4258 Valley Forge Pl
• ~ CITY OF EAGAN 107$ 5
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 PHONE: 4648100
eU1LDING rERMIT ttecrlpt ~
To M w~ f~r ~'i' Jw'(',fC,iu=: Est. Value $ ~'(1, QOC Oate tiCTI;US'.!' J 19 85
Slte l?ddrsm 4258 VA i, I' Y FOR GF Erect ~J Occup-cy i
lot 12 Block ~ Sac/Sub. I`-i0F;.`'T1.ili7fiW [•:i:.Ai?'~Remodel ? Zoning !..1
ParcM No. Repair ? Type of Const. c
Addition ? No. Stwies
Wl~l & ARI~RY 1~.x1MS Move ? I.e?roth 44
W N°~e Demolish ? Depth 48
2976 ~ Address Bt3R~1SInE P.,V}~, intlmpr. O
E:AGAN ~ ~ sa. Ft.
City Phone Install ?
~ Name SAME AvMovob ieti ~
qddrm Assessment Permit • U 0
City phqne Woter b Sew. Surcharqe 30 • 00
~ VoUu P~en Raview 156.50
E ~W N«ne ~":,4NSl~A~ PLAN Fln SAC 525.G0
F Address Enp. Water Conn. S G 0. L3 0
RW City Phone Plonne? Water Meter O~
C•ouncil Road Unit
Ip I hereby acknowledpe thot I haw read this opplicotion ond state that gldg, p{{, 7/ 1 ~ 5 Tr. PI. ' C~'
F` f!e iniormation Is tomct ai?d oqree to comply wifh all applicoble
A~
I Stote of MinrwsoM StatuMs and Gty of Eoson Ordirances. Fe?ks
_ Ver.Orte Copies t
Siprwtun of P~rmittN - ' - e~ ,-~T. .i U
I? Buildir,p P.nnit Is i:swd ro: WM r; Y AI)AN1S on rhe •texp.s cadiNon thw
oll work sFwll be dorw in oooordonte with oll cpplimble 5taft oi Minresoto Statutes ond Cily of Eoqar? Ordinoncm
Buildinp Ofllciol " ' -
pwmlt No. hnnk Holder Daa TeNphone s
PlumbhN ` 144-1~1e( n k_.
H.VA.C. C~ Yl~ ~ C
Ebett+c 5u69 ' Z61g
soh«wr
lenpeetion Daw Insp. Othw
Footings 1
Footings II
Foundatlon
Fnminp jr-;73,
RooHnp 174LII-tf "
Rou9h Plbp. r=
Rou9h HW -Z~t-
InwL ~
F1?eplaw
Flnal Flta.
Final Plbp. -16'
Finsl
Cwt/Oee.
Water Oowibn Loeation:
WNI
Swver
Pr. DIsP.
Receipt ~ PLUMBING PERMIT Permit No.
CITY OF EAGAN
Fm
Frll in numbered spacea 'S/C
Type or Prini /egib/y 7.at.
1. Date 2. Installation Cost
3. Job Address Lot Bik. Tract
4. Owner
~
5. Contractor Phone
6. Address
~fr--~~yl. C rf
7. City State -117 Zip
_ . .
8. Building Yype: Residential ~ Commercial Cl (nstitutional ?
9. Work Description: New ? Add ? Alter ? Repair ?
10. Describe
11. No. Fixtures No. Fixtures
Water Closet Cesspool/Drainfield
-OL-_ Bath tubs Septic Tank
4- Lavatory 5oftner
Shower Well
Kitchen Sink
Urinal/Bidet Other
~ Laundry Tray
t 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 nd codes governing this type of work.
. I
Signed:;'~~,~ for
Raugh F inal
Inspections: Oate Insp. Date fnsp.
This is your permit when numbered and approved.
Approved CITY OF EAGAN 454-8100
RniPt MECH/W ICAL PERMIT Penmk No. ~ CITY OF EAQAN
FN
f1/1 /n rwmDard spm.w S/C
- rYPe or PrJnt JsoJbly ToL
1. Date v 6~ 2. Installation Cost
3. Job Addna " l.otBlk. v Tract
4.Owner ~ .
~ -
~ .
5. Contractor Phone
.
