ Est. va?ue ~i'~ Date J~ Z6 , 1s ~ Site Rd~~ss 961 STANHIX RD ~ Lot Block Sec/Sub. SQ OFFlCE USE ONLY Parcel Mo. occupancy - Fees , JA~E$ C PIlTS1.1COfi zoning ZS~~ W Name (Actual) Const - Bldg. Permit ~ Address 1 STANWIX RD (Allowable) - Surcharge ° ~ ot stories Clry PhOn@ ~Z plan Review Lergth ~ F Name s~ Depth SAC, City Addf@5S S.F. Total - SAC, MCWCC _ ~ City Phone S.F. Footprints _ On Site Sewage ~ Water Conn ~w Nd1118 ~ On Site Well - Water Meter W AddfeSS MWCC System - q~t. D osit <W Ci1y Phone atywacer - ~ PRV Required - ~ Pe~^~ I hereby acknowlege thal I have read this application and state that the Booster Pump - ~N Surcharge information is correct and agree to comply with all applicabie State of Minnesota Statutes and City of Eagan Ordir~ances. Treatment Pi $ignatureofPermitee if"f`t-`-.~ ,/C-! .G~'1'~'vf•T-~~ APPROVALS RoadUnit A Buikling Permit is iss~ied to: JAHEa G PITTELImH Planner - P~ p~ on Ihe express oondition thal all work shall be done in accordance with all C.: ncil applicable State of Minnesota Statutes and City of Eagan Ordinances. Bldg. Off. _ Copies ,,BuildingOtliCial ~ ~ Variance - TOTAL ~ Permk No. Permit Hoider Oate Tefephone # WATER SEWEH PLUMBING * H.V.A.C. ELECTRIC Inspee6on Date I~sp. Comments Footings I Foundation . FrSming Roofing Rough Plbg. Ftou9h FIt9•. I~I. Freplace Final Htg. Final Plbg. Const. Meter Pibg. Inspecta - No6(y Plumber Engr.lPlan Bkig. Final Deck Ftg. DecJ( Final t i C weu L' ~ r,~ _ Pr. oisp. //Yis ~ ~ ~~~v r,~ ` OG C.y Kf~'~ `ti'I S S/~' G ' LG , CITY OF EAGAN N~ 15 0 5 6 3830 Pilot Knob Road, P.O. Box 21 •199, Eagan, MN 55121 PHON E: 454-8100 g~o i~ BUILDING PERMIT Receipt # To be used for SF DWG/GAR Est. Value $82 , 000 Date ~Y 24 ,19 88 Site Address 961 STANWIX RD OFFICE USE ONL.Y 28 3 LEXINGTON SQ 7TH On 5ite 5ewage Occupancy R-3 M-1 Lot Block Sec/Sub. MWCC System X Zoning PD R-1 Parcel No. On Site Well (Actual) Conat V-N ~ Name METRO CUSTOM HOMES C~tywater x (Allowable) ~-N i P 0 BOX 1049 PRV Required ~ of Stories Address Booster Pump Length 52 ~ o City BURNSVILLE Phone 454-9383 Depth 46' ¢ Name S.F. Total .o ~ Q Address Footprint S.F. ~ City Phone pPPROVALS FEES ~ ¢ Engr./Assess. Permit 502. 00 V W Name Address Planner Surcharge 41.00 q W City Phone Council Plan Review 251 .00 Bldg. Off. SAC, City 100. 00 I hereby acknowledge that I have read this application and state that the Variance SAC, MWCC 550. 