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854 Sudberry Lane i CITY OF EAGAN SEWER SERVICE PERMIT 3830 PiILt Knob Road P. O. Box 21199 PERMIT NO.: ' 1" ~ Eagan, MN 55121 DATE: ~ ~ Zonirp: l No. of Units: 1 pw,,,,; Joseph ~:iller Const Address: Site Addreu: 854 Sudberry Lar?e L8 32 Sheffield '-(.~uire hlech Plumber. j-22-8.i 33732 i.om. ro @",i, wkh w. c*y of Eagan ca,n.crion aarge: 7 c0~,, ~ Oedlwnam Acoount Deposit: 1, ~ Pem~it Fee: , y Surchorpe: • By Misc. Chorqes; Dcte of lnsp.: ToMI: Insp.: Doh Pald: CITY OF EAGAN WATER SERVICE PERMIT 3830 PiJqt Knob Road P. O. Box 21199 PERMIT NO.: ' iJ.L Esgan, MN 55121 DATE: 115-3-.'+,3 Zonirg: No.ofUnits: Owner: SL /lddreas: Stte Addreas: g54 Sud7trry Lane L~ !~2 5he ie o plt,nber Mcuuire :'.eciz Metar No.: Connection Chorpe: 5 0. 0 Size: AcCOUnt De poslt: Raadsr No.: Permit Fee: ~ . 1 pme !o oomOlp Mfih tw Cifp ef Ea9as Surclwrge: Oedhwwen. Miac. Charpes: J, Totol: BY Date Pa1d: Date of Insp.: Insp.; ' "I • r 1 !s t . ' . , CITY OF EAGAN r~503 • 2795 PAaf Kwob Rood Ee9an, MN 55122 PHONEs 454-8100 BUILDING PERMIT Receipt Te be awd fm 'r DWG/F,~l1R Est Value $55..000 Oate Septemb er 22 19 83 Site Addreu 354 u erry ane E?ecr `i~3 ~ Occupency Lot 3 Block ` Sec/Sub. Shef f ield Ntter p Zoning Parcel # 10•-67fi00-030--02 Repoir ? Fire Zone ~osep 1 M. ~Uller onst., nc. Enlarge p Type of Const. W Nome Move 0 # Storie~s z 1611-1 e ar ve. o. ~ Address Demolish p Length Ci Farminrtoii Phone 54- 753 Groda p Depth -77- Sq. Ft. ~ N~ wner Approvob Fees o , ~U Address /lssessment Permit _z 7 ~ Ci Phone Woter 8 Sew. Surchorge 149. ou Police Plan check ~ W W Nome Fire SAC ' ~Z Address Eny. Woter Conn. 450.00 i W Ci Phore Plonner Water Meter -?70 Council Rood Unit 253•00 I hereby ocknowledge thot I hove reod this applicotion and stote that gldg, pff. fhe informution is correcr and agree to wmply with oll applicoble APC T~o~ ~ . . 50 Stafe of Minr?esota Statutes and City of Eagan Ordinonces. Sipncture of Permittee jUMeptl M. CLILL fi. InC . /1 Building Permit Is issued to: on ths express tor?dition thcii all work shall be done in accordarxe with oll opptiqoble Stete F Mifjnesota-Srotutes ond City of Eaqon Ordirwnces. Buildinfl Officiol ~ Psrmit No. Permit Holdsr Misc. Pwmit No. Holdar VKV.A.C~ c wo ZS$ t~ Jlti i 1c~ ~c.e..rta. lo-zy Inspsction Date Insp. Other MHVAInwlation ~ Final Plbp. Final HVAC ~ Ftnal ~ Wour Dacribe Location: YVell ' Sow+r Pr. Dhp. - .~.-NP i .'c~• = L .:y'T': ' T~^, _'v.•~~ R,~.r."^-~..~ of ~agan 11epttrtmrtit nf liuilditug JniiVrriimt Tbir Certi catt issuad PursHant to the reqs~irtmcntt of Sution 306 ot the U~:i orm Buildin h f g,~ {"';A Codc catifriRg that at the tinet o/ itsuanct tbi.r ttructurc wat in coAt pliartce with the vuriouJ ordinanat o f the City regxlrtting 6xildaig ronnruction or Hrr. For the follaering: SF DWG/GAR 8503 u.. CY.&.em Bidg. Pemmt r,o. o«.wKr Trw R3 'nw camamwO. V F,R z. NA z., o,.., Rl a,,,,,u ,f &Wdft Joseph M. Miller Add„,48133 Cedar Ave. So., Farming, 854 Sudberry Lane Lot 8,Block 2,Sheffield ~ ~November 18, 1983 ~ euiYiyofficid R..~ naa: . ~ . rwr corwcuou~ nacc _ _ _ _ a ~ ~~~y~~~ ~ . ' ~.`yp~a~~ Ja w`~.':~`D'~'...:~;~:I ~~`-~"1~~r'+~.'~~,~'".~~~~.~.~~ry~~}"~.~~'f~+l~`"t~~' -~•~Ija-~~'~~~~n~d~~~~~~~~'~ c~.,, . Receipt MECHANICAL PERMIT Permit No. CITY OF EAGAN Fee • Fill in numbered spaces S/C Type or Prin[ legib/y Tot. 1. Date 2. Installation Cost 3. Job Address Lot Blk. Tract - 4. Owner 5. Contractor Phone 6. Address 7. City 4 State Zip 8. Building Type: Residential ? Commercial ? Institutional ? 9. Work Description: New ? Add ? Alter O Repair ? 10. Describe Fuel Type 11. No, EQuioment 9TU - M. Ea. No. EQUiament CFM Forced Air Air Handling: Mfg. Boilers Mfg Mech, Exhaust . Unit Heater Mfg. Other Air Cond. Mfg. Gas, Piping Outlets 12. I hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this tYpe of work. Signed : - for Rough F inal Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 464-8100 Receipt ` PLUMBING PEfRM1T Permit No. CITY OF EAGAN - 'Fes Fill in numbered spaces S/C Type or Print legibty Tot. 1. Date c'~ 2. Installation Cost L. 3. Job Address Lot y Blk. Tract 4. Owner , . 