6. Address
7. Gty Stats - 2ip.5
8. Buildin9 fype: Residential ~ Commeraal ? institutional ?
9. Work Desaiption: New O Add ? Alter O Repair ?
10. Desaibe Fuel Type
11. No• Equ,jpmpi BTU - M. Ea. No, Eouipment CFM
Foroed Air Air Handling:
Mfg.
Bakn Mech. Exhaust
Mfg.
Unit Heater
Mfg. Otfier
AIr Cond.
Mfg.
Gss, P'iping Outlets
12. 1 hereby oertify that the above information is true and correct, end I ayree to
oomply with al( ordinanas and coties governing this type of work.
.
Siyned : for
Rouyh Flnal
Inspections: Date Insp. Date In:p.
This is your permit when numbered and approved.
Approved CITY OF EAGAN 464-8100
CITY OF EAGAN Remarks
Addition NORTHVIEW MEADOWS Lot 12 Rik 5 Parcel 102100-120-0
Owner street 4258 VALLEY FQRGE PLACS Oftate EAGAN NW 55123
Improvement Date Amount Annual Years Payment Receipt Date
STREETSURF. 1984 76.75 '74y 1
STREET RESTOR.
GRADING
15.89 e79 20 • /S G -
5AN SEW TRUNK 1981 13$ .48 6.92 20 576 - 9(o f70 16 G '-ZG
SEWER LATERAL 8•34 1-8.drr 15 .2 .ZO•ZD O(p6 '
+8 1-.44 zo s /3 j/o 1~o 16 7 -z?S-
WATERMAIN _S 1984 70.67 4.71 15 Sfo - 5
WATEA LATERAL 571- 1 1 i •24 -04 49 ls 7
WATER AREA `j 1981 j 6.9 2 20 ~o. 9& .4y 1 lo ~
1982 29 . 52 . k-.46 20 °Z 0• 70 ~O /lo lo ~7 ~--3~ -83~
STORM SEW TRK D 1984 392.32 '?I. i39-.23 1-@S c~~~n C/y
' -
STORM SEW LAT
1984 33.97 333r40 10 .3, ko
DRAINAGE
CURB & GUTTER '
SIDEWALK
STREET LIGHT
WATER CONN. it
BUILOING PER. 1107815 Ir
SAC n n
' PARK ,
i
; CITY OF EAGAN
3830 Pib! ~nob Road MrATER SERVICE PERMR
~ P. 0. Box 21199 PERMIT NO.:
Eagan. MN 55121 DA7E:
~
Zonirv: . t41 No..of kM(ts: ~
Own~r: -:4 i?nterurises .
~ Addmm
Slh Add?eu: 4258 V 1+~" ' FOrgF'_`'-1.) ~r ,:i~7`J1CW_ '''~.'acbwz
PlUfl'Iblr: Atl$Il-O . i
( MWsr No.: 3 5-7 Canneetion Qw?qp: 5 . OOrY..i
y r
SiZei AppplJ?It ppppwt;
~ Reoder No.: 61P Ln "Q~ ~ Permit Fee: ~ • `1 ~~d
, ~-ow h - M wNl~ 1V G1y of Vome Surchorpe:
Mt,c. cF,orpss: 132OGpc: TP ,
Total: 6 .00pd tCietLr
I
~
L
i By7Dor. Pctd:
i Date of Irap.: ~ I
rop.:
I
CITY OF EAGAN SEWER SERVICE PERMR ~
3830 Pilot Knob Road )
P. 0. Box 21195 PERMIT NO.:
Eagan, MN 55121 DATE:
Zaninp: Na of Unih: _ • i
Ow?wr. a y-r'1ta"'-,: t~r~ ~ i
/lddress:
JJ , ~ t
SitQ - ~WMn: , ~ ~7:_ ~e=] 1 T.12 FZT:a '+..)i i t ~Jaartirv~ '
PlUITIbl/: - - 1
1opw h6 myli w!K IM d1r oi Ew¦ ConewcNoe+ Ganpw. 425.00~3
OrliMmam Aooourrt Gpodt: 15. ~47=~ ~
PemgM FN:
r
SNKh0fQe: h'
BY Misc. Choro.s:
Dah of Irnp.: Totol: y
Insp.: Da» Poid: ~
,i
CITY OF EAGAN N°_ 10785
3830 Pilot Knob Road, P.O. Box 21•199, Eagan, MN 55121
~j ~
BUILDING PERMIT PHONE: 454-8100 Receipt #
Te M wid fer SF DWG/GAR Est.Value $60,000 Date AUGUST 13 ~ 85
19_
SiteQdtlresa 425$ VALLEY FORGE Erect ~ Occupancy R3
Lot1 2 8lock_ 5 Sec/Sub. NORTHVIEW MEADSRemodel ? 2oninq R1
Percal No. Repair ? Type of Const. X7
Addition ? No.Stories
W Narrme WM & MARY ADAMS Move Cl Length 44
Demolish ? De th
= 2976 SURNSIDE AVE p 48
~ Address Int ImPr. ? Sq. Ft.
