4333 Woodgate Lane N
otificate of cccqanc~
~ #?cpartmcut o f 13Ki[bing ~3uBlpecrioA
This Certificase issued pursuant to t!u rcquircments of tke Unifornr Bui(ding Code
cerrifying thal al the time of issuartce this stnrcturc was in compliance wirh the various
o?dinances of tlu Ciry iegulatireg building constnrction or use. For the following:
U. aMirco-i CF Th1C: ews. rt„Mil ra. 33527
pceop-ey 7ypo RIf J 1 Zoeint Distria A 1 Type CM". IN
Ownet of Build'iqe /Wdress DADV~SW ~~i-
eu;&ang Aaam 4331 lm r i.om?iry 1.55, Bi T T 4M
p,e.
`~=T
~ BIUj&Og CkTCw / L
ii
PpST IN A CONSPICUOUS PLACE
w ~ fN-SPEUTION
/CITY OF EAGAN PERMIT TYPE:
U 3830 Pilot Knob Road Permit Number.
Eagan, Minnesota 55122-1897 Date Issued: io ~ 0,4 /'a Ft I
(612) 681-4675
SITE ADDRESS:` APPLICANT: i
~ t? f: f: r~ i. r. : ~
, -tlilLiATF 1 ANf N ! . , . I~ ~ ,~i~~ . ~ ~ rlt• i
~r I! „ ~ ,~I•!
PERMIT SUBTYPE: TYPE OF WORK:
i
INSPECTION . D.
~ rsrr~PlIlIr iNI;
i r• Jil n i 1~,t•I r t'1 nr I
,11111,H (1-4 111~,
~ i M)t:t'• 1'! AN i.'1 V[E41t fi }iY 6JHYh`t 14I f i i;
1,11lMfif. R I5 fit'NZ RYAN Nf
II ~ ~
l:
Pamtit Holder Date Telephone •
PLUMBING
HVAC
Inapection at Ins . CommenU
FOOTINGS ~
FOUND
FRAMING
(i'v
ROOFING 14
ROUGH
PWMBING
PLBG
AIR TEST
ROUGH
HEATING
GAS SVC
TEST
INSUL ~
GYP BOARD
FIREPLACE
FIREPLACE
AIR TEST
FINAL PIBG '
FINAL HTG
ORSAT
,TEST
IBLOG FINAL
DOMESTIC
METER
IPRIGATION
M ETER
FLUSH
MAINS
IT o raoucnvirv
EST
H v DFlOSTATIC
I7FST
i BSMT R.I.
BSMT FINAL
~ DECK FTG
C
DECK FINAL
I - - ~ - - -
Address 4333 tUC^%V TAT rr Zip 5512_3
I.ot 55 Bik i Sub ranT.raur: a mc a[tt
THESE ITE S WERE / WERE NOT COMPLETE AT THE TIME OF THE FINAL INSPECTION.
Date: Yes No Inspector:
Final gra/de (6" from siding) ?
Permanentsteps (garage) i/
Permanent steps (main entry)
Pecmanent driveway j/
Permanent gas
Sod/Seeded grass
TraiUcurb damage ?
Porch
Basement £nis6 V
Deck
Please verify with the builder the removal of roof test caps from the plumbing sysrem and the shut-off of water supply to
the outside lawn faucet before freeze potential exists.
Contact engineering division at 681-4645 before working in rightof-way ar installing underground sprinkler system. ~
W6ite - City Copy Yellow - Resident Copy Pink - Contractor CoPY
PERMIT
~ CITy OFf-AGAN
3830 Pilot Knob Road PERMIT TYPE: B U I L D I N G
Eagan, Minnesota 55122-1897 Permit Number: 0 3 3 5 2 2
(612) 681-4675 Date Issued: 10 ( 0 9/ 9 8
SITE ADDRESS:
4333 WOODGHTE LFlNE N
LOT: 55 BLOCK: 1
MALLARD PARK 4TH
P.I.N.: 10-47253-550-01
DESCRIPTION:
BuildingPermit Type SF DWG
Building Work Type NEW
~'UBC Occupancy\~ R-3.U-1
~ Construotion Typq VN
% Zoning \ R-1
Building Length 75
. ~ Building Width ~ 29
Bu~ilding stori.es ~2
~ "StY uare Feet 2,175
Cer~sus^Gode 101 1- FAM. DETACH
i
REMARKS:
PLAN REVIEWED BY WAYNE MILLER.
S& W PLUMBER IS GENZ RYAN PLUMBING PHONE #923-1149.
ppki REQUIRED
FEE SUMMARY:
VALUATION $170,000
Base Fee $1.237.25 MISC. FEES $1,592.50
Plan Review $804.21 Total Fee $4,715.96
3urcharge $85.09
SAC $1,000.00
SAC % 100
SAC Units 1
Subtotal $3,126.46
COKITRACTOR: - Applicant - sT. LIc. OWNER:
PETERSEN CONST, SVEND 15845144 0001769 PETERSEN CONSTRUC7ION
102'14 PARK VIEW CIR 10214 PARKVIEW CIR
BLO~OMINGTON MN 55437 BLOOMINGTON MN 55431
(612) 884-5144 (612)889-5144
I hereby acknowledge that I have read this application and state that Che
information is o rect and agree to comply with all applicable 5tate of Mn.
Statutes and 'i of Eaqan Ordinances.
