3411 Highlander DrJun. 8. 2011 2:42PM SELA ROOFING
*City oi6api
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
No.6530 P. 2
Use BLUE or BLACK Ink
Permit # 9Z
s
Permit Fee: �_339 4,9
Date Received:
Staff:
/ j2011 RESIDENTIAL BUILDING PERMIT ijAPPLICATIO
Y L Site Address: _ 1( 301 t { lni #'
RESIDENT 1
OWNER
Name: 166 QW)f,/ .gone%5a—g —567 r'
Address I City t Zip: CJ`Io I (5467D M 511,1 i ) t -Applicant
is: Owner /\ Contractor
TYPE OF WORK
Description of work4 1!A ' ! /"moi.1101 ditLIL._,� I.
gir
Construction Cost O4 . 0� /�V Multi -Family Building: (Yes / No )
CONTRACTOR
Company: acorl N 67 Contact: 6444- tC, V ilay
Address: IO6 t OL W City: L . l Ill 1' L:
State: rtC.9 Zip; 554 1 Phone: Le/(2---62,96-4
License #: OD `0 60 Lead Certificate #: itiki ^ 6 5. V,3`L - i
If the project is exempt
from lead certification, please explain why: (see Page 3 for additional information)
In the last 12 months,
Yes No If
COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
has the City of Eagan issued a permit for a similar plan based on a master plan?
yes, date and address of master plan:
Licensed Plumber:
Mechanical Contractor:
Sewer & Water Contractor:
Phone:
Phone:
Phone:
NOTE: Prins and supporting.documents that you. submit are considered: to be public inforrnation. Portions of
the information may beclassified as non-public if you provide specific reasons that would permit the Cityto
conclude that they are trade secrets.
CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage.
Call 48 hours before you intend to dig to receive locates of underground utilities. www.aooherstateonecall.orq
I hereby acknowledge that this information is complete and accurate; that the work will be in oonformance
Eagan; that I understand this is not a permit, but only an application for a permit, and work is riot t0 Start
accordance with the approved plan in the case of work which requires a review and approv— plans.
phcanrs Signature
(SAM Uk-AAJ 10_10
Applicant's Printed Name
the ordinances and codes of the City of
r flout a per i t; that the work wilt be in
7
Page 1 of 3
DEC -29-2009 12:17 From:SAMSUNG
City of Earn
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
To:6516755694 Page:2'2
Use BLUE or BLACK Ink
For ^ffceir
as
Permit
Permit Fee: g o ` (/ t/
Date Received;
Staff:
20.099 RESIDENTIAL BUILDING PERMIT APPLICATION
Date: /2- ^c70.-�vv / Site Address: 3`1 i 1 -rt be-fi
eViehA �c- /✓£� i
Tenant
J
Suite #: ^1 /A
RESIDENT / OWNER
Name: MC -el 6 iE Phone: 67501 - e7;'- 6 4/� 7
)
Address / City / Zip: 3Z% 1) I -1-t gh 1.f1 rJA UL ..t(Z 11 L.
Applicant is: Owner X_ Contractor C -
,(4 0 L2 .
TYPE OF WORK
Description of work: 4714ee Ai / -• - ,JQ A 1-r'£-4-• of U IE,J a
Ic
Construction Cost � e' Multi -Family Building: (Yes X ! NO )
CONTRACTOR
Name: A t.Ls%ali- G;.,JSilzarfr69,1 OA nl PMtJfLicense #: Z.O 3 i S -75-
tsAddress:
Address:5 -It -IS /n4iNuis'Tre_:At__ Sr .. .iTri i0
City: /1/10./1/10. Pte aa...,, ;->_.) State: %n/+/ Zip: 553j $
�/
Phone: 95 "-40- ' 717/-/ Contact Person: -fit * A Lt-c--,--04-")COMPLETE
In the last 12 months, has
Yes No If yes,
THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING
the City of Eagan issued a permit for a similar plan based on a master plan?
