3953 Stonebridge Dr N
REAGIT~TAr- FO-k DEEK5/7/92 ~ . . . , ,
~JW ,TAQIET-687•-0275 CITY OF EAGAN n
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
PHONE:454-8100
BUILDING PERMIT Receipt # ! ' •
To be used for $F DRiG/GAR Est. Value $1601000 Date An 22 199L
Site Address 3953 S'TOIiEERID6E DR 11
Lot 15 Block 4 SeGSub. _HI..,1.L8 r OFFICE USE ONLY
- Parcei No. DTUNZJMLUUE OccuPancY R-3 FEES
' zoning PD 1E-1
W Name POSSLM COtIl~TRUCTIOII (AGual) Const !1 aidg. Per,nit
780, 00
; Address 045RI : (nnowawe) -Y=11
0 City Z.AICMLWE Phone i- 614 +r ot stones surcnarge 70.00
Length ?7 1 Plan Review 307,
Name SAME oeptn 1' snc, ciry IOQ.00
o~
Address S.F. Total b~~~
U~ CItY Phone S.F. FootpriMS _ SAC, MCWCC
pn Site ggM,age Water Conn 6W.oo
' r. Lu Name On Si?e weu wa?er Meter 95,
00
Q~ Address MwCC System x
30.00
<W City Phone CityWater
PRV Required _ S/W Permil
I hereby aCknowlege that I have read this appliCation and state that the 8ooster Pump - S/yy Surcharge •50
information is correCt and agree to comply with all applicable State ol
Minnesota Statutes end City of Eagan Ordinances. T~~tnwt Pi 276.
~
Signalure of Permitee - )K ' y ~-y APPROYALS Road Unit 370.00
A Building Permit is issued to: FWsUH WNSTRUCTI011 Pla^^w - Park Ded.
on the ezpress condition that all work shall be done in accordance with all Couridi
applicable Slate of Minnesota Statutes and City of Eagan Ordmances. gldg, pff. _ Copies
Building Official ~ ' Varianve - TOTAL 3.568• ~
Permit No. Pwmit Holder Oaft TdpfarN I
WATER
SEINER._
PLUMBING
H.vAc. ~p 9
euECrWIc
rap.cu«, n.te wmqL couwnwies
Footinps t
Fa,naeua, - - ps
Framing
Roofing
Rayh Plbp• -
Roug^ "tg-
l5ul. (n
Ffep18CB
Fin21 Htg.
OrSf9t TeSt ~ -
Final Plbp• /tg. Inspector - ?Joti/Y P1u
Const. Meter
ErgrJPlen
Bldg. Final
Dedc F1p.
Oedc Rnal
WeM
Pr. Disp.
~
RKIICTLVA'lE POt IMM-5/7/42
- ` J-.
- Citp of Cagan
llrpwftTruY o# WuOwg.Jmvrrtian `
Thtr Cerlirxate isruwdpursuant ta [he reQuiremeW ojSection 306 ojllee Unijonn Building
Cade Qa*rcg lhal at lJre tinu of issuarroe this suuctum Kar irr oonrplianoe wirh tlu marious
ondinanm ojtlre CYty regulabing butlding c»nstruclion or use For the fo!lawiW.
uftclm~ 5F nt,rr_ iGAR ewc. % NX _.10.44t--19428
O-Wor-7 '[ype 7oniac Diwia ~ n t Type comt
Oweer af Y~76~
A4*ry iiTMt fR= Ml..Ev _ T_ 1 T Wi - T 7 C_CE SIC'11~'RRlTY37
Daft
POST IN A OONSPICUOUS PLACE
I '
. .
~ .
.
r
J • .
SEWER dc WATER PERMIT OFFICE USE ONLY
CM CW EAsAW METEH #6~Y LI 7_30 F PERMIT DATE 04/ 23 / 91
3= PIIOt Kn0b Rd.
Eagan, MN 55122-1887 cHIP # 0,2 /.s 23v7 PERMIT # 11938
METER SIZE B.P. RECEIPT # C 130n3
pqTE APK 22. 1991 ISSUE DATE 7' Z3-21 B.P. RECEIPT DATE 04 22 41
_ PRV _ BOOSTER PUMP
SITE ADDRE55 3953 STpNRART DR N PERMIT REQUESTEO
LOT 15 BLOCK 4 SEC/SUB HILLS OP STONEBRIDGE
X SEWER --!-WATER _ TAPS
APPLICANT:
ADDRESS: - COMM/IND -1- RESIDENTIAL
CITY, STATE 21P _L_ NEyy - EXISTING
PHONE:
ALTA 1~CHANLCAL LeN?n Sprinkler Meters are to be Installed
PLUMBER: Ahead of Domestic Meters on Water Line.
ADDRESS: 12651 ZENITB AYE S STE 110 Credi;,lqIILL NOT be iven for Deduct Meters.
CfTY, STATE BURNSVTLI.E MN Zip 55337 4`f
,
pHpNE: 840-3779
1 AGREE TO COMPLY WR'H CtT'If OF
OWNER: FOSSUM CONSTRUCTION EAGAN ORDINANCES
ADDRESS: 20452 IBERIA
CITY, STATE LAKEVILLE HN ZIP 55044
pHpNE; 469-3614 NATU E WHEN METER ISSUED
/
PLEAS~ ~OW TWd WO~KIN~'~A~.rY-S FaR PROC~SS~Nl3. CALL 4544220 FOR iNSPECTIONS. FOR STORM
8EWER PERMITS, CONTACT ENQINEERING DEPT.
f f;
SEWER 8 WATER PERMIT OFFICE USE ONLY ~
CITYK~ EAbkN METER # PERMIT DATE U4 / 2 3/ 91
3830 Pilot Knob Rd.
Eagan, MN 55122-1897 CHIP ~ PERMIT ~ 119 3 8
METER SIZE B.P. RECEIPT # C 13003
DATE APk 22. 1991 ISSUE DATE B.P. RECEIPT DATE n4 22 9l
- PRV _ BOOSTER PUMP
SffE ADDRESS 3453 STOt.EBRIriGE DR N PERMIT REGIUESTED
LOT 15 BLOCK 4 SEC/SUB HILLG OF STOVEBRIDGE
f~ SEWER X WATER - TAPS
APPLICANT:
ADDRESS: - COMM/IND x RESIDENTIAL
CITY, STATE ZIP X NEW _ EXISTING
PHONE:
Ai.TA , i~C~ANICAL ~wn Sprinkler Meters are to be Installed
PLUMBER: Ahead of Domestic Meters on Water Line.
ADDRESS: 12651 Z°NxTH AVE 6 STE 110 Credit WILL NOT be given for Deduct Meters.
CITY, STATE BUF.tvSYILLE MN Zip .',5337
PHONE: 394-3779 . -
I AGREE TO COMPLY WITH CITY OF
OWNER: FOSSUM CONSTRUCTION EAGAN ORDINANCES
ADDRESS: 20452 I BEF IA
CITY, STATE I 4iCE V I LLB M N ZIp 5 5044
PHONE: 459--3614 SIGNATURE WHEN NIETER ISSUED
PLEASE ALLOW TWO WORKING DAYS FOR PROCESSING. CALL 454-6220 FOR INSPECTIONS. FOR STORM
SEWEA PERMRS, CONTACT ENGINEERING DEPT.
fj;. DATE: "a 23. 1991
RE: 3953 STONEBRIDGL DR N (FOSSUM COt1STRUCTION)
x Your Sewer & Water Permit for the above property has been completed. It will be held at the
Public Works Garage (3501 Coachman Road) until the meter is picked up. BE SURE TO
CALL PUBUC WORKS (454-5220) FOR YOUR PERMANENT WATER TURN ON.
Your Sewer & Water Permit for the above property cannot be completed for the following
reasons:
.
Your Sewer & Water Permit for the above property has been completed, but the meter cannot
be issued or occupancy allowed untfl further notfce.
COMMERCIAL PROJECTS ONLY: Please pay for meter at City Hall_ Meter size must be
confirmed by Bill Adams or Dirk House (Plumbing Inspectors - 454-8100) before issuance.
WARNING: BEFORE aIGGING, CALL LOCAL UTILITIES - TELEPHONE, ELECTRIC, GAS, ETC.
- REQUIRED BY LAW.
CONTACT COMMUNITY DEVELOPMENT DEPARTMENT FOR WATER TURN ON POLICY.
Secretary, Building Inspections Dept.
~ CASH RECEIPT
CITY OF EAGAN
38.30 PILOT KNOB ROAD ~
EAGAN, MINNESOTA 55122
DATE
FIECErveo "
f110Y
AMOUNT
_ . ~ .
a oauas
,oo
O CASH ~ CHECK
~
;
FUND OBJECT ` AMOUNT
Thank You
BY
C 13003 ft*--Fft copy
I"'~ -•,+c,+rA. a.~t,~,,,3t~.~ '~.eC.~'ti°"i='~iR"s""'^ " " _:d~'~ _
HOUSE HEATING TEST RECORD
~
ADDRE55 FLOOR CITY 4 suauae
, .
OCCUPANT 0
HEAT LOSS "ff! DATE HTG. INST. SOI.D BY INS7ALLED BY '
Electrical Wsrk 6;, t Gas Line Bp
TYPE OF MEAT GAFA LHrll STEAM SPACE HTR. UNi7 HTR. OTHER
GAS DESIGN CONVERSION
MAKE MAKE OF BURNER '
Mod•I , ~ f f ' AAod.l
S~riol - " AAox. BTU Rating
INPUT bAAKE OF FURNACE
~ Mod.l _
~ CONTROLS
THERMOSTAT Heat Plup Vent Sise
Valv ~ - KIND OF LINER SIZE NGNE -
Limit , Drah Hood Rpvlorot
Limif Seffinq Ffihrs Siso Nunibw
Fao Setfiny ' Chfmnwr Locotion Inside Outsfdo
Pilot TYPe Oiimner Construefion ~
Pilor Make
Pifot Modet Swwb Bomb Wiriny
Pilot T(miny _ Dra{t Test To0'
L.W. Cut Oft , Doa Pnssw• . Liyhtin' (nsf.
, Pnasure - ~ Percont C02 Doh Tested _
Input CFH~ PNCent 02 Companr Testiny ~
Stock Tomp. Pwant CO Namt oi TostM
Fwm 235
t,
/I /60210~ e/3r~-r
'
ReQuest Oate ~ na No Ro in Inspection
tl~ ? Reatly Now JI NoOfy Inspector
( es G No VJM1en Reatly+
I~ficensed contractor ? owner hereby request inspection of above electrical work at:
.bE Atltlress (SVeet. Box or Roule No,I Qly
Q 5 3 dl 4
SecLO~ No Townshp Name or No Range No Couny
Occupant(PRINT)- Phona No
~`"O $SD /-I CO/!
Powar Sup0lier Atltlress . /
/ n.. (
~4 /C o?~ ~~reG f'rn ~ 7on i
Elech¢al Gonllactor (COmpany Name) ConV or5 License No
~ ~ S' ~fr c ~ ~ ~e, O Y/
Mailin9 Adare55 (COnlractor Or Own9r Makin Inslellali n) e
7' ,~w ~ S 5 y3 '
Aolbonzetl SignaWre nvactorlOwner Making lallalio Phone Number
75`7G'>6
MINNESOTA STATE BOAPp OF ELECTRICITt/ TMIS INSPECTION REQUEST WILL NOT
Grig9e-Mltlway Bltlg. - Poom S473 BE AGGEPTED BV THE SWTE 80ARD
1821 University Ave, St. Peul. MN SStOd UNLE55 PRaPER INSPECTION FEE I$
Vhone (612) 643-0800 ENCLOSED
REQUEST FOR ELECTRICAL INSPECTION eeooom-oa
~,ee msVG'WOns lar complellng this larm on back ol yellow copY
6 21 Q "7C" Below Work Covered by This Reques! '~.,~`•y_
H
ew a0 Rep TypeofBudding AppliancesWired EqmpmentWired
Home Range Temporary Service
Duplex Water Heater Electric Heating
Apt Bwlding Dryer Other (Specify)
Comm./Industnal 'FUrnace
Farm Air Condilioner
Omer (speciy) CoNracmr5 Remarks
Compute Inspechon Fee 8elow.
# Other Fee # ServiceEntrenceS¢e Fee # Circwts/Feeders Fee
Swimming Pool to 200 Amps 0 to 100 Amps
Transformers Above 20D _ Amps Above 100 _ Amps
SignS Inspecmr's Use Only TAL 5-
Irngation Booms e~,r
Special Inspecnon
Alarm/Communication THIS INSTALLATION MAV BE OflDERED DISCONNECTED IF NOT
Other Fee COMPLETED WITHIN 18 M THS. (
I, the Electncal Inspector, hereby Raugh+n axa~ t ~
cerhfy that the above inspection has F,hai oa p
been made
OFFICE USE ONLV ~
This requesl wid 18 monfis tmm
Address: 3953 SfOf1EBRIllCCE DRIVE N. Lot 15 Blk 4 Sec/Sub HILI.S OF STONEBKIDGE
ihese items were/were not complete at the time of the final inspection.
pate: 8/8/91 Yes No
Final grade (6" from siding)
Permanent steps - garage
Permanent steps - main entry
Permanent driveway
Permanent gas ?
Sod/seeded grass
Trail/curb damage
Porch ~
Basement finish
Deck
Please verify vith the builder the removal of roof test caps from the plumbing
system and the shut-o£f of water supply to the outside lawn faucet before
freeze potential exists. ~
?
.ammnnn
White • City copy Yellow - Resident copy Pink - Contractor copy
CITY OF EAGAN NO 18928
3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121
BUILDING PERMIT PHONE:454-8100 Receipt # 0 / 3 OO~
Tobeusedtor SF DWG/GAR Est.Value $140,000 Date APR 22 , ~g4L
Site Address 3953 STONEBRIDGE DR N
OFFICE USE ONLV
Lot 15 Block 4 Sec/Sub. HILLS OF
Parcel No. occuPancy R-3 M-1 FEES
zoning PD R-1
w Name FOSSUM CONSTRUCTION (AC1uaqConst V-N Bltlg Permil 780.00
3 Address 20452 IBERIA (qllowable) V-N
~ City LAKEVILLE phone 469-3614 M ol5lorie5 Surcnarga 70.00
Lenglh 77' Plan Review 507.00
io Name SA~ Depth 311
SAQCny 100.00
gQ Address S F. Total - SAC, MCWCC 650.00
~ City Phone S.F. Footprints _
0
On Sle Sawage - Water Conn 660.0
~
°w Name onstewen
Fw X WaterMeter 95.00
s~ Address MwCCSystem
~z Acct oeposit 30.00
i W City Phone City waier -2L
PRV Reqmrad _ S/W Permit 3~•
I hereby acknowlege thal I have read this application antl state that ihe Booster Pump - SM/ Surcharga .5
0
inlormahon is correct and agree to ply with all ap cable State of
-coT Minnesota Statutes and City of Ea r' ances. Treatment PI 276.0
0
SgnaWre ofPermitee APPHOVALS qoadUnn 370.00
A Builtling Permit is issued to: FOSSUM CONSTRUCTION Planner - park Ded.
on Ihe express condmon ihat all work shall be done in accortlance wilh all Council
applicable State of Minnesota Statutes antl City ol Eagan Ordinances. Biag. Ofl _ Copies
BwldingOlficial Variance _ 7p7qL 3,568.50
' 1991 BUILDING PERMIT APPLICATION
CITY OF EAGAN
SINGLE FAMILY DWELLINGS MULTIPLE DWELLINGS COMMERCIAL
2 SETS OF PLANS 2 SETS OF PIANS 2 SETS OF ARCHITECTURAL
3 REGISTERED SITE SURVEYS REGISTERED SITE SURVEYS - & STRUCTURAL PLANS
1 SET OF ENERGY CALCULATIONS (CHECK WITH BLDG. DEPT.) 1 SET OF SPECIFICATIONS
1 SET OF ENERGY CALCULATIONS 1 SET OF ENERGY CALCS
# OF RENTAL UNITS
OF FOR SALE UNITS
YENALTY APPLIES WHEN: TYPING OF PERMIT IS REQUESTED, BUT NOT PICKED UP SY LAST WORKING DAY
OF MONTH IN WHICH REQUEST IS MADE.
IAT CHANGE IS REQUESTED ONCE PERMIT IS ISSUED.
NOTE: ADDRESSES FOR CORNER LATS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS
DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED.
PROCESSING TIME FOR SEWER & WATER PERMITS IS TWO DAYS ONCE A PERMIT HAS BEEN COMPLETED.
PERMIT MIISS SHOW A LICENSED PLUMBER.
To Be Used For: Valuation: Date:
Site Address )yJg Jlmd)'Urlho, IlM &P vc) a OFFICE USE ONLY
/ P
Lot B1ock "L
FEES n
Occupancy '3 M- Bldg. Permit 76o,0z;
Zoning Surcharge 7 0-00
Parcel/Sub 2~fy~~wr~ Actual Const Plan Review 6~0 DO
Allowable v-/J SAC, City IQOiDd
Owner fi~~[<i/e-# of stories SAC, MWCC $tl,00
~ Length Water Conn. (p(pO~OJ
Address Depth Water Meter S,pD
S.F. Total Acct. DeposiL 30,00
City/Zip Code Footprint S.F. S/w Permit ,10,00
S/W Surcharge ,50
Phone On site sewage_ Treatment P1. 2p(n,00
/J On site well Road Unit 3 ~ DiDV
Contractor ~SS'(~~77 C pil/fJ`' MWCC System Park Ded.
/ City water ? Trail Ded.
Address PRV _ Copies
Booster Pump
City/Zip Code SUBTOTAL
APPROVAIS Penalty
Phone Planner Lot Change
Council TOTAL ,j ,~j
Arch./Engr. Bldg. Off. ~1-19910s
Variance
Address
City/Zip Code
Phone tt l~f~ ' DIi2y
agrees that all work shall be done in accordance with
(Signature of Contractor)
all applicable State of Minnesota Statutes and City of Eagan Ordinances.
VA L U~T---.~C'~'~
~A2 AGE
'75$ x I5 = 11,3~v
$SN1''!',
t15 x~6: ll~10 '
y x ~ ; (3 z)
Ii3a M iu = lsgs2
brr Ft_oors
13s~~
2t~~t`Ii 4~ X~3
~ N,D Ro o r'L
x 3~ : ~'1b't K5~3 = 50986
13902~ oR ~tiu,vo~''
,
A P P. - 1 0- 9 1 T H U B: 4 6 M A I E R S T E W A R T & A S S O C. P_ @ 2
i
Land 3urveying dc Engineering, Inc. Certlflcate ~~°.A~^Y ~T~ fsal Of $urvey
FOR:
SCALE J 40, ELDON FOSSUM
ND1ES:
O DENOTES lRON MoNUMEN7
(412.e)x DENP'SES EX{STIP18 ELEYAIIWl3
DENOTE9 5URFACIC ORAINAGE
01 FINISHED GARAGE FLOOR
ELEV. 915.8
6934 Jg+
. ~
01 kt . y,b,
. /
io
y
V .
r ~
~ ~ W
a
~
~
p
~ U272 . p ~ Y' -33. e
~ S0`
TOP OF IRO
3
e12.eo iAAL - 'I-/ -
DRAINAGE dt UTILITY EACztfiW E~71aE1`rGL-RbIN: .
EASEMEN? FlNISFiEO
E7LCARAGE
4ELEV013.2 L07 15,BLOCK4
l0T 18 HILLS OF SYONEgRIpGf
DAKOTA COUNTY~MINNESOTA
wE HEREBY (MIFY iHAT 'fHl9 IS A TRUE AND CORftECT REPRfiSENTAiION OF A SURVEY 0F THE BOUNDARIES OF THE
LAND DESCItIBEp ABOVE AND 7HE LOCA71(1N OF All BUILAIN09 TIIEREON, ANO ALL VISIBIE ENCROACHMENI'3 IF ANY,
fROM OR ON SAID LAND, 1HAT 7HIS SURVEY WA3 PRfPARfA BY ME Oq UNDER ~IY OIiiECT SUPERVlSION ANb 1HAT 1
AM A DuLY pEd91ERED LAND SuRVEYOR UNDER 'R1E LAWS OF THE 37ATf OF MINNESOTA.
AS 9URYEV - q ME '(}{lg oaY ov I~PR'~L t9~_
BYi _.~_al4_.~ MINN£SOTA RECISTRATION N0. 1~Z ~s
joe No, Eoa.ooz.45
Baak lFl Pape 8 -
S,a, 4 T z 7 R, Z 3
. • ?121/Y
. . MINNE507A STATE ENERGY CODE CALCULATIONS
BASED ON CHAPTER 5 OF THE
MODEL ENERGY CODE - 1983 EDITION
Adoption Effective 1/1/84
Owner Phone Da[e
' S i te Address ~0., ~4t. H o y~~ of CMMF8R Ip4P4ff
Contractor Phone
Buitding Classification: Type Al (Single Family & Duplex)ype A2(Residential)
(3 stories or less
NOTE: Complete pages 3 and 4 first. (pther) '
(Over 3 stories)
GENERAL INFORMATION
N ~
1. Buildfng Perimeter~~p-L 4K ft.
2. Wall height (ground to eave) ~ ft.
Z,~ 2~
3• I. x 2. (above) gross wall area_jj~ //ft. ~
~--~----t----~
4. Building dimensions (i.) X(W) t.2 roof 6 floo'r area
5• Square foot area of rim joist - Floor )oist size (2 x /01 ) I
Ia X Perime[er = Rim joist area = ~ft2
FZ
6. Doors - Area
Thfckness in. U factor, l . . '
Type of Construction Perimeter ft. I
Manufacturer I
I
7. Total door's perimeter ft. -
. ~
8. Windows: Manufacturer State approved
. U factor TYPE SIZE AREA (Ft.2) NUMBER OF TOTAL FEET 2
EACH UNITS
~~G NUv~/F-~ ~N
I I
9. Total ft.Z Glass
10. Fireplace area: Width X hejght = X = Ft.Z
I1. Exposed foundatlon: Hei9ht X Perimeter X~~ Z~~? _ ~ J~ Ft.2
COMPLETION OF THIS FORM IS REQUIRED FOR ALL EA-W CONSTRUCTION, MAJOR REMODELING AND BUILDINGS BEIN(
MOV E O W H E R E E N E R G Y , O T H E R T H A N T H E M I N I M A L CODE ALLOWANCE, IS USED.
12. F'raming area = 10% of gross wall area.
13. Gross wall area ft.2
Window area A ft.Z U windows = ~3~0 U x A=
Rim joist area A ~ 1~p ,r~f 1 ft.2 U rim joist = jo4 U x A=
1 oor area A' ft.~ U door area = U x A=
W~~~area A ft.z U fireplace = U x A= r~"f
Exposed foundation A (s, !5L4?2 ft.Z U foundation = . 0 ~O U x A= l~ Z(O
Framing area A Z~'g~ ~j~~• ~q~ ft,2 U framing'area = i0 `?,i~ U x A=
L
Net wall area A '(p((J22_ft. U walt .r U x A= ~r ~(O
. ~ (138) TOTAL . . . . s . . . . . U x A
s
14. 6ross wall area z 0.11 (A-1 single family & duolex = allowable U x A/Code
(13. above) .
x 0.23 (A-2 other residential)
x .23 (Other buildings)
x .28 (Over 3 stories) '
^1q 1 ~Z~ZrI~ BTUH Must be larger than
A x U Code. . a O
= F. 138 above
15. Ceiling framing area (Af) equals 10% of ceiling area or the same as)
15A. Gross ceilin9 area =(L) T-' x(W) ft.2
158 Joist area (Af) = lOa ceiling area = I~~Q ft.z
15C. Net ceiling area (Ac) (15A - 15B) _ ~~J" ft.2
U ceiling x A C_ ,6Z2 x (O~ = Z 3, o (:9
U framing x A p= x11ca_ = Z(a+
15D. TOTAL U x A ~v .
16. Ceiling area (15A) x"0.026 (A-1 single family 8 duplex - code allowable U x A
x 0.033 (9-2 other residential)
x 0.06 (other)
~ k p'Z(p BaUH Must be larger than 15D (above)
A (15A1 I~(D4 x U (codel= ~di Z ~O F (or the same as )
NOTE: Use U and A values obtained from pages 1, 3 and 4.
CERTIFICATION: I hereby certify tha[ I have calculated the "U" factors and "R" values
herein and that the building here described meets or exceeds the Sta e of Minneso[a
Energy Conservation Act.
Date Signature
2.
~g,~~XC ~~~~3-~ ~~,~3-~- 2t~-I-~~ _ ~ I ?g ~ 41
2A 19 -
~ I I o4 ~ ~ t--~-r: - - - .
- -
I~II ~Lzx~- = ~z.sX4 = 90~0
(Ill ce-lx%2 =5?5X4 55,0
111~ c~2x~ = Z~,~ X3 ~ g2,5_
II aj ujl~; - Il.0 X 2-= ZZ, O~
71-~3-7
~
~
- - - 1os'` a - - - -
YnLUI bf1Ll.ULI111V1~.]
. • R 4ALUE U VALUE
• ~ ' Inaide air film .68 '
i
UALI. Interior wall •45 (Nall) U~ 1
SECTION J ~ . R •
Ineulatlon 11.0
Sheathin
~ s Z,oco .043 .
Slding
I
Outs(de air film .17
R TOTAL Z3 , O ~j
I Instde.alr film ~ .68
STUD Inter(ot wall .45
SECTION ~ 4" stud R= (p,'5 (Framtng) U. R ~
~ Sheathing ~ Z .O10
siai„g .cn1 , °9,5
Outslde'alr fllm ' .ll
R TOTAI, 9-7 F
= -68
I ~
~ Interlot vall •
SECTION. Ineulat[on all ) U e~
f~ Exterlor wall cover n
Exterior air fllm R ..11
R TOTAL
lnterlor air fllm R= ,68
R I!I ~
insulatlon 19. 00
JOIST 'tk inch eoft aood H=1.88 (Rim U= R=
Joist) '
~ Sheathing
Extetlor t+all covering .(p1 ~
E:ctetlor air fLlm {t= ,17
~ R TOTAL Z..q". 4(p
Interlor air fllm R= .68
Lnsulatlon
~ Fnunda[Lon (Fdn.) U = R =
Exterior alr Elln R' .17
~ R TOTAL 8luck
.~•~~~-'~`,rade 3.
CEILING WITH VENTEO ATTIC SPACE ABOVE
, • ' • R YALUE V1F,LUE
° FRAMItIG CEILING
~ 0.61 Air F11m 0.61 '
Insulation 44,0
aoist
.5 Ceilin9 . -rj(p
: ~ • -
0.61 Air F11m 0.61
Z~EO Total R
1
U = R
OZZ
a
FLAT ROOF OR CATHEDRAL CEILING
~g - - R Ya ue R 9ALUE
FRAI•IING CEILR;G
I
- q- 0.61 Inslde air film 0.61
Ceiling
Joist (stu •
[nsulation
Air space
Roof decking
Insuiation
Built-up roof
0.17 Outside air film 0.17
Total R
I = U
R
Jindow infiltration .5 cfm/lineal foot of crack
tesidentfal door infiltr-ation 0.5 cfm/square foot or door and minimum code requfrement
lon-residential door infiltration 11.0 cfm/lineal foot of crack
Jb 12" concrete block no insulation =,q7 R2,1
)b 12" concrete block insulated cores =.26 R 3.8
JS 12" lightweiqht block =.32 R 3.1
1b 12" lightweight block insdlated cores =.12 R 8.3
J single glass = 1.13; with storm window .54 1 double glass = .55
J triple glass = .41
M exterior walls and ceilings must have a vapor barrier (0.10 perm max.).
:anor barrier must be on the inside (heated side) of wall.
iapor barriers of the polyethelene tliin film have no R.value.
4.
2000 BUILDING PERMtT APPLICATION (RESIDENTIAL)
~ 3 CIT,? oF ~G~,
3830 PILOT KNOB RD • 55122
851-681•4875
New ConsfiucNOn ReaWremenh Remodel/Reoalr Reaulremenh
> 3 reglstered dte wrveys ahowinq sq. fl. ol bl, aq. tt. of houae 2 copies of plan
and gp roofetl areas f20% mWmum lof covaraae albwedf 1 set of energy cdculaMOns tor heated addlMOru
> 2 coplea of plane (show beam & wlnWw sizea: poure0 tnd. deslpn; efc.) 1 site survey for exterlor additlons & decks
> 1 set Of enefyy CalculaHons
> 3 coples of hea preservaflon plan 11 lot plalfetl afler 7/1/93 ~ OV
/DATE: CONSfRUCTION COST:
DESCRIPTION OF WORK: e
STREET ADDRESS:
LOT: Is- BLOCK: SUBD./P.I.D. tl:
~ ~ Phone
Name:~A U ZU~ -
PROPERTY 90 Flnt
OWNER SheetAddress:-Y/~--,~ ~l L2 Dx ~C~
CUy State: /nL) Zip: 5~37,;Z-~
Companv&lSS~/ .Phone t?: ~5-7 7`,~~7
' (area code)
CONTRACTOR
Sheei Address: z'-- 11-2Uki S r~ llcense p4~ (53 ~ExP. ~
City ~iJ S Slate: Zip:
ARCHITECT/
ENGINEER Company: Name:
~ Telephone #Y: ( )
Sheet Address: ReglshaHon
Ci}y State: Zip:
Sewedwater licensed plumber (H Installina sewer/w terPhone
I hereby acknowledpe Mwf I have read Mis applkalbn, state ttw1 Ihe i fortnalion b c'~r ect. and agree to comply wilh all appflcabie StatE
of Minnesotc StaluTes and Clty o/ Eayan Ordinances.
Signalure of Applicanf:
OFFICE USE ONLY
Certificates of Survey Received _ Yes _ No Tree Preservation Plan Recetved _ Yes _ No _ Not Required
OFFICE USE ONLY
BUILDING PERMIT SUBTYPES
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 21 Porch (3-sea.) ? 31 Ext Att - Muki
? 02 SF Dwelfing ? 08 06-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF
? 03 01 of _ plex ? 09 07-plex ? 18 Deck C 23 °cr^h (screened) ? 36 MuRi
? 04 02-plex ? 10 08-plex ? 19 Lower Level ? 24 Storm Damage
? OS 03-plex ? 11 10-plex Plbg _Y or _ N ? 25 Miscellaneous
+7 06 04-plex ? 72 12-plex ? 20 Pool ? 30 Accessory Bldg.
WORK TYPE
? 31 New ? 36 Move Bidg, ? 43 Reroof
? 32 Addition ? 37 Demolish (Bldg)' ? 44 Siding
? 33 Alteration ? 38 Demolish (Interior) ? 45 Fire Repair
? 34 Repair O 42 Demolish (Foundation) ? 46 Window;/Doors
' Give PCA handout to applicant for demolition permit
GENERAL INFORMATION
SAC Code # of Stories sq. ft.
No. of Units Length sq. ft.
No. of Buildings Width Footprint sq. ft.
Const. (Actual) Basement sq. ft. Census Code
(Allowable) Main level sq. ft. MClES System
UBC Occupancy sq. ft. City Water
Zoning sq. ft. Booster Pump
PRV
Fire Sprinklered
MISCELLANEOUS INSPECTIONS
? Stucco/Stone
APPROVALS
Planning Building Engineering Variance
Permit Fee Valuation: $
Surcharge
Plan Review '
License
MC/ES SAC
City SAC Water Conn.
Water Meter
Acct. Deposit
S/W Permit
S/W Surcharge
Treatment PI.
Park Ded.
Trails Ded.
Other
Copies
Total:
SAC Units
% SAC
CITY OF EAGAN
CASHIER: JS TERMINAL NO: 767
DATE: 08/18/00 TIME: 10:23:34
ID:
NAME: M:;NNESOTA EXTERIORS INC
3210 9001 3953 STNBRG DR 209.2!
2155 9001 3953 STNBRG DR 6.01
Total Receipt Amount: 215.2!
CR136069
_ iJSER ID: JAN
2000 BUILDING PERMIT APPLICATION (RESIDENTIAL)
CITY OF EAGAN
3830 PILOT KNOB RD • 55122
651-681-4875 4
New CauhucMOn Reaulremenh Remodel/Reoalr Reaulrertrenta
? J replateretl tlie wneys ahowlnp sq. R. of lol, sq. fl. of house 2 copies ot plan
and Qy rooted areas (20X rtwWmum lot coveraae Wlowetl) 1 sat of energy calculatbns for heated additlons
? 2 coples ol plans (alww be(im a wlndow dzea; poured tnd. deslpn; efc.) 1 aite wrvey for exteAOr addlHOns & decka
? 1 set of eneryy CalculaNOns
D 3 coples ot hee preservaHOn plan If lol plalted afler 7/1/93
~
DA7E: ~ CONSTRUCTION COST:
DESCRIPTION O WORK: R( D~~~ e \ fl I~t'V~ ~'1'~1 ~~d lC.
STREET ADDRESS: Cl S r V
LOT: `J BLOCK: SUBD./P.I.D. A: CN S 1"1~bY i~
l~J~-LX;h~, Phone N:~iJ~'I~jj
Name:`("X~
PROPERTY la t Flrst
OWNER
Sfreet Address: -Z) CIk,
ciy q c, csta?e: 1rn zip:
company: vM i nv\fso4r, I \NC Pr,oner:(-~~'O `;Cl
(area code)
CONTRACTOR
Sfreet Address: ~~~P •lte fS~t~ ~ VC b.1xv` o~O lJcense 8 Cg- Exp. 3 I
a+r bs5f~ sta?a: rv,~ zip: ~S~31o~1
ARCHITECT/
ENGINEER Compcny: Name:
Telephone q: ( )
Shset Address: ReglshaNon p:
Clty State: Zip:
Sewer/water licensed plumber (Ii Inatallina sewerlwaterl: Phone tt:
I hereby ocknowledye ttqt I have read Ihb applkalbn, slafe fhaf ihe Infortnalbn b corr an ' gr , focomply wHh ap appAcaWe State
of Minnesola Statutes and CHy of Eayan Ordinances. /
Signature of Applicant:
/
dFFICE USE ONLY RECEIVED
Certificates of Survey Received _ Yes _ No AUG 1? 2000
Tree Preservation Plan Received - Yes - No _ Not Required
BY:___
OFFICE USE ONLY
BUILDING PERMIT SUBTYPES
? 01 Foundation ? 07 05-plex ? 13 16-plex ? 21 Porch (3-sea.) ? 31 ExL Alt - Muki
O 02 SF Dwelling ? 08 06-plex ? 17 Garage ? 22 Poroh/Addn. (4-sea.) ? 33 Ext. Aft - SF
? 03 01 of _ plex ? 09 07-plex ? 18 Deck ? 23 Porch (screened) ? 36 Mutti
? 04 02-plex ? 10 OS-plex ? 19 Lower Levei ? 24 Storm Damage
? 05 03-plex ? 11 10-plex Plbg _Yor_N 0 25 Miscellaneous
? 06 04-plex ? 12 12-plex ? 20 Pool ? 30 Accessory Bidg.
WORK TYPE
? 31 New ? 36 Move Bldg. O 43 Reroof
? 32 Addition ? 37 Demolish (Bldg)' ? 44 Siding
? 33 Alteration [3 38 Demolish (Interior) ? 45 Fire Repair
O 34 Repair O 42 Demolish (Foundation) ? 46 Windows/Doors
' Give PCA handout to applicant for demolition permit
GENERAL INFORMATION
SAC Code # of Stories sq. ft.
No. of Units Length sq. ft.
No. of Buildings Width Footprint sq. ft.
Const. (Actuat) Basement sq. ft. Census Code
(Allowable) Main level sq. ft. MC/ES System
UBC Occupancy sq. ft. City Water
Zoning sq. ft. Booster Pump
PRV
Fire Sprinklered
MISCELLANEOUS INSPECTIONS
? StuccolStone
APPROVALS
Planning Building Engineering Variance
Permit Fee Valuation: $
Surcharge
Plan Review
License
MC/ES SAC
City SAC
Water Conn. .
Water Meter
Acct. Deposit
S/W Permit °
S/W Surcharge
Treatment PI.
Park Ded.
Trails Ded.
Other
Copies
Total:
SAC Units
°/a SAC
PERMI7 M, cirY oF enc~?N It~c
1992 BUILDING PERMIT APPLICATION
681-4675
SINGLE 8 MULTI-FAMILY 2 sets of plans, 3 registered site surveys, 1 copy of energy
calcs.
COMMERCIAL 2 sets of architectural 6 structural plans, 1 set of
specifications, 1 copy of energy calcs.
Penalty applies when typing of permit is requested, but not picked up by last working day
of month in which re uest is made or lot chan e is re uested once ermit is issued.
Date r~1a~ /0 / q~ qa Valuation of work
Site Address:_3~53 S-Ivnebrkdne i~)(- ~ I
STREET STE Y
Tenant Name: C,~e mes.~-- S°- Cc~c o\ So.~_)que."~
Lot _5 eLa[ 'i suso. ~A P.I.D.
r
S-4o~e. o- a - ISG - o4
Descri tion of work: 7)0r-1<
The appl i cant i s: Owner ? Contractor ? Other (Deccrtbe)
Name ~.')eC1e~cCA_ C.ncb\ Phane 68`l-O5
Property LAT FIR:T
Owner qddress 39 53
c1a ~ D<
STREEi ' STE /
City Ec,c,oc,\ State T~lr~ Zip
Company Phone
C017tr8Ct0r Address License N Exp.
City State Zip
Architect/ Company Phone
Engfneer Name Registration #
Address
CitY State Zip
Sewer 8 water licensed plumber ' . Processing time for
sewer & water permits is two days once area has been approved.
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.
Signature of Applicant: ~ . , ~
urrm;t uat UrvLT
BUILDING PERMIT TYPE
t
? 01 Foundation O 05 Apt. Bldg O 09 Basement Finish ? 13 Public Fac. '
? 02 SF Dwg. ? 06 Garage/Accessory ? 10 Swim Pool O 14 Agricultural
? 03 Two family ? 07 Fireplace ? 11 Res. Add./Porch ? 15 Miscellaneous
? 04 Multi-fam. T.H. fg OB Deck O 12 Lomn./Ind.
WORK TYPE
31 New ? 34 Repair O 37 Demolish
? 32 Addition ? 35 Tenant Finish 99 Undefined
? 33 Alterations ? 36 Move GENERAL INFORMATION
Const. (Actual Basement sq. ft. MWCC System
(Allowable; lst F1. sq. ft. City Water
UBC Occupancy R-3 2nd F1. sq. ft. PRV Required
Zoning Sq. Ft. total Booster Pump
# of Stories Footprint Sq. ft. Fire Sprinkler
Length IG' On-site well Lensus Code -z7--3V-
Depth 1zOn-site sewage SAC Code
APPROVALS
Planning Building Assessments
Engineering Variance
REGIUIRED INSPECTIONS
? Site E~ Footing ? Framing . ? Insulation
? Mallboard Q Final ? Draintile O Fireplace
Permit Fee ti G wimc;a,: :
Surcharge
Plan Review
License v
MWLC SAC
City SAC
Water Conn.
Water Meter
Acct. Deposit
S/M Permit
5/W Surcharge
Treatment P1.
Road Unit
Park Ded.
Trails Ded.
Copies
Other
Total: SAC %
SAC Units '
_ _ . . . ' ~ . .J. . ~ . a. a a ai ~ r . b 1
.
Laad Surveying & Engineering, Inc.
Certiflcate
~:Wn;r~Y ~ WW-AM P~~TA fs;l ~ ~ Of $urvay
FOR:
~
S
ELDON FOSSUM
NOTES:
O DENOTES (RON MoNUbpNT
(912.8)x Ri3i0SE3 EXFSi1N6 0.EYA1WN3
W DENOTES SVRFACE CRAINAOE
o, FINISHED GARAG£ FLOOR
ELEV. 915.8
/ ~ S 69`~4Jg,
~ 4
I ~ kb
~
~j.~ ~ ~ Q PEc~ ~ 1 ~ io
~ • ~ , ~z O ~T' ,Rs~O d l;~ 0~
, ~
k• C9 P°d i atte ~j ~
. ,
Oi S Jz 21 ~pv
TOP Of IR
- - ~ ~f / ~
DRniNncE ac uTiurr 912.80
EASEMENT
FlNI3FiED
, E7LCARACE
ROOR
+ELEV.913.2 LO7 45,BL4qC4
LOT 18 HILLS OF STOPiE9RIDGE
DAKOTA COUNTYsMINNE50TA
WE HEREBY CERIFY THAT 'M19 IS A iRU6 AND CORRECT REPRESENTAiION Of A SURVEY OF ITiE BOUNDARIES OF 1HE
AB
FRCM R ON SAiDLAND. THATMIHIS SURV~EY AS PRfPSUMNOS AREO BY ~IOR .UNDER UY D RECr SuPE,RVtS10N wb TM rYi
AM A DUIY REd9TERED LAND 3URVEYOR UNDER 1HE UWS Of iHE S7ATE Of AIINNESOTA.'
BYr ~M..d. IS DAY oF_-_APRlL i psL
!:ESOTA RECISIRATION N0. - 7 s
Job Ne, Eob.oo2.4f
Boak jr7 Papea.~
_ Sea 4 T L7 R, 23
~
~ CITY OF EAGAN FOR CITY DSE ONLY
i 3630 PIIAT SIiOB ROAD
~ EAGAN, MN 55122 PF.R1iIT k
' PflONE: (612) 454-8100 RECEIPT k ~~~v5
. ftmIQIC' PzmT DATE: 9
R~ESIDEN3+IA2.:; PLEASE COIiPLETE IIPPER PORTION ONLY FOR SINGLE FAtiILY DiTELLINGS b
TOWNHOMES/CONDOS VHEN PER2fITS ARE REQIIZRED FOR EACH IINIT.
WORK DESCRIPTION COMPLETE THE FOLLOWING:
N0. FIXTURES F.A. TOTAL
NEW CONST ADD-ON HINIMUM 15.00
ADD ON SHOWER 3.00
REPAIR WATER CiASET 3.00 C
oL BATH TUB 3.00
1"~ IAVATORY 3.00
OWNER NAME: ~~L7Y1S1'`~(.ZC:YID~'1 .+f KITCHEN SINK 3.00 ~
~S Skor'¢.bri dcjy rivR~ = IAUNDRY TRAY 3.00 SITE A?DRESS: HOT TUB/SPA 3.00 '
WATER HEATER 3.00 ~
IAT:16 Bi6CK 4_1 SUBD. ::Z: FIAOR 'Ji..a.t: .°..CC
/~I1't~~1 O GAS PIPING OUT.
INSTALLER: t1
r7'A ~tTLf (MINIMUM - 1) 3.00
C I_ ~ ROUGH OPENINGS 1.50
ADDRESS: Ia0 SI 2P{~j-~'h A.S. ~-1c«IID _ OTHER
WATER SOFTENER 5.00
CITY: Bl.l1rY1SALA Vo ZIP: 5S337 _ PRIVATE DISP. 15.00
YHONE U.G. SPRINKLER 3.00
~ SUBTOTAL $ 43. SU
ST. SUFtCHARGE .50
SIGNA E OF PERMITTEE
TOTAL: S U4 r
COMMERCiAI:JiNDIISTRFAL:. PLEASE COHPLETE TAIS PORTION FOR ALL C0M4fERCIAL/INDUSTRIAL BUILDINGS AND
MULTI-FAMILY BUILDINGS WHEN SEPARATE PERMITS ARE NOT REQUIRED FOR EACH
DWELLING UNIT.
°
CONTRACT PRICE: FEES
OWNER NAME: 18 OF GONTRnrT FEF, ,
STATE SURCHARGE - $.50 FOR
SITE ADDRESS: EACH $1,000 OF PERMIT FEE.
IAT: BIACK _ SUBD. $25.00 MINIMUM FEE.
INSTALLER: CONTRACT PRICE x 18 $
ADDRE55: STATE SURCHAEtGE $
CITY: ZIP:
TOTAL: $
PHONE
( S I GNATIJRE )
FOR:
CITY OF EAGAN
. CITY OF EAGAN FOR CZTY USE ONLY
~ 3830 PILOT KNOB ROAD
EAGAN, MN 55122 PERMIT # A"k
PHONE: (612) 454-8100 RECEIPT # 06S
34EC'HANTCA7,:,"RMTT DATE: CO 3 r/
RE~IDE3~TIAL: PLEASE COMPLETE IIPPER PORTION ONLY FOR SINGLE FAMILY DWELLINGS &
TOWNHOMES/CONDOS WHEN PERMITS ARE REQIIIRED FOR EACH UNIT.
WORK DESCRIPTION FEES
NEW CONST X ADD-ON MINIMUM $15.00
ADD ON _ HVAC 0-100 M BTU 24.00
REPAIR _ ADDITIONAL 50 M BTU 6.00
GAS OUTLETS - MINIMUM 3.00
OWNER NAME: y(')SSV. OF 1 PER PERMIT
SUBTOTAL: $
SITE ADDRESS; Sc S3 S'~Q~'~E?b(` ~c ~S STATESURCHARGE: ~
LOT:BI.OCK SUBD. ~ \ TOTAL: $~27_5o
INSTALLER: \ ~ (A
pd~ `
ADDRESS: ~OCi rX,~.~d_ ?6TUR C
E OF PERMITTEE
CITY: V:n ZIP: C7
PHONE \ ~~O~--COOc~~
COMMERCIAL/INDUSTRIAL:, PLEASE COMPLETE THIS PORTION FOR ALL COMMERCIAL/INDUSTRIAL BUILDINGS,
APARTMENT BUILDINGS, AND MULTI-FAMILY BUILDINGS WHEN SEPARATE PERMITS ARE
NOT REQUIRED FOR EACH DWELLING UNIT.
CONTRACT PRICE: FEES
OWNER NAME: 1$ OF CONTRACT FEE.
STATE SURCHARGE - $.50 FOR
SITE ADDRESS: EACH $1,000 OF PERMIT FEE.
PROCESSED PIPING - $25.00
LOT: BLOCK _ SUBD. $25.00 MINIMUM FEE.
INSTALLER: CONTRACT PRICE x 1$ $
ADDRESS: STATE SURCHARGE $
CITY: ZIP:
TOTAL: $
PHONE
(SIGNATURE)
FOR:
CITY OF EAGAN
City of Eagan
3830 Pilot Knob Rd
Eagan, MN 55122
(651) 675 -5675
www.ci.eagan.mn.us
Site Address: 3953 Stonebridge Dr N
Lot: 15 Block: 4 Addition: Hills of Stonebridge
PID:10- 32990 - 150 -04
Use:
Description:
Sub Type: e - Furnace & Air Conditioner
Work Type: New
Description: Fumace & Air Conditioner
Fee Summary:
Total:
Contractor:
Apple Lake Heating & Air Conditioning
207 150th Street West
Apple Valley MN 55124
(952) 431 -4328
ME - Permit Fee (Replacements)
Surcharge -Fixed
Applicant/Permitee: Signature
PERMIT
City of Eaan
Permit Type:
Permit Number:
Date Issued:
Permit Category:
Comments: Quesetions regarding electrical permit requirements should be directed to Mark Anderson, State Electrical Inspector, (952)
445 -2840
- Applicant -
Owner:
Clement J Jauquet
3953 Stonebridge Dr N
Eagan MN 55123
$50.00 0801.4088
$0.50 9001.2195
$50.50
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
Issued By: Signature
Mechanical
EA088804
04/21/2009
ePermit
PERMIT
City of Eagan Permit Type:Building
Permit Number:EA164410
Date Issued:09/28/2020
Permit Category:ePermit
Site Address: 3953 Stonebridge Dr N
Lot:15 Block: 4 Addition: Hills Of Stonebridge
PID:10-32990-04-150
Use:
Description:
Sub Type:Windows/Doors
Work Type:Replace
Description:One Window/Door
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: 1,500.00
Fee Summary:BL - Base Fee $1500 $62.50 0801.4085
Surcharge - Based on Valuation $1500 $0.75 9001.2195
$63.25 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 -
Clement J Jauquet
3953 Stonebridge Dr N
Eagan MN 55123
(651) 279-1665
Pella Northland
15300 25th Ave N #100
Plymouth MN 55447
(763) 745-1400
Applicant/Permitee: Signature Issued By: Signature