Ciiy EAGAN phone 454-5822 Install ?
g Name SAME ' vVrorah fos
q~rmy Azsezunenf Permit .~0
l- City Phone Woter 6 Sew. Surcharge 30.00
Poliu planReview 156.50
P. Neme HANSON PLAN SERVICE Firo SAC 525.00
4- Adtlress
'Q Erq. WaterConn. 500.00
"u City Phone Plonner WeterMeter 00
Council RaadUnit 280•oo
I hercby ackrwwledga thot I how re d this apPlication nnd stote fhat Bldg. Off. 7 1 7 8$ 7r. PI. 132.00
fho informotion is correct nd ogree to comply with all opplicoble
Stota of Minnewta $toture and Ciry of Eaqon 'ran s, p'PC Parks
Var. Date Gapies _~_5 0
Siprwture af PertniMee Total
A Building Permif Is iuued fo: WM & MA-RY ADAMS on the axpnaf condiflon thoo
all work :hall be done in accordance with all app/li'm~bla Stofe of Min ~t~o St-otulea ond Cih o'r Eopen Ordinonces.
Buildlrp Offlciol
1985 BUILDING PERMIT APPLICATION - CITY OF EAGAN
NOTE: ALL CONTRAC?ORS MUST BE LICENSED NITH THE CITY OF EAGAN
INCLUDE 2 SETS OF PLANS
3 CERTIFICATES OF SURVEY
1 SET OF ENERGY CALCULATIONS
To Be Used For: ~"/C Valuation; 60 Date:
Site Address: OFFICE USE ONLY
/
Lot: Block ,5' Sect/Sub Erect X Occupancy
Remodel Zoning Q-~
Parcel 11 Repair ~ Type of Const Q
Addition /I of Stories
Owner Move _ Length ~
Demolish Depth 48
Address Int.Impr. Sq Ft
Znstall
City/Zip Code
Phone APPROVALS FEES
Contractor ~
Assessments Permit
Water/Sewer Surcharge 30
Address Z9]C~~~~~_ Police Plan Revieu
Fire SAC 525.'°
City/Zip Code Engr Water Conn Soo.
Planner Water Meter (0 3.
Phone Council Road Unit 280.
Bldg Off?
i Treatment P1 02.=
Arch./Engr, z-, APC - Parks ~
Variance Copies
Address ' TOTAL
/
City/Zip Code
Phone I1
Certificate For:
Mr.•Bill Adams
,
DELMAR H. SCHWANZ
iAHOSUAVEVONS INC
qaOf~M Unalr LAM! oI TIM Ctl1O 01 Min~Mr
14750 SOUTM ROBERT TRAIL ROSEMOUNT. MINNESOTA 550E6 M10NE !tt 42116-1769
SURVEYOR'S CERTIFICATE
;q - - -
! o
701z~
3o ~ (or2, gy K S( o0
~ I I - - 3
, ~ N GA~•/ / / ~ I
~ ~-t- 2z.73/ .f3 I
` s > < - ?D ~ ~ -
i
i
Proposed Elevatic
~ U Scale: 1 inch - 30 feet
I hereby certify that this is a true and correct repreBentation
of a su:vey of the boundaries of the Pollowing described tract
of land:
Lot 12, Block 5, NORTHVIEW MEADOWS, Dakota County, Minn.
Also showing the location of a proposed houae thereon.
