3633 Windtree Dr
~ CITY OF '-A(3AN SEWER $ERVICE PtRMR
3830 Pilot Knob Road 7023
I P. O. Box 21199 PERMIT NO^
! Eagen, MN 55727
ZorAng, Rl DeVries B ra Inc No. of Units:
i
Owner
~ /lddress:
~ sin Addrom 3633 Wiadtrea Drive B WindCrea .
~ Plumber. notr um g
10- 0-84 46929 100.00
Iopm te eewph? wMr tiM Gyr ef fogo. Can?Netlan ChaMe: 425.00 Dd
Ori1.eMar. /locax+t Qepomit: 13599 plj-_.--
porrnK Fw; 10.00 od
Surehorpe: .50 pd~.
~ By Mise. G+orp.s:
f Doft of Insp.: Total:
! Insp.: Dnft Poid:
i
CITY OF EAGAN
3830 Pilot Knob Road WATER SERVICE PERMI'T
P. Q. 130,c 211M PERMIT NO.:
Eapan, MN 55121 pATE.
Zoninp: : 1 No. of Units: I I
pwner. ' Devries Bldrs Inc
/lddrcss: .
Siri Add,;w 3633 Flindtree Erive 1,2 E3 tli.ndtre 3 i
~ Plunber, o _.,tta b g r.c I
; MWftr No.: Conneejon Chargo: 470.00 pd ~
Stze: Accourrt Depoalt: p ~
i Reade? No.: Permit Fee: ~
O!46 " ee007 nMh 1w Qhr of foles Surdwrya: . . . ~
I~•a~. Misc, Chargm 63.00 pd meter
Total: •
B1' Date Poid:
i Date of Insp.:
Imp.: ~
I
~ -
CITY OF EAGAN
3$30 Pilox Knob Raad WATER SERVICE PERMIT
P. O. Box 21199 PERMiT NO.: 5`74
Eagan.'tJIN 55121 DATE: t . 1")
Zoninp: R1 No. of Units: l
pwner: Fevries B1 ~Address: I
31te Addlesf: 363' fitiUiridtre
T
umbar: ~
C~ I
r No.: 3Y9 ~-f~.t.Ie~ 1q~~rD -~U11~D! 470.00
Siu: ~ ~t: - ~ c
[taader No.: .6_~I_ L,1n Z d A PeRnit Fee: 10• Pe
1 Nrw h eoinpfy wkb !iw Cky of hqgw Surtharpe: . ?'cl
O''uMiK. Chorpes: _ 63.00 rd BiC'tP_i
TO?Gl: .
gy Dots Paid:
Dots of Insp.: Insp.:
r ~a 5
CITY OF EAGAN
' 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 ~
PHONE:4548100
eU1LDING PERMIT ReceiPt #
Te ?e wnd ie. SF DWG/GAR Est, Volue $ 61, 0 0 0 Date OCTOBER 10 , 1 9 8 4
SiteAess 3633 WINDTREE DR Erect EIX Occupancy R3
Lot " Block Sec/Sub. WINDTREE 3 Remodel ? Zoning
Psrcel No. Repeir ? Type of Const. V
Enlarge ? No. Stwi~
ag, Name DEVRIES SLDRS Move O Length
~ 64 MARINER DR Demolish ? Depth
Ci~N~.sAPLE GRV phone 420-4685 Grode ? Sq. Ft.
c AME Awovols Fen
~ Name Q
A~~ Assessment Permit ~ O
~ City Phone Wote? 3 Sew. SurcFarpe ,
Police Plan check158.00
tcK G W Name WM F GAGE Fin S/~C 5'~ Q
Z~ Addr E?q. Water Conn. 470.00
i W City S~Aone Planner Water AAeter 63 ' b 0
Countll Rood Unit 260.00
I hercby acknowled9a that I hove reod this opplication ond state thot gldg. Off.l 0 Z O 84 *66(C0 1r 1.00
tM in(ormotion la correct and agree to comply with oll applicoble qPC Total
Stah of Minnesota Stctutes and City of Ecqan Ordinorxes.
