4444 Slater RdCity of Eaall
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Use BLUE or BLACK Ink
r
For Office Use -2,1t20
Permit #: 1
Permit Fee: 1 b`
Date Received:
Staff:
2014 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: Lt -1---V (L( Site Address: 1 C% Unit #:
Resident/
Owner
Type of Work
Contractor
Name:
Address / City / Zip:
Applicant is: Owner
Description of work: RA -C.,
Construction Cost:
Phone:CS [ 7q6 -1)1-7
Contractor
Multi -Family Building: (Yes
/ No )
Company: , C C\ C (r jontact: Y v G• -in
` �� J City 6� �5
Address: �,,Q l � I �1 �,�N� S �
State] J Zip: 5S c, Cr? Phone: �r `-- J 5
License #: a�� �L Lead Certificate #: Z -1S` (1j - %T1
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:
Mechanical Contractor:
Sewer & Water Contractor:
Phone:
Phone:
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 they are trade secrets.
CALL BEFORE YOU DIG. Call Gopher State One CaII 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.orq
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180
days of permit issuance.
Applicant's Printed pamVt-tACkt-(.1
x
Applica ignature
Page 1 of 3
cmr c^ EA<iAN SEWER SERVICE PERMIT
J79'~ 'Ntot K*ob Roea PERMIT NO.:
Eadon, MN 55122 DATE:
Zaninp• No. of Units. • .1ex
Ownur: 7F.CsI`-vn ti0uie9 I.ic
/lddress:
$itt AddlESS: 4li4fl ,71a.~'i@2' 1.6 ) C !1i1.~.rC,; ii'
Plumber.
100.00 i~..
1 ym M eeniply wkb 11w Ciryr of Ee"s Connettion Chorye: 425
O?alnenea. Accaunt Deposif:
Permit Fee:
Surrharpe:
By Mtsc. Chorom
Dote of Insp.: Total:
I nsp.: Qoir Paid:
CITY OF EAGAN
3830 Ailot Knob Road MrATER SERVICE PER1MlIT j
P. O. Box 21199 PERMIT NO.: 4883 ~
Fagan, MN 55121 DI~TE: 7 13 83 '
~ 2onirg' R2 No. of uP ex ~
i QNr~r; ZBC~II Hq1LGi Units: I
~ IIIC
Address: !
~ Sica Address: 444 Slater Road, B3 Cinnemaa Rtdge 3
~ Plumber. 7
; hheter No.: Connection Charfle: S. 0 pd :
51ze: Account DePosft:
j
i Reader No.:
Permit Fee: Z4 -QQ ~d I
~on'" to oemPFp wille 11e Ci1y of Eagon Surcharge: . 50 d ~ I
~ o.dis.no«. Mtac. Charges: U. DO pd meter i
i
' By Toful: ~ Dote of lnsp.: Doft Poid:
Infp.:
- - - I
SEVUER SERVICE PERMIT
~ CITIf pF UdAN :
PERMIT NO.:
3795 PY•of Kneb Rea
ieoes, DATE:
MN 55122
No. of Units:
Zoninp:
Owner:
7
Addrcss: 4 1+ Jl~ ° s. ~ 2
Site /?ddress: ~ , _ 0.00 pci
Plumber. 5 .
~ton Charpe• OQ
1e/rN h oom't~? wteh ~~°f ~O~°a
Accour~t DePoet: .
pedleenan. permit Fee:
Surchar0e: `
Miac. CharOes:
gy Totol:
Dote of Insp.: ~e Pab:
Insp.:
aTY or encAN VYATER SERVICE PERMIT ~
383u'oot Knob Road
P. C.ux 21199 PERMIT NQ:
Eagun, MN 55121 DATE:
aupiez
2~ing; No. of Units:
Owner: 'l.fl.Chm8n HC7tei ZIIC
Addrcss:
5ita Addross: 444 slater Road, L B3 Cianamon Ridge 3rd.
Plumber: WestoIIkB I
Meter No.: Connection Charye: 450.00 pd i
S{ze: Acoount Oeposit: ~
Reader No.: Pertnit Fee: t0. Qa Dd ~
1 yree fo aorsply wilh !Iw Citp d Eeoaw Surthorfle: 60.00 pd mEtCT ~
p„alMnces, Misc. Choroes: I
Totol: +
gy Dnte Poid: i
Dote of Insp.: InaR:
II
I
~ - - _ ,
CI1Y Of EAGAN
, 3793 PIIM Kwey Rood Easen, MN S5122
IF;~
' PHONEs 434-8100
dU1LDING PERMIT Reujpt
~
Tio wed fa ]/2 DUPLE% & W Est. Vclue $34.000 Date T,n 1
Stte llddrcss 4444 Slater i2oad (Unit B) Erw ~ pccupancy _ R-3
Lot __6Biock _3^ Sac/Sub,Cinnaaon RidQe 3rd AIter ? Zontny (Pll) R-2
Porcel # 10 17402 060 03 Repair ? Fire Zone IdA
Enlarya p Typa of Const. V
W Na,,,, 7.ac1_unan.Iiomes, Inc. MovQ
~ /~ddress 7760 "S1tChe11 RoBd pemli~ Q ~n~hte24
Ci Eden Pr.airie pha,e 937-9520 Grode ? Depth-A6L-Sq, Ft.
ac Naffie `,)Wner ApProrols ftes
v
Addross ' Assessment Permit _ 211.00
C~ Water 3 Sew. Surcherflt 17 .Ot!
Police Plon check 105.5G
~Z Nome Firo SAC ?25.00
u~ ~ress En0• Water ConnL 5n nn
<W Ci p{~pe Plonner Water Meter ~Q , Qt}
CcunNf Road Unit 2,50.00
I hercby ocknowledge thot I hove rood this opplicotion ond stote that g~~ Off,
rhe information is cor?ect ond Qyree to comply with oll applicoble
Stete of Minnespto Stotutes and Ciry of Eogon Ordinances. APC Totol T1 1 8.SQ
Siynoture of Psrmittee Zachman liomea; Inc .
/1 Buildinp PeRnit is issued to: on tM express conditlon that
oll work zholl be dons in ocaordonce wlth oppiiwbly'$tate of i.~we~ote Stotutes ond City of E~on Ordinonces.
Buiidirq Official '
- ~;"r
Prrmit No. PKmit Holder Misc. Pe?mit No. HoMer
PwmUn, 3u 31 6fhZ -7- -v-$3
H.v.aa
o~.
s.w.?
ebeftk e 4 ro&E ~LLC~ ~-3-$3
inw.ceion ww insp. oen..
Foutlnyt
Foundrtia+
Frominp
Rou~h Plba r I
RougAh HVA
IMUlttian
Firnl Plbs -7
Final HVAC
Final w
Wabr Dheri6o Loation: -
7/1,
P?. Disp.
~
Reoaipt MECHANICAL PERMIT Parmit No.
CITY OF EAGAN
; Fse
~ Fill !n numaered spaces S/C Type or Pr)nt Jeglbly Tot.
~ -
1. Date 2. Installation Cost
3. Job Address 4y'yy J~11~-•~+~Lot Blk. ~ Tract
r
4. Owner
RAY N. WELTER HEATING CO.
5. Contractor &one
s. Address Minneapolis, MN 55407-3592
7. City State Zip
8. Building Type: Residential 2-- Commercial ? Institutional ?
9. Work Description: New a" Add ? Alter O Repair ? ~
r•j~ / ~ l ; ,
10. Describe t~'S C lGac•~ !J /~n[ FueI Type
11. No. E_quipmenc BTU - M. Ea. No. Eauiament CFM
Forced Air )1~~ Air Handling:
Mfg.
Boilers Mech. Exhaust
Mfg.
Unit Heater
Mfg, Other
Air Cond.
Mfg,
Gas, P'iping Outlets
12. I hereby oenify that tpe above information is true and correct, and I agree to
comply with all or ances a s verniryg this type of work.
Signed: ` ` ~ . : • for
~
Rough , Finel
Inspections: Date Insp. Date Insp.
This is you? permit when numbered and approved.
Approved CITY OF EAGAN 464-8100
Repeipt PLUMGING PERMIT Permit No.,' I
„ CITY OF EAGAN
~ Fee
~
Fill in numbered s,vaces S/C ;
Type or Print legiblY Tot. _ i
I
1. Date 2. installation Cost • ;
_ ~ Cti ;
3. Job Address Lot ~J Blk. 3 Tract 1 r c1 ~
4. Owner ~ ~ •_;.a-~/ ~
,
5. Contractor Phone _
6. Address 1
7. City , 1 /'K .•v ' - State Zip ~t.
i
8. Building Type: Residential~ Commercial O Institutional 11 ~i 9. Work Description: Ne*Cl Add 0 Alter ? Repair ? ~
10. Describe ~
11. No. Fixtures No. Fixtures ~
~ Water Closet Cesspool/Drainfield ~
Bath tubs ~
f Septic Tank I
i -7_ Lavatory Softner ~
Shower Wel l i
Kitchen Sink ~
Urinal/Bidet pther ~
~ LaundrY Tray ~
~ Floor Drains i
Drinking Ftn. '
51op Sink
~ Gas Piping Outlets
12. I hereby certify that the above in rmation is true and correct, and I agree to ~
comply with all ordinanM anddes governing this type of work.
Signed : -11 for ~
-~Rough final i
Inspections: Date Insp. Date Insp. j
This is your permit when numbered and approved. ?
Approved CITY OF EAGAN 454$700 ~
' cirr aF Z?owN
(s
asss rae~ K~ R«a 1090P, Mr+ 551u c~ ~j' ~
• 1
?HOrus 454-8100
SUILDING PERMfT _ aeuio 2(( _
To Mwed h. 1/2 DUPLEX b GAR Est. Volue $47,000 Date June 1 19-al-
Sit. Addrcu 4446 Slater Road (Unit A) E~ ~ ~~pancy R-3
:'Lot 6- Bicck _3 „ Sac/Sub.Cicnamoa Ridge 3rd Alter ? Zaning (PD) R-2
parcel # ln 17402 060 03 Repolr ? Fire Zone NA
Enlorqe ? Type of Const. V
W Nary,e Zachman Fiomes, Inc. Mow ? aqt 5rories
~ Addron 7760 *iitchell Road pemolish ? Length24._
Ci Eden Prairie pF„e 937-9520 Grode O Depth--42_.Sq. Ft.
~ Name Owner AVVrovols F•es
~t Addreu Assessment Permit 269.50
Water 3 Sew. SurcFwrga 23.50
PhOtQ 134.75
Police Plon check
GW Name Fln SAC 525.00
/1ddrom Erp. Water Conn 450. OQ
~ W ci phor,e Plonnsr Water Meter 60. 00
Courxll Road Unit 250s00
I hereby ackrawiedpa thot 1 how rcad this applicotion ond stote that Bldp. Off.
tibe intormotion is Correct ond agree to tomply with oll opplicable A~ T~a~ $1712.75
Stote of Minnesata Statutes and City of Eoqan Ordinonces.