00 information is correct and agree y with 'cable State of Water Conn. 5 50 _ 00 Minnesota Statutes and Ci Water Meter ~]L.QQ Signature of Permitte - Road Unit S nn A euilding Permit is issued to: ME 0_ CliSTOM HOMES Treatment P1 204.00 on the express condition that all work shall be done in accordance with all applicable State ot Minnesota Statutes and City of Eagan Ordinances. Parks !1 _ _',1 ~ ~ TOTAL 2, 590.00 Building ~fficial~l14dd1~~ ~_c~ r I CITY OF EAGAN ~1J0 ~$O6O ~ 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 . PHONE:454-8100 ~~~-J~-~1 BUILDING PERMIT Feceipt u ~ To be used for DECK Est. Value ~ 1~ 000 py~e JUNE 2fi , ~ g 90 Site Address 961 STANWIX RD Lot 28 Block 3 Sec/Sub. LEXINGTON SQ 7TH OFFICE USE ONLY P2fC21 NO. Occupancy - FEES Zoning - w Name JAMES G PITTELKOW (AC[ual)Const - BIdq.Permi[ 25.00 3 Address 961 STANWIX RD (Allowable) - Surcharge - Sn ° Cit EAGAN Phone 725-2000 :v o~ siories - Y Lengih ~i]X12 Plan Reviaw , o Name S~E Dap[h 1~~+ SAC, City o~ AddfOSS S.f.Total _ ~Q SAC,MCWCC ~ City Phone S.F. Foo~prinls - On Site Sewage _ Wa~er Conn ww Name OnSiteWell - WaterMeler z MWCC S slem Address ry Y - AwL Deposit iw City Phone Ci Wa~er - PRV Required - SNJ Permit I hereby acknowlege that I have read this applicalion and stale that the Booster Pump - SMI Surcharge information is correct antl agree to comply with all applicable Slate of Minnesota Statutes and City of Eagan Ordinances. Treatment PI ~ r_ APPROVALS Signature al Permitee Roatl UNt A Building Parmit is is ed lo: JAMES G PITTELKOW Planner - park Ded. on the express condition that all work shall 6e done in accordance with all Cwncil - applicable State of Minnesota Statutes and City of Eagan Ortlinances. ~dy_ p~~, _ Copies nw~<A 'Raj I~rn~ Variance - TOTAL Z$.50 BuildingOificial +a~~ This requesl void~~/~/b/'~%% 18 ~nths (rom ~ ~ O j E 2:7 2 7 3,~, ~ Requ t Uate~ Fire No. Roup n Insuer,tion y Req d? ~Readv Now ~,b411-Nolifv. Insper- ~ ~%¢S ?NO ~or Whan Ready nseA ElecVical Contractor 1 hereby reques~ ins0action oi abova Owner electrical work ine~alled at: Sv t4d ress, eox or Ro e o. ^ Ci~V j h~f ecuon o. Township Nome or No. Hange No. Caunly Oc uVAm IPflINT) Pha e No. ~ 5 J ^g o° Po er Su r Atldress Electrical Convactor (Comoeny Namel C mra tor's License No. Ma~lin G~ F.T.F.('.TRIC 14540 vPENNOCICe L~~~~ ~ Autho~iie u ( r ner ~ I I Phnne Number f MlNNE50TA STATE BDA0.D OF ELECTflICITV THIS INSPECTION flEQUEST WItL NOT Griggs•Midwev B~de• - poom N•191 BE ACCEPTED 6Y THE STATE BOARD 1821 Univarsitv Ave.. St. Peul. MN 661QC UNLESS PNOPEN INSPECTION FEE IS nw....e ~c~o~ ae~.nenn ENCLOSED. [p`PJ7/~8" REQUEST FOR ELECTRICAL INSPECTION ee-ooyoaoi-os , See instructions lor comple~ieg t~is form on beck of vellow copy. (~yt~~ / E ~ 7 L?