5. Contractor.G;. Phone 4 L,% 6, Address r7 7. City _ • State Zip " - 8. 8uilding Type: Residential Commercial ? Institutional ? 9. Work Description: New L`}~ Add ? Alter ? Repair 0 10. Describe 11. No. Fixtures No. Fixtures -N Water Closet Cesspool/Drainfield i Bath tubs Septic Tank Lavatory , Softner I Shower " Well ~ Kitchen Sink Urinal/Bidet Other ~ Laundry Tray 1 Floor Drains Drinking Ftn. Slop Sink ~ Gas Piping Outlets ~ . 12. I hereby certify that the above information is true and correct, and I agree to comply with all ordinances and codes governing this type of work. Signed : for Rough Final Inspections: Date Insp. Date Insp. This is your permit when numbered and approved. Approved CITY OF EAGAN 454-8100 , CASH RECEIPT . CITY OF EAGAN 3795 PILOT KNOB ROAD EAGAN, MINNESOTA 55122 DATE 19 R[CEIVRD RROM AMOUNT $ I 4 DOLLARS ~eo EICASH ? CHECK ROR FUND COOt AMOUNT Th k u ~r e v ~ YVhite-Payars Copy Yellow-Posting Copy Pink-File Copy CITY OF EAGAN "t^ 11044 3830 Pilot Knob Road, P.O. Boz 21-199, Eagan, MN 55121 PHONE: 454-8100 BUILDING PERMIT Receipt ~t Te be rwd ia Est. Value I.i i, pate r , 19 Site Address Erect ? Occupancy Remodel 2oning Lot Block SeclSub. - ? Percel No. Repair ? Type of Const. AddiUon ? No. Stories W Neme Move ? Length Demolish ? Depth ~ Address 'In[ Impr. ? Sq. Ft. City Phone - ~ Install C,7 ~ Name - , ~ Approrak fus g~i A~~ Nssessment Permit ~ City Phone Woter & Sew. Surcharpe Police Plan Review 49 F~W N&^B firo SAC Address Enq. Water Conn. ccW City Phone Plonner WaterMeter Council Road Unit 1 hereby acknowledge that 1 hove read rhis application ond stote that gldg. Off. / 1Tc PI. the inlormation is correct ond ogree to wmply with oli opplitable APC pa~s Stote of Minnesoto Stotutes and City of Eogan Ordinonces. Var. Date Copies Si9noturo of Permittee Total ' • h Building Permit Is luued to: ' on the axpress torditfon Ihat op work shall be done in ocwrdance with oll oppiioable State of Mfn?xsoto Stotutes ond City of Eoqan Ordinonces. Buildinp Officiol Pwmk No. Pamit Holder Date Talephona # Plumbirq H.VA.C. EI~etHe Soft~r Inmpeetion Date Insp. Other Footings 1 Footinys 11 F Framing Foundation Roofin9 Rouph Plby. Rough Htg. Insul. Firoplaee ~ Final Htq. Final Plby. Flnal CKt/Occ. Water ~?ibe l.ocation: w.ii pr. w~r Disp. CITY OF EAGAN 3830 Pilot Kno6 Road, P.O. Box 21-199, Eagan, MN 55121 NO AO6~? PHONE: 454-8100 ~ , ~ BUILDING PERMIT Receier Te be wod fw D1:C'` Est. Value $ 900. Qate 19 8 4 ~ - - - - - - - ' f,54 siJnr5' ~ Site Add~n ~ Ercct Occuponry Lot Block Sec/Sub. Alter C] Zoninp ~ Parcel No. .10 - fi 1 6 0 lj L Repoir ? FI re Zone Enlorpe D TYpe of Const. oe Name Move ? # Stories Z Address Demolish p l.ength i ~ City Phone 4~' '-7450 Cxvde p Depth Sq. Ft. ~ ~ • _ - Aoprovals Fees Name A~r~ Assessment Pertnit Y 1 i:1 . , , ~ city Phone Water b Saw. Surchorye •)0 Police Plan check I F W°w` Name Firo 5/1C ~ ~Z Address Enp. Water Conn. ~ W City Phone Plonner Water Meter Council Rood Unit I hereby acknowledge that I have read this opplicotion ond state that gld9, pff. the intormotion fs rnrrect ond ogree to comply with oll applicable I(~ , r~ ~ State of Minnesota Sfotutes and City of Eogan Ordinonces. /?PC Totol - Sipnoture of Permittee Ji:l'F f~~.i.i'.}• A Bullding Permit {s issued to: on the express condltlon tlxn oll work sholl be done in ~ a' with oll oppH 0)15_State of Minnesoto Statutes end City of Eaflen Ordinances. Buildinp Official ~ . Halder EDi.p. Permit No. Permit Holdar Mise. Permit No Elsctrie Inspection Date Insp. Other Footings Foundation Framiny Rouyh PI6q. Rouph HVAC Inwlation Final Plbq. Final HVA Finsl Weer Deacribe Location: V1hll Sewsr Pr. Disp. Receipt (t! C ' PLUMBING PERMIT Permit No. ~ )ea' Lo CITY OF EAGAN Fee S~? Fill in numbered spaces S/C Type or Print legibly Tot 1. Date 2. Installation Cost 3. Job Address Lot!gBlk. 2- Trac'5~'t~ 4. Owner 5. Contractor~.-4~'~~'!L?/l/1. tPhone 6. Address r 7. City State Zip 8. Building Type: Residential Commercial ? Institutional D 9. Work Description: New ~ Add ? Alter ? Repair ? 