~
$ipnofun of Pertnlttae
A Bullding Permit Is issued to: ZaChman on the exprcss condition tlx»
oll work sholl be done in accordanu with oll oppl ble Stote of iJn± c?.+?Lfts ond Gty of Eoqan Ordinonces.
8uilding Offidal 1~-!
Permit No. Permit Holdar Mise. Psrmit No. Holdsr
Piumbirq 3a CE112 n 7-27 13
Kvi?.r- 3~ ~ 7-4-g3
W.ll
wac..
Disp.
S~w~r
Ehctric 1~J0(p~~02 PoolE lt(E<• -3-$3
Inspeetion Oah Inup. Othtr
Footinyt J
Foundatioti
Fnminq fir,
Rouoh PIb4 0'I , , rr ( •
Rough HVA
Insubtion ~ I
Find PIb4
Final HVAC
Finat
Wa"r Dacribe Location: "
YIINI "
Sowmr • .
Pr. Dhp.
1
Receipt i r MECHANICAL PERMIT Permit No. -7
; CITY OF EAGAN Fim a~
• fill rn numbened waces S/C i
Type or Prlnt JegiWy Tot.
1. Date 71er A"3 2. InstallatiQn Cost
/ I I a
( L f 1
3. Job Address 4i'`ir': .~•~i 1,~~- ~~1Lot ' l uf B Ik. ~ Tract oj'' L!
4. Owner ~AY N.'. WEL'T~ER HEATING CO.
4637 Chicago Ave. So.
5. Contractor Minneapolis, MN 55407
6. Addreu 825-6867
7. City State Zip
8. Building Type: Residential t~ Commercial ? Institutional O
9. Work Description: New L7 Add ? Alter O Repair ? ~
~
10. Describe Z/tll iiAt 4)IA '/L,/juel TYPe /o i6~lj
11. No. Equipment 8TU - M. Ea. No. Eauiament CFM
Forced Air
Air Handling: ~
Mfg. ~
Boilers Mech. Exhaust
Mfg.
Unit Heater
Mfg, Other
Air Cond.
Mfg.
Gas, Piping Outlets
I
L
12. I hereby certify that #he above information is Vue and correct, and I ayree to ~
wmply with all oydinances,end oodes gokernjhg this type of work.
Signed: fie !i.f/ ,
~ 7= for
~ Rough / 1. Finel
Inspections: Date • Insp. Date Insp.
This is your permit when numbered and approved.
Approved C+TY OF EAGAN 464,8100
Receipt 7{i Cl ~ PLUMIWNG PERMIT Psrmit No.
CITY OF EAGAN '
Fse 2 ~ - - '
. Fill in numbered speces S/C I
Type a Prini /egibJy Tot, I
1. Date 2. Installation Cost I
3. Job Address Lot (0 Blk. ~ Tract
~ 4. Owner t`/ A I
I 5. Contractor Phone
i '
~ B. Address
7. City - State ' - L Zip
~
8. Bullding Type: Residentia~,' Commercial O Institutionel ?
9. Work Description: New Add O Alter O Repair O
10. Describe `
11, No• Fixturea No. Fixtures
Water Closet Couppp1/prainfield
Bath tubs Septic Tank
LavatorY Sohner
' Shower Well
l Kitchen Sink
Urinal/Bidet Other
%Laundry Tray
Floor Drains
Drinking Ftn.
Slop Sink
Gas Piping Outleu
12. I hereby certify that the above i~formation is true and oorrect, and I apree to
comply with all ordinances and codes governing this type of work.
Signed :
for
Rouyh Final
Inspections: Date Insp. Date Insp.
This is your permit when numbered and approved.
Approved _ CITY OF EAGAN 464-8100
~ CASH RECEIPT ~
CITY OF EAGAN
3795 PILOT KNOB ROAD
EAGAN, MINNIESOTA 55122
aa rs ~ s
weccIven ,
PROM
AMOUNT $ ~
6 DOLLARS
~eo
? CASH ? CHECK
FOR.
1
FUND CODE AMOUNT
Thank You
BY
p F
• White-Payers CoPY
Yellow-Posting Copy
Pink-Fife Copy
CITY OF EAGAN Remarks ~.I U. I S t 2 D
Addition,,, CIr]N?MDN AIDGE 3RD ADDN Lo= Dt Of 6 Rlk 3 Parcel
owner lir~ ~ k~~,_ street 4444 SIATBR ROAD state EA6AN MK 55122
Improvement Date Amount Annual Years Payment Receipt Date
STREET SUFiF.
STREET RESTOR.
GRADING
SAN SEW TRUNK
SEWERLATERAL 621.03 C009468 9-7-84
WATERMAIN
WATERIATERAL lr 529.12 C009468 9-7-84
WATER AREA 1073 PAJA lindn,
X 337.60 C449468 9-7-84
STORM SEW TRK
STORM SEW LAT X 941.86 C009468 9-7-84
CURB & GUTTER '
SIDEWALK
STREET LIGHT
WATER CONN. .450.00 of it
BUILDING PER. 8091
SAC
525-00
PARK
CITY UF EAGAN Remarks- p1' 0 - 152- 2 U ~i P'-~
Addition, CINMMN RIDGE 3RD ADDN Lot pt Of 6 Rlk 3 Pa?
owner screet 4446 SI.ATER ROAD stace EAGAN MN 5512 .
Improvement Date Amount Annuai Years Payment Receipt Date
STREETSURF. Q $67.60 C009912 11-15-84
STREET RESTOR.
GRADING
5AN SEW TRUNK I 127.3 P
SEWER LATERAL , 621.03 C009912 11-15-84
WATERMAIN
WATER LATERAL X 529.12 C009912 11-15-84
WATER AREA
337.60 C009912 11-15-84
STORM SEW TRK
STORM SEW LAT 941.86 188.37 5 941.86 C009912 11-15-84
CURB & GUTTER '
SIDEWALK
STREET LIGHT
250,00 36096 6-1-83
WATER CONN. 4SO.00 " "
9UILDING PER.
SAC
PARK
Y OF EAGAN Remarks .
Additio CINNAMON RIDGE 3RD ADDN Lot 6 Qik 3 Pefcei 10-17402-060-03
Owner Screet 4444 & 4446 SLATER ROAD STate EAGAN MN 55122
Improvement Date Amount Annual Years Payment ReceDate
STREET SURF. Q -03
STREET RESTOR. IN,
GRADING
SAN SEW TRUNK 197.3 1 . 22 6.81 15 .31 A012714 9-7-83
SEWER LATERAL
WATERMAIN
WATER LATERAL
WATER AREA ZDI 173 131.44 8 1$ 3
STORM SEW TRK 1979 381.69 19. 08 286.29 A012714 9-7-83
STORM SEW LAT
CURB & GUTTEfi
SIDEWALK
STREET LIGHT
6183
- -
ROAD UNIT 500.00 3609
WATER CONN. 900.00 9UILDIN R. $090 & gl
u
SAC 1050.00
K
2004 RESIDENTIAL BUILDING PERMIT APPLICATION
' City Of Eagan
3830 Pilot Knob Road, Eagan MN 55122
Telephone # 651-675-5675 FAX 9 651-675-5694
New Construdion Reauirements RemodeVReoair Reowrements O(fioe Use OnN _
3 regislered site surveys shaxing sq. R of lot, sq. ft of house; and ali roofed areas 2 copies of plan Cert oi Survey Recd.;; _Y'-- N
(20%maaimum lot coverage allowed) 1 sel of Energy Calculations for heated add"Aions Tree P2sPmn Recd';` N,
2 copies of plan showing 6eam 8 window s'izes; poured found design, etc. 1 site survey for addNons & decks Tree Pres Require,d : i Y _ N
isetotEnergyCalculaGons Addition - indicatei(on-sifesepticsysfem On-siiOSepticSystem~~;,,,Y._N
3 copies of Tree Pmservafion Plan if lol platted after 711/93 `
Rim Joist Detail Options selecfion sheet (bldgs with 3 or less units J
~
Date y l/G / O Y Constructi(o~n Cost Sa~ °
Site Address UniUSte #
Description ot Work ~ .4e--z2~x
Multi-Family Bldg ~ Y_ N Fireplace(s) _ 0 _ 1 _ 2
Property Owner~ Telephone # (6, s'l) yli ? - jv 3 3
Contractar
Address 9~,4, Su City
State Zip ~Y ~)U Telephone #(9f-)
`+j +O
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
- Minnesota Rules 7670 Cateeorv I _ Minnesota Rules 7672
Energy Code Category . Residential Venhlafion Category 7 Worksheet • New Energy Code Worksheet
(4 submission type) Submitted Submitted
. Energy Envelope Calculations Submitted
Have you 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 # ( ) ]!31";
Sewer/Water Coniractor Telephone #
I hereby apply for a Residential Building Permit and aclrnowledge that the information
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 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.
~ G? L? ' M AG
pplicanYs Printed Name ApplicanYs Signature
OFFICE USE ONLY
Sub Types ~
? 01 Foundation ? 07 OS-plex ? 13 16-plex ? 20 Pool ? 30 Accessory Bldg
0 02 SF Dwelling ? OS 06-plex ? 16 Fireplace ? 21 Porch (3-sea.) ? 31 Exl. Alt - Multi
? 03 07 ot _ plex ? 09 07-plex ? 17 Garage ? 22 Porch/Addn. (4-sea.) ? 33 Eut. Alt - SF
? 04 02-plex ? 10 OB-plex ? 18 Deck ? 23 Porch (screen/gazebo) ? 36 Multi Misc.
? OS 03-plex ? 11 10-plex ? 19 Lower Level ? 24 Storm Damage
? 06 04-pleX ? 12 12-plex Plbg_Y or _ N ? 25 MiSCellaneOUS
Work Types
? 31 New ? 35 Int Improvement ? 38 Demolish Interior ? 44 Siding
? 32 Addition ? 36 Move Building ? 42 Demolish Foundation ? 45 Fire Repair
? 33 Alteration ? 37 Demolish Building` ? 43 Reroof ? 46 Windows/Doors
? 34 Replacement 'Demolition (Entire Bldg) - Give PCA handout to applicant
Valuation Occupancy 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) _ FinaUC.O.
_ Footings (deck) _ FinaVNo C.O.