~ 3 "R~' Be/ow Work Cove~ed by 7his Request paC~ TVDe ot 6uiltling AOO~~~~~ea Wired Equipment Wired Home Range ~ ie rary Service Duplex Water Heater i~htiny Fiztures Apt. Buildinc~ D r Electric Heatin Cominercial Bldg. umace Silo Unlonder Industrial Bldg. Air Conditioner Bulk Milk Tank Farm O~he~ oeci y Other (5nedfyl i e. Suerify Other O~he. ompu[e lnspectian Fee Below p Fee Sarvice EntrancaSize H Fee Feaders~5ubleede~s k Fee Circui~s 0 to 200 Am s 0 to 30 Am s 0 to 30 Am s Above 200 Amps 31 to 100 Amps 31 ta 100 A s Swimming Pool Above 100_Amps Above 700_Amps Transformers Irngation Boorns Partia6'Other Fee Signs Special Inspection S h emarks J T AL FEf_ G i~ RouBh-in r D, e~j ~ a1 ~e~ Inspectoq M1ereby rtilv lhat t~e abava Final ~ nspection hes been mede. ~~iarequestvoltllBmontOSimm / ,/3/~8~ REQUEST FOR ELECTRICAL INSPECTION ea-aoooi-os ~ Sea inshuctions (or campleting this (orm on bnck ot vallow coOV~ ~~oJ~~ E 1~ l!1 ~ '"X" Below Woik Covered by lhis Request HAd flep.. Type oi 0uileing Appliancea Wired Equipmem Wire!1 ' Home ~ange em~wrary Service Duplex Water Heater Li~h[iny Fixiwes Apt. BuilAinq Dryer Electri~ Heatin Commerdal Bldg Fumace Silo Unloader Industrial 81dg. Air Conditioner Bulk Milk Tnnk Farm O~n,,, Spen v 15nec;rvl t _r Syeci(y ther Oth~ir ampute lnspection Fee Belaw p Fee Se~viceEntrenceSize M Fee Fextlers~Subtexders N Fxe Circuits U to 200 qm S 0 to 30 qm ~s 0 tn 30 Am ~s A6ove 200 Amps 31 to 100 qmps 31 to 100 Am s Swimming Pool Above 100_Am s A.bove 700_Am~s Transrormers ~rrigation Boorc~s Par ~ Fee Signs Speciallnspection flemarks OT EE •Q floueh-in D` ~e the Electr' i~ , na,eov c rtify thet the ebove Final ~ msvaction hes been ~ea. This repuesl voiC tB monttn Irom . This rnpuesf voitl~'/~~j~(r 18 npnths from E 16019 ~ Re~; Da ~ ~y Fire No h-in InsGer ion x x e ortetl? / ~ReaAY Now ~ Will Nntify InsDee- (J 1'es ?No <M1'hen Ready ~ce~seA ElecVical Convactor 1 hereby request inspection of ebave ? Owner elacVical work installetl et s~~d~=. . , o. ~~~~-~r~~J ecu n o. ns - N me or R nge No. County Occ IPRI Phune No. s. n~r,~ s --9'3 3 Powe~ Su ~ r AtlAress . T. ~I~ Ele ~ a ~ `wy N e) T-{+ Convar.t r's licvnse No. g~"1~ ~l^,I~ ~,~~T~:v Mailin ~ C n (ac(tor Or.Ow s tionl ~L • ~f1•L~_+i t Avt r~zed S~e~ature IConvactor/Owner Making Installation) Phone Number MINNESOTA STATE BOARO OF ELECTRICITY TH~S INSPECTION REQUEST WILI NOT Griggs-Midwny Bltly. - Room N•191 BE ACCEPTED BY THE STATE BOANO UNLESS PROVEN INSPECTION FEE IS 1821 Universilv Ave.. SL Paul, MN 55104 cn..~o ~6i~~ aa9-nAOO ENCLOSED. i - 1988 BDILDIN; PERMIT APPLZCATION - CITY OF EAGAN . SINGLE FAMILY DWELLINGS ' ~O ~ ~ • INCLUDE 2 SETS OF PLANS~ 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS NOTE: ADDRESSE3 FOR CDRNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WIiICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BIIILDING PERMIT IS ISSUED. MULTIPLE DWELLINGS RENTAL [TNITS FOR SALE UNITS ~ OF UNIT3 INCLUDE 2 SETS OF PLANS, CERTIFIC9TE OF SURVEY - CHECR WITH BLDG. DEPT., 1 SET OF ENERGY CALCULATIONS COI•AIERCIAL INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS~ 1 SET OF SPECIFICATIONS AND 1 SET OF ENERGY CALCULATIONS To Be Used For: s%n~/~ Valuation: Uc~ Date: ~~7 Site Address Sfr.tnW~ac' ~l~ ~OFFICE QSE ONLY ~~ODo Lot C~.7~ Bloek ~ On si~e sewage_ Occupancy R-3 M-i 7~~/ ~ MWCC system ~ Zoning Pp+ R_I Parcel/Sub ~~C~h~~~ S~, //h~~d" On site well Actual Const V-N /~~y- ~Q--~[~~~~ 1... City water ~ Allowable V- N Owner /y(X~1/!iT'(~Gt~i(,/9•y~••(KJ~~+~o~.l-nCo PRV required of stories p Booster Pump Length S 2 Address /~~C~~ q Depth ~ n S.F. Total City/Zip Code ~Urnsvj~~~ /X/~V5~31' 1 Footprint S.F. Phone / J~~ 7` q 3~~ APPROVALS FEES Contractor cS~i Engr/Assess Permit ,~jbZ,Oo Planner Sureharge YI, o0 Address Council Plan Review 2 Sl. O ~ Bldg. Off. ~5~19 SAC, City 00~00 City/Zip Code Variance SAC, MWCC ,00 Water Conn SS~+DO Phone Water Meter (e'~y0o Road Unit , 00 Areh./Engr. Treatment P1 y~oa Parks Address Copies ~ TOTAL 1 S;~i' City/Zip Code Phone f~ V,~1LU AT 1 O N m4~ i ~AQAGrE ~~IX2..Z~SZ$ X 14~ ~392 ~ ~ a~ . ~3s mr. y I x I~} = 574 lo x Zy = LUo ~ X L - 42 gs~~~3 = iirzs ylx2~l = ~lgy I yLx ~ 3 - 2'° ~Zx lL : 192 Z ~ ? : ?W ~2~ ~ = ~ Z ~C ~t~ = ~ g~92` ~ ~ _ MErxo C~srom y~s ~i O B E C~HSULTIHO EH6IHEE!!S ENGiNE~R1NG PLANNEAS nnd LAHD ~UAVEYO!!S 8a~~c l04 ~ COMPAN't, INC. ~ 1000 EAST 1461~ STREET~ 811RN5Y1LLE , YINHESOia 5333? PH ~~2°~OQCI Cer~i~i ccz~`e ~-'t-zr'e r~ ~?Q~I ~,.JCT'~c~2ort: LOT 28, BLOCK 3, LEX/N6TaN 54t.~4RE 7TN ADDIT/ON, `y DAKOTA CD~NT,Y MiNNESorA ~ L~~~~~ DRA/NA6E AND ~f ~ ~ o ~ fJTlL17Y F~15~MEn/T Z~ p~OrES EXISTlNG EC.EI/<JT~'Oh / \ (SSy.2) DEN07E$ P/ZOPoSEO ELEi//dTlati, ~ ~ ~ o ~h / ~ J ~ /Np/G/'iTES D/RECT/0/V DF `~i ~'1~ ~ SURGACE DR.91NA6E ~ / F_ \ s~~- 889. so _ F/NiSHED GAR.96E FGOa~ ~~~'~,o'~ :i \ R2 ~ \ ELEi/fl?/ON <y ~ ~ ~ 6 ~ o, < ~ \ 6' 'r,~,~ ~ 0. , ~ ~ . \ \ ~0y. ,y, ~ \ ~ \ ~ D. VS~ o"~ ~~iN ,F,PdGIL~IEEIiI1V DF..~'~'. \ g~ 5~~\`°~~`L" ay ~ ~0 l.~ a ~ ~ ~ S' \ C~~ Q~'o~~ s~''~~p,~~yv 80~~ ~:r ~ ~ ~ ~i ~0/~0~ ~l./~1' l ~ ~ >a 6s \ ~'R ^`ry' i ~ ~ l$~ ~ , ~ A ~ ~ \ s, / s y H ~o ~ °o., ~ ~SO ^i ry1 ~ / pb" ~ ~ \ ~ ~ ~ 1°~ ,p~" L'~ / / b ' / `'?o ,Vp(~{90 oIQ/ '/~~bY o a Q y~ ti~~ ~ Q y ~y ~op 30' FROn/T 8?/[.D/N6 ~ ~o ~Z 5E7"Bf{CK UNE ~l ~yl~ ~ aa ~ `gel°' '~i ~ ~ . ~,S ScACE . = 30' - c~ r~yr I her:h cartif that thia ia n t:ue and c~rrect repr'zsentitia~ ~ f~~~~ Y Y l+nd as ehoxn'and deacribed heraon.