APPLICANT/PERMITEE STGNATURE ISSUED 8V. SI NATURE
• ~ . , 1998 BUILDING PERMIT APPLICATION (RESIDENTIAL)
' CITY OF EAGAN
3830 PII.OT KNOB RD - 65122 q,
681-4675
New Construction Reauvements RemodeUReoair Reauirements
(3i.~C.X1L~ b
? 3 rogisterad sde surveys ? 2 copies of plan
? 2 copies of plana (inGude Deam d window sizes; poureG ME. design; etc.) ? 2 site surveys (eMerior addRions 3 decks)
? t energy ealeulatians ? t energy ralwlations for heated add'Rions
? 3 copies of tree preservation plan il lot platted aRer 7/11/93
required: _Yea No
DATE: /S~ - 9-P CONSTRUCTION COST; G~a
DESCRIPTION OF WORK: Ne~-76~11 I
STREET ADDRESS: y3 3 3 N. e~1000 L/?
yTN /7no
LOT: .~5 BLOCK: / SUBD./P.I.D. Ml~"L ~I ~I) ~Ii 1
Name: ~.~L'7L"~s~~? (~Ol?)-~ /h/ ~ Phone#:
PROPERTY Lut First
OWNER
Street Address:
City State: Zip:
Company:J"_ ~S~/? C~O tiS-~ / A"(-, Phone
CONTRACTOR
Street Address: k,~ / Ll -~j7 "2lC cy//,- <2 License #
City /JL o O/y iNls- Tv State: Zip: 5.~v -3/
ARCHITECT/
ENGINEER Company: PhoneN:
Name: Registration
Street Address:
Ciry Sute: Zip:
Sewer 8 water licensed plumber (new construction ony): Penalty applies when address chang
and lot change is requested once pertnit is issued. 4
I hereby acknowledge that I have read this application and state that the iniortnation is corr d agree ta comply wkh all appiicabl
State of Minnesota Statutes and City of Eagan Ordinances.
Signature of Applic /
OFFICE USE ONLY
Certificates of Survey Received ~Yes _ No ~ 2 5 0
Tree Preservation Plan Received - Yes _ No " Not Required ~
OFFICE USE ONLY •
BUILDING PERMIT TYPE
? 01 Foundation O 06 Duplex O 11 Apt./Lodging ? 16 Basement Finish
4EC'02 SF Dwelling ? 07 4-plex ? 12 Multi Repair/Rem. ? 17 Swim Pool
? 03 SF Addition ? 08 S-plex ? 13 Garage/Accessqry O 20 Public Facility
? 04 SF Porch ? 09 12-plex O 14 Fireplace O 21 Miscellaneous
? 05 SF Misc. ? 10 = plex 15 Deck
WORK TYPE
~ 31 New ? 33 Alterations ? 36 Move
32 Addition ? 34 Repair ? 37 Demolition
GENERAL INFORMATION
Const. (Actuat) ?N Basement sq. ft. / 35' 7 MC/WS System ~
(Allowable) VA-7 Main level sq. ft. / 35 7 City Water
UBC Occupancy R3•~z U/AEX sq. ft. 7-1 Fire Sprinklered
Zoning ( 2 Gff/~ sq. ft. 76eY PRV
# of Stories ~2 sq. ft. Booster Pump
Length '75 sq. ft. Census Code. 1,91
Depth A dj' Footprint sq. ft. z126 SAC Code aI
Census Bldg 1
Census Unit ~
APPROVALS
Planning Building Engineering Variance
Permit Fee Valuation: $ ~ -7 d rOoO
Surcharge '
Plan Review 8`^5c Mcn~
License q6 X 133y
MCM/S SAC - G° x R= 13
'
City SAC / 3 y 7 X~ 5 = alD2 05`
Water Conn.
Water Meter yb xP, 133'-1
Acd. Oeposit - 6` x:X= 1 3
S/W Pertnit " s- / d
S/W Surcharge 13577 x> N = 7 3.27$
Treatment PI. ~ fp,;&
Park Ded. 31 y aq
Traiis Ded.
/I ~y u5H : (~33`~
apee5
6,4RAGE
Total: auu 23-= 7~S
~ tq u y
% s,ac
SAC Units 76cJ ?c l b = J~.30~
/69' i1s3
Certificdte of House Location Ebr: '
. H98182
Sve,ndrPetersen Constnxction, Inc. 192/56
DELMAR H. SCHWANZ
LANO SORVEYOR9 INC.
RaObtbM UnM LE`s M TM SbN o~ Minnoau
11750 SOUTH ROBEHT TRAII ROSEMOUNT. MINNESOTA 55088 612/429-1769
SURVEVOR'S CERTIFICATE
Proeerty Addres5: 333 North woodgate Iane
• = Iron pipe montnnent
Set c,ood hub at building offset Proposed garage floor elev.
q3~ = EScisting spot elevation Proposed top of block elev. 4/,~
Q= Proposea elevation Proposed lowest level etev. ~J .
Proposed direction of drainage
•F,
oA'9 C~QC~~1~1
s~oo ~ n ~~'~1~1~~~~ .
°~0 ~0 POND BP-23 BY
NML - 931,31 ~ DATE 2 9
~ HML - 933. s BVIL01NG INSPF_C1 iuilS DEPT.
' OFAINAGE 6 UTILITY EASEMENTS
r ~ / ~5~ ''+'1 E \ ~d+ ~ ~v •
0
931.3 / h2•5~ V3
~OND ELEV. 9-16-98 + i ~'~a ~ ~j!~ •
' . ~ 1r 932.1 ' 19'E \ c~'
4 LOT 55 -
\ 947.4 ~
938.9
+
A ~ Ft
BLOCK 1 938.3
V, ~ sasA ~q`'P a9 y~
~ + ~s yo
•~tf ~ ~s> p6F'
vPP 43 937.5
934. ~ ~,lO u~
O '1
• u ~ 6 940.0 O5~ a 2 + 5.4 qqfi4
3.Q~' Q 5 6• 934.6 /
942.3 '.Q ~9 9011 a 934.3
.
a. ~ .
..'.w9QAIV~RTCsI 3.
S-~GS 937.