July 16, 1985
r
MINNESOTA REGISTRATION NO. 8625
~
~ /!,SXTcRIGR ti!'.E_.. - r:'-'^.qr"1i5= "I_I ('L71'ir,UTFII-_K
(-lf'EF- I_:' ;_I :i /.`uRFri
REQUIRF=U
1. I'0 i AL !JALL AF'L-A 1046 .11 200. C,,3
2. l'0"ii''iL n00i= Fil'iEil J lOO X. (")^6 28.6
ACHSI-VG:U
AF:El, U U X AREA
A. lJ?i iDOW AREA 147.64 .5 71.32
R. DpOR AREA 79.8 .077 3.0646
C. '_LIP.E GLAgg HFC;', 13.04 .48 6.4512
D. FIi;Er LACc AREr=, i, 0 ci
, L. 4JALL FFAPIE AREA 134.6 .041 7.5686
! F. NET 4dALL AREA 1250.52 .049 61.27543
i G. F'II~1 JOIST AREA 116.2 .1'l+}'b J.I)pFJ._2
~ H. FOLqNll {JIf•IDOW AnEr"a ii 0 i~
i I. FOUilD ABOVE GF'F?DF 93.E .135 12.667,
~ TOTAL WALL AREA 1846 169.9092
~
( J. :_f:'iLiTE 0 q
~ F. F.nDr FRAi9E 110 ,032
~ L. t•!ET ROGF AREA 990 .025 24.'75
i
' 7. -f'OTAL RnOr AREA 1100 23.27
i
~ i SU!•1 1. +2. ^_.?1.66
~ SUi1 3, +.1, .
~ 19B.179?
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Cities Di itg a1 Quality Control
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j CITY OF EAGAN .
~ C~~:
«~iiy APPLZCATIvPI FOR P°B:•1ZT
SE:dER AND/OR WATLR CONNECTIODi
(PIEASE PPIHi)
1) PROP= ACDP.F.SS: .~J
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PL~J!!BERS LiL:ASE:
PLCzESS: Accive
CITY...STATE. ZIP: Ezpire
t, r Record
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to.r ~i'3a
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ADDRESS:
CIT!, STAT'E, ZIP:
PFiQ.^IE:
5) PqDIG,TE ;•1HZCH PER;•LIT IS BEI.:C REQUESTID:
ID CC..=IOV 'IC) CIT'! SE:v'E2
Q CC:].~=G:] 'R7 CZTY WATE??
? CMIM (PLGSE'DESCRiHE)
6) IIiDIG,.:.
~ ? PI.r Sc f:OLD r1PPRGVED PEP:MlIT FO4 PICi:-G"P BY C^+'E OF AE('~'E
?-°I=-',S :-aIL APP!?W`',~ PEP:•tIT TJ 1, 2. 3, 4 ASMTE , 1j~
/e C~
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7) SIa.;,~,:v.:
!~lo1i~~~osrv~~:aar.aa~~ar+~ • I"'. ,
FOR C I T Y U S E OC]LY
p-.'.`?IT " ISSliED
rr=S:
$
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.r..,E)
$ S'u WAT°a aFRItrm (Ii:CLUDc SiiRCHARG'c)
WAT°R MET°R/COPPEaapRN/OUTS?'J° R::;CER
$ {{,pTra Tpp ( ZvCL'JDE CORPORATIQ'] S^OP )
5 S::•ic TA?
$ UV -._..~'i;::'•^ ~=?r-.c__ - =3
$ AC^Ou?:T DF.?pSIT - pi:y^_'=R
$ ~~O OKJ WnC
$ SJ ~ ~G S:.C
$ T.°.[i`?K i•It1T°R nSSz55:i=:iT
, $ TRU::y SE:;cB nS5E55:1°_:•iT
$ LnT :3ni, 17LIVG[ IT/TOLiI:( SEt:EF
$ LATERyL BENc: ZT/TDU:'Iri :•:ATz'R
$ WATLR TREAT.•ff*:T PLrL\T SURCHARGE
. S OTHER:
+S TO i.-`,L
$ '->a ~U n2.10li::T PAZDjRECEi?^
DO:S UTZLIT'L COi:::ECTION REQUIP.E EXC.~\VATION ID7 PUBLIC RIGriT OF [QAy?
YES ZF YES, THE.t A"PE3~1IT FOR :90RK WITHIliq
PUBLIC ROADWAY" MUST BE ISSUED BY TY.E
=,NO ENGINEERIPiG DIVZSION_ LZST AS A CONDI-
TZON.
SG2JECT TO TfiE FOLLOS4ING COAIDITIONS:
APPROVED.BY:
TI':LE: ' .
