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675 Farm Rd411011 City of Earn 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Use BLUE or BLACK Ink For Office Use /�} Permit #: /[.,1ar'✓ 3 7 Permit Fee: 6`' C;) Date Received: Staff: 2012 MECHANICAL PERMIT APPLICATION ❑ Please submit two (2) sets of plans with all commercial applications. Date: ° r'7k Site Address: L, % J - %� 4 —v` Tenant: Suite #: —a RESID : , Name: 0,v16� S (2t)r45 S j' S 1.,„ 49 5`1 Phone: Address/City/Zip: Lo%,( i4,' i gd t .Cti Azov; S 7a - 'Y I" CONTRACT a„` , Name: C{. 7. License #: Address: City: State: Zip: Phone: Contact: Email: TYPE New X Replacement Additional Alteration Demolition Description of work: G 4 j,N,-/. az_ -6 m ® e . e d g � f ° a$.I -r et-},ap�Ci „Ie 1 s tu, j -t0 be SCreenedby Citi s v rnfr�°�°u ° '° . t =.e screening methods.” PER IT RESIDENTIAL Furnace COMMERCIAL New Construction Interior Improvement -Air Conditioner Install Piping Processed - Air Exchanger Gas Exterior HVAC Unit Heat Pump Under / Above ground Tank ( Install / Remove) Other RESIDENTIAL FEES: $60.00 Minimum Add-on or alteration to an existing unit (includes $5.00 State burned out appliances, ductwork, etc.) (includes Surcharge) $5.00 State Surcharge) = $ TOTAL FEE $100.00 Fire repair (replace COMMERCIAL FEES: $75.00 Underground tank installation/removal $60.00 Minimum (includes State (includes $5.00 State Surcharge) Surcharge) $10,010, surcharge is $ 5.00 surcharge increases by $.50 for each $1,000 Permit Fee requires a $ 5.50 surcharge) OR Contract Value $ x 1% = $ Permit Fee - If the Permit Fee is less than = $ Surcharge - If the Permit Fee is > $10,010, Fee = $ TOTAL FEE (i.e. a $10,010-$11,010 Permit CALL BEFORE YOU DIG. CaII Gopher State One CaII at (651) 454-0002 for protection against underground utility damage. CaII 48 hours before you intend to dig to receive locates of underground utilities. www.000herstateonecall.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. x -h s P. 80(6.-511 Applicant's Printed Name x Applicant's Signature ' FOR OFFICE ground Roug) as Service Test i1%ttoor Heat .: ;. Final WAIVER OF HEARING NO 747 SPECIAL ASSESSMENT AUTHORIZATION FOR UNPAID PERMIT FEES I/We hereby request and authorize the City of Eagan, MN (Dakota County) to assess thefollowing described property owned by me/us: ry" 1Z obi (01 675 FARM ROAD PID: 10-20900-040-03 For the unpaid permit fees: ITEM QUANTITY RATE AMOUNT Permit Charges 1 $6,640.00 $6,640.00 TOTAL: $6,640.00 to be spread for a term of 5 years at an annual interest rate of 6.0% against any remaining unpaid balances. You may pay any portion of these special assessments within thirty (30) days of signing the Waiver without interest at the Eagan Municipal Center. If you pay after the thirty (30) day period, interest will be charged from the signing date to December 31st of the current year. The undersigned, for themselves, their heirs, executors, administrators, successors and assigns, hereby consent to the assessment of these unpaid permit fees, and further, hereby waive notice of any and all hearings necessary, and waive objections to any technical defects in any proceedings related to these assessments, and further waive the right to object to or appeal from these assessments made pursuant to this agreement. Dated: 7-76- /0 cla_. 13c-1--- FeeOwner: CHARLES BORASH Dated: 7-16 r[ +� . FeeOwner: LINDA BORASH Notary ' y 1 Y \ t ,�.L ti UNDA MARIE DRALLE NOTARY PUUtIC- A Commit ienEepilesakaSt,E5 CityofEaaall Sewer Service Water Service Sewer lateral charge @ $62.70/ff Water lateral charge © $63.30/ff er trunk @ $1,275 /connection k @ $1,325 /connection $ 100.00 $ 2,100.00 $ 1,185.00 Address: 2010 SEWER AND WATER CONNECTION AND AVAILABILITY CHARGE' EXISTING RESIDENTIAL PROPERTY ��rli e o r�4 Via/ - �� /� Plumber: A 1` i dk Property Owner: Telephone #: Date of Inquiry: 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 6.75 t '�• l oa Contact Name: c t t° Tel 1 � /46� ! Sewer Service Sewer lateral charge Sewer trunk City SAC MCES SAC Receipt #: , Date: Septic abandonment Permit Fee State Surcharge TOTAL: -o-- y3 //3 32.7 $ 100.00 $ 2,100.00 $ 50.00 $ 50.00 $ 5.00 Water City SAC MCES SAC Receipt # Water sup storage R-. °pt# , Date atment plant 'Septic abandonment Permit Fee State Surcharge *Plumbing Permit Required — water meter to be acquired with building permit TOTAL: Service Water la I charge Water trunk Water supply stora Receipt #: , Date: Treatment Plant Permit Fee State Surc ge ' 0 *Plumbin. ° ermit Required — water meter to be ac. ' -d with building permit $ 50.00 $ 100.00 $ 5.00 r Use BLUE or BLACK Ink O 9 s47 C q 1� Permit Fee: Permit #: Date Received: Staff: TOTAL: $ 1,185.00 $ 735.00 $ 50.00 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 PERMIT City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 675 Farm Rd Lot: PID: Use: 4 Block: 3 Addition: Dodd View 10- 20900 - 040 -03 Description: Sub Type: Work Type: Description: Residential Sewer Only Waiver - Special Assessment Fees Only Meter Size Meter Type Manufacturer Fee Summary: Contractor: Valley Rich 147 Jonathan Blvd N #4 Chaska MN 55318 (952) 448 -3002 Applicant/Permitee: Signature 4" sewer service $0.00 City SAC (01 Unit) $100.00 Septic Abandonment $0.00 Sewer lateral charge $3,113.00 Sewer Permit $0.00 Sewer Trunk $1,327.00 Surcharge -Fixed $0.00 SAC (1 unit) - Single Family House $2,100.00 Total: $6,640.00 - Applicant - Permit Type: Permit Number: Date Issued: Sewer & Water EA094959 07/17/2010 Serial Number Remote Number Line Size Comments: 7/16/10 Homeowner is paying for the Sewer Lateral Charge, Sewer Trunk, City Sac, MCES Sac for a total of $6,640.00 via Waiver Special Assessment. This permit 94959 has been issued for these fees. A separate permit, #94957 has been issued for the actual cost of the permit - Septic Abanddonment permit fee & the Sewer permit fee & state surcharge for a total of $105.00. Owner: Charles Borash 1319 Raspberry Lane Eagan MN 55123 9379.4611 9379.4681 0801.4087 9379.4611 6201.4532 9379.4611 9001.2195 9220.2275 I hereby acknowledge that I have read this application and state that the 'nformation is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Issued By: Signature SPECIAL ASSESSMENT AUTHORIZATION FOR UNPAID PERMIT FEES I /We hereby request and authorize the City of Eagan, MN (Dakota County) to assess the following described property owned by me /us: 675 FARM ROAD PID: 10- 20900 - 040 -03 For the unpaid permit fees: ITEM QUANTITY RATE AMOUNT Permit Charges 1 $6,640.00 $6,640.00 TOTAL: $6,640.00 to be spread for a term of 5 years at an annual interest rate of 6.0% against any remaining unpaid balances. You may pay any portion of these special assessments within thirty (30) days of signing the Waiver without interest at the Eagan Municipal Center. If you pay after the thirty (30) day period, interest will be charged from the signing date to December 31 of the current year. The undersigned, for themselves, their heirs, executors, administrators, successors and assigns, hereby consent to the assessment of these unpaid permit fees, and further, hereby waive notice of any and all hearings necessary, and waive objections to any technical defects in any proceedings related to these assessments, and further waive the right to object to or appeal from these assessments made pursuant to this agreement. Dated: Dated: 0 Notar', 7 -/ / 7-1 WAIVER OF HEARING NO 747 cla_ FeeOwner: CHARLES BORASH FeeOwner: LINDA BORASH LINDA MARIE DRALLE NOTARY PUBLIC • MNE84TA lily Colon Wes km. 81, 2016 0 ti PERMIT City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 675 Farm Rd Lot: 4 Block: 3 Addition: Dodd View PID: 10- 20900 - 040 -03 Use: Description: Sub Type: Work Type: Description: Fee Summary: Contractor: Valley Rich 147 Jonathan Blvd N #4 Chaska MN 55318 (952) 448 -3002 Residential Sewer Only SEE COMMENTS Meter Size Meter Type Manufacturer Comments: 7/16/10 Homeowner is paying for the Sewer Lateral Charge, Sewer Trunk, City Sac, MCES Sac for a total of $6,640.00 via Waiver Special Assessment. A separate permit has been issued for these fees. This permit #94957 is for the actual cost of the permit - Septic Abanddonment permit fee & the Sewer permit fee & state surcharge for a total of $105.00. 4" sewer service City SAC (01 Unit) Septic Abandonment Sewer lateral charge Sewer Permit Sewer Trunk Surcharge -Fixed Total: Applicant/Permitee: Signature Permit Type: Permit Number: 41P10 „ Date Issued: C ity 0 Eaaan - Applicant - Serial Number Remote Number $0.00 $0.00 $50.00 $0.00 $50.00 $0.00 $5.00 $105.00 Owner: Charles Borash 1319 Raspberry Lane Eagan MN 55123 I hereby acknowledge that I have read this application and state that the 'nformation is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. 9379.4611 9379.4681 0801 .4087 9379.4611 6201.4532 9379.4611 9001.2195 Issued By: Signa Sewer & Water EA094957 07/16/2010 Line Size