Ap
Description: ~
Lot 55, Block 1, MALdARD PARK 47H ADDITION, 5.
according to the record plat thereof,
DdkOta CAUiIi'y• M1I1i1250td. ~f \ 933. ~ .
r~
Also showing the location of a proposed ~
house staked thereon. ' 10° ~ ~
~o p° ~
~i~mun~
I hereDy carllly ihEl Ihq turvey, plen, or reDOrt wea `~.0\\~~~\~......s.(~/Oi/vx..
preperod by me or unde my AIr1cI luDeryislon anA ••;9
thel 1 am e duly Regletered Lend Burveyor under ';S} ~
ihe lewa ol lhe Slete o1 Mlnnesole. `~+DEL~AR H. .
= ? SCHWANZ
09-23-98 c Dalmar H. Schwenz
Y Deted - SSLS Mlnneeote Regtetretbo No. 8625
f ..:Q
~ •
pIUt1~J~~"``\v
LOT SURVEY CHECKLIST FOR RESIDENTIAL
B ILDING PERMIT APPLICATION
~ ~F
~ PROPERTY LEGAL:
~ DATE OF SURVEY: Z3
21 LATEST REVISION:
~ m DOCUMENT STANDARDS
< z
~p ? • Registered Land Surveyor signature and company
~ ? • Building Permit Applicant
? • Legaldescription
~ ? • Address
LJf ~ ? • North arrow and scale
B~ O ? • House type (rambler, walkout, split w/o, split entry, lookout, etc.)
o% ? • Directional drainage arrows with slope/gradient 96
? ? ? • Proposed/ebsting sewer and water services & invert elevation
?~'13 O • Street name
0~ ? ? • Driveway
ELEVATIONS
Existina
? ? ? • Sewer service (or Proposed)
q,-,[] ? • Property corners
o% ? • Top of curb at the driveway
o% ? • Elevadons of any ebsting adjacent homes
ro ose
O-'O ? • Garage 8oor
R-'0 ? • First floor , I
0~ o ? • Lowest exposed elevation (walkouVwindow)
? ? • Properrycorners
[5 O ? • Front and rear of home at the foundadon
PONDING AREA (if apoiicable)
Ca~/o ? • Easement line
? ? • NWL
d/ ? ? • HWL
O ? • Pond # designation
? • Emergency Overflow Elevation
DIMENSIONS
f ~ ? • Lot lines/Bearings & dimensions
0-o ? • Right-of-way and sUeet width (to back of curb)
ef ? ? • Proposed home dimensions including any proposed decks, overhangs greater than 2',
porches, etc. (.e. all structures requiring pertnanent footings)
m ? ? • Show all easemenLS of record and any Cily utilfies within those easements
0~, ? ? • Setbacks o( proposed strudure and sideyard setback of adjacent ebsdng sVuctures
0 0/ ? • Retaining wall requirements, if any
Reviewed:
ame fjbate
January 1996
CRAIGI piEIBLOGPRMT.FM
FROM : WILLMUS CO PHONE N0. : 612 633 5701 Se . 16 1998 11:21AM P1
L
i
W
W 3 !
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~ x
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~ v
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I \ ~ m
. I ~ ,
LO
4~n
N
.
W
~ Fo_r0_ffic,Use I
e
Clty Of ~apIl ; Pemit #
I Permit Fee: ~ I
3830 Pilot Knob Road
Eagan MN 55122 ~ Date Received:
i i
Phone: (651) 675-5675
Fax: (651) 675-5694 I Stan: I
I
2008 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: 10-02-7-0d Site Address: q~ ~3 W0064-m~ A)
Tenant: 7~tCk- maz(5~& Suite#:
RESIDENT / OWNER Name: ~?~~~C' Phone:
Address / City / Zip: Y ~ ~J ~j ~ ?ViJI~~'j-E L/? ~V
Applicant is: _ Owner Contractor
~~F
TYPE OF WORK Description of work: 02CEocr
ConshuctionCost:_j/Qocrp Multi-FamilyBuilding:(Yes_/No~
' -3,ab9
CONTRACTOR Name: 00 tlJ ~SZ License aol2Address: ~ ei2oLl-)Ivj 6t- ~
Ciry: M4GI)5 VIC~~ State: /K- zip:
Phone: CO 0- b 3( -7s 5 -5Contact Person: '92?t-c/
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Cateaorv 1 Minnesota Rules 7672
Energy Code . Residential Ventilation Category 1 Worksheet • New Energy Code Worksheet
Category Submitted Submitted
(4 submisSiOn type) • Energy Envelope Calculations Submined
In the last 12 months, has the City of Eagan issued a pertnit 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 classi/ied as non-pu6lic if you provide specific reasons that would permif the City to
conclude ihat the are trade secrets.
I hereby acknowledge that ihis information is complete and accurate; that Ihe work will be in conformance with the ordinances and codes of the City ot
Eagan; ihat I understand ihis is not a permit, but only an application for a permit, and work is not to start wilhout permit; that Ihe work will be in
accorlapproved plan in the case of work which requires a review and app lans
x .J m~/~/S'o~? x
Applicant's Printed Name Applicant' ignature
Page 1 of 3
Cities Di ital ualitv Control
The following image represents the best
available image from the original page.
Every effort was made to capture the content
from the original page.
FROM : WILLMUS CO PFONE ND. : 612 633 5701 Sep. 16 1998 11:21HM P2
r-
t .qrc
pT i ELEV.-NRME-SIZE•..