• ~e PreParsd by me oa thi~ ~/,7__'~'~_ ~a'~ /1'JAY 19 SS . i'~ Hinn. ~fe~< ~c~~ i~ A--~ ~ v - i ` i i ~ ' O ~ O ~~rrr,,, 1990 BUILDING PERMIT APPLICATION ~ CITY OF EAGAN SINGLE FAMILY DWELLINGS MULTIPLE DWELLINGS COMMERCIAL -b 2 SETS OF PLANS 2 SETS OF PIANS 2 SETS OF ARCHITECTURAL 3 REGISTERED SITE SURVEYS REGISTERED SITE SURVEYS - & STRUCTURAL PLANS 1 SET OF ENERGY CALCULATIONS (CHECK WITH BLDG. DEPT.) 1 SET OF SPECIFICATIONS 1 SET OF ENERGY CALCULATIONS 1 SET OF ENERGY CALCS # OF RENTAL UNITS # OF FOR SALE UNITS PENALTY APPLIES WHEN: TYPING OF PERMIT IS REQUESTED, BUT NOT PICKED UP BY LAST WORKING DAY OF MONTH IN WHICH REQUEST IS MADE. LOT CHANGE IS REQUESTED ONCE PERMIT IS ISSUED. NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED. PROCESSING TIME FOR SEWER & WATER PERMITS IS TWO DAYS ONCE A PERMIT HAS BEEN COMPLETED, PERMIT M[JST SHOW A LICENSED PLUMBER. ~pH 2 2 Reco To Be Used For: ~,C~G~ Valuation: /~(7D Date: G'j~a -~[3 ~ Site Address ~~p~ ST~4A~Gt1/X /Q~ OFFICE USE ONLY Lot ~ Block y~ FEES S~ ~ ~ Occupancy Zoning Parcel/Sub Actual Const Bldg. Permit ~=L~ Allowable Surcharge p Owner .._1 /i/ylE S (i, ~'ft'~L/~O~ # of stories Plan Review q Length I~ SAC, City Address ,Sf~}~111i.~1 ~ ~ Depth [hX2y SAC, MWCC S.F. Total Water Conn City/Zip Code ~J~i~iC/ J°~3 /a '3 Footprint S.F. Water Meter Acct. Deposit Phone ~~~'-TG j'~~ On site sewage_ S/W Permit ~D~ On site well _ S/W Surcharge ~a~"'~~~~ ~~~3 MWCC System _ Treatment Pl. City water _ Road Unit Address PRV _ Park Ded. Booster Pump _ Copies City/2ip Code SUBTOTAL APPROVALS Penalty Phone Planner TOTAL S"~ 0 Council Arch./Engr. Sldg. Off. ~lq~2~ Variance Address City/Zip Code Phone ~ ME,-v.~ ~sTOm y:m~s . ~ a O 8 E ' i¢sa.~~ COHSllLT1N0 tt{61lIEERS . ENGiNE~i~ING a~nt+t+Ens a~a ~n?io 3UAVE~rons soo~~ io4- ~ COMPANY, INC, ~ 1000 GST 146tl1 STRE:7~ BURNSVILLE, 11~}iHE:OTx SS:37 PH i:2-30pp CE'7"~Z~Z CCL~E ~7'~Ye C~ ~~~I _~'..J~T'~p~tarz: LOT ZB, BLOCK 3, LEX/NG~N S4GWRE 7TN ADD/T/G;~ ~ ' OAKOTA COUNT ,Y MINNESoTA ~ h\ ~ L, DRAINA6E AND e C3.81.-?~ DFJJOTES EXI.,, ~Nv" ELEV~- ~ ~ ~ ~ UT/Ll7Y EAS6MF~/7 ~~DO ~ j~\ (8B$. Z) OENOTES PROPoS~D EG8vs1- r \ ~~1 / i f~ . . ~ J ~ %NO/G~' D/RE~: /ON a~ ` \ ~ 1? ~y~ ~i x p~1~ ~ SURFAC~ oRA~Nf76c ~ ~ ~ ~ s~~_ ~ 989. 50 = F/N/$NED GA,FA6c F~~~'%C / ~ r- a~°~ / ; ~ R~~ ' E[~i/s7T/O.V ~-ja;~~ ~/O ~ ~ \ sja" i ~ f~,• ~ t, ; ~ , . \ ~ \ ~ , ~ ` ? ~.~~oti~ \ ~ ~eb. 0 ~ p, ~.y ~ ~o ~;r~' ' ~ a~ ; i ~ 5 a~'' 4.d ~0 ; '1 ~ ~ s \ ~ ~oj~ Q~+,D~h~ s'~~iijv \ \ 01 ~ ~ ~ .1 apN ~aq' L /$1~ l ~ ~ ~>a 6S \ ry~ ~ l~j ( ~ ~ R`f ' ~ C ~ ti io . . ~O" \ / p~F~ SO ~ qh, / ~ int ~ ' ~ ~ 1'~ ,p,W o . ~i . ` / Y~ . / `'?~'c DC° y~ o,~ ~c' ~ ~ ~p,~br P~ a y QY ~ ~ n 0~ ~~40;t ` ~p ' . i:, ti',~ ~Q 30' F~?On/T BJ/LO/N6 c~ ~a k2/ ~ $c'TB/JGC' G/A/c' ~1 ~ bl P~ / ~ -1--.~-. LQ}° ii C~'~ ~ I \Q~ j ~~Lc . c " 2S - o~ i9~yr,} •~*~ty that t;~is ie a t:~~e and carract rnprzaantxtian a~' ~ 7"+~~4 lihc'wt:vahcvn~~nd deecribed he:-on.