941 Trail Ct .
,
r
INSPECTION RECURD
~ ~ ` 1? ! 1 1{. i. l ~~y (1
CITY'OF EAGAN PERMIT TYPE:
3830 Pilot Knob Road Permit Number:
Eagan, Minnesota 55122-1897 Date issued:
(612) 681-4675
SITEADDRESS: ; APPLICANT:
r •AT1
I t ,1 I t : I410
PERNIIT SUBTYPE: TYPE OF WORK:
INSPECTION .
: i ~ : <<~~t ~ r~~. '
:
~ ~
. Permit No. Permk Holder Date Telephone f
, ELECTRIC
~
• PLUMBING ~~j~ 88 9 7 77v ;Qi7 7?
HVAC F' ~
Inspection Dste Inap. Comments
FOOTINGS 7 ~
/
FOUND ~347 [n' / ~ 4
FRAMING AAal
ROOFING
ROUGH n
PLUMBING -
PLBG
AIR TEST 7
ROUGH n
HEATING ,~~r
GiAS SVC
TEST
INSUL
GYPBOARD
FIREPLACE
FIREPLACE
AIR TEST
FINAL PLBG GJ C~
!
FINAL HTG 4 497,
ORSAT
TEST
BLDG FINAL Iota.fq
BSMT R.I.
BSMT FINAL
DECK FTG
DECK FINAL
%RL'ftf[CRtC 0f CCC1ipQltC~
Kitij of Wagan
Zeyartmeat oF !Sai[bing ani3pectiun
This Certijcate issued pursuant 1o the rcqurremertts of the Unifarm Building Code
ce'tiJying that at the time of issuance this rtructure was in compliance wirh the various
oniirtances of the Ciry regulating bui(ding coutructian or use. For tke follawing:
uYc,vzir~: SF UwG Bae No 30376
o«~p-'Y rrx R-3 U-1 Z..i~a oe-1 rra co.v. Vn
a,,,K„f8,,;l&,,e HETEO, CLASSIC HOHEZ,. 8703 HEATHERTON R1DGE DR., SAVAGE, 4
eWaNgp~ 941_TRAIL :.T ~;,y L4, Sl. T&A1LS EA1D
om,: -7
` etfiw.gaw~ ~
POST IN A CANSPICUOUS PLACE
e,
Aodress 941 TxniL CT Zip 5512_
L.ot 4 Blk 1 Sub TRAILS Erm
THESE ITEMS WERE / WERE NOT COMPLETE AT THE TIME OF THE FINAL INSPECI'ION.
Date; 9 0 Yes No Inspector.
Final grade (6" from siding) ~
Permanent steps (garage)
Permanent steps (main entry) ~
Permanent driveway . t/
Percnanent gas V/
Sod/Seeded grass ~
Trail/curb damage ~
Porch ?
Basement finish t/
Deck ?
Please verify with the builder the removal of roof test caps from the plumbing system and the shut-0ff of water supply to
the outside lawn faucet before freeze potenaal exists. Contact engineering division at 681-4645 before working in rightrof-way or installing underground sprinkler system. ~
White - City Copy Yellow - Resident Copy Pink - Contractoc Copy
• " ~ . S
~ 2005 RESIDENTIAL BiJII,DING PERNIIT APPLICATION Z
City Of Eagan
~
_
3830 Pilot Knob Road, Eagan MN 55122 S r rF~
Telephone # 651-675-5675 FAX 9 651-675-5694
New Construdlon Reauirements RemodeVReoairReuuirements Ofiice Use Onlv
3 registemd sXe surveys shrnvirg sq. ft. of lol sq. ft. of house; and all roofed areas 2 copies of plan CeR ot Survey Recd _ Y_ N
(20% maximum lot coverege albwed) ns Tree Pres Plan Recd _ Y_ N.
2 copies of plan showlig beam & wiMow skes; poured found design, elc. 1 she survey for addilions 8 decks Trea P2s Required _ Y_ N
lsetofEnergyCalculations Add'dion-indicatei/on-sitesep6csysfem On-siteSepticSystem _Y_N
3 coples ol Tree Preservatbn Plan'rf lot platted after 7f 7193
R'un Joist Detail Options saledion sheet (6utldings wAh 3 or less unb)
Date 05_ / 10_ Construction Cost
Site Address Q~, i rai 1 COurA ~ UniUSte #
Description of Work l0 LAil ~ In C~F Glr, ~JCS Yl(~ S Cm ~ Ic GtCJ
Multi-Family Bldg _ Y~ N Fireplace(s) ~0 _ 1 _ 2
PropertyOwner C~3 exx~qc, 3' c1c~'R`[1'ih\E~.Nltc~ Telephone#(612, ) a6A-
- g - C9624
Contractor
Address Cih'
State Zip Telephone # ( )
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
- Minnesota Rules 7670 Cateeorv 1 _ Minnesota Rules 7672
Energy Code Category . Residenlial Ventilation Category 1 Worksheet • New Energy Code Worksheel
(4 submission lype) Submitted Submitted
. Energy Envelope Calculations Submitted
Have yov previously constructed a building in Eagan with a similar plan? _ Y _ N If so, 25% plan review
fee applies.
Licensed Plumber Telephone ~
Mechanical Contractor Telephone )
Sewer/Water Contractor Telephone )
I hereby apply for a Residential Building Permit and acknowledge that the information is complete and accurate;
that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN
Statutes; I understand this is not a permit, but only an application for a permit, and wark is not to start without a
permit; that the work will be in accordance with the approved plan in the case of work-which re and
approval of plans.
MAY 1 12005 ~ i
~
Applicant's Prinfe Name Applioant's Signature I~L1 -
n„
OFFICE USE ONLY
Sub Types
? 01 Foundation O 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
? 02 SF Dwelling ? 08 06-plez ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Ait - Multl
? 03 01 of _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF
? 04 02-plex ? 10 OS-plex 18 Deck ? 23 Porch (screen/gazebo) ? 36 Multi Misc.