10. Describe 11. No. Fixtures . Na fixtures . Water Closet Cesspool/Drainfield Bath tubs Septic Tank Lavatory - Softner Shower Well Kitchen Sink Urinal/Bidet Other Laundry Tray Floor Drains Drinking Ftn. Slop Sink Gas Piping Outlets 12. I hereby certify that the above information is true and correct, and I agree to comply with a~rdinances and codes governing this type of work. Signed : " f i for Rough Final Inspections: Date Insp. Date Insp. This is tour permit when numbered and approved. Approved CITY OF EAGAN 454-8100 CITY OF EAGAN Remarks Addition SHEFFIELD ADDN Lot 8 Blk 2 Parcel Zo-67600-080-02 85 SUDBERRY LANE Owner Street State Improvement Date Amount Annual Years Payment Receipt Date STREET SURF. 181 28.68 1.43 20 STREET RESTOR. 19$4 178.09 17.81 10 GRADING Si5l 1981 91.10 .07 15 66.82 A013224 12-2-83 Sewer Lateral 517 1981 152.9 10.20 15 112.22 " " SAN SEW TRUNK 1981 3. 3~ t4.22 15 45.aZ it of SEWER LATERAL 19 1 9• SQ 15 77-77 tt n Sewer Lateral &qj 19 2 5•~ 15 52.07 A013225 WATERMAIN 51 19 1 12 15 93.96 A013224 * WATER LATERAL Z 1982 •1. 3.21 15 38.53 A 1 2 WATER AREA 1981 3. 3O .22 15 ;g6 46.42 A013224 • Powerline 1982 15 STORM SEW TRK 1985 456.09 91.22 5 -G .o C~DO 3 3 oc,.~~ STORM SEW LAT Draina e 1984 91.75 9.18 10 91.75 C008518 -1 -8 a o -o cPo 612.3 3 d~ CURB & GUT ER SIDEWALK STREET LIGHT Street 893 / f-0 3 3 91 10 ~ t1 t~ WATER CONN, 450.00 9UILDING PER. 8503 SAC tt PARK CITY OF EAGAN 3830 Pilot Knob Road, P.O. Box 21-199, Eagan, MN 55121 N? 9067 + PHONE: 454•8100 BUILDtNG PERMIT Receipt # To M uwd fee DECK Esr. Volue $ 900. pate MAY 11 , 1 q 84 854 SUDBERRY LN Site Ad ~ ss Erect ~ Occuponty Lot elock 2 SeclSub. SHEFFIELD Alter ? Zoning Parcel tuo. 10-67600-080-02 Repair ? FireZone JEFF DALEY Eniarge ? Type of Const. W Name Move ? # $tories = Address SAME DemolisA ? Length- city Pnone 454-7450 Grade ? Depth Sq. Ft.- Approvals Fees Name SAME Zo u Assessment Permit $ 16.00 o Address u§ City Phone Water & Sew. Surcharge .50 ~ Police Plun check ,'~',~w Nama Fire SAC . r Address Eng. Water Conn. <w City Phone Plunner Water Mefer Council Road Unit I hereby acknowledge that I have read this application ond stote thnt Bidg. Off. fhe informofion is wrrect and ogree to comply with oll opplicable $ 16.50 Stote of Minnesoto Statules ond City of Eagon Ordinunces. APC Total . $ipnoture of PermiMee A Building Permit is issued to: .7EFF DALEY on the expresa condition thnt olI work shall be done in cco a e with cll oppli bl tate of Minne:otc Stotutea end City of Eogcn Ordinances. Buildirq Official VJJ CITY OF EAGAN Include 7 sets of plans, (d 1 Gertificate of Survey,& BUILDING PERMIT APPLICATION 1 set of energy calculations. To Be Used For ~J ~ L k Valuation Date Site Pddress OFFICE USE ONLY Iat ~ Block a Sec./Sub. S e e Erectvl- Occtiipancy Parcel J07} -bqQ --UZ Alter Zoning Repair Fire Zone Owner: ~ Enlarge Type of Const. Address: p Move # Stories . ~ S y S v cX 4~r ~ U. "ish Front £t. City/Zip Code: S 5-034rade Depth ft. Phone 514,S O APPROVALS FEES Contractor: ~ Assessnents Permit ` ?aater/Sewer Surcharge Address: Police Plan Check City/Zip Cocle: Fire SAC Phone ~g. Water Conn. Planner Water Meter Council Road Unit Bldg. Off. Address: APC City/Zip Cocle: Phone # : TO'i'AL CITY OF EAGAN NQ 8503 9793 Pilot Kno6 Roed . Eagon, MN $5122 . ~ ' PHONE: 454-8100 7 BUILDING PERMIT Receipt # !j Te M mad for SF DWG/GAR Est. Value $55,000 pate Septemb er 22 lq 83 Site Address $54 SudbeTry Lane Erect OccupancY R-3 Lot 8 Block Z $ec/Su6. Sheffield Alter ~ Zaning R-1 ? Pnrcel # 10-67600-080-02 RepOir ? Fire Zone NA Enlarge ? Type of Consf. V : Nome Joseph M. Miller Const., Inc. Move ? # $rories Z Addrea 18133 Cedar Ave. So. pemolish ? Length 40 ~ Farmington ~om 454-4753 Grade ? Depth 46 Sq. Ft.- p Name 0`^meT ADOrovals Feea Address Assessment Permit 298.00 Z~~50 Cit Phone Wafer & Sew. $urcMrge F Police Plon check 149.00 W W Nnme Fire SAC 525,90 -W 45a. 0~ x~ Address Eng. Woter Conn. w Z. Ci phaM Planner WaterMeter 60.00 - Council Rwd Unit 250.00 I hereby ockrwwled9e thot I hove read fhis applicotion ond state tFwf gldg. Off. the inlormotion is correcl and cgree to wmply wirh all applicable $1759.50 Stote of Minnewra Stotutes and Ciry of Eagan Ordirwnces. APC Totol . Signoture of PertniMee osep M. er on , Inc. A Building Permit is issued fo: / on the exprea cordiHOn Ihnr pll work shall be done in accordance with oll op fso Stofuhrrertd City of Eagan Ordlnances. Buildinp OfS{ciol oj~ ~ kk ; 57 'lIQ~OL capoD aTZ/1413 ' sesaip(~ii , 3p ,hpLH ~td ~ , y7 s8~91~i ~4W~ •wop ~4~1! _ ~ :epop dt7,/AA oi[S 3pm u?'