• 1~s PrsParnd by me on t!~~s %7;H~ d~f ~f ti, a c q, . Hi~n. St:~, Ha~ ibc_ - - RESIDENTIAL / o~ ~ a ~ BUILDING PERMIT APPLICATION S`t' I/ ~ CITY OF EAGAN 3830 PILOT KNOB RD, EACAN MN 55122 651-681-4675 Naw ConslrucNon Reauiremenb RemodellReoair Reouirements • 3 registered site surveys showirg sq. fi. of lot, sq. ft. of house; and all roofed areas • 2 copies of plan (20Yo maximum b~ coverege allowed) . i set of Energy CalcWations for heated additions • 2 copies of plan showing beam 8 window s¢es; paured found design, etc.) • 1 site survey for eztenor addilions & tlecks • i set of Energy Calculatlons . IfMicate if home served by septlc system for addAions • 3 copies of Tree PreservaGOn Plan if lut platted after 711/93 . Rim Joist Oetail Oplions selection sheet (61dgs with 3 orless unAS) DATE ~ 1 D~ VALUATION `~-~~~J SITE ADDRESS I V~-~~7J ~ MULTI-FAMILY BLDG Y v N TYPE OF WORK I ~~J ~C~ ~ ~ C~ IREPLACE(S) _ 0_ 1_ 2 APPLICANT ~ STREETADDRESS~ CI STAT _ZIP~~~ TELEPHONE # PHONE # FAX # PROPERTYOWNER 1~ ~,13~.~4~.~ TELEPHONE#lC~~l'~~(~ l'LX-LJ COMPLETE THIS SECTION FOR "NEW" RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESO"f:1 RULES 7670 CATCGORY I NIINNF_SOTA RliLFS 7G72 (d su6mission type) • Residen6al Ventilation Category 1 Worksheet Submitted • New Energy Code Worksheet Su6mitted • Energy Envelope Calculations Submitted Plumbing Conkactor: Phone # Plutnbing system includcs _ Water SoFtener Lawn Sprinklcr Fee: $90.00 Water Heater No. of R.I. Baths No. of Baths i Mechanical Contractor. Pho Mcchanical sys[em includes: Air Conditioning I I~ ~ 8~-~ I~.~~ Heat Recovery System U Sewer/Water Conhactor: Pho eY# I hereby acknowledge that I have read this application, state that the information is correct, and agree to comply with all applicable StaTe of Minnesota Statutes and City of Ea ,rdinanc s. Slgnature of Applica ~ OFFICE USE ONLY CeRificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ Updated 4102 OFFICE USE ONLY ? 01 Foundation ? 07 O5-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg ? 02 SF Dwelling ? OS 06-plex ? 16 Fireplace ? 21 Porch {3-sea.) ? 31 Ext. Alt - Multi ? 03 01 of _ plex ? O9 07-plex ? 17 Garage ? 22 PorchfAddn. (4-sea.) ? 33 EM. Alt - SF ? 04 02-plex ? 10 OS-plex ? 18 Deck ? 23 Porch (screened) ? 36 Multi ? OS 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-plex Plbg_Y or_ N ? 25 Miscellaneous ? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding ? 32 Addition ? 36 Move Bldg. ? 42 Demolish (Foundation) ? 45 Fire Repair ? 33 Alteration ? 37 Demolish (Bldg)• O 43 Reroof ? 46 Windows/Doors ? 