ZG 938.9 ORk-36"
21 945.5 OHK-32.' •-.z,.~
22 956.1 OrIK-30"
24 949.7 ORK-26'"
21 448.3 ORR-20" ~ '394
3'n
948.6 CqK-23" 395
4i 555.1 90XELDfR-2-i3" 396
_ 43 955.4 80XEl.DER-16" x 409
~ 44 956-0 BOXELDER-14" X 410
45 953.4 BOxELDER-14" 412
4' 953.4 BOXELDER-14" 413
48 954.8 EOXELOER-i°" 414
61
955.5 OfiK-30" 4;5
56 442.7 OAk-34" eiE
64 95G J OflK-16" 417
933.3 POPLRk-22" 420
d" `?32.5 NSLLOW-20" ac
°3L 92~.' 0TTONN000-18120. x 430
96 935.4 CHERRY-1^u"" 4~1?
39 925.8 CHERRY-8% 438
'G? 932.9 'rINE-30 '4 X 43c
I1,c 926.n ?CMtIuER-IS""'i." X 4yC
i5 955.5 ORk-32 ae!
x 442
' ;4!.4 OnK-26" • 4aa
)4%.5 OPK-26" aec
i~94!.S CRK-20'&37" ,r 45i
:3u °•35.1 POFL'nR-20' x sa~
r>p .i7 aa; .C ofiK-30 ----'-K 4~~~
qc:
! 9a: , rOFK-ze. 46G
i40 947.0 ^vfll(-I~'." 4Ec
144 944.1 6AK-16" 163
14; 941.9 CrIK-20'' 36E
14 1
?3-1,5 rHERR'f-iu . 4E7
• 158 534.6 6RK-12"
loe 535.1 ORK-30" 473
°.3E.1 OF.N-24" 479
~ !7i 956-7 BCXEL7ER-;6" 460
! 946.0 O89-3+.' qg_
955.3 BOXtLDER-i6" qe~:
'.64 943.3 BOkE:~ER-:5" 484
i85 945.0 BOXELDER-ta" aBE
195 962.6 BOaE' OER- IS" 488
Y iG^e 0167.2 BOXELDER-!2" 48S
x 2!0 9P.9 BOXELnER-19" 43i
X 213 965.1 ElM-8" ;~a
2ia 56C.3 =.r:
r!c 360.9 OPK-26" SuE
x e!; 92p.9 OAK-24"
e21 955.4 BOXELCER-:3" x 5C,F
222 956.5 BOXEL?ER-i2" x SGS
1,23 959.1 -tr-@'- x ;,r
2c` 948.E BCxELDER-ia" y c:;
225 94:;.8 BOXEI~ER-;;'g„p" x Gi,
22e 949.4 BOXELDER-!2" a 5:13
C,?1
$53.8 80XEL~JER-!2" x 5;5
~'?2 95G.) ELM-IC" r 526
23; 935.5 MPpLE-16" 52i
2~0 941.7 60XELuER-14" x 5e2
24~ 944.5 80XELJER-12" 523
248 945.0 BOXELOER-16" k 525
e52 959.9 HDxELpER-!6"
255 963_4 80XELDER-,t2"& 7'="` 257:
.
Contractor S. Petersen Const.lnc.
Job 4333 N Woodaate Ln Enerav calculation
9-24-98
1 Total exsposed wall area 4700 0.11 517.00
2 Total roof/Ceiling area 1611 0.026 41.89
3 Porch exposed floor 0 0.11 0.00
Total 558.89
A Total window area 363 0.32 116.16
B Total Door area 102 0.128 13.06
C Total sliding Glass area 40 0.32 12.80
D Total fireplace area 10 0.128 1.28 ,
E Total framing area (av.10%) 570 0.719 67.83
F Tot. net wall area above floor 3198 0.045 143.91
G Total rim joist area 225 0.047 10.58 ~
H Total foundation Window area 18 0.32 5.76
I Tot. net foundation above grade 174 0.065 11.31
--J-' Total ezposed-bedroom-floor-floor 3.1.9, 0.045__ 14.36
Total #1 397.04~j
J Roof windows 0 0.14 0.00
Tot. roor/ceiling framing (10%) 38 0.049 1.86
L Total net insulated roof/ceiling are 1573 0.0193 30.36
Total #2 32.22
Total of land 2 429.26
' .
. . • CITY OF EAGAN
• ' EXTERIOR ENVELOPE AVERAOE 'U' COMPUTATION
" (BASED ON 1994 STATE ENERGY CODE)
OWNER: _
SITE ADDRESS:
CONTRACTOR: DATE: PHONE:
Detertnine working sauare footage and overell 'U' value of each
1. ToWI exposed walllfoundation area above grade 7,!90 sq. ft x.11 = 5-1-7
2. Total exposed roof/ceiling area . . . . . . . . . . . . ~ 611 sq. it. x .026 = g y
3. Total exposed floor/cantilevered area . . . . . . . sq. ft. x .04 =
12eSermine sauare footaae of each exRosed wall/foundation area "segmenY":
a. Total wall window area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ;3
`
b. Total door area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. Total sliding glass area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Total fireplace wall area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. Total wall framing (averege 10°/a) - See Fig. 1 . . . . . . . . . . . . . . . . . . . ~F-Z
f. Total W wall area above floor (rim joist) - See Fig. 2 . . . . . . . . . . . . . 3~y / N
g. Total rim joist area - See Fig. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total ex osed wall area V 5~~ ~
p above foundation = . . . . . . . . . . . . . . . . . .
h. Total foundation window area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i. Total W foundation area above grade - See Fig. 4 . . . . . . . . . . . . . . . IM
Total exposed foundation area = . . . . . . . . . . . . . . . . . . . . . . . . . . . / 2 7
, Detertnine 'U' value of each e:oesed walllfoundation area "sggmen
a. 34~17 x'U' ,3z
b. x'U' , i2y - i 3,03
C. v c) X v' , 32
- l 2, SSo
d. _ r D x'U' / 25f - l, zif
e. 570 x'u' i4t / - ~ 7, fl3
f. x'U' 1 ZQC15- - / 5' 3, y/
g. 22 ~ x'U' o Dy7 - leD „5~
n. ~ x'U' 13Z - 76
i . i 7 Al x'U' , 06.AI; - 1
4. Total actual 'U' value for exposed wall/foundatlon area = ~i ~'D 2~ 6 6
(If Item #4 is the same as, ar less than item #1, you have met the intent of the State Energy Code.)