? 05 03-plex O 11 10-plex ? 19 Lower Level ? 24 Storm Damage
O 08 04-plex ? 12 12-plex Plbg_Y or_ N? 25 Miscellaneous
Work Types
? 31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding
Ik 32 Addilion ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair
? 33 Alteration ? 37 Demolish Building' ? 43 Reroof ? 46 Windows/Doors
? 34 ReplaCement "Demolition (Entire Bldg) - Glve PCA handout to applicant
Valuation ~f ~OC) Occupancy rt MCES System
Census Code ~ Zoning ~ City Water
SAC Units Stories Booster Pump
# of Units Sq. Ft. PRV
# of Bldgs Length Fire Sprinklered
Type of Const Width
REQUIRED INSPECTIONS
Footings (new bldg) FinaVC.O.
~ Footings (deck) Final/No C.O.
_ Footings (addition) _ Plumbing
Foundation HVAC
Drain Tile Other
Roof _ Ice & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests Final
_ Framing _ Siding _ Stucco _ Stone _ Brick
_ Fireplace _ R.I. _ Air Test _ Final _ Windows
_ Insulation _ Retaining Wall
Approved By: Building Inspector
Base Fee
Surcharge
Plan Review o cod
MC/ES SAC
City SAC
Utility Connection Charge L?
S&W Pertnit & Surcharge
Treatment Plant
License Search
Copies
Other
Total
. • '
I
/
;
2422 Enterpriea Drive
Mendolo Mm9ht5, MN 55120
* ~ (St 2) 681-181 4 fAXt 681--948A
~ PI~Q'~-T~II`EIEFe _ .a.o s~,~~cvaas • ch~ cna~cns - -
~L ~n~ L~H~ Plnn~!EP's~ U4~f~M: M[wiCCS 62.i Highl~y 10 N.E.
QAoin r1~;ne, MN fi5434
8
* * * I (e~p) 783-1860 FAX:78~-4~13
~
C;ertificate of Survey ~or: N1ETR0 CLASSIC HOMES
941 TRAIL CCURT
F'i
(''U~
~
iV~6-N89°41'55"W 92.00 ~O84.0
_ ~ ---~s ~I n~~05
y!, `sPRA1NAGE & V'IW7Y
~ _ _
' EASEMEN7 FER PLAT' - ~ ~
• r~,~ ~
8e7.6 4 " 8.4
$ e~s.s x
Lf)
` I c ~ Z
00~ Ic1.00 887.: I( I 4.03P,5.2
o~ ..I~' -I ~ 4~
O 8p9.1
~ ~ I i N\\ P H~e '
z p M I i M 13_67
a; ~ 883.6 83A.8
v
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4.33
1(
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o
R, 20.DC^ ------1-21.00~_ C
889.< 889.5
SE,qCN ~?ARK y
o Si 1 1 -----9eNCH MA;3s~
TCP OF PIP~: or f 7C7F Of PIPE
ELEN.e889.7'.-'''-`' ° "a I g ELEV. =~d98.J4
~ L_.._ -C)~M -----J
~YJ 8A8.5 ~NV.m8780~" 967.4 ~
° 888.6 Sa9°52057-w i ~~71~~ 12 ~ 887.9 °
- „ ~ aas.z 48.53 ry ~
COU
A~i, RT u7_~~t;c~x~_,
aanvnSFn HOUSE ~AT~Oj1^
u7Tf: ?RpPGSEO GRAGES SMO'hN ^ER GRPOWC ?LAh 0Y: M[OLiINO • 6/pjb
NO/C Bl1ROINC DIMENS10Y$ SNOYM AkE fOR HURIZONtq'. AN7 tifRJ'AL LOCATION, ~~'ryEST FIOOR ELEbATIDK:
ui STRUCTURES ONLY. SFE GRCniTEC/UN- 7LAN3 I'OR BU'~OIM6 h~~~ TOP UF 3LOCK E~EVAnUN; L ~L' L,_
iCVN:AYION DIGEN~~S
~;~7r '7
6 ti0 Sr^EGifiC SGILS tN~T50GAnCN NA9 dEEN COMF4ETED ON ~N'S LOT BY 7HE GAAAGE S~aB ELE`/AT'~N' L' ~ ,
SVA%EY00.. TNf SUITAB~'-iTY Ps SU46 TD SU°FORT 't+E SPCCIPIC NOIiSE ~
GROPOSE6 IS NOT ME hiSFONSEWT' Of `.RC SUiI''EY04. g pCAAC DENOTES "iYTiNG LlEVahON
N01E'. 1n~5 CEft11FIGAiC DtlES N3T QURPbRT f0 7h¢Y+~ CASEMEN!5 OTHCft !H~.u ~ ppG.CO ) DENOTES fR~h'OSED F.IF\'.~7iuW
rnOSE SNOYm 9N TNE RECOADEO >LaT. pCN0iE5 PaPfflRGf AND UTUr E~tSEMENi
UFPiN>C[ fICW 9~ECflJ'!