34 Replacement 'Demolition (Entire Bldg only) - Give PCA handout to applicant Valuation Occupancy MC/ES System Census Code Zoning Ciry Water SAC Units Staries Booster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs Length Fire Sprinklered Type of Const W idth REQUIRED INSPECTIONS _ Footings (new bldg) FinallC.O. _ Footings (deck) Final~o C.O. _ Footings (addition) Plumbing _ Foundarion HVAC _ Drain Tile Other Roof _ Ice & Water _ Final Pool Ftgs Air/Gas Tesu Final _ Framing _ Siding Stucco Stone _ Fireplace _ R.I. _ Air Test _ Final Windows (new/replacement) _ Insulation _ Retaining Wall Approved By , Building Inspector Base Fee Surcharge Plan Review MC/ES SAC City SAC Water Supply 8 Storage S&W Permit 8 Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies Other Total . : f " # ~ APRLICATION FOR PERMIT *~'E° pAYMFNt OF FEE AT TIME OF i ~ t APPLICAIZON DOPS DUP C17N- 3 ~ ~ • STINIE APPRfTJAL OF PER6IIT. ' • SEWER AND/OR WATER CONNECTIQN oF s~ u~/oa s~+~a ; xrisrnttJ+rionis was. tr~m Be sc~ ' ~ L~Nl'IL PfRPIIT HAS BEFS7 APPROVID. ~ ~ • ffRttSfflllk!ltfiffifMli4Ye!**1~fi+lF~~~4+*> ~ Iti~ OF G~~9C~FCOt9 (PLEASE PRINT 1) PROPERTY ADDRESS: 9 L. ~ S'~~¢.,,i W.,r. LFGAL DESCRIPTION: . . L `,I S~ ~ ~ L . J G "7. T'4 . LotJBlock S vision-o~ Parcel ID IF EXISTING STRL~I'[JRE, DATE OF ORIGINAL BUILDING PERMIT ISSUANCE: Nbnt Year PRESEL~Yi' ZONING/PROPOSID LSE: Q CONE~7ERCIAL/REPAIL/OFFICE ,~R-1 SINGLE FAMILY Q INDLSTRIAL ~ R-2 DUPLEX (',i~ C'nits) a INSTIZ4JTIONAL/GOVERPA7ENT ~ R-3 TOW~i00SE (Three L~its) ( Dnits) Q R-4 APARTMENP/CODIDOMINIUM ( Dnits) . . z> ~ D ~fs~,~ ~X ~ . ~~~ss: ~653 ?~ac.o~.~.. C,~ . CITY. STATE, ZIP: ~/'~Lf ff~4Lf.~y7 N?~ . PHONE: . ~,~7 ^S7 % f For City Use 3) •~+u c 7 NAME: a ~ G Pl erum~s License: Active ADDRESS: +fOC~ lSl~ CT . F~cpired CITY, STATE, ZIP: ~p~f ~JML~E~r ~Yl,vl• Not recorded PHONE: 7 2... 90.7 c~ MASTER LICENSE ~/Y( 9 St Initia 4) ~ o NAME: [1/t E ~ 26 ~ Gy~,~ ~ S ADDRFSS: ~0 86X 10 ~ ~j CITY, STATE. ZIP: y~~2.~f ~E r,"t/? • PHONE: ~,f' - ~I ~ ~3 5) s o i~o ~ CONNECTION TO CITY SEWER ~CONL~CTION ~ CITY WATER O OTf~R 6) a~ti:S~ C~ ~.fl a ~ S~ v ~r:Fik~k***************************:Y**:F***~t*************************:F~k9r****~let ~k********~k***iF9F***1F*******~ * * THE GOLD COPY OF 7i~ PERMLT WILL BE SEPTr DIl2ECCLY Z+0 PUBLIC WORKS ~ FACII~iTATE ME'i'ER PIQC-tJP. * ~ PLRASE 11LI.OW 7WD f+X)RKING DAYS FOR PROCFSSING. SOI+IDONE FR~I Tf~ CITY WILL CONPALT YOU IF R~~RE ~ * ARE ANY PROBLEMS. * ,~********~~*********,r+*,t*********,t****,e***********~***,r+.