Var. Date
Signotun of Pennittas
A Bu11Aing Permit Is Issued to: DEVR7ES SLDR on the sxpress corditbn tho+
)sntn~cmufes ond CiN of Eopan Ordinonces.
all worlc shall be done in aaordonte with oll/cpplicable Stcm of Minn
Bulldinp Officiol ' ~ - ` ~ ~'t'~• ~
~
Pe mk No. Pwnk Holdw o.a
rlumwng ~ Le o' 3 114 B- 5
H.vA.c. fYlrCn~.~t ll - Li -LY C , p S z
EMetrie • ~
Soltwwr '
InWection Dm 1 nsp. Oth er
Footinyt
~ Foundation I
Framinp '
I Rouyh Plb¢
Rouph HVA
Inwlation
Final Plbp.
Finel HVAC
Finsl
CNt/Oce. ~
Wmr Describs Loc ion:
Y11sll
Sswsr
Pr. Dhp.
Reaeipt PLUMBING PERMIT • Permit No.
CITY OF EAGAN _
, Fse
Fill in numbered spaces S/C
Type or Piini /egib/y Tot. -
1. Date 2, Installation Cost
3. Job A'ddress y-c Lot ' Blk. Tract
_I • . .
4. Owner ~t . ~ ~ ~ ~ c_~~ . • < , r -J -
5. Contractor Phone = r
.
6. Address ~ l G ~
7. CitY State f Zip
8. Building Type: Residential O Commercial O Institutional ?
9. Work Description: New Z1 Add ? Alter ? Repair ?
10. Describe
11. No. Fixtures No. Fixtures
,
f- Water Closet Cesspool/Drainfield
r
' Bath tubs Septic Tank
j Lavatory Softner
' Shower Well
Kitchen Sink
Urinal/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 454-8100
Reaipt MECHANICAI PERMIT Permit No. ~
CITY OF EAGAN FN
fill in num6er+ed apacea S/C ~
~ Type or Prinr legiwy Ta. r
' 1. Date , •r 2. Instailation Cost
Job Address k: Lot ~ Blk. Tract
4. Owner - t
f
• d , ~ t
~ 5. Contractor Phone
6. Address
1
: 7. City SUte ' Zip
f
! B. Building Type: Residential JL~• Commercial O Institutional 13
~ 9. Work Description: New,L'1, Add ? Alter ? Repair ?
10. Desai6e Fuei 7ype ' . ; .
'r 11. No• EqtiiQmeat 8TU - M. Ea. No. Eauiament CFM
i ~Forced Ai r Air Handling:
Mfg. ~
Boilers Mech. Exhaust ~ - ~
Mfg.
Unit Heater
Mfy. Other j
Air Cond. ~
Mfg. +
Go, Pipinp Outlets ~
~
i
~
~
12. I hereby certify that the above information is tsue and correct, and 1 agree to ~
vomply with all ordinenoes and codes goveming this type of work. ?
Signed : for r ~ ~
Rou9h Find
Inspection:: Date Insp. Date Insp. ~
This is your permit when numbered and approved. j
~ Appro+red CITY OF EAGAN 464-8100 !
~ CASH RECEIPT ~
CITY aF EAGAN
P. O, BOX 21-199
EAGAN, MINNESOTA 55121
DATE 19
R<C tI V tD
FROM
AMQUNT $
& DOLLAR8 I
loe
? CASN ? CHECK
FOR
FUND COCE AMOUNT
Than You
BY
White-Payers Copy
Yellow-Posting Copy
Pink-File CopY
CITY OF EAGAN Remarks
Addition WINDTREE 3RD ADDITION l.ot 2 Rik 3 Parcei-
Owner Street 3633 Windtree Drive State
Improvement Date Amount Annual Years Payment Receipt Date
STREET SUFiF, aj 1975 161.30 16.13 10 Pfiln
STREET RESTOR. r,~, 1984 2315.25 463.05 5 1852-20 17009498
GRADING 6 1983 613.25 122.65 5 367.95 C009498 9-27-84
SAN SEW TRUNK 151 1971 160.46 8.02 20 48.18 C009498 9-27-84
SEWERLATERAL 1983 3256.80 651.36 5 1954.08 C009498 9-27-84
Sewer Lat Trk 1983 188.16 37.63 5 112.90 C009498 9-27-84
WATERMAIN 1983 260.34 52.07 5 156.22 C009498 9-27-84
WATER LATERAL
WATER AREA 67 1972 236.39 11.82 20 82.86 C009498 9-27-84
STORMSEW TRK 147 1983 771.36 154.27 5 462.82 C009498 9-27-84
S70RM SEW LAT
CURB & GUTTER '
SIDEWALK
$TREET LIGHT
Road Unit #46929 10-10-RE~
WATER CONN. 470.00 " "
BUILDING PER. #9580 sac 525.00
"
PARK •
Z/ IEQUEST FOR ElECTRICAL INSPECTION EeD°0D1-0°
qA 1 Sea :.ctruetions tw eo.mletinplthis f$m m buek W ret~ coor.