_ Footings (addirion) _ Plumbing
Founda[ion _ HVAC
Drain Tile Other
Roof _ Tce & Water _ Final _ Pool _ Ftgs _ Air/Gas Tests Final
_ Framing _ Siding _ Stucco _ Stone _ Brick
_ Fireplace _ R.I. _ AirTes[ _ Final _ Windows
Insularion 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
W-i q U
L ' 9
CLAIM VOUCIIER - REFUND REQUEST
CITY OF EAGAN
MAKE CHECK PAYABLE TO: WREN BUILDERS
ADDRESS: 9218 llTH AVE S
BLOOMINGTON MN 55420
PERMIT #'S 63892
RECEIPT #/DATE: 65419 4-20-04 VALUATION: $4,000
REASON FOR REFLTND: Over charged
TYPE OF REFUND:
Accaunt De osi[ 92202252 $
Buildin Permit Base Fee 0801.4085 $ 40.75
Construcrion Meter De Refund 92202254 $
Curb Box De osit Refund 9220.2253 $
Fire Su ression Permit 0801.4096 $
Ove a ent 9001.2250 $
Plan Review Fee 0720.4222 $
Plumbin Permit 0801.4087 $
SAC MC/WS 9220.2275 $
' SAC (City) 9379.4681 $
SAC Admin 0801.4246 $
Sewer Pemut 6201.4532 $
Surchu e 9001.2195 $
TreatrnentPlant 6101.4685 $
Water Pernrit 6101.4507 $
Water Meter 6101.4509 $
Water Su 1& Stora e 6101.4680 $
Other (Copy) 9001.4230 $
Total $ 40.75
I declaze under the penalries of law that this account, claim, or demand is just and that no part of it has been paid.
~ "k, April 20 2004
SIGNATURE DATE
~
; - . PERMIT
Clty Of EagaII Permit Type: Building
3830 PILOT KNOB RD Permit Number: EA063892
EAGAN, MN 55122 - - - .
(651) 675-5675 „ Date Issued: 04/20/2004
Site Address: 4444 Slater Rd
Lot: 062 Block: 03 Addition: Cinnamon Ridge 3rd
PID: 10-17402-062-03
Use:
Description:
Sub Type: Exterior-Multiple Dwelling Occupancy:
Work Type: ReroOf Construction Type:
Description: Duplex - Includes 4446 Zoning:
Census Code: 434 Square FeeC
Remarks' Two inspections are required: Ice & water and a fnal inspection. Qd)
~ Over charged by $40.75 sent in for refund. 4-19-04 (Id)
Fee Summary: Valuation: $4,000.00
Surcharge - Based on Valuation 2 00 9001.2195 BL - Base Fee 4075 0801.4085
BL - Base Fee 97.25 0801.4085
Total Fees: S140.00
Contractor: _ ApPl;caz,i _ Owner:
Wren Builders NLIA A WRYCZA
9218 l lth Ave S SC Lic.: 4360
4444 SLATER RD
Bloommgton, MN 55420
(952) 888-4952
EAGAN, MN 55122
I hereby acknowledge that I have read this application and state that the information is conect and agree to comply with all applicable State
of Minnesota Statutes and City of Eagan Ordinances.
Applicant/Permitee: Signature Issued By: Signature
EALVIN H. HEDLUND 7726 MORGAN AVE. 50.
MINNEAPOLIS, MINN. 55423
lona Surroyor Civli Enyfneer PHONE NO. 866-2523
ert~te
srrrr~er~org~ G'~j
q- 49g
JOB N0. B- 49 9 -
SURVEY FOR: ZACNMAQ IiOME~- _7-NC,
DESCRIBED AS~Lot 6, Block 3, CINNAMON RIDGE 3RD ADDITION, City of Eagan,
Dakota County, Minnesota, and reserving eaeementa of record.
~ Nor}hern Nalura/ Gas Co P,pel:ne
80.00 N48°32'35"e 117.0} l~0
- - \
I-'-- -
3 ~I 4o I
N~ 3 Top oF Founidaf7on = 915.33
' cp i ~ rn N Basernent Fioor• 918.33
°C4 Ir 917.y~WIo `W/D qtT-_ 00N Garaye Floor= 918,0
VNIT \ ~ ~ a Proposed E/evdtions O
~ 2 Exis4in9 E/evat:ons _
N\
loQS STaitES ~15.92 ~1 \ ~N fs.92 Drainaye Direcfton
4 AsS. \ FEC ~
~ Denoies Loh Cornei O
\
I p-R \_1R. I IO~O STPKES
/ -7 I~---• N~\ 24\I.
C) % - 9111
j
I
j- A , ^ ° J
914.2, - - - - - ~
916.9 1
$6.0p N 48° 32' S"E
~ T4 M ' .T
4
0
M
9)3.9 SLATEFZ ROAD 916.6
CERTIFICATE OF SURVEY
I hereDy certify fhot on 5- I6-83 Isurvoyed the property descriped opov• and fhot
the aDovt plot i• o correct represenloti0n of sold wrvey.
7o5a4.' W. W_4vw"~
Colrln H. Nedlun0, Minn. Req. No. 5942
CITY USE ONLY
PERMIT fl: RECEIPT DATE:
SOOE RUIDENTIAL MECtIAftICAI. ~EUIT APPLIClETION
crrY oF gwsAN
S$SO PILOT KNOB RD
f.AHAA EtN 55122
851-691-4675
AL'YYYkI'TERl2?10/OE 651$75-5675
Please complete for: ? single family dwellings
townhomes and condos when permits are required for each unit
Date:
SITEADDRESS:
OWNERNAME: 0,40QoN ~/~•/Qr~~ TELEPHONE#:
INSTALLER NAME: ~'"a c L- ~r Sys-tP~ S TELEPHONE 9S~ - 93 3'~~~ ~
STREETADDRESS: QG
CITY: Arf.n S STATE: ZIP: -Sf3 I73
Place a check mark next to the permit work type
_ Add-on, mo ificat oton r alteration to existin dwelling unit $ 30.00
• furnace replacement
• air exc anger
• air conditioner
• other
Nature of work: n
1 I
II I' ~ ~ ~ 11 ~
lP I E,',r, 2C?2 I~
~
State Surchar e $ .50
TOtal $
S19hA'I'T.JR PERMITTEE
L/
CITY USE ONLY
PERMIT RECEIPT DATE:
APPROVED BY: , INSPECTOR
8008 COMMEtCIi4L MECHANICAI. PEfiMIT i4PPLICATION
C[TY OF EAfiAN
3850 P1LOT KNOB RD
fAfiAN, MN 55] EE
651-6$1-4675
Please complete for: all commercial/industrial buildings
multi-family buildings when separate permits are not required for each dwelling unit
DATE:
SITE ADDRESS:
OWNER NAME: PHONE
TENANT NAME (IMPROVEMENTS ONLY):
WAS THERE A PREVIOUS TENANT IN THIS SPACE? Y N. NAME:
INSTALLER:
STREET ADDRESS:
CITY: STATE: Zip;
TELEPHONE
WORK TYPE: _ New construction Install U.G. Tank
_ Interior Improvement Remove U.G. Tank
_ Processed Pipmg
Specify Nature of Work:
Wlien isstalling/reinoving u»dergrouied tank, cal! 651-681-4675 for inspectian by Fire Marshal and
Plumbing inspector.
Fees: 1%ofcontract price OR $50.00 minimum fee, whichever is grea[er,
Underground [ank removaVms[alla[ion = minimum fee
Conhact price: $ x 1%= $ (Base Fee)
State sumharge calcula[e a[ $.50 for each $1,000 Base Fee
TOTAL $
SIGNATURE OF PERMITTEE
Updated 1/02
SUBTERRANEAN ENGINEERING INC.
7415 WAYZATA BLVD. Phons 548-8938
• •:~•i..
MINNEAPOLIS, MINNESOTA 55428 DATE
EARTH WORK OBSERVATION REPORT
p? OBSERVED
Job Nams / Job No. EXCAVATION:
Job Locatlon 41, LOt
7 //Pst Block
Earthwork Plat
Contractor + ~~'J Cllent ~ WAI
Arrlva Job ~d Mlleage Y'4~1 . Total 777???FILL PLACEMENT:
Decart Job YS Travel Tlme ~ Fhargeable ~ Lot 3~ S
lab. Time ~ f, Hours Block
Total Fiours Eng'r Plat
On Job r• Report TImeCl~. Review Time
Summary o} Tachnlcel and /or Engineering Services performed including Fleld Test Data, Locatfons,
Elevattons, and Deothe are estlmated. THE LIMITATI9N OF LIABILITY STATEMENTS ON 7HE REVERSE
SIDE OF YHE COMPACTION QUALITY CONTROL TEST REPORT CONSTITUTE AN INTEGRAL PART HEREOF.
feet deep at feet deep
1. Excavation le Elevatlon end , grading to Elevatlon at end
2. Sids Slopea ara approx.: vert. ? 1/2 horiz.: 7vert. ? 1 horiz.: 1 vert. ?
2 horiz: 1 vert. /tlatter than 2:5 ? other
E 3. Conetructlon Staking Is: adequate C~ not available ? Incomplete ?
X 4. Excavation la oversized feet outalde ot building Iines.
c 5. Excavation le: dry p wet ?
A 5a. Water Is aeeping }rom
v 5b. Depth of water In axcavatlon approx.
A Sc. Dewatering Is: nacessary ? not required ?
T S. Excavation le with : draglina ? backhoe ? acraper ? dozer ?
1 7. All unsultable solls have been excevated. YES ? NO ?
0 7a, feet of soll remalns to be removed.
N S. Soll at azcavatlon base Is:
Sllty Clay ? Sandy Clay ? Clayey Sllt ? Sllty Sand ?
Clayey Sand ? Clean Sand ? Other
9• feet of flll reaulred to reach desian suharnds.
10. Excavation Is: Approved ? Not Approved ? tor flll placement.
11. FIII la , S r (type oi soil)
.
17a. Imported On-slte borrow p!
11b. Compactlon la with sheepsfoot roller [3-'~ manual tamper O vlbratory ~
f smooth drum roller ? selt-propelled M/ non-vibratory ?
I 12. Performed 15 fleld denslty teats, See Compactlon Ouallty Control
L ~ Teat Report No. ~
L 13• 7D fest ot }III remalna to be plaeed.
14, enslty teets mest compactlon apeclflcatlons. YES NO ?
14a. Test No's. dld not meet comp on speclfications.
1S.Addltlonal obaervatlons ntl/o tests are re ulred. /YES NO ?
FROST pDJACENT /
~ DEWATERiNG: PROTECTION: STRUCTURES: WEATHER CONDITIONS:
P N well polnts ? straw blankets [3 Hot ? Dry Q~
~ ~-deaD wells? loose soll p Warm ?/F3eln ?
I T opsn dlteh ? troat rlpping ? wlthin 20 feet ? Cool L~Y Snow ?
~ N sump pump ? temp. heat ? 20-40 feet ? > 32'F ?