. 4
~ . ~
. Determine sauare footaae of each ex ased roof/ceilina area "segmen
j. Total skylight area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
k. Total roof/ceiling framing area (average 10%) - See Fig. 516 . 3~
-
1. Total = insulated roof/ceiling area - See Fig. 5/6 5 7 3
Total exposed rooHceiling area . . . . . . . . . . . . . . . . . . . . . . . .
Detertnine 'U' value of each exoosed roof/ceilina area "seament,,:
j. 0 x'U' -
k. 3~ X'u'
i. ~ h r 3 X -u-, o l 93 = 3~
5. Totai aetual 'U' value for roof/ceiling area =
~
(If #5 is the same as, or less than #2, you have met the intent of the State Energy Code.)
Datermine sauare footaae of each exposed floor/cantilevered area "seamenY':
m. Total floor/cantilevered framing area (average 10%) - See Fig. 6. -3
n. Total = insulated floor/ceiling area - See Fig. 6 . . . . . . . . . . . . .
Total exposed flooNcantilevered area . . . . . . . . . . . . . . . . . . . . .
Determine 'U' value of each exnosad floorlcantilevered area "segment":
M. X.u. o, y;,-
n. X 'U' _
6. Total actual'U' value for floor/eantilevered area
(If #6 is the same as, or less than #3, you have met the lntent of the State Energy Code.)
Altemate Building Envelope Design
To utilize the total envelope system method, the values established by the sum of Item #4, #5, and #6 shall not be
greater than the sum of Item #1, #2, and #3.
1. s / -7 +2. +3. 1 2 , 76 =
4. +5. 3Z, 27 +6 1~-/,3~
I hereby certify that I have calculated the 'U' factors and 'R' values herein and that the building herein described
meets, or exceeds, the 1994 State of Minnesota Energy Code.
ignature
ate
V CITY USE ONLY
LOT ~55f ~ BL RECEIP'C /DO ~ S
UBD. n ~ RECEIPT DATE:
199$ MECHih1VICi4L PEfiMIT (g£SIDEN1'IAL)
crrY oF EasAv
S$SO PILOT KNOB RD
f.A6AN MN 55122
1~ l~/j,~,,,~ (612) 6$1-4675
Date: ~ ~(~l
Complete this section onfv if you are installing HVAC in single family, townhomes or condos under
construction and not owner /occupied
• HVAC: 0-100 M B T U $ 24.00 ~
ADDITIONAL 50 M BTU 6.00 ~
• Gas outlets ( minimum of one required @$3.00 ea.) /Z • DD
• State Surchazge: .50
• TOTAL: 4Z' 60
Complete this section on/v if you aze remodeling, adding to, or repairing existing single family dwellings,
townhomes, or condos. Note: Mechanical permit is not reauired for alteration/add-on to ductwork in
• existing residential units; but is required for the following:
Install fumace Install air conditioning
_ Install air exchanger, i.e. Vanee system, etc. _ Other
Minimum fee applies to all remodel or add-ons of existing residences $ 20.00
State Surchazge .50
Total: $ 20.50
33
SITE ADDRESS: lwOod x^-' 1,L
U(9-4f ~144-
' C . PHONE
ke(M
OWNER NAME:
iNSTALLER NAME' i 444- PHONE
STREET ADD SS: l4l ` ' ~
CITY: S ATE: ZIP:
SIGNA RE OF PERMITTE
JS/FORMS BLD/MECH PERMIT (RES) - 1998
V/ ~e,55131- CITY USE ONLY RECEIPT ~~~0 (0,
SUBD ~ RECEIPT DATE: /7
1998 PLUtyIDING PERMIT (RESIDENTIAL)
CITY OF EAGAN
3830 PILOT KNOS RD
EAGAN, MN 55122
(612) 681-4675
Please complete for: ? single family dwellings
? townhomes and condos when pertnits are required for each unit
? backflow preventer for underground sprinkler system
- -
FIXTURES EACH # TOTAL
Shower 3.00 x ~ = 3
Water Closet 3.00 x
Bath Tub 3,00 x
Lavatory 3.00 x
Kitchen Sink 3.00 x
Laundry Tray 3.00 x
Hot Tub/Spa 3.00 x ~ = 3
Water Heater 3.00 x = 3
Floor Drain 3.00 x ~ = 3
Gas Piping Outlet " minimum - 1 3.00 x
Rough Openings 1.50 x
Water SOftener `for dwellings under construction 5.00 x =
Water Softener ' for existing dwelling 20.00 X =
U.G. Sprinkler ' for dwelling under const 3.00 =
U.G. Sprinkler " for existing dwelling 20.00 =
AlteretiOnS `to existing residence 20.00
Water Turn Around 20.00 =
Private Disposal System ' MPC iic 75.00 =
(new and refurbished systems)
Private Disposal Systems'Abandonment 20.00 =
RPZ (new installation only) 20.00 =
STATE SURCHARGE 50
TOTAL o(z)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - tha- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
I hereby acknowledge that I have read this application, state t the infortnation is cortect, and agree to comply wkh all applicable Ciry of Eagan ordinances
It is the appliwnt's responsibiliry to notify the property owner that the City of Eagan assumes no liabiliry for any damages caused by the City during its
nortnal operetional and i n ctivities to the facilities constructed under this permit within City property/right-of-way/easement.
SITE ADDRESS:
OWNER NAME: J•~~vJ~(1 ~n~~ r v~c~-~~ o n
INSTALLER NAME: OIXI TELEPHONE ~-ic~(~l ~ ~`-1`-?