n X" Be/aw Work'Covered by 7his Request
Add ibp. Tppe o/ BuiMi.p Apotianeu Mired EOUipment Virad
71 Home Range Femporary S¢rvice
Dupleac Water Heater Lightiny Fixtures
Apt Building Dryer ElecRic Heaun
Cunuercial Bldg. Furnace $ifo ttntoader
lnAistrial 81dg. Air Conditioner Butk Mifk Tank
Farm ~ne~ w:c~ v cue. Isoecihl
~ 11 O~hc~ Ocl*er
Compute lnspection Fee Below
k fea ServiceE'rtmrce5ize A Faa Feeders~SuEteeders K F¢e Gircuits
d 0 m200 Antps 0 to30q Oto 30 Anys
Above 200 Amps 31 to 100 Amps / , fJ 31 to lOQ Arnps
Swimming Pool Above 100_Mq~6 Abov¢ 100_A
Trartstomters Irtigation Boorts i p Partial'Otlter Fee
. Sigis Special Inspection ~fle7,rl~s TOTAL FEE
3 y-~
,vg
flouph-in ~aL~' Elecv~l
? ~y_l3- ~m..b.trb,.
pelitr tAax [Ir ahove
Firel D'~t nametim Ms 4ae.
omde-
tm.
~ y CITY OF EAGAN N? 9580
` 3830 Pilot Knob Road, P.O. Box 21•199, Eagan, MN 55121
PHONE:454-8100
BUILDING PERMIT Receipr
Te M YMA for SF DWG/GAR Est, Volue $61,000 pate OCTOBER 10 ly 84
SiteAddress 3633 WINDTREE DR Erect ?X Occupancy R3
Lot 2 Block 3 Sec/Sub. WINDTREE 3 Remodel ? Zoning RI
Parcel No. Repair ? Type of Const. V
Enlarge ? No. Stories
~ Name DEVRIES BLDRS Move ? Lenqth 5U-_
Z Address 7564 MARINER DR Damolish ? Depth 42
9 City MAPLE GRV pnone 420-4685 Grade ? Sq. Ft.
Approvols Fees
zo Name SAME . O
o~ Address Assessment Permil
u~ City Phone ~Nater 8 Sew. Surchorge 30.50
Police Plun check 158.00
r'W Name WM E GAGE Fire SAC 525.00
`-z 7232 BOONE AVE
x~ Address Enp. WaterConn. 470.00
~W City BROOKLYN CTpRne 533-5026 planner WaterMeter 63.00
Council Road Unil 260.00
I hereby acknowledge thaf I hove read this application ond state that g)dg. Off.l0 ]_0 $t} ( CO y_ P
the informotion is correcf ond agree to wmply with oll opplicable APC Total
State of Minnesoto Stotutes and Cify of Eogon Ordiran es. ~
/ Var. Date
SiOnalure of PermiMee
A Building Permit Is issued to: DEVRIES A3;DR on the expreu corditlon Ihai
all work sholl ba done in accordonce with oll pic le State of n ures ond Ciry of Eapan Ordinances.
Buildinp Officiol
. .