[a : obxr4=M " # aiotid ~ S'1VI1Q1ddY V~ . •Wm ~zI~FO =N~r ~lr~"'.~ • R1~~~fY~T~ ! tlattlO ~u 1TodelI q O _ Q 0 ~ Z. ~ ~ : # S~~d ~'F~r .~c~•~ 7pole ~ ~o'I - ~ ~ ~ UOT4v[tlvA iaa pmn aa clt 4 ~ [DILYJ J,~d JNYQIIf1H / ~ ` wpy~nnoD mw~ jD ~ ~ . w+oTavn~ta/M+ ulld +.wla ao .a•• opq-,va Thi~.;esl void't) -Z-7 •118 monchs fmm W078819 Reques[ Date Fire No. Rnueh-in Insper.tion Q fleqwr ~Ready Nnw i Notity Insoer 6 ._J es ?NO tor When Ready j9wfMcensed EI¢ctrical Contrac[or I hereby request inspec<ion oi above ? Owner elecHical wark installed aL SVeet AAdress, Boz or Rou[e No. ~ CitY 5 V 1...3+-'~%t- ection o. I ns ip Name or N Range o. Cow y~ 4 a Occupant(PfllNT) Ph°^e No. Po er Suppii r P.ddress , ~o~'o 4 ~le~~,~; ~ Fqnmr ElecVical ConVa cor (CO an Namel n ractor's License No. . cfi,;~ S//(a/d - Mailin0 AAdress (ConVactor or Ow Making Instnila onl oo! v~+•suil iS533 Au[hori SiOnaw (Co Vactor/OwnerMakinglnstalla~ n) Phon~~b=r~~~ THIS INSPECTION qEQUEST WILL NOT MINNESOTp STATE BOAND OF ECTqICITY "-^--Midwey Blde• - Room N•191 gE ACCEPTED BY TME STqTE BOABD ^ St. Paul, MN 55104 UNLESS PROPER INSPECTION FEE IS ENCLOSED. . REQUEST FOR ELECTRICAL INSPECTION EB-ODUV~-..,. ~ ' See inatructions 1or completing this iorm on back oi yellow copy. C78 819 q X" Below Work Covered by This Request 3 I s 7CO New Htl Rep. TyDe of BuiltlinB ApPliances Wired Equiument Wired Home Runge Temporary Service Duplex Water Heater iyhtiny Fixtures Apt. Building Dryer Electric Heatin Commercial Bldy. mace Silo Unlodder Industrial Bldg. Air Conditioner Bulk Milk Tank Farm otnar paci v rine, l5uedtvi t er 1 uer.ify lher Oth.;r Compute lnspection Fee Below N Fee ServicaEnfraneeSize il Fee Feedars/Subteaders N Fee Ciecuits Q U to 200 qm s 0 to 30 Am s 0 tn 30 Am s Above 200 qm ps31 to 700 qinps 31 to 100 Am s Swimming Pool Above 100-Amps AAove 100_Am s Transiormers Irrigation Booms ? :YCIPartial,'Other Fee Pemarks $igns Speciallnspection. $ 39 TAL FE r 3o~~ y , HouBh-ia 1)j~~~~~ I. the Elecbical l Inspectoq hereby ' certitV thnt the above Final Unie stgpecoion hes been metle. Tnia rwnuwxt veltl 18 monlha hom ~ CITY OF EAGAN N° 1 10 4 4 3830 Pilot Krwb Road, P.O. Box 27•199, Eagan, MN 55121 PHONE:4548100 BUILDING PERMIT Rece+cr # Te M med 4er FIREPLACE Est, yalue $2,000 pate SEPTEMBER 27 19 $S SiteAddreu 854 SUDBERRY LN Erect ? Occupancy Lot 8 Block 2 Sec/Sub. SHEFFIELD ADD Remodel ? Zoning Repair ? Type of Const. Parcel No. Addition ? No. Stories JEFF DALEY MOVe El Length m Neme ~ Demolish ? Depeh Address SAME -7450 intlmpc ? gy.pt. City Phone 454 Instali LR SAME 372-4206 (W) Aoprevob Faes o Name Address Azsessment Permit • u~ City phone Woter 8 Sew. Surcherge 1.00 - Palice Plen RevlBw tW Name Fira SAC Address Erp. WaterConn ~W City Phone Vlonner WBterMeter Countil Road Unit I hereby ockrwwledge thot I have reod this apDlication ond stote that Bldg. Off. 8 23 85 Tr. PI. the inlormotion is correcf ardogrec to wmply wiih oll aDPlicable APC Stata of Minne:oro Stat ez and Ciry~ Eagq Ordirwncez. Parks ` Var. Date Copiea Sipnature of Permittee °J JEFF DALEY iotai $"~'1 _ 5h A Bullding Permit Is issued to on tha expreu condiNon Ihat -11 work zhall be done in accordance with eil a b Stote f Mi esoto Sratutes and City of Eapan Ordirwnces. , RESIDENTIAL BUILDING PERMIT APPLICATION cinr oF eacaN fl ~ 3830 PILOT KNOB RD, EAGAN MN 551Yt 651-687-4675 lJ New Conatrunbn BeaulremeiNS flemadeVReoalr ReauiremeMs • 3 registared sAe surveys 5mwing sq. iL of bt, sq. fl. of trouse; arW ig roofed areas • 2 copies of plan (20% maximum bt caverage albwed) • 1 set of Energy Caloulations tor heated add'dions • 2 capies of plen showhip Geem & wind(yw s¢es; poured foun0 Oesign, elc.) • 7 stte survey for e#eoor addnbns 8 decks • 1 set of Energy Cakulatbns • IndXxte H home served by septk system lar atl0mons • 3 Copies of Tree Preservetion Plan if bt platted aRer 7/1/93 • RYnJOIS10eNailOptbnsselecli0nsheet(bklgswd113orlessunil5) DATE (p VALUATION 51TE ADDRESS PYi'd . 