S othsr ? otfier f] 40 ar r+!ore }pot ? S,4-+soezing ?
RECOMMENDATIONS/SUM~ RY/Ws RK PROGRESS: K ~
Q'7'i ~~o~ _S^a.,~ T f'PS
DISTRIBUTION:'
~ cc: ~v7
ah
m 7
cc:
cc: ~ G!! 6y P
/ cc: S ERRANEAN ENGINEERING INC.
L cc:
THESE LIMITATION OF LIABILITY STATEMENTS SHOULD BE
CONSIDERED TO BE AN INTEGRAL PART OF THIS REPORT:
1. In performing our professional services wiih regard io earthwork inspecfion end queG4y
wrrtrol, our findings will be obfeined end our recommendetions mede, in eccordance
wi+h generelly eccapfad engineering principles end prec4ices. We will observe, monrtor
end +es4 fhis work, end mey edvise or meke recommerdations, bu4 we ere nof guarenfon.
This werrenfy is in Geu of ell other werrenfies either erpressed or implied.
2. $ubferrenean Enginaering inc. does not pracfice in the field o4 lend surveying, end
is no4 rosponsible for the eccurary of grede sfekes end/or building locefion siakx at
fhis jobsite. There musf be edsqua+e consfruction sfekes, cleerly merked, to eneble our
wil impec4or to proparly euess the exceve#ion. We will not be ro:ponsible for arry herm-
ful wnsequences resuking from impropar or ineorreef wns#nxiion s#eking.
3. The field densify fed de+a presented wifh 4his report represenfs the velues a4 per-
ticler locel'ized poin4s wifhin the eerfhwork. Alhough this is believed to be feirfy repre-
tentatire of the eondifion of iha fiill pkoed and eompected on 4his de4e, wnditioru e}
other locetions erd elevetions in fhe fill mey very, and we do no4 wertant or guerentes
uniform fill deruitiex.
4. We cennof eer+ify, eifhsr expressly or by implicefion, the queGfy of arry work on fhis
project which we did nof heve fhe opportunify fo observe at fin} hend. InspeeFion of this
eerfhwork projeef e+ inegular irrtervels does no4 permi} the inspecFor }o essess }he full
urope of the con+recfor's ectivifies.
5. If the drudura is redesiqned in sixe end shape, or if if is otherwise movsd wbsequerrt
to our inspection, we should be notified w ihet we un euen if eddifionel intpec+ion
work is required, or suggasf wund enginearing ekernefives. We ere rro# respornible
for eny soil•founde+ion sy:fem where the s+ruciure hes been reloceted wifh respeeF fo
e:eevefion and fill eree, sub:equen+ to our impedion.
SUBTERRANEAN ENGINEERING INC.
MINNEAPOLIS, MINNESOTA PHONE 546-6938
COMPACTION QUALITY CONTROL TESTS
Project cinnamon Ridqe Report No. 39
C'aAar Ave. So. & Cliff Road, Ea4an, Minn. Job No. S-8 134
Sand Cone Method 0 Indicoted Percent Compaction: ASTM
Nuclear ? Cg % Max. Modified Proctor Dry Density D-1557
Other ? Max. Standard Proctor Dry Density D-698
ELEV. ANDJOR
DEPTH BELOW Wel Denslt
Y Ory Density MaRimum
D018 T8S1 FOO1f2Of Tolal MOISTURE Laborofo %
Floor Grade ( Corrected ry RECOMMENDATIONS REMARKS
NO. Desi n Grode 'Sample CONTENT FOr Stone ) D`Y Density Compaction
Fill Surfacs IrKludingStore) % prt
;ept.28, 0.5'
1982 182 924.5' 144.2 5.6 127.4 129.5 98.3 Meets Specs
183 -3.0'
922.0' 136.9 5.0 126.0 129.5 97.3 Meets Specs
„ -0.5'
184 924.5' 143.4 8.9 129.0 129.5 99.6 Meets Specs
" 185 -3.0'
922.0' 144.1 8.4 127.3 129.5 98.3 Meets Specs
-0.5'
" 186 924.5' 141.0 5.5 126.5 129.5 97.7 Meets Specs
NOTES- I.) ALL TESTS CORRECTED FOR STONE CONTENT, WHERE APPLICABLE.
2.) APPROXIMATE DENSITY TEST LOCATIONS ARE SHOWN BELOW.
~ S
.4 o ~
Z"
IS`f 85
• ~
t-3 183
~ ~8~ • 4 r,+.tvik
e
APPLICATION AND AU71lORIZATION FOR DELAYED PAYMENT OF TAX
' ON SPECIAL ASSESSA4ENTS FOR SENIOR CITI S' HOM TEAD
~ ~
LAWS 1974, G'HAPT'ER 206 V'
STATE OF MINNESO'fA) a C@ ~i ~
COUNTY OF DAKOTA ) '
T0: County Auditor, Dakota County, Minnesota .DATE.
-
• I, the undersigned declare er pe ies of perju
That I reside at <i-~-\j ~ - A
~ N ~ ? `7~
That I am not less tZ n'6~yeyrs ~ age an that t date of my birth is
That I am th~ owner of the property legall describ/~ed as; _
.p \ ci "t.- C' q V
~ ) l ~
~~Px`o~er~y~~Ii'e~i~ii'
That my anterest in the ownership of the above property was aquired on -
and is as follows: •
1. Sole ownership (Enter Yes, if applicable) if Cj
2. Joint tenancy, held with
. 3. OTHER undivided interest (Specify)
That on January 2, June 1, I owned and occupied the above vroperty as my
homestead and such occupancy began on I(,~~ 1, /Q[~ 1
That the installments for improvements on the SPECIAL ASSESSMENTS duly adopted in ordin-
ance by thef:~_„ r?'{~ ~'G96:! OF AS OFpC'1~" IY - j G0.~`~
which have been/allocated a ainst the subject property would create undue personal hard-
ship on my behalf and I respectfuliy request that payment be delayed and that such in-
stallment be so deferred for the years to
SIGNED: ~ r ~ r a . - - - ~ - -k7vER - - - - SPOUSE
- - - - - - - - - - - - - - - - - - - - -
I. Clerlc of the OF ~a<p„yl
IN County, State of Mirinesota, do hereb certiFy'that t application
of ' i~,,•~ , , : u` above named,. has been duly reviewed an-9 that in ac:erdance with .e minutes of official record in said chambers was duly : APPROVEDJa- DS -0 rj or 9ENF£B es e€ „
That in accordance with approval granted, the SPECIAL.ASSESSMENTS listed below on the
affiants subject property levied for annual collection in the amounts and for the years
shown be so deferred with interest at the annual rate shown tmtil such time as it is
deemed the applicant no longer qualifies or the property loses its eligibility.
ASSESSMENT' D/P N0. ' TO'fAL AMOUNT YEARS INTEREST RATE
e-
~ I
~03&,91-0 a88~s-v s y,s
DATED ~ a- os - a oos
Clerk
. (over)
~
DAKOTA COUNlY pUDITORS OFFICE
posting check list
Record Posted by Date
Defened taxes/assessment book
1Yansfer card (red dot)
Local improvement assessment card
Data processing notified .
7'ERMINATION ORDER
Date terminated
Reason (s) :
By:
Authorized Signature
m 1040 mentofthe7reasu
r ry-Internal Revenue Servi~
U.S. Individual Income Tax 200
ForNeyearJan 1_0~ 31,2004,aoihertax Return
year begimm~g (99) IRS Use Only-DO not wnta or slaple in tMS spaoe
La bel L Your first name an0 mtlial 2004, endmg 20
A JULIA Lastname OMBNo 7545-007a
(See B A WRYCZA ' ~ Yoursocialsecuritynumber
instruCtionS ) E It a )omt reNm, spouse's firsl name antl inltial
L Last name ~
475-BO-8839
Use the IRS ' SDouse's social securiry num6er
Otherwise18be1. , E Home atldress (number and streeq If you have a P,p_ box, see instructions.
q 9944 SLATER RD
please print E Apt no.
c~
0rtype N. ~own or post oKCe, state, and ZIP ~otle. I/you have a foreign adaress, see mSVUCtionS ~ ImPortant! .
Presieentiai EAGAN You must enter
Election Campaign Mbl 55122 YoUr SSN(5) above.
(SBe i05tNCtionS.)' po~. Checking "Yes" wtll nat 1hange your fax or reduce your refuntl.
you, or your spouse d(Iing a ,oint retum, want 83 to go to this funtl'
YOU $POU50
Filing Status ~M Single Yes E No ?Yes ONp
q? Head of householtl (with qualifying person). (See mstr.)
2? Marned filing jointly (even if only one had income) if qualifying person is a child but not your tlependent, enter
3? Marned filing separately Enter spouse's SSN above this child's name here. ?
°p and full name here. ?
~ °~uawa~elS
Kel' pue a6e
~
liouaialay aa 6a yaurself. If someone can claim 5?' Quahfying widow(er) with dependent child (see instmctions)
ons b Spouse . . . . . . you as a dependent, do not check box 6a . . . eo,os
;r . . cneckaa on 1
6a antl 6b
y~e7f,1=0,/, c Dependents: . . . . ' ' No. of chiiaren
(i) Frst nama Lasl name (2 DepentlenYS (3) p¢pentlanCS f Iv Op 6C WhO:
x~ef0U! .0secunrynumber relalionshipto th)IC(wU~jQjy~
'm asee oa aeEit (sga mslr ) ~ IiveC with you -
• tlitl not Iive wi[h
' you tlua to Civorce
l orseparatlon
Z` (88lI11gWl _
Q~ DePentlente on Bc
d Totalnumberofexemptionsclaimed . noee„terea,pove
Atldnumben ?
diZ °-e --P 7 Wages, salaries, tips, etc Attach For(s) W-Z ~
aeov.
'w` 1
Attach Schedule B d required . . . . . 7 9, 786
1~Woobv ms c~ 8a Taxable interest m
,ZL s b Tax-exempt in}erest. Do not include on line 8a , 8a p
21 9a Ordinary dividends. qttach Schedule B if required 8b 0
~s u :1SO b Qualified drwdends (see instmchons) . . 9a
~~5) 70 Taxahle refunds, cretlits, or offsets of state gy 30
and local income tazes (see mstruchons) . 9 3
aa o~ I 1 Alimony received e x 12 Business income or poss). Attach Schedule C or C-EZ 'O 0
d .
m~.~iaW3 a •~a~ 13 CapRal gain or (toss). Anarn scnel o drequlree If nol reqwree, ci ry~ne ' "
"
14 Other gains or (losses). Attach Form 4797 , 12 0
pieg ; ? ~ 13 -3, 000
15a IRA distributions . " ' . . . .