~ C M
ALL COTOOST BE L ENSED WITH THE CITY OF EAGAN
~ INCLUDE Q SETS OF PLANS,3
E CERTIFICATES OF SURVEY
~ rDW(:1 /~pR 11 SET OF ENERGY CALCOLATIONS
To Be Used For: Valuation: Date:
Site Address: 3 i ~ •
Lot: a~ Block:3 Sect/Sub: ezF 3-) ' Erect: X Occupancy: 2-3
Parcel Remodel: Zoning: K-I
Repair: Type Of Const: -_v--
Owner: Enlarge: # Stories:
Move: Length:
Address: Demolish: _ Depth:
City/Zip Code: Grade: Sq. Ft.:
Phone
Contractor:_OE U~res ($cp~. ~
Address: 7SCc4 Assessments: Permit:
City/Zip Code: ry)qPLE- 6PJve- th ,i,s~369 Water/Sewer: Surcharge:
Police: Plan Rev.: ~ S.-
Phone y~ P-5- Fire: SAC: 525."-
Engr.: Water Conn: [}1p
Arch./Eng: /,/n, C loAbd- Planner: Water Meter (03
Address: `7932 Baaa.r R~~~ Council: Road Unit:
Bldg. Off.: /c Parks:
City/Zip Code: S 33 APC: 2
nh,,,,oe• Variancev 7047117M 1 ga3. So
z¢x 3( _ ~4~Fx s4= 4on(o
~
41 ~ ~I2)0
20 ~ 2,q- ~6 ~ I I = 5 2 0~
572G 4
~
i- .
y
~
~ • ,
• ! . 10-#
316• +
30•5+
' 158 • +
525 • +
470• +
63•+
260• +
' 1•+
1r823•5*
w
2004 RESIDENTIAL BUILDING PERMIT APPLICATION
,f-. . City Of Eagan ~
3830 Pilot Knob Road, Eagan MN 55122
C) Telephune # 651-675-5675 FAX # 651-675-5694 -d~-
New Conslruction Reomrements RemodeVReoair Requirements OKCe Use Oniv
3 registered site surveys showing sq. ft of lot, sq. ft of house, and all roofed areas 2 copies of plan Cert of Survey Real Y_N
(70°k maaimum lot coverage allowed) 1 set of Energy Calculations for heated adddions Tree Pres Plan Recd Y_ N
2 copies of plan 5howing beam & window sizes; pouretl found design, etc. 7 site survey for addNons & decks Tree Pres Required Y_ N
1 set ot Energy CalculaUOns Addition - indlcate d on-site sepfic sysfem On-site SepUC System _ Y_ N
3 copies of Tree Preservallon Plan if lot platted aker 711/93
Rim Joist Defail Options seledion sheet (bldgs with 3 or less units
Date ~ / Construction Cost A/ C9 o ~
Si[eAddress UniUS[e#
~ s s ~ a 3
Description of Work h-~~L ~ /LDt7m ~~~~7~0 ~ ~ L,~?t` L
Multi-Family Bldg _ Y~ N Fireplace(s) _ 0 _ 1 _ 2
Property Owner ~ e`~1Ali y eJ- C1 C/L y~ TAC o s S o..~ Telephone ,ln S9.3 O.j
r« C,s-/ 7 - 3so-S`
Contractor /1'7 y.s L LY t N_t1j S)
Address 5/9','hr A ,9irc9 ?t City
State Zip Telephone # ( )
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
- Minnesota Rules 7670 Cateeorv 1 Minnesota Rules 7672
Energy Code Category . Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet
(J submission type) Submitted Submitted
. Energy Envelope Calculations Submitted
Have you previously constructed a building in Eagan with a similar plan? _ Y _ N If so, 25% plan review
fee applies.
Licensed P{umber Telephone )
Mechanical Contractor Telephone ~ ~ _
~~21~n~~~~ U~
Sewer/WaterContractor Telephone#( )V
IIII IvUV " L U4
I hereby apply for a Residential Building Permit and acknowledge that the informati yis com e and acc ate;
that the work will be in conformance with the ordinances and codes of the City of agan anlc-the State' 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.
y
_ll ~tlnJ~ S ~ J ,Q C v ~v S o-J (~Appl
Applicant's Printed Name canYs Signat e
OFFICE USE ONLY ,
Sub Types
• • ~'~r~.
? 01 Foundation ? 07 OS-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? OS 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 EM. Alt - Multi
? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF
? 04 02-plex ? 10 OB-plex ? 18 Deck ? 23 Porch (screen/gazebo) ? 36 Multi Misc.