date and address of master plan:
Licensed Plumber: Phone:
Mechanical Contractor:
Sewer & Water Contractor:
Phone:
Phone:
NOTE: Plans and supporting documents that you submit are considered ftp. be public informations 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 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.nopherstateonecall.orq
I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances a 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 sta witt 5 : • : at a work will be in
accordance with the approved plan in the case of work which requires a review and approval pf plans_
x,�.. f�i-i%E.wt
Applicant's Printed Name
Applicant's Signature
Page 1 of 3
Clly of Eaali
Date: /0
Site Address:
x J'e (`e/6'7
Applicant's Printed Name
3V)) 1 lot/yin
2009
Fo
Use BLUE or BLACK Ink
Permit 1 1
Permit Fee:
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
2009 RESIDENTIAL BUILDING PERMIT APPLICATION C \1kkc( /6--/(7
Date Received: V 1
Staff:
Tenant: Suite
RESIDENT OWNER
TYPE OF WORK
CONTRACTOR
Name:
i ke i1 e /6,,
Address City Zip:
Applicant is: )(Owner
Contractor
Phone: 73 a9a
Description of work:
Construction Co
a c- Ac_ce 50 Ad t5i) eel- toe K se.i,
Multi Family Building: (Yes No
0000
License
Name:
Address:
City: State: Zip:
Phone: Contact Person:
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:
Phone:
Sewer Water Contractor:
NOTE Plans and upportin docum that you submit are consi
th e informati n may be classified as non public IT you provide speci
conclud that they ,ire trade secr
h e C
f o be public informati
so ns that would per
fiS
CALL BEFORE YOU DIG. CaII 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.gooherstateonecall.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.
nt's Signature
Page 1 of 3
SUB TYPES
Foundation
Single Family
Multi
01 of Plex
Accessory Building
WORK TYPES
New Interior Improvement
Addition Move Building
x Alteration Fire Repair
Replace Repair
Retaining Wall
DESCRIPTION
Valuation
Plan Review
(25 100
Census Code
of Units
of Buildings
Type of Construction
REQUIRED INSPECTIONS
Footings (New Building)
Footings (Deck)
Footings (Addition)
Foundation
Drain Tile
Roof: Ice Water _Final
)e Framing
Fireplace: Rough In Air Test _Final
•i< Insulation
Meter Size:
Reviewed By:
RESIDENTIAL FEES
Base Fee
Surcharge
Plan Review
MCES SAC
City SAC
Utility Connection Charge
S&W Permit Surcharge
Treatment Plant
Copies
Fireplace
Garage
Deck
Lower Level
ae, L 0 L44
TOTAL
DO NOT WRITE BELOW THIS LINE
7Z
Storm Damage
Exterior Alteration (Single Family)
Exterior Alteration (Multi)
Pool Miscellaneous
Porch (3- Season)
Porch (4- Season)
Porch (Screen /Gazebo /Pergola)
Occupancy
Code Edition
Zoning
Stories
Square Feet
Length
WMtI�
iev
Siding
Reroof
Windows
Egress Window
m� of S
7t
prrf
1'7G CL IC, V OO
Demolish Building*
Demolish Interior
Demolish Foundation
Water Damage
*Demolition of entire building give PCA handout to applicant
MCES System
SAC Units
City Water
Booster Pump
PRV
**Sprinklers
Sheetrock
y Final C.O. Required
Final No C.O. Required
0
9 00
HVAC
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
Page 2of3
guu. cross Amount Due To Seller
101. Contract sales .rice
43,931.00
401. Contract sales rice
43,931.00
102. Personal .ro.e
502. Settlement cha es to seller line 1400
503. Exlstin a loan s taken sub ect to
504. Pa off of first mort: a e loan
402. Personal .ro.ert
205.
103. Settlement cha !e to borrowe line 1400
471.00
403.
206. certlfed assessment
104. .rorated assoc dues 9/24/2009 to 10/1/2009
58.68
404..rorated assoc dues 9/24/2009 to 10/1/2009
58.68
105.
Ad ustments For Items Paid B Seller In Advance
106. Clt /Town taxes
507.
405.
Ad ustments For Items Paid B Seller In Advance
406. Clt /Town taxes
208.
107. Count taxes
508.
407. Coun taxes
209.
Ad ustments For Items Un ald B Seller
210. CI /Town taxes
211. Coun taxes 7/1/2009 to 9/24/2009
212. Assessments
108. Assessments
509.