STREET ADDRESS: -7 r::) So 'PC]U-1 4 ~
CITY: STATE: rn~ ZIP.
~
SLIGNATURE OF PERMITTEE
CD/PERMIT FORMS/RPLBG PERMIT (RES) - 1998
.
� Use BLUE or BLACK Ink
` r________________--+
I For Office Use � I
� � Permit#: t�`� v �
clt� of ����� � ,^� �, �
� Permit Fee: V� I
3830 Pilot Knob Road � I
Eagan MN 55122 EcEoe�ED � Date Received: '�) ' �
Phone: (651)675-5675 R I I
Fax: (651)675-5694 ��L � $ 26,� i Staff: �C7 i
_________________�a
A
2014 RESIDENTIAL BUILDING PERMIT APPLICATION �ti� ,'
��
Date: Site Address: Unit#:
Name.C-�(�'r-.� � .���`C �� Phone: .,
Resident/ � �� S ! � ��'�t�'
�- OWII�I'� . � � ' Address/City/Zip: ���� � �✓�d!'� �� �dl
Applicant is: Owner � Contractor
Type of WOrk-; Description of work: / C "X� l L> � S�c.s j'a•. ��r�-�
�w
, ' Construction Cost: 2���� Multi-Family Building: (Yes /No��
Company: /7�(� �rsvlcl�cy—� i��C Contact: Vt�` ��'G.-S',v�
COI1tCaCt01' Address:Z� � �r�°C �� ��City:
State�'1�' Zip: �'LU'Il Phone:S���" ���Email: C�^ � ��''`��'`Pd((r�",. C�"
License#: C� �] Lead Certificate#:
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
,\
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 consideretl to be public informafion. :Portions of
the information may be classified as non-public if you provide specific reasons that would permit the City to
conclude fhat the are#rade secrets.
CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.qopherstateonecall.ora
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 State Building Code must be completed within 180
day of pe mit issuance.
X � x � ��r'�^'Y c'L �!�
li Ys Printed Name Applicant's Signature
Page 1 of 3
,
�3 s3 ���� �"� �� �'1/ � „
DO NOT WRITE BEL W THIS LINE � �"� ���
SUB TYPES
_ Foundation _ Fireplace � Porch(3-Season) _ Exterior Alteration (Single Family)
Single Family Garage Porch (4-Season) _ Exterior Alteration (Multi)
Multi Deck Porch (Screen/Gazebo/Pergola) _ Miscellaneous
_ 01 of_Plex _ Lower Level _ Pool _ Accessory Building
WORK TYPES
_ New _ Interior Improvement _ Siding _ Demolish Building*
�Addition _ Move Building _ Reroof _ Demolish Interior
Alteration Fire Repair Windows _ Demolish Foundation
_ Replace _ Repair _ Egress Window _ Water Damage
Retaining Wall *Demolition of entire building—give PCA handout to applicant
DESCRIPTION
Valuation Occupancy � MCES System
Plan Review Code Edition �t SAC Units
(25%_ 100%�) Zoning i� City Water
Census Code Stories Booster Pump
#of Units Square Feet PRV
#of Buildings Length Fire Sprinklers
Type of Construction � Width
REQUIRED INSPECTIONS
Footings (New Building) Meter Size:
Footings (Deck) Final/C.O. Required
� Footings (Addition) � Final/ No C.O. Required
Foundation HVAC Gas Service Test Gas Line Air Test
Roof:_Ice &Water _Final Pool:_Footings _Air/Gas Tests _Final
� Framing Drain Tile
Fireplace:_Rough In _Air Test _Final Siding: _Stucco Lath _Stone Lath _Brick
� Insulation Windows
Sheathing Retaining Wall: _Footings_ Backfill _Final
Sheetrock Radon Control
Fire Walls Erosion Control
Braced Walls Other:
Reviewed By: �� , Building Inspector
RESIDENTIAL FEES
Base Fee �
Surcharge � � ���� ���
Plan Review ���b'�.,�.--'�
MCES SAC
City SAC I ' � � /� � ' � "� ��
Utility Connection Charge � C�� � �
S&W Permit& Surcharge �
Treatment Plant
Copies
TOTAL
Page 2 of 3
Certif i�dte of House Loc.ation For: �/�j
, '. H98182 � � � ( ��
Sve,nd;PetPxSen Constzuct.ion, Inc. . 192JSb
DELMAR H. SCHINANZ .
LANO SUNYEYOA! IMC.
RaqiMa�O lMA�l�w e1 Tnr Stab W MNnMSen
14750 SOUTH ROBERT TRAIL ROSEMQUNT. MINNESOTA 55068 612/<23-1769
SURVEYOR'S CERTIFICATE
Prop�rty �ddress: 333 North wboclgate Lane ....
• = Iron pipe m�nume,nt
C] = Set wrx�d hub at building offset Proposed garage ftoor elev. 93�2
q3� = Existinq spot elevation Proposed top of block etev. � 4/.�
Q = Proposed elevatian PropQSed low�est lev+el elev. 9 .
� = Pro�osed directian of drai.nage . .
9'� �
,oa'� [�QC�(�1(�l
�' s� - ���OC���E� , � .
o�e �°°
°� PONp BP-23 BY
Nw�. - s3�.3 � DATE�a 9 S�,�ry�
�� HML = 939.� /�--- �\� B�ILDING 1NSPF�� +���S DEPT.
� �� �
DRAINAGE 6 i1TILITY EASEMENTS / i � � -�� �
/ � �� '��•� \ �
�a 931.3 / h�A�� \� � ,
�flND ELEV, s-ss-se + � �,.. ��
( � �r 932.i �` �• .
f � � 48 . ��, ��Y
�"` ` \'V �� N7S��9��9 E \� ��• � —
�� � ,_._.` �� L�T 55 , �.