? 05 03-plex ? 11 10-piex O 19 Lower Level ? 24 Storm Damage
? 06 04-plex ? 12 12-plex Pibg_Y or _ N ? 25_ Miscellaneous
Work Types
? 31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding
'01 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair
? 33 Alteration ? 37 Demolish Building" ? 43 Reroof ? 46 Windows/Doors
? 34 ReplaCemOnt 'Demolition (Entire Bldg) • Give PCA handout to appliwnt '
Valuation /L~ aoU •av Occupancy I~ -3 MCES System
Census Code `I 3cl Zoning City Water
SAC Units Stories Booster Pump
# of Units Sq. Ft. PRV
# of Bldgs Length ~y Fire Sprinklered
Type of Const Width 17-Z
REQUIRED INSPECTIONS
_ Footings (new bldg) _ FinaVC.O.
_ Footings (deck) ,o FinaVNo C.O.
)4 Footings (addition) _ Plumbing
-~gd Foundation _ HVAC
Zc Drain Tile Other
Roof ` i Ice & Water ~O_ Final _ Pool _ Ftgs _ A's/Gas Tests Final
)6 Framing _ Siding _ S[ucco _ S[one _ Brick
Fireplace _ R.I. _ Air Test _ Final _ Windows
?c Insulation _ Retaining Wail
Approved By: Yl Q214 , Building Inspector
Base Fee ~`6~ • S q
Surcharge 5-U J y}{ ~ Z`Z =/7c~ ss F> ~c Sv.o 190-0.
Plan Review
MCIES SAC
City SAC
Utility Connection Charge
S8W Permit & Surcharge
Treatment Plant
License Search
Copies
Other
Total
(
RLScheck-Web /
` O ~J O ~
Page I of I
3633 c1b/vd 7-12 C r- Aoe. 9
~ Sign In or Register (optional) I
{~C ~?/~~/~/~j~ C6 si) s87- 3 S o i I
i~S{r~l~k~1 ~~V~ Registered members can save and -i
recall project information. Re gistration i
, - - -
Project Enveiope 11 htechanical ~~New [?Check Compliance I; gjReports I CiPrint ~ QHelp i
Row: Edit Go Duplicate ? Move Up j Move Down I rX Delete !
r-- Prop.osed and Maximum U-Factors
Add: Skylight Window i
( ~eiling (Wall 'i Door ~ 8asement Floor I Crawl - i
Cavit Continuous ~
Assembly Gross CaviUqontinuo s
i
~ Wall: Insulated Concrete Forms PeriA6eter 19.0
2 j
121 Door. Solid 20 0.37( ~
z ~
J Window: Wood, Double Pane 20 0.37( ~
z ~
4D Wall: Wood Frame, 16" o.c. 262 19.0 19.0 f
ft2 ~
Ceiling: Flat or Scissor Truss 168 38.0 38.0
~
r
J Skylight: Wood Frame, Double Pane ftZ 5 0.50( RZ I~I U
Skylight: Wood Frame, Double Pane ftZ 5 0.50( II~I N~QV~0~~4 U ~
LILI
Floor: Unheated Slab-On-Grade 52 5.0 Sy
ft ~
` - - -i
-I - - - - - - - - ~ - - ; ~ ~
r __Passes _ 2.7 "/o Better Than Code _Max UA: 73.0 Your UA: 71.0 j
http://bldgcode.pnl.gov/REScheck Web/tradeOtlMain.jsp?fromPage=Welcome.jsp I I /9/04
• • 'DRlvt °
WINpTREE ~R~M.~, ~
65.00
. 0 o32'qe
r4.73
'Po A w
~
~
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1 - ~
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240 N 1n5~~1~ A 1
'i5o) ~ ~C89~' w
i ~o W A 1g 50 ~J
50~jGAR~ A ~
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o / 6 /gE~/
HOU E
W / I J
p 43.50 `g9~'\ . ~
0
; 1j7g ~q.o ~ N
~ N
~ ,W~1 ~...iV
n N
LOT `
I = 30 1
`
DEp5EMEN1 PERI~ 5
LA?~1\
'
~909•0) • ~
. \ 0 ....r ~ 'll 85.00
\ N~3~39Ii1
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7
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This rcWUt:; wid
18 n4~ths f~ E 3 3 I a- I 3 i~ Y
A 083075 ~ P LJ,
I ReQUes~ Qatc Firc No. I Rowh-in In,cpcction
Hes retl! ~Aeatly Glow ~q~ll Naliry.l~sp¢c-
~ ~ - ej~es ? No Ua When IYn&dY
pLice~ned Elcclriwi Contrdclor
Cl I herebv FMuest inspvetion of oE~
? Owner electriml wmk incbiMA at:
Stree[ Atldress. Boz w flouie Na G:ir
?,.--3 3 ~ n4Jc'~
ct-on Twnchi0 Name o1 No. liange No_ Coe[ney///
U'dcupant (P111tM . Hh~ No.