16a Pensions antl annuities 14
LL6EE ~ns 16a b Taxable amouM (see inswctions) 15b
dtl NM011do 17 Rental real estate, royalhes, partneiship b Taxable amount
ONI 1 18 Farm income or (loss). Attach Schedule F. (see instrucnons) 16b
s, S corporations, trusts, etc . Attach Schedule E , 0
o*dRP~~'a~y 19 Unemploymentcompensahon . . ' ' ' ' ' " '
+P 18 p
tl OOSI ' . . . . . . . . . . . . . . . . .
ZOa Social security beriefits . . . . . I20 ' 19
~w ~'~O V• Other income. list type antl amount (see - I instrucb Taxable amount (see msvucnons) 20b p
00 ZZ hons) _
:no,r,~ww 5 Add the amounts in the far ri ht column for hnes 7 throu h 27 This is ourtotal income . 21
OU z3 Educator expenses (see instructions)
°'""9 ~°"OS ~ 24 Certain business ezpenses of reservists, peAorminq artists, and ZZ
a fee-basis government officials. Attach Form 2706 or 21p6-EZ , 23
wwui ~mopai a ' 25 IRq tleduction (see instructions) . ' 424
26 Student loan interest deduction (see instruchons) . . . 25
27 Tuition and fees deduction (see instructions) . . . . ' 26
2$ Health savings account deduction Attach Form 8889 . 27 0
29 Moving ezpenses. Attach Form 3903 28 ~
30 One-hal( of sel!-employment tax. Attach Schedule SE 29 0 31 Self-employed health insurance deduction (see instructions) , 30 0 32 Self-employed SEP, SIMPLE, and qualified plans . 31 0
33 Penalty on early withdrawal of savings . . ' " 32 0
34a Alimony paid b Recipient's SSN ~ . . . ' 33
35 Atld lines 23 through 34a 34a
36 Subtract line 35 from line 22 This is your adj Noustetlice, gross i see ncome 35 0
For Disclosure, Privacy p ?
KIA ~~antl Paperwork Reduction Act t. '
36 1.829 .
instructions
Form 0(2004)
m 1040 Department of the Treasury-intemal Revenue Sernce
U.S. Individual Income Tax Return 20 04
For ihe yqar Jan Dec 31, 2004, pr other lax ye& Eeginnmg (99) IR$ Use Oniy-0o nol wrrte or staple m this space,
La bel L Your first name and inNal 2004, erwing 20 OMB No. 1545-0074
Last name
A
(See JULIA p WR YCZr^, i Yoursocialsecuri[ynumber
e ~
inStfUChonS.) E a Jom[ return, spouse's first name antl imtial Last name 475-80-8839
Use the IRS L ~ Spouse's social securiry number
IabeL E Home address (number and streeq If you have a P 0 box, see ins[mctions.
Otherwise, R 9494 SLATER RD APt.no.
please print e . ' Important! .
0r typE. City, town pr post oKCe, state, antl ZIP cotle. If ypu have a tpreign address, see mSVUCtions. YOU AiuSt BntBr
Presitlential EAGFN MN 55122 YourSSN(s)above.
Election Campaign
(See instructi0ns Note. Checking "Yes" will not change your tax or reduce your reluna. YoU
Do you, or your spouse dfling a tomt retum, want $3 to go to this Pond7 , nSpOUSB
~ n Single . ~ ? Yes E No L.I Yes 11 No
Filing Status q? Heatl of householG (with qualiTymg person). (See instr.)
2? Married filing jointly (even if only one had income) If 9ualifying person is a child but not your dependent, enter
---=-'--'v 3? Mavied filing separately, Enter spouse's SSN above this child's name here. ?
and full name here. ?
Iuawa)elS
icey pue a6e' 5 Quahfying widow(er) with dependent child (see instructions)
Lfi
fouajajay aa 6a X Yourself. If someone can claim you as a dependent, do no[ check box 6a ~.ea
;ie~OflS b
' . . . . . . . . . . . . . 1
? Spouse checkadon -
Ba antl 6b
G D¢5n., : ' No. of chiltlren
OL' 6! (1) Las; name IZI D epentlenpa (3) DapenEY (
S y1%rtqua on 6C wh0:
ldving
soaal secunty numCer relatians~ipenlo Uila /or chilQlaz • livetl wiM you
x ~am~ 81 f011f ou creEil (see insV ) ~
m a~e~S 9l 01 5¢e • tlitl not liva wiN
yov tlue m tlWorce
' or aeparatlon
~ Isee mstructlona)
Oepentlan[e on 6c
QF notenleretlabova
d Totalnumberofezemptionsclaimed . aaa,,,,meero
. . on linos 1
aPo- dR P-e 's"P 7 Wages, salaries, tips, etc. Attach Form(s) W-2 . a~y' ~
b Tax_exemp . . . . . . . . 8a
nSea-u.p..d.GoL 8a Taxable mterest. Attach Schedule 8 if reqwred . . . . f 4 8 6
t interest Do not include on line 8a 0
5 9a Ordinary dividentls. Attach Schedule B if reqwred Bb 0
so b Qualifed drvidends (see mstrudions) . 9a 4 3
~
5) 'IO Taxable refunds, credits, or offsets of state antl local mcome taxes see instru c ons) 30
11 Alimony received '
0 0
72 Business mcome or (loss). Attach Schedule C or C-EZ CapltBl g2in Of (IOSS). Aitacn Scheauie o i/ reqmred II not reqwrea, ch¢ck hera . . . . 12 0
10389 Other gains or (losses). Attach Form 4797 . ~ ~ ~ 13 -3, 000
~ 15a IR4 distributions 74
16a Pensions and annuities ~ Sa b Taxable amount (see instructions) 15b 0
LLb£E ~~5
oi~do
aa Nnn 17 Rental real estate, royalties, partnerships, S corporations, trusts etc Attach Schedole E nsvucnons) 1'~
ONI 1 18 Farm income or (loss). Attach Schedule F
e9no d¢puv'sa1y 19 Unemploymentcompensation 18 0
tl o~~ 20a Social security benefits . . 19
. ' I Zoa- b Taxable amount (see insirunions) 20b 0
~ 'd1° K• 21 Other income List type and amount (see mstrucBOns)
.na,~!wrv s
~ 22 Atld the amounts in the far ri ht column for lines 7 throu h 21. This is ourtotal income _ _ 21
OU z3 Educator expenses (see instructions) ? 22
~!'"'°`i"'°S ~ 24 Certain business expenses o( reservists, pedorming artists, and 23
fee-basis government officials. Attach Form 2106 or 2106-EZ . 0
w~~i i°'wi x ' 25 IRA deduction (see instrucUOns) . . ' 24
26 Student loan interest deduction (5ee instruCtions) 25
27 Tuition antl fees deduction (see mstruchons) Zs
2$ Health savings account deduction. Attach Form gggg . 27 0
29 Moving expenses. Attach Form 3903 . Z$ 0
30 One-half of self-employment taz Attach Schedule SE . 29 o
31 Self-employed health
32 insurance deduction (see instructions) 3~ Q
Self-employed SEP, SIMPLE, and qualifed plans .
33 Penalty on early withdrewal of savings 32 034a Alimony paid b RecipienYs SSN ~ . . 33
35 Add lines 23 through 34a . 34a
36 Subtract line 35 from line 22. This is youradjusted gross income
KIA For Disclosure, Privacy qct, and Paperwork Retluction Act Natice, see instructions. ? 36 1, 829 .
Form 4 (Zppq)
• Property I~ ~ E
Properiy ID House# Sireet Name Unit Today's date. 12t6l2005 Release: 1 02.07 Logged on user JWOBSCHALL
J 1 0-1 74 02-062-03 J Address: 44qq Slater Rd
SingIePID parcel5eerch qeer Print VewPhotos
ParcelAdministration
C-~N SpecielAssessments ~
~ \SQ°rch
&AssessmeniSenrch E'Summary
Master Information
~ Comments
Mass Add pIp: 7 6-1 74 02-06 2-03 Address: 4444Slater Rd
, . ~
Mess Comments Update Lot 000 Block 003 AddiLOn: Cinneman Ridge 3rd
Mass PnyoH
Number Comrersion S/A Flags:
D'ndsionmg parcel Status: Adive P 81 Year 2005
- ~
-~Rollover P81Cert: f0.00
~ CounyTrensters (FTFy)
Reports and Inquines
Database U61i6es 7 Assessment Detail Records, Total Payof( _$286.50
!:itl SecurityAdminisUation S/A4 DescripUOn YearTer InterestReTOtalAssessm PrinapelAmoPayoNAmouStatus
? 100008 WATERL4T 0 1 0.0000 % $529.12 50.00 $0.00 qosed
100011 STORM SEW LAT 0 1 0.0000 % $941 86 $0 00 50.00 Closed
100012 SERVICES 0 1 0 0000 % E337 60 $0.00 $0.00 qosed
100889 SVJSS357 196 5 10.5000 % $621.03 $000 $0.00 qosed
100890 ST357 198 5 10.5000 % E867.60 E0.00 $0.00 qosed
101585 DELIN UTIL 196 1 9 0000 % $22.50 $0.00 $0.00 qosed
103600 ST 878-GN RIDGE 200 5 4 5000 % $288 50 $0 00 8286.50 Levied
. _ . . _ a ' r " ' . m . . .
. _ System
Property ID House# Street Name Unit Today's date: 1 1 11 612 00 5 Release: 1.02 05 Logged on user. JWOBSCFIALL
J 10-17402-062-03 ~ Address 4444 Slnter Rd
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~ Master IntormaLon LOt 000 _ Blodc' 003 Addition: Cinnamon Ridge 3rd _
~ Commenis
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PereMPID ~ D'nrisonPrvcessDate: 11n/7983 ~i
Diwsion Number 075220 Yeer Spli[ ~
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Agenda Information Memo
December 5, 2005 Eagan City Council Meeting
F. APPROVE SENIOR CITIZEN SPECIAL ASSESSMENT DEFERMENT
APPLICATION - PARCEL 10-17402-062-03 (PROJECT 878 CINNAMON
RIDGE STREET REHABILITATION)
ACTION TO BE CONSIDERED: To approve an application for a senior citizen
deferment of special assessments.
FACTS:
• Section 2.75 of the Eagan City Code allows for the deferment of special
assessments for senior citizens, if certain conditions are met.
. The City has received a request for a defermenf from a property owner in the
Cinnamon Ridge 3rd Addition. '
• The assessment was levied for street rehabilitation improvements related to
project 878.
• Staff has reviewed the application and determined that the eligibility
, requirements are met.
ATTACHMENTS:
• Enclosed without page number is a copy of the application for deferment.