� � � , . �
�� \ 947.4 \ �� ,
\\ + ��_�•-'� h�3 .i s39.�
�V`� y . BLOC�- 1 � 938.3 ��,,,�
�.�1" ��, \ 949.1 Q�`� �{'+ �� ��
��,�/'�l/l� •�S \�+ �;�"'`(� t�,,p��s ' �'`�'t�+�
�V \ � �(�� 1� � �'P ,�0 �� 937.5
� � � 934. .' \
• � '�0 3
� �j •
p� O
,r`� \ �1 ' �oJ� � 6� ��,� �
� \a ,.. `� ' '• , i1�'� � � j� ��� i g40.0 �OQpSF'� 6� � 2� 934.6 , 5.4 �fj 4
l��
" _ • 942.3 tiQ c� R c� '/� � � � 934.3
� . � . .c�"-� , . ,: � . 0'''', �/r.h�.J . . '� �' ' . .
-..,, r' � . .. ��'��� q.�26 �J�'. "'/• .. � � . .
.�gC�V�T��Cu��'�°,ry�' ' � :s� - ,� • '"• � �!•� • •�►' 3,
tioG 937.e �� � �o�3
s'�` ' a �i"-
� / �
D@SCtI.�tOIl: �D \/ jp � �
IAt 55� BIoCk l� MALZ,ARp PARK 4TEI A►DDITIONi 5. � �� ��
according to the reoozd ptat tl�ereof, �' �
Dakota CQUnty. Minnesota. � .
��� 533. .
Also shvwirig the location of a proposed � • �
house staked thereon. �
„'o �� � �n ��.._,,- ,
0 ��] � V o u u � � `�� L�+�t� u�---� �J
�,�."�`��u�u�i�ittnttr,tti„ � !�° °
I fieraby cer�lty Ihat fhia turvey�p1en,or report wae ��� ��,��S Q��,f�� �
prepered by me ar unda my dlnot Iup�rvltion�nd ����:.•' •. =�,
thet 1 am s duly Registered Lend Surveyot under � '•;��
iAe isws o�tne State oi Mlnnssola, '��� RELP�AR H. • � �, /��
. = SCHWANZ ; =
"; 09-23-98 = • '�Oeimer+�. Schwenz
�Oeted � �• --$625-- =Q�M��^esota Regletratlon No. 8625
a '.f,,,��;•• :yp�4�
, !,,''�����Ifis�Upt�ilv��```�`\
, � Use BLUE or BLACK Ink
�——————————
/ \�, I For Office Use I
0� l� � , �
C• � �- ; Pe�,�t#: /3l ��,� �-__..,
lt� Of ����Il ��:c������:�� ,�, ► I� �
��� 2 � ,IQ�� b � Permit Fee: l'7 �. �V
3830 Pilot Knob Road .�;
Eagan MN 55722 � Date Received: '� 'J �
Phone: (651)675-5675 � �
Fax: (651)675-5694 I Staff: �
1 I
2015 RESIDENTIAL BUILDING PERMIT APPLICATION
Date• �� Site Address: �f 33 C.IC�t tTnit#:
;x
"� �� � � Name: �(Z�iP.�i1 � �,Q/��.� ��,1 Phone: GQS�'75[.' !d 3�
����i��n�1 � �T�Q �/� - L- /�� � / �—�j
(�� Address/City/Zip: ��3� �. I�DUGvil�l�i (.lri ��lG{� /I/1/(/ W/ 2-2
� ; Applicant is: XOwner Contractor
�
� � Descri tion of work: �� ���I��Q�Z
7������� � p —t��r�.r�l
_ �,�� � "� . Construction Cos�� �Q U Multi-Famity Building: (Yes /No��
� �� - ���F �
° � ', �� � �'�� Company: Contact: �°�° �
��
�����, Address: C�ty: i
' ' �: � State: Zip: Phone: Email: I'
� �
License#: Lead Certificate#:
If the project is exempt from lead certification, please explain why:
� ��
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 8�Water Contractor: Phone: � �
Fire Suppression Contractor: • � Phone:
r; �`l� F��is��Aca�`1���oc����,�#�� �� ' ��� �e {y�``����'�� �i
_ ��������� '�!y �} f,� �y,] g �y3 .�y� p�i {�.`
s
y � �"w.W�«C`����'{�����if#�R�3���T�7���� 'W���7F1�:9P��m��`�i�������.�
, ' � �-�. � - y � � �
,: � �'� ���i��� �.-� � � ..�, �w � � �. l
,�,.�a.c . ' 6 :- .
,_, �, .i ., .o. , .x ,,..,_ , r, :. .: ,e<, � > :�'.
., .... . .... ,.,,.-, �. �. . ��.
V�c
CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.popherstateonecall.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 State Building Code must be completed within 180
days of permit issuance.
�����" �x X
ApplicanYs Printed Name A i s Signatu e
Page 1 of 3
..
DO NOT WRITE BELOW THIS LINE ' �
SUB TYPES !