) `7 / "i -o? /
Powe, Supplia Apdress
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ElecViql Contractrc ICanpanV Nartcl r- ConLacmi s Lice,r.,c No_
PIQ-
Mailinq AEdress Cmtraclw O~r Makieg Imtaila[ionl
661-0 /-i
Auth ized Sigfature ICwnrac~rn/q...cr Yakinp Inslallation Rbre NunA¢r
INNESOTA y7AlE gpppp OF CT111CITY iH15 IttSPECTION IiEUUFST MLL NOT
Griyps-MiduaY Bldp- - Ibm N-191 0E ACGEVIED 87 THE STATE BWim
1821 Uniwrsity Ave.. St. Poul. YN 55100 U~USS PROPEA INSIECTOM FEE 6
ow...r Im,. 1m11i• ERCLOSED.
'43M EYOR~S CERTIFICATE DEVRIES BUILDERS
~ DENOTES PROPOSED SURFACE DRAINAGE SCALE: 1 INCH = 3~- FEET
O DENOTES IRON MONUMENT SET PROP05ED GARAGE FLOOR = g9 8,° FEET '
~ DENOTES IRON P!ONUMENT FOUND PROPOSED LOWEST FLOOR - 0 FEET
X000.0 DENOTES EXISTING ELEVATION PROPOSED TOP OF BLOCK = 6y9.4 FEET
(000.0) DENOTES PROPOSED ELEVATIOPI ~
NOTE
PROPOSED ELEVATIONS SHOWN AREAS TAKEN
FROM THE GRADING PLAN FOR 41INDTREE 3RD
ADDITION BY JAMES R. HILL, INC.
I HEREBV CERTIFY TO DEURIES BUILDERS THl1T'THIS IS A TRUE AND CORRECT REPRESENTATION
OF A SURVEY OF THE BOUNDARIES OF :
Lot 2, Block 3, WINDTREE 3RD ADDITION, according to the recorded plat thereof,
Dakota County, Minnesota.
AND OF THE LOCATION OF A PROPOSED BUILDING. IT DOES NOT PURPORT TO SHOIJ IMPROVEMENTS
OR ENCROACHMENTS, IF ANY, THEREON. AS SURVEYED BY ME, OR UNDER MY DIRECT SUPERVISION,
THIS 8TH DAY OF OCTOBER, 1984.
SIGNED: JAMES R. HILL, INC.
.
BY: L/
HAR LD C. PE ERS , E R
MINNESOTA LICENSE N0. 12294
SHEET 1 OF 2 SHEETS
PROJECT NO. BOOK / PAGE
~ - JAMES R. HILL, INC.
84917 . Planner;; / Englneers / Surveyors flLE NO, ' I
. 8200 HumDoldt Avenu• 8outh I
. FOLDER Bborninflton, Mn. 66431 012-884-3020
rYORVS. CERTIFICATE DEVRIES BUILDERS
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SHEET 2 OF 2 SHEETS
PROJECT NO. BOOK / PAGE JqMES R. H1LL, INC.
84 917 Planners / Engineers / Surveyors
FILE NO. 8200 Humboldt Avenue 8outh
; FOLDER Bbornlnyton, Mn. 66431 012-884-9020 . •
- • .
i
2/84
CITY OF EAGAN
I t ~
~-~,11111 APPLSCATIOV FOR PE&MIT
• SE:4ER AND/OR WATER CONNECTIODI
(PLEASE PRIHT)
1) PROPEf7I"_' ADDRESS: 3 :3
rFru. DESCRI"TzcN:
(Lot/Block/Su:divisicn or Ta: Parcel I.D. Ntzrb2r)
~ S'r' S?'RUCIL^:2E, Dtl'I E OF OiZIGi IAL 'ciiII.DP:G P~: ST ISS.:?2~C.:
e=;
PDF'C'L'`T „-~1rNr,1P.ROPOS=-D L'S: ~-1 SL;GLE FPNSLY ? R-2 DUPLE? ('IL•;O L'NITS)
0 ?-3 ZC7.v?CUSE + [,^1IT5) ( LNI^S) °
? R~--! AFaR'~~/.C~,~T:T~//r~~,t ~ ~1~iIZTJ)
? / lT.~.1/~T.1"1i~'~c~}-C~~~T~']rL/ I~L:l111y0C1 L Il..'...
? 11\lJVJ1lJt\L
.
? T-N$TITC,'rlOi]AI,/GC'lI7E.Rt~~'=:T
2) pppLIC >TT (PLEASE PRltlT)
NAh~: SW P4
ADDRESS:
CIT"l, STATE, ZIP: .
PHOLNE:
3) P=,iBER NAME: PLEAS" P IN1') ~A- C_ FOR CITY USE ONLY
o LU~~i~
, ~ )/ro ~~GViJ L/~/ ~J~~ PLUHBERS LICEASE:
ADDRESS_ ~ Ac t i v e
CITY, STATE, ZIP: Ni ~ 7jTff g/ ~Expired
DIE: ~icn HC~f~J Record
PHO SJ ~ PLIIMBER LICENSE
arr initia
l,f ASE PNIt 3
C//" L 'P P J
4) OCC[7?wT/CSvm.F.it t~1ME: /PJ
ADDRESS: ZS6
CITY, STA'Ir, ZIP:
PFiO^IE:
5) INDIC:,TE WFiICE! PEPJIIT ZS BEING RE.QUESTGD:
,ff CONNECfION 'I`O CITY SEWER
~ NIECIZON 'lq CITY [-]ATLR
? diE+ER (PLEASE DESCRZBE)
6) I2:DIG,:'L C:tE:
~ PLE_'~SE E?OID APPP,pVID PERtilIT FOR PICFC-UP BY ONE OF AEGVE
~ PLEASE 6TAiL APPF2(7VF.p PII2:•LIT TJ 1. 2, a 4 AHOVE
(Circle one)
7) SIC~TV'F2E: 47 DATE: ~ 0 T
~F Qal~illb.~ i~ i sa l~:aacla r7 ss sae ~ i s~saa:~ a~[ ~ E:~.a~ry~y~ ~~~:ls Et~r
t
F O R C I T Y U S E O N L Y
PEZ;`4IT ? ISSUED
F°i'S: $ ~p . •~~o SE-i•iER nERptIm (ZNCTLDE JUP.C:IAaGG)
$ WATER PERMIT (Ii:CL'JDE Sli?C:?ARGc'.)
$ WATER METER/COPPERHORN/OUTSZDc REnDEt?
$ WATEP, TAP (INCLUDE COP.PORATION STO?)
$ SE,•iE4 TA?
$ o-O ACCOliVT D.F,PpSIT - PIATEB
•S WnC
$ SP.C
$ TROVK WATER ASSESSb+.E?iT
$ TRiiNK SES7ER aSSE55i:ENT
$ LATEP,P,L BEivEFIT/TRUDIR SE[IER
$ LATERrIL BENEFIT/TRU.`]K SQAT°_R
$ OTHER '
$ TOTAL
AMOli`:T PAID/RECEZPT #
<Z 79 ~i
DOES UTILZTY COi]NECTION REQUIRE EXC.-IVATION IN PUBLZC RIGiiT OF WAY?
~ YES ZF YES, THEC] A"PERh1IT FOR `r70RK LJITHI-tq
~ PUBLIC ROADWAY" MUST BE ZSSUED BY TY.E
NO ENGZNEERIPIG DIVZSION. LIST AS A CONDZ-
TION.
SUBJECT TO Tf1E FOLL0WING CONDITIONS: '
APPROVED BY: c7YG_e
TITLE:
DAT°:
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. . .