•
30
~.2Ss~ ~~s.so
2006 RESIDENTIAL PLUMBING PeRnniTaPPUCarioN
CITY OF EAGAN
3830 PILOT KNOB ROAD, EAGAN MN 55122
651-675-5675
Please complete for modifications to existing residential dwellings.
Date3/7 / 1J(0 n
Sya~~'~C QaA Unit#
Site Street Address 1`
Property Owner ~.1 ll`~ 0, ujd~L Z6,_ Telephone 6~) `6`rO- 71157
Contractor 1 0.~`~ 0 1 1 l uvAb i~ L'~L. Telephone #((°SI ) y63 "76I I
Address G, D Sn - ~.l ~.~"h S~. W. city 1 As vv\i 1, 91'0 r state MkJ zip SSOd
The Applicant is: _ Owner _~Contractor _ Other
Septic System _ New _ Refurbished Submit 2 sets of plans and MPC license Includes County fee
$ 100.00
Per as-built $ 10.00
Alterations to existing dwelling $ 50.00
_ Add plumbing fixtures. This fee includes installation of a water softener and/or water
heater at the same time. If you are installing onlv a water softener and/or water
heater, do not complete this section; move to the next section and check the
appliance(s) you are installing. _
~ .
_Septic System Abandonment
=WaterTurnaround (add $130.00 if a 5/8" meter is required) uu I
Other.
-
Water Softener ~ Water Heater $ 15.00
_ new ~ replacement
Lawn Irrigation _RPZ _PVB _new _repair _rebuild ' 30.00
State Surcharge $ 50
Total $ ~SSD
I hereby apply for a Residential Plumbing 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 plumbing codes; that I
understand this is not a permit, but only an application for a permit, work is not to start without a permit and work will be in
accordance with the approved plan in the event a plan is require.dn to ~be reviewed and approved.
N~ark ; wA ~ e,', 7~ ` ~
ApplicanYs Printed Name ApplicanYs Signature
Thisrenuest void p-~ L(~~ B31 C('nh J7~~~
,s ~,w„ms f.om Q
W 064862 $b'o o
Renuest Date Fire No. Roueh-in Insuecuon
Feqwrodl ea~y Now ? Will Nnuty Inspec-
•~l~Llf IZ 3 ;RVus ?No tor Whan Ready
~Licensed Elactncal Contracror I hereby request inaoechon of abova
Owner electrical work ingtelled el:
S[reet Atldress, Box or Route No. CItV
Sl St -9 '9 S~A " EAGAAJ
ecuon o. Township Name or No. Range No. Coumy
0
O upant (PqINT) Phone No.
G .l 14
Power Supoliar AOdr
D 1<0 ~E , Aswc~ ~ n
Elec ncal Comeoctor ICompany Nemel Conhuctor's Li .n~5e o.
AON -Q e
Mailina AdJress (COntrnctor or Owner Mnkine tn Ila[ion)
4.30 ,.i OGL l c~ GY
Aut zetl $ipnflture nu ace wner Making Ins[allatio I Ph n Numbar
~ ~ "~8C°2 /
MINNESOTA S TE BOAND OF ELECTqICITY THIS INSPECTION REQUEST WILL NOT
Grigge-Midwey Bldg. - Noam N-791 6E qCCEPTEO BY THE STATE BOAPD
1821 Univarsity Ave., St. Paul, MN 55100 UNLESS PHOPEfl INSPECTION FEE IS
ENC LOSED.
REQUEST FOR ELECTRICAL INSPECTION r E8-00001-04
See inehuctions fer comoletin this torm on bock of ~
~ g yellaw coDY•
W"X~ Berow 6York CoVered by This Request 3 7?~ f
Ada Rao. 7vae o1 e.umn.o AppIiO11CB5 WuBd Enuion,ani wi.ed
Home Range Temporary Service
Duple.x Water Heater LiGhtiny Fixtures
Apt. Building Dryer Electric Heaun
Commercial 81dy. Fumace Silo Unloader
Industrial Bldy. Air Conditioner Bulk Miik Tunk
Farm th«n oeci v 0he1 (Snec~ivl
t er uec7v t er Othiv
Compute Inspection Fee Below
a Fee ServiceEntrenceSixe k Fee Fexdars/SUbineders P Foo Cvcuits
U to 200 Am s 0 to 30 Am s 0 in 30 ;.n+ o
ItAs Above 200 qmps 31 to 100 qmps 31 to 100 Am s
Swimming Pool Above 100-Am s Above 100_Amps
Trenstormers Irrigation Booms Partial-'Oth
Signs Special Inspection 5 TOTAL F
Remarks V r /~,An(„~ k, Or~
L.nY
Rovgh-in Ihe Elecvicxl
soector, hefoby
certdy thxt the nbove
Final 0teinspection hes been
? mede.
Thlv ronuovl vnltl 1 R mnnf Rs from
CITY OF EAGAN
. ' 7795 Pllot Knob Rmd Eogan, MN 55122 T7 lr O 8091
PHONEs 4348100 i BUILDING PERMIT Receipt # , t"v
T. M wed hr 1/2 DUPLEX & GAR Est. Volue $47,000 Dare June 1 1 q 83
Site Addreu 4446 Slater Road (Unit A) Erecr gF{ OccuPOncy R-3
Loe 6 BI«k 3 Sec/Sub.Cinnamon Ridge 3rd qirer ? Zonin9 (PD) R-2
parcel # 10 17402 060 03 Repair ? Fire Zone NA
Enlarge ? Typc of Const. V
oc Nar„e Zachman Homes, Inc. µo„e ? # Srories
~
Addrass 7760 Mitchell Road
Demolish Q Length 24
Ci Eden Prairie pho„e 937-9520 Groee ? Depth 42Sq. Ft.-
~ Nome OwneT ApOrorals Fees
0
or' Address Assessment Permit •
u~ Cit Phone Water 8 Sew. Surchorge 23.50
Police Plon check 134.7$
Gw Nome Fire $AC 525.00
Address Eng. Woter Conn.450.00
iW Ci Phone Plonner WaterMeter 60.00
Council Road Unit 250.00
I hereby acknowledga thot I hove reod this apDlicotion ond sfate thaf Bldg. Off.
the inlormotion is corrett ond ogree 1o tomply with oll opDlicoble APC Totol $1712.~$
Stote of Minnewto Statutes and City of Eogon Ordirances.
$Ipnoture of Pertniffea
A Buildir,q Perrr,ir is issued ro: Zachman Hc,,, onr r nn the exprea conditlon 1hm
oll work sholl be done in accordanct with all op/~{I ~dble~/ 5tat~e of in tutqs ond City of Eopon Ordinances.
Buildin0 OfHclol /I J~\ J i ;LG~~.
CITf OF ~Ca,'V Inciude 2 sets o£ plzns,
,
n 1 site plan w/elevations s
U O~ BUILDI\G P£&RIT APPLICATION 1 set oi energy calculations.
r ~ flu~~~;~
?b Be (,s For _~Elle fmlril, Valuation %j6pqe& Date 5/13/83
Site Address: 4446 Slater Road OFFICE USE OPII,Y
Lot 6 A BlOCk 3 Sec./Sub. Cinnamon RidggL2ct 4_ pccupancy
Parcel f 0 ( 7,q0 Z p(Qa o 3ra Aaa. Alter Zoning
Repair Fire Zone /
Rwrer: Zachman xomes, 3nc. Enlar9e _'iYPe of Const.
Pddress: 7760 Mitchell Roaa Nb ve r Stories
peirplish Front ft.
Clty/Zip Cor?z- Eden Prairie, Mn 55344 Grade Depth ft.
Phone 917-952n p,pPROUp,T;
E•'EES
Contractor: Game as above ~ AssessTents PeTmit 10
Pddress: Water/Sew-er Surcnarge 3 -6-0
Police Plan Check- 5a5
, City/Zio Code: Fire SAC
Phone Or. ~.hg.- Water Conn. 60
Planr.er S4ater Rleter ~D
AzC'ii_/Eng,: same as above Council ad Unit a-
FL'dress: A.°Bldg. Off. ~
- C I
ciry/zio ccti'e:
. CITY OF EAGAN TT
3793 Pild Knob Road Eagon, MN SSils lr O $090
BUILDING PERMIT VHONF: 454-8100
ReceiPt #
To ba uwd fer 1/2 DUPLEX & GAR Est. Value $34,000 Dore June 1 1983
5ite address 4444 Slater Road (Unit B) R-3
Erect ~ Occuponcy
Lor 6 ei«k 3 Sec/Sub.Cinnamon Ridge 3rd Airer ? Zonin9 (PD) R-2
Parcel # 10 17402 060 03 Repair ? Flre Zone NA
Enlarge ? Type of Const. V
~ Nome Zachman Homes, Inc. Move ? # Stones
z Addrcu 7760 Mitchell Road pemoiish ? Length 24
C; Eden Prairie phom 937-9520 Grode ? Depth 44 Sq. Ft.-
o Nome Owcier ApDrovab Fees
ou Address Assessment Permit 211.00
u~ Cit Phone V?ater 8 Sew. Surchorge 17.00
Police Plon check 105.50
~w Name Fire SAC 52$.00
~Z
Addrem En9• WaterConn450.00
Ci Phone Planner Woter Meter 60.00
Council Rood Unit 250.00
I hereby ocknowledge that I hava read this applicotion ond state that gldg. Off.
the informotion is wrrect and ogree to comply with all applicoble APC Totol $1618.50
Sfote of Minnewta Starutes and City of Eogon Ordirances.
Signature of Permittee
, nc.
A Building Permit Is issued to: ac man ome on tha express condiMon 1hnt
atf, pli b fate ta Statutes ond City of Eaqon Ordinonces.
oll work sholl be done in accordance
Buildinp Offitinl
1
CITY OF E?G?,N 7nciude 2 sets of plans,
~1 site plan w/elevaticns & '
BUILDIVG PER'KIT PPPLICATION 1 set oi energy calcula:ions.
~ e~q1E K1-~oc~ r- (f 3 y e-o-o _
Tb Be Used For F Valuation 49q4*9=:Rp' Date 5/13/83
r
Slt2 PL'c'sEEss: 4444 Slater Road OFFICE US~' ONLY
Lot 66J Block 3 Sec./Sub. Cinnmon aidge Erect _ C Occupancy 3
Parcel Id (7~~(~z G~26 0 3 3rd ~ter Zoning.
Repair Fire Zor.e
p,me~r• 7arhman Hnmac Tnr Enlarge _ 'I}rpe of Const_
N~,e r Stories
Pddress: 7760 Mitchell xd pefrolish Front
Cit /Zin Code: Grade Depth Et.
Y Eden Prairie. Mn. 55344
Phone 937-9520 p,pPROVALS - FTS
CAntractor: same as above ASSessaents Pesmit ~L
Pddress: Water/Sec.eer Surcnarge 17 ,PS'Z
Police Plan Checx . / 0 :T'.S~r1Z
City/Zip Coc'e: Fire SAC
Phone Ir. -13 • Water Corn. Sp
Planner ater ~~ter (op
ArCh_/Enq.: same as above Council ~ROad Un1t 4v
Bldg. Off j g
Pddress: ppC
Citv/Zio C'rr?p. o - ~
~ ~9~ ~ ~
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PERMIT
City of Eagan Permit Type:Plumbing
Permit Number:EA108057
Date Issued:11/14/2012
Permit Category:ePermit
Site Address: 4444 Slater Rd
Lot:062 Block: 03 Addition: Cinnamon Ridge 3rd
PID:10-17402-03-062
Use:
Description:
Sub Type:e - Water Heater
Work Type:Replace
Description:Water Heater
Meter Size Meter Type Manufacturer Serial Number Remote Number Line Size
Comments:Brian Nerison
430 E. County Road D
Little Canada, MN 55117
651-481-9155
Fee Summary:PL - Permit Fee (WS &/or WH)$55.00 0801.4087
Surcharge-Fixed $5.00 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 -
Julia A Wrycza
4444 Slater Rd
Eagan MN 55122
KB Service Company
430 E. County Rd. D
Little Canada MN 55117
(651) 748-4933
Applicant/Permitee: Signature Issued By: Signature
PERMIT
City of Eagan Permit Type:Mechanical
Permit Number:EA108058
Date Issued:11/14/2012
Permit Category:ePermit
Site Address: 4444 Slater Rd
Lot:062 Block: 03 Addition: Cinnamon Ridge 3rd
PID:10-17402-03-062
Use:
Description:
Sub Type:e - Furnace
Work Type:Replace
Description:Furnace
Comments:Questions regarding electrical permit requirements should be directed to Mark Anderson , State Electrical Inspector,
952-445-2840
Brian Nerison
430 E. County Road D
Fee Summary:ME - Permit Fee (Replacements)$55.00 0801.4088
Surcharge-Fixed $5.00 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 -
Julia A Wrycza
4444 Slater Rd
Eagan MN 55122
KB Service Company
430 E. County Rd. D
Little Canada MN 55117
(651) 748-4933
Applicant/Permitee: Signature Issued By: Signature
Date:
C!ty of Eaaan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax:
(651) 675-5694
Use BLUE or BLACK Ink
For Office Use
Permit #: 1 121
Permit Fee: 311. t:1 C 1
Date Received: 1 19 ,1-3
Staff:
2013 RESIDENTIAL BUILDING PERMIT APPLICATION 1 1
I ) Site Address: 1/ IN `j sI4e-7 /4 ki SSi LZ Unit #:
Resident/
Owner
Name: v .t C+{ �,.i r y C7^
Address / City / Zip: 51,04/ e-6
Applicant is: Owner contractor
Phone: € $ f 'Z/0
r
Description of work: ' [/J1r , - reivh1n. ` t tIs 4-&J I� �l w v✓�dc Dut
Z-
Construction Cost: 11 / 410, ^4 Multi -Family Building: (Yes C.No _) .{-v„i,
Company: Auer fib(!weeContact:h tt9
J
Address: 1/di CIA 14l/ti S City: SW-'< T17t F>atiL
State: MW Zip: 5.51111—Phone: (tS/ off -/Y / ? Z. 3
License #: 6 e 6, L6 S-13. 5 Lead Certificate #: /Va f - I Ya 3a - )
If the project is exempt from lead certification, please explain why: (see Page 3 for additional information)
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan?
_Yes _No If yes, date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor: Phone:
Sewer & Water Contractor: Phone:
OTE: Plans and supporting documents that you submit are considered to be pudic information. Portions
he information may, be classified as non-public if you provide specific reasons that would permit the City
conclude that the are trade secrets.
CALL. BEFORE YOU DIG. Call Gopher State One Call at (651) 464-0002 for protection against underground utility damage. Call 48 hours
before you intend to dig to receive locates of underground utilities, www.gopherstateonecall orq
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of
Eagan, that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit, that the work will be in
accordance with the approved plan in the case of work which requires a review and approval of plans.
Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180
days of permit issuance.
x /41 //* ';:mbrS g-6,
Applicant's Printed Name
x
Applicant's Signature
Page 1 of 3
44'-fqtccto
DO NOT WRITE BELOW THIS LINE
I 118 7a --
SUB TYPES
Foundation
Single Family
Multi
01 of Plex
Accessory Building
WORK TYPES
New
Addition
Alteration
Replace
_ Retaining Wall
DESCRIPTION
Valuation
Plan Review
(25% 100%
Census Code
# of Units
# of Buildings
Type of Construction
Fireplace
Garage
Deck
Lower Level
_ Interior Improvement
Move Building
Fire Repair
Repair
REQUIRED INSPECTIONS
Footings (New Building)
Footings (Deck)
Footings (Addition)
Foundation
Drain Tile
Roof: _Ice & Water Final
y. Framing
Fireplace: Rough In Air Test
Insulation
Sheathing
Sheetrock
Reviewed By:
Porch (3 -Season)
Porch (4 -Season)
Porch (Screen/Gazebo/Pergola)
Pool
Occupancy
Code Edition
Zoning
Stories
Square Feet
Length
Width
Final
1
Siding
Reroof
Windows
Egress Window
Storm Damage
Exterior Alteration (Single Family)
Exterior Alteration (Multi)
Miscellaneous
Demolish Building`
Demolish Interior
Demolish Foundation
Water Damage
'Demolition of entire building - give PCA handout to applicant
41,13
MCES System
SAC Units
City Water
Booster Pump
PRV
Fire Sprinklers
Meter Size:
Final / C.O. Required
y Final / No C.O. Required
HVAC Gas Service Test Gas Line Air Test
Other:
Pool: _Footings Air/Gas Tests Final
Siding: _Stucco Lath _Stone Lath _Brick
Windows
Retaining Wall: Footings _ Backfill Final
Radon Control
Erosion Control
Building Inspector
RESIDENTIAL FEES
Base Fee
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S&W Permit & Surcharge
Treatment Plant
Copies
TOTAL
roily
1
Page 2 of 3
411!0/
City of Ea�all
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
r
1.
Use BLUE or BLACK Ink
For Office Use
Permit #: 1 'a 11
Permit Fee: (I)
Date Received:'1 (3( ( L
Staff:
2013 RESIDENTIAL PLUMBING L//PLUMBING PERQMIT APPLICATION
Date: 7" �/ /?' `� �3 Site Address: (Nes 7 "s(4
Tenant: Suite #:
Restdent/Owlner
Name: l� fit / v'C( f/'�f�' �/6CI Phone:
//// f .Sl/ �
Address / City / Zip: 4/e/` Y" /6 C(.,���,) / "") CC -42;
Contractor
Name: 4,vl ek,,,,'l,k% N. �1� License #: (!)&20fa7—'/(1.
(,) city: 2,�G''I%'�'�'
Address: 27V 7 6 Dq A.
I ���'
State: 1/1/11`11/1/11`1Zip: 3� Phone: 7�DSR-'.67W
Contact: .7;641 Email: Th/1144,0S/C'e/ ® //49' 01'`7
art'
Type of Work
New Replacement Repair Rebuild Modify Space Work in R.O.W.
_
Description of work:
Permit Type
RESIDENTIAL
Water Heater
Water Softener217 C -2
Lawn Irrigation (_ RPZ / PVB)
%yd
41 Add Plumbing Fixtures (_ Main / Lower Level)
_
Septic System
Water Turnaround
New
Abandonment
RESIDENTIAL FEES:
$60.00 Water Heater,
$60.00 Lawn Irrigation
$60.00 Add Plumbing
*Water Turnaround
$105.00 Septic System
Water Softener, or Water Heater and Softener
(includes $5.00 State Surcharge)
Turnaround* (includes $5.00 State Surcharge)
and $5.00 State Surcharge)
TOTAL FEES $
(includes $5.00 minimum State Surcharge)
Fixtures, Septic System Abandonment, Water
(add $200.00 if a 5/8" meter is required)
New ($10.00 per as built) (includes County fee
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.orq
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of
Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start wit;, t 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 pl• s.
4)i7, oNy /yl sF,2lf
Applicant's Rtinted Name
x
Applicant's Sign •!
Mil 9i49slcri-cr
frALLS AND INTERIOR PARTITIONS, WOOD FRAMED
GA FILE NO. WP 3005
PROPRIETARY"
GYPSUM WALLBOARD, WOOD STUDS
One layer 54" proprietary type X gypsum wallboard or gypsum veneer base applied parapet
or at right angles to each side of 2 x 4 wood studs 16" o.c. with 15,4" Type S drywall
screws 12" o.c, Vertical joints centered over studs and staggered one stud cavity on
opposite sides. Horizontal joints need not be staggered or backed: (LOAD-BEARING)
Sound tested with resilient channels on one side, 314 glass fiberinsulation and a double
layer of 54 propnetary type X gypsum wallboardapplied with screws spaced 12 o,c.
PROPRIETARY GYPSUM BOARD
United States Gypsum Company 54" SHEETROCOi Brand iJltraLlght
Panels FIRECODE* 30
50 to 54 STC
SOUND
Thickness: 434" tFire)
" 614" tSound)
Approx. WeIght: 7 psi
Fire Test' UL R1319. 11NK03873,
4-15-11
UL Design U407
Sound Test RAL TL11-132, 5-23-11
GA FILE NO. WP 3010
GENERIC
GYPSUM WALLBOARD, RESILIENT CHANNELS,
GLASS FIBER INSULATION, W000 STUDS
Resilient channels 24" ox. attached at right angles to ONE SIDE of 2 x 4 wood studs 16"
0,c. with 1" Type 5 drywall screws. Base layer 5111" type X gypsum wallboard or gypsum
veneer base applied at right angles to channets with 1" Type S drywall screws 12" 0,e
Face layer 54- type X gypsum wallboard or gypsum veneer base applied at right angles
to channels with 34" daubs of adhesive 12' o,e. vertically and horizontally.
OPPOSITE SIDE: Base layer 54" type X gypsum wallboard or gypsum veneer base applied
parallel to studs with 50 coated nails, 154long, 0,086" shank, 1544" heads, 32
Second ae 2 type X gypsum wallboard or gypsum veneer base applied parallel to
studs with 8d coated nails, 234" long, 0.113" shanic, 542" heads. 17 o c. Face layer 3/8"
regular gypsum wallboard applied parallel to studs with 31( daubs of adhesive 12" de
vertically and horizontally, 2' glass fiber insulation. 0,90 pef, stapled to three layer side
in stud space,
Joints staggered 16" each tayer and side. (LOAD-8EARING)
60 to 64 STC
SOUND
Thickness: 674'
Approx. Weight: 12 psf
Fire Test. UL R3660-2, 12-3-68,
UL Design U313
Sound Test: RAI. TL69-117, 12-16-68
W6 -rt 91-14Z( t +e r ?-a
Plastic
Penetrating
Item and
Diameter
1-1/2", 2", 3" or 4"
sched. 40 PVC pipe
4" sched, 40 PVC or ABS pipe
Floor, Roof
or Wall :.