..-r DENOTES
1,OTE: CONTRPCTOR MV31 `~ERiSV D0.1VEWA" DESIG^~. DENOTES HONUMENT
NOTE 6EARiNGS 5:10`HN ARE L'~SEO ON AN ASSU+AE3 9AT'JN _-.e."- OENGTES OFiSET 4UB
WE HEREE3Y CER71fY TU NEYFC CL/~SSII) 'ta0lLE5 7NAT THS i5 A TRUE ANO CORRECT RE?RESENTATION ':~r A
SURVtY 6F THE BOVNDAFIES OF:
I.OT 4, BLOCK t, TRA!LS END
OAKOTA COUN?Y, MINNE.50TA
;r ES NCT I'URPG~' TG SH~~~1'UPROV'EMERiS CR ENCHROACHMENTS, EXCE?T AS SHOWId, AS S~FVE`.`EJ 8Y ME 0
GO '
F JUNZ~.iNGER MY DIREf.T SV?EflVISiOPJ TH!S 19TH DAY G, t'397. Si*E:L:)/ '1ONEER Ft.C`~
• = e"` ~
SCALE A INCH 30 FEET
ohn C. Lnrwn, L.S. F<ep. No. 19828
~ .c1 n-i.oa> no GWK ,
PERMIT
Y,'CITY OF EAGAN
\3830 Pilot Knob Road PERMITTYPE: suzLosnG
Eagan, Minnesota 55122-1897 Permit Number: 0 3 0 3 7 6
(612) 681-4675 Date Issued: 0 7/ 16 / 9 7
SITE ADDRESS:
941 TRAIL CT
L07: 4 BLOCK: 1
TRAILS END
P.I.N.: 10-77160-040-01
DESCRIPTION:
Btiildingl„Permit Type SF DWG
Building Work Type NEW
~11IBG AGCUpancy%, R-3 U-1
` Conatrudtion Typ,e VN
i
fZanrngR-1
Build3ng Length % 46
Building Width: 46
~ Squa,t^s fieat 1 , 856 u.s C o~d ~`e 101 1- F A M. D E T A C H
i ° ~-~>.~„rf:: ea i
REMARKS:
S&W PLUMBER = ALTA MECNANICAL
FEE SUMMARY:
VALUATION $94,000
Base Fee $849.75 MISC FEES $1,539.50
Plan Review $552.34 7ota1 Fee $3,943.59
5urcharge $47.00
SAC $950.00
SAC ~ 100
SHC Units 1
Lic. Search Fee $5.00
Subtotal $2,404.09
CONTRACTOR: - Applicant - sT. LIC. OWNER:
ME'fR0 CLASSIC HOMES 14456100 9322 METRO CLASSIC HOMES
8703 HEATHERTON RIDGE RD 8703 HEATHERTON RIDGE DR
S4VAGE MN 55378 SAVAGE MN 55378
(612) 445-6100 (612)445-6100
F- .
I hereby aeknowledge thaC T have reatl this app7,3GaCion an.d state th=at bhe
information Is correct d egree to comply with a11 applicable 5tate ofi Mn.
Stat es d City of a,gan Ordinancas.
r
AP LICANT/ M NATURE ISSUED BY: SIGNAT E
•3>Y.,~::ic~;:~?:>}>f;f'~,.wtd~;%~;4;k... '~~~?x?k>Y.'~~r>,t~#~~F~k:~?
C:I:T'Y f:us F.
i; 1E:ftt4.T.tJAL. iJO;; 90
PFfT1=',tt Ci"r'!:I.t,;.`:)i' T:f.ME:e .5;,(l'1.::L2
3D„
NAME'd P?LI:[!..BE'.RS i'It]F'.'i'G61GE cxn;PoRr-rr.r.aN
~,.~i.i= ':'Ij[I: c7~j.1. 7~?r':T.I... (.:T 1i3,~n4~'.i~~.°i`.:i
c_c.~!..r . . .
?',:1'i:•i:!.I. I':e['o:Li't i-`:IilOl1%11t,^. 3c94.'3.Jj
rRi_i7"87¢3
USi::.''i .(11, Ni"iP:li-:Y
1997 BUILDING PERMIT APPLICATION (RESIDENTIAL) ~ 9
3 O~ ~ r CITY OF EAGAN
u~ 5830 PILOT KNOB RD - 65122 /1 v
681 -4675
New Construction Reaulrements $emodeUReoeir Reauiroments -71
~ ,
? 8 registered sfte aurveys ? 2 copies W plan
• 2 copies of plens (indude beam & window saes; poured Md. deafgn; ek.) ? 2 ake surveys (euteriar adtlitans 8 dedcs)
? 1 energy celwlaUons ? 1 energy calwlatlons for heated addttions
? 8 copiea of tree pieservation plan H bt plaltetl eRer 7!1/93
required: _ Yea _ No DATE: 4~9 CONSTRUCTION COST:
DESCRIPTION OF WORK: le: i. / i?'lar
STREET ADDRESS: T
LOT BLOCK _L SUBD./P.I.D. /ZW~
~'~oena. 1-krner
PROPERTY Name: 1~i/71dPhone
OWNER u.. )
Street Address: ~03 l~C4TL~~2Tt"Jhl ieic4ft 6- A2 ,
City: z-. State: Zip: ~~3 -7P
coNTwacroR Company: /yE%20 e~~97C ~iylc~'t Phone ~ 0,
Street Address: 7CJ.3 E 760~0- ~,Aj License g~~
~ G K.
City: State: Zip: SS"3~~3
ARCHITECT/ Company: ~ e,(S Phone#: -017-'f"d Jd
ENGINEER
Name: r/~~"-d Registration
Street Ad~ress:
City I~l ci /L State: je2je~: Zip: ST3'7 Z
Sewer 8 water licersed plumber (new consUuction onty): ~/~T~ • . Penaliy applies when address change
and lot change are iequested once permft is issued.