DAT°_: .
wsiawwwk+wtAE w~mpv im~~cawm sams~mS,
O.o~ '?39-7~
~ Fy`y,djfice U~e ~
City of EaEdIl I Permit #
~ a~
70,
~ Permit Fee: i l/^ ~T i
3830 Pilot Knob Road ~e
Eagan MN 55122 j Date Received: j
Phone: (651) 675-5675 i scan: i
Fax: (651) 675-5694 i 1
2008 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: SiteAddress: ~/GC f C1f 6
Tenant: Suite
RESIDENT/OWNER Name: Phone:IQSI- ! ly'
Address / City / Zip:
Applicant is: _ Owner Contractor
TYPE OF WORK Description of work: fiP, -f 00f
Construction Cost: Multi-Family Building: (Yes No NJ
CONTRACTOR Name: Qr)*CA License#:
~
Address: 5GLII CV
City: &T11IU~er State: ~W Zip: S5`JC~~
Phone:C061 'L1~ I•~&~-0 ContactPerson: KcAren
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
Minnesota Rules 7670 Cateaorv 1 Minnesota Rules 7672
En¢fyy COdO . Residential Venlilation Category 1 Worksheet • New Energy Code Worksheet
Category submined Submitted
(4 SubmiSSion type) • Energy Envelope Calculalions Submitled
In fhe last 12 months, has the City ot Eagan issued a permN for a similar plan based on a master plan?
_Yes _NO If yes, date and address of master plan:
Licensed Plumber: PhOne:
Mechanical Contrector: Phone:
Sewer & Water Contractor: Phone:
NOTE: Plans and supporting documents that you submit are considered fo.be publlc informatlon. Port/ons o/
" fhe in/ormation may be classifie'd as.non=public ify you pro"vlde specific reasons that woWd permit the City to
oonclude.thaPthe are~trade'secrels.o~~~)
I hereby acknowledge that Ihis information is complete and accurate; ihat Ihe work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand ihis is not a permit, but only an applica0on for a permit, and work is not to staA without a permit; that ihe work will be in
accordance with the approved plan in the case of work which requires a review and approval of p ns.
,c (l~~e,~1le 41~or~n x U., ~s
Applicant's Printed Name Applicant' Signature
Page 1 of 3
~ F'or_O.ffice Us I
I
I
Permit
1
Clty of Ea~~n I #
i Permil Fee. ~
3830 Pilot Knob Road
Eagan MN 55122 ~ Date Recerved. j
Phone: (651) 675-5675
~ I
Fax: (651) 675-5694 ~ staff. ~
2009 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Address: jo L
Tenant: Suite
RESIDENT ! OWNER Name ~ i C~~~ c~ T1-.~1 I C•h H Phone: S I- qq c/ - cjt Li L
Address / City / Zip. LI ZL S B r/ 4. L s~)i~- ~'O L
~
Applicant is: _ Owner ~ Contractor
TYPE OF WORK Description of work R e S•~C ~L
Construction Cost:f / V / 1 c L
S/ MuIU-Family Building: (Yes No~
CONTRACTOR NamW.n ' thL _T~_~'- w_J~,L e) L, License#:
Address. A L v'trtiJ- , CT
City: 14 StateM Zip: -7 7
Phone' Contact Person:
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 suwnined subrr,ined
(4 submission type) • Energy Emelope Calculahons Submittetl
In the last 72 months, has the City of Eagan issued a permit for a simflar plan based on a master plan7
_Yes _No If yes, date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer 8 Water Contractor: Phone:
- NOTE: Plans and supporting documents, that you.,submit areconsidereii4o tie public infoimation: Portions of"
the.information may be classi/ied;as,non-pub!!c if yoa;provide specific'reasons thafwou/d peimit the Ciry to '
conclude tFiat the~ are-tiade.se'crets °
I hereby acknowledge ihat this informalion is complete and accurate; that the work will be in conformance vnth the ordinances and cotles of the City of
Eagan; [hat I untlerstand this is not a permit, but oNy an application for a permit, and work is not to start vnthout a permit; that the work will be in
accorCance with the approved plan in the case of work which requires a review and ap al of plans. ~
. LJ.ti.~L ~..,.+C wJ~ r
x
Ap IicanYs Printed Name ApplicanYs Signature
Page 1 of 3
r.