Ad ustments For Items Un aid B Seller
510. Clt /Town taxes
511. Count taxes 7/1/2009 to 9/24/2009
512. Assessments
408. Assessments
213.
109.
513.
409.
214.
110.
410.
111.
411.
112.
516.
412.
113.
517.
413.
218.
114.
518.
414.
219.
115.
519.
415.
220, Total Paid B /For Borrower
116.
418.
,q ROD A.,
117.
417.
118.
418.
119.
419.
120. Gross Amount Due From Borrower
44 460.88
420. Gross Amount Due To Seller
da ONO RR
201. De•oslt or eamest mone
501. Earnest mone
202. Princl.al amount of new loan for
203. Exlstin a loan s taken sub ect to
204. earnest mono
2 000.00
502. Settlement cha es to seller line 1400
503. Exlstin a loan s taken sub ect to
504. Pa off of first mort: a e loan
13 048.04
205.
505. Pa off of second morte a e loan
206. certlfed assessment
388.23
506. certifed assessment
388.23
207. A. ent credit for title oil
180.00
507.
208.
508.
209.
Ad ustments For Items Un ald B Seller
210. CI /Town taxes
211. Coun taxes 7/1/2009 to 9/24/2009
212. Assessments
251.86
509.
Ad ustments For Items Un aid B Seller
510. Clt /Town taxes
511. Count taxes 7/1/2009 to 9/24/2009
512. Assessments
251.88
213.
513.
214.
514.
215.
515.
218.
516.
217.
517.
218.
518.
219.
519.
220, Total Paid B /For Borrower
2 820.09
520. Total Reduction Amount Due Seller
,q ROD A.,
A. Settlement Statement
FINAL.
B. Type Of Loan r
FHA 2 E FmHA 3 E jCarv.unlne
6. File Number.
920682
Kristy Larson
7. Loan Number.
E VA 5 L C onv.In
C. Note: This form Is furnished to give you a statement of actual settlement costs. Amounts pald to and by the settlement agent are shown. Items marked
"(p.o.c.)" were paid outside the closing; they are shown here for Informational purposes and are not Included In the totals.
D. Name Address Of Borrower.
Michael A. Overby
3411 Highlander Drive
Eagan, MN 55122 -1309
E. Name Address Of Seller.
Endure Financial Federal Credit Union f /k/a
Honeywell Federal Credit Union
820 Lilaa Drive
Minneapolis, MN 55422
H. Settlement Agent
Edina Realty Title, Inc.
Place Of Settlement
1519 Central Parkway
Ste 100
Eagan, MN 55121
IVFw QVvAi,_& t.
0. Property Location:
3411 Highlander Drive
Eagan, MN 55122 -1309
Dakota 10-73003-060-01
Lot 6, Block 1, Surrey Heights 4th Addition
J. Summary Of Borrower's Transaction
100. Gross Amount Du
U.S. Department of Housing
and Urban Development
K. Summary Of Seller's Transaction
F. Name Address Or Lender:
OMB Approved No. 2502.0205
8. Mortgage ineumnce Case Number.
Settlement Dale: 09/24/2009
Prorallon Date:
Funding Date: 09/24/2009
Amount s Pald y Or I n Be Of Borrower
500. Reductions In Amount Due To Se
300 Caah At Settlement From Borrower
301. Gross amount due from borrower(Ilne 120)
302. Less amounts pald by/for borrower(Ilne 220)
44,460.68
2,820.09
41,040.89
601. Gross amount due to selier(line 420)
602. Less reductions In amount due seiler(Ilne 520)
603. Cash
ri From Seller
303. Cash
Previous editions are obsolete
From t To Borrower
Page 1 of 3
800. Cash At Settlement To /From Seller
Created by Kristy Larson on 09/24/2009 at 3:15 :29 PM
43,989.68
13,688.13
30,301.55
HUD-1 Settlement Statement Certification
Title Company, In its capacity as Escrow Agent, is and has been authorized to deposit all funds
It receives In this transaction in any financial institution, whether affiliated or not. Such
flnanclal Institution may provide Title Company computer accounting and audit services directly or
through a separate entity, which, if affiliated with Title Company, may charge the flnanclal
institution reasonable and proper compensation therefore, and retain any profits there from. Any
escrow fees paid by any party Involved in this transaction shall only be for check writing and input
to the computers, but not for aforesaid accounting and audit services. Title Company shall not be
liable for any Interest or other charges on the earnest money In flnanclal institutions with which
Title Company has or may have other banking relationships and further consent to the retention by
Title Company and /or its affiliates of any and all benefits (including advantageous Interest rates
on loans) Title Company and /or Its affiliates may receive from such flnanclal institutions by reason
of their maintenance of said escrow accounts.