*~~*~*,r*~**a*********~*~~*~***,t,t******~****$ . r . FOR -CITY USE ONLY . PERMIT # ISSL~ED ~ j ~ c' Pd w/Bldg. Permit FEES: $ S /C'~,~7% SEWER PERMIT (INCLUDE SDRCHARGE) $ S ~ ~ 571 WATER PERMIT (INCLL~DE SL~RCHARGE) $ C~%~~~"C~ $ WATER METER/COPPERHORN/OL~TSIDE READER $ $ WATER TAP (INCLL~DE CORPORATION STOP) S $ SEWER TAP $ $ ~~~~C~ C'~ ACCOUNT DEPOSIT - SEWER $ $ •Cf-7~ ACCOONT DEPOSIT - WATER $ ~ .S~D S WAC $ .r7 ~ ~ U $ SAC $ $ TRUNK WATER ASSESSMENT $ $ TRONK SEWER ASSESSMENT $ S LATERAL BENEFIT/TRDNK SEWER $ S LATERAL BENEFIT/TRLNK WATER $ ~ (`v ~ $ WATER TREATMENT PLANT SURCHARGE $ $ OTHER: S ~ v ~ ~ • C9 S 5' / ~ TOTAL .~~E~/% ~'~n I~ RECEIPT RECEIPT DOES LTILITY CONNECTION REQUIRE EXCAVATION IN PUBLIC RIGHT OF WAY? ~ YES IF YES, THEN A"PERMIT FOR WORK 6VITHIN PL~BLIC Q ROADWAY" MUST BE ISSUED BY THE ENGINEERING NO DIVISION. LIST AS A CONDITION. SUBJECT TO THE FOLLOWING CONDITIONS: APPROVED BY: /?~c-e~-,-t~ /~S1 a'~:,'~V TITLE: DATE: _~JLC,I~~~ PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA143341 Date Issued:06/13/2017 Permit Category:ePermit Site Address: 961 Stanwix Rd Lot:28 Block: 3 Addition: Lexington Square 7th PID:10-45081-03-280 Use: Description: Sub Type:Residential Work Type:Alteration Description:Basement Fixtures Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size Comments:Please call Building Inspections at (651) 675-5675 to schedule a final inspection. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Building Code). Fee Summary:PL - Permit Fee (miscellaneous)$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 - James Gosh 961 Stanwix Rd Eagan MN 55123 Weld & Sons Plumbing 3410 Kilmer Lane North Plymouth MN 55441 (763) 475-0296 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA175429 Date Issued:04/04/2022 Permit Category:ePermit Site Address: 961 Stanwix Rd Lot:28 Block: 3 Addition: Lexington Square 7th PID:10-45081-03-280 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 - James & Nellie Gosh 961 Stanwix Rd Eagan MN 55123 One Hour Heating & Air 15191 Boulder Ct Rosemount MN 55068 (651) 437-4177 Applicant/Permitee: Signature Issued By: Signature PERMIT City of Eagan Permit Type:Building Permit Number:EA176647 Date Issued:05/25/2022 Permit Category:ePermit Site Address: 961 Stanwix Rd Lot:28 Block: 3 Addition: Lexington Square 7th PID:10-45081-03-280 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. If water damage is encountered, please call (651) 675-5675 to schedule a site visit to verify the extent of the damage. Any repairs must be inspected prior to covering. The inspector will determine if an additional permit will be required to repair the water damage. 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 - James & Nellie Gosh 961 Stanwix Rd Eagan MN 55123 (612) 306-1597 Principles Building & Remodeling Llc 7287 153rd St W P O Box 241477 St Paul MN 55124 (651) 340-5057 Applicant/Permitee: Signature Issued By: Signature