DO NOT WRITE BELOW THIS LINE
SUB TYPES
_ Foundation _ Fireplace _ Porch (3•Season) _ Storm Damage
_ Single Family _ Garege _ Porch (4•5eason) _ Exterior Alteration (Single Family)
Multi Deck Porch (ScreenlGazebolPergola) Exterior Alteration (Multi)
01 of Plex Lower Level Pool Miscellaneous
Accessory Building
WORK TYPES
New Interior Improvement _ Siding _ Demolish Building'
Addi[ion Move Building _ Reroof _ Demolish In[erior
_ Alteration _ Fire Repair _ Windows _ Demolish Foundation
_ Replace _ Repair _ Egress Window _ Water Damage
Ret2ining Wall 'Demolition oi entira building - give PCA handout [o 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
REQUIREDINSPECTIONS
Footings (New Building) Sheetrock
Footings (Deck) _ Final 1 C.O. Required
Footings (Addition) Final f No C.O. Required
Foundation HVAC
Drain Tile Other:
Roof: Ice 8 Water Final Pool: _Footings _Air/Gas Tests _Final
Freming _ Siding: _Stucco Lath _Stone Lath _Brick
Fireplace: _Rough In Air Test _Final _ Windows
Insulation Retaining Wall
Meter Size: Erosion Control
Reviewed By: , Building Inspector
RESIDENTIAL FEES
Base Fee
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
Copies
TOTAL
Page 2 of 3
Use BLUE or BLACK Ink
�-----------------
� For Offlce Use �
C� j Permit#: ���7"�l j
l�� af�a�a� � Permit Fee: �u�-�� �
3830 Pilot Knob Road � �
Eagan MN 55722 j Date Received: '4 �
Phone:(651)675-5675 I I
Fvc:(651)675-5694 I Staff: I
I I
�_�___��_� ��____J
2014 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Site Add�s: Unit#:
� ' Name:�CA.�C71� ��1�ri �✓��'�1'"C9 M , Phone:
��Sili�@i1�/ (� y
Q�yh� Address/City/Zip: y�s Q, 'CC) �, /�/)C--�, �Q{ j� ��f�
Applicant is: Owner �Contractor
,#.���,���� Description of work: �p�C���
Construction Cost: 1 Multi-Family Building:(Yes /No
Company: �.SQ`�'i.S7 nOM Co1'1��'rl�cs�"�oy� Contact: �'��C� ��`
�Qtt�l"�Gf�t ! ' Address o`�o�"O� ��ol'��"1 C@. ,�'$j'►7� City:��Y1 c3'3° '�71'v�1
�� State:�1�/ Zip:��0�� Phone:��°�i �"'��S�mail: �����,�orig�[►���1I,�1+�j
' �icense#: �C.�'S����� �ead Certifica�#: IU�T -- �d'T�O��
If the project is exempt from lead certifcation, 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:
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�he fnformation rnay�clas��fied as nor�-p�rbfic if you prrcr�ri�1�s�e�f�ic reasc�n.s that wc�uld permit the;Cfiy tc�
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CALL BEFORE YOU DIG Call Gopher State One Cal1 at(651)454-0OU2 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities. www.aopherstateonecall.Qg
I hereby acknowledge that this information is complete and accurate;that the virork 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 v�k 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.
Euterior work authorized by a building permit issued in accordance with the Minnesota Stake Building Code must be completed within 180
days of permit issu�ce.
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ApplicanYs Printed N� plicaht's Signature
Page 1 of 3
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA148359
Date Issued:03/23/2018
Permit Category:ePermit
Site Address: 4258 Valley Forge Pl
Lot:12 Block: 5 Addition: Northview Meadows
PID:10-52100-05-120
Use:
Description:
Sub Type:Residential
Work Type:Replace
Description:Furnace
Comments:Questions regarding electrical permit requirements should be directed to State Electrical Inspector, Mark Anderson at (952)
445-2840.
Please call Building Inspections at (651) 675-5675 to schedule a final inspection.
Fee Summary:ME - Permit Fee (Replacements)$59.00 0801.4088
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 -
Jason Bergstrom
4258 Valley Forge Pl
Eagan MN 55123
(651) 775-1312
Summit Heating & Air
1711 Cty. Rd. H2
White Bear Township MN 55110
(651) 775-1312
Applicant/Permitee: Signature Issued By: Signature