The parties have read the above sentences, recognize that the recitations herein are material,
agree to same, and recognize Title Company is relying on the same.
I have carefully reviewed the HUD -1 Settlement Statement and to the best of my knowledge and belief, It Is a true and accurate statement of all
receipts and disbursements made on my account or by me In this transaction. 1 further certify that I have received a copy of the HUD -1 Settlement
Statement.
Buyers Signatures:
Michael A. Overby
Settlement Agent:
Previous editions are obsolete
Sellers Signatures:
Endure Financial Federal Credit Union f /Wa Honeywell Federal
Credit Union
John Ferstl, Vice President Sales
Date:
/-L-ii/cp
Edina Realty 1tle, Inc.
WARNING:It is a crime to knowingly ma -false statements o Unit= t s on this or any form. Penalties upon conviction can Include a fine
and Imprisonment. For details see: Title 18 U.S. 615119 Seetion4001. -an. action 1010.
Page 3 of 3 Created by Kristy Larson on 09/24/2009 at 3:15 :29 PM
Escrow 920682
Form No. 7 -M WARRANTY DEED
Corporation, Partnership or Limited Liability Company to Individual(s)
STATE DEED TAX DUE HEREON:
Date: 3 Z® o
FOR VALUABLE CONSIDERATION, Endure Financial Federal Credit Union f /k /a Honeywell Federal Credit Union a
federal credit union under the laws of Grantor, hereby conveys and
warrants to Michael A. Overby, Grantee(s), real property in Dakota County, Minnesota, described as follows:
SEE ATTACHED EXHIBIT A
together with all hereditaments and appurtenances belonging thereto, subject to the following exceptions:
easements, covenants and restrictions of record.
Chox if applicable:
he Seller certifies that the seller does not know of any wells on the described property.
A well disclosure certificate accompanies this document.
I am familiar with the property described in this instrument and I certify that the status and number of wells on
the described real property have not changed since the last previously filed well disclosure certificate.
Affix Deed Tax Stamp Here
STATE OF MINNESOTA
COUNTY OF tkt a Pi
SS.
NOTARIAL STAMP OR SEAL (OR OTHER TITLE OR RANK):
JEFFREY D SMRCKA
NOTARY PUBLIC MINNESOTA
MY COMMISSION EXPIRES 1414010
THIS INSTRUMENT WAS DRAFTED BY (NAME AND ADDRESS):
Edina Realty Title
6800 France Ave. South
Edina, MN 55435
End inanci. ederal
Howl Fe;�I Cr
n Ferstl, Vice President Sales
This instrument was acknowledged before me on C 1( by Johns Ferstl Vice President of sales for
Endura Financial Federal Credit Union f /k/a Honeywell Federal Credit Union, a federal credi union on behalf of the
federal credit union grantor(s).