Type
CW, CF
CW, CF
=
+ '
Minimum Depth
Wrap, Type A
or Type IA'
Wrap, Type A or Type IA'
Forming
Material
—
—
Minimum
Varies
1/4"
Maximum
Varies
Varies
Rating
F
2
2
T
1
2
UL
System
Number
C -AJ -2301
C -AJ -2304
Reference
ARL
SA727
SA727
Index
79
80
1-1/2" or 2" sched. 40 PVC pipe
CW, CF
1/2" Type IA
Foam Backer
3/8"
3/4"
2
1-1/2
C -AJ -2295
SA727
81
or SDR17 CPVC pipe
1" Type 1A
Foam Backer
1/4"
3/8"
2
1-1/2
3/4" PEX tube or 1" ENT
CW, CF
1/2" Type A
Foam Backer
1/4"
7/16"
2
1-1/2-
C -AJ -2296
SA727
82
1-3/4
1" sched. 40 PVC pipe
FSD
1"Type IA
Foam Backer
1/4"
7/16"
3
1-1/2
F -A-2062
SA727
83
4" sched. 40 PVC pipe or
CW, CF
1/2" Type IA
Foam Backer
0"
1-1/2"
1
1
F -A-2063
SA727
84
4" SDR17 CPVC pipe or
4" sched. 40 PVC conduit
6" sched. 40 PVC or
CF
Wrap, Type A or Type IA'
—
Varies
Varies
2-3
1-1/2-
F -A-2064
SA727
85
6" SDR135 CPVC pipe
2-1/2
3" sched. 40 PVC or ABS plse
bW
Wrim,1/2"TypeIA :
Foam Backer
/2"
,1, .
1-1/2" sched. 40 PVC
or ABS pipe
WF
1/2" Type IA
Foam Backer
0"
1"
1
1
F -C-2180
87
1-1/2" sched. 40 PVC
or ABS pipe
WF
1/2" Type IA
Foam Backer'
0"
1"
1
1
F -C-2181
SA727
88
3" sched. 40 PVC pipe or
WF
1/2" Type IA
Foam Backer
0"
1/2"
1
1
F -C-2182
SA727
89
3" SDR17 CPVC pipe or
3" sched. 40 PVC conduit
4" sched. 40 PVC or sched.
WF
1/2" Type IA
Foam Backer
0"
1/2"
1
3/4
F -C-2183
SA727
90
40 ABS or SDR17 CPVC pipe
2" SDR13.5 CPVC pipe
CW
1/2" Type IA
Foam Backer
1/4"
1-3/8"
2
0
W -J-2068
SA727
91
2", 3" or 4" sched. 40 PVC pipe
GW
Wrap, Type A
or Type IA'
Vanes
Varies
2
1
W -L-2220
SA727
92
Up to 4" sched. 40 PVC or
GW
Wrap, Type A or Type IA'
—
Varies
Varies
1
0-1
W -L-2221
SA727
93
1-1/4" SDR135 CPVC pipe
6" sched. 40 PVC pipe
GW
Wrap, 1/4" Type A or
—
0"
3/8"
2
1-1/2
W -L-2222
SA727
94
Type IA
2" SDR13.5 CPVC pipe
GW
1/2"Type IA
Foam Backer
1/4"
1-3/8"
1-2
1-2
W -L-2223
SA727
95
3/4" PEX tube or 1" EMT
GW
1/2" Type IA
Foam Backer
1/4"
3/8"
1-2
3M4
W -L-22224 "
SA72?
.#
1-1/2-
•
1-3/4
• 1-1/2" sched. 40 PVC pipe
GW
1"Type IA
Foam Backer
1/4"
5/8"
2
2
W -L-2225
SA727
97
2" sched. 40 PVC pipe
GW
1/2"Type IA
Foam Backer
0"
7/8"
1
0
W -L-2226
SA727
98
(a) Pipe covering material (b) Minimum depth dependent upon annular space dimensions (c) Optional (d) Ceramic Liber (e) 2 -hr. wall (n 2 -hr. (two layers 718" backer
rod); 1 -hr. (bond breaker tape) (g) Two layers 7/8" backer rod (h) Formerly Type A -SP
13 USG Fire Stop Systems
Performance Selector
Copper
Penetrating
Item and
Floor, Roof
or Wall
Firestopping
Material
Forming
Annular
Space
Rating
UL
System
Reference
Diameter
Type
Minimum Depth
Material
Minimum
Maximum
F
T
Number
ARL
Index
Pipe up to 6"
CW, CF
1" Type FC or RFC
3", min. 4 pcf
1/4"
4"
3
0
C -AJ -1081
SA727
45
Tubing and pipe up to 4"
CW, CF
1" Type FC or RFC
3", min. 4 pcf
1/4"
4"
3
0
C -AJ -1081
SA727
46
Tubing and pipe up to 4"
CW, CF
1/2" Type A
3", min. 6 pcf°
0"
7/8"
2
0
C -AJ -1347
SA727
47
Tubing and pipe up to 4"
CW, CF
1" Type IA
4", min. 4 pcf
1/2"
1-3/8"
2
0
C -AJ -1348
SA727
48
Insulated tubing and pipe up to 4"
CW, CF
1/2" Type A
4", min. 4 pcf
3/8"
1-1/2"
1-1/2-2
1/2-1
C -AJ -5146
SA727
49
Insulated tubing and pipe up to 2"
CW, CF
1"Type IA
Foam Backer
1/8"
1/4"
2
1
C -AJ -5147
SA727
50
Insulated tubing and pipe up to 4"
CW, CF
1"Type IA
3-1/2", min. 4 pcf
1/2"
1-1/2"
2
1/2-1
C -AJ -5149
SA727
51
Tubing and pipe up to 4"
FSD
1/2" Type A
4", min. 4 pcf
1/4"
1-5/8"
3
0
F -A-1020
SA727
52
Insulated tubing and pipe up to 4"
FSD
1/2" Type A
4", min. 4 pcf
1/4"
5/8"
3
1
F -A-5014
SA727
53
Tubing and pipe up to 4"
WF
1/2" Type IA
Foam Backer
0"
7/8"
1
1/4
F -C-1069
SA727
54
Insulated tubing and pipe up to 4"
WF
1/2" Type IA
Foam Backer
0"
7/8"
1
3/4-1
F -C-5042
SA727
55
Tubing and pipe up to 4"
CW
1/2" Type IA
Foam Backer
0"
1"
2
0
W -J-1091
SA727
56
Pipe up to 6"
GW
1"Type FC
2-1/2", min. 4 pcf
1"
1-5/8"
2
0
W -L-1027
SA727
57
Pipe up to 4"
GW
1/2"Type FC or RFC
2-1/2", min, 4 pcf
1/4"
1-5/8"
1
0
W -L-1039
SA727
58
Tubing up to 4"
GW
1" Type FC or RFC
—
1/4"
1-5/8"
2
0
W -L-1063
SA727
59
to 4"
GW
1" Type FCS ROC
=
1/4"
1 ll4.a
t ,
G.
'
` ._ v
Insulated tubing up to 4"
GW
1/4" Type FC or RFC
2", min. 4 pcf
1/4"
1/2"
2
1
W -L-5043
SA727
61
Insulated pipe or tubing up to 4"
GW
1" Type FC or RFC
1", min. 4 pcf'
1/2"
5/8"
2
3/4
W -L-5044
SA727
62
Insulated tubing and pipe up to 4"
GW
1"Type IA
Foam Backer
0"
3/8"
2
1/2
W -L-5114
SA727
63
Insulated tubing and pipe up to 3"
GW
1/2" Type IA
Foam Backer
1/4"
1-1/8"
1-2
1/2-1
W -L-5115
SA727
64
Cables
Cables
CW, CF
1"Type FC or RFC
3", min. 4 pcf
1/4"
4"
3
0
C -AJ -3045
SA727
65
Cables
CW, CF
1/2" Type IA
4", min. 4 pcf
Varies
Varies
2
0-1/2-1
C -AJ -3174
SA727
66
Cables
CW, CF
1/2"Type IA
4", min. 4 pcf
3/4"
3-3/16"
2
1/2
C -AJ -3175
SA727
67
Cables
WF
1/2" Type IA
Foam Backer
Varies
Varies
1
3/4
F -C-3054
SA727
68
Cables
GW
1"Type FC or RFC
3", min. 4 pcf
1/4"
4-1/2"
2
0
W -L-3023
SA727
69
Cables
GW
1/2" Type FC or RFC
3-7/8", min. 4 pcf
1/2"
3-7/8"
1
0-1
W -L-3034
SA727
70
Cables
GW
1/2"Type IA
Foam Backer
1/2"
1-1/2"
1-2
1/4-1/2
W -L-3162
SA727
71
Cables
GW
1/2"Type IA
Foam Backer
1/4"
1"
1-2
1/4-1/2
W -L-3163
SA727
72
Air Ducts
Steel duct, Nom. 18" x 6"
CW, CF
1" Type IA
1", min. 4 pcf
Varies
1"
3
0
C -AJ -7062
SA727
73
Steel duct, Nom. 4"
CW, CF
1/2" Type IA
4", min. 4 pcf
1/2"
1-3/8"
2
0
C -AJ -7063
SA727
74
Steel duct, 24-ga., up to 3" x 10"
GW
1/2" Type FC or RFC
2-1/2", min. 4 pcf
7/16"
1-5/8"
1
0
W -L-7001
SA727
75
Steel duct, 28-ga. galv., nom. 4" x 6"
GW
1"Type FC or RFC
2-1/2", min. 4 pcf
1/2"
1-5/8"
2
1/2
W -L-7002
SA727
76
4", 26-ga., galv. steel vent duct
GW
1/2"Type IA
Foam Backer
0"
1"
1-2
0
W -L-7057
SA727
77
Glass Pipe
Glass pipe, nom. N GW 1/2" Type IA Foam Backer 1/2" 1-1/8" 1 0 W -L-2227 SA727 78
(a) Pipe covering material (b) Minimum depth dependent upon annular space dimensions (c) Optional (d) Ceramic fiber (e) 2 -hr. wall (f) 2 -hr. (two layers 7/8" backer
rod); 1 -hr. (bond breaker tape) (g) Two layers 7/8" backer rod (h) Formerly Type A -SP
12 USG Fire Stop Systems