3442 Highlander DrRESIDENT t
OWNER
Name: f .11 _: sl. 9 At/AY?) - Gum l i iLe ne:15 - l aa- 55
0 c o r
Address / City / Zip: r 0 Fri 1 / / / O * 1
II
Applicant is: Owner _, Contractor
TYPE OF WORK
Description of work: " ' i /.yi Il t 1 _. d
Pill, I
Construction Cost: 40 Multi - Family Building: (Yes i I No )
CONTRACTOR
_
Company: ccah 146 r1 Contac / 1 V d,k U. il.
Address :4 6 De g D City: t,t,s
State: Zip: (664 1( Phone: Lp fa P3 1 - -G /C G a
,
License #: a)61060 Lead Certificate #: NM 6 " A5064" 064"
If the project is exempt
from lead certification, please explain why: (see Page 3 for additional information)
In the lest 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: Plans and supporting documents that you submit are considered to be public information. Portions of
the information may be classified as nonpublic if you provide specific reasons that would permit the City.to
conclude that they are trade secrets. _^
Jun. 8. 2011 2:46PM SELA ROOFING
4 111 '
City of Eagli
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Date:
2011 RESIDENTIAL BUILDING PERMIT APPLICATION
Site Address: b tit C/4 • L� 34 Anit #:
x (9 V 1 l
Applicant's Printed Name
Applicant's Signature
No. 6530 P. 20
Use BLUE or BLACK Ink
Wegr.W.Pr
Permit #: 9
Permit Fee: 1,31/. as
Date Received:
Staff:
GALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454 - 0002 fot protection against underground utility damage.
Call 48 hours before you intend to dig to receive locates of underground utilities. www.gpphersteteonecall.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 : rt without a permit; that the work will be in
accordance with the approved plan in the case of work which requires a review and approy.of plans.
Page 1 of 3
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