_ Foundation _ Fireplace _ Porch(3-Season) _ Exterior Alteration(Single Family)
� Single Family � _ Garage .Porch(4-Season) _ Exterior Alteration(Multi)
_ Multi " ' _ Deck _ Porch(ScreeNGazebo/Pergola) _ Miscellaneous
_ 01 of_Plex _ Lower Level _ Pool _ Accessory Building
WORK TYPES
_ New _ Interior Improvement _ Siding _ Demolish Building"
_ Addition _ Move Building _ Reroof _ Demolish Interior
�C Alteration _ Fire Repair _ Windows _ Demolish Foundation
_ Replace _ Repair _ Egress Window _ Water Damage
_ Retaining Wall *Demolition of entire building—give PCA handout to applicant
DESCRIPTION
Valuation �"Z l (o�•� Occupancy 3�ZG- ( MCES System
Plan Review Code Edition �1��.o►,� SAC Units
(25%_100%�) Zoning R—) City Water
Census Code Stories Booster Pump
#of Units Square Feet PRV
#of Buildings Length Fire Suppression Required
Type of Construction V� Width
REQUIRED INSPECTIONS
Footings (New Building) Meter Size:
Footings (Deck) Final/C.O. Required
Footings (Addition) � Final/No C.O. Required
Foundation �C HVAC_Gas Service Test Gas Line Air Test
Roof:_Ice &Water _Final Pool:_Footings _Air/Gas Tests _Final
� Framing Drain Tile
Fireplace:_Rough In _Air Test _Final Siding:_Stucco Lath _Stone Lath _Brick
� Insulation Windows
Sheathing Retaining Wall:_Footings_Backfill_Final
Sheetrock Radon Control
Fire Walls Fire Suppression:_Rough In_Final
Braced Walls Erosion Control
Other:
Reviewed By: T�Y1/� ��/.� , Building Inspector
RESIDENTIAL FEES � 2� X� ,
Base Fee
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S8�W Permit& Surcharge
Treatment Plant
Copies
TOTAL
Page 2 of 3
Use BLUE or BLACK Ink
r————————————————�
I For Office Use
� ' � � �oK� �
CltV 0� ��o�Il ; Permit#: I
d �a I �G/ I
� Permit Fee: �
3830 Pilot Knob Road � i
Eagan MN 55122 I Date Received: �
Phone: (651) 675-5675 I �
� Staff: �
Fax: (651) 675-5694 �___ ______�
2015 RESIDENTIAL PLUMBING PERMIT APPLICATION
Date: ��ZZ'�� Site Address: ���� � �a0�v1,�--�� �-�'l
Tenant: Suite#:
� � �� .:
#:����� �� ��� �;� . /
�' �' Name: ._!GL��,e. 1�.�X Phone: �l 2� 5 0/� 7�.6�
,ReSlden#/
� �x
� . `���.� ���; `�" Address/City/Zip: 33� � ��0� x� ��
� �� � ���,
� . �� �j �f
Name: ��� r"�(��''��/��- License#: �l U 6Z 7�/
� b � tx . =.; ,
Address: ��� � /1��'�.. ��a��V CT City: ��`du��
�� Contra���
��� ` ����� State: �I� Zip: -�-���fJ Phone: �'S2 - Z3�- d 1��
�� ; ��''���� :
�,�} ,° t � . Contact: �U�� �t�t��vC.�pY � Email:
# New � Replacement _Repair _Rebuild _Modify Space Work in R.O.W.
����� � �� — — —
������ Description of work: fnZa(/'2 � � � GC c' �E s LJ �
< ��� ��` ' RESIDENTIAL
��
. � _:��-� Water Heater
' � ��` � �� " Water Softener
� �° ��. ����� Lawn Irrigation(_RPZ/_PVB)
� �� � ' ��e Add Plumbing Fixtures�Main/_Lower Level)
�
Septic System
�r`� � Water Turnaround
�� _New
� 5����� Abandonment
RESIDENTIAL FEES:
$60.00 Water Heater, Water Softener, or Water Heater and Softener(includes State Surcharge)
$60.00 Lawn Irrigation(includes State Surcharge)
$60.00 Add Plumbing Fixtures, Septic Svstem Abandonment, Water Turnaround*(includes State Surcharge)
"Water Turnaround(add$210.00 if a 5/8"meter is required)
$115.00 Septic SVstem New(includes County fee and State Surcharge)
TOTAL FEES$
CALL BEFORE YOU DIG. Call Gopher State One Call at(651)454-0002 for protection against underground utility damage.
Call 48 hours before you intend to dig to receive locates of underground utilities. www.qopherstateonecall.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 rmit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approval of pl ,s.
X �r�� �u��o�� X
ApplicanYs Printed Name A cant's Signature
� � �� �x��
�# R O�Fi��JSE �� � � ���a+�ed � ��- '�� �� ���� �.�M.� .���
��� � ' � � ��e ������- �� � fla#+a �����
� ,s... �� � ' � � �� �� � � �
�2�:quired�,�����#lor�s� #�� � Under Ground ����}��� ��i 1n � ��r�"�st �as'� �� F�r��l �
� ���� ���� � � � ¥����� �� � ` ���� _�
:
Meter Relatex���e�i�: % 11��#�er�iz� ° R�d��a � rn�ter��� � �S#��f: ' ����
r.n.w� � .. s��.�{�.. x v� �
�
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA147876
Date Issued:02/13/2018
Permit Category:ePermit
Site Address: 4333 Woodgate Lane N
Lot:55 Block: 1 Addition: Mallard Park 4th
PID:10-47253-01-550
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Water Softener
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.
Allow an 18" minimum radius clearance to the water meter from all appliances (i.e. furnace, water heater, water softener).
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 -
Corey L Cox
4333 Woodgate Lane N
Eagan MN 55122
Dakota Water Treatment
17484 Goodland Path
Lakeville MN 55044
(952) 953-4643
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA179826
Date Issued:10/21/2022
Permit Category:ePermit
Site Address: 4333 Woodgate Lane N
Lot:55 Block: 1 Addition: Mallard Park 4th
PID:10-47253-01-550
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:
This permit shall be null and void if work does not start within 180 days of issuance, or if work is suspended for 180 days or more after
started.
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 -
Corey L & Jacqueline A Cox
4333 Woodgate Ln N
Eagan MN 55122--228
Mikes Custom Mechanical Inc
P O Box 171
Champlin MN 55316
(763) 568-7148
Applicant/Permitee: Signature Issued By: Signature