.r red
Check here If p= I of the land Is Registered (Torrens)
SIGNAT
0 ARY PUBLIC OR OTHER OFFICIAL
Tax Statements for the real property described In this instrument should
be sent to (Include name and address of Grantee):
City of Eaall
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Date: f O /q /Q LI Site Address:
Permit Fee:
2008 MECHANICAL PERMIT APPLICATION
3 i/j iprn0
Permit /4.6 4
Date Received:
Staff: v
Tenant: Suite
RESIDENT OWNER
CONTRACTOR
TYPE OF WORK
PERMIT TYPE
Name: N l L 1 rc
Phone: f S'a a9a-6G Y
Address City Zip:
License
Name:
Address:
City: State: Zip:
Phone: Contact Person:
New Replacement Additional Alteration
Demolition
Description of work:
NOTE: Both roof mounted.and ground mounted mechanical equipment is required to
be screened by City Code Please conta the Mechanical Inspector or one the
Planners for; information on permitted screening methods
RESIDENTIAL
Furnace
Air Conditioner
Air Exchanger
T Heat Pump
Other
COMMERCIAL
New Construction Interior Improvement
Install Piping Processed
Gas Exterior HVAC Unit
HVAC units must be screened
Under Above ground Tank Install Remove)
When installing /removing tank(s), call for inspection by Fire
Marshal and Plumbing Inspector
RESIDENTIAL FEES:
$50.50 Minimum Add or alteration to an existing unit (includes $.50 State Surcharge)
$90.50 Fire repair (replace burned out appliances, ductwork, etc.) (includes $.50 State Surcharge)
TOTAL FEE
COMMERCIAL FEES:
$70.50 Underground tank installation /removal
$50.50 Minimum (includes State Surcharge)
OR
If Permit Fee is less than $1,000, surcharge is $.50.
If Permit Fee is $1,000, surcharge increases by $.50 for each
$1,000 Permit Fee (Le. a $1,001 $2,000 Permit Fee requires a $1.00 surcharge).
Contract Value x 1%
Permit Fee
State Surcharge
TOTAL FEE
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.
x t/it� e 0U•r6
Applicants Printed Name
x
Applicants Signature
FOR OFFICE USE
Required Inspections.
Under.Ground
ough In _Air Test
RESIDENT OWNER
Name: M 1 Y e. 0 Ot i'b Phone: 95'.)- a 1)- 64'
i 97
Address City Zip:
CONTRACTOR
Name: License
Address:
City: State: Zip:
Phone: Person:
TYPE OF WORK
Contact
New Replacement t.— pair Rebuild Modify Space Work in R.O.W.
Description of work:
PERMIT TYPE
RESIDENTIAL
Water Heater Water Softener
Lawn Irrigation Add Plumbing Fixtures
RPZ PVB) Main Lower Level)
Septic System Water Turnaround
New
Abandonment
RESIDENTIAL FEES:
$50.50 Minimum Water Heater, Water Softener, or Water Heater and Softener (includes $.50 State Surcharge)
$30.50 Lawn Irrigation
$50.50 Add Plumbing
*Water Turnaround
$100.50 Septic System
$90.50 Fire Repair (replace
(includes $.50 State Surcharge)
Fixtures, Septic System Abandonment, Water Turnaround* (includes $.50 State Surcharge)
(add $165.00 if a 5/8" meter is required)
New ($10.00 per as built) (includes County fee and $.50 State Surcharge)
burned out appliances, ductwork, etc.) (includes $.50 State Surcharge)
TOTAL FEES
City ofEaQali
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Date: '7la'
Tenant:
x a(/z 6- 1
Applicant's Printed Name
Site Address: 3 o /4,4,4 Lan)
Applicant's Signature
Use BLUE or BLACK Ink
Permit q/5
Permit Fee:
Date Received:
Staff:
2009 RESIDENTIAL PLUMBING PERMIT APPLICATION
Suite
1
J
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
1 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.
FOR OFFICE US
Required Inspect
Reviewed
Date:
Ground Rough -In:'
as Tes,
RESIDENT OWNER
k kt, U v yt ✓s i
Name: N N e' Phone: 1. .r2 2,5 z. 6 6/ I
Address City Zip: c Z Z G(..)(-- /Z --l/✓ eC u )LL SYo 1-1—
CONTRACTOR
Name: J 1 Lc -S Pc u 1-1 h i L C.c., -S License 6 ?-1&/ 1 1-
Address: S Z J' CJ l/r 47R; I v`r�
City: /3 c. LA.-n, N c.jk. �--t, State: VI r‘ Zip: S.S
Phone: 61 --4 t~>7 6/ 1 r Contact Person: /ct ie e w
TYPE OF WORK
New t Rep i ment Repair Rebuil Modify Space Work in R.O.W.