I hereby acknowledge that i have read this appiicaTion and state that the irdormation i co t agree to compl ith applicable
State of Minnesota Statutes and City of Eagan Ordinances. ~
Signature of Applicant:
OFFICE USE ONLY CEIVED
Certificates of Survey Received ?Yes _ No J Ui1 3 0 1997
Tree Preservation Plan Received _ Yes _ No Not Required
, OFFICE USE ONLY ,
BUILDING PERMIT TYPE
o 01 .Foundation o 06 Duplex ? 11 Apt./Lodging o 16 Basement Finish
02 SF Dwelling ? 07 4-plex ? 12 Multi RepaidRem. ? 17 Swim Pool
x0 03 SF Addition o 08 8-plex o 13 Garage/Accessory o 20 Pubiic Facility
0 04 SF Porch o 09 12-plex ' 0 14 Fireplace n 21 Miscelianeous
n 05 SF Misc. 0 10 _-plex , 0 15 Deck
WORK TYPE
~ 31 New o 33 Afterations o 36 Move
0 32 Addition ? 34 Repair o 37 Demolition
GENERAL INFORMATION
Const. (Actuai) VN Basement sq. ft. MC/WS System '
(Allowable) VA- Main level sq, ft. City Water
UBC Occupancy W i sq. ft. Fire Sprinklered
2oning l~l sq. ft. PRV Y.10
# of Stories sq. ft. Booster Pump
Length sq. ft. Census Code.
Depth !v Footprint sq. ft. -~7 SAC Code ~
Census Bldg 1
Census Unit ~
APPROVALS
Planning Buitding 1'I11 , Engineering Variance
Permit Fee Valuation: $ zD,
Surcharge "
Plan Review
License
MCNVS SAC /L -F,4 j~
City SAC
Water Conn.
Water Meter
Acct. Deposit
S/W Pertnit
S/W Surcharge
Treatment PI. ~
Park Dedt J10~
Trails Ded.
Other Copies
Total:
7~PVO.nD
% SAC
SAC Units 70
9 o~°I ~
2422 Enterprse D+ive
Merdoto Heights. M.Y 55120
aF
^
pMONEEp .a,~ 5,,~~~nas • CMl iNq'N_~MS (612) 681-1914 FAX:681-9488
~ ~~•~~...e^
~ enn eering lANO 0.MWEMS0 LANDS~Mi AMM1EC3 I 61J H~19h.Y10Y 10 N E.
Bla;ne, M.N 55434
(8'92) 783-1860 FAX:78.'~--4883
Uertificate of Survey '[or: N1ETR0 CLASSlC HOMES _
941 TRAIL CCURT
(
G'
i N89°41'55"W 92.00 eea.o
f5
~
5I~~EASB EtiT FERTIPLAT'~
e67.6 8884 M 8~6 3 z 4 ~ " I M
1A ~ I ~
p.~- _~1.00 887.3 14) 884-9Lt.00~_ gP5.2 ~
O 8~39.1 ~ 46.00
~ gy~z ROFO5E 0 l± / ~
I ~ N H0~
zw n ~ ~ M 13.67
883.6 4. 0 ~ Y - fS88.8 ~ [Ul \AFAGEF}9Q.2 N`20-0C~ ?1.00BEiJC11 !.lARK 889.5
>BtNCH lAA,?:a
iGP ELELC= OF 889. PIP71tC1P OF PI?E
° 5~ 5 0 ` ELEV.::398.Ja
o ~
v,ti M n
sERV ~'i
4CL17,
967.9
° S8g°J2'FJ7-W i d~2°16~ 12 ~ 887.8 °
- 888.6
e
~v
48.53
- - _ ~
AIL COURT
~T r 1"" Tyr "v4v
N6TE:' ?RCfCSE9 GR/1GES SXCYP.J TFP G4AOiNG Plat: UY: yCOIUNG rPP(12(1SFI1 HOUSE `VATi0jL
6 njw
FO'E' BUROINC OINENSIqvS SIi01'R+ Akt ipR HORIZGNtqI,. AN^ ~"'ICAL LOCATION LCWEST FiOOR FLEV.4iIDK: (L~?.'..~---
Jf fiTRUC7URE5 ON_Y. SSF. ARCRITEC'UAl PLAN3 f'UR 9:LDI43 1.MC ~ t)
rCUN:4T10N 6IMENS(%`iS. TO? OF BLOCK ELEVAT'ION: ?r~~1Q=L.-
.0 Sr'ECIFiC SGILS WVT_ST?f>A;!0H HA5 aE=N C(M'FL0E3 ON Y~K5 '_OT Br IME
$URVTYOR. '/lf SUI7A91'-sTY O' $OI.s To suaFCar -~F _acciric N~aE GAAAGE S~_AB ELEvA7_ON
vqqPOSED I6 N.? f*E RESF0N991u'Y OP :nC SUR'JE"O?.
% OCO.00 OENOTES EX~STiNG cl.EV~Tipv
NOTEi ',n,S CERUPiCATE i%)ES NOT PURPORi f0 SH9w £ASEMEN'S OTHCR Trt4N ~=CO j DfiNOSES PRqFOSCD E'-EV'4YiCH
TMOSF $MOVm 9N TMF. RnCO4CEC Plat_._. = DENOTES ORANkGE AND UtUTY EASE4AENi
fATE: CONT?MtOR HUST VEWR ~]RIVEWA'! DMGN. OEfi'OttS UFPWACt fL'JW ORLCifNJ
DYNtlTES MONUMENT
MCTE: BEAR;NGS SiO'HN hRE B+SEG OV IN F~'UNEa DPTUU __g-- DENGTES OFiSET 4t18
wE HEREBY CERTiF1' 7p NE'P.C Cl nSSi~ NOrVcS TNAT TMS 15 t+ TP.UE AND CORFE4 i REPRFSENiaTiON QK p
SURvEY OF THE BOUhDa.RIES GF:
LOT 4, BLOCK 1, TRAILS END
DAKOTA COUNtY, MINNE50TA ,
(f COES NOT PURPGR7 "G SWG'N '+nPR3YEMErt iS CR ENCHROaCHMENTS, EXCE?T AS SHOWI:, AS'S.'FVE`iE9 BY ME OR
~.,JryGER µY DIRECi Su'lft2ViSiQN 7HI5 191'H ?AY OF JuNE, 1997.
5~^ EC:~ :dNEER tr~Gi~E~Ri~
SCALE INCH = 3C FEET er:~. ~ _
~
,
ohn C. Lnrson, L5. Rng. Nc. 198~8
, '.01 o»co nn swK mwmm~
io - d
LOT SURVEY CHECKLIST FOR RESIDENTIAL
' . BUILDINGPERMRAPPLICATIO
PROPERTY LEGAL:
DATE OF SURVEY:
LATEST REVISION:
DOCUMENTSTANDARDS
s
~ o • Registered Land Surveyor si8nature and company
~ o • Buiiding PermB Applicant
? • Legal description
? ? • Address
? 0 ? • North arrow and scale
Cd~~ ? • House type (rembier, walkout, split w/o, split entry, lookout, etc.)
~ ? • Directional drainage arrows wft siope/grad(ent %
~ ? • Proposed/epsting sewer and water services 8 invert elevation
C~? ? • Street name
Gl-' ? ? • Driveway
ELEVATIONS
ExistlnS
Gy'o o • Sewer service (or Proposed)
G?O ? • PropeAy comers
e'~ ? ? • Top of curb at the dfireway
;/~o ? • Elevatlons of any existing adjacent homes
/ Prooosed
i9"~ ? • Garage floor
ED] j~ ? • First floor
ef ? ? • Lowest exposed elevation (walkoutNvindow)
? • Propertycomers
rd--'o ? • Front and rear of home at the foundation
PONDING AREA (if aooiicable)
0 ~ ? • Easement line
? ? • NWL
? ? ? • HWL
? o • Pond # designation
? ? • Emergency Overtlow Elevation
DIMENSIONS
? • Lot IinesBearings & dimensions
O'/ ? ? • Right-of-way and street width (to back of curb)
4 ? ? • Proposed home dimensions including any proposed decks, overhangs greater than 2',
/ porches, etc. (.e. all structures requiring permanent footings)
eT ? ? • Show all easements of record and any City utilfies within those easements
IT" ? • Setbacks of proposed structure and sideyard setback of adjacent ebsting sUuctures
? o ? • Retaining wall requirements, if
Reviewed: 7- ~
Na ~ e
January 1996 .
CRAIG1BBfliBLOGPRhTI.FM
I ~~T ' , 1, . , ~ t ~ I . I ` I I I ; ;
' ,
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i
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.
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EX'fER10R GNVELOPF, liNliliCY COUR COMPU'I'A170N W(1RK5f(EET
. -
• 1b D-termine Oomp].{ance wtth the Fti.rviPS?ta FE7iergy Code
(Section 502 oE tha State rimerxled 1.993 Mrxlp-1 F.nergy Ccxle)
Pro7'ect Title ' ~ ~'iL f~p~~'
site Address
i. EXPOSED WALL CALCULA'1'IONS
J1RFn "U" VAfAJE 11FtF1\ x "I1"
A. Opaque Wa]1
1. Masonry/Concrete
a, x =
b. ~ _ _ _ - -
- . . - -
c. r =
2. Fou
a.,12 dc~c LJALLE.~XN_~h~AL~ ~1~ --/SG.oo x .07~2 _ //.B.S
b. x =
3. WaA Frame wall ~ . •
a, Insulated Area .6411 3g
b. Framing Acea (11ve. 158 at 16" ec) 2-7 7.LZ x ~083 = 23,00
c. Framing Area (Ave. 108 at 24 oc) x =
4. Peripheral Floor F.c33e/Rim Joist
b._31`c~ x 032. _--6' 7'/
B. Glazing
1. Windo,os
a. Vr7~~,z CsmT X_a~ __Loz.8 3
b. x =
~ 2. Doors ~
C. DooCs 7.7~ k-AT.a Vc? x o.y'/v = /v.Y_`L
,
1. Wbod
a. Solid x =
b. With stocm door x =
Z• M?tal ?cA[HTRr,r RiI
3. Overhead
4. Other X _ D. 'PD'i'AL i+iAti, ARF]?, sq. E t . . . . . . . . . . . . . . . . . . . . . Z 3 72. GY~
E. 'iUTAt, oE ARE1 x "U" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 SZ
U. ROOP/CEILINCi CALCULATIONS
A. RmE/Oeillng Insulated Area x . oz 1 = 2G. av
B. Ioof/Ceiling Framing (Ave. 15% at 15" x) x =
C. RooE/Ceiling Framing (Ave, 108 at 24" oc) i60 x , oY~ = 4_38
D. Skylight x =
E. TO'I'AL AODF/CEILIM 1\RF9, sq. Et
F. '79w cF aREA x^o^ 33.18
~
a.v~aiu~~ ~~•.uuvi o nnqvnnmcno
, e . .
, 1(YM NiF11 RDQf1iRFD ALLOMABLB
_ (F[cm I.D 6 II.E) (Ftan V.) (Aten 1t "(J")
A. ES[posed Wall s 2372.Ur~ x ZGDe 9Z
a. Aoof/Ceiling= a 6269 - 3<o .87
C. 7VI91I, AI.LAWAH[E BUII!)ING IIJVELOPE ('tbtal of n~ e above) 2 97. 79
IY. ACTUAL BUILDtN(3 BNVELOPB
Ar,TUAL
(Acee x "U")
A. Exq7osed Wall (Ftvn I.E)
B. EboE/C'eilirg (Fran II.F)
C. ZUTAI, ACIUA[, BUIIDING FNJIEIDPE (Total of A 6 B) Z lo% 70
•(NeOls te& requlrewnts 1f tess then IILt)
Y. R6QUIRBD "U" YALUE3
~
( - WF1I.I.S R70E'/(EILING
J Detached ore ard two family dwellings ~ .026
R Wlti-Family Pesidential euildinys .238 .033
0 staries ac less in height)
* All Other aonstruction Types (3 etories or leae) .238 .06
• All Other Constructirn 7ypes (More than 3 atories) .28 .06
• 9+e04 en 8001 heatleq de9ree dsyt (lyrlt/St. ?anl)
IWJvft •U' raiues occordln9ly tor ether Ixattons
cBnUetcnnvN
I hereby oertify that I have carpleted the above informtio, a?,a cnat it ccvpiies Nitt, the
Mlme9ots 8ta6e Energy Code.
igtwture Date 4Z-041-7 ~
BM 3-89
CC/SA1/8574
CITY USE ONLY
LOT ~ BL RECEIPT#:
SUBD. RECEIPT DATE: ~IWF/
MECHANICAL PERMIT # ~I O~
1999 MECHARICAL PEii.MIT (RESID£NT1AL)
crrY oF E?snx
3$30 PILOT KNO$ iiD
BA&AN MN 551EE
A~ CCGi
Date: (651) 691-4675
Complete this section onlv if you are installing HVAC in a single family dwelling, townhome or condo under
construction and not owner /occuoied.
• :NAC: 3-100MFTU $ 30.00
ADDITIONAL 50 M BTU 6.00
• Gas outlets (minimum of one required @$3.00 ea.)
3tate Surchazge .50
Total $
Complete this section oxlv if you are remodeling, adding to, or repairing an existing single family dwelling,
townhome, or condo. Please indicate if it i* a new item, alteration, or repair.
/
_ New ~Alteration Repair _ Other
Reminder: Ca11681-9675forinspectians.
_ Furnace V Air conditioning
_ Air exchanger _ Other
$ 30.00
State Surcharge .50
Minimum Total Due $ 30.50
SITE ADDkE5S:
OWNER NAME: PHONE I%
(AREA C
INSTALLER NAME PHONE ~y - 7 7~P l R l'~
Home Energy Center (AREA CODE)
STREET ADDRESS 15200 25th Ave N#128
' Plymouth MN 55447
CITY: STATE: ZIP:
NATCTRE F PERMIT
CITY USE ONLY
L _ BL _ RECEIPT#:
SUBD. RECEIPT DATE:
APPROVED BY: , INSPECTOR MECHANICALPERMIT#:
r
. 1999 M£CHAN1CAL P£RM[T (COMhIEitC1AL)
CITY OF £lkfiAN
S$SO PILOT KNO$ RD
n:AuiRAl, hiid 55122
(651)681-4675
Please complete for: all commercial/industrial buiidings
multi-family buildings when separate permits are not required for each dwelling unit
DATE: i.ON1'"rWCT YI'uCE:
WORK TYPE: _ NEW CONSTRUCT'ION INTERIOR IMPROVEMENT
DESCRIPTION OF WORK:
FEES: 1% of contract price OR $30.00 minimum fee, whichever is greater.
Processed piping - $30.00
CONTRACT PRICE x 1%
PROCESSED PIPING
PERMIT FEE
STATE SURCHARGE ($.50 per $1,000 of cermit fee due on all permiu.)
TOTAL
SITE ADDRESS:
OWNER NAME: PHONE
(AREA CODE)
TENANT NAME (IMPROVEMENTS ONLY):
INSTALLER:
ADDRESS: PHONE -
fa.xsn cone>
CITY: STATE: ZIP:
S[GNATURE OF PERMITTEE
V/ CITY USE ONLY
LOT ~ BL RECEIPT
SUBD. ?/~/LCu.~ ( a 09 RECETPT DATE: -2
1997 MECHANICAL PERMIT (RESIDENTIAL) CITY OF EAGAN
3530 PILOT KNOB RD
EAGAN MN 55122
~ I 7 1 n-7 (612) 6814675
Date: '"t
Complete this section only if vou are installinp- HVAC in single family, townhome, or condos that are
under construction and are 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.) 9 1(Z
• State Surcharge: .50
. TOTAL:
. Complete this section onlv if vou are remodeting addiniz to, or repairin¢ existine sinele familv
dwellings, townhomes, or condos.
Add-on fumace _ Add on air conditioning
_ Add-on air exchanger, i.e. Vanee system, etc. _ Other
Minimum fee applies to all remodel or add-ons of existing residences $ 20.00
State Surcharge •50
Total: $ 20.50
siTE nDDxESS: cty 1 ~cu:\S onuc-~
OWNERNAME: \ 1 l'ekCf:) PHONE ~yS-~ JCO
INSTALLERNAME: Q`TCq PHONE I-Je-I0 ' S77
STREETADDRESS: I "1 all2b
CrTY: Pc ~ oc l1SJ(-c STATE: Y" )J_ ZIP: 5S-.37
S G r F PERMITTEE
ciTV use oNLr
L _ BL _ RECEIPT
SUBD. RECEIPT DATE:
1997 MECHANICAL PERMIT (COMMERCIAL)
CITY OF EAGAN
3830 PILOT KNOB RD
EAGAN, MN 55122
(672) 681-4675
Please complete for: ? all commerciaVindustrial buildings.
? mufti-famity buildings when separate pertnits are not required for each dwelling
unit.
DATE: CONTRACT PRICE:
WORK TYPE: NEW CONSTRUCTION INTERIOR IMPROVEMENT
DESCRIPTION OF WORK:
FEES: ?$25.00 minimum fee or 1% of contract price, whichever is greater.
? Processed piping - $25.00
? State surcharge of $.50 per $1,000 of ermit fee due on all pertnits.
CONTRACT PRICE x 1%
PROCESSED PIPING
STATE SURCHARGE
TOTAL
SITE ADDRESS:
OWNER NAME: TELEPHONE
TENANT NAME: (InnaROVenneNrs oNLv)
INSTALLER:
ADDRESS:
CITY: STATE: ZIP:
PHONE
SIGNATURE:
SIGNATURE OF PERMITTEE CITY 1NSPECTOR
/ CITY USE ONLY
V L~ BL I RECEIPT#:
SUBD. ( Q WL RECEIPT DATE:
1997 PLUMBING PERMIT (RESIDENTIAL)
cirr oF encaN
3830 PILOT KNOB RD
EAGAN, MN 55122
(612) 681-4675
Please complete for: . single family dwellings
~ townhomes and condos when permits are required for each unit
. backflow preventer for underground sprinkler system
FIXTURES EACrH NQ. TOTAL
Shower 3.00 x 21 _ L .a'D
Water Closet 3.00 x .2 _ ~ ~Cso
Bath Tub 3.00 x 1 = ~
Lavatory 3.00 x
Kitchen Sink 3.00 x ! _ ~d
Laundry Tray 3.00 x I = 3• c0
Hot Tub/Spa 3.00 x =
Water Heater 3.00 x I = 3•~
Floor Drain 3.00 x I = '3-ao
GaS Piping Outlet ' minimum -1 3.00 x •cp
Rough Openings 1.50 x
Water Saftener ' 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 'forexistingdwelling 20.00 =
AltefetionS ' to existing residence 20.00 =
Water Turn Around 20.00 =
Private Disposal System ' Dak Cty lic. 75.00 =
(new and refurbished systems)
Private Disposal Systems' Abandonment 20.00 =
STATE SURCHARGE .50
TOTAL q/~Lo
1 hereby acknowledge that I have read this application, state that the informatlon is cortect, and agree to compty with all epplicable City
of Eagen ordinanoes. It is tha appllcanYs responsibility to notiy the properry owner that the Ci[y of Eagan assumes no liability for any
dameges ceused by ihe City during ifs nortnal operedonal and maintenance adivities to the facildies construded under this pertnit within
City properry/right-af-wayfeasement.
SITE ADDRESS: ~Li
'~5 ~!C`
OWNER NAME: ~'VC D0 Vj-SS:
INSTALLER NAME: ~ L--'~& TELEPHONE LILI~ ~~77 %
STREET ADDRESS: I q pz,6 my-y^-~~
cIn: ~r~)c l ~~e- STATE: VYW ziP: ~;-537Q,
a -
S NA URE F PERMITTEE
I
City of Eagan
3830 Pilot Knob Rd
Eagan, MN 55122
(651) 675 -5675
www.ci.eagan.mn.us
Site Address: 944 Trail Ct
Lot: 8 Block: 1 Addition: Trails End
PID:10- 77160 - 080 -01
Use:
Description:
Sub Type:
Work Type: Reroof & Siding
Description:
Zoning:
Square Feet: 0
Comments:
Fee Summary:
Valuation: 6,000.00
Contractor:
Krech Exteriors Corporation
5866 Blackshire Path
Inver Grove Hgts MN 55076
(651) 688 -6368
Total:
Applicant/Permitee: Signature
PERMIT
City of Eaan
e- Reroof & Siding Construction Type:
Census Code: 434 - Occupancy:
If there is no ice protection inspection prior to final, the contractor must meet the
Pictures are not acceptable in lieu of inspections.
When installing ventilated soffit material, remove existing material (i.e. deb
BL - Base Fee $6K
Surcharge - Based on Valuation $6K
- Applicant -
$132.75
$3.00
$135.75
Owner:
Jean A Olsen
944 Trail Ct
Eagan MN 55123
Permit Type:
Permit Number:
Date Issued:
Permit Category:
0801
9001
Issued By: Signature
Building
EA090385
07/28/2009
ePermit
nspector w/ a ladder and flat bar.
s that could block vents) and take steps to
I hereby acknowledge that I have read this application and state that the informa
of Minnesota Statutes and City of Eagan Ordinances.
on is correct and agree to comply
h all applicable State
Use BLUE or BLACK Ink
r
I For Office Use
/ I
Permit / I
City of EaPermit Fee:
1
3830 Pilot Knob Road I f I
7f ED I _6
Eagan MN 55122 R F". I Date Received: I
Phone: (651) 675-5675
I
Fax: (651) 675-5694 APB. I al 14 1 Staff:
I
2014 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: i Unit
Name: Phone:
Resident/
Owner Address/ City /Zip: i Applicant is: Owner Contractor
k.~
Description of work: ~lr
Type of Work
Construction Cost: Multi-Family Building: (Yes / No
s .
~I
Company: Contact:
i
Contractor Address: City: & X~
i State:'!c1 + Zip: Phone:
License 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:
i
Sewer & Water Contractor: Phone:
NOTE: Plans and supporting documents that you submit are considered to be public information. Portions of ;
the information may be classified as non-public if you provide specific reasons that would permit the City to
conclude that the are trade 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.gopherstateonecall.oro
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 Buil in C e must be completed within 180
days of permit issuance.
xLFJ 1-~- Q✓~Y1 x
Applicant's P inted Name Applicant's S nature
Page 1 of 3
I
Y • r
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 (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 SAC Units
(25% 100%) Zoning 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) ~L Final / No C.O. Required
Foundation T 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 J 160
Surcharge J
Owl
Plan Review
MCE
S SAC X D,r~e
City SAC
Utility Connection Charge 1 j o~
S&W Permit & Surcharge
Treatment Plant
Copies
TOTAL
Page 2 of 3
2422 Enterprise Olive
Mendota Helyhts, MN 55120
~y`/ (612) 681-1914 FAX: 681-..9488
RIB~Nawl AA0 mnVFY0R5 CIVIL 4NIANCERS ~~-~--a•
r..-r.-a:.Lp.NSe I.ANDS'GnP':. AftcHIlEC'!S 162.J Highuiay 10 N.E. -
anginscring 81ane, MN 'fif)434
* * * 1(6122) 7'83-1880 FAX:78«,- IBFJ3
"ertlficate of Survey .or: METRO CLASSIC HOMES
941 TRAIL COURT
r' bE"o , 6)
N819°4155W 92M 84.0
5( `.-DRAINAGE & UTILITY f' 5
EASEMENT PER PLAT'
I 13$7.6 ~ x8 .4 ~
x$6..3 X
Q le) 887.3 ( e1.00I_ BRt 5.2 t
C]Ir T
o 46.0(}
F~'JCJSE /
890.2' 1 0 P F'
HO SE 0 j
\ In z
I
z w M \ M 13.67 ( aU R
r cYi I $83,6 A a-~- 81158,8 I
L!1 `j Nt Y \j I/
~y 1 Gam. ARAGE~o 41~!¢~ y1/
\r,°,\ !,1 21 00
$9Q.2 72'(70 20.OG ' - :
o ti
- 889.5
f~k:N;~N PAARK I E89.4 ( 4 Iti~ BENCH !.AX
TOP OF PIPS. o>- ~ Ln TQP OF PIPE
ELEb'.=8&9.71 0 5I 1 IZn<e, 5
ton o ELEV. 1388.014
SERVi(cc \ a~
8 8.g ;PJV,=a78.0.0"~ 397.9
888.6 589052'57-W A=02116812" 887.9
yv 888.2 48.53
`Ak COURT
ACA
lOS r) H USE LLVATIOrL
NOTE: Pf~OPGSED GRADES SHOIPRJ PER GRADING PLAN BY. HEDLLIND an
NOTt`~ 9UkLDIN0 DIMENS1014S SH04N ARE FOR HORIZONTA'. ANT) Vr-R-%;AL LOCATION, LOWEST FLOOR FL.EV.4TION: l1._~ -
4F STRUCTURES ON;.Y. SEE ARCHITECTIJAL PLANS FOR 9O LOING AND G) r J -
iCUNi.41I0N DIb1ENS101VS. TOP OF BLOCK ELEVATION: 1~--~---L
r{°
,MOTE- NO SPECIFIC SOILS INVESTIGATION HAS BEEN COMPLETED ON TKS LOT BY THE
SUaVEYOR. THE SUITA9i'-ITY OF -501LS TO 5VAPCRT THF. SPECIFIC HOUSE GARAGE SLAB ELEVAT'ON•
PROPOSED IS NOT R!E hE5PONsiBw-. f or The SURvc o3.
X OGOAO DENOTES EXi51iNC ,T.l.C~'ATiO!i
NOTE; 'iHiS CERIWICATE DOES NOT PURPORT CID SHOW ;;ASEMIENTS OTHER THAN { oco.0 j DENOTES PROPOSED E`-6.1'.'IYiCI'a
THOSE SHOWN ON THE RECORDED PLAT. DENOTES DRAT;CAGE AND UTILITY EASEMENT
NOTE: CONTRACTOR HOST VERIFY DRIVEWAY DESIGN. DEtio%$ OFAiNACE FLOW DIRECTION
_~-gyp--- DENOTES NOhItJ'~I£NT
NOTE: BEARINGS SHOWN ARE 8.4SEG QV AN ASSUMED L~ATU'A OENGTES OFFSET WIJ8
WE ~iEREV CERTIFY TO VETP0 CLASSIC HOMES THAT 7HS IS A 7RUr AND CORRECT REPRESENTATION Or A
SURVEY OF THE SCUNDARIES OF:
LOT 4y BLOCK 1, TRAILS END
DAKOTA COUNTY, MINNESOTA AS S'~!<VE;`E7 BY ME OR
I DOES NOT NURPOR, TG SHO' 'MPROVEM£t-fS OR ENCHP.oACHMENTS, EXCEPT AS SHOWN,
UNDER MY DIRECT Sij?£R\hSiON THIS 19TH ~QY OF jUNi i997. ~ 1 ~
tii JEC: / IONEER ENCIN -'RiNG~rP.i,,
SCALE , 1 INCH T 30 FEET e-
ohn C. Larson. L.S. Fang. NG. 196:18
Aoni c,~o5~ I10 -,WK
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA133356
Date Issued:10/07/2015
Permit Category:ePermit
Site Address: 941 Trail Ct
Lot:4 Block: 1 Addition: Trails End
PID:10-77160-01-040
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:Two or More Windows/Doors
Census Code:434 -
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow
windows, call for framing inspection. Call for final inspection after installation.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Valuation: 4,000.00
Fee Summary:BL - Base Fee $4K $103.25 0801.4085
Surcharge - Based on Valuation $4K $2.00 9001.2195
$105.25 Total:
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Contractor:Owner:- Applicant -
Peter B Martin
941 Trail Ct
Eagan MN 55123--245
(651) 405-3056
Crew2 Inc
2650 Minnehaha Ave
Suite 100
Minneapolis MN 55406
(612) 276-1680
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA152538
Date Issued:10/19/2018
Permit Category:ePermit
Site Address: 941 Trail Ct
Lot:4 Block: 1 Addition: Trails End
PID:10-77160-01-040
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:Two or More Windows/Doors
Census Code:434 - Residential Additions, Alterations
Zoning:
Square Feet:0
Occupancy:
Construction Type:
Comments:Improvements to the home require smoke detectors in all bedrooms. If altering window openings or installing Bay or Bow
windows, call for framing inspection. Call for final inspection after installation.
Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State
Valuation: 4,000.00
Fee Summary:BL - Base Fee $4K $103.25 0801.4085
Surcharge - Based on Valuation $4K $2.00 9001.2195
$105.25 Total:
I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Contractor:Owner:- Applicant -
Jason Kirk
941 Trail Ct
Eagan MN 55123
(651) 470-5064
Sandau Construction
9025 Hwy 101 W
Savage MN 55378
(952) 403-9100
Applicant/Permitee: Signature Issued By: Signature