1e- MULTI-FAMILY BLDG _ Y _ N TYPE OF WORK L°G1` ~ FIREPLACE(S) _ 0_ 1_ 2 APPLICANT STREET ADDRESS S SU c / CITY c~ STATE ZIP TELEPHONE #4q-QLfrJ-/1/LTI CELL PHONE # FAX # PROPERTY OWNER ~ TELEPHONE # COMPLETE THIS SECTION FOR ^NEW RESIDENTIAL BUILDINGS ONLY Energy Code Category _ MINNESOTA RULES 7670 CATEGORY 1 _ MINNESOTA RULES 7672 (J submission type) • Residential Ventilatlon Category 1 WoAwheet Submitted • New Energy Code Worksheet Submitted • Energy Envalope Calculations Submitted Plumbing Conhacfor: Phone # Plumbing system includes: _ Water Softener _ Lawn Sprinkler Fee: $90.00 Water Heater No. of R.I. Baths No. of Baths Mechanlcal Conhacfor: Phone # Mechanical system includes: _ Air Conditioning A~ Q~;~ _ Heat Recovery System JUN 0 4 ZOUZ Sewer/Water Conhactor. Phone # Y 8------°-°------ I hereby acknowledge thaT I have read ihis application, state ihat the information is correct, and agree to comply with all applicable State of Mlnnesota Statutes and CiTy of Eagan i nces. n Signature of ApplicanAc OFFICE USE ONLY Certificates of Survey Received _ Tree Preservation Plan Received _ Not Required _ UpdateC 4102 OFFICE USE ONLY , ? 01 Foundation O 07 Orplex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg ? 02 SF Dwelling ? OB OGplex ? 16 Fireplace ? 21 Porch (3-sea.) O 31 Ext. Att - Multi ? 03 01of_plex O 09 07-plex ? 17 Garage ? 22 Porch/Addn.(4-sea.) ? 33 Ext.Alt - SF ? 04 02-plex ? 10 08-piex ~ 18 Deck ? 23 Porch (screened) ? 36 Multi O 05 03-plex ? 11 10.plex ? 19 Lower Leval ? 24 Starm Damage ? 06 04plex ? 12 12-plex Plbg_Yor_N ? 25 Miscellaneous ? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding ~ 32 Addition O 36 Move Bldg. O 42 Demolish (Foundation) ? 45 Fire Repair ? 33 Atteration 0 37 Demolish (Bldg)' ? 43 Reroof 0 46 Windows/DOOrs ? 34 Replacement •Demalition (EMire Bldg only) - Give PCA handout to applican! Valuation Occupancy MC/ES System Census Code I Zoning City Water ~ SAC Units Stories Booster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs , 1 Length Fire Sprinklered Type of Const W idth REQUIRED INSPECTIONS Footings (new bldg) FinaVC.O. V Footings (deck) ~ FinaUNo C.O. ?Footings (addition) _ Plumbing _ Foundation HVAC _ Drain Tile pther Roof _ Ice & Water _ Final _ Pool _ Ftgs _ AidGas Tests _ Final _ Framing _ Siding Stucco Stone _ Fireplace _ R.I. _ Air Test _ Final _ Windows (new/replacement) _ Insulation _ Retaining Wall ~r Approved By , Building Inspector Base Fee -----Y-+--~-^ Surcharge Plan Review 0 MC/ES SAC City SAC Water Supply & Storage S&W Permit & Surcharge Treatment Plant Plumbing Permit Mechanical Permit License Search Copies ~ Other Total I _ . ~ e for: . ~ ; er Const. dar Ave. 3 Ce O. plan 95087 ington, Mn. 55024 . DELMAlt H. SCHWANZ w+osu~vevo~s ~K. nNUe«w undv vr. a rn. Weu a M+"~U 3976 - 1MTH iTREET W. -OOX M 11aMpYOlMT. 1ROMO7A 111011111111 MIOM! 612 173-77N fU11VEV0111 CtRT1i1CATE S C Q ~ Q N 1 i n ch - 30 ~Qe,-~ ~9~ ~,L 0 N(yLA.1 \tiq 3~i ~ o.~ ~ y sQ r Z'4A v Ns9 .O ~ O ~ / Oo 2 ` 11 .28 gCAygs 1 inch ~ 30 teet 0 Denotes setback hub Denotes proposed drainage ~i Dsnotes proposed finiehed grade Propoeed garage floor '9~~•~ • Proposed top of block 90>'•8~ • Propoeod baaement tloor 89G•~7~ . . ~~e8ebBlock t 2fy SHthat SPFISLD~ according to d the rscord d plat t thereoPf Dakota County, Minnssota. Alao ehowing the location of a propcsed hous• thereon. Dated: June 9, 1983 ` etc 1 MINNE80TA REGI6TRATION N0.8825 ~ 1 / 2000 BUILDINC PERMIT APPLICATION (RESIDENTIAL) cirv oF EAcaN ~ I 13 .~5 ~f 3 z3~ '~30 PILOT KNOB RD - 55122 851•881-4675 New Consfiuctlon Raauiremenb > 3 regiatered alfe wrveys alrowlnp eq. K ol lof, aq. tt. ol houae Y copiea of plan antl qj( rooted areaa l20% mmAmum bt covemae albwedl i set of enetgy calculadons fa heafed addlHau > 2 coples ol plans (ahow beam & window alzes: poured Mtl. deNgn: efc.) 1 site wrveY ror extedor addlMOns R decks ~ 1 aef ol energy calculWlons > 3 coplea of hee prefervallon plan H lot plattetl aHer 7/1/93 DATE: ~ /(%d CONSiRUCTION C05f: y DESCRIPTION OF WORK: G1yv STREETADDRESS: LOT: ~ BLOCK: SUBD./P.I.D. U: ShetFl ~Q Name: PhoneU: LS/ ~ 6~7- 0 /8'J PROPERTY laar Firat OWNER SheetAddress: -5~4- MP Cly State: np: Company: ~.T ,9*/lV .fS Phone#: QS~ (area code) COMRACTOR A SheefAddreas:_,/,JJ.a wa.