Description of work: t -(.C- t,' ta ',Y,4.(A-`' (A C.0l.(it6: 1'1C e
PERMIT TYPE
RESIDENTIAL c 9 W 2_
Water Heater Water Softener
Lawn Irrigation Add Plumbing Fixtures
RPZ PVB) Main Lower Level)
Septic System Water Turnaround
New
Abandonment
RESIDENTIAL FEES:
$50.50 Minimum Water Heater, Water Softener, or Water Heater and Softener (includes $.50 State Surcharge)
$30.50 Lawn Irrigation
$50.50 Add Plumbing
*Water Turnaround
$100.50 Septic System
$90.50 Fire Repair (replace
(includes $.50 State Surcharge)
Fixtures, Septic System Abandonment, Water Turnaround* (includes $.50 State Surcharge)
(add $165.00 if a 5/8" meter is required)
New ($10.00 per as built) (includes County fee and $.50 State Surcharge)
burned out appliances, ductwork, etc.) (includes $.50 State Surcharge)
TOTAL FEES
C!tyofEaall
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Date: /0 7 •q Site Address: 3 r 1 6/e-- /emu.
x '1
Applicant's Printed Name
Applicant's Signature
I L.-
Use BLUE or BLACK Ink
1
i A /6---04/L.
2009 RESIDENTIAL PLUMBING PERMIT APPLICATION
OWL
Permit
Permit Fee:
Date Received:
Staff:
J
Tenant: Suite
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.aoDherstateonecall.orq
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 1 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 pins.
Dat e:'
FOR OFFICE USE
Required Inspections: Under Ground
Rough -In
Test
Gas Te
6
Perfection
HEATING E AIR CONDITIONING
1770 GERVAIS AvE LICENSED
MAPLEWOOD, MN 55109 INSURED
PH: 651-777-7620 BONDED
FAX: 651-777-3252
EQUIPMENT
I-"-' 1 LI V l' 16i! r- 1 RJ 1 �/ ( g r� �
ADDRESS 3 '1// I^/i9 ` 9 nod '11
TYPE /"!d t„�
MAKE e et/o. j e;2
P---./.2
CITY 6 vq gin/ ZIP
MODEL, l,./ j4p p —
V lA/0...
.1"
HM PH WK PH
SERIAL / ' ?5712.2. -7/TECH
DATE 3 �; // Y.
,
INPUT 66 000
ORSAT TEST RECORD
CO2 6, 9 % METERED INPUT 67; 0 00 cfh CHIMNEY TYPE /3 -Vey/
02 d , / % LIMIT SETTING /90 FLUE SIZE 6 in.
CO O % PILOT OUTAGE fivci/ sec CONNECTOR SIZE 1/ in.
NET STACK TEMP 3 Z 7 TOTAL CHIMNEY INPUT /0d 00O tuh
`` L
.J�
WORK PERFORMED:
PRICE
RECOMMENDATIONS:
TOTAL)
I AUTHORIZE AND AGREE TO
WARRANTY INSTALL
CASH CHECK #
PAY FOR THIS WORK
CARD # VISA MC
_
EXP DATE AUTH #
Customer Signature
7a lieu/
START
, , - ; WATER SERA Iff PERMIT
to " .,.. Knob Road P ERMIT 1_ 0.:
55122
F' I DATE:
Owner; No. of Units:
r Co 1.4 € d a11 €a t
Address: tii; �.ander or L608 Bi. R 5th -411 S e s s 1 Pi 14 .n of./ pd
' Connection Charge: '
Account Deposit: ,� . C1 l' d
Size: Permit Fee:
Reader No.: -, F
to comply with the Village of Eagan Surcharge: C .. p meter
1:ogr misc. Charges
Ordinances
• Total:
/. Date Paid:
Date of Insp.: ®�it Insp.:
VILLAGES OF EAGAN SEWER SERVICE PERMIT
3795. Pilot Knob Road PERMIT NO.:
Eagan, MN 55122 DATE:
Zoning: No. of. Units: •
Owner: i.. d r
Address:
Site Address: 4 +
Plumber: a 1 I 1 -r : ) k " : 1 e`: ,
350.
i agree to comply with the Village of Eagan Connection % Charge: ,
Ordinances. Account Deposit ,� + r ,_ , _,
Permit Fee:
Surcharge:
B y : Misc. Charges:
Date of Insp.: Total:
Insp.: Date Paid: