3428 Highlander DrRESIDENT /
OWNER
Name: A 11 ! —.A, 44114 "FJ A . IL!', :. 4 40 _ t i r.1 —119A- %2
Address / City / Zip: r a /1 ♦ 0 i fyyl�L
Applicant is: — Owner Contractor
TYPE OF WORK
i
Description of work: /. L A!. . Ji i . � A • .. /
/ r
UQ / 1 t . it 1
Construction Cost J �' Multi- Family :wilding: (Yes ! No )
CONTRACTOR
_
Company:( Q J / /lL L/ Contact SA-111 V hay I N
Address:'T 1w C Zda4st -e B a::.. City: Car Luis p -LIK,
j // 3 h ".G _
State: r r (5
Zip: `t U1491 i, Phone:
I S
License #: /0 Lead Certificate #i: Ai / V s 4 -1
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
Licensed Plumber:
Mechanical Contractor:
Sewer & Water Contractor:
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: _
Phone:
_ Phone:
Phone:
more 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.
Jun. 8. 2011 2:43PM SELA ROOFING
Date;
'Thigri City oJiaau
Applicant's Printed Name
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
c+ ‘
Applicant's Signature
2011 RESIDENTIAL RI IILDIN(Z PERMIT APPLICATION
Permit It
No. 6530 P. 8
Use BLUE or BLACK Ink
C / 1 /6S
Permit Fee: /3 7y (9'
Date Received:
Staff:
J
l Site Address: ` .4. del • c.3`t - d
CALL BEFORE YOU DIG. Gall 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.nonherstateonecail.or t
t 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 wog 's not to st- , without a per pit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approv
,E.1
O JT
Page I of 3
k �� WATER SE PERM
� y i of Knob Road PERMIT`, NO " �s` '�$
. , - £MN 55122 DATE
z N o =of U nits
-.Address- r4 ".S, va i�`i a, ��', . , .. _ s t e+, r,,,d
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Plumber . ' , ., .. ' i
'Meter "No ? = - ` Conn ection Charge:
E .t
Account Deposit:
<; Size - P erm i t ",Fee ., •
ReaderNo .`
f
F 1 agree to aomp wi th the City of;Edgcn . Surc harge: C
Or Mist • ` Charges:
" I nsp.
: Total
B a Date Paid
Y irr
Date of • I nsp r O
CITY` EA AN ' SEW SER } PERMIT.;
}
a�, ilot Knob Ro P. E fi J. NC
` MN 55122 �' DATE t
- of U its '
Owne , % - _
▪ Address ??
Site ; Addr es s.' ° ` - - - �T x .fie z n„ . • , '1' r .a #'", •
Plumber ' 4 , ,
1 agre to comply with th e'City of Eagan Connection Charge , - •
Ordinances. Account Deposit:
Permi :Fee . 3
Surcharge: .•
BY
Mis G horges• T3
Dates,of Insp : To taL
Date P aid: 1