~a 01u~- ucenset792~OS" Exp.4S,01 ~ Cly State: zip: .5 .Sf,~~ ARCHRECT/ ENGINEER Company:- /y Name: Telephone i: ( ) Sfreet Address: ReglslraHon M: Gy State: Zip: Sewer/water licensed plumber (if instalflna sewerhvaterPhone L~ I herebY aeknowledge Mwt I have read Ihis uPPlicalion, slate Nwf fhe infomwtbn is cortecf, and agree to comply wNh all aPPncable Sta1c of MinnesoM Stalutea and Ciy of Eagan Ordinances. Signature of Apptleant OFFICE USE ONLY Certifiptes of Survey Received _ Yes _ No Tree Preservatlon Plan Received _ Yes - No _ Not Required OFFICE USE ONLY BUILDING PERMIT SUBTYPES ? 01 Foundation ? 07 05-plex ? 13 16-plex ? 21 Poroh (&sea.) ? 31 Ext. Alt - Multi ? 02 SF Dweliing ? 08 06-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Att - SF ? 03 01 of _ plex ? 09 07-plex ? 18 Deck ? 23 Porch (screened) ? 36 Mufti ? 04 02-plex ? 10 08-plex ? 19 Lower Level ? 24 Storm Damage 0 OS 03-plex O 11 10-plex Plbp _Yor_N O 25 Miscellaneous ? 06 04-plex O 12 12-plex ? 20 Pool ? 30 Accessory Bidg. WORK TYPE ? 31 New O 36 Move Bldg. O 43 Reroof ? 32 Addition ? 37 Demolish (Bldg)` 0 44 Siding ? 33 Alteration ? 38 Demolish (Interior) ? 45 Fire Repair ? 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. (Actual) 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 ? 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 / 7985 BUILDING PERMIT APPLICATION - CITY OF EAGAN NOTE: ALL CONTRACYOHS NUST BE LICENSED iiITH THE CITY OF EAG6N INCLUDE 2 SETS OF PLANS 3 CERTIFICATES OF SURVEY 1 SET OF ENERGY CALCULATIONS ~ r~ elac.e ~ To Be Used For: Valuation: 600 Date; Site Address: R,j y SVA'Qeif OFFICE USE ONLY Lot: $ Block ~ Sect/Sub ~Erect _ Occupancy Remodel Zoning Parcel li Repair Type of Const Addition # of Stories Owner C, Move ~ Length p Demolish Depth Address Sucr Int.Impr, ~ Sq Ft j~ Znstall + City/2ip Code ~'o.c,p ~N SSia3 -~-C----------------------- Phone SH - ySo APPROVALS FEES Contractor essments Permit 32.5- Wa er/Sewer Surcharge Address . Po ice Plan Review Fire SAC City/Zip Code Engr Water Conn Planner Water Meter Phone Council Road Unit Bldg Off~ s reatment P1 Arch./Engr. APC Parks Variance Copies Address ipTp1, ~ 5 Q City/Zip Code Phone D yao(o, ~ G ~ G n NZ3 I W I ~ ~ ~ ~ ~ o1-6! ~i ~rb IOID o rc A- ~ s CA ~ . I I ' ~ w.~ ~ • q " SOS 7 •-x ° EXTERTOR EWI:I,CIPT% 11`J£R1~GS U" COMPL'TATSOH _ ~._.r,_. ` i ~c,I~ • • '1' . DATL•' Pl10NE: , YSTB AAURE7S5: . - (7CN'l'R7ICTOR: yl~~ M pQtarmine vmzking square footayu of eacn Z gs_ _i Total exposad wall area...... ct:. x ft. X ~_QS SI , S 2. Toal roofJceiling aiea flbtal nxposed vall azea aLove floor Total wall windnw nroa................................. 'Mtal door nXC+e . c. Total slidina 91ams doos azua 4. ibtal fisoplaca xali asea , . ~ Total wall lreminq araa (averqga 10e)•••••••••••••• t. Total ziS ioi.t um 1• ~ Vut alfA ak10Ve flOOX ........•L•. a. vall area abave iloor i vall area eEarve f!loor .i• _ w11 area ntwva lloor ' Total sxposad foundation area k. 'abtal fcrir.dation winda? area ~ 1, Total net fourdetion area above gzade petcrmine "l%" valuc of cach wall .^.c9ment (e.g. window, door, encn separnCC k.,ill sc~ctionr a. x Otul. _ x _ ° _ 14.4 L. - X ,.up" LJb _ c. e. d. v 1~~ _--_.---o-- x qu„ ,r,~.~ ~ ' x °U., X . U" h. X SPUN, ~ 1. lf item 1.? is thc 3nunt, x "U" or lcss t:han itcm ttl, met thc iotent of k. X „ul: 51aC GGO~, (c) 2. 7 . ~ I.L..,- 3. Yotal = a`!QiSIL_- . . 7 Of ilWQlOpO LA4eraga "u" Cwn[wlation 7'otal expoe:ed raA/criliMl ar,:.. _f02~ ' . , skyliqAt area - ' qI rmt/ ~'llSnq lrami~ug area~ Ir~vcraqo :loL) • _.JD_3 . i wt ,,lra........... _azip ' apA eV' W11M LOC CaCh 1!'OOf/cCiling ~ ~ . ' •~i x •y~ ` . ~ .w , 025 • ..........b~1~~~~~~~• 61" u~ af 1M~ UWA II, YW hs'~~ m~:C t!ir irt, ,,e oE {Q) 1 • 111Mrnst4 ildir Rnvel Dtain R m oE ~ aathnAr tho valuec ~,st.+b'• i;fl:• •i 1•~ ehe s~ ' w ~ I ite thc Wfal uw~lop~ 'i11~ u a7td A{ Y411 n0L De aTMtl~'than Ch0 sws of iII: a-. ~ • : • ,,,,_.~1r' .I.~~.r' - ' 33t. , S ~M.~ • r_ ~ 4. ~'t.. ~ . 4 r~ • i 1 .pF~ , . , • ~ . . ~ ~ ' . ; ~ ~4 . , ~ . _ • ^ . . . . fir . . . . . • . . . ,,,i.• . ttrtti. °:r.cT.c,N, ~f~TEs U^•n 14t uf r•~~a~:ua w;~ll nren for - Crn•:tr~r:~ ir,n fYmm~ con::t racilun _ • - _.~.<<'! 4(7j 1. 1u1~~}.+,,,._,t~ i I I q, .4S • 2. ~ s •~n,:i~.s ::~i~. ~ 3. ~~f.,_._._ , . s. ~.w.c~. . _ .~Z ~ 6, t:Kl:criur. etr ti'.m IC ' - • . 0.17 Z7 ~ ~ rta. ~i r~~wtaf a ` MtSuL. 1. IDCrtInL' ,lir :11m O.GfI ' . 1lWlo MALL 7 • J~~~~LYP__~D • . . _ _r ~ + • ,JP+~s,t1r__....__..._------~3~ . ~ ' • lE~4.__.._ . . _ . _ ._64L 6. Extcrioc .vr tili., , .r..__,~, ~r„~.,?l t0~9 na. 12 - V = ~ ~ S . . ; s. .at~u.{„ 3~?'B . ....../;.P. l. _.2Xli7... _ . . . . _ 1•8'9 '~'•~G . 4. ._L~t ~fr"ts._ . _ _ . . ---G :L .._StCINCa_._ ~ 'ipl'11 7.~• ,7v ~'C,~, u v . . m 2,i ~TION ~A j°...a. A• l. " ._.DDl~L • _ _~L.~ . . _ ~ . _ f_..~ ~ ~ n 'Q. +..rvoi0c ~ 5. . . -v-~ ; - . ~~r .p• ' ~ r•,;~`~. G. fyxtcrirr .~_u•..!tr~ _ _ r :i ~~~r~;~;,1-' Z,~3 . . ~ n• SIJ~I~ P!I .INUE . ~ ~ ~ ,,t . 6 Y ~ f r (1 ~ , • , . . . ~~l~~ ~ ~rr e1ct. n< 'I~ r• ' i/il Ir'" l+r . . ' , ,i,rri: • ' . ' ~ ~ ~.i, ,~,.,t -r ;.,;~:t • e ' - . _ . -V luc ~~~~?~i ' • ' R.._- ~ Construction Iv, t.. • ' • . ~ Interlor air illn ~ .0.61 2, /B bYP Ltio PQ•Y YAf'~12 l~SPQRRk I 3 , Ul. TI = i r l t l 4 Extcrinr ~ I l~ii11;1~ : ' lt.~ ~ ~ : . . ~0. ~ ~ • • J?M14rf li . • • 1, Interlar air fiSm 0.62 ~+~P . 3 4. . ~ • ' Fxt.er or ~ r . i n s t i ~ • ~ • ~ . . Total ~ "~j . (O ~ , . . , . T~a. !s' • : U - CJ. 0-7 . . • . • . . . . • . , . . . . . • . . • ' . ~ . coA.o.si + • , air FJ , 2. Inslda filin ' • ' ' 3. ' . . ~ . , 1. 0. 1 i. 1• S. Outside ais film , . • Total • ~1 , . . , . t ~ • . F.togo+E 0.61 , f~ Z 3 4, • 1, Tnside air film T. ~ llov vP • . ~ ~ i+wstad . 4. 1-7 1Va= . , , • • S, Outside air fi.lm~ , , ~ , • ToWl •'~6• ~6~ . . ' . . . ~ fil,~ . • ' 0.61 ~ 2. ~ •J ~ti.~~ ~ ~ ~ • f~yQ,~i!^~^~1 ~ . - U.17 ~ r•~.,,: ~ s. cucg,ae 3;' T~ 1 ~ . , • . . . if ttote: Dse additio»~1 sheets mora sPaco . • ~ ~-P1!tT2D • ~ , ~ . yeeded for deGails =d cdl°u-ations- ~ • . . . . • . . . . • . , . • ' • ti ~ tLOV VP . • . • • ' • HAND F~MED~ R~38 • am. e7 , • ' - . . • . RESIDENTIAL BUILDING Permit Application City Of Eagao 3830 Pilot Knob Road, Eagan Mn 55122 Telep6one # 651-675-5675 FAX # 651-675-5694 New Construdion Reauiremen6 RemodeVReoair Reauiremeft Office Uu Onlv 3 registered site surveys showing sq. R of bt sq. ft of hause; and all roofed areas 2 copies of plan Cen of Survey Recd (20% maximum lot coverage allowed) 7 set of Eneryy Calculafions br heated additbns Tree Pres Plan Recd 2 copies of plan showing beam 8 window sizes; poured found desiqn, etc. 1 sile survey fa addifbns & decks Tree Pres Nol Reqd lsetofEnergyCalalations Addifion - irMitateBon-sdeSepGcsystem _ On-sitaSepticSystem 3 copies of Tree PreservaUOn Plan 'rf lot platted after 711/93 Rim Joist DefalOptions seleaion sheet (bldgs with 3 or less units Date d t~ l Z T l`LUd 3 I , Construction Cost SiteAddress S~3 1 b-emft y UniUSte # Description of Work tv w i N~io-S0lt Multi-Family Bldg _ Y AN Fireplace(s) _ 0_ 1 _ 2 Property Owner (2 A f /~C C K y Telephone ff ( ) SELA ROOFING & REMODELING, INC. Contractor 4100 EXCELSIOR BLVD. Address 3T. LQUIS PARK, MN 55416 City State Zip Telephone # (FiIZ ) ~'7 3 - FU `f o' COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING Minnesota Rules 7670 Cateeorv 1 TRI!Ivlinriesota Rul'es 7672 Energy Code Category ~ ' ~ , ~ Residential Ventilation Category 1 Worksheet • New Energy Code Works (J submission rype) heet Submitted , `Subrr~itted ` i ' • I9 . Energy Envelope Calalations SubmiUed 1) I i ! Licensed Plumber TelepllonQ 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 work is not to star[ 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 ofplans. Lr 2 ~c ~l~ir~~vty ApplicanYs Printed Name ApplicanN Signa[ure OFFICE U5E ONLY Sub Types ? 01 Foundation ? 07 05-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg ? 02 SF Dwelling ? 08 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Ext. Alt • Multi ? 03 01 of _ plex ? 09 07-ptex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Ext. Alt - SF ? 04 02-plex ? 10 08-plex ? 18 Deck ? 23 Porch (screenigazebo) ? 36 Multi Misc. ? 05 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage ? 06 04-plex ? 12 12-plex Plbg_Yar_N ? 25 Miscellaneous Work Types ? 31 New ? 35 Int Improvement ? 38 Demolish (Interior) ? 44 Siding ? 32 Additlon ? 36 Move 81dg. 42 Demolish (Foundation) ? 45 Fire Repair ? 33 Alteration ? 37 Demolish (Bldg)' ? 43 Reroof ? 46 Windows/Doors ? 34 Replacement •Demolition (Entire Bldg) • Give PCA handout to applicant Valuation Occupancy MC/ES System Census Code Zoning City Water SAC Units Stories Booster Pump Nbr. of Units Sq. Ft. PRV Nbr. of Bldgs Length Fire Sprinklered Type of Const Width REQUIRED INSPECTI0IVS _ Footings (new bldg) _ FinaUC.O. _ Footings(deck) _ FinaVNo C.O. _ Footings (addition) _ Plumbing Foundarion HVAC Drain Tile Other Roof _ Ice & Warer _ Final _ Pool _ Ftgs _ Air/Gas Tests _ Final . _ Framing _ Siding Stucco Stone _ Fireplace _ R.I. _ Air Test _ Final _ Windows (new/replacement) _ Insulation _ Retaining Wall Approved By , Building Inspector - Base Fee Surcharge Plan Review MC/ES SAC City SAC Utility Connection Charge S&W Permit & Surcharge Treatment Plant License Search Copies Other Total PERMIT City of Eagan Permit Type:Building Permit Number:EA114576 Date Issued:09/17/2013 Permit Category:ePermit Site Address: 854 Sudberry Lane Lot:8 Block: 2 Addition: Sheffield PID:10-67600-02-080 Use: Description: Sub Type:Reroof Work Type:Replace Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:If there is no ice protection inspection prior to final, the contractor must meet the inspector w/ a ladder and flat bar. Pictures are not acceptable in lieu of inspections. Carbon monoxide detectors are required by law in ALL single family homes . Elizabeth Hess 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 - Patricia A Mcclary 854 Sudberry Lane Eagan MN 55123 Sela Roofing Remodeling 4100 Excelsior Blvd St. Louis Park MN 55416 (612) 823-8046 Applicant/Permitee: Signature Issued By: Signature E For Office Use s-76,3/ „� • � Permit#: EAGAN •..+ Permit Fee: Date Received: 3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810 (651)675-5675 I TDD: (651)454-8535 I FAX: (651)675-5694 Staff: buildinginspections@cityofeagan.com 2019 RESIDENTIAL BUILDING PERMIT APPLICATION Date: Site Address: Unit#: Name: Fa T 1 C l Phone: Resident/ S3- � / Owner Address/City/Zip. / S' b rr� VUe__ E��►� / 5 2 2_ Applicant is: b< Owner Contractor T e of Work Description of work: 5,1 b)�j j wPYt L D(�C>S Construction Cost l%I S7O Multi-Family Building: (Yes /No bic) � 2S-s?)Company: Contractor Address: 11,0 R7 goy, )s / City: -5-C -Q) State: _Zip: 3 Phone:65 1.0 ' i ' Email: License#: S C()a g-7 0 Co Lead Certificate#: L-P'_3 / 3 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&Water Contractor: Phone: Fire Suppression Contractor: Phone: NOTE:Plans and supporting documents that you submit are considered to be public information. Portions of the information maybe classified as non-public If you provide specific reasons that would permit the City to conclude that they are trade secrets. You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update on the City's website at www.citvofeacian.com/subscribe. 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. 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.00pherstateonecall.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 wo . ' 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 approv- • ans. x , C-fl J1- OSS eX x �/ Applicant's Printed Name Appli•tent's Signature PERMIT City of Eagan Permit Type:Plumbing Permit Number:EA157614 Date Issued:08/29/2019 Permit Category:ePermit Site Address: 854 Sudberry Lane Lot:8 Block: 2 Addition: Sheffield PID:10-67600-02-080 Use: Description: Sub Type:Residential Work Type:Alteration Description:Fixtures 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. Carbon monoxide detectors are required within 10 feet of all sleeping room openings in residential homes (Minnesota State Building Code). Fee Summary:PL - Permit Fee (miscellaneous)$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 - Patricia A Mcclary 854 Sudberry Lane Eagan MN 55123 Master Plumbing Services Llc PO Box 2451 Inver Grove Heights MN 55076 (651) 248-1008 Applicant/Permitee: Signature Issued By: Signature